[Federal Register Volume 59, Number 100 (Wednesday, May 25, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-12461]
[[Page Unknown]]
[Federal Register: May 25, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 405, 406, 408, 410, 413, and 418
[BPD-791-FC]
RIN 0938-AG64
Medicare Program; Self-Implementing Coverage and Payment
Provisions: 1993 Legislation
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final rule with comment period.
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SUMMARY: This rule updates Medicare regulations to conform them to
certain self-implementing provisions on coverage of services and
payment requirements under the Omnibus Budget Reconciliation Act of
1993 (OBRA 93). OBRA 93 was enacted on August 10, 1993 and several of
the cited changes to the statute are already in effect and the others
will be shortly. We are also implementing a related provision of the
Omnibus Budget Reconciliation Act of 1990 (OBRA 90) as necessary for
consistency and clarity of the OBRA 93 provisions.
DATES: Effective date: These regulations are effective June 24, 1994.
Comment period: Comments will be considered if we receive them at
the appropriate address, as provided below, no later than 5 p.m., July
25, 1994.
ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address:
Health Care Financing Administration, Department of Health and Human
Services, Attention: BPD-791-FC, P.O. Box 26676, Baltimore, MD 21207.
If you prefer, you may deliver your written comments (1 original
and 3 copies) 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.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-791-FC. 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).
FOR FURTHER INFORMATION CONTACT: Matt Plonski, (410) 966-4662.
SUPPLEMENTARY INFORMATION:
I. Background
On August 10, 1993, the Omnibus Budget Reconciliation Act of 1993
(OBRA 93) (Pub. L. 103-66) was enacted. This law contains numerous
provisions relating to coverage of services and payments for services
furnished to Medicare beneficiaries. Some of these provisions are self-
implementing; that is, the provisions are stated in terms that neither
require nor permit exercise of discretion in implementing them.
The plain wording of the law causes a conflict with several of our
existing regulations; in other cases, the regulations simply do not
take the amendments into account. We are, therefore, making the
necessary changes to incorporate the new provisions into regulations.
A discussion of the individual legislative provisions and the
accompanying regulations follows.
II. Reductions in Payments for Skilled Nursing Facility Services--
Elimination of Return on Equity for Proprietary Skilled Nursing
Facilities
A. Legislative Provision
Section 1861(v)(1)(B) of the Social Security Act (the Act) provides
that proprietary skilled nursing facilities (SNFs) receive, in addition
to payments for the costs of providing services, return on equity
payments, which provide the investors in the facilities a return on
their investment equivalent to what they would have earned had they
invested the same amount in specified government securities. Section
13503(c) of OBRA 93 amended sections 1861(v)(1)(B) and 1878(f)(2) of
the Act to eliminate payments to SNFs for return on equity capital,
applicable to portions of cost reporting periods beginning on or after
October 1, 1993.
B. Regulations Revision
We are revising Sec. 413.157(b)(3), Rate of return related to
proprietary SNFs, to limit its application to services furnished before
October 1, 1993.
III. Reductions in Payments for Hospice Services
A. Legislative Provision
Under section 1814(i) of the Act, we pay for hospice services on a
daily rate basis. Payments are adjusted by a market basket percentage
increase. Section 13504 of OBRA 93 amended section 1814(i) of the Act
to decrease the amount of the market basket (as defined by section
1886(b)(3)(B)(iii) of the Act) percentage increase that will be applied
in fiscal years (FY) 1994 through 1997. These decreases are:
FY 1994--the market basket percentage increase minus 2 percentage
points;
FYs 1995 and 1996--the market basket percentage increase minus 1.5
percentage points; and
FY 1997--the market basket percentage increase minus .5 percentage
points.
After FY 1997, the full market basket percentage increase will
again apply.
B. Regulations Revisions
We are revising Sec. 418.306, Determination of payment rates, by
updating paragraph (b)(2) to exclude FYs 1994 through 1997 from the
application of the market basket percentage increase without
modification and to add a new paragraph (b)(3) to add the statutory
decreases.
IV. Reduction in Part A Premium for Certain Individuals With 30 or
More Quarters of Social Security Coverage
A. Legislative Provision
Under section 226(a) of the Act, individuals generally become
entitled to benefits under Medicare Part A when they reach age 65 based
on hospital insurance (Part A) taxes they paid under the Federal
Insurance Contributions Act (FICA) while they were working. By paying
the Part A portion of the FICA tax, individuals acquire quarters of
coverage (QCs), which are used to insure them for Part A coverage.
Insured individuals are not required to pay monthly premiums for Part A
coverage. Under section 1818 of the Act, individuals age 65 or over who
do not have enough QCs to be insured for premium-free Part A may enroll
in the Part A program if they pay a monthly premium. The Part A premium
is determined under section 1818(d) of the Act and is based on the
actuarial value of benefits under Part A. In addition, under section
1818A of the Act, disabled individuals who lose eligibility for
premium-free Part A solely because they have returned to work may
enroll in Part A if they pay a monthly premium, the amount of which is
determined under section 1818(d).
Section 13508 of OBRA 93 amended section 1818(d) to reduce, on a
phased-in basis, the amount of the Part A premium for workers with 30
or more QCs and for spouses (including surviving spouses) of these
workers with 30 or more QCs after having been married at least one
year. The reduction also applies to divorced spouses (including
surviving divorced spouses) of workers with 30 or more QCs provided
that, at the time the divorce became final, the worker had 30 or more
QCs and the marriage had lasted for at least 10 years. The reductions
are as follows:
1994--25 percent
1995--30 percent
1996--35 percent
1997--40 percent
1998 and later years--45 percent
The reduction will begin with premium payments beginning January 1994.
B. Regulations Revisions
We are adding to Sec. 406.32, Monthly premiums, a new paragraph
(b)(3) to show the year by year reductions required by the statute and
a new paragraph (c) to show the requirements for qualifying for the
reduction. We are redesignating paragraph (b)(3) as (b)(4) and revising
its contents, which concern rounding off fractions of dollars, to
specify that the paragraph applies to the unreduced and the reduced
Part A premium. We are redesignating current paragraphs (c) through (f)
as (d) through (g), respectively.
V. Extension of 10 Percent Reduction in Payments for Capital-
Related Costs of Outpatient Hospital Services
A. Legislative Provision
Under 1861(v)(1)(S)(ii)(I) of the Act, Medicare pays the capital
costs of hospitals allocated to outpatient departments on the basis of
reasonable cost principles, subject to a 10 percent reduction through
FY 1995. (Sole community hospitals and rural primary care hospitals are
exempt from these reductions.) Section 13521 of OBRA 93 amended section
1861(v)(1)(S)(ii)(I) of the Act to extend the 10 percent reduction
through FY 1998.
B. Regulations Revisions
We are revising Sec. 413.130(j)(1)(ii), Reduction to capital-
related costs, to extend to 1998 the year through which the 10 percent
reduction applies.
VI. Extension of Reduction in Payments for Other Costs for
Outpatient Hospital Services
A. Legislative Provision
Under section 1861(v)(1)(S)(ii)(II) of the Act, Medicare payments
for hospital outpatient services made on a reasonable cost basis and
the cost portion of outpatient services paid on the basis of a blended
amount are both reduced by 5.8 percent through FY 1995. Section 13522
of OBRA 93 amended section 1861(v)(1)(S)(ii)(II) of the Act to extend
the application of the reduction through FY 1998.
B. Regulations Revisions
We are revising Sec. 413.124, Reduction to hospital outpatient
operating costs, to extend to 1998 the year through which the 5.8
percent reductions apply.
VII. Reduction in Payments for Intraocular Lenses
A. Legislative Provision
Section 1833(i)(2)(A)(iii) of the Act includes in the cost of
surgery to insert an intraocular lens during or after cataract surgery
a payment that is reasonable and related to the cost of acquiring the
class of lens involved. Section 4151 of Public Law 101-508 (the Omnibus
Budget Reconciliation Act of 1990 (OBRA 90)) froze the amount of
payment for the lens at $200. Section 13533 of OBRA 93 reduced the
payment amount for intraocular lenses inserted during or after cataract
surgery in an ambulatory surgical center on or after January 1, 1994
and before January 1, 1999. For that period, the payment is $150.
B. Regulations Revisions
Our regulations do not contain the specific amounts allowable for
intraocular lenses, which are, instead, contained in our administrative
guidelines. Therefore, we are making no changes to regulations to
implement the legislation.
VIII. Payment for Parenteral and Enteral Nutrients, Supplies and
Equipment During 1994 and 1995
A. Legislative Provision
In the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-
509), section 9340 provided that reasonable charges for parenteral and
enteral nutrition supplies and equipment may not exceed the lowest
charge levels at which the supplies and equipment are widely and
consistently available. Under our regulations at 42 CFR 405.511(c)
those levels are set at the 25th percentile of the charges for the
items or services, in the locality designated by the carrier for this
purpose, during the three month period of July 1 through September 30
preceding the fee screen year for which the item or service was
furnished. Section 13541 of OBRA 93 requires that in determining the
amount of Part B payment for parenteral and enteral nutrients, supplies
and equipment during 1994 and 1995, the charges determined to be
reasonable with respect to these items may not exceed the charges
determined to be reasonable for them during 1993.
B. Regulation Revision
As our payment regulations do not specifically address payments for
parenteral and enteral nutrients, supplies and equipment, we do not
need to revise our regulations to implement this provision of OBRA 93
but will make any necessary changes in our program manuals.
IX. Increase in Annual Cap on Amount of Medicare Payment for
Outpatient Physical Therapy and Occupational Therapy Services
A. Legislative Provision
Section 1833(g) of the Act limits the amount payable annually for
covered outpatient physical and occupational therapy services provided
by independently practicing physical and occupational therapists.
Section 6133(a) of the Omnibus Budget Reconciliation of 1989 (OBRA 89)
(Pub. L. 101-239) amended section 1833(g) of the Act to increase the
maximum amount of incurred expenses that can be recognized for payment
purposes from $500 to $750, for services furnished on or after January
1, 1990, and section 13555 of OBRA 93 amended section 1833(g) of the
Act to increase the maximum amount of incurred expenses that can be
recognized for payment purposes from $750 to $900, effective for
services furnished on or after January 1, 1994.
B. Regulations Revisions
We are revising paragraph (c)(2) of 42 CFR 410.60, Outpatient
physical therapy services: Conditions, to show the various caps since
before 1982 through 1994 for physical therapy services furnished by
independent physical therapists. There is currently no corresponding
regulation section for occupational therapy but we will include the
$900 cap when we publish final regulations on those services.
X. Rural Health Clinics and Federally Qualified Health Centers
A. Legislative Provision
Under section 1861(aa) of the Act, Medicare pays for services
furnished in certain qualified health centers that are known as
Federally qualified health centers (FQHCs). Each center is: An entity
that is receiving a grant under section 329, 330, or 340 of the Public
Health Service Act or is under contract with the recipient of a grant
under section 329, 330, or 340 of the Public Health Service Act and
meets the requirements for receiving such a grant; or is determined,
based on the recommendations of the Health Resources and Services
Administration within the Public Health Service, to meet the
requirements for meeting such a grant; or was treated by the Secretary
as a comprehensive Federally funded health center as of January 1,
1990. Section 13556 of OBRA 93 amended section 1861(aa)(4) of the Act
to include as FQHCs outpatient programs and facilities operated by
Indian tribes or tribal organizations under the Indian Self-
Determination Act (25 U.S.C. 450). The amendment took effect as if
included in the enactment of section 4161(a)(2)(C) of OBRA 90, which
was effective October 1, 1991. Section 13556 of OBRA 93 also provides
that an outpatient health program or facility operated by an urban
Indian organization receiving funds under Title V of the Indian Health
Care Improvement Act (25 U.S.C. 1601ff) is included in the Medicare
program, effective October 1, 1991.
B. Regulations Revision
We are adding a new paragraph to the definition of Federally
qualified health centers in Sec. 405.2401(b) to include outpatient
health programs and facilities operated by Indian tribes under the
Indian Self-Determination Act or by urban Indian organizations under
title V of the Indian Health Care Improvement Act.
XI. Reduction in Payments for Epoetin
A. Legislation
Medicare is the principle purchaser of epoetin (EPO), an anti-
anemia drug used by dialysis patients with a specified level of anemia.
Section 1881(b)(11)(B) of the Act provides that payments to ESRD
facilities are made based on increments of 1,000 unit doses, rounded to
the nearest 100 units, with a maximum payment of $11 per 1,000 units.
Under section 1861(s)(2)(P) of the Act, Medicare considers as a medical
or other health service EPO for home dialysis patients competent to use
the drug in the home without medical or other supervision, subject to
methods and standards established by the Secretary by regulation for
the safe and effective use of the drug, and items related to the use of
the drug.
Section 13566 of OBRA 93 decreased the maximum payment for EPO to
$10 per 1,000 units. OBRA 93 also amended section 1861(s)(2)(P) to
remove the word ``home'' from ``home dialysis patients'', the effect of
which is to allow coverage of EPO when used at home by dialysis
patients who do not dialyze at home. The effective date of section
13566 of OBRA is January 1, 1994.
B. Regulations Revision
The change in payment rate requires no revision to regulations
because we announce the rate in a notice published in the Federal
Register rather than in regulations. To implement the provision
allowing dialysis patients who do not dialyze at home to use EPO in the
home, we are revising Secs. 405.2137, 405.2163, 410.10(k), and 410.52
to show the effective dates of the various sections for use of EPO at
home by patients who do not dialyze at home.
XII. Part B Premium
A. Legislative Provision
Section 1839(e) of the Act establishes the amount of the Medicare
Part B premium at 50 percent of the monthly actuarial rate for
enrollees age 65 and over for months in calendar years 1984 through
1990; section 4301 of the Omnibus Budget Reconciliation Act of 1990
added specific premiums for 1991 through 1995 based on Congressional
Budget Office estimates, at the time, of premium amounts that would
equal 50 percent of that actuarial rate. Section 13571 of OBRA 93
amended section 1839(e) of the Act to again have the premium determined
annually so that it equals 50 percent of the monthly actuarial rate for
enrollees age 65 and over for calendar years 1996, 1997 and 1998.
B. Regulations Revisions
To reflect OBRA 90 and 93 we are revising 42 CFR 408.20, Monthly
premiums, by adding calendar years 1991 through 1995, and calendar
years after 1998, to the heading and content of paragraph (b), which
currently contains the methodology for the period July 1976 through
December 1983 and the periods after 1990. We are specifying that the
rates cited in section 1839(e)(1)(B) of the Act apply to 1991 through
1995. To reflect OBRA 93, we are adding calendar years 1996 through
1998 to the heading and content of paragraph (c), which currently
discusses the methodology for determining premiums for calendar years
1984 through 1990.
XIII. Waiver of Proposed Rulemaking
We ordinarily publish a notice of proposed rulemaking for a
regulation in the Federal Register and provide a period for public
comment. However, we may waive that procedure if we find good cause
that prior notice and comment are impracticable, unnecessary, or
contrary to the public interest.
As noted earlier, this rule updates our rules to properly reflect
explicit statutory requirements that are clear on their face and that
we are not interpreting in any way beyond their commonly understood
meanings. Without these changes, certain regulation requirements are in
conflict with the statute, possibly misleading those who rely on our
regulations. In addition, some of the statutory changes included in
these regulations have been enacted with retroactive effective dates or
effective dates close to the date of enactment of OBRA 93. Under these
circumstances, prompt publication of the correct up-to-date rules best
serves those governed by these regulations. Because this rule does not
create any legal requirements and because publishing a notice of
proposed rulemaking here would perpetuate conflicts between clear
statutory directives and our regulations, we find that publishing a
notice of proposed rulemaking before issuing this final rule would be
unnecessary and contrary to the public interest. However, we are
providing a 60-day comment period for public comments on the final rule
as indicated at the beginning of this rule.
XIV. Response to Comments
Because of the large number of items of correspondence we normally
receive on FR 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 comments in the preamble to that document.
XV. 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 final rule will not
have a significant economic impact on a substantial number of small
entities. For purposes of the RFA, all Medicare-participating
facilities are considered to be small entities. Individuals and States
are not included in the definition of small entity.
Also, section 1102(b) of the Act requires the Secretary to prepare
a regulatory impact analysis if a final rule will 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
Metropolitan Statistical Area and has fewer than 50 beds.
This final rule with comment period updates our regulations to
incorporate numerous self-implementing statutory provisions that are
not interrelated. None of the regulations interprets or extends
requirements beyond those included in the self-implementing
legislation.
The amendments to which this rule pertains are already in effect or
will go into effect independent of the publication of this rule.
Consequently, there are no actions to be taken that would flow from
further analyses of the impact of these provisions on entities.
Therefore, 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 E.O. 12866, this final rule
with comment period was not reviewed by the Office of Management and
Budget.
XVI. 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 1980 (44 U.S.C. 3501 et seq.).
List of Subjects
42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
42 CFR Part 406
Health facilities, Kidney diseases, Medicare.
42 CFR Part 408
Medicare.
42 CFR Part 410
Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Rural areas, X-rays.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and
recordkeeping requirements.
42 CFR chapter IV is amended as follows:
A. Part 405 is amended as follows:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
1. Part 405, subpart U is amended to read as follows:
Subpart U--Conditions for Coverage of Suppliers of End-Stage Renal
Disease (ESRD) Services
a. The authority citation for part 405, subpart U continues to read
as follow:
Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, and 1881 of
the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 1395hh,
1395kk, and 1395rr), unless otherwise noted.
b. In Sec. 405.2137, the introductory statement of paragraph (b)(7)
is revised to read as follows:
Sec. 405.2137 Condition: Patient long-term program and patient care
plan.
* * * * *
(b) Standard: Patient care plan. * * *
(7) Beginning July 1, 1991, for a home dialysis patient, and
beginning January 1, 1994, for any dialysis patient, who uses EPO in
the home, the plan must provide for monitoring home use of EPO that
includes the following:
* * * * *
c. In Sec. 405.2163, introductory paragraphs (g) and (g)(2) are
republished and paragraph (g)(2)(i) is revised to read as follows:
Sec. 405.2163 Condition: Minimal service requirements for a renal
dialysis facility or renal dialysis center.
* * * * *
(g) Use of EPO at home: Patient selection. The dialysis facility,
or the physician responsible for all dialysis-related services
furnished to the patient, must make a comprehensive assessment that
includes the following:
* * * * *
(2) Conditions the patient must meet. The assessment must find that
the patient meets the following conditions:
(i) On or after July 1, 1991, is a home dialysis patient or, on or
after January 1, 1994, is a dialysis patient;
* * * * *
2. Part 405, subpart X is amended as follows:
Subpart X--Rural Health Clinic and Federally Qualified Health
Center Services
a. The authority citation for subpart X is revised to read as
follows:
Authority: Sec. 1102, 1833, 1861(aa), 1871 of the Social
Security Act; 42 U.S.C. 1302, 13951, 1395x(aa), and 1395hh.
b. In the definition of ``Federally qualified health center'' in
Sec. 405.2401(b), the introductory paragraph, and paragraphs (2) and
(3) are revised and a new paragraph (4) is added to read as follows:
Sec. 405.2401 Scope and definitions.
* * * * *
Federally qualified health center (FQHC) means an entity that has
entered into an agreement with HCFA to meet Medicare program
requirements under Secs. 405.2434 and--
* * * * *
(2) Based on the recommendation of the PHS, is determined by HCFA
to meet the requirements for receiving such a grant;
(3) Was treated by HCFA, for purposes of part B, as a comprehensive
federally funded health center (FFHC) as of January 1, 1990; or
(4) Is an outpatient health program or facility operated by a tribe
or tribal organizations under the Indian Self-Determination Act or by
an Urban Indian organization receiving funds under title V of the
Indian Health Care Improvement Act.
B. Part 406 is amended as follows:
PART 406--HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT
1. The authority citation for part 406 is revised to read as
follows:
Authority: Secs. 202(t), 202(u) 226, 226A, 1102, 1818 and 1871
of the Social Security Act (42 U.S.C. 402(t), 402(u), 426, 426-1,
1302, 1395i-2, and 1395hh) and sec. 3103 of Pub. L. 89-97 (42 U.S.C.
426a), unless otherwise noted.
2. In Sec. 406.32, paragraph (b)(3) is redesignated as (b)(4) and
paragraphs (c) through (f) are redesignated as paragraphs (d) through
(g), respectively. New paragraphs (b)(3) and (c) are added and
redesignated paragraph (b)(4) is revised to read as follows:
Sec. 406.32 Monthly premiums.
* * * * *
(b) Monthly premiums: Determination of dollar amount.
* * * * *
(3) Effective for months beginning January 1994, if an individual
meets the requirements in paragraph (c) of this section, the monthly
premium determined under paragraph (b)(1) of this section is reduced in
each month in which the individual meets the requirements by 25 percent
in 1994, 30 percent in 1995, 35 percent in 1996, 40 percent in 1997 and
45 percent in 1998 and thereafter.
(4) The amount determined under paragraphs (b) (1), (2), or (3) of
this section is rounded to the next nearest multiple of $1. (Fifty
cents is rounded to the next higher dollar.)
(c) Qualifying for a reduction in monthly premium. An individual
who qualifies for the reduction described in paragraph (b)(3) of this
section must be an individual who--
(1) Has 30 or more quarters of coverage (QCs) as defined in 20 CFR
404.140 through 404.146;
(2) Has been married for at least the previous one year period to a
worker who has 30 or more QCs;
(3) Had been married to a worker who had 30 or more QCs for a
period of at least one year before the death of the worker;
(4) Is divorced from, after at least 10 years of marriage to, a
worker who had 30 or more QCs at the time the divorce became final; or
(5) Is divorced from, after at least 10 years of marriage to, a
worker who subsequently died and who had 30 or more QCs at the time the
divorce became final.
* * * * *
C. Part 408 is amended as follows:
PART 408--PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE
1. The authority citation for part 408 continues to read as
follows:
Authority: Secs. 1102, 1818, 1837-1840, 1843, 1871, and 1881(d)
of the Social Security Act (42 U.S.C. 1302, 1395i-2, 1395p-1395s,
1395v, 1395hh and 1395rr(d)) and the Federal Claims Collection Act
(31 U.S.C. 3711).
2. In Sec. 408.20, the headings of paragraphs (b) and (c),
introductory paragraphs (b)(1) and (c), and paragraph (b)(2) are
revised and new paragraph (b)(3) is added to read as follows:
Sec. 408.20 Monthly premiums.
* * * * *
(b) Criteria and procedures for the period from July 1976 through
December 1983, the period from January 1991 through December 1995, and
for periods after December 1998. (1) For periods from July 1976 through
December 1983 and after December 1998, the Secretary determines and
promulgates as the standard monthly premium (for disabled as well as
aged enrollees) the lower of the following:
* * * * *
(2) For periods after December 1998, the Secretary determines the
standard monthly premium in the manner specified in paragraph (b)(1) of
this section, but promulgates it in September for the following
calendar year.
(3) The premiums for calendar years 1991 through 1995 are those
amounts as specified by section 1839(e)(1)(B) of the Act as follows:
(i) In 1991, $29.90;
(ii) In 1992, $31.80;
(iii) In 1993, $36.60;
(iv) In 1994, $41.10; and
(v) In 1995, $46.10.
(c) Premiums for calendar years 1984 through 1990 and 1996 through
1998. For calendar years 1984 through 1990 and 1996 through 1998, the
standard monthly premium for all enrollees--
* * * * *
D. Part 410 is amended as follows:
PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
1. The authority citation for part 410 is revised to read as
follows:
Authority: Secs. 1102, 1832, 1833, 1834, 1835, 1861 (r), (s),
(aa), (cc), and (mm), 1871 and 1881 of the Social Security Act (42
U.S.C. 1302, 1395k, 1395l, 1395m, 1395n, 1395x (r), (s), (aa), (cc),
and (mm), 1395hh, and 1395rr).
2. In Sec. 410.10, the introductory paragraph is republished and
paragraph (k) is revised to read as follows:
Sec. 410.10 Medical and other health services: Included services.
Subject to the conditions and limitations specified in this
subpart, ``medical and other health services'' includes the following
services:
* * * * *
(k) Home dialysis supplies and equipment; on or after July 1, 1991,
epoetin (EPO) for home dialysis patients, and, on or after January 1,
1994, for dialysis patients, competent to use the drug; self-care home
dialysis support services; and institutional dialysis services and
supplies.
* * * * *
3. In Sec. 410.52(a), the introductory paragraph is republished and
paragraph (a)(4) is revised to read as follows:
Sec. 410.52 Home dialysis services, supplies and equipment: Scope and
conditions.
(a) Medicare Part B pays for the following services, supplies, and
equipment furnished to an ESRD patient in his or her home:
* * * * *
(4) On or after July 1, 1991, epoetin (EPO) for use at home by a
home dialysis patient and, on or after January 1, 1994, by a dialysis
patient, if it has been determined, in accordance with Sec. 405.2163 of
this chapter, that the patient is competent to use the drug safely and
effectively.
* * * * *
4. In Sec. 410.60, the heading of paragraph (c) is republished,
paragraph (c)(2) is revised to read as follows and footnote 2 is
deleted:
Sec. 410.60 Outpatient physical therapy services: Conditions.
* * * * *
(c) Special provisions for services furnished by physical
therapists in independent practice.
* * * * *
(2) Limitation on incurred expenses. (i) Before 1982, not more than
$100 of reasonable charges incurred in a calendar year are recognized
as incurred expenses.
(ii) From 1982 through 1989, not more than $500 of reasonable
charges incurred in a calendar year are recognized as incurred
expenses.
(iii) From 1990 through 1993, not more than $750 of reasonable
charges incurred in a calendar year are recognized as incurred
expenses.
(iv) After 1993, not more than $900 of reasonable charges incurred
in a calendar year are recognized as incurred expenses.
E. Part 413 is amended as follows:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES
1. The authority citation for part 413 continues to read as
follows:
Authority: Secs. 1102, 1122, 1814(b), 1815, 1833(a), 1861(v),
1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C.
1302, 1320a-1, 1395f(b), 1395g, 13951(a), 1395x(v), 1395hh, 1395rr,
and 1395ww).
2. Section 413.124(a) is revised to read as follows:
Sec. 413.124 Reduction to hospital outpatient operating costs.
(a) Except for sole community hospitals, as defined in Sec. 412.92,
and rural primary care hospitals, the reasonable costs of outpatient
hospital services (other than capital-related costs of such services)
are reduced by 5.8 percent for services rendered during portions of
cost reporting periods occurring on or after October 1, 1990 and before
October 1, 1998.
* * * * *
3. In Sec. 413.130 the introductory paragraph of paragraph (j) is
republished and paragraph (j)(l)(ii) is revised to read as follows:
Sec. 413.130 Introduction to capital-related costs.
* * * * *
(j) Reduction to capital-related costs. (1) Except for sole
community hospitals and rural primary care hospitals, the amount of
capital-related costs of all hospital outpatient services is reduced
by--
(i) * * *
(ii) 10 percent for portions of cost reporting periods occurring on
or after October 1, 1991 through September 30, 1998.
* * * * *
4. Section 413.157(b)(3) is revised to read as follows:
Sec. 413.157 Return on equity capital of proprietary providers.
* * * * *
(b) General rule.
* * * * *
(3) Rate of return related to proprietary SNFs. (i) For cost
reporting periods beginning on or after October 1, 1985, the rate used
in determining the return for SNF services furnished before October 1,
1993 is a percentage equal to the average of the rates of interest
described in paragraph (b)(1) of this section.
(ii) There is no allowance for return for SNF services furnished on
or after October 1, 1993.
F. Part 418 is amended as follows:
PART 418--HOSPICE CARE
1. The authority citation for part 418 is revised to read as
follows:
Authority: Secs. 1102, 1812(a)(4) and (d), 1813(a)(4),
1814(a)(7) and (i), 1816(e)(5), 1861(dd) and 1871 of the Social
Security Act (42 U.S.C. 1302, 1395d(a)(4) and (d), 1395e(a)(4),
1395f(a)(7) and (i), 1395h(e)(5), 1395x(dd), and 1395hh); and sec.
353 of the Public Health Service Act (42 U.S.C. 263a).
2. In Sec. 418.306(b), the introductory language is republished,
paragraph (b)(2) is revised and a new paragraph (b)(3) is added to read
as follows:
Sec. 418.306 Determination of payment rates.
* * * * *
(b) Payment rates. The payment rates for routine home care and
other services included in hospice care are as follows:
* * * * *
(2) Except for the period beginning October 21, 1990 through
December 31, 1990, the payment rates for routine home care and other
services included in hospice care for Federal fiscal years 1991, 1992,
and 1993 and those that begin on or after October 1, 1997, are the
payment rates in effect under this paragraph during the previous fiscal
year increased by the market basket percentage increase as defined in
section 1886(b)(3)(B)(iii) of the Act, otherwise applicable to
discharges occurring in the fiscal year. The payment rates for the
period beginning October 21, 1990 through December 31, 1990 are the
same as those shown in paragraph (b)(1) of this section.
(3) For Federal fiscal years 1994 through 1997, the payment rate is
the payment rate in effect during the previous fiscal year increased by
a factor equal to the market basket percentage increase minus--
(i) 2 percentage points in FY 1994;
(ii) 1.5 percentage points in FYs 1995 and 1996; and
(iii) 0.5 percentage points in FY 1997.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: February 15, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: April 7, 1994.
Donna E. Shalala,
Secretary.
[FR Doc. 94-12461 Filed 5-24-94; 8:45 am]
BILLING CODE 4120-01-P