[Federal Register Volume 68, Number 206 (Friday, October 24, 2003)]
[Notices]
[Pages 60997-61002]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-26456]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-8017-N]
RIN 0938-AM91


Medicare Program; Monthly Actuarial Rates and Monthly 
Supplementary Medical Insurance Premium Beginning January 1, 2004

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

ACTION: Notice.

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

SUMMARY: In accordance with section 1839 of the Social Security Act 
(the Act), this notice announces the monthly actuarial rates for aged 
(age 65 and over) and disabled (under age 65) enrollees in the Medicare 
Supplementary Medical Insurance (SMI) (Medicare Part B) program for 
2004. It also announces the monthly SMI premium to be paid by all 
enrollees during 2004. The monthly actuarial rates for 2004 are $133.20 
for aged enrollees and $175.50 for disabled enrollees. The monthly SMI 
premium for 2004 is $66.60. (The 2003 premium was $58.70.) The 2004 
Part B premium is equal to 50 percent of the monthly actuarial rate. 
Included in the monthly premium is $3.02 for home health services 
transferred into Part B.

EFFECTIVE DATE: January 1, 2004.

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

SUPPLEMENTARY INFORMATION: 

I. Background

    The Medicare Supplementary Medical Insurance (SMI) (Medicare Part 
B) program is the voluntary 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 (HI) (Medicare Part A). The SMI program is available to 
individuals who are entitled to HI 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 the Department of Health and Human Services (the 
Secretary) 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 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 (Pub. L. 92-603), the premium, 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 
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) (Pub. L. 97-248) 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 (Pub. L. 98-21), section 2302 
of the Deficit Reduction Act of 1984 (DEFRA '84) (Pub. L. 98-369), 
section 9313 of the Consolidated Omnibus Budget Reconciliation Act of 
1985 (COBRA '85) (Pub. L. 99-272), section 4080 of the Omnibus Budget 
Reconciliation Act of 1987 (OBRA '87) (Pub. L. 100-203), and section 
6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89) (Pub. 
L. 101-239) extended the

[[Page 60998]]

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 for 1991 through 1995 was legislated by section 
1839(e)(1)(B) of the Act, as added by section 4301 of the Omnibus 
Budget Reconciliation Act of 1990 (OBRA '90) (Pub. L. 101-508). 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 '93) (Pub. L. 103-66) 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.
    Section 4571 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-
33) permanently 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).
    The BBA included a further provision affecting the calculation of 
the SMI actuarial rates and premiums for 1998 through 2003. Section 
4611 of the BBA modified the home health benefit payable under the HI 
program for individuals enrolled in the SMI program. Under this 
section, expenditures for home health services not considered ``post-
institutional'' are payable under the SMI program rather than the HI 
program, beginning in 1998. However, section 4611(e)(1) of the BBA 
required that there be a transition from 1998 through 2002 for the 
aggregate amount of the expenditures transferred from the HI program to 
the SMI program. Section 4611(e)(2) of the BBA also provided a specific 
yearly proportion for the transferred funds. The proportions were 1/6 
for 1998, 1/3 for 1999, 1/2 for 2000, 2/3 for 2001, and 5/6 for 2002. 
For purposes of determining the correct amount of financing from 
general revenues of the Federal Government, it was necessary to include 
only these transitional amounts in the monthly actuarial rates for both 
aged and disabled enrollees, rather than the total cost of the home 
health services being transferred.
    Section 4611(e)(3) of the BBA also specified, for the purposes of 
determining the premium, that the monthly actuarial rate for enrollees 
age 65 and over shall be computed as though the transition would occur 
for 1998 through 2003 and that 1/7 of the cost would be transferred in 
1998, 2/7 in 1999, 3/7 in 2000, 4/7 in 2001, 5/7 in 2002, and 6/7 in 
2003. Therefore, the transition period for incorporating this home 
health transfer into the premium was 7 years, while the transition 
period for including these services in the actuarial rate was 6 years. 
As a result, the premiums for 1998-2003 were less than 50 percent of 
the actuarial rate for aged enrollees.
    New section 1933(c) of the Act, as added by section 4732(c) of the 
BBA, required the Secretary to allocate money from the SMI trust fund 
to the State Medicaid programs for the purpose of providing Medicare 
Part B premium assistance from 1998 through 2002 for the section 1933 
qualifying low-income Medicaid beneficiaries. This allocation, while 
not a benefit expenditure, was an expenditure of the trust fund and was 
included in calculating the SMI actuarial rates through 2002. Section 
403 of the Consolidated Appropriations Resolution, 2003 (CAR) (Pub. L. 
108-7) extended the authorization for this allocation to September 30, 
2003.
    As determined according to section 1839(a)(3) of the Act and 
section 4611(e)(3) of the BBA, the premium for 2004 is $66.60. Included 
in the premium is $3.02 for home health services transferred into Part 
B.
    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 (MCCA 1988) (Pub. L. 100-360). (The 
Medicare Catastrophic Coverage Repeal Act of 1989 (Pub. L. 101-234) did 
not repeal the revisions to section 1839(f) made by MCCA 1988.) Section 
1839(f) of the Act, referred to as the hold-harmless provision, 
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 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 decrease in payment 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 of the Act 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.
    Generally, if a beneficiary qualifies for hold-harmless protection 
(that is, if the beneficiary was in current payment status for November 
and December of the previous year) the reduced premium for the 
individual for that January and each of the succeeding 11 months for 
which he or she is entitled to benefits, under section 202 or 203 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 of the Act 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. The increase is a 
percentage of the premium and is based on the new premium before any 
reductions under section 1839(f) are made.

II. Notice of Monthly Actuarial Rates and Monthly Premium

    The monthly actuarial rates applicable for 2004 are $133.20 for 
enrollees age 65 and over, and $175.50 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 will be 
$66.60 during 2004. Included in the monthly premium is $3.02 for home 
health services transferred into Part B.

[[Page 60999]]

III. Statement of Actuarial Assumptions and Bases Employed in 
Determining the Monthly Actuarial Rates and the Monthly Premium for the 
Supplementary Medical Insurance Program Beginning January 2004

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. This 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 in 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, and 
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 both 
factors as the trends vary over time.
    Table 1 summarizes the estimated actuarial status of the trust fund 
as of the end of the financing period for 2002 and 2003.

   Table 1.--Estimated Actuarial Status of the Supplementary Medical Insurance Trust Fund as of the End of the
                                                Financing Period
                                            [In millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                                                                                    Assets less
                     Financing period ending                          Assets        Liabilities     liabilities
----------------------------------------------------------------------------------------------------------------
Dec. 31, 2002...................................................         $34,301          $9,053         $25,248
Dec. 31, 2003...................................................          25,537           8,037          17,500
----------------------------------------------------------------------------------------------------------------

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, the Medicaid transfer 
(for 1998 through 2003), 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 2004 
is determined by first establishing per-enrollee cost by type of 
service from program data through 2002 and then projecting these costs 
for subsequent years. The projection factors used are shown in Table 2. 
The projected values for financing periods from January 1, 2001 through 
December 31, 2004, 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 2004 is $135.65. The monthly actuarial rate of $133.20 also 
provides an adjustment of -$2.49 for interest earnings and $0.04 for a 
contingency margin. Based on current estimates, it appears a positive 
contingency margin is needed to increase assets toward a level that is 
sufficient to cover the amount of incurred, but unpaid expenses and to 
provide for a moderate degree of variation between actual and projected 
costs.

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 (ESRD) program. Projected monthly costs for disabled enrollees 
(other than those with ESRD) are prepared in a fashion parallel to the 
projection for the aged using appropriate actuarial assumptions (see 
Table 2). Costs for the ESRD 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 
2004 is $154.33. The monthly actuarial rate of $175.50 also provides an 
adjustment of -$1.33 for interest earnings and $22.50 for a contingency 
margin. Based on current estimates, it appears that a positive 
contingency margin is needed to increase assets to a level that is 
sufficent to cover the amount of incurred, but unpaid expenses and 
provide for a moderate degree of variation between actual and projected 
costs.

D. Sensitivity Testing

    Several factors contribute to uncertainty about future trends in 
medical care costs. It is appropriate to test the adequacy of the rates 
using alternative assumptions. The results of those assumptions are 
shown in Table 5. One set represents increases that are lower and, 
therefore, more optimistic than the current estimate. The other set 
represents increases that are higher and, therefore, more pessimistic 
than the current estimate. The values for the alternative assumptions 
were determined from a statistical analysis of the historical variation 
in the respective increase factors.
    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 $21,636 million by the end of December 2004. 
This amounts to 15.8 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 $10,426 million by 
the end of December 2004, which amounts to 6.8 percent of the estimated 
total incurred expenditures for the following year. Under fairly 
optimistic assumptions, the monthly actuarial rates would result in

[[Page 61000]]

a surplus of $33,450 million by the end of December 2004, which amounts 
to 27.6 percent of the estimated total incurred expenditures for the 
following year.

E. Premiums Determined by Section 1839(a)(3) of the Act and Section 
4611(e)(3) of the BBA, the Monthly Premium for 2004, for Both Aged and 
Disabled Enrollees, is $66.60

                                    Table 2.--Projection Factors \1\ 12-Month Periods Ending December 31 of 2001-2004
                                                                      [In percent]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                   Physicians' services                                             Other
----------------------------------------------------------   Durable    Carrier    carrier    Outpatient    Home     Hospital       Other       Managed
                                        Fees    Residual     medical    lab \4\   services     hospital    health    lab \6\    intermediary      care
            Calendar year               \2\        \3\      equipment                \5\                   agency               services \7\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Aged:
    2001............................      5.2         4.2        12.8       7.0        16.1         12.2     -11.6        3.9            18.8        4.9
    2002............................     -4.0         6.1        14.4       8.1        17.3          5.1      10.1       16.0            13.1       11.5
    2003............................      1.4         3.4         9.7       6.1        17.0          5.0      -1.9        5.7            -1.3        3.2
    2004............................     -4.4         4.7         8.1       6.2        14.1          4.0       6.4        6.2            -4.6        2.6
Disabled:
    2001............................     -5.2         5.0        15.6       8.7        19.6         12.3     -18.3       10.9             1.0        4.3
    2002............................     -4.0         6.9        19.6      10.4        20.4          9.9      10.1       12.0            15.1        4.5
    2003............................      1.4         3.5        10.8       6.1        17.2          5.2      -4.0        6.6             1.5       -1.3
    2004............................     -4.4         4.7         8.1       6.2        13.0          4.0       6.0        6.2            -0.5       2.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ All values for services other than managed care are per fee-for-service enrollee. Managed care values are per managed care enrollee.
\2\ As recognized for payment under the program.
\3\ Increase in the number of services received per enrollee and greater relative use of more expensive services.
\4\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
\5\ Includes physician administered drugs, ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies,
  etc.
\6\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\7\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric
  hospitals, etc.


                  Table 3.--Derivation of Monthly Actuarial Rate for Enrollees Age 65 and Over
                     [Financing periods ending December 31, 2001 through December 31, 2004]
----------------------------------------------------------------------------------------------------------------
                                                                               Financing periods
                                                             ---------------------------------------------------
                                                                CY 2001      CY 2002      CY 2003      CY 2004
----------------------------------------------------------------------------------------------------------------
Covered services (at level recognized):
    Physician fee schedule..................................        62.27        64.96        68.77        69.01
    Durable medical equipment...............................         7.32         8.57         9.49        10.29
    Carrier lab \1\.........................................         2.70         2.99         3.20         3.41
    Other carrier services \2\..............................        12.55        15.07        17.80        20.36
    Outpatient hospital.....................................        21.60        23.24        24.63        25.69
    Home health.............................................     \5\ 5.32     \5\ 5.99         5.94         6.33
    Hospital lab \3\........................................         2.05         2.44         2.60         2.77
    Other intermediary services \4\.........................         7.78         9.01         8.98         8.59
    Managed care............................................    \6\ 20.89    \6\ 20.73        20.27        20.49
                                                             --------------
        Total services......................................   \7\ 142.48   \7\ 153.01   \7\ 161.69       166.94
Cost-sharing:
    Deductible..............................................        -3.80        -3.81        -3.87        -3.81
 
    Coinsurance.............................................       -26.02       -27.61       -29.41       -29.94
                                                             ==============
        Total benefits......................................       112.67       121.59       128.41       133.19
Administrative expenses.....................................         2.18         2.36         2.40         2.45
                                                             --------------
Incurred expenditures.......................................       114.85       123.95       130.81       135.65
Value of interest...........................................        -3.57        -3.20        -2.35        -2.49
Adjustment for home health agency services transferred from     \8\ -2.04    \8\ -1.13  ...........  ...........
 HI.........................................................
Contingency margin for projection error and to amortize the         -8.24       -10.31        -9.76         0.04
 surplus or deficit.........................................
                                                             ==============
        Monthly actual rate.................................      $101.00      $109.30      $118.70     $133.20
----------------------------------------------------------------------------------------------------------------
\1\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
 
\2\ Includes physician administered drugs, ambulatory surgical center facility costs, ambulance services,
  parenteral and enteral drug costs, supplies, etc.
\3\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\4\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health
  centers, rehabilitation and psychiatric hospitals, etc.
\5\ This amount includes the full cost of the fee-for-service home health services being transferred from the HI
  program as a result of the BBA as if the transition did not apply, as well as the cost of furnishing all home
  health services to those individuals enrolled in SMI only.
\6\ This amount includes the full cost of the managed care home health services being transferred from the HI
  program as a result of the BBA as if the transition did not apply, as well as the cost of furnishing all other
  SMI services to individuals enrolled in managed care.

[[Page 61001]]

 
\7\ Includes transfers to Medicaid. Section 1933(c)(2) of the Act, as added by section 4732(c) of the BBA and
  extended by section 403 of the CAR, allocates an amount to be transferred from the SMI trust fund to the state
  Medicaid programs. This transfer is for the purpose of paying the SMI premiums for certain low-income
  beneficiaries. It is not a benefit expenditure but is used in determining the SMI actuarial rates since it is
  an expenditure of the trust fund.
\8\ Section 4611 of the BBA specifies that expenditures for home health services not considered ``post-
  institutional'' will be payable under the SMI program rather than the HI program beginning in 1998. However,
  section 4611(e)(1) requires there be a transition from 1998 through 2002 for the aggregate amount of the
  expenditures transferred from the HI program to the SMI program. For 1998, the amount transferred is \1/6\ of
  the full cost for such services, for 1999, \1/3\, for 2000, \1/2\, for 2001, \2/3\, and for 2002, \5/6\.
  Therefore, the adjustment for 2001 represents \1/3\ of the full cost, and for 2002, \1/6\. This amount adjusts
  the actuarial rate to reflect the correct amount attributable to home health services.


                      Table 4.--Derivation of Monthly Actuarial Rate for Disabled Enrollees
                     [Financing periods ending December 31, 2001 through December 31, 2004]
----------------------------------------------------------------------------------------------------------------
                                                                               Financing periods
                                                             ---------------------------------------------------
                                                                CY 2001      CY 2002      CY 2003      CY 2004
----------------------------------------------------------------------------------------------------------------
Covered services (at level recognized):
    Physician fee schedule..................................        63.71        65.65        68.97        68.95
    Durable medical equipment...............................        11.92        14.30        15.88        17.16
    Carrier lab \1\.........................................         3.07         3.53         3.78         4.01
    Other carrier services \2\..............................        13.65        16.22        18.99        21.51
    Outpatient hospital.....................................        27.33        30.27        31.91        33.13
    Home health.............................................     \5\ 3.59     \5\ 3.99         3.84         4.07
    Hospital lab \3\........................................         3.11         3.51         3.72         3.95
    Other intermediary services \4\.........................        31.79        33.64        33.84        33.79
    Managed care............................................     \6\ 9.80     \6\ 9.28         8.93         9.26
                                                             --------------
        Total services......................................   \7\ 167.98   \7\ 180.40   \7\ 189.87       195.81
Cost-sharing:
    Deductible..............................................        -3.67        -3.68        -3.70        -3.71
    Coinsurance.............................................       -36.38       -38.24       -40.33       -40.56
                                                             ==============
    Total benefits..........................................       127.93       138.47       145.84       151.54
Administrative expenses.....................................         2.48         2.69         2.73         2.79
                                                             --------------
Incurred expenditures.......................................       130.41       141.16       148.57       154.33
    Value of interest.......................................        -2.26        -2.12        -1.40        -1.33
Adjustment for home health agency services transferred from      \8\-1.38     \8\-0.76
 HI.........................................................
Contingency margin for projection error and to amortize the          5.43       -15.18        -6.17        22.50
 surplus or deficit.........................................
                                                             ==============
        Monthly actuarial rate..............................      $132.20      $123.10      $141.00     $175.50
----------------------------------------------------------------------------------------------------------------
\1\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
 
\2\ Includes physician administered drugs, ambulatory surgical center facility costs, ambulance services,
  parenteral and enteral drug costs, supplies, etc.
\3\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\4\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health
  centers, rehabilitation and psychiatric hospitals, etc.
\5\ This amount includes the full cost of the fee-for-service home health services being transferred from the HI
  program as a result of the BBA as if the transition did not apply, as well as the cost of furnishing all home
  health services to those individuals enrolled in SMI only.
\6\ This amount includes the full cost of the managed care home health services being transferred from the HI
  program as a result of the BBA as if the transition did not apply, as well as the cost of furnishing all other
  SMI services to individuals enrolled in managed care.
\7\ Includes transfers to Medicaid. Section 1933(c)(2) of the Act, as added by section 4732(c) of the BBA and
  extended by section 403 of the CAR, allocates an amount to be transferred from the SMI trust fund to the state
  Medicaid programs. This transfer is for the purpose of paying the SMI premiums for certain low-income
  beneficiaries. It is not a benefit expenditure but is used in determining the SMI actuarial rates since it is
  an expenditure of the trust fund.
\8\ Section 4611 of the BBA specifies that expenditures for home health services not considered ``post-
  institutional'' will be payable under the SMI program rather than the HI program beginning in 1998. However,
  section 4611(e)(1) requires there be a transition from 1998 through 2002 for the aggregate amount of the
  expenditures transferred from the HI program to the SMI program. For 1998, the amount transferred is 1/6 of
  the full cost for such services, for 1999, \1/3\, for 2000, \1/2\, for 2001, \2/3\, and for 2002, \5/6\.
  Therefore, the adjustment for 2001 represents \1/3\ of the full cost, and for 2002, \1/6\. This amount adjusts
  the actuarial rate to reflect the correct amount attributable to home health services.


 Table 5.--Actuarial Status of the SMI Trust Fund Under Three Sets of Assumptions for Financing Periods Through
                                                December 31, 2004
----------------------------------------------------------------------------------------------------------------
                      As of December 31,                             2002             2003             2004
----------------------------------------------------------------------------------------------------------------
This projection: Actuarial status (in millions):
    Assets...................................................         34,301           25,537           30,566
    Liabilities..............................................          9,053            8,037            8,929
                                                              ------------------
    Assets less liabilities..................................         25,248           17,500           21,636
    Ratio (in percent) \1\...................................             20.5             13.5             15.8
Low cost projection: Actuarial status (in millions):
    Assets...................................................         34,301           25,537           41,943
    Liabilities..............................................          9,053            7,264            8,493
                                                              ------------------
    Assets less liabilities..................................         25,248           18,273           33,450

[[Page 61002]]

 
    Ratio (in percent) \1\...................................             21.8             15.6             27.6
High cost projection: Actuarial status (in millions):
    Assets...................................................         34,301           25,537           19,783
    Liabilities..............................................          9,053            8,798            9,356
                                                              ------------------
    Assets less liabilities..................................         25,248           16,739           10,426
    Ratio (in percent) \1\...................................             19.3             11.8              6.8 
----------------------------------------------------------------------------------------------------------------
\1\ Ratio of assets less liabilities at the end of the year to the total incurred expenditures during the
  following year, expressed as a percent.

IV. Regulatory Impact Analysis

    We have examined the impact of this notice as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review) and the 
Regulatory Flexibility Act (RFA) September 19, 1980 (Pub. L. 96-354). 
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).
    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 to $29 
million in any 1 year (65 FR 69432). For purposes of the RFA, States 
and individuals are not considered to be small entities.
    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 of a Metropolitan 
Statistical Area and has fewer than 100 beds. We have determined that 
this notice will not have a significant effect on a substantial number 
of small entities nor on the operations of a substantial number of 
small rural hospitals. Therefore, we are not preparing analyses for 
either the RFA or section 1102(b) of the Act.
    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 expenditure in any 1 year by State, 
local, or tribal governments, in the aggregate, or by the private 
sector, of $110 million. This notice has no consequential effect on 
State, local, or tribal governments. We believe the private sector 
costs of this notice fall below this threshold as well.
    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 compliance costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have determined that this notice does not 
significantly affect the rights, roles, and responsibilities of States.
    This notice announces that the monthly actuarial rates applicable 
for 2004 are $133.20 for enrollees age 65 and over, and $175.50 for 
disabled enrollees under age 65. It also announces that the monthly SMI 
premium for calendar year 2004 is $66.60. The SMI premium of $66.60 is 
13.5 percent higher than the $58.70 premium for 2003. We estimate that 
the cost of this increase from the current premium to the approximately 
39 million SMI enrollees will be about $3.7 billion for 2004. 
Therefore, this notice is a major rule as defined in Title 5, United 
States Code, section 804(2) and is an economically significant rule 
under Executive Order 12866.
    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

V. Waiver of Proposed Notice

    The Medicare statute requires the publication of the monthly 
actuarial rates and the Part B premium amounts in September. We 
ordinarily use general notices, rather than notice and comment 
rulemaking procedures, to make such announcements. In doing so, we note 
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, for 
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 applying that formula. Moreover, the statute 
establishes the time period for which the premium will apply, and 
delaying publication of the SMI premium such that it would not be 
published before that time would be contrary to the public interest. 
Therefore, we find good cause to waive publication of a proposed notice 
and solicitation of public comments.

(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 12, 2003.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: October 3, 2003.
Tommy G. Thompson,
Secretary.
[FR Doc. 03-26456 Filed 10-16-03; 10:06 am]
BILLING CODE 4120-01-P