[Federal Register: June 4, 2007 (Volume 72, Number 106)]
[Rules and Regulations]
[Page 30706-30711]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr04jn07-4]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
42 CFR Part 136
Center for Medicare & Medicaid Services
42 CFR Part 489
[CMS-2206-F]
RIN 0917-AA02
Section 506 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003--Limitation on Charges for Services Furnished
by Medicare Participating Inpatient Hospitals to Individuals Eligible
for Care Purchased by Indian Health Programs
AGENCY: Indian Health Service (IHS), Center elsewhere for Medicare &
Medicaid Services (CMS), Health and Human Services (HHS).
ACTION: Final rule.
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SUMMARY: The Secretary of the Department of Health and Human Services
(HHS) hereby issues this final rule establishing regulations required
by section 506 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA), (Pub. L. 108-173). Section 506 of the
MMA amended section 1866 (a)(1) of the Social Security Act to add
subparagraph (U) which requires hospitals that furnish inpatient
hospital services payable under Medicare to participate in the contract
health services program (CHS) of the Indian Health Service (IHS)
operated by the IHS, Tribes, and Tribal organizations, and to
participate in programs operated by urban Indian organizations that are
funded by IHS (collectively referred to as I/T/Us) for any medical care
purchased by those programs. Section 506 also requires such
participation to be in accordance with the admission practices, payment
methodology, and payment rates set forth in regulations established by
the Secretary, including acceptance of no more than such payment rates
as payment in full.
DATES: These final regulations are effective July 5, 2007.
FOR FURTHER INFORMATION CONTACT: Carl Harper, Director, Office of
Resource Access and Partnerships, IHS, 801 Thompson Avenue, Twinbrook
Metro Plaza Suite 360, Rockville, Maryland 20852, telephone (301) 443-
2694. Dorothy Dupree, Director, Tribal Affairs Group, OEA, CMS, 7500
Security Boulevard, Mail Stop: C1-13-11, Baltimore, Maryland 21244,
telephone (410) 786-1942. (These are not toll free numbers.)
SUPPLEMENTARY INFORMATION:
I. Background
On April 28, 2006, IHS and CMS published proposed rules in the
Federal Register (71 FR 25124) as mandated by section 506(c) of the
MMA, which requires the Secretary to publish rules implementing the
requirements of section 506 of the MMA. Under that statutory provision,
hospitals that furnish inpatient hospital services payable under
Medicare are required to participate both in the contract health
service (CHS) program of IHS operated by IHS, Tribes, and Tribal
organizations, and in programs operated by urban Indian organizations
(I/T/Us) that are funded by the IHS, for medical care purchased by
those programs. Section 506 also requires such participation to be in
accordance with the admission practices, payment methodology, and
payment rates set forth in regulations established by the Secretary,
including acceptance of no more than such rate as payment in full. The
proposed rule provided interested persons until June 27, 2006 to submit
written comments.
II. Provisions of the Proposed Regulations
a. The Proposed Rule
We proposed to amend the IHS regulations at 42 CFR part 136, by
adding a new subpart D to describe the payment methodology and other
requirements for Medicare-participating hospitals and critical access
hospitals (CAHs) that furnish inpatient services, either directly or
under arrangement, to individuals who are authorized to receive
services from such hospitals under a CHS program of the IHS, Tribes,
and Tribal organizations, and IHS-funded programs operated by urban
Indian organizations (collectively, I/T/U programs). As provided in the
statute, we also proposed to amend CMS regulations at 42 CFR part 489
to require Medicare-participating hospitals and critical access
hospitals (CAHs) that furnish inpatient hospital services to
individuals who are eligible for and authorized to receive items and
services covered by such I/T/U programs to accept no more than the
payment methodology under 42 CFR part 136, subpart D as payment in full
for such items and services. The proposed rule did not include
additional regulation of admission practices.
b. Summary of Changes in the Final Rule
In reviewing several comments, IHS and CMS determined that the
payment methodology in the proposed rule was not adequately explained.
Therefore, we are clarifying the payment methodologies established by
this regulation to include more detail. For hospital services that
would be paid under prospective payment systems (PPS) by the Medicare
program, the basic payment methodology under this rule is based on the
applicable PPS. For example, inpatient hospital services of acute care
hospitals, psychiatric hospitals, rehabilitation hospitals, and long-
term care hospitals will be paid based on the same four Medicare PPS
systems as would be used to pay for similar hospital services to the
hospitals' Medicare patients, as described under 42 CFR part 412, while
outpatient hospital services and skilled nursing facility services
(SNF) will be paid based on their Medicare PPS systems, as described
under 42 CFR part 419 (outpatient) and 42 CFR part 413
[[Page 30707]]
(SNF) respectively. The basic payment methodology under this rule for
Medicare-participating hospitals that furnish inpatient services but
are exempt from PPS and currently receive reasonable cost reimbursement
under the Medicare program (for example, critical access hospitals
(CAHs), children's hospitals, cancer hospitals, and certain other
hospitals reimbursed by Medicare under special arrangements), is based
on 42 CFR part 413, which addresses reasonable cost reimbursement.
In addition, based on the comments received, IHS and CMS determined
that the requirement that providers participate in IHS and Tribal CHS
programs and IHS-funded urban Indian organization programs was not
clear in the proposed rule and additional guidance was needed.
Therefore, we clarified that hospitals participating in Medicare that
furnish inpatient hospital services will be required to accept the
payment methodology and no more than the rates established under 42 CFR
part 136, subpart D as payment in full for such services. This change
also clarifies that such hospitals may not refuse service to an
individual on the basis that the individual may be eligible for payment
under such CHS and IHS-funded urban Indian programs. We did not include
additional prohibitions on discrimination in admission practices
because such requirements are already covered and enforced by the HHS
Office for Civil Rights under existing regulations at 45 CFR part 80.
III. Analysis of and Responses to Public Comments
The IHS received 35 comments from Tribes, Tribal organizations,
hospital associations, CAHs, and individuals. The IHS, in partnership
with CMS, carefully reviewed the submissions by individuals, groups,
Indian, and non-Indian organizations. We did not consider 4 of these
comments, because they were received after the closing date. Of the 31
timely comments, 26 comments supported the proposed regulation. Several
comments requested clarification of certain sections of the rule.
Comment: We received 10 comments that expressed serious concern
regarding the long delay in publication of the proposed rule and
requested expedited publication of a final rule.
Response: The development of this final rule has been a long and
careful process, involving consultation with the Tribes through the CMS
Tribal Technical Advisory Group, and close collaboration between IHS
and CMS. An incidental benefit of this process has been greater
understanding by all parties of the service delivery and payment
processes that are at issue in this rule.
Comment: A number of the comments from Tribes and Tribal
organizations expressed concerns that affected Indian health programs
would need training to fully implement and monitor the participation
and payment requirements.
Response: IHS is authorized to provide technical assistance
regarding implementation of this final rule. Tribal program
representatives can contact Mr. Carl Harper at the phone number listed
in the contact information.
Comment: One commenter expressed concern that American Indian/
Alaska Native (AI/AN) populations have many complications and co-
morbidities that do not exist to the same extent in the patient
population as a whole, including diabetes, cardiovascular disease,
injury, trauma, and alcoholism. The commenter suggested that costs to
treat this population are higher and suggested IHS would be paying less
for its patient population than Medicare actually pays for services
furnished to a comparable population.
Response: Patients who are more seriously ill tend to require a
higher level of hospital resources than patients who are less seriously
ill even though they may be admitted to the hospital for the same
reason. Recognizing this, Medicare payments can be higher for patients
in certain diagnostic-related groups (DRGs) based on a secondary
diagnosis that could indicate specific complications or co-morbidities.
Also, the DRG groupings take into consideration co-morbidity factors,
and payment adjustments that would be available to reflect the higher
costs of disproportionate share hospital adjustments and outlier
payments are provided for exceptionally high cost cases, all of which
would address high costs of this patient population. As a result, IHS
payment under this rule will reflect the serious health issues faced by
its patient population.
Comment: One commenter expressed concern that the CHS program
payments are not always timely and should be paid in accordance with
Medicare timeline requirements.
Response: This regulation addresses practices, payment
methodologies, and rates of payment that are not already addressed
under current laws or regulations. The time frame for paying claims
authorized by IHS under the CHS program is already governed by section
220 of the Indian Health Care Improvement Act (IHCIA).
Comment: One commenter expressed concern that payment for services
should be absolute for services rendered, not at the service unit's
discretion. In addition, this commenter suggested IHS set the timeline
for notification of emergency services at a minimum of 30 days
following services rendered.
Response: Payment for services is based on a medical priority
system which is based on the availability of funds as established under
42 CFR part 136, subpart C. Under subpart C of title 42, notification
of emergency services must be provided within 72 hours after the
beginning of treatment or admission to a health care facility. The
timeline for notification of emergency services for the elderly and
disabled is currently set at 30 days in accordance with section 406 of
the IHCIA.
Comment: One commenter expressed concern that the proposed rule
places an additional burden on hospitals by capping rates paid to
public and private non-IHS funded hospitals, with no additional
responsibility or accountability placed on I/T/U programs regarding
payments to such hospitals.
Response: This rule would provide for rates that hospitals accept
under the Medicare program. We do not believe these rates place an
additional burden on hospitals.
Comment: One commenter asked whether the payment rates required
under this rule would apply to claims for services furnished by long-
term care hospitals, independent inpatient rehabilitation facilities,
and inpatient psychiatric facilities to individuals who were authorized
for the service by an I/T/U program.
Response: Long-term care hospitals, independent inpatient
rehabilitation facilities, and inpatient psychiatric facilities are
covered by these rules because they meet the criteria of section 506 of
the MMA: They are covered by the definition of ``hospital'' in section
1861(e) or (f), as applicable, of the Social Security Act and they
furnish inpatient hospital services. They will be paid based upon their
respective Medicare PPS systems.
Comment: A commenter asked whether agents will be precluded from
charging the I/T/U for the records needed for payment determination or
quality assurance in cases in which a facility is using an outside
agent to manage its medical records and patient information.
Response: Under section 136.30(j), additional payment would not be
available for the cost of copying of medical records to an outside
agent who
[[Page 30708]]
manages medical records and patient information.
Comment: One commenter expressed concern that the proposed rule
does not clearly define what it means to ``participate'' in programs
operated by IHS, Tribes, Tribal organizations, or urban Indian (I/T/U)
programs.
Response: Participation in I/T/U programs means that all hospitals
covered by this rule must accept the admission practices, payment
methodology, and no more than the rates of payment established under
this rule as payment in full for items and services purchased by I/T/U
programs for individuals eligible for and referred by such programs. To
clarify that acceptance of these requirements is mandatory for
participation in Medicare, IHS has revised the proposed rule in two
ways. First, subsections (a) and (b) of 42 CFR 136.30 have been amended
to clarify which entities are affected by the rule and the services
that will be covered. Second, 42 CFR 489.29 has also been amended to be
consistent with 42 CFR part 136, subpart D. Paragraph (b) has been
added to 42 CFR 489.29 to clarify that hospitals cannot deny services
to an individual on the basis that payment for such services is
authorized by an I/T/U program. However, the rule does not provide
additional regulation of discrimination in admission practices because
such requirements are already covered and enforced by the HHS Office
for Civil Rights under existing regulations at 45 CFR part 80.
Comment: One commenter asked whether hospitals which are not
reimbursed on a reasonable cost basis will be reimbursed based on the
Medicare DRGs or other prospective payment rate.
Response: We have clarified the payment methodology in the final
rule in response to this comment. We are clarifying that, for hospital
services that would be paid under prospective payment systems (PPS) by
the Medicare program, the basic payment methodology under this rule is
based on the applicable PPS. For example, inpatient services furnished
by acute care hospitals, psychiatric hospitals, rehabilitation
hospitals, and long-term care hospitals will be paid based on their
respective PPS used in the Medicare program to pay for similar hospital
services to the hospitals' Medicare patients, as described under 42 CFR
part 412, while outpatient hospital services and skilled nursing
facility (SNF) services will be paid based on their Medicare PPS, as
described under 42 CFR part 419 (outpatient) and 42 CFR part 413 (SNF)
respectively. Under the basic payment methodology of this rule for
Medicare-participating hospitals that furnish inpatient services but
are exempt from PPS and currently receive reasonable cost reimbursement
under the Medicare program (for example, CAHs, children's hospitals,
cancer hospitals, and certain other hospitals reimbursed by Medicare
under special arrangements), I/T/Us will reimburse such hospitals for
claims in accordance with 42 CFR part 413, which addresses reasonable
cost reimbursement. In other words, hospitals reimbursed by Medicare on
a reasonable cost basis will not be paid by use of DRGs or other case
classification systems used under the various Medicare PPS payment
methods. To clarify what hospitals can expect to receive as
reimbursements, IHS has created two basic payment determinations under
section 136.30(c) in the final rule; one for PPS based payments and one
for payments based on reasonable costs.
Comment: Two commenters recommended that payment adjustments for
organ acquisition costs, blood clotting factors, new technology
services, and disproportionate share be included in the interim payment
calculations in order to provide for an appropriate level of
reimbursement.
Response: IHS agrees that payment adjustments for the types of
services listed above should be included in the payment calculations in
order to provide for an appropriate level of reimbursement. Payment
adjustments for disproportionate share and new medical technology
already are included in the PPS methodology under subparts F and G of
part 412. Moreover, to ensure that hospitals receiving PPS payment
include these payment adjustments, IHS will use the Medicare PRICER
system (or a similar system) in calculating final payment. The system
includes adjustments such as those above. For items not adjusted within
the system, the IHS fiscal intermediary will be instructed to use
standard payments calculated by CMS (for example, payments based on the
Average Sales Price (ASP) for hemophilia clotting factors). To clarify
that such payments will be added to the basic rate calculation, IHS has
added a new section 136.30(d) to the rule.
Comment: Several commenters expressed concern that the interim
payment rates will have a financial impact on CAHs. Another commenter
expressed concern about the per diem mechanism used to make interim
payments to CAHs because there is no requirement to follow Medicare
regulations by the I/T/U.
Response: The economic financial impact study conducted by an IHS
fiscal intermediary demonstrates that the interim payment rates will
have limited financial impact on rural and small rural hospitals as
explained in section VI of this final rule, Regulatory Impact
Statement. Moreover, in revising the proposed adoption of the Medicare
payment methodologies in section 136.30(c) of the final rule, IHS has
identified two basic determinations for payment. Payments to CAHs are
covered under section 136.30(c)(2). IHS will follow payment guidance
based on the reasonable cost methodology under 42 CFR 413.70, ``Payment
for services of a CAH''. As with other payments based on reasonable
cost, payments to CAHs will be based on the interim payment rate
established under 42 CFR part 413, subpart E.
Comment: One commenter asked whether the final rule will be applied
to claims which are received after the effective date, regardless of
the date of service, or only to claims with a date of service after the
effective date.
Response: The requirements of the final rule will apply to claims
with a date of service on or after the effective date of the final
regulation.
Comment: A commenter asked whether contracts will become
invalidated by this regulation or remain in effect until they expire in
situations in which a hospital contract is currently in place with IHS,
which has rates that are not based on Medicare or are not less than
Medicare rates.
Response: Medicare-participating hospitals that furnish inpatient
services must accept the rate methodology established under this
regulation as a condition of participation in the Medicare program.
Current hospital contract rates that are lower than the rates
established by this regulation will continue to apply in accordance
with section 136.30(c).
Comment: One commenter asked if the Medicare timely filing
guidelines will be waived and/or modified for claims when the I/T/U (1)
is not the primary payor and the patient has alternate resources or,
(2) delayed in sending out a timely purchase order.
Response: Under 42 CFR 136.61, as applied in this rule, the I/T/U
program is the payor of last resort for individuals eligible for any
alternate resources. The timely filing period under 42 CFR 424.44 and
provisions of the Medicare Claims Processing Manual will apply to all
claims submitted to an I/T/U program for payment.
Comment: One commenter asked the IHS to remove the Health Insurance
Portability and Accountability Act
[[Page 30709]]
(HIPAA) requirement for electronic claim submission.
Response: If the I/T/U program accepts paper claims, this is still
an acceptable format for claims submission. However, if non-I/T/U
providers generally submit their claims electronically to other payers,
they should also do so for I/T/U payers that accept electronic claims.
HIPAA requires electronic claims to be filed using the standard 837
format.
IV. Collection of Information Requirements
This document does not impose any new information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 35). Note: The burden
requirements in section 136.30(h)(1) for submitting a claim form are
currently approved under OMB approval number 0938-0279.
V. Regulatory Impact Statement
The IHS has examined the impact of this final rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-
354), section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any 1 year). This action
is not a significant regulatory action under Executive Order 12866.
Further regulatory evaluation is not necessary because the economic
impact will be minimal.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and government agencies.
Most hospitals and most other providers and suppliers are small
entities, either by nonprofit status or by having revenues of $6
million to $29 million in any 1 year. Individuals and States are not
included in the definition of a small entity.
The I/T/Us have entered into contracts with many public and private
non-I/T Medicare-participating hospitals at rates less than or equal to
the rate proposed in this rule. IHS intends to continue existing
contracts with these hospitals; however, to the extent that I/T/Us are
not able to negotiate a contract with a hospital, payment rates
established by this rule will apply. This action will alleviate the
need for and administrative burden of negotiating rates through
individual contracts by IHS as well as the Medicare-participating
hospitals.
The IHS conducted a study to determine the financial impact the
interim payment rates, as proposed by this regulation, would have on
public and private non-I/T/U hospitals. As part of this study, IHS
compared the interim rates to the rates that IHS has negotiated per
contracts with public and private non-I/T/U hospitals. For FY 2003, of
the 387 hospitals that IHS does business with, IHS has negotiated
contracts with 48 percent of these hospitals. Based on IHS data, the
findings revealed the overall negative impact on these public and
private non-I/T/U hospitals would be less than 1 percent. Of the 387
hospitals in the study, 105 are rural hospitals. Out of the 105 rural
hospitals, 84 are small rural hospitals (less than 100 beds). By
comparing the interim rate to full billed charges, (that is, what IHS
pays if a contract is not negotiated) revealed a negative financial
impact of 8 percent on these rural hospitals. Further analysis of the
inpatient bed utilization by hospital revealed IHS represents less than
2 percent of the rural and small rural hospitals total business meaning
that 98 percent of the hospitals' income comes from other sources. For
these reasons, IHS has determined that the rates proposed by these
regulations will not have a significant economic impact on a
substantial number of small entities within the meaning of the
Regulatory Flexibility Act, 5 U.S.C. 601 et seq.
In addition, section 1102(b) of the Act requires IHS to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, IHS defines a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. For the reasons provided
above, IHS has determined that this rule will not have a significant
impact on the operations of a substantial number of small rural
hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose requirements mandate expenditure in any 1 year
by State, local, or Tribal governments, in the aggregate, or by the
private sector, of $120 million. This proposal would not impose
substantial Federal mandates on State, local or Tribal governments or
private sector.
Executive Order 13132 establishes certain requirements that an
Agency must meet when it promulgates a final rule that imposes
substantial direct requirement costs on State and local governments,
preempts State law, or otherwise has Federalism implications. It has
been determined that this action would not have a substantial direct
effect on the States, on the relationship between the national
Government and the States, or on the distribution of power and
responsibilities among the various levels of government, and therefore
would not have Federalism implications.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance)
List of Subjects
42 CFR Part 136
American Indian, Alaska Natives, Health, Medicare.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
Dated: November 2, 2006.
Charles W. Grim,
Assistant Surgeon General, Director, Indian Health Service.
Dated: November 16, 2006.
Leslie V. Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: April 18, 2007.
Michael O. Leavitt,
Secretary.
0
The Indian Health Service is amending 42 CFR Chapter I as set forth
below:
PART 136--INDIAN HEALTH
0
1. The authority citation for part 136 continues to read as follows:
Authority: 25 U.S.C. 13; 42 U.S.C. 1395cc(a)(1)(U), 42 U.S.C.
2001 and 2003, unless otherwise noted.
[[Page 30710]]
0
2. Add new subpart D consisting of Sec. Sec. 136.30 through 136.32, to
read as follows:
Subpart D--Limitation on Charges for Services Furnished by Medicare-
Participating Hospitals to Indians
Sec.
136.30 Payment to Medicare-participating hospitals for authorized
Contract Health Services.
136.31 Authorization by urban Indian organization.
136.32 Disallowance.
Subpart D--Limitation on Charges for Services Furnished by
Medicare-Participating Hospitals to Indians
Sec. 136.30 Payment to Medicare-participating hospitals for
authorized Contract Health Services.
(a) Scope. All Medicare-participating hospitals, which are defined
for purposes of this subpart to include all departments and provider-
based facilities of hospitals (as defined in sections 1861(e) and (f)
of the Social Security Act) and critical access hospitals (as defined
in section 1861(mm)(1) of the Social Security Act), that furnish
inpatient services must accept no more than the rates of payment under
the methodology described in this section as payment in full for all
items and services authorized by IHS, Tribal, and urban Indian
organization entities, as described in paragraph (b) of this section.
(b) Applicability. The payment methodology under this section
applies to all levels of care furnished by a Medicare-participating
hospital, whether provided as inpatient, outpatient, skilled nursing
facility care, as other services of a department, subunit, distinct
part, or other component of a hospital (including services furnished
directly by the hospital or under arrangements) that is authorized
under part 136, subpart C by a contract health service (CHS) program of
the Indian Health Service (IHS); or authorized by a Tribe or Tribal
organization carrying out a CHS program of the IHS under the Indian
Self-Determination and Education Assistance Act, as amended, Pub. L.
93-638, 25 U.S.C. 450 et seq.; or authorized for purchase under Sec.
136.31 by an urban Indian organization (as that term is defined in 25
U.S.C. 1603(h)) (hereafter ``I/T/U'').
(c) Basic determination. (1) Payment for hospital services that the
Medicare program would pay under a prospective payment system (PPS)
will be based on that PPS. For example, payment for inpatient hospital
services shall be made per discharge based on the applicable PPS used
by the Medicare program to pay for similar hospital services under 42
CFR part 412. Payment for outpatient hospital services shall be made
based on a PPS used in the Medicare program to pay for similar hospital
services under 42 CFR part 419. Payment for skilled nursing facility
(SNF) services shall be based on a PPS used in the Medicare program to
pay for similar SNF services under 42 CFR part 413.
(2) For Medicare participating hospitals that furnish inpatient
services but are exempt from PPS and receive reimbursement based on
reasonable costs (for example, critical access hospitals (CAHs),
children's hospitals, cancer hospitals, and certain other hospitals
reimbursed by Medicare under special arrangements), including provider
subunits exempt from PPS, payment shall be made per discharge based on
the reasonable cost methods established under 42 CFR part 413, except
that the interim payment rate under 42 CFR part 413, subpart E shall
constitute payment in full for authorized charges.
(d) Other payments. In addition to the amount payable under
paragraph (c)(1) of this section for authorized inpatient services,
payments shall include an amount to cover: The organ acquisition costs
incurred by hospitals with approved transplantation centers; direct
medical education costs; units of blood clotting factor furnished to an
eligible patient who is a hemophiliac; and the costs of qualified non-
physician anesthetists, to the extent such costs would be payable if
the services had been covered by Medicare. Payment under this
subsection shall be made on a per discharge basis and will be based on
standard payments established by the Centers for Medicare & Medicaid
Services (CMS) or its fiscal intermediaries.
(e) Basic payment calculation. The calculation of the payment by I/
T/Us will be based on determinations made under paragraphs (c) and (d)
of this section consistent with CMS instructions to its fiscal
intermediaries at the time the claim is processed. Adjustments will be
made to correct billing or claims processing errors, including when
fraud is detected. I/T/Us shall pay the providing hospital the full PPS
based rate, or the interim reasonable cost rate, without reduction for
any co-payments, coinsurance, and deductibles required by the Medicare
program from the patient.
(f) Exceptions to payment calculation. Notwithstanding paragraph
(e) of this section, if an amount has been negotiated with the hospital
or its agent by the I/T/U, the I/T/U will pay the lesser of: The amount
determined under paragraph (e) of this section or the amount negotiated
with the hospital or its agent, including but not limited to capitated
contracts or contracts per Federal law requirements;
(g) Coordination of benefits and limitation on recovery. If an I/T/
U has authorized payment for items and services provided to an
individual who is eligible for benefits under Medicare, Medicaid, or
another third party payor--
(1) The I/T/U shall be the payor of last resort under Sec. 136.61;
(2) If there are any third party payers, the I/T/U will pay the
amount for which the patient is being held responsible after the
provider of services has coordinated benefits and all other alternative
resources have been considered and paid, including applicable co-
payments, deductibles, and coinsurance that are owed by the patient;
and
(3) The maximum payment by the I/T/U will be only that portion of
the payment amount determined under this section not covered by any
other payor; and
(4) The I/T/U payment will not exceed the rate calculated in
accordance with paragraph (e) of this section or the contracted amount
(plus applicable cost sharing), whichever is less; and
(5) When payment is made by Medicaid it is considered payment in
full and there will be no additional payment made by the I/T/U to the
amount paid by Medicaid (except for applicable cost sharing).
(h) Claims processing. For a hospital to be eligible for payment
under this section, the hospital or its agent must submit the claim for
authorized services--
(1) On a UB92 paper claim form (until abolished, or on an
officially adopted successor form) or the HIPAA 837 electronic claims
format ANSI X12N, version 4010A1 (until abolished, or on an officially
adopted successor form) and include the hospital's Medicare provider
number/National Provider Identifier; and
(2) To the I/T/U, agent, or fiscal intermediary identified by the
I/T/U in the agreement between the I/T/U and the hospital or in the
authorization for services provided by the I/T/U; and
(3) Within a time period equivalent to the timely filing period for
Medicare claims under 42 CFR 424.44 and provisions of the Medicare
Claims Processing Manual applicable to the type of item or service
provided.
(i) Authorized services. Payment shall be made only for those items
and
[[Page 30711]]
services authorized by an I/T/U consistent with part 136 of this title
or section 503(a) of the Indian Health Care Improvement Act (IHCIA),
Public Law 94-437, as amended, 25 U.S.C. 1653(a).
(j) No additional charges. A payment made in accordance with this
section shall constitute payment in full and the hospital or its agent
may not impose any additional charge--
(1) On the individual for I/T/U authorized items and services; or
(2) For information requested by the I/T/U or its agent or fiscal
intermediary for the purposes of payment determinations or quality
assurance.
Sec. 136.31 Authorization by urban Indian organization.
An urban Indian organization may authorize for purchase items and
services for an eligible urban Indian (as those terms are defined in 25
U.S.C. 1603(f) and (h)) according to section 503 of the IHCIA and
applicable regulations. Services and items furnished by Medicare-
participating inpatient hospitals shall be subject to the payment
methodology set forth in Sec. 136.30.
Sec. 136.32 Disallowance.
(a) If it is determined that a hospital has submitted inaccurate
information for payment, such as admission, discharge or billing data,
an I/T/U may as appropriate--
(1) Deny payment (in whole or in part) with respect to any such
services, and;
(2) Disallow costs previously paid, including any payments made
under any methodology authorized under this subpart. The recovery of
payments made in error may be taken by any method authorized by law.
(b) For cost based payments previously issued under this subpart,
if it is determined that actual costs fall significantly below the
computed rate actually paid, the computed rate may be retrospectively
adjusted. The recovery of overpayments made as a result of the adjusted
rate may be taken by any method authorized by law.
0
The Centers for Medicare & Medicaid Services is amending 42 CFR Chapter
IV, as set forth below:
PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
0
3. The authority citation for part 489 continues to read as follows:
Authority: Sec. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart B--Essentials of Provider Agreements
0
4. A new Sec. 489.29 is added to subpart B to read as follows:
Sec. 489.29 Special requirements concerning beneficiaries served by
the Indian Health Service, Tribal health programs, and urban Indian
organization health programs.
(a) Hospitals (as defined in sections 1861(e) and (f) of the Social
Security Act) and critical access hospitals (as defined in section
1861(mm)(1) of the Social Security Act) that participate in the
Medicare program and furnish inpatient hospital services must accept
the payment methodology and no more than the rates of payment
established under 42 CFR part 136, subpart D as payment in full for the
following programs:
(1) A contract health service (CHS) program under 42 CFR part 136,
subpart C, of the Indian Health Service (IHS);
(2) A CHS program under 42 CFR part 136, subpart C, carried out by
an Indian Tribe or Tribal organization pursuant to the Indian Self-
Determination and Education Assistance Act, as amended, Public Law 93-
638, 25 U.S.C. 450 et seq.; and
(3) A program funded through a grant or contract by the IHS and
operated by an urban Indian organization under which items and services
are purchased for an eligible urban Indian (as those terms are defined
in 25 U.S.C. 1603 (f) and (h)).
(b) Hospitals and critical access hospitals may not refuse service
to an individual on the basis that the payment for such service is
authorized under programs described in paragraph (a) of this section.
[FR Doc. 07-2740 Filed 6-1-07; 8:45 am]
BILLING CODE 4165-16-P
