[Federal Register Volume 75, Number 140 (Thursday, July 22, 2010)]
[Notices]
[Pages 42886-42942]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-17628]
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Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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Medicare Program; Prospective Payment System and Consolidated Billing
for Skilled Nursing Facilities for FY 2011; Notice
Federal Register / Vol. 75 , No. 140 / Thursday, July 22, 2010 /
Notices
[[Page 42886]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1338-NC]
RIN 0938-AP87
Medicare Program; Prospective Payment System and Consolidated
Billing for Skilled Nursing Facilities for FY 2011
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice with comment period.
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SUMMARY: This notice with comment period sets forth an update to the
payment rates used under the prospective payment system for skilled
nursing facilities for fiscal year 2011, and implements section 10325
of the Patient Protection and Affordable Care Act.
DATES: Effective Date: The rate updates in this notice with comment
period are effective on October 1, 2010.
Comment Date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on September 20, 2010.
ADDRESSES: In commenting, please refer to file code CMS-1338-NC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions under
the ``More Search Options'' tab.
2. By regular mail. You may mail written comments to the following
address only: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1338-NC, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address only: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1338-NC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. Centers for Medicare & Medicaid Services, Department of Health
and Human Services, Room 445-G, Hubert H. Humphrey Building, 200
Independence Avenue, SW., Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal Government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. Centers for Medicare & Medicaid Services, Department of Health
and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Ellen Berry, (410) 786-4528 (for information related to clinical
issues).
Abby Ryan, (410) 786-4343 (for information related to the development
of the payment rates and case-mix indexes).
Kia Sidbury, (410) 786-7816 (for information related to the wage
index).
Bill Ullman, (410) 786-5667 (for information related to level of care
determinations, consolidated billing, and general information).
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
To assist readers in referencing sections contained in this
document, we are providing the following Table of Contents.
Table of Contents
I. Background
A. Current System for Payment of SNF Services Under Part A of
the Medicare Program
B. Requirements of the Balanced Budget Act of 1997 (BBA) for
Updating the Prospective Payment System for Skilled Nursing
Facilities
C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 1999 (BBRA)
D. The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA)
E. The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA)
F. The Patient Protection and Affordable Care Act (ACA)
G. Skilled Nursing Facility Prospective Payment--General
Overview
1. Payment Provisions--Federal Rate
2. FY 2011 Rate Updates Using the Skilled Nursing Facility
Market Basket Index
II. FY 2011 Annual Update of Payment Rates Under the Prospective
Payment System for Skilled Nursing Facilities
A. Federal Prospective Payment System
1. Costs and Services Covered by the Federal Rates
2. Methodology Used for the Calculation of the Federal Rates
B. Case-Mix Adjustments
1. Background
2. Parity Adjustment
C. Wage Index Adjustment to Federal Rates
D. Updates to Federal Rates
E. Relationship of Case-Mix Classification System to Existing
Skilled Nursing Facility Level-of-Care Criteria
F. Example of Computation of Adjusted PPS Rates and SNF Payment
III. The Skilled Nursing Facility Market Basket Index
A. Use of the Skilled Nursing Facility Market Basket Percentage
B. Market Basket Forecast Error Adjustment
C. Federal Rate Update Factor
IV. Consolidated Billing
V. Application of the SNF PPS to SNF Services Furnished by Swing-Bed
Hospitals
VI. Collection of Information Requirements
VII. Response to Comments
VIII. Regulatory Impact Analysis
A. Overall Impact
B. Anticipated Effects
C. Alternatives Considered
D. Accounting Statement
E. Conclusion
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IX. Waiver of Proposed Rulemaking
Addendum:
FY 2011 CBSA-Based Wage Index Tables (Tables A & B)
Abbreviations
In addition, because of the many terms to which we refer by
abbreviation in this notice, we are listing these abbreviations and
their corresponding terms in alphabetical order below:
ACA Patient Protection and Affordable Care Act, Public Law 111-148
AIDS Acquired Immune Deficiency Syndrome
ARD Assessment Reference Date
BBA Balanced Budget Act of 1997, Public Law 105-33
BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999, Public Law 106-113
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Public Law 106-554
CAH Critical Access Hospital
CBSA Core-Based Statistical Area
CFR Code of Federal Regulations
CMI Case-Mix Index
CMS Centers for Medicare & Medicaid Services
FQHC Federally Qualified Health Center
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
HCPCS Healthcare Common Procedure Coding System
HR-III Hybrid Resource Utilization Groups, Version 3
MDS Minimum Data Set
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Public Law 108-173
MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Public
Law 110-173
MSA Metropolitan Statistical Area
OMB Office of Management and Budget
OMRA Other Medicare Required Assessment
PPS Prospective Payment System
RAI Resident Assessment Instrument
RAVEN Resident Assessment Validation Entry
RFA Regulatory Flexibility Act, Public Law 96-354
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RUG-III Resource Utilization Groups, Version 3
RUG-IV Resource Utilization Groups, Version 4
RUG-53 Refined 53-Group RUG-III Case-Mix Classification System
SCHIP State Children's Health Insurance Program
SNF Skilled Nursing Facility
SOM State Operations Manual
STM Staff Time Measurement
STRIVE Staff Time and Resource Intensity Verification
UMRA Unfunded Mandates Reform Act, Public Law 104-4
I. Background
Annual updates to the prospective payment system (PPS) rates for
skilled nursing facilities (SNFs) are required by section 1888(e) of
the Social Security Act (the Act), as added by section 4432 of the
Balanced Budget Act of 1997 (BBA, Pub. L. 105-33, enacted on August 5,
1997), and amended by the Medicare, Medicaid, and State Children's
Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999
(BBRA, Pub. L. 106-113, enacted on November 29, 1999), the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
(BIPA, Pub. L. 106-554, enacted December 21, 2000), and the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA,
Pub. L. 108-173, enacted on December 8, 2003). Our most recent annual
update occurred in a final rule (74 FR 40288, August 11, 2009) that set
forth updates to the SNF PPS payment rates for fiscal year (FY) 2010.
We subsequently published a correction notice (74 FR 48865, September
25, 2009) with respect to those payment rate updates.
A. Current System for Payment of Skilled Nursing Facility Services
Under Part A of the Medicare Program
Section 4432 of the BBA amended section 1888 of the Act to provide
for the implementation of a per diem PPS for SNFs, covering all costs
(routine, ancillary, and capital-related) of covered SNF services
furnished to beneficiaries under Part A of the Medicare program,
effective for cost reporting periods beginning on or after July 1,
1998. In this notice, we update the per diem payment rates for SNFs for
FY 2011. Major elements of the SNF PPS include:
Rates. As discussed in section I.G.1. of this notice, we
established per diem Federal rates for urban and rural areas using
allowable costs from FY 1995 cost reports. These rates also included a
``Part B add-on'' (an estimate of the cost of those services that,
before July 1, 1998, were paid under Part B but furnished to Medicare
beneficiaries in a SNF during a Part A covered stay). We adjust the
rates annually using a SNF market basket index, and we adjust them by
the hospital inpatient wage index to account for geographic variation
in wages. We also apply a case-mix adjustment to account for the
relative resource utilization of different patient types. As further
discussed in section I.F, for FY 2011 this adjustment will utilize a
``hybrid'' RUG-III system that incorporates the specific revisions
relating to concurrent therapy and the look-back period that are
components of the Resource Utilization Groups, version 4 (RUG-IV) case-
mix classification system, and will use information obtained from the
required resident assessments using version 3.0 of the Minimum Data Set
(MDS 3.0). (The resident assessment is approved under OMB
0938-0739.) Additionally, as noted in the final rule for FY 2006 (70 FR
45028, August 4, 2005), the payment rates at various times have also
reflected specific legislative provisions, including section 101 of the
BBRA, sections 311, 312, and 314 of the BIPA, and section 511 of the
MMA.
Transition. Under sections 1888(e)(1)(A) and (e)(11) of
the Act, the SNF PPS included an initial, three-phase transition that
blended a facility-specific rate (reflecting the individual facility's
historical cost experience) with the Federal case-mix adjusted rate.
The transition extended through the facility's first three cost
reporting periods under the PPS, up to and including the one that began
in FY 2001. Thus, the SNF PPS is no longer operating under the
transition, as all facilities have been paid at the full Federal rate
effective with cost reporting periods beginning in FY 2002. As we now
base payments entirely on the adjusted Federal per diem rates, we no
longer include adjustment factors related to facility-specific rates
for the coming FY.
Coverage. The establishment of the SNF PPS did not change
Medicare's fundamental requirements for SNF coverage. However, because
the case-mix classification is based, in part, on the beneficiary's
need for skilled nursing care and therapy, we have attempted, where
possible, to coordinate claims review procedures with the existing
resident assessment process and case-mix classification system. As
further discussed in section II.E, in FY 2011, under the hybrid RUG-III
system, this approach includes an administrative presumption that
utilizes a beneficiary's initial classification in one of the upper 35
RUGs of the 53-group RUG-III case-mix classification system (RUG-53) to
assist in making certain SNF level of care determinations. In the July
30, 1999 final rule (64 FR 41670), we indicated that we would announce
any changes to the guidelines for Medicare level of care determinations
related to modifications in the case-mix classification structure (see
section II.E. of this notice for a more detailed discussion of the
relationship between the case-mix classification system and SNF level
of care determinations).
Consolidated Billing. The SNF PPS includes a consolidated
billing provision that requires a SNF to submit consolidated Medicare
bills to its fiscal intermediary or Medicare
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Administrative Contractor for almost all of the services that its
residents receive during the course of a covered Part A stay. In
addition, this provision places with the SNF the Medicare billing
responsibility for physical therapy, occupational therapy, and speech-
language pathology services that the resident receives during a
noncovered stay. The statute excludes a small list of services from the
consolidated billing provision (primarily those of physicians and
certain other types of practitioners), which remain separately billable
under Part B when furnished to a SNF's Part A resident. A more detailed
discussion of this provision appears in section IV. of this notice.
Application of the SNF PPS to SNF services furnished by
swing-bed hospitals. Section 1883 of the Act permits certain small,
rural hospitals to enter into a Medicare swing-bed agreement, under
which the hospital can use its beds to provide either acute or SNF
care, as needed. For critical access hospitals (CAHs), Part A pays on a
reasonable cost basis for SNF services furnished under a swing-bed
agreement. However, in accordance with section 1888(e)(7) of the Act,
these services furnished by non-CAH rural hospitals are paid under the
SNF PPS, effective with cost reporting periods beginning on or after
July 1, 2002. A more detailed discussion of this provision appears in
section V. of this notice.
B. Requirements of the Balanced Budget Act of 1997 (BBA) for Updating
the Prospective Payment System for Skilled Nursing Facilities
Section 1888(e)(4)(H) of the Act requires that we provide for
publication annually in the Federal Register:
1. The unadjusted Federal per diem rates to be applied to days of
covered SNF services furnished during the upcoming FY.
2. The case-mix classification system to be applied with respect to
these services during the upcoming FY.
3. The factors to be applied in making the area wage adjustment
with respect to these services.
Along with other revisions discussed later in this preamble, this
notice provides these required annual updates to the Federal rates.
C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999 (BBRA)
There were several provisions in the BBRA that resulted in
adjustments to the SNF PPS. We described these provisions in detail in
the SNF PPS final rule for FY 2001 (65 FR 46770, July 31, 2000). In
particular, section 101(a) of the BBRA provided for a temporary 20
percent increase in the per diem adjusted payment rates for 15
specified groups in the original, 44-group Resource Utilization Groups,
version 3 (RUG-III) case-mix classification system. In accordance with
section 101(c)(2) of the BBRA, this temporary payment adjustment
expired on January 1, 2006, upon the implementation of a refined, 53-
group version of the RUG-III system, RUG-53 (see section I.G.1. of this
notice). We included further information on BBRA provisions that
affected the SNF PPS in Program Memorandums A-99-53 and A-99-61
(December 1999).
Also, section 103 of the BBRA designated certain additional
services for exclusion from the consolidated billing requirement, as
discussed in section IV. of this notice. Further, for swing-bed
hospitals with more than 49 (but less than 100) beds, section 408 of
the BBRA provided for the repeal of certain statutory restrictions on
length of stay and aggregate payment for patient days, effective with
the end of the SNF PPS transition period described in section
1888(e)(2)(E) of the Act. In the final rule for FY 2002 (66 FR 39562,
July 31, 2001), we made conforming changes to the regulations at Sec.
413.114(d), effective for services furnished in cost reporting periods
beginning on or after July 1, 2002, to reflect section 408 of the BBRA.
D. The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA)
The BIPA also included several provisions that resulted in
adjustments to the SNF PPS. We described these provisions in detail in
the final rule for FY 2002 (66 FR 39562, July 31, 2001). In particular:
Section 203 of the BIPA exempted CAH swing beds from the
SNF PPS. We included further information on this provision in Program
Memorandum A-01-09 (Change Request 1509), issued January 16,
2001, which is available online at http://www.cms.gov/transmittals/downloads/a0109.pdf.
Section 311 of the BIPA revised the statutory update
formula for the SNF market basket, and also directed us to conduct a
study of alternative case-mix classification systems for the SNF PPS.
In 2006, we submitted a report to the Congress on this study, which is
available online at http://www.cms.gov/SNFPPS/Downloads/RC_2006_PC-PPSSNF.pdf.
Section 312 of the BIPA provided for a temporary increase
of 16.66 percent in the nursing component of the case-mix adjusted
Federal rate for services furnished on or after April 1, 2001, and
before October 1, 2002; accordingly, this add-on is no longer in
effect. This section also directed the Government Accountability Office
(GAO) to conduct an audit of SNF nursing staff ratios and submit a
report to the Congress on whether the temporary increase in the nursing
component should be continued. The report (GAO-03-176), which GAO
issued in November 2002, is available online at http://www.gao.gov/new.items/d03176.pdf.
Section 313 of the BIPA repealed the consolidated billing
requirement for services (other than physical therapy, occupational
therapy, and speech-language pathology services) furnished to SNF
residents during noncovered stays, effective January 1, 2001. (A more
detailed discussion of this provision appears in section IV. of this
notice.)
Section 314 of the BIPA corrected an anomaly involving
three of the RUGs that section 101(a) of the BBRA had designated to
receive the temporary payment adjustment discussed above in section
I.C. of this notice. (As noted previously, in accordance with section
101(c)(2) of the BBRA, this temporary payment adjustment expired upon
the implementation of case-mix refinements on January 1, 2006.)
Section 315 of the BIPA authorized us to establish a
geographic reclassification procedure that is specific to SNFs, but
only after collecting the data necessary to establish a SNF wage index
that is based on wage data from nursing homes. To date, this has proven
to be unfeasible due to the volatility of existing SNF wage data and
the significant amount of resources that would be required to improve
the quality of that data.
We included further information on several of the BIPA provisions
in Program Memorandum A-01-08 (Change Request 1510), issued
January 16, 2001, which is available online at http://www.cms.gov/transmittals/downloads/a0108.pdf.
E. The Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA)
The MMA included a provision that resulted in a further adjustment
to the SNF PPS. Specifically, section 511 of the MMA amended section
1888(e)(12) of the Act, to provide for a temporary increase of 128
percent in the PPS per diem payment for any SNF residents with Acquired
Immune Deficiency Syndrome (AIDS), effective with services furnished on
or after October 1, 2004. This special AIDS add-on was to remain in
effect until `` * * * the
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Secretary certifies that there is an appropriate adjustment in the case
mix * * * to compensate for the increased costs associated with [such]
residents * * * '' The AIDS add-on is also discussed in Program
Transmittal 160 (Change Request 3291), issued on
April 30, 2004, which is available online at http://www.cms.gov/transmittals/downloads/r160cp.pdf. In the SNF PPS final rule for FY
2010 (74 FR 40288, August 11, 2009), we did not address the
certification of the AIDS add-on in that final rule's implementation of
the case-mix refinements for RUG-IV, thus allowing the temporary add-on
payment created by section 511 of the MMA to remain in effect.
For the limited number of SNF residents that qualify for the AIDS
add-on, implementation of this provision results in a significant
increase in payment. For example, using FY 2008 data, we identified
less than 3,300 SNF residents with a diagnosis code of 042 (Human
Immunodeficiency Virus (HIV) Infection). For FY 2011, an urban facility
with a resident with AIDS in hybrid RUG-III (HR-III) group ``SSB''
would have a case-mix adjusted payment of $318.73 (see Table 4B) before
the application of the MMA adjustment. After an increase of 128
percent, this urban facility would receive a case-mix adjusted payment
of approximately $726.70. Similarly, an urban facility with a resident
with AIDS in RUG-IV group ``HC2'' would have a case-mix adjusted
payment of $394.48 (see Table 4A) before the application of the MMA
adjustment. After an increase of 128 percent, this urban facility would
receive a case-mix adjusted payment of approximately $899.41.
In addition, section 410 of the MMA contained a provision that
excluded from consolidated billing certain services furnished to SNF
residents by rural health clinics (RHCs) and Federally Qualified Health
Centers (FQHCs). (Further information on this provision appears in
section IV. of this notice.)
F. The Patient Protection and Affordable Care Act (ACA)
Section 10325 of the ACA (Pub. L. 111-148, enacted on March 23,
2010) includes a self-implementing provision involving the SNF PPS.
Section 10325 postpones the implementation of the RUG-IV case-mix
classification system published in the FY 2010 SNF PPS final rule (74
FR 40288, August 11, 2009), requiring that the Secretary not implement
the RUG-IV case-mix classification system before October 1, 2011.
Notwithstanding this postponement of overall RUG-IV implementation,
section 10325 further specifies that the Secretary is required to
implement, effective October 1 2010, the changes related to concurrent
therapy and the look-back period that were finalized as components of
RUG-IV (see 74 FR 40315-19, 40322-24). Because these changes were
already subject to notice and public comment and finalized in the FY
2010 SNF PPS final rule, we believe that this ACA requirement is
largely self-implementing and requires no substantive exercise of
discretion by the Secretary. In addition, section 10325 of the ACA
specifies that version 3.0 of the Minimum Data Set (MDS 3.0) shall
proceed as planned, with an implementation date of October 1, 2010 (see
74 FR 40342-43). The MDS is approved under OMB 0938-0872. The
MDS 3.0 RAI Manual and MDS 3.0 Item Set are scheduled to be published
on the CMS Web site, http://www.cms.gov, in October 2010.
The statutory mandate to adopt RUG-IV's concurrent therapy and
look-back revisions (along with MDS 3.0) prior to implementing the
overall RUG-IV system itself will necessitate implementing those
particular revisions within the framework of the existing RUG-53 case-
mix classification system. While there is currently an existing grouper
(the software program that uses assessment data to assign each SNF
resident to the appropriate RUG) that utilizes RUG-53 and the MDS 2.0,
as well as a revised grouper that utilizes RUG-IV and the MDS 3.0, no
grouper currently exists that incorporates the particular combination
of features mandated by the statute: The use of the new RUG-IV
revisions on concurrent therapy and the look-back period as well as the
MDS 3.0, but within the overall context of the existing RUG-53 system.
Moreover, attempting to develop and implement such a modified grouper
within the short timeframe available before the ACA provision's October
1, 2010 effective date would potentially cause significant disruption
to providers, suppliers, and State agencies.
Accordingly, as we continue to build the payment infrastructure
needed to incorporate the combination of features mandated by section
10325 of the ACA for FY 2011, we will apply, effective October 1, 2010,
interim payment rates that reflect not only the use of MDS 3.0 but also
the new RUG-IV system in its entirety as finalized in the FY 2010 SNF
PPS final rule (74 FR 40288, August 11, 2009). As discussed above, the
only grouper that currently exists that utilizes MDS 3.0 is the RUG-IV
grouper. Once the necessary infrastructure is in place, we will then
retroactively adjust claims to reflect a hybrid RUG-III (HR-III) system
which incorporates RUG-IV's specific revisions on concurrent therapy
and the look-back period within the framework of the existing RUG-53
system, along with the use of MDS 3.0. Tables 4 and 5 set forth both
the RUG-IV rates that will be used on an interim basis effective
October 1, 2010 and the HR-III rates that will apply once we build the
infrastructure necessary to support this system. The FY 2011 rates will
be based on the rates that were finalized for FY 2010, as modified to
reflect the market basket adjustment, the forecast error adjustment,
the applicable case-mix adjustment, and the parity adjustment (as
discussed below).
We note that a parity adjustment was applied to the RUG-53 nursing
case-mix weights when the RUG-III system was initially refined in 2006,
in order to ensure that the implementation of the refinements would not
cause any change in overall payment levels (70 FR 45031, August 4,
2005). A detailed discussion of the parity adjustment in the specific
context of the RUG-IV payment rates appears in the FY 2010 SNF PPS
proposed rule (74 FR 22236-38, May 12, 2009) and final rule (74 FR
40338-39, August 11, 2009). Consistent with our policy set forth in the
FY 2006 SNF PPS final rule (70 FR 45031) when we transitioned from the
RUG-III 44 group model to the RUG-53 model, and in the FY 2010 SNF PPS
final rule (74 FR 40338-39) when we finalized the transition from RUG-
53 to RUG-IV, in calculating the rates under the HR-III model, we will
apply a parity adjustment to the nursing case-mix weights under the HR-
III system to ensure parity between overall payments under the RUG-53
model currently in effect and anticipated payments under the HR-III
system required by the ACA. As discussed in section II.B.2 of this
notice, we are calculating and applying this parity adjustment using
the same methodology finalized in both the FY 2006 SNF PPS final rule
and the FY 2010 SNF PPS final rule.
Accordingly, as discussed above, effective October 1, 2010, on an
interim basis, we will implement and pay claims under the RUG-IV system
that was finalized in the FY 2010 SNF PPS final rule, until we build
the payment infrastructure necessary to support the HR-III system
required by the ACA. Once that infrastructure is in place, we will then
retroactively adjust claims back to October 1, 2010 as necessary to
implement the rates effective under HR-III. In this notice, we also
invite public comment on our implementation of section 10325 of the
ACA.
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As discussed above, we will implement the MDS 3.0 (including the
MDS 3.0 swing bed assessment (see 74 FR 40356-57)) effective October 1,
2010 as specified in the FY 2010 SNF PPS final rule. We will also
implement effective October 1, 2010, all other non-RUG-IV changes
finalized in the FY 2010 SNF PPS final rule for implementation
effective FY 2011, including without limitation revisions to certain
therapy reporting and assessment procedures effective with the MDS 3.0
(74 FR 40346-49) (that is, updated reporting procedures for short-stay
patients, implementation of an optional, abbreviated start-of-therapy
OMRA, a revised Assessment Reference Date (ARD) requirement for the
end-of-therapy OMRA, and an abbreviated end-of-therapy OMRA).
G. Skilled Nursing Facility Prospective Payment--General Overview
We implemented the Medicare SNF PPS effective with cost reporting
periods beginning on or after July 1, 1998. This methodology uses
prospective, case-mix adjusted per diem payment rates applicable to all
covered SNF services. These payment rates cover all costs of furnishing
covered skilled nursing services (routine, ancillary, and capital-
related costs) other than costs associated with approved educational
activities and bad debts. Covered SNF services include post-hospital
services for which benefits are provided under Part A, as well as those
items and services (other than physician and certain other services
specifically excluded under the BBA) which, before July 1, 1998, had
been paid under Part B but furnished to Medicare beneficiaries in an
SNF during a covered Part A stay. A comprehensive discussion of these
provisions appears in the May 12, 1998 interim final rule (63 FR
26252).
1. Payment Provisions--Federal Rate
The PPS uses per diem Federal payment rates based on mean SNF costs
in a base year (FY 1995) updated for inflation to the first effective
period of the PPS. We developed the Federal payment rates using
allowable costs from hospital-based and freestanding SNF cost reports
for reporting periods beginning in FY 1995. The data used in developing
the Federal rates also incorporated an estimate of the amounts that
would be payable under Part B for covered SNF services furnished to
individuals during the course of a covered Part A stay in an SNF.
In developing the rates for the initial period, we updated costs to
the first effective year of the PPS (the 15-month period beginning July
1, 1998) using an SNF market basket index, and then standardized for
the costs of facility differences in case mix and for geographic
variations in wages. In compiling the database used to compute the
Federal payment rates, we excluded those providers that received new
provider exemptions from the routine cost limits, as well as costs
related to payments for exceptions to the routine cost limits. Using
the formula that the BBA prescribed, we set the Federal rates at a
level equal to the weighted mean of freestanding costs plus 50 percent
of the difference between the freestanding mean and weighted mean of
all SNF costs (hospital-based and freestanding) combined. We computed
and applied separately the payment rates for facilities located in
urban and rural areas. In addition, we adjusted the portion of the
Federal rate attributable to wage-related costs by a wage index.
The Federal rate also incorporates adjustments to account for
facility case-mix, using a classification system that accounts for the
relative resource utilization of different patient types. The RUG-IV
classification system uses beneficiary assessment data from the MDS 3.0
completed by SNFs to assign beneficiaries to one of 66 RUG-IV groups.
The original RUG-III case-mix classification system used beneficiary
assessment data from the MDS, version 2.0 (MDS 2.0) completed by SNFs
to assign beneficiaries to one of 44 RUG-III groups. Then, under
incremental refinements that became effective on January 1, 2006, we
added nine new groups--comprising a new Rehabilitation plus Extensive
Services category--at the top of the RUG-III hierarchy. The May 12,
1998 interim final rule (63 FR 26252) included a detailed description
of the original 44-group RUG-III case-mix classification system. A
comprehensive description of the refined RUG-53 system appeared in the
proposed and final rules for FY 2006 (70 FR 29070, May 19, 2005, and 70
FR 45026, August 4, 2005), and a detailed description of the 66-group
RUG-IV system appeared in the proposed and final rules for FY 2010 (74
FR 22208, May 12, 2009, and 74 FR 40288, August 11, 2009).
Further, in accordance with section 1888(e)(4)(E)(ii)(IV) of the
Act, the Federal rates in this notice reflect an update to the rates
that we published in the final rule for FY 2010 (74 FR 40288, August
11, 2009) and the associated correction notice (74 FR 48865, September
25, 2009), equal to the full change in the SNF market basket index,
adjusted by the forecast error correction. A more detailed discussion
of the SNF market basket index and related issues appears in sections
I.F.2. and III. of this notice.
2. FY 2011 Rate Updates Using the Skilled Nursing Facility Market
Basket Index
Section 1888(e)(5) of the Act requires us to establish a SNF market
basket index that reflects changes over time in the prices of an
appropriate mix of goods and services included in covered SNF services.
We use the SNF market basket index to update the Federal rates on an
annual basis. In the SNF PPS final rule for FY 2008 (72 FR 43425
through 43430, August 3, 2007), we revised and rebased the market
basket, which included updating the base year from FY 1997 to FY 2004.
The proposed FY 2011 market basket increase is 2.3 percent, which is
based on IHS Global Insight, Inc. second quarter 2010 forecast with
historical data through first quarter 2010.
In addition, as explained in the final rule for FY 2004 (66 FR
46058, August 4, 2003) and in section III.B. of this notice, the annual
update of the payment rates includes, as appropriate, an adjustment to
account for market basket forecast error. As described in the final
rule for FY 2008, the threshold percentage that serves to trigger an
adjustment to account for market basket forecast error is 0.5
percentage point effective for FY 2008 and subsequent years. This
adjustment takes into account the forecast error from the most recently
available FY for which there is final data, and applies whenever the
difference between the forecasted and actual change in the market
basket exceeds a 0.5 percentage point threshold. For FY 2009 (the most
recently available FY for which there is final data), the estimated
increase in the market basket index was 3.4 percentage points, while
the actual increase was 2.8 percentage points, resulting in the actual
increase being 0.6 percentage point lower than the estimated increase.
Accordingly, as the difference between the estimated and actual amount
of change exceeds the 0.5 percentage point threshold, the payment rates
for FY 2011 include a negative 0.6 percentage point forecast error
adjustment. As we stated in the final rule for FY 2004 that first
promulgated the forecast error adjustment (68 FR 46058, August 4,
2003), the adjustment will ``* * * reflect both upward and downward
adjustments, as appropriate.'' Table 1 shows the forecasted and actual
market basket amounts for FY 2009.
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II. FY 2011 Annual Update of Payment Rates Under the Prospective
Payment System for Skilled Nursing Facilities
A. Federal Prospective Payment System
This notice sets forth a schedule of Federal prospective payment
rates applicable to Medicare Part A SNF services beginning October 1,
2010. The schedule incorporates per diem Federal rates that provide
Part A payment for almost all costs of services furnished to a
beneficiary in a SNF during a Medicare-covered stay.
1. Costs and Services Covered by the Federal Rates
In accordance with section 1888(e)(2)(B) of the Act, the Federal
rates apply to all costs (routine, ancillary, and capital-related) of
covered SNF services other than costs associated with approved
educational activities as defined in Sec. 413.85. Under section
1888(e)(2)(A)(i) of the Act, covered SNF services include post-hospital
SNF services for which benefits are provided under Part A (the hospital
insurance program), as well as all items and services (other than those
services excluded by statute) that, before July 1, 1998, were paid
under Part B (the supplementary medical insurance program) but
furnished to Medicare beneficiaries in a SNF during a Part A covered
stay. (These excluded service categories are discussed in greater
detail in section V.B.2. of the May 12, 1998 interim final rule (63 FR
26295 through 26297)).
2. Methodology Used for the Calculation of the Federal Rates
The FY 2011 rates reflect an update using the latest market basket
index, and adjusting for the FY 2009 forecast error correction. The FY
2011 market basket increase factor is 2.3 percent which, when combined
with a negative 0.6 percentage point forecast error adjustment for FY
2009, results in a net FY 2011 update of 1.7 percent. A complete
description of the multi-step process used to calculate Federal rates
initially appeared in the May 12, 1998 interim final rule (63 FR
26252), as further revised in subsequent rules. As explained above in
section I.C of this notice, under section 101(c)(2) of the BBRA, the
previous temporary increases in the per diem adjusted payment rates for
certain designated RUGs (as specified in section 101(a) of the BBRA and
section 314 of the BIPA) are no longer in effect due to the
implementation of case-mix refinements as of January 1, 2006. However,
the temporary increase of 128 percent in the per diem adjusted payment
rates for SNF residents with AIDS, enacted by section 511 of the MMA,
remains in effect.
We used the SNF market basket to adjust each per diem component of
the Federal rates forward to reflect cost increases occurring between
the midpoint of the Federal FY beginning October 1, 2009, and ending
September 30, 2010, and the midpoint of the Federal FY beginning
October 1, 2010, and ending September 30, 2011, to which the payment
rates apply. In accordance with section 1888(e)(4)(E)(ii)(IV) of the
Act, we update the payment rates for FY 2011 by a factor equal to the
full market basket index percentage increase. As explained in section
I.G.2 of this notice, we adjust the market basket index by the forecast
error from the most recently available FY for which there is final data
and apply this adjustment whenever the difference between the
forecasted and actual change in the market basket exceeds a 0.5
percentage point threshold. We further adjust the rates by a wage index
budget neutrality factor, described later in this section. Tables 2 and
3 reflect the updated components of the unadjusted Federal rates for FY
2011, prior to adjustment for case-mix.
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B. Case-Mix Adjustments
1. Background
Section 1888(e)(4)(G)(i) of the Act requires the Secretary to make
an adjustment to account for case-mix. The statute specifies that the
adjustment is to reflect both a resident classification system that the
Secretary establishes to account for the relative resource use of
different patient types, as well as resident assessment and other data
that the Secretary considers appropriate. In first implementing the SNF
PPS (63 FR 26252, May 12, 1998), we developed the RUG-III case-mix
classification system, which tied the amount of payment to resident
resource use in combination with resident characteristic information.
Staff time measurement (STM) studies conducted in 1990, 1995, and 1997
provided information on resource use (time spent by staff members on
residents) and resident characteristics that enabled us not only to
establish RUG-III, but also to create case-mix indexes (CMIs).
Although the establishment of the SNF PPS did not change Medicare's
fundamental requirements for SNF coverage, there is a correlation
between level of care and provider payment. One of the elements
affecting the SNF PPS per diem rates is the case-mix adjustment derived
from a classification system based on comprehensive resident
assessments using the MDS. Case-mix classification is based, in part,
on the beneficiary's need for skilled nursing care and therapy. The
case-mix classification system uses clinical data from the MDS, and
wage-adjusted staff time measurement data, to assign a case-mix group
to each patient record that is then used to calculate a per diem
payment under the SNF PPS. The original RUG-III grouper logic was based
on clinical data collected in 1990, 1995, and 1997. As discussed in the
SNF PPS proposed rule for FY 2010 (74 FR 22208, May 12, 2009), we
subsequently conducted a multi-year data collection and analysis under
the Staff Time and Resource Intensity Verification (STRIVE) project to
update the case-mix classification system for FY 2011. The resulting
RUG-IV case-mix classification system reflected the data collected in
2006-2007 during the STRIVE project, and was finalized in the FY 2010
SNF PPS final rule (74 FR 40288, August 11, 2009) to take effect in FY
2011 concurrently with an updated new resident assessment instrument,
the MDS 3.0, which collects the clinical data used for case-mix
classification under RUG-IV.
Under the BBA, each update of the SNF PPS payment rates must
include the case-mix classification methodology applicable for the
coming Federal FY. As indicated in section I.F of this notice, the
payment rates set forth herein reflect the use of the HR-III case-mix
classification system from October 1, 2010 through September 30, 2011.
However, due to time constraints in preparing the HR-III grouper, the
66-group RUG-IV case-mix classification system that we discussed in
detail in the proposed and final rules for FY 2010 will be used
beginning October 1, 2010. Once the HR-III Grouper is ready for
implementation, payments will be retroactively adjusted to the October
1, 2010 date.
2. Parity Adjustment
Consistent with the policy finalized in the FY 2010 SNF PPS final
rule (74 FR 40338-39), the updated RUG-IV rates set forth in Tables 4A
and 5A reflect an upward adjustment to the nursing CMIs to achieve
parity in overall payments between the existing RUG--53 model and the
RUG-IV model. As explained in the FY 2010 SNF PPS final rule, we
applied an upward adjustment of 59.4 percent to the RUG-IV nursing CMIs
to achieve parity between the RUG-53 and RUG-IV models, based on an
analysis using FY 2008 claims data. However, after the FY 2010 SNF PPS
final rule was published, final FY 2009 claims data became available.
As we stated in the FY 2010 SNF PPS final rule (74 FR 40339), in the
absence of actual RUG-IV utilization data, we believe the most recent
final claims data are the best source available to estimate RUG-IV
utilization for FY 2011, as they are closest to the FY 2011 timeframe.
Thus, we updated our analysis described in the FY 2010 SNF PPS proposed
and final rules using final FY 2009 claims data to enhance the accuracy
of our calculation of the adjustment necessary to achieve parity
between the RUG-53 model and the RUG-IV model. Using the methodology
finalized in the FY 2010 SNF PPS final rule with updated FY 2009 claims
data, the adjustment to the RUG-IV nursing CMIs necessary to achieve
parity is an upward adjustment of 61 percent.
Consistent with this policy, and using the same methodology
finalized in the FY 2006 SNF PPS final rule and the FY 2010 SNF PPS
final rule, we have calculated and applied a parity adjustment to the
HR-III nursing CMIs so that overall payments under the HR-III case-mix
classification system maintain parity with overall payments under the
existing RUG-53 model. We used FY 2009 claims data, the most recent
final claims data available, to compare the distribution of payment
days by RUG category in the RUG-53 model with anticipated payments by
RUG category in the new HR-III model. Our projections of future
utilization patterns under the HR-III system indicated that the HR-III
system would
[[Page 42893]]
produce lower overall payments than under the RUG-53 model. Therefore,
consistent with our policy in place when we transitioned to the RUG-53
model in FY 2006, and our policy in FY 2010 when we finalized the
transition from the RUG-53 model to the RUG-IV model, we are providing
for an adjustment to the nursing CMIs under the HR-III system that
would achieve ``parity'' between the RUG-53 and the HR-III models (that
is, would not cause any change in overall payment levels). Based on our
analysis of the FY 2009 claims data, the adjustment to the nursing CMIs
under the HR-III model necessary to achieve ``parity'' is an upward
adjustment of 34.2 percent. Our calculation of the parity adjustment
uses the most recent data available to estimate HR-III utilization for
FY 2011. In the absence of actual HR-III utilization data, we believe
the most recent data are the best source available, as they are closest
to the FY 2011 timeframe. As actual HR-III utilization becomes
available, we intend to assess the effectiveness of the parity
adjustment in maintaining budget neutrality and, if necessary, to
recalibrate the adjustment in the future.
We list the case-mix adjusted RUG-IV payment rates separately for
urban and rural SNFs in Tables 4A and 5A, with the corresponding case-
mix values which reflect the parity adjustment discussed above.
Similarly, the HR-III case-mix adjusted payment rates (reflecting the
parity adjustment) are listed on Tables 4B and 5B. These tables do not
reflect the AIDS add-on enacted by section 511 of the MMA, which we
apply only after making all other adjustments (wage and case-mix).
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C. Wage Index Adjustment to Federal Rates
Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the
Federal rates to account for differences in area wage levels, using a
wage index that we find appropriate. Since the inception of a PPS for
SNFs, we have used hospital wage data in developing a wage index to be
applied to SNFs. We are maintaining that practice for FY 2011, as we
continue to believe that in the absence of SNF-specific wage data,
using the hospital inpatient wage index is appropriate and reasonable
for the SNF PPS. As explained in the update notice for FY 2005 (69 FR
45786, July 30, 2004), the SNF PPS does not use the hospital area wage
index's occupational mix adjustment, as this adjustment serves
specifically to define the occupational categories more clearly in a
hospital setting; moreover, the collection of the occupational wage
data also excludes any wage data related to SNFs. Therefore, we believe
that using the updated wage data exclusive of the occupational mix
adjustment continues to be appropriate for SNF payments.
Finally, we continue to use the same methodology discussed in the
SNF PPS final rule for FY 2008 (72 FR 43423) to address those
geographic areas in which there are no hospitals and, thus, no hospital
wage index data on which to base the calculation of the FY 2011 SNF PPS
wage index. For rural geographic areas that do not have hospitals and,
therefore, lack hospital wage data on which to base an area wage
adjustment, we use the average wage index from all contiguous Core-
Based Statistical Areas (CBSAs) as a reasonable proxy. This methodology
is used to construct the wage index for rural Massachusetts. However,
we do not apply this methodology to rural Puerto Rico due to the
distinct economic circumstances that exist there, but instead continue
using the most recent wage index previously available for that area.
For urban areas without specific hospital wage index data, we use the
average wage indexes of all of the urban areas
[[Page 42901]]
within the State to serve as a reasonable proxy for the wage index of
that urban CBSA. The only urban area without wage index data available
is CBSA 25980, Hinesville-Fort Stewart, GA.
To calculate the SNF PPS wage index adjustment, we apply the wage
index adjustment to the labor-related portion of the Federal rate,
which is 69.311 percent of the total rate. This percentage reflects the
labor-related relative importance for FY 2011, using the revised and
rebased FY 2004-based market basket. The labor-related relative
importance for FY 2010 was 69.840, as shown in Table 9. We calculate
the labor-related relative importance from the SNF market basket, and
it approximates the labor-related portion of the total costs after
taking into account historical and projected price changes between the
base year and FY 2011. The price proxies that move the different cost
categories in the market basket do not necessarily change at the same
rate, and the relative importance captures these changes. Accordingly,
the relative importance figure more closely reflects the cost share
weights for FY 2011 than the base year weights from the SNF market
basket.
We calculate the labor-related relative importance for FY 2011 in
four steps. First, we compute the FY 2011 price index level for the
total market basket and each cost category of the market basket.
Second, we calculate a ratio for each cost category by dividing the FY
2011 price index level for that cost category by the total market
basket price index level. Third, we determine the FY 2011 relative
importance for each cost category by multiplying this ratio by the base
year (FY 2004) weight. Finally, we add the FY 2011 relative importance
for each of the labor-related cost categories (wages and salaries,
employee benefits, non-medical professional fees, labor-intensive
services, and a portion of capital-related expenses) to produce the FY
2011 labor-related relative importance. Tables 6A and 7A below show the
Federal rates for RUG-IV by labor-related and non-labor-related
components. Similarly, Tables 6B and 7B show the Federal rates for HR-
III.
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BILLING CODE 4120-01-C
Section 1888(e)(4)(G)(ii) of the Act also requires that we apply
this wage index in a manner that does not result in aggregate payments
that are greater or less than would otherwise be made in the absence of
the wage adjustment. For FY 2011 (Federal rates effective October 1,
2010), we apply an adjustment to fulfill the budget neutrality
requirement. We meet this requirement by multiplying each of the
components of the unadjusted Federal rates by a budget neutrality
factor equal to the ratio of the weighted average wage adjustment
factor for FY 2010 to the weighted average wage adjustment factor for
FY 2011. For this calculation, we use the same 2009 claims utilization
data for both the numerator and denominator of this ratio. We define
the wage adjustment factor used in this calculation as the labor share
of the rate component multiplied by the wage index plus the non-labor
share of the rate component. The budget neutrality factor for this year
is 0.9997. The wage index applicable to FY 2011 is set forth in Tables
A and B, which appear in the Addendum of this notice.
In the SNF PPS final rule for FY 2006 (70 FR 45026, August 4,
2005), we adopted the changes discussed in the Office of Management and
Budget (OMB) Bulletin No. 03-04 (June 6, 2003), available online at
http://www.whitehouse.gov/omb/bulletins/b03-04.html, which announced
revised definitions for Metropolitan Statistical Areas (MSAs), and the
creation of Micropolitan Statistical Areas and Combined Statistical
Areas. In addition, OMB published subsequent bulletins regarding CBSA
changes, including changes in CBSA numbers and titles. As indicated in
the FY 2008 SNF PPS final rule (72 FR 43423, August 3, 2007), this and
all subsequent SNF PPS 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 SNF PPS wage
index. The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html.
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, the 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 (both using FY 2002
hospital data). We referred to the blended wage index as the FY 2006
SNF PPS transition wage index. As discussed in the SNF PPS final rule
for FY 2006 (70 FR 45041), subsequent to the expiration of this 1-year
transition on September 30, 2006, we used the full CBSA-based wage
index values, as now presented in Tables A and B in the Addendum of
this notice.
D. Updates to the Federal Rates
In accordance with section 1888(e)(4)(E) of the Act, as amended by
section 311 of the BIPA, the payment rates in this notice reflect an
update equal to the full SNF market basket, estimated at 2.3 percentage
points. In addition, as discussed in sections I.G.2
[[Page 42910]]
and III. of this notice, the annual update includes a negative 0.6
percentage point adjustment to account for market basket forecast
error, for a net update of 1.7 percent for FY 2011. We continue to
disseminate the rates, wage index, and case-mix classification
methodology through the Federal Register before the August 1 that
precedes the start of each succeeding FY.
E. Relationship of RUG-IV and HR-III Classification System to Existing
Skilled Nursing Facility Level-of-Care Criteria
As discussed in Sec. 413.345, we include in each update of the
Federal payment rates in the Federal Register the designation of those
specific RUGs under the classification system that represent the
required SNF level of care, as provided in Sec. 409.30. As set forth
in the FY 2010 SNF PPS final rule (74 FR 40341, August 11, 2009), this
designation reflects an administrative presumption under the 66-group
RUG-IV system that beneficiaries who are correctly assigned to one of
the upper 52 RUG-IV groups on the initial 5-day, Medicare-required
assessment are automatically classified as meeting the SNF level of
care definition up to and including the assessment reference date on
the 5-day Medicare required assessment.
A beneficiary assigned to any of the lower 14 RUG-IV groups is not
automatically classified as either meeting or not meeting the
definition, but instead receives an individual level of care
determination using the existing administrative criteria. This
presumption recognizes the strong likelihood that beneficiaries
assigned to one of the upper 52 RUG-IV groups during the immediate
post-hospital period require a covered level of care, which would be
less likely for those beneficiaries assigned to one of the lower 14
RUG-IV groups.
In this notice, we designate the upper 52 RUG-IV groups for
purposes of this administrative presumption, consisting of all groups
encompassed by the following RUG-IV categories:
Rehabilitation plus Extensive Services;
Ultra High Rehabilitation;
Very High Rehabilitation;
High Rehabilitation;
Medium Rehabilitation;
Low Rehabilitation;
Extensive Services;
Special Care High;
Special Care Low; and,
Clinically Complex.
By contrast, under the HR-III system discussed in section I.F of
this notice, we will revert to the 53-group classification structure of
the previous, RUG-53 case-mix classification system. Under that
structure, as discussed in section III.B.5 of the FY 2010 SNF PPS final
rule (74 FR 40304, August 11, 2009), the administrative level-of-care
presumption applies to the upper 35 groups (as encompassed by the
Rehabilitation plus Extensive Services, Ultra High Rehabilitation, Very
High Rehabilitation, High Rehabilitation, Medium Rehabilitation, Low
Rehabilitation, Extensive Services, Special Care, and Clinically
Complex categories), while it does not apply to the lower 18 groups.
F. Example of Computation of Adjusted PPS Rates and SNF Payment
Using the hypothetical SNF XYZ described in Tables 8A and 8B below,
the following shows the adjustments made to the Federal per diem rate
to compute the provider's actual per diem PPS payment, for RUG-IV and
HR-III, respectively. SNF XYZ's 12-month cost reporting period begins
October 1, 2010. SNF XYZ's total PPS payment would equal $41,979 for
RUG-IV and $36,517 for HR-III, respectively. We derive the Labor and
Non-labor columns from Table 6A for RUG-IV and Table 6B for HR-III.
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III. The Skilled Nursing Facility Market Basket Index
Section 1888(e)(5)(A) of the Act requires us to establish a SNF
market basket index (input price index), that reflects changes over
time in the prices of an appropriate mix of goods and services included
in the SNF PPS. This notice incorporates the latest available
projections of the SNF market basket index. Accordingly, we have
developed a SNF market basket index that encompasses the most commonly
used cost categories for SNF routine services, ancillary services, and
capital-related expenses.
Each year, we calculate a revised labor-related share based on the
relative importance of labor-related cost categories in the input price
index. Table 9 below summarizes the updated labor-related share for FY
2011.
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A. Use of the Skilled Nursing Facility Market Basket Percentage
Section 1888(e)(5)(B) of the Act defines the SNF market basket
percentage as the percentage change in the SNF market basket index from
the average of the previous FY to the average of the current FY. For
the Federal rates established in this notice, we use the percentage
increase in the SNF market basket index to compute the update factor
for FY 2011. This is based on the IHS Global Insight, Inc. (formerly
DRI-WEFA) second quarter 2010 forecast (with historical data through
the first quarter 2010) of the FY 2011 percentage increase in the FY
2004-based SNF market basket index for routine, ancillary, and capital-
related expenses, to compute the update factor in this notice. Finally,
as discussed in section I.A. of this notice, we no longer compute
update factors to adjust a facility-specific portion of the SNF PPS
rates, because the initial three-phase transition period from facility-
specific to full Federal rates that started with cost reporting periods
beginning in July 1998 has expired.
B. Market Basket Forecast Error Adjustment
As discussed in the June 10, 2003, supplemental proposed rule (68
FR 34768) and finalized in the August 4, 2003, final rule (68 FR 46057-
59), the regulations at Sec. 413.337(d)(2) provide for an adjustment
to account for market basket forecast error. The initial adjustment
applied to the update of the FY 2003 rate for FY 2004, and took into
account the cumulative forecast error for the period from FY 2000
through FY 2002, resulting in an increase of 3.26 percent. Subsequent
adjustments in succeeding FYs take into account the forecast error from
the most recently available FY for which there is final data, and apply
whenever the difference between the forecasted and actual change in the
market basket exceeds a specified threshold. We originally used a 0.25
percentage point threshold for this purpose; however, for the reasons
specified in the FY 2008 SNF PPS final rule (72 FR 43425, August 3,
2007), we adopted a 0.5 percentage point threshold effective with FY
2008. As discussed previously in section I.G.2. of this notice, as the
difference between the estimated and actual amounts of increase in the
market basket index for FY 2009 (the most recently available FY for
which there is final data) exceeds the 0.5 percentage point threshold,
the payment rates for FY 2011 include a forecast error adjustment.
C. Federal Rate Update Factor
Section 1888(e)(4)(E)(ii)(IV) of the Act requires that the update
factor used to establish the FY 2011 Federal rates be at a level equal
to the full market basket percentage change. Accordingly, to establish
the update factor, we determined the total growth from the average
market basket level for the period of October 1, 2009 through September
30, 2010 to the average market basket level for the period of October
1, 2010 through September 30, 2011. Using this process, the market
basket update factor for FY 2011 SNF PPS Federal rates is 2.3 percent,
adjusted by the negative 0.6 percentage point forecast error
adjustment, for a net update of 1.7 percent for FY 2011. We used this
update factor to compute the SNF PPS rate shown in Tables 2 and 3.
IV. Consolidated Billing
Section 4432(b) of the BBA established a consolidated billing
requirement that places the Medicare billing responsibility for
virtually all of the services that the SNF's residents receive with the
SNF, except for a small number of services that the statute
specifically identifies as being excluded from this provision. As noted
previously in section I. of this notice, subsequent legislation enacted
a number of modifications in the consolidated billing provision.
Specifically, section 103 of the BBRA amended this provision by
further excluding a number of individual ``high-cost, low-probability''
services, identified by the Healthcare Common Procedure Coding System
(HCPCS) codes, within several broader categories (chemotherapy and its
administration, radioisotope services, and customized prosthetic
devices) that otherwise remained subject to the provision. We discuss
this BBRA amendment in greater detail in the proposed and final rules
for FY 2001 (65 FR 19231 through 19232, April 10, 2000, and 65 FR 46790
through 46795, July 31, 2000), as well as in Program Memorandum AB-00-
18 (Change Request 1070), issued March 2000, which is
available online at http://www.cms.gov/transmittals/downloads/ab001860.pdf.
Section 313 of the BIPA further amended this provision by repealing
its Part B aspect; that is, its applicability to services furnished to
a resident during a SNF stay that Medicare Part A does not cover.
(However, physical therapy, occupational therapy, and speech-language
pathology services remain subject to consolidated billing, regardless
of whether the resident who receives these services is in a covered
Part A stay.) We discuss this BIPA amendment in greater detail in the
proposed and final rules for FY 2002 (66 FR 24020 through 24021, May
10, 2001,
[[Page 42913]]
and 66 FR 39587 through 39588, July 31, 2001).
In addition, section 410 of the MMA amended this provision by
excluding certain practitioner and other services furnished to SNF
residents by RHCs and FQHCs. We discuss this MMA amendment in greater
detail in the update notice for FY 2005 (69 FR 45818 through 45819,
July 30, 2004), as well as in Program Transmittal 390 (Change
Request 3575), issued December 10, 2004, which is available
online at http://www.cms.gov/transmittals/downloads/r390cp.pdf.
Further, while not substantively revising the consolidated billing
requirement itself, a related provision was enacted in the Medicare
Improvements for Patients and Providers Act of 2008 (MIPPA, Pub. L.
110-275). Specifically, section 149 of MIPPA amended section
1834(m)(4)(C)(ii) of the Act to add subclause (VII), which adds SNFs
(as defined in section 1819(a) of the Act) to the list of entities that
can serve as a telehealth ``originating site'' (that is, the location
at which an eligible individual can receive, via a telecommunications
system, services of a physician or other practitioner who is located
elsewhere at a ``distant site'').
As explained in the Medicare Physician Fee Schedule (PFS) final
rule for Calendar Year (CY) 2009 (73 FR 69726, 69879, November 19,
2008), a telehealth originating site receives a facility fee which is
always separately payable under Part B outside of any other payment
methodology. Section 149(b) of MIPPA amended section 1888(e)(2)(A)(ii)
of the Act to exclude telehealth services furnished under section
1834(m)(4)(C)(ii)(VII) of the Act from the definition of ``covered
skilled nursing facility services'' that are paid under the SNF PPS.
Thus, a SNF `` * * * can receive separate payment for a telehealth
originating site facility fee even in those instances where it also
receives a bundled per diem payment under the SNF PPS for a resident's
covered Part A stay '' (73 FR 69881). By contrast, under section
1834(m)(2)(A) of the Act, a telehealth distant site service is payable
under Part B to an eligible physician or practitioner only to the same
extent that it would have been so payable if furnished without the use
of a telecommunications system. Thus, as explained in the CY 2009
Physician Fee Schedule final rule (73 FR 69726), eligible distant site
physicians or practitioners can receive payment for a telehealth
service that they furnish--
* * * only if the service is separately payable under the PFS
when furnished in a face-to-face encounter at that location. For
example, we pay distant site physicians or practitioners for
furnishing services via telehealth only if such services are not
included in a bundled payment to the facility that serves as the
originating site (73 FR 69880).
This means that in those situations where a SNF serves as the
telehealth originating site, the distant site professional services
would be separately payable under Part B only to the extent that they
are not already included in the SNF PPS bundled per diem payment and
subject to consolidated billing. Thus, for a type of practitioner whose
services are not otherwise excluded from consolidated billing when
furnished during a face-to-face encounter, the use of a telehealth
distant site would not serve to unbundle those services. In fact,
consolidated billing does exclude the professional services of
physicians, along with those of most of the other types of telehealth
practitioners that the law specifies at section 1842(b)(18)(C) of the
Act, that is, physician assistants, nurse practitioners, clinical nurse
specialists, certified registered nurse anesthetists, certified nurse
midwives, and clinical psychologists (see section 1888(e)(2)(A)(ii) of
the Act and 42 CFR 411.15(p)(2)). However, the services of clinical
social workers, registered dietitians and nutrition professionals
remain subject to consolidated billing when furnished to a SNF's Part A
resident and, thus, cannot qualify for separate Part B payment as
telehealth distant site services in this situation. Additional
information on this provision appears in Program Transmittal
1635 (Change Request 6215), issued November 14, 2008,
which is available online at http://www.cms.gov/transmittals/downloads/R1635CP.pdf. To date, the Congress has enacted no further legislation
affecting the consolidated billing provision.
V. Application of the SNF PPS to SNF Services Furnished by Swing-Bed
Hospitals
In accordance with section 1888(e)(7) of the Act, as amended by
section 203 of the BIPA, Part A pays CAHs on a reasonable cost basis
for SNF services furnished under a swing-bed agreement. However,
effective with cost reporting periods beginning on or after July 1,
2002, the swing-bed services of non-CAH rural hospitals are paid under
the SNF PPS. As explained in the final rule for FY 2002 (66 FR 39562,
July 31, 2001), we selected this effective date consistent with the
statutory provision to integrate swing-bed rural hospitals into the SNF
PPS by the end of the SNF transition period, June 30, 2002.
Accordingly, all non-CAH swing-bed rural hospitals have come under
the SNF PPS as of June 30, 2003. Therefore, all rates and wage indexes
outlined in earlier sections of this notice for the SNF PPS also apply
to all non-CAH swing-bed rural hospitals. A complete discussion of
assessment schedules, the MDS and the transmission software (RAVEN-SB
for Swing Beds) appears in the final rule for FY 2002 (66 FR 39562,
July 31, 2001) and in the final rule for FY 2010 (74 FR 40288, August
11, 2009). As finalized in the FY 2010 SNF PPS final rule (74 FR 40356-
57), effective October 1, 2010, non-CAH swing-bed rural hospitals will
be required to complete an MDS 3.0 swing-bed assessment which is
limited to the required demographic, payment, and quality items. The
latest changes in the MDS for swing-bed rural hospitals appear on the
SNF PPS Web site, www.cms.gov/snfpps.
VI. Collection of Information Requirements
The information collection requirements referenced in this notice
with comment period are approved under OMB's 0938-0739 and
0938-0872.
VII. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
VIII. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this notice as required by
Executive Order 12866 on Regulatory Planning and Review (September 30,
1993), the Regulatory Flexibility Act (September 19, 1980, RFA, Pub. L.
96-354), section 1102(b) of the Social Security Act, section 202 of the
Unfunded Mandates Reform Act of 1995 (UMRA, Pub. L. 104-4), Executive
Order 13132 on Federalism (August 4, 1999), and the Congressional
Review Act (5 U.S.C. 804(2)).
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize
[[Page 42914]]
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
This notice is an economically significant rule under Executive Order
12866, because we estimate the FY 2011 impact of the standard update
will be to increase payments to SNFs by approximately $542 million. As
discussed in the final rule for FY 2010 (74 FR 40358, August 11, 2009),
we estimate that there will be no aggregate impact on payments as a
result of the implementation of the RUG-IV model, which is introduced
on a budget neutral basis. Similarly, there would be no impact with HR-
III, as we are introducing this on a budget neutral basis. Furthermore,
we are also considering this a major rule as defined in the
Congressional Review Act (5 U.S.C. 804(2)).
The update set forth in this notice applies to payments in FY 2011.
Accordingly, the analysis that follows describes the impact of each
system on an annual basis. In accordance with the requirements of the
Act, we will publish a notice for each subsequent FY that will provide
for an update to the payment rates and include an associated impact
analysis.
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities as
that term is used in the RFA includes small businesses, nonprofit
organizations, and small government jurisdictions. Most SNFs and most
other providers and suppliers are small entities, either by their
nonprofit status or by having revenues of $13.5 million or less in any
1 year. For purposes of the RFA, approximately 51 percent of SNFs are
considered small businesses according to the Small Business
Administration's latest size standards, with total revenues of $13.5
million or less in any 1 year. (For details, see the Small Business
Administration's final rule that sets forth standards for health care
industries, at 65 FR 69432, November 17, 2000). Individuals and States
are not included in the definition of a small entity. In addition,
approximately 29 percent of SNFs are nonprofit organizations.
This notice updates the SNF PPS rates published in the final rule
for FY 2010 (74 FR 40288, August 11, 2009) and the associated
correction notice (74 FR 48865, September 25, 2009), thereby increasing
net payments by an estimated $542 million. As indicated in Tables 10A
and 10B, the effect on facilities will be an aggregate positive impact
of 1.7 percent. We note that some individual providers may experience
larger increases in payments than others due to the distributional
impact of the FY 2011 wage indexes and the degree of Medicare
utilization.
Guidance issued by the Department of Health and Human Services on
the proper assessment of the impact on small entities in rulemakings,
utilizes a revenue impact of 3 to 5 percent as a significance threshold
under the RFA. While this notice is considered economically
significant, its relative impact on SNFs overall is small because
Medicare is a relatively minor payer source for nursing home care. We
estimate that Medicare covers approximately 10 percent of service days,
and approximately 20 percent of payments. However, the distribution of
days and payments is highly variable, with the majority of SNFs having
significantly lower Medicare utilization. As indicated in Tables 10A
and 10B, the effect on facilities is projected to be an aggregate
positive impact of 1.7 percent. As the overall impact is positive on
the industry as a whole, and on small entities specifically, the
Secretary has determined that this notice would not have a significant
impact on a substantial number of small entities. Therefore, in view of
the positive economic impact on small entities, it is not necessary to
consider regulatory alternatives.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. The notice will affect
small rural hospitals that (a) furnish SNF services under a swing-bed
agreement or (b) have a hospital-based SNF. We anticipate that the
impact on small rural hospitals will be similar to the impact on SNF
providers overall. Therefore, the Secretary has determined that this
notice will not have a significant impact on the operations of a
substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2010, that
threshold is approximately $135 million. This notice would not impose
spending costs on State, local, or tribal governments in the aggregate,
or by the private sector, of $135 million.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates regulations that impose
substantial direct requirement costs on State and local governments,
preempts State law, or otherwise has Federalism implications. This
notice would have no substantial direct effect on State and local
governments, preempt State law, or otherwise have Federalism
implications.
B. Anticipated Effects
This notice sets forth updates of the SNF PPS rates contained in
the final rule for FY 2010 (74 FR 40288, August 11, 2009) and the
associated correction notice (74 FR 48865, September 25, 2009). Based
on the above, we estimate the FY 2011 impact would be a net increase of
$542 million on payments to SNFs. The impact analysis of this notice
represents the projected effects of the changes in the SNF PPS from FY
2010 to FY 2011. We assess the effects by estimating payments while
holding all other payment-related variables constant. Although the best
data available is utilized, there is no attempt to predict behavioral
responses to these changes, or to make adjustments for future changes
in such variables as days or case-mix.
Certain events may occur to limit the scope or accuracy of our
impact analysis, as this analysis is future-oriented and, thus, very
susceptible to forecasting errors due to certain events that may occur
within the assessed impact time period. Some examples of possible
events may include newly legislated general Medicare program funding
changes by the Congress, or changes specifically related to SNFs. In
addition, changes to the Medicare program may continue to be made as a
result of previously enacted legislation, or new statutory provisions.
Although these changes may not be specific to the SNF PPS, the nature
of the Medicare program is that the changes may interact and, thus, the
complexity of the interaction of these changes could make it difficult
to predict accurately the full scope of the impact upon SNFs.
In accordance with section 1888(e)(4)(E) of the Act, we update the
payment rates for FY 2010 by a factor equal to the full market basket
index percentage increase adjusted by the FY 2009 forecast error
adjustment to
[[Page 42915]]
determine the payment rates for FY 2011. The special AIDS add-on
established by section 511 of the MMA remains in effect until `` * * *
such date as the Secretary certifies that there is an appropriate
adjustment in the case mix * * * '' We have not provided a separate
impact analysis for the MMA provision. Our latest estimates indicate
that there are less than 3,300 beneficiaries who qualify for the AIDS
add-on payment. The impact to Medicare is included in the ``total''
column of Tables 10A and 10B. In updating the rates for FY 2011, we
made a number of standard annual revisions and clarifications mentioned
elsewhere in this notice (for example, the update to the wage and
market basket indexes used for adjusting the Federal rates). These
revisions would increase payments to SNFs by approximately $542
million.
The FY 2011 impacts appear in Tables 10A and 10B. The breakdown of
the various categories of data in the table follows.
The first column shows the breakdown of all SNFs by urban or rural
status, hospital-based or freestanding status, and census region.
The first row of figures in the first column describes the
estimated effects of the various changes on all facilities. The next
six rows show the effects on facilities split by hospital-based,
freestanding, urban, and rural categories. The urban and rural
designations are based on the location of the facility under the CBSA
designation. The next twenty-two rows show the effects on urban versus
rural status by census region.
The second column in the table shows the number of facilities in
the impact database.
The third column of the table shows the effect of the annual update
to the wage index. This represents the effect of using the most recent
wage data available. The total impact of this change is zero percent;
however, there are distributional effects of the change.
The fourth column shows the distributional effect due to the RUG-IV
and HR-III classification systems. Though the aggregate impact shows no
change in total payments, it is estimated that some facilities will
experience payment increases while others experience payment decreases
due to Medicare utilization under RUG-IV in Table 10A, and in HR-III in
Table 10B. For example, in Table 10A under RUG-IV, providers in the
urban Pacific region only show increases of 0.1 percent, while
providers in the urban Mountain region show a decrease of 0.8 percent.
Similarly, in Table 10B under HR-III, providers in the urban East South
Central region only show increases of 0.3 percent, while providers in
the urban South Atlantic region show a decrease of 0.9 percent.
The fifth column shows the effect of all of the changes on the FY
2011 payments. The update of 1.7 percent, consisting of the market
basket increase of 2.3 percentage points, adjusted by the negative 0.6
percentage point forecast error adjustment is constant for all
providers and, though not shown individually, is included in the total
column. It is projected that aggregate payments will increase by 1.7
percent, assuming facilities do not change their care delivery and
billing practices in response.
As can be seen from Tables 10A and 10B, the combined effects of all
of the changes vary by specific types of providers and by location. For
example, nearly all facilities would experience payment increases in FY
2011 total payments under RUG-IV, ranging from 5.2 percent in urban
Outlying regions to 0.5 percent in the rural Pacific region. Of those
facilities showing decreases under RUG-IV, facilities in the rural
South Atlantic area of the country show the smallest decrease of 0.1
percent and facilities in the rural East North Central area show the
largest decrease of 0.4 percent.
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C. Alternatives Considered
Section 1888(e) of the Act establishes the SNF PPS for the payment
of Medicare SNF services for cost reporting periods beginning on or
after July 1, 1998. This section of the statute prescribes a detailed
formula for calculating payment rates under the SNF PPS, and does not
provide for the use of any alternative methodology. It specifies that
the base year cost data to be used for computing the SNF PPS payment
rates must be from FY 1995 (October 1, 1994, through September 30,
1995). In accordance with the statute, we also incorporated a number of
elements into the SNF PPS (for example, case-mix classification
methodology, the MDS assessment schedule, a market basket index, a wage
index, and the urban and rural distinction used in the development or
adjustment of the Federal rates). Further, section 1888(e)(4)(H) of the
Act specifically requires us to disseminate the payment rates for each
new FY through the Federal Register, and to do so before the August 1
that precedes the start of the new FY. Accordingly, we are not pursuing
alternatives with respect to the payment methodology as discussed
above.
D. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 11 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this update notice. This
table provides our best estimate of the change in Medicare payments
under the SNF PPS as a result of the policies in this update notice
based on the data for 15,307 SNFs in our database. All expenditures are
classified as transfers to Medicare providers (that is, SNFs).
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E. Conclusion
Overall estimated payments for SNFs in FY 2011 are projected to
increase by $542 million, or 1.7 percent, compared with those in FY
2010. We estimate that under RUG-IV, SNFs in urban and rural areas
would experience a 1.9 and 0.7 percent increase, respectively, in
estimated payments compared with FY 2010. Providers in the urban New
England region would show an increase in payments of 2.0 percent. We
estimate that under HR-III, SNFs in urban and rural areas would
experience a 1.8 and 1.5 percent increase in estimated payments,
respectively, compared with FY 2010. Providers in the rural Pacific
region and the East South Central region would both show increases in
payments of 1.5 percent.
Finally, in accordance with the provisions of Executive Order
12866, this notice was reviewed by the Office of Management and Budget.
IX. Waiver of Proposed Rulemaking
We would ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide a period for public comment before the
provisions of a notice such as this take effect. However,
[[Page 42919]]
we can waive this procedure if we find good cause that a notice and
comment procedure is impracticable, unnecessary, or contrary to the
public interest and incorporate a statement of the finding and its
reasons in the notice issued.
We believe it is unnecessary to undertake notice and comment
rulemaking in this instance, as the statute requires annual updates to
the SNF PPS rates, and the methodologies used to update the rates and
the policies initiated in this notice have been previously subject to
public comment and finalized.
As discussed in section I.F, section 10325 of the ACA requires that
the Secretary postpone implementation of the RUG-IV case-mix
classification system. Notwithstanding this postponement, section 10325
further specifies that the Secretary is required to implement certain
components of RUG-IV effective October 1, 2010 (that is, the changes
relating to concurrent therapy and the lookback period). Because the
concurrent therapy and look back period changes were already subject to
notice and public comment and finalized in the FY 2010 SNF PPS final
rule (74 FR 40288, August 11, 2009), we believe that these ACA
requirements are largely self-implementing and require no substantive
exercise of discretion by the Secretary. In addition, section 10325 of
the ACA specifies that the implementation of the MDS 3.0 shall proceed
as planned (see 74 FR 40342 through 40343), with an effective date of
October 1, 2010. Similarly, we believe this provision is self-
implementing and does not require the exercise of discretion. Thus, we
find that notice and comment procedures are unnecessary.
However, as discussed in section I.F, there are some operational
issues that arise in connection with the implementation of section
10325 of the ACA in the context of the existing RUG-III case-mix
classification system. Thus, we are providing a 60-day comment period
for public comment.
Authority: Catalog of Federal Domestic Assistance Program No.
93.773, Medicare--Hospital Insurance; and Program No. 93.774,
Medicare--Supplementary Medical Insurance Program.
Dated: May 19, 2010.
Marilyn Tavenner,
Acting Administrator and Chief Operating Officer, Centers for Medicare
& Medicaid Services.
Approved: July 14, 2010.
Kathleen Sebelius,
Secretary.
Note: The following Addendum will not appear in the Code of
Federal Regulations.
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[FR Doc. 2010-17628 Filed 7-16-10; 4:15 pm]
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