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50214 Federal Register / Vol. 72, No.

169 / Friday, August 31, 2007 / Rules and Regulations

Commander, Coast Guard Sector ACTION: Notice of enforcement of side of all parade vessels. No person or
Baltimore. regulation. vessel shall anchor, block, loiter in, or
(2) Official Patrol means any vessel impede the transit of ship parade
assigned or approved by Commander, SUMMARY: The Coast Guard will enforce participants or official patrol vessels.
Coast Guard Sector Baltimore with a the special local regulations in the When hailed by U.S. Coast Guard patrol
commissioned, warrant, or petty officer navigable waters of San Francisco Bay personnel by siren, radio, flashing light,
on board and displaying a Coast Guard for the annual U.S. Navy and City of San or other means, a person or vessel shall
ensign. Francisco sponsored Fleet Week Parade come to an immediate stop. Persons or
(3) Participant includes all vessels of Navy Ships and Blue Angels Flight vessels shall comply with all directions
participating in the 2007 Cambridge Demonstration to be held on October 4, given.
Offshore Challenge under the auspices 2007, through October 7, 2007. This The Coast Guard may be assisted by
of the Marine Event Permit issued to the action is necessary to ensure the safety other Federal, State, or local law
event sponsor and approved by of event participants and spectators. enforcement agencies in enforcing this
Commander, Coast Guard Sector During the enforcement period, no regulation.
Baltimore. persons or vessels may enter the This notice is issued under authority
regulated area without permission of the of 33 CFR 100.1105 and 5 U.S.C 552(a).
(b) Regulated area includes all waters
Captain of the Port (COTP) or his In addition to this notice in the Federal
of the Choptank River, from shoreline to
designated representative. Register, the Coast Guard will provide
shoreline, bounded to the west by the
Route 50 Bridge and bounded to the east DATES: The regulations in 33 CFR the maritime community with extensive
by a line drawn along longitude 076° W, 100.1105(b)(1), regulated area ‘‘Alpha’’ advance notification of this enforcement
between Goose Point, MD and for Navy Parade of Ships, will be period via the Local Notice to Mariners,
Oystershell Point, MD. All coordinates enforced from 11:30 a.m. to 1 p.m. on and Broadcast Notice to Mariners.
reference Datum: NAD 1983. October 6, 2007. The regulations in 33 Dated: 20 August 2007.
(c) Special local regulations: (1) CFR 100.1105(b)(2), regulated area
W.J. Uberti,
Except for event participants and ‘‘Bravo’’ for the U.S. Navy Blue Angels
Activities, will be enforced from 11:30 Captain, U.S. Coast Guard, Captain of the
persons or vessels authorized by the Port, San Francisco.
Coast Guard Patrol Commander, no a.m. to 5 p.m. on October 4, 2007, and
12:30 p.m. to 5 p.m. on October 5, 2007, [FR Doc. E7–17340 Filed 8–30–07; 8:45 am]
person or vessel may enter or remain in BILLING CODE 4910–15–P
the regulated area. through October 7, 2007. If the U.S.
(2) The operator of any vessel in the Navy Blue Angels Activities are delayed
regulated area must: by inclement weather, the regulation
will also be enforced on October 8, DEPARTMENT OF HEALTH AND
(i) Stop the vessel immediately when HUMAN SERVICES
directed to do so by any Official Patrol. 2007, from 12:30 p.m. to 5 p.m.
(ii) Proceed as directed by any Official FOR FURTHER INFORMATION CONTACT:
Centers for Medicare & Medicaid
Patrol. Lieutenant Eric Ramos, Waterways
Services
(iii) When authorized to transit the Safety Branch, U.S. Coast Guard Sector
regulated area, all vessels shall proceed San Francisco, at (415) 556–2950
42 CFR Part 418
at the minimum speed necessary to extension 143, or the Sector San
Francisco Command Center, at (415) [CMS–1539–F]
maintain a safe course that minimizes
wake near the race course. 399–3547. RIN 0938–AO72
(d) Enforcement period. This section SUPPLEMENTARY INFORMATION: The Coast
will be enforced from 10:30 a.m. on Guard will enforce the special local Medicare Program; Hospice Wage
September 22, 2007 to 5:30 p.m. on regulation for the annual San Francisco Index for Fiscal Year 2008
September 23, 2007. Bay Navy Fleet Week Parade of Ships
and Blue Angels Demonstration in 33 AGENCY: Centers for Medicare &
Dated: August 23, 2007. Medicaid Services (CMS), HHS.
CFR 100.1105; the Navy Parade of Ships
Fred M. Rosa, Jr., ACTION: Final rule.
will be enforced from 11:30 a.m. to 1
Rear Admiral, U.S. Coast Guard Commander, p.m. on October 6, 2007; and the U.S.
Fifth Coast Guard District. SUMMARY: This final rule sets forth the
Navy Blue Angels Activities will be
[FR Doc. E7–17337 Filed 8–30–07; 8:45 am] hospice wage index for fiscal year 2008.
enforced from 11:30 a.m. to 5 p.m. on
This final rule also revises the
BILLING CODE 4910–15–P October 4, 2007, and 12:30 p.m. to 5
methodology for updating the wage
p.m. on October 5, 2007, through
index for rural areas without hospital
October 7, 2007. If the U.S. Navy Blue
DEPARTMENT OF HOMELAND wage data and provides clarification of
Angels Activities are delayed by
SECURITY selected existing Medicare hospice
inclement weather, the regulation will
regulations and policies.
Coast Guard also be enforced on October 8, 2007,
from 12:30 p.m. to 5 p.m. These EFFECTIVE DATES: These regulations are
regulations can also be found in the effective on October 1, 2007.
33 CFR Part 100
October 1, 1993, issue of the Federal FOR FURTHER INFORMATION CONTACT:
Register 58 FR 51242. Under the Terri Deutsch, (410) 786–9462.
[Docket No. COTP San Francisco Bay 07– provisions of 33 CFR 100.1105 a vessel SUPPLEMENTARY INFORMATION:
038]
may not enter the regulated area, unless
it receives permission from the COTP. I. Background
Special Local Regulations for Marine
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Events; San Francisco Bay Navy Fleet Additionally, no person or vessel may A. General
Week Parade of Ships and Blue Angels enter or remain within 500 yards ahead
of the lead Navy parade vessel, within 1. Hospice Care
Demonstration, San Francisco Bay, CA
200 yards astern of the last parade Hospice care is an approach to
AGENCY: Coast Guard, DHS. vessel, and within 200 yards on either treatment that recognizes that the

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Federal Register / Vol. 72, No. 169 / Friday, August 31, 2007 / Rules and Regulations 50215

impending death of an individual functioning under a process established 2. Raw Wage Index Values
warrants a change in the focus from by the Negotiated Rulemaking Act of Raw wage index values (that is,
curative care to palliative care for relief 1990, was comprised of: National inpatient hospital pre-floor and pre-
of pain and for symptom management. hospice associations; rural, urban, large reclassified wage index values) as
The goal of hospice care is to help and small hospices; multi-site hospices; described in the August 8, 1997 hospice
terminally ill individuals continue life consumer groups; and a government wage index final rule (62 FR 42860), are
with minimal disruption to normal representative. On April 13, 1995, the subject to either a budget neutrality
activities while remaining primarily in Hospice Wage Index Negotiated adjustment or application of the wage
the home environment. A hospice uses Rulemaking Committee signed an index floor. Raw wage index values of
an interdisciplinary approach to deliver agreement for the methodology to be 0.8 or greater are adjusted by the budget
medical, social, psychological, used for updating the hospice wage neutrality adjustment factor. Budget
emotional, and spiritual services index. neutrality means that, in a given year,
through use of a broad spectrum of
In the August 8, 1997 Federal estimated aggregate payments for
professional and other caregivers, with
Register (62 FR 42860), we published a Medicare hospice services using the
the goal of making the individual as
final rule implementing a new updated wage index values will equal
physically and emotionally comfortable
methodology for calculating the hospice estimated payments that would have
as possible. Counseling services and
wage index based on the been made for these services if the 1983
inpatient respite services are available
to the family of the hospice patient. recommendations of the negotiated wage index values had remained in
Hospice programs consider both the rulemaking committee. The committee effect. To achieve this budget neutrality,
patient and the family as a unit of care. statement was included in the appendix the raw wage index is multiplied by a
Section 1861(dd) of the Social of that final rule (62 FR 42883). budget neutrality adjustment factor. The
Security Act (the Act) provides for budget neutrality adjustment factor is
The hospice wage index is updated
coverage of hospice care for terminally calculated by comparing what we would
annually. Our most recent annual
ill Medicare beneficiaries who elect to have paid using current rates and the
update notice, published in the
receive care from a participating 1983 wage index to what would be paid
September 1, 2006 Federal Register (71
hospice. Section 1814(i) of the Act using current rates and the new wage
FR 52080), set forth updates to the
provides payment for Medicare index. The budget neutrality adjustment
hospice wage index for FY 2007. On
participating hospices. factor is computed and applied
October 3, 2006, we published a
annually. For the FY 2008 hospice wage
2. Medicare Payment for Hospice Care correction notice in the Federal Register
index in the final rule, FY 2007 hospice
(71 FR 58415) and we published a
Our regulations at 42 CFR part 418 payment rates were used in the budget
subsequent correction notice on January
establish eligibility requirements, neutrality adjustment factor calculation.
26, 2007 (72 FR 3856), to correct
payment standards and procedures, Raw wage index values below 0.8 are
technical errors that appeared in the
define covered services, and delineate adjusted by the greater of: (1) The
September 1, 2006 notice.
the conditions a hospice must meet to hospice budget neutrality adjustment
be approved for participation in the 1. Changes to Core-Based Statistical factor; or (2) the hospice wage index
Medicare program. Part 418 subpart G Areas floor (a 15 percent increase) subject to
provides for payment in one of four a maximum wage index value of 0.8. For
prospectively-determined rate categories The annual update to the hospice example, if County A has a pre-floor,
(routine home care, continuous home wage index is published in the Federal pre-reclassified hospital wage index
care, inpatient respite care, and general Register and is based on the most (raw wage index value) of 0.4000, we
inpatient care) to hospices, based on current available hospital wage data, as would perform the following
each day a qualified Medicare well as any changes by the Office of calculations using the budget neutrality
beneficiary is under a hospice election. Management and Budget (OMB) to the factor (which for this example is
definitions of MSAs. The August 4, 1.060988) and the hospice wage index
B. Hospice Wage Index 2005 final rule (70 FR 45130) adopted floor to determine County A’s hospice
Our regulations at § 418.306(c) require the changes discussed in the OMB wage index:
each hospice’s labor market to be Bulletin No. 03–04 (June 6, 2003), Raw wage index value below 0.8
established using the most current which announced revised definitions multiplied by the budget neutrality
hospital wage data available, including for Micropolitan Statistical Areas and adjustment factor:
any changes to the Metropolitan the creation of MSAs and Combined (0.4000 × 1.060988 = 0.4244).
Statistical Areas (MSAs) definitions, Statistical Areas. In adopting the OMB Raw wage index value below 0.8
which have been superseded by Core- Core-Based Statistical Area (CBSA) multiplied by the hospice wage index
Based Statistical Areas (CBSAs). geographic designations, we provided floor:
The hospice wage index is used to for a 1-year transition with a blended (0.4000 × 1.15 = 0.4600).
adjust payment rates for hospice wage index for all providers for FY Based on these calculations, County
agencies under the Medicare program to 2006. For FY 2006, the hospice wage A’s hospice wage index would be
reflect local differences in area wage index for each provider consisted of a 0.4600.
levels. The original hospice wage index blend of 50 percent of the FY 2006
was based on the 1981 Bureau of Labor MSA-based wage index and 50 percent 3. Hospice Payment Rates
Statistics hospital data and had not been of the FY 2006 CBSA-based wage index. Section 4441(a) of the Balanced
updated since 1983. In 1994, because of As discussed in the August 4, 2005 final Budget Act of 1997 (BBA) amended
disparity in wages from one rule and in the September 1, 2006 section 1814(i)(1)(C)(ii) of the Act to
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geographical location to another, a notice, for FY 2007 and subsequent establish updates to hospice rates for
committee was formulated to negotiate years we will use the full CBSA-based FYs 1998 through 2002. Hospice rates
a wage index methodology that could be wage index values, as presented in were to be updated by a factor equal to
accepted by the industry and the Tables A and B of this final rule for FY the market basket index, minus 1
government. This committee, 2008. percentage point. Payment rates for FY

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50216 Federal Register / Vol. 72, No. 169 / Friday, August 31, 2007 / Rules and Regulations

2008 will be updated according to A. Annual Update to the Hospice Wage see the September 4, 1996 proposed rule
section 1814(i)(1)(C)(ii)(VII) of the Act, Index (61 FR 46579) and the August 8, 1997
which states that the update to the We did not propose any modifications final rule (62 FR 42860).
payment rates for subsequent FYs will to the hospice wage index methodology As indicated in the proposed rule, we
be the market basket percentage for the as described in the 1997 final rule (62 did not propose any changes in the
fiscal year. Accordingly, the FY 2008 methodology used in calculating the
FR 42860). In accordance with our
update to the payment rates for each of hospice wage index values and we did
regulations and the agreement signed
the four levels of care (routine home not solicit comments. However, we
with other members of the Hospice
care, continuous home care, general received eight items of correspondence
Wage Index Negotiated Rulemaking
inpatient care and inpatient respite care) pertaining to future changes, the
Committee, we use the most current
will be the full market basket percentage methodology for computing the wage
hospital data available to adjust for area
increase for FY 2008. The rate update index for Puerto Rico, the publication of
wage differences. As noted above,
for FY 2008 is implemented through a the market basket update through
payment rates for each of the four levels
separate administrative instruction and administrative issuance, and the
of care (routine home care, continuous
is not part of this rule. Historically, the inadequacy of rural payment rates.
home care, general inpatient care and Comment: We received two comments
rate update has been published through inpatient respite care) are adjusted stating that any future changes proposed
a separate administrative instruction annually based upon the hospital for hospice payments should follow the
issued annually in July to provide market basket for that year and are negotiated rulemaking process rather
adequate time to implement necessary promulgated through administrative than notice and comment. The same
system changes and allow for provider instructions issued annually in July in commenters also expressed support for
notification. Providers determine their order to allow for sufficient time for a more reasonable and consistent
payment rates by applying the wage system changes and provider approach to constructing wage index
index in this rule to the labor portion of notification. adjustments for hospitals and post acute
the published hospice rates. We use the previous fiscal year’s providers. The commenters also
hospital wage index data to calculate indicated that any changes in the wage
4. Proxy for the Hospital Market Basket the hospice wage index values. For the index approach should require an
As discussed above, the hospice FY 2008 proposed and final hospice extended transition period to prevent
payment rates for fiscal years after 2002 wage index values, we used the FY 2007 disruptive swings.
are adjusted each year based upon the hospital pre-floor and pre-reclassified Response: We thank the commenters
full hospital market basket percentage hospital wage data. This means that the for their suggestions and we will keep
increase. In the FY 2007 update notice hospital wage data used for the hospice them under advisement as we analyze
(72 FR 52082) published on September wage index is not adjusted to take into the need for future refinements.
1, 2006, we indicated that beginning in account any geographic reclassification Comment: One commenter suggested
April 2006, with the publication of of hospitals including those in that the hospice payment rates be
March 2006 data, the Bureau of Labor accordance with sections 1886(d)(B) or published with the hospice wage index
Statistic’s (BLS’s) Employment Cost 1886(d)(10) of the Act. We also do not regulations as is done in other
Index (ECI) began using a different take into account reclassifications in prospective payment systems.
classification system, the North accordance with section 508 of the Response: As we discussed in the
American Industrial Classification MMA or the out-migration adjustment proposed rule, historically the payment
System (NAICS), instead of the Standard for hospitals (section 505 of the MMA). rate updates have been promulgated
All hospice wage index values for FY through a separate administrative
Industrial Classification System (SIC),
2008 are adjusted by either the FY 2008 instruction or administrative issuance in
which no longer exists. The ECIs had
budget neutrality adjustment factor or July of each year to provide adequate
been used as the data source for wages
the wage index floor adjustment. For time to implement necessary system
and salaries and other price proxies in
wage index values 0.8 or greater, the changes. As the hospice wage index
the hospital market basket. In the FY
value is multiplied by the budget regulation is scheduled for publication
2007 update notice we noted that no
neutrality adjustment factor. Wage at the end of August, inclusion of the
changes would be made to the usage of
index values that are below 0.8, receive hospice payment updates in this
the NAICS-based ECI; however, input
the greater of a 15 percent increase or regulation would not allow sufficient
was solicited on this issue. We received the budget neutrality adjustment factor time for system changes to be made to
no comments. As a result, in the subject to a maximum wage index value accommodate the October 1
proposed rule we did not propose any of 0.8. In other words, the floor implementation date of the payment
changes. adjustment is the greater of the raw updates.
II. Provisions of the Proposed wage index value multiplied by the Comment: Several commenters noted
Regulation and Analysis of and proposed budget neutrality adjustment that there are challenges in furnishing
Responses to Public Comments factor or the raw wage index value for hospice care in rural areas, citing
that area is multiplied by 15 percent underdevelopment, long distances for
On May 1, 2007, we published a subject to a maximum value of 0.8. staff to travel, staff recruitment
proposed rule in the Federal Register Budget neutrality means that, in a given challenges and the need for rural
(72 FR 24116) that set forth the year, estimated aggregate payments for hospices to be competitive in the wages
proposed hospice wage index for FY Medicare hospice services using the and benefits that they provide. One
2008. The following is a summary of updated wage index will equal commenter stated that rural areas
each of the proposed provisions estimated payments that would have adjacent to urban areas are at a greater
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followed by our response to public been made for the same services if the disadvantage as they are competing for
comments. We received 19 timely items wage index adopted for hospices in staff in urban areas with higher wages.
of correspondence, one from a 1983 had remained in effect. For a Another commenter stated that rural
physician, 6 from hospice providers, detailed discussion of the methodology home based salary adjustment based on
and 12 from associations. used to compute the hospice wage index the hospital wage index is inadequate

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and should be reimbursed at a higher notice of the committee deliberations adopted the policy that for urban labor
rate. The commenter also stated that and they had an opportunity to apply to markets without an urban hospital from
there are extra costs for mileage be on the committee, and were which a hospital wage index data could
expenses for rural staff and suggested encouraged to attend and make a be derived, all of the CBSAs within the
that an ‘‘expansive geography index’’ be statement to the committee. A detailed State would be used to calculate a
applied to the hospice wage index description of the methodology is statewide urban average wage index
formula for rural counties. Another contained in both the September 4, 1996 data to use as a reasonable proxy for
commenter indicated willingness to proposed rule (61 FR 46579) and the these areas. In the August 2005 final
discuss this issue further to investigate August 8, 1997 final rule (62 FR 42860). rule and in the September 2006 update
ways to encourage hospice care in rural The commenter is incorrect in stating notice, we applied the average wage
areas. that the payment rates for Puerto Rico index data from all urban areas lacking
Response: We thank the commenters will decrease 2.6 percent in FY 2008. hospital wage data in that state.
for their comments and suggestions. We We indicated in the proposed rule that Currently, the only CBSA that is
recognize that there are challenges in the impact analysis demonstrates the affected by this policy is CBSA 25980,
providing health care in urban as well impact of the FY 2008 wage index Hinesville-Fort Stewart, Georgia. We
as in rural areas. Recruitment values and is not a projection of the proposed to continue this approach for
challenges, competitiveness in wages anticipated expenditures of hospice urban areas where there are no hospitals
and benefits and commuting difficulties payments for FY 2008. The impact and, thus, no hospital wage index data
are factors that are facing all health care analysis compares hospice payments on which to base the calculations for the
providers. We believe that the hospital using the FY 2007 hospice wage index FY 2008 and subsequent hospice wage
wage data reflects these factors and as to the estimated payments using the FY indexes.
a result, the hospice wage index values 2008 wage index. For urban Puerto Rico, In the proposed rule we noted that
are also reflective of these challenges. In the proposed rule indicated that, using under the CBSA labor market areas,
addition, the application of the hospice the FY 2007 payment rates and the FY there are no rural hospitals in rural
floor for raw values below 0.8 provides 2008 wage index values, payments are locations in Massachusetts and Puerto
a higher wage index value to many rural anticipated to decrease 2.6 percent, Rico. In the August 2005 final rule (70
areas. However, we will consider these which represents only the affects of the FR 45135) and in the September 2006
comments and suggestions as we wage index and does not reflect the update notice (71 FR 52081), we applied
analyze the need for future refinements payment increase for FY 2008. As noted the FY 2005 pre-floor, pre-reclassified
to the hospice payment methodology. above, the FY 2008 hospice payment hospital wage data in both FY 2006 and
Comment: One hospice provider from rates will reflect the market basket FY 2007 for rural Massachusetts and
Puerto Rico provided us with a study update. rural Puerto Rico. In the proposed rule,
that it had undertaken. It requested that We do not understand the study’s we considered alternatives in our
this report be used by CMS to make the comparison between Puerto Rico and methodology to update the wage index
‘‘right’’ decision about the correct wage Albuquerque, New Mexico or New for rural areas without hospital wage
index for Puerto Rico. This study England regions and as a result cannot index data consistent with other
concluded that 34 hospices in Puerto respond. However, it is important to prospective payment systems. We noted
Rico will see a decrease in their hospice note that wage index values fluctuate that we believe that the best imputed
payments by 2.6 percent in FY 2008. from year to year for counties as well as proxy for rural areas, would: (1) Use
Several of the conclusions presented in regions and we do not believe that pre-floor, pre-reclassified hospital data;
this study compare a hospice in comparisons to other regions provide (2) use the most local data available to
Arecebo, Puerto Rico to hospitals in any substantive information. It is also impute a rural wage index; (3) be easy
New England and Albuquerque, New important to note that the FY 2007 to evaluate and; (4) be easy to update
Mexico, list the economic challenges in hospital pre-floor, pre-reclassified from year to year. Although our current
Puerto Rico, and suggested the payment hospital wage data reflects data from the methodology meets the first three
rate that it believes should be used for FY 2003 hospital cost reports and the criteria, it could not be easily updated
Puerto Rico. data provided in the Puerto Rico study from year to year because the FY 2005
Response: We thank the commenter reflect data from later years. We will pre-floor, pre-reclassified hospital wage
for sending its study to us. However, as share the information provided in this data would continue to be used.
the study concludes that payment rates study with the organizational Therefore, in cases where there is a rural
and wage index values should be component within CMS that develops area without rural hospital wage data,
determined utilizing the same the inpatient hospital wage data, as it we proposed using the average pre-floor,
methodology used for the hospital wage appears that the study relates to the pre-reclassified wage index data from all
index values, we believe the study is development of the hospital wage index. contiguous CBSAs to represent a
based on an erroneous and incorrect reasonable proxy for the rural area. This
understanding of the content of the B. Rural Areas Without Hospital Wage
approach meets all of the stated criteria
hospice wage index proposed rule as Data
(72 FR 24118).
well as the methodology that had been When adopting OMB’s new labor We noted in the proposed rule that we
developed and agreed upon through the market designations, we identified some interpret the term ‘‘contiguous’’ to mean
negotiated rulemaking committee. geographic areas where there were no ‘‘sharing a border’’. We cited the
As noted above, the methodology for hospitals, and thus, no hospital wage example of Massachusetts, where the
the hospice wage index was developed, index data on which to base the entire rural area consists of Dukes and
and an agreement on the methodology calculation of the hospice wage index Nantucket counties. We determined that
was signed, by members of the Hospice (70 FR 45135, August 4, 2005). For FY the borders of Dukes and Nantucket
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Wage Index Negotiated Rulemaking 2006 and FY 2007, we adopted a policy counties are contiguous with Barnstable
Committee. We note that Puerto Rico to use the FY 2005 pre-floor, pre- and Bristol counties. Therefore, the pre-
was represented by the hospice reclassified hospital wage index value floor, pre-reclassified wage index values
associations’ participants on the for rural areas where no rural hospital for the counties of Barnstable (CBSA
committee. Hospices in Puerto Rico had wage data were available. We also 12700, Barnstable Town, MA) and

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50218 Federal Register / Vol. 72, No. 169 / Friday, August 31, 2007 / Rules and Regulations

Bristol (CBSA 39300, Providence-New employed for urban areas without a geographic location for services
Bedford-Fall River, RI-MA) would be hospital from which to derive hospital provided there, but is silent as to what
averaged resulting in an imputed pre- wage data. wage index value should be used for
floor, pre-reclassified rural wage index Response: We thank the commenters hospice services provided in an
for rural Massachusetts. for their support. We continue to believe inpatient setting. We believe that the
While we believe that this policy that our proposed methodology results application of the wage index values
could be readily applied to other rural in the most appropriate imputed proxy should reflect the location of the
areas that lack hospital wage data for rural areas in meeting the criteria we services provided rather than the
(possibly due to hospitals converting to identified as follows: (1) Use pre-floor, location of an office. We believe such
a different provider type, such as a pre-re-classified hospital data, (2) use application results in a reimbursement
critical access hospital (CAH), that do the most local data available to impute rate that is a more accurate reflection of
not submit the appropriate wage data), a rural wage index, (3) be easy to the wages paid by the hospice for the
should a similar situation arise in the evaluate; and (4) be easy to update from staff used to furnish care. We proposed
future, we may re-examine this policy. year to year. We will consider the that effective January 1, 2008, all
In the proposed rule we noted that we suggestion for evaluating the policy if payment rates (routine home care,
do not believe that this policy would be needed in other situations. continuous home care, inpatient respite
appropriate for Puerto Rico. There are and general inpatient care) be adjusted
sufficient economic differences between C. Nomenclature Changes
by the geographic wage index value of
hospitals in the United States and those We proposed to clarify that all the area where hospice services are
in Puerto Rico, including the payment hospice rules and notices are considered provided. This would require hospice
of hospitals in Puerto Rico using to incorporate the CBSA changes providers to include the geographic
blended Federal/Commonwealth- published in the most recent OMB location of the inpatient facility for
specific rates that we believe necessitate bulletin that applies to the hospital general inpatient and inpatient respite
a separate and distinct policy for Puerto wage index data used to determine the levels of care on claims submitted for
Rico. Consequently, any alternative current hospice wage index (72 FR payment. We proposed to modify
methodology for imputing a wage index 24119). We received no comments on § 418.302 accordingly.
for rural Puerto Rico would need to take this proposal. In the proposed rule we also indicated
into account those differences. Our D. Payment for Hospice Care Based on that as hospice claims do not contain
policy of imputing a rural wage index the Location Where Care Is Furnished information identifying the location of
based on the wage index(es) of CBSAs the facility where general inpatient and
contiguous to the rural area in question Under the Medicare hospice program, respite care are provided, we are unable
does not recognize the unique hospice providers receive payment for to predict the savings or costs associated
circumstances of Puerto Rico. We also four levels of care based upon the with the changes associated with this
noted that while we have not yet individual’s needs. The payment rates proposed provision. However, we
identified an alternative methodology are adjusted to reflect the variation in believe most hospice providers provide
for imputing a wage index for rural geographic locations. Section 4442 of hospice care in the same geographic
Puerto Rico, we will continue to the BBA amended section 1814(i)(2) of location as their offices. Therefore, we
evaluate the feasibility of using existing the Act, effective for services furnished believe the impact of implementing this
hospital wage data and, possibly, wage on or after October 1, 1997, required the proposal will be negligible.
data from other sources. Accordingly, application of the local wage index Comment: We received eight items of
we propose to continue using the most value of the geographic location at correspondence, of which six supported
recent pre-floor, pre-reclassified wage which the service is furnished for the provision to base payment rates on
index previously available for Puerto hospice care provided in the home. the geographic wage index value of the
Rico, which is 0.4047 (72 FR 24118–19). Prior to this provision, local wage index area where inpatient hospice services
Comment: We received four items of values were applied based on the are provided.
correspondence in response to our geographic location of the hospice Response: We thank the commenters
proposal for rural areas without hospital provider, regardless of where the for their support of this provision.
wage data. Two commenters supported hospice care was furnished. In the Comment: One commenter suggested
the proposal. Two commenters stated proposed rule, we noted that we believe that we suspend the implementation of
that the proposed methodology, while that for the majority of hospice this provision until we have additional
not ideal, comes closest to what the providers the office and the site for the data from providers on the impact.
commenters believe is an equitable provision of home and inpatient care Response: In the proposed rule we
solution in resolving a perceived flaw in occur in the same geographic area. indicated that, as hospice claims do not
using hospital data to adjust payment to However, with the substantial growth of contain information identifying the
non-hospital providers. The hospice providers in multiple states and location of the facility where inpatient
commenters also assumed that a better with multiple sites within a State, care is provided, we are unable to
alternative would emerge over the next hospice providers have been able to predict the savings or costs associated
few years in the course of revising the inappropriately maximize with changes in this provision. Effective
hospital wage index. One commenter reimbursement by locating their offices January 1, 2007, hospice providers were
agreed with the methodology but asked in high-wage areas and delivering required to indicate the type of location
that we do not use this formula for other services in a lower-wage area. We also where care was provided (for example,
situations without review and believe that hospice providers are able nursing home, assisted living facility,
reexamination of the policy. The same to inappropriately maximize hospital unit), but not the geographic
commenter commended us for reimbursement by locating their location (which would be used to adjust
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demonstrating flexibility and good inpatient services either directly or payments). As we have indicated, we
judgment in creating a different system under contractual arrangements in believe that for most providers, the
for Massachusetts and Puerto Rico. lower wage areas than their offices. location of the inpatient facility and the
We note that we received no Section 4442 of the BBA applies the hospice provider are the same. We do
comments on the methodology wage index value of a home’s not believe that postponing the

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implementation of this provision would contracts with all hospitals in an area. (MMA) of 2003 (Pub. L. 108–173).
enable us to collect any additional Some commenters indicated patients Section 408 of the MMA, Recognition of
information. have choices about where to receive Attending Nurse Practitioners as
Comment: One commenter indicated care and would complain if they were Attending Physicians to Serve Hospice
that this change will significantly forced to receive inpatient care out of Patients, amended sections
increase the complexity of filing hospice their area. 1861(dd)(3)(B) and 1814(a)(7) of the Act
claims and will increase hospice costs Response: While we appreciate the to add nurse practitioners (NPs) to the
due to the need to include the CBSA for commenters objection to the statement definition of an attending physician for
the geographic location, as well as the that we made about hospice providers beneficiaries who have elected the
code of where the patient is receiving being able to inappropriately maximize hospice benefit. Section 408 of the
hospice services. reimbursement by locating their offices MMA was implemented through an
Response: We appreciate the concern in a higher age area, we concur with the administrative issuance (Change
regarding the complexity of filing claims commenter that nothing prohibits a Request (CR) 3226, Transmittals 22 and
and the perceived increased costs to hospice from locating its inpatient 304, September 24, 2004). In the August
hospices. We are in the process of services, either directly or under 4, 2005 FY 2006 final rule (70 FR
developing operational instructions that contractual arrangements, in a higher 45139), we revised § 418.3 to reflect that
we believe will help simplify the billing wage area, as well. In fact, we have an attending physician can be a nurse
process. Hospice providers currently are received anecdotal information that practitioner who meets the training,
required to identify the geographic leads us to believe that there are hospice education and experience requirements
location of their patients for the routine offices that have been intentionally as the Secretary may prescribe.
home care and continuous home care located in higher wage areas than those We indicated in the proposed rule
levels of care, and the location of the of their patients in order to maximize that we believe that the definition of
hospice office for general inpatient care their reimbursement. We supported our attending physician, which includes
and inpatient respite care. We are now proposal by noting the potential for nurse practitioners under the Medicare
also requiring hospice providers to maximizing reimbursement based on hospice benefit, should be consistent
identify the geographic location where the location of the main office, which with the provisions of section 410.75
inpatient care is provided. We believe was the same rationale used by the that provide for Medicare Part B
that for the majority of hospice congressional committee when the BBA coverage of nurse practitioner services.
providers, the location of the facility for 1997 provision requiring the application Therefore, to ensure consistency, we
the provision of both the general of the local wage index of the proposed to revise the definition of
inpatient and inpatient respite levels of geographic location where the service is ‘‘attending physician’’ at § 418.3(1)(ii) to
care will be the same as the location of furnished for hospice care provided in cross reference the training, education,
the hospice office. For those majority of the home was enacted. We believe that and experience requirements as
cases, this change will require the the same rationale applies to the described in § 410.75(b).
hospice provider to indicate the same inpatient facility locations as well. Our Comment: We received six items of
CBSA location of the office on the intent for this provision is to have all correspondence regarding our proposal
claims as the location of the facility levels of payment adjusted by the wage to conform the educational
where inpatient levels of care are index that applies to the site where the requirements for nurse practitioners
provided. As a result, we believe that service is being provided. serving as the attending physician to the
the impact on hospices for Comment: One commenter requirements described in § 410.75. All
implementing this provision should be interpreted the proposed provision as commenters supported this provision.
negligible as most hospices currently reducing reimbursement to a lesser One commenter requested that the
provide this information on the claims. amount based on distance from the hospice physician definition be revised
Comment: Several commenters main office. The same commenter stated to include nurse practitioners, although
concurred with the provision but that staff were paid at the home office the commenter recognized that any such
objected to the statement that hospice area rate and suggested that payment be revision could not allow nurse
providers are able to inappropriately based on the costs at the main office. practitioners to certify the terminal
maximize reimbursement by having Response: We believe that the illness of a patient. Another commenter
their offices located in a higher wage suggestion that using distance from the suggested that the definition of
area. One commenter indicated that the main office determines payment rates is attending physician be clarified by
statement was misleading and a misinterpretation of the intent of this using the term ‘‘attending nurse
unnecessarily harsh. Another provision as well as the statement practitioner’’ instead of referring to
commenter suggested removing the concerning maximizing reimbursement nurse practitioners as ‘‘attending
statement. One commenter interpreted based upon the location of the hospice physicians.’’ One commenter requested
this statement as being demeaning and main office. As we have discussed in that the nurse practitioner qualifications
inflammatory. The same commenter the proposed rule, we were not provisions at § 410.75 be amended to
stated that most hospices would not proposing to modify the methodology reflect current and evolving educational
benefit from manipulating the location used for computing the hospice wage requirements for advanced practice
of an inpatient facility. Several index values. The intent of the proposal registered nurses. The commenter
commenters indicated that there is is to employ the same methodology for requested that the term ‘‘master’s
nothing prohibiting a hospice from applying the wage index value for degree’’ in § 410.75(b)(ii)(4) be replaced
having their inpatient facilities in a geographic variations regardless of with ‘‘graduate degree’’ to reflect nurse
higher wage area, though the where hospice care is provided. practitioners with doctoral degrees.
commenters stated it was doubtful that Response: We thank the commenters
E. Educational Requirements for Nurse
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a hospice would do this or arrange for their support of this provision. As


contracts in order to manipulate Practitioners noted in the proposed rule and earlier
reimbursement. Some commenters On December 8, 2003, the Congress in this rule, the implementation of
stated that urban areas have higher rates enacted the Medicare Prescription Drug, section 408 of the MMA, which
and that hospices generally have Improvement, and Modernization Act amended sections 1861(dd)(3)(B) and

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50220 Federal Register / Vol. 72, No. 169 / Friday, August 31, 2007 / Rules and Regulations

1814(a)(7) of the Act to add nurse required cannot be provided in any made. In the proposed rule, we
practitioners to the definition of an other settings. Inpatient respite care is indicated that inpatient respite care
attending physician, was discussed in available for family members, who serve could be used in situations where there
the August 4, 2005 final rule (70 FR as the primary caregivers, to obtain rest is caregiver breakdown. However, in
45130). Section 418.304(e)(2)(iv) for a period of no more than 5 days at situations where there is a lack of a
specifies that nurse practitioners may a time. Hospice providers should submit caregiver at the time of the election, the
bill and receive payment for services claims for inpatient respite care in inpatient respite level of care does not
provided as the attending physician, situations where there is an unexpected apply. Inpatient respite care is
only if the services are not related to the loss of the individual’s support unavailable when there is no caregiver
certification of the terminal illness in structure that results in an inability to to whom relief must be provided. The
§ 418.22(c)(1)(ii). Section 418.22(c) maintain the individual in his or her established policy that the level of care
specifies that certification of the home, but the individual does not required to provide pain and symptom
terminal illness is obtained from ‘‘the require an inpatient level of care. management determines payment and
medical director of the hospice or the Medicare policy states that skilled not the location of where the individual
physician member of the hospice nursing care may be required by a resides or receives hospice services, also
interdisciplinary group’’. Therefore, we patient whose home support has broken applies in situations where there is not
believe it would be inconsistent with down, if this breakdown makes it no an appropriate caregiver. We recognize
statute and regulations to allow nurse longer feasible to furnish needed care in the difficulties surrounding the
practitioners to bill and receive payment the home setting. If the hospice and the provision of hospice care to an
for certifying an individual’s terminal caregiver, working together, are no individual who is terminally ill and
illness. As the role of the nurse longer able to provide the necessary who does not have caregivers at home.
practitioner is explicit in statute, nurse skilled nursing care in the individual’s This may be particularly challenging in
practitioners are not included as a home, and if the individual’s pain and rural areas. Section 409 of the MMA
hospice physician and may not serve in symptom management can no longer be (Pub. L. 108–173) established the Rural
that role. provided at home, then the individual Hospice Demonstration which hopes to
We concur with the commenter that may be eligible for a short term general test alternative mechanisms for
the definition of attending physician inpatient level of care. To receive providing hospice services for
should use the term ‘‘attending nurse payment for general inpatient care beneficiaries who lack an appropriate
practitioner’’. However, as the statute at under the Medicare hospice benefit, caregiver and who reside in rural areas.
sections 1861(dd)(3)(B) and § 1814(a)(7) beneficiaries must require an intensity In this demonstration, a hospice
explicitly uses the term ‘‘attending of care directed towards pain control organization may provide all services in
physician’’ for a nurse practitioner and symptom management that cannot an inpatient facility which serves as a
serving as the attending physician, we be managed in any other setting. It is the beneficiary’s home; however, payment
do not accept this recommendation. level of care provided to meet the for inpatient care must meet the usual
We did not propose to replace the individual’s needs and not the location level of care requirements. In this
term master’s degree in 410.75(b)(ii)(4) of where the individual resides, or demonstration, inpatient respite care is
with ‘‘graduate degree’’. Therefore, we caregiver breakdown, that determine not possible since there is no caregiver.
will not make the change in this final payment rates for Medicare services. For specific information on this
rule. However, we will provide your Caregiver breakdown is the loss of the demonstration, refer to: http://
suggestion to the area within CMS individual’s support structure and www.cms.hhs.gov/
responsible for advanced practitioner should not be confused with the DemoProjectsEvalRpts/MD/
educational requirements. coverage requirements for medically itemdetail.aspitemID=CMS1183983.
reasonable and necessary care for pain Comment: We received nine items of
F. Caregiver Breakdown and General
and symptom management that cannot correspondence regarding the
Inpatient Care
be managed in any other setting. clarification of the general inpatient
In the proposed rule, we discussed a Therefore, caregiver breakdown should level of care and its use when there is
concern that some hospice providers are not be billed as general inpatient care a breakdown in caregiver support.
requesting payment for the general unless the coverage requirements for Several commenters supported the
inpatient level of care for circumstances this level of care are met. As discussed clarification, however the majority did
that do not qualify under the statute at above, for the general inpatient level of not, as we describe below. Several
section 1861(dd)(1)(G) of the Act, our care, the intensity of interventions commenters stated that they shared our
regulations at § 418.202(e), or Medicare required for pain and symptom concern that the general inpatient level
hospice policy in Chapter 9 of the management is such that it cannot be of care not become a source of abuse
Medicare Benefit Policy Manual. We provided in any setting other than an and the need to focus on hospice
provided clarification of existing statute, inpatient setting. providers who use the general inpatient
regulation and policy in the proposed As explained in the proposed rule, level of care inappropriately. Two
rule and did not propose any changes this is a clarification of current commenters stated that they supported
(72 FR 24120). Medicare policy and as such does not steps to eliminate any potential
As discussed in the proposed rule, the create new limitations on access to collusion or inducements in this area.
Medicare hospice benefit places hospice care. As noted in the proposed Response: We appreciate the
emphasis on the provision of items and rule, we intend to monitor the usage of comments and thank those who were in
services to enable an individual to general inpatient care. Additionally, the support of this provision. The intent of
remain at home in the company of circumstances addressed by this policy, this clarification was to ensure that the
family and friends. Section and the clarification discussed above, general inpatient level of care be
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1861(dd)(1)(G) of the Act provides for should not be construed as similar to utilized appropriately and in
short-term inpatient hospice care to be situations where an individual does not accordance with statute, regulations and
available when an individual’s pain and have family, friends or other individuals policy. Our focus was not on fraudulent
symptoms must be closely monitored or who are able to take on the role of a or abusive use of the general inpatient
the intensity of interventions that are caregiver when a hospice election is level of care, but rather on ensuring that

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the general inpatient level of care is which recognizes caregiver breakdown with each level of care. In cases where
properly utilized in accordance with as an indication for the general inpatient a particular level of care is provided
established criteria. level of care. The Medicare Benefit because of circumstances that are
Comment: Some commenters Policy Manual, Chapter 9—Coverage of inappropriate to warrant that particular
believed that the clarification was Hospice Services, section 40.1.5—Short- level of care (here, general inpatient
overly prescriptive while others Term Inpatient Care, indicates that provided because of caregiver
believed that this was not a clarification skilled nursing care may be needed by breakdown), it is inappropriate for the
of existing policy, but was a new a patient whose home support has hospice to bill and receive payment for
interpretation. Some commenters broken down. In the proposed rule we the general inpatient level of care.
expressed that the intent of the general acknowledged this and indicated that if Comment: Several commenters
inpatient level of care, at the inception the hospice and the caregiver, working indicated that the general inpatient level
of the benefit, was to address the need together, are no longer able to provide of care was appropriate in rare
for pain control and symptom the necessary skilled nursing care in the circumstances where the patient’s care
management as well as care for patients individual’s home, and if the network breakdown is not recoverable
whose caregiver or home support has individual’s pain and symptom after a short period of inpatient respite
broken down, making it no longer management can no longer be provided care. Other commenters expressed the
feasible to furnish care in the home. One at home, then the individual may be need to provide inpatient care
commenter indicated that use of the eligible for a short term general immediately for caregiver breakdown.
general inpatient level of care in the inpatient level of care. Section The same commenters believe that the
event of caregiver breakdown met the 1861(dd)(1) of the Act defines hospice immediate need would prohibit the use
requirements in 418.302 as a condition care as the items and services to be of inpatient respite care, which they
of participation. The same commenter provided to a terminally ill individual indicated was a planned admission. One
added that the proposed interpretation by a hospice directly or under commenter strongly objected to the
shifts the focus from caring for patients arrangement. The statute goes on to statement in the proposed rule that
in the appropriate setting to a billing specify the items and services, but does specified the requirement for the
and reimbursement issue. Some not include caregiver services. This provision of an intensity of care to
commenters stated that this provision means that Medicare does not pay for support the general inpatient level of
was designed to reduce expenditures caregiver services under the hospice care. However, some commenters stated
without regard to patient safety and benefit. In further support, § 418.98 sets that more frequent use of general
hospice expenses. forth the hospice conditions of inpatient level of care is appropriate as
Other commenters also strongly participation requiring hospices to make hospices are experiencing difficulty
disagreed with the clarification. They available ‘‘inpatient care* * * for pain finding adequate caregivers.
indicated that Medicare policy has been Some commenters stated that general
control, symptom management and
interpreted for more than twenty years inpatient level of care provided the only
respite purposes * * *.’’ Section
to mean that general inpatient level of option other than discharging patients
418.202 lists the covered hospice
care can be used for caregiver from the hospice benefit to long term
services and includes short-term
breakdown and the practice of billing at care facilities. Others stated that the
inpatient care at § 418.202(e), stating
the higher level of care in those proposed clarification implied that
‘‘inpatient care may be required for
circumstances is consistent with written hospice care must be terminated when
procedures necessary for pain control or
CMS and fiscal intermediary guidance. there is a situation of caregiver
Some commenters stated that the acute or chronic symptom management.
breakdown, as there was no Medicare
definition of general inpatient care in Inpatient care may also be furnished as hospice benefit category to care for
the hospice regulations supported the a means of providing respite for the patients without caregiver support.
use of general inpatient level of care for individual’s family or other persons Some commenters stated that we did
caregiver breakdown. One commenter caring for the individual at home.’’ not address how caregiver breakdown
stated that it was inappropriate to Further, § 418.302(b)(4) provides that ‘‘a situations should be addressed while
punish patients by removing a long general inpatient care day is a day on others implied that unless hospices
established benefit for the hospice which an individual who has elected could bill for general inpatient level of
program because of the perception that hospice care receives general inpatient care for caregiver breakdown, patients’
some hospices are using the general care in an inpatient facility for pain symptoms could be uncontrolled
inpatient level of care inappropriately. control or acute or chronic symptom necessitating the general inpatient level
Response: We disagree with the management which cannot be managed of care.
commenter who believes that this in other settings.’’ Response: We disagree with the
clarification is a new interpretation. We believe that there is no support for comment that we did not indicate how
Rather, we seek to clarify here our the comments that suggest that the caregiver breakdown situations should
established policy by providing what we intent of the general inpatient level of be addressed. We indicated in the
believe is a helpful explanation of how care was to include care for patients proposed rule that there is nothing
our policies should be interpreted and whose home support has broken down. prohibiting a Medicare approved facility
applied. We are not making any policy We also disagree with the comment that from serving as the individual’s home.
changes with this clarification. We this clarification shifts the focus from However, Medicare daily per-diem
believe that this clarification is needed caring for patients to a purely billing payments are based on medically
because, as some commenters recognize, and reimbursement issue and that there reasonable and necessary levels of care
the general inpatient level of care has needs to be a humane and practical as described in the Medicare regulations
been used for situations where caregiver alternative. Our discussions in the at § 418.302: A routine home care day is
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breakdown has occurred. proposed rule and in this final rule have a day on which an individual is at home
The level of care needed to manage focused on the provision of care and the and is not receiving continuous care; a
pain and symptoms is the basis for the level of care needed by the patient. continuous home care day is a day on
general inpatient level of care in the However, certain billing requirements which an individual is not in an
statute, regulations and policy, none of and payment amounts are associated inpatient facility and receives hospice

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care consisting predominantly of fiscal intermediaries have allowed the quantify the use of the general inpatient
nursing care on a continuous basis at use of general inpatient care for level of care for caregiver breakdown. In
home during brief periods of crisis as caregiver breakdown. the proposed rule we provided an
described in § 418.204(a), to maintain Response: We disagree that our example of the potential impact, as we
the terminally ill patient at home; an clarification on the use of the general did not have empirical data to suggest
inpatient respite care day is a day on inpatient level of care represents a the actual usage. This example
which the individual receives care in an reduction in the Medicare hospice demonstrated the cost savings to
approved facility on a short-term basis benefit and that it will result in a Medicare by using as an example, what
for respite; and a general inpatient care limitation on access to hospice care. As we believe could be a cost saving if we
day is a day on which an individual we noted above, we are not making any assumed that 5 percent of the days and
receives general inpatient care in an policy changes concerning general expenditures for general inpatient level
inpatient facility for pain control or inpatient care, rather, we are clarifying of care were attributable to caregiver
acute or chronic symptom management our established policy. We also disagree breakdown. However, the unavailability
which cannot be managed in other that there has been an erosion of the use of exact utilization rates does not
setting. Medicare payment is made of general inpatient level of care. Our preclude us from ensuring that the
based on the medically reasonable and data, which is available on the hospice general inpatient level of care is being
necessary level of care provided, and Web site at http://www.cms.hhs.gov/ billed as we intended. Based upon the
not simply where that care is provided. center/hospice.asp demonstrates that comments we received, we believe that
As discussed above, it is not appropriate use and payment for the general the use of the general inpatient level of
to bill Medicare for the general inpatient inpatient level of care has been care for caregiver breakdown may be
care day for situations where the increasing each year. We also do not more pervasive than we had envisioned
individual’s caregiver support has agree that better compliance with at the time of the proposed rule.
broken down unless the coverage statute, regulations and policy will limit We disagree with the commenter who
requirements for the general inpatient access to hospice care nor do we see our suggested that the original legislation
level of care are otherwise met. clarification as an inducement to and regulation intended for the average
We disagree with the comments that increase hospital admissions. length of stay to be at a specified level.
patients will need to be discharged from Comment: One commenter questioned While the statute defines the terminal
the hospice benefit to long term care why this clarification was being made diagnosis as having a prognosis of six
facilities because discharge for caregiver when we were unable to quantify the months or less if the disease runs its
breakdown does not meet the discharge extent of the use of general inpatient in normal course, this does not imply that
requirements in the regulations at the event of caregiver breakdown and there is, or ever was, a targeted length
§ 418.26. The requirements for discharge suggested that further analysis be done. of stay that is required. The regulations
at § 418.26 state that a hospice may The same commenter indicated that the require that an individualized plan of
discharge a patient if the patient moves cost savings were inaccurate as our care be developed and updated to
out of the hospice service area or assumption of potential savings is based identify patient and family needs and
transfers to another hospice; the hospice on current reimbursement rates for the medically reasonable and necessary
determines that the patient is no longer inpatient respite services. The same items and services that are required to
terminally ill; or the hospice discharges commenter believes that the inpatient meet these needs. In addition, as
the patient for cause. We also disagree respite care payment rate is inadequate. individuals vary in their responses to
with the comment that patients will be Several other commenters indicated that illness and care, we expect to see some
forced to revoke the hospice benefit if the reimbursement rate for inpatient variability in lengths of stay. We do not
there is caregiver breakdown. respite care was inadequate. believe that it is feasible or prudent to
Revocation of the hospice benefit as Several commenters suggested the specify or predetermine what lengths of
described in § 418.28 is an action following: Extending the current 5-day stay should or must be achieved to
initiated by the individual (patient) and limitation on inpatient respite care; measure or evaluate the effectiveness of
not by the hospice provider. Finally, we revising policy to allow for the use of care provided.
disagree with the comment that denying the general inpatient level of care when Regarding the comment that the
the use of the general inpatient level of documentation indicates that a reimbursement rate for inpatient respite
care for caregiver breakdown will result sufficient caregiver network cannot be care is inadequate, in the proposed rule,
in limitation of access. We have restored in a few days; or establishing we did not propose to make any
discussed various ways of providing an alternative payment mechanism in adjustments on the payment rates and
care in this situation, such as the use of the hospice benefit for situations where merely indicated that the hospice
inpatient respite or use of alternative there is caregiver breakdown. payment rates are adjusted annually
sources of payment for room and board, One commenter suggested that based upon the full market basket
that we believe are appropriate Medicare work with hospice providers percentage increase. We are aware of
alternatives to meeting the needs of the to increase the average length of stay to studies which suggest that the inpatient
individual. that which was originally intended in respite care payment rate may not
Comment: One commenter stated that legislation and in regulation. The same reflect the costs for providing this level
hospices have seen an erosion of the use commenter stated that studies show that of care. We will consider the comments
of the inpatient benefit and many offer hospice care saves Medicare dollars. made concerning the inpatient respite
very little inpatient care. This Several offered to work with CMS to care rate as we continue to examine
commenter concluded that the find an alternative policy to meet Medicare hospice payment policy.
clarification represents a reduction in patient needs while protecting the
the benefit and will create a new Medicare trust fund. G. Certification of the Terminal Illness
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limitation on access to hospice care and Response: We appreciate these Section 1814(a)(7)(A)(i) of the Act
patients will seek inpatient hospital suggestions and will keep them in mind stipulates that the individual’s attending
admissions instead of receiving hospice as we continue to evaluate Medicare physician and the hospice medical
services at the general inpatient level of hospice payment policy. We noted in director initially certify the individual’s
care. Several commenters stated that the proposed rule that we are unable to terminal diagnosis with a prognosis of

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six months or less if the disease runs its A. Annual Update to the Hospice Wage situation arise in the future, we may re-
normal course. Our regulations at Index examine this policy.
§ 418.22 discuss the requirements of the As discussed in the proposed rule, as
The FY 2008 hospice wage index
certification, including documentation there are sufficient economic differences
values have been computed utilizing
requirements. As discussed in the between hospitals in the United States
OMB’s geographic location definitions
proposed rule, we are aware that some and those in Puerto Rico, we do not
(CBSA). The budget neutrality
providers permit the hospice admission believe that this policy would be
adjustment factor was computed
nurse to determine eligibility for appropriate for Puerto Rico. We also
utilizing data from the FY 2006 claims
hospice services and to certify the noted that as we have not yet identified
processed through June 2007. The FY
individual’s terminal diagnosis. In the an alternative methodology for imputing
2008 budget neutrality adjustment factor
proposed rule, we explained that the a wage index for rural Puerto Rico, we
of 1.066671 was applied to hospital
statute is explicit in the requirement will continue to evaluate the use of
wage data above 0.8. The budget
that the attending physician and the other sources. Accordingly, we will
neutrality adjustment factor or the
hospice medical director determine the continue to use the most recent pre-
hospice floor was applied to the
terminal diagnosis, and his or her floor, pre-reclassified wage index
hospital wage data below 0.8, not to
signature on the certification attests to previously available for Puerto Rico.
exceed 0.8. The wage index values are
that fact. reflected in Table A and Table B of the C. Nomenclature Changes
Comment: We received three items of Addendum. Specifically, Table A This final rule and all subsequent
correspondence regarding this reflects the FY 2008 wage index values hospice rules and notices are considered
clarification. One commenter supported for urban areas under the CBSA to incorporate the CBSA changes
the clarification of the responsibility of designations. Table B reflects the FY published in the most recent OMB
the hospice medical director and the 2008 wage index values for rural areas bulletin that applies to the hospital
attending physician to certify the under the CBSA designations. wage data used to determine the current
terminal illness. One commenter asked B. Rural Areas Without Hospital Wage hospice wage index. The tables in this
if a hospice medical director visit is Data final rule reflect changes made by these
required at the time of admission to a bulletins. The OMB bulletins may be
For FY 2008 and subsequent hospice
hospice and what is the time frame for accessed at http://www.whitehouse.gov/
wage index values, for urban labor
the visit. Another commenter stated that omb/bulletins/index.html.
markets without an urban hospital from
concurrence of the hospice medical which hospital wage index data could D. Payment for Hospice Care Based on
director and the attending physician be derived, all of the CBSAs within the the Location Where Care Is Furnished
may be tacit and no communication is State will be used to calculate a
required between them. Effective January 1, 2008, all payment
statewide urban average wage index to rates (routine home care, continuous
Response: As discussed above, section use as a reasonable proxy for these home care, inpatient respite and general
1814(a)(7)(A)(i) of the Act stipulates that areas. Currently, the only CBSA that is inpatient care) will be adjusted by the
the individual’s attending physician and affected by this is CBSA 25980, geographic wage index value of the area
the hospice medical director each Hinesville-Fort Stewart, Georgia. where hospice services are provided. In
initially certify that the individual is For FY 2008 and subsequent hospice other words, the wage component of
terminally ill with a medical life wage index values, in cases where there each payment rate is multiplied by the
expectancy of six months or less if the is a rural area without rural hospital wage index value applicable to the
disease runs its normal course. Our wage data, we will use the average pre- location in which the hospice services
regulations at § 418.25(a) of hospice floor, pre-reclassified wage index data are provided. Section 418.302 is
regulations indicate, that the hospice from all contiguous CBSAs to represent amended to reflect this change. Hospice
admits a patient only on the a reasonable proxy for the rural area. providers will be required to indicate on
recommendation of the medical director This approach meets the criteria that we hospice claims, the CBSA for the
in consultation with, or with input, believe would be the best imputed location where hospice care is provided.
from the patient’s attending physician proxy for rural areas, which (1) uses pre-
floor, pre-reclassified hospital data; (2) E. Educational Requirements for Nurse
(if any). As noted in the proposed rule,
uses the most local data available to Practitioners
the requirements of the physician
certification, including supportive impute a rural wage index; (3) is easy to In order to align the hospice
documentation, were discussed in the evaluate; and (4) is easy to update from qualifications for nurse practitioners
Medicare Program; Hospice Care year-to-year. Currently there are no under § 418.3 and Part B nurse
hospitals in rural locations in practitioners under § 410.75, the
Amendments proposed rule (67 CFR
Massachusetts and Puerto Rico. definition of ‘‘attending physician’’ at
70363) and final rule (70 CFR 70548).
We interpret the term ‘‘contiguous’’ to § 418.3 is revised to cross reference the
Current regulations do not address a
mean sharing a border. For example, we training, education and experience
time frame for a physician or hospice
have determined that the borders of requirements described in § 410.75(b).
medical director visit. Dukes and Nantucket counties are
contiguous with Barnstable and Bristol F. Caregiver Breakdown and General
III. Provisions of the Final Regulations
Counties. Therefore, the pre-floor, pre- Inpatient Care
In this final rule, we are adopting the reclassified wage index values for the We are not implementing any changes
following provisions, as set forth in the counties of Barnstable (CBSA 12700, regarding the general inpatient level of
proposed rule, without change. We are Barnstable Town, MA) and Bristol care and caregiver breakdown, but are
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also publishing the FY 2008 urban and (CBSA 39300, Providence-New Bedford- providing clarification of existing
rural wage index values for hospices in Fall River, RI–MA) would be averaged policy, statute, and hospice regulations.
the addendum as well as the table that resulting in an imputed pre-floor, pre- The Medicare hospice benefit provides
reflects the impact of the FY 2008 wage reclassified rural wage index for rural for care that is medically reasonable and
index values. Massachusetts. Should a similar necessary for the palliation and

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management of terminal and related recordkeeping requirements. is not an economically significant rule
conditions, and is structured in such a Consequently, it need not be reviewed under this Executive Order.
way to enable the individual with a by the Office of Management and The RFA requires agencies to analyze
terminal condition to remain at home, Budget under the authority of the options for regulatory relief of small
in the company of family and friends. Paperwork Reduction Act of 1995 (44 businesses. For purposes of the RFA,
The statute, our regulations at U.S.C. 35). small entities include small businesses,
§ 418.202(e), and Medicare hospice nonprofit organizations, and small
policy require that in order to receive V. Regulatory Impact Analysis
governmental jurisdictions. Most
payment for general inpatient care A. Overall Impact hospices and most other providers and
under the Medicare hospice benefit, We have examined the impacts of this suppliers are small entities, either by
beneficiaries must require an intensity nonprofit status or by having revenues
final rule as required by Executive
of care directed towards pain control of $6.5 million to $31.5 million in any
Order 12866 (September 1993,
and symptom management that cannot one year (for details, see the Small
Regulatory Planning and Review), the
be managed in any other setting. It is the Business Administration’s regulation at
Regulatory Flexibility Act (RFA)
level of care provided to meet the 65 FR 69432, that sets forth size
(September 19, 1980, Pub. L. 96–354),
individual’s needs that determines standards for health care industries). For
section 1102(b) of the Act, the
payment rates for Medicare services. In purposes of the RFA, most hospices are
Unfunded Mandates Reform Act of 1995
other words, caregiver breakdown small entities. As indicated in Table 1
(Pub. L. 104–4), and Executive Order
should not be billed as general inpatient below, there are 2,956 hospices.
13132. We estimated the impact on
care regardless where the services are Approximately 53 percent of Medicare
provided, unless the intensity-of-care hospices, as a result of the changes to
the FY 2008 hospice wage index. As certified hospices are identified as
requirement is met. If an individual no voluntary, government, or other
longer is able to remain at home or if the discussed previously, the methodology
for computing the wage index was agencies and, therefore, are considered
individual’s caregiver is no longer able small entities. Because the National
to provide care, and the required care determined through a negotiated
rulemaking committee and Hospice and Palliative Care
does not meet the requirements for Organization estimates that
general inpatient care, the hospice may implemented in the August 8, 1997 final
rule (62 FR 42860). This final rule approximately 79 percent of hospice
not bill this care at the general inpatient patients are Medicare beneficiaries, we
level of care. This situation is updates the hospice wage index in
accordance with our regulation and that have not considered other sources of
considered to be caregiver breakdown. revenue in this analysis. Furthermore,
This does not imply or suggest that the methodology, incorporating the CBSA
designations used in the FY 2007 the wage index methodology was
individual must be discharged from the previously determined by consensus,
hospice if caregiver breakdown occurs. hospital wage index data.
• Table 1 categorizes the impact of through a negotiated rulemaking
It does mean that the hospice must find committee that included representatives
alternative means for the provision of the FY 2008 wage index values on
hospices by various geographic and of national hospice associations, rural,
caregiver services, which may include urban, large and small hospices, multi-
payment for room and board, as provider characteristics. We estimate
that the total hospice payments will site hospices, and consumer groups.
Medicare does not pay for caregiver
increase $2,860,000 as a result of the Based on all of the options considered,
services, nor does it pay for room and
application of the FY 2008 wage index the committee agreed on the
board.
values. As discussed in the proposed methodology described in the
G. Certification of Terminal Illness rule as well as in this final rule, the committee statement, and it was
We are not making any changes to the impact analysis only reflects the FY adopted into regulation in the August 8,
certification of terminal illness 2008 wage index values. The FY 2008 1997 final rule. In developing the
requirements. We are clarifying that the hospice payment rates are promulgated process for updating the wage index in
statute requires that the attending through administrative issuance and are the 1997 final rule, we considered the
physician and the hospice medical not included in the impact analysis. impact of this methodology on small
director, not the admission nurse, • Table A reflects the FY 2008 wage entities and attempted to mitigate any
initially certify the terminal diagnosis index values for urban areas potential negative effects.
with a prognosis of six months or less designations. In addition, section 1102(b) of the Act
if the disease runs its normal course. • Table B reflects the FY 2008 wage requires us to prepare a regulatory
The regulations require that there be index values for rural areas impact analysis if a rule may have a
documentation in the medical record to designations. significant impact on the operations of
support the initial as well as any Executive Order 12866 (as amended a substantial number of small rural
subsequent certifications. The by Executive Order 13258, which hospitals. This analysis must conform to
admission nurse may obtain information merely reassigns responsibility of the provisions of section 604 of the
supporting the terminal illness in order duties) directs agencies to assess all RFA. For purposes of section 1102(b) of
to allow the attending physician and the costs and benefits of available regulatory the Act, we define a small rural hospital
medical director to have the necessary alternatives and, if regulation is as a hospital that is located outside a
information to make the terminal illness necessary, to select regulatory CBSA and has fewer than 100 beds. We
determination. But, the determination of approaches that maximize net benefits have determined that this final rule will
the terminal illness cannot be delegated (including potential economic, not have a significant impact on the
to an admission nurse or any other environmental, public health and safety operations of a substantial number of
employee. effects, distributive impacts, and small rural hospitals. We are not
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equity). A regulatory impact analysis preparing an analysis for the RFA


IV. Collection of Information (RIA) must be prepared for major rules because we have determined that this
Requirements with economically significant effects rule will not have a significant
This document does not impose any ($100 million or more in any one year). economic impact on a substantial
information collection and We have determined that this final rule number of small entities.

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Section 202 of the Unfunded was adjusted from 1,250,678 to compares hospice payments using the
Mandates Reform Act of 1995 also 1,188,144. The number of inpatient FY 2007 hospice wage index to the
requires that agencies assess anticipated respite days was adjusted from 96,646 to estimated payments using the FY 2008
costs and benefits before issuing any 159,180. While inpatient respite wage index. We note that estimated
rule that may result in expenditures in expenditures increased from payments for FY 2008 are determined
any one year by State, local, and tribal $14,000,000 to $23,058,570, general by using the wage index for FY 2008
governments, in the aggregate, or by the inpatient care expenditures decreased and payment rates for FY 2007. We also
private sector, of $120 million or more. from $737,300,000 to $700,435,000. In note that the results in the impact
This final rule is not anticipated to have total, if 5.0 percent of patient days that analysis table (Table 1) in this final rule
an effect on State, local, or tribal were attributed to general inpatient care differ from the proposed rule, because
governments or on the private sector of in FY 2005 were allocated to the we have incorporated the most recent
$120 million or more. inpatient respite level of care, it would data to determine the budget neutrality
Executive Order 13132 establishes have resulted in net savings of adjustment factor. As noted in previous
certain requirements that an agency $27,806,430. sections, payment rates for FY 2008 are
must meet when it promulgates a The impact analysis of this final rule published through administrative
proposed rule (and subsequent final represents the projected effects of the issuance.
rule) that imposes substantial direct changes in the hospice wage index from Table 1 demonstrates the results of
requirement costs on State and local FY 2007 to FY 2008. We estimate the our analysis. In column 1 we indicate
governments, preempts State law, or effects by estimating payments for FY the number of hospices included in our
otherwise has Federalism implications. 2008 using the FY 2007 wage index analysis. In column 2, we indicate the
We have reviewed this final rule under values while holding all other payment number of routine home care days that
the threshold criteria of Executive Order variables constant. were included in our analysis, although
13132, Federalism, and have We note that certain events may the analysis was performed on all types
determined that it will not have an combine to limit the scope or accuracy of hospice care. Column 3 estimates
impact on the rights, roles, and of our impact analysis because such an payments using the FY 2007 wage index
responsibilities of State, local, or tribal analysis is future oriented and, thus, values and the FY 2007 payment rates.
governments. susceptible to forecasting errors due to Column 4 estimates payments using FY
In accordance with the provisions of other changes in the forecasted impact 2008 wage index values as well as the
Executive Order 12866, this regulation time period. The nature of the Medicare FY 2007 payment rates. Column 5
was reviewed by the Office of program is such that the changes may compares columns 3 and 4 and shows
Management and Budget. interact, and the complexity of the the percentage change in estimated
interaction of these changes could make hospice payments based on the hospice
B. Anticipated Effects
it difficult to predict accurately the full category.
As discussed in the proposed rule, we scope of the impact upon hospices. Table 1 also categorizes hospices by
are unable to quantify the extent of the For the purposes of this final rule, we various geographic and provider
usage of the general inpatient level of compared estimated payments using the characteristics. The first row displays
care in the event of caregiver FY 1983 hospice wage index to the aggregate result of the impact for all
breakdown. Therefore, we are unable to estimated payments using the FY 2008 Medicare-certified hospices. The second
definitively anticipate the impact of our wage index and determined the hospice and third rows of the table categorize
clarification of the general inpatient wage index to be budget neutral. Budget hospices according to their geographic
level of care policy in the event of neutrality means that, in a given year, location (urban and rural). Our analysis
caregiver breakdown. For this reason, estimated aggregate payments for indicated that there are 1,974 hospices
we solicited comment on what the Medicare hospice services using the FY located in urban areas and 982 hospices
impact of our clarification might be. We 2008 wage index would equal estimated located in rural areas. The next two
did not receive any substantive aggregate payments that would have groupings in the table indicate the
comments on the impact. Based on been made for the same services if the number of hospices by census region,
anecdotal evidence as well as 1983 wage index had remained in effect. also broken down by urban and rural
substantial increases in the number of Budget neutrality to 1983 does not hospices. The sixth grouping shows the
claims submitted for general inpatient imply that estimated payments would impact on hospices based on the size of
care, however, we believe a small not increase since the budget neutrality the hospice’s program. We determined
proportion of patient days attributed to applies only to the wage index portion that the majority of hospice payments
general inpatient care would be and not the total payment rate, which are made at the routine home care rate.
appropriately allocated to inpatient accommodates inflation. Therefore, we based the size of each
respite care with this clarification. As discussed above, we use the latest individual hospice’s program on the
Significant savings could be realized claims file available to us to develop the number of routine home care days
even if only a small proportion of impact table when we issue the annual provided in FY 2006. The next grouping
patient days attributed to general yearly wage index update. For the shows the impact on hospices by type
inpatient care were allocated to purposes of this final rule, data were of ownership. The final grouping shows
inpatient respite care. obtained from the National Claims the impact on hospices defined by
In the proposed rule we cited an History file using FY 2006 claims whether they are provider-based or
example to determine the impact. In processed through June 2007, which freestanding. As indicated in Table 1
that example, we allocated 5.0 percent was the most recent available data. We below, there are 2,956 hospices.
of general inpatient care days to deleted bills from hospice providers that Approximately 53 percent of Medicare-
inpatient respite care, using the FY 2005 have since closed. For the purposes of certified hospices are identified as
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patient days, expenditures and number this final rule, this file is adequate to voluntary, government, or other
of beneficiaries electing the hospice demonstrate the impact of the FY 2008 agencies and, therefore, are considered
benefit to estimate the impact of the wage index values and is not intended small entities. Because the National
clarification of existing policy in this to project the anticipated expenditures Hospice and Palliative Care
final rule. The number of inpatient days for FY 2008. This impact analysis Organization estimates that

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approximately 79 percent of hospice the location of the site of service. As the 2. Geographic Location
patients are Medicare beneficiaries, we location of the beneficiary’s home and
have not considered other sources of the location of the facility may vary, Our analysis demonstrates that the
revenue in this analysis. Furthermore, there will still be variability in proposed FY 2008 wage index values
the wage index methodology was geographic location. We anticipate that will result in little change in estimated
previously determined by consensus, the location of the various sites will payments with urban hospices
through a negotiated rulemaking correspond with the geographic location anticipated to experience no change
committee that included representatives of the hospice and thus we will while rural hospices are anticipated to
of national hospice associations; rural, continue to use the location of the experience a slight increase of 0.3
urban, large, and small hospices; multi- hospice for our analyses. For this percent. For urban hospices, the greatest
site hospices; and consumer groups. analysis, we use payments to the increase of 0.9 percent is anticipated to
Based on all of the options considered, hospice in the aggregate based on the be experienced by the Mountain
the committee agreed on the location of the hospice. The impact of regions, followed by an increase for East
methodology described in the hospice wage index changes has been North Central of 0.7 percent and Pacific
committee statement, and it was analyzed according to the type of regions of 0.6 percent. The remaining
adopted into regulation in the August 8, hospice, geographic location, type of urban regions are anticipated to
1997 final rule. In developing the ownership, hospice base, and size. experience a decrease ranging from 0.1
process for updating the wage index in Our analysis shows that most percent in the West North Central and
the 1997 final rule, we considered the hospices are in urban areas and provide Middle Atlantic regions to 0.6 percent
impact of this methodology on small the vast majority of routine home care in the East South Central region. The
entities and attempted to mitigate any days. Most hospices are medium-sized greatest decrease of 2.4 percent is
potential negative effects. followed by large hospices. Hospices are anticipated for Puerto Rico.
As stated previously, the following almost equal in numbers by ownership For rural hospices, Puerto Rico is
with 1,578 designated as non-profit and anticipated to experience no change.
discussions are limited to demonstrating
1,378 as proprietary. The vast majority Two regions are anticipated to
trends rather than projected dollars. We
of hospices are freestanding. experience a decrease of 1.1 percent for
used the CBSA designations and wage
indices as well as the data from FY 2006 1. Hospice Size New England and 0.3 percent for the
claims processed through June 2007 in mountain regions. The remaining
Under the Medicare hospice benefit,
developing the impact analysis. For FY regions are anticipated to experience an
hospices can provide four different
2008, the wage index is the variable that increase ranging from 0.1 percent for the
levels of care days. The majority of the
differs between the FY 2007 payments South Atlantic region to 0.6 percent for
days provided by a hospice are routine
and the FY 2008 estimated payments. the Middle Atlantic, East South Central
home care (RHC) days representing over
FY 2007, payment rates are used for and West North Central regions.
70 percent of the services provided by
both FY 2007 actual payments and the a hospice. Therefore, the number of 3. Type of Ownership
FY 2008 estimated payments. The FY RHC days can be used as a proxy for the
2008 payment rates will be adjusted to size of the hospice, that is, the more By type of ownership, non-profit
reflect the full FY 2008 hospital market days of care provided, the larger the hospices are anticipated to experience a
basket, as required by section hospice. As discussed in the August 4, slight increase of 0.1 percent in payment
1814(i)(1)(C)(ii)(VII) of the Act. As 2005 final rule, we currently use three while government hospices are
previously noted, we publish these rates size designations to present the impact anticipated to experience a slight
through administrative issuances. analyses. The three categories are: small increase of 0.2 percent. No change is
As discussed in the FY 2006 final rule agencies having 0 to 3,499 RHC days; anticipated for proprietary hospices. Not
(70 FR 45129), hospice agencies may medium agencies having 3,500 to 19,999 specified hospices in the ‘‘other’’
use multiple wage indices to compute RHC days; and large agencies having category are anticipated to experience a
their payments based on potentially 20,000 or more RHC days. Using RHC slight decrease of 0.2 percent.
different geographic locations. For the days as a proxy for size, our analysis 4. Hospice Base
purposes of this final rule, the location indicates that the proposed FY 2008
of the beneficiary is used for routine and wage index values are anticipated to No change in payment is anticipated
continuous home care or the CBSA for have virtually no impact on hospice for freestanding facilities. Home health,
the location of the hospice agency for providers, with a slight increase of 0.1 hospital, and skilled nursing facilities
respite and general inpatient care. As percent anticipated for medium are anticipated to experience an
noted above, beginning January 1, 2008, hospices while no change is anticipated increase of 0.1, 0.3, and 0.7 percent,
the wage index utilized will be based on for small or large hospices. respectively.

TABLE 1.—IMPACT OF HOSPICE WAGE INDEX CHANGE


Estimated
Number of Payments Payments Percent
Number of Routine Home using FY 2007 using FY 2008 Change in
Hospices Care Days in Wage Index in CBSA Wage Hospice Pay-
Thousands Thousands Index in Thou- ments
sands

(1) (2) (3) (4) (5)


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ALL HOSPICES: .................................................................. 2956 61,125 9,148,694 9,151,554 0.0


URBAN HOSPICES ...................................................... 1974 52,426 8,048,410 8,048,224 0.0
RURAL HOSPICES ...................................................... 982 8,699 1,100,284 1,103,330 0.3
BY REGION—URBAN:
NEW ENGLAND ........................................................... 112 1,772 313,059 311,816 ¥0.4

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TABLE 1.—IMPACT OF HOSPICE WAGE INDEX CHANGE—Continued


Estimated
Number of Payments Payments Percent
Number of Routine Home using FY 2007 using FY 2008 Change in
Hospices Care Days in Wage Index in CBSA Wage Hospice Pay-
Thousands Thousands Index in Thou- ments
sands

(1) (2) (3) (4) (5)

MIDDLE ATLANTIC ...................................................... 198 5,211 843,068 842,000 ¥0.1


SOUTH ATLANTIC ....................................................... 285 11,385 1,839,567 1,831,476 ¥0.4
EAST NORTH CENTRAL ............................................. 294 7,568 1,158,628 1,166,376 0.7
EAST SOUTH CENTRAL ............................................. 157 4,333 586,642 583,333 ¥0.6
WEST NORTH CENTRAL ............................................ 151 3,413 471,129 470,666 ¥0.1
WEST SOUTH CENTRAL ............................................ 336 7,113 1,007,361 1,002,636 ¥0.5
MOUNTAIN ................................................................... 182 4,531 702,881 709,230 0.9
PACIFIC ........................................................................ 225 6,302 1,054,910 1,061,223 0.6
PUERTO RICO ............................................................. 34 797 71,165 69,468 ¥2.4
BY REGION—RURAL:
NEW ENGLAND ........................................................... 26 144 21,134 20,910 ¥1.1
MIDDLE ATLANTIC ...................................................... 43 408 52,441 52,765 0.6
SOUTH ATLANTIC ....................................................... 124 1,840 238,972 239,136 0.1
EAST NORTH CENTRAL ............................................. 140 1,125 146,434 146,747 0.2
EAST SOUTH CENTRAL ............................................. 142 1,982 240,058 241,528 0.6
WEST NORTH CENTRAL ............................................ 188 944 120,343 121,061 0.6
WEST SOUTH CENTRAL ............................................ 163 1,307 153,527 153,934 0.3
MOUNTAIN ................................................................... 103 576 74,972 74,718 ¥0.3
PACIFIC ........................................................................ 52 365 51,809 51,936 0.2
PUERTO RICO ............................................................. 1 7 595 595 0.0
ROUTINE HOME CARE DAYS:
0–3499 DAYS (small) ................................................... 617 1,060 142,491 142,458 0.0
3500–19,999 DAYS (medium) ...................................... 1429 14,208 1,994,694 1,996,162 0.1
20,000+ DAYS (large) .................................................. 910 45,856 7,011,509 7,012,935 0.0
TYPE OF OWNERSHIP:
VOLUNTARY ................................................................ 1220 27,555 4,270,787 4,274,723 0.1
PROPRIETARY ............................................................ 1378 30,166 4,380,444 4,379,751 0.0
GOVERNMENT ............................................................ 193 986 133,503 133,745 0.2
OTHER ......................................................................... 165 2,417 363,960 363,335 ¥0.2
HOSPICE BASE:
FREESTANDING .......................................................... 1767 45,209 6,752,227 6,750,239 0.0
HOME HEALTH AGENCY ........................................... 620 9,105 1,369,110 1,370,605 0.1
HOSPITAL .................................................................... 555 6,606 994,451 997,560 0.3
SKILLED NURSING FACILITY .................................... 14 205 32,906 33,149 0.7
Note: FY 2007 payment rates were used for estimated payments for FY 2008. FY 2008 payment rates will be adjusted to reflect the full hos-
pital market basket and will be promulgated through administrative issuance.

C. Conclusion rulemaking committee. As noted above, PART 418—HOSPICE CARE


the payment rates used reflect the FY
Our impact analysis compared the FY 2007 rates. The FY 2008 payment rates ■ 1. The authority citation for part 418
2007 wage index to the estimated will be adjusted to reflect the full FY continues to read as follows:
payments using the FY 2008 wage 2008 hospital market basket, as required Authority: Secs. 1102 and 1871 of the
index. Through the analysis, we by section 1814(i)(1)(C)(ii)(VII) of the Social Security Act (42 U.S.C. 1302 and
estimate that total hospice payments, 1395hh).
Act. We publish these rates through
based on the FY 2008 wage index
administrative issuances.
values, will effectively be budget neutral Subpart A—General Provision and
with an estimated increase from FY In accordance with the provisions of Definitions
2007 of $2,860,000. As discussed, the Executive Order 12866, this regulation
budget neutrality adjustment factor is was reviewed by the Office of ■ 2. Section 418.3 is amended by
determined by using the pre-floor, pre- Management and Budget. revising paragraph (1)(ii) in the
reclassified hospital wage data. The definition of ‘‘attending physician’’ to
List of Subjects for 42 CFR Part 418 read as follows:
impact analysis compares the wage
index values, which have had either the Health facilities, Hospice care, § 418.3 Definitions.
budget neutrality adjustment factor or Medicare, Reporting and recordkeeping
the hospice floor applied. Additionally, * * * * *
requirements.
we compared estimated payments using (1) * * *
For the reasons set forth in the
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the FY 1983 hospice wage index to ■ (ii) Nurse practitioner who meets the
estimated payments using the FY 2008 preamble, the Centers for Medicare & training, education, and experience
wage index and determined the current Medicaid Services amends 42 CFR requirements as described in § 410.75
hospice wage index to be budget Chapter IV as set forth below: (b) of this chapter.
neutral, as required by the negotiated * * * * *

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Subpart G—Payment for Hospice Care on the basis of the geographic location Dated: July 19, 2007.
where the services are provided. Leslie V. Norwalk,
■ 3. Section 418.302 is amended by Acting Administrator, Centers for Medicare
(Catalog of Federal Domestic Assistance
revising paragraph (g) to read as follows: & Medicaid Services.
Program No. 93.773, Medicare—Hospital
§ 418.302 Payment procedures for hospice Insurance; and Program No. 93.774, Approved: August 17, 2007.
care. Medicare—Supplementary Medical Michael O. Leavitt,
* * * * * Insurance Program) Secretary.
(g) Payment for routine home care, (Catalog of Federal Domestic Assistance BILLING CODE 4120–01–P
continuous home care, general inpatient Program No. 93.778, Medical Assistance
care and inpatient respite care is made Program)
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[FR Doc. 07–4292 Filed 8–30–07; 8:45 am]


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BILLING CODE 4120–01–C

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