[Federal Register Volume 75, Number 78 (Friday, April 23, 2010)]
[Rules and Regulations]
[Pages 21175-21179]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-8902]
[[Page 21175]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 483
[CMS-2266-F]
RIN 0938-AO82
Medicare and Medicaid Programs; Waiver of Disapproval of Nurse
Aide Training Program in Certain Cases
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule will permit a waiver of a nurse aide training
disapproval as it applies to skilled nursing facilities, in the
Medicare program, and nursing facilities, in the Medicaid program, that
are assessed a civil money penalty of at least $5,000 for noncompliance
that is not related to quality of care. This is a statutory provision
enacted by section 932 of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted December
8, 2003).
DATES: Effective Date: These regulations are effective on May 24, 2010.
FOR FURTHER INFORMATION CONTACT: Pat Miller, (410) 786-6780.
SUPPLEMENTARY INFORMATION:
I. Background
Waiver of Disapproval of Nurse Aide Training Program in Certain Cases
To participate in the Medicare and/or Medicaid programs, long-term
care facilities must be certified as meeting Federal participation
requirements. Long-term care facilities include skilled nursing
facilities (SNFs) for Medicare and nursing facilities (NFs) for
Medicaid. The Federal participation requirements for these facilities
are specified in regulations at 42 CFR part 483, subpart B.
Section 1864(a) of the Social Security Act (the Act) authorizes the
Secretary to enter into agreements with State survey agencies to
determine whether SNFs meet the Federal participation requirements for
Medicare. Section 1902(a)(33)(B) of the Act provides for State survey
agencies to perform the same survey tasks for facilities participating
or seeking to participate in the Medicaid program. The results of
Medicare and Medicaid related surveys are used by the Centers for
Medicare & Medicaid Services and the State Medicaid agency,
respectively, as the basis for a decision to enter into or deny a
provider agreement, recertify facility participation in one or both
programs, or impose remedies on a noncompliant facility.
To assess compliance with Federal participation requirements,
surveyors conduct onsite inspections (surveys) of facilities. In the
survey process, surveyors directly observe the actual provision of care
and services to residents and the effect or possible effects of that
care to evaluate whether the care furnished meets the assessed needs of
individual residents.
Sections 1819(b)(5) and 1919(b)(5) of the Act and implementing
regulations at Sec. 483.75(e) require that all individuals employed by
a facility as nurse aides must have successfully completed a nurse aide
training program.
Sections 1819(f)(2) and 1919(f)(2) of the Act provide that
facility-based nurse aide training could be offered either by the
facility or in the facility by another entity approved by the State.
Therefore, a facility in good standing (that is, one that is not
subject to an event that results in disapproval of a nurse aide
training program) may offer a facility-based program in one of two
ways: It can either conduct its own facility-based State-approved nurse
aide training and have the State or a State-approved entity administer
the nurse aide competency evaluation program, or it can offer the
entire nurse aide training and competency evaluation program through an
outside entity which has been approved by the State to conduct both
components.
Further, these sections prohibit States from approving a nurse aide
training and competency evaluation program or a nurse aide competency
evaluation program offered by or in a SNF or NF when any of the
following specified events have occurred in that facility--
The facility has operated under a nurse staffing waiver;
The facility has been subject to an extended or partial
extended survey unless the survey shows the facility is in compliance
with the participation requirements; or
The facility has been assessed a civil money penalty of
not less than $5,000, or has been subject to a denial of payment, the
appointment of a temporary manager, termination, or in the case of an
emergency, been closed and had its residents transferred.
Program disapproval is a required, rather than a discretionary,
response whenever any of these events occur. Since facilities are
required to employ nurse aides who have successfully completed a
training program, when a facility loses its ability to conduct
facility-based training, it must, for the duration of the 2-year
program disapproval, provide the required training through either the
State or another State-approved outside organization as provided by
Sec. 483.151(a). However, sections 1819(f)(2)(C) and 1919(f)(2)(C) of
the Act permit a waiver for program disapproval of programs offered in
(but not by) a facility if the State--
Determines that there is no other such program offered
within a reasonable distance of the facility;
Assures that an adequate environment exists for operating
the program in the facility; and
Notifies the State Long Term Care Ombudsman of this
determination and these assurances.
Section 932(c)(2)(B) of the MMA added sections 1819(f)(2)(D) and
1919(f)(2)(D) of the Act which allows the Secretary to waive a
facility's disapproval of its nurse aide training program upon
application of a facility if the disapproval resulted from the
imposition of a civil money penalty of at least $5,000 and that is not
related to quality of care provided to residents in the facility.
II. Summary of the Proposed Provisions and Response to Comments
In the November 23, 2007 Federal Register 72 FR 65692, we published
the proposed rule entitled, ``Medicare and Medicaid Programs; Waiver of
Disapproval of Nurse Aide Training Program in Certain Cases and Nurse
Aide Petition for Removal of Information for Single Finding of
Neglect'' and provided for a 30 day comment period.
A. Waiver of Disapproval of Nurse Aide Training Program in Certain
Cases
The statutory provisions set forth in the published proposed rule
pertain specifically and only to the civil money penalty disapproval
trigger under sections 1819(f)(2)(B)(iii)(I)(c) and
1919(f)(2)(B)(iii)(I)(c) of the Act and establish authority for CMS to
approve a facility's request to waive disapproval of its nurse aide
training program when that facility has been assessed a civil money
penalty of at least $5,000 for deficiencies that are not related to
quality of care.
We received a total of 23 comments from various States, health care
associations and consumer advocacy organizations. The comments for this
[[Page 21176]]
proposal ranged from general support or general opposition of the
proposal to more specific comments regarding the new training program
disapproval waiver.
B. Nurse Aide Petition for Removal of Information for Single Finding of
Neglect
We received nine comments on the proposed rule provision requiring
the State to establish a procedure to permit a nurse aide to petition
the State to have a single finding of neglect removed from the nurse
aide registry if the State determines that the employment and personal
history of the nurse aide does not reflect a pattern of abusive
behavior or neglect and the neglect involved in the original finding
was a single occurrence as found at sections 1819(g)(1)(D) and
1919(g)(1)(D) of the Social Security Act (section 4755 of the Balanced
Budget Act of 1997--Pub. L. 105-33, enacted on August 5, 1997). The
thoughtful comments received on these provisions of the proposed rule
necessitate that CMS take additional time to further explore the issues
put forth in the comments and analyze the statute to reconsider whether
regulatory action is necessary and the available options before
proceeding. In the event that the Secretary determines that regulatory
action is required for this issue, we will publish a new notice of
proposed rulemaking. Therefore, we are not finalizing these provisions
in this final rule and are removing them from this final rule at this
time.
General Comments
Waiver of Disapproval of Nurse Aide Training Program in Certain Cases
Comment: One commenter suggested that CMS propose a legislative
change that would remove the loss of nurse aide training as an
automatic consequence to the three specified events discussed earlier
in this preamble, and, instead, establish the training program
disapproval as another available enforcement remedy. This commenter
believes it would be more rational to create the training program
disapproval as another enforcement option to be considered when
deficiencies bear a relationship to the care and services that a nurse
aide provides. The loss of the training program in this case would be
appropriate because the facility's deficiencies demonstrate that it is
not providing a positive training model for its nurse aides.
Another commenter believes that the 2-year program disapproval
period is excessive and that it impedes a facility's ability to recruit
and retain staff. This commenter is particularly concerned about the 2-
year program disapproval based on a facility having a nurse staffing
waiver because the ``lock out'' contradicts the staffing waiver
criteria and it does not permit a facility to begin a training program
once it has acquired the needed staff.
Response: This comment falls outside the purview of this
regulation. This rule specifically pertains to permitting a waiver of a
facility's nurse aide training program disapproval when the facility is
assessed a civil money penalty of at least $5,000 for noncompliance
that is not related to quality of care.
Regarding the length of the disapproval period, we note that the 2-
year disapproval period is a statutory provision. Such a legislative
change falls outside the purview of this regulation.
Comment: One commenter suggested that the variability in the use of
civil money penalties among States could create inequities in the
waiver application process.
Response: Some variations may exist given the fact that these
penalties are a discretionary remedy and are, therefore, not imposed
with identical frequency and amount from State to State. We have
expended great efforts to ensure all determinations are made as
consistently as possible, particularly with civil money penalty
determinations.
Comment: One commenter suggested that the word ``assessed'' not be
used as it relates to the $5,000 civil money penalty threshold amount
that enables a facility to request a training program disapproval
waiver. Since ``assessed'' has been defined in CMS's State Operations
Manual to mean the final amount determined to be owed after a hearing,
waiver of right to a hearing, or settlement, this commenter believes
that it allows a facility to delay the imposition of the nurse aide
training prohibition for too long. Instead, the commenter proposed that
CMS redefine ``assessed'' to mean the final decision of CMS to impose a
civil money penalty.
Response: We do not have the authority to hasten or otherwise
change the timeframe in which determinations are made about nurse aide
training disapproval based on imposition of civil money penalties of at
least $5,000 or more. The statute is explicit that a nurse aide
training program must be prohibited when a facility is ``assessed'' a
civil money penalty of at least $5,000. Additionally, a facility has a
right to appeal a certification of noncompliance that leads to an
enforcement remedy, such as a civil money penalty, and/or to waive its
right to a hearing which reduces the assessed penalty amount under 42
CFR 488.436(b) before the final penalty amount owed by the facility is
determined. Indeed, under 42 CFR 498.3(b)(14) and (d)(10)(i), a
facility may only challenge the scope and severity level of
noncompliance found by CMS if a successful challenge would affect the
range of the civil money penalty that could be collected by CMS or
impact upon the facility's nurse aide training program. Since various
events could result in a different amount of civil money penalty
``assessed'' than the original amount, decisions about training program
disapproval prior to knowing the final assessed penalty amount would be
contrary to the intent of the statute. Nurse aide training program
disapproval takes effect after a final civil money penalty amount is
assessed if the amount exceeds at least $5,000.
Comment: One commenter wanted to know if a facility would still
lose its nurse aide training program if it had other disapproval-
causing events, even though it had a civil money penalty that qualified
for a training program disapproval waiver. In other words, does each
separate event, that requires nurse aide training disapproval, stand
alone?
Response: Yes. This waiver does not eliminate the loss of nurse
aide training based on other occurring events that also require
training disapproval, such as if, within the previous 2 years, a
facility is subjected to an extended (or partial extended) survey under
sections 1819(g)(2)(B)(i) or 1919(g)(2)(B)(i) or when a facility has
been subject to a remedy described in sections 1819(h)(2)(B)(i), or
(iii), 1819(h)(4), 1919(h)(1)(B)(i) or 1919(h)(2)(A)(i), (iii) or (iv)
of the Act.
Comment: One commenter wondered whether the waiver request should
be submitted to the State or to CMS. This commenter also asked whether
the training program disapproval waiver applies only to facilities that
operate their own training program or if it also applies to facilities
that serve as a training site for another program, for example, a
technical college.
Response: Waivers should be submitted to the State. Waiver
determinations will be made by CMS on a case-by-case basis after
considering the recommendation and facts of that case as provided by
the State. This point was made in the November 23, 2007 proposed rule
on page 65694 in the preamble to the proposed rule and will be included
in manual guidance that will be developed in collaboration with
interested stakeholders.
Regarding the waiver's applicability, the new training program
disapproval
[[Page 21177]]
waiver provision cross-references to sections 1819(f)(2)(B)(iii)(I) and
1919(f)(2)(B)(iii)(I) of the Act, which specifically apply only to
training programs ``offered by or in'' a facility. Therefore, the
training program disapproval waivers would also apply to a facility
that serves as a training site for another program because it is being
offered within the facility.
Comment: One commenter believes that CMS should make waiver
determinations, as well as the rationale for the determinations,
available to the public in order to ensure transparency in the process.
Response: While this comment is outside the scope of this final
rule, we appreciate the recommendation and will consider expanding
current disclosure policies in a separate regulatory document.
Comment: Some commenters believe that broader and more specific
direction needs to be provided about what factors will be considered in
making waiver request determinations. One commenter stressed the need
for specific timeframes and procedures relative to submitting and
approving these requests. Other commenters disagreed with the examples
and rationale provided in the preamble to the proposed rule to
demonstrate the general expectation of the rule's applicability. These
commenters urged that different and expanded examples and decision
making criteria be provided, and some offered criteria. A few of these
commenters believe that such additional direction should be provided in
this final rule rather than issued as manual guidance in CMS's State
Operations Manual in order to ensure appropriate public awareness and
comment. Other commenters requested that stakeholders be included in
developing the manual guidance.
Response: While we do not intend to include instructions in this
final rule on these operational issues, we will work with all
interested stakeholders to develop the guidance necessary to implement
the regulatory provisions set forth in this final rule. Participation
of all interested parties will ensure that the various perspectives are
represented and considered.
Comment: One commenter expressed concern about the distinction that
the proposed rule made between per instance civil money penalties and
per day civil money penalties relative to determining how discrete and
aggregate noncompliance should be evaluated in applying the waiver
provision. This commenter contends that no such flexibility exists in
the supporting legislation because it does not specifically
differentiate between civil money penalties that are based on single,
or multiple, instances of noncompliance. CMS is urged to remove the
flexibility and instead require that any noncompliance with quality of
care should, regardless of whether singularly or in combination with
other non-quality of care noncompliance, prevent a training disapproval
waiver.
Response: We do not agree with this comment. The statute refers to
civil money penalties generally so it does not specifically acknowledge
the two civil money penalty types, that is, the per day and per
instance, nor does it preclude differentiating between them. Since
civil money penalties can be assessed for specific instances of
noncompliance (per instance) as well as for aggregate noncompliance
(per day), we needed a method of determining how discrete and aggregate
noncompliance should be evaluated for waiver approval purposes. As
stated in the preamble to the proposed rule, when a per instance civil
money penalty of at least $5,000 is assessed for noncompliance with a
specific participation requirement, the evaluation of that specific
deficiency's direct impact on residents is clear-cut. However, when the
civil money penalty of at least $5,000 is per day, the evaluation
becomes more difficult because the penalty amount is not directly
attributable to any one deficiency but, instead, is for the total
noncompliance of the facility. Additionally, aggregate noncompliance
may be comprised of a combination of quality of care and non quality of
care deficiencies as well as various levels of severity and scope. When
this is the case, all of the deficiencies would need to be reviewed to
determine if individually or in total they are indicative of an overall
facility failure or inability to directly provide quality care to
residents. A single care-giving deficiency, among other non care-giving
deficiencies (none of which meet other criteria for nurse aide training
disapproval), may result in a conclusion that the facility, overall, is
providing quality care to its residents and therefore, is providing a
positive training model for its nurse aides. However, it is also
possible that the seriousness of that single facility failure, among
other non care-giving deficiencies, may result in a conclusion that the
facility, overall, is not providing quality care to its residents and
therefore, is not providing a positive training model for its nurse
aides. The ability to make these determinations is critical to ensure
that rational and defensible conclusions can be made relative to the
facility's ability to provide quality care to its residents as well as
whether the loss of its nurse aide training program is appropriate or
eligible for a waiver.
Part 483--Requirements for States and Long Term Care Facilities
Section 483.151 State Review and Approval of Nurse Aide Training and
Competency Evaluation Programs
We proposed to redesignate the current Sec. 483.151(c), (d), and
(e) as Sec. 483.151(d), (e), and (f), respectively. We also proposed
to add a new paragraph (c)(1) in Sec. 483.151 where a facility may
request that we waive the disapproval of its nurse aide training
program when the facility has been assessed a civil money penalty of
not less than $5,000 if the civil money penalty was not related to the
quality of care furnished to residents in the facility. We proposed to
add a new paragraph (c)(2) in Sec. 483.151 to define the term quality
of care furnished to residents, as the direct hands-on care and
treatment that a health care professional or direct care staff provides
to a resident. We proposed to add a new paragraph (c)(3) in Sec.
483.151 to specify that any waiver of disapproval of a nurse aide
training program does not waive any civil money penalty imposition.
Comment: Several commenters believe that the proposed definition of
``quality of care'', as direct hands-on care and treatment that a
health care professional or direct care staff provides to a resident,
is too limited and should be expanded to include other aspects of care
and services that the facility provides to residents. These commenters
contend that issues related to, for example, resident's rights,
cleanliness, and safety can impact a resident's quality of care as
significantly as those that constitute direct hands-on care and they
should also preclude a training program disapproval waiver.
Response: While we do not disagree that all care and services
provided by a nursing home are important, Congressional intent about
what constitutes ``quality of care'' is made clear on page 776 of the
Conference Report to the MMA (H.R. Rep. No. 108-391 (2003), reprinted
in 2004 U.S.C.C.A.N. 1808, 2130), which states that, ``* * * Quality of
care in such instances refers to direct, hands on care furnished to
residents of a facility.'' In order to address this reference, it was
necessary to identify care-giving requirements, that is, care and
treatment that a health care professional or direct care staff provides
to a resident. That
[[Page 21178]]
determination will lead to conclusions about the impact the
noncompliance may have on the facility's ability to provide a positive
training model to its nurse aides. Additionally, it is important to
note as we did in the preamble to the proposed rule, that noncompliance
need not be in a care-giving requirement in order to be assessed a
civil money penalty of at least $5,000 nor to disapprove a nurse aide
training program. Noncompliance with any requirement, whether care-
giving or non-care-giving, may result in the imposition of a civil
money penalty or other remedy. Once a $5,000 or greater civil money
penalty remedy or other triggering remedies are imposed, a facility's
ability to provide nurse aide training is prohibited for 2 years unless
a waiver is approved and no other training-disapproval event has
occurred.
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 30-day notice in the Federal Register and solicit public
comment when a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
Therefore, we are soliciting public comment on each of these issues
for the following information collection requirements discussed below.
Section 483.151 State Review and Approval of Nurse Aide Training and
Competency Evaluation Programs
Section 483.151(c)(1) states that a facility may request that CMS
waive disapproval of its nurse aide training program when a facility
has been assessed a civil money penalty of not less than $5,000 if the
civil money penalty was not related to the quality of care furnished to
residents in the facility.
The burden associated with this requirement is the time and effort
put forth by the facility to request a waiver as well as the time and
effort for States to make determinations on each waiver request. We
estimate it would take one facility 1 hour to submit a waiver and one
State 1 hour to make a determination on the request. We believe that
462 facilities may potentially request a waiver annually; therefore,
the total annual burden associated with this requirement is 462 hours
for facilities and 462 hours for States.
As required by section 3504(h) of the Paperwork Reduction Act of
1995, we have submitted a copy of this final regulation to OMB for its
review of these information collection requirements described above.
If you comment on these information collection and record keeping
requirements, please mail copies directly to the following:
Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Division of Regulations Development,
Attn.: Melissa Musotto, CMS-2266-F, Room C5-14-03, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
Office of Information and Regulatory Affairs, Office of Management
and Budget, Room 10235, New Executive Office Building, Washington, DC
20503, Attn.: Katherine T. Astrich, CMS Desk Officer, CMS-2266-F,
[email protected]. Fax (202) 395-6974.
V. Regulatory Impact Statement
We have examined the impact of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993, as
further amended), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-
4), and Executive Order 13132 on Federalism (August 4, 1999), and the
Congressional Review Act (5 U.S.C. 804 (2)).
Executive Order 12866 (as amended by Executive Order 13258, directs
agencies to assess all costs and benefits of available regulatory
alternatives and, if regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, distributive impacts,
and equity). A regulatory impact analysis (RIA) must be prepared for
major rules with economically significant effects ($100 million or more
in any 1 year). This regulatory requirement will not reach the economic
threshold and thus is not considered a major rule.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, non-profit organizations and government agencies. For
purposes of the RFA, most nursing homes are considered to be small
entities. We are not preparing an analysis for the RFA for this
regulatory proposal because we have determined that this rule will not
have a significant economic impact on a substantial number of small
businesses or other small entities. Therefore, the Secretary has
determined that this final rule will not have a significant economic
impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. We are
not preparing an analysis for section 1102(b) of the Act for this
regulatory proposal because we have determined, and the Secretary has
determined, that this rule 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 2008 that
threshold was approximately $125 million. This regulatory proposal will
have no consequential effect on State, local, or Tribal governments in
the aggregate or by the private sector, of $127 million.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. Since this regulation will not impose a substantial
direct cost on State or local governments, preempt States, or otherwise
have a Federalism implication, the requirements of E.O. 13132 are not
applicable.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 483
Grant programs--health, Health facilities, Health professions,
Health Records, Medicaid, Medicare, Nursing
[[Page 21179]]
homes, Nutrition, Reporting and recordkeeping requirements, Safety.
0
For the reasons set forth in the preamble, the Centers for Medicare and
Medicaid Services amends 42 CFR chapter IV as set forth below:
PART 483--REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES
0
1. The authority citation for part 483 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
* * * * *
0
2. Section 483.150(a) is revised to read as follows:
Sec. 483.150 Statutory basis: Deemed meeting or waiver of
requirements.
(a) Statutory basis. This subpart is based on sections 1819(b)(5),
1819(f)(2), 1919(b)(5), and 1919(f)(2) of the Act, which establish
standards for training nurse-aides and for evaluating their competency.
* * * * *
0
3. Section 483.151 is amended by--
0
A. Revising the section heading.
0
B. Redesignating paragraphs (c), (d), and (e) as paragraphs (d), (e),
and (f) respectively.
0
C. Adding new paragraph (c).
The revision and addition reads as follows:
Sec. 483.151 State review and approval of nurse aide training and
competency evaluation programs.
* * * * *
(c) Waiver of disapproval of nurse aide training programs.
(1) A facility may request that CMS waive the disapproval of its
nurse aide training program when the facility has been assessed a civil
money penalty of not less than $5,000 if the civil money penalty was
not related to the quality of care furnished to residents in the
facility.
(2) For purposes of this provision, ``quality of care furnished to
residents'' means the direct hands-on care and treatment that a health
care professional or direct care staff furnished to a resident.
(3) Any waiver of disapproval of a nurse aide training program does
not waive any requirement upon the facility to pay any civil money
penalty.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: January 14, 2010.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: April 12, 2010.
Kathleen Sebelius,
Secretary.
[FR Doc. 2010-8902 Filed 4-22-10; 8:45 am]
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