I
119THCONGRESS
1
STSESSION H. R. 1153
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
FEBRUARY10, 2025
Mrs. H
ARSHBARGER(for herself, Ms. SCHRIER, 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 com-
mittee 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-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Rural Physician Work-4
force Production Act of 2025’’. 5
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SEC. 2. ELECTIVE RURAL SUSTAINABILITY PER RESIDENT 1
PAYMENT FOR RESIDENTS TRAINING IN 2
RURAL TRAINING LOCATIONS. 3
(a) I
NGENERAL.—Section 1886 of the Social Secu-4
rity Act (42 U.S.C. 1395ww) is amended by adding at the 5
end the following new subsection: 6
‘‘(u) E
LECTIVERURALSUSTAINABILITYPERRESI-7
DENTPAYMENTAMOUNT FORRESIDENTSTRAINING IN 8
R
URALTRAININGLOCATIONS.— 9
‘‘(1) D
ETERMINATION OF ELECTIVE RURAL 10
SUSTAINABILITY PER RESIDENT PAYMENT 11
AMOUNT.— 12
‘‘(A) I
N GENERAL.—The elective rural sus-13
tainability per resident payment amount deter-14
mined under this subsection for an applicable 15
hospital (as defined in paragraph (7)(A)) that 16
makes an election under paragraph (2), with re-17
spect to each full-time-equivalent resident in an 18
approved medical residency training program 19
that receives training in a rural training loca-20
tion (as defined in paragraph (7)(C)), is an 21
amount equal to the difference between— 22
‘‘(i) the total elective rural sustain-23
ability amount determined under subpara-24
graph (B) (or, in the case of an applicable 25
hospital not located in a rural area, the 26
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total elective rural sustainability amount or 1
urban total elective rural sustainability 2
amount, as applicable, determined under 3
such subparagraph); and 4
‘‘(ii) the amount (if any) the applica-5
ble hospital otherwise receives for direct 6
graduate medical education costs under 7
subsection (h) or section 1814(l), as appli-8
cable, with respect to each such resident. 9
‘‘(B) T
OTAL ELECTIVE RURAL SUSTAIN -10
ABILITY AMOUNT.— 11
‘‘(i) E
STABLISHMENT FOR INITIAL 12
COST REPORTING PERIODS .— 13
‘‘(I) I
N GENERAL.—Subject to 14
subclause (II), for cost reporting peri-15
ods beginning during the first year be-16
ginning on or after the date of the en-17
actment of this subsection, the Sec-18
retary shall establish a total elective 19
rural sustainability amount for time 20
spent by each full-time-equivalent resi-21
dent in an approved medical residency 22
training program that receives train-23
ing in a rural training location. Such 24
amount shall be the amount that the 25
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Secretary determines is equal to the 1
median national direct GME training 2
costs per full-time-equivalent resident 3
for 2015 described in table 9 on page 4
33 of the March 2018 GAO report on 5
Physician Workforce (GAO–18–240), 6
updated for each subsequent year 7
through the first year beginning on or 8
after the date of the enactment of this 9
subsection, by the annual percentage 10
increase in the consumer price index 11
for all urban consumers (all items; 12
United States city average). 13
‘‘(II) A
PPLICATION TO URBAN 14
HOSPITALS.—For cost reporting peri-15
ods beginning during the first year be-16
ginning on or after the date of the en-17
actment of this subsection, in the case 18
of an applicable hospital that is not 19
located in a rural area— 20
‘‘(aa) with respect to such 21
residents that receive training in 22
a rural track or an integrated 23
rural track, the total elective 24
rural sustainability amount per 25
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resident shall be equal to the 1
amount established under sub-2
clause (I); and 3
‘‘(bb) with respect to such 4
residents that receive training in 5
a rural training location and who 6
are not participating in a rural 7
track or an integrated rural 8
track, the total elective rural sus-9
tainability amount per resident 10
shall be equal to 50 percent of 11
the amount established under 12
subclause (I) (referred to in this 13
subsection as the ‘urban total 14
elective rural sustainability 15
amount’). 16
‘‘(ii) U
PDATING FOR SUBSEQUENT 17
COST REPORTING PERIODS .—For each sub-18
sequent cost reporting period, the total 19
elective rural sustainability amount under 20
clause (i)(I) and clause (i)(II)(aa) and the 21
urban total elective rural sustainability 22
amount under clause (i)(II)(bb), respec-23
tively, are equal to such amounts deter-24
mined under such clause for the previous 25
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cost reporting period updated, through the 1
midpoint of the period, by projecting the 2
estimated percentage change in the con-3
sumer price index for all urban consumers 4
(all items; United States city average) dur-5
ing the 12-month period ending at that 6
midpoint, with appropriate adjustments to 7
reflect previous under- or over-estimations 8
under this clause in the projected percent-9
age change in the consumer price index for 10
medical care services. 11
‘‘(C) C
LARIFICATION.—The total elective 12
rural sustainability amount, the urban total 13
elective rural sustainability amount, and the 14
elective rural sustainability per resident pay-15
ment amount determined under this paragraph 16
shall not be discounted or otherwise adjusted 17
based on the Medicare patient load (as defined 18
in subsection (h)(3)(C)) of an applicable hos-19
pital or discharges in a diagnosis-related group. 20
‘‘(2) E
LECTION.—For cost reporting periods 21
beginning on or after the date that is 1 year after 22
the date of the enactment of this subsection, an ap-23
plicable hospital may elect to receive the elective 24
rural sustainability per resident payment amount for 25
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each full-time-equivalent resident in an approved 1
medical residency training program that receives 2
training in a rural training location in accordance 3
with this subsection. An applicable hospital may 4
make an election under the preceding sentence re-5
gardless of whether the applicable hospital is other-6
wise eligible for a payment or adjustment for indi-7
rect and direct graduate medical education costs 8
under subsections (d)(5)(B) and (h) or section 9
1814(l), as applicable, with respect to such resi-10
dents. 11
‘‘(3) A
PPLICATION.—The provisions of this sub-12
section, or the application of such provisions to an 13
applicable hospital— 14
‘‘(A) shall not result in— 15
‘‘(i) the establishment of a limitation 16
on the number of residents in allopathic or 17
osteopathic medicine for purposes of sub-18
sections (d)(5)(B) and (h) with respect to 19
an approved medical residency training 20
program of an applicable hospital (or be 21
taken into account in determining such a 22
limitation during the cap building period of 23
an applicable hospital); or 24
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‘‘(ii) the counting of any resident with 1
respect to which the applicable hospital re-2
ceives an elective rural sustainability per 3
resident payment amount under this sub-4
section towards the application of the limi-5
tation described in clause (i) for purposes 6
of subsections (d)(5)(B) and (h); and 7
‘‘(B) shall not have any effect on the de-8
termination of— 9
‘‘(i) the additional payment amount 10
under subsection (d)(5)(B); or 11
‘‘(ii) hospital-specific approved FTE 12
resident amounts under subsection (h). 13
‘‘(4) A
LLOCATION OF PAYMENTS .—In providing 14
for payments under this subsection, the Secretary 15
shall provide for an allocation of such payments be-16
tween parts A and part B (and the trust funds es-17
tablished under the respective parts) as reasonably 18
reflects the proportion of such costs associated with 19
the provision of services under each respective part. 20
‘‘(5) E
LIGIBILITY FOR PAYMENT.— 21
‘‘(A) I
N GENERAL.—An applicable hospital 22
shall be eligible for payment of the elective 23
rural sustainability per resident payment 24
amount under this subsection for time spent by 25
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a resident training in a rural training location 1
if the following requirements are met: 2
‘‘(i) The resident spends the equiva-3
lent of at least 8 weeks over the course of 4
their training in a rural training location. 5
‘‘(ii) The hospital pays the salary and 6
benefits of the resident for the time spent 7
training in a rural training location. 8
‘‘(B) T
REATMENT OF TIME SPENT IN 9
RURAL TRACKS OR INTEGRATED RURAL 10
TRACKS.—An applicable hospital shall be eligi-11
ble for payment of the elective rural sustain-12
ability per resident payment amount under this 13
subsection for all time spent by residents in an 14
approved medical residency program (or sepa-15
rately defined track within a program) that pro-16
vides more than 50 percent of the total resi-17
dency training time in rural training locations, 18
regardless of where the training occurs and re-19
gardless of specialty. 20
‘‘(6) D
ETERMINATION OF FULL -TIME-EQUIVA-21
LENT RESIDENTS.—The determination of full-time- 22
equivalent residents for purposes of this subsection 23
shall be made in the same manner as the determina-24
tion of full-time-equivalent residents under sub-25
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section (h)(4), but not taking into account the limi-1
tation under subparagraph (F) of such subsection. 2
‘‘(7) D
EFINITIONS.—In this subsection: 3
‘‘(A) A
PPLICABLE HOSPITAL .—The term 4
‘applicable hospital’ means a hospital, critical 5
access hospital, sole community hospital (as de-6
fined in subsection (d)(5)(D)(iii)), or rural 7
emergency hospital (as defined in section 8
1861(kkk)(2)). 9
‘‘(B) A
PPROVED MEDICAL RESIDENCY 10
TRAINING PROGRAM ; DIRECT GRADUATE MED -11
ICAL EDUCATION COSTS ; RESIDENT.—The 12
terms ‘approved medical residency training pro-13
gram’, ‘direct graduate medical education 14
costs’, and ‘resident’ have the meanings given 15
those terms in subsection (h)(5). 16
‘‘(C) R
URAL TRAINING LOCATION .—The 17
term ‘rural training location’ means a location 18
in which training occurs that, based on the 19
2010 census or any subsequent census adjust-20
ment, meets one or more of the following cri-21
teria: 22
‘‘(i) The training occurs in a location 23
that is a rural area (as defined in section 24
1886(d)(2)(D)), not including any hospital 25
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treated as being located in a rural area 1
pursuant to section 1886(d)(8)(E) . 2
‘‘(ii) The training occurs in a location 3
that has a rural-urban commuting area 4
code equal to or greater than 4.0. 5
‘‘(iii) The training occurs in a sole 6
community hospital (as defined in sub-7
section (d)(5)(D)(iii)) or in a location that 8
is within 10 miles of a sole community hos-9
pital. 10
‘‘(8) B
UDGET NEUTRALITY REQUIREMENT .— 11
The Secretary shall ensure that aggregate payments 12
for direct medical education costs and indirect med-13
ical education costs under this title, including any 14
payments under this subsection, for each year (effec-15
tive beginning on or after the date that is 1 year 16
after the date of enactment of this subsection) are 17
not greater than the aggregate payments for such 18
costs that would have been made under this title for 19
the year without the application of this subsection. 20
For purposes of carrying out the budget neutrality 21
requirement under the preceding sentence, the Sec-22
retary may make appropriate adjustments to the 23
amount of such payments for direct graduate med-24
ical education costs and indirect medical education 25
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costs under subsections (h) and (d)(5)(B), respec-1
tively.’’. 2
(b) T
REATMENT OF CRITICALACCESSHOSPITALS 3
ANDSOLECOMMUNITYHOSPITALS.— 4
(1) C
RITICAL ACCESS HOSPITALS .—Section 5
1814(l) of the Social Security Act (42 U.S.C. 6
1395f(l)) is amended by adding at the end the fol-7
lowing new paragraph: 8
‘‘(6) For cost reporting periods beginning on or after 9
the date that is 1 year after the date of enactment of this 10
paragraph, the following shall apply: 11
‘‘(A) A critical access hospital may elect to be 12
treated as a hospital or as a non-provider setting for 13
purposes of counting resident time for indirect med-14
ical education costs and direct graduate medical edu-15
cation costs for the time spent by the resident in 16
that setting under subsections (d)(5)(B) and (h), re-17
spectively, of section 1886. 18
‘‘(B) Direct medical education costs shall not be 19
considered reasonable costs of a critical access hos-20
pital for purposes of payment under paragraph (1), 21
to the extent that the critical access hospital is 22
treated as a non-provider setting of another hospital 23
or another hospital receives payment for such costs 24
for the time spent by the resident in that setting 25
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pursuant to subsection (d)(5)(B), subsection (h), or 1
subsection (u) of section 1886.’’. 2
(2) S
OLE COMMUNITY HOSPITALS .—Section 3
1886(d)(5)(D) of the Social Security Act (42 U.S.C. 4
1395ww(d)(5)(D)) is amended by adding at the end 5
the following new clause: 6
‘‘(vi) For cost reporting periods beginning on or after 7
the date that is 1 year after the date of enactment of this 8
paragraph, the hospital-specific payment amount deter-9
mined under clause (i)(I) with respect to a sole community 10
hospital shall not include direct medical education costs, 11
to the extent that the sole community hospital receives 12
payment for such costs for the time spent by the resident 13
in that setting pursuant to subsection (u).’’. 14
(c) C
ONFORMINGAMENDMENTS.— 15
(1) Section 1886 of the Social Security Act (42 16
U.S.C. 1395ww) is amended— 17
(A) in subsection (d)(5)(B), in the matter 18
preceding clause (i), by striking ‘‘The Sec-19
retary’’ and inserting ‘‘Subject to subsection 20
(u), the Secretary’’; and 21
(B) in subsection (h)— 22
(i) in paragraph (1), by inserting 23
‘‘subject to subsection (u)’’ after 24
‘‘1861(v),’’; and 25
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(ii) in paragraph (3), in the flush 1
matter following subparagraph (B), by 2
striking ‘‘subsection (k)’’ and inserting 3
‘‘subsection (k) or subsection (u)’’. 4
SEC. 3. SUPPORTING NEW, EXPANDING, AND EXISTING 5
RURAL TRAINING TRACKS. 6
(a) D
IRECTGRADUATEMEDICALEDUCATION.—Sec-7
tion 1886(h) of the Social Security Act (42 U.S.C. 8
1395ww(h)) is amended— 9
(1) in paragraph (4)— 10
(A) in subparagraph (F)(i)— 11
(i) by striking ‘‘130 percent’’ and in-12
serting ‘‘for cost reporting periods begin-13
ning on or after October 1, 1997, and be-14
fore the date that is 1 year after the date 15
of enactment of the Rural Physician Work-16
force Production Act of 2025, 130 per-17
cent’’; and 18
(ii) by adding at the end the fol-19
lowing: ‘‘For cost reporting periods begin-20
ning on or after the date that is 1 year 21
after the date of enactment of the Rural 22
Physician Workforce Production Act of 23
2025, such rules shall provide that any 24
full-time-equivalent resident in an ap-25
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proved medical residency program (or sep-1
arately defined track within a program) 2
that provides more than 50 percent of the 3
total residency training time in rural train-4
ing locations (as defined in subsection 5
(u)(6)(C)), regardless of where the training 6
occurs and regardless of specialty, shall 7
not be taken into account for purposes of 8
applying the limitation under this subpara-9
graph.’’; and 10
(B) in subparagraph (H)— 11
(i) in clause (i), in the second sen-12
tence, by inserting the following before the 13
period: ‘‘, in accordance with the second 14
sentence of clause (i) of such subpara-15
graph’’; and 16
(ii) in clause (iv), by inserting the fol-17
lowing before the period: ‘‘, in accordance 18
with the second sentence of clause (i) of 19
such subparagraph’’; and 20
(2) in paragraph (5), by adding at the end the 21
following new subparagraph: 22
‘‘(L) S
PECIAL RULES REGARDING APPLICA -23
TION OF ELECTIVE RURAL SUSTAINABILITY PER 24
RESIDENT PAYMENT AMOUNT .—For special 25
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rules regarding application of the elective rural 1
sustainability per resident payment amount 2
under subsection (u), see paragraph (3) of such 3
subsection.’’. 4
(b) I
NDIRECT MEDICALEDUCATION.—Section 5
1886(d)(5)(B)(v) is amended— 6
(1) by striking ‘‘130 percent’’ and inserting 7
‘‘for cost reporting periods beginning on or after Oc-8
tober 1, 1997, and before the date that is 1 year 9
after the date of enactment of the Rural Physician 10
Workforce Production Act of 2025, 130 percent’’; 11
and 12
(2) by adding at the end the following: ‘‘For 13
cost reporting periods beginning on or after the date 14
that is 1 year after the date of enactment of the 15
Rural Physician Workforce Production Act of 2025, 16
such rules shall provide that any full-time-equivalent 17
resident in an approved medical residency program 18
(or separately defined track within a program) that 19
provides more than 50 percent of the total residency 20
training time in rural training locations (as defined 21
in subsection (u)(6)(C)), regardless of where the 22
training occurs and regardless of specialty, shall not 23
be taken into account for purposes of applying the 24
limitation under this subparagraph. For special rules 25
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regarding application of the elective rural sustain-1
ability per resident payment amount under sub-2
section (u), see paragraph (3) of such subsection.’’. 3
Æ
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