[Federal Register Volume 83, Number 130 (Friday, July 6, 2018)]
[Notices]
[Pages 31536-31555]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-14533]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2414-N]
RIN 0938-ZB48


Medicaid Program; Final FY 2016 and Preliminary FY 2018 
Disproportionate Share Hospital Allotments, and Final FY 2016 and 
Preliminary FY 2018 Institutions for Mental Diseases Disproportionate 
Share Hospital Limits

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

ACTION: Notice.

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SUMMARY: This notice announces the final federal share disproportionate 
share hospital (DSH) allotments for federal fiscal year (FY) 2016 and 
the preliminary federal share DSH allotments for FY 2018. This notice 
also announces the final FY 2016 and the preliminary FY 2018 
limitations on aggregate DSH payments that states may make to 
institutions for mental disease and other mental health facilities. In 
addition, this notice includes background information describing the 
methodology for determining the amounts of states' FY DSH allotments.

DATES: This notice is applicable August 6, 2018. The final allotments 
and limitations set forth in this notice are applicable for the fiscal 
years specified.

FOR FURTHER INFORMATION CONTACT: Stuart Goldstein, (410) 786-0694 and 
Richard Cuno, (410) 786-1111.

SUPPLEMENTARY INFORMATION:

I. Background

A. Fiscal Year DSH Allotments

    A state's federal fiscal year (FY) disproportionate share hospital 
(DSH) allotment represents the aggregate limit on the federal share 
amount of the state's DSH payments to DSH hospitals

[[Page 31537]]

in the state for the FY. The amount of such allotment is determined in 
accordance with the provisions of section 1923(f)(3) of the Social 
Security Act (the Act), with some state-specific exceptions as 
specified in section 1923(f) of the Act. Under such provisions, in 
general a state's FY DSH allotment is calculated by increasing the 
amount of its DSH allotment for the preceding FY by the percentage 
change in the Consumer Price Index for all Urban Consumers (CPI-U) for 
the previous FY.
    The Patient Protection and Affordable Care Act of 2010 (Pub. L. 
111-148), as amended by the Health Care and Education Reconciliation 
Act of 2010 (Pub. L. 111-152) (collectively, the Affordable Care Act), 
amended Medicaid DSH provisions, adding section 1923(f)(7) of the Act. 
Section 1923(f)(7) of the Act would have required reductions to states' 
FY DSH allotments from FY 2014 through FY 2020, the calculation of 
which was described in the Disproportionate Share Hospital Payment 
Reduction final rule published in the September 18, 2013 Federal 
Register (78 FR 57293). Subsequent legislation, most recently by the 
Bipartisan Budget Act of 2018 (Pub. L. 115-123, enacted February 9, 
2018), delayed the start of these reductions until FY 2020. A proposed 
rule delineating a revised methodology for the calculation of DSH 
allotment reductions previously scheduled to begin in FY 2018 was 
published in the July 28, 2017 Federal Register (82 FR 35155).
    Because there are no reductions to DSH allotments for FY 2016 and 
FY 2018 under section 1923(f)(7) of the Act, as amended, this notice 
contains only the state-specific final FY 2016 DSH allotments and 
preliminary FY 2018 DSH allotments, as calculated under the statute 
without application of the reductions that would have been imposed 
under the Affordable Care Act provisions beginning with FY 2014. This 
notice also provides information on the calculation of such FY DSH 
allotments, the calculation of the states' institutions for mental 
diseases (IMDs) DSH limits, and the amounts of states' final FY 2016 
IMD DSH limits and preliminary FY 2018 IMD DSH limits.

B. Determination of Fiscal Year DSH Allotments

    Generally, in accordance with the methodology specified under 
section 1923(f)(3) of the Act, a state's FY DSH allotment is calculated 
by increasing the amount of its DSH allotment for the preceding FY by 
the percentage change in the CPI-U for the previous FY. Also in 
accordance with section 1923(f)(3) of the Act, a state's DSH allotment 
for a FY is subject to the limitation that an increase to a state's DSH 
allotment for a FY cannot result in the DSH allotment exceeding the 
greater of the state's DSH allotment for the previous FY or 12 percent 
of the state's total medical assistance expenditures for the allotment 
year (this is referred to as the 12 percent limit).
    Furthermore, under section 1923(h) of the Act, federal financial 
participation (FFP) for DSH payments to IMDs and other mental health 
facilities is limited to state-specific aggregate amounts. Under this 
provision, the aggregate limit for DSH payments to IMDs and other 
mental health facilities is the lesser of a state's FY 1995 total 
computable (state and federal share) IMD and other mental health 
facility DSH expenditures applicable to the state's FY 1995 DSH 
allotment (as reported on the Form CMS-64 as of January 1, 1997), or 
the amount equal to the product of the state's current year total 
computable DSH allotment and the applicable percentage specified in 
section 1923(h) of the Act.
    In general, we determine states' DSH allotments for a FY and the 
IMD DSH limits for the same FY using the most recent available 
estimates of or actual medical assistance expenditures, including DSH 
expenditures in their Medicaid programs and the most recent available 
change in the CPI-U used for the FY in accordance with the methodology 
prescribed in the statute. The indicated estimated or actual 
expenditures are obtained from states for each relevant FY from the 
most recent available quarterly Medicaid budget reports (Form CMS-37) 
or quarterly Medicaid expenditure reports (Form CMS-64), respectively, 
submitted by the states. For example, as part of the initial 
determination of a state's FY DSH allotment (referred to as the 
preliminary DSH allotments) that is determined before the beginning of 
the FY for which the DSH allotments and IMD DSH limits are being 
determined, we use estimated expenditures for the FY obtained from the 
August submission of the CMS-37 submitted by states prior to the 
beginning of the FY; such estimated expenditures are subject to update 
and revision during the FY before such actual expenditure data become 
available. We also use the most recent available estimated CPI-U 
percentage change that is available before the beginning of the FY for 
determining the states' preliminary FY DSH allotments; such estimated 
CPI-U percentage change is subject to update and revision during the FY 
before the actual CPI-U percentage change becomes available. In 
determining the final DSH allotments and IMD DSH limits for a FY we use 
the actual expenditures for the FY and actual CPI-U percentage change 
for the previous FY.

II. Provisions of the Notice

A. Calculation of the Final FY 2016 Federal Share State DSH Allotments, 
and the Preliminary FY 2018 Federal Share State DSH Allotments

1. Final FY 2016 Federal Share State DSH Allotments
    Addendum 1 to this notice provides the states' final FY 2016 DSH 
allotments determined in accordance with section 1923(f)(3) of the Act. 
As described in the background section, in general, the DSH allotment 
for a FY is calculated by increasing the FY DSH allotment for the 
preceding FY by the CPI-U increase for the previous fiscal year. For 
purposes of calculating the states' final FY 2016 DSH allotments, the 
preceding final fiscal year DSH allotments (for FY 2015) were published 
in the November 3, 2017 Federal Register (82 FR 51259). For purposes of 
calculating the states' final FY 2016 DSH allotments we are using the 
actual Medicaid expenditures for FY 2016. Finally, for purposes of 
calculating the states' final FY 2016 DSH allotments, the applicable 
historical percentage change in the CPI-U for the previous FY (FY 2015) 
was 0.3 percent; we note that this is the same as the estimated 0.3 
percentage change in the CPI-U for FY 2015 that was available and used 
in the calculation of the preliminary FY 2016 DSH allotments which were 
published in the October 26, 2016 Federal Register (81 FR 74432).
2. Calculation of the Preliminary FY 2018 Federal Share State DSH 
Allotments
    Addendum 2 to this notice provides the preliminary FY 2018 DSH 
allotments determined in accordance with section 1923(f)(3) of the Act. 
The preliminary FY 2018 DSH allotments contained in this notice were 
determined based on the most recent available estimates from states of 
their FY 2018 total computable Medicaid expenditures. Also, the 
preliminary FY 2018 allotments contained in this notice were determined 
by increasing the preliminary FY 2017 DSH allotments. The estimated 
percentage increase in the CPI-U for FY 2017 was 2.4 percent (CMS 
originally published the preliminary FY 2017 DSH allotments in the 
November 3, 2017 Federal Register (82 FR 51259)).

[[Page 31538]]

    We will publish states' final FY 2018 DSH allotments in a future 
notice based on the states' four quarterly Medicaid expenditure reports 
(Form CMS-64) for FY 2018 available following the end of FY 2018 
utilizing the actual change in the CPI-U for FY 2017.

B. Calculation of the Final FY 2016 and Preliminary FY 2018 IMD DSH 
Limits

    Section 1923(h) of the Act specifies the methodology to be used to 
establish the limits on the amount of DSH payments that a state can 
make to IMDs and other mental health facilities. FFP is not available 
for DSH payments to IMDs or other mental health facilities that exceed 
the IMD DSH limits. In this notice, we are publishing the final FY 2016 
and the preliminary FY 2018 IMD DSH limits determined in accordance 
with the provisions discussed above.
    Addendums 3 and 4 to this notice detail each state's final FY 2016 
and preliminary FY 2018 IMD DSH limit, respectively, determined in 
accordance with section 1923(h) of the Act.

III. Collection of Information Requirements

    As it relates to the Paperwork Reduction Act of 1995 (44 U.S.C. 
3501 et seq.), this notice does not impose any new or revised 
collection of information requirements or burden. While discussed in 
section I.B. and in Addendums 3 and 4 of this notice, the requirements 
and burden associated with Form CMS-37 and Form CMS-64 are unaffected 
by this notice. Both forms are approved by the Office of Management and 
Budget (OMB) under control number 0938-1265. Since this notice will not 
impose any new or revised requirements/burden, we are not making any 
changes under that control number.

IV. Regulatory Impact Analysis

    We have examined the impact of this notice as required by Executive 
Order 12866 on Regulatory Planning and Review (September 1993), the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), 
section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform 
Act of 1995 (Pub. L. 104-4; enacted on March 22, 1995) (UMRA '95), 
Executive Order 13132 on Federalism (August 4, 1999) and the 
Congressional Review Act (5 U.S.C. 804(2)), and Executive Order 13771 
on Reducing Regulation and Controlling Regulatory Costs (January 30, 
2017).
    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). This notice 
reaches the $100 million economic threshold and thus is considered a 
major rule under the Congressional Review Act.
    The final FY 2016 DSH allotments being published in this notice are 
approximately $11 million more than the preliminary FY 2016 DSH 
allotments published in the October 26, 2016 Federal Register (81 FR 
74432). The increase in the final FY 2016 DSH allotments is a result of 
being calculated by multiplying the actual increase in the CPI-U for 
2015 by the final FY 2015 DSH allotments, while the preliminary FY 2016 
DSH allotments were calculated by multiplying the estimated CPI-U for 
2015 by the preliminary FY 2015 DSH allotments. Although the estimated 
and actual increase in the CPI-U remained the same at 0.3 percent, the 
preliminary FY 2015 DSH allotments were lower than the final FY 2015 
DSH allotments and therefore the final FY 2016 DSH allotments are 
higher than the preliminary FY 2016 DSH allotments. The final FY 2016 
IMD DSH limits being published in this notice are approximately $14 
million more than the preliminary FY 2016 IMD DSH limits published in 
the October 26, 2016 Federal Register (81 FR 74432). The increases in 
the IMD DSH limits are because the DSH allotment for a FY is a factor 
in the determination of the IMD DSH limit for the FY. Since the final 
FY 2016 DSH allotments were increased as compared to the preliminary FY 
2016 DSH allotments, the associated FY 2016 IMD DSH limits for some 
states were also increased.
    The preliminary FY 2018 DSH allotments being published in this 
notice have been increased by approximately $288 million more than the 
preliminary FY 2017 DSH allotments published in the November 3, 2017 
Federal Register (82 FR 51259). The increase in the DSH allotments is 
due to the application of the statutory formula for calculating DSH 
allotments under which the prior fiscal year allotments are increased 
by the percentage increase in the CPI-U for the prior fiscal year. The 
preliminary FY 2018 IMD DSH limits being published in this notice are 
approximately $24 million more than the preliminary FY 2017 IMD DSH 
limits published in the November 3, 2017 Federal Register (82 FR 
51259). The increases in the IMD DSH limits are because the DSH 
allotment for a FY is a factor in the determination of the IMD DSH 
limit for the FY. Since the preliminary FY 2018 DSH allotments are 
greater than the preliminary FY 2017 DSH allotments, the associated 
preliminary FY 2018 IMD DSH limits for some states also increased.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses, if a rule has a significant impact on a 
substantial number of small entities. For purposes of the RFA, small 
entities include small businesses, nonprofit organizations, and small 
governmental jurisdictions. Most hospitals and most other providers and 
suppliers are small entities, either by nonprofit status or by having 
revenues of less than $7.0 million to $34.5 million in any one year. 
Individuals and states are not included in the definition of a small 
entity. We are not preparing an analysis for the RFA because the 
Secretary has determined that this notice will not have significant 
economic impact on a substantial number of small entities. 
Specifically, any impact on providers is due to the effect of the 
various controlling statutes; providers are not impacted as a result of 
the independent regulatory action in publishing this notice. The 
purpose of the notice is to announce the latest DSH allotments and IMD 
DSH limits, as required by the statute.
    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 Core-Based 
Statistical Area for Medicaid payment regulations and has fewer than 
100 beds. We are not preparing analysis for section 1102(b) of the Act 
because the Secretary has determined that this notice will not have a 
significant impact on the operations of a substantial number of small 
rural hospitals.
    The Medicaid statute specifies the methodology for determining the 
amounts of states' DSH allotments and IMD DSH limits; and as described 
previously, the application of the methodology specified in statute 
results in the decreases or increases in states' DSH allotments and IMD 
DSH limits for the applicable FYs. The statute applicable to these 
allotments and limits does not apply to the determination of the 
amounts of DSH payments made to specific DSH hospitals; rather, these

[[Page 31539]]

allotments and limits represent an overall limit on the total of such 
DSH payments. For this reason, we do not believe that this notice will 
have a significant economic impact on a substantial number of small 
entities.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2018, that 
threshold is approximately $150 million. This notice will have no 
consequential effect on spending by state, local, or tribal 
governments, in the aggregate, or on the private sector.
    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. Since this notice does not impose any costs on state or 
local governments or otherwise have Federalism implications, the 
requirements of E.O. 13132 are not applicable.
    Executive Order 13771, titled ``Reducing Regulation and Controlling 
Regulatory Costs,'' was issued on January 30, 2017. It has been 
determined that this notice is a transfer rule and is not a regulatory 
action for the purposes of Executive Order 13771.

A. Alternatives Considered

    The methodologies for determining the states' fiscal year DSH 
allotments and IMD DSH limits, as reflected in this notice, were 
established in accordance with the methodologies and formula for 
determining states' allotments and limits as specified in statute. This 
notice does not put forward any further discretionary administrative 
policies for determining such allotments and limits, or otherwise.

B. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 1, we have 
prepared an accounting statement showing the classification of the 
estimated expenditures associated with the provisions of this notice. 
Table 1 provides our best estimate of the change (decrease) in the 
federal share of states' Medicaid DSH payments resulting from the 
application of the provisions of the Medicaid statute relating to the 
calculation of states' FY DSH allotments and the increase in the FY DSH 
allotments from FY 2017 to FY 2018.

Table 1--Accounting Statement: Classification of Estimated Expenditures,
                       From the FY 2017 to FY 2018
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $288.
From Whom To Whom?                          Federal Government to
                                             States.
------------------------------------------------------------------------

Congressional Review Act
    This proposed regulation is subject to the Congressional Review Act 
provisions of the Small Business Regulatory Enforcement Fairness Act of 
1996 (5 U.S.C. 801 et seq.) and has been transmitted to the Congress 
and the Comptroller General for review.
    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

    Dated: May 30, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
    Dated June 28, 2018.
Alex M. Azar II,
Secretary, Department of Health and Human Services.

           Key to ADDENDUM 1--Final DSH Allotments for FY 2015
------------------------------------------------------------------------
     The Final FY 2016 DSH Allotments for the NON-Low DSH States are
presented in the top section of this addendum, and the Final FY 2016 DSH
Allotments for the Low-DSH States are presented in the bottom section of
                             this addendum.
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          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  FY 2016 FMAPs. This column contains the
                            States' FY 2016 Federal Medical Assistance
                            Percentages.
Column C.................  Prior FY (2015) DSH Allotments. This column
                            contains the States' prior FY 2015 DSH
                            Allotments.
Column D.................  Prior FY (2015) DSH Allotments (Col C) x (100
                            percent + Percentage Increase in CPIU):
                            100.3 percent. This column contains the
                            amount in Column C increased by 1 plus the
                            percentage increase in the CPI-U for the
                            prior FY (100.3 percent).
Column E.................  FY 2016 TC MAP Exp. Including DSH. This
                            column contains the amount of the States' FY
                            2016 total computable (TC) medical
                            assistance expenditures including DSH
                            expenditures.
Column F.................  FY 2016 TC DSH Expenditures. This column
                            contains the amount of the States' FY 2016
                            total computable DSH expenditures.
Column G.................  FY 2016 TC MAP Exp. Net of DSH. This column
                            contains the amount of the States' FY 2016
                            total computable medical assistance
                            expenditures net of DSH expenditures,
                            calculated as the amount in Column E minus
                            the amount in Column F.
Column H.................  12 percent Amount. This column contains the
                            amount of the ``12 percent limit'' in
                            Federal share, determined in accordance with
                            the provisions of section 1923(f)(3) of the
                            Act.
Column I.................  Greater of FY 2015 Allotment or 12 percent
                            Limit. This column contains the greater of
                            the State's prior FY (FY 2015) DSH allotment
                            or the amount of the 12 percent Limit,
                            determined as the maximum of the amount in
                            Column C or Column H.
Column J.................  FY 2016 DSH Allotment. This column contains
                            the States' final FY 2016 DSH allotments,
                            determined as the minimum of the amount in
                            Column I or Column D. For states with ``na''
                            in Columns I or D, refer to the footnotes in
                            the addendum.
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        Key to ADDENDUM 2--Preliminary DSH Allotments for FY 2018
------------------------------------------------------------------------
  The Preliminary FY 2018 DSH Allotments for the NON-Low DSH States are
  presented in the top section of this addendum, and the Preliminary FY
 2018 DSH Allotments for the Low-DSH States are presented in the bottom
                        section of this addendum.
-------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  FY 2018 FMAPs. This column contains the
                            States' FY 2018 Federal Medical Assistance
                            Percentages.
Column C.................  Prior FY (2017) DSH Allotments. This column
                            contains the States' prior preliminary FY
                            2017 DSH Allotments.
Column D.................  Prior FY (2017) DSH Allotments (Col C) x (100
                            percent + Percentage Increase in CPIU):
                            102.4 percent. This column contains the
                            amount in Column C increased by 1 plus the
                            estimated percentage increase in the CPI-U
                            for the prior FY (102.4 percent).
Column E.................  FY 2018 TC MAP Exp. Including DSH. This
                            column contains the amount of the States'
                            projected FY 2018 total computable (TC)
                            medical assistance expenditures including
                            DSH expenditures.
Column F.................  FY 2018 TC DSH Expenditures. This column
                            contains the amount of the States' projected
                            FY 2018 total computable DSH expenditures.
Column G.................  FY 2018 TC MAP Exp. Net of DSH. This column
                            contains the amount of the States' projected
                            FY 2018 total computable medical assistance
                            expenditures net of DSH expenditures,
                            calculated as the amount in Column E minus
                            the amount in Column F.
Column H.................  12 percent Amount. This column contains the
                            amount of the ``12 percent limit'' in
                            Federal share, determined in accordance with
                            the provisions of section 1923(f)(3) of the
                            Act.
Column I.................  Greater of FY 2017 Allotment or 12 percent
                            Limit. This column contains the greater of
                            the State's preliminary prior FY (FY 2017)
                            DSH allotment or the amount of the 12
                            percent Limit, determined as the maximum of
                            the amount in Column C or Column H.
Column J.................  FY 2018 DSH Allotment. This column contains
                            the States' preliminary FY 2018 DSH
                            allotments, determined as the minimum of the
                            amount in Column I or Column D. For states
                            with ``na'' in Columns I or D, refer to the
                            footnotes in the addendum.
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           Key to ADDENDUM 3--Final IMD DSH Limits for FY 2016
------------------------------------------------------------------------
     The final FY 2016 IMD DSH Limits for the Non-Low DSH States are
  presented in the top section of this addendum and the preliminary FY
 2016 IMD DSH Limits for the Low-DSH States are presented in the bottom
                        section of the addendum.
-------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  Inpatient Hospital Services FY 95 DSH Total
                            Computable. This column contains the States'
                            total computable FY 1995 inpatient hospital
                            DSH expenditures as reported on the Form CMS-
                            64 as of January 1, 1997.
Column C.................  IMD and Mental Health Services FY 95 DSH
                            Total Computable. This column contains the
                            total computable FY 1995 mental health
                            facility DSH expenditures as reported on the
                            Form CMS-64 as of January 1, 1997.
Column D.................  Total Inpatient Hospital & IMD & Mental
                            Health FY 95 DSH Total Computable, Col. B +
                            C. This column contains the total
                            computation of all inpatient hospital DSH
                            expenditures and mental health facility DSH
                            expenditures for FY 1995 as reported on the
                            Form CMS-64 as of January 1, 1997
                            (representing the sum of Column B and Column
                            C).
Column E.................  Applicable Percentage, Col. C/D. This column
                            contains the ``applicable percentage''
                            representing the total Computable FY 1995
                            mental health facility DSH expenditures
                            divided by total computable all inpatient
                            hospital and mental health facility DSH
                            expenditures for FY 1995 (the amount in
                            Column C divided by the amount in Column D)
                            Per section 1923(h)(2)(A)(ii)(III) of the
                            Act, for FYs after FY 2002, the applicable
                            percentage can be no greater than 33
                            percent.
Column F.................  FY 2016 Federal Share DSH Allotment. This
                            column contains the states' FY 2016 DSH
                            allotments from Addendum 1, Column J.
Column G.................  FY 2016 FMAP.
Column H.................  FY 2016 DSH Allotments in Total Computable,
                            Col. F/G. This column contains states' FY
                            2016 total computable DSH allotment
                            (determined as Column F/Column G).
Column I.................  Applicable Percentage Applied to FY 2016
                            Allotments in TC, Col E x Col H. This column
                            contains the applicable percentage of FY
                            2016 total computable DSH allotment
                            (calculated as the percentage in Column E
                            multiplied by the amount in Column H).
Column J.................  FY 2016 TC IMD DSH Limit. Lesser of Col. I or
                            C. This column contains the total computable
                            FY 2016 TC IMD DSH Limit equal to the lesser
                            of the amount in Column I or Column C.
Column K.................  FY 2016 IMD DSH Limit in Federal Share, Col.
                            G x J. This column contains the FY 2016
                            Federal Share IMD DSH limit determined by
                            converting the total computable FY 2016 IMD
                            DSH Limit from Column J into a federal share
                            amount by multiplying it by the FY 2016 FMAP
                            in Column G.
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        Key to ADDENDUM 4--Preliminary IMD DSH Limits for FY 2018
------------------------------------------------------------------------
  The preliminary FY 2018 IMD DSH Limits for the Non-Low DSH States are
  presented in the top section of this addendum and the preliminary FY
 2018 IMD DSH Limits for the Low-DSH States are presented in the bottom
                        section of the addendum.
-------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  Inpatient Hospital Services FY 95 DSH Total
                            Computable. This column contains the States'
                            total computable FY 1995 inpatient hospital
                            DSH expenditures as reported on the Form CMS-
                            64 as of January 1, 1997.
Column C.................  IMD and Mental Health Services FY 95 DSH
                            Total Computable. This column contains the
                            total computable FY 1995 mental health
                            facility DSH expenditures as reported on the
                            Form CMS-64 as of January 1, 1997.
Column D.................  Total Inpatient Hospital & IMD & Mental
                            Health FY 95 DSH Total Computable, Col. B +
                            C. This column contains the total
                            computation of all inpatient hospital DSH
                            expenditures and mental health facility DSH
                            expenditures for FY 1995 as reported on the
                            Form CMS-64 as of January 1, 1997
                            (representing the sum of Column B and Column
                            C).
Column E.................  Applicable Percentage, Col. C/D. This column
                            contains the ``applicable percentage''
                            representing the total Computable FY 1995
                            mental health facility DSH expenditures
                            divided by total computable all inpatient
                            hospital and mental health facility DSH
                            expenditures for FY 1995 (the amount in
                            Column C divided by the amount in Column D)
                            Per section 1923(h)(2)(A)(ii)(III) of the
                            Act, for FYs after FY 2002, the applicable
                            percentage can be no greater than 33
                            percent.
Column F.................  FY 2018 Federal Share DSH Allotment. This
                            column contains the states' preliminary FY
                            2017 DSH allotments from Addendum 1, Column
                            J.
Column G.................  FY 2018 FMAP.
Column H.................  FY 2018 DSH Allotments in Total Computable,
                            Col. F/G. This column contains states' FY
                            2018 total computable DSH allotment
                            (determined as Column F/Column G).
Column I.................  Applicable Percentage Applied to FY 2018
                            Allotments in TC, Col E x Col H. This column
                            contains the applicable percentage of FY
                            2018 total computable DSH allotment
                            (calculated as the percentage in Column E
                            multiplied by the amount in Column H).
Column J.................  FY 2018 TC IMD DSH Limit. Lesser of Col. I or
                            C. This column contains the total computable
                            FY 2018 TC IMD DSH Limit equal to the lesser
                            of the amount in Column I or Column C.
Column K.................  FY 2018 IMD DSH Limit in Federal Share, Col.
                            G x J. This column contains the FY 2018
                            Federal Share IMD DSH limit determined by
                            converting the total computable FY 2018 IMD
                            DSH Limit from Column J into a federal share
                            amount by multiplying it by the FY 2018 FMAP
                            in Column G.
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[FR Doc. 2018-14533 Filed 7-5-18; 8:45 am]
 BILLING CODE 4120-01-P