Proposed Rule: Medicaid: Outpatient Clinic and Hospital Facility Services Definitions and Payment Limits

55158 Federal Register / Vol. 72, No.
188 / Friday, September 28, 2007 / Proposed Rules
DEPARTMENT OF HEALTH AND Centers for Medicare & Medicaid a comment. We post all comments
HUMAN SERVICES Services, Department of Health and received before the close of the
Human Services, Attention: CMS–2213– comment period on the following Web
Centers for Medicare & Medicaid P, P.O. Box 8016, Baltimore, MD 21244– site as soon as possible after they have
Services 8016. been received: http://www.cms.hhs.gov/
Please allow sufficient time for mailed eRulemaking. Click on the link
42 CFR Parts 440 and 447 comments to be received before the ‘‘Electronic Comments on CMS
close of the comment period. Regulations’’ on that Web site to view
[CMS–2213–P] 3. By express or overnight mail. You public comments.
may send written comments (one Comments received timely will also
RIN 0938–AO17 be available for public inspection as
original and two copies) to the following
address ONLY: Centers for Medicare & they are received, generally beginning
Medicaid Program; Clarification of
Medicaid Services, Department of approximately 3 weeks after publication
Outpatient Clinic and Hospital Facility
Health and Human Services, Attention: of a document, at the headquarters of
Services Definition and Upper Payment
CMS–2213–P, Mail Stop C4–26–05, the Centers for Medicare & Medicaid
Limit
7500 Security Boulevard, Baltimore, MD Services, 7500 Security Boulevard,
AGENCY: Centers for Medicare & 21244–1850. Baltimore, Maryland 21244, Monday
Medicaid Services (CMS), HHS. 4. By hand or courier. If you prefer, through Friday of each week from 8:30
ACTION: Proposed rule. you may deliver (by hand or courier) a.m. to 4 p.m. To schedule an
your written comments (one original appointment to view public comments,
SUMMARY: This proposed rule would and two copies) before the close of the phone 1–800–743–3951.
amend the regulatory definition of comment period to one of the following I. Introduction
outpatient hospital services for the addresses. If you intend to deliver your
Medicaid program. Outpatient hospital comments to the Baltimore address, Title XIX of the Social Security Act
services are a mandatory part of the please call telephone number (410) 786– (the Act) authorizes the Secretary of the
standard Medicaid benefit package. The 7195 in advance to schedule your Department of Health and Human
current regulatory definition at 42 CFR arrival with one of our staff members: Services (the Secretary) to provide
440.20 is broader than the definition in grants to States to partially finance
Room 445–G, Hubert H. Humphrey
Medicare, and can overlap with other programs furnishing medical assistance
Building, 200 Independence Avenue,
covered benefit categories. The purpose (State Medicaid programs) to specified
SW., Washington, DC 20201; or 7500
of this amendment is to align the groups of needy individuals in
Security Boulevard, Baltimore, MD
Medicaid definition more closely to the accordance with an approved State
21244–1850.
Medicare definition in order to improve Plan. ‘‘Medical Assistance’’ is defined at
(Because access to the interior of the section 1905(a) as payment for part or
the functionality of the applicable upper HHH Building is not readily available to
payment limits under 42 CFR 447.321 all of the cost of a list of specified care
persons without Federal Government and services, including at section
(which are based on a comparison to identification, commenters are
Medicare payments for the same 1905(a)(2)(A), ‘‘outpatient hospital
encouraged to leave their comments in services.’’
services), provide more transparency in the CMS drop slots located in the main Details concerning the scope of
determining available coverage in any lobby of the building. A stamp-in clock covered services, the groups of eligible
State, and generally clarify the scope of is available for persons wishing to retain individuals, the payment methodologies
services for which Federal financial a proof of filing by stamping in and for covered services, and all other
participation (FFP) is available under retaining an extra copy of the comments information necessary to assure that the
the outpatient hospital services benefit being filed.) plan can be a basis for Federal Medicaid
category. Comments mailed to the addresses funding must be set forth in the
DATES: To be assured consideration, indicated as appropriate for hand or approved Medicaid State Plan. For
comments must be received at one of courier delivery may be delayed and approval, the Medicaid State plan must
the addresses provided below, no later received after the comment period. comply with requirements set forth in
than 5 p.m. on October 29, 2007. For information on viewing public section 1902(a) of the Social Security
ADDRESSES: In commenting, please refer comments, see the beginning of the Act (the Act), as implemented and
to file code CMS–2213–P. Because of SUPPLEMENTARY INFORMATION section. interpreted in applicable regulations
staff and resource limitations, we cannot FOR FURTHER INFORMATION CONTACT: and guidance issued by the Centers for
accept comments by facsimile (FAX) Jeremy Silanskis, (410) 786–1592. Medicare & Medicaid Services (CMS).
transmission. SUPPLEMENTARY INFORMATION: The Secretary has delegated overall
You may submit comments in one of Submitting Comments: We welcome authority for the Federal Medicaid
four ways (no duplicates, please): comments from the public on all issues program, including State Plan approval,
1. Electronically. You may submit set forth in this rule to assist us in fully to CMS.
electronic comments on specific issues considering issues and developing Medicaid services are jointly funded
in this regulation to http:// policies. You can assist us by by the Federal and State governments in
www.cms.hhs.gov/eRulemaking. Click referencing the file code CMS–2213–P accordance with section 1903(a) of the
on the link ‘‘Submit electronic and the specific ‘‘issue identifier’’ that Act. Section 1903(a)(1) of the Act
comments on CMS regulations with an precedes the section on which you provides for payments to States of a
open comment period.’’ (Attachments choose to comment. percentage of expenditures under the
pwalker on PROD1PC71 with PROPOSALS
should be in Microsoft Word, Inspection of Public Comments: All approved State Plan for covered medical
WordPerfect, or Excel; however, we comments received before the close of assistance. The percentage of Federal
prefer Microsoft Word.) the comment period are available for financial participation (FFP) is the
2. By regular mail. You may mail viewing by the public, including any ‘‘Federal Medicaid assistance
written comments (one original and two personally identifiable or confidential percentage’’ (FMAP). For ordinary
copies) to the following address ONLY: business information that is included in medical assistance, the FMAP varies
VerDate Aug<31>2005 16:55 Sep 27, 2007 Jkt 211001 PO 00000 Frm 00054 Fmt 4702 Sfmt 4702 E:\FR\FM\28SEP1.SGM 28SEP1
Federal Register / Vol. 72, No. 188 / Friday, September 28, 2007 / Proposed Rules 55159
among the States based on a complex definition of ‘‘outpatient hospital service payments to what Medicare
formula set forth in section 1905(b) of services’’ those types of items and would pay for equivalent services. This
the Act. services that are not generally furnished proposed regulation would clarify the
Section 1902(a)(30)(A) of the Act by most hospitals in the State. scope of services that may be included
requires a State Medicaid plan to meet An ‘‘outpatient’’ is defined in in the State Plan definition of outpatient
certain requirements in setting payment § 440.2(a) as ‘‘a patient of an organized hospital services to clarify coverage and
amounts for covered care and services. medical facility, or distinct part of that payment requirements for outpatient
One of these requirements is that State facility who is expected by the facility services.
Plan methodologies must assure that to receive and who does receive
professional services for less than a 24- B. Medicaid Outpatient Hospital
payments are consistent with efficiency, Services Upper Payment Limit as
economy, and quality of care. This hour period regardless of the hour of
admission, whether or not a bed is used, Currently Defined
provision provides authority for specific
upper payment limits (UPLs) set forth in or whether or not the patient remains in Limitations on aggregate State
Federal regulations in 42 CFR part 447 the facility past midnight.’’ payments for outpatient hospital and
relating to certain Medicaid covered Because the regulatory definition of clinic services are established in
services. The UPL applicable to outpatient hospital services is so broad, regulation at § 447.321, ‘‘Outpatient
outpatient hospital services is at there is a high possibility of overlap hospital services and clinic services:
§ 447.321. between outpatient hospital services Application of upper limits of
The purpose of this proposed rule is and other covered benefits. This overlap payments.’’ This regulation requires that
to clarify the definition of the benefit for results in circumstances in which aggregate State Medicaid payments for
‘‘outpatient hospital services’’ under payment for services is made at the high outpatient hospital and/or clinic
section 1905(a)(2)(A) of the Act, and the levels customary for outpatient hospital services not exceed a reasonable
application of that definition under the services instead of the levels associated estimate of the amount the provider
applicable UPL. This rule proposes to with the other covered benefits. For would be paid under Medicare payment
describe the scope of services States example, there have been instances of principles, forming a UPL for these
may include in the outpatient hospital claims for payment of physician services. The aggregate Medicaid
UPL and define appropriate Medicare services as outpatient hospital services, payments and corresponding UPL for
references that States must use when which result in payment far in excess of outpatient hospital and/or clinic
calculating the UPL for Medicaid the rates available in the State for services are calculated for private
outpatient hospital services. The rule physician services. In addition, the Fifth facilities. FFP is not available for State
proposes to align the Medicaid Circuit Court of Appeals, in Louisiana expenditures that exceed the upper
definition of outpatient services with Department of Health and Hospitals v. payment limit.
CMS, 346 F. 3d 571 (2003), found that Before 1981, States were required to
the Medicare definition of outpatient
hospital-based rural health clinic pay rates for hospital and long-term care
services and clarify Medicaid’s
services were within the current services that were directly related to
corresponding UPLs for outpatient
definition of outpatient hospital services Medicare reasonable cost
hospital and clinic services.
and, although paid under a separate reimbursement. To comply with this
II. Background methodology, could be included in requirement, many States set Medicaid
calculating supplemental payments for hospital rates using reasonable costs as
A. Medicaid Outpatient Hospital
uncompensated care costs of outpatient determined by Medicare. The Congress
Services as Currently Defined
hospital services. The result of these removed the Medicare cost-based
Section 1905(a)(2)(A) of the Act lists overlapping definitions is payment for reimbursement requirements by
outpatient hospital services as a benefit identical services of a higher amount enacting legislation in 1980 and 1981,
that can be covered under a State under the outpatient hospital benefit collectively referred to as the Boren
Medicaid program, and it is among than otherwise available under the State Amendment.
those benefits that is mandatory for the Plan. Under section 962 of the Omnibus
most eligible Medicaid populations In addition, the current broad Reconciliation Act of 1980 (ORA 1980),
under sections 1902(a)(10)(A) and definition of outpatient hospital services Pub. L. 96–499, and Section 2173 of the
1902(a)(10)(C)(iv) of the Act. The statute is not clear on whether outpatient Omnibus Budget Reconciliation Act of
does not provide a definition for these hospital services can include types of 1981 (OBRA 1981), Pub. L. 97–85, the
services. The current implementing services that are outside the normal Congress provided States flexibility to
regulation at § 440.20 describes responsibility of outpatient hospitals, deviate from Medicare cost
‘‘outpatient hospital services’’ as such as practitioner, school-based, and determinations for hospital
preventive, diagnostic, therapeutic, rehabilitative services. In other words, reimbursement. In lieu of using
rehabilitative, or palliative services the current broad definition does not Medicare cost reimbursement rates,
that— clearly limit the scope of the outpatient States were allowed to set rates based on
(1) Are furnished to outpatients; hospital service benefit to those services the costs of efficiently and economically
(2) Are furnished by or under the over which the outpatient hospital has operated facilities.
direction of a physician or dentist; and oversight and control. Though the Boren Amendment
(3) Are furnished by an institution Also important, as we discuss further removed the specific requirement that
that—(i) Is licensed or formally in the following section below, the States adhere to Medicare cost
approved as a hospital by an officially broad definition of Medicaid outpatient principles, the legislative history
designated authority for State standard- hospital services is inconsistent with indicates the intent that the Secretary
setting; and (ii) Meets the requirements the applicable UPL, which is based on continue to require that payments made
for participation in Medicare as a the premise of some level of to hospitals and other inpatient facilities
hospital; comparability between the Medicare under the State Plan not exceed
(4) May be limited by a Medicaid and Medicaid definitions of outpatient Medicare payment principles.
agency in the following manner: A hospital and clinic services. The UPL The Senate Finance Committee stated
Medicaid agency may exclude from the regulation at § 447.321 limits outpatient that ‘‘the Secretary would be expected
55160 Federal Register / Vol. 72, No. 188 / Friday, September 28, 2007 / Proposed Rules
to continue to apply current regulations data or accurately reflect Medicare In addition, a number of States have
that require that payments made under payment and/or charge rates. To requested that we clarify in regulation
State plans do not exceed amounts that establish standardization across all the requirements for calculating
would be determined under Medicare States, the proposed rule would require Medicare comparable UPLs on
principles of reimbursement (S. Rep. States to base the ‘‘reasonable estimate’’ outpatient and clinic services. The
No. 471, 96th Cong. 1st Sess. (1979)).’’ upon service charge ratios reported in current regulation at § 447.321 limits
These limitations provide us with the the most recently filed Medicare outpatient hospital and rural health
authority to establish UPLs for hospital cost report, or a State cost clinic payments in privately operated
outpatient and inpatient hospital report for which the State can clearly facilities to ‘‘a reasonable estimate of the
services. demonstrate gathers data elements amount that would be paid for services
The Congress allowed for even more directly from the proposed standard furnished by the group of facilities
flexibility for State payments to hospital worksheets and lines on the most under Medicare payment principles.’’
and other providers under the Balanced recently filed Medicare cost report. We The current regulation does not
Budget Act of 1997 (BBA), Pub. L. 105– believe that these standards will provide address how this estimate should be
33. The BBA effectively replaced the an accurate resource for the ‘‘reasonable made, nor does it address the treatment
requirements of the Boren Amendment estimate’’ of what Medicare would pay of services that are not comparable to a
with a public process to determine the for equivalent Medicaid services. service furnished under Medicare. As
rates of payment under the State Plan. States provide an array of services in a
The public process requires that States C. General Intention of Proposed Rule variety of settings authorized under
publish proposed and final rates, the In our review of Medicaid State Plans, § 440.90, we are proposing to set forth
methodologies underlying the we have noted instances where the State effective UPLs to limit Medicaid
established rates, and the justification allows non-facility services and/or non- payments in all clinic settings.
for the rates. Providers, beneficiaries, traditional outpatient hospital services To address these concerns, as
and other concerned State residents to be paid under the outpatient hospital discussed below in more detail, in
have an opportunity to review and benefit. The definition of outpatient addition to revising the definition of
comment on the rates before they hospital services in current regulation ‘‘outpatient hospital services’’ for
become final. may allow States to include such non- consistency between Medicare and
Section 705 of the Medicare, Medicaid, we are proposing changes to
facility services (that is, physician and
Medicaid, and SCHIP Benefits address the method for calculating the
professional services) and/or non-
Improvement and Protection Act of UPL. The proposed UPL definition of
traditional outpatient hospital services
2000 (BIPA) required that we publish outpatient hospital services and clinics
(that is, school-based and rehabilitative
final regulations authorizing transition would establish payments as reported
services) within the State Plan
periods for States to comply with the on the most recently filed Medicare cost
definition of outpatient hospital
UPL regulations. In response to this report, or a State cost report for which
services. We do not believe that such a
statutory directive, we modified the the State can clearly demonstrate
broad definition of outpatient hospital
UPL regulations for inpatient and gathers data elements directly from the
services is consistent with congressional
outpatient hospital services through a proposed standard worksheets and lines
final regulation on January 12, 2001 (66 intent when enacting section
1905(a)(2)(A) of the Act. on the most recently filed Medicare cost
FR 3147). report, as the standard for the
In addition, on May 29, 2007 (72 FR Therefore, as discussed in more detail
below, we are proposing to change the reasonable estimate of what Medicare
29748), CMS published a final rule
definition and scope of outpatient would pay for equivalent Medicaid
(CMS–2258–FC) which will impact the
hospital services, and the corresponding services. The Medicare cost report
outpatient and inpatient hospital upper
UPL for outpatient hospital and clinic reflects cost-to-charge ratios for all
payment limits for services provided by
services, in an effort to clarify the outpatient services reimbursed
units of government. Congress has
current regulatory language and make it prospectively or reimbursed under a fee
enacted a one year moratorium that
consistent with the intent of the schedule by Medicare. Additionally,
delays CMS from implementing the
Congress in enacting section payment-to-charge ratios may be
policies established under that final
1905(a)(2)(A) of the Act. This revised derived from the Medicare cost report
rule. The provisions proposed in this
definition of outpatient hospital services for all facility payments reported to the
regulation address completely different
would align the outpatient services Medicare fiscal intermediary. Medicare
policy matters than those set forth in
covered by Medicaid with those covered regularly updates these payment
CMS–2258–FC.
The current outpatient hospital UPL by Medicare. As a result, the calculation systems to recover costs for providers.
regulation prohibits States from paying of the Medicaid UPLs would reflect a We believe that the Medicare costs or
more, in the aggregate, for Medicaid comparison of like services. The revised payments reported in the most recently
outpatient hospital services than the definition would also narrow the scope filed Medicare cost reports, or an
‘‘reasonable estimate’’ that Medicare of Medicaid outpatient services to those equivalent State cost report as described
would pay for equivalent services in traditionally and typically recognized as above, provide the most accurate
privately operated facilities. outpatient facility services. While we measure of what Medicare would pay
As with the scope of outpatient recognize that Medicaid covers certain for Medicaid-equivalent outpatient
hospital services that may be included services that are not covered by hospital services.
under the State Plan, the ‘‘reasonable Medicare, this regulation would not D. Medicaid Outpatient Hospital Service
estimate’’ of what Medicare would pay prohibit States from covering any Definition
for equivalent Medicaid services has Medicaid service allowable under

had varied interpretations. Some States section 1905(a) of the Act. Rather, the Scope of Outpatient Hospital Services—
have proposed to use their own hospital regulation would only define services Proposed Rule
cost reports to assess the ‘‘reasonable that may be covered, and reimbursed, The BBA required CMS (formerly the
estimate’’ of Medicare payment. These under the outpatient hospital services Health Care Financing Administration)
cost reports may not represent finalized benefit in the Medicaid State Plan. to implement an outpatient prospective
payment system (OPPS) for hospital We have considered other options and another Medical Assistance services
services reimbursed under the Medicare believe that the services recognized category under the State Plan. However,
program. Before the implementation of under Medicare regulations as States may continue to cover any service
OPPS, services were reimbursed on a outpatient hospital services represent an that is authorized under section 1905(a)
formula-driven basis. As part of the industry-accepted class of services. By of the Act within the State Plan under
development process for the OPPS, we including services reimbursed to a coverage benefit that is distinct from
published a proposed rule on September outpatient hospitals under Medicare outpatient hospital services.
8, 1998 (63 FR 47552) that, among other OPPS and outpatient services Finally, the proposed rule would
provisions, described the services that reimbursed through Medicare fee make a clear distinction between
would be paid for by Medicare on a schedules within the Medicaid outpatient services billed by a
prospective basis. The final rule was definition, we would provide greater recognized hospital facility in which
published in the Federal Register on consistency between the two federally services are furnished and those billed
April 7, 2000 (65 FR 18434). funded programs. In addition, we are by physicians and other professionals.
Regulations at 42 CFR part 419— proposing to adopt Medicare’s Under Medicaid, States generally pay a
Prospective Payment System for definition of a department of a provider fee schedule rate for physician and
hospital Outpatient Department meeting the requirements of provider- other professional services and a
Services—describes the categories of based status, into Medicaid regulation to separate rate to hospitals providing
hospitals and the services that are assure that all providers that are outpatient services. We are restricting
included and excluded from the reimbursed for outpatient hospital the Medicaid outpatient hospital
Medicare hospital OPPS. The proposed services have a legal relationship with a definition to facility services only to
rule references the services that main provider that is defined under prevent duplicative payments for
Medicare pays for under the OPPS, regulation. This is consistent with professional services that are
defined at § 419.2. In addition, the efficiency and economy as set forth in reimbursed under a separate payment
proposed rule references other section 1902(a)(30)(A) of the Act. methodology, under a different benefit
outpatient hospital facility services that The proposed rule also would exclude category under section 1905(a) of the
Medicare pays through an alternate States from covering under the Act.
methodology, such as a fee schedule, as Medicaid outpatient hospital benefit
E. Upper Payment Limits—Proposed
coverable Medicaid outpatient hospital services that are covered under another
Rule
medical assistance service category
services. While Medicare pays for both We are proposing to revise § 447.321
under the State Plan. Our review of
professional and facility services to clarify the appropriate Medicare
State Plan methodologies recently
through alternate payment references that States may use to derive
submitted to CMS finds that States may
methodologies, the proposed rule would the reasonable estimate of what would
include non-facility and/or non-
limit Medicaid coverage and payment be paid for Medicaid outpatient and
traditional hospital services (that is,
for outpatient hospital services to clinic services furnished by the group of
school-based services and rehabilitation
facility services only. For example, facilities under Medicare payment
services) within the definition of
States may cover and reimburse principles.
covered outpatient hospital services. For
prosthetic devices, prosthetics, supplies,
example, States have proposed Outpatient Hospital Upper Payment
and orthotic devices, durable medical including school-based, adult day
equipment, and clinical diagnostic Limit
health and rehabilitative services in the
laboratory services as outpatient outpatient hospital coverage section of The revisions to the outpatient UPL,
hospital services. the State Plan. In many cases, these as defined in the proposed rule, would
In addition, the proposed rule would services are already covered and paid limit the services that may be included
allow States to cover outpatient services for under another methodology under in the outpatient hospital UPL for
provided outside of the hospital only in the plan. In at least one instance, a State privately operated facilities to those
a department of a provider that meets reimburses non-traditional hospital with a Medicare equivalent as reported
the standards defined under Medicare services at the rate that community through the most recently filed
regulations in 42 CFR part 413, subpart providers receive, as defined under the Medicare cost report, for each outpatient
E—Payments to Providers. This section distinct payment methodology for those hospital Medicaid service provider, or a
of the regulations describes the services under the State Plan, rather State cost report for which the State can
relationship that facilities with than the higher outpatient rate that clearly demonstrate gathers data directly
provider-based status must have with a should be paid for a covered outpatient from the proposed standardized
hospital in order to receive Medicare service. Medicare cost report references. The
payments equivalent to those received Such inconsistencies have the proposed rule would allow States to
by hospitals. Specifically, our intention potential to enhance the UPL for include within the UPL calculation only
is to ensure that a department of a outpatient services by increasing the services that (1) may be covered under
hospital that meets the Medicare scope of outpatient hospital services the Medicaid outpatient coverage
requirements for provider-based status that might be included in the UPL definition; and (2) that show up on
and is reimbursed for Medicaid calculation. We are proposing to outpatient-specific Medicare hospital
outpatient hospital services is treated exclude non-facility and/or non- cost report worksheets. Thus, the scope
the same as the main provider. In traditional hospital services from the of outpatient hospital services as
contrast, a provider-based entity that is outpatient definition in this proposed defined by Medicaid would be the same
not a department of the main provider rule to assure efficiency and economy services as those included in the
would be treated as a separate, non- within the scope of outpatient hospital outpatient hospital UPL. Though we
hospital, entity for this purpose (by services as outpatient service rates are recognize that Medicaid covers more
definition, under 42 CFR 413.65(a)(2), generally higher than rates for other services than Medicare, we believe that
provider-based entities provide health Medicaid non-facility services. An an economic and efficient UPL should
care services of a different type from outpatient hospital service may not be include only services to which there
those of the main provider). covered and/or reimbursed under exists a Medicare equivalent.
Restricting the permissible scope of between the proposed Medicare cost However, only those costs, charges, and
Medicaid outpatient hospital services to report references that may be included payments included in the above
Medicare’s definition would allow us to in a UPL demonstration and the State’s worksheets and lines on the CMS 2552–
define standard references that States reporting system. 96 (the current standard Medicare
may use to calculate the UPL. All For a cost-to-charge UPL hospital cost report form at the issuance
Medicare-certified institutional demonstration, the link to Medicare is of this proposed rule) may be included
providers, including hospitals, are made through reference to ancillary and in the outpatient UPL demonstration for
required to submit annual cost reports outpatient hospital services cost center Medicaid services.
to a fiscal intermediary. These cost cost-to-charge ratios as found on Depending on which UPL
reports include information such as Worksheet C, Column 9, lines 37—68 or demonstration methodology the State
facility characteristics, utilization data, Worksheet D, Part V, Column 1.01, lines utilizes, the Medicare cost-to-charge
cost and charges by cost center (in total 37–68 of the CMS 2552–96. These ratio or the Medicare payment-to-charge
and for Medicare), Medicare settlement ratios, which must be determined for ratio for each provider, this ratio is
data, and financial Statement data. The each provider, include all cost multiplied by the Medicaid outpatient
Medicare hospital cost report captures regardless of payer for all ancillary and hospital charges associated with paid
all of the services that are included in outpatient cost centers and charges claims for each provider as reported to
the proposed revised definition of made to all payers including Medicaid. the Medicaid Management Information
Medicaid outpatient hospital services, CMS will not accept a UPL that is System (MMIS). We have considered
and it is the most accurate reflection of inflated by adjusting Medicare’s allowed other methods and believe that the use
what Medicare would pay for Medicaid cost as reported on these worksheets. of adjudicated claims excludes
equivalent services. The applicable outpatient hospital outpatient services paid for by Medicare
As previously stated, the Medicare service payment references for a for patients dually eligible for Medicare
hospital cost report includes line items payment-to-charge UPL demonstration and Medicaid and helps to assure that
that calculate a cost-to-charge ratio may be found on Worksheet E, Part B of charges represent covered Medicaid
(ratio of the provider’s actual costs vs. the CMS 2552–96. While Worksheet E
services. The Medicaid charge data must
the amount the provider charges). The represents what Medicare pays for
exclude clinical diagnostic laboratory
cost-to-charge ratio on the Medicare cost services within hospitals, States must
services, which are limited to a separate
report captures the highest possible make certain adjustments in order to
UPL under section 1903(i)(7) of the Act,
amount that Medicare would pay for an reflect equivalent Medicaid outpatient
and all professional services.
outpatient service. The proposed rule hospital provider services that may be
included in the UPL demonstration. For The resulting product is an estimate
would allow States to use either the
example, all lines that report payments of the actual cost or payment associated
cost-to-charge ratio, as reported on the
associated with professional services with Medicaid outpatient hospital
most recently filed Medicare hospital
cost report, or a payment-to-charge ratio must be removed from the numerator. facility services. The total estimate of
(the ratio of the amount that Medicare Additionally, States must ensure that Medicaid cost or payment is compared
actually pays for outpatient hospital bad debts are not over-reported by to actual Medicaid paid claims to
services through the fiscal intermediary including deductibles and coinsurance determine whether outpatient hospital
vs. the amount of the hospital’s charges and reimbursable bad debt in Medicare payments exceed the UPL.
for such services) to develop the payments. If deductible and coinsurance States may choose to trend the UPL
foundation of a reasonable estimate of are added on to the Medicare payment, data to the current rate year. Under the
what Medicare would pay for the State should remove reimbursable proposed rule, we are proposing that all
Medicaid’s outpatient hospital services. bad debts included in the Medicare data must be trended uniformly in
For either UPL methodology, the dates payment. The resulting payments successive years and use the Medicare
of service as reported to the Medicare reported from Worksheet E should Market Basket Index as the trending
hospital cost report for Medicare cost or represent allowable Medicare payments factor. The State must demonstrate to
payment must match the dates of for purposes of the UPL demonstration. CMS the effect of the trended data for
service for Medicare charges as reported The source of Medicare charge data, each successive year from the base year
to the cost report. reflected in the ratio’s denominator, to the current rate year. In addition, the
We currently require that States must come from Worksheet D, Part V State must demonstrate its methodology
demonstrate compliance with the UPL and Part VI of the Medicare cost report. for any proposed volume trending.
for outpatient hospital services using We note that a payment-to-charge Clinic Upper Payment Limit
one of the methods described above ratio UPL methodology may not be
when the State submits a Medicaid State inclusive of the full scope of outpatient For privately operated clinics that are
plan amendment for outpatient services. hospital services because payments and not providing outpatient hospital
The UPL demonstration must include a charges on the Medicare cost report do services under § 440.20 (those that
formula that clearly accounts for either not include payments and charges would not be paid by Medicare in that
the ratio of Medicare cost to Medicare reimbursed on a fee-for-service basis setting under OPPS or under an
charges multiplied by Medicaid through the Medicare Part B Carrier. For alternative outpatient hospital service
outpatient charges, or the ratio of example, durable medical equipment payment methodology) but instead are
Medicare payments to Medicare charges payments and charges are not included covered under the authority of § 440.90,
multiplied by Medicaid outpatient on Worksheets E and D. We believe the UPL is the reasonable estimate of
charges. The State must cite all States should have the flexibility to what would be paid for clinic services
references from the most recently filed determine the UPL through a furnished by the group of facilities
Medicare hospital cost report that are comparison of Medicare payment. under Medicare payment principles. In
included in the Medicare cost-to-charge We also note that the specific line calculating the reasonable estimate of
ratio or Medicare payment-to-charge references from the Medicare hospital what Medicare would pay for Medicaid
ratio portion of the UPL formula. States cost report are subject to change as the clinic services, we must consider
utilizing a State-specific cost report Medicare cost report and reporting Medicare’s reimbursement methods for
must demonstrate a clear crosswalk requirements are modified by CMS. these services.
Medicare does not typically pay for Medicare would pay for equivalent specify the scope of facility services
clinic services on the basis of cost as services. This demonstration must show covered under the Medicaid program.
reported by the facility. Rather, through a comparison by CPT code of the We propose to substitute in § 440.20(a)
the resource-based relative value amount paid by Medicare for equivalent the term ‘‘by an institution’’ for ‘‘in a
(RBRVS) system, used to determine the Medicaid services. The calculation may facility.’’ We believe this term better
fee-for-service rate, Medicare recognizes be conducted in the aggregate for clinic describes outpatient hospital settings
specific clinic costs eligible for type or by specific facilities (ESRD, where Medicaid services may be
reimbursement in a clinic setting. For ASC, etc.). Under the second option, a covered.
clinic services, a reasonable estimate of State may pay more than Medicare for We proposed to modify the
what Medicare would pay for equivalent some services or facilities, and less than requirements for a participating facility
Medicaid services is the non-facility Medicare for others, as long as the to include those described in § 413.65.
professional rate for those services. aggregate Medicaid payment is equal to Though the current regulation requires
We propose two options for States to or less than the amount that Medicare that participating facilities meet the
demonstrate compliance with the would pay in the aggregate. requirements for participation in
proposed UPL rule for clinic services We include a special provision for Medicare as a hospital, we included the
provided in privately operated facilities, dental services provided in clinics for criteria for provider-based status as a
which requires payment that does not purposes of UPL calculations because department of an outpatient hospital
exceed a reasonable estimate of what we recognize that Medicare does not facility, as described in § 413.65, to
Medicare would pay for equivalent generally cover dental services. Since recognize all settings where Medicaid
Medicaid services. A State may choose there is no Medicare payment for dental outpatient hospital services may be
to limit clinic reimbursement to a services in clinic settings, we allow the provided. In accordance with § 413.65,
percentage, not to exceed 100 percent, State to incorporate the Medicaid State a department of a provider must furnish
of what Medicare pays under the non- Plan fee schedule rate as the reasonable health care services of a same type as
facility professional rate for equivalent estimate of what Medicare would pay those of the main provider under the
Medicaid services. for dental services. As a result, dental name, ownership, and administrative
This first option would require States clinic providers are not excluded from and financial control of the main
to include language in the State Plan the State’s aggregate clinic UPL provider.
that specifies the percentage of the calculation. We proposed to add to the current
Medicare facility fee schedule that definition a comprehensive list of the
would be paid for services in clinic III. Provisions of the Proposed Rule scope of services that may be included
settings. If the State pays a percentage A. Overview under the Medicaid outpatient hospital
of what Medicare pays under a facility- services benefit. The modified
specific fee schedule or the non-facility Under our proposal, the outpatient definition allows States to cover
professional rate and wishes to make hospital services covered under the outpatient services paid for under the
supplemental payments up to 100 Medicaid program would continue to be Medicare OPPS and all other outpatient
percent of what Medicare pays, the State set forth in regulation under § 440.20. In hospital facility services that Medicare
must demonstrate per CPT code what addition, the UPL requirements for pays under a fee schedule. These
Medicare would pay for equivalent outpatient hospital services would services are limited only to hospital
Medicaid services. The calculation may continue to be defined under § 447.321. facility services and exclude all
be conducted in the aggregate for clinic However, both current definitions professional services. Professional
type or by specific facilities (end-stage would undergo significant revision to services may continue to be billed under
renal disease (ESRD), ambulatory clarify the scope of outpatient hospital a separate fee schedule rate. The
surgical center (ASC), etc.). If a State services recognized by the Medicaid Medicare provision for OPPS covered
opts to pay 100 percent of what program and to standardize Medicare services may be found at § 419.2(b).
Medicare pays under a facility-specific cost and payment principles as the basis Finally, we excluded all services,
fee schedule or the non-facility to accurately determine the reasonable other than outpatient hospital services,
professional rate for equivalent estimate of what Medicare would pay that are covered and paid under medical
Medicaid services, the State would not for equivalent Medicaid services in a assistance under section 1905(a) of the
have the option of making supplemental privately operated outpatient facility. Act. For example, services paid for
payments. However, the State would not under a fee schedule (for example,
B. General Provisions
be required to submit documentation for Federally Qualified Health Centers) or
a clinic UPL demonstration. The revised definitions would begin services that are typically covered under
As a second option, a State may with existing § 440.20 that describes a different section of the State Plan (for
develop a fee schedule for Medicaid outpatient hospital services and rural example, rehabilitative services).
clinic services, which is not based on health clinic services. The definition of
the Medicare professional fee schedule. rural health clinic services would be 2. Outpatient Hospital and Clinic
Clinical diagnostic laboratory services revised to apply to all clinic settings. In Services: Application of Upper Payment
may not be included in this addition, the existing § 447.321 that Limits (Proposed § 447.321)
demonstration because section describes UPLs for Medicaid services We propose to modify the existing
1903(i)(7) of the Act requires that these provided in outpatient hospitals and definition of UPLs for outpatient
services not exceed the Medicare fee clinics would be revised. hospital and clinic services to provide
schedule. For all other clinic services, States with clear and accurate guidance
the State may pay through an encounter 1. Outpatient Hospital Services and on the ‘‘reasonable estimate of the
rate or a Medicaid specific fee schedule Rural Health Clinic Services (Proposed amount that would be paid for the
that is not based on Medicare payment § 440.20) services furnished by the group of
principles. Under this option, a UPL Existing § 440.20 sets forth definitions facilities under Medicare payment
demonstration is required to for outpatient hospital services and principles in subchapter B of this
demonstrate that Medicaid clinic rural health clinic services. We are chapter.’’ The proposed rule would
reimbursement would not exceed what proposing to change § 440.20(a) to allow States to include within the UPL
calculation only services that may be IV. Collection of Information Furthermore, with respect to the one
covered under the Medicaid outpatient Requirements State that CMS believes currently
coverage definition and that appear on This document does not impose includes non-hospital services under
the Medicare hospital cost report. information collection and the outpatient hospital benefit category,
All hospitals throughout the nation recordkeeping requirements. this rule would not impact the rates of
Consequently, it need not be reviewed payment for these services under the
report cost and charge data through
by the Office of Management and State plan. While the current regulation
Medicare hospital cost reports. Since
Budget under the authority of the might permit payment at a higher
these reports reflect Medicare data for
Paperwork Reduction Act of 1995 (44 outpatient hospital payment rate, that
all outpatient hospital payments made State currently pays for such services at
by Medicare, we require States to U.S.C. 35).
the same rate that is paid for such
reference the Medicare hospital cost V. Response to Comments services outside of the outpatient
reports, or a State cost report for which hospital benefit category.
Because of the large number of public
the State can clearly demonstrate The rule would have an
comments we normally receive on
gathers data directly from the proposed undetermined effect on the aggregate
Federal Register documents, we are not
standardized Medicare cost report able to acknowledge or respond to them upper payment limit for private
references, when calculating the individually. We will consider all outpatient hospital services within the
Medicaid outpatient UPL for privately comments we receive by the date and State. As part of the upper payment
operated facilities. From the Medicare time specified in the DATES section of limit calculation the State includes the
cost reports, States may use payment-to- this preamble, and, when we proceed non-hospital services. This effectively
charge ratios or cost-to-charge ratios and with a subsequent document, we will raises the limit that Medicaid may pay
apply the ratios to Medicaid outpatient respond to the comments in the to hospitals. The rule would prevent the
hospital charges from the MMIS to preamble to that document. State from defining these services as
determine the outpatient UPL. We base outpatient hospital services and
the UPL calculation on Medicare VI. Regulatory Impact Statement including them in the UPL calculation.
hospital cost reports because we believe We have examined the impact of this States calculate the UPL, the
they provide the most accurate rule as required by Executive Order reasonable estimate of Medicare
reflection of what Medicare would pay 12866 (September 1993, Regulatory payment for equivalent Medicaid
for equivalent Medicaid outpatient Planning and Review), the Regulatory services, in the aggregate for all
hospital services. Flexibility Act (RFA) (September 19, Medicaid services provided by all
1980, Pub. L. 96–354), section 1102(b) of private providers. This total for all
Medicare pays on a different basis for providers is reduced by actual Medicaid
the Social Security Act, the Unfunded
clinic services. These rates incorporate payments in a rate year to determine a
Mandates Reform Act of 1995 (Pub. L.
some of the facility costs and are higher 104–04), and Executive Order 13132. pool of funding that may be distributed
than traditional fee schedule payments Due to a lack of available data, we as supplemental payments to outpatient
for professional services. States may cannot determine the fiscal impact of hospital providers. Supplemental
continue to calculate the reasonable this proposed rule. The proposed rule payments for outpatient hospital
estimate of what Medicare would pay defines the scope of services that may be services up to the UPL may be
for equivalent Medicaid clinic services reimbursed under the outpatient distributed to any hospital within the
using these rates. However, States must hospital benefit category covered in the private category. States are not required
demonstrate a clinic UPL by either Medicaid State plan. In addition, the to equitably distribute supplemental
specifying a percentage, not to exceed rule clarifies the appropriate methods payments among providers or exhaust
100 percent, of the Medicare rate that is States may use to calculate the Medicaid the available supplemental payment
paid by Medicaid. Or a State can upper payment limit for those services pool.
demonstrate that, in the aggregate, paid to private service providers. CMS Considering the UPL is calculated in
Medicaid-specific payment rates that are does not intend to eliminate or limit the the aggregate for all outpatient hospital
not directly related to Medicare rates are scope of Medicaid services that are service for all private providers, it is
less than what Medicare would pay defined under Title XIX of the Act. impossible to isolate the exact fiscal
based on a comparison of what We have reviewed the effects of the impact of removing non-hospital
Medicaid pays by CMS Common proposed rule and have determined that services from the UPL calculation. Even
Procedure Coding System (CPT) code to it would clarify current vague regulatory if the payments for these services could
the amount paid by Medicare for language but would not significantly be isolated in a particular year, the
equivalent Medicaid services. alter current practices in most States. difference between the reasonable
This proposed rule is a proactive estimate of Medicare payment for a
In addition, Medicare generally does attempt to clarify and clearly define particular service and Medicaid
not reimburse for dental services. With regulatory language and prevent over payments for these services could vary
this in mind, we added a provision calculation of the outpatient hospital drastically from year-to-year as payment
allowing States to use the Medicaid fee upper payment limit. Therefore, we do amounts for services change within each
schedule rate for dental services to not believe the proposed rule would program. Additionally, the UPL
calculate the UPL for such services. This have significant economic effects. calculation considers the volume of a
provision would allow dental services Over the past 4 years, CMS has particular service rendered to Medicaid
to be included in the aggregate clinic approved outpatient hospital beneficiaries, which also varies between
UPL calculation, and, thus, allow dental reimbursement methodologies rate years. Therefore, we cannot
providers to be eligible for supplemental submitted by 32 States. As part of our determine the exact fiscal impact of
payments. Since Medicare generally review process, we have determined removing non-hospital services from the
does not pay for dental services, we that only one of the 32 States currently private UPL calculation within this one
believe this is the best alternative for defines non-hospital services as part of State.
inclusion of dental services in the clinic the outpatient hospital Medicaid State We believe the fiscal impact would be
UPL calculation. plan service benefit. minimal because most States
historically have not made a Metropolitan Statistical Area and has 2. Section 440.20 is amended by
supplemental payments to private fewer than 100 beds. We are not revising the section heading and
providers up to the upper payment preparing an analysis for section 1102(b) paragraph (a) to read as follows:
limit. In fact, the State that we suspect of the Act because we have determined
could be affected by this rule has that this rule would not have a § 440.20 Outpatient clinic and hospital
facility services and rural health clinic
recently reported paying approximately significant impact on the operations of services.
$68 million under the outpatient a substantial number of small rural
hospital UPL to private facilities. We do (a) Outpatient hospital services means
hospitals.
not believe the services that would be preventive, diagnostic, therapeutic,
Section 202 of the Unfunded
removed by this proposed rule would rehabilitative, or palliative services
Mandates Reform Act of 1995 also
cause such a significant impact on the that—
requires that agencies assess anticipated (1) Are furnished to outpatients;
UPL calculation. We invite public costs and benefits before issuing any (2) Are furnished by or under the
comment on the potential impact of the rule that may result in expenditures in direction of a physician or dentist;
rule. any 1 year by State, local, or tribal (3) Are furnished in a facility that—
Executive Order 12866 directs governments, in the aggregate, or by the (i) Is licensed or formally approved as
agencies to assess all costs and benefits private sector, of $110 million. The a hospital by an officially designated
of available regulatory alternatives and, proposed rule would not prevent States authority for State standard-setting; and
if regulation is necessary, to select from receiving FFP for Medicaid (ii) Meets the requirements for
regulatory approaches that maximize covered services. Therefore, the net participation in Medicare as a hospital;
the net benefits (including potential change in appropriate FFP that can be (4) Are limited to the scope of facility
economic, environmental, public health received by States for Medicaid services that—
and safety effects, distributive impacts expenditures is economically (i) Would be included, in the setting
and equity). A regulatory impact insignificant. The proposed rule would delivered, in the Medicare outpatient
analysis (RIA) must be prepared for not result in anticipated costs or prospective payment system (OPPS) as
major rules with economically benefits to the private sector. defined under § 419.2(b) of this chapter
significant effects ($100 million or more Executive Order 13132 establishes or are paid by Medicare as an outpatient
in any 1 year). The rule proposes to certain requirements that an agency hospital service under an alternate
clarify the definition of outpatient must meet when it promulgates a payment methodology;
hospital services and the UPL for these proposed rule (and subsequent final (ii) Are furnished by an outpatient
services to provide additional guidance rule) that imposes substantial direct hospital facility, including an entity that
to States that interpret these definitions. requirement costs on State and local meets the standards for provider-based
Under the revised regulations, States governments, preempts State law, or status as a department of an outpatient
would not be prevented from covering otherwise has Federalism implications. hospital set forth in § 413.65 of this
Medicaid services under the State Plan. Because the proposed rule seeks to curb chapter;
Rather, a few States may need to move inappropriate Federal revenue (iii) Are not covered under the scope
services that are not outpatient in of another Medical Assistance service
maximization, the proposed rule would
nature, as defined by Medicare, to the category under the State Plan; and
not impose any additional costs to
appropriate coverage and payment (5) May be limited by a Medicaid
States. Again, States may receive FFP
methodology in the State Plan. With this agency in the following manner: A
for all appropriate Medicaid
in mind, the rule would not reach the Medicaid agency may exclude from the
expenditures for covered services.
economic threshold and thus is not definition of ‘‘outpatient hospital
In accordance with the provisions of
considered a major rule. services’’ those types of items and
The RFA requires agencies to analyze Executive Order 12866, this regulation
was reviewed by the Office of services that are not generally furnished
options for regulatory relief of small by most hospitals in the State.
entities. For purposes of the RFA, small Management and Budget.
* * * * *
entities include small businesses, List of Subjects
nonprofit organizations, and PART 447—PAYMENTS FOR
government agencies. Most hospitals 42 CFR Part 440
SERVICES
and most other providers and suppliers Grant programs—health, Medicaid.
are small entities, either by nonprofit 3. The authority citation for part 447
status or by having revenues of $6 42 CFR Part 447 continues to read as follows:
million to $29 million in any 1 year. Accounting, Administrative practice Authority: Sec. 1102 of the Social Security
Individuals and States are not included and procedure, Drugs, Grant programs— Act (42 U.S.C. 1302).
in the definition of a small entity. We health, Health facilities, Health 4. Section 447.321 is amended by
are not preparing an analysis for this professions, Medicaid, Reporting and revising paragraphs (a) and (b) to read
RFA because we have determined that recordkeeping requirements, Rural as follows:
this rule would not have a significant areas.
economic impact on a substantial For the reasons set forth in the § 447.321 Outpatient hospital and clinic
number of small entities. preamble, the Centers for Medicare & services: Application of upper payment
In addition, section 1102(b) of the Act Medicaid Services would amend 42 CFR limits.
requires us to prepare a regulatory chapter IV as set forth below: (a) Scope. This section applies to rates
impact analysis if a rule may have a set by the agency to pay for outpatient
significant impact on the operations of PART 440—SERVICES GENERAL services furnished by hospitals and
a substantial number of small rural PROVISIONS clinics within one of the following
hospitals. This analysis must conform to categories:
the provisions of section 603 of the 1. The authority citation for part 440 (1) State government operated
RFA. For purposes of section 1102(b) of continues to read as follows: facilities (that is, all facilities that are
the Act, we define a small rural hospital Authority: Sec. 1102 of the Social Security operated by the State) as defined at
as a hospital that is located outside of Act (42 U.S.C. 1302). § 433.50(a) of this chapter.
(2) Non-State government operated Management Information System DEPARTMENT OF COMMERCE

facilities (that is, all governmentally (MMIS).
operated facilities that are not operated National Oceanic and Atmospheric
(ii) Private Clinic Services. For
by the State) as defined at § 433.50(a) of Administration
privately operated clinics that are not
this chapter. providing outpatient hospital services
(3) Privately operated facilities that is, 50 CFR Part 648
under § 440.20 (those that would not be
all facilities that are not operated by a [Docket No. 070827484–7485–01]
paid by Medicare in that setting under
unit of government as defined at
OPPS or under an alternative outpatient RIN 0648–AV99
§ 433.50(a) of this chapter.
(b) General rules. (1) For privately hospital service payment methodology),
the reasonable estimate of what Fisheries of the Northeastern United
operated facilities, upper Payment Limit
Medicare would pay for equivalent States; Recreational Management
(UPL) refers to a reasonable estimate of
Medicaid services may be determined Measures for the Summer Flounder
the amount that would be paid for the
through: Fishery; Fishing Year 2008
services furnished by the group of
facilities under Medicare payment (A) A State Plan reimbursement AGENCY: National Marine Fisheries
principles in subchapter B of this methodology for covered services that is Service (NMFS), National Oceanic and
chapter. a defined percentage, not to exceed 100 Atmospheric Administration (NOAA),
(i) Private Outpatient Hospital percent, of what Medicare pays under Commerce.
Services. Services included in the the non-facility fee schedule; or ACTION: Proposed rule; request for
calculation of the private outpatient comments.
(B) For reimbursement methodologies
hospital UPL must meet all of the
based upon a Medicaid-specific fee SUMMARY: NMFS proposes coastwide
criteria for outpatient hospital services
defined in § 440.20 of this chapter. A schedule or encounter rate, a summer flounder recreational
reasonable estimate of the amount that comparison by CPT code of the amount management measures to
would be paid for outpatient hospital paid by Medicare for equivalent administratively complete the
services under Medicare payment Medicaid services. The calculation may rulemaking process initiated in March
principles is determined through— be conducted in the aggregate for clinic 2007. This action is necessary to
(A) Calculation of estimated Medicare type or by specific facilities (ESRD, propose appropriate coastwide
payment for Medicaid equivalent ASC, etc). Clinical diagnostic laboratory management measures to be in place on
outpatient services reimbursed under services or any other services for which January 1, 2008, following the
current Medicare payment systems, the Act defines a separate upper limit expiration of the current state-by-state
including— for Medicaid reimbursement must be conservation equivalency management
(1) Outpatient hospital services paid excluded from the clinic UPL. measures on December 31, 2007. The
under the Medicare outpatient (C) For dentists providing services in intent of these measures is to prevent
prospective payment system as defined clinics, the clinic UPL calculation may overfishing of the summer flounder
under § 419.2 of this chapter; and include payment amounts at the amount resource during the interim between the
(2) Outpatient hospital services or aforementioned expiration of the 2007
that Medicaid would pay outside of the
clinic services paid under a Medicare recreational measures and the
facility.
outpatient hospital or clinic fee implementation of measures for 2008.
schedule or alternate payment * * * * * DATES: Comments must be received by
methodology. (Catalog of Federal Domestic Assistance 5 p.m. local time, on October 15, 2007.
(B) The estimated Medicare payment Program No. 93.778, Medical Assistance
ADDRESSES: You may submit comments
may be based on the Medicare cost Program)
by any of the following methods:
report, or an accepted State cost report Dated: March 15, 2007. • E-mail: 0648–AV99@noaa.gov.
that reports the same data from the Leslie V. Norwalk, Include in the subject line the following
Medicare cost report references in Acting Administrator, Centers for Medicare identifier: ‘‘Comments on 2008 Summer
paragraphs (b)(1)(i)(B)(1) through & Medicaid Services. Flounder Interim Recreational
(b)(1)(i)(B)(2) of this section, as the Measures.’’
Approved: June 20, 2007.
source to determine either: • Federal e-rulemaking portal: http://
(1) The ratio of costs-to-charges for all Michael O. Leavitt,
www.regulations.gov
services included in the outpatient Secretary. • Mail: Patricia A. Kurkul, Regional
hospital UPL calculation. The Medicare Editorial Note: This document was Administrator, NMFS, Northeast
cost-to-charges ratios for outpatient received at the Office of the Federal Register Regional Office, One Blackburn Drive,
hospital services are found on on September 24, 2007. Gloucester, MA 01930. Mark the outside
Worksheet C and Worksheet D, Part V of the envelope: ‘‘Comments on 2008
of the Medicare cost report; or [FR Doc. E7–19154 Filed 9–27–07; 8:45 am] Summer Flounder Interim Recreational
(2) The ratio of payments-to-charges BILLING CODE 4120–01–P Measures.’’
for all services included in the • Fax: (978) 281–9135.
outpatient hospital UPL calculation. Copies of the Supplemental
Medicare outpatient payments are found Environmental Assessment, as well as
on Worksheet E, Part B and outpatient the original Environmental Assessment,
charges are found on Worksheet D, Part Regulatory Impact Review, and Initial
V of the Medicare cost report. Regulatory Flexibility Analysis (EA/

(3) The charge ratios in paragraphs RIR/IRFA) completed for the 2007
(b)(1)(i)(B)(1) through (b)(1)(i)(B)(2) of recreational management measures are
this section for Medicare equivalent available from Daniel T. Furlong,
services are multiplied by Medicaid Executive Director, Mid-Atlantic
charges as reported to the Medicaid Fishery Management Council, Room

Proposed Rule: Medicaid: Outpatient Clinic and Hospital Facility Services Definitions and Payment Limits

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Proposed Rule: Medicaid: Outpatient Clinic and Hospital Facility Services Definitions and Payment Limits

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55158 Federal Register / Vol. 72, No.

188 / Friday, September 28, 2007 / Proposed Rules

for equivalent Medicaid services has Medicaid service allowable under

(2) Non-State government operated Management Information System DEPARTMENT OF COMMERCE

V of the Medicare cost report. Regulatory Flexibility Analysis (EA/

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