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[Federal Register: June 28, 2002 (Volume 67, Number 125)]
[Notices]
[Page 43616-43629]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr28jn02-75]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1198-NC]
RIN 0938-AL16
Medicare Program; Update to the Prospective Payment System for
Home Health Agencies for FY 2003
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice with comment period.
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SUMMARY: This notice with comment period sets forth an update to the
60-day national episode rates and the national per-visit amounts under
the Medicare prospective payment system for home health agencies.
DATES: Effective Date: The rate updates in this notice with comment
period are effective on October 1, 2002.
Comment Period: We will consider comments if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on August
27, 2002.
ADDRESSES: In commenting, please refer to file code CMS-1198-NC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission. Mail written comments (one original and
three copies) to the following address only: Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Attention:
CMS-1198-NC, P.O. Box 8016,Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be timely
received in the event of delivery delays.
If you prefer, you may deliver (by hand or courier) your written
comments (one original and three copies) to one of the following
addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue,
SW., Washington, DC 20201, or Room C5-14-03, 7500 Security
Boulevard,Baltimore, MD 21244-1850.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and could be considered late.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Susan Levy, (410) 786-9364; Chester
Robinson, (410) 786-6959
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: Comments received timely will be
available for public inspection as they are received, generally
beginning approximately 3 weeks after publication of a document, at the
headquarters of the Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view
public comments, phone (410) 786-7197.
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Government Printing Office.
I. Background
Payment to Home Health Agencies
A. Balanced Budget Act of 1997
The Balanced Budget Act of 1997 (BBA), Public Law 105-33, enacted
on August 5, 1997, significantly changed the way Medicare pays for
Medicare home health services. Until the implementation of a home
health
[[Page 43617]]
prospective payment system (HH PPS) on October 1, 2000, home health
agencies (HHAs) received payment under a cost-based reimbursement
system. Section 4603 of the BBA governed the development of the HH PPS
by adding section 1895 to the Social Security Act (the Act).
B. System for Payment of Home Health Services
Generally, Medicare makes payment under the home health prospective
payment system on the basis of a national standardized 60-day episode
payment, adjusted for case-mix and wage index. For episodes with four
or fewer visits, Medicare pays on the basis of a national per-visit
amount by discipline, referred to as a low utilization payment
adjustment (LUPA). Medicare also adjusts the 60-day episode payment for
certain intervening events that give rise to a partial episode payment
(PEP) adjustment or a significant change in condition (SCIC)
adjustment. For certain cases that exceed a specific cost threshold, an
outlier adjustment may also be available. For a complete and full
description of the home health prospective payment system as required
by the BBA and as refined by the Omnibus Consolidated and Emergency
Supplemental Appropriations Act (OCESAA) for FY 1999, Pub. L. 105-277,
enacted on October 21, 1998, and the Medicare, Medicaid and SCHIP
Balanced Budget Refinement Act of 1999 (BBRA), Public Law 106-113,
enacted on November 29, 1999, see the July 3, 2000 HH PPS final rule
(65 FR 41128).
C. Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000
Section 1895(b)(3)(A)(i)(III) of the Act, as redesignated by
section 501 of the Medicare, Medicaid and SCHIP Benefits Improvement
and Protection Act of 2000 (BIPA), Public Law 106-554, enacted on
December 21, 2000, delays until FY 2003 the application of the 15
percent reduction on the interim payment limits for home health
services as applied to the home health prospective payment rates
required by earlier legislation. Section 501 of BIPA also amends
section 302(c) of the BBRA, to now require a report to the Congress by
the Comptroller General of the United States no later than April 1,
2002 on the 15 percent reduction issue.
Section 502 of the BIPA sets forth a special rule for payment for
FY 2001 based on adjustment of the published prospective payment
amounts. This special payment rule has the effect of restoring the
market basket reduction already incorporated into the home health
prospective payment system (HH PPS) rates. The adjustment provides the
effect of a full market basket adjustment to the HH PPS rates for FY
2001. The statute also requires paying episodes and national per-visit
amounts for low utilization payment adjustments (LUPAs) ending on or
after April 1, 2001 and before October 1, 2001 an additional 2.2
percent.
Section 508 of the BIPA also requires, for home health services
furnished in a rural area (as defined in section 1886(d)(2)(D) of the
Act) on or after April 1, 2001 and before April 1, 2003, that the
Secretary increase the payment amount otherwise made under section 1895
of the Act for the services by 10 percent. The statute waives budget
neutrality for purposes of this increase since it specifically states
that the Secretary not reduce the standard prospective payment amount
(or amounts) under section 1895 of the Act applicable to home health
services furnished during a period to offset the increase in payments
resulting in the application of this section of the statute.
II. Analysis of and Responses to Comments on the Home Health
Prospective Payment System June 29, 2001 Notice With Comment Period
On June 29, 2001, we published a notice with comment period in the
Federal Register (66 FR 34687) that set forth an update to the 60-day
national episode rates and the national per-visit amounts under the
Medicare prospective payment system for home health agencies (HHAs) for
FY 2002. In this section, we respond to the two public comments that we
received on the FY 2002 HH PPS:
Comment: Commenters recommended that we use the hospital wage index
with consideration of statutorily established floors and
administratively determined classifications. Further the commenter
asked that the wage index used in determining the home health payment
rate should be the same hospital wage index used and published for
hospitals during the same fiscal year.
Response: As we have explained in the June 29, 2001 notice with
comment period, we believe the use of the most recent available pre-
floor and pre-reclassified hospital wage index data results in the
appropriate adjustment to the labor portion of the costs as required by
statute. By statute, the hospital wage index is adjusted to account for
geographic reclassification of hospitals. The geographic
reclassification applies only to hospitals. In addition, the hospital
wage index has specific floors that are required by statute and apply
only to hospitals. Because these reclassifications and floors do not
apply to HHAs, we use the most recent available pre-floor and pre-
classified hospital wage index data to adjust the home health payment
rates. We recognize that the pre-floor and pre-classified hospital wage
index differs slightly from the numbers published in the Medicare
inpatient hospital prospective payment system (PPS) regulations but
note that the wage indices published in the July 3, 2000 HH PPS final
rule and subsequent annual updates reflect the most recent available
pre-floor and pre-classified hospital wage index available at the time
of publication.
Comment: Commenters suggested that we recalculate the base HH PPS
rates to incorporate a different assumption than the published
assumption of the 5 percent low utilization payment adjustment episodes
in the base year of HH PPS. The commenters believe the recalculation
should be characterized as an error on the face of the original
calculation rather than viewed as a rebasing.
Response: In establishing the payment unit for HH PPS, including
the 5 percent low utilization payment adjustment episode, we used the
best available data in determining the payment rates for the base year
for HH PPS. The statute provides for an annual update of the HH PPS
payment rates. The statute does not contemplate a recalculation of the
initial base year after the rates are established. We further note that
the statute provides for a limitation on review of the HH PPS, in
particular the establishment of the payment unit and the computations
of the initial standardized prospective payment amounts.
III. Provisions of this Notice with Comment Period
A. National Standardized 60-Day Episode Rate
Medicare HH PPS has been effective since October 1, 2000. As set
forth in the final rule published July 3, 2000 in the Federal Register
(65 FR 41128), the unit of payment under Medicare HH PPS is a national
standardized 60-day episode rate. As set forth in the July 3, 2000
final rule at 42 CFR 484.220, we adjust the national standardized 60-
day episode rate by case-mix and wage index based on the site of
service for the beneficiary. The FY 2003 HH PPS rates use the same
case-mix methodology and application of the wage index adjustment to
the labor portion of the HH PPS rates as set forth in the July 3, 2000
final rule. We multiply the national 60-day episode
[[Page 43618]]
rate by the patient's applicable case-mix weight. We divide the case-
mix adjusted amount into a labor and nonlabor portion. We multiply the
labor portion by the applicable wage index based on the site of service
of the beneficiary. The labor portion of the rate continues to be
.77668 and the nonlabor portion of the rate continues to be .22332. We
add the wage adjusted portion to the nonlabor portion yielding the
case-mix and wage adjusted 60-day episode rate subject to applicable
adjustments.
For FY 2003, we use again the design and case-mix methodology
described in section III.G of the July 3, 2000 HH PPS final rule (65 FR
41192 through 41203). For FY 2003, we base the wage index adjustment to
the labor portion of the PPS rates on the most recent pre-floor and
pre-reclassified hospital wage index available at the time of
publication of this notice, which is discussed in section III.D of this
notice with comment period.
As discussed in the July 3, 2000 HH PPS final rule, for episodes
with four or fewer visits, Medicare pays the national per-visit amount
by discipline, referred to as a LUPA. We update the national per-visit
amounts by discipline annually by the applicable home health market
basket. We adjust the national per-visit amount by the appropriate wage
index based on the site of service for the beneficiary as set forth in
Sec. 484.230. We adjust the labor portion of the updated national per-
visit amounts by discipline used to calculate the LUPA by the most
recent pre-floor and pre-reclassified hospital wage index available at
the time of publication of this notice, as discussed in section III.D
of this notice with comment period.
As outlined in the July 3, 2000 HH PPS final rule, Medicare pays
the 60-day case-mix and wage adjusted episode payment on a split
percentage payment approach. The split percentage payment approach
includes an initial percentage payment and a final percentage payment
as set forth in Sec. 484.205(b)(1) and (b)(2). We may base the initial
percentage payment on the submission of a request for anticipated
payment and the final percentage payment on the submission of the claim
for the episode, as discussed in regulations in Sec. 409.43. The claim
for the episode that the HHA submits for the final percentage payment
determines the total payment amount for the episode and whether we make
an applicable adjustment to the 60-day case-mix and wage adjusted
episode payment. The end date of the 60-day episode as reported on the
claim determines the rate level at which Medicare will pay the claim
for the fiscal period.
As discussed in the July 3, 2000 HH PPS final rule, we may adjust
the 60-day case-mix and wage adjusted episode payment based on the
information submitted on the claim to reflect the following:
A low utilization payment provided on a per-visit basis as
set forth in Sec. 484.205(c) and Sec. 484.230.
A partial episode payment adjustment as set forth in
Sec. 484.205(d) and Sec. 484.235.
A significant change in condition adjustment as set forth
in Sec. 484.205(e) and Sec. 484.237.
An outlier payment as set forth in Sec. 484.205(f) and
Sec. 484.240.
This notice with comment period reflects the updated national 60-
day episode rate, the national per-visit amounts used to calculate the
LUPA, and imputed costs for the outlier payment for FY 2003 that are
effective October 1, 2002.
B. FY 2003 Update to the Home Health Market Basket Index
Section 1895(b)(3)(B)(ii) of the Act requires the standard
prospective payment amounts to be increased by a factor equal to the
home health market basket minus 1.1 percentage points for FY 2003. This
has been codified in regulations in Sec. 484.225.
FY 2003 Adjustments
In calculating the annual update for the FY 2003 60-day episode
rates, we first looked at the FY 2002 rates as a starting point. The FY
2002 national 60-day episode rate is $2,274.17. Second, we took into
account section 501 of BIPA.
As stated in the background section of this update notice, section
501 of BIPA revised the statute to require the application of the 15
percent reduction on payment limits under the interim payment system
(IPS), which is no longer in effect for home health services, for FY
2003. This statutory provision required an estimation of what Medicare
spending would have been in FY 2001 if the IPS were still in effect and
its limits reduced by 15 percent updated to FY 2003 in determining the
HH PPS rates. It is important to note that HH PPS, not the interim
payment system, has been in effect since October 1, 2000. Originally,
the Balanced Budget Act of 1997 (BBA), Public Law 105-33, enacted on
August 5, 1997, statutory language required the base year PPS rates to
be budget neutral to what we would have paid under the IPS if the per-
beneficiary and per-visit limits had been reduced by 15 percent. At the
time of the BBA, when HHAs were paid the lower of their actual costs or
the cost limits, most HHAs were paid at their limits. Absent any
behavioral offset, lowering the IPS limits by 15 percent would have
resulted in a straight reduction of 15 percent of Medicare spending for
home health services.
At the time the BBA was enacted, we believed that the industry
would eventually alter their behavior to avoid reaching the cost
limits, and therefore upon implementation of the 15 percent reduction,
not all HHAs would reach the level of the limits as reduced. We
believed that the industry would respond to the reduced limits by
increasing the number of low-cost beneficiaries served, thereby
increasing the costs and decreasing the effect of the limits.
As a result of this anticipated behavior, we determined that the
level by which actual payments would be reduced by lowering the limits
would not be the same as the percent by which the limits themselves
would be lowered. That is, the application of the 15 percent reduction
in cost limits would lead to a 7 percent reduction in aggregate home
health spending, hence, equivalently a 7 percent reduction in HH PPS
payments. The statute requires us to look at the 15 percent reduction
to the IPS limits updated to FY 2003. In determining how to calculate
and implement the HH PPS rates using the required 15 percent reduction
in cost limits, we still believe the HHAs would have altered their
behavior to avoid reaching the limits. Thus, we retain our assumptions
that result in the 7 percent reduction in overall payments. Based on
the latest available reliable date, our best estimate is that a 15
percent reduction in cost limits would result in a 7 percent reduction
in aggregate home health spending and, therefore, equivalently a 7
percent reduction on home health spending.
Accordingly, we calculate the FY 2003 HH PPS rates by first
reducing the FY 2002 HH PPS rates by 7 percent. That amount is updated
by the applicable home health market basket increase minus 1.1
percentage points, as required by the statute. It is important to note
that Medicare home health payments are projected to continue to grow,
even with the effect of the 15 percent reduction to the IPS limits.
Under President Bush's FY 2003 budget, which assumes no further delays
in the reduction, Medicare's total home health spending is projected to
increase 12.2 percent in FY 2003, 8.3 percent in FY 2004, and 7.4
percent in FY 2005.
In order to calculate the FY 2003 national 60-day episode rate, the
FY 2002 national 60-day episode rate ($2,274.17) is multiplied by .93
to take into account section 501 of BIPA. The annual update for FY 2003
is the home
[[Page 43619]]
health market basket minus 1.1 percentage points as defined in section
1895(b)(3)(B)(ii) of the Act. The home health market basket increase
for FY 2003 is 3.2 percent. The previous amount is increased by the FY
2003 home health market basket increase minus 1.1 percentage points
(2.1 percent) to yield the updated FY 2003 national 60-day episode rate
($2,159.39).
National 60-Day Episode Amounts Reduced by 7% Per Analysis of Section 501 of BIPA, Updated by the Home Health
Market Basket Minus 1.1% for FY 2003 Before Case-Mix Adjustment, Wage Index Adjustment Based on the Site of
Service for the Beneficiary or Applicable Payment Adjustment
----------------------------------------------------------------------------------------------------------------
Multiply by 1 Final FY 2003
7% Reduction plus the Home Updated
Total standardized prospective payment amount per 60-day episode Due to Section Health Market National 60-
for FY 2002 501 of BIPA Basket minus day Episode
1.1% Rate
----------------------------------------------------------------------------------------------------------------
$2,274.17....................................................... x .93 x 1.021 $2,159.39
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National Per-visit Amounts Used to Pay LUPAs and Compute
Imputed Costs used in Outlier Calculations.
As discussed previously in this notice with comment period, the
policies governing the LUPAs and outlier calculations set forth in the
July 3, 2000 HH PPS final rule will continue during FY 2003. In
calculating the annual update for the FY 2003 national per-visit
amounts we use to pay LUPAs and to compute the imputed costs in outlier
calculations, we again looked at the FY 2002 rates as a starting point.
We used the same approach to implement section 501 of BIPA. The statute
requires us to look at the 15 percent reduction to the IPS limits in FY
2003, 2 years after HH PPS has been implemented and the IPS has ended.
As stated previously, we believe the HHAs would have altered their
behavior to avoid reaching the IPS limits. We have determined that
behavioral response would translate the required 15 percent reduction
in cost limits into a 7 percent reduction in overall payments in FY
2003. In response to section 501 of BIPA, we reduced the national per-
visit amounts by home health discipline by 7 percent. Those amounts are
then increased by the FY 2003 home health market basket increase minus
1.1 percentage points to yield the updated per-visit amounts for each
home health discipline for FY 2003. (See table below.)
National Per-Visit Amounts for LUPAs and Outlier Calculations Reduced by 7% Per Analysis of Section 501 of BIPA,
Updated by the Home Health Market Basket Minus 1.1% for FY 2003 Before Wage Index Adjustment Based on the Site
of Service for the Beneficiary or Applicable Payment Adjustment Updated by the Home Health Market Basket Minus
1.1% for FY 2003
----------------------------------------------------------------------------------------------------------------
Final per-visit Multiply by 1 Final per-visit
amounts per 60- 7% Reduction plus Home payment amount
Home Health Discipline type day episode for Due to section Health Market per discipline
FY 2002 for 501 of BIPA Basket minus for FY 2003 for
LUPAs 1.1% LUPAs
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Home Health Aide............................ $44.95 x .93 x 1.021 $42.68
Medical Social Services..................... $159.14 x .93 x 1.021 $151.11
Occupational Therapy........................ $109.28 x .93 x 1.021 $103.77
Physical Therapy............................ $108.55 x .93 x 1.021 $103.07
Skilled Nursing............................. $99.28 x .93 x 1.021 $94.27
Speech-Language Pathology................... $117.95 x .93 x 1.021 $112.00
----------------------------------------------------------------------------------------------------------------
C. Rural Add-On as Required by the BIPA
Section 508 of the BIPA requires, for home health services
furnished in a rural area (as defined in section 1886(d)(2)(D) of the
Act) on or after April 1, 2001 and before April 1, 2003, that the
Secretary increase by 10 percent the payment amount otherwise made
under section 1895 of the Act for services. The statute waives budget
neutrality related to this provision as it specifically states that the
Secretary shall not reduce the standard prospective payment amount (or
amounts) under section 1895 of the Act applicable to home health
services furnished during a period to offset the increase in payments
resulting in the application of this section of the statute.
Section 508 provides for payment for the national standardized
episode amounts and LUPA national per-visit amounts for the first half
of FY 2003 by an additional 10 percent for home health services
furnished in rural areas where the site of service for the beneficiary
is a non-MSA area. By statute, the 10 percent rural add-on applies to
home health services furnished in a rural area (as defined in section
1886(d)(2)(D) of the Act) on or after April 1, 2001 and before April 1,
2003. Therefore, the 10 percent rural add-on ends mid-FY 2003 for
episodes ending on or after April 1, 2003. The applicable case-mix and
wage index adjustment is subsequently applied for the provision of home
health services where the site of service is the non-Metropolitan
Statistical Area (MSA) of the beneficiary. Similarly, the applicable
wage index adjustment is subsequently applied to the LUPA per-visit
amounts adjusted for the provision of home health services where the
site of service for the beneficiary is a non-MSA area. We implemented
this provision for FY 2001 on April 1, 2001 through the Program
Memorandum, ``Restoration of Full Home Health Market Basket Update for
Home Health Services for Fiscal Year 2001 and Temporary 10 Percent
Payment Increase for Home Health Services Furnished in a Rural Area for
24 Months Under the
[[Page 43620]]
Home Health Prospective Payment System (HH PPS)'' (Transmittal A-01-06
issued January 16, 2001) and for FY 2002 through the FY 2002 annual HH
PPS update notice published on June 29, 2001 in the Federal Register
(66 FR 34687). (See FY 2003 add-on noted in tables below.)
FY 2003 Rural Add-On to 60-day Episode Payment Amounts Ending Before
April 1, 2003 for Beneficiaries Who Reside in a Non-MSA Area Before Case-
Mix Adjustment, Wage Index Adjustment Based on the Site of Service of
the Beneficiary, or Applicable Payment Adjustment
------------------------------------------------------------------------
FY 2003 Final
payment amount
per 60-day
episode ending
Payment amount per 60-day episode for before April 1,
FY 2003 10% add-on 2003 for a
beneficiary who
60-day resides
in a rural non-
MSA area
------------------------------------------------------------------------
$2,159.39............................. x 1.10 $2,375.33
------------------------------------------------------------------------
FY 2003 Rural Add-On to LUPA Per-Visit Amounts For Episodes Ending Before April 1, 2003 Before Wage Adjustment
Based on the Site of Service of the Beneficiary Who Resides in a Non-MSA Area or Payment Applicable Adjustment
----------------------------------------------------------------------------------------------------------------
FY 2003 Final per-
Final per- visit payment amount
visit payment per 60-day episodes
amount per 60- ending Before April
Home Health Discipline type day episodes 10% add-on 1, 2003 for LUPAs
for FY 2003 for a beneficiary
for LUPAs who resides in a non-
MSA area
----------------------------------------------------------------------------------------------------------------
Home Health Aide.......................................... $ 42.68 x 1.10 $ 46.95
Medical Social Services................................... $151.11 x 1.10 $166.22
Occupational Therapy...................................... $103.77 x 1.10 $114.15
Physical Therapy.......................................... $103.07 x 1.10 $113.38
Skilled Nursing........................................... $ 94.27 x 1.10 $103.70
Speech-Language pathology................................. $112.00 x 1.10 $123.20
----------------------------------------------------------------------------------------------------------------
D. Wage Index
Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the
Secretary to establish area wage adjustment factors that reflect the
relative level of wages and wage-related costs applicable to the
furnishing of home health services and to provide appropriate
adjustments to the episode payment amounts under HH PPS to account for
area wage differences. We apply the appropriate wage index value to the
labor portion of the HH PPS rates based on the geographic area in which
the beneficiary received home health services. We determine each HHA's
labor market area based on definitions of MSAs issued by the Office of
Management and Budget (OMB).
As discussed previously and set forth in the July 3, 2000 final
rule, the statute provides that the wage adjustment factors may be the
factors used by the Secretary for purposes of section 1886(d)(3)(E) of
the Act for hospital wage adjustment factors. Again, as discussed in
the July 3, 2000 final rule, we used the most recent pre-floor and pre-
reclassified hospital wage index available at the time of publication
of this notice to adjust the labor portion of the HH PPS rates based on
the geographic area in which the beneficiary receives the home health
services. We believe the use of the most recent available pre-floor and
pre-reclassified hospital wage index data results in the appropriate
adjustment to the labor portion of the costs as required by statute.
(See addenda A and B of this notice with comment period, respectively,
for the rural and urban hospital wage indexes.)
E. Clarification of Policy Governing Current Accelerated Payment Policy
Since the implementation of the HH PPS in 2000, we have received
questions concerning the regulations governing accelerated payments
under HH PPS. We wish to clarify the provisions for accelerated
payments for HHAs set forth in Sec. 484.245(a). This general rule was
not meant to be restrictive, but to complement the regulations
governing intermediary accelerated payments to providers in
Sec. 413.64(g). The regulations at Sec. 413.64(g) governing the
criteria for accelerated payments to providers have not changed under
HH PPS. Accelerated payments are permitted under HH PPS for HHAs that
meet the longstanding qualifying criteria. When a provider requests an
accelerated payment, it may be made to the provider, as set forth in
Sec. 413.64(g). This provision includes an HHA that is receiving
payment under the HH PPS under several conditions. For example, an HHA
continues to be eligible to receive accelerated payment under
Sec. 413.64(g) if it is experiencing financial difficulties because
there is a delay by the intermediary in making payments or in
exceptional situations, in which the HHA has experienced a temporary
delay in preparing and submitting bills to the intermediary beyond its
normal billing cycle.
IV. Waiver of Proposed Rulemaking
We ordinarily publish a proposed notice in the Federal Register to
provide
[[Page 43621]]
a period for public comment before the provisions of a notice such as
this take effect. We can waive this procedure, however, if we find good
cause that a notice-and-comment procedure is impracticable,
unnecessary, or contrary to the public interest and we incorporate a
statement of finding and its reasons in the notice issued.
We believe it is unnecessary to undertake a proposed notice with
comment period as the statute requires annual updates to the HH PPS
rates, the methodologies used to update the rate have been previously
subject to public comment, and this notice reflects the application of
previously established methodologies. Further, the rural add-on and
adjustments to FY 2001 HH PPS rates that were required by the BIPA
before this annual update for the FY 2003 PPS rates are dictated by
statute and do not require an exercise of discretion. In addition, the
clarification to the accelerated payment policy reflects no substantive
change in policy and practice. Therefore, for good cause, we waive
prior notice and comment procedures. As indicated previously, we are,
however, providing a 60-day comment period for public comment.
V. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).
VI. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will respond to the major comments in the preamble to that
document.
VII. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this notice as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review)
and the Regulatory Flexibility Act (RFA) (September 19, 1980 Pub. L.
96-354). Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any 1 year). The update
set forth in this notice applies to Medicare payments under HH PPS in
FY 2003. Accordingly, the analysis that follows describes the impact in
FY 2003 only. We estimate that there will be an additional $320 million
in FY 2003 expenditures attributable to the FY 2003 market basket
increase of 2.1 percent. The statute requires the FY 2003 home health
market basket increase of 3.2 percent to be reduced by 1.1 percentage
points. Section 501 of BIPA requires the application of the 15 percent
reduction on payment limits under the IPS, which is no longer in
effect, for home health services updated to FY 2003. This statutory
provision requires the estimation of what Medicare spending would have
been if the IPS limits were reduced by 15 percent and updated to FY
2003. To achieve this level of home health spending, we will reduce the
HH PPS rates by 7 percent. The impact on providers due to the
implementation of the 7 percent reduction is to reduce Medicare home
health spending by $821 million in FY 2003, $1,132 million in FY 2004,
and $1,212 million in FY 2005. As stated above, the expenditures
outlined in this notice exceed the $100 million yearly threshold for a
major rule as defined in title 5, USC, section 804(2), and for a
significant regulatory action as defined in E.O. 12866.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a MSA and has fewer
than 100 beds. We have determined that this notice with comment period
will not have a significant economic impact on the operations of a
substantial number of small rural hospitals.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and government agencies.
Most hospitals and most other providers and suppliers are small
entities, either by nonprofit status or by having revenues of $10
million or less annually. For purposes of the RFA, we consider most
HHAs to be small entities. Individuals and States are not included in
the definition of a small entity. This notice with comment period
reflects the statutory update to the HH PPS rates published in the July
3, 2000 final rule as amended by the BIPA, but will have a significant
positive effect upon small entities.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule that may result in expenditure in any 1 year by State,
local, or tribal governments, in the aggregate, or by the private
sector, of $110 million. We believe this notice with comment period
will not mandate expenditures in that amount.
Executive Order 13132 establishes certain requirements that an
agency must meet when it publishes a notice with comment period that
imposes substantial direct requirement costs on State and local
governments, preempts State law, or otherwise has Federalism
implications. We have reviewed this notice under the threshold criteria
of Executive Order 13132, Federalism. We have determined that this
notice will not have substantial direct effects on the rights, roles,
and responsibilities of States.
B. Anticipated Effects
In accordance with the requirements of section 1895(b)(3) of the
Act, we publish an update for each subsequent fiscal year that will
provide an update to the payment rates. Section 1895(b)(3) of the Act
requires us, for FY 2003, to increase the prospective payment amounts
by the home health market basket increase minus 1.1 percentage points.
The home health market basket increase for FY 2003 is 3.2 percent.
Taking into account the provisions of section 1895(b)(3) of the Act,
the FY 2003 home health market basket increase of 3.2 percent is
reduced by 1.1 percentage points yielding a 2.1 percent increase for FY
2003. For the sake of clarity, we have also included the amounts as
increased by the rural add-on provision under section 508 of the BIPA.
Before we determine the impact of the update of the FY 2002
national 60-day episode rate by the applicable home health market
basket increase, we need to review prior legislation affecting home
health payment systems. Section 4602 of the BBA implemented IPS for FY
1998 through FY 1999, which was composed of both per-visit limits and a
per-beneficiary limit. The per-visit limits were similar to the per-
visit limits
[[Page 43622]]
previously in place but reduced to 105 percent of the median (previous
limits were set at 112 percent of the mean) and applied in the
aggregate (that is, across disciplines, while the limits were specified
for each of six disciplines). The per-beneficiary limit was a blend of
an agency-specific rate and a national rate for agencies having a 1994
cost report and a national rate for those agencies not in existence in
FY 1994. An agency was paid the lower of the following:
Its actual costs.
The costs from applying each of the per-discipline limits
to the number of visits of that discipline, in the aggregate.
The costs from applying the agency-specific limit to the
number of beneficiaries served by that agency.
Section 4603 of BBA required that a PPS be implemented beginning
with FY 2000. The implementation of PPS was, however, postponed until
FY 2001 by section 5101(c) of OCESAA. BBA required that initial budget
neutrality under HH PPS for FY 2000 be calculated for what expenditures
would have been in FY 2000 if the IPS had continued to be in effect,
but with both the per-visit and per-beneficiary limits in effect on
September 30, 1999 (the last day of FY 1999) reduced by 15 percent.
That is, we had to estimate what Medicare expenditures would have been
if the IPS had continued for another year, but with the per-visit and
per-beneficiary limits reduced by 15 percent. This further reduction of
the per-visit and per-beneficiary limits was to ensure that home health
spending was below the levels of the IPS.
BIPA did not delay the starting date for HH PPS. However, it did
delay application of the 15-percent reduction in the IPS cost limits.
The statute requires that HH PPS rates, beginning with FY 2003, be
equal to the amounts that would have been effective for the IPS for FY
2001 with a 15-percent reduction in per-visit and per-beneficiary cost
limits in effect on September 30, 2000, the last day of the IPS. The
updates for FY 2003, as otherwise applied, would be added to the HH PPS
reduced rates.
The key to the calculation is the estimation of what Medicare home
health expenditures would have been in FY 2001. The determination of
those expenditures requires, by statute, an estimation of those
expenditures with the per-visit and per-beneficiary limits reduced by
15 percent. The estimate entails three key elements.
First, it requires an estimate of the distribution of agencies'
costs relative to per-visit and per-beneficiary aggregate limits. For
example, if all agencies' costs were at or above the per-visit or per-
beneficiary limits, lowering the limits by 15 percent would have saved
15 percent. Similarly, if some agencies' costs were between 85 percent
and 100 percent of either cost limit, lowering the cost limits by 15
percent would achieve less than 15 percent savings. Likewise, if some
agencies' costs were below 85 percent of both cost limits, lowering the
limits by 15 percent would not achieve savings (since agencies would be
paid their actual costs).
Second, an estimation of home health expenditures for FY 2001
requires an estimate of the annual increase in the cost limits under
IPS if the IPS cost limits were continued. Since IPS did not apply for
FY 2001, the annual increase in cost limits that would have applied
must be estimated. We also need to estimate how costs have increased
relative to the cost limits. For example, the cost limits were
increased by the market basket but agency costs would have most likely
increased by some higher percentage.
Finally, under the statutory parameters, the estimate requires an
assessment of the behavioral response of HHAs to a lowering of the per-
visit and per-beneficiary limits that we estimate for FY 2001 home
health expenditures. An assessment of behavioral response is
particularly important given the patterns of Medicare home health
spending and utilization that have fluctuated dramatically over the
last 10 years. Dramatic increases in home health spending reflect very
large increases in the number of visits per person served and increases
in the number of persons receiving home health services. This is the
behavioral response expected under a cost-based reimbursement system.
Furthermore, HH PPS provides an incentive for agencies to provide fewer
visits than before since they are paid a flat dollar amount to cover
all services within a 60-day time period. Preliminary FY 2001 data show
that the number of home health visits in the first year of HH PPS has
decreased by a significant percentage compared to FY 2000, the last
year of IPS. Meanwhile, reimbursement per visit is projected to
increase substantially. This is the type of behavioral response that is
consistent with the incentives of the new payment system.
Taking into account all these considerations and using the latest
available reliable data, we have determined that at the time the BBA
was passed, the 15-percent reduction in the limits would result in a 7-
percent reduction in aggregate home health spending. We continue to
believe that this is the best estimate of the level to which spending
would have been reduced under the conditions prescribed by the BBA,
namely extension of the IPS through FY 2001 (the first year of HH PPS)
but with a 15-percent reduction in each of the IPS cost limits.
Therefore, to achieve this level of home health spending, we will
reduce the HH PPS payments by 7 percent.
At the time the BBA's enactment, the most recent settled cost
report data for HHAs showed that most agencies' costs were at about the
level of the existing cost limits. If the limits were lowered by 15
percent then, absent changes in the level of services provided, the
resulting reduction in the HH PPS rates would be 15 percent. For
example, if home health spending costs were $10 billion and all
agencies were at the level of the limits, this level would also be $10
billion. If the level of the cost limits were lowered to $10 billion
multiplied by (1 minus .15) it would be equal to $8.5 billion. Then
savings to the Medicare program would be cost-limits divided by costs,
for example, 1.5 billion divided by 10 billion or 15 percent.
CMS actuaries believed, based on past experience, that agencies
would alter the nature and quantity of the services provided to achieve
costs below the cost limits. Therefore, a full 15 percent reduction
would not be required. The actuaries assumed that 50 percent of total
HHA costs would be for agencies that reached the per beneficiary limits
and 45 percent of total HHA costs would be for agencies that reached
the per-visit limit. The actuaries further assumed that the remaining 5
percent of total HHA costs were under both limits before the 15 percent
reduction. After the reduction, about 5 percent of their costs would
now be over the limits. The actuaries assumed that 65 percent of the
savings from the per beneficiary limit reduction would be lost and 50
percent of the savings from the per-visit limit reduction would be
lost. For example, (.65 multiplied by .5) added to (.5 multiplied by
.45) or 55 percent of the 15 percent reduction would be lost. This
results in a net savings of (1-.55) multiplied by .15) added to (.05
multiplied by.05), or 7 percent. Thus, the actuaries estimate that HHAs
faced with a potential 15 percent reduction would alter HHA behavior
and would likely sustain a real reduction of only 7 percent. Because
the real conditions under which behavior would change cannot be
replicated, the actuaries continue to believe this model is the most
appropriate expression of the statute's requirement for an estimate.
Both the applicable home health market basket increase of 2.1
percent for
[[Page 43623]]
FY 2003 and the 7 percent reduction in aggregate home health PPS
payments due to the required 15 percent reduction in the estimation of
the IPS limits apply to all Medicare participating HHAs. We do not
believe there is a differential impact due to the aggregate nature of
the update.
We implemented the rural add-on amounts for FY 2002, effective on
April 1, 2001 through the Program Memorandum, ``Restoration of Full
Home Health Market Basket Update for Home Health Services for Fiscal
Year 2001 and Temporary 10 Percent Payment Increase for Home Health
Services Furnished in a Rural Area for 24 Months Under the Home Health
Prospective Payment System (HH PPS)'' (Transmittal A-01-06, issued
January 16, 2001) and the FY 2002 HH PPS Update Notice (66 FR 34687).
Section 508 of the BIPA provides a 10 percent rural add-on for home
health services furnished to beneficiaries whose site of service is a
rural area (non-MSA) for 24 months beginning with episodes ending on or
after April 1, 2001 and before April 1, 2003. The 10 percent rural add
on applies to episodes ending before April 1, 2003 and, therefore, will
end mid FY 2003, as required by the statute.
1. Effects on the Medicare Program
This notice with comment period merely provides a percentage update
to all Medicare HHAs. Therefore, we have not furnished any impact
tables. We increase the payment to each Medicare HHA equally by the
home health market basket update for FY 2003, as required by statute.
There is no differential impact among provider types. The impact is in
the aggregate. We estimate that there will be an additional $320
million in FY 2003 expenditures attributable to the applicable FY 2003
market basket increase of 2.1 percent. As stated above, expenditures
outlined in this notice exceed the $100 million yearly threshold for a
major rule, as defined in Title 5, U.S.C., section 804(2) and for a
significant regulatory action, as defined in E.O. 12866.
As discussed previously, section 501 of BIPA impacts the estimated
Medicare home health expenditures in FY 2003. Section
1864(b)(3)(A)(i)(III) of the Act, as redesignated by section 501 of the
BIPA, requires for FY 2003 the estimation of what would have been paid
under the IPS with the IPS cost limits reduced by 15 percent, if the
IPS had been updated to FY 2003. At that time of the BBA, lowering the
limits by 15 percent would have resulted in a reduction of 15 percent
from Medicare home health spending, without any behavioral offset.
However, as explained previously, we anticipate that due to the
behavioral responses, the level by which actual payments would be
reduced by lowering the IPS cost limits would not be the same as the
percent by which the cost limits themselves would be lowered. The full
impact of Medicare savings attributable to the 15 percent reduction in
the IPS limits is lower due to the behavioral responses of the
industry. The total savings reflecting the behavioral responses is
divided by the estimates for spending, which yields the percent at
which aggregate home health spending is lowered. That is,
implementation of the 15 percent reduction in IPS cost limits would
lead to a 7 percent reduction in aggregate home health spending and,
therefore, equivalently a 7 percent reduction in home health payments.
The statute requires us to look at the 15 percent reduction to the IPS
limits updated to FY 2003. We believe the HHAs would have altered their
behavior to avoid the cost limits and maintain that our assumptions
surrounding the 7 percent reduction in overall payments is correct.
Based on the latest available data, our best estimate is that a 15
percent reduction in cost limits would result in a 7 percent reduction
in aggregate home health spending and, therefore yield a 7 percent
increase in home health payments. Both the home health market basket
increase of 2.1 percent for FY 2003 and the 7 percent reduction in
aggregate home health PPS payments due to the application of the
required 15 percent reduction in estimated IPS cost limits apply to all
Medicare participating HHAs. We do not believe there is a differential
impact because of the aggregate nature of the update.
As discussed above, we implemented a rural add-on of a 10-percent
payment increase to the episode and per-visit payment amounts under the
HH PPS for Medicare home health services furnished in a rural area for
a 24-month period. The 10-percent rural add-on increases estimated
Medicare home health expenditures by $220 million in FY 2003.
(Source: President's FY 2003 Budget)
We provide impact tables below that display projected Medicare home
health spending, which includes the 15 percent reduction in the IPS
cost limits, as required by statute, that translate into a 7 percent
reduction in HH PPS rates in FY 2003. Under the President's FY 2003
Budget, which assumes no further delays in the reduction, Medicare's
total home health spending is projected to increase 12.2 percent in FY
2003, 8.3 percent in FY 2004, and 7.4 percent in FY 2005.
The President's Budget for FY 2003 projects a 12.2 percent increase
in home health spending in FY 2003. Approximately 6.8 percent of this
increase is because payments for services rendered in FY 2002 will not
be actually paid until FY 2003, hence a ``cash lag'' occurs. Per
episode payments incurred in FY 2002 but not paid until FY 2003 will be
at higher levels than payments for the same services both provided and
paid in FY 2003 because per-episode rates will be reduced in FY 2003 to
reflect the payment reduction required by BIPA. The remaining 5.4
percent is accounted for by additional assumptions concerning projected
increases in utilization and case mix, a 2.1 percent inflation
increase, and the 10 percent rural add-on required by BIPA. These
factors interact with the rate reduction required by BIPA to produce
the 5.4 percent increase in overall spending.
Includes 7% reduction due to the ``15% Cut in IPS Limits'' Effective 10/1/2002 as Required by Section 501 of
BIPA
----------------------------------------------------------------------------------------------------------------
FY 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
In millions..................................................... $14,851 $16,080 $17,268
% increase...................................................... 12.2 8.3 7.4
------------------------------------------------------------------------
Additional FY 2003
Medicare Home Health
FY 2003 update to Home Health PPS rates estimated expenditures
required by the Act due to annual update
required by statute
------------------------------------------------------------------------
Section 1895(b)(3)(B) of the Act requires HH $320 million.
PPS rates increased by home health market
basket minus 1.1 percentage points in FY
2003 (2.4% increase).
[[Page 43624]]
------------------------------------------------------------------------
Additional FY 2003
Provision of Medicare, Medicaid, and SCHIP Medicare Home Health
Benefits Improvement and Protection Act of estimated expenditures
2000 (BIPA) due to the BIPA provision
------------------------------------------------------------------------
Section 508--10-percent rural add-on for $220 million.
Medicare home health services furnished in a
rural area.
------------------------------------------------------------------------
(Source: President's FY 2003 Budget)
2. Effects on Providers
This notice implements statutorily required adjustments to Medicare
HH PPS rates for providers of Medicare home health services. We do not
anticipate specific effects on other providers. This notice with
comment period reflects the statutorily required annual update to the
Medicare HH PPS rates published in the July 3, 2000 final rule and
applies to the Medicare HHAs. We do not believe there is a differential
impact because of the consistent and aggregate nature of the update.
C. Alternatives Considered
As discussed in section II, this notice with comment period
reflects an annual update to the HH PPS rates as required by statute.
Due to the lack of discretion provided in the statutory requirements
governing this notice with comment period, we believe the statute
provides no latitude for alternatives other than the approach set forth
in this notice reflecting the FY 2003 annual update to the HH PPS
rates. Also, as discussed in section II, for clarification this notice
addresses the 10 percent rural add-on required under section 508 of the
BIPA for home health services furnished to beneficiaries who reside in
a rural non-MSA area. Other than the positive effect of the market
basket increase, this notice with comment period will not have a
significant economic impact nor will it impose an additional burden on
small entities. When a regulation or notice imposes additional burden
on small entities, we are required under the RFA to examine
alternatives for reducing burden. Since this notice with comment period
will not impose an additional burden, we have not examined
alternatives.
D. Conclusion
We have examined the economic impact of this notice with comment
period on small entities and have determined that the economic impact
is positive, significant, and that all HHAs will be affected. To the
extent that small rural hospitals are affiliated with HHAs, the impact
on these facilities will also be positive. Finally, we have determined
that the economic effects described above are largely the result of
BIPA provisions that this notice addresses. We continue to analyze the
appropriateness and accuracy of payments for differing case mixes.
In accordance with the provisions of Executive Order 12866, this
notice with comment period was reviewed by the Office of Management and
Budget.
Addendum A.--FY 2002 Wage Index for Rural Areas--Pre-Floor and Pre-
Reclassified
------------------------------------------------------------------------
MSA Name Wage Index
------------------------------------------------------------------------
ALABAMA.................................................... 0.7339
ALASKA..................................................... 1.1862
ARIZONA.................................................... 0.8681
ARKANSAS................................................... 0.7489
CALIFORNIA................................................. 0.9659
COLORADO................................................... 0.8811
CONNECTICUT................................................ 1.2077
DELAWARE................................................... 0.9589
FLORIDA.................................................... 0.8794
GEORGIA.................................................... 0.8295
GUAM....................................................... 0.9611
HAWAII..................................................... 1.1112
IDAHO...................................................... 0.8718
ILLINOIS................................................... 0.8053
INDIANA.................................................... 0.8721
IOWA....................................................... 0.8147
KANSAS..................................................... 0.7812
KENTUCKY................................................... 0.7963
LOUISIANA.................................................. 0.7596
MAINE...................................................... 0.8721
MARYLAND................................................... 0.8859
MASSACHUSETTS.............................................. 1.1454
MICHIGAN................................................... 0.9000
MINNESOTA.................................................. 0.9035
MISSISSIPPI................................................ 0.7528
MISSOURI................................................... 0.7891
MONTANA.................................................... 0.8655
NEBRASKA................................................... 0.8142
NEVADA..................................................... 0.9727
NEW HAMPSHIRE.............................................. 0.9779
NEW JERSEY \1\............................................. ...........
NEW MEXICO................................................. 0.8676
NEW YORK................................................... 0.8547
NORTH CAROLINA............................................. 0.8535
NORTH DAKOTA............................................... 0.7879
OHIO....................................................... 0.8668
OKLAHOMA................................................... 0.7566
OREGON..................................................... 1.0027
PENNSYLVANIA............................................... 0.8607
PUERTO RICO................................................ 0.4800
RHODE ISLAND \1\........................................... ...........
SOUTH CAROLINA............................................. 0.8512
SOUTH DAKOTA............................................... 0.7861
TENNESSEE.................................................. 0.7928
TEXAS...................................................... 0.7712
UTAH....................................................... 0.9051
VERMONT.................................................... 0.9466
VIRGINIA................................................... 0.8241
VIRGIN ISLANDS............................................. 0.6747
WASHINGTON................................................. 1.0209
WEST VIRGINIA.............................................. 0.8067
WISCONSIN.................................................. 0.9066
WYOMING.................................................... 0.8747
------------------------------------------------------------------------
\1\ All counties within the State are classified as Urban.
Addendum B.--FY 2002 Wage Index for Urban Areas--Pre-Floor and Pre-
Reclassified
------------------------------------------------------------------------
Urban area (Constituent
MSA Counties) Wage index
------------------------------------------------------------------------
0040....................... ABILENE, TX................... 0.7965
0060....................... AGUADILLA, PR................. 0.4683
0080....................... AKRON, OH..................... 0.9876
0120....................... ALBANY, GA.................... 1.0640
0160....................... ALBANY-SCHENECTADY-TROY, NY... 0.8500
0200....................... ALBUQUERQUE, NM............... 0.9759
0220....................... ALEXANDRIA, LA................ 0.8029
0240....................... ALLENTOWN-BETHLEHEM-EASTON, PA 1.0077
0280....................... ALTOONA, PA................... 0.9126
0320....................... AMARILLO, TX.................. 0.8711
0380....................... ANCHORAGE,AK.................. 1.2570
0440....................... ANN ARBOR, MI................. 1.1098
0450....................... ANNISTON, AL.................. 0.8276
0460....................... APPLETON-OSHKOSH-NEENAH, WI... 0.9241
[[Page 43625]]
0470....................... ARECIBO, PR................... 0.4630
0480....................... ASHEVILLE, NC................. 0.9200
0500....................... ATHENS, GA.................... 0.9842
0520....................... ATLANTA, GA................... 1.0058
0560....................... ATLANTIC-CAPE MAY, NJ......... 1.1293
0580....................... AUBURN-OPELIKA, AL............ 0.8230
0600....................... AUGUSTA-AIKEN, GA-SC.......... 0.9970
0640....................... AUSTIN-SAN MARCOS, TX......... 0.9630
0680....................... BAKERSFIELD, CA............... 0.9519
0720....................... BALTIMORE, MD................. 0.9856
0733....................... BANGOR, ME.................... 0.9593
0743....................... BARNSTABLE-YARMOUTH, MA....... 1.3626
0760....................... BATON ROUGE, LA............... 0.8149
0840....................... BEAUMONT-PORT ARTHUR, TX...... 0.8442
0860....................... BELLINGHAM, WA................ 1.1826
0870....................... BENTON HARBOR, MI............. 0.8887
0875....................... BERGEN-PASSAIC, NJ............ 1.1689
0880....................... BILLINGS, MT.................. 0.9352
0920....................... BILOXI-GULFPORT-PASCAGOULA, MS 0.8440
0960....................... BINGHAMTON, NY................ 0.8446
1000....................... BIRMINGHAM, AL................ 0.8808
1010....................... BISMARCK, ND.................. 0.7984
1020....................... BLOOMINGTON, IN............... 0.8842
1040....................... BLOOMINGTON-NORMAL, IL........ 0.9038
1080....................... BOISE CITY, ID................ 0.9050
1123....................... BOSTON-WORCESTER-LAWRENCE- 1.1383
LOWELL-BROCKTON, M.
1125....................... BOULDER-LONGMONT, CO.......... 0.9799
1145....................... BRAZORIA, TX.................. 0.8209
1150....................... BREMERTON, WA................. 1.0758
1240....................... BROWNSVILLE-HARLINGEN-SAN 0.9012
BENITO, TX.
1260....................... BRYAN-COLLEGE STATION, TX..... 0.9328
1280....................... BUFFALO-NIAGARA FALLS, NY..... 0.9459
1303....................... BURLINGTON, VT................ 0.9883
1310....................... CAGUAS, PR.................... 0.4699
1320....................... CANTON-MASSILLON, OH.......... 0.8956
1350....................... CASPER, WY.................... 0.9496
1360....................... CEDAR RAPIDS, IA.............. 0.8699
1400....................... CHAMPAIGN-URBANA, IL.......... 0.9306
1440....................... CHARLESTON-NORTH CHARLESTON, 0.9206
SC.
1480....................... CHARLESTON, WV................ 0.9264
1520....................... CHARLOTTE-GASTONIA-ROCK HILL, 0.9336
NC-SC.
1540....................... CHARLOTTESVILLE, VA........... 1.0566
1560....................... CHATTANOOGA, TN-GA............ 0.9369
1580....................... CHEYENNE, WY.................. 0.8288
1600....................... CHICAGO, IL................... 1.1046
1620....................... CHICO-PARADISE, CA............ 0.9856
1640....................... CINCINNATI, OH-KY-IN.......... 0.9473
1660....................... CLARKSVILLE-HOPKINSVILLE, TN- 0.8337
KY.
1680....................... CLEVELAND-LORAIN-ELYRIA, OH... 0.9457
1720....................... COLORADO SPRINGS, CO.......... 0.9744
1740....................... COLUMBIA, MO.................. 0.8686
1760....................... COLUMBIA, SC.................. 0.9492
1800....................... COLUMBUS, GA-AL............... 0.8440
1840....................... COLUMBUS, OH.................. 0.9565
1880....................... CORPUS CHRISTI, TX............ 0.8341
1890....................... CORVALLIS, OR................. 1.1646
1900....................... CUMBERLAND, MD-WV............. 0.8306
1920....................... DALLAS, TX.................... 0.9936
1950....................... DANVILLE, VA.................. 0.8613
1960....................... DAVENPORT-ROCK ISLAND-MOLINE, 0.8638
IA-IL.
2000....................... DAYTON-SPRINGFIELD, OH........ 0.9225
2020....................... DAYTONA BEACH, FL............. 0.8972
2030....................... DECATUR, AL................... 0.8775
2040....................... DECATUR, IL................... 0.7987
2080....................... DENVER, CO.................... 1.0328
2120....................... DES MOINES, IA................ 0.8779
2160....................... DETROIT, MI................... 1.0487
2180....................... DOTHAN, AL.................... 0.7948
2190....................... DOVER, DE..................... 1.0296
2200....................... DUBUQUE, IA................... 0.8519
2240....................... DULUTH-SUPERIOR, MN-WI........ 1.0284
[[Page 43626]]
2281....................... DUTCHESS COUNTY, NY........... 1.0532
2290....................... EAU CLAIRE, WI................ 0.8899
2320....................... EL PASO, TX................... 0.9215
2330....................... ELKHART-GOSHEN, IN............ 0.9638
2335....................... ELMIRA, NY.................... 0.8415
2340....................... ENID, OK...................... 0.8357
2360....................... ERIE, PA...................... 0.8716
2400....................... EUGENE-SPRINGFIELD, OR........ 1.1471
2440....................... EVANSVILLE-HENDERSON, IN-KY... 0.8514
2520....................... FARGO-MOORHEAD, ND-MN......... 0.9267
2560....................... FAYETTEVILLE, NC.............. 0.9027
2580....................... FAYETTEVILLE-SPRINGDALE- 0.8445
ROGERS, AR.
2620....................... FLAGSTAFF, ARIZONA-UTAH....... 1.0556
2640....................... FLINT, MI..................... 1.0913
2650....................... FLORENCE, AL.................. 0.7845
2655....................... FLORENCE, SC.................. 0.8722
2670....................... FORT COLLINS-LOVELAND, CO..... 1.0045
2680....................... FORT LAUDERDALE, FL........... 1.0293
2700....................... FORT MYERS-CAPE CORAL, FL..... 0.9374
2710....................... FORT PIERCE-PORT ST. LUCIE, FL 1.0214
2720....................... FORT SMITH, AR-OK............. 0.8053
2750....................... FORT WALTON BEACH, FL......... 0.9002
2760....................... FORT WAYNE, IN................ 0.9203
2800....................... FORT WORTH-ARLINGTON, TX...... 0.9394
2840....................... FRESNO, CA.................... 0.9984
2880....................... GADSDEN, AL................... 0.8792
2900....................... GAINESVILLE, FL............... 0.9481
2920....................... GALVESTON-TEXAS CITY, TX...... 1.0313
2960....................... GARY, IN...................... 0.9530
2975....................... GLENS FALLS, NY............... 0.8336
2980....................... GOLDSBORO, NC................. 0.8709
2985....................... GRAND FORKS, ND-MN............ 0.9069
2995....................... GRAND JUNCTION, CO............ 0.9569
3000....................... GRAND RAPIDS-MUSKEGON-HOLLAND, 1.0048
MI.
3040....................... GREAT FALLS, MT............... 0.8870
3060....................... GREELEY, CO................... 0.9495
3080....................... GREEN BAY, WI................. 0.9208
3120....................... GREENSBORO-WINSTON-SALEM-HIGH 0.9539
POINT, NC.
3150....................... GREENVILLE, NC................ 0.9289
3160....................... GREENVILLE-SPARTANBURG- 0.9217
ANDERSON, SC.
3180....................... HAGERSTOWN, MD................ 0.8365
3200....................... HAMILTON-MIDDLETOWN, OH....... 0.9287
3240....................... HARRISBURG-LEBANON-CARLISLE, 0.9425
PA.
3283....................... HARTFORD, CT.................. 1.1533
3285....................... HATTIESBURG, MS............... 0.7476
3290....................... HICKORY-MORGANTON-LENOIR, NC.. 0.9367
3320....................... HONOLULU, HI.................. 1.1539
3350....................... HOUMA, LA..................... 0.7975
3360....................... HOUSTON, TX................... 0.9631
3400....................... HUNTINGTON-ASHLAND, WV-KY-OH.. 0.9616
3440....................... HUNTSVILLE, AL................ 0.8883
3480....................... INDIANAPOLIS, IN.............. 0.9698
3500....................... IOWA CITY, IA................. 0.9859
3520....................... JACKSON, MI................... 0.9257
3560....................... JACKSON, MS................... 0.8491
3580....................... JACKSON, TN................... 0.9013
3600....................... JACKSONVILLE, FL.............. 0.9223
3605....................... JACKSONVILLE, NC.............. 0.7622
3610....................... JAMESTOWN, NY................. 0.8050
3620....................... JANESVILLE-BELOIT, WI......... 0.9739
3640....................... JERSEY CITY, NJ............... 1.1178
3660....................... JOHNSON CITY-KINGSPORT- 0.8617
BRISTOL, TN-VA.
3680....................... JOHNSTOWN, PA................. 0.8723
3700....................... JONESBORO, AR................. 0.8425
3710....................... JOPLIN, MO.................... 0.8727
3720....................... KALAMAZOO-BATTLE CREEK, MI.... 1.0639
3740....................... KANKAKEE, IL.................. 0.9889
3760....................... KANSAS CITY, MO-KS............ 0.9536
3800....................... KENOSHA, WI................... 0.9568
3810....................... KILLEEN-TEMPLE, TX............ 0.8471
3840....................... KNOXVILLE, TN................. 0.8890
[[Page 43627]]
3850....................... KOKOMO, IN.................... 0.9126
3870....................... LA CROSSE, WI-MN.............. 0.9250
3880....................... LAFAYETTE, LA................. 0.8544
3920....................... LAFAYETTE, IN................. 0.9121
3960....................... LAKE CHARLES, LA.............. 0.7765
3980....................... LAKELAND-WINTER HAVEN, FL..... 0.9067
4000....................... LANCASTER, PA................. 0.9296
4040....................... LANSING-EAST LANSING, MI...... 0.9653
4080....................... LAREDO, TX.................... 0.7849
4100....................... LAS CRUCES, NM................ 0.8621
4150....................... LAWRENCE, KS.................. 0.7812
4120....................... LAS VEGAS, NV-AZ.............. 1.1182
4200....................... LAWTON, OK.................... 0.8682
4243....................... LEWISTON-AUBURN, ME........... 0.9287
4280....................... LEXINGTON, KY................. 0.8791
4320....................... LIMA, OH...................... 0.9470
4360....................... LINCOLN, NE................... 1.0173
4400....................... LITTLE ROCK-NORTH LITTLE ROCK, 0.8955
AR.
4420....................... LONGVIEW-MARSHALL, TX......... 0.8571
4480....................... LOS ANGELES-LONG BEACH, CA.... 1.1948
4520....................... LOUISVILLE, KY-IN............. 0.9529
4600....................... LUBBOCK, TX................... 0.8449
4640....................... LYNCHBURG, VA................. 0.9103
4680....................... MACON, GA..................... 0.8957
4720....................... MADISON, WI................... 1.0337
4800....................... MANSFIELD, OH................. 0.8708
4840....................... MAYAGUEZ, PR.................. 0.4860
4880....................... MCALLEN-EDINBURG-MISSION, TX.. 0.8378
4890....................... MEDFORD-ASHLAND, OR........... 1.0314
4900....................... MELBOURNE-TITUSVILLE-PALM BAY, 0.9913
FL.
4920....................... MEMPHIS, TN-AR-MS............. 0.8978
4940....................... MERCED, CA.................... 0.9947
5000....................... MIAMI, FL..................... 0.9950
5015....................... MIDDLESEX-SOMERSET-HUNTERDON, 1.1469
N.
5080....................... MILWAUKEE-WAUKESHA, WI........ 0.9971
5120....................... MINNEAPOLIS-ST. PAUL, MN-WI... 1.0930
5140....................... MISSOULA, MONTANA............. 0.9364
5160....................... MOBILE, AL.................... 0.8082
5170....................... MODESTO, CA................... 1.0820
5190....................... MONMOUTH-OCEAN, NJ............ 1.0851
5200....................... MONROE, LA.................... 0.8201
5240....................... MONTGOMERY, AL................ 0.7359
5280....................... MUNCIE, IN.................... 0.9939
5330....................... MYRTLE BEACH, SC.............. 0.8771
5345....................... NAPLES, FL.................... 0.9699
5360....................... NASHVILLE, TN................. 0.9754
5380....................... NASSAU-SUFFOLK, NY............ 1.3643
5483....................... NEW HAVEN-BRIDGEPORT-STAMFORD- 1.2238
WATERBURY-DANB.
5523....................... NEW LONDON-NORWICH, CT........ 1.1526
5560....................... NEW ORLEANS, LA............... 0.9036
5600....................... NEW YORK-NEWARK, NY-NJ-PA..... 1.4427
5640....................... NEWARK, NJ.................... 1.1622
5660....................... NEWBURGH, NY-PA............... 1.1113
5720....................... NORFOLK-VIRGINIA BEACH-NEWPORT 0.8579
NEWS, VA-NC.
5775....................... OAKLAND, CA................... 1.5319
5790....................... OCALA, FL..................... 0.9556
5800....................... ODESSA-MIDLAND, TX............ 1.0104
5880....................... OKLAHOMA CITY, OK............. 0.8694
5910....................... OLYMPIA, WA................... 1.1350
5920....................... OMAHA, NE-IA.................. 0.9712
5945....................... ORANGE COUNTY, CA............. 1.1123
5960....................... ORLANDO, FL................... 0.9642
5990....................... OWENSBORO, KY................. 0.8334
6015....................... PANAMA CITY, FL............... 0.9061
6020....................... PARKERSBURG-MARIETTA, WV-OH... 0.8133
6080....................... PENSACOLA, FL................. 0.8361
6120....................... PEORIA-PEKIN, IL.............. 0.8773
6160....................... PHILADELPHIA, PA-NJ........... 1.0947
6200....................... PHOENIX-MESA, AZ.............. 0.9638
6240....................... PINE BLUFF, AR................ 0.7895
6280....................... PITTSBURGH, PA................ 0.9560
[[Page 43628]]
6323....................... PITTSFIELD, MA................ 1.0278
6340....................... POCATELLO, ID................. 0.9448
6360....................... PONCE, PR..................... 0.5218
6403....................... PORTLAND, ME.................. 0.9427
6440....................... PORTLAND-VANCOUVER,OR-WA...... 1.1111
6483....................... PROVIDENCE-WARWICK-PAWTUCKET, 1.0805
RI.
6520....................... PROVO-OREM, UT................ 0.9843
6560....................... PUEBLO, CO.................... 0.8604
6580....................... PUNTA GORDA, FL............... 0.9015
6600....................... RACINE, WI.................... 0.9333
6640....................... RALEIGH-DURHAM-CHAPEL HILL, NC 0.9818
6660....................... RAPID CITY, SD................ 0.8869
6680....................... READING, PA................... 0.9583
6690....................... REDDING, CA................... 1.1155
6720....................... RENO, NV...................... 1.0421
6740....................... RICHLAND-KENNEWICK-PASCO, WA.. 1.0960
6760....................... RICHMOND-PETERSBURG, VA....... 0.9678
6780....................... RIVERSIDE-SAN BERNADINO, CA... 1.1112
6800....................... ROANOKE, VA................... 0.8371
6820....................... ROCHESTER, MN................. 1.1462
6840....................... ROCHESTER, NY................. 0.9347
6880....................... ROCKFORD, IL.................. 0.9204
6895....................... ROCKY MOUNT, NC............... 0.9109
6920....................... SACRAMENTO, CA................ 1.1831
6960....................... SAGINAW-BAY CITY-MIDLAND, MI.. 0.9590
6980....................... ST. CLOUD, MN................. 0.9851
7000....................... ST JOSEPH, MO................. 0.7891
7040....................... ST. LOUIS, MO-IL.............. 0.8931
7080....................... SALEM, OR..................... 1.0011
7120....................... SALINAS, CA................... 1.4684
7160....................... SALT LAKE CITY-OGDEN, UT...... 0.9863
7200....................... SAN ANGELO, TX................ 0.8193
7240....................... SAN ANTONIO, TX............... 0.8584
7320....................... SAN DIEGO, CA................. 1.1265
7360....................... SAN FRANCISCO, CA............. 1.4140
7400....................... SAN JOSE, CA.................. 1.4193
7440....................... SAN JUAN-BAYAMON, PR.......... 0.4762
7460....................... SAN LUIS OBISPO-ATASCADERO- 1.0990
PASO ROBLES, CA.
7480....................... SANTA BARBARA-SANTA MARIA- 1.0802
LOMPOC, CA.
7485....................... SANTA CRUZ-WATSONVILLE, CA.... 1.3970
7490....................... SANTA FE, NM.................. 1.0194
7500....................... SANTA ROSA, CA................ 1.3034
7510....................... SARASOTA-BRADENTON, FL........ 1.0090
7520....................... SAVANNAH, GA.................. 1.0018
7560....................... SCRANTON-WILKES-BARRE- 0.8683
HAZLETON, PA.
7600....................... SEATTLE-BELLEVUE-EVERETT, WA.. 1.1361
7610....................... SHARON, PA.................... 0.7926
7620....................... SHEBOYGAN, WI................. 0.8427
7640....................... SHERMAN-DENISON, TX........... 0.9373
7680....................... SHREVEPORT-BOSSIER CITY, LA... 0.9050
7720....................... SIOUX CITY, IA-NE............. 0.8767
7760....................... SIOUX FALLS, SD............... 0.9139
7800....................... SOUTH BEND, IN................ 0.9993
7840....................... SPOKANE, WA................... 1.0668
7880....................... SPRINGFIELD, IL............... 0.8676
7920....................... SPRINGFIELD, MO............... 0.8567
8003....................... SPRINGFIELD, MA............... 1.0881
8050....................... STATE COLLEGE, PA............. 0.9133
8080....................... STEUBENVILLE-WEIRTON, OH-WV... 0.8637
8120....................... STOCKTON-LODI, CA............. 1.0815
8140....................... SUMTER, SC.................... 0.7794
8160....................... SYRACUSE, NY.................. 0.9621
8200....................... TACOMA, WA.................... 1.1616
8240....................... TALLAHASSEE, FL............... 0.8527
8280....................... TAMPA-ST. PETERSBURG- 0.8925
CLEARWATER, FL.
8320....................... TERRE HAUTE, IN............... 0.8532
8360....................... TEXARKANA, TX-TEXARKANA, AR... 0.8327
8400....................... TOLEDO, OH.................... 0.9809
8440....................... TOPEKA, KS.................... 0.8912
8480....................... TRENTON, NJ................... 1.0416
8520....................... TUCSON, AZ.................... 0.8967
[[Page 43629]]
8560....................... TULSA, OK..................... 0.8902
8600....................... TUSCALOOSA, AL................ 0.8171
8640....................... TYLER, TX..................... 0.9641
8680....................... UTICA-ROME, NY................ 0.8329
8720....................... VALLEJO-FARIFIELD-NAPA, CA.... 1.3562
8735....................... VENTURA, CA................... 1.0994
8750....................... VICTORIA, TX.................. 0.8328
8760....................... VINELAND-MILLVILLE-BRIDGETON, 1.0441
NJ.
8780....................... VISALIA-TULARE-PORTERVILLE, CA 0.9628
8800....................... WACO, TX...................... 0.8129
8840....................... WASHINGTON, DC-MD-VA-WV....... 1.0962
8920....................... WATERLOO-CEDAR FALLS, IA...... 0.8041
8940....................... WAUSAU, WI.................... 0.9696
8960....................... WEST PALM BEACH-BOCA RATON, FL 0.9777
9000....................... WHEELING, WV-OH............... 0.7985
9040....................... WICHITA, KS................... 0.9606
9080....................... WICHITA FALLS, TX............. 0.7867
9140....................... WILLIAMSPORT, PA.............. 0.8628
9160....................... WILMINGTON-NEWARK, DE-MD...... 1.0877
9200....................... WILMINGTON, NC................ 0.9409
9260....................... YAKIMA, WA.................... 1.0567
9270....................... YOLO, CA...................... 0.9701
9280....................... YORK, PA...................... 0.9441
9320....................... YOUNGSTOWN-WARREN, OH......... 0.9563
9340....................... YUBA CITY, CA................. 1.0359
9360....................... YUMA, AZ...................... 0.8989
------------------------------------------------------------------------
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: March 12, 2002.
Thomas A. Scully,
Administrator, Health Care Financing Administration.
Dated: May 10, 2002.
Tommy G. Thompson,
Secretary.
[FR Doc. 02-16409 Filed 6-27-02; 8:45 am]
BILLING CODE 4120-01-P
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