[Federal Register Volume 59, Number 21 (Tuesday, February 1, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-2278]


[[Page Unknown]]

[Federal Register: February 1, 1994]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[MB-079-N]
RIN: 0938-AG61

 

Medicaid Program; Limitations on Aggregate Payments to 
Disproportionate Share Hospitals: Federal Fiscal Year 1994

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice announces the preliminary Federal fiscal year 
(FFY) 1994 national target and individual State allotments for Medicaid 
payment adjustments made to hospitals that serve a disproportionate 
number of Medicaid recipients and low-income patients with special 
needs. We are publishing this notice in accordance with the provisions 
of section 1923(f)(1)(C) of the Social Security Act (the Act) and 
implementing regulations at 42 CFR 447.297 through 447.299. The 
preliminary FFY 1994 State DSH allotments published in this notice will 
be superseded by final FFY 1994 DSH allotments to be published in the 
Federal Register by April 1, 1994.

EFFECTIVE DATE: The preliminary DSH payment adjustment expenditure 
limits included in this notice apply to Medicaid DSH payment 
adjustments that are applicable to FFY 1994.

FOR FURTHER INFORMATION CONTACT: Richard Strauss, (410) 966-2019.

SUPPLEMENTARY INFORMATION:

I. Background

    Section 1923(f) of the Social Security Act and implementing 
Medicaid regulations at 42 CFR 447.297 through 447.299 require us to 
estimate and publish in the Federal Register the national target and 
each State's allotment for disproportionate hospital share (DSH) 
payments for each Federal fiscal year (FFY). (See 57 FR 55118, November 
24, 1992 and 58 FR 43156, August 13, 1993.) DSH payments are payment 
adjustments made to Medicaid-participating hospitals that serve a large 
number of Medicaid recipients and other low-income individuals with 
special needs. Preliminary amounts must be published by October l of 
each FFY and final amounts by April l of each FFY.
    The implementing regulations provide that the national aggregate 
DSH limit for a FFY specified in the Act is a target rather than an 
absolute cap when determining the amount that can be allocated for DSH 
payments. The national DSH target is 12 percent of the total amount of 
medical assistance expenditures (excluding total administrative costs) 
that are projected to be made under approved Medicaid State plans 
during the FFY.

    (Note: Whenever the phrases ``total medical assistance 
expenditures'' or ``total administrative costs'' are used in this 
notice, they mean both the State and Federal share of expenditures 
or costs.)

    In addition to the national DSH target, there is a specific State 
DSH limit for each State for each FFY. The State DSH limit is a 
specified amount of DSH payment adjustments applicable to a FFY above 
which FFP will not be available. This is called the ``State DSH 
allotment''.
    Each State's DSH allotment for FFY 1994 is calculated by first 
determining whether the State is a ``high-DSH State,'' or a ``low-DSH 
State.'' This is determined by using the State's ``base allotment.'' A 
State's base allotment is the greater of: (1) The total amount of the 
State's actual and projected DSH payment adjustments made under the 
State's approved State plan applicable to FFY 1992, as adjusted by 
HCFA; or (2) $1,000,000.
    A State whose base allotment exceeds 12 percent of the State's 
total medical assistance expenditures (excluding administrative costs) 
projected to be made in FFY 1994 is referred to as a ``high-DSH 
State.'' The FFY 1994 State DSH allotment for a high-DSH State is 
limited to the State's base allotment.
    A State whose base allotment is equal to or less than 12 percent of 
the State's total medical assistance expenditures (excluding 
administrative costs) projected to be made in FFY 1994 is referred to 
as a ``low-DSH State.'' The FFY 1994 State DSH allotment for a low-DSH 
State is equal to the State's DSH allotment for FFY 1993 increased by 
growth amounts and supplemental amounts, if any. However, the FFY 1994 
DSH allotment for a low-DSH State cannot exceed 12 percent of the 
State's total medical assistance expenditures for FFY 1994 (excluding 
administrative costs).
    The growth amount for FFY 1994 is equal to the projected percentage 
increase (the growth factor) in a low-DSH State's total Medicaid 
program expenditures between FFY 1993 and FFY 1994 multiplied by the 
State's final DSH allotment for 1993. Because the national DSH limit is 
considered a target, low-DSH States whose programs grow from one year 
to the next can receive growth that would not be permitted if the 
national limit was viewed as an absolute cap.
    There is no growth factor and no growth amount for any low-DSH 
State whose Medicaid program does not grow (that is, stayed the same or 
declined) between fiscal years FFY 1993 and FFY 1994. Furthermore, 
because a low-DSH State's FFY 1994 DSH allotment cannot exceed 12 
percent of the State's total medical assistance expenditures, it is 
possible for its FFY 1994 DSH allotment to be lower than its FFY 1993 
DSH allotment. This situation occurs when the State experiences a 
decrease in its program expenditures between years and its prior FFY 
DSH allotment is greater than 12 percent of the total projected medical 
assistance expenditures for the current FFY. This is the case for the 
State of Rhode Island.
    There is no supplemental amount available for redistribution for 
FFY 1994. The supplemental amount, if any, is equal to a low-DSH 
State's proportional share of a pool of funds (the redistribution 
pool). The redistribution pool is equal to the national 12-percent DSH 
target reduced by the total of the base allotments for high-DSH States, 
the total of the State DSH allotments for the previous FFY for low-DSH 
States, and the total of the low-DSH State growth amounts. Since the 
sum of these amounts is above the projected FFY 1994 national 12 
percent DSH target, there is no redistribution pool and, therefore, no 
supplemental amounts for FFY 1994.
    As prescribed in the law and regulations, no State's DSH allotment 
will be below a minimum of $1 million.
    We are publishing in this notice the preliminary FFY 1994 national 
DSH target and State DSH allotments based on the best available data we 
have at this time from the States as adjusted by HCFA. This data is 
taken from each State's August 1993 Form HCFA-37 and is adjusted as 
necessary. The final FFY 1994 DSH allotments will be published in the 
Federal Register by April 1, 1994.

II. Calculations of the Preliminary FFY 1994 DSH Limits

    We have calculated the preliminary FFY 1994 State DSH allotments in 
this notice in accordance with section 1923(f) of the Act and the 
applicable regulations. The results of these calculations are presented 
in chart format in section III. of this notice.
    The total of the preliminary State DSH allotments for FFY 1994 is 
equal to the sum of the base allotments for all high-DSH States, the 
FFY 1993 State DSH allotments for all low-DSH States, and the growth 
amounts for all low-DSH States.
    We classified States as high-DSH or low-DSH States. If a State's 
base allotment exceeded 12 percent of its total unadjusted medical 
assistance expenditures (excluding administrative costs) projected to 
be made under the State's approved plan in FFY 1994, we classified that 
State as a ``high-DSH'' State. If a State's base allotment was 12 
percent or less of its total unadjusted medical assistance expenditures 
projected to be made under the State's approved State plan under title 
XIX of the Act in FFY 1994, we classified that State as a ``low-DSH'' 
State. There were 35 low-DSH States and 15 high-DSH States for FFY 1994 
as a result of this classification.
    We estimated the preliminary FFY 1994 national total medical 
assistance expenditures for these States to be $145,839,070,000. The 
expenditures were estimated using the August 1993 State budget 
projections (Form HCFA-37) for FFY 1994. Thus, the overall preliminary 
national FFY 1994 DSH expenditure target is approximately $17.5 billion 
(12 percent of $145.8 billion).
    The high-DSH States' base allotments and the final low-DSH States' 
DSH allotments for 1993 total approximately $18.0 billion. This amount, 
which does not include growth or any State supplemental amounts for FFY 
1994, is approximately $0.5 billion over the FFY 1994 preliminary 
national DSH target amount.
    In addition, we have provided a total of $623,650,000 ($357,351,000 
Federal share) in growth amounts for the 35 low-DSH States. The growth 
factor percentage for each of the low-DSH States was determined by 
calculating the Medicaid program growth percentage for each low-DSH 
State between FFY 1993 and FFY 1994. To compute this percentage, we 
first ascertained each low-DSH State's estimate of total FFY 1993 
medical assistance and administrative expenditures as reported on the 
State's Medicaid Budget Report (Form HCFA-37) submitted in August 1993. 
Next, we compared those estimates to each low-DSH State's total 
estimated unadjusted FFY 1994 medical assistance and administrative 
expenditures as reported to HCFA on the State's August 1993 Form HCFA-
37 submission.
    The growth factor percentage was multiplied by the low-DSH State's 
final FFY 1993 DSH allotment amount to establish the State's 
preliminary growth amount for FFY 1994.
    Since the sum of the total of the base allotments for high-DSH 
States and the total of the State DSH allotments for the previous FFY 
for low-DSH States ($17,977,185,000) is greater than the preliminary 
FFY 1994 national target ($17,500,688,000), there is no preliminary FFY 
1994 redistribution pool.
    The low-DSH State's growth amount was then added to the low-DSH 
State's final FFY 1993 DSH allotment amount to establish the 
preliminary total low-DSH State DSH allotment for FFY 1994. As noted 
above, if a State's growth amount, when added to its final FFY 1993 DSH 
allotment amount, exceeded 12 percent of its FFY 1994 estimated medical 
assistance expenditures, the State received a partial growth amount 
which, when added to its final FFY 1993 allotment, made its total State 
DSH allotment for FFY 1994 equal to 12 percent of its estimated FFY 
1994 medical assistance expenditures. For this reason, eight of the 
low-DSH States received partial growth amounts.
    As explained above, Rhode Island's preliminary 1994 DSH allotment 
is lower than its FFY 1993 DSH allotment because the State experienced 
a decrease in its program between years and its prior FFY DSH allotment 
is greater than 12 percent of the total projected medical assistance 
expenditures for the current year.
    In summary, the total of all preliminary State DSH allotments for 
FFY 1994 is $18,598,427,000 ($10,656,898,000 Federal share). This total 
is composed of $17,977,185,000 in base allotments plus $623,650,000 in 
growth amounts for all low-DSH States plus $0 in supplemental amounts 
for low-DSH States. The total of all preliminary FFY 1994 State DSH 
allotments is 12.81 percent of the total medical assistance 
expenditures (excluding administrative costs) projected to be made by 
these States in FFY 1994. The total of all preliminary DSH allotments 
for FFY 1994 is $1,097,739,000 over the FFY 1994 preliminary national 
target amount of $17,500,688,000.
    Each State should monitor and make any necessary adjustments to its 
DSH spending during FFY 1994 to ensure that its actual FFY 1994 DSH 
payment adjustment expenditures do not exceed its final State DSH 
allotment for FFY 1994 which will be published by April 1, 1994. As the 
ongoing reconciliation between actual FFY 1994 DSH payment adjustment 
expenditures and the final FFY 1994 DSH allotments takes place, each 
State should amend its plans as may be necessary to make any 
adjustments to its FFY 1994 DSH payment adjustment expenditure patterns 
so that the State will not exceed its final FFY 1994 DSH allotment.
    The FFY 1994 reconciliation of DSH allotments to actual 
expenditures will take place on an ongoing basis as States file 
expenditure reports with HCFA for DSH payment adjustment expenditures 
applicable to FFY 1994. In addition, additional DSH payment adjustment 
expenditures made in succeeding FFYs that are applicable to FFY 1994 
will continue to be reconciled back to each State's final FFY 1994 DSH 
allotment as additional expenditure reports are submitted to ensure 
that the final FFY 1994 DSH allotment is not exceeded. Any DSH payment 
adjustment expenditures in excess of the final DSH allotment will be 
disallowed.
    Any DSH expenditures that are disallowed will be subject to the 
normal Medicaid disallowance procedures.

III. Preliminary FFY 1994 DSH Allotments Under Public Law 102-234 

                              Key to Chart                              
------------------------------------------------------------------------
    Column                            Description                       
------------------------------------------------------------------------
Column A=....  Name of State.                                           
Column B=....  Final FFY 1993 DSH Allotments For All States. For a high-
                DSH State, this is the State's base allotment which is  
                the greater of the State's FFY 1992 allowable DSH       
                payment adjustment expenditures applicable to FFY 1992, 
                or $1,000,000. For a low-DSH State, this is equal to the
                final DSH allotment for FFY 1993 which was published in 
                the Federal Register on August 13, 1993.                
Column C=....  Growth Amounts For Low-DSH States. This is an increase in
                a low-DSH State's final FFY 1993 DSH allotment to the   
                extent that the State's Medicaid program grew between   
                FFY 1993 and FFY 1994.                                  
Column D=....  Preliminary FFY 1994 State DSH Allotments. For high DSH  
                States this is equal to the base allotment from column  
                B. For low-DSH States, this is equal to the final State 
                DSH allotments for FFY 1993 from column B plus the      
                growth amounts from column C and the supplemental       
                amounts, if any, from column D.                         
Column E=....  High or Low DSH State Designation. ``High'' indicates the
                State is a high-DSH State and a ``Low'' indicates the   
                State is a low-DSH State.                               
------------------------------------------------------------------------


    Preliminary Federal Fiscal Year 1994 Disproportionate Share Hospital Allotments Under Public Law 102-234    
                     [Amounts are State and Federal Shares Dollars are in Thousands (000)]                      
----------------------------------------------------------------------------------------------------------------
                                          Final FFY 93                                 Preliminary              
                                         DSH allotments  Growth amounts for low DSH   FFY 94 state   High or low
                 State                   for all states         states(\1\)          DSH allotments   DSH state 
                                                                                                     designation
----------------------------------------------------------------------------------------------------------------
(A)                                                 (B)  (C).......................             (D)  (E)        
AL.....................................        $417,458  Not Applicable............        $417,458  High.      
AK.....................................          17,830  $781......................          18,611  Low.       
AR.....................................           2,806  210.......................           3,016  Low.       
CA.....................................       2,191,451  Not Applicable............       2,191,451  High.      
CO.....................................         302,014  Not Applicable............         302,014  High.      
CT.....................................         408,933  Not Applicable............         408,933  High.      
DE.....................................           5,194  372.......................           5,565  Low.       
DC.....................................          38,000  2,823.....................          40,823  Low.       
FL.....................................         239,693  61,520....................         301,213  Low.       
GA.....................................         343,078  53,121....................         396,199  Low.       
HI.....................................          45,844  5,411.....................          51,256  Low.       
ID.....................................           1,659  402.......................           2,060  Low.       
IL.....................................         381,534  20,290....................         401,824  Low.       
IN.....................................         320,475  Not Applicable............         320,475  Low.       
IA.....................................           5,027  538.......................           5,565  Low.       
KS.....................................         188,935  Not Applicable............         188,935  High.      
KY.....................................         264,289  Not Applicable............         264,289  High.      
LA.....................................       1,217,636  Not Applicable............       1,217,636  High.      
ME.....................................         165,317  Not Applicable............         165,317  High.      
MD.....................................         119,381  12,659....................         132,040  Low.       
MA.....................................         489,547  66,987....................         556,534  Low.       
MI.....................................         559,732  62,577....................         622,309  Low.       
MN.....................................          48,579  5,393.....................          53,971  Low.       
MS.....................................         152,342  6,122.....................         158,464  Low.       
MO.....................................         731,894  Not Applicable............         731,894  High.      
MT.....................................           1,154  153.......................           1,307  Low.       
NE.....................................           3,730  574.......................           4,304  Low.       
NV.....................................          73,560  Not Applicable............          73,560  High.      
NH.....................................         392,006  Not Applicable............         392,006  High.      
NJ.....................................       1,094,113  Not Applicable............       1,094,113  High.      
NM.....................................          13,512  2,063.....................          15,575  Low.       
NY.....................................       2,784,477  91,455....................       2,875,932  Low.       
NC.....................................         345,545  67,705....................         413,251  Low.       
ND.....................................           1,086  8.........................           1,094  Low.       
OH.....................................         509,924  74,440....................         584,364  Low.       
OK.....................................          23,568  Not Applicable............          23,568  Low.       
OR.....................................          20,279  2,814.....................          23,093  Low.       
PA.....................................         967,407  Not Applicable............         967,407  High.      
RI(\2\)................................          97,160  Not Applicable............          94,751  Low.       
SC.....................................         439,759  Not Applicable............         439,759  High.      
SD.....................................           1,163  235.......................           1,397  Low.       
TN.....................................         430,611  18,562....................         449,173  Low.       
TX.....................................       1,513,029  Not Applicable............       1,513,029  High.      
UT.....................................           5,003  701.......................           5,704  Low.       
VT.....................................          24,403  1,585.....................          25,988  Low.       
VA.....................................         174,251  21,287....................         195,537  Low.       
WA.....................................         270,374  34,501....................         304,875  Low.       
WV.....................................         121,883  7,097.....................         128,980  Low.       
WI.....................................           9,325  1,108.....................          10,433  Low.       
WY.....................................           1,216  158.......................           1,374  Low.       
    Total..............................      17,977,185  623,650...................      18,598,427  ...........
----------------------------------------------------------------------------------------------------------------
Notes: (1) There were 3 low DSH states which had negative growth and 8 low DSH states which got partial growth  
  up to 12% of FFY 94 map.                                                                                      
(2) Prior year's allotment exceeded 12 percent of FFY 94 map so allotment was reduced to 12 percent of FFY 94   
  map.                                                                                                          

IV. Regulatory Impact Statement

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612), unless the Administrator certifies that a notice would 
not have a significant economic impact on a substantial number of small 
entities. For purposes of a RFA, States and individuals are not 
considered small entities. However, providers are considered small 
entities. Additionally, section 1102(b) of the Act requires the 
Secretary to prepare a regulatory impact analysis if a notice may have 
a significant impact on the operations of a substantial number of small 
rural hospitals. Such an 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 Metropolitan Statistical Area and has fewer than 50 beds.
    This notice does not contain rules; rather, it reflects the DSH 
allotments for each State as determined in accordance with 
Secs. 447.297 through 447.299.
    We have discussed the method of calculating the preliminary FFY 
1994 national aggregate DSH target and the preliminary FFY 1994 
individual State DSH allotments in the previous sections of this 
preamble. These calculations should have a positive impact on payments 
to DSHs. Allotments will not be reduced for high-DSH States since we 
are now interpreting the 12-percent limit as a target. Low-DSH States 
will get their base allotments plus their growth amounts.
    In accordance with the provisions with Executive Order 12886, this 
notice was reviewed by the Office of Management and Budget.

(Catalog of Federal Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: October 8, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: November 23, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-2278 Filed 1-31-94; 8:45 am]
BILLING CODE 4120-01-P