[Federal Register Volume 59, Number 83 (Monday, May 2, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-10417]


[[Page Unknown]]

[Federal Register: May 2, 1994]


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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[MB-088-N]
RIN: 0938-AG

 

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 final 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.

EFFECTIVE DATE: The final 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). 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. Our regulations provide for publication of preliminary 
amounts 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 Federal financial participation 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. This is the case 
for Oklahoma, Rhode Island, and West Virginia. 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 Rhode Island. 
The DSH allotments for Oklahoma and West Virginia remained unchanged 
from FFY 1993 since each State's prior year DSH allotment is less than 
12 percent of its projected FFY 1994 medical assistance expenditures.
    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. As an exception to the above 
requirements, section 1923(f)(1)(A)(i)(II) of the Act and regulations 
at 42 CFR 447.296(b)(5), allow a State to increase its aggregate DSH 
payments for a FFY to meet the minimum payment adjustments required by 
Medicare methodology described in section 1923(c)(1) of the Act. 
Nebraska meets this exception criteria. We are, therefore, revising 
Nebraska's final FFY 1993 and 1994 State DSH allotments.
    We are publishing in this notice the final FFY 1994 national DSH 
target and State DSH allotments based on the best available data we 
have received, as of March 18, 1994, from the States as adjusted by 
HCFA. These data are taken from each State's actual Medicaid 
expenditures reported on the quarterly Form HCFA-64 submissions for FFY 
1993 and the projected Medicaid expenditures reported on the February 
1994 Form HCFA-37 for FFY 1994 and are adjusted as necessary. The final 
FFY 1994 State DSH allotments published in this notice supersede the 
preliminary FFY 1994 DSH allotments that were published in the Federal 
Register on February 1, 1994 (59 FR 4717).

II. Calculations of the Final FFY 1994 DSH Limits

    The total of the final 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. A State-by-State breakdown is presented in section 
III of this notice.
    There are 34 low-DSH States and 16 high-DSH States for FFY 1994. 
This change from the preliminary notice which listed 35 low-DSH States 
and 15 high-DSH States for FFY 1994 is due to the reclassification of 
Tennessee as a high-DSH State.
    Using the most recent data from the February 1994 budget 
projections (Form HCFA-37), we estimate the FFY 1994 national total 
medical assistance expenditures for the States to be $144,326,703,000. 
Thus, the overall final national FFY 1994 DSH expenditure target is 
approximately $17.3 billion (12 percent of $144.3 billion). This is a 
decrease of approximately $0.2 billion from the $17.5 billion 
preliminary target (12 percent of $145.8 billion) in the preliminary 
notice.
    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 $0.7 billion over the final FFY 1994 national 
DSH target amount.
    In addition, in the final FFY 1994 State DSH allotments we provide 
a total of $511,372,000 ($287,455,000 Federal share) in growth amounts 
for the 34 low-DSH States. To compute the growth factor percentage, we 
first ascertained each low-DSH State's total FFY 1993 medical 
assistance and administrative expenditures as reported on the State's 
quarterly expenditure reports (Form HCFA-64) for FFY 1993. Next, we 
compared the FFY 1993 reported expenditures to each low-DSH State's 
total estimated unadjusted FFY 1994 medical assistance and 
administrative expenditures as reported to HCFA on the State's February 
1994 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 final 
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 FFY 1993 for low-
DSH States ($17,981,455,000) is greater than the final FFY 1994 
national target ($17,319,204,000), there is no final 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 final 
total low-DSH State DSH allotment for FFY 1994. Six States received 
partial growth amounts because each 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.
    As explained above, Rhode Island's final 1994 DSH allotment is 
lower than its final FFY 1993 DSH allotment.
    As explained above, we revised Nebraska's final FFY 1993 State DSH 
allotment to $8,000,000 and its final FFY 1994 State DSH allotment to 
$11,000,000.
    In summary, the total of all final State DSH allotments for FFY 
1994 is $18,490,099,000 ($10,614,651,000 Federal share). This total is 
composed of the prior FFY's DSH allotments ($17,981,455,000) plus the 
growth amounts for all low-DSH States ($511,372,000) minus the 
reduction in Rhode Island's FFY 1993 DSH allotment ($2,728,000 
decrease). The total of all final 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 $18,490,099,000 total of all final DSH allotments for FFY 1994 is 
$1,170,895,000 over the FFY 1994 final national target amount of 
$17,319,204,000.
    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 published in this notice. 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. 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. Final 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.....   =  Final 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.                       
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.             
                                                                        



       Final 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 DSH     Growth amounts   Final FFY    High or low DSH
                       State                          allotments    for low DSH      94 state         state     
                                                       for all       states\1\         DSH         designation  
                                                        states                      allotments                  
----------------------------------------------------------------------------------------------------------------
A                                                              B                C            D  E               
                                                                                                                
----------------------------------------------------------------------------------------------------------------
AL.................................................     $417,458   Not applicable     $417,458  High            
AK.................................................       17,830           $1,759       19,589  Low             
AR.................................................        2,806              232        3,039  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              730        5,924  Low             
DC.................................................       38,000            3,039       41,039  Low             
FL.................................................      239,693           46,785      286,478  Low             
GA.................................................      343,078           39,266      382,344  Low             
HI.................................................       45,844           18,233       64,078  Low             
ID.................................................        1,659              327        1,985  Low             
IL.................................................      381,534           13,459      394,993  Low             
IN.................................................      320,475           16,324      336,799  Low             
IA.................................................        5,027              470        5,497  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           10,162      129,543  Low             
MA.................................................      489,547           77,580      567,128  Low             
MI.................................................      559,732           57,968      817,700  Low             
MN.................................................       48,579            6,815       55,394  Low             
MS.................................................      152,342            6,122      158,464  Low             
MO.................................................      731,894   Not applicable      731,894  High            
MT.................................................        1,154              145        1,300  Low             
NE\2\..............................................        8,000            3,000       11,000  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            2,245       15,757  Low             
NY.................................................    2,784,477           47,387    2,831,864  Low             
NC.................................................      345,545           43,721      389,266  Low             
ND.................................................        1,086               69        1,155  Low             
OH.................................................      509,924           57,001      566,925  Low             
OK.................................................       23,568   Not applicable       23,568  Low             
OR.................................................       20,279            4,778       25,058  Low             
PA.................................................      967,407   Not applicable      967,407  High            
RI\3\..............................................       97,160   Not applicable       94,432  Low             
SC.................................................      439,759   Not applicable      439,759  High            
SD.................................................        1,163              140        1,302  Low             
TN.................................................      430,611   Not applicable      430,611  High            
TX.................................................    1,513,029   Not applicable    1,513,029  High            
UT.................................................        5,003              511        5,514  Low             
VT.................................................       24,403            2,259       26,662  Low             
VA.................................................      174,251           11,496      185,746  Low             
WA.................................................      270,374           37,618      307,993  Low             
WV.................................................      121,883   Not applicable      121,883  Low             
WI.................................................        9,325            1,556       10,881  Low             
WY.................................................        1,216              173        1,389  Low             
                                                    -------------------------------------------                 
    Total..........................................   17,981,455          511,372   18,490,099  ................
----------------------------------------------------------------------------------------------------------------
Notes:                                                                                                          
\1\There were 3 low DSH states which had negative growth and 6 low DSH states which got partial growth up to 12%
  of FFY 94 map.                                                                                                
\2\Allotment based upon minimum payment adjustment amount.                                                      
\3\Prior year's allotment exceeded 12 percent of FFY 94 map so allotment was reduced to 12 percent of FFY 94    
  map.                                                                                                          


IV. Impact Statement

    We generally prepare a 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 an 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 final FFY 1994 
national aggregate DSH target and the final 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 of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

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

    Dated: March 30, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: April 12, 1994.
Donna E. Shalala,
Secretary.
[FR Doc. 94-10417 Filed 4-26-94; 1:21 pm]
BILLING CODE 4120-01-P