[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2005] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR412.63] [Page 483-488] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 412_PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES --Table of Contents Subpart D_Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs Sec. 412.63 Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004. (a) General rule. (1) CMS determines a national adjusted prospective payment rate for inpatient operating costs for each inpatient hospital discharge in Federal fiscal years 1985 through 2004 involving inpatient hospital service of a hospital in the United States, subject to the PPS, and determines a regional adjusted PPS rate for operating costs for such discharges in each region for which payment may be made under Medicare Part A. (2) Each such rate is determined for hospitals located in urban or rural areas within the United States and within each such region, respectively, as described under paragraphs (b) through (u) of this section. (b) Geographic classifications. Effective for fiscal years 1985 through 2004, the following rules apply. (1) For purposes of this section, the definitions set forth in Sec. 412.62(f) apply, except that, effective January 1, 2000, a hospital reclassified as rural may mean a reclassification that results from a geographic redesignation as set forth in Sec. 412.62(f)(1)(iv) or a reclassification that results from an urban hospital applying for reclassification as rural as set forth in Sec. 412.103. (2) For hospitals within an MSA or NECMA that crosses census division boundaries, the following provisions apply: (i) The MSA or NECMA is deemed to belong to the census division in which most of the hospitals within the MSA or NECMA are located. (ii) A hospital that met the conditions specified in Sec. 412.62(f)(2)(ii) and therefore did not receive a lower Federal rate that would have applied for cost reporting periods beginning before October 1, 1984, receives the lower Federal rate applicable to all hospitals in the MSA or NECMA in which it is located effective with the hospital's cost reporting period that begins on or after October 1, 1984. (iii) The higher Federal rate is payable to all hospitals in the MSA or NECMA if an equal number of hospitals within the MSA or NECMA are located in each census division. [[Page 484]] (3) For discharges occurring on or after October 1, 1988, a hospital located in a rural county adjacent to one or more urban areas is deemed to be located in an urban area and receives the Federal payment amount for the urban area to which the greater number of workers in the county commute if the rural county would otherwise be considered part of an urban area, under the standards for designating MSAs or NECMAs if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or central counties of all adjacent MSAs or NECMAs. These EOMB standards are set forth in the notice of final standards for classification of MSAs published in the Federal Register on January 3, 1980 (45 FR 956), and available from CMS, East High Rise Building, room 132, 6325 Security Boulevard, Baltimore, Maryland 21207. (4) For purposes of this section, any change in an MSA or NECMA designation is recognized on the October 1 following the effective date of the change. (5) For discharges occurring on or after October 1, 1988, for hospitals that consist of two or more separately located inpatient hospital facilities the national adjusted prospective payment rate is based on the geographic location of the hospital facility at which the discharge occurs. (c) Updating previous standardized amounts. (1) For discharges occurring in fiscal year 1985 through fiscal year 2003, CMS computes average standardized amounts for hospitals in urban areas and rural areas within the United States, and in urban areas and rural areas within each region. For discharges occurring in fiscal year 2004, CMS computes an average standardized amount for hospitals located in all areas. (2) Each of those amounts is equal to the respective adjusted average standardized amount computed for fiscal year 1984 under Sec. 412.62(g)-- (i) Increased for fiscal year 1985 by the applicable percentage increase in the hospital market basket; (ii) Adjusted by the estimated amount of Medicare payment for nonphysician services furnished to hospital inpatients that would have been paid under Part B were it not for the fact that such services must be furnished either directly by hospitals or under arrangements; (iii) Reduced by a proportion equal to the proportion (estimated by CMS) of the total amount of prospective payments that are additional payment amounts attributable to outlier cases under subpart F of this part; and (iv) Adjusted for budget neutrality under paragraph (h) of this section. (3) For fiscal year 1986 and thereafter. CMS computes, for urban and rural hospitals in the United States and for urban and rural hospitals in each region, average standardized amount equal to the respective adjusted average standardized amounts computed for the previous fiscal year-- (i) Increased by the applicable percentage increase determined under paragraphs (d) through (g) of this section; (ii) Adjusted by the estimated amount of Medicare payment for nonphysician services furnished to hospital inpatients that would have been paid under Part B were it not for the fact that such services must be furnished either directly by hospitals or under arrangements; and (iii) For discharges occurring on or after October 1, 1985 and before October 1, 1986, reduced by a proportion (estimated by CMS) of the amount of payments based on the total amount of prospective payments that are additional payment amounts attributable to outlier cases under subpart F of this part, and for discharges occurring on or after October 1, 1986, reduced by a proportion (estimated by CMS) of the amount of payments that, based on the total amount of prospective payments for urban hospitals and the total amount of prospective payments for rural hospitals, are additional payments attributable to outlier cases in such hospitals under subpart F of this part. (4) For fiscal years 1987 through 1990 CMS standardizes the average standardized amounts by excluding an estimate of the payments for hospitals that serve a disproportionate share of low-income patients. [[Page 485]] (5) For fiscal years 1987 through 2004, CMS standardizes the average standardized amounts by excluding an estimate of indirect medical education payments. (6) For fiscal years 1988 through 2003, CMS computes average standardized amounts for hospitals located in large urban areas, other urban areas, and rural areas. The term large urban area means an MSA with a population of more than 1,000,000 or an NECMA, with a population of more than 970,000 based on the most recent available population data published by the Census Bureau. For fiscal year 2004, CMS computes an average standardized amount for hospitals located in all areas. (d) Applicable percentage change for fiscal year 1986. (1) The applicable percentage change for fiscal year 1986 is-- (i) For discharges occurring on or after October 1, 1985 and before May 1. 1986, zero percent; and (ii) For discharges occurring on or after May 1, 1986, one-half of one percent. (2) For purposes of determining the standardized amounts for discharges occurring on or after October 1, 1986, the applicable percentage increase for fiscal year 1986 is deemed to have been one-half of one percent. (e) Applicable percentage change for fiscal year 1987. The applicable percentage change for fiscal year 1987 is 1.15 percent. (f) Applicable percentage change for fiscal year 1988. (1) The applicable percentage change for fiscal year 1988 is-- (i) For discharges occurring on or after October 1, 1987 and before November 21, 1987, zero percent; (ii) For discharges occurring on or after November 21, 1987 and before April 1, 1988, 2.7 percent; and (iii) For discharges occurring on or after April 1, 1988 and before October 1, 1988-- (A) 3.0 percent for hospitals located in rural areas; (B) 1.5 percent for hospitals located in large urban areas; and (C) 1.0 percent for hospitals located in other urban areas. (2) For purposes of determining the standardized amounts for discharges occurring on or after October 1, 1988 (for Federal fiscal year 1989), the applicable percentage change for fiscal year 1988 is deemed to have been-- (i) 3.0 percent for hospitals located in rural areas; (ii) 1.5 percent for hospitals located in large urban areas; and (iii) 1.0 percent for hospitals located in other urban areas. (g) Applicable percentage change for fiscal year 1989. The applicable percentage change for fiscal year 1989 is the percentage increase in the market basket index (as defined in Sec. 413.40(a)(3) of this chapter)-- (1) Minus 1.5 percentage points for hospitals located in rural areas; (2) Minus 2.0 percentage points for hospitals in large urban areas; and (3) Minus 2.5 percentage points for hospitals in other urban areas. (h) Applicable percentage change for fiscal year 1990. (1) The applicable percentage change for fiscal year 1990 is-- (i) For discharges occurring on or after October 1, 1989 and before January 1, 1990, 5.5 percent; and (ii) For discharges occurring on or after January 1, 1990 and before October 1, 1990-- (A) 9.72 percent for hospitals located in rural areas; (B) 5.62 percent for hospitals located in large urban areas; and (C) 4.97 percent for hospitals located in other urban areas. (2) For purposes of determining the standardized amounts for discharges occurring on or after October 1, 1990, the applicable percentage change for fiscal year 1990 is deemed to have been the percentage change provided for in paragraph (h)(1)(ii) of this section. (i) Applicable percentage change for fiscal year 1991. (1) The applicable percentage change for fiscal year 1991 is-- (i) For discharges occurring on or after October 1, 1990 and before October 21, 1990, 5.2 percent; (ii) For discharges occurring on or after October 21, 1990 and before January 1, 1991, 0.0 percent; and (iii) For discharges occurring on or after January 1, 1991 and before October 1, 1991-- (A) 4.5 percent for hospitals located in rural areas; and (B) 3.2 percent for hospitals located in large urban areas and other urban areas. [[Page 486]] (2) For purposes of determining the standardized amounts for discharges occurring on or after October 1, 1991, the applicable percentage change for fiscal year 1991 is deemed to have been the percentage change provided for in paragraph (i)(1)(iii) of this section. (j) Applicable percentage change for fiscal year 1992. The applicable percentage change for fiscal year 1992 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a)(3) of this chapter)-- (1) Minus 0.6 percentage points for hospitals located in rural areas. (2) Minus 1.6 percentage points for hospitals located in large urban areas and other urban areas. (k) Applicable percentage change for fiscal year 1993. The applicable percentage change for fiscal year 1993 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a)(3) of this chapter)-- (1) Minus 0.55 percentage points for hospitals located in rural areas. (2) Minus 1.55 percentage points for hospitals located in large urban areas and other urban areas. (l) Applicable percentage change for fiscal year 1994. The applicable percentage change for fiscal year 1994 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this chapter)-- (1) Minus 1.0 percentage point for hospitals located in rural areas. (2) Minus 2.5 percentage points for hospitals located in large urban areas and other urban areas. (m) Applicable percentage change for fiscal year 1995. The applicable percentage change for fiscal year 1995 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this chapter)-- (1) Plus, for hospitals located in rural areas, the percentage increase necessary so that the average standardized amounts computed under paragraph (c) through (i) of this section are equal to the average standardized amounts for hospitals located in an urban area other than a large urban area. (2) Minus 2.5 percentage points for hospitals located in large urban areas and other urban areas. (n) Applicable percentage change for fiscal year 1996. The applicable percentage change for fiscal year 1996 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this chapter) minus 2.0 percentage points for all areas. (o) Applicable percentage change for fiscal year 1997. The applicable percentage change for fiscal year 1997 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this chapter) minus 0.5 percentage point for all areas. (p) Applicable percentage change for fiscal year 1998. The applicable percentage change for fiscal year 1998 is 0 percent for hospitals in all areas. (q) Applicable percentage change for fiscal year 1999. The applicable percentage change for fiscal year 1999 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this subchapter) minus 1.9 percentage points for hospitals in all areas. (r) Applicable percentage change for fiscal year 2000. The applicable percentage change for fiscal year 2000 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this chapter) minus 1.8 percentage points for hospitals in all areas. (s) Applicable percentage change for fiscal year 2001. The applicable percentage change for discharges occurring in fiscal year 2001 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this subchapter) for hospitals in all areas as follows: (1) For discharges occurring on October 1, 2000 or before April 1, 2001 the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 41340(a) of this subchapter) for sole community hospitals and the increase in the market basket index minus 1.1 percentage points for other hospitals in all areas; and [[Page 487]] (2) For discharges occurring on April 1, 2001 or before October 1, 2001 the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this subchapter) for sole community hospitals and the increase in the market basket index plus 1.1 percentage points for other hospitals in all areas. (t) Applicable percentage change for fiscal years 2002 and 2003. The applicable percentage change for fiscal years 2002 and 2003 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this subchapter) minus 0.55 percentage points for hospitals in all areas. (u) Applicable percentage change for fiscal year 2004. The applicable percentage change for fiscal year 2004 is the percentage increase in the market basket index for prospective payment hospitals (as defined in Sec. 413.40(a) of this subchapter) for hospitals in all areas. (v) Maintaining budget neutrality for fiscal year 1985. (1) For fiscal year 1985, CMS will adjust each of the reduced standardized amounts determined under paragraph (c) of this section as required for fiscal year 1985 to ensure that the estimated amount of aggregate payments made, excluding the hospital-specific portion (that is, the total of the Federal portion of transition payments, plus any adjustments and special treatment of certain classes of hospitals for fiscal year 1985) is not greater or less than 50 percent of the payment amounts that would have been payable for the inpatient operating costs for those same hospitals for fiscal year 1985 under the law as in effect on April 19, 1983. (2) The aggregate payments considered under this paragraph exclude payments for per case review by a utilization and quality control quality improvement organization, as allowed under section 1866(a)(1)(F) of the Act. (w) Computing Federal rates for inpatient operating costs for hospitals located in large urban and other areas. For each discharge classified within a DRG, CMS establishes for the fiscal year a national prospective payment rate and a regional prospective payment rate for inpatient operating costs, for each region, as follows: (1) For hospitals located in a large urban area in the United States or that region respectively, the rate equals the product of-- (i) The adjusted average standardized amount (computed under paragraph (c) of this section) for the fiscal year for hospitals located in a large urban area in the United States or in that region; and (ii) The weighting factor determined under Sec. 412.60(b) for that DRG. (2) For hospitals located in an other area in the United States or that region respectively, the rate equals the product of-- (i) The adjusted average standardized amount (computed under paragraph (c) of this section) for the fiscal year for hospitals located in an other area in the United States or that region; and (ii) The weighting factor (determined under Sec. 412.60(b)) for that DRG. (x) Adjusting for different area wage levels. (1) CMS adjusts the proportion (as estimated by CMS from time to time) of Federal rates for inpatient operating costs computed under paragraph (j) of this section that are attributable to wages and labor-related costs for area differences in hospital wage levels by a factor (established by CMS based on survey data) reflecting the relative level of hospital wages and wage-related costs in the geographic area (that is, urban or rural area as determined under the provisions of paragraph (b) of this section) of the hospital compared to the national average level of hospital wages and wage-related costs. The wage index is updated annually. (2)(i) CMS makes a midyear correction to the wage index for an area only if a hospital can show that-- (A) The intermediary or CMS made an error in tabulating its data; and (B) The hospital could not have known about the error, or did not have the opportunity to correct the error, before the beginning of the Federal fiscal year. (ii) A midyear correction to the wage index is effective prospectively from the date the change is made to the wage index. (3) If a judicial decision reverses a CMS denial of a hospital's wage data [[Page 488]] revision request, CMS pays the hospital by applying a revised wage index that reflects the revised wage data as if CMS's decision had been favorable rather than unfavorable. [50 FR 12741, Mar. 29, 1985] Editorial Note: For Federal Register citations affecting Sec. 412.63, see the List of Sections Affected, which appears in the finding Aids section of the printed volume and on GPO Access.