; 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)