[Federal Register: August 31, 2007 (Volume 72, Number 169)]
[Rules and Regulations]
[Page 50214-50249]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr31au07-8]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1539-F]
RIN 0938-AO72
Medicare Program; Hospice Wage Index for Fiscal Year 2008
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule sets forth the hospice wage index for fiscal
year 2008. This final rule also revises the methodology for updating
the wage index for rural areas without hospital wage data and provides
clarification of selected existing Medicare hospice regulations and
policies.
EFFECTIVE DATES: These regulations are effective on October 1, 2007.
FOR FURTHER INFORMATION CONTACT: Terri Deutsch, (410) 786-9462.
SUPPLEMENTARY INFORMATION:
I. Background
A. General
1. Hospice Care
Hospice care is an approach to treatment that recognizes that the
[[Page 50215]]
impending death of an individual warrants a change in the focus from
curative care to palliative care for relief of pain and for symptom
management. 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 services 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. Section 1814(i) of
the Act provides payment for Medicare participating hospices.
2. Medicare Payment for Hospice Care
Our regulations at 42 CFR part 418 establish eligibility
requirements, payment standards and procedures, define covered
services, and delineate the conditions a hospice must meet to be
approved for participation in the Medicare program. Part 418 subpart G
provides for payment in one of four prospectively-determined rate
categories (routine home care, continuous home care, inpatient respite
care, and general inpatient care) to hospices, based on each day a
qualified Medicare beneficiary is under a hospice election.
B. Hospice Wage Index
Our regulations at Sec. 418.306(c) require each hospice's labor
market to be established using the most current hospital wage data
available, including any changes to the Metropolitan Statistical Areas
(MSAs) definitions, which have been superseded by Core-Based
Statistical Areas (CBSAs).
The hospice wage index is used to adjust payment rates for hospice
agencies under the Medicare program to reflect local differences in
area wage levels. The original hospice wage index was based on the 1981
Bureau of Labor Statistics hospital data and had not been updated since
1983. In 1994, because of disparity in wages from one geographical
location to another, a committee was formulated to negotiate a wage
index methodology that could be accepted by the industry and the
government. This committee, functioning under a process established by
the Negotiated Rulemaking Act of 1990, was comprised of: National
hospice associations; rural, urban, large and small hospices; multi-
site hospices; consumer groups; and a government representative. On
April 13, 1995, the Hospice Wage Index Negotiated Rulemaking Committee
signed an agreement for the methodology to be used for updating the
hospice wage index.
In the August 8, 1997 Federal Register (62 FR 42860), we published
a final rule implementing a new methodology for calculating the hospice
wage index based on the recommendations of the negotiated rulemaking
committee. The committee statement was included in the appendix of that
final rule (62 FR 42883).
The hospice wage index is updated annually. Our most recent annual
update notice, published in the September 1, 2006 Federal Register (71
FR 52080), set forth updates to the hospice wage index for FY 2007. On
October 3, 2006, we published a correction notice in the Federal
Register (71 FR 58415) and we published a subsequent correction notice
on January 26, 2007 (72 FR 3856), to correct technical errors that
appeared in the September 1, 2006 notice.
1. Changes to Core-Based Statistical Areas
The annual update to the hospice wage index is published in the
Federal Register and is based on the most current available hospital
wage data, as well as any changes by the Office of Management and
Budget (OMB) to the definitions of MSAs. The August 4, 2005 final rule
(70 FR 45130) adopted the changes discussed in the OMB Bulletin No. 03-
04 (June 6, 2003), which announced revised definitions for Micropolitan
Statistical Areas and the creation of MSAs and Combined Statistical
Areas. In adopting the OMB Core-Based Statistical Area (CBSA)
geographic designations, we provided for a 1-year transition with a
blended wage index for all providers for FY 2006. For FY 2006, the
hospice wage index for each provider consisted of a blend of 50 percent
of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-
based wage index. As discussed in the August 4, 2005 final rule and in
the September 1, 2006 notice, for FY 2007 and subsequent years we will
use the full CBSA-based wage index values, as presented in Tables A and
B of this final rule for FY 2008.
2. Raw Wage Index Values
Raw wage index values (that is, inpatient hospital pre-floor and
pre-reclassified wage index values) as described in the August 8, 1997
hospice wage index final rule (62 FR 42860), are subject to either a
budget neutrality adjustment or application of the wage index floor.
Raw wage index values of 0.8 or greater are adjusted by the budget
neutrality adjustment factor. Budget neutrality means that, in a given
year, estimated aggregate payments for Medicare hospice services using
the updated wage index values will equal estimated payments that would
have been made for these services if the 1983 wage index values had
remained in effect. To achieve this budget neutrality, the raw wage
index is multiplied by a budget neutrality adjustment factor. The
budget neutrality adjustment factor is calculated by comparing what we
would have paid using current rates and the 1983 wage index to what
would be paid using current rates and the new wage index. The budget
neutrality adjustment factor is computed and applied annually. For the
FY 2008 hospice wage index in the final rule, FY 2007 hospice payment
rates were used in the budget neutrality adjustment factor calculation.
Raw wage index values below 0.8 are adjusted by the greater of: (1)
The hospice budget neutrality adjustment factor; or (2) the hospice
wage index floor (a 15 percent increase) subject to a maximum wage
index value of 0.8. For example, if County A has a pre-floor, pre-
reclassified hospital wage index (raw wage index value) of 0.4000, we
would perform the following calculations using the budget neutrality
factor (which for this example is 1.060988) and the hospice wage index
floor to determine County A's hospice wage index:
Raw wage index value below 0.8 multiplied by the budget neutrality
adjustment factor:
(0.4000 x 1.060988 = 0.4244).
Raw wage index value below 0.8 multiplied by the hospice wage index
floor:
(0.4000 x 1.15 = 0.4600).
Based on these calculations, County A's hospice wage index would be
0.4600.
3. Hospice Payment Rates
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 FYs 1998 through 2002. Hospice rates were to be updated by a
factor equal to the market basket index, minus 1 percentage point.
Payment rates for FY
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2008 will be updated according to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the payment rates for subsequent
FYs will be the market basket percentage for the fiscal year.
Accordingly, the FY 2008 update to the payment rates for each of the
four levels of care (routine home care, continuous home care, general
inpatient care and inpatient respite care) will be the full market
basket percentage increase for FY 2008. The rate update for FY 2008 is
implemented through a separate administrative instruction and is not
part of this rule. Historically, the rate update has been published
through a separate administrative instruction issued annually in July
to provide adequate time to implement necessary system changes and
allow for provider notification. Providers determine their payment
rates by applying the wage index in this rule to the labor portion of
the published hospice rates.
4. Proxy for the Hospital Market Basket
As discussed above, the hospice payment rates for fiscal years
after 2002 are adjusted each year based upon the full hospital market
basket percentage increase. In the FY 2007 update notice (72 FR 52082)
published on September 1, 2006, we indicated that beginning in April
2006, with the publication of March 2006 data, the Bureau of Labor
Statistic's (BLS's) Employment Cost Index (ECI) began using a different
classification system, the North American Industrial Classification
System (NAICS), instead of the Standard Industrial Classification
System (SIC), which no longer exists. The ECIs had been used as the
data source for wages and salaries and other price proxies in the
hospital market basket. In the FY 2007 update notice we noted that no
changes would be made to the usage of the NAICS-based ECI; however,
input was solicited on this issue. We received no comments. As a
result, in the proposed rule we did not propose any changes.
II. Provisions of the Proposed Regulation and Analysis of and Responses
to Public Comments
On May 1, 2007, we published a proposed rule in the Federal
Register (72 FR 24116) that set forth the proposed hospice wage index
for FY 2008. The following is a summary of each of the proposed
provisions followed by our response to public comments. We received 19
timely items of correspondence, one from a physician, 6 from hospice
providers, and 12 from associations.
A. Annual Update to the Hospice Wage Index
We did not propose any modifications to the hospice wage index
methodology as described in the 1997 final rule (62 FR 42860). In
accordance with our regulations and the agreement signed with other
members of the Hospice Wage Index Negotiated Rulemaking Committee, we
use the most current hospital data available to adjust for area wage
differences. As noted above, payment rates for each of the four levels
of care (routine home care, continuous home care, general inpatient
care and inpatient respite care) are adjusted annually based upon the
hospital market basket for that year and are promulgated through
administrative instructions issued annually in July in order to allow
for sufficient time for system changes and provider notification.
We use the previous fiscal year's hospital wage index data to
calculate the hospice wage index values. For the FY 2008 proposed and
final hospice wage index values, we used the FY 2007 hospital pre-floor
and pre-reclassified hospital wage data. This means that the hospital
wage data used for the hospice wage index is not adjusted to take into
account any geographic reclassification of hospitals including those in
accordance with sections 1886(d)(B) or 1886(d)(10) of the Act. We also
do not take into account reclassifications in accordance with section
508 of the MMA or the out-migration adjustment for hospitals (section
505 of the MMA).
All hospice wage index values for FY 2008 are adjusted by either
the FY 2008 budget neutrality adjustment factor or the wage index floor
adjustment. For wage index values 0.8 or greater, the value is
multiplied by the budget neutrality adjustment factor. Wage index
values that are below 0.8, receive the greater of a 15 percent increase
or the budget neutrality adjustment factor subject to a maximum wage
index value of 0.8. In other words, the floor adjustment is the greater
of the raw wage index value multiplied by the proposed budget
neutrality adjustment factor or the raw wage index value for that area
is multiplied by 15 percent subject to a maximum value of 0.8. Budget
neutrality means that, in a given year, estimated aggregate payments
for Medicare hospice services using the updated wage index will equal
estimated payments that would have been made for the same services if
the wage index adopted for hospices in 1983 had remained in effect. For
a detailed discussion of the methodology used to compute the hospice
wage index see the September 4, 1996 proposed rule (61 FR 46579) and
the August 8, 1997 final rule (62 FR 42860).
As indicated in the proposed rule, we did not propose any changes
in the methodology used in calculating the hospice wage index values
and we did not solicit comments. However, we received eight items of
correspondence pertaining to future changes, the methodology for
computing the wage index for Puerto Rico, the publication of the market
basket update through administrative issuance, and the inadequacy of
rural payment rates.
Comment: We received two comments stating that any future changes
proposed for hospice payments should follow the negotiated rulemaking
process rather than notice and comment. The same commenters also
expressed support for a more reasonable and consistent approach to
constructing wage index adjustments for hospitals and post acute
providers. The commenters also indicated that any changes in the wage
index approach should require an extended transition period to prevent
disruptive swings.
Response: We thank the commenters for their suggestions and we will
keep them under advisement as we analyze the need for future
refinements.
Comment: One commenter suggested that the hospice payment rates be
published with the hospice wage index regulations as is done in other
prospective payment systems.
Response: As we discussed in the proposed rule, historically the
payment rate updates have been promulgated through a separate
administrative instruction or administrative issuance in July of each
year to provide adequate time to implement necessary system changes. As
the hospice wage index regulation is scheduled for publication at the
end of August, inclusion of the hospice payment updates in this
regulation would not allow sufficient time for system changes to be
made to accommodate the October 1 implementation date of the payment
updates.
Comment: Several commenters noted that there are challenges in
furnishing hospice care in rural areas, citing underdevelopment, long
distances for staff to travel, staff recruitment challenges and the
need for rural hospices to be competitive in the wages and benefits
that they provide. One commenter stated that rural areas adjacent to
urban areas are at a greater disadvantage as they are competing for
staff in urban areas with higher wages. Another commenter stated that
rural home based salary adjustment based on the hospital wage index is
inadequate
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and should be reimbursed at a higher rate. The commenter also stated
that there are extra costs for mileage expenses for rural staff and
suggested that an ``expansive geography index'' be applied to the
hospice wage index formula for rural counties. Another commenter
indicated willingness to discuss this issue further to investigate ways
to encourage hospice care in rural areas.
Response: We thank the commenters for their comments and
suggestions. We recognize that there are challenges in providing health
care in urban as well as in rural areas. Recruitment challenges,
competitiveness in wages and benefits and commuting difficulties are
factors that are facing all health care providers. We believe that the
hospital wage data reflects these factors and as a result, the hospice
wage index values are also reflective of these challenges. In addition,
the application of the hospice floor for raw values below 0.8 provides
a higher wage index value to many rural areas. However, we will
consider these comments and suggestions as we analyze the need for
future refinements to the hospice payment methodology.
Comment: One hospice provider from Puerto Rico provided us with a
study that it had undertaken. It requested that this report be used by
CMS to make the ``right'' decision about the correct wage index for
Puerto Rico. This study concluded that 34 hospices in Puerto Rico will
see a decrease in their hospice payments by 2.6 percent in FY 2008.
Several of the conclusions presented in this study compare a hospice in
Arecebo, Puerto Rico to hospitals in New England and Albuquerque, New
Mexico, list the economic challenges in Puerto Rico, and suggested the
payment rate that it believes should be used for Puerto Rico.
Response: We thank the commenter for sending its study to us.
However, as the study concludes that payment rates and wage index
values should be determined utilizing the same methodology used for the
hospital wage index values, we believe the study is based on an
erroneous and incorrect understanding of the content of the hospice
wage index proposed rule as well as the methodology that had been
developed and agreed upon through the negotiated rulemaking committee.
As noted above, the methodology for the hospice wage index was
developed, and an agreement on the methodology was signed, by members
of the Hospice Wage Index Negotiated Rulemaking Committee. We note that
Puerto Rico was represented by the hospice associations' participants
on the committee. Hospices in Puerto Rico had notice of the committee
deliberations and they had an opportunity to apply to be on the
committee, and were encouraged to attend and make a statement to the
committee. A detailed description of the methodology is contained in
both the September 4, 1996 proposed rule (61 FR 46579) and the August
8, 1997 final rule (62 FR 42860).
The commenter is incorrect in stating that the payment rates for
Puerto Rico will decrease 2.6 percent in FY 2008. We indicated in the
proposed rule that the impact analysis demonstrates the impact of the
FY 2008 wage index values and is not a projection of the anticipated
expenditures of hospice payments for FY 2008. The impact analysis
compares hospice payments using the FY 2007 hospice wage index to the
estimated payments using the FY 2008 wage index. For urban Puerto Rico,
the proposed rule indicated that, using the FY 2007 payment rates and
the FY 2008 wage index values, payments are anticipated to decrease 2.6
percent, which represents only the affects of the wage index and does
not reflect the payment increase for FY 2008. As noted above, the FY
2008 hospice payment rates will reflect the market basket update.
We do not understand the study's comparison between Puerto Rico and
Albuquerque, New Mexico or New England regions and as a result cannot
respond. However, it is important to note that wage index values
fluctuate from year to year for counties as well as regions and we do
not believe that comparisons to other regions provide any substantive
information. It is also important to note that the FY 2007 hospital
pre-floor, pre-reclassified hospital wage data reflects data from the
FY 2003 hospital cost reports and the data provided in the Puerto Rico
study reflect data from later years. We will share the information
provided in this study with the organizational component within CMS
that develops the inpatient hospital wage data, as it appears that the
study relates to the development of the hospital wage index.
B. Rural Areas Without Hospital Wage Data
When adopting OMB's new labor market designations, we identified
some geographic areas where there were no hospitals, and thus, no
hospital wage index data on which to base the calculation of the
hospice wage index (70 FR 45135, August 4, 2005). For FY 2006 and FY
2007, we adopted a policy to use the FY 2005 pre-floor, pre-
reclassified hospital wage index value for rural areas where no rural
hospital wage data were available. We also adopted the policy that for
urban labor markets without an urban hospital from which a hospital
wage index data could be derived, all of the CBSAs within the State
would be used to calculate a statewide urban average wage index data to
use as a reasonable proxy for these areas. In the August 2005 final
rule and in the September 2006 update notice, we applied the average
wage index data from all urban areas lacking hospital wage data in that
state. Currently, the only CBSA that is affected by this policy is CBSA
25980, Hinesville-Fort Stewart, Georgia. We proposed to continue this
approach for urban areas where there are no hospitals and, thus, no
hospital wage index data on which to base the calculations for the FY
2008 and subsequent hospice wage indexes.
In the proposed rule we noted that under the CBSA labor market
areas, there are no rural hospitals in rural locations in Massachusetts
and Puerto Rico. In the August 2005 final rule (70 FR 45135) and in the
September 2006 update notice (71 FR 52081), we applied the FY 2005 pre-
floor, pre-reclassified hospital wage data in both FY 2006 and FY 2007
for rural Massachusetts and rural Puerto Rico. In the proposed rule, we
considered alternatives in our methodology to update the wage index for
rural areas without hospital wage index data consistent with other
prospective payment systems. We noted that we believe that the best
imputed proxy for rural areas, would: (1) Use pre-floor, pre-
reclassified hospital data; (2) use the most local data available to
impute a rural wage index; (3) be easy to evaluate and; (4) be easy to
update from year to year. Although our current methodology meets the
first three criteria, it could not be easily updated from year to year
because the FY 2005 pre-floor, pre-reclassified hospital wage data
would continue to be used. Therefore, in cases where there is a rural
area without rural hospital wage data, we proposed using the average
pre-floor, pre-reclassified wage index data from all contiguous CBSAs
to represent a reasonable proxy for the rural area. This approach meets
all of the stated criteria (72 FR 24118).
We noted in the proposed rule that we interpret the term
``contiguous'' to mean ``sharing a border''. We cited the example of
Massachusetts, where the entire rural area consists of Dukes and
Nantucket counties. We determined that the borders of Dukes and
Nantucket counties are contiguous with Barnstable and Bristol counties.
Therefore, the pre-floor, pre-reclassified wage index values for the
counties of Barnstable (CBSA 12700, Barnstable Town, MA) and
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Bristol (CBSA 39300, Providence-New Bedford-Fall River, RI-MA) would be
averaged resulting in an imputed pre-floor, pre-reclassified rural wage
index for rural Massachusetts.
While we believe that this policy could be readily applied to other
rural areas that lack hospital wage data (possibly due to hospitals
converting to a different provider type, such as a critical access
hospital (CAH), that do not submit the appropriate wage data), should a
similar situation arise in the future, we may re-examine this policy.
In the proposed rule we noted that we do not believe that this
policy would be appropriate for Puerto Rico. There are sufficient
economic differences between hospitals in the United States and those
in Puerto Rico, including the payment of hospitals in Puerto Rico using
blended Federal/Commonwealth-specific rates that we believe necessitate
a separate and distinct policy for Puerto Rico. Consequently, any
alternative methodology for imputing a wage index for rural Puerto Rico
would need to take into account those differences. Our policy of
imputing a rural wage index based on the wage index(es) of CBSAs
contiguous to the rural area in question does not recognize the unique
circumstances of Puerto Rico. We also noted that while we have not yet
identified an alternative methodology for imputing a wage index for
rural Puerto Rico, we will continue to evaluate the feasibility of
using existing hospital wage data and, possibly, wage data from other
sources. Accordingly, we propose to continue using the most recent pre-
floor, pre-reclassified wage index previously available for Puerto
Rico, which is 0.4047 (72 FR 24118-19).
Comment: We received four items of correspondence in response to
our proposal for rural areas without hospital wage data. Two commenters
supported the proposal. Two commenters stated that the proposed
methodology, while not ideal, comes closest to what the commenters
believe is an equitable solution in resolving a perceived flaw in using
hospital data to adjust payment to non-hospital providers. The
commenters also assumed that a better alternative would emerge over the
next few years in the course of revising the hospital wage index. One
commenter agreed with the methodology but asked that we do not use this
formula for other situations without review and reexamination of the
policy. The same commenter commended us for demonstrating flexibility
and good judgment in creating a different system for Massachusetts and
Puerto Rico.
We note that we received no comments on the methodology employed
for urban areas without a hospital from which to derive hospital wage
data.
Response: We thank the commenters for their support. We continue to
believe that our proposed methodology results in the most appropriate
imputed proxy for rural areas in meeting the criteria we identified as
follows: (1) Use pre-floor, pre-re-classified hospital data, (2) use
the most local data available to impute a rural wage index, (3) be easy
to evaluate; and (4) be easy to update from year to year. We will
consider the suggestion for evaluating the policy if needed in other
situations.
C. Nomenclature Changes
We proposed to clarify that all hospice rules and notices are
considered to incorporate the CBSA changes published in the most recent
OMB bulletin that applies to the hospital wage index data used to
determine the current hospice wage index (72 FR 24119). We received no
comments on this proposal.
D. Payment for Hospice Care Based on the Location Where Care Is
Furnished
Under the Medicare hospice program, hospice providers receive
payment for four levels of care based upon the individual's needs. The
payment rates are adjusted to reflect the variation in geographic
locations. Section 4442 of the BBA amended section 1814(i)(2) of the
Act, effective for services furnished on or after October 1, 1997,
required the application of the local wage index value of the
geographic location at which the service is furnished for hospice care
provided in the home. Prior to this provision, local wage index values
were applied based on the geographic location of the hospice provider,
regardless of where the hospice care was furnished. In the proposed
rule, we noted that we believe that for the majority of hospice
providers the office and the site for the provision of home and
inpatient care occur in the same geographic area. However, with the
substantial growth of hospice providers in multiple states and with
multiple sites within a State, hospice providers have been able to
inappropriately maximize reimbursement by locating their offices in
high-wage areas and delivering services in a lower-wage area. We also
believe that hospice providers are able to inappropriately maximize
reimbursement by locating their inpatient services either directly or
under contractual arrangements in lower wage areas than their offices.
Section 4442 of the BBA applies the wage index value of a home's
geographic location for services provided there, but is silent as to
what wage index value should be used for hospice services provided in
an inpatient setting. We believe that the application of the wage index
values should reflect the location of the services provided rather than
the location of an office. We believe such application results in a
reimbursement rate that is a more accurate reflection of the wages paid
by the hospice for the staff used to furnish care. We proposed that
effective January 1, 2008, all payment rates (routine home care,
continuous home care, inpatient respite and general inpatient care) be
adjusted by the geographic wage index value of the area where hospice
services are provided. This would require hospice providers to include
the geographic location of the inpatient facility for general inpatient
and inpatient respite levels of care on claims submitted for payment.
We proposed to modify Sec. 418.302 accordingly.
In the proposed rule we also indicated that as hospice claims do
not contain information identifying the location of the facility where
general inpatient and respite care are provided, we are unable to
predict the savings or costs associated with the changes associated
with this proposed provision. However, we believe most hospice
providers provide hospice care in the same geographic location as their
offices. Therefore, we believe the impact of implementing this proposal
will be negligible.
Comment: We received eight items of correspondence, of which six
supported the provision to base payment rates on the geographic wage
index value of the area where inpatient hospice services are provided.
Response: We thank the commenters for their support of this
provision.
Comment: One commenter suggested that we suspend the implementation
of this provision until we have additional data from providers on the
impact.
Response: In the proposed rule we indicated that, as hospice claims
do not contain information identifying the location of the facility
where inpatient care is provided, we are unable to predict the savings
or costs associated with changes in this provision. Effective January
1, 2007, hospice providers were required to indicate the type of
location where care was provided (for example, nursing home, assisted
living facility, hospital unit), but not the geographic location (which
would be used to adjust payments). As we have indicated, we believe
that for most providers, the location of the inpatient facility and the
hospice provider are the same. We do not believe that postponing the
[[Page 50219]]
implementation of this provision would enable us to collect any
additional information.
Comment: One commenter indicated that this change will
significantly increase the complexity of filing hospice claims and will
increase hospice costs due to the need to include the CBSA for the
geographic location, as well as the code of where the patient is
receiving hospice services.
Response: We appreciate the concern regarding the complexity of
filing claims and the perceived increased costs to hospices. We are in
the process of developing operational instructions that we believe will
help simplify the billing process. Hospice providers currently are
required to identify the geographic location of their patients for the
routine home care and continuous home care levels of care, and the
location of the hospice office for general inpatient care and inpatient
respite care. We are now also requiring hospice providers to identify
the geographic location where inpatient care is provided. We believe
that for the majority of hospice providers, the location of the
facility for the provision of both the general inpatient and inpatient
respite levels of care will be the same as the location of the hospice
office. For those majority of cases, this change will require the
hospice provider to indicate the same CBSA location of the office on
the claims as the location of the facility where inpatient levels of
care are provided. As a result, we believe that the impact on hospices
for implementing this provision should be negligible as most hospices
currently provide this information on the claims.
Comment: Several commenters concurred with the provision but
objected to the statement that hospice providers are able to
inappropriately maximize reimbursement by having their offices located
in a higher wage area. One commenter indicated that the statement was
misleading and unnecessarily harsh. Another commenter suggested
removing the statement. One commenter interpreted this statement as
being demeaning and inflammatory. The same commenter stated that most
hospices would not benefit from manipulating the location of an
inpatient facility. Several commenters indicated that there is nothing
prohibiting a hospice from having their inpatient facilities in a
higher wage area, though the commenters stated it was doubtful that a
hospice would do this or arrange contracts in order to manipulate
reimbursement. Some commenters stated that urban areas have higher
rates and that hospices generally have contracts with all hospitals in
an area. Some commenters indicated patients have choices about where to
receive care and would complain if they were forced to receive
inpatient care out of their area.
Response: While we appreciate the commenters objection to the
statement that we made about hospice providers being able to
inappropriately maximize reimbursement by locating their offices in a
higher age area, we concur with the commenter that nothing prohibits a
hospice from locating its inpatient services, either directly or under
contractual arrangements, in a higher wage area, as well. In fact, we
have received anecdotal information that leads us to believe that there
are hospice offices that have been intentionally located in higher wage
areas than those of their patients in order to maximize their
reimbursement. We supported our proposal by noting the potential for
maximizing reimbursement based on the location of the main office,
which was the same rationale used by the congressional committee when
the BBA 1997 provision requiring the application of the local wage
index of the geographic location where the service is furnished for
hospice care provided in the home was enacted. We believe that the same
rationale applies to the inpatient facility locations as well. Our
intent for this provision is to have all levels of payment adjusted by
the wage index that applies to the site where the service is being
provided.
Comment: One commenter interpreted the proposed provision as
reducing reimbursement to a lesser amount based on distance from the
main office. The same commenter stated that staff were paid at the home
office area rate and suggested that payment be based on the costs at
the main office.
Response: We believe that the suggestion that using distance from
the main office determines payment rates is a misinterpretation of the
intent of this provision as well as the statement concerning maximizing
reimbursement based upon the location of the hospice main office. As we
have discussed in the proposed rule, we were not proposing to modify
the methodology used for computing the hospice wage index values. The
intent of the proposal is to employ the same methodology for applying
the wage index value for geographic variations regardless of where
hospice care is provided.
E. Educational Requirements for Nurse Practitioners
On December 8, 2003, the Congress enacted the Medicare Prescription
Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-
173). Section 408 of the MMA, Recognition of Attending Nurse
Practitioners as Attending Physicians to Serve Hospice Patients,
amended sections 1861(dd)(3)(B) and 1814(a)(7) of the Act to add nurse
practitioners (NPs) to the definition of an attending physician for
beneficiaries who have elected the hospice benefit. Section 408 of the
MMA was implemented through an administrative issuance (Change Request
(CR) 3226, Transmittals 22 and 304, September 24, 2004). In the August
4, 2005 FY 2006 final rule (70 FR 45139), we revised Sec. 418.3 to
reflect that an attending physician can be a nurse practitioner who
meets the training, education and experience requirements as the
Secretary may prescribe.
We indicated in the proposed rule that we believe that the
definition of attending physician, which includes nurse practitioners
under the Medicare hospice benefit, should be consistent with the
provisions of section 410.75 that provide for Medicare Part B coverage
of nurse practitioner services. Therefore, to ensure consistency, we
proposed to revise the definition of ``attending physician'' at Sec.
418.3(1)(ii) to cross reference the training, education, and experience
requirements as described in Sec. 410.75(b).
Comment: We received six items of correspondence regarding our
proposal to conform the educational requirements for nurse
practitioners serving as the attending physician to the requirements
described in Sec. 410.75. All commenters supported this provision. One
commenter requested that the hospice physician definition be revised to
include nurse practitioners, although the commenter recognized that any
such revision could not allow nurse practitioners to certify the
terminal illness of a patient. Another commenter suggested that the
definition of attending physician be clarified by using the term
``attending nurse practitioner'' instead of referring to nurse
practitioners as ``attending physicians.'' One commenter requested that
the nurse practitioner qualifications provisions at Sec. 410.75 be
amended to reflect current and evolving educational requirements for
advanced practice registered nurses. The commenter requested that the
term ``master's degree'' in Sec. 410.75(b)(ii)(4) be replaced with
``graduate degree'' to reflect nurse practitioners with doctoral
degrees.
Response: We thank the commenters for their support of this
provision. As noted in the proposed rule and earlier in this rule, the
implementation of section 408 of the MMA, which amended sections
1861(dd)(3)(B) and
[[Page 50220]]
1814(a)(7) of the Act to add nurse practitioners to the definition of
an attending physician, was discussed in the August 4, 2005 final rule
(70 FR 45130). Section 418.304(e)(2)(iv) specifies that nurse
practitioners may bill and receive payment for services provided as the
attending physician, only if the services are not related to the
certification of the terminal illness in Sec. 418.22(c)(1)(ii).
Section 418.22(c) specifies that certification of the terminal illness
is obtained from ``the medical director of the hospice or the physician
member of the hospice interdisciplinary group''. Therefore, we believe
it would be inconsistent with statute and regulations to allow nurse
practitioners to bill and receive payment for certifying an
individual's terminal illness. As the role of the nurse practitioner is
explicit in statute, nurse practitioners are not included as a hospice
physician and may not serve in that role.
We concur with the commenter that the definition of attending
physician should use the term ``attending nurse practitioner''.
However, as the statute at sections 1861(dd)(3)(B) and Sec. 1814(a)(7)
explicitly uses the term ``attending physician'' for a nurse
practitioner serving as the attending physician, we do not accept this
recommendation.
We did not propose to replace the term master's degree in
410.75(b)(ii)(4) with ``graduate degree''. Therefore, we will not make
the change in this final rule. However, we will provide your suggestion
to the area within CMS responsible for advanced practitioner
educational requirements.
F. Caregiver Breakdown and General Inpatient Care
In the proposed rule, we discussed a concern that some hospice
providers are requesting payment for the general inpatient level of
care for circumstances that do not qualify under the statute at section
1861(dd)(1)(G) of the Act, our regulations at Sec. 418.202(e), or
Medicare hospice policy in Chapter 9 of the Medicare Benefit Policy
Manual. We provided clarification of existing statute, regulation and
policy in the proposed rule and did not propose any changes (72 FR
24120).
As discussed in the proposed rule, the Medicare hospice benefit
places emphasis on the provision of items and services to enable an
individual to remain at home in the company of family and friends.
Section 1861(dd)(1)(G) of the Act provides for short-term inpatient
hospice care to be available when an individual's pain and symptoms
must be closely monitored or the intensity of interventions that are
required cannot be provided in any other settings. Inpatient respite
care is available for family members, who serve as the primary
caregivers, to obtain rest for a period of no more than 5 days at a
time. Hospice providers should submit claims for inpatient respite care
in situations where there is an unexpected loss of the individual's
support structure that results in an inability to maintain the
individual in his or her home, but the individual does not require an
inpatient level of care.
Medicare policy states that skilled nursing care may be required by
a patient whose home support has broken down, if this breakdown makes
it no longer feasible to furnish needed care in the home setting. If
the hospice and the caregiver, working together, are no longer able to
provide the necessary skilled nursing care in the individual's home,
and if the individual's pain and symptom management can no longer be
provided at home, then the individual may be eligible for a short term
general inpatient level of care. To receive payment for general
inpatient care under the Medicare hospice benefit, beneficiaries must
require an intensity of care directed towards pain control and symptom
management that cannot be managed in any other setting. It is the level
of care provided to meet the individual's needs and not the location of
where the individual resides, or caregiver breakdown, that determine
payment rates for Medicare services.
Caregiver breakdown is the loss of the individual's support
structure and should not be confused with the coverage requirements for
medically reasonable and necessary care for pain and symptom management
that cannot be managed in any other setting. Therefore, caregiver
breakdown should not be billed as general inpatient care unless the
coverage requirements for this level of care are met. As discussed
above, for the general inpatient level of care, the intensity of
interventions required for pain and symptom management is such that it
cannot be provided in any setting other than an inpatient setting.
As explained in the proposed rule, this is a clarification of
current Medicare policy and as such does not create new limitations on
access to hospice care. As noted in the proposed rule, we intend to
monitor the usage of general inpatient care. Additionally, the
circumstances addressed by this policy, and the clarification discussed
above, should not be construed as similar to situations where an
individual does not have family, friends or other individuals who are
able to take on the role of a caregiver when a hospice election is
made. In the proposed rule, we indicated that inpatient respite care
could be used in situations where there is caregiver breakdown.
However, in situations where there is a lack of a caregiver at the time
of the election, the inpatient respite level of care does not apply.
Inpatient respite care is unavailable when there is no caregiver to
whom relief must be provided. The established policy that the level of
care required to provide pain and symptom management determines payment
and not the location of where the individual resides or receives
hospice services, also applies in situations where there is not an
appropriate caregiver. We recognize the difficulties surrounding the
provision of hospice care to an individual who is terminally ill and
who does not have caregivers at home. This may be particularly
challenging in rural areas. Section 409 of the MMA (Pub. L. 108-173)
established the Rural Hospice Demonstration which hopes to test
alternative mechanisms for providing hospice services for beneficiaries
who lack an appropriate caregiver and who reside in rural areas. In
this demonstration, a hospice organization may provide all services in
an inpatient facility which serves as a beneficiary's home; however,
payment for inpatient care must meet the usual level of care
requirements. In this demonstration, inpatient respite care is not
possible since there is no caregiver. For specific information on this
demonstration, refer to: http://www.cms.hhs.gov/DemoProjectsEvalRpts/
MD/itemdetail.aspitemID=CMS1183983.
Comment: We received nine items of correspondence regarding the
clarification of the general inpatient level of care and its use when
there is a breakdown in caregiver support. Several commenters supported
the clarification, however the majority did not, as we describe below.
Several commenters stated that they shared our concern that the general
inpatient level of care not become a source of abuse and the need to
focus on hospice providers who use the general inpatient level of care
inappropriately. Two commenters stated that they supported steps to
eliminate any potential collusion or inducements in this area.
Response: We appreciate the comments and thank those who were in
support of this provision. The intent of this clarification was to
ensure that the general inpatient level of care be utilized
appropriately and in accordance with statute, regulations and policy.
Our focus was not on fraudulent or abusive use of the general inpatient
level of care, but rather on ensuring that
[[Page 50221]]
the general inpatient level of care is properly utilized in accordance
with established criteria.
Comment: Some commenters believed that the clarification was
overly prescriptive while others believed that this was not a
clarification of existing policy, but was a new interpretation. Some
commenters expressed that the intent of the general inpatient level of
care, at the inception of the benefit, was to address the need for pain
control and symptom management as well as care for patients whose
caregiver or home support has broken down, making it no longer feasible
to furnish care in the home. One commenter indicated that use of the
general inpatient level of care in the event of caregiver breakdown met
the requirements in 418.302 as a condition of participation. The same
commenter added that the proposed interpretation shifts the focus from
caring for patients in the appropriate setting to a billing and
reimbursement issue. Some commenters stated that this provision was
designed to reduce expenditures without regard to patient safety and
hospice expenses.
Other commenters also strongly disagreed with the clarification.
They indicated that Medicare policy has been interpreted for more than
twenty years to mean that general inpatient level of care can be used
for caregiver breakdown and the practice of billing at the higher level
of care in those circumstances is consistent with written CMS and
fiscal intermediary guidance.
Some commenters stated that the definition of general inpatient
care in the hospice regulations supported the use of general inpatient
level of care for caregiver breakdown. One commenter stated that it was
inappropriate to punish patients by removing a long established benefit
for the hospice program because of the perception that some hospices
are using the general inpatient level of care inappropriately.
Response: We disagree with the commenter who believes that this
clarification is a new interpretation. Rather, we seek to clarify here
our established policy by providing what we believe is a helpful
explanation of how our policies should be interpreted and applied. We
are not making any policy changes with this clarification. We believe
that this clarification is needed because, as some commenters
recognize, the general inpatient level of care has been used for
situations where caregiver breakdown has occurred.
The level of care needed to manage pain and symptoms is the basis
for the general inpatient level of care in the statute, regulations and
policy, none of which recognizes caregiver breakdown as an indication
for the general inpatient level of care. The Medicare Benefit Policy
Manual, Chapter 9--Coverage of Hospice Services, section 40.1.5--Short-
Term Inpatient Care, indicates that skilled nursing care may be needed
by a patient whose home support has broken down. In the proposed rule
we acknowledged this and indicated that if the hospice and the
caregiver, working together, are no longer able to provide the
necessary skilled nursing care in the individual's home, and if the
individual's pain and symptom management can no longer be provided at
home, then the individual may be eligible for a short term general
inpatient level of care. Section 1861(dd)(1) of the Act defines hospice
care as the items and services to be provided to a terminally ill
individual by a hospice directly or under arrangement. The statute goes
on to specify the items and services, but does not include caregiver
services. This means that Medicare does not pay for caregiver services
under the hospice benefit. In further support, Sec. 418.98 sets forth
the hospice conditions of participation requiring hospices to make
available ``inpatient care* * * for pain control, symptom management
and respite purposes * * *.'' Section 418.202 lists the covered hospice
services and includes short-term inpatient care at Sec. 418.202(e),
stating ``inpatient care may be required for procedures necessary for
pain control or acute or chronic symptom management. Inpatient care may
also be furnished as a means of providing respite for the individual's
family or other persons caring for the individual at home.'' Further,
Sec. 418.302(b)(4) provides that ``a general inpatient care day is a
day on which an individual who has elected hospice care receives
general inpatient care in an inpatient facility for pain control or
acute or chronic symptom management which cannot be managed in other
settings.''
We believe that there is no support for the comments that suggest
that the intent of the general inpatient level of care was to include
care for patients whose home support has broken down. We also disagree
with the comment that this clarification shifts the focus from caring
for patients to a purely billing and reimbursement issue and that there
needs to be a humane and practical alternative. Our discussions in the
proposed rule and in this final rule have focused on the provision of
care and the level of care needed by the patient. However, certain
billing requirements and payment amounts are associated with each level
of care. In cases where a particular level of care is provided because
of circumstances that are inappropriate to warrant that particular
level of care (here, general inpatient provided because of caregiver
breakdown), it is inappropriate for the hospice to bill and receive
payment for the general inpatient level of care.
Comment: Several commenters indicated that the general inpatient
level of care was appropriate in rare circumstances where the patient's
care network breakdown is not recoverable after a short period of
inpatient respite care. Other commenters expressed the need to provide
inpatient care immediately for caregiver breakdown. The same commenters
believe that the immediate need would prohibit the use of inpatient
respite care, which they indicated was a planned admission. One
commenter strongly objected to the statement in the proposed rule that
specified the requirement for the provision of an intensity of care to
support the general inpatient level of care. However, some commenters
stated that more frequent use of general inpatient level of care is
appropriate as hospices are experiencing difficulty finding adequate
caregivers.
Some commenters stated that general inpatient level of care
provided the only option other than discharging patients from the
hospice benefit to long term care facilities. Others stated that the
proposed clarification implied that hospice care must be terminated
when there is a situation of caregiver breakdown, as there was no
Medicare hospice benefit category to care for patients without
caregiver support. Some commenters stated that we did not address how
caregiver breakdown situations should be addressed while others implied
that unless hospices could bill for general inpatient level of care for
caregiver breakdown, patients' symptoms could be uncontrolled
necessitating the general inpatient level of care.
Response: We disagree with the comment that we did not indicate how
caregiver breakdown situations should be addressed. We indicated in the
proposed rule that there is nothing prohibiting a Medicare approved
facility from serving as the individual's home. However, Medicare daily
per-diem payments are based on medically reasonable and necessary
levels of care as described in the Medicare regulations at Sec.
418.302: A routine home care day is a day on which an individual is at
home and is not receiving continuous care; a continuous home care day
is a day on which an individual is not in an inpatient facility and
receives hospice
[[Page 50222]]
care consisting predominantly of nursing care on a continuous basis at
home during brief periods of crisis as described in Sec. 418.204(a),
to maintain the terminally ill patient at home; an inpatient respite
care day is a day on which the individual receives care in an approved
facility on a short-term basis for respite; and a general inpatient
care day is a day on which an individual receives general inpatient
care in an inpatient facility for pain control or acute or chronic
symptom management which cannot be managed in other setting. Medicare
payment is made based on the medically reasonable and necessary level
of care provided, and not simply where that care is provided. As
discussed above, it is not appropriate to bill Medicare for the general
inpatient care day for situations where the individual's caregiver
support has broken down unless the coverage requirements for the
general inpatient level of care are otherwise met.
We disagree with the comments that patients will need to be
discharged from the hospice benefit to long term care facilities
because discharge for caregiver breakdown does not meet the discharge
requirements in the regulations at Sec. 418.26. The requirements for
discharge at Sec. 418.26 state that a hospice may discharge a patient
if the patient moves out of the hospice service area or transfers to
another hospice; the hospice determines that the patient is no longer
terminally ill; or the hospice discharges the patient for cause. We
also disagree with the comment that patients will be forced to revoke
the hospice benefit if there is caregiver breakdown. Revocation of the
hospice benefit as described in Sec. 418.28 is an action initiated by
the individual (patient) and not by the hospice provider. Finally, we
disagree with the comment that denying the use of the general inpatient
level of care for caregiver breakdown will result in limitation of
access. We have discussed various ways of providing care in this
situation, such as the use of inpatient respite or use of alternative
sources of payment for room and board, that we believe are appropriate
alternatives to meeting the needs of the individual.
Comment: One commenter stated that hospices have seen an erosion of
the use of the inpatient benefit and many offer very little inpatient
care. This commenter concluded that the clarification represents a
reduction in the benefit and will create a new limitation on access to
hospice care and patients will seek inpatient hospital admissions
instead of receiving hospice services at the general inpatient level of
care. Several commenters stated that fiscal intermediaries have allowed
the use of general inpatient care for caregiver breakdown.
Response: We disagree that our clarification on the use of the
general inpatient level of care represents a reduction in the Medicare
hospice benefit and that it will result in a limitation on access to
hospice care. As we noted above, we are not making any policy changes
concerning general inpatient care, rather, we are clarifying our
established policy. We also disagree that there has been an erosion of
the use of general inpatient level of care. Our data, which is
available on the hospice Web site at http://www.cms.hhs.gov/center/
hospice.asp demonstrates that use and payment for the general inpatient
level of care has been increasing each year. We also do not agree that
better compliance with statute, regulations and policy will limit
access to hospice care nor do we see our clarification as an inducement
to increase hospital admissions.
Comment: One commenter questioned why this clarification was being
made when we were unable to quantify the extent of the use of general
inpatient in the event of caregiver breakdown and suggested that
further analysis be done. The same commenter indicated that the cost
savings were inaccurate as our assumption of potential savings is based
on current reimbursement rates for inpatient respite services. The same
commenter believes that the inpatient respite care payment rate is
inadequate. Several other commenters indicated that the reimbursement
rate for inpatient respite care was inadequate.
Several commenters suggested the following: Extending the current
5-day limitation on inpatient respite care; revising policy to allow
for the use of the general inpatient level of care when documentation
indicates that a sufficient caregiver network cannot be restored in a
few days; or establishing an alternative payment mechanism in the
hospice benefit for situations where there is caregiver breakdown.
One commenter suggested that Medicare work with hospice providers
to increase the average length of stay to that which was originally
intended in legislation and in regulation. The same commenter stated
that studies show that hospice care saves Medicare dollars. Several
offered to work with CMS to find an alternative policy to meet patient
needs while protecting the Medicare trust fund.
Response: We appreciate these suggestions and will keep them in
mind as we continue to evaluate Medicare hospice payment policy. We
noted in the proposed rule that we are unable to quantify the use of
the general inpatient level of care for caregiver breakdown. In the
proposed rule we provided an example of the potential impact, as we did
not have empirical data to suggest the actual usage. This example
demonstrated the cost savings to Medicare by using as an example, what
we believe could be a cost saving if we assumed that 5 percent of the
days and expenditures for general inpatient level of care were
attributable to caregiver breakdown. However, the unavailability of
exact utilization rates does not preclude us from ensuring that the
general inpatient level of care is being billed as we intended. Based
upon the comments we received, we believe that the use of the general
inpatient level of care for caregiver breakdown may be more pervasive
than we had envisioned at the time of the proposed rule.
We disagree with the commenter who suggested that the original
legislation and regulation intended for the average length of stay to
be at a specified level. While the statute defines the terminal
diagnosis as having a prognosis of six months or less if the disease
runs its normal course, this does not imply that there is, or ever was,
a targeted length of stay that is required. The regulations require
that an individualized plan of care be developed and updated to
identify patient and family needs and the medically reasonable and
necessary items and services that are required to meet these needs. In
addition, as individuals vary in their responses to illness and care,
we expect to see some variability in lengths of stay. We do not believe
that it is feasible or prudent to specify or predetermine what lengths
of stay should or must be achieved to measure or evaluate the
effectiveness of care provided.
Regarding the comment that the reimbursement rate for inpatient
respite care is inadequate, in the proposed rule, we did not propose to
make any adjustments on the payment rates and merely indicated that the
hospice payment rates are adjusted annually based upon the full market
basket percentage increase. We are aware of studies which suggest that
the inpatient respite care payment rate may not reflect the costs for
providing this level of care. We will consider the comments made
concerning the inpatient respite care rate as we continue to examine
Medicare hospice payment policy.
G. Certification of the Terminal Illness
Section 1814(a)(7)(A)(i) of the Act stipulates that the
individual's attending physician and the hospice medical director
initially certify the individual's terminal diagnosis with a prognosis
of
[[Page 50223]]
six months or less if the disease runs its normal course. Our
regulations at Sec. 418.22 discuss the requirements of the
certification, including documentation requirements. As discussed in
the proposed rule, we are aware that some providers permit the hospice
admission nurse to determine eligibility for hospice services and to
certify the individual's terminal diagnosis. In the proposed rule, we
explained that the statute is explicit in the requirement that the
attending physician and the hospice medical director determine the
terminal diagnosis, and his or her signature on the certification
attests to that fact.
Comment: We received three items of correspondence regarding this
clarification. One commenter supported the clarification of the
responsibility of the hospice medical director and the attending
physician to certify the terminal illness. One commenter asked if a
hospice medical director visit is required at the time of admission to
a hospice and what is the time frame for the visit. Another commenter
stated that concurrence of the hospice medical director and the
attending physician may be tacit and no communication is required
between them.
Response: As discussed above, section 1814(a)(7)(A)(i) of the Act
stipulates that the individual's attending physician and the hospice
medical director each initially certify that the individual is
terminally ill with a medical life expectancy of six months or less if
the disease runs its normal course. Our regulations at Sec. 418.25(a)
of hospice regulations indicate, that the hospice admits a patient only
on the recommendation of the medical director in consultation with, or
with input, from the patient's attending physician (if any). As noted
in the proposed rule, the requirements of the physician certification,
including supportive documentation, were discussed in the Medicare
Program; Hospice Care Amendments proposed rule (67 CFR 70363) and final
rule (70 CFR 70548). Current regulations do not address a time frame
for a physician or hospice medical director visit.
III. Provisions of the Final Regulations
In this final rule, we are adopting the following provisions, as
set forth in the proposed rule, without change. We are also publishing
the FY 2008 urban and rural wage index values for hospices in the
addendum as well as the table that reflects the impact of the FY 2008
wage index values.
A. Annual Update to the Hospice Wage Index
The FY 2008 hospice wage index values have been computed utilizing
OMB's geographic location definitions (CBSA). The budget neutrality
adjustment factor was computed utilizing data from the FY 2006 claims
processed through June 2007. The FY 2008 budget neutrality adjustment
factor of 1.066671 was applied to hospital wage data above 0.8. The
budget neutrality adjustment factor or the hospice floor was applied to
the hospital wage data below 0.8, not to exceed 0.8. The wage index
values are reflected in Table A and Table B of the Addendum.
Specifically, Table A reflects the FY 2008 wage index values for urban
areas under the CBSA designations. Table B reflects the FY 2008 wage
index values for rural areas under the CBSA designations.
B. Rural Areas Without Hospital Wage Data
For FY 2008 and subsequent hospice wage index values, for urban
labor markets without an urban hospital from which hospital wage index
data could be derived, all of the CBSAs within the State will be used
to calculate a statewide urban average wage index to use as a
reasonable proxy for these areas. Currently, the only CBSA that is
affected by this is CBSA 25980, Hinesville-Fort Stewart, Georgia.
For FY 2008 and subsequent hospice wage index values, in cases
where there is a rural area without rural hospital wage data, we will
use the average pre-floor, pre-reclassified wage index data from all
contiguous CBSAs to represent a reasonable proxy for the rural area.
This approach meets the criteria that we believe would be the best
imputed proxy for rural areas, which (1) uses pre-floor, pre-
reclassified hospital data; (2) uses the most local data available to
impute a rural wage index; (3) is easy to evaluate; and (4) is easy to
update from year-to-year. Currently there are no hospitals in rural
locations in Massachusetts and Puerto Rico.
We interpret the term ``contiguous'' to mean sharing a border. For
example, we have determined that the borders of Dukes and Nantucket
counties are contiguous with Barnstable and Bristol Counties.
Therefore, the pre-floor, pre-reclassified wage index values for the
counties of Barnstable (CBSA 12700, Barnstable Town, MA) and Bristol
(CBSA 39300, Providence-New Bedford-Fall River, RI-MA) would be
averaged resulting in an imputed pre-floor, pre-reclassified rural wage
index for rural Massachusetts. Should a similar situation arise in the
future, we may re-examine this policy.
As discussed in the proposed rule, as there are sufficient economic
differences between hospitals in the United States and those in Puerto
Rico, we do not believe that this policy would be appropriate for
Puerto Rico. We also noted that as we have not yet identified an
alternative methodology for imputing a wage index for rural Puerto
Rico, we will continue to evaluate the use of other sources.
Accordingly, we will continue to use the most recent pre-floor, pre-
reclassified wage index previously available for Puerto Rico.
C. Nomenclature Changes
This final rule and all subsequent hospice rules and notices are
considered to incorporate the CBSA changes published in the most recent
OMB bulletin that applies to the hospital wage data used to determine
the current hospice wage index. The tables in this final rule reflect
changes made by these bulletins. The OMB bulletins may be accessed at
http://www.whitehouse.gov/omb/bulletins/index.html.
D. Payment for Hospice Care Based on the Location Where Care Is
Furnished
Effective January 1, 2008, all payment rates (routine home care,
continuous home care, inpatient respite and general inpatient care)
will be adjusted by the geographic wage index value of the area where
hospice services are provided. In other words, the wage component of
each payment rate is multiplied by the wage index value applicable to
the location in which the hospice services are provided. Section
418.302 is amended to reflect this change. Hospice providers will be
required to indicate on hospice claims, the CBSA for the location where
hospice care is provided.
E. Educational Requirements for Nurse Practitioners
In order to align the hospice qualifications for nurse
practitioners under Sec. 418.3 and Part B nurse practitioners under
Sec. 410.75, the definition of ``attending physician'' at Sec. 418.3
is revised to cross reference the training, education and experience
requirements described in Sec. 410.75(b).
F. Caregiver Breakdown and General Inpatient Care
We are not implementing any changes regarding the general inpatient
level of care and caregiver breakdown, but are providing clarification
of existing policy, statute, and hospice regulations. The Medicare
hospice benefit provides for care that is medically reasonable and
necessary for the palliation and
[[Page 50224]]
management of terminal and related conditions, and is structured in
such a way to enable the individual with a terminal condition to remain
at home, in the company of family and friends. The statute, our
regulations at Sec. 418.202(e), and Medicare hospice policy require
that in order to receive payment for general inpatient care under the
Medicare hospice benefit, beneficiaries must require an intensity of
care directed towards pain control and symptom management that cannot
be managed in any other setting. It is the level of care provided to
meet the individual's needs that determines payment rates for Medicare
services. In other words, caregiver breakdown should not be billed as
general inpatient care regardless where the services are provided,
unless the intensity-of-care requirement is met. If an individual no
longer is able to remain at home or if the individual's caregiver is no
longer able to provide care, and the required care does not meet the
requirements for general inpatient care, the hospice may not bill this
care at the general inpatient level of care. This situation is
considered to be caregiver breakdown. This does not imply or suggest
that the individual must be discharged from the hospice if caregiver
breakdown occurs. It does mean that the hospice must find alternative
means for the provision of caregiver services, which may include
payment for room and board, as Medicare does not pay for caregiver
services, nor does it pay for room and board.
G. Certification of Terminal Illness
We are not making any changes to the certification of terminal
illness requirements. We are clarifying that the statute requires that
the attending physician and the hospice medical director, not the
admission nurse, initially certify the terminal diagnosis with a
prognosis of six months or less if the disease runs its normal course.
The regulations require that there be documentation in the medical
record to support the initial as well as any subsequent certifications.
The admission nurse may obtain information supporting the terminal
illness in order to allow the attending physician and the medical
director to have the necessary information to make the terminal illness
determination. But, the determination of the terminal illness cannot be
delegated to an admission nurse or any other employee.
IV. Collection of Information Requirements
This document does not impose any information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 35).
V. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this final rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA) (September 19, 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. We estimated the
impact on hospices, as a result of the changes to the FY 2008 hospice
wage index. As discussed previously, the methodology for computing the
wage index was determined through a negotiated rulemaking committee and
implemented in the August 8, 1997 final rule (62 FR 42860). This final
rule updates the hospice wage index in accordance with our regulation
and that methodology, incorporating the CBSA designations used in the
FY 2007 hospital wage index data.
Table 1 categorizes the impact of the FY 2008 wage index
values on hospices by various geographic and provider characteristics.
We estimate that the total hospice payments will increase $2,860,000 as
a result of the application of the FY 2008 wage index values. As
discussed in the proposed rule as well as in this final rule, the
impact analysis only reflects the FY 2008 wage index values. The FY
2008 hospice payment rates are promulgated through administrative
issuance and are not included in the impact analysis.
Table A reflects the FY 2008 wage index values for urban
areas designations.
Table B reflects the FY 2008 wage index values for rural
areas designations.
Executive Order 12866 (as amended by Executive Order 13258, which
merely reassigns responsibility of duties) 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 one
year). We have determined that this final rule 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 small governmental
jurisdictions. Most hospices and most other providers and suppliers are
small entities, either by nonprofit status or by having revenues of
$6.5 million to $31.5 million in any one 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. As indicated in Table 1 below,
there are 2,956 hospices. Approximately 53 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. 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. In developing
the process for updating the wage index in the 1997 final rule, we
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 a CBSA and has fewer
than 100 beds. We have determined that this final rule will not have a
significant impact on the operations of a substantial number of small
rural hospitals. We are not preparing an analysis for the RFA because
we have determined that this rule will not have a significant economic
impact on a substantial number of small entities.
[[Page 50225]]
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 expenditures in any one year by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $120 million or more. This final rule is not
anticipated to have an effect on State, local, or tribal governments or
on the private sector of $120 million or more.
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 final rule under the threshold
criteria of Executive Order 13132, Federalism, and have determined that
it will not have an impact on the rights, roles, and responsibilities
of State, local, or tribal governments.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
B. Anticipated Effects
As discussed in the proposed rule, we are unable to quantify the
extent of the usage of the general inpatient level of care in the event
of caregiver breakdown. Therefore, we are unable to definitively
anticipate the impact of our clarification of the general inpatient
level of care policy in the event of caregiver breakdown. For this
reason, we solicited comment on what the impact of our clarification
might be. We did not receive any substantive comments on the impact.
Based on anecdotal evidence as well as substantial increases in the
number of claims submitted for general inpatient care, however, we
believe a small proportion of patient days attributed to general
inpatient care would be appropriately allocated to inpatient respite
care with this clarification. Significant savings could be realized
even if only a small proportion of patient days attributed to general
inpatient care were allocated to inpatient respite care.
In the proposed rule we cited an example to determine the impact.
In that example, we allocated 5.0 percent of general inpatient care
days to inpatient respite care, using the FY 2005 patient days,
expenditures and number of beneficiaries electing the hospice benefit
to estimate the impact of the clarification of existing policy in this
final rule. The number of inpatient days was adjusted from 1,250,678 to
1,188,144. The number of inpatient respite days was adjusted from
96,646 to 159,180. While inpatient respite expenditures increased from
$14,000,000 to $23,058,570, general inpatient care expenditures
decreased from $737,300,000 to $700,435,000. In total, if 5.0 percent
of patient days that were attributed to general inpatient care in FY
2005 were allocated to the inpatient respite level of care, it would
have resulted in net savings of $27,806,430.
The impact analysis of this final rule represents the projected
effects of the changes in the hospice wage index from FY 2007 to FY
2008. We estimate the effects by estimating payments for FY 2008 using
the FY 2007 wage index values while holding all other payment variables
constant.
We note that certain events may combine to limit the scope or
accuracy of our impact analysis because such an analysis is future
oriented and, thus, susceptible to forecasting errors due to other
changes in the forecasted impact time period. The nature of the
Medicare program is such that the changes may interact, and the
complexity of the interaction of these changes could make it difficult
to predict accurately the full scope of the impact upon hospices.
For the purposes of this final rule, we compared estimated payments
using the FY 1983 hospice wage index to estimated payments using the FY
2008 wage index and determined the hospice wage index to be budget
neutral. Budget neutrality means that, in a given year, estimated
aggregate payments for Medicare hospice services using the FY 2008 wage
index would equal estimated aggregate payments that would have been
made for the same services if the 1983 wage index had remained in
effect. Budget neutrality to 1983 does not imply that estimated
payments would not increase since the budget neutrality applies only to
the wage index portion and not the total payment rate, which
accommodates inflation.
As discussed above, we use the latest claims file available to us
to develop the impact table when we issue the annual yearly wage index
update. For the purposes of this final rule, data were obtained from
the National Claims History file using FY 2006 claims processed through
June 2007, which was the most recent available data. We deleted bills
from hospice providers that have since closed. For the purposes of this
final rule, this file is adequate to demonstrate the impact of the FY
2008 wage index values and is not intended to project the anticipated
expenditures for FY 2008. This impact analysis compares hospice
payments using the FY 2007 hospice wage index to the estimated payments
using the FY 2008 wage index. We note that estimated payments for FY
2008 are determined by using the wage index for FY 2008 and payment
rates for FY 2007. We also note that the results in the impact analysis
table (Table 1) in this final rule differ from the proposed rule,
because we have incorporated the most recent data to determine the
budget neutrality adjustment factor. As noted in previous sections,
payment rates for FY 2008 are published through administrative
issuance.
Table 1 demonstrates the results of our analysis. In column 1 we
indicate the number of hospices included in our analysis. In column 2,
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 estimates payments using the FY 2007 wage index
values and the FY 2007 payment rates. Column 4 estimates payments using
FY 2008 wage index values as well as the FY 2007 payment rates. Column
5 compares columns 3 and 4 and shows the percentage change in estimated
hospice payments based on the hospice category.
Table 1 also categorizes hospices by various geographic and
provider characteristics. The first row displays the aggregate result
of the impact 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 indicated that there are 1,974
hospices located in urban areas and 982 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 FY 2006. 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. As indicated in Table 1 below, there are 2,956 hospices.
Approximately 53 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
[[Page 50226]]
approximately 79 percent of hospice patients are Medicare
beneficiaries, we have not considered other sources of revenue in this
analysis. 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. In developing
the process for updating the wage index in the 1997 final rule, we
considered the impact of this methodology on small entities and
attempted to mitigate any potential negative effects.
As stated previously, the following discussions are limited to
demonstrating trends rather than projected dollars. We used the CBSA
designations and wage indices as well as the data from FY 2006 claims
processed through June 2007 in developing the impact analysis. For FY
2008, the wage index is the variable that differs between the FY 2007
payments and the FY 2008 estimated payments. FY 2007, payment rates are
used for both FY 2007 actual payments and the FY 2008 estimated
payments. The FY 2008 payment rates will be adjusted to reflect the
full FY 2008 hospital market basket, as required by section
1814(i)(1)(C)(ii)(VII) of the Act. As previously noted, we publish
these rates through administrative issuances.
As discussed in the FY 2006 final rule (70 FR 45129), hospice
agencies may use multiple wage indices to compute their payments based
on potentially different geographic locations. For the purposes of this
final rule, the location of the beneficiary is used for routine and
continuous home care or the CBSA for the location of the hospice agency
for respite and general inpatient care. As noted above, beginning
January 1, 2008, the wage index utilized will be based on the location
of the site of service. As the location of the beneficiary's home and
the location of the facility may vary, there will still be variability
in geographic location. We anticipate that the location of the various
sites will correspond with the geographic location of the hospice and
thus we will continue to use the location of the hospice for our
analyses. For this analysis, we use payments to the hospice in the
aggregate based on the location of the hospice. The impact of hospice
wage index changes has been analyzed according to the type of hospice,
geographic location, type of ownership, hospice base, and size.
Our analysis shows that most hospices are in urban areas and
provide the vast majority of routine home care days. Most hospices are
medium-sized followed by large hospices. Hospices are almost equal in
numbers by ownership with 1,578 designated as non-profit and 1,378 as
proprietary. The vast majority of hospices are freestanding.
1. Hospice Size
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 (RHC) days representing over 70 percent
of the services provided by a hospice. Therefore, the number of RHC
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. As discussed in the
August 4, 2005 final rule, we currently use three size designations to
present the impact analyses. The three categories are: small agencies
having 0 to 3,499 RHC days; medium agencies having 3,500 to 19,999 RHC
days; and large agencies having 20,000 or more RHC days. Using RHC days
as a proxy for size, our analysis indicates that the proposed FY 2008
wage index values are anticipated to have virtually no impact on
hospice providers, with a slight increase of 0.1 percent anticipated
for medium hospices while no change is anticipated for small or large
hospices.
2. Geographic Location
Our analysis demonstrates that the proposed FY 2008 wage index
values will result in little change in estimated payments with urban
hospices anticipated to experience no change while rural hospices are
anticipated to experience a slight increase of 0.3 percent. For urban
hospices, the greatest increase of 0.9 percent is anticipated to be
experienced by the Mountain regions, followed by an increase for East
North Central of 0.7 percent and Pacific regions of 0.6 percent. The
remaining urban regions are anticipated to experience a decrease
ranging from 0.1 percent in the West North Central and Middle Atlantic
regions to 0.6 percent in the East South Central region. The greatest
decrease of 2.4 percent is anticipated for Puerto Rico.
For rural hospices, Puerto Rico is anticipated to experience no
change. Two regions are anticipated to experience a decrease of 1.1
percent for New England and 0.3 percent for the mountain regions. The
remaining regions are anticipated to experience an increase ranging
from 0.1 percent for the South Atlantic region to 0.6 percent for the
Middle Atlantic, East South Central and West North Central regions.
3. Type of Ownership
By type of ownership, non-profit hospices are anticipated to
experience a slight increase of 0.1 percent in payment while government
hospices are anticipated to experience a slight increase of 0.2
percent. No change is anticipated for proprietary hospices. Not
specified hospices in the ``other'' category are anticipated to
experience a slight decrease of 0.2 percent.
4. Hospice Base
No change in payment is anticipated for freestanding facilities.
Home health, hospital, and skilled nursing facilities are anticipated
to experience an increase of 0.1, 0.3, and 0.7 percent, respectively.
Table 1.--Impact of Hospice Wage Index Change
----------------------------------------------------------------------------------------------------------------
Estimated
Number of Payments using Payments using Percent Change
Number of Routine Home FY 2007 Wage FY 2008 CBSA in Hospice
Hospices Care Days in Index in Wage Index in Payments
Thousands Thousands Thousands
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
ALL HOSPICES:................... 2956 61,125 9,148,694 9,151,554 0.0
URBAN HOSPICES.............. 1974 52,426 8,048,410 8,048,224 0.0
RURAL HOSPICES.............. 982 8,699 1,100,284 1,103,330 0.3
BY REGION--URBAN:
NEW ENGLAND................. 112 1,772 313,059 311,816 -0.4
[[Page 50227]]
MIDDLE ATLANTIC............. 198 5,211 843,068 842,000 -0.1
SOUTH ATLANTIC.............. 285 11,385 1,839,567 1,831,476 -0.4
EAST NORTH CENTRAL.......... 294 7,568 1,158,628 1,166,376 0.7
EAST SOUTH CENTRAL.......... 157 4,333 586,642 583,333 -0.6
WEST NORTH CENTRAL.......... 151 3,413 471,129 470,666 -0.1
WEST SOUTH CENTRAL.......... 336 7,113 1,007,361 1,002,636 -0.5
MOUNTAIN.................... 182 4,531 702,881 709,230 0.9
PACIFIC..................... 225 6,302 1,054,910 1,061,223 0.6
PUERTO RICO................. 34 797 71,165 69,468 -2.4
BY REGION--RURAL:
NEW ENGLAND................. 26 144 21,134 20,910 -1.1
MIDDLE ATLANTIC............. 43 408 52,441 52,765 0.6
SOUTH ATLANTIC.............. 124 1,840 238,972 239,136 0.1
EAST NORTH CENTRAL.......... 140 1,125 146,434 146,747 0.2
EAST SOUTH CENTRAL.......... 142 1,982 240,058 241,528 0.6
WEST NORTH CENTRAL.......... 188 944 120,343 121,061 0.6
WEST SOUTH CENTRAL.......... 163 1,307 153,527 153,934 0.3
MOUNTAIN.................... 103 576 74,972 74,718 -0.3
PACIFIC..................... 52 365 51,809 51,936 0.2
PUERTO RICO................. 1 7 595 595 0.0
ROUTINE HOME CARE DAYS:
0-3499 DAYS (small)......... 617 1,060 142,491 142,458 0.0
3500-19,999 DAYS (medium)... 1429 14,208 1,994,694 1,996,162 0.1
20,000+ DAYS (large)........ 910 45,856 7,011,509 7,012,935 0.0
TYPE OF OWNERSHIP:
VOLUNTARY................... 1220 27,555 4,270,787 4,274,723 0.1
PROPRIETARY................. 1378 30,166 4,380,444 4,379,751 0.0
GOVERNMENT.................. 193 986 133,503 133,745 0.2
OTHER....................... 165 2,417 363,960 363,335 -0.2
HOSPICE BASE:
FREESTANDING................ 1767 45,209 6,752,227 6,750,239 0.0
HOME HEALTH AGENCY.......... 620 9,105 1,369,110 1,370,605 0.1
HOSPITAL.................... 555 6,606 994,451 997,560 0.3
SKILLED NURSING FACILITY.... 14 205 32,906 33,149 0.7
----------------------------------------------------------------------------------------------------------------
Note: FY 2007 payment rates were used for estimated payments for FY 2008. FY 2008 payment rates will be adjusted
to reflect the full hospital market basket and will be promulgated through administrative issuance.
C. Conclusion
Our impact analysis compared the FY 2007 wage index to the
estimated payments using the FY 2008 wage index. Through the analysis,
we estimate that total hospice payments, based on the FY 2008 wage
index values, will effectively be budget neutral with an estimated
increase from FY 2007 of $2,860,000. As discussed, the budget
neutrality adjustment factor is determined by using the pre-floor, pre-
reclassified hospital wage data. The impact analysis compares the wage
index values, which have had either the budget neutrality adjustment
factor or the hospice floor applied. Additionally, we compared
estimated payments using the FY 1983 hospice wage index to estimated
payments using the FY 2008 wage index and determined the current
hospice wage index to be budget neutral, as required by the negotiated
rulemaking committee. As noted above, the payment rates used reflect
the FY 2007 rates. The FY 2008 payment rates will be adjusted to
reflect the full FY 2008 hospital market basket, as required by section
1814(i)(1)(C)(ii)(VII) of the Act. We publish these rates through
administrative issuances.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects for 42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and
recordkeeping requirements.
0
For the reasons set forth in the preamble, the Centers for Medicare &
Medicaid Services amends 42 CFR Chapter IV as set forth below:
PART 418--HOSPICE CARE
0
1. The authority citation for part 418 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart A--General Provision and Definitions
0
2. Section 418.3 is amended by revising paragraph (1)(ii) in the
definition of ``attending physician'' to read as follows:
Sec. 418.3 Definitions.
* * * * *
(1) * * *
(ii) Nurse practitioner who meets the training, education, and
experience requirements as described in Sec. 410.75 (b) of this
chapter.
* * * * *
[[Page 50228]]
Subpart G--Payment for Hospice Care
0
3. Section 418.302 is amended by revising paragraph (g) to read as
follows:
Sec. 418.302 Payment procedures for hospice care.
* * * * *
(g) Payment for routine home care, continuous home care, general
inpatient care and inpatient respite care is made on the basis of the
geographic location where the services are provided.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
Dated: July 19, 2007.
Leslie V. Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: August 17, 2007.
Michael O. Leavitt,
Secretary.
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