; and (2) by adding at the end the following new clause: (iv) Floor on area wage index for hospitals in all-urban States (I) In general For discharges occurring on or after October 1, 2021, the area wage index applicable under this subparagraph to any hospital in an all-urban State (as defined in subclause (IV)) may not be less than the minimum area wage index for the fiscal year for hospitals in that State, as established under subclause (II). (II) Minimum area wage index For purposes of subclause (I), the Secretary shall establish a minimum area wage index for a fiscal year for hospitals in each all-urban State using the methodology described in section 412.64(h)(4) of title 42, Code of Federal Regulations, as in effect for fiscal year 2018. (III) Waiving budget neutrality Pursuant to the fifth sentence of clause (i), this subsection shall not be applied in a budget neutral manner. (IV) All-urban State defined In this clause, the term all-urban State means a State in which there are no rural areas (as defined in paragraph (2)(D)) or a State in which there are no hospitals classified as rural under this section. . (b) Waiving budget neutrality (1) Technical amendatory correction Section 10324(a)(2) of Public Law 111–148 is amended by striking third sentence and inserting fifth sentence . (2) Waiver Section 1886(d)(3)(E)(i) of the Social Security Act ( 42 U.S.C. 1395ww(d)(3)(E)(i) ) is amended, in the fifth sentence— (A) by striking and the amendments and inserting , the amendments