[Federal Register Volume 59, Number 109 (Wednesday, June 8, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-13506]


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[Federal Register: June 8, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Part 413

[BPD-409-P]
RIN 0938-AD02

 

Medicare Program; Optional Payment System for Low Medicare Volume 
Skilled Nursing Facilities

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

ACTION: Proposed rule.

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SUMMARY: This proposed rule would implement section 9126 of the 
Consolidated Omnibus Budget Reconciliation Act of 1985 by allowing 
skilled nursing facilities (SNFs) that provide fewer than 1,500 days of 
care to Medicare beneficiaries in a cost reporting period to have the 
option of receiving prospectively determined payment rates in the 
following cost reporting period. The prospectively determined payment 
rates would be based on components of SNF costs such as routine 
operating costs, capital-related costs, and a return on equity for 
proprietary facilities for routine services furnished before October 1, 
1993. This proposed rule would also specify, as required by section 
13503(c) of the Omnibus Budget Reconciliation Act of 1993, that the 
return on equity provision for proprietary SNFs is eliminated for 
services furnished on or after October 1, 1993.

DATES: Comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on August 
8, 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-409-P, P.O. Box 7517, 
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-409-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).
    For comments that relate to information collection requirements, 
mail a copy of comments to: Allison Herron Eydt, HCFA Desk Officer, 
Office of Information and Regulatory Affairs, Room 3001, New Executive 
Office Building, Washington, DC 20503.
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
Documents, 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) 275-
6802. The cost for each copy is $4.50. As an alternative, you can view 
and photocopy the Federal Register document at most libraries 
designated as Federal Depository Libraries and at many other public and 
academic libraries throughout the country that receive the Federal 
Register.

FOR FURTHER INFORMATION CONTACT:

David Goldberg--Simplified Cost Reporting (410) 966-4517
Robert Kuhl--All Other Issues (410) 966-4597

SUPPLEMENTARY INFORMATION:

I. Background

A. Payment on a Reasonable Cost Basis

    Skilled nursing facilities (SNFs) are paid on the basis of 
reasonable cost as defined by section 1861(v)(1) of the Social Security 
Act (the Act). Under this section, the Secretary is also authorized to 
establish limits on the allowable costs incurred by providers of health 
care services, such as SNFs, in furnishing care to Medicare 
beneficiaries. The limits are based on estimates of the costs necessary 
for the efficient delivery of needed health services. Implementing 
regulations appear at 42 CFR 413.30.
    Sections 1861(v)(1)(A), (v)(1)(E), (v)(7), and 1888 of the Act 
provide authority for the payment of routine service costs to SNFs. 
Section 1888 of the Act provides for the following:
     Separate cost limits for hospital-based and freestanding 
SNFs.
     Cost limits for freestanding SNFs are to be set at 112 
percent of the mean inpatient routine service costs for freestanding 
SNFs in urban and rural areas respectively.
      Cost limits for hospital-based SNFs are to be set at the 
freestanding limit plus 50 percent of the difference between 112 
percent of mean per diem hospital-based inpatient routine service costs 
for urban and rural SNFs, respectively, and the freestanding limit.
     For cost reporting periods beginning before October 1, 
1993, cost differences between hospital-based and freestanding SNFs 
attributable to excess overhead allocations resulting from Medicare 
payment principles are recognized as an add-on to the cost limit for 
hospital-based SNFs, as determined by the Secretary. Section 
13503(a)(3) of the Omnibus Budget Reconciliation Act of 1993 (Pub. L. 
103-66) eliminated this add-on for cost reporting periods beginning on 
or after October 1, 1993.

B. Legislation

    On April 7, 1986, the Consolidated Omnibus Budget Reconciliation 
Act of 1985 (Pub. L. 99-272) was enacted. Section 9126(a) of Public Law 
99-272 added a new section (d) to section 1888 of the Act to require 
the establishment of prospectively determined payment rates for routine 
services furnished by certain SNFs. (Technical changes to section 
1888(d) of the Act were subsequently made in sections 1895(b)(7)(A) and 
(b)(7)(B) of the Tax Reform Act of 1986 (Pub. L. 99-514).)
    In response to a strong interest by Congress in beneficiary access 
to SNF care, HCFA conducted a study of SNF payment on a reasonable cost 
basis. The first results of this study were reported to Congress in 
1985 (See Health Care Financing Review, Fall 1986, Vol. 8, No. 1). This 
study showed that it was widely believed that the current payment 
system contributed to the limited access to care and that the reporting 
burden involved plus the time delay in determining exact payment 
amounts inherent in this system due to retrospective payment 
adjustments may have discouraged facilities that would have had a low 
Medicare patient load from furnishing services to Medicare 
beneficiaries. A change was needed to increase beneficiary access to 
SNF services by easing the reporting burden for low volume SNFs. In 
enacting section 9126(a) of Public Law 99-272, Congress made this 
change possible.
    Section 1888(d) of the Act provides that the prospectively 
determined payment rate is optional for the eligible SNFs, and it is to 
be determined on a per diem basis for the cost of furnishing inpatient 
routine services and associated capital-related costs. As specified in 
the Conference Committee Report accompanying Public Law 99-272 (H.R. 
Rep. No. 453, 99th Cong., 2nd Sess. 480 (1985)), the rates paid to 
proprietary SNFs were to include a component for return on equity 
related to routine service costs.
    The specific provisions of section 9126 of Public Law 99-272 are as 
follows:
 Requirements for Eligibility To Receive SNF Prospectively 
Determined Payment Rate: Maximum Medicare Inpatient Days
    Under section 1888(d)(1) of the Act, SNFs that had fewer than 1,500 
Medicare inpatient days in one cost reporting period have the option of 
being paid on the basis of a prospectively determined payment rate in 
the following cost reporting period.
 Determining the Amount of Payment for Routine Services
    Section 1888(d)(2) of the Act requires that the amount of payment 
under the SNF prospectively determined payment rate system be 
determined on a per diem basis. However, it may not exceed the limit on 
routine service costs set forth in section 1888(a) of the Act with 
respect to the facility, adjusted to take into account average capital-
related costs with respect to the type and location of the facility. 
The limit used for this purpose is the applicable routine service cost 
limit in effect when the provider elects to be paid a prospectively 
determined payment rate.
    For SNFs located in an urban area, the prospectively determined 
payment amount is equal to 105 percent of the mean of the per diem 
reasonable routine service and routine capital-related costs of 
services for SNFs in urban areas within the same census region. The 
mean per diem is determined without regard to the limitations of 
section 1888(a) of the Act and is adjusted for different area wage 
levels.
    For SNFs located in a rural area, the prospectively determined 
payment amount is equal to 105 percent of the mean of the per diem 
reasonable routine service and routine capital-related costs of covered 
services for SNFs in rural areas within the same census region. The 
mean per diem is determined without regard to the limitations of 
section 1888(a) of the Act and is adjusted for different area wage 
levels.
 Determining Area Prospectively Determined Payment Rates
    Section 1888(d)(3) of the Act requires that, for purposes of 
determining SNF prospectively determined payment rates, urban and rural 
areas be determined in the same manner as for purposes of section 
1888(a) of the Act (that is, the provisions governing the SNF cost 
limits). It further requires that the term ``region'' have the same 
meaning as that under section 1886(d)(2)(D) of the Act. That section 
defines ``region'' for purposes of the inpatient hospital prospective 
payment system as one of the nine census divisions, comprising the 50 
States and the District of Columbia, that are established by the Bureau 
of the Census for statistical and reporting purposes. Since rates must 
be determined on a regional basis, eligibility is limited to SNFs 
within the areas for which rates are available.
 Notification Required
    Under section 1888(d)(4) of the Act, the Secretary is required to 
establish the prospectively determined payment rates for each Federal 
fiscal year, at least 90 days prior to the beginning of that fiscal 
year. The law also requires an SNF to notify the Secretary of its 
intention to be paid a prospectively determined payment rate no later 
than 30 days before the beginning of the cost reporting period for 
which the request is made.
 Cost Report Simplification
    Under section 1888(d)(5) of the Act, the Secretary is required to 
provide for a simplified cost report to be filed by SNFs being paid 
under prospectively determined payment rates. This cost report must 
require only the cost information necessary for determining 
prospectively determined payment rates in accordance with section 
1888(d)(2) of the Act and reasonable costs of ancillary services.
 Payment for Ancillary Services
    Section 1888(d)(6) of the Act provides that, in the case of an SNF 
receiving prospectively determined payment rates, the Secretary may pay 
for ancillary services on a reasonable charge basis, rather than on a 
cost basis, if the Secretary determines that a reasonable charge basis 
provides an equitable level of payment and eases the SNF's reporting 
burden.
 Costs of Implementing Nursing Home Reform Provisions
    Section 1888(d)(7) of the Act requires that the computation of the 
rates of payment take into account the additional costs of implementing 
nursing home reform provisions (including the costs of conducting nurse 
aide training and competency evaluation programs). In the manual 
issuances effective on or after October 1, 1989, we have allowed for an 
adjustment to the prospectively determined payment rates to account for 
these additional costs. However, this adjustment is necessary only if 
the cost data used to develop the prospectively determined payment 
rates were compiled from cost reporting periods that began prior to 
October 1, 1990, the effective date of the nursing home reform 
provisions. In the future, when later cost report data reflect these 
additional costs, the resulting prospectively determined payment rates 
will automatically include these costs and an adjustment will not be 
necessary. Therefore, we believe that it is not necessary to implement 
this provision in the proposed regulations.
    In addition, section 9311(a) of the Omnibus Budget Reconciliation 
Act of 1986 (Pub. L. 99-509), which was enacted on October 21, 1986, 
amended section 1815 of the Act to identify situations in which we are 
to provide (or continue to provide) payment on a periodic interim 
basis. Section 1815(e)(2)(C) of the Act specifically directs that 
periodic interim payments be made available to facilities furnishing 
extended care services, including facilities being paid on a reasonable 
cost basis as well as those being paid prospectively determined payment 
rates.
    Section 1815(e)(2) of the Act provides that periodic interim 
payments be made under the standards established under Sec. 405.454(j) 
of the regulations (now redesignated as Sec. 413.64(h); see 51 FR 
34790, September 30, 1986). Section 413.64(h)(2) sets forth the 
requirements that providers of health care services (such as SNFs) must 
meet in order to qualify for periodic interim payments. The 
requirements concern the level of a provider's estimated annual 
Medicare payment, whether a Medicare cost report has been filed, and 
recordkeeping and financial matters.
    While SNFs that elect prospectively determined payment rates may 
qualify for periodic interim payments, we note that electing a bill-by-
bill payment method has the advantage of providing a payment amount for 
routine services under prospectively determined payment rates that 
would not create the need for retroactive payment adjustments. Such 
adjustments would be necessary under the periodic interim payment 
method and are the source of some criticism under payment on a 
reasonable cost basis.
    On August 10, 1993, Public Law 103-66 was enacted. Section 13503(c) 
of Public Law 103-66 amended section 1861(v)(1)(B) of the Act to 
eliminate the provision for payment for a return on equity for services 
furnished by proprietary SNFs on or after October 1, 1993. Also, we 
note that section 13503(b) states that the Secretary may not change the 
amount of any prospectively determined payment rate paid to a SNF under 
section 1888(d) of the Act for services furnished during cost reporting 
periods beginning during FYs 1994 and 1995, except as necessary to take 
into account the elimination of the return on equity provision.

C. Manual Issuance

    As noted above, section 1888(d) of the Act, as enacted by section 
9126(a) of Public Law 99-272, provides for the optional prospectively 
determined payment rate system for SNF routine services. In order to 
provide the public with information on the rates as soon as possible 
and to implement the prospectively determined rates, we issued sections 
2820 through 2822 of Chapter 28 of the Provider Reimbursement Manual 
(HCFA Pub. 15-1) in August 1986.
    In the manual transmittal, we provided guidelines for implementing 
per diem prospectively determined payment rates for SNF routine 
services. The rates were effective for cost reporting periods beginning 
on or after October 1, 1986, but before October 1, 1987. Additional 
transmittals were issued providing rates for subsequent cost reporting 
periods. The provisions of Chapter 28 of the Provider Reimbursement 
Manual closely adhere to the requirements of section 1888(d) of the 
Act, as described below. In calculating the prospectively determined 
payment rates announced in the manual transmittals, we used the most 
recent data available at that time.
    The provisions of Chapter 28 of the Provider Reimbursement Manual 
are as follows:
 Eligibility Criteria
    We stipulated the statutory criterion that an SNF may choose to be 
paid under the prospectively determined payment rate option for general 
inpatient routine services if the facility had, in its immediately 
preceding cost reporting period, fewer than 1,500 Medicare patient 
days.
 Classification Criteria
    For prospectively determined payment rate purposes, we grouped SNFs 
by census region, and by urban area or rural area designation within 
the region. As required by section 1888(d)(3) of the Act and as stated 
above, the term ``region'' means one of the nine census divisions, 
comprising the fifty States and the District of Columbia. The term 
``urban area'' means an area within a Metropolitan Statistical Area 
(MSA) (as defined by the Office of Management and Budget (OMB)). The 
term ``rural area'' means any area outside an urban area.
 Adjustment of SNF Cost Data by Wage Index
    We adjust the labor portion of the prospectively determined payment 
rate to account for area wage differences through the application of an 
appropriate wage index.
    The labor-related costs are those costs in the market basket that 
change with local wage variations. This method of adjusting labor-
related costs is the same as that used in implementing the current SNF 
limits. The wage index values are the same as those used to compute the 
SNF limits in effect for the same period as the prospectively 
determined payment rates.
 Use of SNF Market Basket Index
    We based the prospectively determined payment rate on reported 
costs, adjusted for actual and projected cost increases by applying the 
SNF market basket index. The methodology of applying this index is the 
same as that described in our October 7, 1992 notice of SNF limits (57 
FR 46177). Capital costs are not adjusted for inflation because 
depreciation is fixed on a straight line basis, capital-related 
interest is long term fixed rate debt and, where appropriate, return on 
equity can fluctuate from year to year. We cannot predict the amount or 
direction of fluctuations in equity.
 Ancillary Services
    For SNFs electing to receive payment under prospectively determined 
payment rates, ancillary services are paid on the basis of reasonable 
cost with retroactive adjustment based on an annual cost report.

II. Discussion of Proposed Regulations

    We stated in the original manual transmittal discussed above that 
we planned to pursue rulemaking to establish a framework in regulations 
for payment to SNFs under prospectively determined payment rates. 
Below, we describe proposed regulations that would be effective for 
revising the prospectively determined payment rates for the Federal 
fiscal year that begins at least 30 days after the publication of a 
final rule. In the interim, we will continue to update the 
prospectively determined payment rates through Chapter 28 of the 
Provider Reimbursement Manual.
    We are proposing to add a new Subpart I, Optional Prospectively 
Determined Payment Rates for Certain Skilled Nursing Facilities, to 42 
CFR part 413. This new subpart would set forth regulations that are 
consistent with the statutory changes to section 1888 of the Act made 
by provisions in Public Laws 99-272, 99-514, and 103-66.

A. General Provisions

    We are proposing to add new Sec. 413.300 to introduce the contents 
of Subpart I. This section would broadly list the conditions and 
procedures for making prospectively determined payments to qualifying 
SNFs. In new Sec. 413.302, we would provide definitions of the terms 
``area wage level'', ``census region'', ``routine operating costs'', 
``routine capital-related costs'', and ``urban'' and ``rural'' areas as 
described above.

B. Eligibility Criteria

    We are proposing to add new Sec. 413.304 to describe the 
eligibility criteria specified in section 1888(d)(1) of the Act. SNFs 
that furnished fewer than 1,500 Medicare covered inpatient days in a 
cost reporting period as reported on the Medicare cost report would be 
allowed the option of being paid on the basis of prospectively 
determined payment rates during the next cost reporting period. If an 
SNF's preceding Medicare cost reporting period was shorter than a full 
calendar year, it must have had an average daily Medicare census (that 
is, the total Medicare inpatient days divided by the total number of 
inpatient days) for the period of not greater than 4.1 to qualify for 
prospectively determined payment. This figure was determined by 
dividing 1,499 (that is, the largest number of Medicare inpatient days 
fewer than 1,500) by the number of days in a calendar year. If there is 
no preceding cost reporting period for which an SNF was approved for 
Medicare participation, we propose that the SNF would automatically 
qualify for prospectively determined payment.

C. Approval Process

    In the new Sec. 413.308, we would establish rules to govern the 
process by which SNFs may request and be approved for payment under the 
prospectively determined payment rate option. Under section 1888(d) of 
the Act, we are required to establish the prospectively determined 
payment rates at least 90 days prior to the beginning of each Federal 
fiscal year (that is, by July 1 of each year). An SNF may request to 
receive prospectively determined payments by notifying its fiscal 
intermediary of its intention at least 30 days prior to the beginning 
of the cost reporting period for which the request is made. The 
intermediary would notify the SNF as to whether the SNF qualifies for 
the option.
    In most cases, a final count of Medicare inpatient days cannot be 
made for a cost reporting period prior to the beginning of the next 
cost reporting period. Therefore, the intermediary's initial 
determination of provider eligibility would be a tentative approval or 
disapproval. The final determination would be made once a count of the 
total Medicare inpatient days in the preceding cost reporting period is 
available. We would provide that the intermediary notify the SNF of the 
final determination within 10 working days after the data necessary to 
make the determination are available. If tentative approval was given 
and the final determination is that the SNF does not qualify to be paid 
on the basis of a prospectively determined payment rate, the 
intermediary will adjust payments to reflect payment on a reasonable 
cost basis.
    For a newly certified SNF with no preceding cost reporting period, 
the election must be made within 30 days of its notification of 
approval to participate in Medicare.
    The election by the SNF and any approval by the intermediary would 
be effective for only one cost reporting period at a time. We would 
also specify that once an election has been made and approved and the 
cost reporting period has begun, the SNF may not revoke its election 
for that period. Each SNF electing to receive a prospectively 
determined payment rate would agree to accept that rate prior to the 
start of the cost reporting period, regardless of what its final costs 
for the period would be. Under this proposed rule, the provider has 
traded the opportunity for any retroactive adjustments for the 
opportunity to operate at a profit and the foreknowledge of a specified 
rate. To allow a provider to reverse its election would entirely defeat 
the purpose and the philosophy of a prospectively determined payment 
program.

D. Basis of Payment

    We propose to add new Sec. 413.310 to set forth the basis of 
payment to be used for routine service costs, capital-related costs, 
and return on equity (for services furnished before October 1, 1993), 
as well as for ancillary service costs, as specified in sections 1888 
(d)(2) and (d)(6) of the Act. We would specify the following:
     Prospectively determined payment is in lieu of payment on 
a reasonable cost basis for routine services.
     The routine operating component of the prospectively 
determined payment rate excluding capital cost, and excluding return on 
equity (if applicable) may not exceed the amount of the provider's 
routine service cost limit determined under Sec. 413.30 that is in 
effect when the provider elects to be paid a prospectively determined 
payment rate.

E. Methodology for Calculating Rates

    We are proposing to add new Sec. 413.312 to establish the 
methodology for determining the prospectively determined payment rates 
as specified in sections 1888 (d)(2) and (d)(6) of the Act. Under these 
sections of the Act, mean per diem routine operating costs, capital-
related costs, and, for proprietary SNFs, return on equity for services 
furnished before October 1, 1993, are determined separately for SNFs 
located in urban areas and those in rural areas for the nine census 
regions. To reflect those statutory provisions, the basic methodology 
discussed below would be established in regulations. This methodology 
would be used to establish the prospectively determined payment rates 
each year. The rates would be published in the Federal Register as 
described in Sec. 413.320. Amendments to the regulations would be 
proposed to implement changes to the basic methodology described in 
Secs. 413.312 through 413.314.
    The capital-related portion of the per diem rate would be 
calculated from the SNF's capital costs as reported on the Medicare 
cost report. The capital-related portion includes both direct and 
indirect capital costs allocated to routine services. A per diem 
capital amount would be determined by dividing each SNF's capital-
related costs by its inpatient days. A group mean would be computed and 
the mean multiplied by 105 percent.
    For services furnished before October 1, 1993, the return on equity 
portion of the per diem rate would be calculated using the return on 
equity from each proprietary SNF's cost report. The current allowable 
return on equity is equal to 100 percent of the average rate of 
interest of public debt obligations issued by the Federal Hospital 
Insurance Trust Fund. For cost reporting periods beginning prior to 
October 1, 1985, the allowable return on equity was equal to 150 
percent of the average rate. Therefore, the return on equity data from 
cost reports for periods beginning prior to October 1, 1985 must be 
adjusted and is multiplied by 67 percent to reflect the decrease in the 
rate of return on equity. (The 67 percent represents the ratio of 100 
percent to 150 percent. When future updates of the prospectively 
determined payment rates use later cost report data that include the 
current allowable return on equity, this adjustment would no longer be 
needed.) The per diem would then be determined by dividing the SNF's 
adjusted return on equity by its inpatient days. A group mean would be 
determined and each group mean multiplied by 105 percent to determine 
that portion of the rate.

F. Determining Routine Per Diem Rate

    In Sec. 413.314, we describe proposed methodology for determining 
the routine per diem rate for an SNF. We explain that the per diem rate 
would be composed of a routine operating portion, a capital-related 
cost portion applicable to routine services, and, for proprietary SNFs, 
a return on equity portion for services furnished before October 1, 
1993. The labor-related costs of the routine operating portion would be 
adjusted to reflect area wage differences. The total rate would be 
adjusted by using a factor based on the projected increase in the 
market basket index to reflect a different cost reporting period if an 
SNF's cost reporting period is other than October 1 through September 
30.
    We would also provide that the prospectively determined payment 
rate, excluding capital, and excluding return on equity (if applicable) 
may not exceed the amount of an SNF's routine service cost limit that 
is in effect when the provider elects to be paid a prospective payment 
rate.
    In developing the proposed prospectively determined payment rates, 
we considered: a rate for freestanding facilities based on freestanding 
SNF cost data and a rate for hospital-based facilities based on 
hospital-based SNF cost data; and a single rate (for urban and rural 
locations, respectively) based on combined freestanding and hospital-
based SNF cost data. The current and the proposed single prospectively 
determined payment rates are based on combined freestanding and 
hospital-based SNF cost data. We believe that the proposed methodology 
of basing the prospectively determined payment rates on combined 
freestanding and hospital-based SNF cost data is consistent with and 
represents the most accurate reading of section 1888(d)(2)(B) of the 
Act. We are especially interested in receiving public comments on the 
proposed methodology.

G. Determining Payment Amount for Ancillary Services

    In searching for a way to implement section 1888(d)(6) of the Act 
and bring ancillary services under the prospectively determined payment 
rate system, we considered a number of different payment methodologies.
    We determined that only one methodology could clearly fit the 
requirement for a method for determining payment rates prospectively 
based on reasonable charges. This method would develop reasonable 
charge payment screens applicable to ancillary services furnished by 
all SNFs in a particular area. These payment screens would function 
similarly to current Medicare reasonable charge based fee schedule 
amounts. However, we have no data at this time upon which to base 
payment screens that would provide an equitable level of payment, as 
required under 1888(d)(6) of the Act.
    We also considered the following alternative payment methodologies, 
some of which may not be consistent with the reasonable charge 
methodology intended by the statute, while others clearly are not based 
on charges. However, we believe that it may be beneficial to discuss 
and solicit comments on these methodologies in this proposed rule.
    Currently, ancillary payments are determined by applying the 
provider's cost-to-charge ratio to ancillary charges. One method we 
considered was establishing an average total cost-to-charge ratio for 
urban and rural areas within each census area. This ratio could be used 
by all SNFs within the geographic area and could be applied to the 
charges for all services. While this would be a simplified approach, we 
do not believe that it would provide appropriate payment in all cases. 
It would not account for the wide variation among SNFs in the kinds of 
services furnished, or the wide variations in the providers' cost-to-
charge ratios. It could also discriminate against those SNFs furnishing 
more resource-intensive ancillary services and could encourage 
substituting low cost services for more costly services. Some of these 
problems could be ameliorated by the use of a separate ratio for each 
service. We did not review the data for this option because we do not 
believe this payment methodology meets the statutory requirements.
    We considered a method of paying for ancillary services on the 
basis of estimated cost with no retroactive cost settlement. Payment 
would be based on current charges converted to estimated cost, using 
the cost-to-charge ratio from the cost report for the most recent 12-
month cost reporting period for which a Notice of Amount of Program 
Reimbursement (NPR) has been issued. From that cost report, we would 
obtain the cost-to-charge ratio (not to exceed 1.0) for each ancillary 
cost center and multiply the ratio by the same cost center's ancillary 
charges in the period for which the election to receive prospectively 
determined payment is made. The average cost-to-charge ratio (not to 
exceed 1.0) for the urban and rural area within each census region 
would be used if, for any reason, there is no prior year period for 
which an NPR has been issued. Capital cost would also be reflected in 
the cost-to-charge ratio; therefore, no additional capital payment 
would be made. This methodology would be used to determine payment 
under both Part A and Part B of Medicare. All applicable coinsurance 
and deductibles would continue to be applied.
    While this approach does present some positive features, it could 
be problematic. First, this method is not consistent with the statutory 
requirement that ancillary services be paid on the basis of either 
actual cost or reasonable charges. In addition, it is possible that 
there would be a wide variation between estimated cost and actual cost. 
However, as in a prior approach, we did not review the data for this 
option because we do not believe this payment methodology meets the 
statutory requirements.
    We considered two methodologies for establishing a prospective per 
diem rate for ancillary services. The rate would be based on historical 
cost report data, as follows:
     Develop a flat average per diem in the aggregate for all 
ancillary services, by location; or
     Develop an average by ancillary service equal to 105 
percent of the appropriate group mean, by location.
    While both of these approaches would have the advantage of being 
easy to administer and informing the provider precisely how much it 
would be paid, there are some problems with implementing an average per 
diem cost based rate. First, neither approach meets the alternative 
statutory methodology of payment for ancillary services on the basis of 
reasonable charges. The first approach would also not recognize the 
wide variations in the types of ancillary services provided by 
different SNFs. Neither approach would take into consideration the fact 
that, with respect to SNFs, ancillary services may be provided by 
outside suppliers. Either approach could also act as a disincentive to 
providing resource-intensive services, or in some cases, any ancillary 
services. The historical data used in either approach do not take into 
account any changes, especially increases, in patient acuity levels 
that could impact on the utilization of current ancillary services.
    We considered a facility specific prospectively determined per diem 
payment for ancillary services subject to an adjustable limit. Both the 
payment amount and the adjustable limit would be based on historical 
cost data. Therefore, in addition to not meeting the mandate for an 
alternate methodology of payment on the basis of reasonable charges, 
the historical data do not account for changes in utilization of 
ancillary services due to increases in patient acuity.
    We considered one methodology even though it does not meet the 
alternate prospective methodology of payment on the basis of reasonable 
charges but does meet the requirement of 1861(v)(1)(A). That is, 
similar to the current routine cost limit system, we would make 
payments for ancillary services not to exceed 105 percent of the 
appropriate group mean for SNFs by location. Since this payment could 
not be prospectively determined, we did not consider incorporating this 
methodology into this proposed notice.
    Finally, we considered developing a case-mix adjusted per diem 
payment for ancillary services. HCFA is currently studying the 
feasibility of a case-mix type payment system for Medicare SNFs. The 
data to develop a case-mix adjusted ancillary cost per diem are not 
currently available.
    In reviewing these various methodologies for payment of ancillary 
costs, we are interested in a methodology that would be easy to apply 
and that would result in payment commensurate with the services 
provided. We also would prefer to adopt a methodology that recognizes 
the wide variation in services among SNFs. We were unable to develop a 
methodology based on available data that met these requirements. We 
therefore are soliciting comments on any of the methodologies described 
above or any additional methodologies not mentioned.
    Until such time as a methodology can be developed, ancillary 
services would continue to be paid on the basis of reasonable costs.

H. Publication of Rates

    In new Sec. 413.320, we would provide that HCFA will update the 
routine prospectively determined payment rates in a Federal Register 
notice published no later than July 1 of each year. In the notices, we 
would establish the rates for routine services under the prospectively 
determined payment rate system.

I. Simplified Cost Report

    All Medicare providers with low Medicare utilization have had, at 
the intermediary's discretion, the option of filing less than a full 
Medicare cost report. This option would continue to be available to 
those SNFs that qualify for it.
    In addition, in new Sec. 413.321, we would provide that a 
simplified cost report would be filed by certain SNFs receiving a 
prospectively determined rate. At this time, a simplified form is 
available only for freestanding SNFs. The simplified form is not 
applicable to hospital-based SNFs or SNFs that are a part of a health 
care complex. Another simplified form to be used by those facilities 
will be available in the future.
    The new simplified cost report requires inputting only the cost 
information necessary for determining prospective payment rates. The 
report employs a simplified method of cost finding to be used in lieu 
of the cost finding methods described in Sec. 413.24(d). This method is 
specified in the instructions for Form-HCFA 2540S, contained in 
sections 3000-3027.3 of Part 2 of the Provider Reimbursement Manual. We 
are also proposing to change Sec. 413.24(d) to clarify that the cost 
finding provisions of that regulation do not apply to those SNFs that 
qualify for the simplified method of cost finding. In addition, 
Sec. 413.24(h) would be revised to clarify that the waiver of full cost 
reporting for low program utilization also applies to providers filing 
a simplified cost report.

III. Impact Statement

    Unless the Secretary certifies that a proposed rule would not have 
a significant economic impact on a substantial number of small 
entities, we generally prepare a regulatory flexibility analysis that 
is consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612). For purposes of the RFA, we consider SNFs as small 
entities.
    Medicare payments to SNFs comprise only about 5.3 percent of total 
SNF revenues and this rule would only have a small impact on those 
revenues. Moreover, the purpose of this rule is to ease the compliance 
burden for small entities, and we believe the rule would have a 
positive impact on small entities.
    Also, section 1102(b) of the Act requires the Secretary to prepare 
a regulatory impact statement if a proposed rule may have a significant 
economic impact on the operations of a substantial number of small 
rural hospitals. Such an analysis must conform to the provisions of 
section 603 of the RFA. With the exception of hospitals located in 
certain rural counties adjacent to urban areas, for purposes of section 
1102(b) of the Act, we define a small rural hospital as a hospital with 
fewer than 50 beds.
    We have determined, and the Secretary certifies, that this proposed 
rule would not have a significant effect on the operations of a 
substantial number of small entities or on small rural hospitals. 
Therefore, we have not prepared a regulatory flexibility analysis or an 
analysis of the effects of this rule on small rural hospitals.
    In accordance with the provisions of Executive Order 12866 this 
regulation was not reviewed by the Office of Management and Budget.

IV. Response to Comments

A. Public Comment

    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.

B. Paperwork Reduction Act

    Section 413.308 of this proposed rule contains information 
collection requirements. As required by section 3504(h) of the 
Paperwork Reduction Act of 1980 (44 U.S.C. 3501-3511), we have 
submitted a copy of this proposed rule to the Executive Office of 
Management and Budget (EOMB) for its review of these information 
collection requirements. Total public reporting burden for this 
collection of information is estimated to be 1,200 hours during the 
first 12-month period that the rule would be in effect. A notice will 
be published in the Federal Register after approval is obtained. 
Organizations and individuals desiring to submit comments on the 
information collection requirements should direct them to the OMB 
official whose name appears in the ADDRESSES section of this preamble.

List of Subjects in 42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

    For the reason set out in the preamble 42 CFR part 413 is proposed 
to be amended as follows:
    A. The title of part 413 is amended to read as follows:

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED 
PAYMENT RATES FOR SKILLED NURSING FACILITIES

    B. Part 413 is amended as follows:
    1. The authority citation for part 413 continues to read as 
follows:

    Authority: Secs. 1102, 1814(b), 1815, 1833 (a), (i), and (n), 
1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 
U.S.C. 1302, 1395f(b), 1395g, 1395l (a), (i), and (n), 1395x(v), 
1395hh, 1395rr, 1395tt, and 1395ww); sec. 104(c) of Public Law 100-
360 as amended by sec. 608(d)(3) of Public Law 100-485 (42 U.S.C. 
1395ww (note)); sec. 101(c) of Public Law 101-234 (42 U.S.C. 1395ww 
(note)); and sec. 13503 of Public Law 103-66 (42 U.S.C. 1395ww 
(note)).

Subpart A--Introduction and General Rules

    2. In Sec. 413.1, a new paragraph (g) is added to read as follows:


Sec. 413.1  Introduction.

* * * * *
    (g) Prospectively determined payment rates for low Medicare volume 
SNFs. Rules governing requests by SNFs for prospectively determined 
payment rates under section 1888(d) of the Act are set forth in subpart 
I of this part.

Subpart B--Accounting Records and Reports

    3. In Sec. 413.24 the introductory text of paragraph (d), and 
paragraph (h), are revised to read as follows:


Sec. 413.24  Adequate cost data and cost finding.

* * * * *
    (d) Cost finding methods. After the close of the accounting period, 
providers must use one of the following methods of cost finding to 
determine the actual costs of services furnished during that period. 
These provisions do not apply to SNFs that elect and qualify for 
prospectively determined payment rates under subpart I of this part for 
cost reporting periods beginning on or after October 1, 1986. For the 
special rules that are applicable to those SNFs, see Sec. 413.321. For 
cost reporting periods beginning after December 31, 1971, providers 
using the departmental method of cost apportionment must use the step-
down method described in paragraph (d)(1) of this section or an ``other 
method'' described in paragraph (d)(2) of this section. For cost 
reporting periods beginning after December 31, 1971, providers using 
the combination method of cost apportionment must use the modified cost 
finding method described in paragraph (d)(3) of this section. Effective 
for cost reporting periods beginning on or after October 1, 1980, HHAs 
not based in hospitals or SNFs must use the step-down method described 
in paragraph (d)(1) of this section. (HHAs based in hospitals or SNFs 
must use the method applicable to the parent institution.) However, an 
HHA not based in a hospital or SNF that received less than $35,000 in 
Medicare payment for the immediately preceding cost reporting period, 
and for whom this payment represented less than 50 percent of the total 
operating cost of the agency, may use a simplified version of the step-
down method, as specified in instuctions for the cost report issued by 
HCFA.
* * * * *
    (h) Waiver of full or simplified cost reporting for low program 
utilization--(1) If the provider has had low utilization of covered 
services by Medicare beneficiaries (as determined by the intermediary) 
and has received correspondingly low interim payments for the cost 
reporting period, the intermediary may waive a full cost report or the 
simplified cost report described in Sec. 413.321 if it decides that it 
can determine, without a full or simplified report, the reasonable cost 
of covered services provided during that period.
    (2) If a full or simplified cost report is waived, the provider 
must submit within the same time period required for full or simplified 
cost reports:
    (i) The cost reporting forms prescribed by HCFA for this situation; 
and
    (ii) Any other financial and statistical data the intermediary 
requires.
    4. A new subpart I is added to read as follows:

Subpart I--Prospectively Determined Payment Rates for Skilled Nursing 
Facilities

Sec.
413.300  Basis and scope.
413.302  Definitions.
413.304  Eligibility for prospectively determined payment rates.
413.308  Rules governing election of prospectively determined 
payment rates.
413.310  Basis of payment.
413.312  Methodology for calculating rates.
413.314  Determining payment amounts: Routine per diem rate.
413.316  Determining payment amounts: Ancillary services.
413.320  Publication of prospectively determined payment rates or 
amounts.
413.321  Simplified cost reports for SNFs.

Subpart I--Prospectively Determined Payment Rates for Skilled 
Nursing Facilities


Sec. 413.300  Basis and scope.

    (a) Basis. This subpart implements section 1888(d) of the Act, 
which provides for optional prospectively determined payment rates for 
qualified SNFs.
    (b) Scope. This subpart sets forth the eligibility criteria an SNF 
must meet to qualify, the process governing election of prospectively 
determined payment rates, and the basis and methodology for determining 
prospectively determined payment rates.


Sec. 413.302  Definitions.

    For purposes of this subpart--
    Area wage level means the average wage per hour for all 
classifications of employees as reported by health care facilities 
within a specified area.
    Census region means one of the nine census divisions, comprising 
the fifty States and the District of Columbia, established by the 
Bureau of the Census for statistical and reporting purposes.
    Routine capital-related costs means the capital-related costs, 
allowable for Medicare purposes (as described in subpart G of this 
part), that are allocated to the SNF participating inpatient routine 
service cost center as reported on the Medicare cost report.
    Routine operating costs means the cost of regular room, dietary, 
and nursing services, and minor medical and surgical supplies for which 
a separate charge is not customarily made. It does not include the 
costs of ancillary services, capital-related costs, or, where 
appropriate, return on equity.
    Rural area means any area outside an urban area in a census region.
    Urban area means a Metropolitan Statistical Area (MSA) or New 
England County Metropolitan Area (NECMA), as defined by the Office of 
Management and Budget, or a New England county deemed to be an urban 
area, as listed in Sec. 412.62(f)(ii)(B) of this chapter.


Sec. 413.304  Eligibility for prospectively determined payment rates.

    (a) General rule. An SNF may receive a prospectively determined 
payment rate for a cost reporting period only if it had fewer than 
1,500 Medicare covered inpatient days as reported on a Medicare cost 
report in its immediately preceding cost reporting period. This 
criterion applies even if the SNF received a prospectively determined 
payment rate during the preceding cost reporting period.
    (b) Less than a full cost reporting period. If the cost reporting 
period that precedes an SNF's request for prospectively determined 
payment is not a full cost reporting period, the SNF may receive 
prospectively determined payment rates only if the average daily 
Medicare census for the period (Medicare inpatient days divided by the 
total number of days in the cost reporting period) is not greater than 
4.1.
    (c) Newly-participating SNFs. An SNF may receive prospectively 
determined payment rates for its first cost reporting period for which 
it is approved to participate in Medicare.


Sec. 413.308  Rules governing election of prospectively determined 
payment rates.

    (a) Requirements. An SNF must notify its intermediary at least 30 
calendar days before the beginning of the cost reporting period for 
which it requests to receive such payment that it elects prospectively 
determined payment rates. A separate request must be made for each cost 
reporting period for which an SNF seeks prospective payment. A newly 
participating SNF with no preceding cost reporting period must make its 
election within 30 days of its notification of approval to participate 
in Medicare.
    (b) Intermediary notice. After evaluating an SNF's request for 
prospectively determined payment rates, the intermediary notifies the 
SNF in writing as to whether the SNF meets any of the eligibility 
criteria described in Sec. 413.304. The intermediary must notify the 
SNF of its determination within 10 working days after it receives all 
the data necessary to make the determination. The intermediary's 
determination is limited to one cost reporting period.
    (c) Prohibition against revocation. An SNF may not revoke its 
request after it has received final determination of eligibility from 
the intermediary and the cost reporting period has begun.


Sec. 413.310  Basis of payment.

    (a) Method of payment. Under the prospectively determined payment 
rate system, a qualified SNF receives a per diem payment of a 
predetermined rate for inpatient services furnished to Medicare 
beneficiaries. Each SNF's routine per diem payment rate is determined 
according to the methodology described in Sec. 413.312 and is based on 
various components of SNF costs.
    (b) Payment in full. The payment rate represents payment in full 
for routine services as described in Sec. 413.314 (subject to 
applicable coinsurance as described in subpart G of part 409 of this 
title). Payment is made in lieu of payment on a reasonable cost basis 
for routine services.


Sec. 413.312  Methodology for calculating rates.

    (a) Data used--(1) To calculate the prospectively determined 
payment rates, HCFA uses:
    (i) The SNF cost data that were used to develop the applicable 
routine service cost limits;
    (ii) A wage index to adjust for area wage differences; and
    (iii) The most recent projections of increases in the costs from 
the SNF market basket index.
    (2) In the annual schedule of rates published in the Federal 
Register under the authority of Sec. 413.320, HCFA announces the wage 
index and the annual percentage increases in the market basket used in 
the calculation of the rates.
    (b) Calculation of per diem rate--(1) Routine operating component 
of rate--(i) Adjusting cost report data. The SNF market basket index is 
used to adjust the routine operating cost from the SNF cost report to 
reflect cost increases occurring between cost reporting periods 
represented in the data collected and the midpoint of the initial cost 
reporting period to which the payment rates apply.
    (ii) Calculating a per diem cost. For each SNF, an adjusted routine 
operating per diem cost is computed by dividing the adjusted routine 
operating cost (see paragraph (b)(1)(i) of this section) by the SNF's 
total patient days.
    (iii) Adjusting for wage levels--(A) The SNF's adjusted per diem 
routine operating cost calculated under paragraph (b)(1)(ii) of this 
section is then divided into labor-related and nonlabor-related 
portions.
    (B) The labor-related portion is obtained by multiplying the SNF's 
adjusted per diem routine operating cost by a percentage that 
represents the labor-related portion of cost from the market basket. 
This percentage is published when the revised rates are published as 
described in Sec. 413.320.
    (C) The labor-related portion of each SNF's per diem cost is 
divided by the wage index applicable to the SNF's geographic location 
to arrive at the adjusted labor-related portion of routine cost.
    (iv) Group means. SNFs are grouped by urban or rural location by 
census region. Separate means of adjusted labor-related and nonlabor 
routine operating costs for each SNF group are established in 
accordance with the SNF's region and urban or rural location. For each 
group, the mean labor-related and mean nonlabor-related per diem 
routine operating costs are multiplied by 105 percent.
    (2) Computation of routine capital-related cost. (i) The SNF 
routine capital-related cost for both direct and indirect capital costs 
allocated to routine services, as reported on the Medicare cost report, 
is obtained for each SNF in the data base.
    (ii) For each SNF, the per diem capital-related cost is calculated 
by dividing the SNF's routine capital costs by its inpatient days.
    (iii) SNFs are grouped by urban and rural location by census 
region, and mean per diem routine capital-related cost is determined 
for each group.
    (iv) Each group mean per diem capital-related cost is multiplied by 
105 percent.
    (3) Computation of return on owner's equity for services furnished 
before October 1, 1993--(i) Each proprietary SNF's Medicare return on 
equity is obtained from its cost report and the portion attributable to 
the routine service cost is determined as described in Sec. 413.157.
    (ii) For each proprietary SNF, per diem return on equity is 
calculated by dividing the routine cost related return on equity 
determined under paragraph (b)(3)(i) of this section by the SNF's total 
Medicare inpatient days.
    (iii) Separate group means are computed for per diem return on 
equity of proprietary SNFs, based on regional and urban or rural 
classification.
    (iv) Each group mean is multiplied by 105 percent.


Sec. 413.314  Determining payment amounts: Routine per diem rate.

    (a) General rule. An SNF that elects to be paid under the 
prospectively determined payment rate system is paid a per diem rate 
for inpatient routine services. This rate is adjusted to reflect area 
wage differences and the cost reporting period beginning date (if 
necessary) and is subject to the limitation described below.
    (b) Per diem rate. The prospectively determined payment rate for 
each urban and rural area in each census region is comprised of the 
following:
    (1) A routine operating component, which is divided into:
    (i) A labor-related portion adjusted by the appropriate wage index; 
and
    (ii) A nonlabor-related portion.
    (2) A routine capital-related cost portion.
    (3) For proprietary SNFs only, a portion that is based on the 
return on owner's equity related to routine cost, applicable only for 
services furnished before October 1, 1993.
    (c) Adjustment for cost reporting period. (1) If a facility has a 
cost reporting period beginning after the beginning of the Federal 
fiscal year, the intermediary increases the labor-related and nonlabor-
related portions of the prospective payment rate that would otherwise 
apply to the SNF by an adjustment factor. Each factor represents the 
projected increase in the market basket index for a specific 12-month 
period. The factors are used to account for inflation in costs for cost 
reporting periods beginning after October 1. Adjustment factors are 
published in the annual notice of prospectively determined payment 
rates described in Sec. 413.320.
    (2) If a facility uses a cost reporting period that is not 12 
months in duration, the intermediary must obtain a special adjustment 
factor from HCFA for the specific period.
    (d) Limitation of prospectively determined payment rate. The per 
diem prospectively determined payment rate for an SNF, excluding 
capital-related costs and excluding return on equity for services 
furnished prior to October 1, 1993, may not exceed the individual SNF's 
routine service cost limit. Under Sec. 413.30, the routine service cost 
limit is the limit determined without regard to exemptions, exceptions, 
or retroactive adjustments, and is the actual limit in effect when the 
provider elects to be paid a prospectively determined payment rate.


Sec. 413.316  Determining payment amounts: Ancillary services.

    Ancillary services are paid on the basis of reasonable cost in 
accordance with section 1861(v)(1) of the Act and Sec. 413.53.


Sec. 413.320  Publication of prospectively determined payment rates or 
amounts.

    At least 90 days prior to the beginning of a Federal fiscal year to 
which revised prospectively determined payment rates are to be applied, 
HCFA publishes a notice in the Federal Register:
    (a) Establishing the prospectively determined payment rates for 
routine services; and
    (b) Explaining the basis on which the prospectively determined 
payment rates are calculated.


Sec. 413.321  Simplified cost report for SNFs.

    SNFs electing to be paid under the prospectively determined payment 
rate system may file a simplified cost report. The cost report contains 
a simplified method of cost finding to be used in lieu of cost methods 
described in Sec. 413.24(d). This method is specified in the 
instructions for Form HCFA-2540S, contained in sections 3000-3027.3 of 
part 2 of the Provider Reimbursement Manual. This form may not be used 
by hospital-based SNFs or SNFs that are part of a health care complex. 
Those SNFs must file a cost report that reflects the shared services 
and administrative costs of the hospital and any other related 
facilities in the health care complex.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance).

    Dated: March 29, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: May 24, 1994.
Donna E. Shalala,
Secretary.
[FR Doc. 94-13506 Filed 6-7-94; 8:45 am]
BILLING CODE 4120-01-P