[Federal Register Volume 61, Number 193 (Thursday, October 3, 1996)]
[Rules and Regulations]
[Pages 51611-51617]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-25282]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Part 413

[BPD-805-F]
RIN 0938-AG68


Medicare and Medicaid Programs; New Payment Methodology for 
Routine Extended Care Services Provided in a Swing-Bed Hospital

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

ACTION: Final rule.

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

SUMMARY: This final rule revises the regulations governing the 
methodology for payment of routine extended care services furnished in 
a swing-bed hospital. Medicare payment for these services is determined 
based on the average rate per patient day paid by Medicare for these 
same services provided in freestanding skilled nursing facilities 
(SNFs) in the region in which the hospital is located. The reasonable 
cost for these services is the higher of the reasonable cost rates in 
effect for the current calendar year or for the previous calendar year. 
In addition, this final rule revises the regulations concerning the 
method used to allocate hospital general routine inpatient service 
costs for purposes of determining payments to swing-bed hospitals. 
These changes are necessary to conform the regulations to section 1883 
of the Social Security Act (the Act), and section 4008(j) of the 
Omnibus Budget Reconciliation Act of 1990.

EFFECTIVE DATE: These regulations are effective on November 4, 1996.

FOR FURTHER INFORMATION CONTACT: John Davis (410) 786-0008.

SUPPLEMENTARY INFORMATION:

I. Background

    Before the enactment of the Omnibus Budget Reconciliation Act of 
1980 (Public Law 96-499), small rural hospitals had difficulty in 
establishing separately identifiable units for Medicare and Medicaid 
long-term care because of limitations in their physical plant and 
accounting capabilities. These hospitals often had an excess of 
hospital beds, while their communities had a scarcity of long-term care 
beds in Medicare and Medicaid participating facilities. To alleviate 
this problem, Congress enacted section 904 of Public Law 96-499, known 
as the ``swing-bed provision,'' which authorized a cost-efficient means 
of providing nursing home care in rural communities. This provision 
added sections 1883 and 1913 of the Social Security Act (the Act), 
under which certain rural hospitals with fewer than 50 beds could use 
their inpatient facilities to furnish long-term care services to 
Medicare and Medicaid patients. These hospitals were paid at rates that 
were deemed appropriate for those services and were generally lower 
than hospital rates. Medicare payment for routine SNF services was made 
at the average Statewide Medicaid rate for the previous calendar year. 
Payment for ancillary services was made based on reasonable cost.

[[Page 51612]]

    On December 22, 1987, the Omnibus Budget Reconciliation Act of 1987 
(OBRA 1987) (Public Law 100-203) was enacted. Section 4005(b) of OBRA 
1987 amended section 1883(b)(1) of the Act to provide for an expansion 
of the existing Medicare swing-bed program to include rural hospitals 
with more than 49 but fewer than 100 beds, effective for swing-bed 
agreements entered into after March 31, 1988. Although rural hospitals 
having more than 49 beds but fewer than 100 beds can be swing-bed 
hospitals, they are subject to additional payment limitations that do 
not apply to the smaller swing-bed hospitals.
    Also, sections 4201(a)(3), 4204, 4211(h)(9), and 4214 of OBRA 1987 
provide that effective with services furnished on or after October 1, 
1990, the terms ``skilled nursing facilities'' (SNFs) and 
``intermediate care facilities'' (ICFs) are no longer to be used for 
the purpose of certifying a facility for the Medicaid program. Instead, 
they are replaced by the term ``nursing facility'' (NF). Thus, for 
purposes of the Medicaid program, facilities are no longer certified as 
ICFs but instead are certified only as NFs, and can provide services as 
defined in section 1919(a)(1) of the Act. Effective October 1, 1990, 
these long-term care services furnished by swing-bed hospitals to 
Medicaid and to other non-Medicare patients have been referred to as 
NF-type services.
    On November 5, 1990, the Omnibus Budget Reconciliation Act of 1990 
(OBRA 1990) (Public Law 101-508) was enacted. Section 4008(j) of OBRA 
1990 amended section 1883(a)(2)(B)(ii)(II) of the Act to provide for a 
new methodology to pay for routine SNF services provided in a swing-bed 
hospital. Effective for services furnished on or after October 1, 1990, 
Medicare payment for routine SNF services in a swing-bed hospital is 
based on the average rate per patient day paid by Medicare for routine 
services provided in freestanding SNFs in the region in which the 
hospital is located. The rates are calculated using the regions as 
defined in section 1886(d)(2)(D) of the Act.
    Section 4008(j)(2) of OBRA 1990 also provides for a ``hold-harmless 
harmless'' provision. Under this provision, if the reasonable cost of 
routine SNF services furnished by a hospital during a calendar year is 
less than the reasonable cost of these services determined for the 
prior calendar year, payment is to be based on the reasonable cost 
determination for the prior calendar year.

II. Provisions of the Proposed Rule

    On April 22, 1996, we published a proposed rule in the Federal 
Register (61 FR 17677), in which we included the following provisions.

New Payment Rate Methodology

    We proposed to implement in regulations a revised methodology for 
Medicare payment of routine SNF services provided in a swing-bed 
hospital. Under the proposed rule, Medicare payment to a swing-bed 
hospital for routine SNF services would be based on the average rate 
per patient day paid by Medicare for routine SNF services provided in a 
freestanding SNF in the region in which the hospital is located. These 
rates would be determined prospectively based on the most current SNF 
settled cost reporting data available (increased in a compounded 
manner, using the increase applicable to the SNF routine cost limits, 
up to and including the calendar year for which the rates are in 
effect). Rates would be calculated using the regions as defined in 
section 1886(d)(2)(D) of the Act (that is, one of the nine census 
divisions established by the Bureau of the Census). Payment for 
ancillary services furnished as SNF services in swing-bed hospitals 
would continue to be paid on a reasonable cost basis.
    We published the rates applicable to calendar years 1990 through 
1994 (see below), which had been published in section 2231 of the 
Provider Reimbursement Manual (HCFA Pub. 15-1). We stated our intent to 
continue to publish annual updates in that manual.
    We described the methodology for calculating the Medicare swing-bed 
rates, and provided the rates for services furnished on or after 
October 1, 1990, and before December 31, 1990, as well as for services 
furnished in calendar years 1991, 1992, 1993, 1994, and 1995.
    In accordance with section 4008(j)(2) of OBRA 1990, we also 
proposed a hold-harmless provision for Medicare swing-bed payments. As 
noted above, this provision would allow for payment of the higher of 
the payment rate in effect for the current calendar year or the payment 
rate received by the swing-bed hospital for the prior calendar year.

Development of Medicare Swing Bed Rates Effective for Services 
Furnished on or after October 1, 1990 and before January 1, 1995

--Data--In developing the Medicare payment rates for swing-bed care, we 
used the actual freestanding SNF inpatient routine service payments 
obtained from settled Medicare cost reports. For fiscal years 1990-
1993, cost reports used were for periods ending on or after June 30, 
1989 and through May 31, 1990; for 1994, cost reports used were for 
periods ending on or after September 30, 1990 through August 31, 1991; 
and for 1995, cost reports used were for periods ending on or after 
October 31, 1992 through September 30, 1993. The data consist of 
routine service payments that were adjusted for utilization review, 
primary payor amounts, and application of lower of cost or charges. For 
proprietary providers, the return on equity portion of the swing-bed 
rate was adjusted to include only the routine portion (that is, the 
return on equity component related to ancillary services costs was 
removed).

    HCFA adjusts these data, using the SNF market basket index (the 
annual percent increase in SNF expenditures, considering inflation plus 
an allowance for new technology) to inflate costs from the cost 
reporting periods in the data base to the midpoint of the applicable 
year to which the rates apply.
--Group Means--HCFA calculated the means of adjusted routine service 
payments and the routine portion of return on equity for each census 
region as shown in Tables A through D.
(We noted that effective October 1, 1993, section 13503(c) of the 
Omnibus Budget Reconciliation Act of 1993 amended sections 
1861(v)(1)(B) and 1878(f)(2) of the Act to eliminate return on equity 
capital for SNF services furnished in a proprietary hospital. The 
return on equity capital component was not added to the routine payment 
rate for the months of October, November, and December of 1993 (Table 
D) nor for any subsequent years.)

[[Page 51613]]



 Table A.--Medicare Swing Bed Rates--for Services Furnished on or After 
              October 1, 1990 and Before December 31, 1990              
------------------------------------------------------------------------
                                                  Routine     Return on 
                    Region                        payment     equity \1\
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).......       $86.51        $1.42
2. Middle Atlantic (PA, NJ, NY)...............        86.39         1.27
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC,                          
 VA, WV)......................................        75.28         1.48
4. East North Central (IL, IN, MI, OH, WI)....        75.03         1.18
5. East South Central (AL, KY, MS, TN)........        65.79         1.21
6. West North Central (IA, KS, MN, MO, NB, ND,                          
 SD)..........................................        74.09         1.34
7. West South Central (AR, LA, OK, TX)........        67.85         1.87
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..        81.32         1.47
9. Pacific (AK, CA, HI, OR, WA)...............        86.73        1.07 
------------------------------------------------------------------------
\1\ The return of equity component is included only in the rate paid to 
  proprietary hospitals.                                                


 Table B.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1991 and Before December 31, 1991              
------------------------------------------------------------------------
                                                  Routine     Return on 
                    Region                        payment     equity \2\
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).......       $90.92        $1.42
2. Middle Atlantic (PA, NJ, NY)...............        90.73         1.27
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC,                          
 VA, WV)......................................        79.03         1.28
4. East North Central (IL, IN, MI, OH, WI)....        78.78         1.18
5. East South Central (AL, KY, MS, TN)........        69.14         1.21
6. West North Central (IA, KS, MN, MO, NB, ND,                          
 SD)..........................................        77.83         1.34
7. West South Central (AR, LA, OK, TX)........        71.22         1.87
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..        85.34         1.47
9. Pacific (AK, CA, HI, OR, WA)...............        91.10        1.07 
------------------------------------------------------------------------
\2\ The reutrn on equity component is included in the rate paid to      
  propriety hospitals.                                                  


 Table C.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1992 and Before December 31, 1992              
------------------------------------------------------------------------
                                                  Routine     Return on 
                    Region                        payment     equity \3\
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).......       $95.10        $1.42
2. Middle Atlantic (PA, NJ, NY)...............        94.91         1.27
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC,                          
 VA, WV)......................................        82.67         1.48
4. East North Central (IL, IN, MI, OH, WI)....        82.40         1.18
5. East South Central (AL, KY, MS, TN)........        72.32         1.21
6. West North Central (IA, KS, MN, MO, NB, ND,                          
 SD)..........................................        81.41         1.34
7. West South Central (AR, LA, OK, TX)........        74.50         1.87
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..        89.27         1.47
9. Pacific (AK, CA, HI, OR, WA)...............        95.29        1.07 
------------------------------------------------------------------------
\3\ The return on equity component is included only in the rate paid to 
  proprietary hospitals.                                                


 Table D.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1993 and Before December 31, 1993              
------------------------------------------------------------------------
                                                  Routine     Return on 
                    Region                        payment     equity \4\
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).......      $100.05        $1.42
2. Middle Atlantic (PA, NJ, NY)...............        99.84         1.27
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC,                          
 VA, WV)......................................        86.97         1.48
4. East North Central (IL, IN, MI, OH, WI)....        86.69         1.18
5. East South Central (AL, KY, MS, TN)........        76.08         1.21
6. West North Central (IA, KS, MN, MO, NB, ND,                          
 SD)..........................................        85.64         1.34
7. West South Central (AR, LA, OK, TX)........        78.37         1.87
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..        93.91         1.47
9. Pacific (AK, CA, HI, OR, WA)...............       100.24        1.07 
------------------------------------------------------------------------
\4\ The return on equity component should be included in the rate paid  
  to proprietary hospitals only for the months of January through       
  September of this calendar year.                                      


[[Page 51614]]


 Table E.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1994 and Before December 31, 1994              
------------------------------------------------------------------------
                                                               Routine  
                           Region                              payment  
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................      $108.48
2. Middle Atlantic (PA, NJ, NY)............................       104.33
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....        89.47
4. East North Central (IL, IN, MI, OH, WI).................        88.76
5. East South Central (AL, KY, MS, TN).....................        79.44
6. West North Central (IA, KS, MN, MO, NB, ND, SD).........        83.84
7. West South Central (AR, LA, OK, TX).....................        84.97
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       100.11
9. Pacific (AK, CA, HI, OR, WA)............................       104.58
------------------------------------------------------------------------


 Table F.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1995 and Before December 31, 1995              
------------------------------------------------------------------------
                                                               Routine  
                           Region                              payment  
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................      $121.71
2. Middle Atlantic (PA, NJ, NY)............................       117.28
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....       105.22
4. East North Central (IL, IN, MI, OH, WI).................       105.73
5. East South Central (AL, KY, MS, TN).....................        94.61
6. West North Central (IA, KS, MN, MO, NB, ND, SD).........        99.75
7. West South Central (AR, LA, OK, TX).....................        99.63
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       117.21
9. Pacific (AK, CA, HI, OR, WA)............................       125.80
------------------------------------------------------------------------


 Table G.--Medicare Swing Bed Rates--for Services Furnished on or After 
              January 1, 1996 and Before December 31, 1996              
------------------------------------------------------------------------
                                                               Routine  
                           Region                              payment  
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................      $126.65
2. Middle Atlantic (PA, NJ, NY)............................       121.74
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....       109.04
4. East North Central (IL, IN, MI, OH, WI).................       109.51
5. East South Central (AL, KY, MS, TN).....................        99.11
6. West North Central (IA, KS, MN, MO, NB, ND, SD).........       103.38
7. West South Central (AR, LA, OK, TX).....................       102.89
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       121.31
9. Pacific (AK, CA, HI, OR, WA)............................       130.62
------------------------------------------------------------------------

The Carve-Out Method

    In a swing-bed hospital, acute care services and long-term care 
services are furnished interchangeably. To determine payment for 
inpatient hospital services in a swing-bed hospital, section 1883(e) of 
the Act provides that the costs attributable to routine long-term care 
(SNF-type and ICF-type) services for all classes of patients are to be 
subtracted (``carved out'') from the total allowable inpatient cost for 
general inpatient routine services. The resulting amount represents the 
general inpatient routine costs applicable to hospital routine care. 
Once amounts attributable to SNF-type and ICF-type services have been 
carved out, the average per diem cost of general routine hospital 
services for swing-bed hospitals not subject to the prospective payment 
system is then determined by dividing the remaining amount by the total 
number of inpatient general routine hospital days (excluding SNF days 
and ICF days). This method was chosen to avoid imposing a burdensome 
cost finding process to allocate general routine service costs between 
hospital and long-term care.
    Swing-bed hospitals subject to the prospective payment system (PPS) 
are paid for SNF-type services in the same manner as any other swing-
bed hospital. The carve-out method would be used primarily to determine 
proper payment of pass-through costs. The prospective payment rates 
based on diagnosis related groups (DRGs) for inpatient hospital 
services under PPS are unaffected by the carve-out method.
    As stated above, with the enactment of OBRA 1987, effective October 
1, 1990, the distinction between SNFs and ICFs was eliminated under the 
Medicaid program and the two types of facility were combined under the 
term ``nursing facility'' (NF). This presented a problem in attempting 
to determine the amount of the carve-out. Since Medicaid payment is now 
determined based on a NF rate, the carve-out method could not be used 
as previously defined.
    The proposed rule revised Sec. 413.53(a)(2) to set forth our 
current policy regarding the carve-out method (presently explained in 
section 2230.5B of the Provider Reimbursement Manual) for SNF and NF 
services furnished on or after October 1, 1990. Under the revised 
carve-out method, the reasonable cost of hospital routine services is 
determined

[[Page 51615]]

by subtracting the reasonable costs attributable to routine SNF-type 
and NF-type services from total inpatient routine service costs. For 
swing-bed SNF days covered by Medicare, the amount subtracted, or 
carved out, is based on the regional Medicare swing-bed SNF rate. If, 
under the hold-harmless provision explained above, a swing-bed hospital 
is paid based on the swing-bed SNF rate that was in effect during the 
prior calendar year, that higher rate would also be used for purposes 
of calculating the reasonable cost of routine Medicare SNF days, to be 
subtracted from total routine costs under the carve-out method. For all 
non-Medicare swing-bed days, the amount subtracted is based on the 
average statewide rate paid for routine services in NFs under the State 
Medicaid plan during the prior calendar year, adjusted to approximate 
the average NF rate for the current calendar year. (The NF rate is used 
for non-Medicare covered swing-bed days because such services may 
encompass services that were formerly known as ICF and SNF-type 
services.)

Definitions

    As discussed above, effective for services furnished on or after 
October 1, 1990, the terms SNFs and ICFs were no longer to be used for 
the purpose of certifying a facility for the Medicaid program, in 
accordance with the provisions of OBRA 1987. Instead, they were 
replaced by the term ``nursing facility'' (NF). Effective October 1, 
1990, extended care services furnished by swing-bed hospitals to 
Medicaid and to other non-Medicare patients have been referred to as 
NF-type services.
    To reflect the above provisions, we are making changes to the 
definitions in Sec. 413.53(b) by (1) Revising the definition of 
``average cost per diem for general routine services''; (2) removing 
the definition of ``ICF-type services;'' (3) adding a definition of 
``nursing facility (NF)-type services;'' and (4) revising the 
definition of ``SNF-type services.''

III. Analysis of and Responses to Public Comments

    In response to the April 22, 1996 proposed rule, we received one 
item of correspondence from the American Health Care Association. The 
Association essentially supports the proposed rule in that it modifies 
the regulations to conform with policies that have been in existence 
since 1990, and that are contained in the Provider Reimbursement 
Manual. However, the commenter points out that rural hospitals with 
more than 49 beds but less than 100 beds are subject to an additional 
payment limitation. The Medicare payment for SNF services by the 
hospital may not be made for more than five days (excluding weekends 
and holidays), after a bed in a SNF becomes available in the geographic 
region, unless the patient's physician certifies within the five-day 
period that the transfer is not medically appropriate. The commenter is 
concerned that hospitals are not strictly adhering to the five-day 
rule.
    Response: We are not currently aware of any hospital that is 
violating the five-day rule. However, the hospital is subject to a 
periodic certification survey. It is during this survey that a sampling 
of the records for swing-bed patients is examined to ensure that the 
five-day rule is being followed correctly. Violators would endanger 
their continued certification as a swing-bed facility.
    In addition to this periodic certification survey, if someone is 
aware that a hospital is violating the five-day rule, he or she can 
contact the State Department of Licensure and Certification and request 
that a complaint survey be done. A complaint survey is done within a 
matter of weeks or months, which is much faster than the three to six 
years that a periodic one takes.

IV. Provisions of the Final Regulations

    This final rule incorporates the provisions of the proposed rule. 
The rates applicable to calendar year 1996 were not published in the 
proposed rule, but have been published in the Provider Reimbursement 
Manual. For the convenience of the reader, we are including them as 
Table G above in this final rule. Subsequent updates will be provided 
in the Provider Reimbursement Manual.

V. Impact Statement

    For final rules such as this, 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 a RFA, States and 
individuals are not considered small entities. However, providers are 
considered to be small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory flexibility analysis for any final rule that may have a 
significant impact on the operations of a substantial number of small 
rural hospitals. Such an analysis must conform to the provisions of 
section 604 of the RFA. With the exception of hospitals located in 
certain rural counties adjacent to urban ares, 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.
    In accordance with the provisions of section 1883 of the Act, as 
amended by section 4008(j) of OBRA 1990, this final rule revises the 
regulations to incorporate a new methodology for payment of routine 
extended care services provided in a swing-bed hospital. As the statute 
specifies, Medicare payment for these services is determined based on 
the average rate per patient day paid by Medicare for these same 
services provided in freestanding skilled nursing facilities (SNFs) in 
the region in which the hospital is located, during the most recent 
year for which cost reporting data are available. This final rule also 
provides that the reasonable cost for these services is the higher of 
the reasonable cost rates in effect for the current calendar year or 
for the previous calendar year.
    In addition to the changes mandated by section 4008(j) of OBRA 1990 
regarding payment for routine extended care services, we are changing 
to the out method of determining routine inpatient hospital costs of 
swing-bed hospitals. As discussed above, with the enactment of OBRA 
1987, the distinction between SNFs and ICFs was eliminated under the 
Medicaid program. Thus, the carve-out out method as described in 
Sec. 413.53(a)(2) for computing costs associated with routine SNF and 
ICF-type services cannot be used. This final rule codifies in 
regulations existing policy concerning the carve-out out method as set 
forth in section 2230.5B of the Provider Reimbursement Manual.
    As noted above, the major provisions of this final rule are 
required by section 1883 of the Act, as amended by section 4008(j) of 
OBRA 1990. Thus, a majority of the costs associated with these final 
rules are the result of legislation, and this rule, in and of itself, 
has little or no independent effect or burden. Although we are unable 
to provide a quantifiable estimate of impact, we note that the only 
discretionary aspect of this rule is to set forth in regulations our 
current policy concerning the carve-out out method. Codifying this 
existing policy would have no economic impact.
    Thus, we have determined, and we certify, that this final rule does 
not have a significant impact 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.

[[Page 51616]]

    In accordance with the provisions of Executive Order 12866, this 
final rule was not reviewed by the Office of Management and Budget.
    This is not a major rule as defined by U.S.C. 804(2).

V. 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 1995 (44 U.S.C. 3501 et seq.).

List of Subjects in 42 CFR Part 413

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

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, 1861(v)(1)(A), and 1871 of the Social 
Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh).

Subpart D--Apportionment

    2. Section 413.53 is amended by revising paragraph (a)(1)(ii)(C) 
and (a)(2); under paragraph (b), definition of ``average cost per diem 
for general routine services'', paragraph (2) is revised; the 
definition of ``ICF-type services'' is removed; a new definition of 
``nursing facility (NF) type services'' is added; and the definition of 
``SNF-type services'' is revised, to read as follows:


Sec. 413.53   Determination of cost of services to beneficiaries.

    (a) Principle. * * *
    (1) Departmental method
* * * * *
    (ii) Exception: Indirect cost of private rooms. For cost reporting 
periods starting on or after October 1, 1982, except with respect to a 
hospital receiving payment under part 412 of this chapter (relating to 
the prospective payment system), the additional cost of furnishing 
services in private room accommodations is apportioned to Medicare only 
if these accommodations are furnished to program beneficiaries, and are 
medically necessary. To determine routine service cost applicable to 
beneficiaries--
* * * * *
    (C) Effective October 1, 1990, do not include private rooms 
furnished for SNF-type and NF-type services under the swing-bed 
provision in the number of days in paragraphs (a)(1)(ii)(A) and (B) of 
this section.
    (2) Carve-out out method--(i) The carve-out out method is used to 
allocate hospital inpatient general routine service costs in a 
participating swing-bed hospital, as defined in Sec. 413.114(b). Under 
this method, effective for services furnished on or after October 1, 
1990, the reasonable costs attributable to the inpatient routine SNF-
type and NF-type services furnished to all classes of patients are 
subtracted from total inpatient routine service costs before computing 
the average cost per diem for inpatient routine hospital care.
    (ii) The cost per diem attributable to the routine SNF-type 
services covered by Medicare is based on the regional Medicare swing-
bed SNF rate in effect for a given calendar year, as described in 
Sec. 413.114(c). The Medicare SNF rate applies only to days covered and 
paid as Medicare days. When Medicare coverage runs out, the Medicare 
rate no longer applies.
    (iii) The cost per diem attributable to all non-Medicare swing-bed 
days is based on the average statewide Medicaid NF rate for the prior 
calendar year, adjusted to approximate the average NF rate for the 
current calendar year.
    (iv) The sum of total Medicare SNF-type days multiplied by the cost 
per diem attributable to Medicare SNF-type services and the total NF-
type days multiplied by the cost per diem attributable to all non-
Medicare days is subtracted from total inpatient general routine 
service costs. The cost per diem for inpatient routine hospital care is 
computed based on the remaining inpatient routine service costs.
* * * * *
    (b) Definitions. As used in this section--
* * * * *
    Average cost per diem for general routine services means the 
following:
* * * * *
    (2) For swing-bed hospitals, the amount computed by--(i) 
Subtracting the routine costs associated with Medicare SNF-type days 
and non-Medicare NF-type days from the total allowable inpatient cost 
for routine services (excluding the cost of services provided in 
intensive care units, coronary care units, and other intensive care 
type inpatient hospital units and nursery costs); and
    (ii) Dividing the remainder (excluding the total private room cost 
differential) by the total number of inpatient hospital days of care 
(excluding Medicare SNF-type days and non-Medicare NF-type days of 
care, days of care in intensive care units, coronary care units, and 
other intensive care type inpatient hospital units; and newborn days; 
but including total private room days).
* * * * *
    Nursing facility (NF)-type services, formerly known as ICF and SNF-
type services, are routine services furnished by a swing-bed hospital 
to Medicaid and other non-Medicare patients. Under the Medicaid 
program, effective October 1, 1990, facilities are no longer certified 
as SNFs or ICFs but instead are certified only as NFs and can provide 
services as defined in section 1919(a)(1) of the Act.
* * * * *
    Skilled nursing facility (SNF)-type services are routine services 
furnished by a swing-bed hospital that would constitute extended care 
services if furnished by an SNF. SNF-type services include routine SNF 
services furnished in the distinct part SNF of a hospital complex that 
is combined with the hospital general routine service area cost center 
under Sec. 413.24(d)(5). Effective October 1, 1990, only Medicare 
covered services are included in the definition of SNF-type services.
* * * * *

Subpart F--Specific Categories of Costs

    3. In Sec. 413.114, paragraphs (c)(1) and (2) are removed, 
paragraph (c)(3) is redesignated as paragraph (c)(2), and a new 
paragraph (c)(1) is added to read as follows:


Sec. 413.114   Payment for posthospital SNF care furnished by a swing-
bed hospital.

* * * * *
    (c) Principle. The reasonable cost of posthospital SNF care 
furnished by a swing-bed hospital is determined as follows:
    (1) The reasonable cost of routine SNF services is based on the 
average Medicare rate per patient day for routine services provided in 
freestanding SNFs in the region where the swing-bed hospital is 
located. The rates are calculated using the regions as defined in 
section 1886(d)(2)(D) of the Social Security Act. The rates are based 
on the most recent year for which settled cost reporting period data 
are available, increased in a compounded manner, using the increase 
applicable to the SNF routine cost limits, up to and including the 
calendar year for which the rates are in effect. If the current 
Medicare swing-bed rate for routine extended care services furnished by 
a swing-bed

[[Page 51617]]

hospital during a calendar year is less than the rate for the prior 
calendar year, payment is made based on the prior calendar year's rate.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance;) Catalog of Federal Domestic 
Assistance Program No. 93.778, Medical Assistance Program)

    Dated: September 3, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 96-25282 Filed 10-2-96; 8:45 am]
BILLING CODE 4120-01-P