[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 230 Introduced in Senate (IS)]

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118th CONGRESS
  1st Session
                                 S. 230

   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

                            February 2, 2023

Mr. Tester (for himself, Mr. Barrasso, Ms. Murkowski, Ms. Collins, Ms. 
  Sinema, Mrs. Hyde-Smith, Mr. Cramer, Mr. Kelly, Mr. Heinrich, Mrs. 
Capito, and Ms. Cortez Masto) 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 2023''.

SEC. 2. ELECTIVE RURAL SUSTAINABILITY 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) Elective Rural Sustainability Per Resident 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 
                sustainability per resident payment amount determined 
                under this subsection for an applicable hospital (as 
                defined in paragraph (7)(A)) that makes an election 
                under paragraph (2), with respect to each full-time-
                equivalent resident in an approved medical residency 
                training program that receives training in a rural 
                training location (as defined in paragraph (7)(C)), is 
                an amount equal to the difference between--
                            ``(i) the total elective rural 
                        sustainability amount determined under 
                        subparagraph (B) (or, in the case of an 
                        applicable hospital not located in a rural 
                        area, the 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 applicable 
                        hospital otherwise receives for direct graduate 
                        medical education costs under subsection (h) or 
                        section 1814(l), as applicable, with respect to 
                        each such resident.
                    ``(B) Total elective rural sustainability amount.--
                            ``(i) Establishment for initial cost 
                        reporting periods.--
                                    ``(I) In general.--Subject to 
                                subclause (II), for cost reporting 
                                periods beginning during the first year 
                                beginning on or after the date of the 
                                enactment of this subsection, the 
                                Secretary shall establish a total 
                                elective rural sustainability amount 
                                for time spent by each full-time-
                                equivalent resident in an approved 
                                medical residency training program that 
                                receives training in a rural training 
                                location. Such amount shall be the 
                                amount that the 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 periods 
                                beginning during the first year 
                                beginning on or after the date of the 
                                enactment 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 
                                        resident shall be equal to the 
                                        amount established under 
                                        subclause (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 
                                        sustainability 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 subsequent 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), respectively, are equal to such 
                        amounts determined under such clause for the 
                        previous cost reporting period updated, through 
                        the midpoint of the period, by projecting the 
                        estimated percentage change in the consumer 
                        price index for all urban consumers (all items; 
                        United States city average) during the 12-month 
                        period ending at that midpoint, with 
                        appropriate adjustments to reflect previous 
                        under- or over-estimations under this clause in 
                        the projected percentage 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 payment 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 
                hospital 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 applicable hospital may elect to receive 
        the elective rural sustainability per resident payment amount 
        for 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 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.
            ``(3) Application.--The provisions of this subsection, 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 
                        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); or
                            ``(ii) the counting of any resident with 
                        respect to which the applicable hospital 
                        receives an elective rural sustainability per 
                        resident payment amount under this subsection 
                        towards the application of the limitation 
                        described in clause (i) for purposes of 
                        subsections (d)(5)(B) and (h); and
                    ``(B) shall not have any effect on the 
                determination 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 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.
            ``(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 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 or 
                integrated rural tracks.--An applicable hospital shall 
                be eligible for payment of the elective rural 
                sustainability 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 more than 
                50 percent of the total residency training time in 
                rural training locations, regardless of where the 
                training occurs and regardless of specialty.
            ``(6) 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), but not taking into account the limitation 
        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 defined 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 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 sole 
                        community hospital (as defined in subsection 
                        (d)(5)(D)(iii)) or in a location that is within 
                        10 miles of a sole community hospital.
            ``(8) 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 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.''.
            (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 TRACKS.

    (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 2023, 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 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.''; 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)(II), 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 
                elective rural sustainability per resident payment 
                amount.--For special rules regarding application of the 
                elective rural sustainability per resident payment 
                amount under subsection (u), see paragraph (3) of such 
                subsection.''.
    (b) Indirect Medical Education.--Section 1886(d)(5)(B)(v) of such 
Act (42 U.S.C. 1395ww(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 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 
        sustainability per resident payment amount under subsection 
        (u), see paragraph (3) of such subsection.''.
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