[Federal Register Volume 59, Number 28 (Thursday, February 10, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-3098]


[[Page Unknown]]

[Federal Register: February 10, 1994]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Part 489

[BPD-748-P]
RIN 0938-AG03

 

Medicare Program; Change in Provider Agreement Regulations 
Related to Federal Employee Health Benefits

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

ACTION: Proposed rule.

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

SUMMARY: This proposed rule would amend current Medicare regulations to 
require that payment for inpatient hospital services furnished to 
retired Federal workers age 65 and older who are enrolled in a Federal 
Employee Health Benefits (FEHB) plan but who are not entitled to 
receive hospital benefits under Medicare Part A (Hospital Insurance) 
may not exceed the hospital payments established for Medicare purposes 
for inpatient hospital services. The rule would also amend current 
Medicare regulations to authorize HCFA to consider termination or 
nonrenewal of a hospital's Medicare provider agreement for knowingly 
and willfully failing to accept, on a repeated basis, the Medicare rate 
as payment in full from an FEHB plan. This proposed rule would 
implement section 7002(f) of the Omnibus Budget Reconciliation Act of 
1990, enacted on November 5, 1990.

DATES: Comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on April 
11, 1994.

ADDRESSES: Mail written comments to the following address:

Health Care Financing Administration, Department of Health and Human 
Services, Attention: BPD-748-P, P.O. Box 26676, Baltimore, MD 21207.

    If you prefer, you may deliver your written comments to one of the 
following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore, 
MD 21207.

    Due to staffing and resource limitations, we cannot accept comments 
by facsimile (FAX) transmission. In commenting, please refer to file 
code BPD-748-P. Comments received timely will be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, in room 309-G of the 
Department's offices at 200 Independence Avenue SW., Washington, DC, on 
Monday through Friday of each week from 8:30 a.m. to 5 p.m. (phone: 
(202) 690-7890).
    Copies: To order copies of the Federal Register containing this 
document, send your request to: Superintendent of Documents, U.S. 
Government Printing Office, ATTN: New Order, P.O. Box 371954, 
Pittsburgh, PA 15250-7954.
    Specify the date of the issue requested and enclose a check or 
money order payable to the Superintendent of Documents, or enclose your 
Visa or Master Card number and expiration date. Credit card orders can 
also be placed by calling the order desk at (202) 783-3238 or by faxing 
to (202) 512-2250. The cost for each copy is $4.50. In addition, you 
may view and photocopy the Federal Register document at most libraries 
designated as U.S. Government Depository Libraries and at many other 
public and academic libraries throughout the country that receive the 
Federal Register. The order desk operator will be able to tell you the 
location of U.S. Government Depositories.

FOR FURTHER INFORMATION CONTACT: Mel Lewis, (410) 966-4615.

SUPPLEMENTARY INFORMATION:

I. Background

    The Office of Personnel Management (OPM) administers Federal 
Employee Health Benefit (FEHB) plans. These plans provide a variety of 
health services packages to current Federal employees and their 
families as well as to retired Federal workers and any eligible 
dependents. Most retired Federal employees age 65 and older are 
eligible to receive hospital insurance benefits under Medicare Part A 
(Hospital Insurance), one of two insurance programs created by the 
Social Security Amendments of 1965 when the Medicare program was 
established by the addition of title XVIII to the Social Security Act 
(the Act). There are, however, some retired Federal workers age 65 and 
older who are not entitled to receive hospital insurance benefits under 
Medicare Part A.
    Present Medicare conditions of participation (requirements that 
hospitals must meet to qualify for participation in the Medicare 
program) mandate that a provider not charge a beneficiary for services 
for which the beneficiary is entitled to have payment made under 
Medicare. A provider is defined in 42 CFR 400.202 as a hospital, a 
skilled nursing facility (SNF), a comprehensive outpatient 
rehabilitation facility (CORF), a home health agency (HHA), or, 
effective November 1, 1983 through September 30, 1986, a hospice that 
has in effect an agreement to participate in Medicare, or a clinic, a 
rehabilitation agency, or a public health agency that has a similar 
agreement but only to furnish outpatient physical therapy or speech 
pathology services. Under the requirement not to charge a beneficiary 
for services for which the beneficiary is entitled to have payment made 
under Medicare, the provider agrees to accept Medicare payment in full 
for services covered under Medicare and furnished by the provider. 
Existing Medicare conditions of participation and provider agreements 
do not require that hospitals accept the Medicare prospective payment 
system (PPS) rate as payment in full when issued by an FEHB plan for an 
enrollee not entitled to Medicare Part A.
    Reforms in the Health Benefits Program under section 7002(f) of the 
Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on 
November 5, 1990) require that FEHB plans limit their inpatient payment 
for retired FEHB enrollees who are age 65 and older but who are not 
entitled to receive hospital insurance benefits under Medicare to rates 
that would have been paid by Medicare under the inpatient hospital 
prospective payment system. The prospective payment system is a system 
of payment for acute inpatient hospital stays under Medicare Part A 
based on prospectively set rates. Under this system, Medicare payment 
is made at a predetermined, specific rate for each hospital discharge.
    Section 7002(f) of Public Law 101-508 also requires that the OPM 
notify the Secretary of Health and Human Services (the Secretary) of 
incidents when a hospital knowingly and willfully attempts to collect, 
on a repeated basis, the difference between the Medicare payment rates 
and the hospital's charge, less any deductible or coinsurance 
obligation. The Secretary may consider these incidents as violations of 
the Medicare provider agreement and may consider termination or 
nonrenewal of the agreement. A Medicare provider agreement is an 
agreement between HCFA and one of the providers specified in 
Sec. 489.2(b) to furnish services to Medicare beneficiaries and to 
comply with section 1886 of the Act, which establishes hospital 
payments. HCFA may terminate a provider agreement if any of the 
failings listed in Sec. 489.53(a), which sets forth the basis for 
HCFA's termination of an agreement with any provider, is attributable 
to a provider.
    The committee and conference reports accompanying Public Law 101-
508 support the implementation of the changes in the provider agreement 
regulations. The Report of the Committee on the Budget of the House of 
Representatives (H.R. Rep. No. 881, 101st Cong., 2d Sess. 177 (1990)) 
accompanying Public Law 101-508 explains that section 8002(d) of the 
House bill:

    * * * Requires the Office of Personnel Management, in 
consultation with the Department of Health and Human Services, to 
develop and implement a system through which health benefits plan 
carriers will be able to identify Medicare-eligible FEHBP 
annuitants. Establishment of this system will ensure that payments 
under coordination of benefits with Medicare do not exceed the 
present or future statutory maximum which physicians may charge 
Medicare beneficiaries.

    The Conference Report to Accompany H.R. 5835 (H.R. Rep. No. 964, 
101st Cong., 2d Sess. 976 (1990)) states that section 8002 of the House 
bill:

    * * * Requires improved coordination between the Office of 
Personnel Management and the Department of Health and Human Services 
in order to ensure that Medicare's payments and limits can be 
correctly applied when the FEHBP carriers make a secondary payment.

    The Conference Report also points out that:

    Section 8005 of the Senate amendment applies Medicare part A 
hospital payment limits to payments to providers of services to 
FEHBP annuitant enrollees who are age 65 and older but not eligible 
for Medicare.

    The report states that the Conference agreement encompasses the 
House and Senate provisions, including a requirement for:

    * * * Improved coordination between the Office of Personnel 
Management and the Department of Health and Human Services in order 
to ensure that Medicare's payment and limits can be correctly 
applied * * * and the Senate provision which applies Medicare 
hospital payment limits to payments to providers of services to 
FEHBP annuitant enrollees who are age 65 and older but not eligible 
for Medicare.

II. Provisions of the Proposed Regulations

    We are proposing to revise the following regulations to implement 
section 7002(f) of Public Law 101-508:
    We would amend Sec. 489.21, which sets forth specific limitations 
on charges under Medicare provider agreements, by revising the 
introductory text to make the limitations for inpatient hospital 
services applicable to retired FEHB plan enrollees age 65 or older who 
are not entitled to Medicare benefits. We would also add a new 
paragraph (i) under Sec. 489.21 to require that the provider not charge 
for inpatient hospital services that are in excess of the hospital 
payments, after applicable copayments have been satisfied, established 
for Medicare purposes for inpatient hospital services under section 
1886 of the Act furnished to a retired Federal employee age 65 or older 
who is enrolled in an FEHB plan and who is not entitled to receive 
hospital benefits under Medicare Part A.
    We would amend Sec. 489.53, which sets forth the basis for 
termination of provider agreements by HCFA. We would add to Sec. 489.53 
a new paragraph (a)(13) stating that we may terminate the agreement 
with any provider if we find that the provider knowingly and willfully 
charges, on a repeated basis, more than the hospital payments, after 
applicable copayments have been satisfied, established for Medicare 
purposes for inpatient hospital services under section 1886 of the Act.

III. 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 Secretary certifies that a proposed rule would 
not have a significant economic impact on a substantial number of small 
entities. For purposes of the RFA, all hospitals are considered to be 
small entities.
    Also, section 1102(b) of the Act requires the Secretary to prepare 
a regulatory impact analysis if a proposed 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 603 
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 100 beds.
    This proposed rule would add a new paragraph (i) under Sec. 489.21 
to require that payment for inpatient hospital services furnished to 
retired Federal workers age 65 or older who are enrolled in an FEHB 
plan but who are not entitled to receive hospital benefits under 
Medicare Part A may not exceed the hospital payments established for 
Medicare purposes for inpatient hospital services.
    In addition, we may terminate the Medicare agreement with any 
provider if the provider knowingly and willfully charges, on a repeated 
basis, an amount in excess of the hospital payments, after applicable 
copayments have been satisfied, established for Medicare purposes for 
inpatient hospital services under section 1886 of the Act.
    Prospective payment rates tend to be substantially below the rates 
most hospitals charge most private insurers, including those private 
insurers participating in the Federal Employee Health Benefit Program. 
This new requirement will therefore result in substantial savings to 
the FEHBP. The requirement became effective January 1, 1992, without 
rulemaking. Hospitals have been notified of their obligations through 
OPM administrative procedures, savings will accrue directly through the 
OPM program, and compliance will be obtained and monitored by OPM.
    HCFA is involved only because the Congress required that we 
establish a sanction mechanism in case any hospitals knowingly and 
willfully violate the requirement on a repeated basis. These sanction 
procedures would come into play only after an OPM determination of a 
problem and notification to HCFA. Hospitals that do not charge more 
than the hospital payments established for Medicare purposes would not 
be affected by this rule. We do not believe that any hospitals would 
knowingly refuse to comply, or that any hospital would lose provider 
status. Therefore, this proposed rule would have negligible economic 
effects.
    For these reasons, we are not preparing analyses for either the RFA 
or section 1102(b) of the Act since we have determined, and the 
Secretary certifies, that this proposed rule would not result in a 
significant economic impact on a substantial number of small entities 
and would not have a significant economic impact on the operations of a 
substantial number of small rural hospitals.
    In accordance with the provisions of Executive Order 12866 this 
proposed rule was not reviewed by the Office of Management and Budget.

IV. Other Required Information

A. Paperwork Reduction Act

    This proposed rule contains no information collection requirements. 
Consequently, this rule need not be reviewed by the Office of 
Management and Budget under the authority of the Paperwork Reduction 
Act (44 U.S.C. 3501 et seq.).

B. Response to Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, we will consider all comments that we 
receive by the date and time specified in the ``DATES'' section of this 
preamble, and when we proceed with the final rule, we will respond to 
the comments in the preamble to the final rule.

List of Subjects in 42 CFR Part 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.
    For the reasons set forth in the preamble, 42 CFR chapter IV, 
subchapter E, part 489 is proposed to be amended as set forth below:

PART 489--PROVIDER AND SUPPLIER AGREEMENTS

    1. The authority citation for part 489 continues to read as 
follows:

    Authority: Secs. 1102, 1861, 1864(m), 1866, and 1871 of the 
Social Security Act (42 U.S.C. 1302, 1395x, 1395aa(m), 1395cc, and 
1395hh).

Subpart B--Essentials of Provider Agreements

    2. Section 489.21 is amended by revising the introductory text of 
the section and by adding a new paragraph (i) to read as follows:


Sec. 489.21  Specific limitations on charges.

    Except as specified in subpart C of this part, the provider agrees 
not to charge a beneficiary for any of the services enumerated in this 
section, or in the instance of a retired Federal Employee Health 
Benefit (FEHB) plan enrollee age 65 or older not entitled to Medicare 
benefits, other than a prepayment enrollee, for those services listed 
exclusively in paragraph (i) of this section.
* * * * *
    (i) Inpatient hospital services that are in excess of the hospital 
payments, after applicable copayments have been satisfied, established 
for Medicare purposes for inpatient hospital services under section 
1886 of the Act furnished to a retired Federal employee age 65 or older 
who is enrolled in an FEHB plan, other than a prepayment plan, and who 
is not entitled to receive hospital benefits under Medicare Part A.

Subpart E--Termination of Agreement and Reinstatement After 
Termination

    3. In Sec. 489.53, the introductory text to paragraph (a) is 
republished and a new paragraph (a)(13) is added to read as follows:


Sec. 489.53  Termination by HCFA.

    (a) Basis for termination of agreement with any provider. HCFA may 
terminate the agreement with any provider if HCFA finds that any of the 
following failings is attributable to that provider:
* * * * *
    (13) It knowingly and willfully charges, on a repeated basis, more 
than the hospital payments, after applicable copayments have been 
satisfied, established for Medicare purposes for inpatient hospital 
services under section 1886 of the Act.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)

    Dated: October 13, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Approved: December 1, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-3098 Filed 2-9-94; 8:45 am]
BILLING CODE 4120-01-P