[Federal Register Volume 61, Number 206 (Wednesday, October 23, 1996)]
[Notices]
[Pages 55002-55009]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-27290]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[OACT-052-N]
RIN 0938-AH42


Medicare Program; Monthly Actuarial Rates and Monthly 
Supplementary Medical Insurance Premium Rate Beginning January 1, 1997

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

ACTION: Notice.

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SUMMARY: As required by section 1839 of the Social Security Act, this 
notice announces the monthly actuarial rates for aged (age 65 or over) 
and disabled (under age 65) enrollees in the Medicare Supplementary 
Medical Insurance (SMI) program for 1997. It also announces the monthly 
SMI premium rate to be paid by all enrollees during 1997. The monthly 
actuarial rates for 1997 are $87.50 for aged enrollees and $110.40 for 
disabled enrollees. The monthly SMI premium rate for 1997 is $43.80.

EFFECTIVE DATE: January 1, 1997.
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
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the GPO Access User Support Team by sending Internet e-mail to 
help@eids05.;eids gpo.gov; by faxing to (202) 512-1252; or by calling 
(202) 512-1530 between 7 a.m. and 5 p.m. Eastern time, Monday through 
Friday, except for Federal holidays.

FOR FURTHER INFORMATION CONTACT:
Carter S. Warfield, (410) 786-6396.

SUPPLEMENTARY INFORMATION:

I. Background

    The Medicare Supplementary Medical Insurance (SMI) program is the 
voluntary Medicare part B program that pays all or part of the costs 
for physicians' services, outpatient hospital services, home health 
services, services furnished by rural health clinics, ambulatory 
surgical centers, comprehensive outpatient rehabilitation facilities, 
and certain other medical and health services not covered by hospital 
insurance (Medicare Part A). The SMI program is available to 
individuals who are entitled to hospital insurance and to U.S. 
residents who have attained age 65 and are citizens, or aliens who were 
lawfully admitted for permanent residence and have resided in the 
United States for 5 consecutive years. This program requires enrollment 
and payment of monthly premiums, as provided in 42 CFR part 407, 
subpart B, and part 408, respectively. The difference between the 
premiums paid by all enrollees and total incurred costs is met from the 
general revenues of the Federal government.
    The Secretary of Health and Human Services is required by section 
1839 of the Social Security Act (the Act) to issue two annual notices 
relating to the SMI program.
    One notice announces two amounts that, according to actuarial 
estimates, will equal respectively, one-half the expected average 
monthly cost of SMI for each aged enrollee (age 65 or over) and one-
half the expected average monthly cost of SMI for each disabled 
enrollee (under age 65) during the year beginning the following 
January. These amounts are called ``monthly actuarial rates.''
    The second notice announces the monthly SMI premium rate to be paid 
by aged and disabled enrollees for the year beginning the following 
January. (Although the costs to the program per disabled enrollee are 
different than for the aged, the law provides that they pay the same 
premium amount.) Beginning with the passage of section 203 of the 
Social Security Amendments of 1972 (Public Law 92-603), enacted on 
October 30, 1972, the premium rate, which was determined on a fiscal 
year basis, was limited to the lesser of the actuarial rate for aged 
enrollees, or the current monthly premium rate increased by the same 
percentage as the most recent general increase in monthly title II 
social security benefits.
    However, the passage of section 124 of the Tax Equity and Fiscal 
Responsibility Act of 1982 (TEFRA) (Public Law 97-248), enacted on 
September 3, 1982, suspended this premium determination process. 
Section 124 of TEFRA changed the premium basis to 50 percent of the 
monthly actuarial rate for aged enrollees (that is, 25 percent of 
program costs for aged enrollees). Section 606 of the Social Security 
Amendments of 1983 (Public Law 98-21), enacted on April 20, 1983; 
section 2302 of the Deficit Reduction Act of 1984 (DRA) (Public Law 98-
369), enacted on July 18, 1984; section 9313 of the Consolidated 
Omnibus Budget Reconciliation Act of 1985 (COBRA 1985) (Public Law 99-
272), enacted on April 7, 1986; section 4080 of the Omnibus Budget 
Reconciliation Act of 1987 (OBRA 1987) (Public Law 100-203), enacted on 
December 22, 1987; and section 6301 of the Omnibus Budget 
Reconciliation Act of 1989 (OBRA 1989) (Public Law 101-239), enacted on 
December 19, 1989, extended the provision that the premium be based on 
50 percent of the monthly actuarial rate for aged enrollees (that is, 
25 percent of program costs for aged enrollees). This extension expired 
at the end of 1990.
    The premium rate for 1991 through 1995 was legislated by section 
1839(e)(1)(B) of the Act, as added by section 4301 of the Omnibus 
Budget

[[Page 55003]]

Reconciliation Act of 1990 (OBRA 1990) (Public Law 101-508), enacted on 
November 5, 1990. In January 1996, the premium determination basis 
would have reverted to the method established by the 1972 Social 
Security Act Amendments. However, section 13571 of the Omnibus Budget 
Reconciliation Act of 1993 (OBRA 1993) (Public Law 103-66), enacted on 
August 10, 1993, changed the premium basis to 50 percent of the monthly 
actuarial rate for aged enrollees (that is, 25 percent of program costs 
for aged enrollees) for 1996 through 1998. In January 1999, the premium 
determination basis will revert to the method established by the 1972 
Social Security Act Amendments.
    As determined according to section 1839(a)(3) of the Act, the 
premium rate for 1997 is $43.80.
    A further provision affecting the calculation of the SMI premium is 
section 1839(f) of the Act, as amended by section 211 of the Medicare 
Catastrophic Coverage Act of 1988 (Public Law 100-360), enacted on July 
1, 1988. (The Medicare Catastrophic Coverage Repeal Act of 1989 (Public 
Law 101-234), enacted on December 13, 1989, did not repeal the 
revisions to section 1839(f) made by Public Law 100-360.) Section 
1839(f) provides that if an individual is entitled to benefits under 
section 202 or 223 of the Act (the Old-Age and Survivors Insurance 
Benefit and the Disability Insurance Benefit, respectively) and has the 
SMI premiums deducted from these benefit payments, the premium increase 
will be reduced to avoid causing a decrease in the individual's net 
monthly payment. This occurs if the increase in the individual's social 
security benefit due to the cost-of-living adjustment under section 
215(i) of the Act is less than the increase in the premium. 
Specifically, the reduction in the premium amount applies if the 
individual is entitled to benefits under section 202 or 223 of the Act 
for November and December of a particular year and the individual's SMI 
premiums for December and the following January are deducted from the 
respective month's section 202 or 223 benefits. (A check for benefits 
under section 202 or 223 is received in the month following the month 
for which the benefits are due. The SMI premium that is deducted from a 
particular check is the SMI payment for the month in which the check is 
received. Therefore, a benefit check for November is not received until 
December, but has the December's SMI premium deducted from it.) (This 
change, in effect, perpetuates former amendments that prohibited SMI 
premium increases from reducing an individual's benefits in years in 
which the dollar amount of the individual's cost-of-living increase in 
benefits was not at least as great as the dollar amount of the 
individual's SMI premium increase.)
    Generally, if a beneficiary qualifies for this protection (that is, 
the beneficiary must have been in current payment status for November 
and December of the previous year), the reduced premium for the 
individual for that January and for each of the succeeding 11 months 
for which he or she is entitled to benefits under section 202 or 223 of 
the Act is the greater of the following:
    (1) The monthly premium for January reduced as necessary to make 
the December monthly benefits, after the deduction of the SMI premium 
for January, at least equal to the preceding November's monthly 
benefits, after the deduction of the SMI premium for December; or
    (2) The monthly premium for that individual for that December.
    In determining the premium limitations under section 1839(f) of the 
Act, the monthly benefits to which an individual is entitled under 
section 202 or 223 do not include retroactive adjustments or payments 
and deductions on account of work. Also, once the monthly premium 
amount has been established under section 1839(f) of the Act, it will 
not be changed during the year even if there are retroactive 
adjustments or payments and deductions on account of work that apply to 
the individual's monthly benefits.
    Individuals who have enrolled in the SMI program late or have 
reenrolled after the termination of a coverage period are subject to an 
increased premium under section 1839(b) of the Act. That increase is a 
percentage of the premium and is based on the new premium rate before 
any reductions under section 1839(f) are made.

II. Notice of Monthly Actuarial Rates and Monthly Premium Rate

    The monthly actuarial rates applicable for 1997 are $87.60 for 
enrollees age 65 and over, and $110.40 for disabled enrollees under age 
65. Section III of this notice gives the actuarial assumptions and 
bases from which these rates are derived. The monthly premium rate will 
be $43.80 during 1997.

III. Statement of Actuarial Assumptions and Bases Employed in 
Determining the Monthly Actuarial Rates and the Monthly Premium Rate 
for the Supplementary Medical Insurance Program Beginning January 1997

A. Actuarial Status of the Supplementary Medical Insurance Trust Fund

    Under the law, the starting point for determining the monthly 
premium is the amount that would be necessary to finance the SMI 
program on an incurred basis; that is, the amount of income that would 
be sufficient to pay for services furnished during that year (including 
associated administrative costs) even though payment for some of these 
services will not be made until after the close of the year. The 
portion of income required to cover benefits not paid until after the 
close of the year is added to the trust fund and used when needed.
    The rates are established prospectively and are, therefore, subject 
to projection error. Additionally, legislation enacted after the 
financing has been established but, effective for the period for which 
the financing has been set, may affect program costs. As a result, the 
income to the program may not equal incurred costs. Therefore, trust 
fund assets should be maintained at a level that is adequate to cover a 
moderate degree of variation between actual and projected costs in 
addition to the amount of incurred but unpaid expenses. An appropriate 
level for assets to cover a moderate degree of variation between actual 
and projected costs depends on numerous factors. The most important of 
these factors are: (1) The difference from prior years between the 
actual performance of the program and estimates made at the time 
financing was established, and (2) the expected relationship between 
incurred and cash expenditures. Ongoing analysis is made of the former 
as the trends in the differences vary over time.
    Table 1 summarizes the estimated actuarial status of the trust fund 
as of the end of the financing period for 1995 and 1996.

[[Page 55004]]



    Table 1.--Estimated Actuarial Status of the Supplementary Medical   
       Insurance Trust Fund as of the End of the Financing Period       
                        [In billions of dollars]                        
------------------------------------------------------------------------
                                                             Assets less
      Financing period ending          Assets   Liabilities  liabilities
------------------------------------------------------------------------
Dec. 31, 1995......................    $20.023      $2.726      $17.297 
Dec. 31, 1996......................     25.078       3.596       21.482 
------------------------------------------------------------------------

B. Monthly Actuarial Rate for Enrollees Age 65 and Older

    The monthly actuarial rate for enrollees age 65 and older is one-
half of the monthly projected cost of benefits and administrative 
expenses for each enrollee age 65 and older, adjusted to allow for 
interest earnings on assets in the trust fund and a contingency margin. 
The contingency margin is an amount appropriate to provide for a 
moderate degree of variation between actual and projected costs and to 
amortize any surplus or unfunded liabilities.
    The monthly actuarial rate for enrollees age 65 and older for 1997 
was determined by first establishing per-enrollee cost by type of 
service from program data through 1994 and then projecting these costs 
for subsequent years. Although the actuarial rates are now applicable 
for calendar years, projections of per-enrollee costs were determined 
on a July to June period, consistent with the July annual fee screen 
update used for benefits before the passage of section 2306(b) of 
Public Law 98-369.
    Accordingly, the values for the 12-month period ending June 30, 
1994 were established from program data, and subsequent periods were 
projected using a combination of program data and data from external 
sources. The projection factors used are shown in Table 2. Those per-
enrollee values are then adjusted to apply to a calendar year period. 
The projected values for financing periods from January 1, 1994, 
through December 31, 1997, are shown in Table 3.
    The projected monthly rate required to pay for one-half of the 
total of benefits and administrative costs for enrollees age 65 and 
over for 1997 is $89.27. The monthly actuarial rate of $87.60 provides 
an adjustment of -$1.54 for interest earnings and -$0.13 for a 
contingency margin. Based on current estimates, it appears that the 
assets are more than sufficient to cover the amount of incurred but 
unpaid expenses and to provide for a moderate degree of variation 
between actual and projected costs. Thus, a negative contingency margin 
is needed to reduce assets to a more appropriate level.

C. Monthly Actuarial Rate for Disabled Enrollees

    Disabled enrollees are those persons enrolled in SMI because of 
entitlement (before age 65) to disability benefits for more than 24 
months or because of entitlement to Medicare under the end-stage renal 
disease program. Projected monthly costs for disabled enrollees (other 
than those suffering from end-stage renal disease) are prepared in a 
fashion exactly parallel to the projection for the aged, using 
appropriate actuarial assumptions (see Table 2). Costs for the end-
stage renal disease program are projected differently because of the 
different nature of services offered by the program. The combined 
results for all disabled enrollees are shown in Table 4.
    The projected monthly rate required to pay for one-half of the 
total of benefits and administrative costs for disabled enrollees for 
1997 is $110.28. The monthly actuarial rate of $110.40 provides an 
adjustment of -$0.82 for interest earnings and $0.94 for a contingency 
margin. Based on current estimates, it appears that assets alone are 
not sufficient to cover the amount of incurred but unpaid expenses and 
to provide for a moderate degree of variation between actual and 
projected costs. Thus, a positive contingency margin is needed to build 
assets to more appropriate levels.

D. Sensitivity Testing

    Several factors contribute to uncertainty about future trends in 
medical care costs. In view of this, it is appropriate to test the 
adequacy of the rates announced here using alternative assumptions. The 
most unpredictable factors that contribute significantly to future 
costs are outpatient hospital costs, physician residual (as defined in 
Table 2), and increases in physician fees as governed by the program's 
physician fee schedule that began implementation January 1, 1992. Two 
alternative sets of assumptions and the results of those assumptions 
are shown in Table 5. One set represents increases that are lower and 
is, therefore, more optimistic than the current estimate. The other set 
represents increases that are higher and is, therefore, more 
pessimistic than the current version. The values for the alternative 
assumptions were determined by studying the average historical 
variation between actual and projected increases in the respective 
increase factors. All assumptions not shown in Table 5 are the same as 
in Table 2.
    Table 5 indicates that, under the assumptions used in preparing 
this report, the monthly actuarial rates would result in an excess of 
assets over liabilities of $21.453 billion by the end of December 1997. 
This amounts to 24.2 percent of the estimated total incurred 
expenditures for the following year. Assumptions that are somewhat more 
pessimistic (and, therefore, test the adequacy of the assets to 
accommodate projection errors) produce a surplus of $7.538 billion by 
the end of December 1997, which amounts to 7.7 percent of the estimated 
total incurred expenditures for the following year. Under fairly 
optimistic assumptions, the monthly actuarial rates would result in a 
surplus of $34.382 billion by the end of December 1997, which amounts 
to 42.7 percent of the estimated total incurred expenditures for the 
following year.

E. Premium Rate

    As determined by section 1839(a)(3) of the Act, the monthly premium 
rate for 1997, for both aged and disabled enrollees, is $43.80.

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IV. Waiver of Notice of Proposed Rulemaking

    The Medicare statute, as discussed previously, requires publication 
of the monthly actuarial rates and the Part B premium amount in 
September. The amounts are determined according to the statute. As has 
been our custom, we use general notices, rather than formal notice and 
comment rulemaking procedures, to make such announcements. In doing so, 
we acknowledge that, under the Administrative Procedure Act, 
interpretive rules, general statements of policy, and rules of agency 
organization, procedure or practice are excepted from the requirements 
of notice and comment rulemaking.
    We considered publishing a proposed notice to provide a period for 
public comment. However, we may waive that procedure if we find good 
cause that prior notice and comment are impracticable, unnecessary, or 
contrary to the public interest. We find that the procedure for notice 
and comment is unnecessary because the formula used to calculate the 
SMI premium is statutorily directed, and we can exercise no discretion 
in following that formula. Moreover, the statute establishes the time 
period for which the premium rates will apply and delaying publication 
of the SMI premium rate would be contrary to the public interest. 
Therefore, we find good cause to waive publication of a proposed notice 
and solicitation of public comments.
    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

(Section 1839 of the Social Security Act; 42 U.S.C. 1395r)

(Catalog of Federal Domestic Assistance Program No. 93.774, 
Medicare--Supplementary Medical Insurance)

    Dated: September 26, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: October 2, 1996.
Donna E. Shalala,
Secretary.
[FR Doc. 96-27290 Filed 10-21-96; 12:15 pm]
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