[Federal Register Volume 68, Number 189 (Tuesday, September 30, 2003)]
[Notices]
[Pages 56478-56508]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-24817]



[[Page 56477]]

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

Part X





Department of Health and Human Services





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



Centers for Medicare & Medicaid Services



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



Medicare Program; Hospice Wage Index for Fiscal Year 2004; Notice

  Federal Register / Vol. 68, No. 189 / Tuesday, September 30, 2003 / 
Notices  

[[Page 56478]]


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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1233-N]
RIN 0938-AM67


Medicare Program; Hospice Wage Index for Fiscal Year 2004

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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

SUMMARY: This notice announces the annual update to the hospice wage 
index as required by statute. This fiscal year 2004 update is effective 
from October 1, 2003 through September 30, 2004. The wage index is used 
to reflect local differences in wage levels. The hospice wage index 
methodology and values are based on recommendations of a negotiated 
rulemaking advisory committee and were originally published in the 
August 8, 1997 Federal Register.

EFFECTIVE DATE: October 1, 2003.

FOR FURTHER INFORMATION CONTACT: Terri Deutsch, (410) 786-9462.

SUPPLEMENTARY INFORMATION:

I. Background

    Hospice care is an approach to treatment that recognizes that the 
impending death of an individual warrants a change in the focus from 
curative care to palliative care (relief of pain and other 
uncomfortable symptoms). The goal of hospice care is to help terminally 
ill individuals continue life with minimal disruption to normal 
activities while remaining primarily in the home environment. A hospice 
uses an interdisciplinary approach to deliver medical, social, 
psychological, emotional, and spiritual services through use of a broad 
spectrum of professional and other caregivers, with the goal of making 
the individual as physically and emotionally comfortable as possible. 
Counseling and inpatient respite services are available to the family 
of the hospice patient. Hospice programs consider both the patient and 
the family as a unit of care.
    Section 1861(dd) of the Social Security Act (the Act) provides for 
coverage of hospice care for terminally ill Medicare beneficiaries who 
elect to receive care from a participating hospice. The statutory 
authority for payment to hospices participating in the Medicare program 
is contained in section 1814(i) of the Act.
    Our existing regulations under 42 CFR part 418 establish 
eligibility requirements and payment standards and procedures, define 
covered services, and delineate the conditions a hospice must meet to 
be approved for participation in the Medicare program. Subpart G of 
part 418 provides for payment to hospices based on one of four 
prospectively determined rates for each day in which a qualified 
Medicare beneficiary is under the care of a hospice. The four rate 
categories are routine home care, continuous home care, inpatient 
respite care, and general inpatient care. Payment rates are established 
for each category.
    The regulations at Sec.  418.306(c), which require the rates to be 
adjusted by a wage index, were revised in the August 8, 1997 final rule 
(62 FR 42860). This rule implemented a new methodology for calculating 
the hospice wage index based on the recommendations of a negotiated 
rulemaking committee. The committee reached consensus on the 
methodology. We included the resulting committee statement, describing 
that consensus, as an appendix to the August 8, 1997 final rule (62 FR 
42883). The provisions of the final hospice wage index rule are as 
follows:
    [sbull] The revised hospice wage index will be calculated using the 
most current available hospital wage data.
    [sbull] The revised hospice wage index was phased in over a 3-year 
transition period. For the first year of the transition period, October 
1, 1997 through September 30, 1998, a blended index was calculated by 
adding two-thirds of the 1983 index value for an area to one-third of 
the revised wage index value for that area. During the second year of 
the transition period, October 1, 1998 through September 30, 1999, the 
calculation was similar, except that the blend was one-third of the 
1983 index value and two-thirds of the revised wage index value for 
that area. We fully implemented the revised wage index during the third 
year of the transition period, October 1, 1999 through September 30, 
2000.
    Payments to hospices under the revised wage index (as published in 
the August 8, 1997 final hospice wage index rule) are subject to a 
budget neutrality adjustment to ensure that aggregate payments are not 
greater than they would have been using the original 1983 wage index. 
To achieve this budget neutrality, the hospice wage index is multiplied 
by a budget-neutrality factor. The budget neutrality factor is computed 
and applied annually.
    The hospice budget-neutrality adjustment is not applied uniformly 
to all providers in calculating payments. Based on the methodology 
developed and signed by the negotiated rulemaking committee and adopted 
by CMS, a hospice's area wage index is adjusted using either the 
budget-neutrality factor or the hospice wage index floor described 
below.
    Hospice wage index values of 0.8 or greater are multiplied by the 
budget neutrality factor.
    Hospice wage index values below 0.8 are adjusted by the greater of: 
(1) the hospice budget neutrality factor; or (2) the hospice wage index 
floor (a 15 percent increase, subject to a maximum wage index value of 
0.8).
    The wage index is to be updated annually, in the Federal Register, 
based on the most current available hospital wage data. These data will 
include any changes to the definitions of Metropolitan Statistical 
Areas (MSAs).
    Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended 
section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice 
rates for fiscal years (FYs) 1998 through 2002. Hospice rates were to 
be updated by a factor equal to the market basket index, minus 1 
percentage point. However, neither the BBA nor subsequent legislation 
specified the market basket adjustment to be used to compute payment 
for FY 2004. Therefore, payment rates for FY 2004 will be updated 
according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states 
that the update to the payment rates after 2002 will be the market 
basket percentage for the FY. Accordingly, the FY 2004 rates will be 
the full market basket percentage increase for the FY 2004. This rate 
update is implemented through a separate program memorandum and is not 
part of this notice. Historically the rate update has been published 
through a separate program memorandum issued annually in July to 
provide adequate time to implement system change requirements. For FY 
2004 the hospice rates were published on July 3, 2003. The wage index 
in this notice is applied to the labor portion of the rates published 
in the program memorandum in order for providers to determine their 
payment rates.

II. Provisions of the Notice

A. Update to the Hospice Wage Index

    This annual update is effective October 1, 2003 through September 
30, 2004. In accordance with the agreement we signed with other members 
of the Hospice Wage Index Negotiated Rulemaking Committee, we are using 
the most current hospital data available to us, including any changes 
to the

[[Page 56479]]

definitions of MSAs. The FY 2003 hospital wage index was the most 
current hospital wage data available when the FY 2004 wage index values 
were calculated. We used the pre-reclassified and pre-floor hospital 
area wage index data.
    All wage index values are adjusted by a budget-neutrality factor of 
1.061238 and are subject to the wage index floor adjustment, if 
applicable. We have completed all of the calculations described above 
and have included them in the wage index values reflected in both 
Tables A and B below. A detailed description of the method used to 
compute the hospice wage index is contained in both the September 4, 
1996 proposed rule (61 FR 46579) and the August 8, 1997 final rule (62 
FR 42860).
1. Metropolitan Statistical Areas (MSA)
    As explained in the September 4, 1996 hospice wage index proposed 
rule, each hospice's labor market area would be established by the MSA 
definitions issued by the Office of Management and Budget (OMB) on 
December 28, 1992 based on the 1990 census, and updated by OMB based on 
the decennial census. Any changes to the MSA definitions would be 
effective annually and announced in the notice updating the hospice 
wage index.
2. MSA Wage Index Values Lower Than Rural Values
    As explained above, any area not included in an MSA is considered 
to be nonurban and receives the statewide rural rate. We are aware that 
in the past, a number of MSAs have had wage index values that were 
lower than their rural statewide value. This difference is due to 
variations in local wage data as compared to national wage data. The 
hospice wage index is computed by dividing the hourly wage rate for an 
MSA or nonurban area by a national hourly wage rate. Nonurban areas 
could receive a higher wage index value than urban areas in the same 
State if the hourly wage rate in the nonurban area increased at a 
greater rate.

B. Tables

BILLING CODE 4120-01-P

[[Page 56480]]

[GRAPHIC] [TIFF OMITTED] TN30SE03.010


[[Page 56481]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.011


[[Page 56482]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.012


[[Page 56483]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.013


[[Page 56484]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.014


[[Page 56485]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.015


[[Page 56486]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.016


[[Page 56487]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.017


[[Page 56488]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.018


[[Page 56489]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.019


[[Page 56490]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.020


[[Page 56491]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.021


[[Page 56492]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.022


[[Page 56493]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.023


[[Page 56494]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.024


[[Page 56495]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.025


[[Page 56496]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.026


[[Page 56497]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.027


[[Page 56498]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.028


[[Page 56499]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.029


[[Page 56500]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.030


[[Page 56501]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.031


[[Page 56502]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.032


[[Page 56503]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.033


[[Page 56504]]


[GRAPHIC] [TIFF OMITTED] TN30SE03.034

BILLING CODE 4120-01-C

III. Waiver of Proposed Rulemaking and Waiver of 30-Day Delay in 
Effective Date

    We are waiving notice and comment rulemaking, as well as the 30-day 
delay in the effective date, before the provisions of this notice take 
effect. We may waive notice and comment rulemaking procedures if we 
find good cause to do so (that is, notice and comment procedures are 
impracticable, unnecessary, or contrary to the public interest) and the 
agency incorporates a statement of the finding and the reasons for 
waiver in the notice issued.
    In addition, under the Administrative Procedure Act (5 U.S.C. 
section 553 (d)), an agency may waive the 30-day delay in the effective 
date if the agency finds good cause to do so (meaning, once again, that 
the delay is impracticable, unnecessary, or contrary to the public 
interest), and the agency incorporates a statement of the finding and 
its reasons in the rule at the time it is issued.
    We find it unnecessary to undertake notice and comment rulemaking 
because the methodologies used to determine the hospice wage index have 
been previously subjected to public comments, and this notice merely 
reflects the application of those previously established methodologies. 
In this notice, we are not changing the methodologies, but merely 
performing the ministerial function of applying methodologies 
previously subject to notice and public comment. Therefore, we believe 
it is unnecessary to engage in notice and comment rulemaking and for 
good cause, we waive notice and comment procedures.
    We also believe that good cause exists to waive both notice and 
comment rulemaking and the 30-day delay in the effective date, because 
it is in the public interest to make this notice effective on October 
1, 2003. The statute in 1814(i)(1)(C)(ii)(VII) of the Act requires 
annual updates to the hospice payment rates and wage indices. In 
addition, the Federal Regulations at 42 CFR 418.306(b)(2) and (c) 
require annual updates to hospice wage indices and require that such 
updates be effective for the FY, beginning on October 1. We do not have 
sufficient time to either engage in notice and comment rulemaking or 
apply a 30-day delay in the effective date prior to such date. 
Moreover, if we do not make this notice effective on the implementation 
date of October 1, 2003, the hospice agencies would be required to 
continue to use the previous 2003 FY wage index for the 2004 payment 
rates.
    Finally, for the reasons stated above, at this time, we believe it 
would be impracticable to both meet the requirement that updated rates 
be in effect by October 1, 2003, and also engage in notice and comment 
rulemaking or apply the 30-day delay in the effective date prior to 
that date.
    Therefore, for the reasons stated above, we find there is good 
cause to waive notice and comment procedures, as well as the 30-day 
delay in the effective date of the Administrative Procedure Act.

IV. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this notice as required by 
Executive Order 12866 (September 1993, Regulatory Planning and Review), 
the Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-
354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of 
1995 (Pub. L. 104-4), and Executive Order 13132. In this notice, we 
identified the impact on hospices as a result of updating the hospice 
wage index. The methodology for computing the wage index for FY 2004 
was determined through a negotiated rulemaking committee and 
implemented in the August 8, 1997 final rule (62 FR 42860). This notice 
only updates the hospice wage index in accordance with that 
methodology. We

[[Page 56505]]

believe these changes to be insignificant. As Table C below indicates, 
we estimate that the total hospice payments will increase from last 
year by 0.6 percent, or $24,271,000.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). We have 
determined that this notice is not an economically significant rule 
under this Executive Order.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and government agencies. 
Most hospitals and most other providers and suppliers are small 
entities, either by nonprofit status or by having revenues of $6 
million to $29 million in any 1 year (for details, see the Small 
Business Administration's regulation at 65 FR 69432. that sets forth 
size standards for health care industries). For purposes of the RFA, 
most hospices are small entities. Approximately 70 percent of Medicare 
certified hospices are identified as voluntary, government, or other 
agencies, and, therefore, are considered small entities. Because the 
National Hospice and Palliative Care Organization estimates that 
approximately 79 percent of hospice patients are Medicare 
beneficiaries, we have not considered other sources of revenue in this 
analysis.
    As discussed below, rural hospices will receive a slight increase 
in payment. Overall rural hospices will receive an increase of 0.9 
percent and urban hospices will receive an increase of 0.6 percent. 
Urban hospices in New England, Middle-Atlantic, and Puerto Rico regions 
will experience a decrease of 0.4 percent, 1.1 percent, and 0.5 percent 
respectively. Middle Atlantic and Puerto Rico rural regions will also 
experience a decrease of 0.7 and 5.1 percent respectively. Of the urban 
hospices, the Pacific region will experience the greatest increase of 
2.3 percent. The remaining rural regions will experience an increase in 
payment ranging from 0.2 in New England to a 2.6 increase in West South 
Central. Puerto Rico will experience decreased payment in both its 
urban and rural areas. Overall, Puerto Rico rural hospices will receive 
the largest decrease of 5.1 percent. The Middle Atlantic rural and 
urban hospices will also receive decreased payment. Most regions will 
experience an increase in payment in both urban and rural regions. The 
South Atlantic urban and East North Central rural hospices will 
experience a slight increase of 0.1 percent respectively. Therefore, 
based upon analysis of the wage index changes for FY 2004, the urban 
and rural Puerto Rico and Middle Atlantic hospices will be negatively 
impacted the most. The Pacific and West South Central urban regions as 
well as the West South Central and South Atlantic rural regions will be 
positively impacted. The payment decreases in certain areas indicate 
that this notice will have an impact on a small number of small 
entities. However, nationwide, hospices will receive an overall 
increase in estimated payments. We estimate that total hospice payments 
will increase by 0.6 percent, or $24,271,000. Rural hospices, with the 
exception of Puerto Rico and Middle Atlantic regions will receive the 
largest increase in payments for FY 2004. We estimate that rural 
hospice payments overall will increase by $4,284,000. We believe the 
anomaly of Puerto Rico rural region, with the greatest decrease overall 
in payment, the West South Central rural region increase of 2.6 
percent, and the Pacific urban region increase of 2.3 percent are 
attributable to changes in the MSA hospital wage indices.
    Under the Medicare hospice benefit, hospices can provide four 
different levels of care days. The majority of the days provided by a 
hospice are routine home care days. Therefore, the number of routine 
home care days can be used as a proxy for the size of the hospice, that 
is, the more days of care provided, the larger the hospice. Using 
routine home care days as a proxy for size, our analysis indicates that 
the impact of the wage index update on small hospices (those that 
provide up to 1,754 days of routine home care) will experience a 1.3 
percent increase. Rural Puerto Rico with 4 hospices and 28,000 routine 
care days will experience a decrease of 5.1 percent while rural West 
North Central with 178 hospices and 492,000 routine home care days will 
have an increase of 0.8 percent. However, most small entities will 
experience a slight increase in payment. Therefore, we certify that 
this rule will not have a significant impact on a substantial number of 
small entities, in accordance with the RFA.
    Furthermore, the wage index methodology was previously determined 
by consensus through a negotiated rulemaking committee that included 
representatives of national hospice associations; rural, urban, large 
and small hospices; multi-site hospices; and consumer groups. Based on 
all of the options considered, the committee agreed on the methodology 
described in the committee statement, and it was adopted into 
regulation in the August 8, 1997 final rule. The committee also agreed 
that this was favorable for the hospice community, as well as for 
beneficiaries. In developing the process for updating the wage index in 
the 1997 final rule, we fully considered the impact of this methodology 
on small entities and attempted to mitigate any potential negative 
effects.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside an MSA and has fewer 
than 100 beds. We have determined that this notice will not have a 
significant impact on a substantial number of small rural hospices.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in an expenditure in any 1 year by 
State, local, and tribal governments, in the aggregate, or by the 
private sector, of $110 million or more. This notice has no substantial 
effect on State, local or tribal governments or on the private sector. 
We have determined that this notice will not have a significant impact 
on the operations of a substantial number of small rural hospitals.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have reviewed this notice under the threshold criteria 
of Executive Order 13132, Federalism, and have determined that this 
notice will not have an impact on the rights, roles, and 
responsibilities of State, local, or tribal governments.

B. Anticipated Effects

    We have compared estimated payments using the FY 1983 hospice wage 
index to estimated payments using the FY 2004 wage index and determined 
the current hospice rates to be budget

[[Page 56506]]

neutral. This impact analysis compares hospice payments using the FY 
2003 hospice wage index to the estimated payments using the FY 2004 
wage index. The data used in developing the quantitative analysis for 
this notice were obtained from the March 2003 update of the national 
claims history file of all bills submitted during FY 2002. We deleted 
bills from hospices that have since closed.
    Table C below demonstrates the results of our analysis. In column 2 
of Table C, we indicate the number of routine home care days that were 
included in our analysis, although the analysis was performed on all 
types of hospice care. Column 3 of Table C indicates payments that were 
made using the FY 2003 wage index. Column 4 of Table C is based on FY 
2003 claims (for hospices in business during that time period) and 
estimates payments to be made to hospices using the FY 2004 wage index. 
The final column, which compares columns 3 and 4, shows the percent 
change in estimated hospice payments made based on the category of the 
hospice.
    Table C categorizes hospices by various geographic and provider 
characteristics. The first row displays the results of the impact 
analysis for all Medicare certified hospices. The second and third rows 
of the table categorize hospices according to their geographic location 
(urban and rural). Our analysis indicted that there are 1,314 hospices 
located in urban areas and 840 hospices located in rural areas. The 
next two groupings in the table indicate the number of hospices by 
census region, also broken down by urban and rural hospices. The sixth 
grouping shows the impact on hospices based on the size of the 
hospice's program. We determined that the majority of hospice payments 
are made at the routine home care rate. Therefore, we based the size of 
each individual hospice's program on the number of routine home care 
days provided in 2002. The next grouping shows the impact on hospices 
by type of ownership. The final grouping shows the impact on hospices 
defined by whether they are provider-based or freestanding.
    The results of our analysis shows that the majority of hospices are 
in urban areas and provide the vast majority of routine home care days. 
However rural hospices will receive a larger percent increase in 
payment of 0.9 percent in contrast to 0.6 percent for urban hospices.
    The greatest increases in payment are for urban Mountain and rural 
West Central regions with a 2.3 percent and 2.6 percent increase, 
respectively. The greatest decrease in payment is for rural Puerto Rico 
with a 5.1 percent decrease and the urban Middle Atlantic region with a 
1.1 percent decrease. With the exception of the Middle Atlantic with a 
0.7 percent decrease, the remainder of the rural areas range from 0.1 
percent increase in the East North Central to an increase of 2.6 
percent in the West South Central. The remainder of the urban areas 
varies from a decrease of 0.5 percent in Puerto Rico to an increase of 
1.8 percent in the West South Central region.
    The breakdown by size indicates an increase of 1.3 percent in 
payment are for hospices with routine home care day under 9,681 while 
large size hospices with the greatest number of routine home care days 
will increase by 0.5 percent.
    Government owned hospices will have a 1.9-percent increase while 
voluntary owned hospices with the largest number of routine home care 
days will receive 0.2-percent increase in payment.
    Home health agency based hospices will have a 1 percent payment 
increase in contrast to a decrease of 0.1 percent for skilled nursing 
facility based hospices with the lowest number of routine home care 
days. In contrast, freestanding hospices, which represent the largest 
number of hospices agencies, with the greatest number of routine home 
care days will have an estimated 0.7 percent increase in payment.

BILLING CODE 4120-01-P

[[Page 56507]]

[GRAPHIC] [TIFF OMITTED] TN30SE03.035

BILLING CODE 4120-01-C

[[Page 56508]]

C. Conclusion

    Our impact analysis compared hospice payments by using the FY 2003 
wage index to the estimated payments using the FY 2004 wage index. 
Through the analysis, we estimate that total hospice payments will 
increase from last year by 0.6 percent or by $24,271,000. Additionally, 
we compared estimated payments using the FY 1983 hospice wage index to 
estimated payments using the FY 2004 wage index and determined the 
current hospice wage index to be budget neutral, as required by the 
negotiated rulemaking committee. We have determined that this rule is 
not an economically significant rule under Executive Order 12866. 
Although we believe that this rule will not have a significant economic 
impact on a substantial number of small entities, we took any negative 
effects into consideration during the negotiated rulemaking process. We 
have determined that this rule will not have a significant impact on 
the operations of a substantial number of small rural hospitals. 
Finally, this rule will not have a consequential effect on State, 
local, or tribal governments.

OMB Review

    In accordance with the provisions of Executive Order 12866, the 
Office of Management and Budget reviewed this notice.

    Authority: Section 1814(i) of the Social Security Act (42 U.S.C. 
1395f (i)(1)).

(Catalog of Federal Domestic Assistance Program No. 93.773 
Medicare--Hospital Insurance Program; and No. 93.774, Medicare--
Supplementary Medical Insurance Program)
    Dated: June 24, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.

    Dated: July 28, 2003.
Tommy G. Thompson,
Secretary.
[FR Doc. 03-24817 Filed 9-29-03; 8:45 am]
BILLING CODE 4120-01-P