[Federal Register Volume 59, Number 204 (Monday, October 24, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-26207]


[[Page Unknown]]

[Federal Register: October 24, 1994]


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OFFICE OF MANAGEMENT AND BUDGET

 

Cost of Hospital and Medical Care and Treatment Furnished by the 
United States; Certain Rates Regarding Recovery From Tortiously Liable 
Third Persons

    By virtue of the authority vested in the President by Section 2(a) 
of P.L. 87-693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the 
Director of the Office of Management and Budget by Executive Order No. 
11541 of July 1, 1970 (35 Federal Register 10737), the three sets of 
rates outlined below are hereby established. These rates are for use in 
connection with the recovery, from tortiously liable third persons, of 
the cost of hospital and medical care and treatment furnished by the 
United States (Part 43, Chapter I, Title 28, Code of Federal 
Regulations) through three separate Federal agencies. The rates have 
been established in accordance with the requirements of OMB Circular A-
25, requiring reimbursement of the full cost of all services provided. 
The rates are established as follows:
    (1). Department of Defense. The FY 1995 inpatient rates are based 
on the cost per DRG, which is the inpatient full reimbursement rate per 
hospital discharge, weighted to reflect the intensity of the principal 
diagnosis involved. The average cost per Relative Weighted Product 
(RWP) for large urban, other urban, rural, and overseas facilities will 
be published annually as an inpatient standardized amount.
    The adjusted standardized amounts (ASA) per Relative Weighted 
Product (RWP) for use in the Direct Care System will be comparable to 
procedures utilized by Health Care Financing Administration (HCFA) and 
the Civilian Health and Medical Program for the Uniformed Services 
(CHAMPUS). These expenses will include all direct care expenses. The 
average cost per relative weighted product for large urban, other 
urban, rural and overseas will be published annually as an inpatient 
standardized amount and will include the cost of inpatient professional 
services. The DRG rates will apply to reimbursement from all sources. A 
relative weight for each DRG using the standardized amount will be the 
same as the DRG weights published annually for hospital reimbursement 
rates under the Civilian Health and Medical Program for the Uniformed 
Services (CHAMPUS) pursuant to 32 CFR 199.14(a)(1) which includes 
adjustments for outliers, area wages, and indirect medical education.
    (2) Department of Health and Human Services. The sum of obligation 
for each cost center providing medical service is broken down into 
amounts attributable to impatient care on the basis of the proportion 
of staff devoted to each cost center. Total inpatient costs and 
outpatient costs thus determined are divided by the relevant workload 
statistic (inpatient day, outpatient visit) to produce the inpatient 
and outpatient rates. In calculation of the rates, the Department's 
unfunded retirement liability cost and capital and equipment 
depreciation cost were incorporated to conform to requirements set 
forth in OMB Circular A-25. In addition, each cost center's obligations 
include all costs for account, such as Medicare and Medicaid 
collections and Contract Health funds used to support direct program 
operation. Inclusion of these funds yields a more accurate indication 
of the cost of care in HHS facilities.
    (3) Department of Veterans Affairs. The actual costs and per diem 
rates by type of care for the previous year are added to the estimated 
cost for depreciation of buildings and equipment, administrative 
overhead, and Government employee retirement and disability charges. In 
addition, the calculation of the rates included two new cost elements 
as required by OMB Circular A-25. The new cost elements were ``Interest 
on capital for land, buildings and equipment (net book value)'' and 
``research''. These computed rates are then adjusted by the budgeted 
percentage change to arrive at the estimated rates.
    These rates represent the reasonable cost of hospital, nursing 
home, medical, surgical, or dental care and treatment (including 
prostheses and medical appliances) furnished or to be furnished by the 
United States in Federal hospitals, nursing homes, and outpatient 
clinics administered by the Department of Defense, the Department of 
Veterans Affairs and the Department of Health and Human Services.
    For such care and treatment furnished at the expense of the United 
States in a facility not operated by the United States, the rates shall 
be the amounts expended for such care and treatment.
    For the Department of Defense, effective October 1, 1994 and 
thereafter:

Inpatient, Outpatient and Other Rates and Charges

                          I. Inpatient Rates\1\                         
------------------------------------------------------------------------
                                                                Full    
                                                           reimbursement
                                                                rate    
------------------------------------------------------------------------
                   (Per Inpatient Day)                                  
A. Burn Center...........................................       $3,781  
B. Surgical care Services (Cosmetic Surgery).............        1,122  
C. All Other Inpatient Services (Based on Diagnosis                     
 Related Groups (DRG) Charges)...........................               
------------------------------------------------------------------------

1. FY 1995 Direct Care Inpatient Reimbursement Rates

Adjusted Standard

------------------------------------------------------------------------
                                                                   Full 
            Amount third party               IMET   Interagency    cost 
------------------------------------------------------------------------
Large Urban:                                                            
  $3,908.................................   $1,670     $3,679     $3,908
Other Urban:                                                            
  $4,267.................................    1,954      3,997      4,267
Rural:                                                                  
  $5,066.................................    2,085      4,744      5,066
Overseas:                                                               
  $5,089.................................    2,146      4,794      5,089
------------------------------------------------------------------------

2. Overview

    The FY 1995 inpatient rates are based on the cost per DRG, which is 
the inpatient full reimbursement rate per hospital discharge, weighted 
to reflect the intensity of the principal diagnosis involved. The 
average cost per Relative Weighted Product (RWP) for large urban, other 
urban, rural, and overseas facilities will be published annually as an 
inpatient standardized amount. (See item 1 above). The adjusted 
standardized amounts (ASA) per Relative Weighted Product (RWP) for use 
in the Direct Care System will be comparable to procedures utilized by 
Health Care Financing Administration (HCFA) and the Civilian Health and 
Medical Program for the Uniformed Services (CHAMPUS). These expenses 
will include all direct care expenses. The average cost per relative 
weighted product for large urban, other urban, rural and overseas will 
be published annually as an inpatient standardized amount and will 
include the cost of inpatient professional services.
    The DRG rates will apply to reimbursement from all sources. A 
relative weight for each DRG using the standardized amount will be the 
same as the DRG weights published annually for hospital reimbursement 
rates under the Civilian Health and Medical Program for the Uniformed 
Services (CHAMPUS) pursuant to 32 CFR 199.14(a)(1) which includes 
adjustments for outliers, area wages, and indirect medical education. 
An example of how to arrive at DoD recoverable costs using DRG 
standardized weights is provided below.

3. Example of Adjusted Standardized Amounts Procedures Performed

Large Urban Area--Example

    a. The cost to be recovered is DoD's cost for medical services 
provided in a large urban area. Billings will be at the full cost rate.
    b. DRG: Nervous System infection except viral meningitis Relative 
Weight of Procedure 1.8427.
    c. The DoD adjusted standardized amount to be recovered is $3,908 
(i.e., full cost rate as shown in the table).
    d. DoD cost to be recovered is the RWP factor (1.8427) in item 3b, 
above, times the amount ($3,908) in item 3c, above.

Cost to be recovered is $7,201.

                        II. Outpatient Charges\1\                       
                            [MEPRSPer Visit]                            
------------------------------------------------------------------------
                                                               Full     
       Code\2\                 Clinical service           reimbursement 
                                                              rate      
------------------------------------------------------------------------
                             A. Medical Care                            
------------------------------------------------------------------------
                                                                        
BAA...................  Internal Medicine..............             $153
BAC...................  Cardiology.....................              121
BAF...................  Endocrinology..................              138
BAG...................  Gastroenterology...............              145
BAH...................  Hematology.....................              210
BAJ...................  Nephrology.....................              143
BAK...................  Neurology......................              126
BAM...................  Oncology.......................              116
BAN...................  Pulmonary Disease..............              125
BAO...................  Rheumatology...................              130
BAP...................  Dermatology....................               91
BAQ...................  Infectious Disease.............               98
BAR...................  Physical Medicine..............              120
BAB...................  Allergy........................               49
BAE...................  Diabetes.......................               54
BAI...................  Hypertension...................               56
BAL...................  Nutrition......................               35
------------------------------------------------------------------------
                            B. Surgical Care                            
------------------------------------------------------------------------
                                                                        
BBA...................  General Surgery................              141
BBB...................  Cardiovascular/Thoracic Surgery              169
BBC...................  Neurology......................              195
BBD...................  Ophthalmology..................              112
BBE...................  Organ Transplant...............              268
BBF...................  Otolaryngology.................              126
BBG...................  Plastic Surgery................              160
BBH...................  Proctology.....................              114
BBI...................  Urology........................              158
BBJ...................  Pediatric Surgery..............               64
------------------------------------------------------------------------
                C. Obstetrical and Gynecological (OB-GYN)               
------------------------------------------------------------------------
                                                                        
BCA...................  Family Planning................              105
BCB...................  Gynecology.....................              106
BCC...................  Obstetrics.....................               99
------------------------------------------------------------------------
                            D. Pediatric Care                           
------------------------------------------------------------------------
                                                                        
BDA...................  Pediatric......................               86
BDB...................  Adolescent.....................               83
BDC...................  Well Baby......................               55
------------------------------------------------------------------------
                           E. Orthopaedic Care                          
------------------------------------------------------------------------
                                                                        
BEA...................  Orthopaedic....................              140
BEC...................  Hand Surgery...................               78
BED/BLC...............  Neuromuscularskeletal..........               55
BEE...................  Orthopaedic Appliance..........               93
BEF...................  Podiatry.......................               77
------------------------------------------------------------------------
                 F. Psychiatric and/or Mental Healthcare                
------------------------------------------------------------------------
                                                                        
BFB...................  Psychology.....................              104
BFC...................  Child Guidance.................               84
BFA/BFD...............  Mental Health..................              114
BFE...................  Social Work....................               86
BFF...................  Substance Abuse Rehabilitation.               87
------------------------------------------------------------------------
                         G. Primary Medical Care                        
------------------------------------------------------------------------
                                                                        
BGA/BHA...............  Family Practice/Primary........               96
BHB...................  Medical Examination............               91
BHC...................  Optometry......................               64
BHD...................  Audiology Clinic...............               54
BHE...................  Speech Pathology...............               82
BHF...................  Community Health...............               75
BHG...................  Occupational Health............               76
BHI...................  Immediate Care Clinic..........              125
------------------------------------------------------------------------
                        H. Emergency Medical Care                       
------------------------------------------------------------------------
                                                                        
BIA...................  Emergency Care Clinic..........              151
------------------------------------------------------------------------
                        I. Flight Medicine Clinic                       
------------------------------------------------------------------------
                                                                        
BJA...................  Flight Medicine................              132
------------------------------------------------------------------------
                       J. Underseas Medicine Care                       
------------------------------------------------------------------------
                                                                        
BKA...................  Underseas Medicine Clinic......               90
------------------------------------------------------------------------
                       K. Rehabilitative Services                       
------------------------------------------------------------------------
                                                                        
DHB...................  Occupational Therapy...........               51
DHD...................  Physical Therapy...............               38
------------------------------------------------------------------------
                           L. Same Day Surgery                          
------------------------------------------------------------------------
                                                                        
                        Same Day Surgery...............              361
------------------------------------------------------------------------
\1\Note: Pursuant to the provisions of 10 U.S.C. 1095, the inpatient    
  Diagnosis Related Groups are 95 percent hospital ad 5 percent         
  professional fee. The outpatient per visit percentages are 57 percent 
  hospital, 33 percent ancillary, and 10 percent professional.          
\2\The Medical Expense and Performance Reporting System (MEPRS) code is 
  a three digit code which defines the summary account and the          
  subaccount within a functional category in the DoD medical system. An 
  example of this hierarchial arrangement is as follows:                


                  Outpatient Care (Functional Category)                 
------------------------------------------------------------------------
                                                             MEPRS code 
------------------------------------------------------------------------
Medical Care (Summary Account)...........................  BA           
Internal Medicine (Subaccount)...........................  BAA          
------------------------------------------------------------------------
MEPRS codes are used to ensure that consistent financial and operating  
  performance data is reported in the DoD military medical system.      


                       III. Other Rates and Charge                      
------------------------------------------------------------------------
                                                               Full     
                                                          reimbursement 
                                                               rate     
------------------------------------------------------------------------
A. Immunizations.......................................              $19
B. Hyperbaric Services: Charges may be prorated based                   
 on usage                                                               
1-60 minutes...........................................              169
61-120 minutes.........................................              338
121-180 minutes........................................              506
181-240 minutes........................................              675
C. Family Member Rate, (Formerly Military Dependent                     
 Rate).................................................             9.50
------------------------------------------------------------------------

    For the Department of Health and Human Services, Indian Health 
Service, effective October 1, 1994 and thereafter:

Hospital Care Inpatient Day:                                            
                                   HHS                                  
------------------------------------------------------------------------
                                                                        
General Medical Care...........................................   $1,940
Outpatient Medical Treatment:                                           
  Outpatient Visit.............................................      201
                                                                        

    For the Department of Veterans Affairs, effective October 1, 1994 
and thereafter: 

Hospital Care Inpatient Day:                                            
                                   VA                                   
------------------------------------------------------------------------
                                                                        
  General Medical Care.........................................     $849
  Surgical Care................................................    1,350
  Psychiatric Care.............................................      411
  Intermediate Care............................................      322
  Neurology....................................................      762
  Rehabilitation Medicine......................................      612
  Blind Rehabilitation.........................................      676
  Substance Abuse (Alcohol and drug treatment).................      290
  Nursing Home Care............................................      244
  Spinal Cord Injury Care......................................      775
Outpatient Medical and Dental Treatment:                                
  Outpatient Visit.............................................      194
  Emergency Dental Outpatient Visit............................      119
  Prescription filled..........................................       21
                                                                        

    For the period beginning October 1, 1994, the rates prescribed 
herein superseded those established by the Director of the Office of 
Management and Budget on October 26, 1993 (58 FR 57638) and on July 29, 
1994 (59 FR 38648).
Alice M. Rivlin,
Director, Office of Management and Budget.
[FR Doc. 94-26207 Filed 10-21-94; 8:45 am]
BILLING CODE 3110-01-M