81 FR 80063 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible Beginning January 1, 2017

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 81, Issue 220 (November 15, 2016)

Page Range		80063-80071
FR Document		2016-27425

This notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under age 65) beneficiaries enrolled in Part B of the Medicare Supplementary Medical Insurance (SMI) program beginning January 1, 2017. In addition, this notice announces the monthly premium for aged and disabled beneficiaries, the deductible for 2017, and the income-related monthly adjustment amounts to be paid by beneficiaries with modified adjusted gross income above certain threshold amounts. The monthly actuarial rates for 2017 are $261.90 for aged enrollees and $254.20 for disabled enrollees. The standard monthly Part B premium rate for all enrollees for 2017 is $134.00, which is equal to 50 percent of the monthly actuarial rate for aged enrollees (or approximately 25 percent of the expected average total cost of Part B coverage for aged enrollees) plus $3.00. (The 2016 standard premium rate was $121.80, which includes the $3.00 repayment amount.) The Part B deductible for 2017 is $183.00 for all Part B beneficiaries. If a beneficiary has to pay an income-related monthly adjustment, they will have to pay a total monthly premium of about 35, 50, 65, or 80 percent of the total cost of Part B coverage plus $4.20, $6.00, $7.80, or $9.60.

Federal Register, Volume 81 Issue 220 (Tuesday, November 15, 2016)

[Federal Register Volume 81, Number 220 (Tuesday, November 15, 2016)]
[Notices]
[Pages 80063-80071]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2016-27425]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-8064-N]
RIN 0938-AS72

Medicare Program; Medicare Part B Monthly Actuarial Rates,
Premium Rate, and Annual Deductible Beginning January 1, 2017

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces the monthly actuarial rates for aged
(age 65 and over) and disabled (under age 65) beneficiaries enrolled in
Part B of the Medicare Supplementary Medical Insurance (SMI) program
beginning January 1, 2017. In addition, this notice announces the
monthly premium for aged and disabled beneficiaries, the deductible for
2017, and the income-related monthly adjustment amounts to be paid by
beneficiaries with modified adjusted gross income above certain
threshold amounts. The monthly actuarial rates for 2017 are $261.90 for
aged enrollees and $254.20 for disabled enrollees. The standard monthly
Part B premium rate for all enrollees for 2017 is $134.00, which is
equal to 50 percent of the monthly actuarial rate for aged enrollees
(or approximately 25 percent of the expected average total cost of Part
B coverage for aged enrollees) plus $3.00. (The 2016 standard premium
rate was $121.80, which includes the $3.00 repayment amount.) The Part
B deductible for 2017 is $183.00 for all Part B beneficiaries. If a
beneficiary has to pay an income-related monthly adjustment, they will
have to pay a total monthly premium of about 35, 50, 65, or 80 percent
of the total cost of Part B coverage plus $4.20, $6.00, $7.80, or
$9.60.

DATES: Effective Date: January 1, 2017.

FOR FURTHER INFORMATION CONTACT: M. Kent Clemens, (410) 786-6391.

SUPPLEMENTARY INFORMATION:

I. Background

Part B is the voluntary portion of the Medicare program that pays
all or part of the costs for physicians' services, outpatient hospital
services, certain home health services, services furnished by rural
health clinics, ambulatory surgical centers, comprehensive outpatient
rehabilitation facilities, and certain other medical and health
services not covered by Medicare Part A, Hospital Insurance. Medicare
Part B

[[Page 80064]]

is available to individuals who are entitled to Medicare Part A, as
well as to U.S. residents who have attained age 65 and are citizens,
and aliens who were lawfully admitted for permanent residence and have
resided in the United States for 5 consecutive years. Part B requires
enrollment and payment of monthly premiums, as described in 42 CFR part
407, subpart B, and part 408, respectively. The premiums paid by (or on
behalf of) all enrollees fund approximately one-fourth of the total
incurred costs, and transfers from the general fund of the Treasury pay
approximately three-fourths of these costs.
The Secretary of the Department of Health and Human Services (the
Secretary) is required by section 1839 of the Social Security Act (the
Act) to announce the Part B monthly actuarial rates for aged and
disabled beneficiaries as well as the monthly Part B premium. The Part
B annual deductible is included because its determination is directly
linked to the aged actuarial rate.
The monthly actuarial rates for aged and disabled enrollees are
used to determine the correct amount of general revenue financing per
beneficiary each month. These amounts, according to actuarial
estimates, will equal, respectively, one-half of the expected average
monthly cost of Part B for each aged enrollee (age 65 or over) and one-
half of the expected average monthly cost of Part B for each disabled
enrollee (under age 65).
The Part B deductible to be paid by enrollees is also announced.
Prior to the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (MMA) (Pub. L. 108-173), the Part B deductible was set in
statute. After setting the 2005 deductible amount at $110, section 629
of the MMA (amending section 1833(b) of the Act) requires that the Part
B deductible be indexed beginning in 2006. The inflation factor to be
used each year is the annual percentage increase in the Part B
actuarial rate for enrollees age 65 and over. Specifically, the 2017
Part B deductible is calculated by multiplying the 2016 deductible by
the ratio of the 2017 aged actuarial rate to the 2016 aged actuarial
rate. The amount determined under this formula is then rounded to the
nearest $1.
The monthly Part B premium rate to be paid by aged and disabled
enrollees is also announced. (Although the costs to the program per
disabled enrollee are different than for the aged, the statute provides
that they pay the same premium amount.) Beginning with the passage of
section 203 of the Social Security Amendments of 1972 (Pub. L. 92-603),
the premium rate, which was determined on a fiscal year basis, was
limited to the lesser of the actuarial rate for aged enrollees, or the
current monthly premium rate increased by the same percentage as the
most recent general increase in monthly Title II social security
benefits.
However, the passage of section 124 of the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA) (Pub. L. 97-248) suspended this
premium determination process. Section 124 of TEFRA changed the premium
basis to 50 percent of the monthly actuarial rate for aged enrollees
(that is, 25 percent of program costs for aged enrollees). Section 606
of the Social Security Amendments of 1983 (Pub. L. 98-21), section 2302
of the Deficit Reduction Act of 1984 (DEFRA 84) (Pub. L. 98-369),
section 9313 of the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA 85) (Pub. L. 99-272), section 4080 of the Omnibus Budget
Reconciliation Act of 1987 (OBRA 87) (Pub. L. 100-203), and section
6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) (Pub.
L. 101-239) extended the provision that the premium be based on 50
percent of the monthly actuarial rate for aged enrollees (that is, 25
percent of program costs for aged enrollees). This extension expired at
the end of 1990.
The premium rate for 1991 through 1995 was legislated by section
1839(e)(1)(B) of the Act, as added by section 4301 of the Omnibus
Budget Reconciliation Act of 1990 (OBRA 90) (Pub. L. 101-508). In
January 1996, the premium determination basis would have reverted to
the method established by the 1972 Social Security Act Amendments.
However, section 13571 of the Omnibus Budget Reconciliation Act of 1993
(OBRA 93) (Pub. L. 103-66) changed the premium basis to 50 percent of
the monthly actuarial rate for aged enrollees (that is, 25 percent of
program costs for aged enrollees) for 1996 through 1998.
Section 4571 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-
33) permanently extended the provision that the premium be based on 50
percent of the monthly actuarial rate for aged enrollees (that is, 25
percent of program costs for aged enrollees).
The BBA included a further provision affecting the calculation of
the Part B actuarial rates and premiums for 1998 through 2003. Section
4611 of the BBA modified the home health benefit payable under Part A
for individuals enrolled in Part B. Under this section, beginning in
1998, expenditures for home health services not considered ``post-
institutional'' are payable under Part B rather than Part A. However,
section 4611(e)(1) of the BBA required that there be a transition from
1998 through 2002 for the aggregate amount of the expenditures
transferred from Part A to Part B. Section 4611(e)(2) of the BBA also
provided a specific yearly proportion for the transferred funds. The
proportions were \1/6\ for 1998, \1/3\ for 1999, \1/2\ for 2000, \2/3\
for 2001, and \5/6\ for 2002. For the purpose of determining the
correct amount of financing from general revenues of the Federal
Government, it was necessary to include only these transitional amounts
in the monthly actuarial rates for both aged and disabled enrollees,
rather than the total cost of the home health services being
transferred.
Section 4611(e)(3) of the BBA also specified, for the purpose of
determining the premium, that the monthly actuarial rate for enrollees
age 65 and over be computed as though the transition would occur for
1998 through 2003 and that \1/7\ of the cost be transferred in 1998,
\2/7\ in 1999, \3/7\ in 2000, \4/7\ in 2001, \5/7\ in 2002, and \6/7\
in 2003. Therefore, the transition period for incorporating this home
health transfer into the premium was 7 years while the transition
period for including these services in the actuarial rate was 6 years.
Section 811 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Pub. L. 108-173, also known as the Medicare
Modernization Act, or MMA), which amended section 1839 of the Act,
requires that, starting on January 1, 2007, the Part B premium a
beneficiary pays each month be based on their annual income.
Specifically, if a beneficiary's ``modified adjusted gross income'' is
greater than the legislated threshold amounts (for 2017, $85,000 for a
beneficiary filing an individual income tax return, and $170,000 for a
beneficiary filing a joint tax return) the beneficiary is responsible
for a larger portion of the estimated total cost of Part B benefit
coverage. In addition to the standard 25 percent premium, these
beneficiaries now have to pay an income-related monthly adjustment
amount. The MMA made no change to the actuarial rate calculation, and
the standard premium, which will continue to be paid by beneficiaries
whose modified adjusted gross income is below the applicable
thresholds, still represents 25 percent of the estimated total cost to
the program of Part B coverage for an aged enrollee. However, depending
on income and tax filing status, a beneficiary can now be responsible
for 35, 50, 65, or 80 percent of the estimated total cost of Part B

[[Page 80065]]

coverage, rather than 25 percent. (For 2018 and subsequent years, the
income thresholds are lower for the two highest income ranges, as a
result of the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) (Pub. L. 114-10).) The end result of the higher premium is that
the Part B premium subsidy is reduced and less general revenue
financing is required for beneficiaries with higher income because they
are paying a larger share of the total cost with their premium. That
is, the premium subsidy continues to be approximately 75 percent for
beneficiaries with income below the applicable income thresholds, but
will be reduced for beneficiaries with income above these thresholds.
The MMA specified that there be a 5-year transition to full
implementation of this provision. However, section 5111 of the Deficit
Reduction Act of 2005 (DRA) (Pub. L. 109-171) modified the transition
to a 3-year period.
Section 4732(c) of the BBA added section 1933(c) of the Act, which
required the Secretary to allocate money from the Part B trust fund to
the state Medicaid programs for the purpose of providing Medicare Part
B premium assistance from 1998 through 2002 for the low-income Medicaid
beneficiaries who qualify under section 1933 of the Act. This
allocation, while not a benefit expenditure, was an expenditure of the
trust fund and was included in calculating the Part B actuarial rates
through 2002. For 2003 through 2015, the expenditure was made from the
trust fund because the allocation was temporarily extended. However,
because the extension occurred after the financing was determined, the
allocation was not included in the calculation of the financing rates
for these years. Section 211 of MACRA permanently extended this
expenditure, which is included in the calculation of the Part B
actuarial rates for 2016 and subsequent years.
Another provision affecting the calculation of the Part B premium
is section 1839(f) of the Act, as amended by section 211 of the
Medicare Catastrophic Coverage Act of 1988 (MCCA 88) (Pub. L. 100-360).
(The Medicare Catastrophic Coverage Repeal Act of 1989 (Pub. L. 101-
234) did not repeal the revisions to section 1839(f) of the Act made by
MCCA 88.) Section 1839(f) of the Act, referred to as the ``hold-
harmless'' provision, provides that if an individual is entitled to
benefits under section 202 or 223 of the Act (the Old-Age and Survivors
Insurance Benefit and the Disability Insurance Benefit, respectively)
and has the Part B premium deducted from these benefit payments, the
premium increase will be reduced, if necessary, to avoid causing a
decrease in the individual's net monthly payment. This decrease in
payment occurs if the increase in the individual's social security
benefit due to the cost-of-living adjustment under section 215(i) of
the Act is less than the increase in the premium. Specifically, the
reduction in the premium amount applies if the individual is entitled
to benefits under section 202 or 223 of the Act for November and
December of a particular year and the individual's Part B premiums for
December and the following January are deducted from the respective
month's section 202 or 223 benefits. The ``hold-harmless'' provision
does not apply to beneficiaries who are required to pay an income-
related monthly adjustment amount.
A check for benefits under section 202 or 223 of the Act is
received in the month following the month for which the benefits are
due. The Part B premium that is deducted from a particular check is the
Part B payment for the month in which the check is received. Therefore,
a benefit check for November is not received until December, but has
December's Part B premium deducted from it.
Generally, if a beneficiary qualifies for hold-harmless protection,
the reduced premium for the individual for that January and for each of
the succeeding 11 months is the greater of either--
The monthly premium for January reduced as necessary to
make the December monthly benefits, after the deduction of the Part B
premium for January, at least equal to the preceding November's monthly
benefits, after the deduction of the Part B premium for December; or
The monthly premium for that individual for that December.
In determining the premium limitations under section 1839(f) of the
Act, the monthly benefits to which an individual is entitled under
section 202 or 223 of the Act do not include retroactive adjustments or
payments and deductions on account of work. Also, once the monthly
premium amount is established under section 1839(f) of the Act, it will
not be changed during the year even if there are retroactive
adjustments or payments and deductions on account of work that apply to
the individual's monthly benefits.
Individuals who have enrolled in Part B late or who have re-
enrolled after the termination of a coverage period are subject to an
increased premium under section 1839(b) of the Act. The increase is a
percentage of the premium and is based on the new premium rate before
any reductions under section 1839(f) of the Act are made.
Section 1839 of the Act, as amended by section 601(a) of the
Bipartisan Budget Act of 2015 (Pub. L. 114-74), specified that the 2016
actuarial rate for enrollees age 65 and older be determined as if the
hold-harmless provision did not apply. The premium revenue that was
lost by using the resulting lower premium (excluding the foregone
income-related premium revenue) was replaced by a transfer of general
revenue from the Treasury, which will be repaid over time to the
general fund.
Starting in 2016, in order to repay the balance due (which includes
the transfer amount and the foregone income-related premium revenue),
the Part B premium otherwise determined will be increased by $3.00.
These repayment amounts will be added to the Part B premium otherwise
determined each year and paid back to the general fund of the Treasury
and will continue until the balance due is paid back.
High-income enrollees pay an additional $1.20, $3.00, $4.80, or
$6.60 as part of the income-related monthly adjustment amount (IRMAA)
premium dollars, which reduce (dollar for dollar) the amount of general
revenue received by Part B from the general fund of the Treasury.
Because of this general revenue offset, the repayment IRMAA premium
dollars are not included in the direct repayments made to the general
fund of the Treasury from Part B in order to avoid a double repayment.
(Only the $3.00 monthly repayment amounts are included in the direct
repayments).
These repayment amounts will continue until the total amount
collected is equal to the beginning balance due. (In the final year of
the repayment, the additional amounts may be modified in order to avoid
an overpayment.) The repayment amounts (excluding the repayment amounts
for high-income enrollees) are subject to the hold harmless provision.
The beginning balance due was $9,066,409,000, consisting of
$1,625,761,000 in forgone income-related premium revenue plus a
transfer amount of $7,440,648,000. It is estimated that $701,088,000
will have been collected for repayment to the general fund by the end
of 2016.

II. Provisions of the Notice

A. Notice of Medicare Part B Monthly Actuarial Rates, Monthly Premium
Rates, and Annual Deductible

The Medicare Part B monthly actuarial rates applicable for 2017 are
$261.90 for enrollees age 65 and over

[[Page 80066]]

and $254.20 for disabled enrollees under age 65. In section II.B. of
this notice, we present the actuarial assumptions and bases from which
these rates are derived. The Part B standard monthly premium rate for
all enrollees for 2017 is $134.00.
Section 1839 of the Act requires the Secretary to determine the
monthly actuarial rates, including an appropriate amount for a
contingency margin, and the Part B premium each year. For 2017, the
Secretary made the determination that a 13 percent target reserve ratio
by the end of 2017 is appropriate and reasonable to balance both the
level of premium increase necessary for the incurred expenditures and
the reserve ratio. With the selected target reserve ratio, the Part B
premium in 2017 is a 10 percent increase from 2016.
The following are the 2017 Part B monthly premium rates to be paid
by (or on behalf of) beneficiaries who file an individual tax return
(including those who are single, head of household, qualifying
widow(er) with dependent child, or married filing separately who lived
apart from their spouse for the entire taxable year), or a joint tax
return.

----------------------------------------------------------------------------------------------------------------
Income-related Total
Beneficiaries who file an individual tax return Beneficiaries who file a joint monthly monthly
with income: tax return with income: adjustment premium
amount amount
----------------------------------------------------------------------------------------------------------------
Less than or equal to $85,000.................. Less than or equal to $170,000... $0.00 $134.00
Greater than $85,000 and less than or equal to Greater than $170,000 and less 53.50 187.50
$107,000. than or equal to $214,000.
Greater than $107,000 and less than or equal to Greater than $214,000 and less 133.90 267.90
$160,000. than or equal to $320,000.
Greater than $160,000 and less than or equal to Greater than $320,000 and less 214.30 348.30
$214,000. than or equal to $428,000.
Greater than $214,000.......................... Greater than $428,000............ 294.60 428.60
----------------------------------------------------------------------------------------------------------------

In addition, the monthly premium rates to be paid by (or on behalf
of) beneficiaries who are married and lived with their spouse at any
time during the taxable year, but file a separate tax return from their
spouse, are as follows:

------------------------------------------------------------------------
Beneficiaries who are married and lived Income-related Total
with their spouse at any time during the monthly monthly
year, but file a separate tax return from adjustment premium
their spouse: amount amount
------------------------------------------------------------------------
Less than or equal to $85,000............. $0.00 $134.00
Greater than $85,000 and less than or 214.30 348.30
equal to $129,000........................
Greater than $129,000..................... 294.60 428.60
------------------------------------------------------------------------

The Part B annual deductible for 2017 is $183.00 for all
beneficiaries.

B. Statement of Actuarial Assumptions and Bases Employed in Determining
the Monthly Actuarial Rates and the Monthly Premium Rate for Part B
Beginning January 2017

Except where noted, the actuarial assumptions and bases used to
determine the monthly actuarial rates and the monthly premium rates for
Part B are established by the Centers for Medicare & Medicaid Services
Office of the Actuary. The estimates underlying these determinations
are prepared by actuaries meeting the qualification standards and
following the actuarial standards of practice established by the
Actuarial Standards Board.
1. Actuarial Status of the Part B Account in the Supplementary Medical
Insurance Trust Fund
Under section 1839 of the Act, the starting point for determining
the standard monthly premium is the amount that would be necessary to
finance Part B on an incurred basis. This is the amount of income that
would be sufficient to pay for services furnished during that year
(including associated administrative costs) even though payment for
some of these services will not be made until after the close of the
year. The portion of income required to cover benefits not paid until
after the close of the year is added to the trust fund and used when
needed.
The premium rates are established prospectively and are, therefore,
subject to projection error. Additionally, legislation enacted after
the financing was established, but effective for the period in which
the financing is set, may affect program costs. As a result, the income
to the program may not equal incurred costs. Therefore, trust fund
assets must be maintained at a level that is adequate to cover an
appropriate degree of variation between actual and projected costs, and
the amount of incurred, but unpaid, expenses. Numerous factors
determine what level of assets is appropriate to cover variation
between actual and projected costs. The three most important of these
factors are the: (1) Difference from prior years between the actual
performance of the program and estimates made at the time financing was
established; (2) likelihood and potential magnitude of expenditure
changes resulting from enactment of legislation affecting Part B costs
in a year subsequent to the establishment of financing for that year;
and (3) expected relationship between incurred and cash expenditures.
These factors are analyzed on an ongoing basis, as the trends can vary
over time.
Table 1 summarizes the estimated actuarial status of the trust fund
as of the end of the financing period for 2015 and 2016.

[[Page 80067]]

Table 1--Estimated Actuarial Status of the Part B Account in the Supplementary Medical Insurance Trust Fund as
of the End of the Financing Period
----------------------------------------------------------------------------------------------------------------
Assets less
Financing period ending Assets ($ in Liabilities ($ liabilities ($ in
millions) in millions) millions)
----------------------------------------------------------------------------------------------------------------
December 31, 2015...................................... 68,157 24,712 43,445
December 31, 2016...................................... 85,169 26,487 58,682
----------------------------------------------------------------------------------------------------------------

2. Monthly Actuarial Rate for Enrollees Age 65 and Older
The monthly actuarial rate for enrollees age 65 and older is one-
half of the sum of monthly amounts for: (1) The projected cost of
benefits; and (2) administrative expenses for each enrollee age 65 and
older, after adjustments to this sum to allow for interest earnings on
assets in the trust fund and an adequate contingency margin. The
contingency margin is an amount appropriate to provide for possible
variation between actual and projected costs and to amortize any
surplus assets or unfunded liabilities.
The monthly actuarial rate for enrollees age 65 and older for 2017
is determined by first establishing per-enrollee cost by type of
service from program data through 2016 and then projecting these costs
for subsequent years. The projection factors used for financing periods
from January 1, 2014 through December 31, 2017 are shown in Table 2.
As indicated in Table 3, the projected per-enrollee amount required
to pay for one-half of the total of benefits and administrative costs
for enrollees age 65 and over for 2017 is $238.61. Based on current
estimates, the assets associated with the aged Medicare beneficiaries
at the end of 2016 are not sufficient to cover the amount of incurred,
but unpaid, expenses and to provide for a significant degree of
variation between actual and projected costs. Thus, a positive
contingency margin is needed. The monthly actuarial rate of $261.90
provides an adjustment of $25.07 for a contingency margin and -$1.78
for interest earnings.
The contingency margin for 2017 is affected by several factors. As
noted previously, for most Part B beneficiaries the hold-harmless
provision prevents their benefits under Section 202 or 223 of the Act
from decreasing as a result of an increase in the Part B premium. For
2016, social security benefits received no cost-of-living adjustment
and therefore the majority of Part B enrollees were held harmless and
paid a premium of $104.90, rather than the 2016 premium of $121.80. On
October 18, 2016, the Social Security Administration announced that the
increase in the benefits under Section 202 and 223 of the Act will be
0.3 percent for 2017. As a result, the average 2017 social security
benefit increase will be about $4.00 and the average 2017 premium paid
by Part B enrollees who are held harmless will be about $109.00.
Consequently, a minority of Part B enrollees will pay (or have paid on
their behalf) a larger-than-normal premium, resulting from an increased
contingency margin. The Part B premium of $134.00 for 2017 will be paid
by (or on behalf of) approximately 30 percent of beneficiaries (those
not subject to the hold-harmless provision). (As noted previously,
individuals with higher incomes would not be held harmless and would
pay a 2017 premium that is higher than $134.00.)
Two other factors affect the contingency margin for 2017. Starting
in 2011, manufacturers and importers of brand-name prescription drugs
have paid a fee that is allocated to the Part B account of the SMI
trust. For 2017, the total of these brand-name drug fees is estimated
to be $3.9 billion. The contingency margin has been reduced to account
for this additional revenue.
Another factor impacting the contingency margin comes from the
requirement that certain payment incentives, to encourage the
development and use of health information technology (HIT) by Medicare
physicians, are to be excluded from the premium determination. HIT
positive incentive payments or penalties will be directly offset
through transfers with the general fund of the Treasury. The monthly
actuarial rate includes an adjustment of -$0.13 for HIT incentive
payments in 2017.
The traditional goal for the Part B reserve has been that assets
minus liabilities at the end of a year should represent between 15 and
20 percent of the following year's total incurred expenditures. To
accomplish this goal, a 17 percent reserve ratio has been the normal
target used to calculate the Part B premium. The Secretary, who
determines the Part B premium each year under section 1839 of the Act,
directed the Office of the Actuary to use a target reserve ratio for
the Part B premium determination of 13 percent by the end of 2017. This
targets a 2017 reserve ratio that is lower than the reserve ratio
expected for the end of 2016. The Office of the Actuary has estimated
that a target reserve ratio of 14 percent is the minimally financially
adequate level for the Part B premium determination. The target reserve
ratio of 13 percent is below this level resulting in a non-trivial risk
of Part B income and trust fund assets being inadequate to cover Part B
costs, which would occur if experience is significantly worse than
current estimates. Financing rates in future years will likely need to
be increased to restore the contingency reserve to an adequate level.
The actuarial rate of $261.90 per month for aged beneficiaries, as
announced in this notice for 2017, reflects that combined effect of the
factors previously described and the projected assumptions listed in
Table 2.
3. Monthly Actuarial Rate for Disabled Enrollees
Disabled enrollees are those persons under age 65 who are enrolled
in Part B because of entitlement to Social Security disability benefits
for more than 24 months or because of entitlement to Medicare under the
end-stage renal disease (ESRD) program. Projected monthly costs for
disabled enrollees (other than those with ESRD) are prepared in a
fashion parallel to the projection for the aged using appropriate
actuarial assumptions (see Table 2). Costs for the ESRD program are
projected differently because of the different nature of services
offered by the program.
As shown in Table 4, the projected per-enrollee amount required to
pay for one-half of the total of benefits and administrative costs for
disabled enrollees for 2017 is $285.21. The monthly actuarial rate of
$254.20 also provides an adjustment of -$2.67 for interest earnings and
-$28.34 for a contingency margin, reflecting the same factors described
previously for the aged actuarial rate at magnitudes appropriate to the
disabled rate determination. Based on current estimates, the assets
associated with the disabled Medicare beneficiaries at the end of 2016
are more-than sufficient to cover the amount of incurred, but unpaid,
expenses and to provide for a significant

[[Page 80068]]

degree of variation between actual and projected costs. Thus, a
negative contingency margin is needed to decrease assets to an
appropriate level.
The actuarial rate of $254.20 per month for disabled beneficiaries,
as announced in this notice for 2017, reflects the combined net effect
of the factors described previously for aged beneficiaries and the
projection assumptions listed in Table 2.
4. Sensitivity Testing
Several factors contribute to uncertainty about future trends in
medical care costs. It is appropriate to test the adequacy of the rates
using alternative cost growth rate assumptions. The results of those
assumptions are shown in Table 5. One set represents increases that are
higher and, therefore, more pessimistic than the current estimate. The
other set represents increases that are lower and, therefore, more
optimistic than the current estimate. The values for the alternative
assumptions were determined from a statistical analysis of the
historical variation in the respective increase factors.
As indicated in Table 5, the monthly actuarial rates would result
in an excess of assets over liabilities of $45,497 million by the end
of December 2017 under the cost growth rate assumptions shown in Table
2 and assuming that the provisions of current law are fully
implemented. This amounts to 13.7 percent of the estimated total
incurred expenditures for the following year.
Assumptions that are somewhat more pessimistic (and that therefore
test the adequacy of the assets to accommodate projection errors)
produce a surplus of -$1,387 million by the end of December 2017 under
current law, which amounts to -0.4 percent of the estimated total
incurred expenditures for the following year. Under fairly optimistic
assumptions, the monthly actuarial rates would result in a surplus of
$89,869 million by the end of December 2017, or 31.0 percent of the
estimated total incurred expenditures for the following year.
The sensitivity analysis indicates that the premium and general
revenue financing established for 2017, together with existing Part B
account assets would not be adequate to cover estimated Part B costs
for 2017 under current law if actual costs prove to be somewhat greater
than expected.
5. Premium Rates and Deductible
As determined in accordance with section 1839 of the Act, listed
are the 2017 Part B monthly premium rates to be paid by beneficiaries
who file an individual tax return (including those who are single, head
of household, qualifying widow(er) with dependent child, or married
filing separately who lived apart from their spouse for the entire
taxable year), or a joint tax return.

In addition, the monthly premium rates to be paid by beneficiaries
who are married and lived with their spouse at any time during the
taxable year, but file a separate tax return from their spouse, are
listed as follows:

Table 2--Projection Factors \1\ 12-Month Periods Ending December 31 of 2014-2017
[In percent]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physicians' services Other
------------------------ Durable Carrier carrier Outpatient Home Hospital Other Managed
Calendar year Residual medical lab \4\ services hospital health lab \6\ intermediary care
Fees \2\ \3\ equipment \5\ agency services \7\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Aged:
2014...................... 0.5 0.6 -14.3 6.5 2.7 12.6 -0.6 -29.1 4.5 6.4
2015...................... -0.4 0.6 6.7 2.6 4.4 6.8 -1.4 2.4 5.0 2.1
2016...................... -0.4 0.1 -5.1 -1.6 6.3 5.4 0.4 3.1 4.4 3.7
2017...................... 0.4 1.2 0.6 5.8 2.8 7.5 2.1 2.9 5.3 4.8
Disabled:
2014...................... 0.5 1.9 -11.0 13.6 4.2 13.6 -1.3 -35.9 7.3 9.4
2015...................... -0.4 0.6 7.6 6.6 6.7 7.0 -1.0 0.6 9.9 1.4
2016...................... -0.4 0.8 -4.6 -12.9 6.7 5.5 0.5 4.4 8.7 4.5
2017...................... 0.4 1.2 0.5 5.8 3.1 7.4 2.4 2.8 5.4 4.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ All values for services other than managed care are per fee-for-service enrollee. Managed care values are per managed care enrollee.
\2\ As recognized for payment under the program.
\3\ Increase in the number of services received per enrollee and greater relative use of more expensive services.
\4\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
\5\ Includes physician-administered drugs, ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, supplies,
etc.
\6\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\7\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation, and psychiatric
hospitals, etc.

[[Page 80069]]

Table 3--Derivation of Monthly Actuarial Rate for Enrollees Age 65 and Over for Financing Periods Ending
December 31, 2014 Through December 31, 2017
[in dollars]
----------------------------------------------------------------------------------------------------------------
CY 2014 CY 2015 CY 2016 CY 2017
----------------------------------------------------------------------------------------------------------------
Covered services (at level recognized):
Physician fee schedule...................... 76.97 75.48 74.34 74.57
Durable medical equipment................... 6.07 6.34 5.95 5.90
Carrier lab \1\............................. 4.36 4.38 4.26 4.45
Other carrier services \2\.................. 22.05 22.53 23.66 24.01
Outpatient hospital......................... 41.35 43.20 45.00 47.78
Home health................................. 9.70 9.36 9.28 9.36
Hospital lab \3\............................ 2.25 2.25 2.29 2.33
Other intermediary services \4\............. 16.79 17.25 17.80 18.51
Managed care................................ 73.65 78.38 83.02 88.95
---------------------------------------------------------------
Total services.......................... 253.19 259.17 265.59 275.85
Cost sharing:
Deductible.................................. -5.63 -5.64 -6.36 -7.00
Coinsurance................................. -28.18 -28.02 -28.14 -28.48
Sequestration of benefits....................... -4.39 -4.51 -4.62 -4.81
HIT payment incentives.......................... -2.38 -1.08 -0.59 -0.13
---------------------------------------------------------------
Total benefits.......................... 212.61 219.92 225.88 235.42
Administrative expenses......................... 3.24 2.82 3.00 3.19
Incurred expenditures........................... 215.84 222.74 228.88 238.61
Value of interest............................... -1.93 -1.86 -1.75 -1.78
Contingency margin for projection error and to -4.11 -11.08 10.47 25.07
amortize the surplus or deficit................
---------------------------------------------------------------
Monthly actuarial rate.................. 209.80 209.80 237.60 261.90
----------------------------------------------------------------------------------------------------------------
\1\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
\2\ Includes physician-administered drugs, ambulatory surgical center facility costs, ambulance services,
parenteral and enteral drug costs, supplies, etc.
\3\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\4\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health
centers, rehabilitation and psychiatric hospitals, etc.

Table 4--Derivation of Monthly Actuarial Rate for Disabled Enrollees for Financing Periods Ending December 31,
2014 Through December 31, 2017
[in dollars]
----------------------------------------------------------------------------------------------------------------
CY 2014 CY 2015 CY 2016 CY 2017
----------------------------------------------------------------------------------------------------------------
Covered services (at level recognized):
Physician fee schedule...................... 83.44 81.07 79.87 79.59
Durable medical equipment................... 11.96 12.44 11.65 11.48
Carrier lab \1\............................. 7.18 7.41 6.34 6.58
Other carrier services \2\.................. 25.33 25.70 26.56 26.83
Outpatient hospital......................... 59.58 61.51 63.56 66.98
Home health................................. 8.28 7.92 7.79 7.82
Hospital lab \3\............................ 2.85 2.79 2.86 2.89
Other intermediary services \4\............. 44.96 45.19 46.82 48.21
Managed care................................ 65.16 72.59 79.66 87.19
---------------------------------------------------------------
Total services.......................... 308.74 316.61 325.13 337.55
Cost sharing:
Deductible.................................. -5.29 -5.30 -5.97 -6.57
Coinsurance................................. -43.12 -42.78 -43.11 -43.70
Sequestration of benefits....................... -5.20 -5.37 -5.52 -5.74
HIT payment incentives.......................... -2.55 -1.14 -0.63 -0.14
---------------------------------------------------------------
Total benefits............................ 252.57 262.02 269.91 281.40
---------------------------------------------------------------
Administrative expenses......................... 3.84 3.36 3.58 3.81
Incurred expenditures........................... 256.41 265.38 273.49 285.21
Value of interest............................... -2.49 -2.22 -2.25 -2.67
Contingency margin for projection error and to -35.02 -8.36 11.36 -28.34
amortize the surplus or deficit................
---------------------------------------------------------------
Monthly actuarial rate.................. 218.90 254.80 282.60 254.20
----------------------------------------------------------------------------------------------------------------
\1\ Includes services paid under the lab fee schedule furnished in the physician's office or an independent lab.
\2\ Includes physician-administered drugs, ambulatory surgical center facility costs, ambulance services,
parenteral and enteral drug costs, supplies, etc.
\3\ Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
\4\ Includes services furnished in dialysis facilities, rural health clinics, federally qualified health
centers, rehabilitation and psychiatric hospitals, etc.

[[Page 80070]]

Table 5--Actuarial Status of the Part B Account in the SMI Trust Fund Under Three Sets of Assumptions for
Financing Periods Through December 31, 2017
----------------------------------------------------------------------------------------------------------------
As of December 31, 2015 2016 2017
----------------------------------------------------------------------------------------------------------------
Actuarial status (in $ millions):
Assets...................................................... 68,157 85,169 73,296
Liabilities................................................. 24,712 26,487 27,798
-----------------------------------------------
Assets less liabilities..................................... 43,445 58,682 45,497
Ratio (in percent) \1\...................................... 14.7 18.6 13.7
Low cost projection:
Actuarial status (in $ millions):
Assets...................................................... 68,157 100,826 116,438
Liabilities................................................. 24,712 24,748 26,569
-----------------------------------------------
Assets less liabilities..................................... 43,445 76,078 89,869
Ratio (in percent) \1\...................................... 15.7 26.6 31.0
High cost projection:
Actuarial status (in $ millions):
Assets...................................................... 68,157 69,173 27,830
Liabilities................................................. 24,712 28,265 29,217
-----------------------------------------------
Assets less liabilities..................................... 43,445 40,908 -1,387
Ratio (in percent) \1\...................................... 13.9 11.8 -0.4
----------------------------------------------------------------------------------------------------------------
\1\ Ratio of assets less liabilities at the end of the year to the total incurred expenditures during the
following year, expressed as a percent.

III. Collection of Information Requirements

This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).

IV. Regulatory Impact Analysis

A. Statement of Need

Section 1839 of the Act requires us to annually announce (that is
by September 30th of each year) the Part B monthly actuarial rates for
aged and disabled beneficiaries as well as the monthly Part B premium.
We also announce the Part B annual deductible because its determination
is directly linked to the aged actuarial rate.

B. Overall Impact

We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22,
1995, Pub. L. 104-4), Executive Order 13132 on Federalism (August 4,
1999), and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct 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 notices
with economically significant effects ($100 million or more in any 1
year). For 2017 approximately 70 percent of Part B enrollees will be
held harmless from the full increase in the Part B premium but will pay
a small increase in their Part B premium. However, all Part B enrollees
will experience a deductible that increases from $166 in 2016 to $183
in 2017. In addition, the standard Part B premium rate and the Part B
income-related premium rates are higher than the respective amounts for
2016. All of these changes together have an annual effect on the
economy of $100 million or more. As a result, this notice is
economically significant under section 3(f)(1) of Executive Order 12866
and is a major action as defined under the Congressional Review Act (5
U.S.C. 804(2)).
As discussed earlier, this notice announces that the monthly
actuarial rates applicable for 2017 are $261.90 for enrollees age 65
and over and $254.20 for disabled enrollees under age 65. It also
announces the 2017 monthly Part B premium rates to be paid by
beneficiaries who file an individual tax return (including those who
are single, head of household, qualifying widow(er) with a dependent
child, or married filing separately who lived apart from their spouse
for the entire taxable year), or a joint tax return.

[[Page 80071]]

The RFA requires agencies to analyze options for regulatory relief
of small businesses, if a rule has a significant impact on a
substantial number of small entities. For purposes of the RFA, small
entities include small businesses, nonprofit organizations, and small
governmental jurisdictions. Individuals and states are not included in
the definition of a small entity. This notice announces the monthly
actuarial rates for aged (age 65 and over) and disabled (under 65)
beneficiaries enrolled in Part B of the Medicare SMI program beginning
January 1, 2017. Also, this notice announces the monthly premium for
aged and disabled beneficiaries as well as the income-related monthly
adjustment amounts to be paid by beneficiaries with modified adjusted
gross income above certain threshold amounts. As a result, we are not
preparing an analysis for the RFA because the Secretary has determined
that this notice will not have a significant economic impact on a
substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. As we discussed
previously, we are not preparing an analysis for section 1102(b) of the
Act because the Secretary has determined that this notice will not have
a significant effect on a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1-year of $100
million in 1995 dollars, updated annually for inflation. In 2016, that
threshold is approximately $146 million. Part B enrollees who are also
enrolled in Medicaid have their monthly Part B premiums paid by
Medicaid. The 2017 premium increase is estimated to be a cost to each
state Medicaid program that is less than the threshold. This notice
does not impose mandates that will have a consequential effect of the
threshold amount or more on state, local, or tribal governments or on
the private sector.
Executive Order 13132 establishes certain requirements that an
agency must meet when it publishes a proposed rule (and subsequent
final rule) that imposes substantial direct compliance costs on state
and local governments, preempts state law, or otherwise has Federalism
implications. We have determined that this notice does not
significantly affect the rights, roles, and responsibilities of states.
Accordingly, the requirements of Executive Order 13132 do not apply to
this notice.
In accordance with the provisions of Executive Order 12866, this
notice was reviewed by the Office of Management and Budget.

V. Waiver of Proposed Notice

The Medicare statute requires the publication of the monthly
actuarial rates and the Part B premium amounts in September. We
ordinarily use general notices, rather than notice and comment
rulemaking procedures, to make such announcements. In doing so, we note
that, under the Administrative Procedure Act, interpretive rules,
general statements of policy, and rules of agency organization,
procedure, or practice are excepted from the requirements of notice and
comment rulemaking.
We considered publishing a proposed notice to provide a period for
public comment. However, we may waive that procedure if we find, for
good cause, that prior notice and comment are impracticable,
unnecessary, or contrary to the public interest. The statute
establishes the time period for which the premium rates will apply, and
delaying publication of the Part B premium rate such that it would not
be published before that time would be contrary to the public interest.
Moreover, we find that notice and comment are unnecessary because the
formulas used to calculate the Part B premiums are statutorily
directed. Therefore, we find good cause to waive publication of a
proposed notice and solicitation of public comments.

Dated: November 8, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: November 8, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-27425 Filed 11-10-16; 4:15 pm]
BILLING CODE 4120-01-P

Federal Register / Vol. 81, No. 220 / Tuesday, November 15, 2016 / Notices 80069

TABLE 3—DERIVATION OF MONTHLY ACTUARIAL RATE FOR ENROLLEES AGE 65 AND OVER FOR FINANCING PERIODS
ENDING DECEMBER 31, 2014 THROUGH DECEMBER 31, 2017
[in dollars]

CY 2014 CY 2015 CY 2016 CY 2017

Covered services (at level recognized):
Physician fee schedule ............................................................................. 76.97 75.48 74.34 74.57
Durable medical equipment ...................................................................... 6.07 6.34 5.95 5.90
Carrier lab 1 ............................................................................................... 4.36 4.38 4.26 4.45
Other carrier services 2 ............................................................................. 22.05 22.53 23.66 24.01
Outpatient hospital .................................................................................... 41.35 43.20 45.00 47.78
Home health ............................................................................................. 9.70 9.36 9.28 9.36
Hospital lab 3 ............................................................................................. 2.25 2.25 2.29 2.33
Other intermediary services 4 ................................................................... 16.79 17.25 17.80 18.51
Managed care ........................................................................................... 73.65 78.38 83.02 88.95
Total services .................................................................................... 253.19 259.17 265.59 275.85
Cost sharing:
Deductible ................................................................................................. ¥5.63 ¥5.64 ¥6.36 ¥7.00
Coinsurance .............................................................................................. ¥28.18 ¥28.02 ¥28.14 ¥28.48
Sequestration of benefits ................................................................................. ¥4.39 ¥4.51 ¥4.62 ¥4.81
HIT payment incentives ................................................................................... ¥2.38 ¥1.08 ¥0.59 ¥0.13
Total benefits ..................................................................................... 212.61 219.92 225.88 235.42
Administrative expenses .................................................................................. 3.24 2.82 3.00 3.19
Incurred expenditures ...................................................................................... 215.84 222.74 228.88 238.61
Value of interest ............................................................................................... ¥1.93 ¥1.86 ¥1.75 ¥1.78
Contingency margin for projection error and to amortize the surplus or def-
icit ................................................................................................................. ¥4.11 ¥11.08 10.47 25.07
Monthly actuarial rate ........................................................................ 209.80 209.80 237.60 261.90
1 Includes services paid under the lab fee schedule furnished in the physician’s office or an independent lab.
2 Includes physician-administered drugs, ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, sup-
plies, etc.
3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals,
etc.

TABLE 4—DERIVATION OF MONTHLY ACTUARIAL RATE FOR DISABLED ENROLLEES FOR FINANCING PERIODS ENDING
DECEMBER 31, 2014 THROUGH DECEMBER 31, 2017
[in dollars]

CY 2014 CY 2015 CY 2016 CY 2017

Covered services (at level recognized):
Physician fee schedule ............................................................................. 83.44 81.07 79.87 79.59
Durable medical equipment ...................................................................... 11.96 12.44 11.65 11.48
Carrier lab 1 ............................................................................................... 7.18 7.41 6.34 6.58
Other carrier services 2 ............................................................................. 25.33 25.70 26.56 26.83
Outpatient hospital .................................................................................... 59.58 61.51 63.56 66.98
Home health ............................................................................................. 8.28 7.92 7.79 7.82
Hospital lab 3 ............................................................................................. 2.85 2.79 2.86 2.89
Other intermediary services 4 ................................................................... 44.96 45.19 46.82 48.21
Managed care ........................................................................................... 65.16 72.59 79.66 87.19
Total services .................................................................................... 308.74 316.61 325.13 337.55
Cost sharing:
Deductible ................................................................................................. ¥5.29 ¥5.30 ¥5.97 ¥6.57
Coinsurance .............................................................................................. ¥43.12 ¥42.78 ¥43.11 ¥43.70
Sequestration of benefits ................................................................................. ¥5.20 ¥5.37 ¥5.52 ¥5.74
HIT payment incentives ................................................................................... ¥2.55 ¥1.14 ¥0.63 ¥0.14
Total benefits ........................................................................................ 252.57 262.02 269.91 281.40
Administrative expenses .................................................................................. 3.84 3.36 3.58 3.81
Incurred expenditures ...................................................................................... 256.41 265.38 273.49 285.21
Value of interest ............................................................................................... ¥2.49 ¥2.22 ¥2.25 ¥2.67
Contingency margin for projection error and to amortize the surplus or def-
icit ................................................................................................................. ¥35.02 ¥8.36 11.36 ¥28.34
mstockstill on DSK3G9T082PROD with NOTICES

Monthly actuarial rate ........................................................................ 218.90 254.80 282.60 254.20
1 Includes services paid under the lab fee schedule furnished in the physician’s office or an independent lab.
2 Includes physician-administered drugs, ambulatory surgical center facility costs, ambulance services, parenteral and enteral drug costs, sup-
plies, etc.
3 Includes services paid under the lab fee schedule furnished in the outpatient department of a hospital.
4 Includes services furnished in dialysis facilities, rural health clinics, federally qualified health centers, rehabilitation and psychiatric hospitals,
etc.

VerDate Sep<11>2014 22:00 Nov 11, 2016 Jkt 241001 PO 00000 Frm 00055 Fmt 4703 Sfmt 4703 E:\FR\FM\15NON1.SGM 15NON1

Document Created: 2016-11-15 00:48:04
Document Modified: 2016-11-15 00:48:04

Category		Regulatory Information
Collection		Federal Register
sudoc Class		AE 2.7: GS 4.107: AE 2.106:
Publisher		Office of the Federal Register, National Archives and Records Administration
Section		Notices
Action		Notice.
Contact		M. Kent Clemens, (410) 786-6391.
FR Citation		81 FR 80063
RIN Number		0938-AS72

81 FR 80063 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible Beginning January 1, 2017

DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services

Federal Register Volume 81, Issue 220 (November 15, 2016)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services