Page Range | 79991-80562 | |
FR Document |
Page and Subject | |
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81 FR 80091 - Sunshine Act: Notice of Agency Meeting | |
81 FR 80092 - Sunshine Act Meeting | |
81 FR 80055 - Sunshine Act Meeting | |
81 FR 80086 - Filing of Plats of Survey, Wyoming | |
81 FR 80084 - Final Long Range Transportation Plan for U.S. Fish and Wildlife Service Lands in the Northeast Region | |
81 FR 79998 - Establishment of and Modification to Restricted Areas; Fort Sill, OK | |
81 FR 80056 - Valeant Pharmaceuticals International, Inc.; Analysis To Aid Public Comment | |
81 FR 80166 - Tribal Health Programs-Community Care Consolidation | |
81 FR 80159 - Agency Information Collection Activities: Proposed Request | |
81 FR 80041 - South Atlantic Fishery Management Council; Public Meetings | |
81 FR 80016 - Mid-Atlantic Fishery Management Council (MAFMC); Meeting | |
81 FR 80083 - Collection of Information Under Review by Office of Management and Budget; OMB Control Number: 1625-0066 | |
81 FR 80044 - Agency Information Collection Activities: Submission for OMB Review; Comment Request | |
81 FR 80049 - Agency Information Collection Activities; Comment Request; Integrated Postsecondary Education Data System (IPEDS) 2016-2019 | |
81 FR 80063 - Medicare Program; Medicare Part B Monthly Actuarial Rates, Premium Rate, and Annual Deductible Beginning January 1, 2017 | |
81 FR 80078 - Federal Financial Participation in State Assistance Expenditures; Federal Matching Shares for Medicaid, the Children's Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2017 Through September 30, 2018 | |
81 FR 80003 - Medicaid Program; Covered Outpatient Drug; Delay in Change in Definitions of States and United States | |
81 FR 80058 - Agency Forms Undergoing Paperwork Reduction Act Review | |
81 FR 80091 - Meetings of Humanities Panel | |
81 FR 80006 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering Sea and Aleutian Islands Management Area | |
81 FR 80073 - Paul S. Singh: Debarment Order | |
81 FR 80077 - Louis Daniel Smith: Debarment Order | |
81 FR 80006 - Reef Fish Fishery of the Gulf of Mexico; 2017 Recreational Accountability Measures and Closure for Gulf of Mexico Gray Triggerfish | |
81 FR 80047 - Defense Advisory Committee on Women in the Services (DACOWITS); Notice of Federal Advisory Committee Meeting | |
81 FR 80056 - Change in Bank Control Notices; Acquisitions of Shares of a Bank or Bank Holding Company | |
81 FR 80038 - Fisheries of the Northeastern United States; Summer Flounder Fishery; 2017 and 2018 Summer Flounder Specifications | |
81 FR 80051 - Amendment to Procedures Established Pursuant to the Nuclear Non-Proliferation Act of 1978 | |
81 FR 80048 - Submission for OMB Review; Comment Request | |
81 FR 80087 - Notice Pursuant to the National Cooperative Research and Production Act of 1993-Cooperative Research Group on Energy Storage System Evaluation and Safety II | |
81 FR 80087 - Notice Pursuant to the National Cooperative Research and Production Act of 1993-ASTM International Standards | |
81 FR 80045 - Privacy Act of 1974; System of Records | |
81 FR 80087 - Notice Pursuant to the National Cooperative Research and Production Act of 1993-Vendor Security Alliance | |
81 FR 80161 - Qualification of Drivers; Exemption Applications; Vision | |
81 FR 80164 - Qualification of Drivers; Exemption Applications; Diabetes | |
81 FR 80059 - Proposed Data Collection Submitted for Public Comment and Recommendations | |
81 FR 80048 - Agency Information Collection Activities; Submission to the Office of Management and Budget for Review and Approval; Comment Request; Trends in International Mathematics and Science Study (TIMSS 2019) Field Test Recruitment and Pilot Test | |
81 FR 80050 - Agency Information Collection Activities; Comment Request; Principal Follow-Up Survey (PFS 2016-17) to the National Teacher and Principal Survey (NTPS 2015-16) | |
81 FR 80015 - Trade Promotion Coordinating Committee | |
81 FR 80161 - Second RTCA SC-236 Joint Plenary With EUROCAE WG-96 | |
81 FR 80161 - Nineteenth RTCA SC-227 Standards of Navigation Performance Navigation Information on Electronic Maps | |
81 FR 80060 - Medicare Program; CY 2017 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts | |
81 FR 80071 - Medicare Program; CY 2017 Part A Premiums for the Uninsured Aged and for Certain Disabled Individuals Who Have Exhausted Other Entitlement | |
81 FR 80087 - Baseline Specifications for Law Enforcement Service Pistols With Security Technology | |
81 FR 80083 - Notice of Advisory Council on Historic Preservation Quarterly Business Meeting | |
81 FR 80002 - Benefits Payable in Terminated Single-Employer Plans; Interest Assumptions for Paying Benefits | |
81 FR 80016 - Takes of Marine Mammals Incidental to Specified Activities; Taking Marine Mammals Incidental to Operation, Maintenance, and Repair of the Northeast Gateway Liquefied Natural Gas Port and the Algonquin Pipeline Lateral Facilities in Massachusetts Bay | |
81 FR 80053 - Columbia Gas Transmission, LLC; Notice of Request Under Blanket Authorization | |
81 FR 80052 - Hampshire Paper Company, Inc., KE Emeryville, LLC; Notice of Application for Transfer of License and Soliciting Comments, Motions To Intervene, and Protests | |
81 FR 80053 - Western Water and Power Production Limited LLC; Notice of Petition for Enforcement | |
81 FR 80052 - Big Rivers Electric Corporation v. Midcontinent Independent System Operator, Inc.; Notice of Complaint | |
81 FR 80157 - Submission for OMB Review; Comment Request | |
81 FR 80137 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Amend Rule 7014 and the Nasdaq Growth Program | |
81 FR 80093 - Self-Regulatory Organizations; Bats BYX Exchange, Inc.; Notice of Filing of a Proposed Rule Change in Connection With the Proposed Corporate Transaction Involving Bats Global Markets, Inc. and CBOE Holdings, Inc. | |
81 FR 80157 - Self-Regulatory Organizations; Chicago Board Options Exchange, Incorporated; Notice of Filing of a Proposed Rule Change in Connection With a Proposed Corporate Transaction Involving CBOE Holdings, Inc. and Bats Global Markets, Inc. | |
81 FR 80132 - Self-Regulatory Organizations; C2 Options Exchange, Incorporated; Notice of Filing of a Proposed Rule Change in Connection With a Proposed Corporate Transaction Involving CBOE Holdings, Inc. and Bats Global Markets, Inc. | |
81 FR 80101 - Self-Regulatory Organizations; Bats BZX Exchange, Inc.; Notice of Filing of a Proposed Rule Change in Connection With the Proposed Corporate Transaction Involving Bats Global Markets, Inc. and CBOE Holdings, Inc. | |
81 FR 80146 - Self-Regulatory Organizations; Bats EDGA Exchange, Inc.; Notice of Filing of a Proposed Rule Change in Connection With the Proposed Corporate Transaction Involving Bats Global Markets, Inc. and CBOE Holdings, Inc. | |
81 FR 80114 - Self-Regulatory Organizations; Bats EDGX Exchange, Inc.; Notice of Filing of a Proposed Rule Change in Connection With the Proposed Corporate Transaction Involving Bats Global Markets, Inc. and CBOE Holdings, Inc. | |
81 FR 80154 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Amend Commentary .14 to Rule 4770 (Compliance With Regulation NMS Plan To Implement a Tick Size Pilot) | |
81 FR 80123 - Self-Regulatory Organizations; NASDAQ BX, Inc.; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Amend Commentary .14 to Rule 4770 (Compliance With Regulation NMS Plan To Implement a Tick Size Pilot) | |
81 FR 80134 - Self-Regulatory Organizations; NASDAQ PHLX LLC; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Amend Commentary .14 to Rule 3317 (Compliance With Regulation NMS Plan To Implement a Tick Size Pilot) | |
81 FR 80109 - Self-Regulatory Organizations; NASDAQ BX, Inc.; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Adopt Cease and Desist Authority Rules | |
81 FR 80140 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing and Immediate Effectiveness of Proposed Rule Change To Adopt Cease and Desist Authority Rules | |
81 FR 80125 - Self-Regulatory Organizations; BOX Options Exchange LLC; Notice of Filing of Proposed Rule Change To Amend Rule 5050 Series of Options Contracts Open for Trading To Provide for the Listing and Trading on the Exchange of RealDayTM | |
81 FR 80051 - Secretary of Energy Advisory Board | |
81 FR 80050 - Hydrogen and Fuel Cell Technical Advisory Committee (HTAC) | |
81 FR 80008 - Appliance Standards and Rulemaking Federal Advisory Committee: Notice of Open Meetings for the Circulator Pumps Working Group To Negotiate a Notice of Proposed Rulemaking (NOPR) for Energy Conservation Standards and Test Procedures | |
81 FR 80089 - MET Laboratories, Inc.: Application for Expansion of Recognition and Proposed Modification to the NRTL Program's List of Appropriate Test Standards | |
81 FR 80088 - Proposed Extension of Information Collection; Radiation Sampling and Exposure Records (Pertains to Underground Metal and Nonmetal Mines) | |
81 FR 80081 - National Institute of Neurological Disorders and Stroke; Notice of Closed Meetings | |
81 FR 80082 - National Institute of Mental Health; Notice of Closed Meetings | |
81 FR 80081 - National Institute of Allergy and Infectious Diseases; Notice of Closed Meetings | |
81 FR 80083 - National Heart, Lung, and Blood Institute; Notice of Closed Meeting | |
81 FR 80082 - Government-Owned Inventions; Availability for Licensing | |
81 FR 80081 - Center For Scientific Review; Notice of Closed Meeting | |
81 FR 80054 - Information Collection Being Reviewed by the Federal Communications Commission | |
81 FR 80054 - Information Collection Being Reviewed by the Federal Communications Commission Under Delegated Authority | |
81 FR 80075 - Agency Information Collection Activities; Proposed Collection; Comment Request; Evaluation of the Food and Drug Administration's Education at the Point of Sale Campaign | |
81 FR 80011 - Standards for Safeguarding Customer Information | |
81 FR 80012 - Federal Acquisition Regulation: Clarification of Requirement for Justifications for 8(a) Sole Source Contracts | |
81 FR 79991 - Energy Conservation Program for Consumer Products and Certain Commercial and Industrial Equipment: Final Determination of Compressors as Covered Equipment | |
81 FR 80170 - Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements | |
81 FR 80009 - Airworthiness Directives; Gulfstream Aerospace Corporation Airplanes |
International Trade Administration
National Oceanic and Atmospheric Administration
Army Department
Federal Energy Regulatory Commission
National Nuclear Security Administration
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Food and Drug Administration
National Institutes of Health
Coast Guard
Fish and Wildlife Service
Land Management Bureau
Antitrust Division
Justice Programs Office
Mine Safety and Health Administration
Occupational Safety and Health Administration
National Endowment for the Humanities
Federal Aviation Administration
Federal Motor Carrier Safety Administration
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Office of Energy Efficiency and Renewable Energy, Department of Energy.
Final rule.
The U.S. Department of Energy (DOE) is classifying certain varieties of compressors as covered equipment under Part A-1 of Title III of the Energy Policy and Conservation Act (EPCA), as amended. Accordingly, this document establishes the definition of equipment that are considered compressors.
This rule is effective December 15, 2016.
This rulemaking can be identified by docket number EERE-2012-BT-DET-0033 and/or Regulatory Information Numbers (RIN) 1904-AC83.
A link to the docket Web page can be found at:
For further information on how to review the docket, contact the Appliance and Equipment Standards Program staff at (202) 586-6636 or by email:
James Raba, U.S. Department of Energy, Office of Energy Efficiency and Renewable Energy, Building Technologies Office, EE-5B, 1000 Independence Avenue SW., Washington, DC 20585-0121. Telephone: (202) 586-8654. Email:
Mary Greene, U.S. Department of Energy, Office of the General Counsel, GC-33, 1000 Independence Avenue SW., Washington, DC 20585-0121. Telephone: (202) 586-1817. Email:
Title III of the Energy Policy and Conservation Act of 1975, as amended (“EPCA” or, in context, “the Act”), sets forth a variety of provisions designed to improve energy efficiency. (42 U.S.C. 6291,
EPCA provides that DOE may include a type of industrial equipment, including compressors, as covered equipment if it determines that to do so is necessary to carry out the purposes of Part A-1. (42 U.S.C. 6311(2)(B)(i) and 6312(b)). Industrial equipment, including compressors, must be of a type that consumes, or is designed to consume, energy in operation; is distributed in commerce for industrial or commercial use; and is not a covered product as defined in 42 U.S.C. 6291(a)(2) of EPCA. (42 U.S.C. 6311 (2)(A)). DOE has determined that compressors, the definition of which DOE is adding to subpart T of 10 CFR 431 and discusses in this rule, meet the statutory requirements under 42 U.S.C. 6311(2)(B)(i) and 6312(b) and is classifying them as covered equipment.
Separately, DOE is conducting rulemakings to consider test procedures, and energy conservation standards for compressors. Pursuant to EPCA, any new or amended energy conservation standard for compressors must be designed to achieve the maximum improvement in energy efficiency that is technologically feasible and economically justified. (42 U.S.C. 6295(o)(2)(A) and 6316(a)). Furthermore, the new or amended standard must result in a significant conservation of energy. (42 U.S.C. 6295(o)(3)(B) and 6316(a)). DOE will determine if compressors satisfy these provisions during the course of the energy conservation standards rulemaking.
On December 31, 2012 (77 FR 76972), DOE issued a Proposed Determination of Coverage (2012 NOPD) that proposed to determine that compressors qualify as covered equipment under part A-1 of Title III of EPCA, as amended (42 U.S.C. 6311
On February 5, 2014 (79 FR 6839), DOE published a notice of public meeting and provided a framework document that addressed potential standards and test procedures rulemakings for compressors. DOE held a public meeting to discuss the framework document on April 1, 2014. At this meeting, DOE discussed and received comments on the framework document, which covered the analytical framework, models, and tools that DOE used to evaluate potential standards; and all other issues raised relevant to the development of energy conservation standards for the different categories of compressors. On March 18, 2014 (79 FR 15061), DOE extended the comment period.
On May 5, 2016 (81 FR 27219), DOE issued a notice of proposed rulemaking (NOPR) to propose a definition for the term “compressor” and to propose test procedures for certain compressors (hereafter, the “test procedure NOPR”). On May 19, 2016 (81 FR 31680), DOE issued a NOPR to propose energy conservation standards for certain varieties of compressors (hereafter, the “energy conservation standards NOPR”). On June 20, 2016, DOE held a public meeting to discuss the test procedure and energy conservation standards NOPRs and to accept comments from interested parties.
In this final rule, DOE responds to the seven comments received from interested parties in response to the 2012 NOPD. DOE notes that certain comments received in response to the 2012 NOPD discussed topics such as: Technology options to improve the efficiency of compressors, scope of potential energy conservations standards, and test methods for compressors, among other comments. These comments relate to the ongoing test procedure and/or energy conservation standards rulemakings and are, or will, be addressed in those rulemakings, as applicable. In this document, DOE also responds to certain comments that were submitted in response to the test procedure NOPR and pertain to the definition of “compressor.”
In this document, DOE addresses comments submitted by the following: The Air-Conditioning, Heating, and Refrigeration Institute (AHRI); American Council for an Energy-Efficient Economy (ACEEE); Appliance Standards Awareness Project (ASAP); Alliance to Save Energy (ASE); Atlas Copco AB (Atlas Copco); the Compressed Air & Gas Institute (CAGI); Compressed Air Systems; the Edison Electric Institute (EEI); Ingersoll Rand; Kaeser Compressors; the National Rural Electric Cooperative Association (NRECA); the Northwest Energy Efficiency Alliance (NEEA); the Northeast Energy Efficiency Partnerships (NEEP); the National Resources Defense Council (NRDC); the Pacific Gas and Electric Company (PG&E), San Diego Gas and Electric (SDG&E), Southern California Edison (SCE), and Southern California Gas Company (SCGC), collectively referred to as the California Investor Owned Utilities (CA IOUs); Scales Industrial Technologies; Sullair; Saylor-Beall Manufacturing Company and Sullivan-Palatek, collectively referred to as Sullivan-Palatek.
DOE will identify comments received in response to the test procedure NOPR by the number of the docket maintained at
“Compressor” is not an existing defined term under EPCA. In the 2012 NOPD, DOE tentatively determined to add compressors as a type of covered equipment and proposed a definition for “compressor.” 77 FR 76972, 76973 (Dec 31, 2012). Specifically, DOE proposed to define compressor as an electric-powered device that takes in air or gas at atmospheric pressure and delivers the air or gas at a higher pressure. DOE also clarified that compressors typically have a specific ratio, the ratio of delivery pressure to supply pressure, greater than 1.20 and compressors are classified as positive-displacement, dynamic, or hybrid. 77 FR 76972, 76973-76974 (Dec 31, 2012). Finally, DOE noted that compressors may have pistons, rollers, rotors, impeller wheels, spiral disks, cylinders, lubricant, motors and transmissions, controls, treatment equipment, filters, and/or a lubricant/air separators. 77 FR 76972, 76974 (Dec 31, 2012). In the 2016 test procedure NOPR, after considering comments in response to the February 5, 2014 framework document (79 FR 6839), DOE proposed revisions to its initial proposed “of a compressor”. Specifically, DOE proposed that a compressor means a machine or apparatus that converts different types of energy into the potential energy of gas pressure for displacement and compression of gaseous media to any higher pressure values above atmospheric pressure and has a pressure ratio greater than 1.3. 81 FR 27220, 27224 (May 5, 2016)
Several parties commented in response to the definition of “compressor” considered in the 2012 NOPD and proposed in the 2016 test procedure NOPR (and its associated public meeting). These comments are discussed by topic, in the sections that follow.
In response to the 2012 NOPD, AHRI stated that DOE's proposed definition of “compressor” may unintentionally include some products as covered equipment. Specifically AHRI was concerned that heating, ventilating, air conditioning, and refrigeration (HVACR) equipment may meet the proposed definition, and suggested that DOE include a statement to exclude them. (AHRI, No. 0002 at pp. 1-2) AHRI stated that the energy consumption of HVACR compressors is already accounted for in the efficiency ratings for regulated HVACR equipment, which means that covering those compressors under separate regulations would lead to unwarranted double regulation on
EEI commented that certain electric motors sized under 500 horsepower (which are used on certain compressors), are already subject to DOE energy conservation standards, and DOE should take this into consideration in any future energy conservation standards, in order to avoid duplicative regulation of these motors. (EEI, No. 0009 at p. 4)
This final rule establishes a definition for “compressors” and classifies them as covered equipment under EPCA; it does not establish scope for any potential energy conservation standards. As such, AHRI's comment that compressors in HVACR systems and EEI comments regarding motors should be excluded from regulation will be addressed in the ongoing energy conservation standards rulemaking.
In response to the 2016 test procedure NOPR, Atlas Copco commented that DOE should harmonize with international precedent to aid manufacturers in exporting their products, and reduce the minimum pressure ratio from 1.3 to 1.1, as is stated in European Union (EU) Lot 31 draft standard.
In response to Atlas Copco, DOE reiterates that it proposed a lower-bound pressure ratio of 1.3 to align the coverage determination of compressors with the coverage determination being considered in the fans and blowers rulemaking, with the intent that DOE regulations do not leave any gaps in coverage. 81 FR 27220, 27224 (May 5, 2016). DOE further reiterates that an Appliance Standards Rulemaking Advisory Committee (ASRAC) Working Group was established to negotiate proposed energy conservation standards for fans and blowers and this group discussed and came to general agreement on a maximum fan energy limit of 25 kJ/kg, which translates approximately to a 1.3 pressure ratio, as the appropriate cutoff to distinguish between fans and compressors. (EERE-2014-BT-TP-0054, Docket No. EERE-2013-BT-STD-0006; EERE-2014-BT-TP-0054, Public Meeting, No. 84 at p. 11) and 81 FR 27220, 27224 (May 5, 2016). If, through the fans and blowers rulemaking, DOE establishes coverage for equipment that incorporates a maximum1.3 pressure ratio limit, DOE would have the authority to establish test procedures and energy conservation standards for equipment with pressure ratios between 1.1 and 1.3, under the coverage of fans and blowers, rather than compressors. (
Additionally, incorporating a definition for “compressor” as covered equipment by itself has no material impact on manufacturers. Rather, a decision by DOE to establish test procedures and/or energy conservation standards for certain compressors could materially impact manufacturers and trade. As such, DOE's decision to establish coverage for compressors based on a minimum pressure ratio of 1.3 has no impact on manufacturing or exporting, as claimed by Atlas Copco.
In response to the 2012 NOPD, CAGI commented that the 1.2 compression ratio proposed by DOE is too low. CAGI suggested a compression ratio of 2.5 instead. CAGI noted that what are referred to as “low-pressure blowers” can reach pressure ratios below 2.5, but are not generally viewed as compressors. CAGI also stated that a compression ratio of 1.2 may result in the inclusion of blowers for hand drying and vending machine compressors. (CAGI, No. 0003 at pp. 6-7) Both Ingersoll Rand and Kaeser Compressors supported CAGI's recommendation to use a pressure ratio of 2.5 instead of 1.2. (Kaeser Compressors, No. 0007 at p. 1; Ingersoll Rand, No. 0004 at pp. 1-2). However, DOE notes that, in response to the 2016 test procedure NOPR, CAGI and Ingersoll Rand updated their opinions and provided support for the definition of “compressor,” with a 1.3 minimum pressure ratio, as proposed by DOE in the test procedure NOPR. (EERE-2014-BT-TP-0054, CAGI, No. 0010 at p. 3; EERE-2014-BT-TP-0054, Ingersoll Rand, No. 0011 at p. 1; EERE-2014-BT-TP-0054, Sullair, No. 0006 at p. 1) Kaeser Compressors provided no updated comments related minimum pressure ratio, in response to the 2016 test procedure NOPR.
In response to the 2016 test procedure NOPR, Scales Industrial Technologies commented that the term “compressor” was historically used for equipment with pressure values above 18-25 psig, corresponding to pressure ratios of 2.2-2.7, and that equipment with pressure values below this range were referred to as “blowers.” (EERE-2014-BT-TP-0054, Scales Industrial Technologies, No. 0013, at p. 3)
In response to Kaeser Compressors and Scales Industrial Technologies, DOE acknowledges that lower pressure compressors are often termed “blowers” in industry. However, significant industry precedent exists that classifies blowers (and other lower pressure ratio machines) as sub-varieties of compressors. Specifically, in the test procedure NOPR, DOE noted that the International Organization for Standardization (ISO) Technical Report 12942:2012, “Compressors—Classification—Complementary information to ISO 5390,” (ISO/TR 12942:2012) defines “compressor” as a machine or apparatus converting different types of energy into the potential energy of gas pressure for displacement and compression of gaseous media to any higher pressure values above atmospheric pressure with pressure-increase ratios exceeding 1.1. 81 FR 27219, 27223 (May 5, 2016). Additionally, the European Union (EU) Lot 31 draft standard,
Finally, DOE notes that the CA IOUs, CAGI, Sullivan-Palatek, Ingersoll Rand, and Sullair all support the definition of “compressor” with a 1.3 minimum pressure ratio, as proposed in the test procedure NOPR. (EERE-2014-BT-TP-0054, CA IOUs, No. 0012 at p. 3; EERE-
In response to the 2012 NOPD, Ingersoll Rand made two recommendations regarding which components should be included in the definition of “compressor.” First, Ingersoll Rand suggested that “compressor” should be defined to include “onboard” controls that are integrated into the compressor package and solely for the operation of the compressor package to which they are mounted. (Ingersoll Rand, No. 0004 at p. 2).
Second, Ingersoll Rand suggested that “compressor” should be defined to include filters and treatment equipment that are integral and necessary to operate the compressor, such as oil coolers, aftercoolers, and filters, and deliver a certain quality of compressed air. (Ingersoll Rand, No. 0004 at p. 2).
In response, this final rule establishes a definition for “compressors” and classifies them as covered equipment under EPCA; it does not establish scope for any potential energy conservation standards. To that end, DOE notes that the definition of “compressor” adopted in this final rule (see section III.H), is broad and does not exclude the components recommended by Ingersoll Rand. However, DOE notes that it may limit the applicability of any test procedures and energy conservations standards it chooses to pursue in the future to address the (components/controls) identified by Ingersoll Rand.
In response to the 2012 NOPD, CAGI commented that the definition of “compressor” should not apply to compressors that are connected through a wall outlet using a plug connection. CAGI explained that these compressors generally have intermittent usage patterns, are small, and are not designed for continuous duty and, therefore, do not represent significant energy use. (CAGI, No. 0003 at p. 7)
DOE recognizes the benefits of focusing on compressors likely to account for significant energy use for the purposes of setting regulatory requirements. However, DOE notes that compressors can be modified to add or remove electrical plugs, without great cost or difficulty, by a party aiming to circumvent standards. Additionally, for certain compressor sizes (
Finally, DOE prefers to use attributes more native to a compressor (
In response to the 2012 NOPD, EEI commented that DOE should use a definition that applies to non-electric in addition to electric compressors, arguing that limiting the definition to electric compressors would be inconsistent with DOE's other recent actions for similar products, and equipment such as pumps and fans, and would be inconsistent with the intent of EPCA. (EEI, No. 0009, at p. 2) NRECA also commented that any compressor definition should be fuel-neutral. (NRECA, No. 0008, at p. 2) EEI also noted that DOE provided no rationale supporting the exclusion of non-electric compressors, and that there are significant numbers of fossil fuel-driven compressors operating in the United States. (EEI, No. 0009, at p. 5)
Further, in response to the 2012 NOPD, EEI stated that excluding non-electric compressors carries the potential to distort markets—presumably by incentivizing end users to substitute unregulated compressors. (EEI, No. 0009, at p. 7) NRECA also commented that an electric-only compressor definition could encourage fuel-switching to non-electric compressors and not result in economic or energy savings. (NRECA, No. 0008, at p. 2)
In response to EEI's and NRECA's argument not to limit the definition of “compressor” to electric compressors, DOE notes that it is adopting a fuel-neutral definition of “compressor.”
In response to the 2016 test procedure NOPR, Compressed Air Systems commented that the term “compressor” may unintentionally include other equipment, such as refrigerators, air conditioners, bellows, hand air pumps, or turbochargers, and suggested a more narrow definition of the term that would encompass just the products intended for regulation. (EERE-2014-BT-TP-0054, Compressed Air Systems, No. 0008 at p. 1).
In response, DOE notes that the definition of “compressor,” as proposed in the test procedure NOPR, does not specifically include or exclude compressors installed as components of other covered products or equipment such as refrigerators and air conditioners. Nonetheless, it may apply to subcomponents of such equipment. Further, if equipment commonly referred to as bellows, hand air pumps, or turbochargers meets the definition of “compressor,” as proposed in the test procedure NOPR and adopted in this document, such equipment would fall within the coverage determination for compressors. However, DOE will determine appropriate scope(s) of applicability for future test procedure and energy conservation standards rulemakings based on the particular circumstances of the market.
In response to DOE's May 19, 2016 energy conversation standards NOPR (81 FR 31680), the CA IOUs, ASAP, ACEEE, NEEA, NRDC, NEEP, and ASE commented that if there are no energy conservation standards for reciprocating compressors, then reciprocating compressors should not be covered equipment in order to allow states to pursue standards. (EERE-2013-BT-STD-0040, CA IOUs, No. 0059 at pp. 2-3; EERE-2013-BT-STD-0040, CA IOUs, Public Meeting Transcript, No. 0044 at p. 153; EERE-2013-BT-STD-0040, ASAP, ACEEE, NEEA, NRDC, NEEP, ASE, No. 0060 at pp. 2-3)
In this final rule, DOE is establishing a broad definition for “compressors;” it is not establishing a definition for specific categories of compressors. DOE will define specific categories of compressors and the scope of applicability of test procedures and energy conservation standards in their respective rules. In turn, DOE is classifying compressors as covered equipment under EPCA because the agency concludes that commercial and industrial compressors qualify as covered equipment under part A-1 of Title III of EPCA, as amended. (42 U.S.C. 6311
Ultimately, for the reasons discussed in this section and established in the test procedure NOPR, DOE is adopting the definition of “compressor,” as proposed in the test procedure NOPR, with one minor modification in nomenclature. Specifically, DOE is replacing the term “pressure ratio” with “pressure ratio at full-load operating pressure.”.
DOE will develop specific methods to determine pressure ratio at full-load operating pressure as a part of a separate test procedure rulemaking process.
The following sections describe DOE's evaluation of whether compressors fulfill the criteria for being added as covered equipment pursuant to 42 U.S.C. 6311(2) and 42 U.S.C. 6312. Compressors are listed as a type of industrial equipment at 42 U.S.C. 6311(2)(B)(i). The following discussion addresses DOE's consideration of the three requirements of 42 U.S.C. 6311(2)(A) and 42 U.S.C. 6312.
In the 2012 NOPD, DOE cited data from the 2002 United States Industrial Electric Motor Systems Market Opportunities Assessment, which estimated total annual industrial compressor energy use (from Manufacturing SIC codes 20-39) at 91,050 million kWh per year.
In response to DOE's NOPD conclusions, EEI commented that data referenced in the proposed determination of coverage was neither accurate nor current. EEI noted that although DOE asserted industrial activity in 2012 exceeded that of 2002, the amount of industrial electricity consumed and number of industrial customers in 2011 were lower than in 2003 and 2004, respectively. (EEI, No. 0009 at pp. 2-3).
In its energy conservation standards NOPR, DOE revised the sources used to characterize the compressor market, DOE revised both initial shipments, (discussed in section IV.B) and industrial and commercial growth indicators. DOE projected future growth using Energy Information Administration's (EIA's) Annual Energy Outlook (AEO) Macroeconomic projections for the Value of Manufacturing Shipments, and Commercial Floor Space for industrial and commercial sectors, respectively.
In the 2012 NOPD, DOE tentatively concluded that compressors are distributed in commerce for both the industrial and commercial sectors. Specifically, DOE estimated that 1.3 million motors are shipped annually to drive compressors in the U.S. commercial and industrial sectors, based on the 2011 International Energy Agency (IEA) Survey. DOE also assumed that only a small fraction of these motors are used as a motor only replacement in compressor systems (based on additional 2004 U.S. Census data); consequently, DOE estimated that nearly 1.3 million compressors were distributed in commerce annually for industrial or commercial use. 77 FR 76972, 76974 (Dec 31, 2012).
In response to DOE's NOPD conclusions, Ingersoll Rand commented that the estimate of annual compressor shipments provided by DOE is grossly inflated. (Ingersoll Rand, No. 0004 at p. 2) CAGI commented that DOE's estimates most likely incorporate compressors going into consumer applications, and if only commercial and industrial applications were counted, the number would be significantly lower. (CAGI, No. 0003 at p. 7) EEI recommended that DOE elaborate on how it derived the 1.3 million compressor shipment estimate, if DOE is to use it in in any future energy conservation standards analyses. (EEI, No. 0009 at p. 3)
In response to comments from Ingersoll Rand, CAGI, and EEI, DOE sought, and received, shipments data for rotary screw compressors from a number of manufacturer stakeholders and subject matter experts, which DOE published in its energy conservation standards NOPR. However, DOE was able to find only limited shipments data for reciprocating compressors, so DOE continued to use the data from the U.S. Census Bureau.
Compressors are not currently included as covered products under Title 10 of the Code of Federal Regulations, part 430.
The purpose of part A-1 of EPCA is to improve the energy efficiency of electric motors, pumps and certain other industrial equipment to conserve the energy resources of the Nation. (42 U.S.C. 6312 (a)). In the 2012 NOPD, DOE proposed that coverage of compressors was necessary to carry out the purposes of part A-1 of EPCA because coverage will promote the conservation of energy resources. DOE concluded that efficiency standards that may result from coverage would help to capture some portion of the potential for improving the efficiency of compressors. 77 FR 76972, 76974 (Dec 31, 2012).
In response to DOE's conclusion that efficiency standards that may result from coverage of compressors would help to capture some portion of the potential for improving the efficiency of compressors, CAGI commented that compressor designs are mature and compressor manufacturers have already incorporated the most efficient motor designs and technologies available in the market. CAGI believes that including compressors as covered equipment would inhibit investment in research and development because of the hurdles involved in approving new designs for the market. (CAGI, No. 0003 at p. 8) CAGI also argued that, due to variation in field applications that lead to changes in overall efficiency, regulation of compressor packages is an ineffective way to capture significant energy savings. CAGI suggested that, therefore, DOE exclude commercial and industrial compressors under Part A-1 of Title III of EPCA. (CAGI, No. 0003 at pp. 4-5)
Kaeser Compressors commented that since manufacturers already publish test data at various load levels and that data is verified by a third-party and since annual energy costs are dependent on the dynamics of an individual system, Kaeser does not believe that including
DOE published consumer saving for lubricated rotary screw, lubricant-free rotary screw, and reciprocating compressors in its energy conservation standard NOPR TSD.
These estimated saving presented in the energy conservation standard TSD and NOPR are an indication that coverage will result in conservation of energy resources. While DOE proposed new energy conservation standards for a sub-set of compressor designs currently available in commerce, broadening of the energy conservations standards beyond lubricated rotary screw compressors will likely increase the amount of energy savings.
Based on the preceding discussion, DOE reaffirms its conclusion that incorporating compressors as covered equipment is necessary to carry out the purposes of Part A-1 of EPCA, and that efficiency standards that may result from coverage would improve the efficiency of compressors and help to capture some portion of the potential for energy savings from this improved efficiency. Based on the information in sections IV.A, IV.B, and IV.C of this rule, DOE determines that commercial and industrial compressors qualify as covered equipment under part A-1 of Title III of EPCA, as amended (42 U.S.C. 6311
DOE has reviewed this final rule, which determines coverage for compressors, under the following executive orders and acts.
The Office of Management and Budget (OMB) has determined that coverage determination rulemakings do not constitute “significant regulatory actions” under section 3(f) of Executive Order 12866, Regulatory Planning and Review, 58 FR 51735 (Oct. 4, 1993). Accordingly, this final action was not subject to review under the Executive Order by the Office of Information and Regulatory Affairs (OIRA) in the OMB.
The Regulatory Flexibility Act (5 U.S.C. 601
DOE reviewed this final rule under the provisions of the Regulatory Flexibility Act and the policies and procedures published on February 19, 2003. This final rule sets no test procedures or standards; it only positively determines that compressors meet the criteria for classification as covered equipment and that future standards may be warranted to regulate their energy use. Economic impacts on small entities would be considered in the context of such rulemakings. On the basis of the foregoing, DOE certifies that the determination has no significant economic impact on a substantial number of small entities. Accordingly, DOE has not prepared a regulatory flexibility analysis for this final rule. DOE will transmit this certification and supporting statement of factual basis to the Chief Counsel for Advocacy of the Small Business Administration for review under 5 U.S.C. 605(b).
This final rule, which concludes that compressors meet the criteria for a covered product for which the Secretary may prescribe an energy conservation standard pursuant to 42 U.S.C. 6295(o) and (p), imposes no new information or record-keeping requirements. Accordingly, the OMB clearance is not required under the Paperwork Reduction Act. (44 U.S.C. 3501
In this document, DOE positively determines that compressors meet the criteria for classification as covered equipment and that future standards may be warranted to regulate their energy use. Should DOE pursue that option, the relevant environmental impacts would be explored as part of that rulemaking. As a result, DOE has determined that this action falls into a class of actions that are categorically excluded from review under the National Environmental Policy Act of 1969 (42 U.S.C. 4321
Executive Order (E.O.) 13132, “Federalism” 64 FR 43255 (Aug. 10, 1999), imposes certain requirements on agencies formulating and implementing policies or regulations that preempt State law or that have Federalism implications. The Executive Order requires agencies to examine the constitutional and statutory authority supporting any action that would limit the policymaking discretion of the States and to assess carefully the necessity for such actions. The Executive Order also requires agencies to have an accountable process to ensure meaningful and timely input by State and local officials in developing regulatory policies that have Federalism implications. On March 14, 2000 (65 FR 13735), DOE published a statement of policy describing the intergovernmental
With respect to the review of existing regulations and the promulgation of new regulations, section 3(a) of E.O. 12988, “Civil Justice Reform” 61 FR 4729 (Feb. 7, 1996), imposes on Federal agencies the duty to: (1) Eliminate drafting errors and ambiguity; (2) write regulations to minimize litigation; (3) provide a clear legal standard for affected conduct rather than a general standard; and (4) promote simplification and burden reduction. Section 3(b) of E.O. 12988 specifically requires that Executive agencies make every reasonable effort to ensure that the regulation specifies the following: (1) The preemptive effect, if any; (2) any effect on existing Federal law or regulation; (3) a clear legal standard for affected conduct while promoting simplification and burden reduction; (4) the retroactive effect, if any; (5) definitions of key terms; and (6) other important issues affecting clarity and general draftsmanship under any guidelines issued by the Attorney General. Section 3(c) of E.O. 12988 requires Executive agencies to review regulations in light of applicable standards in sections 3(a) and 3(b) to determine whether these standards are met, or whether it is unreasonable to meet one or more of them. DOE completed the required review and determined that, to the extent permitted by law, this final rule meets the relevant standards of E.O. 12988.
Title II of the Unfunded Mandates Reform Act of 1995 (UMRA) (Pub. L. 104-4, codified at 2 U.S.C. 1501
Section 654 of the Treasury and General Government Appropriations Act of 1999 (Pub. L. 105-277) requires Federal agencies to issue a Family Policymaking Assessment for any rule that may affect family well-being. This final rule does not have any impact on the autonomy or integrity of the family as an institution. Accordingly, DOE has concluded that it is not necessary to prepare a Family Policymaking Assessment.
Pursuant to E.O. 12630, “Governmental Actions and Interference with Constitutionally Protected Property Rights” 53 FR 8859 (Mar. 15, 1988), DOE determined that this final rule does not result in any takings that might require compensation under the Fifth Amendment to the U.S. Constitution.
The Treasury and General Government Appropriation Act of 2001 (44 U.S.C. 3516, note) requires agencies to review most disseminations of information they make to the public under guidelines established by each agency pursuant to general guidelines issued by the OMB. The OMB's guidelines were published at 67 FR 8452 (Feb. 22, 2002), and DOE's guidelines were published at 67 FR 62446 (Oct. 7, 2002). DOE has reviewed this final rule under the OMB and DOE guidelines and has concluded that it is consistent with applicable policies in those guidelines.
E.O. 13211, “Actions Concerning Regulations That Significantly Affect Energy Supply, Distribution, or Use,” 66 FR 28355 (May 22, 2001), requires Federal agencies to prepare and submit to OMB a Statement of Energy Effects for any proposed significant energy action. A “significant energy action” is defined as any action by an agency that promulgates a final rule or is expected to lead to promulgation of a final rule, and that: (1) Is a significant regulatory action under E.O. 12866, or any successor order; and (2) is likely to have a significant adverse effect on the supply, distribution, or use of energy; or (3) is designated by the Administrator of the Office of Information and Regulatory Affairs (OIRA) as a significant energy action. For any proposed significant energy action, the agency must give a detailed statement of any adverse effects on energy supply, distribution, or use if the proposal is implemented, and of reasonable alternatives to the proposed action and their expected benefits on energy supply, distribution, and use.
DOE has concluded that this regulatory action establishing certain definitions and determining that compressors meet the criteria for a covered product for which the Secretary may prescribe an energy conservation standard pursuant to 42 U.S.C. 6295(o) and (p) does not have a significant adverse effect on the supply, distribution, or use of energy. This action is also not a significant regulatory action for purposes of E.O. 12866, and the OIRA Administrator has not designated this final determination as a significant energy action under E.O. 12866 or any successor order. Therefore, this final rule is not a significant energy action. Accordingly, DOE has not prepared a Statement of Energy Effects.
As required by 5 U.S.C. 801, DOE will report to Congress on the promulgation of this rule prior to its effective date. The report will state that it has been determined that the rule is a “major rule” as defined by 5 U.S.C. 804(2).
On December 16, 2004, OMB, in consultation with the Office of Science and Technology Policy (OSTP), issued its Final Information Quality Bulletin for Peer Review (the Bulletin). 70 FR 2664 (Jan. 14, 2005). The Bulletin establishes that certain scientific information shall be peer reviewed by qualified specialists before it is disseminated by the Federal government, including influential scientific information related to agency regulatory actions. The purpose of the Bulletin is to enhance the quality and credibility of the Government's scientific information. DOE has determined that the analyses conducted for the regulatory action discussed in this document do not constitute “influential scientific information,” which the Bulletin defines as “scientific information the agency reasonably can determine will have or does have a clear and substantial impact on important public policies or private sector decisions.” 70 FR 2667 (Jan. 14, 2005). The analyses were subject to pre-dissemination review prior to issuance of this rulemaking.
DOE will determine the appropriate level of review that would apply to any future rulemaking to establish energy conservation standards for compressors.
The Secretary of Energy has approved publication of this final rule.
For the reasons stated in the preamble, DOE amends part 431 of chapter II of Title 10, Code of Federal Regulations as set forth below:
42 U.S.C. 6291-6317; 28 U.S.C. 2461 note.
This subpart contains and energy conservation requirements for compressors, pursuant to Part A-1 of Title III of the Energy Policy and Conservation Act, as amended, 42 U.S.C. 6311-6317.
Federal Aviation Administration (FAA), DOT.
Final rule.
This action establishes 2 new restricted areas (R-5601G and R-5601H) to the special use airspace (SUA) complex located at Fort Sill, OK, to provide additional maneuvering airspace for current and planned hazardous training activities. Specifically, the restricted areas provide participating fighter and bomber aircraft with non-eye safe laser firing and maneuvering airspace when training at the Falcon Bombing Range contained in R-5601C, the West Range Target Area contained in R-5601B, or the East Range Target Area contained in R-5601A. Additionally, the using agency information for all Fort Sill restricted areas is updated for standardization and to reflect the current organization. This action also updates a number of geographic coordinates for R-5601A-E, G, and H as a result of more accurate digital charting capabilities, updates the arc radius distance in R-5601B and R-5601H from statute miles to nautical miles (NM), and corrects the controlling agency information for R-5601H. This action ensures realistic U.S. Army training on current tactics for employing hazardous targeting laser systems and weapons capabilities at longer ranges from the target area.
Effective date 0901 UTC, March 2, 2017.
Colby Abbott, Airspace Policy Group, Office of Airspace Services, Federal Aviation Administration, 800 Independence Avenue SW., Washington, DC 20591; telephone: (202) 267-8783.
The FAA's authority to issue rules regarding aviation safety is found in Title 49 of the United States Code. Subtitle I, Section 106 describes the authority of the FAA Administrator. Subtitle VII, Aviation Programs, describes in more detail the scope of the agency's authority. This rulemaking is promulgated under the authority described in Subtitle VII, Part A, Subpart I, Section 40103. Under that section, the FAA is charged with prescribing regulations to assign the use of the airspace necessary to ensure the safety of aircraft and the efficient use of airspace. This regulation is within the scope of that authority as it restructures the restricted airspace at Fort Sill, OK, enhancing safety and accommodating essential military training.
On October 19, 2015, the FAA published in the
In their response to the NPRM, AOPA raised several substantive issues. AOPA contended the proposed airspace design would have a negative impact on general aviation aircraft and offered the following recommendations to mitigate the negative effects: consider other types of SUA before establishing additional restricted areas; change the ceiling of R-5601G so it aligns with the Minimum Enroute Altitude (MEA) of V-436; if
Having considered the issues and recommendations provided by AOPA, the FAA offers the following responses.
The purpose of a restricted area is to confine or segregate activities considered hazardous to nonparticipating aircraft. The FAA recognizes that R-5601G and H, when activated, would restrict access by non-participating aircraft. As noted in the NPRM, the U.S. Army requested this action to allow realistic training on current tactics developed and refined during recent combat operation for employing hazardous (non-eye safe) combat targeting laser systems and weapons capabilities at longer ranges from the target area. It was also noted that there was no alternative SUA complex within 200 NM where combat lasers could be employed that would support this aircrew training requirement. Therefore, the FAA has determined restricted area airspace is the appropriate SUA solution for conducting the hazardous activities associated with the U.S. Army's training requirement.
This recommendation would drop the ceiling of R-5601G from “to but not including 8,000 feet MSL” to 5,400 feet MSL. Such a lowered ceiling would prevent laser employment at ranges beyond 10 miles due to graze angle restrictions and result in loss of the increased standoff ranges proposed for realistic aircrew combat training. Additionally, the western portion of R-5601G overlies the Wichita Mountains National Wildlife Refuge. As mitigation to adverse effects when R-5601F was established in 2007, the Army agreed to restrict flights below 5,500 feet MSL over the Wildlife Refuge. Observing this local flight restriction to not overfly the Wildlife Refuge below 5,500 feet MSL and AOPA's recommended restricted area ceiling of 5,400 feet MSL would actually result in no available restricted area airspace over the Wichita Mountains National Wildlife Refuge and compression of the remaining portions of R-5601G to the point that the restricted area would not meet the military's training requirements any longer. The FAA does not support lowering the R-5601G ceiling as recommended.
The R-5601G boundaries description information in the regulatory text is being amended to reflect the U.S. Army's local flight restriction to not overfly the Wichita Mountains National Wildlife Refuge below 5,500 feet MSL and match the corresponding flight restriction documented in the R-5601F legal description and on the applicable aeronautical charts.
It is common practice for the FAA to depict Air Traffic Service (ATS) Routes and SUA areas on IFR and VFR aeronautical charts in accordance with established charting standards. Additionally, SUA times are published in a tab on the associated IFR and VFR charts to identify the SUA times of use. As such, V-436 will be charted on the IFR enroute charts, depicting it running through R-5601G and the R-5601 times of use will be published on the associated charts.
The FAA acknowledges that amending the proposed R-5601G northern boundary to provide a 4 NM buffer from the V-436 centerline would allow unimpeded use of the airway when the restricted area is active. However, this recommendation reduces the north-south lateral dimension of R-5601G by approximately 7 NM at its northeast corner. One of the stated purposes of this action, as noted in the NPRM, was to allow realistic training on current tactics developed during recent combat operation for employing hazardous targeting laser systems and weapons capabilities at longer ranges from the target area. Modern rangefinder and laser designators can be employed at ranges out to 25 NM. As proposed, the distance from the target arrays in R-5601C (Falcon Range) to the northeast corner of R-5601G is approximately 22 NM and the distance from the targets in R-5601B to the proposed northeast corner is approximately 17 NM. Amending the R-5601G northern boundary as recommended by AOPA would reduce these distances to 17 NM and 12 NM, respectively. As such, the FAA does not support this recommendation since the reduced distances to the target areas would be inadequate for the military to conduct realistic training on current tactics employing targeting laser systems and weapons systems at longer ranges.
The FAA normally makes regulatory airspace actions, including restricted areas, effective on a 56-day enroute chart date; however, consideration is given to selecting a sectional aeronautical chart date when deemed appropriate based on the potential aeronautical impacts associated with the airspace action being taken. This action is being made effective on a sectional chart date that matches the 56-day enroute chart dates.
Subsequent to publication of the NPRM, the FAA identified a number of geographic lat./long. coordinate updates to the R-5601A-E, G, and H boundaries information to more accurately reflect the existing boundaries using digital charting capabilities. Additionally, the arc radius distance listed in the R-5601B and R-5601H descriptions was determined to be described using statute miles and is being updated to reflect the corresponding nautical mile distance. Finally, the R-5601H controlling agency title proposed in the NPRM did not match the controlling agency title for the other R-5601 complex restricted areas and is being updated to match. The using agency, controlling agency, and boundaries updates are administrative in nature and do not affect the overall restricted area boundaries; designated altitudes; times of designation; or activities conducted within those restricted areas. The following restricted area updates are incorporated in this action.
The geographical lat./long. coordinates for the points located on Interstate Highway 44 (I-44) listed in the R-5601A and R-5601B descriptions, and a corresponding point listed in the R-5601H description, are actually located west of I-44. The geographical coordinates are updated to accurately reflect the points on I-44.
The 3-mile arc radius distance listed in the existing R-5601B and proposed R-5601H descriptions is not clear that it is defined in reference to statute miles. The 3-mile [statute miles] arc radius is updated to reflect it as 2.6 NM to retain the boundary, unchanged, and comply with FAA Order JO 7400.2, Procedures for Handling Airspace Matters, guidance.
The geographical lat./long. coordinates listed for the eastern-most point located on the 2.6 NM arc radius (formerly 3-mile arc radius as noted above) in the existing R-5601B and proposed R-5601H descriptions is actually located north of the arc. The geographical coordinates are updated to accurately reflect the point on the 2.6 NM arc.
The geographical lat./long. coordinates listed for the northern boundary point located on Oklahoma State Highway No. 115 in the R-5601B and R-5601C descriptions, and the corresponding point listed in the R-5601D description, is actually located east of the highway. The geographical coordinates are updated to accurately reflect the point on Oklahoma State Highway No. 115.
The geographical lat./long. coordinates for one point listed in the R-5601E description does not match the geographical coordinates for the corresponding point listed in the R-5601B and R-5601C descriptions. The geographical coordinates for the point are updated to match the information published in the R-5601B and R-5601C descriptions.
The geographical lat./long. coordinates for the first point listed in the R-5601G description does not create a shared boundary with R-5601F and results in a gap between the two restricted areas. The geographical lat./long. coordinates for the point are updated to ensure a shared R-5601F and R-5601G boundary.
The controlling agency information listed in the R-5601H description does not match the controlling agency information verbatim in all the other R-5601 restricted areas. The controlling agency information is updated to standardize the information in all R-5601 restricted areas.
The FAA is amending 14 CFR part 73 to establish 2 new restricted areas (R-5601G and R-5601H) at Fort Sill, OK, and update the using agency information listed for the existing restricted areas (R-5601A-F) as noted in the NPRM. The FAA is also incorporating the restricted area updates noted in the Differences from the NPRM section. The FAA is taking this action to ensure containment of the hazardous activities associated with aircrew training missions that are incorporating non-eye safe targeting laser employment and weapons delivery tactics used by the military today, at increased distances from the target range, within restricted area airspace. The amendments are as follows:
The two new restricted areas allow participating aircraft to maneuver within the current Fort Sill Approach Control Airspace and contain the hazardous combat laser energy within restricted airspace. As noted in the NPRM, R-5601G will be used for aircraft maneuvering and combat laser targeting employment and R-5601H will be used for aircraft conducting Close Air Support (CAS) training. There are no changes to the existing pattern of firing, ordnance delivery runs, or weapons impact areas and all weapons release continue to occur in R-5601A, R-5601B, or R-5601C, as they are now. Further, no supersonic flight will occur.
This action also changes the using agency information “U.S. Army, Commanding General, Fort Sill, OK,” listed for R-5601A-E to “U.S. Army, Commanding General, U.S. Army Fires Center of Excellence (USAFCOE) and Fort Sill, Fort Sill, OK” and the using agency “Commanding General, United States Army Field Artillery Center (USAFACFS), Fort Sill, OK,” listed for R-5601F is changed to “U.S. Army, Commanding General, U.S. Army Fires Center of Excellence (USAFCOE) and Fort Sill, Fort Sill, OK.” These changes reflect the current organizational responsibilities and match the using agency information published in R-5601G and R-5601H.
The boundaries, designated altitudes, times of designation, and controlling agency information for restricted areas R-5601A-F are not changed by this action.
The FAA has determined that this regulation only involves an established body of technical regulations for which
In accordance with FAA Order 1050.1F, paragraphs 6-3.c and 8-2, the FAA has conducted an independent evaluation of the U.S. Army's Final Environmental Assessment (EA) for the Creation of Restricted Areas (RAs) R-5601G and R-5601H. The FAA determined that no significant impacts would occur as a result of the Federal action and therefore, preparation of an Environmental Impact Statement is not warranted and a Finding of No Significant Impact in accordance with 40 CFR 1501.4(e) is appropriate. Subsequently, and in accordance with 40 CFR 1506.3, the FAA adopted the U.S. Army's final EA and prepared a Finding of No Significant Impact/Record of Decision dated November 7, 2016.
Airspace, Prohibited areas, Restricted areas.
In consideration of the foregoing, the Federal Aviation Administration amends 14 CFR part 73 as follows:
49 U.S.C.106 (f), 106(g); 40103, 40113, 40120; E.O. 10854, 24 FR 9565, 3 CFR, 1959-1963 Comp., p. 389.
By removing the current boundaries and using agency information and substituting the following:
By removing the current boundaries and using agency information and substituting the following:
By removing the current boundaries and using agency information and substituting the following:
By removing the current boundaries and using agency information and substituting the following:
By removing the current boundaries and using agency information and substituting the following:
By removing the current using agency and substituting the following:
Pension Benefit Guaranty Corporation.
Final rule.
This final rule amends the Pension Benefit Guaranty Corporation's regulation on Benefits Payable in Terminated Single-Employer Plans to prescribe interest assumptions under the regulation for valuation dates in December 2016. The interest assumptions are used for paying benefits under terminating single-employer plans covered by the pension insurance system administered by PBGC.
Effective December 1, 2016.
Deborah C. Murphy (
PBGC's regulation on Benefits Payable in Terminated Single-Employer Plans (29 CFR part 4022) prescribes actuarial assumptions—including interest assumptions—for paying plan benefits under terminating single-employer plans covered by title IV of the Employee Retirement Income Security Act of 1974. The interest assumptions in the regulation are also published on PBGC's Web site (
PBGC uses the interest assumptions in Appendix B to Part 4022 to determine whether a benefit is payable as a lump sum and to determine the amount to pay. Appendix C to Part 4022 contains interest assumptions for private-sector pension practitioners to refer to if they wish to use lump-sum interest rates determined using PBGC's historical methodology. Currently, the rates in Appendices B and C of the benefit payment regulation are the same.
The interest assumptions are intended to reflect current conditions in the financial and annuity markets. Assumptions under the benefit payments regulation are updated monthly. This final rule updates the benefit payments interest assumptions for December 2016.
The December 2016 interest assumptions under the benefit payments regulation will be 0.75 percent for the period during which a benefit is in pay status and 4.00 percent during any years preceding the benefit's placement in pay status. In comparison with the interest assumptions in effect for November 2016, these interest assumptions represent an increase of 0.25 percent in the immediate rate and are otherwise unchanged.
PBGC has determined that notice and public comment on this amendment are impracticable and contrary to the public interest. This finding is based on the need to determine and issue new interest assumptions promptly so that the assumptions can reflect current market conditions as accurately as possible.
Because of the need to provide immediate guidance for the payment of benefits under plans with valuation dates during December 2016, PBGC finds that good cause exists for making the assumptions set forth in this amendment effective less than 30 days after publication.
PBGC has determined that this action is not a “significant regulatory action” under the criteria set forth in Executive Order 12866.
Because no general notice of proposed rulemaking is required for this amendment, the Regulatory Flexibility Act of 1980 does not apply. See 5 U.S.C. 601(2).
Employee benefit plans, Pension insurance, Pensions, Reporting and recordkeeping requirements.
In consideration of the foregoing, 29 CFR part 4022 is amended as follows:
29 U.S.C. 1302, 1322, 1322b, 1341(c)(3)(D), and 1344.
Centers for Medicare & Medicaid Services (CMS), HHS.
Interim final rule with comment period.
The Covered Outpatient Drug final rule with comment period was published in the February 1, 2016
In commenting, please refer to file code CMS-2345-IFC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one of the ways listed)
1.
2.
Please allow sufficient time for mailed comments to be received before the close of the comment period.
3.
4.
a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.
For information on viewing public comments, see the beginning of the
Wendy Tuttle, (410) 786-8690.
Comments received timely will be also available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.
The Covered Outpatient Drug final rule with comment period was published in the February 1, 2016
We stated in the preamble to the final rule with comment period that U.S. territories may use existing waiver authority to elect not to participate in the MDR program consistent with the statutory waiver standards. The Northern Mariana Islands and American Samoa may seek to opt out of participation under the broad waiver that has been granted to them in accordance with section 1902(j) of the Act. Puerto Rico, the Virgin Islands, and Guam may use waiver authority under section 1115(a)(1) of the Act to waive section 1902(a)(54) of the Act, which requires state compliance with the applicable requirements of section 1927 of the Act (81 FR 5203 through 5204).
We also stated in the final rule with comment period that, effective with the change in the definition of “United States,” drug manufacturers would be required to include prices paid by entities located in one of the U.S. territories in the same manner in which they include prices paid by entities located in one of the 50 states and District of Columbia (81 FR 5224) in their calculations of average manufacturer price (AMP) and best price. This change requires manufacturers to include eligible sales and associated discounts, rebates, and other financial transactions that take place in the U.S. territories in their calculations of AMP and best price once the revised definitions of States and United States become effective, regardless of whether the U.S. territories seek to waive participation in the MDR program.
Based on discussions with the U.S. territories, it has become evident that interested U.S. territories could not be ready to implement the program by April 1, 2017, although a few territories have expressed interest in participating once they have made the necessary systems changes. Specifically, the territories need time to develop and change electronic claims processing systems to identify and report utilization (taking into account all of the complexities in tracking utilization by National drug code numbers) and to match utilization with the unit rebate amounts to generate rebate invoices. Further, these systems must be capable of collecting, reporting, validating and tracking drug utilization on an ongoing basis. In addition, they require extensive advance planning and budgeting. We received comments during the comment period of the proposed rule which requested that CMS delay the inclusion of the territories in the MDR program because the manufacturers and territories would need this additional time to implement provisions necessary to include territories in all aspects of the MDR program. We took these comments into consideration and in the final rule delayed the inclusion of the territories into the definitions of States and United States until 1 year after the effective date of the final rule (81 FR 5203, 5204). Despite this 1 year delay, it has since become evident that we underestimated the timeline required, particularly in light of other demands on territorial systems development and the fact that the territories are at various stages of planning and development with respect to these systems. While the U.S. territories have the ability to seek a waiver from the requirements that they would have to meet when classified as “states,” doing so would impose some burdens on a territory, particularly for those territories that are not included in the broad waiver authority under section 1902(j) of the Act. Moreover, waivers under section 1115 of the Act are limited to requirements applicable to states or territories under section 1902(a) of the Act, and would not apply to the requirements placed on drug manufacturers that sell in the territories. These manufacturers cannot be waived from the section 1927 of the Act requirements under which manufacturers must include sales that take place in the U.S. territories when determining AMP and best price.
We have heard from various stakeholders who have reiterated many of the concerns that were summarized in the final rule with comment (81 FR 5224) that drug manufacturers will likely be prompted to increase drug prices, including prices paid by U.S. territory Medicaid programs. This would result in the U.S. territories that receive a waiver realizing an increase in their Medicaid drug costs without the offsetting benefit of receiving Medicaid rebates. Furthermore, the increase in Medicaid costs could adversely impact territories because of their Medicaid funding cap.
For the reasons discussed in the Background section, this interim final rule with comment period amends the regulatory definitions of “States” and “United States” under § 447.502 to include the U.S. territories (American Samoa, Northern Mariana Islands, Guam, Puerto Rico, and the Virgin Islands) beginning April 1, 2020 rather than April 1, 2017.
We ordinarily publish a notice of proposed rulemaking in the
As discussed in section I.B. of this interim final rule with comment period, in light of the longer time frames needed by territories for planning, budgeting and developing systems necessary to implement the Medicaid drug rebate program, the competing demand on system development resources, and the long time frames for manufacturer pricing determinations, we believe it is necessary to provide territories and manufacturers with advance notice of any change in the timing for the inclusion of territories in the Medicaid drug rebate program. Issuance of a proposed rule would be impracticable because it would result in a notice of the final rule without sufficient time for territories or manufacturers to adjust their actions to take into account the revised timing. Thus, we find good cause to waive the requirement for proposed rulemaking because the short time frame before the inclusion of territories would otherwise take effect does not permit sufficient time to both undertake proposed rulemaking and provide the necessary advance notice for territories and manufacturers to meaningfully adjust planning and systems development to accommodate the revised timing. Furthermore, we find good cause to waive the requirement for proposed rulemaking
Therefore, we find good cause to waive the notice of proposed rulemaking and to issue this final rule on an interim basis. We are providing a 60-day public comment period.
This rule's delay in including the territories in the definitions of “States” and “United States” until April 1, 2020, does not impose any new or revised information collection, reporting, recordkeeping or third-party disclosure requirements or burden. 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
Because of the large number of public comments we normally receive on
We have examined the impact 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 rules with economically significant effects ($100 million or more in any 1 year). This rule does not reach the economic threshold and thus is not considered a major rule.
The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $7.5 million to $38.5 million in any 1 year. Individuals and states are not included in the definition of a small entity. We are not preparing an analysis for the RFA because we have determined, and the Secretary certifies, that this interim final rule with comment period 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 for Medicare payment regulations and has fewer than 100 beds. We are not preparing an analysis for section 1102(b) of the Act because we have determined, and the Secretary certifies, that this interim final rule with comment period 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 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. This rule will have no consequential effect on state, local, or tribal governments or on the private sector.
Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts state law, or otherwise has federalism implications. Since this regulation does not impose any costs on state or local governments, the requirements of Executive Order 13132 are not applicable.
In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget.
Accounting, Administrative practice and procedure, Drugs, Grant programs—health, Health facilities, Health professions, Medicaid, Reporting and recordkeeping requirements, Rural areas.
For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below:
Sec. 1102 of the Social Security Act (42 U.S.C. 1302).
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Temporary rule; closure.
NMFS implements accountability measures (AMs) for the gray triggerfish recreational sector in the exclusive economic zone (EEZ) of the Gulf of Mexico (Gulf) for the 2017 fishing year through this temporary rule. NMFS has determined that the 2016 recreational annual catch limit (ACL) for Gulf gray triggerfish was exceeded; therefore, NMFS reduces the gray triggerfish recreational ACL and annual catch target (ACT) in 2017. As a result of the recreational ACL and ACT overages in 2016, the gray triggerfish 2017 recreational season in the Gulf EEZ will not open on January 1, 2017, and will remain closed for the entire 2017 fishing year. This closure is necessary to protect the Gulf gray triggerfish resource.
This rule is effective from 12:01 a.m., local time, January 1, 2017, until 12:01 a.m., local time, January 1, 2018.
Rich Malinowski, NMFS Southeast Regional Office, telephone: 727-824-5305, email:
NMFS manages the Gulf reef fish fishery, including gray triggerfish, under the Fishery Management Plan for the Reef Fish Resources of the Gulf (FMP). The Gulf of Mexico Fishery Management Council (Council) prepared the FMP and NMFS implements the FMP under the authority of the Magnuson-Stevens Fishery Conservation and Management Act (Magnuson-Stevens Act) by regulations at 50 CFR part 622. All gray triggerfish weights discussed in this temporary rule are in round weight.
The recreational ACL for Gulf gray triggerfish specified in 50 CFR 622.41(b)(2)(iii) is 241,200 lb (109,406 kg) and the recreational ACT is 217,100 lb (98,475 kg). However, in 2015, gray triggerfish landings exceeded the 2015 ACL by 39,977 lbs. Therefore, the 2016 ACL and ACT were adjusted to 201,223 lb (91,273 kg) and 177,123 lb (80,342 kg), respectively. In 2016, the recreational fishing season did not re-open after the annual spawning season closure from June 1 through July 31, and the recreational harvest of gray triggerfish exceeded the 2016 recreational ACL by 221,213 lb (100,341 kg). Therefore, consistent with the AM requirements specified in 50 CFR 622.41(b)(2)(ii), NMFS reduces the recreational ACL and ACT for gray triggerfish in 2017 by the amount of the recreational ACL overage to 19,987 lb (9,066 kg) and 0 lb (0 kg), respectively.
Under 50 CFR 622.41(b)(2)(i), NMFS is required to close the recreational sector for gray triggerfish when the recreational ACT is reached, or is projected to be reached, by filing a notification to that effect with the Office of the Federal Register. NMFS has determined that the recreational ACT for the 2017 fishing year is 0 lb (0 kg). Therefore, NMFS closes the recreational harvest of gray triggerfish for the 2017 fishing year.
During the recreational closure, the bag and possession limits for gray triggerfish in or from the Gulf EEZ are zero. The prohibition on possession in the Gulf on board a vessel for which a valid Federal charter vessel/headboat permit for Gulf reef fish has been issued applies regardless of whether gray triggerfish were harvested in state or Federal waters.
The recreational sector for gray triggerfish in the Gulf EEZ will reopen on January 1, 2018, the beginning of the 2018 recreational fishing year, unless changed by subsequent notification in the
The Regional Administrator, Southeast Region, NMFS, has determined this temporary rule is necessary for the conservation and management of Gulf gray triggerfish and is consistent with the Magnuson-Stevens Act and other applicable laws.
This action is taken under 50 CFR 622.41(b)(2)(i) and (ii) and is exempt from review under Executive Order 12866.
These measures are exempt from the procedures of the Regulatory Flexibility Act because the temporary rule is issued without opportunity for prior notice and comment.
This action responds to the best scientific information available. The Assistant Administrator for NOAA Fisheries (AA), finds that the need to immediately implement this action to close the recreational sector for gray triggerfish constitutes good cause to waive the requirements to provide prior notice and opportunity for public comment on this temporary rule pursuant to the authority set forth in 5 U.S.C. 553(b)(B), because such procedures are unnecessary and contrary to the public interest. Such procedures are unnecessary because the rule establishing the closure provisions was subject to notice and comment, and all that remains is to notify the public of the closure. Such procedures are contrary to the public interest because the public requires as much advanced notice as possible of season closures to allow time to adequately plan for recreational fishing trips during the 2017 fishing year.
For the aforementioned reasons, the AA also finds good cause to waive the 30-day delay in the effectiveness of this action under 5 U.S.C. 553(d)(3).
16 U.S.C. 1801
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Temporary rule; reallocation.
NMFS is reallocating the projected unused amount of Pacific cod from catcher vessels using trawl gear and catcher vessels greater than or equal to 60 feet (18.3 meters (m)) length overall (LOA) using pot gear to catcher processors (C/Ps) using hook-and-line gear and C/Ps using pot gear in the Bering Sea and Aleutian Islands (BSAI) management area. This action is necessary to allow the 2016 total allowable catch of Pacific cod to be harvested.
Josh Keaton, 907-586-7228.
NMFS manages the groundfish fishery in the Bering Sea and Aleutian Islands (BSAI) according to the Fishery Management Plan for Groundfish of the Bering Sea and Aleutian Islands Management Area (FMP) prepared by the North Pacific Fishery Management Council under authority of the Magnuson-Stevens Fishery Conservation and Management Act. Regulations governing fishing by U.S. vessels in accordance with the FMP appear at subpart H of 50 CFR part 600 and 50 CFR part 679.
The 2016 Pacific cod TAC specified for catcher vessels using trawl gear in the BSAI is 46,638 metric tons (mt) as established by the final 2016 and 2017 harvest specifications for groundfish of the BSAI (81 FR 14773, March 18, 2016) and reallocations (81 FR 69445, October 6, 2016, 81 FR 76530, November 3, 2016). The Regional Administrator has determined that catcher vessels using trawl gear will not be able to harvest 1,500 mt of the remaining 2016 Pacific cod TAC allocated to those vessels under § 679.20(a)(7)(ii)(A)(
The 2016 Pacific cod TAC specified for catcher vessels greater than or equal to 60 feet (18.3 m) LOA using pot gear in the BSAI is 17,598 mt as established by the final 2016 and 2017 harvest specifications for groundfish of the BSAI (81 FR 14773, March 18, 2016) and reallocation (81 FR 69445, October 6, 2016). The Regional Administrator has determined that catcher vessels greater than or equal to 60 feet (18.3 m) LOA using pot gear will not be able to harvest 3,000 mt of the remaining 2016 Pacific cod TAC allocated to those vessels under § 679.20(a)(7)(ii)(A)(
Therefore, in accordance with § 679.20(a)(7)(iii), taking into account the capabilities of the sectors to harvest reallocated amounts of Pacific cod, and following the hierarchies set forth in § 679.20(a)(7)(iii)(A) and § 679.20(a)(7)(iii)(B), NMFS reallocates 4,500 mt of Pacific cod to C/Ps using hook-and-line gear and C/Ps using pot gear in the Bering Sea and Aleutian Islands management area.
The harvest specifications for Pacific cod included in the final 2016 and 2017 harvest specifications for groundfish of the BSAI (81 FR 14773, March 18, 2016, 81 FR 57491, August 23, 2016, 81 FR 61143, September 6, 2016, 81 FR 69445, October 6, 2016, 81 FR 76530, November 3, 2016) are revised as follows: 45,138 mt for catcher vessels using trawl gear, 14,598 for catcher vessels greater than or equal to 60 feet (18.3 m) LOA using pot gear, 111,783 for C/Ps using hook-and-line gear, and 6,607 mt for C/Ps using pot gear.
This action responds to the best available information recently obtained from the fishery. The Assistant Administrator for Fisheries, NOAA (AA), finds good cause to waive the requirement to provide prior notice and opportunity for public comment pursuant to the authority set forth at 5 U.S.C. 553(b)(B) as such requirement is impracticable and contrary to the public interest. This requirement is impracticable and contrary to the public interest as it would prevent NMFS from responding to the most recent fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from multiple sectors to C/Ps using hook-and-line gear and C/Ps using pot gear in the Bering Sea and Aleutian Islands management area. Since these fisheries are currently open, it is important to immediately inform the industry as to the revised allocations. Immediate notification is necessary to allow for the orderly conduct and efficient operation of this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption to the fishing fleet as well as processors. NMFS was unable to publish a notice providing time for public comment because the most recent, relevant data only became available as of November 7, 2016.
The AA also finds good cause to waive the 30-day delay in the effective date of this action under 5 U.S.C. 553(d)(3). This finding is based upon the reasons provided above for waiver of prior notice and opportunity for public comment.
This action is required by § 679.20 and is exempt from review under Executive Order 12866.
16 U.S.C. 1801
Office of Energy Efficiency and Renewable Energy, Department of Energy.
Announcement of public meetings.
The Department of Energy (DOE) announces public meetings and webinars for the Circulator Pumps Working Group. The Federal Advisory Committee Act requires that agencies publish notice of an advisory committee meeting in the
See
The meetings will be held at Navigant, 1200 19th St. NW., Suite 700, Washington, DC, unless otherwise stated in the
Mr. Joe Hagerman, U.S. Department of Energy, Office of Energy Efficiency and Renewable Energy, Building Technologies, EE-5B, 1000 Independence Avenue SW., Washington, DC 20585-0121. Telephone: (202) 586-4549. Email:
Ms. Johanna Jochum, U.S. Department of Energy, Office of the General Counsel, GC-33, 1000 Independence Avenue SW., Washington, DC 20585-0121. Telephone: (202) 287-6307 Email:
On January 20, 2016, ASRAC met and unanimously passed the recommendation to form a circulator pumps working group. The purpose of the working group is to discuss and, if possible, reach consensus on a proposed rule regarding definitions, test procedures, and energy conservation standards, as authorized by the Energy Policy and Conservation Act (EPCA) of 1975, as amended. The working group consists of representatives of parties having a defined stake in the outcome of the proposed standards, and will consult as appropriate with a range of experts on technical issues. Per the ASRAC Charter, the working group is expected to make a concerted effort to negotiate a final term sheet by December 31, 2016. This notice announces the next series of meetings for this working group.
DOE will host public meetings and webinars on the below dates.
• Tuesday, November 29, 2016 from 9:00 a.m. to 5:00 p.m. at 1200 19th St. NW., Suite 700, Washington, DC.
• Wednesday, November 30, 2016 from 8:00 a.m. to 4:00 p.m. at 1200 19th St. NW., Suite 700, Washington, DC.
• Thursday, December 1, 2016 from 8:00 a.m. to 4:00 p.m. at 1200 19th St. NW., Suite 700, Washington, DC.
Members of the public are welcome to observe the business of the meeting and, if time allows, may make oral statements during the specified period for public comment. To attend the meeting and/or to make oral statements regarding any of the items on the agenda, email
Due to the REAL ID Act implemented by the Department of Homeland Security (DHS) recent changes have been made regarding ID requirements for individuals wishing to enter Federal buildings from specific states and U.S. territories. Driver's licenses from the following states or territory will not be accepted for building entry and one of the alternate forms of ID listed below will be required.
DHS has determined that regular driver's licenses (and ID cards) from the following jurisdictions are not acceptable for entry into DOE facilities: Alaska, Louisiana, New York, American Samoa, Maine, Oklahoma, Arizona, Massachusetts, Washington, and Minnesota.
Acceptable alternate forms of Photo-ID include: U.S. Passport or Passport Card; an Enhanced Driver's License or Enhanced ID-Card issued by the states of Minnesota, New York or Washington (Enhanced licenses issued by these states are clearly marked Enhanced or Enhanced Driver's License); A military ID or other Federal government issued Photo-ID card.
Federal Aviation Administration (FAA), DOT.
Notice of proposed rulemaking (NPRM).
We propose to adopt a new airworthiness directive (AD) for certain Gulfstream Aerospace Corporation Model GVI airplanes. This proposed AD was prompted by a report indicating that there are design deficiencies in the software used for monitoring the disconnect for the flight control computer (FCC)-hosted flight controls actuation main ram linear variable differential transducer (LVDT). This proposed AD would require an update of the FCC software. We are proposing this AD to prevent the unsafe condition on these products.
We must receive comments on this proposed AD by December 30, 2016.
You may send comments, using the procedures found in 14 CFR 11.43 and 11.45, by any of the following methods:
•
•
•
•
For service information identified in this NPRM, contact Gulfstream Aerospace Corporation, Technical Publications Dept., P.O. Box 2206, Savannah, GA 31402-2206; telephone: 800-810-4853; fax: 912-965-3520; email:
You may examine the AD docket on the Internet at
Myles Jalalian, Aerospace Engineer, Systems and Equipment Branch, ACE-119A, FAA, Atlanta Aircraft Certification Office (ACO), 1701 Columbia Avenue, College Park, GA 30337; phone: 404-474-5572; fax: 404-474-5606; email:
We invite you to send any written relevant data, views, or arguments about this proposal. Send your comments to an address listed under the
We will post all comments we receive, without change, to
We have received a report indicating that there are design deficiencies in the FCC software used for monitoring the disconnect for the FCC-hosted flight controls actuation main ram LVDT. When a failure occurs, if the actuator LVDT mechanical disconnect monitor and oscillatory monitor are not reliably triggered, there could be an undetected actuation of the main ram LVDT. This condition, if not corrected, could result in undetected actuation of the main ram LVDT. Undetected actuation of the main ram LVDT, if not corrected, could result in mechanical failure of the flight control surface actuator mechanism under force fight (the actuator is working against the intended load forces), causing primary surface hardover, spoiler hardover, and loss of control of the airplane.
We reviewed Gulfstream G650 Aircraft Service Change Number 037, Revision A, dated June 28, 2016; and Gulfstream G650ER Aircraft Service Change Number 037, Revision A, dated June 28, 2016. The service information describes procedures for doing an update of the FCC software. These documents are distinct since they apply to different airplane models. This service information is reasonably available because the interested parties have access to it through their normal course of business or by the means identified in the
We are proposing this AD because we evaluated all the relevant information and determined the unsafe condition described previously is likely to exist or develop in other products of the same type design.
This proposed AD would require accomplishing the actions specified in the service information described previously.
We consider this proposed AD interim action. The manufacturer is currently developing an additional software update that will complete the actions necessary to address the unsafe condition identified in this proposed AD. Once this additional software update is developed, approved, and available, we might consider additional rulemaking.
We estimate that this proposed AD affects 90 airplanes of U.S. registry. We estimate the following costs to comply with this proposed AD:
According to the manufacturer, some of the costs of this proposed AD may be covered under warranty, thereby reducing the cost impact on affected individuals. We do not control warranty coverage for affected individuals. As a result, we have included all costs in our cost estimate.
Title 49 of the United States Code specifies the FAA's authority to issue rules on aviation safety. Subtitle I, section 106, describes the authority of the FAA Administrator. Subtitle VII: Aviation Programs, describes in more detail the scope of the Agency's authority.
We are issuing this rulemaking under the authority described in Subtitle VII, Part A, Subpart III, Section 44701: “General requirements.” Under that section, Congress charges the FAA with promoting safe flight of civil aircraft in air commerce by prescribing regulations for practices, methods, and procedures the Administrator finds necessary for safety in air commerce. This regulation is within the scope of that authority because it addresses an unsafe condition that is likely to exist or develop on products identified in this rulemaking action.
We determined that this proposed AD would not have federalism implications under Executive Order 13132. This proposed AD 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.
For the reasons discussed above, I certify this proposed regulation:
(1) Is not a “significant regulatory action” under Executive Order 12866,
(2) Is not a “significant rule” under the DOT Regulatory Policies and Procedures (44 FR 11034, February 26, 1979),
(3) Will not affect intrastate aviation in Alaska, and
(4) Will not have a significant economic impact, positive or negative, on a substantial number of small entities under the criteria of the Regulatory Flexibility Act.
Air transportation, Aircraft, Aviation safety, Incorporation by reference, Safety.
Accordingly, under the authority delegated to me by the Administrator, the FAA proposes to amend 14 CFR part 39 as follows:
49 U.S.C. 106(g), 40113, 44701.
We must receive comments by December 30, 2016.
None.
This AD applies to Gulfstream Aerospace Corporation Model GVI airplanes, certificated in any category, serial numbers 6001 through 6164 inclusive.
Model GVI airplanes are also referred to by marketing designations G650 and G650ER.
Air Transport Association (ATA) of America Code 27; Flight controls.
This AD was prompted by a report indicating that there are design deficiencies in the software used for monitoring the disconnect for the flight control computer (FCC)-hosted flight controls actuation main ram linear variable differential transducer (LVDT). We are issuing this AD to prevent undetected actuation of the main ram LVDT. Undetected actuation of the main ram LVDT, if not corrected, could result in mechanical failure of the flight control surface actuator mechanism under force fight (the actuator is working against the intended load forces), causing primary surface hardover, spoiler hardover, and loss of control of the airplane.
Comply with this AD within the compliance times specified, unless already done.
Within 24 months after the effective date of this AD, do an FCC software update, in accordance with the Modification Instructions of Gulfstream G650 Aircraft Service Change Number 037, Revision A, dated June 28, 2016; or Gulfstream G650ER Aircraft Service Change Number 037, Revision A, dated June 28, 2016; as applicable.
Although Gulfstream G650 Aircraft Service Change Number 037, Revision A, dated June 28, 2016; and Gulfstream G650ER Aircraft Service Change Number 037, Revision A, dated June 28, 2016; specify to submit certain information to the manufacturer, this AD does not require that action.
(1) The Manager, Atlanta Aircraft Certification Office (ACO), FAA, has the authority to approve AMOCs for this AD, if requested using the procedures found in 14 CFR 39.19. In accordance with 14 CFR 39.19, send your request to your principal inspector or local Flight Standards District Office, as appropriate. If sending information directly to the manager of the ACO, send it to the attention of the person identified in paragraph (j)(1) of this AD.
(2) Before using any approved AMOC, notify your appropriate principal inspector, or lacking a principal inspector, the manager of the local flight standards district office/certificate holding district office.
(1) For more information about this AD, contact Myles Jalalian, Aerospace Engineer, Systems and Equipment Branch, ACE-119A, FAA, Atlanta ACO, 1701 Columbia Avenue, College Park, GA 30337; phone: 404-474-5572; fax: 404-474-5606; email:
(2) For service information identified in this AD, contact Gulfstream Aerospace Corporation, Technical Publications Dept., P.O. Box 2206, Savannah, GA 31402-2206; telephone: 800-810-4853; fax: 912-965-3520; email:
Federal Trade Commission.
Request for public comment; reopening for public comments.
The Federal Trade Commission (“FTC” or “Commission”) is extending the deadline for filing public comments on its recent Request for Public Comment on the Standards for Safeguarding Customer Information (“Safeguards Rule” or “Rule”).
The comment period for the request for public comment published in the
Interested parties may file a comment online or on paper by following the Instructions for Submitting Comments part of the
David Lincicum or Katherine McCarron, Division of Privacy and Identity Protection, Bureau of Consumer Protection, Federal Trade Commission, 600 Pennsylvania Avenue NW., Washington, DC 20580, (202) 326-2773 or (202) 326-2333.
On September 7, 2016 (81 FR 61632), as part of the Commission's systematic review of all current FTC rules and guides, the Commission published a Request for Comments requesting public comment on the overall costs, benefits, necessity, and regulatory impact of the Safeguards Rule, with a deadline for filing comments of November 7, 2016. On September 12, 2016 (81 FR 63435), the Commission published a Request for Public Comment on its Disposal Rule, with a deadline for comments of November 21, 2016. On October 21, 2016, the American Financial Services Association, Consumer Data Industry Association, and the National Auto Dealer Association, requested that the comment period be extended until November 21, 2016 to coincide with the comment period for Disposal Rule Request for Comments. The requesters explained that the two rules are closely related and that comments on the two rules may overlap. Therefore, having the two comment periods coincide would make it easier for commenters to provide feedback on both rules.
The Commission agrees that allowing additional time for filing comments on the Safeguards Rule would help facilitate the creation of a more complete record. In addition, extending the comment period would not harm consumers because the current Rule will remain in effect during the review process. Therefore, the Commission has decided to extend the comment period to November 21, 2016.
You can file a comment online or on paper. For the Commission to consider your comment, we must receive it on or before November 21, 2016. Write “Safeguards Rule, 16 CFR 314, Project No. P145407” on the comment. Your comment, including your name and your state, will be placed on the public record of this proceeding, including, to the extent practicable, on the public Commission Web site, at
In addition, do not include any “[t]rade secret or any commercial or financial information which is . . . privileged or confidential,” as discussed in Section 6(f) of the FTC Act, 15 U.S.C. 46(f), and FTC Rule 4.10(a)(2), 16 CFR 4.10(a)(2). In particular, do not include competitively sensitive information such as costs, sales statistics, inventories, formulas, patterns, devices, manufacturing processes, or customer names.
If you want the Commission to give your comment confidential treatment, you must file it in paper form, with a request for confidential treatment, and you must follow the procedure explained in FTC Rule 4.9(c), 16 CFR 4.9(c). In particular, the written request for confidential treatment that accompanies the comment must include the factual and legal basis for the request, and must identify the specific portions of the comments to be withheld from the public record. Your comment will be kept confidential only if the FTC General Counsel grants your request in accordance with the law and the public interest.
Postal mail addressed to the Commission is subject to delay due to heightened security screening. As a result, we encourage you to submit your comment online. To make sure that the Commission considers your online comment, you must file it at
If you file your comment on paper, write “Safeguards Rule, 16 CFR 314, Project No. P145407” on your comment and on the envelope, and mail your comment to the following address: Federal Trade Commission, Office of the Secretary, 600 Pennsylvania Avenue NW., Suite CC-5610 (Annex B), Washington, DC 20580, or deliver your comment to the following address: Federal Trade Commission, Office of the Secretary, Constitution Center, 400 7th Street SW., 5th Floor, Suite 5610 (Annex B), Washington, DC 20024.
Visit the Commission Web site at
By direction of the Commission.
Department of Defense (DoD), General Services Administration (GSA), and National Aeronautics and Space Administration (NASA).
Proposed rule.
DoD, GSA, and NASA are proposing to amend the Federal Acquisition Regulation (FAR) to clarify the guidance for sole-source 8(a) contract awards exceeding $22 million.
Interested parties should submit written comments to the Regulatory Secretariat Division at one of the addresses shown below on or before January 17, 2017 to be considered in the formation of the final rule.
Submit comments in response to FAR Case 2013-018 by any one of the following methods:
•
•
Ms. Mahruba Uddowla, Procurement Analyst, via email at
DoD, GSA, and NASA are proposing to revise the FAR to further clarify guidance for justifications of 8(a) sole-source contract awards in excess of $22 million. This proposed rule responds to the recommendations made by the Government Accountability Office (GAO) in its report, GAO-13-118, “Slow Start to Implementation of Justifications for 8(a) Sole-Source Contracts.” The GAO report focuses on the revisions made to the FAR to implement section 811 of the National Defense Authorization Act for Fiscal Year 2010 (Pub. L. 111-84) (see 77 FR 23369). Section 811 established the requirement that the head of an agency may not award a sole-source 8(a) contract for an amount exceeding $20 million (subsequently updated to $22 million) unless—
• The contracting officer justifies the use of a sole-source contract in writing;
• The justification is approved by the appropriate official designated to approve contract awards for dollar amounts that are comparable to the amount of the sole-source contract; and
• The justification and related documentation are made available to the public in accordance with 10 U.S.C. 2304(f)(1)(C) and (l), and 41 U.S.C. 253(f)(1)(C) and (j) (recodified at 41 U.S.C. 3304(e)(1)(C) and (f)), as applicable.
The FAR Council published an interim rule in the
On December 12, 2012, the GAO released its report regarding the use of the of the sole-source 8(a) justification across the Federal Government. The GAO-13-118 report indicates that the FAR needed additional clarification of justification and recommended that clarifying guidance is needed to help ensure that agencies are applying the justification requirement consistently. The GAO report recommended that OFPP, in consultation with the FAR Council, promulgate guidance to clarify the circumstances in which an 8(a) justification is required. As recommended, OFPP and the FAR Council agree to clarify the FAR with guidance that will:
• Clarify whether an 8(a) justification is required for 8(a) contracts that are subject to a pre-existing Competition in Contracting Act of 1984 (Pub. L. 98-369) (CICA) class justification.
• Provide additional information on actions contracting officers should take to comply with the justification requirement when the contract value rises above or falls below $22 million between the Small Business Administration's (SBA's) acceptance of the contract for negotiation under the 8(a) program and the contract award.
• Clarify whether and under what circumstances a separate sole-source justification is necessary for out-of-scope modifications to 8(a) sole-source contracts.
• This rule does not expand on the requirements of section 811. The intent of the proposed rule is to further clarify the processes and procedures in the FAR to ensure uniform, consistent, and coherent guidance regarding the use of sole-source 8(a) justifications.
The following is a summary of the proposed FAR amendments associated with this rule:
The proposed rule will clarify that a justification executed under any other authority cannot be substituted for a sole-source 8(a) justification.
The current requirement in the FAR to prepare and approve the sole-source 8(a) justification prior to negotiation remains intact to ensure that the justification “. . . is executed prior to negotiation, a critical juncture in the contract award continuum” (77 FR 23369). However, the FAR will be amended to clarify the appropriate actions contracting officers should take in the event the estimated contract value rises above or falls below $22 million prior to award. DoD, GSA and NASA propose to add the following:
• If the estimated contract value at the time of submission of the offering letter exceeds $22 million, include the approved justification with the offering letter.
• If the estimated contract value at the time of submission of the offering letter is less than or equal to $22 million, but the contract value at time of award exceeds $22 million, send the approved justification prior to contract award.
At FAR 43.102, the FAR provides guidance to contracting officers acting within the scope of their authority. In general, if the modification to the contract is out of scope, then it would be considered a new contract and would therefore, need to go through the appropriate procurement process for a new contract. Agencies' contracting officers use their discretion to determine if a modification is within the scope of the original contract.
Conforming changes were proposed to part 6 and subpart 19.8. Other minor editorial clarifications were made.
Executive Orders (E.O.s) 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). E.O. 13563 emphasizes the importance of quantifying both costs and benefits, of reducing costs, of harmonizing rules, and of promoting flexibility. This is a significant regulatory action and, therefore, was subject to review under Section 6(b) of E.O. 12866, Regulatory Planning and Review, dated September 30, 1993. This rule is not a major rule under 5 U.S.C. 804.
DoD, GSA, and NASA do not expect this proposed rule to 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,
The proposed rule responds to the recommendations made in GAO-113-118 issued on December 12, 2012, to promulgate clarifying guidance in the FAR regarding sole-source 8(a) justifications for contract awards exceeding $22 million. This clarification pertains to processes and procedures that have already been established in the FAR pursuant to section 811 of the National Defense Authorization Act for Fiscal Year 2010.
This rule does not impose any new reporting, recordkeeping, or other compliance requirements. It does not duplicate, overlap, or conflict with any other Federal rules. There are no known alternatives which would accomplish the stated objectives of the applicable statues.
DoD, GSA, and NASA invite comments from small business concerns and other interested parties on the expected impact of this rule on small entities. DoD, GSA, and NASA will also consider comments from small entities concerning the existing regulations in subparts affected by the rule consistent with 5 U.S.C. 610. Interested parties must submit such comments separately and should cite 5 U.S.C. 610 (FAR Case 2013-018), in correspondence.
The proposed rule clarifies guidance that implemented section 811, which prohibited the award of a sole-source contract in an amount over $20 million (subsequently revised to $22 million) under the 8(a) program authority (15 U.S.C. 637(a)) without the contracting officer first obtaining a written justification and approval approved by an appropriate official and making public the justification and approval and related information (see 76 FR 14559). This clarifying guidance pertains to documentation that is internal to the Government and does not contain any information collection requirements that require the approval of the Office of Management and Budget under the Paperwork Reduction Act (44 U.S.C. chapter 35).
Government procurement.
For the reasons set forth in the preamble, 48 CFR parts 5, 6, and 19 are proposed to be amended as follows:
40 U.S.C. 121(c); 10 U.S.C. chapter 137; and 51 U.S.C. 20113.
(d) Sole-source 8(a) justifications for awards exceeding $22 million shall be posted in accordance with 6.305.
(b) No separate justification or determination and findings is required under this part to limit competition to eligible 8(a) contractors except for sole source 8(a) awards exceeding $22 million (see 6.302-5 and 6.303-1).
The revisions read as follows:
(b)(1) In accordance with section 811 of the National Defense Authorization Act for Fiscal Year 2010 (Pub. L. 111-84), the contracting officer shall not award a sole-source contract under the 8(a) authority (15 U.S.C. 637(a)) for an amount exceeding $22 million unless—
(i) The contracting officer justifies the use of a sole-source contract in writing in accordance with 6.303-2; and
(ii) The justification is approved by the appropriate official designated at 6.304; (see 19.804-2(a)(15) and 19.804-2(b) for required information for agency offering letter).
(2) The justification and related information shall be made public after award in accordance with 6.305.
(3) The requirement for a sole-source 8(a) justification and approval shall not be satisfied by any other justification and approval executed under a different authority (
The revisions read as follows:
(b) As a minimum, each justification, except for sole-source 8(a) contracts exceeding $22 million (see paragraph (d) of this section), shall include the following information:
(d) * * *
(2) A specification of the statutory provision providing the exception from the requirement at 19.805-1(a) to use competitive procedures in entering into the contract (15 U.S.C. 637(a); and 10 U.S.C. 2304(c)(5) or 41 U.S.C. 3304(a)(5)).
(b) * * *
(3) Sole source requirements, other than construction, should be forwarded directly to the district office that services the nominated firm. If the contracting officer is not nominating a specific firm, the offering letter should be forwarded to the district office servicing the geographical area in which the contracting office is located. For sole-source requirements with an estimated contract value exceeding $22 million, an approved sole source 8(a) justification (see 6.303-1(b)) shall be included in the agency's offering letter.
This subsection implements section 811 of the National Defense Authorization Act for Fiscal Year 2010, (Pub. L. 111-84), which requires justification for the award of a sole-source 8(a) contract exceeding $22 million.
(a)(1) The contracting officer shall not award a sole-source 8(a) contract exceeding $22 million unless—
(i) The contracting officer has justified, in writing, the use of a sole-source 8(a) contract in accordance with 6.303—1(b) and 6.303-2(d); and
(ii) The justification has been approved by the appropriate official designated at 6.304.
(2) A copy of the approved justification shall be provided to the SBA District Office identified in the agency's offering letter (see 19.804-2(a)(15) and 19.804-2(b)).
(i) If the estimated contract value at the time of submission of the offering letter exceeds $22 million, include the approved justification with the offering letter.
(ii) If the estimated contract value at the time of submission of the offering letter is less than or equal to $22 million, but the contract value at time of award exceeds $22 million, send the approved justification prior to contract award.
(b) The justification and related information shall be made public after award, using the procedures at 6.305.
(a) The SBA may not accept for negotiation a sole-source 8(a) contract that exceeds $22 million unless the requesting agency has submitted an approved sole-source 8(a) justification in accordance with the requirements of 6.303-1(b).
International Trade Administration, U.S. Department of Commerce.
Notice and request for nominations from state, local, and municipal governments to the Trade Promotion Coordinating Committee State and Federal Export Promotion Coordination Working Group; extension of deadline.
The Secretary of Commerce, as Chair of the Trade Promotion Coordinating Committee (TPCC), announces the establishment of the State and Federal Export Promotion Coordination Working Group as a subcommittee of the TPCC. The Trade Facilitation and Trade Enforcement Act of 2015 (the Act) requires the President to establish this Working Group as a subcommittee of the TPCC to identify issues related to the coordination of Federal resources relating to export promotion and export financing with such resources provided by State and local governments. The original notice (FR Doc. 2016-23501) ([citation]) called for nominations to be submitted by October 24, 2016. This notice hereby extends the deadline to November 25, 2016.
Nominations for immediate consideration for the Working Group must be received electronically on or before 5:00 p.m. (ET) on November 25, 2016. After that date, ITA will continue to accept submissions under this notice for a period of up to two years from the deadline to fill any vacancies that may arise.
Patrick Kirwan, Director, Trade Promotion Coordinating Committee Secretariat, Room 31027, U.S. Department of Commerce, 1401 Constitution Avenue NW., Washington, DC 20230, telephone: 202-482-5455, email:
Section 504(a) of the Trade Facilitation and Trade Enforcement Act of 2015 (“Act”), amended the Export Enhancement Act of 1988 to add a new section 2313A. Section 2313A notes that U.S. policy is to promote exports as an opportunity for small businesses, and in exercising their powers and functions to advance that policy, all Federal agencies shall work constructively with State and local agencies engaged in export promotion and export financing activities. Section 2313A directs the President to establish the State and Federal Export Promotion Coordination Working Group (“Working Group”) under the TPCC with the purposes to:
(1) Identify issues related to the coordination of Federal resources relating to export promotion and export financing with such resources provided by State and local governments;
(2) identify ways to improve coordination with respect to export promotion and export financing activities through the TPCC annual strategic plan;
(3) develop a strategy for improving coordination of Federal and State resources relating to export promotion and export financing, including methods to eliminate duplication of effort and overlapping functions; and
(4) develop a strategic plan for considering and implementing the suggestions of the Working Group as part of the TPCC annual strategic plan.
The President issued Executive Order No. 13733, Delegation of Certain Authorities and Assignment of Certain Functions under the Trade Facilitation and Trade Enforcement Act of 2015, on July 22, 2016, assigning to the Secretary of Commerce the function under Section 2313A(b) of establishing the Working Group. In the Executive Order, the President further directed that, in carrying out its functions, the State and Federal Export Promotion Coordination Working Group shall also coordinate with local and municipal governments representing regionally diverse areas.
The Secretary of Commerce shall select the members of the Working Group, who shall include representatives from State trade agencies and local and municipal governments representing regionally diverse areas and representatives of the federal departments and agencies that are represented on the TPCC. The Working Group will comprise up to sixteen members. Representatives from State trade agencies must be: (1) Elected officers of a State, or (2) State employees designated by an elected State officer to represent the State trade agency with authority to act on his or her behalf. Representatives from local and municipal governments must be: (1) Elected officers or (2) local or municipal employees designated by an elected officer to represent the local and municipal government with authority to act on his or her behalf.
Because the Working Group will be an intergovernmental committee composed wholly of full-time or part-time Federal Government officers or employees, State government elected officers or their designees, and local and municipal elected officials or their designees, all of whom will be acting in their official capacities solely to exchange views, information, or advice relating to the management and implementation of Federal programs established by statute that explicitly share intergovernmental responsibilities and administration, the Working Group is not covered by the Federal Advisory Committee Act, 5 U.S.C. App.
Members appointed as representatives from State trade agencies and local and municipal governments will not receive any Federal compensation for their services and will not be reimbursed for travel expenses. Meetings will be held in person and/or via teleconference. The TPCC will make every effort to use technology to allow for remote participation in meetings, but there will be times when in-person meetings will be necessary. The TPCC will strive to provide members of the Working Group notice of meetings at least 15 calendar days in advance.
The TPCC Secretariat seeks nominations for representatives from
(1) Name, title, and relevant contact information (including phone and email address) for the nominee, the state trade agency that the nominee would represent or the local or municipal government the nominee would represent;
(2) A resume or short biography of the nominee, including professional and academic credentials.
(3) A statement of the nominee's role in state, local, or municipal export promotion activities. Should more information be needed, TPCC staff will contact the nominee. If nominees are not an elected official, a letter may be requested from an elected official that indicates the nominee has been designated to participate in the Working Group on his or her behalf.
Nominators should submit the above information via electronic transmission to
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Notice of a public meeting.
The Mid-Atlantic Fishery Management Council (MAFMC) will hold a public meeting of its Atlantic
The meeting will be held on Thursday, December 1, 2016, from 10 a.m. to 5 p.m., to view the agenda see
The meeting will be held at The Doubletree Baltimore-BWI Airport, 890 Elkridge Landing Road, Linthicum, MD 21090; telephone: 410-859-8400. There will be a listen-only Webinar link available, at
Christopher M. Moore, Ph.D., Executive Director, Mid-Atlantic Fishery Management Council, telephone: (302) 526-5255.
The Mid-Atlantic Fishery Management Council's Atlantic
These meetings are physically accessible to people with disabilities. Requests for sign language interpretation or other auxiliary aid should be directed to M. Jan Saunders, (302) 526-5251, at least 5 business days prior to the meeting date.
16 U.S.C. 1801
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Notice; proposed incidental harassment authorization; request for comments and information.
NMFS has received a request from Excelerate Energy, L.P. (Excelerate) and Tetra Tech, Inc. (Tetra Tech), on behalf of the Northeast Gateway® Energy Bridge
Comments and information must be received no later than December 15, 2016.
Comments should be addressed to Jolie Harrison, Chief, Permits and Conservation Division, Office of Protected Resources, National Marine Fisheries Service, 1315 East-West Highway, Silver Spring, MD 20910. The mailbox address for
The Maritime Administration (MARAD) and U.S. Coast Guard (USCG) Final Environmental Impact Statement (Final EIS) on the Northeast Gateway Energy Bridge NEG Deepwater Port license application is available for viewing at
Shane Guan, Office of Protected Resources, NMFS, (301) 427-8401.
Sections 101(a)(5)(A) and (D) of the MMPA (16 U.S.C. 1361
An authorization for incidental takings shall be granted if NMFS finds that the taking will have a negligible impact on the species or stock(s), will not have an unmitigable adverse impact on the availability of the species or stock(s) for subsistence uses (where relevant), and if the permissible methods of taking and requirements pertaining to the mitigation, monitoring and reporting of such takings are set forth. NMFS has defined “negligible impact” in 50 CFR 216.103 as “. . . an impact resulting from the specified activity that cannot be reasonably expected to, and is not reasonably likely to, adversely affect the species or stock through effects on annual rates of recruitment or survival.”
Section 101(a)(5)(D) of the MMPA established an expedited process by which citizens of the U.S. can apply for a one-year authorization to incidentally take small numbers of marine mammals by harassment, provided that there is no potential for serious injury or mortality to result from the activity. Section 101(a)(5)(D) establishes a 45-day time limit for NMFS review of an application followed by a 30-day public notice and comment period on any proposed authorizations for the incidental harassment of marine mammals. Within 45 days of the close of the comment period, NMFS must either issue or deny the authorization.
On June 9, 2015, NMFS received an application from Excelerate and Tetra Tech, on behalf of NEG and Algonquin, for an annual IHA and a subsequent five-year letter of authorization (LOA) pursuant to a rulemaking under section 101(a)(5)(A), to take 14 species of marine mammals by Level B harassment incidental to operations, maintenance, and repair of the NEG Port and the Pipeline Lateral facilities in Massachusetts Bay. They are: North Atlantic right whale, humpback whale, fin whale, sei whale, minke whale, long-finned pilot whale, Atlantic white-sided dolphin, bottlenose dolphin, short-beaked common dolphin, killer whale, Risso's dolphin, harbor porpoise, harbor seal, and gray seal. Since the NEG Port and Pipeline Lateral operation, maintenance, and repair activities have the potential to take marine mammals, a marine mammal take authorization under the MMPA is warranted. NMFS issued an IHA to NEG and Algonquin on December 22, 2015 (81 FR 744; January 7, 2016). The IHA is valid until December 22, 2016. In June 2016 NMFS learned that NEG and Algonquin are considering decommissioning the NEG Port in the foreseeable future. Upon discussion with Excelerate and Tetra Tech, it was agreed that instead of conducting a rulemaking for five years of incidental take authorization that may not be needed, NMFS will process another one-year IHA to NEG and Algonquin to cover marine mammal takes from its operations, maintenance, and repair work from December 23, 2016 through December 22, 2017.
NMFS first issued an IHA to NEG and Algonquin to allow for the incidental harassment of small numbers of marine mammals resulting from the construction and operation of the NEG Port and the Pipeline Lateral (72 FR 27077; May 14, 2007). Subsequently, NMFS issued five one-year IHAs for the take of marine mammals incidental to the operation of the NEG Port activity pursuant to section 101(a)(5)(D) of the MMPA (73 FR 29485; May 21, 2008, 74 FR 45613; September 3, 2009 75 FR 53672; September 1, 2010, and 76 FR 62778; October 11, 2011). After that, NMFS issued two one-year IHAs to NEG and Algonquin to take marine mammals incidental to the operations of the NEG Port as well as maintenance and repair (79 FR 78806; December 31, 2014, 81 FR 744; January 7, 2016).
The proposed NEG and Algonquin activities include the following:
An IHA was previously issued to NEG and Algonquin for this activity on December 22, 2014 (79 FR 78806; December 31, 2014), based on activities described on Excelerate and Tetra Tech's IHA application submitted in June 2014 and on the
Marine mammal species that potentially occur in the vicinity of the Northeast Gateway facility include the North Atlantic right whale, humpback whale, fin whale, sei whale, minke whale, long-finned pilot whale, Atlantic white-sided dolphin, bottlenose dolphin, common dolphin, killer whale, Risso's dolphin, harbor porpoise, harbor seal, and gray seal. General information on the distribution of these marine mammal species can be found in NMFS Stock Assessment Reports (Waring
The highest abundance for humpback whales is distributed primarily along a relatively narrow corridor following the 100-meter (m) (328-feet (ft)) isobath across the southern Gulf of Maine from the northwestern slope of Georges Bank, south to the Great South Channel, and northward alongside Cape Cod to Stellwagen Bank and Jeffreys Ledge. The relative abundance of whales increases in the spring with the highest occurrence along the slope waters (between the 40- and 140-m, or 131- and 459-ft, isobaths) off Cape Cod and Davis Bank, Stellwagen Basin and Tillies Basin and between the 50- and 200-m (164- and 656-t) isobaths along the inner slope of Georges Bank. High abundance is also estimated for the waters around Platts Bank. In the summer months, abundance increases markedly over the shallow waters (<50 m, or <164 ft) of Stellwagen Bank, the waters (100-200 m or 328-656 ft) between Platts Bank and Jeffreys Ledge, the steep slopes (between the 30- and 160-m isobaths) of Phelps and Davis Bank north of the Great South Channel towards Cape Cod, and between the 50- and 100-m (164- and 328-ft) isobath for almost the entire length of the steeply sloping northern edge of Georges Bank. This general distribution pattern persists in all seasons except winter, when humpbacks remain at high abundance in only a few locations including Porpoise and Neddick Basins adjacent to Jeffreys Ledge, northern Stellwagen Bank and Tillies Basin, and the Great South Channel. The best estimate of abundance for Gulf of Maine, formerly western North Atlantic, humpback whales is 823 animals (Waring
Spatial patterns of habitat utilization by fin whales are very similar to those of humpback whales. Spring and summer high-use areas follow the 100-m (328 ft) isobath along the northern edge of Georges Bank (between the 50- and 200-m (164- and 656-ft) isobaths), and northward from the Great South Channel (between the 50-and 160-m, or 164- and 525-ft, isobaths). Waters around Cashes Ledge, Platts Bank, and Jeffreys Ledge are all high-use areas in the summer months. Stellwagen Bank is a high-use area for fin whales in all seasons, with highest abundance occurring over the southern Stellwagen Bank in the summer months. In fact, the southern portion of the Stellwagen Bank National Marine Sanctuary (SBNMS) is used more frequently than the northern portion in all months except winter, when high abundance is recorded over the northern tip of Stellwagen Bank. In addition to Stellwagen Bank, high abundance in winter is estimated for Jeffreys Ledge and the adjacent Porpoise Basin (100- to 160-m, 328- to 656-ft, isobaths), as well as Georges Basin and northern Georges Bank. The best estimate of abundance for the western North Atlantic stock of fin whales is 1,618 (Waring
Like other piscivorous baleen whales, highest abundance for minke whale is strongly associated with regions between the 50- and 100-m (164- and 328-ft) isobaths, but with a slightly stronger preference for the shallower waters along the slopes of Davis Bank, Phelps Bank, Great South Channel and Georges Shoals on Georges Bank. Minke whales are sighted in the SBNMS in all seasons, with highest abundance estimated for the shallow waters (approximately 40 m, or 131 ft) over southern Stellwagen Bank in the summer and fall months. Platts Bank, Cashes Ledge, Jeffreys Ledge, and the adjacent basins (Neddick, Porpoise and Scantium) also support high relative abundance. Very low densities of minke whales remain throughout most of the southern Gulf of Maine in winter. The best estimate of abundance for the Canadian East Coast stock, which occurs from the western half of the Davis Strait to the Gulf of Mexico, of minke whales is 20,741 animals (Waring
North Atlantic right whales are generally distributed widely across the southern Gulf of Maine in spring with highest abundance located over the deeper waters (100- to 160-m (328- to 525-ft) isobaths) on the northern edge of the Great South Channel and deep waters (100-300 m, 328-984 ft) parallel to the 100-m (328-ft) isobath of northern Georges Bank and Georges Basin. High abundance is also found in the shallowest waters (< 30 m, or <98 ft) of Cape Cod Bay, over Platts Bank and around Cashes Ledge. Lower relative abundance is estimated over deep-water basins including Wilkinson Basin, Rodgers Basin and Franklin Basin. In the summer months, right whales move almost entirely away from the coast to deep waters over basins in the central Gulf of Maine (Wilkinson Basin, Cashes Basin between the 160- and 200-m (525- and 656-ft) isobaths) and north of Georges Bank (Rogers, Crowell and Georges Basins). Highest abundance is found north of the 100-m (328-ft) isobath at the Great South Channel and over the deep slope waters and basins along the northern edge of Georges Bank. The waters between Fippennies Ledge and Cashes Ledge are also estimated as high-use areas. In the fall months, right whales are sighted infrequently in the Gulf of Maine, with highest densities over Jeffreys Ledge and over deeper waters near Cashes Ledge and Wilkinson Basin. In winter, Cape Cod Bay, Scantum Basin, Jeffreys Ledge, and Cashes Ledge were the main high-use areas. Although SBNMS does not appear to support the highest abundance of right whales, sightings within SBNMS are reported for all four seasons, albeit at low relative abundance. Highest sighting within SBNMS occurred along the southern edge of the Bank.
The western North Atlantic minimum stock size is based on a census of individual whales identified using photo-identification techniques. A review of the photo-ID recapture database as it existed on 20 October 2014 indicated that 476 individually
The long-finned pilot whale is more generally found along the edge of the continental shelf (a depth of 330 to 3,300 ft or 100 to 1,000 m), choosing areas of high relief or submerged banks in cold or temperate shoreline waters. This species is split between two subspecies: The Northern and Southern subspecies. The Southern subspecies is circumpolar with northern limits of Brazil and South Africa. The Northern subspecies, which could be encountered during operation of the NEG Port, ranges from North Carolina to Greenland (Reeves
In spring, summer and fall, Atlantic white-sided dolphins are widespread throughout the southern Gulf of Maine, with the high-use areas widely located either side of the 100-m (328-ft) isobath along the northern edge of Georges Bank, and north from the Great South Channel to Stellwagen Bank, Jeffreys Ledge, Platts Bank and Cashes Ledge. In spring, high-use areas exist in the Great South Channel, northern Georges Bank, the steeply sloping edge of Davis Bank and Cape Cod, southern Stellwagen Bank and the waters between Jeffreys Ledge and Platts Bank. In summer, there is a shift and expansion of habitat toward the east and northeast. High-use areas are identified along most of the northern edge of Georges Bank between the 50- and 200-m (164- and 656-ft) isobaths and northward from the Great South Channel along the slopes of Davis Bank and Cape Cod. High numbers of sightings are also recorded over Truxton Swell, Wilkinson Basin, Cashes Ledge and the bathymetrically complex area northeast of Platts Bank. High numbers of sightings of white-sided dolphin are recorded within SBNMS in all seasons, with highest density in summer and most widespread distributions in spring located mainly over the southern end of Stellwagen Bank. In winter, high numbers of sightings are recorded at the northern tip of Stellwagen Bank and Tillies Basin.
A comparison of spatial distribution patterns for all baleen whales (Mysticeti) and all porpoises and dolphins combined show that both groups have very similar spatial patterns of high- and low-use areas. The baleen whales, whether piscivorous or planktivorous, are more concentrated than the dolphins and porpoises. They utilize a corridor that extended broadly along the most linear and steeply sloping edges in the southern Gulf of Maine indicated broadly by the 100-m (328-ft) isobath. Stellwagen Bank and Jeffreys Ledge support a high abundance of baleen whales throughout the year. Species richness maps indicate that high-use areas for individual whales and dolphin species co-occur, resulting in similar patterns of species richness primarily along the southern portion of the 100-m (328-ft) isobath extending northeast and northwest from the Great South Channel. The southern edge of Stellwagen Bank and the waters around the northern tip of Cape Cod are also highlighted as supporting high cetacean species richness. Intermediate to high numbers of species are also calculated for the waters surrounding Jeffreys Ledge, the entire Stellwagen Bank, Platts Bank, Fippennies Ledge and Cashes Ledge. The best estimate of abundance for the western North Atlantic stock of white-sided dolphins is 48,819 (Waring
Although these five species are some of the most widely distributed small cetacean species in the world (Jefferson
In the U.S. waters of the western North Atlantic, both harbor and gray seals are usually found from the coast of Maine south to southern New England and New York (Waring
Along the southern New England and New York coasts, harbor seals occur seasonally from September through late May (Schneider and Payne 1983). In recent years, their seasonal interval along the southern New England to New Jersey coasts has increased (deHart 2002). In U.S. waters, harbor seal breeding and pupping normally occur in waters north of the New Hampshire/Maine border, although breeding has occurred as far south as Cape Cod in the early part of the 20th century (Temte
This section includes a summary and discussion of the ways that the types of stressors associated with the specified activity (
When considering the influence of various kinds of sound on the marine environment, it is necessary to understand that different kinds of marine life are sensitive to different frequencies of sound. Based on available behavioral data, audiograms have been derived using auditory evoked potentials, anatomical modeling, and other data. NMFS (2016) designate “marine mammal hearing groups” for marine mammals and estimate the lower and upper frequencies of functional hearing of the groups. The marine mammal hearing groups and the associated frequencies are indicated below (though animals are less sensitive to sounds at the outer edge of their range and most sensitive to sounds of frequencies within a smaller range somewhere in the middle of their hearing range):
• Low frequency cetaceans (13 species of mysticetes): Functional hearing is estimated to occur between approximately 7 Hertz (Hz) and 35 kilo Hertz (kHz);
• Mid-frequency cetaceans (32 species of dolphins, six species of larger toothed whales, and 19 species of beaked and bottlenose whales): Functional hearing is estimated to occur between approximately 150 Hz and 160 kHz;
• High frequency cetaceans (eight species of true porpoises, six species of river dolphins,
• Phocid pinnipeds (true seals): Functional hearing is estimated between 50 Hz to 86 kHz; and
• Otariid pinnipeds (sea lions and fur seals): Functional hearing is estimated between 60 Hz to 39 kHz.
Species found in the vicinity of the NEG Port and Pipeline Lateral operations and maintenance and repair area include five low-frequency cetacean species (North Atlantic right whale, humpback whale, fin whale, sei whale, and minke whale), six mid-frequency cetacean species (long-finned pilot whale, Atlantic white-sided dolphin, bottlenose dolphin, common dolphin, Risso's dolphin, and killer whale), one high-frequency cetacean species (harbor porpoise), and two pinniped species (harbor seal and gray seal) (Table 1).
The proposed NEG Port operations and maintenance and repair activities could adversely affect marine mammal species and stocks by exposing them to elevated noise levels in the vicinity of the activity area.
Marine mammals exposed to high intensity sound repeatedly or for prolonged periods can experience hearing threshold shift (TS), which is the loss of hearing sensitivity at certain frequency ranges (Kastak
In addition, chronic exposure to excessive, though not high-intensity, noise could cause masking at particular frequencies for marine mammals that utilize sound for vital biological functions (Clark
Masking occurs at the frequency band which the animals utilize. Therefore, since noise generated from in-water vibratory pile driving and removal is mostly concentrated at low frequency ranges, it may have less effect on high frequency echolocation sounds by odontocetes (toothed whales). However, lower frequency man-made noises are more likely to affect detection of communication calls and other potentially important natural sounds such as surf and prey noise. It may also affect communication signals when they occur near the noise band and thus reduce the communication space of animals (
Unlike TS, masking can potentially affect the species at population, community, or even ecosystem levels, as well as individual levels. Masking affects both senders and receivers of the signals and could have long-term chronic effects on marine mammal species and populations. Recent science suggests that low frequency ambient sound levels have increased by as much as 20 decibel (dB) (more than 3 times in terms of sound pressure level (SPL)) in the world's ocean from pre-industrial periods, and most of these increases are from distant shipping (Hildebrand 2009). All anthropogenic noise sources, such as those from vessel traffic, vessel docking, and stationing while operating DP thrusters, dredging and pipe laying associated with NEG Port and Pipeline Lateral maintenance and repair, and NEG regasification activities, contribute to the elevated ambient noise levels, thus increasing potential for or severity of masking.
Finally, exposure of marine mammals to certain sounds could lead to behavioral disturbance (Richardson
The biological significance of many of these behavioral disturbances is difficult to predict, especially if the detected disturbances appear minor. However, the consequences of behavioral modification are expected to be biologically significant if the change affects growth, survival, and/or reproduction.
The onset of behavioral disturbance from anthropogenic noise depends on both external factors (characteristics of noise sources and their paths) and the receiving animals (hearing, motivation, experience, demography) and is also difficult to predict (Southall
The proposed action area is considered biologically important habitat for the North Atlantic right, fin, humpback, and minke whales during part of the seasons, and it is adjacent to the SBNMS. There is no critical habitat in the vicinity of the proposed action area.
Operation of the NEG Port will not result in short-term effects, however, long-term effects on the marine environment, including alteration of the seafloor conditions, continued disturbance of the seafloor, regular withdrawal of sea water, and regular generation of underwater noise, will result from NEG Port operations. Specifically, a small area (0.14 acre) along the Pipeline Lateral has been permanently altered (armored) at two cable crossings. In addition, the structures associated with the NEG Port (flowlines, mooring wire rope and chain, suction anchors, and pipeline end manifolds) occupy 4.8 acres of seafloor. An additional area of the seafloor of up to 43 acres (worst case scenario based on severe 100-year storm with Energy Bridge Regasification Vehicle (EBRV) occupying both submerged turret loading (STL) buoys will be subject to disturbance due to chain sweep while the buoys are occupied. Given the relatively small size of the NEG Port area that will be directly affected by Port operations, NMFS does not anticipate that habitat loss will be significant.
EBRVs are currently authorized to withdraw an average of 4.97 million gallons per day (mgd) and 2.6 billion gallons per year of sea water for general ship operations during cargo delivery activities at the NEG Port. However, as we explained in the
• 11 billion gallons of total annual water use at the Port;
• Maximum daily intake volume of up to 56 mgd at a rate of 0.45 ft per second when an EBRV is not able to achieve the heat recovery system (HRS) it is the capability of reducing water use during the regasification process) mode of operation; and,
• Maximum daily change in discharge temperature of 12ºC (53.6ºF) from ambient from the vessel's main condenser cooling system.
Under the requested water-use scenario, Tetra Tech (2011) conducted an environmental analysis on the potential impacts to marine mammals and their prey. To evaluate impacts to phytoplankton under the increased water usage, the biomass of phytoplankton lost from the Massachusetts Bay ecosystem was estimated based on the method presented in the final EIS/EIR. Phytoplankton densities of 65,000 to 390,000 cells/gallon were multiplied by the annual planned activities of withdrawal rate of 11 billion gallons to estimate a loss of 7.15 × 10
In addition, zooplankton losses will also increase proportionally to the increase in water withdrawn. The final EIS/EIR used densities of zooplankton determined by the sampling conducted by the Massachusetts Water Resource Authority (MWRA) to characterize the area around its offshore outfall and assumed a mean zooplankton density of 34.9 x 10
Finally, ichthyoplankton (fish eggs and larvae) losses and equivalent age one juvenile fish estimates under the proposed activity were made based on actual monthly ichthyoplankton data collected in the port area from October 2005 through December 2009 and the proposed activity withdrawal volume of 11 billion gallons per year evenly distributed among months (0.92 billion gallons per month) as a worst-case scenario, representing the maximum number of NEG Port deliveries during any given month. Similarly, the lower, upper, and mean annual entrainment estimates are based on the lower and upper 95 percent confidence limits, of the monthly mean ichthyoplankton densities, and the monthly mean estimates multiplied by the monthly withdrawal rate of 0.92 billion gallons per month. At this withdrawal rate approximately 106 million eggs and 67 million larvae are estimated to be lost (see Table 4.2-2 of the IHA application). The most abundant species and life stages estimated to be entrained under the proposed activity are cunner post yolk-sac larvae (33.3 million), yellowtail flounder/
These estimated losses are not significant given the very high natural mortality of ichthyoplankton. This comparison was done in the final EIS/EIR where ichthyoplankton losses based on historic regional ichthyoplankton densities and a withdrawal rate of approximately 2.6 billion gallons per year were represented by the equivalent number of age-one fish. Under the final EIS/EIR withdrawal scenario, equivalent age-one losses due to entrainment ranged from 1 haddock to 43,431 sand lance (Tetra Tech 2010). Equivalent age-one losses under the conditions when no NEG Port operation occurrence were recalculated using Northeast Gateway monitoring data in order to facilitate comparisons between the permitted scenario and the updated scenario. Using Northeast Gateway monitoring data, withdrawal of 2.6 billion gallons per year would result in equivalent age-one losses ranging from less than 1 haddock to 5,602 American sand lance. By comparison, equivalent age one losses under the proposed activity withdrawal rate of 11 billion gallons per year ranged from less than 1 haddock to 23,701 sand lance and were generally similar to or less than those in the final EIS/EIR. Substantially more equivalent age-one Atlantic herring, pollock, and butterfish were estimated to be lost under the final EIS/EIR at a withdrawal rate of 2.6 billion gallons per year, while substantially more equivalent age-one Atlantic cod, silver hake and hake species, cunner, and Atlantic mackerel are estimated to be lost under the proposed activity.
Although no reliable annual food consumption rates of baleen whales are available for comparison, based on the calculated quantities of phytoplankton, zooplankton, and ichthyoplankton removal analyzed above, it is reasonable to conclude that baleen whale predation rates would dwarf any reasonable estimates of prey removals by NEG Port operations.
As stated earlier, NEG Port will require scheduled maintenance inspections using either divers or remote operated vehicles (ROVs). The duration of these inspections are not anticipated to be more than two 8-hour working days. An EBRV will not be required to support these annual inspections. Water usage during the NEG Port maintenance would be limited to the standard requirements of NEG's normal support vessel. As with all vessels operating in Massachusetts Bay, sea water uptake and discharge is required to support engine cooling, typically using a once-through system. The rate of seawater uptake varies with the ship's horsepower and activity and therefore will differ between vessels and activity type. For example, the
Certain maintenance and repair activities may also require the presence of an EBRV at the NEG Port. Such instances may include maintenance and repair on the STL Buoy, vessel commissioning, and any onboard equipment malfunction or failure occurring while a vessel is present for cargo delivery. Because the requested water-use scenario allows for daily water use of up to 56 mgd to support standard EBRV requirements when not operating in the HRS mode, vessels would be able to remain at the NEG Port as necessary to support all such maintenance and repair scenarios. Therefore, NMFS considers that NEG Port maintenance and repair would have negligible impacts to marine mammal habitat in the proposed activity area.
As stated earlier, proper care and maintenance of the Pipeline Lateral should minimize the likelihood of an unanticipated maintenance and/or repair event. However, unanticipated activities may occur from time to time if facility components become damaged or malfunction. Unanticipated repairs may range from relatively minor activities requiring minimal equipment and one or two diver/ROV support vessels to major activities requiring larger construction-type vessels similar to those used to support the construction and installation of the facility.
Major repair activities, although unlikely, may include repairing or replacement of pipeline manifolds or sections of the Pipeline Lateral. This type of work would likely require the use of large specialty construction vessels such as those used during the construction and installation of the NEG Port and Pipeline Lateral. The duration of a major unplanned activity would depend upon the type of repair work involved and would require careful planning and coordination.
Turbidity would likely be a potential effect of Pipeline Lateral maintenance and repair activities on listed species. In addition, the possible removal of benthic or planktonic species, resulting from relatively minor construction vessel water use requirements, as measured in comparison to EBRV water use, is unlikely to affect in a measurable way the food sources available to marine mammals. Thus, any impacts to marine mammal habitat are not expected to cause significant or long-term consequences for individual marine mammals or their populations.
In order to issue an incidental take authorization under section 101(a)(5)(D) of the MMPA, NMFS must set forth the permissible methods of taking pursuant to such activity, and other means of effecting the least practicable adverse impact on such species or stock and its habitat, paying particular attention to rookeries, mating grounds, and areas of similar significance, and on the availability of such species or stock for taking for certain subsistence uses. NMFS regulations require applicants for incidental take authorizations to include information about the availability and feasibility (economic and technological) of equipment, methods, and manner of conducting such activity or other means of effecting the least practicable adverse impact upon the affected species or stocks and their habitat.
For the proposed NEG's NEG Port operations and maintenance and repair activities, Excelerate and Tetra Tech worked with NMFS to develop mitigation measures to minimize the potential impacts to marine mammal populations in the project vicinity as a result of the NEG Port and Pipeline Lateral operations and maintenance and repair activities. The primary purpose of these proposed mitigation measures is to ensure that no marine mammal would be injured or killed by vessels transiting the NEG Port facility, and to minimize the intensity of noise exposure of marine mammals in the activity area. For the proposed NEG Port and Pipeline Lateral operations and maintenance and repair, the following mitigation measures are proposed.
All vessels shall utilize the International Maritime Organization (IMO)-approved Boston Traffic Separation Scheme (TSS) on their approach to and departure from the NEG Port and/or the repair/maintenance area at the earliest practicable point of transit in order to avoid the risk of whale strikes.
Upon entering the TSS and areas where North Atlantic right whales are known to occur, including the Great South Channel Seasonal Management Area (GSC-SMA) and the SBNMS, EBRVs shall go into “Heightened Awareness” as described below.
(1) Prior to entering and navigating the modified TSS, the Master of the vessel shall:
• Consult Navigational Telex (NAVTEX), NOAA Weather Radio, the NOAA Right Whale Sighting Advisory System (SAS) or other means to obtain current right whale sighting information as well as the most recent Cornell acoustic monitoring buoy data for the potential presence of marine mammals;
• Post a look-out to visually monitor for the presence of marine mammals;
• Provide the USCG required 96-hour notification of an arriving EBRV to allow the NEG Port manager to notify Cornell of vessel arrival.
(2) The look-out shall concentrate his/her observation efforts within the 2-mile radius ZOI from the maneuvering EBRV.
(3) If marine mammal detection was reported by NAVTEX, NOAA Weather Radio, SAS and/or an acoustic monitoring buoy, the look-out shall concentrate visual monitoring efforts towards the areas of the most recent detection.
(4) If the look-out (or any other member of the crew) visually detects a marine mammal within the 2-mile radius ZOI of a maneuvering EBRV, he/she will take the following actions:
• The Officer-of-the-Watch shall be notified immediately; who shall then relay the sighting information to the Master of the vessel to ensure action(s) can be taken to avoid physical contact with marine mammals; and
• The sighting shall be recorded in the sighting log by the designated look-out.
In accordance with 50 CFR 224.103(c), all vessels associated with NEG Port and Pipeline Lateral activities shall not approach closer than 500 yards (yd, 460 m) to a North Atlantic right whale and 100 yd (91 m) to other whales to the extent physically feasible given navigational constraints. In addition, when approaching and departing the project area, vessels shall be operated so as to remain at least 1 kilometer away from any visually-detected North Atlantic right whales.
In response to active right whale sightings and active acoustic detections, and taking into account exceptional circumstances, EBRVs as well as repair and maintenance vessels shall take appropriate actions to minimize the risk of striking whales. Specifically vessels shall:
(1) Respond to active right whale sightings and/or Dynamic Management Areas (DMAs) reported on the Mandatory Ship Reporting (MSR) or SAS by concentrating monitoring efforts towards the area of most recent detection and reducing speed to 10 knots or less if the vessel is within the boundaries of a DMA or within the circular area centered on an area 8 nautical miles (nmi) in radius from a sighting location;
(2) Respond to active acoustic detections by concentrating monitoring efforts towards the area of most recent detection and reducing speed to 10 knots or less within an area 5 nm in radius centered on the detecting auto-detection buoy (AB); and
(3) Respond to additional sightings made by the designated look-outs within a 2-mile radius of the vessel by slowing the vessel to 10 knots or less and concentrating monitoring efforts towards the area of most recent sighting.
All vessels operated under NEG and Algonquin must follow the established specific speed restrictions when calling at the NEG Port. The specific speed restrictions required for all vessels (
(1) Vessels shall reduce their maximum transit speed while in the TSS from 12 knots or less to 10 knots or less from March 1 to April 30 in all waters bounded by straight lines connecting the following points in the order stated below unless an emergency situation dictates for an alternate speed. This area shall hereafter be referred to as the Off Race Point Seasonal Management Area (ORP-SMA) and tracks NMFS regulations at 50 CFR 224.105:
(2) Vessels shall reduce their maximum transit speed while in the TSS to 10 knots or less unless an emergency situation dictates for an alternate speed from April 1 to July 31 in all waters bounded by straight lines connecting the following points in the order stated below. This area shall hereafter be referred to as the GSC-SMA and tracks NMFS regulations at 50 CFR 224.105:
(3) Vessels are not expected to transit the Cape Cod Bay or the Cape Cod Canal; however, in the event that transit through the Cape Cod Bay or the Cape Cod Canal is required, vessels shall reduce maximum transit speed to 10 knots or less from January 1 to May 15 in all waters in Cape Cod Bay, extending to all shorelines of Cape Cod Bay, with a northern boundary of 42°12′ N. latitude and the Cape Cod Canal. This area shall hereafter be referred to as the Cape Cod Bay Seasonal Management Area (CCB-SMA);
(4) All Vessels transiting to and from the project area shall report their activities to the mandatory reporting Section of the USCG to remain apprised of North Atlantic right whale movements within the area. All vessels entering and exiting the MSRA shall report their activities to WHALESNORTH. Vessel operators shall contact the USCG by standard procedures promulgated through the Notice to Mariner system;
(5) All Vessels greater than or equal to 300 gross tons (GT) shall maintain a speed of 10 knots or less, unless an emergency situation requires speeds greater than 10 knots; and
(6) All Vessels less than 300 GT traveling between the shore and the project area that are not generally restricted to 10 knots will contact the Mandatory Ship Reporting (MSR) system, the USCG, or the project site before leaving shore for reports of active DMAs and/or recent right whale sightings and, consistent with navigation safety, restrict speeds to 10 knots or less within 5 miles (mi) (8 km) of any sighting location, when traveling in any of the seasonal management areas (SMAs) or when traveling in any active DMA.
In addition to the general marine mammal avoidance requirements identified above, vessels calling on the NEG Port must comply with the following additional requirements:
(1) EBRVs shall travel at 10 knots maximum speed when transiting to/from the TSS or to/from the NEG Port/Pipeline Lateral area. For EBRVs, at 1.86 mi (3 km) from the NEG Port, speed will be reduced to 3 knots and to less than 1 knot at 1,640 ft (500 m) from the NEG buoys, unless an emergency situation dictates the need for an alternate speed;
(2) EBRVs that are approaching or departing from the NEG Port and are within the Area to be Avoided (ATBA) surrounding the NEG Port, shall remain at least 1 km away from any visually-detected North Atlantic right whale and at least 100 yd (91 m) away from all other visually-detected whales unless an emergency situation requires that the vessel stay its course. During EBRV maneuvering, the Vessel Master shall designate at least one look-out to be exclusively and continuously monitoring for the presence of marine mammals at all times while the EBRV is approaching or departing from the NEG Port;
(3) During NEG Port operations, in the event that a whale is visually observed within 1 km of the NEG Port or a confirmed acoustic detection is reported on either of the two ABs closest to the NEG Port (western-most in the TSS array), departing EBRVs shall delay their departure from the NEG Port, unless an emergency situation requires that departure is not delayed. This departure delay shall continue until either the observed whale has been visually (during daylight hours) confirmed as more than 1 km from the NEG Port or 30 minutes have passed without another confirmed detection either acoustically within the acoustic detection range of the two ABs closest to the NEG Port, or visually within 1 km from the NEG Port.
Vessel captains shall focus on reducing DP thruster power to the maximum extent practicable, taking into account vessel and Port safety, during the operation activities. Vessel captains will shut down thrusters whenever they are not needed.
(1) The Northeast Gateway shall conduct empirical source level measurements on all noise emitting from construction equipment and all vessels that are involved in maintenance/repair work.
(2) If DP systems are to be employed and/or activities will emit noise with a source level of 139 dB re 1 μPa at 1 m, activities shall be conducted in accordance with the requirements for DP systems listed above.
(3) Northeast Gateway shall provide the NMFS Headquarters Office of the Protected Resources, NMFS Northeast Region Ship Strike Coordinator, and SBNMS with a minimum of 30-days notice prior to any planned repair and/or maintenance activity. For any unplanned/emergency repair/maintenance activity, Northeast Gateway shall notify the agencies as soon as it determines that repair work must be conducted. Northeast Gateway shall continue to keep the agencies apprised of repair work plans as further details (
(1) Pipeline maintenance/repair vessels less than 300 GT traveling between the shore and the maintenance/repair area that are not generally
(2) Maintenance/repair vessels greater than 300 GT shall not exceed 10 knots, unless an emergency situation that requires speeds greater than 10 knots.
(3) Planned maintenance and repair activities shall be restricted to the period between May 1 and November 30 when most of the majority of North Atlantic right whales are absent in the area.
(4) Unplanned/emergency maintenance and repair activities shall be conducted utilizing anchor-moored dive vessel whenever operationally possible.
(5) Algonquin shall also provide the NMFS Office of the Protected Resources, NMFS Northeast Region Ship Strike Coordinator, and SBNMS with a minimum of 30-day notice prior to any planned repair and/or maintenance activity. For any unplanned/emergency repair/maintenance activity, Northeast Gateway shall notify the agencies as soon as it determines that repair work must be conducted. Algonquin shall continue to keep the agencies apprised of repair work plans as further details (
(6) If DP systems are to be employed and/or activities will emit noise with a source level of 139 dB re 1 μPa at 1 m, activities shall be conducted in accordance with the requirements for DP systems listed in (5)(b)(ii).
(7) In the event that a whale is visually observed within 0.5 mi (0.8 km) of a repair or maintenance vessel, the vessel superintendent or on-deck supervisor shall be notified immediately. The vessel's crew shall be put on a heightened state of alert and the marine mammal shall be monitored constantly to determine if it is moving toward the repair or maintenance area.
(8) Repair/maintenance vessel(s) must cease any movement and/or cease all activities that emit noises with source level of 139 dB re 1 μPa @1 m or higher when a right whale is sighted within or approaching at 500 yd (457 meters) from the vessel. The source level of 139 dB corresponds to 120 dB received level at 500 yd (457 meters). Repair and maintenance work may resume after the marine mammal is positively reconfirmed outside the established zones (500 yd (457 meters)) or 30 minutes have passed without a redetection. Any vessels transiting the maintenance area, such as barges or tugs, must also maintain these separation distances.
(9) Repair/maintenance vessel(s) must cease any movement and/or cease all activities that emit noises with source level of 139 dB re 1 μPa @1 m or higher when a marine mammal other than a right whale is sighted within or approaching at 100 yd (91 m) from the vessel. Repair and maintenance work may resume after the marine mammal is positively reconfirmed outside the established zones (100 yd (91 meters)) or 30 minutes have passed without a redetection. Any vessels transiting the maintenance area, such as barges or tugs, must also maintain these separation distances.
(10) Algonquin and associated contractors shall also comply with the following:
• Operations involving excessively noisy equipment (source level exceeding 139 dB re 1μPa @1 m) shall “ramp-up” sound sources, allowing whales a chance to leave the area before sounds reach maximum levels. In addition, Northeast Gateway, Algonquin, and other associated contractors shall maintain equipment to manufacturers' specifications, including any sound-muffling devices or engine covers in order to minimize noise effects. Noisy construction equipment shall only be used as needed and equipment shall be turned off when not in operation;
• Any material that has the potential to entangle marine mammals (
• For any material that has the potential to entangle marine mammals, such material shall be removed from the water immediately unless such action jeopardizes the safety of the vessel and crew as determined by the Captain of the vessel; and
• In the event that a marine mammal becomes entangled, the marine mammal coordinator and/or protected species observer (PSO) will notify NMFS (if outside the SBNMS), and SBNMS staff (if inside the SBNMS) immediately so that a rescue effort may be initiated.
(11) All maintenance/repair activities shall be scheduled to occur between May 1 and November 30. However, in the event of unplanned/emergency repair work that cannot be scheduled during the preferred May through November work window, the following additional measures shall be followed for Pipeline Lateral maintenance and repair related activities between December and April:
• Between December 1 and April 30, if on-board PSOs do not have at least 0.5-mile visibility, they shall call for a shutdown. At the time of shutdown, the use of thrusters must be minimized. If there are potential safety problems due to the shutdown, the captain will decide what operations can safely be shut down;
• Prior to leaving the dock to begin transit, the barge shall contact one of the PSOs on watch to receive an update of sightings within the visual observation area. If the PSO has observed a North Atlantic right whale within 30 minutes of the transit start, the vessel shall hold for 30 minutes and again get a clearance to leave from the PSOs on board. PSOs shall assess whale activity and visual observation ability at the time of the transit request to clear the barge for release;
• Transit route, destination, sea conditions and any marine mammal sightings/mitigation actions during watch shall be recorded in the log book. Any whale sightings within 1,000 meters of the vessel shall result in a high alert and slow speed of 4 knots or less and a sighting within 750 m shall result in idle speed and/or ceasing all movement;
• The material barges and tugs used in repair and maintenance shall transit from the operations dock to the work sites during daylight hours when possible provided the safety of the vessels is not compromised. Should transit at night be required, the maximum speed of the tug shall be 5 knots; and
• All repair vessels must maintain a speed of 10 knots or less during daylight hours. All vessels shall operate at 5 knots or less at all times within 5 km of the repair area.
Vessels associated with maintaining the AB network operating as part of the mitigation/monitoring protocols shall adhere to the following speed restrictions and marine mammal monitoring requirements.
(1) In accordance with 50 CFR 224.103 (c), all vessels associated with NEG Port activities shall not approach closer than 500 yd (460 meters) to a North Atlantic right whale.
(2) All vessels shall obtain the latest DMA or right whale sighting information via the NAVTEX, MSR,
NMFS has carefully evaluated the applicant's proposed mitigation measures in the context of ensuring that NMFS prescribes the means of effecting the least practicable impact on the affected marine mammal species and stocks and their habitat. Our evaluation of potential measures included consideration of the following factors in relation to one another:
• The manner in which, and the degree to which, the successful implementation of the measure is expected to minimize adverse impacts to marine mammals;
• The proven or likely efficacy of the specific measure to minimize adverse impacts as planned; and
• The practicability of the measure for applicant implementation.
Any mitigation measure(s) prescribed by NMFS should be able to accomplish, have a reasonable likelihood of accomplishing (based on current science), or contribute to the accomplishment of one or more of the general goals listed below:
(1) Avoidance or minimization of injury or death of marine mammals wherever possible (goals 2, 3, and 4 may contribute to this goal);
(2) A reduction in the numbers of marine mammals (total number or number at biologically important time or location) exposed to received levels of pile driving and pile removal or other activities expected to result in the take of marine mammals (this goal may contribute to 1, above, or to reducing harassment takes only);
(3) A reduction in the intensity of exposures (either total number or number at biologically important time or location) to received levels of pile driving, or other activities expected to result in the take of marine mammals (this goal may contribute to a, above, or to reducing the severity of harassment takes only);
(4) Avoidance or minimization of adverse effects to marine mammal habitat, paying special attention to the food base, activities that block or limit passage to or from biologically important areas, permanent destruction of habitat, or temporary destruction/disturbance of habitat during a biologically important time and
(5) For monitoring directly related to mitigation—an increase in the probability of detecting marine mammals, thus allowing for more effective implementation of the mitigation.
Based on our evaluation of the applicant's proposed measures that include vessel speed reduction, noise level related shutdown measures, and ramping up procedures, NMFS has preliminarily determined that the proposed mitigation measures provide the means of effecting the least practicable impact on marine mammals species or stocks and their habitat, paying particular attention to rookeries, mating grounds, and areas of similar significance.
In order to issue an IHA for an activity, section 101(a)(5)(D) of the MMPA states that NMFS must set forth, “requirements pertaining to the monitoring and reporting of such taking.” The MMPA implementing regulations at 50 CFR 216.104 (a)(13) indicate that requests for IHAs must include the suggested means of accomplishing the necessary monitoring and reporting that will result in increased knowledge of the species and of the level of taking or impacts on populations of marine mammals that are expected to be present in the proposed action area. Tetra Tech submitted a marine mammal monitoring plan as part of the IHA application. It can be found at
Monitoring measures prescribed by NMFS should accomplish one or more of the following general goals:
(1) An increase in the probability of detecting marine mammals, both within the mitigation zone (thus allowing for more effective implementation of the mitigation) and in general to generate more data to contribute to the analyses mentioned below;
(2) An increase in our understanding of how many marine mammals are likely to be exposed to levels of pile driving that we associate with specific adverse effects, such as behavioral harassment, TTS, or PTS;
(3) An increase in our understanding of how marine mammals respond to stimuli expected to result in take and how anticipated adverse effects on individuals (in different ways and to varying degrees) may impact the population, species, or stock (specifically through effects on annual rates of recruitment or survival) through any of the following methods:
Behavioral observations in the presence of stimuli compared to observations in the absence of stimuli (need to be able to accurately predict received level, distance from source, and other pertinent information);
Physiological measurements in the presence of stimuli compared to observations in the absence of stimuli (need to be able to accurately predict received level, distance from source, and other pertinent information); and
Distribution and/or abundance comparisons in times or areas with concentrated stimuli versus times or areas without stimuli;
(4) An increased knowledge of the affected species; and
(5) An increase in our understanding of the effectiveness of certain mitigation and monitoring measures.
Vessel-based monitoring for marine mammals shall be done by trained look-outs during NEG Port and Pipeline Lateral operations and maintenance and repair activities. The observers shall monitor the occurrence of marine mammals near the vessels during NEG Port and Pipeline Lateral related activities. Lookout duties include watching for and identifying marine mammals; recording their numbers, distances, and reactions to the activities; and documenting “take by harassment.” The vessel look-outs assigned to visually monitor for the presence of marine mammals shall be provided with the following:
(1) Recent NAVTEX, NOAA Weather Radio, SAS and/or acoustic monitoring buoy detection data;
(2) Binoculars to support observations;
(3) Marine mammal detection guide sheets; and
(4) Sighting log.
All individuals onboard the EBRVs responsible for the navigation duties and any other personnel that could be assigned to monitor for marine mammals shall receive training on marine mammal sighting/reporting and vessel strike avoidance measures.
While an EBRV is navigating within the designated TSS, there shall be three people with look-out duties on or near the bridge of the ship including the Master, the Officer-of-the-Watch and the Helmsman-on-watch. In addition to the standard watch procedures, while the EBRV is transiting within the designated TSS, maneuvering within the ATBA, and/or while actively engaging in the use of thrusters, an additional look-out shall be designated to exclusively and continuously monitor for marine mammals.
All sightings of marine mammals by the designated look-out, individuals posted to navigational look-out duties, and/or any other crew member while the EBRV is transiting within the TSS, maneuvering within the ATBA and/or when actively engaging in the use of thrusters, shall be immediately reported to the Officer-of-the-Watch who shall then alert the Master. The Master or Officer-of-the-Watch shall ensure the required reporting procedures are followed and the designated marine mammal look-out records all pertinent information relevant to the sighting.
Visual sightings made by look-outs from the EBRVs shall be recorded using a standard sighting log form. Estimated locations shall be reported for each individual and/or group of individuals categorized by species when known. This data shall be entered into a database and a summary of monthly sighting activity shall be provided to NMFS. Estimates of take and copies of these log sheets shall also be included in the reports to NMFS.
Two qualified and NMFS-approved PSOs shall be assigned to each vessel that will use DP systems during maintenance and repair related activities. PSOs shall operate individually in designated shifts to accommodate adequate rest schedules. Additional PSOs shall be assigned to additional vessels if AB data indicates that sound levels exceed 120 dB re 1 µPa, further then 100 m (328 ft) from these vessels.
All PSOs shall receive NMFS-approved marine mammal observer training and be approved in advance by NMFS after review of their resume. All PSOs shall have direct field experience on marine mammal vessels and/or aerial surveys in the Atlantic Ocean/Gulf of Mexico.
PSOs (one primary and one secondary) shall be responsible for visually locating marine mammals at the ocean's surface and, to the extent possible, identifying the species. The primary PSO shall act as the identification specialist and the secondary PSO will serve as data recorder and also assist with identification. Both PSOs shall have responsibility for monitoring for the presence of marine mammals and sea turtles. Specifically PSO's shall:
(1) Monitor at all hours of the day, scanning the ocean surface by eye for a minimum of 40 minutes every hour;
(2) Monitor the area where maintenance and repair work is conducted beginning at daybreak using 25x power binoculars and/or hand-held binoculars. Night vision devices must be provided as standard equipment for monitoring during low-light hours and at night;
(3) Conduct general 360° visual monitoring during any given watch period and target scanning by the observer shall occur when alerted of a whale presence;
(4) Alert the vessel superintendent or construction crew supervisor of visual detections within 2 mi (3.31 km) immediately;and
(5) Record all sightings on marine mammal field sighting logs. Specifically, all data shall be entered at the time of observation, notes of activities will be kept, and a daily report prepared and attached to the daily field sighting log form. The basic reporting requirements include the following:
• Beaufort sea state;
• Wind speed;
• Wind direction;
• Temperature;
• Precipitation;
• Glare;
• Percent cloud cover;
• Number of animals;
• Species;
• Position;
• Distance;
• Behavior;
• Direction of movement; and
• Apparent reaction to construction activity.
In the event that a whale is visually observed within the 2-mi (3.31-km) ZOI of a DP vessel or other construction vessel that has shown to emit noise with source level in excess of 139 dB re 1 μPa @1 m, the PSO will notify the repair/maintenance construction crew to minimize the use of thrusters until the animal has moved away, unless there are divers in the water or an ROV is deployed.
Northeast Gateway shall deploy 10 ABs within the Separation Zone of the TSS for the operational life of the Project. The ABs shall be used to detect a calling North Atlantic right whale an average of 5 nmi from each AB. The AB system shall be the primary detection mechanism that alerts the EBRV Master to the occurrence of right whales, heightens EBRV awareness, and triggers necessary mitigation actions as described above. Northeast Gateway shall conduct short-term passive acoustic monitoring to document sound levels during:
(1) The initial operational events in the 2015-2016 winter heating season;
(2) Regular deliveries outside the winter heating season should such deliveries occur; and
(3) Scheduled and unscheduled maintenance and repair activities.
Northeast Gateway shall conduct long-term monitoring of the noise environment in Massachusetts Bay in the vicinity of the NEG Port and Pipeline Lateral using marine autonomous recording units (MARUs) when there is anticipated to be more than 5 NEG shipments in a 30-day period or over 20 shipments in a 6-month period.
The acoustic data collected shall be analyzed to document the seasonal occurrences and overall distributions of whales (primarily fin, humpback and right whales) within approximately 10 nmi of the NEG Port and shall measure and document the noise “budget” of Massachusetts Bay so as to eventually assist in determining whether or not an overall increase in noise in the Bay associated with the Project might be having a potentially negative impact on marine mammals.
Northeast Gateway shall make all acoustic data, including data previously collected by the MARUs during prior construction, operations, and maintenance and repair activities, available to NOAA. Data storage will be the responsibility of NOAA.
(1) Ten ABs that have been deployed since 2007 shall be used to continuously screen the low-frequency acoustic environment (less than 1,000 Hertz) for right whale contact calls occurring within an approximately 5-nm radius from each buoy (the AB's detection range).
(2) Once a confirmed detection is made, the Master of any EBRVs operating in the area will be alerted immediately.
(1) If the repair/maintenance work is located outside of the detectible range of the 10 project area ABs, Northeast Gateway and Algonquin shall consult with NOAA (NMFS and SBNMS) to determine if the work to be conducted warrants the temporary installation of an additional AB(s) to help detect and provide early warnings for potential occurrence of right whales in the vicinity of the repair area.
(2) The number of ABs installed around the activity site shall be commensurate with the type and spatial extent of maintenance/repair work required, but must be sufficient to detect
(3) Should acoustic monitoring be deemed necessary during a planned or unplanned/emergency repair and/or maintenance event, active monitoring for right whale calls shall begin 24 hours prior to the start of activities.
(4) Source level data from the acoustic recording units deployed in the NEG Port and/or Pipeline Lateral maintenance and repair area shall be provided to NMFS.
(a) Throughout NEG Port and Pipeline Lateral operations, Northeast Gateway and Algonquin shall provide a monthly Monitoring Report. The Monitoring Report shall include:
• Both copies of the raw visual EBRV lookout sighting information of marine mammals that occurred within 2 miles of the EBRV while the vessel transits within the TSS, maneuvers within the ATBA, and/or when actively engaging in the use of thrusters, and a summary of the data collected by the look-outs over each reporting period;
• Copies of the raw PSO sightings information on marine mammals gathered during pipeline repair or maintenance activities. This visual sighting data shall then be correlated to periods of thruster activity to provide estimates of marine mammal takes (per species/species class) that took place during each reporting period; and
• Conclusion of any planned or unplanned/emergency repair and/or maintenance period, a report shall be submitted to NMFS summarizing the repair/maintenance activities, marine mammal sightings (both visual and acoustic), empirical source-level measurements taken during the repair work, and any mitigation measures taken.
(b) During the maintenance and repair of NEG Port and Pipeline Lateral components, weekly status reports shall be provided to NOAA (both NMFS and SBNMS) using standardized reporting forms. The weekly reports shall include data collected for each distinct marine mammal species observed in the repair/maintenance area during the period that maintenance and repair activities were taking place. The weekly reports shall include the following information:
• Location (in longitude and latitude coordinates), time, and the nature of the maintenance and repair activities;
• Indication of whether a DP system was operated, and if so, the number of thrusters being used and the time and duration of DP operation;
• Marine mammals observed in the area (number, species, age group, and initial behavior);
• The distance of observed marine mammals from the maintenance and repair activities;
• Changes, if any, in marine mammal behaviors during the observation;
• A description of any mitigation measures (power-down, shutdown, etc.) implemented;
• Weather condition (Beaufort sea state, wind speed, wind direction, ambient temperature, precipitation, and percent cloud cover etc.);
• Condition of the observation (visibility and glare); and
• Details of passive acoustic detections and any action taken in response to those detections.
In the unanticipated event that survey operations clearly cause the take of a marine mammal in a manner prohibited by the proposed IHA, such as an injury (Level A harassment), serious injury or mortality (
• Time, date, and location (latitude/longitude) of the incident;
• The name and type of vessel involved;
• The vessel's speed during and leading up to the incident;
• Description of the incident;
• Status of all sound source use in the 24 hours preceding the incident;
• Water depth;
• Environmental conditions (
• Description of marine mammal observations in the 24 hours preceding the incident;
• Species identification or description of the animal(s) involved;
• The fate of the animal(s); and
• Photographs or video footage of the animal (if equipment is available).
Activities shall not resume until NMFS is able to review the circumstances of the prohibited take. NMFS shall work with NEG and/or Algonquin to determine what is necessary to minimize the likelihood of further prohibited take and ensure Marine Mammal Protection Act (MMPA) compliance. NEG and/or Algonquin may not resume their activities until notified by NMFS via letter, email, or telephone.
In the event that NEG and/or Algonquin discovers an injured or dead marine mammal, and the lead PSO determines that the cause of the injury or death is unknown and the death is relatively recent (
In the event that NEG or Algonquin discovers an injured or dead marine mammal, and the lead PSO determines that the injury or death is not associated with or related to the activities authorized (if the IHA is issued) (
Prior marine mammal monitoring during NEG Port and Pipeline Lateral operation, maintenance and repair activities and monthly marine mammal observation memorandums (NEG 2010; 2015; 2016) indicate that only a small number of marine mammals were observed during these activities. Only one NEG Port operation occurred within the dates of the current IHA (starting December 23, 2015) and only one unidentified small whale was observed at a distance of 2 nmi from the NEG vessel on January 17, 2016. No other NEG Port and Pipeline Lateral related activity occurred during this period.
Except with respect to certain activities not pertinent here, the MMPA defines “harassment” as: any act of pursuit, torment, or annoyance which (i) has the potential to injure a marine mammal or marine mammal stock in the wild (Level A harassment); or (ii) has the potential to disturb a marine mammal or marine mammal stock in the wild by causing disruption of behavioral patterns, including, but not limited to, migration, breathing, nursing, breeding, feeding, or sheltering (Level B harassment). Only take by Level B harassment is anticipated as a result of NEG's operation and maintenance and repair activities. Anticipated take of marine mammals is associated with operation of dynamic positioning during the docking of the NEG vessels and positioning of maintenance and dive vessels, and by operations of certain machinery during maintenance and repair activities. The regasification process itself is an activity that does not rise to the level of taking, as the modeled source level for this activity is 108 dB. Certain species may have a behavioral reaction to the sound emitted during the activities. Hearing impairment is not anticipated. Additionally, vessel strikes are not anticipated, especially because of the speed restriction measures that are proposed that were described earlier in this document.
The full suite of potential impacts to marine mammals was described in detail in the “Potential Effects of the Specified Activity on Marine Mammals” section found earlier in this document. The potential effects of sound from the proposed NEG Port and Pipeline Lateral operations, maintenance and repair activities might include one or more of the following: masking of natural sounds and behavioral disturbance (Richardson
For non-pulse sounds, such as those produced by operating DP thruster during vessel docking and supporting underwater construction and repair activities and the operations of various machineries that produces non-pulse noises, NMFS uses the 120 dB (rms) re 1 μPa isopleth to indicate the onset of Level B harassment.
The basis for Northeast Gateway and Algonquin's “take” estimate is the number of marine mammals that would be exposed to sound levels in excess of 120 dB, which is the threshold used by NMFS for non-pulse sounds. For the NEG Port and Pipeline Lateral operations and maintenance and repair activities, the take estimates are determined by multiplying the 120-dB ensonified area by local marine mammal density estimates, and then multiplying by the estimated number of days such activities would occur during a year-long period. For the NEG Port operations, the 120-dB ensonified area is 56.8 km
For the purposes of understanding the noise footprint of operations at the NEG Port, measurements taken to capture operational noise (docking, undocking, regasification, and EBRV thruster use) during the 2006 Gulf of Mexico field event were taken at the source. Measurements taken during EBRV transit were normalized to a distance of 328 ft (100 m) to serve as a basis for modeling sound propagation at the NEG Port site in Massachusetts Bay.
Sound propagation calculations for operational activities were then completed at two positions in Massachusetts Bay to determine site-specific distances to the 120/160/180 dB isopleths:
• Operations Position 1—Port (EBRV Operations): 70°36.261′ W. and 42°23.790′ N.; and
• Operations Position 2—Boston TSS (EBRV Transit): 70°17.621′ W. and 42°17.539′ N.
At each of these locations sound propagation calculations were performed to determine the noise footprint of the operation activity at each of the specified locations. Updated acoustic modeling was completed using Tetra Tech's underwater sound propagation program which utilizes a version of the publicly available Range Dependent Acoustic Model (RAM). Based on the U.S. Navy's Standard Split-Step Fourier Parabolic Equation, this modeling methodology considers range and depth along with a geo-referenced dataset to automatically retrieve the time of year information, bathymetry, and seafloor geoacoustic properties along the given propagation transects radiating from the sound source. The calculation methodology assumes that outgoing energy dominates over scattered energy, and computes the solution for the outgoing wave equation. An approximation is used to provide two-dimensional transmission loss values in range and depth,
Modeling analysis conducted for the construction of the NEG Port concluded that the only underwater noise of critical concern during NEG Port construction would be from vessel noises such as turning screws, engine noise, noise of operating machinery, and thruster use. To confirm these modeled results and better understand the noise footprint associated with construction activities at the NEG Port, field measurements were taken of various construction activities during the 2007 NEG Port and Pipeline Lateral Construction period. Measurements were taken and normalized as described to establish the “loudest” potential construction measurement event. One position within Massachusetts Bay was then used to determine site-specific distances to the 120/180 dB isopleths for NEG Port maintenance and repair activities:
Construction Position 1. Port: 70°36.261′ W. and 42°23.790′ N.
Sound propagation calculations were performed to determine the noise footprint of the construction activity. The results showed that the estimated distance from the loudest source involved in construction activities fell to 120 dB re 1 μPa at a distance of 3,500 m.
Modeling analysis conducted during the NEG Port and Pipeline Lateral construction concluded that the only underwater noise of critical concern during such activities would be from vessel noises such as turning screws, engine noise, noise of operating machinery, and thruster use. As with construction noise at the NEG Port, to confirm modeled results and better understand the noise footprint associated with construction activities along the Pipeline Lateral, field measurements were taken of various construction activities during the 2007 NEG Port and Algonquin Pipeline Lateral construction period. Measurements were taken and normalized to establish the “loudest” potential construction measurement event. Two positions within Massachusetts Bay were then used to determine site-specific distances to the 120/160/180 dB isopleths:
• Construction Position 2. PLEM: 70°46.755′ W. and 42°28.764′ N.; and
• Construction Position 3. Mid-Pipeline: 70°40.842′ W. and 42°31.328′ N.
Sound propagation calculations were performed to determine the noise footprint of the construction activity. The results of the distances to the 120-dB are shown in Table 2.
Since the issuance of an IHA to NEG on December 22, 2015, there was only one NEG delivery at the NEG Port in January 2015. NEG expects that when the Port is under full operation, it will receive up to 65 NEG shipments per year, and would require 14 days for NEG Port maintenance and up to 40 days for planned and unplanned Algonquin Pipeline Lateral maintenance and repair.
The density calculation methodology applied to take estimates for this application is derived from the model results produced by Roberts
Based on NEG Gateway's expectations of up to 65 NEG shipments per year, and up to 14 days for NEG Port maintenance and up to 40 days for planned and unplanned Algonquin Pipeline Lateral repair, the total estimated takes in a given year is calculated based on the following equation.
Where N is the take number for a given species with average density of D. A
On August 4, 2016, NMFS released its Technical Guidance for Assessing the Effects of Anthropogenic Sound on Marine Mammal Hearing (Guidance). This new guidance established new thresholds for predicting auditory injury, which equates to Level A harassment under the MMPA. In the
In this case, we performed an analysis using the new Guidance to calculate potential takes of marine mammal by Level A harassment. The results show that given the brief duration of the NEG operations, NEG Port maintenance, and Algonquin Pipeline Lateral repair activities, no marine mammals would be exposed to received noise levels that would cause auditory injury.
Negligible impact is “an impact resulting from the specified activity that cannot be reasonably expected to, and is not reasonably likely to, adversely affect the species or stock through effects on annual rates of recruitment or survival” (50 CFR 216.103). A negligible impact finding is based on the lack of likely adverse effects on annual rates of recruitment or survival (
To avoid repetition, this introductory discussion of our analyses applies to all the species listed in Table 4, given that the anticipated effects of NEG Port and Pipeline Lateral operations, maintenance, and repair activities on marine mammals (taking into account the proposed mitigation) are expected to be relatively similar in nature. Where there are meaningful differences between species or stocks, or groups of species, in anticipated individual responses to activities, impact of expected take on the population due to differences in population status, or impacts on habitat, they are described separately in the analysis below.
No injuries or mortalities are anticipated to occur as a result of NEG Port and Pipeline Lateral operations, maintenance, and repair activities, and none are authorized. Additionally, animals in the area are not expected to incur hearing impairment (
Effects on marine mammals are generally expected to be restricted to avoidance of a limited area around NEG's proposed activities and short-term changes in behavior, falling within the MMPA definition of “Level B harassment.” Mitigation measures, such as controlled vessel speed, dedicated marine mammal observers, and passive acoustic monitoring, will ensure that takes are within the level being analyzed. In all cases, the effects are expected to be short-term, with no lasting biological consequence.
Of the 14 marine mammal species likely to occur in the proposed marine survey area, North Atlantic right, humpback, fin, and sei whales are listed as endangered under the ESA. These species are also designated as “depleted” under the MMPA. None of the other species that may occur in the project area are listed as threatened or endangered under the ESA or
The project area of the NEG and Algonquin's proposed activities is a biologically important area (BIA) for feeding for the North Atlantic right whale in February to April, humpback whale in March to December, fin whale year-round, and minke whale in March to November (LaBrecque
Regarding adverse effect to marine mammal habitat, the major potential impact would be the loss of prey due to water intake for cooling during the NEG regasification process. Under the requested water-use scenario, it is estimated that a dry-weight biomass of 916.5 kg of zooplankton per year (translates to 9.2 kg of large piscivorous fish) would be lost per year. The amount of loss is minor relative to the total biomass of the trophic level in Massachusetts Bay.
Based on the analysis contained herein of the likely effects of the specified activity on marine mammals and their habitat, and taking into consideration the implementation of the proposed monitoring and mitigation measures, NMFS preliminarily finds that the total marine mammal take from NEG and Algonquin's proposed NEG Port and Pipeline Lateral operation, maintenance, and repair activities in Masschusetts Bay are not expected to have adversely affect the affected species or stocks through impacts on annual rates of recruitment or survival, and therefore will have a negligible impact on the affected marine mammal species or stocks.
The requested takes represent less than 3.6 percent of all populations or stocks potentially impacted (see Table 4 in this document). These take estimates represent the percentage of each species or stock that could be taken by Level B behavioral harassment and TTS (Level B harassment). The numbers of marine mammals estimated to be taken are small proportions of the total populations of the affected species or stocks. In addition, the mitigation and monitoring measures (described previously in this document) prescribed in the IHA are expected to reduce even further any potential disturbance to marine mammals.
Based on the analysis contained herein of the likely effects of the specified activity on marine mammals and their habitat, and taking into consideration the implementation of the mitigation and monitoring measures, NMFS finds that small numbers of marine mammals will be taken relative to the populations of the affected species or stocks.
There are no subsistence uses of marine mammals in the proposed project area and, thus, no subsistence uses impacted by this action. Therefore, NMFS has determined that the total taking of affected species or stocks would not have an unmitigable adverse impact on the availability of such species or stocks for taking for subsistence purposes.
Our November 18, 2013,
NMFS' Permits and Conservation Division has preliminarily determined that the activities described in here are the same as those analyzed in the November 21, 2014, Biological Opinion. Therefore, a new consultation is not required for issuance of this IHA.
MARAD and the USCG released a Final EIS/Environmental Impact Report (EIR) for the proposed NEG Port and Pipeline Lateral. NMFS was a cooperating agency (as defined by the Council on Environmental Quality (40 CFR 1501.6)) in the preparation of the Draft and Final EISs. NMFS reviewed the Final EIS and adopted it on May 4, 2007. NMFS issued a separate Record of Decision for issuance of authorizations pursuant to section 101(a)(5) of the MMPA for the construction and operation of the NEG Port Facility in Massachusetts Bay.
We have reviewed the NEG's application for a renewed IHA for ongoing activities for 2015-16 and the 2014-15 monitoring report. Based on that review, we have determined that the proposed action is very similar to that considered in the previous IHA. In addition, no significant new circumstances or information relevant to environmental concerns have been identified. Thus, we have determined preliminarily that the preparation of a new or supplemental NEPA document is not necessary.
As a result of these preliminary determinations, NMFS proposes to issue an IHA to Northeast Gateway and Algonquin for activities associated with Northeast Gateway's NEG Port and Algonquin's Pipeline Lateral operations and maintenance and repair activities in the Massachusetts Bay, provided the previously mentioned mitigation, monitoring, and reporting requirements are incorporated. The proposed IHA language is provided next.
(1) This Authorization is valid from December 22, 2015, through December 21, 2016.
(2) This Authorization is valid only for activities associated with Northeast Gateway's NEG Port and Algonquin's Pipeline Lateral operations and maintenance and repair activities in the Massachusetts Bay. The specific area of the activities is shown in Figure 2-1 of the Excelerate Energy, L.P. and Tetra Tech, Inc.'s IHA application.
(3)(a) The species authorized for incidental harassment takings, Level B harassment only, are: Right whales (
(3)(b) The authorization for taking by harassment is limited to the following acoustic sources and from the following activities:
(i) NEG Port operations;
(ii) NEG Port maintenance and repair; and
(iii) Algonquin Pipeline Lateral operations and maintenance.
(3)(c) The taking of any marine mammal in a manner prohibited under this Authorization must be reported within 24 hours of the taking to the National Marine Fisheries Service (NMFS) Greater Atlantic Regional Administrator or his designee, NMFS Headquarters Chief of the Permits and Conservation Division, Office of Protected Resources, NMFS, at (301-427-8401), or her designee (301-427-8418).
(a) The taking, by incidental harassment only, is limited to the species listed under condition 3(a) above and by the numbers listed in Table 4. The taking by Level A harassment, injury or death of these species or the taking by harassment, injury or death of any other species of marine mammal is prohibited and may result in the modification, suspension, or revocation of this Authorization.
The holder of this authorization is required to implement the following mitigation measures:
(i) All vessels shall utilize the International Maritime Organization (IMO)-approved Boston Traffic Separation Scheme (TSS) on their approach to and departure from the NEG Port and/or the repair/maintenance area at the earliest practicable point of transit in order to avoid the risk of whale strikes.
(ii) Upon entering the TSS and areas where North Atlantic right whales are known to occur, including the Great South Channel Seasonal Management Area (GSC-SMA) and the Stellwagen Bank National Marine Sanctuary (SBNMS), the Energy Bridge Regasification Vessel (EBRV) shall go into “Heightened Awareness” as described below.
(A) Prior to entering and navigating the modified TSS the Master of the vessel shall:
(I) Consult Navigational Telex (NAVTEX), NOAA Weather Radio, the NOAA Right Whale Sighting Advisory System (SAS) or other means to obtain current right whale sighting information as well as the most recent Cornell acoustic monitoring buoy data for the potential presence of marine mammals;
(II) Post a look-out to visually monitor for the presence of marine mammals;
(III) Provide the U.S. Coast Guard (USCG) the required 96-hour notification of an arriving EBRV to allow the NEG Port Manager to notify Cornell of vessel arrival.
(B) The look-out shall concentrate his/her observation efforts within the 2-mile radius zone of influence (ZOI) from the maneuvering EBRV.
(C) If marine mammal detection was reported by NAVTEX, NOAA Weather Radio, SAS and/or an acoustic monitoring buoy, the look-out shall concentrate visual monitoring efforts towards the areas of the most recent detection.
(D) If the look-out (or any other member of the crew) visually detects a marine mammal within the 2-mile radius ZOI of a maneuvering EBRV, he/she will take the following actions:
(I) The Officer-of-the-Watch shall be notified immediately; who shall then relay the sighting information to the Master of the vessel to ensure action(s) can be taken to avoid physical contact with marine mammals.
(II) The sighting shall be recorded in the sighting log by the designated look-out.
(III) In accordance with 50 CFR 224.103(c), all vessels associated with NEG Port and Pipeline Lateral activities shall not approach closer than 500 yd (460 m) to a North Atlantic right whale and 100 yd (91 m) to other whales to the extent physically feasible given navigational constraints. In addition, when approaching and departing the project area, vessels shall be operated so as to remain at least 1 km away from any visually-detected North Atlantic right whales.
(IV) In response to active right whale sightings and active acoustic detections, and taking into account exceptional circumstances, EBRVs, repair and maintenance vessels shall take appropriate actions to minimize the risk of striking whales. Specifically vessels shall:
(A) Respond to active right whale sightings and/or DMAs reported on the Mandatory Ship Reporting (MSR) or SAS by concentrating monitoring efforts towards the area of most recent detection and reducing speed to 10 knots or less if the vessel is within the boundaries of a DMA (50 CFR 224.105) or within the circular area centered on an area 8 nm in radius from a sighting location;
(B) Respond to active acoustic detections by concentrating monitoring efforts towards the area of most recent detection and reducing speed to 10 knots or less within an area 5 nm in radius centered on the detecting AB; and
(C) Respond to additional sightings made by the designated look-outs within a 2-mile radius of the vessel by slowing the vessel to 10 knots or less and concentrating monitoring efforts towards the area of most recent sighting.
(V) All vessels operated under NEG and Algonquin must follow the established specific speed restrictions when calling at the NEG Port. The specific speed restrictions required for all vessels (
(A) Vessels shall reduce their maximum transit speed while in the TSS from 12 knots or less to 10 knots or less from March 1 to April 30 in all waters bounded by straight lines connecting the following points in the order stated below unless an emergency situation dictates for an alternate speed. This area shall hereafter be referred to as the Off Race Point Seasonal Management Area (ORP-SMA) and tracks NMFS regulations at 50 CFR 224.105:
(B) Vessels shall reduce their maximum transit speed while in the TSS to 10 knots or less unless an emergency situation dictates for an alternate speed from April 1 to July 31 in all waters bounded by straight lines connecting the following points in the order stated below. This area shall hereafter be referred to as the GSC-SMA and tracks NMFS regulations at 50 CFR 224.105:
(C) Vessels are not expected to transit the Cape Cod Bay or the Cape Cod Canal; however, in the event that transit through the Cape Cod Bay or the Cape Cod Canal is required, vessels shall
(D) All Vessels transiting to and from the project area shall report their activities to the mandatory reporting Section of the USCG to remain apprised of North Atlantic right whale movements within the area. All vessels entering and exiting the MSRA shall report their activities to WHALESNORTH. Vessel operators shall contact the USCG by standard procedures promulgated through the Notice to Mariner system.
(E) All Vessels greater than or equal to 300 gross tons (GT) shall maintain a speed of 10 knots or less, unless an emergency situation requires speeds greater than 10 knots.
(F) All Vessels less than 300 GT traveling between the shore and the project area that are not generally restricted to 10 knots will contact the Mandatory Ship Reporting (MSR) system, the USCG, or the project site before leaving shore for reports of active DMAs and/or recent right whale sightings and, consistent with navigation safety, restrict speeds to 10 knots or less within 5 miles (8 kilometers) of any sighting location, when traveling in any of the seasonal management areas (SMAs) or when traveling in any active dynamic management area (DMA).
(i) In addition to the general marine mammal avoidance requirements identified in (5)(a) above, vessels calling on the NEG Port must comply with the following additional requirements:
(A) EBRVs shall travel at 10 knots maximum speed when transiting to/from the TSS or to/from the NEG Port/Pipeline Lateral area. For EBRVs, at 1.86 miles (3 km) from the NEG Port, speed will be reduced to 3 knots and to less than 1 knot at 1,640 ft (500 m) from the NEG buoys, unless an emergency situation dictates the need for an alternate speed.
(B) EBRVs that are approaching or departing from the NEG Port and are within the ATBA5 surrounding the NEG Port, shall remain at least 1 km away from any visually-detected North Atlantic right whale and at least 100 yd (91 m) away from all other visually-detected whales unless an emergency situation requires that the vessel stay its course. During EBRV maneuvering, the Vessel Master shall designate at least one look-out to be exclusively and continuously monitoring for the presence of marine mammals at all times while the EBRV is approaching or departing from the NEG Port.
(C) During NEG Port operations, in the event that a whale is visually observed within 1 km of the NEG Port or a confirmed acoustic detection is reported on either of the two ABs closest to the NEG Port (western-most in the TSS array), departing EBRVs shall delay their departure from the NEG Port, unless an emergency situation requires that departure is not delayed. This departure delay shall continue until either the observed whale has been visually (during daylight hours) confirmed as more than 1 km from the NEG Port or 30 minutes have passed without another confirmed detection either acoustically within the acoustic detection range of the two ABs closest to the NEG Port, or visually within 1 km from the NEG Port.
(ii) Vessel captains shall focus on reducing dynamic positioning (DP) thruster power to the maximum extent practicable, taking into account vessel and Port safety, during the operation activities. Vessel captains will shut down thrusters whenever they are not needed.
(A) The Northeast Gateway shall conduct empirical source level measurements on all noise emitting construction equipment and all vessels that are involved in maintenance/repair work.
(B) If dynamic positioning (DP) systems are to be employed and/or activities will emit noise with a source level of 139 dB re 1 μPa at 1 m, activities shall be conducted in accordance with the requirements for DP systems listed in (5)(b)(ii).
(C) Northeast Gateway shall provide the NMFS Headquarters Office of the Protected Resources, NMFS Northeast Region Ship Strike Coordinator, and SBNMS with a minimum of 30 days notice prior to any planned repair and/or maintenance activity. For any unplanned/emergency repair/maintenance activity, Northeast Gateway shall notify the agencies as soon as it determines that repair work must be conducted. Northeast Gateway shall continue to keep the agencies apprised of repair work plans as further details (
(A) Pipeline maintenance/repair vessels less than 300 GT traveling between the shore and the maintenance/repair area that are not generally restricted to 10 knots shall contact the MSR system, the USCG, or the project site before leaving shore for reports of active DMAs and/or recent right whale sightings and, consistent with navigation safety, restrict speeds to 10 knots or less within 5 miles (8 km) of any sighting location, when travelling in any of the seasonal management areas (SMAs) as defined above.
(B) Maintenance/repair vessels greater than 300 GT shall not exceed 10 knots, unless an emergency situation that requires speeds greater than 10 knots.
(C) Planned maintenance and repair activities shall be restricted to the period between May 1 and November 30.
(D) Unplanned/emergency maintenance and repair activities shall be conducted utilizing anchor-moored dive vessel whenever operationally possible.
(E) Algonquin shall also provide the NMFS Office of the Protected Resources, NMFS Northeast Region Ship Strike Coordinator, and SBNMS with a minimum of 30-day notice prior to any planned repair and/or maintenance activity. For any unplanned/emergency repair/maintenance activity, Northeast Gateway shall notify the agencies as soon as it determines that repair work must be conducted. Algonquin shall continue to keep the agencies apprised of repair work plans as further details (
(F) If dynamic positioning (DP) systems are to be employed and/or activities will emit noise with a source level of 139 dB re 1 μPa at 1 m, activities shall be conducted in accordance with the requirements for DP systems listed in (5)(b)(ii).
(G) In the event that a whale is visually observed within 0.5 mile (0.8 kilometers) of a repair or maintenance vessel, the vessel superintendent or on-deck supervisor shall be notified immediately. The vessel's crew shall be put on a heightened state of alert and the marine mammal shall be monitored constantly to determine if it is moving toward the repair or maintenance area.
(H) Repair/maintenance vessel(s) must cease any movement and/or cease all activities that emit noises with
(I) Repair/maintenance vessel(s) must cease any movement and/or cease all activities that emit noises with source level of 139 dB re 1 μPa @1 m or higher when a marine mammal other than a right whale is sighted within or approaching at 100 yd (91 m) from the vessel. Repair and maintenance work may resume after the marine mammal is positively reconfirmed outside the established zones (100 yd (91 m)) or 30 minutes have passed without a redetection. Any vessels transiting the maintenance area, such as barges or tugs, must also maintain these separation distances.
(J) Algonquin and associated contractors shall also comply with the following:
(I) Operations involving excessively noisy equipment (source level exceeding 139 dB re 1μPa @1 m) shall “ramp-up” sound sources, allowing whales a chance to leave the area before sounds reach maximum levels. In addition, Northeast Gateway, Algonquin, and other associated contractors shall maintain equipment to manufacturers' specifications, including any sound-muffling devices or engine covers in order to minimize noise effects. Noisy construction equipment shall only be used as needed and equipment shall be turned off when not in operation.
(II) Any material that has the potential to entangle marine mammals (
(III) For any material that has the potential to entangle marine mammals, such material shall be removed from the water immediately unless such action jeopardizes the safety of the vessel and crew as determined by the Captain of the vessel.
(IV) In the event that a marine mammal becomes entangled, the marine mammal coordinator and/or PSO will notify NMFS (if outside the SBNMS), and SBNMS staff (if inside the SBNMS) immediately so that a rescue effort may be initiated.
(K) All maintenance/repair activities shall be scheduled to occur between May 1 and November 30. However, in the event of unplanned/emergency repair work that cannot be scheduled during the preferred May through November work window, the following additional measures shall be followed for Pipeline Lateral maintenance and repair related activities between December and April:
(I) Between December 1 and April 30, if on-board PSOs do not have at least 0.5-mile visibility, they shall call for a shutdown. At the time of shutdown, the use of thrusters must be minimized. If there are potential safety problems due to the shutdown, the captain will decide what operations can safely be shut down.
(II) Prior to leaving the dock to begin transit, the barge shall contact one of the PSOs on watch to receive an update of sightings within the visual observation area. If the PSO has observed a North Atlantic right whale within 30 minutes of the transit start, the vessel shall hold for 30 minutes and again get a clearance to leave from the PSOs on board. PSOs shall assess whale activity and visual observation ability at the time of the transit request to clear the barge for release.
(III) Transit route, destination, sea conditions and any marine mammal sightings/mitigation actions during watch shall be recorded in the log book. Any whale sightings within 1,000 m of the vessel shall result in a high alert and slow speed of 4 knots or less and a sighting within 750 m shall result in idle speed and/or ceasing all movement.
(IV) The material barges and tugs used in repair and maintenance shall transit from the operations dock to the work sites during daylight hours when possible provided the safety of the vessels is not compromised. Should transit at night be required, the maximum speed of the tug shall be 5 knots.
(V) All repair vessels must maintain a speed of 10 knots or less during daylight hours. All vessels shall operate at 5 knots or less at all times within 5 km of the repair area.
(i) Vessels associated with maintaining the AB network operating as part of the mitigation/monitoring protocols shall adhere to the following speed restrictions and marine mammal monitoring requirements.
(A) In accordance with NOAA Regulation 50 CFR 224.103 (c), all vessels associated with NEG Port activities shall not approach closer than 500 yd (460 meters) to a North Atlantic right whale.
(B) All vessels shall obtain the latest DMA or right whale sighting information via the NAVTEX, MSR, SAS, NOAA Weather Radio, or other available means prior to operations to determine if there are right whales present in the operational area.
(i) Vessel-based monitoring for marine mammals shall be done by trained look-outs during NEG NEG Port and Pipeline Lateral operations and maintenance and repair activities. The observers shall monitor the occurrence of marine mammals near the vessels during NEG Port and Pipeline Lateral related activities. Lookout duties include watching for and identifying marine mammals; recording their numbers, distances, and reactions to the activities; and documenting “take by harassment.”
(ii) The vessel look-outs assigned to visually monitor for the presence of marine mammals shall be provided with the following:
(A) Recent NAVTEX, NOAA Weather Radio, SAS and/or acoustic monitoring buoy detection data;
(B) Binoculars to support observations;
(C) Marine mammal detection guide sheets; and
(D) Sighting log.
(i) All individuals onboard the EBRVs responsible for the navigation duties and any other personnel that could be assigned to monitor for marine mammals shall receive training on marine mammal sighting/reporting and vessel strike avoidance measures.
(ii) While an EBRV is navigating within the designated TSS, there shall be three people with look-out duties on or near the bridge of the ship including the Master, the Officer-of-the-Watch and the Helmsman-on-watch. In addition to the standard watch procedures, while the EBRV is transiting within the designated TSS, maneuvering within the Area to be Avoided (ATBA), and/or while actively engaging in the use of thrusters, an additional look-out shall be designated to exclusively and continuously monitor for marine mammals.
(iii) All sightings of marine mammals by the designated look-out, individuals posted to navigational look-out duties and/or any other crew member while the EBRV is transiting within the TSS, maneuvering within the ATBA and/or when actively engaging in the use of thrusters, shall be immediately reported
(iv) Visual sightings made by look-outs from the EBRVs shall be recorded using a standard sighting log form. Estimated locations shall be reported for each individual and/or group of individuals categorized by species when known. This data shall be entered into a database and a summary of monthly sighting activity shall be provided to NMFS. Estimates of take and copies of these log sheets shall also be included in the reports to NMFS.
(i) Two (2) qualified and NMFS-approved protected species observers (PSOs) shall be assigned to each vessel that will use dynamic positioning (DP) systems during maintenance and repair related activities. PSOs shall operate individually in designated shifts to accommodate adequate rest schedules. Additional PSOs shall be assigned to additional vessels if auto-detection buoy (AB) data indicates that sound levels exceed 120 dB re 1 µPa, further then 100 meters (328 feet) from these vessels.
(ii) All PSOs shall receive NMFS-approved marine mammal observer training and be approved in advance by NMFS after review of their resume. All PSOs shall have direct field experience on marine mammal vessels and/or aerial surveys in the Atlantic Ocean/Gulf of Mexico.
(iii) PSOs (one primary and one secondary) shall be responsible for visually locating marine mammals at the ocean's surface and, to the extent possible, identifying the species. The primary PSO shall act as the identification specialist and the secondary PSO will serve as data recorder and also assist with identification. Both PSOs shall have responsibility for monitoring for the presence of marine mammals and sea turtles. Specifically PSO's shall:
(A) Monitor at all hours of the day, scanning the ocean surface by eye for a minimum of 40 minutes every hour.
(B) Monitor the area where maintenance and repair work is conducted beginning at daybreak using 25x power binoculars and/or hand-held binoculars. Night vision devices must be provided as standard equipment for monitoring during low-light hours and at night.
(C) Conduct general 360° visual monitoring during any given watch period and target scanning by the observer shall occur when alerted of a whale presence.
(D) Alert the vessel superintendent or construction crew supervisor of visual detections within 2 mi (3.31 km) immediately.
(E) Record all sightings on marine mammal field sighting logs. Specifically, all data shall be entered at the time of observation, notes of activities will be kept, and a daily report prepared and attached to the daily field sighting log form. The basic reporting requirements include the following:
• Beaufort sea state;
• Wind speed;
• Wind direction;
• Temperature;
• Precipitation;
• Glare;
• Percent cloud cover;
• Number of animals;
• Species;
• Position;
• Distance;
• Behavior;
• Direction of movement; and
• Apparent reaction to construction activity.
(iv) In the event that a whale is visually observed within the 2-mile (3.31-kilometers) zone of influence (ZOI) of a DP vessel or other construction vessel that has shown to emit noise with source level in excess of 139 dB re 1 µPa @1 m, the PSO will notify the repair/maintenance construction crew to minimize the use of thrusters until the animal has moved away, unless there are divers in the water or an ROV is deployed.
(i) Northeast Gateway shall deploy 10 ABs within the Separation Zone of the TSS for the operational life of the Project.
(ii) The ABs shall be used to detect a calling North Atlantic right whale an average of 5 nm from each AB. The AB system shall be the primary detection mechanism that alerts the EBRV Master to the occurrence of right whales, heightens EBRV awareness, and triggers necessary mitigation actions as described in section (5) above.
(iii) Northeast Gateway shall conduct short-term passive acoustic monitoring to document sound levels during the initial operational events in the 2015-2016 winter heating season, and during both regular deliveries outside the winter heating season should such deliveries occur, and during scheduled and unscheduled maintenance and repair activities.
(iv) Northeast Gateway shall conduct long-term monitoring of the noise environment in Massachusetts Bay in the vicinity of the NEG Port and Pipeline Lateral using marine autonomous recording units (MARUs) when there is anticipated to be more than 5 NEG shipments in a 30-day period or over 20 shipments in a six-month period.
(v) The acoustic data collected in 6(d)(ii) shall be analyzed to document the seasonal occurrences and overall distributions of whales (primarily fin, humpback and right whales) within approximately 10 nm of the NEG Port and shall measure and document the noise “budget” of Massachusetts Bay so as to eventually assist in determining whether or not an overall increase in noise in the Bay associated with the Project might be having a potentially negative impact on marine mammals.
(vi) Northeast Gateway shall make all acoustic data, including data previously collected by the MARUs during prior construction, operations, and maintenance and repair activities, available to NOAA. Data storage will be the responsibility of NOAA.
(A) Ten (10) ABs that have been deployed since 2007 shall be used to continuously screen the low-frequency acoustic environment (less than 1,000 Hertz) for right whale contact calls occurring within an approximately 5-nm radius from each buoy (the AB's detection range).
(B) Once a confirmed detection is made, the Master of any EBRVs operating in the area will be alerted immediately.
(A) If the repair/maintenance work is located outside of the detectible range of the 10 project area ABs, Northeast Gateway and Algonquin shall consult with NOAA (NMFS and SBNMS) to determine if the work to be conducted warrants the temporary installation of an additional AB(s) to help detect and provide early warnings for potential occurrence of right whales in the vicinity of the repair area.
(B) The number of ABs installed around the activity site shall be commensurate with the type and spatial extent of maintenance/repair work required, but must be sufficient to detect vocalizing right whales within the 120-dB impact zone.
(C) Should acoustic monitoring be deemed necessary during a planned or
(D) Revised noise level data from the acoustic recording units deployed in the NEG Port and/or Pipeline Lateral maintenance and repair area shall be provided to NMFS.
(a) Throughout NEG Port and Pipeline Lateral operations, Northeast Gateway and Algonquin shall provide a monthly Monitoring Report. The Monitoring Report shall include:
(i) Both copies of the raw visual EBRV lookout sighting information of marine mammals that occurred within 2 miles of the EBRV while the vessel transits within the TSS, maneuvers within the ATBA, and/or when actively engaging in the use of thrusters, and a summary of the data collected by the look-outs over each reporting period.
(ii) Copies of the raw PSO sightings information on marine mammals gathered during pipeline repair or maintenance activities. This visual sighting data shall then be correlated to periods of thruster activity to provide estimates of marine mammal takes (per species/species class) that took place during each reporting period.
(iii) Conclusion of any planned or unplanned/emergency repair and/or maintenance period, a report shall be submitted to NMFS summarizing the repair/maintenance activities, marine mammal sightings (both visual and acoustic), empirical source-level measurements taken during the repair work, and any mitigation measures taken.
(b) During the maintenance and repair of NEG Port components, weekly status reports shall be provided to NOAA (both NMFS and SBNMS) using standardized reporting forms. The weekly reports shall include data collected for each distinct marine mammal species observed in the repair/maintenance area during the period that maintenance and repair activities were taking place. The weekly reports shall include the following information:
(i) Location (in longitude and latitude coordinates), time, and the nature of the maintenance and repair activities;
(ii) Indication of whether a DP system was operated, and if so, the number of thrusters being used and the time and duration of DP operation;
(iii) Marine mammals observed in the area (number, species, age group, and initial behavior);
(iv) The distance of observed marine mammals from the maintenance and repair activities;
(v) Changes, if any, in marine mammal behaviors during the observation;
(vi) A description of any mitigation measures (power-down, shutdown, etc.) implemented;
(vii) Weather condition (Beaufort sea state, wind speed, wind direction, ambient temperature, precipitation, and percent cloud cover etc.);
(viii) Condition of the observation (visibility and glare); and
(ix) Details of passive acoustic detections and any action taken in response to those detections.
(i) In the unanticipated event that survey operations clearly cause the take of a marine mammal in a manner prohibited by the proposed IHA, such as an injury (Level A harassment), serious injury or mortality (
(A) Time, date, and location (latitude/longitude) of the incident;
(B) The name and type of vessel involved;
(C) The vessel's speed during and leading up to the incident;
(D) Description of the incident;
(E) Status of all sound source use in the 24 hours preceding the incident;
(F) Water depth;
(G) Environmental conditions (
(H) Description of marine mammal observations in the 24 hours preceding the incident;
(I) Species identification or description of the animal(s) involved;
(J) The fate of the animal(s); and
(K) Photographs or video footage of the animal (if equipment is available).
Activities shall not resume until NMFS is able to review the circumstances of the prohibited take. NMFS shall work with NEG and/or Algonquin to determine what is necessary to minimize the likelihood of further prohibited take and ensure MMPA compliance. NEG and/or Algonquin may not resume their activities until notified by NMFS via letter, email, or telephone.
(ii) In the event that NEG and/or Algonquin discovers an injured or dead marine mammal, and the lead PSO determines that the cause of the injury or death is unknown and the death is relatively recent (
(iii) In the event that NEG or Algonquin discovers an injured or dead marine mammal, and the lead PSO determines that the injury or death is not associated with or related to the activities authorized (if the IHA is issued) (
(8) This Authorization may be modified, suspended, or withdrawn if the holder fails to abide by the conditions prescribed herein or if NMFS determines that the authorized taking is having more than a negligible impact on the species or stock of affected marine mammals.
(9) A copy of this Authorization and the Incidental Take Statement must be in the possession of each survey vessel operator taking marine mammals under the authority of this Incidental Harassment Authorization.
(10) Northeast Gateway and Algonquin are required to comply with the Terms and Conditions of the Incidental Take Statement corresponding to NMFS' Biological Opinion.
NMFS requests comment on our analysis, the draft authorization for an IHA, the receipt of notice for a rulemaking, and any other aspect of the Notice of Proposed IHA for Northeast Gateway and Algonquin's proposed NEG Port and Pipeline Lateral
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Proposed specifications; request for comments.
NMFS proposes revised summer flounder specifications for the 2017 and 2018 fishing years. Updated scientific information regarding the status of the summer flounder stock indicates that these proposed catch limits are necessary to constrain summer flounder harvest within scientifically sound recommendations to prevent overfishing. This action is intended to inform the public of proposed reductions for the 2017 and 2018 summer flounder fishing years.
Comments must be received on or before November 30, 2016.
A supplemental environmental assessment (SEA) was prepared for the specifications and describes the proposed action and other considered alternatives, and provides an analysis of the impacts of the proposed measures and alternatives. Copies of the Specifications Document, including the SEA, the Initial Regulatory Flexibility Analysis (IRFA), and the original environmental assessment for the 2016-2018 summer flounder, scup, and black sea bass specifications are available on request from Dr. Christopher M. Moore, Executive Director, Mid-Atlantic Fishery Management Council, Suite 201, 800 North State Street, Dover, DE 19901. These documents are also accessible via the Internet at
You may submit comments on this document, identified by NOAA-NMFS-2016-0138, by either of the following methods:
1. Go to
2. Click the “Comment Now!” icon, complete the required fields
3. Enter or attach your comments.
Emily Gilbert, Fishery Policy Analyst, (978) 281-9244.
The Mid-Atlantic Fishery Management Council and the Atlantic States Marine Fisheries Commission cooperatively manage the summer flounder, scup, and black sea bass fisheries. The Summer Flounder, Scup, and Black Sea Bass Fishery Management Plan (FMP) and its implementing regulations outline the Council's process for establishing specifications. Specifications in these fisheries include various catch and landing subdivisions, such as the commercial and recreational sector annual catch limits (ACLs), annual catch targets (ACTs), and sector-specific landing limits (
On December 28, 2015, NMFS published a final rule implementing the Council's recommended specifications for the summer flounder, scup, and black sea bass fisheries (80 FR 80689) for fishing years 2016 through 2018. The Council intended to reconsider the specifications set for fishing years 2017 and 2018 after reviewing any updated information. Based on updated information on the status of the summer flounder stock, the Council is now recommending adjustments to the previously established summer flounder specifications for the 2017 and 2018 fishing years. An assessment update will be available next summer and notice will be provided in the
When the Council previously recommended summer flounder specifications in 2015, available scientific information indicated that the summer flounder stock size was declining and that overfishing occurred in 2014. In order to minimize disruption to the industry as much as possible, given the necessary reduction in available catch to prevent further overfishing and to increase the stock size, the Council requested its Scientific and Statistical Committee (SSC) to deviate from the standard risk policy and to phase-in the summer flounder catch reductions over the 3-year specifications cycle. The SSC complied with this request, but requested a stock assessment update in July 2016 to determine if its recommended acceptable biological catches (ABCs) remain appropriate for 2017 and 2018.
The SSC met on July 21-22, 2016, to review the stock assessment update for summer flounder compiled by the Northeast Fisheries Science Center. This 2016 update was based on the peer-review approved model from the 2013 benchmark assessment, updated to include data through 2015. More specific information about the
The Council's Summer Flounder Monitoring Committee met July 25, 2016, to discuss specification-related recommendations for the summer flounder fishery, to recommend offsets from the ACL to account for management uncertainty, and to discuss commercial management measure recommendations, as appropriate. The Monitoring Committee determined that no additional reductions were necessary to account for management uncertainty because the recreational fishery has had only minor overages of the recreational harvest limit in recent years, and the commercial landings monitoring and fishery closure system is timely enough to prevent commercial overages. As a result, the Monitoring Committee recommended that ACTs for the commercial and recreational sectors should equal their respective ACLs and made no recommended changes to any other summer flounder management measures.
Following the SSC and Monitoring Committee meetings, the Council and the Commission's Summer Flounder, Scup, and Black Sea Bass Management Board met jointly on August 9, 2016, to consider the recommendations of the SSC, the Monitoring Committee, and public comments, and to make their specification recommendations. More complete details on the SSC, Monitoring Committee, and Council meeting deliberations can be found on the Council's Web site (
While the Board action was finalized at the August meeting, the Council's recommendations must be reviewed by NMFS to ensure that they comply with the FMP and applicable law. NMFS also must conduct notice-and-comment rulemaking to propose and implement the final specifications.
Table 2 summarizes the Council's recommended summer flounder specifications that NMFS is proposing for 2017 and 2018, including the sector-specific estimated discards.
Consistent with the summer flounder regulations, the sum of the recreational and commercial sector ACLs is equal to the ABC for each fishing year. To derive the ACLs, the sum of the sector-specific projected discards are removed from the ABCs to derive the landing allowances. For summer flounder, 60 percent of the landing allowance for each fishing year is allocated to the commercial fishery and 40 percent to the recreational fishery. Using this method ensures that each sector is accountable for its respective discards, rather than simply apportioning the ABCs by the allocation percentages to derive the sector ACLs. Although the derived ACLs are not split exactly according to the allocations specified in the Summer Flounder, Scup, and Black Sea Bass Fishery Management Plan (FMP), the landing portions of the ACLs preserve the appropriate allocation split, consistent with the FMP.
Table 3 presents the proposed state summer flounder allocations for 2017-2018 using the commercial state quota allocations described in the FMP. Any commercial quota adjustments to account for overages will be published in the
The Council and Commission will develop recreational management measures (
Pursuant to section 304(b)(1)(A) of the Magnuson-Stevens Act, the NMFS Assistant Administrator has determined that this proposed rule is consistent with the Summer Flounder, Scup, and Black Sea Bass FMP, other provisions of the Magnuson-Stevens Act, and other applicable law, subject to further consideration after public comment.
These proposed specifications are exempt from review under Executive Order 12866.
An IRFA was prepared by the Council, as required by section 603 of the Regulatory Flexibility Act (RFA), to examine the impacts of these proposed specifications on small business entities, if adopted. A description of the specifications, why they are being considered, and the legal basis for proposing and implementing specifications for the summer flounder fishery are contained in the preamble to this proposed rule. A copy of the detailed RFA analysis is available from NMFS or the Council (see
This action proposes management measures, including annual catch limits, for the summer flounder fishery in order to prevent overfishing and achieve optimum yield in the fishery. A complete description of the action, why it is being considered, and the legal basis for this action are contained in the specifications document, and elsewhere in the preamble to this proposed rule, and are not repeated here.
On December 29, 2015, NMFS issued a final rule establishing a small business size standard of $11 million in annual gross receipts for all businesses primarily engaged in the commercial fishing industry and $7 million in annual gross receipts for all businesses primarily engaged in for-hire fishing activity (NAICS 11411) for Regulatory Flexibility Act (RFA) compliance purposes only (80 FR 81194, December 29, 2015). The North American Industry Classification System (NAICS) is the standard used by Federal statistical agencies in classifying business establishments for the purpose of collecting, analyzing, and publishing statistical data related to the U.S. business economy.
This proposed rule affects commercial and recreational fish harvesting entities engaged in the summer flounder fishery. Individually-permitted vessels may hold permits for several fisheries, harvesting species of fish that are regulated by several different FMPs, even beyond those impacted by the proposed action. Furthermore, multiple-permitted vessels and/or permits may be owned by entities affiliated by stock ownership, common management, identity of interest, contractual relationships, or economic dependency. For the purposes of the RFA analysis, the ownership entities, not the individual vessels, are considered to be the regulated entities.
Ownership entities are defined as those entities with common ownership personnel as listed on the permit application. Only permits with identical ownership personnel are categorized as an ownership entity. For example, if five permits have the same seven persons listed as co-owners on their permit applications, those seven persons would form one ownership entity that holds those five permits. If two of those seven owners also co-own additional vessels, that ownership arrangement would be considered a separate ownership entity for the purpose of this analysis.
The current ownership data set used for this analysis is based on calendar year 2015 (the most recent complete year available) and contains average gross sales associated with those permits for calendar years 2013 through 2015.
A description of the specific permits that are likely to be impacted by this action is provided below, along with a discussion of the impacted businesses, which can include multiple vessels and/or permit types.
According to the commercial ownership database, 553 affiliate firms landed summer flounder during the 2013-2015 period, with 547 of those businesses affiliates categorized as small businesses and 6 categorized as large businesses. The ownership data for the for-hire fleet indicate that there were 411 for-hire affiliate firms generating revenues from fishing recreationally for various species during the 2013-2015 period, all of which are categorized as small businesses. Although it is not possible to derive what proportion of the overall revenues came from specific fishing activities, given the popularity of summer flounder as a recreational species, it is likely that revenues generated from summer flounder recreational fishing is important for some, if not all, of these firms.
There are no new reporting or recordkeeping requirements contained in any of the alternatives considered for this action.
NMFS is not aware of any relevant Federal rules that may duplicate, overlap, or conflict with this proposed rule.
This action proposes to set commercial quotas and recreational harvest limits for the summer flounder fishery for the 2017 and 2018 fishing years that are consistent with the best scientific information available and the most recent catch limit recommendations of the Council's SSC. The proposed landings limits for 2017 include a commercial quota of 5.66 million lb (2,567 mt) and a recreational harvest limit of 3.77 million lb (1,711 mt). For 2018, the proposed measures include a commercial quota of 6.63 million lb (3,006 mt) and a recreational harvest limit of 4.42 million lb (2,004 mt).
The only other alternatives considered in this document are status quo alternatives that are identical to the summer flounder landings limits implemented in December 2015. If these specifications remained in place, they would have greater positive socioeconomic impacts than the preferred alternatives. However, these alternatives were not selected as preferred given that they do not address the new scientific information regarding summer flounder stock status, and, therefore, would likely result in overfishing, which would be inconsistent with the FMP, National Standard 1 guidance under the Magnuson-Stevens Act, and the most recent advice of the Council's SSC. Because these alternatives are inconsistent with the purpose and need of this action, they are not considered further under this analysis.
16 U.S.C. 1801
National Marine Fisheries Service (NMFS), National Oceanic and Atmospheric Administration (NOAA), Commerce.
Notice of public meetings of the South Atlantic Fishery Management Council.
The South Atlantic Fishery Management Council (Council) will hold meetings of the: Advisory Panel Selection Committee (Partially Closed Session); Law Enforcement Committee; Scientific and Statistical Committee (SSC) Selection Committee; Protected Resources Committee; Habitat Protection and Ecosystem-Based Management Committee; Southeast Data, Assessment and Review (SEDAR) Committee (Partially Closed Session); Spiny Lobster Committee; Joint Dolphin Wahoo/Snapper Grouper and Mackerel Cobia Committees; Information and Education Committee; Executive Finance Committee; Snapper Grouper Committee; Personnel Committee (Closed Session); Highly Migratory Species Committee; Mackerel Cobia Committee; Citizen Science Committee; Data Collection Committee; and a meeting of the Full Council.
The Council will take action as necessary. The Council will also hold a formal public comment session. The
The Council meeting will be held from 8:30 a.m. on Monday, December 5, 2016 until 1 p.m. on Friday, December 9, 2016.
Kim Iverson, Public Information Officer, SAFMC; phone (843) 571-4366 or toll free (866) SAFMC-10; fax (843) 769-4520; email:
The items of discussion in the individual meeting agendas are as follows:
1. The Committee will review applications for the SEDAR Pool Advisory Panel and provide recommendations (Closed Session).
2. The Committee will review options for the structure of an advisory panel for the Council's System Management Plan addressing protected areas and provide guidance and timing for the advisory panel as necessary.
1. The Committee will receive a report on the level of commercial logbook reporting at the time of permit renewal, discuss compliance with logbook reporting requirements, and provide recommendations as appropriate.
2. The Committee will also follow up on items from the earlier joint meeting of the Law Enforcement Committee and Advisory panel provide recommendations as appropriate.
The Committee will review the SSC Conflict of Interest Policy, the SSC Public Comment Policy, and the SSC Update on complex analysis review process. The Committee will provide guidance as needed.
The Committee will receive an update from NOAA Fisheries' Protected Resources Office, review the Biological Opinion for Snapper Grouper, appoint a Council member to the Large Whale Take Reduction Team, and receive an update from the U.S. Fish & Wildlife Service.
1. The Committee will receive a report from the Habitat Protection and Ecosystem-Based Management Advisory Panel and provide recommendations as appropriate.
2. The Committee will review and approve the Council's Essential Fish Habitat Policy Statements for the Fishery Ecosystem Plan II.
3. The Committee will receive an update on the Habitat and Ecosystem Tools and Model Development, Council actions pertaining to Habitat, and a report from the Lenfest Ecosystem Task Force and proved recommendations as appropriate.
1. The Committee will discuss and provide recommendations for appointments for the following stock assessments: SEDAR 50 Blueline Tilefish; SEDAR 48
2. The Committee will receive updates on SEDAR projects, review the SEDAR Steering Committee Report, and assessment priorities, including SSC prioritization recommendations and a long-term assessment plan. The Committee will provide recommendations as appropriate.
1. The Committee will receive a presentation on Spiny Lobster regulations in Florida, review recommendations from the SSC for establishing Overfishing Levels and Acceptable Biological Catch for Spiny Lobster, and provide recommendations to staff.
2. The Committee will also receive an overview of a Discussion Document on action to restrict recreational traps in the South Atlantic Exclusive Economic Zone and provide direction to staff.
1. The Committees will receive updates from NOAA Fisheries on commercial and recreational catches of Dolphin and Wahoo versus annual catch limits (ACLs), status of amendments, and the 2015 commercial landings for Yellowtail Snapper.
2. The Committee will review Dolphin Wahoo Amendment 10/Snapper Grouper Amendment 44 addressing allocations of Dolphin and Yellowtail Snapper, provide direction to staff, and recommend approval of the joint amendment for public hearings.
3. The Committees will receive an overview of draft options for a Limited Entry program for federal For-Hire Permits in the Snapper Grouper, Coastal Migratory Pelagic, and Dolphin Wahoo fisheries in the South Atlantic/Atlantic, review options, modify the document if necessary, and provide guidance as appropriate.
The Committee will receive a report from the Information and Education Advisory Panel meeting and provide guidance to staff.
1. The Committee will receive a presentation on the Final Rule for National Standard 1 Guidelines, discuss and provide guidance to staff.
2. The Committee will receive an overview of Electronic Reporting Project Proposals, discuss and take action as necessary.
3. The Committee will receive an update on the status of expenditures for Calendar Year (CY) 2016; review the Draft CY 2017 Budget; review, modify, and approve the Council Follow-up and work priorities; and provide recommendations as appropriate.
3. The Committee will discuss standards and procedures for participating in Council webinar meetings and take action as appropriate.
1. The Committee will receive updates from NOAA Fisheries on the status of commercial and recreational catches versus quotas for species under Annual Catch Limits (ACLs) and the status of amendments currently under Secretarial review.
2. The Committee will receive reports from the Snapper Grouper Advisory Panel meeting and the SSC meeting, discuss and provide recommendations as appropriate.
3. The Committee will receive presentations on the efficacy of descending devices for deepwater grouper and commercial logbook discard data for red grouper, discuss and take action as appropriate.
4. The Committee will review Snapper Grouper Amendment 41 addressing management measures for mutton snapper, modify the document as appropriate, and provide recommendations to approve/disapprove the amendment for formal Secretarial Review.
5. The Committee will receive the Annual Review of the Vision Blueprint for the Snapper Grouper Fishery addressing long-term management needs and provide recommendations as appropriate. The Committee will also review options for the Recreational Visioning Blueprint Amendment (Vision Blueprint Regulatory Amendment 26) and the Commercial Visioning Blueprint Amendment (Vision Blueprint Regulatory Amendment 27), modify the documents as appropriate, and approve for public scoping.
6. The Committee will receive a presentation of Red Snapper landings by County in Florida, receive an overview of management options for Red Snapper to be addressed in Snapper Grouper Amendment 43, modify the document as necessary, and provide recommendations to approve/disapprove the options paper for public scoping.
7. The Committee will consider an emergency rule for the 2017 season of Golden Tilefish and provide guidance to staff for amendment development.
The Committee will conduct the Executive Director's Performance Review.
The Committee will receive a presentation from NOAA Fisheries HMS on draft Amendment 5b to the 2006 Consolidated Atlantic HMS Fishery Management Plan addressing management measures for
1. The Committees will receive status updates from NOAA Fisheries on commercial and recreational catches versus annual catch limits (ACLs) for species under ACLs and amendments currently under Secretarial review.
2. The Committee will receive an overview of Amendment 29 to the Coastal Migratory Pelagic (CMP) Fishery Management Plan for the Gulf of Mexico and South Atlantic Region addressing allocations of Gulf Group King Mackerel, modify as necessary, and provide recommendations to approve/disapprove the amendment for formal Secretarial Review.
3. The Committee will receive an overview of CMP Amendment 30 addressing modifications to the Fishing Year for Atlantic
4. The Committee will review the ASMFC's Public Information Document for the Interstate Fishery Management Plan for Cobia and provide comments and guidance as appropriate.
The Committee will receive a program development update on the Council's Citizen Science Program, discuss and take action as necessary.
1. The Committee will receive an update on the status of the Bycatch Reporting Amendment and the final Standardized Bycatch Reporting Methodology (SBRM) rule from NOAA Fisheries, discuss and provide direction to staff.
2. The Committee will receive an update on the status of voluntary commercial logbook electronic reporting, discuss and take action as necessary.
3. The Committee will receive an update on the status of the Pilot For-Hire Electronic Reporting Project being conducted jointly between the Council and the Atlantic Coastal Cooperative Statistics Program, review and take action as necessary.
4. The Committee will also receive a report on the status of the Headboat Electronic Reporting Program and associated outreach, an overview of the For-Hire Reporting Amendment, review the amendment and provide recommendations for approval/disapproval of the amendment for Secretarial Review.
The Full Council will convene on Friday morning with a Call to Order, announcements and introductions, and approve the September 2016 meeting minutes. The Council will present the Law Enforcement Officer of the Year award and make other presentations as appropriate.
The Council will receive a Legal Briefing on Litigation from NOAA General Counsel (if needed) during Closed Session.
The Council will receive a report from the Snapper Grouper Committee and approve/disapprove Snapper Grouper Amendment 41 (Mutton Snapper) for Secretarial review and approve Snapper Grouper Amendment 43 (red snapper), the Recreational Visioning Amendment, and the Commercial Visioning Amendment for public scoping. The Council will consider other Committee recommendations and take action as appropriate.
The Council will receive a report from the Mackerel Cobia Committee, approve/disapprove Coastal Migratory Pelagic Amendment 29 (Gulf of Mexico King Mackerel Allocations) and Coastal Migratory Pelagic Amendment 30 (Atlantic Cobia Fishing Year) for Secretarial review, consider other Committee recommendations, and take action as appropriate.
The Council will receive a report from the Data Collection Committee and approve/disapprove the Atlantic For-Hire Amendment (Electronic Reporting) for Secretarial Review, consider other committee recommendations, and take action as appropriate.
The Council will receive a report from the Joint Dolphin Wahoo/Snapper Grouper/Mackerel Cobia Committee, approve/disapprove Joint Dolphin Wahoo Amendment 10/Snapper Grouper Amendment 44 (Allocations for Dolphin and Yellowtail Snapper) for public hearings, consider other recommendations, and take action as appropriate.
The Council will continue to receive committee reports from Information & Education, Protected Resources, Advisory Panel Selection, SSC Selection, SEDAR, Habitat and Ecosystem-Based Management, Law Enforcement, Spiny Lobster, HMS, Citizen Science, and Executive Finance Committees, review recommendations and take action as appropriate.
The Council will receive status reports from NOAA Fisheries Southeast Office and the Southeast Fisheries Science Center; review and develop recommendations on Experimental Fishing Permits as necessary; receive agency and liaison reports; and discuss other business and upcoming meetings.
Documents regarding these issues are available from the Council office (see
Although non-emergency issues not contained in this agenda may come before these groups for discussion, those issues may not be the subject of formal action during these meetings. Action will be restricted to those issues specifically identified in this notice and any issues arising after publication of this notice that require emergency action under section 305(c) of the Magnuson-Stevens Fishery Conservation and Management Act, provided the public has been notified of the Council's intent to take final action to address the emergency.
These meetings are physically accessible to people with disabilities. Requests for auxiliary aids should be directed to the Council office (see
The times and sequence specified in this agenda are subject to change.
16 U.S.C. 1801
Bureau of Consumer Financial Protection.
Notice and request for comment.
In accordance with the Paperwork Reduction Act of 1995 (PRA), the Bureau of Consumer Financial Protection (Bureau) is proposing a new information collection titled, “Application Forms for Financial Empowerment Partnerships.”
Written comments are encouraged and must be received on or before December 15, 2016 to be assured of consideration.
You may submit comments, identified by the title of the information collection, OMB Control Number (see below), and docket number (see above), by any of the following methods:
•
•
Documentation prepared in support of this information collection request is available at
Department of the Army, DoD.
Notice to alter a System of Records.
Pursuant to the Privacy Act of 1974 and Office of Management and Budget (OMB) Circular No. A-130, notice is hereby given that the Department of the Army proposes to alter a system of records, A0037-104-3 USMA, entitled “USMA Cadet Account System,” last published at 65 FR 3219, January 20, 2000. This system of records exists to enable Cadets to receive income (salary, scholarship, individual deposits, etc.) and pay for expenses (uniforms, books, a computer, activity fees, etc.) while attending the United States Military Academy (USMA) at West Point. The program is managed by the USMA Treasurer who is charged with ensuring all cadets meet their USMA financial obligations.
This revision reflects considerable administrative changes that in sum warrant an alteration to the system of records notice. There are two significant changes: The categories of records has been updated to provide additional details on the information collected; and the applicable DoD Routine Uses have been incorporated in the notice to provide clarity for the public. There are also modifications to the system name, authorities, purpose, storage, retrievability, safeguards, notification and record access procedures, contesting record procedures, and records source categories to improve readability and update the notice to meet current departmental standards.
Comments will be accepted on or before December 15, 2016. This proposed action will be effective the date following the end of the comment period unless comments are received which result in a contrary determination.
You may submit comments, identified by docket number and title, by any of the following methods:
*
Follow the instructions for submitting comments.
*
Ms. Tracy Rogers, Department of the Army, Privacy Office, U.S. Army Records Management and Declassification Agency, 7701 Telegraph Road, Casey Building, Suite 144, Alexandria, VA 22325-3905 or by calling (703) 428-7499.
The Department of the Army's notices for system of records subject to the Privacy Act of 1974 (5 U.S.C. 552a), as amended, have been published in the
The proposed systems reports, as required by 5 U.S.C. 552a(r) of the Privacy Act, as amended, were submitted on October 20, 2016, to the House Committee on Oversight and Government Reform, the Senate Committee on Homeland Security and Governmental Affairs, and the Office of Management and Budget (OMB) pursuant to paragraph 4 of Appendix I to OMB Circular No. A-130, “Federal Agency Responsibilities for Maintaining Records About Individuals,” revised November 28, 2000 (December 12, 2000 65 FR 77677).
USMA Cadet Account System (January 20, 2000, 65 FR 3219)
Delete entry and replace with: “United States Military Academy (USMA) Cadet Account System”.
Delete entry and replace with “Name, address, Social Security Number (SSN), cadet account number, personal bank account number, monthly deposit listings of Corps of Cadets members showing entitlements, financial statements and schedules, and activities pertaining to funds held in trust by the USMA Treasurer.”
Delete entry and replace with “10 U.S.C. 3013, Secretary of Army; 10 U.S.C. 4340, Quartermaster; 10 U.S.C. 4350, Cadets: Clothing and equipment; Title 7—Fiscal Guidance, General Accounting Office Policy and Procedures Manual for Guidance of Federal Agencies; Army Regulation 210-26, United States Military Academy; and E.O. 9397 (SSN), as amended.”
Delete entry and replace with “To compute debits and credits posted against cadet account balances. Debits include charges to the cadet's account for uniforms, textbooks, computers and related supplies, academic supplies, various fees; credits include advance pay, monthly deposits from payroll, scholarships, initial deposits, interest accumulated on cadet account balances, and individual deposits.”
Delete entry and replace with “In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the records contained herein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
Law Enforcement Routine Use. If a system of records maintained by a DoD Component to carry out its functions indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or by regulation, rule, or order issued pursuant thereto, the relevant records in the system of records may be referred, as a routine use, to the agency concerned, whether federal, state, local, or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order issued pursuant thereto.
Disclosure When Requesting Information Routine Use. A record from a system of records maintained by a DoD Component may be disclosed as a routine use to a federal, state, or local agency maintaining civil, criminal, or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a DoD Component decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant, or other benefit.
Disclosure of Requested Information Routine Use. A record from a system of records maintained by a DoD Component may be disclosed to a federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.
Congressional Inquiries Disclosure Routine Use. Disclosure from a system of records maintained by a DoD Component may be made to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
Data Breach Remediation Purposes Routine Use. A record from a system of records maintained by a Component may be disclosed to appropriate agencies, entities, and persons when (1) The Component suspects or has confirmed that the security or confidentiality of the information in the system of records has been compromised; (2) the Component has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by the Component or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the Components efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.”
Delete entry and replace with “Electronic storage media and microfiche.”
Delete entry and replace with “By Cadet's account number, full name, or SSN.”
Delete entry and replace with “Records are maintained in office areas which are secured and accessible only to authorized personnel. Access to computerized data is restricted by use of Common Access Cards (CACs) and is accessible only by users with an authorized account. The system is maintained in a controlled facility that employs physical restrictions and safeguards such as security guards, identification badges, key cards, and locks.”
Delete entry and replace with “Individuals seeking to determine whether information about themselves is contained in this system should address written inquiries to the Superintendent, U.S. Military Academy, ATTN: USMA Treasurer, West Point, NY 10996-1783.
Individual should provide full name, cadet account number, SSN, graduating class year, current address, telephone number, and signature.
In addition, the requester must provide a notarized statement or an unsworn declaration made in accordance with 28 U.S.C. 1746, in the following format:
If executed outside the United States: `I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Executed on (date). (Signature).'
If executed within the United States, its territories, possessions, or commonwealths: `I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date). (Signature)’ ”
Delete entry and replace with “Individuals seeking access to information about themselves contained in this system should address written inquiries to the Superintendent, U.S. Military Academy, ATTN: USMA Treasurer, West Point, NY 10996-1783.
Individual should provide full name, cadet account number, SSN, graduating
In addition, the requester must provide a notarized statement or an unsworn declaration made in accordance with 28 U.S.C. 1746, in the following format:
If executed outside the United States: `I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Executed on (date). (Signature).'
If executed within the United States, its territories, possessions, or commonwealths: `I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. Executed on (date). (Signature).'
Personal visits may be made to the Treasurer, U.S. Military Academy; individual must provide acceptable identification such as valid driver's license and information that can be verified with his/her payroll.”
Delete entry and replace with “The Army's rules for accessing records, and for contesting contents and appealing initial agency determinations are contained in 32 CFR part 505, Army Privacy Program or may be obtained from the system manager.”
Delete entry and replace with “From the individual, Department of Army, Department of the Treasurer, and financial institutions.”
Department of Defense.
Notice.
The Department of Defense (DoD) is publishing this notice to announce that the following Federal Advisory Committee meeting of the Defense Advisory Committee on Women in the Services (DACOWITS) will take place. This meeting is open to the public.
Thursday, December 8, 2016, from 8:30 a.m. to 3:15 p.m.; Friday, December 9, 2016, from 8:30 a.m. to 11:30 a.m.
Association of the United States Army (AUSA) Conference Center, 2425 Wilson Boulevard, Arlington, VA 22201.
Mr. Robert Bowling or DACOWITS Staff at 4800 Mark Center Drive, Suite 04J25-01, Alexandria, Virginia 22350-9000;
Pursuant to the Federal Advisory Committee Act of 1972 (5 U.S.C. Appendix, as amended), the Government in the Sunshine Act of 1976 (5 U.S.C. 552b), and Section 10(a), Public Law 92-463, as amended, notice is hereby given of a forthcoming meeting of the DACOWITS.
The purpose of the meeting is for the Committee to receive briefings and updates relating to their current work. The Designated Federal Officer (DFO) will open the meeting and give a status update on the Committee's requests for information. This will be followed with four panel discussions on the following topics: Integrated Boxing Programs at the Military Service Academies; the Services' Retention Initiatives; the Services' Efforts to Increase Propensity; and the Services' Sexual Harassment/Sexual Assault Training. This will be followed with a public comment period. The second day of the meeting will open with an awards ceremony to recognize departing members. The Committee will then receive a briefing update on DoD's Childcare Programs and Initiatives. This will be followed by a panel discussion on the Services' Family Care Plan Policies.
Pursuant to 41 CFR 102-3.140, and section 10(a)(3) of the Federal Advisory Committee Act of 1972, interested persons may submit a written statement for consideration by the DACOWITS. Individuals submitting a written statement must submit their statement to the point of contact listed at the address in
Pursuant to 5 U.S.C. 552b and 41 CFR 102-3.140 through 102-3.165, this meeting is open to the public, subject to the availability of space.
Notice.
The Department of Defense has submitted to OMB for clearance, the following proposal for collection of information under the provisions of the Paperwork Reduction Act.
Consideration will be given to all comments received by December 15, 2016.
Fred Licari, 571-372-0493.
Comments and recommendations on the proposed information collection should be emailed to Ms. Jasmeet Seehra, DoD Desk Officer, at
You may also submit comments and recommendations, identified by Docket ID number and title, by the following method:
•
Written requests for copies of the information collection proposal should be sent to Mr. Licari at WHS/ESD Directives Division, 4800 Mark Center Drive, East Tower, Suite 03F09, Alexandria, VA 22350-3100.
National Center for Education Statistics (NCES), Department of Education (ED).
Notice.
In accordance with the Paperwork Reduction Act of 1995, ED is proposing a revision of an existing information collection.
Interested persons are invited to submit comments on or before December 15, 2016.
To access and review all the documents related to the information collection listed in this notice, please use
For specific questions related to collection activities, please contact NCES Information Collections at
The Department of Education (ED), in accordance with the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3506(c)(2)(A)), provides the general public and Federal agencies with an opportunity to comment on proposed, revised, and continuing collections of information. This helps the Department assess the impact of its information collection requirements and minimize the public's reporting burden. It also helps the public understand the Department's information collection requirements and provide the requested data in the desired format. ED is soliciting comments on the proposed information collection request (ICR) that is described below. The Department of Education is especially interested in public comment addressing the following issues: (1) Is this collection necessary to the proper functions of the Department; (2) will this information be processed and used in a timely manner; (3) is the estimate of burden accurate; (4) how might the Department enhance the quality, utility, and clarity of the information to be collected; and (5) how might the Department minimize the burden of this collection on the respondents, including through the use of information technology. Please note that written comments received in response to this notice will be considered public records.
National Center for Education Statistics (NCES), Department of Education (ED).
Notice.
In accordance with the Paperwork Reduction Act of 1995, ED is proposing a revision of an existing information collection.
Interested persons are invited to submit comments on or before January 17, 2017.
To access and review all the documents related to the information collection listed in this notice, please use
For specific questions related to collection activities, please contact NCES Information Collections at
The Department of Education (ED), in accordance with the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3506(c)(2)(A)), provides the general public and Federal agencies with an opportunity to comment on proposed, revised, and continuing collections of information. This helps the Department assess the impact of its information collection requirements and minimize the public's reporting burden. It also helps the public understand the Department's information collection requirements and provide the requested data in the desired format. ED is soliciting comments on the proposed information collection request (ICR) that is described below. The Department of Education is especially interested in public comment addressing the following issues: (1) Is this collection necessary to the proper functions of the Department; (2) will this information be processed and used in a timely manner; (3) is the estimate of burden accurate; (4) how might the Department enhance the quality, utility, and clarity of the information to be collected; and (5) how might the Department minimize the burden of this collection on the respondents, including through the use of information technology. Please note that written comments received in response to this notice will be considered public records.
National Center for Education Statistics (NCES), Department of Education (ED).
Notice.
In accordance with the Paperwork Reduction Act of 1995, ED is proposing a new information collection.
Interested persons are invited to submit comments on or before January 17, 2017.
To access and review all the documents related to the information collection listed in this notice, please use
For specific questions related to collection activities, please contact NCES Information Collections at
The Department of Education (ED), in accordance with the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3506(c)(2)(A)), provides the general public and Federal agencies with an opportunity to comment on proposed, revised, and continuing collections of information. This helps the Department assess the impact of its information collection requirements and minimize the public's reporting burden. It also helps the public understand the Department's information collection requirements and provide the requested data in the desired format. ED is soliciting comments on the proposed information collection request (ICR) that is described below. The Department of Education is especially interested in public comment addressing the following issues: (1) Is this collection necessary to the proper functions of the Department; (2) will this information be processed and used in a timely manner; (3) is the estimate of burden accurate; (4) how might the Department enhance the quality, utility, and clarity of the information to be collected; and (5) how might the Department minimize the burden of this collection on the respondents, including through the use of information technology. Please note that written comments received in response to this notice will be considered public records.
Office of Energy Efficiency and Renewable Energy, Department of Energy.
Notice of open meeting.
This notice announces an open meeting of the Hydrogen and Fuel Cell Technical Advisory Committee (HTAC). The Federal Advisory Committee Act requires notice of the meeting be announced in the
Tuesday, December 6, 2016 9:00 a.m.-5:45 p.m.
Wednesday, December 7, 2016 9:00 a.m.-1:15 p.m.
National Renewable Energy Laboratory, 901 D St SW., Suite 930, Washington, DC 20024.
Department of Energy.
Notice of cancellation of open meeting.
On November 2, 2016, the Department of Energy (DOE) published a notice of open meeting scheduled for December 13, 2016, of the Secretary of Energy Advisory Board. This notice announces the cancellation of this meeting. The meeting is being cancelled because the board will not have a quorum due to scheduling conflicts by members. The next regular meeting will be held at a date to be determined.
The meeting scheduled for December 13, 2016, announced in the November 2, 2016, issue of the
Karen Gibson, Designated Federal Officer, U.S. Department of Energy, 1000 Independence Avenue SW., Washington, DC 20585;
National Nuclear Security Administration, Department of Energy; Department of State, Department of Commerce.
Notice.
Section 3136 of the National Defense Authorization Act for Fiscal Year 2016 (NDAA) mandates that the Office of the Director of National Intelligence (ODNI) also be consulted with respect to each authorization under section 57b.(2) of the Atomic Energy Act of 1954, as amended (AEA), to a covered foreign country as defined in section 3136(i)(2) of the NDAA. This amendment to the Procedures Established Pursuant to the Nuclear Non-Proliferation Act of 1978 implements this consultation requirement.
Mr. Richard Goorevich, Senior Policy Advisor, Office of Nonproliferation and Arms Control (NPAC), National Nuclear Security Administration (NNSA), Department of Energy (DOE), 1000 Independence Avenue SW., Washington, DC 20585,
Section 57b.(2) of the Atomic Energy Act of 1954, as amended (AEA), is implemented through the DOE/NNSA regulations under Title 10 of the Code of Federal Regulations (CPR) Part 810 (Part 810) governing exports of unclassified nuclear technology and assistance. On February 23, 2015, DOE/NNSA published its final rule (80 FR 9359) revising Part 810. The final rule came into effect on March 25, 2015. Before the Secretary of Energy authorizes certain transfers of civil nuclear technology and assistance, DOE/NNSA is required to consult with the Nuclear Regulatory Commission (NRC), the Department of Commerce (DOC), and the Department of Defense (DoD), and obtain the concurrence of the Department of State (DOS). These reviews are accomplished in a manner consistent with Part D of the Procedures Established Pursuant to the Nuclear Non-Proliferation Act of 1978 (the “Procedures”), as published in the
To provide for consultation with the ODNI on applications for specific authorization under section 57b.(2) of the AEA, as implemented by DOE/NNSA regulations at 10 CFR Part 810, Section 12 of Part D of the Procedures is amended as follows:
1. Within 10 days of receipt of an application for specific authorization for a transfer of technology controlled under 10 CFR Part 810, DOE/NNSA conducts a technical review of the application to determine whether the application is properly submitted and falls within the scope of the regulation.
1.a. Concurrent with the internal DOE/NNSA technical review, for
1.b. Within 10 business days of initial notification, ODNI identifies, based on the details of the transfer application and availability, an IC point of contact (POC) to provide a response. DOE/NNSA provides ODNI with any technical reviews or assessments conducted by DOE/NNSA relevant to the technology transfer.
1.c. Within 30 business days of receiving the end user, equipment, and supplier information from DOE/NNSA, ODNI makes its coordinated response available to: DOE/NNSA; DOS; and NRC, DOC, and DoD (collectively herein referred to as the “Consulting Agencies”).
2. After the DOE/NNSA technical review is complete, with expected timelines of not more than 60 days for covered foreign countries and 30 days for other destinations, DOE/NNSA transmits through appropriate means the application and DOE/NNSA analysis to DoD, DOC, DOS, and NRC for review. Within 30 days after receipt, DOS and the Consulting Agencies provide their views on the application and analysis. If DOS or a Consulting Agency notifies DOE/NNSA NPAC in writing that additional information is required, NPAC will provide appropriate time for all Consulting Agencies to consider the application and a new time line will be established for reviews based on individual circumstances. Note that the U.S. Government, through DOS, requests foreign government assurances for specific authorizations, and it is the foreign government's control over how long it may take to deliver these assurances, which may lengthen the time line for interagency review beyond the expected 30 days.
3. Within 100 days following the completion of the interagency consultations, NPAC provides the Secretary of Energy with a recommendation for action on the application, including the views of DOS, the Consulting Agencies, and ODNI, if applicable. In the event that any such agencies recommend further consideration this timeline may be extended.
Information provided to DOE in connection with these procedures may be marked or otherwise identified as business proprietary and/or personally identifiable information and would be subject to protection in accordance with applicable law and Executive Orders. Such information would be made available within the respective agencies only to those personnel who have a need to know for the purpose of reviewing applications for exports of unclassified nuclear technology and assistance under section 57b.(2) of the Atomic Energy Act of 1954, as amended, and otherwise disclosed only with the express consent of DOE/NNSA or when such disclosure is required by law.
On October 24, 2016, Hampshire Paper Company, Inc. (transferor) and KE Emeryville, LLC (transferee) filed an application for the transfer of license of the Emeryville Hydroelectric Project No. 2850. The project is located on the Oswegatchie River in St. Lawrence County, New York. The project does not occupy Federal lands.
The applicants seek Commission approval to transfer the license for the Emeryville Hydroelectric Project from Hampshire Paper Company, Inc. to KE Emeryville, LLC.
Deadline for filing comments, motions to intervene, and protests: 30 days from the date that the Commission issues this notice. The Commission strongly encourages electronic filing. Please file comments, motions to intervene, and protests using the Commission's eFiling system at
Take notice that on November 4, 2016, pursuant to section 206 of the Federal Power Act, 16 U.S.C. 824e, and Rules 206 and 212 of the Federal Energy Regulatory Commission's (Commission) Rules of Practice and Procedure, 18 CFR 385.206 and 385.212 (2016), Big Rivers Electric Corporation (Complainant) filed a formal complaint against Midcontinent Independent System Operator, Inc. (Respondent) alleging that Respondent's application of the relevant Open Access Transmission, Energy and Operating Reserves Markets Tariff provisions to Complainant is not just and reasonable, all as more fully explained in the complaint.
Complainant certifies that a copy of the complaint has been served on MISO and on the Kentucky Public Service Commission.
Any person desiring to intervene or to protest this filing must file in accordance with Rules 211 and 214 of the Commission's Rules of Practice and Procedure (18 CFR 385.211 and 385.214). Protests will be considered by the Commission in determining the appropriate action to be taken, but will not serve to make protestants parties to the proceeding. Any person wishing to become a party must file a notice of intervention or motion to intervene, as appropriate. The Respondent's answer and all interventions, or protests must be filed on or before the comment date. The Respondent's answer, motions to intervene, and protests must be served on the Complainant.
The Commission encourages electronic submission of protests and interventions in lieu of paper using the “eFiling” link at
This filing is accessible on-line at
Take notice that on October 28, 2016, Columbia Gas Transmission, LLC (Columbia), located at 5151 San Felipe, Suite 2500, Houston, Texas 77056, filed in Docket No. CP17-5-000, a prior notice request pursuant to sections 157.205, and 157.208(b) of the Federal Energy Regulatory Commission's regulations under the Natural Gas Act (NGA), seeking authorization to abandon and construct certain natural gas facilities in Gallia, Jackson and Lawrence Counties, Ohio, all as more fully set forth in the application, which is on file with the Commission and open to public inspection. The filing may also be viewed on the Web at
Any questions regarding the Request should be directed to Richard D. Bralow, Counsel, Columbia Gas Transmission, LLC, 700 Louisiana Street, Houston, Texas 77002, by telephone at: 832-320-5177, or by email at
Any person may, within 60 days after the issuance of the instant notice by the Commission, file pursuant to Rule 214 of the Commission's Procedural Rules (18 CFR 385.214) a motion to intervene or notice of intervention. Any person filing to intervene or the Commission's staff may, pursuant to section 157.205 of the Commission's Regulations under the NGA (18 CFR 157.205) file a protest to the request. If no protest is filed within the time allowed therefore, the proposed activity shall be deemed to be authorized effective the day after the time allowed for protest. If a protest is filed and not withdrawn within 30 days after the time allowed for filing a protest, the instant request shall be treated as an application for authorization pursuant to section 7 of the NGA.
Pursuant to section 157.9 of the Commission's rules, 18 CFR 157.9, within 90 days of this Notice the Commission staff will either: complete its environmental assessment (EA) and place it into the Commission's public record (eLibrary) for this proceeding; or issue a Notice of Schedule for Environmental Review. If a Notice of Schedule for Environmental Review is issued, it will indicate, among other milestones, the anticipated date for the Commission staff's issuance of the final environmental impact statement (FEIS) or EA for this proposal. The filing of the EA in the Commission's public record for this proceeding or the issuance of a Notice of Schedule for Environmental Review will serve to notify federal and state agencies of the timing for the completion of all necessary reviews, and the subsequent need to complete all federal authorizations within 90 days of the date of issuance of the Commission staff's FEIS or EA.
Persons who wish to comment only on the environmental review of this project should submit an original and two copies of their comments to the Secretary of the Commission. Environmental commenter's will be placed on the Commission's environmental mailing list, will receive copies of the environmental documents, and will be notified of meetings associated with the Commission's environmental review process. Environmental commenter's will not be required to serve copies of filed documents on all other parties. However, the non-party commentary, will not receive copies of all documents filed by other parties or issued by the Commission (except for the mailing of environmental documents issued by the Commission) and ill not have the right to seek court review of the Commission's final order.
The Commission strongly encourages electronic filings of comments, protests, and interventions via the internet in lieu of paper. See 18 CFR 385.2001(a)(1)(iii) and the instructions on the Commission's Web site (
Take notice that on November 7, 2016, pursuant to section 210(h)(2)(B) of the Public Utility Regulatory Policies Act of 1978 (PURPA), Western Water and Power Production Limited LLC (Petitioner) filed a Petition for Enforcement, requesting the Federal Energy Regulatory Commission (Commission) to exercise its authority and initiate enforcement action against
Any person desiring to intervene or to protest this filing must file in accordance with Rules 211 and 214 of the Commission's Rules of Practice and Procedure (18 CFR 385.211, 385.214). Protests will be considered by the Commission in determining the appropriate action to be taken, but will not serve to make protestants parties to the proceeding. Any person wishing to become a party must file a notice of intervention or motion to intervene, as appropriate. Such notices, motions, or protests must be filed on or before the comment date. On or before the comment date, it is not necessary to serve motions to intervene or protests on persons other than the Petitioner.
The Commission encourages electronic submission of protests and interventions in lieu of paper using the “eFiling” link at
This filing is accessible on-line at
Federal Communications Commission.
Notice and request for comments.
As part of its continuing effort to reduce paperwork burdens, and as required by the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-3520), the Federal Communications Commission (FCC or Commission) invites the general public and other Federal agencies to take this opportunity to comment on the following information collections. Comments are requested concerning: Whether the proposed collection of information is necessary for the proper performance of the functions of the Commission, including whether the information shall have practical utility; the accuracy of the Commission's burden estimate; ways to enhance the quality, utility, and clarity of the information collected; ways to minimize the burden of the collection of information on the respondents, including the use of automated collection techniques or other forms of information technology; and ways to further reduce the information collection burden on small business concerns with fewer than 25 employees. The FCC may not conduct or sponsor a collection of information unless it displays a currently valid OMB control number. No person shall be subject to any penalty for failing to comply with a collection of information subject to the PRA that does not display a valid OMB control number.
Written PRA comments should be submitted on or before January 17, 2017. If you anticipate that you will be submitting comments, but find it difficult to do so within the period of time allowed by this notice, you should advise the contact listed below as soon as possible.
Direct all PRA comments to Nicole Ongele, FCC, via email to
For additional information about the information collection, contact Nicole Ongele at (202) 418-2991.
On October 15, 1997, the FCC released a Report and Order, ET Docket No. 96-2, RM-8165, FCC 97-347, that established a Coordination Zone for new and modified radio facilities in various communications services that cover the islands of Puerto Rico, Desecheo, Mona, Vieques, and Culebra within the Commonwealth of Puerto Rico. The coordination zone and notification procedures enable the Arecibo Radio Astronomy Observatory to receive information needed to assess whether an applicant's proposed operations will cause harmful interference to the Arecibo Observatory's operations, which also promotes efficient resolution of coordination problems between the applicants and the Arecibo Observatory.
Federal Communications Commission.
Notice and request for comments.
As part of its continuing effort to reduce paperwork burdens, and as required by the Paperwork Reduction Act (PRA) of 1995, the Federal Communications Commission (FCC or the Commission) invites the general
Written PRA comments should be submitted on or before January 17, 2017. If you anticipate that you will be submitting comments, but find it difficult to do so within the period of time allowed by this notice, you should advise the contact listed below as soon as possible.
Direct all PRA comments to Nicole Ongele, FCC, via email
For additional information about the information collection, contact Nicole Ongele at (202) 418-2991.
The data will provide the Commission with greater visibility into the availability and health of these networks, allowing it to better track and analyze submarine cable resiliency, and suggest or take appropriate actions when the data so indicate,
The NORS information collection (OMB Control No. 3060-0484) is administered by the FCC's Public Safety and Homeland Security Bureau (PSHSB), which maintains an Internet portal for the electronic submission of NORS reports. This electronic filing requirement entails entering the required information using Commission-approved Web-based outage report templates that are available online at the NORS Internet Web portal. The completion of these online templates results in the information being electronically entered into the Commission's NORS reporting data base in real-time.
Federal Maritime Commission.
November 17, 2016—10 a.m.
800 North Capitol Street NW., First Floor Hearing Room, Washington, DC.
The first portion of the meeting will be held in Open Session and will be streamed live at
Rachel E. Dickon, Assistant Secretary, (202) 523-5725.
The notificants listed below have applied under the Change in Bank Control Act (12 U.S.C. 1817(j)) and § 225.41 of the Board's Regulation Y (12 CFR 225.41) to acquire shares of a bank or bank holding company. The factors that are considered in acting on the notices are set forth in paragraph 7 of the Act (12 U.S.C. 1817(j)(7)).
The notices are available for immediate inspection at the Federal Reserve Bank indicated. The notices also will be available for inspection at the offices of the Board of Governors. Interested persons may express their views in writing to the Reserve Bank indicated for that notice or to the offices of the Board of Governors. Comments must be received not later than November 30, 2016.
1.
Federal Trade Commission.
Proposed Consent Agreement.
The consent agreement in this matter settles alleged violations of federal law prohibiting unfair methods of competition. The attached Analysis to Aid Public Comment describes both the allegations in the complaint and the terms of the consent order—embodied in the consent agreement—that would settle these allegations.
Comments must be received on or before December 7, 2016.
Interested parties may file a comment at
Charles Harwood, FTC Northwest Regional Office, 915 Second Ave., Room 2896, Seattle, WA 98174 (206-220-4480).
Pursuant to Section 6(f) of the Federal Trade Commission Act, 15 U.S.C. 46(f), and FTC Rule 2.34, 16 CFR 2.34, notice is hereby given that the above-captioned consent agreement containing consent order to cease and desist, having been filed with and accepted, subject to final approval, by the Commission, has been placed on the public record for a period of thirty (30) days. The following Analysis to Aid Public Comment describes the terms of the consent agreement, and the allegations in the complaint. An electronic copy of the full text of the consent agreement package can be obtained from the FTC Home Page (for November 7, 2016), on the World Wide Web, at
You can file a comment online or on paper. For the Commission to consider your comment, we must receive it on or before December 7, 2016. Write “In the Matter of Valeant Pharmaceuticals International, Inc., File No. 1510236” on your comment. Your comment—including your name and your state—will be placed on the public record of this proceeding, including, to the extent practicable, on the public Commission Web site, at
Because your comment will be made public, you are solely responsible for making sure that your comment does not include any sensitive personal information, like anyone's Social Security number, date of birth, driver's license number or other state identification number or foreign country equivalent, passport number, financial account number, or credit or debit card number. You are also solely responsible for making sure that your comment does not include any sensitive health information, like medical records or other individually identifiable health information. In addition, do not include any “[t]rade secret or any commercial or financial information which . . . is privileged or confidential,” as discussed in Section 6(f) of the FTC Act, 15 U.S.C. 46(f), and FTC Rule 4.10(a)(2), 16 CFR 4.10(a)(2). In particular, do not include competitively sensitive information such as costs, sales statistics, inventories, formulas, patterns, devices, manufacturing processes, or customer names.
If you want the Commission to give your comment confidential treatment, you must file it in paper form, with a request for confidential treatment, and you have to follow the procedure explained in FTC Rule 4.9(c), 16 CFR
Postal mail addressed to the Commission is subject to delay due to heightened security screening. As a result, we encourage you to submit your comments online. To make sure that the Commission considers your online comment, you must file it at
If you file your comment on paper, write “In the Matter of Valeant Pharmaceuticals International, Inc., File No. 1510236” on your comment and on the envelope, and mail your comment to the following address: Federal Trade Commission, Office of the Secretary, 600 Pennsylvania Avenue NW., Suite CC-5610 (Annex D), Washington, DC 20580, or deliver your comment to the following address: Federal Trade Commission, Office of the Secretary, Constitution Center, 400 7th Street SW., 5th Floor, Suite 5610 (Annex D), Washington, DC. If possible, submit your paper comment to the Commission by courier or overnight service.
Visit the Commission Web site at
The Federal Trade Commission (“Commission”) has accepted for public comment an Agreement Containing Consent Order (“Consent Order”) with Valeant Pharmaceuticals International, Inc. (“Valeant”) to remedy the alleged anticompetitive effects resulting from Valeant's acquisition of Paragon Holdings I, Inc., including wholly-owned subsidiaries Paragon Vision Sciences, Inc. and CRT Technology, Inc. (“Paragon”).
The Complaint alleges that the acquisition violated Section 7 of the Clayton Act, as amended, 15 U.S.C. 18, and Section 5 of the Federal Trade Commission Act, as amended, 15 U.S.C. 45, by lessening competition in the markets for polymer discs, or “buttons,” used to make three different types of rigid gas permeable (“GP”) contact lenses: Orthokeratology contact lenses, large-diameter scleral contact lenses, and general vision correction contact lenses. The Consent Order would remedy the alleged violations by restoring competition in these GP button markets.
Under the terms of the Consent Order, Valeant is required to divest Paragon in its entirety, including the assets of Pelican Products LLC (“Pelican”), a manufacturer of contact lens packaging.
The proposed Consent Order has been placed on the public record for 30 days to solicit comments from interested persons. Comments received during this period will become part of the public record. After 30 days, the Commission will again review the proposed Consent Order and any comments received, and decide whether the Consent Order should be withdrawn, modified, or made final.
Valeant is a Canadian conglomerate that develops and markets prescription and non-prescription pharmaceutical products. Through its subsidiary Bausch + Lomb, Valeant is a leading producer of GP buttons used to make GP contact lenses. Prior to its acquisition by Valeant in May 2015, Paragon was a United States corporation with its principal place of business in Arizona. Paragon produces GP buttons used to make GP contact lenses and also produces finished GP lenses.
After the Paragon acquisition, Valeant also purchased Pelican, a manufacturer of contact lens packaging, and the only producer of FDA-approved vials for wet-shipping finished orthokeratology lenses. Pelican became a subsidiary of Paragon. This acquisition ensured Valeant's access to the vials, after Pelican's owner announced plans to exit the market.
Both parties engage in developing, manufacturing, and selling GP buttons in the United States. The relevant product markets in which to analyze the effects of the acquisition are the manufacture and sale of FDA-approved GP buttons for: Orthokeratology GP lenses, which are worn to reshape the cornea; large-diameter scleral GP lenses, which cover the white of the eye and are used post-surgery, for transplants, and to treat eye disease; and general vision correction GP lenses. Each type of GP lens requires a GP button with parameters unique to that lens type.
GP lenses are used, and in some cases are medically necessary, to address a variety of vision problems, including dry eyes, abnormal curvatures of the eye, corneal disease, post-eye surgery complications, and eye trauma. Optical labs use GP buttons to make GP contact lenses to fulfill prescriptions from eye care professionals. Prescriptions typically specify a particular product and brand of button, and eye care professionals invest significant capital in fitting equipment for the brands they prescribe.
The FDA requires that GP lenses must be made from FDA-approved GP buttons. Thus, there are no alternatives to FDA-approved GP buttons for making each of the types of GP lenses and the relevant geographic market is the United States.
Prior to the acquisition, Valeant and Paragon independently produced buttons for all three types of GP lenses. In the market for orthokeratology GP buttons, the combination of Valeant and Paragon was a merger to monopoly. In the market for scleral GP buttons, the combined company accounted for 70-80 percent of the market. In the market for general vision correction GP buttons, the combined company's market share was approximately 65-75 percent.
The acquisition likely caused significant competitive harm in the relevant markets. Specifically, the acquisition of Paragon eliminated actual, direct, and substantial competition between Valeant and Paragon in the relevant markets for GP buttons and allowed Valeant to unilaterally exercise market power. For instance, following the acquisition, Valeant increased prices in all three GP button markets.
Prior to the acquisition, Valeant and Paragon also competed on innovation, with the incentive to develop new GP lens buttons and improve button materials by investing in research, development, and adoption. This innovation led to broader product lines, improvements to button materials, and marketing and education funding for optical labs. The acquisition also eliminated this innovation competition between Valeant and Paragon.
Entry into the relevant market has not been, and would not be, timely, likely, or sufficient to deter or counteract the anticompetitive effects of the acquisition. Optical labs have limited short-term ability to switch from Valeant and Paragon, which supply the majority of their GP scleral buttons and GP general vision correction buttons, and 100 percent of their GP orthokeratology buttons. Optical labs might try to persuade eye care professionals to switch to a different material and brand, but ultimately the decision is made by the eye care professional, for whom such a change is costly and time-consuming.
Considerable entry barriers also arise from the FDA approval process. For GP orthokeratology buttons, the FDA premarket approval process takes several years because finished orthokeratology lenses worn overnight are Class III medical devices. For GP scleral and general vision buttons, the FDA premarket notification process likely requires at least one year, as the finished lenses incorporating such buttons are Class II medical devices.
We did not find any evidence of efficiencies that would outweigh the competitive concerns arising from the Paragon acquisition.
The proposed Consent Order requires Valeant to divest Paragon in its entirety no later than ten (10) days after the order date, to remedy the concerns raised by the acquisition and restore competition in the relevant markets by instituting Paragon as an independent, viable competitor to Valeant. The proposed Consent Order also requires Valeant to divest Pelican with Paragon to ensure continued access to FDA-approved vials for shipping its finished lenses.
The proposed Consent Order requires that Valeant must divest Paragon and Pelican to Paragon Companies LLC in an upfront transaction. Paragon Companies LLC is a newly created entity owned by Joe Sicari. Mr. Sicari was the president of Paragon prior to its acquisition by Valeant in May 2015.
The Commission may, at any time, appoint a Monitor with the power and authority to ensure that Valeant fulfills all obligations and responsibilities under the Consent Order and Divestiture Agreement.
The Consent Order will remain in effect for ten (10) years, and contains standard compliance and reporting requirements.
By direction of the Commission.
The Centers for Disease Control and Prevention (CDC) has submitted the following information collection request to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork Reduction Act of 1995. The notice for the proposed information collection is published to obtain comments from the public and affected agencies.
Written comments and suggestions from the public and affected agencies concerning the proposed collection of information are encouraged. Your comments should address any of the following: (a) Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility; (b) Evaluate the accuracy of the agencies estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (c) Enhance the quality, utility, and clarity of the information to be collected; (d) Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology,
To request additional information on the proposed project or to obtain a copy of the information collection plan and instruments, call (404) 639-7570 or send an email to
CDC I-Catalyst Program—New—Office of the Associate Director for Science, Centers for Disease Control and Prevention (CDC).
The CDC Office of Technology and Innovation (OTI) within Office of the Associate Director for Science (OADS) is seeking approval for a new CDC generic clearance. OTI fosters innovative science and promotes the testing and implementation of innovative ideas that improve CDC's ability to have public health impact. To arm CDC staff with an expanded skill-set and tools to evaluate and translate their insights and ideas into solutions, CDC developed an experiential innovation curriculum called I-Catalyst based on the NSF I-Corp program. The program was created with the belief that innovation should be customer driven, be based on user research, and is something people at all levels of an organization can engage in.
The purpose of the I-Catalyst program is to teach CDC teams a process of discovering the issues and problems faced by their customers before considerable time and money is spent on a solution that may not be used. Each participating I-Catalyst project team will present with a unique customer problem for which they have a proposed solution. Participating project teams will go through a hypothesis-testing, scientific method of discovery to gather important insights about their customers and their needs.
Each individual collection will be a different problem for which a CDC team is designing a solution. The types of customers or stakeholders teams' interview will be detailed in each collection. For example, teams may interview government employees if the solution is intended to improve how government employees do their work. On the other hand, teams may interview individuals who work in industry and businesses if the problem is one experienced by external customers. This data collection covers qualitative information to be obtained through on-site, unstructured interviews with individuals who represent the customers or stakeholders CDC teams are attempting to serve or benefit.
It is expected that the program will help CDC teams generate information about their customers to help them make the case for key innovation investments to advance important public health solutions and innovations. The ultimate goal of the I-Catalyst program is to give CDC staff skills to successfully transfer knowledge into
CDC anticipates 30 projects over the next three years. Each project team will interview their customers/stakeholders for an average of 30 minutes and maximum of 2 responses per respondent. Each team will interview approximately 50 respondents. Approximately 1500 respondents will be interviewed. Of these respondents, approximately 40% of individuals will be internal CDC/ATSDR staff and 60% will be external partners, stakeholders, or customers. Annualized burden will be 500 hours.
Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS).
Notice with comment period.
The Centers for Disease Control and Prevention (CDC), as part of its continuing efforts to reduce public burden and maximize the utility of government information, invites the general public and other Federal agencies to take this opportunity to comment on proposed and/or continuing information collections, as required by the Paperwork Reduction Act of 1995. This notice invites comment on a proposed project entitled “Reframing How We Talk About Alcohol: Public Perceptions of Excessive Alcohol Use Among Multiple Audiences.” CDC will seek a one-year approval for a new information collection request to assess the public's perceptions and frames regarding alcohol use and its related harms, gain insights on the language the public uses when talking about excessive alcohol use, examine patient-provider communication about alcohol use, and evaluate the influence of other sources of information on the public's understanding of excessive alcohol use.
Written comments must be received on or before January 17, 2017.
You may submit comments, identified by Docket No. CDC-2016-0108, by any of the following methods:
•
•
All public comment should be submitted through the Federal eRulemaking portal (
To request more information on the proposed project or to obtain a copy of the information collection plan and instruments, contact the Information Collection Review Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE., MS-D74, Atlanta, Georgia 30329; phone: 404-639-7570; Email:
Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501-3520), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. In addition, the PRA requires Federal agencies to provide a 60-day notice in the
Comments are invited on: (a) Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility; (b) Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (c) Enhance the quality, utility, and clarity of the information to be collected; (d) Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology (
Reframing How We Talk About Alcohol: Public Perceptions of Excessive Alcohol Use and Related Harms—NEW—National Center on Birth Defects and Developmental Disabilities (NCBDD), Centers for Disease Control and Prevention (CDC).
Excessive alcohol consumption leads to a variety of negative health and social consequences. Those who drink heavily have an increased risk for certain chronic diseases, such as hypertension, psychological disorders, and various forms of cancer. Excessive alcohol use also can result in societal harms, such as unintentional injuries, violence, and high economic costs.
Fortunately effective prevention strategies are available to reduce excessive alcohol use and its related harms. However, it is difficult to craft public health messages and communication strategies to change alcohol-related attitudes and behaviors because the range of knowledge and beliefs about excessive alcohol use and its risks is not well understood. Despite the fact that public health experts recommend that alcohol screening and brief counseling be provided to adults in primary care settings, data indicate that only one of six U.S. adults reported ever discussing alcohol use with a health professional. To develop an effective, consistent messaging strategy, a deeper understanding of how the public thinks and talks about alcohol is required. The research will be used to inform the development of patient and provider materials and messages about excessive alcohol use and related harms.
The one-year study proposes a series of individual in-depth interviews and triads (small group discussions with three participants) with 54 participants identified by contractor staff and professional recruiting firms. Data will be collected through one-time, 90-minute in-depth interviews or triads. Up to 300 individuals will be screened to obtain 54 individuals who will participate in 90-minute in-depth interviews or triads. All data will be collected only one time. Respondents who will participate in these interviews and triads will be selected purposively to inform the development of a messaging strategy. Topics addressed may include alcohol and its related harms, language used when talking about alcohol, how people talk about alcohol with their health care providers, and sources of information about alcohol.
The information gathered through this data collection will allow CDC to develop an effective messaging strategy that reframes the way the public thinks and communicates about excessive alcohol use. Participation is voluntary, and there is no cost to respondents other than their time.
The total estimated annualized burden hours are 132.
Centers for Medicare & Medicaid Services (CMS), HHS.
Notice.
This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year (CY) 2017 under Medicare's Hospital Insurance Program (Medicare Part A). The Medicare statute specifies the formulae used to determine these amounts. For CY 2017, the inpatient hospital deductible will be $1,316. The daily coinsurance amounts for CY 2017 will be: (1) $329 for the 61st through 90th day of hospitalization in a benefit period; (2) $658 for lifetime reserve days; and (3) $164.50 for the 21st through 100th day of extended care services in a skilled nursing facility in a benefit period.
Clare McFarland, (410) 786-6390 for general information.
Gregory J. Savord, (410) 786-1521 for case-mix analysis.
Section 1813 of the Social Security Act (the Act) provides for an inpatient hospital deductible to be subtracted from the amount payable by Medicare for inpatient hospital services furnished to a beneficiary. It also provides for certain coinsurance amounts to be subtracted from the amounts payable by Medicare for inpatient hospital and extended care services. Section 1813(b)(2) of the Act requires us to determine and publish each year the amount of the inpatient hospital deductible and the hospital and extended care services coinsurance amounts applicable for services furnished in the following calendar year (CY).
Section 1813(b) of the Act prescribes the method for computing the amount of the inpatient hospital deductible. The inpatient hospital deductible is an amount equal to the inpatient hospital deductible for the preceding CY, adjusted by our best estimate of the payment-weighted average of the applicable percentage increases (as defined in section 1886(b)(3)(B) of the Act) used for updating the payment rates to hospitals for discharges in the fiscal year (FY) that begins on October 1 of the same preceding CY, and adjusted to reflect changes in real case-mix. The adjustment to reflect real case-mix is determined on the basis of the most recent case-mix data available. The amount determined under this formula is rounded to the nearest multiple of $4 (or, if midway between two multiples of $4, to the next higher multiple of $4).
Under section 1886(b)(3)(B)(i)(XX) of the Act, the percentage increase used to update the payment rates for FY 2017 for hospitals paid under the inpatient prospective payment system is the market basket percentage increase, otherwise known as the market basket update, reduced by 0.75 percentage points (see section 1886(b)(3)(B)(xii)(V) of the Act), and an adjustment based on changes in the economy-wide productivity (the multifactor productivity (MFP) adjustment) (see section 1886(b)(3)(B)(xi)(II) of the Act). Under section 1886(b)(3)(B)(viii) of the Act, for FY 2017, the applicable percentage increase for hospitals that do not submit quality data as specified by the Secretary of the Department of Health and Human Services (the Secretary) is reduced by one quarter of the market basket update. We are estimating that after accounting for those hospitals receiving the lower market basket update in the payment-weighted average update, the calculated deductible will not be affected, since the majority of hospitals submit quality data and receive the full market basket update. Section 1886(b)(3)(B)(ix) of the Act requires that any hospital that is not a meaningful electronic health record (EHR) user (as defined in section 1886(n)(3) of the Act) will have three-quarters of the market basket update reduced by 66
Under section 1886 of the Act, the percentage increase used to update the payment rates for FY 2017 for hospitals excluded from the inpatient prospective payment system is as follows:
• The percentage increase for long term care hospitals is the market basket percentage increase reduced by 0.75 percentage points and the MFP adjustment (see sections 1886(m)(3)(A) and 1886(m)(4)(F) of the Act). In addition, these hospitals may also be impacted by the quality reporting adjustments and the site-neutral payment rates (see sections 1886(m)(5) and 1886(m)(6) of the Act).
• The percentage increase for inpatient rehabilitation facilities is the market basket percentage increase reduced by 0.75 percentage points and the MFP adjustment (see sections 1886(j)(3)(C) and 1886(j)(3)(D)(v) of the Act). In addition, these hospitals may also be impacted by the quality reporting adjustments (see section 1886(j)(7) of the Act).
• The percentage increase used to update the payment rate for inpatient psychiatric facilities is the market basket percentage increase reduced by 0.2 percentage points and the MFP adjustment (see sections 1886(s)(2)(A)(i), 1886(s)(2)(A)(ii), and 1886(s)(3)(E) of the Act). In addition, these hospitals may also be impacted by the quality reporting adjustments (see section 1886(s)(4) of the Act).
• The percentage increase for other types of hospitals excluded from the inpatient hospital prospective payment system (cancer hospitals, children's hospitals, and hospitals located outside the 50 States, the District of Columbia, and Puerto Rico) is the market basket percentage increase (see section 1886(b)(3)(B)(ii)(VIII) of the Act).
The Inpatient Prospective Payment System market basket percentage increase for FY 2017 is 2.7 percent and the MFP adjustment is −0.3 percentage point, as announced in the final rule that appeared in the
To develop the adjustment to reflect changes in real case-mix, we first calculated an average case-mix for each hospital that reflects the relative costliness of that hospital's mix of cases compared to those of other hospitals. We then computed the change in average case-mix for hospitals paid under the Medicare prospective payment system in FY 2016 compared to FY 2015. (We excluded from this calculation hospitals whose payments are not based on the inpatient prospective payment system because their payments are based on alternate prospective payment systems or reasonable costs.) We used Medicare bills from prospective payment hospitals that we received as of July 2016. These bills represent a total of about 7.4 million Medicare discharges for FY 2016 and provide the most recent case-mix data available at this time. Based on these bills, the change in average case-mix in FY 2016 is 2.61 percent. Based on these bills and past experience, we expect the overall case mix change to be 2.7 percent as the year progresses and more FY 2016 data become available.
Section 1813 of the Act requires that the inpatient hospital deductible be adjusted only by that portion of the case-mix change that is determined to
Thus as stated above, the estimate of the payment-weighted average of the applicable percentage increases used for updating the payment rates is 1.70 percent, and the real case-mix adjustment factor for the deductible is 0.5 percent. Therefore, using the statutory formula as stated in section 1813(b) of the Act, we calculate the inpatient hospital deductible for services furnished in CY 2017 to be $1,316. This deductible amount is determined by multiplying $1,288 (the inpatient hospital deductible for CY 2016 (81 FR 56762)) by the payment-weighted average increase in the payment rates of 1.017 multiplied by the increase in real case-mix of 1.005, which equals $1,316.45 and is rounded to $1,316.
The coinsurance amounts provided for in section 1813 of the Act are defined as fixed percentages of the inpatient hospital deductible for services furnished in the same CY. The increase in the deductible generates increases in the coinsurance amounts. For inpatient hospital and extended care services furnished in CY 2017, in accordance with the fixed percentages defined in the law, the daily coinsurance for the 61st through 90th day of hospitalization in a benefit period will be $329 (one-fourth of the inpatient hospital deductible as stated in section 1813(a)(1)(A) of the Act); the daily coinsurance for lifetime reserve days will be $658 (one-half of the inpatient hospital deductible as stated in section 1813(a)(1)(B) of the Act); and the daily coinsurance for the 21st through 100th day of extended care services in a skilled nursing facility in a benefit period will be $164.50 (one-eighth of the inpatient hospital deductible as stated in section 1813(a)(3) of the Act).
Table 1 below summarizes the deductible and coinsurance amounts for CYs 2016 and 2017, as well as the number of each that is estimated to be paid.
The estimated total increase in costs to beneficiaries is about $740 million (rounded to the nearest $10 million) due to: (1) The increase in the deductible and coinsurance amounts; and (2) the increase in the number of deductibles and daily coinsurance amounts paid. We determine the increase in cost to beneficiaries by calculating the difference between the 2016 and 2017 deductible and coinsurance amounts multiplied by the estimated increase in the number of deductible and coinsurance amounts paid.
Section 1813(b)(2) of the Act requires publication of the inpatient hospital deductible and all coinsurance amounts—the hospital and extended care services coinsurance amounts—between September 1 and September 15 of the year preceding the year to which they will apply. These amounts are determined according to the statute as discussed above. As has been our custom, we use general notices, rather than notice and comment rulemaking procedures, to make the announcements. In doing so, we acknowledge that under the Administrative Procedure Act (APA), 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 good cause that prior notice and comment are impracticable, unnecessary, or contrary to the public interest. We find that the procedure for notice and comment is unnecessary here, because the formulae used to calculate the inpatient hospital deductible and hospital and extended care services coinsurance amounts are statutorily directed, and we can exercise no discretion in following the formulae. Moreover, the statute establishes the time period for which the deductible and coinsurance amounts will apply and delaying publication would be contrary to the public interest. Therefore, we find good cause to waive publication of a proposed notice and solicitation of public comments.
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
Section 1813(b)(2) of the Act requires the Secretary to publish, between September 1 and September 15 of each year, the amounts of the inpatient hospital deductible and hospital and extended care services coinsurance applicable for services furnished in the following CY.
We have examined the impact of this notice 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., Part I, Ch. 8).
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). As stated in section IV of this notice, we estimate that the total increase in costs to beneficiaries associated with this notice is about $740 million due to: (1) The increase in the deductible and coinsurance amounts; and (2) the increase in the number of deductibles and daily coinsurance amounts paid. As a result, this notice is economically significant under section 3(f)(1) of Executive Order 12866 and is a major action under the Congressional Review Act. In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget.
The RFA requires agencies to analyze options for regulatory relief of small entities, 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. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $7.5 million to $38.5 million in any 1 year (for details, see the Small Business Administration's Web site at
In addition, section 1102(b) of the Social Security 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 for Medicare payment regulations and has fewer than 100 beds. As discussed above, 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 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 mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. For 2016, that threshold accounting for inflation is approximately $146 million. This notice does not impose mandates that will have a consequential effect of $146 million 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 promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. Since this notice does not impose any costs on state or local governments, preempt state law, or have Federalism implications, the requirements of Executive Order 13132 are not applicable.
Centers for Medicare & Medicaid Services (CMS), HHS.
Notice.
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.
M. Kent Clemens, (410) 786-6391.
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
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
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
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
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.
The Medicare Part B monthly actuarial rates applicable for 2017 are $261.90 for enrollees age 65 and over
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.
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:
The Part B annual deductible for 2017 is $183.00 for all beneficiaries.
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.
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.
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.
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
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.
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.
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:
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
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.
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.
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 also announced and listed in the following chart:
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.
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.
Centers for Medicare & Medicaid Services (CMS), HHS.
Notice.
This annual notice announces Medicare's Hospital Insurance (Part A) premium for uninsured enrollees in calendar year (CY) 2017. This premium is paid by enrollees age 65 and over who are not otherwise eligible for benefits under Medicare Part A (hereafter known as the “uninsured aged”) and by certain disabled individuals who have exhausted other entitlement. The monthly Part A premium for the 12 months beginning January 1, 2017, for these individuals will be $413. The premium for certain other individuals as described in this notice will be $227.
Clare McFarland, (410) 786-6390.
Section 1818 of the Social Security Act (the Act) provides for voluntary enrollment in the Medicare Hospital Insurance Program (Medicare Part A), subject to payment of a monthly premium, of certain persons aged 65 and older who are uninsured under the Old-Age, Survivors, and Disability Insurance (OASDI) program or the Railroad Retirement Act and do not otherwise meet the requirements for entitlement to Medicare Part A. These “uninsured aged” individuals are uninsured under the OASDI program or the Railroad Retirement Act, because they do not have 40 quarters of coverage under Title II of the Act (or are/were not married to someone who did). (Persons insured under the OASDI program or the Railroad Retirement Act and certain others do not have to pay premiums for Medicare Part A.)
Section 1818A of the Act provides for voluntary enrollment in Medicare Part A, subject to payment of a monthly premium for certain disabled individuals who have exhausted other entitlement. These are individuals who were entitled to coverage due to a disabling impairment under section 226(b) of the Act, but who are no longer entitled to disability benefits and free Medicare Part A coverage because they have gone back to work and their earnings exceed the statutorily defined “substantial gainful activity” amount (section 223(d)(4) of the Act).
Section 1818A(d)(2) of the Act specifies that the provisions relating to premiums under section 1818(d) through section 1818(f) of the Act for the aged will also apply to certain disabled individuals as described above.
Section 1818(d)(1) of the Act requires us to estimate, on an average per capita basis, the amount to be paid from the Federal Hospital Insurance Trust Fund for services incurred in the upcoming calendar year (CY) (including the associated administrative costs) on behalf of individuals aged 65 and over who will be entitled to benefits under Medicare Part A. We must then determine the monthly actuarial rate for the following year (the per capita amount estimated above divided by 12) and publish the dollar amount for the monthly premium in the succeeding CY. If the premium is not a multiple of $1, the premium is rounded to the nearest multiple of $1 (or, if it is a multiple of 50 cents but not of $1, it is rounded to the next highest $1).
Section 13508 of the Omnibus Budget Reconciliation Act of 1993 (Pub. L. 103-66) amended section 1818(d) of the Act to provide for a reduction in the premium amount for certain voluntary enrollees (section 1818 and section 1818A of the Act). The reduction applies to an individual who is eligible to buy into the Medicare Part A program and who, as of the last day of the previous month:
• Had at least 30 quarters of coverage under Title II of the Act;
• Was married, and had been married for the previous 1-year period, to a person who had at least 30 quarters of coverage;
• Had been married to a person for at least 1 year at the time of the person's death if, at the time of death, the person had at least 30 quarters of coverage; or
• Is divorced from a person and had been married to the person for at least 10 years at the time of the divorce if, at the time of the divorce, the person had at least 30 quarters of coverage.
Section 1818(d)(4)(A) of the Act specifies that the premium that these individuals will pay for CY 2017 will be equal to the premium for uninsured aged enrollees reduced by 45 percent.
The monthly premium for the uninsured aged and certain disabled individuals who have exhausted other entitlement for the 12 months beginning January 1, 2017, is $413.
The monthly premium for the individuals eligible under section 1818(d)(4)(B) of the Act, and therefore, subject to the 45 percent reduction in the monthly premium, is $227.
As discussed in section I of this notice, the monthly Medicare Part A premium is equal to the estimated monthly actuarial rate for CY 2017 rounded to the nearest multiple of $1 and equals one-twelfth of the average per capita amount, which is determined by projecting the number of Medicare Part A enrollees aged 65 years and over as well as the benefits and administrative costs that will be incurred on their behalf.
The steps involved in projecting these future costs to the Federal Hospital Insurance Trust Fund are:
• Establishing the present cost of services furnished to beneficiaries, by type of service, to serve as a projection base;
• Projecting increases in payment amounts for each of the service types; and
• Projecting increases in administrative costs.
We base our projections for CY 2017 on—(1) current historical data; and (2) projection assumptions derived from current law and the Mid-Session Review of the President's Fiscal Year 2017 Budget.
We estimate that in CY 2017, 48,634,512 people aged 65 years and over will be entitled to (enrolled in) benefits (without premium payment) and that they will incur about $240.891 billion in benefits and related administrative costs. Thus, the estimated monthly average per capita amount is $412.76 and the monthly premium is $413. Subsequently, the full monthly premium reduced by 45 percent is $227.
The CY 2017 premium of $413 is approximately 0.5 percent higher than the CY 2016 premium of $411. We estimate that approximately 654,000 enrollees will voluntarily enroll in Medicare Part A, by paying the full premium. Note that states pay Part A premiums for persons who are enrolled in the Qualified Medicare Beneficiary Program (a Medicaid program which helps certain low-income individuals with Medicare premium and cost-sharing liability). Furthermore, the CY 2017 reduced premium of $227 is approximately 0.5 percent higher than the CY 2016 premium of $226. We estimate an additional 67,000 enrollees will pay the reduced premium. Therefore, we estimate that the total aggregate cost to enrollees paying these premiums in CY 2017, compared to the amount that they paid in CY 2016, will be about $17 million.
We use general notices, rather than notice and comment rulemaking procedures, to make announcements such as this premium notice. In doing so, we acknowledge that, under the Administrative Procedure Act (APA), interpretive rules, general statements of policy, and rules of agency organization, procedure, or practice are excepted from the requirements of notice and comment rulemaking. The agency may also waive notice and comment if there is “good cause,” as defined by the statute. We considered publishing a proposed notice to provide a period for public comment. However, under the APA, we may waive that procedure if we find good cause that prior notice and comment are impracticable, unnecessary, or contrary to the public interest.
We are not using notice and comment rulemaking in this notification of Medicare Part A premiums for CY 2017 as that procedure is unnecessary because of the lack of discretion in the statutory formula that is used to calculate the premium and the solely ministerial function that this notice serves. The APA permits agencies to waive notice and comment rulemaking when notice and public comment thereon are unnecessary. On this basis, we waive publication of a proposed notice and a solicitation of public comments.
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
Section 1818(d) of the Act requires the Secretary of the Department of Health and Human Services (the Secretary) during September of each year to determine and publish the amount to be paid, on an average per capita basis, from the Federal Hospital Insurance Trust Fund for services incurred in the impending CY (including the associated administrative costs) on behalf of individuals aged 65 and over who will be entitled to benefits under Medicare Part A.
We have examined the impact of this notice 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. Part I, Ch. 8).
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). As stated in section IV of this notice, we estimate that the overall effect of the changes in the Part A premium will be a cost to voluntary enrollees (section 1818 and section 1818A of the Act) of about $17 million. As a result, this notice is non-economically significant under section 3(f)(1) of Executive Order 12866 and is not a major action under the Congressional Review Act. In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget.
The RFA requires agencies to analyze options for regulatory relief of small entities, 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. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $7.5 million to $38.5 million in any 1 year (for details, see the Small Business Administration's Web site at
Individuals and states are not included in the definition of a small entity. As discussed above, this annual notice announces Medicare's Hospital Insurance (Part A) premium for uninsured enrollees in CY 2017. 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 Social Security 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 for Medicare payment regulations and has fewer than 100 beds. As discussed above, 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 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 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. This notice does not impose mandates that will have a consequential effect of $146 million 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 promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. Since this notice does not impose any costs on state or local governments, the requirements of Executive Order 13132 are not applicable.
Food and Drug Administration, HHS.
Notice.
The U.S. Food and Drug Administration (FDA or Agency) is issuing an order under the Federal Food, Drug, and Cosmetic Act (the FD&C Act) permanently debarring Paul S. Singh from providing services in any capacity to a person that has an approved or pending drug product application. FDA bases this order on a finding that Dr. Singh was convicted of a felony under Federal law for conduct relating to the regulation of a drug product under the FD&C Act. Dr. Singh was given notice of the proposed permanent debarment and an opportunity to request a hearing within the timeframe prescribed by regulation. Dr. Singh failed to request a hearing. Dr. Singh's failure to request a hearing constitutes a waiver of his right to a hearing concerning this action.
This order is effective November 15, 2016.
Submit applications for special termination of debarment to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852.
Kenny Shade, Division of Enforcement, Office of Enforcement and Import Operations, Office of Regulatory Affairs (ELEM-4144), Food and Drug Administration, 12420 Parklawn Dr., Rockville, MD 20857, 301-796-4640.
Section 306(a)(2)(B) of the FD&C Act (21 U.S.C. 335a(a)(2)(B)) requires debarment of an individual if FDA finds that the individual has been convicted of a felony under Federal law for conduct relating to the regulation of any drug product under the FD&C Act. On July 31, 2015, the U.S. District Court for the Eastern District of California entered judgment against Dr. Singh for one count of mail fraud, in violation of 18 U.S.C. 1341.
FDA's finding that the debarment is appropriate is based on the felony conviction referenced herein. The factual basis for this conviction is as follows: Dr. Singh was the President and Secretary of Paul S. Singh, DO, Inc., and provided obstetric and gynecological services to women. Beginning on or about May 2008, and continuing to at least on or about June 2012, within the Eastern District of California and elsewhere, Dr. Singh devised a scheme and artifice to defraud health care benefit programs, patients, and others of money and property by means of materially false and fraudulent pretenses, representations, and promises.
During the time period described, Dr. Singh provided his patients forms of birth control, including the insertion of an intrauterine device (“IUD”). IUDs are regulated by FDA. At the relevant time, FDA had only approved one IUD, which used copper as its active ingredient, the ParaGard T-380A IUD. ParaGard T-380A was sold only by its manufacturer and was not available on third-party Web sites.
The insertion of a non-FDA approved copper IUD risks a patient's health and safety. Dr. Singh knew of this risk and knew that inserting a non-FDA approved copper IUD was prohibited by FDA. Despite this, Dr. Singh obtained non-FDA approved copper IUDs by purchasing them on the Internet and inserted them in his patients. Dr. Singh failed to inform his patients that he had inserted a non-FDA approved copper IUD, and none of his patients consented to the insertion of one. On or about August 17, 2010, FDA agents met with Dr. Singh and warned him that he could not insert non-FDA approved copper IUDs, and he agreed that he would stop doing so. Notwithstanding this warning, Dr. Singh continued to insert non-FDA approved copper IUDs in his patients and falsely claimed to his patients that he was inserting FDA-approved copper IUDs.
Dr. Singh billed at least 10 different health care benefit programs for payment for the insertion of non-FDA approved copper IUDs in his patients. In submitting these claims, Dr. Singh knowingly misrepresented the type of IUD he had inserted. Dr. Singh caused the U.S. mails to be used to carry out an essential part of his scheme. At all relevant times, Dr. Singh acted with the intent to defraud. As a result of Dr. Singh's conduct, he made false claims of over $83,000 to health care benefit programs, his patients, and others.
As a result of this conviction, FDA sent Dr. Singh by certified mail on August 17, 2016, a notice proposing to permanently debar him from providing services in any capacity to a person that has an approved or pending drug product application. The proposal was based on a finding, under section 306(a)(2)(B) of the FD&C Act, that Dr. Singh was convicted of a felony under Federal law for conduct relating to the regulation of a drug product under the FD&C Act. FDA determined that Dr. Singh's felony conviction was related to the regulation of drug products because the conduct underlying his conviction undermined FDA's regulatory oversight over drug products marketed in the United States—it involved using and misrepresenting as approved unapproved IUDs that presented health risks to patients. The proposal also offered Dr. Singh an opportunity to request a hearing, providing him 30 days from the date of receipt of the letter in which to file the request, and advised him that failure to request a hearing constituted a waiver of the opportunity for a hearing and of any contentions concerning this action. The proposal was received on August 23, 2016. Dr. Singh did not request a hearing and has, therefore, waived his opportunity for a hearing and any contentions concerning his debarment (21 CFR part 12).
Therefore, the Director, Office of Enforcement and Import Operations, Office of Regulatory Affairs, under sections 306(a)(2)(B) of the FD&C Act, under authority delegated to him (Staff Manual Guide 1410.35), finds that Paul S. Singh has been convicted of a felony under Federal law for conduct relating to the regulation of a drug product under the FD&C Act. Section 306(c)(2)(A)(ii) of the FD&C Act requires that Dr. Singh's debarment be permanent.
As a result of the foregoing finding, Paul S. Singh is permanently debarred from providing services in any capacity to a person with an approved or pending drug product application under sections 505, 512, or 802 of the FD&C Act (21 U.S.C. 355, 360b, or 382), or under section 351 of the Public Health Service Act (42 U.S.C. 262), effective (see
Any application by Dr. Singh for special termination of debarment under section 306(d)(4) of the FD&C Act should be identified with Docket No. FDA-2016-N-1311 and sent to the Division of Dockets Management (see
Publicly available submissions will be placed in the docket, and will be viewable at
Food and Drug Administration, HHS.
Notice.
The Food and Drug Administration (FDA) is announcing an opportunity for public comment on the proposed collection of certain information by the Agency. Under the Paperwork Reduction Act of 1995 (the PRA), Federal Agencies are required to publish a notice in the
Submit either electronic or written comments on the collection of information by January 17, 2017.
You may submit comments as follows:
Submit electronic comments in the following way:
•
• If you want to submit a comment with confidential information that you do not wish to be made available to the public, submit the comment as a written/paper submission and in the manner detailed (see “Written/Paper Submissions” and “Instructions”).
Submit written/paper submissions as follows:
•
• For written/paper comments submitted to the Division of Dockets Management, FDA will post your comment, as well as any attachments, except for information submitted, marked and identified, as confidential, if submitted as detailed in “Instructions.”
•
FDA PRA Staff, Office of Operations, Food and Drug Administration, Three White Flint North, 10A63, 11601 Landsdown St., North Bethesda, MD 20852,
Under the PRA (44 U.S.C. 3501-3520), Federal Agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. “Collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes Agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA (44 U.S.C. 3506(c)(2)(A)) requires Federal Agencies to provide a 60-day notice in the
With respect to the following collection of information, FDA invites comments on these topics: (1) Whether the proposed collection of information is necessary for the proper performance of FDA's functions, including whether the information will have practical utility; (2) the accuracy of FDA's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques, when appropriate, and other forms of information technology.
The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) (Pub. L. 111-31) amends
In support of the provisions of the Tobacco Control Act that require FDA to protect the public health, FDA requests OMB approval to collect information to evaluate the effectiveness of the point of sale tobacco education campaign. Data from this outcome evaluation study will be used to examine statistical associations between exposure to the campaign and specific outcomes of interest, which include awareness of the campaign and its messaging, campaign-related attitudes, beliefs and risk perceptions, motivation to quit smoking, self-efficacy for quitting, and increased intention to quit.
Evaluation is an essential organizational practice in public health and a systematic way to account for and improve public health actions. Comprehensive evaluation of FDA's public education campaigns will be used to document whether the intended audience is aware of and understands campaign messages, and whether campaign exposure influences campaign-related attitudes, beliefs and risk perceptions, motivation to quit smoking, self-efficacy for quitting, and increased intention to quit. All of the information collected is integral to that evaluation.
FDA's media contractor has identified 52 potential counties for the campaign. From this list, FDA's evaluation contractor will randomly select 36 counties to be included in the evaluation. Of these, 24 counties will receive the intervention, while 12 counties will not receive it (control counties).
Data will be collected from a longitudinal cohort that will consist of an entirely new sample of adult cigarette smokers. Addresses will be randomly selected from a predetermined list of U.S. counties and merged with household data on age and demographic characteristics commonly associated with smoking status in order to identify households that are likely to contain one or more adult smokers between the ages of 25 and 54. Pre-paid pre-addressed paper screening surveys will be mailed to approximately 71,875 (23,958 annualized) households that meet this criteria. For the purpose of calculating maximum burden, we assume that all 71,875 (23,958 annualized) households will be screened in one of two ways: (1) When an adult member of the household completes and returns the 10-minute screener they received by mail, or (2) during a 10 minute in-person screening interview conducted by trained field interviewers who visit all the addresses that do not return the screener. At 10 minutes per screening, the maximum potential burden hours for the mail screener is 12,219 (4,073 annualized).
Accounting for nonresponse, we estimate that the mail and in-person screenings will result in 5,750 (1,917 annualized) adults who meet criteria for participation and complete the full Wave 1 survey. The Wave 1 survey will be completed during an in-person visit to the home, either as a stand-alone visit (for households that returned the mail screener) or immediately after the in-person screening is completed (for households that did not return the mail screener). We estimate that the Wave 1 survey will take 40 minutes to complete, resulting in 3,853 (1,284 annualized) burden hours. Adjusting for loss to follow-up between waves, we anticipate that 4,600 (1,533 annualized) participants will complete the Wave 2 survey, which will take 40 minutes and result in 3,082 (1,027 annualized) burden hours, and that 3,772 (1,257 annualized) participants will complete the Wave 3 survey, which will take 40 minutes and result in 2,527 (842 annualized) burden hours. Both the Wave 2 and 3 surveys will also be administered in person by trained interviewers. The total burden hours for all three in-person surveys will be 9,462 (3,154 annualized).
We anticipate that approximately
Food and Drug Administration, HHS.
Notice.
The U.S. Food and Drug Administration (FDA or Agency) is issuing an order under the Federal Food, Drug, and Cosmetic Act (the FD&C Act) permanently debarring Louis Daniel Smith from providing services in any capacity to a person that has an approved or pending drug product application. FDA bases this order on a finding that Mr. Smith was convicted of felonies under Federal law for conduct relating to the development or approval, including the process for development or approval, of a drug product, or otherwise relating to the regulation of a drug product under the FD&C Act. Mr. Smith was given notice of the proposed permanent debarment and an opportunity to request a hearing within the timeframe prescribed by regulation. Mr. Smith failed to respond. Mr. Smith's failure to respond constitutes a waiver of his right to a hearing concerning this action.
This order is effective November 15, 2016.
Submit applications for special termination of debarment to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852.
Kenny Shade, Division of Enforcement, Office of Enforcement and Import Operations, Office of Regulatory Affairs (ELEM-4144), Food and Drug Administration, 12420 Parklawn Dr., Rockville, MD 20857, 301-796-4640.
Section 306(a)(2)(A) of the FD&C Act (21 U.S.C. 335a(a)(2)(A)) requires debarment of an individual if FDA finds that the individual has been convicted of a felony under Federal law for conduct relating to the development or approval, including the process for development or approval, of any drug product. Section 306(a)(2)(B) of the FD&C Act requires debarment of an individual if FDA finds that the individual has been convicted of a felony under Federal law for conduct otherwise relating to the regulation of any drug product under the FD&C Act.
On October 27, 2015, the U.S. District Court for the Eastern District of Washington entered judgment against Mr. Smith for one count of conspiracy, in violation of 18 U.S.C. 371, three counts of introducing misbranded drugs into interstate commerce with intent to defraud or mislead, in violation of section 301(a) of the FD&C Act (21 U.S.C. 331(a)), which according to section 303(a)(2) of the FD&C Act (21 U.S.C. 333(a)(2)) constitutes a felony, and one count of smuggling in violation of 18 U.S.C. 545.
The factual basis for this conviction is as follows: Mr. Smith was a managing member of PGL International, LLC (PGL), and served as the director of PGL's operations. PGL is a Nevada corporation, which marketed and sold various health-related products, including Miracle Mineral Solution (MMS), a mixture of sodium chlorite and water. Sodium chlorite is an industrial chemical used as a pesticide and for hydraulic fracking and wastewater treatment. Sodium chlorite cannot be sold for human consumption and suppliers of the chemical include a warning sheet stating that it can cause potentially fatal side effects if swallowed. Mr. Smith obtained chemicals needed to manufacture the misbranded drug MMS without revealing to regulators and suppliers the true purpose of the chemicals; used those chemicals to manufacture the misbranded drug MMS in a facility that was not disclosed to regulators; offered the misbranded drug MMS for sale on Web sites Mr. Smith had established; and sold that drug in interstate commerce.
From on or about September 11, 2004, to at least on or about July 16, 2012, in the Eastern District of Washington and elsewhere, Mr. Smith introduced, delivered for introduction into interstate commerce, and caused the introduction and delivery for introduction into interstate commerce, with the intent to defraud or mislead, misbranded drugs. In addition, he knowingly defrauded the United States and also impeded the lawful government functions of FDA, specifically, FDA's duty to protect the health and safety of the public by, among other things, ensuring that drugs marketed in the United States are safe and effective for their intended uses and are manufactured in establishments that are registered with FDA, and that the labeling of such drugs bears true and accurate information.
As a result of this conviction, FDA sent Mr. Smith by certified mail on August 5, 2016, a notice proposing to permanently debar him from providing services in any capacity to a person that has an approved or pending drug product application. The proposal was based on a finding, under section 306(a)(2) of the FD&C Act, that Mr. Smith was convicted of felonies under Federal law for conduct relating to the development or approval, including the process for development or approval, of a drug product, or conduct otherwise relating to the regulation of a drug product under the FD&C Act. The proposal also offered Mr. Smith an opportunity to request a hearing, providing him 30 days from the date of receipt of the letter in which to file the request, and advised him that failure to request a hearing constituted a waiver of the opportunity for a hearing and of any contentions concerning this action. Mr. Smith received the proposal on August 8, 2016. Mr. Smith did not request a hearing and has, therefore, waived his opportunity for a hearing and any contentions concerning his debarment (21 CFR part 12).
Therefore, the Director, Office of Enforcement and Import Operations, Office of Regulatory Affairs, under section 306(a)(2) of the FD&C Act, under authority delegated to him (Staff Manual Guide 1410.35), finds that Louis Daniel Smith has been convicted of felonies under Federal law for conduct relating to the development or approval, including the process for development or approval, of a drug product, or conduct otherwise relating to the regulation of a drug product under the FD&C Act.
As a result of the foregoing finding, Louis Daniel Smith is permanently debarred from providing services in any capacity to a person with an approved or pending drug product application under sections 505, 512, or 802 of the FD&C Act (21 U.S.C. 355, 360b, or 382), or under section 351 of the Public Health Service Act (42 U.S.C. 262), effective (see
Any application by Mr. Smith for special termination of debarment under section 306(d)(4) of the FD&C Act should be identified with Docket No. FDA-2016-N-1162 and sent to the Division of Dockets Management (see
Publicly available submissions will be placed in the docket, and will be viewable at
Office of the Secretary, DHHS.
Notice.
The Federal Medical Assistance Percentages (FMAP), Enhanced Federal Medical Assistance Percentages (eFMAP), and disaster-recovery FMAP adjustments for Fiscal Year 2018 have been calculated pursuant to the Social Security Act (the Act). These percentages will be effective from October 1, 2017 through September 30, 2018. This notice announces the calculated FMAP rates, in accordance with sections 1101(a)(8) and 1905(b) of the Act, that the U.S. Department of Health and Human Services (HHS) will use in determining the amount of federal matching for state medical assistance (Medicaid), Temporary Assistance for Needy Families (TANF) Contingency Funds, Child Support Enforcement collections, Child Care Mandatory and Matching Funds of the Child Care and Development Fund, Title IV-E Foster Care Maintenance payments, Adoption Assistance payments and Guardianship Assistance payments, and the eFMAP rates for the Children's Health Insurance Program (CHIP) expenditures. Table 1 gives figures for each of the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands. This notice reminds states of available disaster-recovery FMAP adjustments for qualifying states, and adjustments available for states meeting requirements for negative growth in total state personal income. At this time, no states qualify for such adjustments.
This notice also contains the increased eFMAPs for CHIP as authorized under the Patient Protection and Affordable Care Act (Affordable Care Act) for fiscal years 2016 through 2019 (October 1, 2015 through September 30, 2019).
Programs under title XIX of the Act exist in each jurisdiction. Programs under titles I, X, and XIV operate only in Guam and the Virgin Islands. The percentages in this notice apply to state expenditures for most medical assistance and child health assistance, and assistance payments for certain social services. The Act provides separately for federal matching of administrative costs.
Sections 1905(b) and 1101(a)(8)(B) of the Social Security Act (the Act) require the Secretary of HHS to publish the FMAP rates each year. The Secretary calculates the percentages, using formulas in sections 1905(b) and 1101(a)(8), and calculations by the Department of Commerce of average income per person in each state and for the Nation as a whole. The percentages must fall within the upper and lower limits specified in section 1905(b) of the Act. The percentages for the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are specified in statute, and thus are not based on the statutory formula that determines the percentages for the 50 states.
Section 1905(b) of the Act specifies the formula for calculating FMAPs as follows:
“ “Federal medical assistance percentage” for any state shall be 100 per centum less the state percentage; and the state percentage shall be that percentage which bears the same ratio to 45 per centum as the square of the per capita income of such state bears to the square of the per capita income of the continental United States (including Alaska) and Hawaii; except that (1) the Federal medical assistance percentage shall in no case be less than 50 per centum or more than 83 per centum, (2) the Federal medical assistance percentage for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa shall be 55 percent. . .”.
Section 4725(b) of the Balanced Budget Act of 1997 amended section 1905(b) to provide that the FMAP for the District of Columbia for purposes of titles XIX and XXI shall be 70 percent. For the District of Columbia, we note under Table 1 that other rates may apply in certain other programs. In addition, we note the rate that applies for Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands in certain other programs pursuant to section 1118 of the Act. The rates for the States, District of Columbia and the territories are displayed in Table 1, Column 1.
Section 1905(y) of the Act, as added by section 2001 of the Patient Protection and Affordable Care Act of 2010 (”Affordable Care Act”), provides for a significant increase in the FMAP for medical assistance expenditures for individuals determined eligible under the new adult group in the state and who will be considered to be “newly eligible” in 2014, as defined in section 1905(y)(2)(A) of the Act. This newly eligible FMAP is 100 percent for Calendar Years 2014, 2015, and 2016, gradually declining to 90 percent in 2020 where it remains indefinitely. In addition, section 1905(z) of the Act, as added by section 10201 of the Affordable Care Act, provides that states that had expanded substantial coverage to low-income parents and nonpregnant adults without children prior to the enactment of the Affordable Care Act, referred to as “expansion states,” shall receive an enhanced FMAP beginning in 2014 for medical assistance expenditures for nonpregnant childless adults who may be required to enroll in benchmark coverage. These provisions are discussed in more detail in the Medicaid Eligibility proposed rule published on August 17, 2011 (76 FR 51172) and the final rule published on March 23, 2012 (77 FR 17143). This notice is not intended to set forth the newly eligible or expansion state FMAP rates.
For purposes of Title XIX (Medicaid) of the Social Security Act, the Federal Medical Assistance Percentage (FMAP), defined in section 1905(b) of the Social Security Act, for each state beginning with fiscal year 2006 is subject to an adjustment pursuant to section 614 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3. Section 614 of CHIPRA stipulates that a state's FMAP under Title XIX (Medicaid) must be adjusted in two situations.
In the first situation, if a state experiences positive growth in total personal income and an employer in that state has made a significantly disproportionate contribution to a pension or insurance fund, the state's FMAP must be adjusted. Employer pension and insurance fund contributions are significantly disproportionate if the increase in contributions exceeds 25 percent of the increase in total personal income in that state. A
A second situation arises if a state experiences negative growth in total personal income. Beginning with Fiscal Year 2006, section 614(b)(3) of CHIPRA specifies that certain employer pension or insurance fund contributions shall be disregarded when computing the per capita income used to calculate the FMAP for states with negative growth in total personal income. In that instance, for the purposes of calculating the FMAP, for a calendar year in which a state's total personal income has declined, the portion of an employer pension and insurance fund contribution that exceeds 125 percent of the amount of the employer contribution in the previous calendar year shall be disregarded.
We request that states follow the same methodology to determine potential FMAP adjustments for negative growth in total personal income that HHS employs to make adjustments to the FMAP for states experiencing significantly disproportionate pension or insurance contributions. See also the information described in the January 21, 2014
This notice does not contain an FY 2018 adjustment for a major statewide disaster for any state because no state's FMAP decreased by at least three percentage points from FY 2017 to FY 2018.
Section 2105(b) of the Act specifies the formula for calculating the eFMAP rates as follows:
The “enhanced FMAP”, for a state for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the first sentence of section 1905(b)) for the state increased by a number of percentage points equal to 30 percent of the number of percentage points by which (1) such Federal medical assistance percentage for the state, is less than (2) 100 percent; but in no case shall the enhanced FMAP for a state exceed 85 percent.
In addition, Section 2105(b) of the Social Security Act, as amended by Section 2101 of the Affordable Care Act, increases the eFMAP for states by 23 percentage points:
. . . during the period that begins on October 1, 2015, and ends on September 30, 2019, the enhanced FMAP determined for a state for a fiscal year (or for any portion of a fiscal year occurring during such period) shall be increased by 23 percentage points, but in no case shall exceed 100 percent.
The eFMAP rates are used in the Children's Health Insurance Program under Title XXI, and in the Medicaid program for certain children for expenditures for medical assistance described in sections 1905(u)(2) and 1905(u)(3) of the Act. There is no specific requirement to publish the eFMAP rates. We include them in this notice for the convenience of the states, and display both the normal eFMAP rates (Table 1, Column 2) and the Affordable Care Act's increased eFMAP rates (Table 1, Column 3) for comparison.
The percentages listed in Table 1 will be effective for each of the four quarter-year periods beginning October 1, 2017 and ending September 30, 2018.
Thomas Musco or Rose Chu, Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, Room 447D-Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201, (202) 690-6870.
Pursuant to section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. App.), notice is hereby given of the following meetings.
The meetings will be closed to the public in accordance with the provisions set forth in sections 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., as amended. The grant applications and the discussions could disclose confidential trade secrets or commercial property such as patentable material, and personal information concerning individuals associated with the grant applications, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.
Pursuant to section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. App.), notice is hereby given of the following meetings.
The meetings will be closed to the public in accordance with the provisions set forth in sections 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., as amended. The grant applications and the discussions could disclose confidential trade secrets or commercial property such as patentable material, and personal information concerning individuals associated with the grant applications, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.
Pursuant to section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. App.), notice is hereby given of the following meeting.
The meeting will be closed to the public in accordance with the provisions set forth in sections 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., as amended. The grant applications and the discussions could disclose confidential trade secrets or commercial property such as patentable material, and personal information concerning individuals associated with the grant applications, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.
This notice is being published less than 15 days prior to the meeting due to the timing limitations imposed by the review and funding cycle.
Pursuant to section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. App.), notice is hereby given of the following meetings.
The meetings will be closed to the public in accordance with the provisions set forth in sections 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., as amended. The grant applications and the discussions could disclose confidential trade secrets or commercial property such as patentable material, and personal information concerning individuals associated with the grant applications, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.
National Institutes of Health, HHS.
Notice.
The inventions listed below are owned by an agency of the U.S. Government and are available for licensing in the U.S. in accordance with 35 U.S.C. 209 and 37 CFR part 404 to achieve expeditious commercialization of federally-funded research and development. Foreign patent applications are filed on selected inventions to extend market coverage for companies and may also be available for licensing.
Licensing information and copies of the U.S. patent applications listed below may be obtained by writing to the indicated licensing contact at the National Heart, Lung and Blood Institute, Office of Technology Transfer and Development, National Institutes of Health, 31 Center Drive Room 4A29, MSC2479, Bethesda, MD 20892-2479; telephone: 301-402-5579. A signed Confidential Disclosure Agreement may be required to receive copies of the patent applications.
Technology descriptions follow.
Available for nonexclusive licensing for research uses is the cell line, SV-k1, derived from the Organ of Corti. The line was developed from the stria vascularis, an organ localized on the lateral wall of the cochlea, adjacent to the Organ of Corti, containing cell populations specialized in the production of an endolymph very rich in K
• Research
• Hearing research
• Materials
HHS Reference No. E-013-2017/0—Research Material.
Michael Shmilovich, Esq, CLP; 301-435-5019;
Pursuant to section 10(d) of the Federal Advisory Committee Act, as amended (5 U.S.C. App.), notice is hereby given of the following meeting.
The meeting will be closed to the public in accordance with the provisions set forth in sections 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., as amended. The grant applications and the discussions could disclose confidential trade secrets or commercial property such as patentable material, and personal information concerning individuals associated with the grant applications, the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.
Advisory Council on Historic Preservation.
Notice of Advisory Council on Historic Preservation quarterly business meeting.
Notice is hereby given that the Advisory Council on Historic Preservation (ACHP) will hold its next quarterly meeting on Thursday, December 1, 2016. The meeting will be held in Room SR325 at the Russell Senate Office Building at Constitution and Delaware Avenues NE., Washington, DC, starting at 8:30 a.m. EST.
The quarterly meeting will take place on Thursday, December 1, 2016, starting at 8:30 a.m.
The meeting will be held in Room SR325 at the Russell Senate Office Building at Constitution and Delaware Avenues NE., Washington, DC.
Cindy Bienvenue, 202-517-0202,
The Advisory Council on Historic Preservation (ACHP) is an independent federal agency that promotes the preservation, enhancement, and sustainable use of our nation's diverse historic resources, and advises the President and the Congress on national historic preservation policy. The goal of the National Historic Preservation Act (NHPA), which established the ACHP in 1966, is to have federal agencies act as responsible stewards of our nation's resources when their actions affect historic properties. The ACHP is the only entity with the legal responsibility to encourage federal agencies to factor historic preservation into federal project requirements. For more information on the ACHP, please visit our Web site at
The agenda for the upcoming quarterly meeting of the ACHP is the following:
The meetings of the ACHP are open to the public. If you need special accommodations due to a disability, please contact Cindy Bienvenue, 202-517-0202 or
54 U.S.C. 304102.
Coast Guard, DHS.
Thirty-day notice requesting comments.
In compliance with the Paperwork Reduction Act of 1995 the U.S. Coast Guard is forwarding an Information Collection Request (ICR), abstracted below, to the Office of Management and Budget (OMB), Office of Information and Regulatory Affairs (OIRA), requesting approval for reinstatement with change of the following collection of information: 1625-0066, Vessel and Facility Response Plans (Domestic and International), and Additional Response Requirements for Prince William Sound, Alaska. Our ICR describes the information we seek to collect from the public. Review and comments by OIRA ensure we only impose paperwork burdens commensurate with our performance of duties.
Comments must reach the Coast Guard and OIRA on or before December 15, 2016.
You may submit comments identified by Coast Guard docket number [USCG-2016-0262] to the Coast Guard using the Federal eRulemaking Portal at
(1)
(2)
(3)
A copy of the ICR is available through the docket on the Internet at
Contact Mr. Anthony Smith, Office of Information Management, telephone 202-475-3532, or fax 202-372-8405, for questions on these documents.
This Notice relies on the authority of the Paperwork Reduction Act of 1995; 44 U.S.C. Chapter 35, as amended. An ICR is an application to OIRA seeking the approval, extension, or renewal of a Coast Guard collection of information (Collection). The ICR contains information describing the Collection's purpose, the Collection's likely burden on the affected public, an explanation of the necessity of the Collection, and other important information describing the Collection. There is one ICR for each Collection. The Coast Guard invites comments on whether this ICR should be granted based on the Collection being necessary for the proper performance of Departmental functions. In particular, the Coast Guard would appreciate comments addressing: (1) The practical utility of the Collection; (2) the accuracy of the estimated burden of the Collection; (3) ways to enhance the quality, utility, and clarity of information subject to the Collection; and (4) ways to minimize the burden of the Collection on respondents, including the use of automated collection techniques or other forms of information technology. These comments will help OIRA determine whether to approve the ICR referred to in this Notice.
We encourage you to respond to this request by submitting comments and related materials. Comments to Coast Guard or OIRA must contain the OMB Control Number of the ICR. They must also contain the docket number of this request, [USCG-2016-0262], and must be received by December 15, 2016.
We encourage you to submit comments through the Federal eRulemaking Portal at
We accept anonymous comments. All comments received will be posted without change to
OIRA posts its decisions on ICRs online at
This request provides a 30-day comment period required by OIRA. The Coast Guard published the 60-day notice (81 FR 28089, May 9, 2016) required by 44 U.S.C. 3506(c)(2). That Notice elicited no comments. Accordingly, no changes have been made to the Collections.
Fish and Wildlife Service, Interior.
Notice of availability; final long range transportation plan.
We, the U.S. Fish and Wildlife Service (Service), announce the availability of the final long range transportation plan (LRTP). The Final LRTP outlines a strategy for improving and maintaining transportation assets that provide access to Service-managed lands in the Northeast Region (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, New Jersey, Delaware, Maryland, Virginia, and West Virginia) over the next 20 years.
You may view or obtain copies of the final plan by any of the following methods. You may also request a hard copy or a CD-ROM.
Carl Melberg, Acting Regional Transportation Coordinator, 413-253-8586 (phone);
With this notice, we make the Final LRTP for the Northeast Region of the Service available for public review. Notice of availability and request for comments on the Draft LRTP was published in the
This final report also includes changes made in reference to the Federal multi-year transportation funding legislation. The Fixing America's Surface Transportation Act (FAST ACT) was signed in December 2015, and replaces the 2012 Moving Ahead for Progress in the 21st Century Act (MAP-21). Both require all Federal land management agencies to conduct long range transportation planning in a manner that is consistent with metropolitan planning organization and State departments of transportation planning. This LRTP was initiated within the Service to achieve the following:
• Establish a structure for sound transportation planning and decision-making.
• Establish a vision, mission, goals, and objectives for transportation planning in the Service's Northeast Region.
• Implement coordinated and cooperative transportation partnerships in an effort to improve the Service's transportation infrastructure.
• Integrate transportation planning and funding for wildlife refuges and fish hatcheries into existing and future Service management plans and strategies
• Increase awareness of Alternative Transportation Systems and associated benefits.
• Develop best management practices for transportation improvements on Service lands.
• Serve as a pilot project for the implementation of a Regional-level transportation planning process within the Service.
Through a collaborative effort, the National Wildlife Refuge System (Refuge System) and the Fish and Aquatic Conservation programs, in cooperation with the Planning Group and the Division of Refuge Field Support within the Service's Northeast Region, have contributed to defining the mission, goals, and objectives presented in this document. The resulting mission, goals, and objectives are intended to provide a systematic approach to guide the process for evaluating and selecting transportation improvements for the Service lands in the Northeast Region. These guiding principles have shaped the development, conclusions, and recommendations of this LRTP.
To support the Service's mission by connecting people to fish, wildlife, and their habitats through strategic implementation of transportation programs.
This long range transportation plan has six categories of goals: Coordinated Opportunities; Asset Management; Safety; Environmental; Access, Mobility, and Connectivity; and Visitor Experience. Under each goal, we present distinct objectives that move us to the goal.
Objectives:
• Identify and increase key internal and external partnerships at the national, regional, and unit levels.
• Maximize leveraged opportunities by identifying and pursuing funding for projects of mutual interest and benefit.
• Develop best practices for external engagement that illustrates success in forming and nurturing coalitions and partnerships that support the Service's mission.
• Coordinate within Service programs, including the Refuge System, Ecological Services, Migratory Birds, and Fish and Aquatic Conservation during the development of Regional long-range and project-level plans.
Objectives:
• Use asset management principles to maintain important infrastructure at an appropriate condition level.
• Prioritize work programs through the project selection process detailed in this plan or an adaptation thereof.
• Evaluate life cycle costs when considering new assets to determine long-term financial sustainability.
• Consider the impacts of climate change in the planning and management of transportation assets.
Objectives:
• Identify safety issue `hot-spots' within the Service's transportation system with the Safety Analysis Toolkit.
• Implement appropriate safety countermeasures to resolve safety issues and reduce the frequency and severity of crashes (also with the Safety Analysis Toolkit).
• Address wildlife-vehicle collisions with design solutions (Environmental Enhancements).
• Use cooperation and communication among the “4E's” of safety, including: Engineering, education, enforcement, and emergency medical services.
Objectives:
• Follow the Roadway Design Guidelines for best practices in design, planning, management, maintenance, and construction of transportation assets.
• Reduce greenhouse gas emissions and air pollutants by increasing transportation options and use of alternative fuels.
• Protect wildlife corridors, reduce habitat fragmentation, and enhance terrestrial and aquatic organism passage
Objectives:
• Offer a wide range of transportation modes and linkages for onsite and offsite access.
• Provide a clear way for finding information both on and off Service lands.
• Through the Urban Wildlife Conservation Program, integrate Service transportation facilities with local community transportation systems in a way that encourages local visitation and provides economic benefits to partner and gateway communities.
• Through coordinated planning, provide context-appropriate transportation facilities that address the specific needs of local visitor groups and respect the natural setting of the refuge or hatchery.
• Address congestion issues to and within Service units.
Objectives:
• Integrate interpretation, education, and resource stewardship principles into the transportation experience.
• Evaluate the feasibility of alternative transportation systems at all stations and implement where appropriate.
• Encourage connections with existing and planned public and private transportation services.
• Design infrastructures in such a way that highlights the landscape and not the transportation facility.
We solicited comments on the Draft LRTP from March 7 to April 7, 2016 (FR00002485). During the comment period, we received two written responses. Comments received were evaluated and incorporated, as applicable, into this Final LRTP.
After considering the comments we received on the Draft LRTP, we have updated the report to highlight partnership opportunities at the Potomac River National Wildlife Refuge Complex. This final report also includes changes made in referencing the Federal multi-year transportation funding legislation. The FAST Act was signed in December 2015, and replaces the MAP-21.
We will document the Final LRTP, which will be published in the
Bureau of Land Management, Interior.
Notice.
The Bureau of Land Management (BLM) is scheduled to file plats of survey thirty (30) calendar days from the date of this publication in the BLM Wyoming State Office, Cheyenne, Wyoming. The surveys were executed at the request of the Bureau of Land Management, the U.S. Forest Service and the National Park Service and are necessary for the management of these lands. The lands surveyed are:
The plat and field notes representing the dependent resurvey of a portion of the west boundary, Tracts 37, 38 and 40, portions of Tract 41, and portions of the subdivisional lines, and the survey of the subdivision of section 27, Township 13 North, Range 101 West, Sixth Principal Meridian, Wyoming, Group No. 937, was accepted November 8, 2016.
The plat and field notes representing the dependent resurvey of portions of the west and north boundaries, and portions of the subdivisional lines, and the survey of the subdivision of section 6, Township 26 North, Range 71 West, Sixth Principal Meridian, Wyoming, Group No. 941, was accepted November 8, 2016.
The plat and field notes representing the dependent resurvey of portions of Tracts 37 and 38, and portions of the subdivisional lines, and the survey of the subdivision of sections 12, 26 and 27, Township 26 North, Range 72 West, Sixth Principal Meridian, Wyoming, Group No. 942, was accepted November 8, 2016.
The plat and field notes representing the dependent resurvey of portions of the west boundary and subdivisional lines, the survey of the subdivision of section 18, and the survey of the meanders of portions of the left bank of Belle Fourche River, Township 53 North, Range 65 West, Sixth Principal Meridian, Wyoming, Group No. 945, was accepted November 8, 2016.
The plat and field notes representing the dependent resurvey of portions of the subdivisional lines and the survey of the subdivision of sections 12 and 13, Township 53 North, Range 66 West, Sixth Principal Meridian, Wyoming, Group No. 945, was accepted November 8, 2016.
WY957, Bureau of Land Management, 5353 Yellowstone Road, P.O. Box 1828, Cheyenne, Wyoming 82003.
A person or party who wishes to protest against any of the above surveys must file a written notice within thirty (30) calendar days from the date of this publication with the Wyoming State Director, Bureau of Land Management, at the above address, stating that they wish to protest. A statement of reasons for the protest may be filed with the notice of protest and must be filed with the Wyoming State Director within thirty (30) calendar days after the protest is filed. If a protest against the survey is received prior to the date of official filing, the filing will be stayed pending consideration of the protest. A plat will not be officially filed until the day after all protests have been dismissed or otherwise resolved. Before including your address, phone number, email address, or other personal identifying information in your protest, you should be aware that your entire protest—including your personal identifying information—may be made publicly available at any time. While you can ask us to withhold your personal identifying information from public review, we cannot guarantee that we will be able to do so.
Copies of the preceding described plats and field notes are available to the public at a cost of $4.20 per plat and $.13 per page of field notes.
Notice is hereby given that, on September 12, 2016, pursuant to Section 6(a) of the National Cooperative Research and Production Act of 1993, 15 U.S.C. 4301
On September 15, 2004, ASTM filed its original notification pursuant to Section 6(a) of the Act. The Department of Justice published a notice in the
The last notification with the Attorney General was filed on May 18, 2016. A notice was filed in the
Notice is hereby given that, on September 21, 2016, pursuant to Section 6(a) of the National Cooperative Research and Production Act of 1993, 15 U.S.C. 4301
Pursuant to Section 6(b) of the Act, the identities of the parties to the venture are: Allison Transmission, Inc., Indianapolis, IN; BAE Systems, Johnson City, NY; Deere & Company, Moline, IL; Tata Motors European Technical Centre (TMETC), London, United Kingdom; and Underwriters Laboratories, Inc., Northbrook, IL. The general area of EssES-II's planned activity is to develop detailed cell level data on current or near market technology across a diverse number of manufacturers to allow a relative comparison between available technologies. The program will provide performance, life, abuse and consistency of manufacturing test data for member-selected systems in a private, independent third party laboratory format (non-governmental). This will provide members with the data required to assess the pertinent performance characteristics of various battery topologies, chemistries and manufacturers to assist in the selection of cells for a vehicular or stationary energy storage system. Additionally, the level of data and the detail in which it is provided will be sufficient to aid in the development of models, pack integration work and thermal management strategy development.
Notice is hereby given that, on October 19, 2016, pursuant to Section 6(a) of the National Cooperative Research and Production Act of 1993, 15 U.S.C. 4301
Pursuant to Section 6(b) of the Act, the identities of the parties to the venture are: Airbnb, Inc., San Francisco, CA; Atlassian Pty Ltd., Sydney, NSW, Australia; Docker, Inc.; San Francisco, CA; Dropbox, Inc., San Francisco, CA; GoDaddy.com, LLC, Scottsdale, AZ; Palantir Technologies, Inc., Palo Alto, CA; Square, Inc., San Francisco, CA; Twitter, Inc., San Francisco, CA; and Uber Technologies, Inc., San Francisco, CA.
The general area of VSA's planned activity is: Improving Internet security and streamlining vendor security compliance by developing a standardized way for companies to assess cybersecurity practices.
National Institute of Justice, Justice.
Notice.
The National Institute of Justice (NIJ) announces the publication of
Mark Greene, Office of Science and Technology, National Institute of Justice, 810 7th Street NW., Washington, DC 20531; telephone number: (202) 598-9412; email address:
On April 29, 2016, the U.S. Departments of Justice (DOJ), Homeland Security (DHS), and Defense (DoD) submitted a joint report to the President outlining a strategy to expedite deployment of gun safety technology, found here:
The report was published in response to Presidential Memorandum,
To address these issues, the report called on law enforcement agencies to develop “baseline specifications,” which would outline the agencies' operational requirements for any firearms equipped with gun safety technology. By developing baseline specifications, federal, state, and municipal law enforcement agencies can make clear to private manufacturers what they expect from this technology.
DOJ and DHS recently assembled a working group of experts in firearms technology to identify operational needs and prepare a draft document that defines generic baseline specifications for law enforcement service pistols with additional technology to enhance the security of firearms. The additional security specifications that may be addressed by smart gun technology are distinguished from more familiar firearm safety mechanisms. The distinction between safety and security can be nuanced, and the additional security specifications may also function as safety features under certain circumstances. However, this distinction forms the basis of the use of the different terminology. The working group was led by NIJ and was comprised of subject matter experts from various federal law enforcement agencies. The pistols defined by this document are semi-automatic, recoil-operated, magazine-fed, striker-fired, and fire 9 mm Luger or .40 S&W ammunition. The information detailed in this document is informed in part by specifications enumerated in recent handgun solicitations by the Federal Bureau of Investigation (FBI) and Immigration and Customs Enforcement (ICE), which are publicly available on FedBizOpps (
NIJ published a
Mine Safety and Health Administration, Labor.
Request for public comments.
The Department of Labor, as part of its continuing effort to reduce paperwork and respondent burden, conducts a pre-clearance consultation program to provide the general public and Federal agencies with an opportunity to comment on proposed collections of information in accordance with the Paperwork Reduction Act of 1995. This program helps to assure that requested data can be provided in the desired format, reporting burden (time and financial resources) is minimized, collection instruments are clearly understood, and the impact of collection requirements on respondents can be properly assessed. Currently, the Mine Safety and Health Administration (MSHA) is soliciting comments on the information collection for Radiation Sampling and Exposure Records (pertains to underground metal and nonmetal mines).
All comments must be received on or before January 17, 2017.
Comments concerning the information collection requirements of this notice may be sent by any of the methods listed below.
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Sheila McConnell, Director, Office of Standards, Regulations, and Variances, MSHA, at
Under the authority of Section 103 of the Federal Mine Safety and Health Act of 1977, MSHA is required to issue regulations requiring operators to maintain accurate records of employee exposures to potentially toxic materials or harmful physical agents which are required to be monitored or measured under any applicable mandatory health or safety standard promulgated under this Act.
Airborne radon and radon daughters exist in every uranium mine and in several other underground mining commodities. Radon is radioactive gas. It diffuses into the underground mine atmosphere through the rock and the ground water. Radon decays in a series of steps into other radioactive elements, which are solids, called radon daughters. Radon and radon daughters are invisible and odorless. Decay of radon and its daughters results in emissions of alpha energy.
Medical doctors and scientists have associated high radon daughter exposures with lung cancer. The health hazard arises from breathing air contaminated with radon daughters which are in turn deposited in the lungs. The lung tissues are sensitive to alpha radioactivity.
The amounts of airborne radon daughters to which most miners can be exposed with no adverse effects have been established and are expressed as working levels (WL). The current MSHA standard is a maximum personal exposure of 4 working level months (WLM) per year.
Excess lung cancer in uranium miners, just as coal workers'
The standard at 30 CFR 57.5037 established the procedures to be used by the mine operator in sampling mine air for the presence and concentrations of radon daughters. Operators are required to conduct weekly sampling where concentrations of radon daughters exceed 0.3 WL. Sampling is required bi-weekly where uranium mines have readings of 0.1 WL to 0.3 WL and every 3 months in non-uranium underground mines where the readings are 0.1 WL to 0.3 WL. Mine operators are required to keep records of all mandatory samplings. Records must include the sample date, location, and results, and must be retained at the mine site or nearest mine office for at least 2 years.
The standard at 30 CFR 57.5040 requires mine operators to calculate and record individual exposures to radon daughters on MSHA Form 4000-9 “Record of Individual Exposure to Radon Daughters.” The calculations are based on the results of the weekly sampling required by 30 CFR 57.5037. Records must be maintained by the operator and submitted to MSHA annually.
MSHA is soliciting comments concerning the proposed information collection related to Radiation Sampling and Exposure Records (pertains to underground metal and nonmetal mines).
• MSHA is particularly interested in comments that:
• Evaluate whether the collection of information is necessary for the proper performance of the functions of the agency, including whether the information has practical utility;
• Evaluate the accuracy of MSHA's estimate of the burden of the collection of information, including the validity of the methodology and assumptions used;
• Suggest methods to enhance the quality, utility, and clarity of the information to be collected; and
• Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology,
The information collection request will be available on
The public may also examine publicly available documents at USDOL-Mine Safety and Health Administration, 201
Questions about the information collection requirements may be directed to the person listed in the
This request for collection of information contains provisions for Radiation Sampling and Exposure Records (pertains to underground metal and nonmetal mines). MSHA has updated the data with respect to the number of respondents, responses, burden hours, and burden costs supporting this information collection request.
Comments submitted in response to this notice will be summarized and included in the request for Office of Management and Budget approval of the information collection request; they will also become a matter of public record.
Occupational Safety and Health Administration (OSHA), Labor.
Notice.
In this notice, OSHA announces the application of MET Laboratories, Inc. for expansion of its recognition as a Nationally Recognized Testing Laboratory (NRTL) and presents the Agency's preliminary finding to grant the application. Additionally, OSHA proposed to add a new test standing to the NRTL Program's List of Appropriate Test Standards.
Submit comments, information, and documents in response to this notice, or requests for an extension of time to make a submission, on or before November 30, 2016.
Submit comments by any of the following methods:
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2.
3.
4.
5.
6.
Information regarding this notice is available from the following sources:
The Occupational Safety and Health Administration is providing notice that MET Laboratories, Inc. (MET), is applying for expansion of its current recognition as an NRTL. MET requests the addition of five test standards to its NRTL scope of recognition.
OSHA recognition of an NRTL signifies that the organization meets the requirements specified in 29 CFR 1910.7. Recognition is an acknowledgment that the organization can perform independent safety testing and certification of the specific products covered within its scope of recognition. Each NRTL's scope of recognition includes (1) the type of products the NRTL may test, with each type specified by its applicable test standard; and (2) the recognized site(s) that has/have the technical capability to perform the product-testing and product-certification activities for test standards within the NRTL's scope. Recognition is not a delegation or grant of government authority; however, recognition enables employers to use products approved by the NRTL to meet OSHA standards that require product testing and certification.
The Agency processes applications by an NRTL for initial recognition and for an expansion or renewal of this recognition, following requirements in Appendix A to 29 CFR 1910.7. This appendix requires that the Agency publish two notices in the
MET currently has one facility (site) recognized by OSHA for product testing and certification, with its headquarters located at: MET Laboratories, Inc., 914 West Patapsco Avenue, Baltimore, Maryland 21230. A complete list of MET's scope of recognition is available at
MET submitted five applications, four dated July 7, 2015 (OSHA-2006-0028-0026), (OSHA-2006-0028-0027), (OSHA-2006-0028-0028), (OSHA-2006-0028-0029) and one dated August 4, 2015 (OSHA-2006-0028-0025), to expand its recognition to include five additional test standards. OSHA staff performed a detailed analysis of the application packet and reviewed other pertinent information. OSHA did not perform any on-site reviews in relation to this application.
Table 1 below lists the appropriate test standards found in MET's application for expansion for testing and certification of products under the NRTL Program.
Periodically, OSHA will propose to add new test standards to the NRTL list of appropriate test standards following an evaluation of the test standard document. To qualify as an appropriate test standard, the Agency evaluates the document to (1) verify it represents a product category for which OSHA requires certification by an NRTL, (2) verify the document represents an end product and not a component, and (3) verify the document defines safety test specifications (not installation or operational performance specifications). OSHA becomes aware of new test standards through various avenues. For example, OSHA may become aware of
In this notice, OSHA proposes to add a new test standard to the NRTL Program's List of Appropriate Test Standards. Table 1, below, lists the test standard that is new to the NRTL Program. OSHA preliminarily determined that this test standard is an appropriate test standard and proposes to include it in the NRTL Program's List of Appropriate Test Standards. OSHA seeks public comment on this preliminary determination.
MET submitted an acceptable application for expansion of its scope of recognition. OSHA's review of the application file, and pertinent documentation, indicate that MET can meet the requirements prescribed by 29 CFR 1910.7 for expanding its recognition to include the addition of these five test standards for NRTL testing and certification listed above. This preliminary finding does not constitute an interim or temporary approval of MET's application.
OSHA welcomes public comment as to whether MET meets the requirements of 29 CFR 1910.7 for expansion of its recognition as an NRTL. Comments should consist of pertinent written documents and exhibits. Commenters needing more time to comment must submit a request in writing, stating the reasons for the request. Commenters must submit the written request for an extension by the due date for comments. OSHA will limit any extension to 10 days unless the requester justifies a longer period. OSHA may deny a request for an extension if the request is not adequately justified. To obtain or review copies of the exhibits identified in this notice, as well as comments submitted to the docket, contact the Docket Office, Room N-2625, Occupational Safety and Health Administration, U.S. Department of Labor, at the above address. These materials also are available online at
OSHA staff will review all comments to the docket submitted in a timely manner and, after addressing the issues raised by these comments, will recommend to the Assistant Secretary for Occupational Safety and Health whether to grant MET's application for expansion of its scope of recognition. The Assistant Secretary will make the final decision on granting the application. In making this decision, the Assistant Secretary may undertake other proceedings prescribed in Appendix A to 29 CFR 1910.7.
OSHA will publish a public notice of its final decision in the
David Michaels, Ph.D., MPH, Assistant Secretary of Labor for Occupational Safety and Health, 200 Constitution Avenue NW., Washington, DC 20210, authorized the preparation of this notice. Accordingly, the Agency is issuing this notice pursuant to 29 U.S.C. 657(g)(2), Secretary of Labor's Order No. 1-2012 (77 FR 3912, Jan. 25, 2012), and 29 CFR 1910.7.
10:00 a.m., Thursday, November 17, 2016.
Board Room, 7th Floor, Room 7047, 1775 Duke Street (All visitors must use Diagonal Road Entrance), Alexandria, VA 22314-3428.
Open.
1. Share Insurance Fund Quarterly Report.
2. NCUA's Rules and Regulations, Community Development Revolving Loan Fund.
3. 2017/2018 Operating Budget.
4. Board Briefing, 2017 Overhead Transfer Rate.
5. Board Briefing, Share Insurance Fund Equity Ratio Projections and 2017 Premium Range.
Gerard Poliquin, Secretary of the Board, Telephone: 703-518-6304.
National Endowment for the Humanities.
Notice of meetings.
The National Endowment for the Humanities will hold fourteen meetings of the Humanities Panel, a federal advisory committee, during December, 2016. The purpose of the meetings is for panel review, discussion, evaluation, and recommendation of applications for financial assistance under the National Foundation on the Arts and Humanities Act of 1965.
See
The meetings will be held at the National Endowment for the Humanities at Constitution Center at 400 7th Street SW., Washington, DC 20506, unless otherwise indicated.
Elizabeth Voyatzis, Committee Management Officer, 400 7th Street SW., Room 4060, Washington, DC 20506; (202)606-8322;
Pursuant to section 10(a)(2) of the Federal Advisory Committee Act (5 U.S.C. App.), notice is hereby given of the following meetings:
1.
This meeting will discuss applications on the subject of World Studies II: Modern Era, for the Humanities Collections and Reference Resources grant program, submitted to the Division of Preservation and Access.
2.
This meeting will discuss applications for the Humanities Connections grant program, submitted to the Division of Education Programs.
3.
This meeting will discuss applications for Kluge Fellowships, submitted to the Division of Research Programs.
4.
This meeting will discuss applications for the Humanities Connections grant program, submitted to the Division of Education Programs.
5.
This meeting will discuss applications for Kluge Fellowships, submitted to the Division of Research Programs.
6.
This meeting will discuss applications on the subject of Linguistics, for the Humanities Collections and Reference Resources grant program, submitted to the Division of Preservation and Access.
7.
This meeting will discuss applications for the Humanities Connections grant program, submitted to the Division of Education Programs.
8.
This meeting will discuss applications for the Humanities Connections grant program, submitted to the Division of Education Programs.
9.
This meeting will discuss applications for Fellowship Programs at Independent Research Institutions, submitted to the Division of Research Programs.
10.
This meeting will discuss applications for the Humanities Connections grant program, submitted to the Division of Education Programs.
11.
This meeting will discuss applications to the Dialogues on the Experience of War grant program, submitted to the Division of Education Programs.
12.
This meeting will discuss applications to the Dialogues on the Experience of War grant program, submitted to the Division of Education Programs.
13.
This meeting will discuss applications to the Dialogues on the Experience of War grant program, submitted to the Division of Education Programs.
14.
This meeting will discuss applications to the Dialogues on the Experience of War grant program, submitted to the Division of Education Programs.
Because these meetings will include review of personal and/or proprietary financial and commercial information given in confidence to the agency by grant applicants, the meetings will be closed to the public pursuant to sections 552b(c)(4) and 552b(c)(6) of Title 5, U.S.C., as amended. The Committee Management Officer, Elizabeth Voyatzis, has made this determination pursuant to the authority granted her by the Chairman's Delegation of Authority to Close Advisory Committee Meetings dated April 15, 2016.
9:30 a.m., Tuesday, November 15, 2016.
NTSB Conference Center, 429 L'Enfant Plaza SW., Washington, DC 20594.
The one item is open to the public.
1:30 p.m., Tuesday, November 15, 2016.
NTSB Conference Center, 429 L'Enfant Plaza SW., Washington, DC 20594.
The one item is open to the public.
8737A
Telephone: (202) 314-6100.
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Schedule updates, including weather-related cancellations, are also available at
Candi Bing at (202) 314-6403 or by email at
Terry Williams at (202) 314-6100 or by email at
Terry Williams at (202) 314-6100 or by email at
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (the “Act”),
The Exchange filed a proposal in connection with the proposed corporate transaction (the “Transaction”), as described in more detail below, involving its ultimate parent company, Bats Global Markets, Inc. (“BGM”), CBOE Holdings, Inc. (“CBOE Holdings”), and two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”). CBOE Holdings is the parent company of Chicago Board Options Exchange, Incorporated (“CBOE”) and C2 Options Exchange, Incorporated (“C2”), each a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act,
Upon completion of the mergers described below that effectuate the Transaction (the “Closing”), the business of BGM will be carried on by CBOE V. CBOE V, rather than BGM, will be the direct parent company of Bats Global Markets Holdings, Inc. (“BGM Holdings”), which is the direct parent company of the Exchange. As a result, CBOE Holdings will become the ultimate parent company of BGM Holdings and of the Exchange.
To effectuate the Transaction, the Exchange seeks to obtain the Commission's approval of: (i) the resolutions of BGM's board of directors (the “BGM Board”) waiving certain provisions of the Amended and Restated Certificate of Incorporation of BGM (the “BGM Charter”) and making certain related determinations regarding CBOE Holdings and the impact of the Transaction on the Exchange (the “Resolutions”); (ii) the CBOE Holdings Second Amended and Restated Certificate of Incorporation (the “CBOE Holdings Charter”) and the CBOE Holdings Third Amended and Restated Bylaws (the “CBOE Holdings Bylaws”); (iii) the Certificate of Formation of CBOE V (the “CBOE V Certificate”) and the Limited Liability Company Operating Agreement of CBOE V (the “CBOE V Operating Agreement”); (iv) the proposed amendments to the Amended and Restated Certificate of Incorporation of BGM Holdings (the “BGM Holdings Charter”); (v) the proposed amendments to the Fourth Amended and Restated Bylaws of the Exchange (the “Exchange Bylaws”); and (vi) the proposed amendments to BYX Rules 2.3 and 2.10 (the “Exchange Rules”).
The text of the proposed rule change is available at the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in Sections A, B, and C below, of the most significant parts of such statements.
The Exchange submits this Proposed Rule Change to seek the Commission's approval of the organizational and governance documents of the Exchange and its current and proposed future parent companies, and related actions that are necessary in connection with the Closing of the Transaction, as described below.
Other than as described herein and set forth in Exhibits 5A through 5H, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and members) in the manner currently conducted, and will not make any changes to its regulated activities in connection with the Transaction. Except as set forth in this Proposed Rule Change, the Exchange is not proposing any amendments to its trading and regulatory rules at this time. If the Exchange determines to make any such changes, it will seek the approval of the Commission to the extent required by the Act, and the Commission's rules thereunder, and the Rules of the Exchange.
The Exchange, Bats BZX Exchange, Inc. (“BZX”), Bats EDGX Exchange, Inc. (“EDGX”) and Bats EDGA Exchange, Inc. (“EDGA,” and together with the Exchange, BZX and EDGX, the “Bats Exchanges”) are each Delaware corporations that are national securities exchanges registered with the Commission pursuant to Section 6(a) of the Act.
The Exchange and BZX are each direct, wholly owned subsidiaries of BGM Holdings, a Delaware corporation that is a direct, wholly owned subsidiary of BGM. In addition to certain other subsidiaries not registered with the Commission in any capacity, BGM Holdings also owns 100 percent of the equity interest in Bats Trading, Inc. (“Bats Trading”), a Delaware corporation that is a broker-dealer registered with the Commission that provides routing services outbound from, and in certain instances inbound to, each Bats Exchange. EDGX and EDGA are direct, wholly owned subsidiaries of Direct Edge LLC, a Delaware limited liability company that is a direct, wholly owned subsidiary of BGM. BGM, a Delaware corporation, is a publicly traded company listed on BZX.
CBOE Holdings, a Delaware corporation, is a publicly traded company listed on The NASDAQ Stock Market. CBOE Holdings owns 100 percent of the equity interest in the CBOE Exchanges.
In contemplation of the Transaction, CBOE Holdings formed two additional entities, CBOE Corporation, a Delaware corporation, and CBOE V, a Delaware limited liability company, each of which are direct, wholly owned subsidiaries of CBOE Holdings. Each of CBOE Corporation and CBOE V currently have no material assets or conduct any operations.
On September 25, 2016, BGM, CBOE Holdings, CBOE Corporation and CBOE V entered into an Agreement and Plan of Merger (the “Merger Agreement”). Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things:
(i) CBOE Corporation will be merged with and into BGM, whereupon the separate existence of CBOE Corporation will cease and BGM will be the surviving company (the “Merger”);
(ii) by virtue of the Merger and without any action required on the part of BGM, CBOE Corporation or any holder of BGM or CBOE Corporation stock, each share of BGM common stock (whether voting or non-voting) issued and outstanding (with the exception of shares owned by CBOE Holdings, BGM or any of their respective subsidiaries and certain shares held by persons that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings and/or cash, at the election of the holder of such share of BGM common stock (the “Merger Consideration”), and each share of CBOE Corporation issued and outstanding will be converted into one share of BGM, such that BGM will become a wholly owned subsidiary of CBOE Holdings; and
(iii) immediately following the Merger, BGM will be merged with and into CBOE V, whereupon the separate existence of BGM will cease and CBOE V will be the surviving company (the “Subsequent Merger”).
Upon the Closing, the BGM Holdings Charter, the Exchange Bylaws and the Exchange Rules will be amended to take into account the post-Closing corporate structure, described below.
As a result of the Transaction, BGM will cease to exist and the business of BGM will be carried on by CBOE V, which is a wholly owned subsidiary of CBOE Holdings.
The BGM Charter provides that (i) no Person,
However, the BGM Charter provides that each of the BGM Ownership Limitation and the BGM Voting Limitation may be waived (except with respect to Exchange Members and their Related Persons) pursuant to a resolution duly adopted by the BGM Board if, in connection with taking such action, the BGM Board states in such resolution that it is the determination of the BGM Board that the waiver:
• will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder;
• is otherwise in the best interests of BGM, its stockholders, and each Bats Exchange;
• will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder; and
• shall not be effective until it is filed with and approved by the Commission.
In addition, notwithstanding the above, the BGM Charter provides
As described above, as a result of the Merger (and prior to its separate existence ceasing as a result of the Subsequent Merger), BGM will become a wholly owned subsidiary of CBOE Holdings, such that CBOE Holdings will possess ownership and voting rights in BGM in excess of the Ownership Limitation and the Voting Limitation. In addition, as a result of the Subsequent Merger, BGM will merge with and into CBOE V, terminating the BGM Charter and becoming an entity whose ownership and voting is held entirely by CBOE Holdings, in excess of the BGM Ownership Limitation and the BGM Voting Limitation that would otherwise apply.
The BGM Board therefore determined that in order to effect the Transaction, a waiver of the BGM Ownership Limitation and the BGM Voting Limitation with respect to CBOE Holdings would be required. To do so, the BGM Board adopted the Resolutions, attached as Exhibit 5A, making certain determinations with respect to CBOE Holdings and the Transaction that are necessary to waive the BGM Ownership Limitation and BGM Voting Limitation. Specifically, the BGM Board determined that:
• the acquisition of the proposed ownership by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• the acquisition or exercise of the proposed voting rights by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• neither CBOE Holdings nor any of its Related Persons is subject to “statutory disqualification” within the meaning of Section 3(a)(39) of the Act;
• neither CBOE Holdings nor any of its Related Persons is an Exchange Member.
The Exchange has reviewed such Resolutions and requests that the Commission approve such Resolutions. The Exchange believes that the Commission should approve the Resolutions, as the Transaction will not impair the ability of any Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, or the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder. The Bats Exchanges will continue to operate and regulate their markets and members as they have done prior to the Transaction. Thus, each Bats Exchange will continue to enforce the Act, the Commission's rules thereunder, and each Exchange's own rules, in the manner it does today. Further, the Commission will continue to have plenary regulatory authority over the Bats Exchanges, as is currently the case with these entities.
The Exchange also notes that the Resolutions reflect the determination by the BGM Board that the Transaction and CBOE Holdings' resulting ownership and voting rights in BGM following the Merger, and CBOE V's ownership and voting rights following the Subsequent Merger, are otherwise in the best interests of BGM, its stockholders and the Bats Exchanges. The Bats Exchanges will be ultimately held by an entity, CBOE Holdings, that already owns other national securities exchanges and is subject to governance documents that similarly restrict concentration of ownership and voting rights.
As described in more detail below, the Exchange is also requesting approval of the adoption of the CBOE Holdings Charter and the CBOE Holdings Bylaws. The CBOE Holdings Charter includes a number of provisions relating to the Commission's regulatory oversight that have a similar effect as those in the BGM Charter, including the BGM Ownership Limitation and the BGM Voting Limitation. Therefore, notwithstanding the Resolutions and the Transaction, provisions similar (and, in some cases, more stringent) to the BGM Ownership Limitation and the BGM Voting Limitation will remain in place with respect to potential future transactions involving the ultimate parent company of the Bats Exchanges. This means that the Exchange ownership structure will continue to provide the Commission with appropriate oversight tools to ensure that the Commission will have the ability to enforce the Act with respect to the Exchange, its direct and indirect parent companies, and its directors, officers, employees and agents to the extent they are involved in the activities of the Exchange, and protect the independence of the Exchange's self-regulatory activities.
The Exchange therefore requests that the Commission approve the Resolutions, attached as Exhibit 5A.
CBOE Holdings currently holds a direct ownership interest in the CBOE Exchanges. The Commission has previously approved the CBOE Holdings Charter and the CBOE Holdings Bylaws (collectively, the “CBOE Holdings Organizational Documents”), attached as Exhibits 5B and 5C, respectively.
In connection with the Transaction, upon the Closing, CBOE Holdings will become the indirect owner (through CBOE V and BGM Holdings) of the Exchange, BZX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity), and the indirect owner (through CBOE V and Direct Edge LLC) of EDGA and EDGX.
The CBOE Holdings Organizational Documents include various provisions relating to any “Regulated Securities Exchange Subsidiary,” which is defined as any national securities exchange controlled, directly or indirectly, by CBOE Holdings. Upon the Closing, the Exchange will be covered by the definition of Regulated Securities Exchange Subsidiary for purposes of the CBOE Holdings Organizational Documents. As a result, no amendments to the CBOE Holdings Organizational Documents will be necessary to reflect CBOE Holdings' indirect ownership of the Exchange.
The Exchange believes that the CBOE Holdings Organizational Documents will protect and maintain the integrity of the self-regulatory functions of the Exchange and facilitate the ability of the Exchange and the Commission to carry out their regulatory and oversight obligations under the Act, as the CBOE Organizational Documents do with respect to the CBOE Exchanges.
In addition, the CBOE Organizational Documents contain provisions, including those with respect to the following, that are similar to those contained in the BGM Charter and BGM's Amended and Restated Bylaws (the “BGM Bylaws”), which the Commission has previously found to be consistent with the Act:
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As stated above, the Exchange believes that the foregoing provisions will assist the Exchange in fulfilling its self-regulatory obligations and in administering and complying with the requirements of the Act.
Effective as of the Closing of the Transaction, CBOE V will hold direct ownership of (i) BGM Holdings, which will continue to hold direct ownership of the Exchange, BZX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity) and (ii) Direct Edge LLC, which will continue to hold direct ownership of EDGX and EDGA. However, unlike BGM currently, CBOE V will not be the ultimate holding company under the post-Closing corporate structure, but rather will be an intermediate holding company owned by CBOE Holdings. The Exchange believes that the CBOE V Operating Agreement contains provisions relating to its indirect ownership of one or more national securities exchanges, including such exchanges' regulatory functions and Commission oversight, that are appropriate for an intermediate holding company in the ownership chain of a national securities exchange. Many of the provisions of the CBOE V Operating Agreement relating to these matters are similar to the organizational documents of BGM Holdings, which currently is, and following the Subsequent Merger will be, similarly situated as an intermediate holding company of the Exchange. The Commission has previously found the BGM Holdings certificate of incorporation and bylaws to be consistent with the Act.
Although CBOE V will not carry out any regulatory functions, the Exchange notes that its activities with respect to the operation of the Bats Exchanges must be consistent with, and must not interfere with, the self-regulatory obligations of each Bats Exchange. The CBOE V Operating Agreement therefore includes certain provisions that are designed to maintain the independence of the Bats Exchanges' self-regulatory functions, enable the Bats Exchanges to operate in a manner that complies with the federal securities laws, including the objectives of Sections 6(b)
The CBOE V Certificate, attached as Exhibit 5D, includes the following provisions required under Delaware law: (i) the full name of CBOE V as “CBOE V, LLC”, and (ii) the name and address of CBOE V's registered office in the State of Delaware and the name of CBOE V's registered agent at such address.
As the Exchange believes is customary for limited liability companies formed in the State of Delaware, other substantive provisions governing the ownership, operation and management of CBOE V are set forth in the CBOE V Operating Agreement, discussed below.
With respect to ownership and control of CBOE V, the CBOE V Operating Agreement, attached as Exhibit 5E, specifically provides that CBOE V's sole member is CBOE Holdings, until the CBOE V Operating Agreement is amended (subject to Commission approval, as described below).
The CBOE V Operating Agreement also contains several provisions designed to protect the independence of the self-regulatory functions of the Bats Exchanges. The CBOE V Operating Agreement requires that, for so long as CBOE V, directly or indirectly, controls any Exchange Subsidiary, CBOE Holdings, as the sole member of CBOE V, and officers, employees and agents of CBOE V must give due regard to the preservation of independence of the self-regulatory functions of such Exchange Subsidiary, as well as to its obligations to investors and the general public, and not interfere with the effectuation of any decisions by the board of directors of an Exchange Subsidiary relating to its regulatory functions (including disciplinary matters) or which would interfere with the ability of such Exchange Subsidiary to carry out its responsibilities under the Act.
The CBOE V Operating Agreement also would require that CBOE V comply with the U.S. federal securities laws and rules and regulations thereunder and cooperate with the Commission and each Exchange Subsidiary, as applicable, pursuant to and to the extent of their respective regulatory authority.
Furthermore, to the fullest extent permitted by law, CBOE V and its officers, directors, employees and agents will be deemed to irrevocably submit to the jurisdiction of the U.S. federal courts, the Commission, and each Exchange Subsidiary, as applicable, for purposes of any suit, action, or proceeding pursuant to the U.S. federal securities laws or the rules or regulations thereunder arising out of, or relating to, the activities of such Exchange Subsidiary.
The proposed CBOE V Operating Agreement also contains a number of provisions designed to ensure that the Exchange will have sufficient access to the books and records of CBOE V as they relate to any Exchange Subsidiary. Pursuant to the CBOE V Operating Agreement, to the extent they are related to the operation or administration of an Exchange Subsidiary, the books, records, premises, officers, agents, and employees of CBOE V are deemed to be the books, records, premises, officers, agents and employees of such Exchange Subsidiary for the purposes of, and subject to oversight pursuant to, the Act.
The proposed CBOE V Operating Agreement also provides that, to the fullest extent permitted by law, all books and records of any Exchange Subsidiary reflecting confidential information pertaining to the self-regulatory function of such Exchange Subsidiary (including disciplinary matters, trading data, trading practices and audit information) that comes into the possession of CBOE V, shall be retained in confidence by CBOE V, CBOE V's officers, employees and agents and CBOE Holdings, and not used for any non-regulatory purposes.
In addition, the CBOE V Operating Agreement provides that for so long as CBOE V controls, directly or indirectly, any Exchange Subsidiary, before any amendment to or repeal of any provision of the CBOE V Operating Agreement will be effective, those changes must be submitted to the board of directors of each Exchange Subsidiary, and if the same must be filed with, or filed with and approved by, the Commission before the changes may be effective under Section 19 of the Act
The BGM Holdings Charter currently provides that the sole stockholder of BGM Holdings is BGM. However, as a result of the Transaction, CBOE V will become the sole stockholder of BGM Holdings. The Exchange proposes to amend the BGM Holdings Charter to reflect this change, as set forth in Exhibit 5F.
In connection with the Transaction, the Exchange proposes to amend and restate its Fourth Amended and Restated Bylaws and adopt the amended Exchange Bylaws as its Fifth Amended and Restated Bylaws, attached as Exhibit 5G. Specifically, the Exchange proposes to (i) expand the prohibition contained in Section 2 of Article XI of the Exchange Bylaws; and (ii) add a definition of “Trading Permit Holder” to Article I.
Currently, Section 2 of Article XI of the Exchange Bylaws prohibits directors of BGM or BGM Holdings who are not also directors, officers, staff, counsel or advisors of the Exchange from participating in any meetings of the Exchange's board of directors (or any committee thereof) pertaining to the self-regulatory function of the Exchange (including disciplinary matters). This provision refers to BGM and BGM Holdings because they are currently the only direct and indirect owners of the Exchange. However, following the Transaction, the Exchange will be owned indirectly by CBOE V and CBOE Holdings (in addition to its direct ownership by BGM Holdings). Therefore, the Exchange is proposing to remove the reference to BGM and insert references to CBOE V and CBOE Holdings, so that CBOE V and CBOE Holdings will both be covered by this prohibition. The Exchange believes that this amendment will protect the independence of the Exchange's self-regulatory activities.
In addition, as noted above, the CBOE Holdings Charter currently prohibits certain persons from owning or exercising voting rights over certain percentages of ownership of CBOE Holdings. The CBOE Holdings Charter permits the board of directors of CBOE Holdings to waive the limitation on the exercise of voting rights in excess of 20 percent of the then outstanding votes entitled to be cast on such matter only if, among other things, “for so long as [CBOE Holdings] directly or indirectly controls any Regulated Securities Exchange Subsidiary, neither such Person nor any of its Related Persons is a `Trading Permit Holder' (as defined in the Bylaws of any Regulated Securities Exchange Subsidiary as they may be amended from time to time).”
The Exchange does not issue “trading permits,” but admits members. The Exchange believes the provisions of the CBOE Holdings Charter that refer to Trading Permit Holders of its Regulated Securities Exchange Subsidiaries should apply equally to members of the Exchange once it becomes a Regulated Securities Exchange Subsidiary of CBOE Holdings. As a result, the Exchange proposes to add clause (ff) to Article I of the Exchange Bylaws, providing that “ ‘Trading Permit Holder' shall have the same meaning as Exchange Member.” This will ensure that the Exchange's members will be considered Trading Permit Holders of a Regulated Securities Exchange Subsidiary for purposes of the CBOE Holdings Charter.
Pursuant to Exchange Rule 2.3, in order to be eligible for membership in the Exchange, a registered broker or dealer is currently required to be a member of at least one other national securities association or national securities exchange. However, membership in the Exchange's affiliated national securities exchanges, BZX, EDGA or EDGX, is not sufficient for purposes of eligibility for Exchange membership. The Exchange adopted this because the Bats Exchanges have historically not functioned as the designated examining authority for any of its members, and the Exchange wanted to be sure that any member would be appropriately supervised by another national securities association or national securities exchange that has the capacity to function as the member's designated examining authority.
As a result of the Transaction, the Exchange will additionally become affiliated with the CBOE Exchanges. As with the Bats Exchanges, C2 does not currently serve as the designated examination authority for any of its members. CBOE, however, does act as the designated examining authority for certain of its members. Therefore, the Exchange proposes to amend Exchange Rule 2.3 to specify that a registered broker or dealer will be eligible for membership only if it is a member of a national securities association or national securities exchange other than or in addition to the following affiliates of the Exchange: BZX, EDGA, EDGX and C2.
In addition, to ensure there is no confusion with respect to the possibility that a broker or dealer could qualify for membership in the Exchange based solely on membership in CBOE Futures or any other national securities exchange notice-registered with the Commission pursuant to Section 6(g) of the Act
Exchange Rule 2.10 provides that, without prior approval of the Commission, neither the Exchange, nor any of its affiliates, shall directly or indirectly acquire or maintain an ownership interest in a member of the Exchange. This restriction is intended to address potential conflicts of interest that could result from affiliation between the Exchange and a member. Notwithstanding this general restriction, Exchange Rule 2.10 provides that it does not prohibit a member or its affiliate from acquiring or holding an equity interest in BGM that is permitted by the ownership and voting limitations contained in the BGM Charter and the BGM Bylaws. In addition, Exchange Rule 2.10 states that it does not prohibit a member from being or becoming an affiliate of the Exchange, or an affiliate of any affiliate of the Exchange, solely by reason of such member or any officer, director, manager, managing member, partner or affiliate of such member being or becoming either (a) a Director of the Exchange pursuant to the Bylaws of the Exchange, or (b) a Director of the Exchange serving on the Board of Directors of BGM. The Exchange proposes to replace the references to BGM in Rule 2.10 with references to CBOE Holdings to reflect the fact that following the Transaction, CBOE Holdings will replace BGM as the ultimate parent holding company of the Exchange. In addition to these changes, the Exchange proposes to replace all references in Rule 2.10 to “By-Laws” with “Bylaws” in order to maintain consistency with the actual documents referred to and EDGA and EDGX Rules 2.10. The proposed amendments to Exchange Rule 2.10 are set forth in Exhibit 5H.
The Exchange believes that the Proposed Rule Change is consistent with the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange, and, in particular, with the requirements of Section 6(b) of the Act.
The Proposed Rule Change is designed to enable the Exchange to continue to have the authority and ability to effectively fulfill its self-regulatory duties pursuant to the Act and the rules promulgated thereunder. In particular, the Proposed Rule Change includes in the CBOE Holdings Charter and CBOE Holdings Bylaws, like the BGM Charter and BGM Bylaws, various provisions intended to protect and maintain the integrity of the self-regulatory functions of the Exchange upon Closing. For example, the CBOE Holdings Charter, as described above, is drafted to preserve the independence of the Exchange's self-regulatory function and carry out its regulatory responsibilities under the Act. In addition, the CBOE Holdings Charter imposes limitations similar to the BGM Ownership Limitation and BGM Voting Limitation to preclude undue influence over or interference with the Exchange's self-regulatory functions and fulfillment of its regulatory duties under the Act.
Moreover, notwithstanding the Proposed Rule Change, including the change to the indirect ownership of the Exchange, the Commission will continue to have regulatory authority over the Exchange, as is currently the case, as well as jurisdiction over the Exchange's direct and indirect parent companies with respect to activities related to the Exchange.
The Exchange also believes that the Proposed Rule Change furthers the objectives of Section 6(b)(5) of the Act
In addition, as discussed further in the Exchange's Statement on Burden on Competition below, the Exchange expects that the Transaction will foster further innovation while facilitating efficient, transparent and well-regulated markets for issuers and investors, removing impediments to, and perfecting the mechanism of a free and open market and a national market system. The Transaction will benefit investors and the securities market as a whole by, among other things, enhancing competition among securities venues and reducing costs.
Furthermore, the Exchange is not proposing any significant changes to its existing operational and trading structure in connection with the change in ownership; the Exchange will operate in essentially the same manner upon Closing as it operates today. Therefore, the Exchange believes that it will continue to satisfy the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange. The changes that the Exchange is proposing to the Exchange Rules are designed to reflect the prospective affiliation with CBOE Holdings and the CBOE Exchanges. The Exchange believes that the proposed change to its Rules is consistent with the requirements of the Act and the rules and regulations thereunder.
The Exchange does not believe that the Proposed Rule Change would result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act. Indeed, the Exchange believes that the Proposed Rule Change will enhance competition among trading venues, as the Exchange believes that the Transaction will result in various synergies and efficiencies. For example, the Transaction will allow the Bats Exchanges and the CBOE Exchanges to utilize a single technology platform, which the Exchange expects will reduce Bats Exchanges' and the CBOE Exchanges' combined costs, creating the opportunity to further reduce costs to their respective members and other constituents. The potential use of a single technology platform may also reduce investors' costs of connecting to and using the Bats Exchanges and the CBOE Exchanges, including through the combination of data centers and market data services. Combining the expertise of the CBOE Exchanges' personnel with the expertise of the Bats Exchanges' personnel will also facilitate ongoing innovation, including through new product creation and platform improvements.
The Exchange notes that the Bats Exchanges and the CBOE Exchanges generally operate with different business models, target different customer bases and primarily focus on different asset classes, limiting any concern that the Transaction could burden competition. Therefore, the Exchange expects that the Transaction will benefit investors, issuers, shareholders and the market as a whole. The Exchange will continue to conduct regulated activities (including operating and regulating its market and members) of the type it currently conducts, but will be able to do so in a more efficient manner to the benefit of its members. These efficiencies will pass through to the benefit of investors and issuers, promoting further efficiencies, competition and capital formation, placing no burden on competition not necessary or appropriate in furtherance of the Act.
Furthermore, the Exchange's conclusion that the Proposed Rule Change would not result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act is consistent with the Commission's prior conclusions about similar combinations involving multiple exchanges in a single corporate family.
The Exchange has not solicited or received written comments on the Proposed Rule Change.
Within 45 days of the date of publication of this notice in the
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (the “Act”),
The Exchange filed a proposed rule change (the “Proposed Rule Change”) in connection with the proposed corporate transaction (the “Transaction”), as described in more detail below, involving its ultimate parent company, Bats Global Markets, Inc. (“BGM”), CBOE Holdings, Inc. (“CBOE Holdings”), and two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”). CBOE Holdings is the parent company of Chicago Board Options Exchange, Incorporated (“CBOE”) and C2 Options Exchange, Incorporated (“C2”), each a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act,
Upon completion of the mergers described below that effectuate the Transaction (the “Closing”), the business of BGM will be carried on by CBOE V. CBOE V, rather than BGM, will be the direct parent company of Bats Global Markets Holdings, Inc. (“BGM Holdings”), which is the direct parent company of the Exchange. As a result, CBOE Holdings will become the ultimate parent company of BGM Holdings and of the Exchange.
To effectuate the Transaction, the Exchange seeks to obtain the Commission's approval of: (i) The resolutions of BGM's board of directors (the “BGM Board”) waiving certain provisions of the Amended and Restated Certificate of Incorporation of BGM (the “BGM Charter”) and making certain related determinations regarding CBOE Holdings and the impact of the Transaction on the Exchange (the “Resolutions”); (ii) the CBOE Holdings Second Amended and Restated Certificate of Incorporation (the “CBOE Holdings Charter”) and the CBOE Holdings Third Amended and Restated Bylaws (the “CBOE Holdings Bylaws”); (iii) the Certificate of Formation of CBOE V (the “CBOE V Certificate”) and the Limited Liability Company Operating Agreement of CBOE V (the “CBOE V Operating Agreement”); (iv) the proposed amendments to the Amended and Restated Certificate of Incorporation of BGM Holdings (the “BGM Holdings Charter”); (v) the proposed amendments to the Fourth Amended and Restated Bylaws of the Exchange (the “Exchange Bylaws”); and (vi) the proposed amendments to BZX Rules 2.3 and 2.10 (the “Exchange Rules”).
The text of the proposed rule change is available at the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in Sections A, B, and C below, of the most significant parts of such statements.
The Exchange submits this Proposed Rule Change to seek the Commission's approval of the organizational and governance documents of the Exchange and its current and proposed future parent companies, and related actions that are necessary in connection with the Closing of the Transaction, as described below.
Other than as described herein and set forth in Exhibits 5A through 5H, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and members) in the manner currently conducted, and will not make any changes to its regulated activities in connection with the Transaction. Except as set forth in this Proposed Rule Change, the Exchange is not proposing any amendments to its trading and regulatory rules at this time. If the Exchange determines to make any such changes, it will seek the approval of the Commission to the extent required by the Act, and the Commission's rules thereunder, and the Rules of the Exchange.
The Exchange, Bats BYX Exchange, Inc. (“BYX”), Bats EDGX Exchange, Inc. (“EDGX”) and Bats EDGA Exchange, Inc. (“EDGA,” and together with the Exchange, BYX and EDGX, the “Bats Exchanges”) are each Delaware corporations that are national securities exchanges registered with the Commission pursuant to Section 6(a) of the Act.
The Exchange and BYX are each direct, wholly owned subsidiaries of BGM Holdings, a Delaware corporation that is a direct, wholly owned subsidiary of BGM. In addition to certain other subsidiaries not registered with the Commission in any capacity, BGM Holdings also owns 100 percent of the equity interest in Bats Trading, Inc. (“Bats Trading”), a Delaware corporation that is a broker-dealer registered with the Commission that provides routing services outbound from, and in certain instances inbound to, each Bats Exchange. EDGX and EDGA are direct, wholly owned subsidiaries of Direct Edge LLC, a
CBOE Holdings, a Delaware corporation, is a publicly traded company listed on The NASDAQ Stock Market. CBOE Holdings owns 100 percent of the equity interest in the CBOE Exchanges.
In contemplation of the Transaction, CBOE Holdings formed two additional entities, CBOE Corporation, a Delaware corporation, and CBOE V, a Delaware limited liability company, each of which are direct, wholly owned subsidiaries of CBOE Holdings. Each of CBOE Corporation and CBOE V currently have no material assets or conduct any operations.
On September 25, 2016, BGM, CBOE Holdings, CBOE Corporation and CBOE V entered into an Agreement and Plan of Merger (the “Merger Agreement”). Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things:
(i) CBOE Corporation will be merged with and into BGM, whereupon the separate existence of CBOE Corporation will cease and BGM will be the surviving company (the “Merger”);
(ii) by virtue of the Merger and without any action required on the part of BGM, CBOE Corporation or any holder of BGM or CBOE Corporation stock, each share of BGM common stock (whether voting or non-voting) issued and outstanding (with the exception of shares owned by CBOE Holdings, BGM or any of their respective subsidiaries and certain shares held by persons that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings and/or cash, at the election of the holder of such share of BGM common stock (the “Merger Consideration”), and each share of CBOE Corporation issued and outstanding will be converted into one share of BGM, such that BGM will become a wholly owned subsidiary of CBOE Holdings; and
(iii) immediately following the Merger, BGM will be merged with and into CBOE V, whereupon the separate existence of BGM will cease and CBOE V will be the surviving company (the “Subsequent Merger”).
Upon the Closing, the BGM Holdings Charter, the Exchange Bylaws and the Exchange Rules will be amended to take into account the post-Closing corporate structure, described below.
As a result of the Transaction, BGM will cease to exist and the business of BGM will be carried on by CBOE V, which is a wholly owned subsidiary of CBOE Holdings.
The BGM Charter provides that (i) no Person,
However, the BGM Charter provides that each of the BGM Ownership Limitation and the BGM Voting Limitation may be waived (except with respect to Exchange Members and their Related Persons) pursuant to a resolution duly adopted by the BGM Board if, in connection with taking such action, the BGM Board states in such resolution that it is the determination of the BGM Board that the waiver:
• Will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder;
• is otherwise in the best interests of BGM, its stockholders, and each Bats Exchange;
• will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder; and
• shall not be effective until it is filed with and approved by the Commission.
In addition, notwithstanding the above, the BGM Charter provides
As described above, as a result of the Merger (and prior to its separate existence ceasing as a result of the Subsequent Merger), BGM will become a wholly owned subsidiary of CBOE Holdings, such that CBOE Holdings will possess ownership and voting rights in BGM in excess of the Ownership Limitation and the Voting Limitation. In addition, as a result of the Subsequent Merger, BGM will merge with and into CBOE V, terminating the BGM Charter and becoming an entity whose ownership and voting is held entirely by CBOE Holdings, in excess of the BGM Ownership Limitation and the BGM Voting Limitation that would otherwise apply.
The BGM Board therefore determined that in order to effect the Transaction, a waiver of the BGM Ownership Limitation and the BGM Voting Limitation with respect to CBOE Holdings would be required. To do so, the BGM Board adopted the Resolutions, attached as Exhibit 5A, making certain determinations with respect to CBOE Holdings and the Transaction that are necessary to waive the BGM Ownership Limitation and BGM Voting Limitation. Specifically, the BGM Board determined that:
• The acquisition of the proposed ownership by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• the acquisition or exercise of the proposed voting rights by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• neither CBOE Holdings nor any of its Related Persons is subject to “statutory disqualification” within the meaning of Section 3(a)(39) of the Act;
• neither CBOE Holdings nor any of its Related Persons is an Exchange Member.
The Exchange has reviewed such Resolutions and requests that the Commission approve such Resolutions. The Exchange believes that the Commission should approve the Resolutions, as the Transaction will not impair the ability of any Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, or the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder. The Bats Exchanges will continue to operate and regulate their markets and members as they have done prior to the Transaction. Thus, each Bats Exchange will continue to enforce the Act, the Commission's rules thereunder, and each Exchange's own rules, in the manner it does today. Further, the Commission will continue to have plenary regulatory authority over the Bats Exchanges, as is currently the case with these entities.
The Exchange also notes that the Resolutions reflect the determination by the BGM Board that the Transaction and CBOE Holdings' resulting ownership and voting rights in BGM following the Merger, and CBOE V's ownership and voting rights following the Subsequent Merger, are otherwise in the best interests of BGM, its stockholders and the Bats Exchanges. The Bats Exchanges will be ultimately held by an entity, CBOE Holdings, that already owns other national securities exchanges and is subject to governance documents that similarly restrict concentration of ownership and voting rights.
As described in more detail below, the Exchange is also requesting approval of the adoption of the CBOE Holdings Charter and the CBOE Holdings Bylaws. The CBOE Holdings Charter includes a number of provisions relating to the Commission's regulatory oversight that have a similar effect as those in the BGM Charter, including the BGM Ownership Limitation and the BGM Voting Limitation. Therefore, notwithstanding the Resolutions and the Transaction, provisions similar (and, in some cases, more stringent) to the BGM Ownership Limitation and the BGM Voting Limitation will remain in place with respect to potential future transactions involving the ultimate parent company of the Bats Exchanges. This means that the Exchange ownership structure will continue to provide the Commission with appropriate oversight tools to ensure that the Commission will have the ability to enforce the Act with respect to the Exchange, its direct and indirect parent companies, and its directors, officers, employees and agents to the extent they are involved in the activities of the Exchange, and protect the independence of the Exchange's self-regulatory activities.
The Exchange therefore requests that the Commission approve the Resolutions, attached as Exhibit 5A.
CBOE Holdings currently holds a direct ownership interest in the CBOE Exchanges. The Commission has
In connection with the Transaction, upon the Closing, CBOE Holdings will become the indirect owner (through CBOE V and BGM Holdings) of the Exchange, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity), and the indirect owner (through CBOE V and Direct Edge LLC) of EDGA and EDGX.
The CBOE Holdings Organizational Documents include various provisions relating to any “Regulated Securities Exchange Subsidiary,” which is defined as any national securities exchange controlled, directly or indirectly, by CBOE Holdings. Upon the Closing, the Exchange will be covered by the definition of Regulated Securities Exchange Subsidiary for purposes of the CBOE Holdings Organizational Documents. As a result, no amendments to the CBOE Holdings Organizational Documents will be necessary to reflect CBOE Holdings' indirect ownership of the Exchange.
The Exchange believes that the CBOE Holdings Organizational Documents will protect and maintain the integrity of the self-regulatory functions of the Exchange and facilitate the ability of the Exchange and the Commission to carry out their regulatory and oversight obligations under the Act, as the CBOE Organizational Documents do with respect to the CBOE Exchanges.
In addition, the CBOE Organizational Documents contain provisions, including those with respect to the following, that are similar to those contained in the BGM Charter and BGM's Amended and Restated Bylaws (the “BGM Bylaws”), which the Commission has previously found to be consistent with the Act:
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Effective as of the Closing of the Transaction, CBOE V will hold direct ownership of (i) BGM Holdings, which will continue to hold direct ownership of the Exchange, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity) and (ii) Direct Edge LLC, which will continue to hold direct ownership of EDGX and EDGA. However, unlike BGM currently, CBOE V will not be the ultimate holding company under the post-Closing corporate structure, but rather will be an intermediate holding company owned by CBOE Holdings. The Exchange believes that the CBOE V Operating Agreement contains provisions relating to its indirect ownership of one or more national securities exchanges, including such exchanges' regulatory functions and Commission oversight, that are appropriate for an intermediate holding company in the ownership chain of a national securities exchange. Many of the provisions of the CBOE V Operating Agreement relating to these matters are similar to the organizational documents of BGM Holdings, which currently is, and following the Subsequent Merger will be, similarly situated as an intermediate holding company of the Exchange. The Commission has previously found the BGM Holdings certificate of incorporation and bylaws to be consistent with the Act.
Although CBOE V will not carry out any regulatory functions, the Exchange notes that its activities with respect to the operation of the Bats Exchanges must be consistent with, and must not interfere with, the self-regulatory obligations of each Bats Exchange. The CBOE V Operating Agreement therefore includes certain provisions that are designed to maintain the independence of the Bats Exchanges' self-regulatory functions, enable the Bats Exchanges to operate in a manner that complies with the federal securities laws, including the objectives of Sections 6(b)
The CBOE V Certificate, attached as Exhibit 5D, includes the following provisions required under Delaware law: (i) The full name of CBOE V as “CBOE V, LLC”, and (ii) the name and address of CBOE V's registered office in the State of Delaware and the name of CBOE V's registered agent at such address.
As the Exchange believes is customary for limited liability companies formed in the State of Delaware, other substantive provisions governing the ownership, operation and management of CBOE V are set forth in the CBOE V Operating Agreement, discussed below.
With respect to ownership and control of CBOE V, the CBOE V Operating Agreement, attached as Exhibit 5E, specifically provides that CBOE V's sole member is CBOE Holdings, until the CBOE V Operating Agreement is amended (subject to Commission approval, as described below).
The CBOE V Operating Agreement also contains several provisions designed to protect the independence of the self-regulatory functions of the Bats Exchanges. The CBOE V Operating Agreement requires that, for so long as CBOE V, directly or indirectly, controls any Exchange Subsidiary, CBOE Holdings, as the sole member of CBOE V, and officers, employees and agents of CBOE V must give due regard to the preservation of independence of the self-regulatory functions of such Exchange Subsidiary, as well as to its obligations to investors and the general public, and not interfere with the effectuation of any decisions by the board of directors of an Exchange Subsidiary relating to its regulatory functions (including disciplinary matters) or which would interfere with the ability of such Exchange Subsidiary to carry out its responsibilities under the Act.
The CBOE V Operating Agreement also would require that CBOE V comply with the U.S. federal securities laws and
Furthermore, to the fullest extent permitted by law, CBOE V and its officers, directors, employees and agents will be deemed to irrevocably submit to the jurisdiction of the U.S. federal courts, the Commission, and each Exchange Subsidiary, as applicable, for purposes of any suit, action, or proceeding pursuant to the U.S. federal securities laws or the rules or regulations thereunder arising out of, or relating to, the activities of such Exchange Subsidiary.
The proposed CBOE V Operating Agreement also contains a number of provisions designed to ensure that the Exchange will have sufficient access to the books and records of CBOE V as they relate to any Exchange Subsidiary. Pursuant to the CBOE V Operating Agreement, to the extent they are related to the operation or administration of an Exchange Subsidiary, the books, records, premises, officers, agents, and employees of CBOE V are deemed to be the books, records, premises, officers, agents and employees of such Exchange Subsidiary for the purposes of, and subject to oversight pursuant to, the Act.
The proposed CBOE V Operating Agreement also provides that, to the fullest extent permitted by law, all books and records of any Exchange Subsidiary reflecting confidential information pertaining to the self-regulatory function of such Exchange Subsidiary (including disciplinary matters, trading data, trading practices and audit information) that comes into the possession of CBOE V, shall be retained in confidence by CBOE V, CBOE V's officers, employees and agents and CBOE Holdings, and not used for any non-regulatory purposes.
In addition, the CBOE V Operating Agreement provides that for so long as CBOE V controls, directly or indirectly, any Exchange Subsidiary, before any amendment to or repeal of any provision of the CBOE V Operating Agreement will be effective, those changes must be submitted to the board of directors of each Exchange Subsidiary, and if the same must be filed with, or filed with and approved by, the Commission before the changes may be effective under Section 19 of the Act
The BGM Holdings Charter currently provides that the sole stockholder of BGM Holdings is BGM. However, as a result of the Transaction, CBOE V will become the sole stockholder of BGM Holdings. The Exchange proposes to amend the BGM Holdings Charter to reflect this change, as set forth in Exhibit 5F.
In connection with the Transaction, the Exchange proposes to amend and restate its Fourth Amended and Restated Bylaws and adopt the amended Exchange Bylaws as its Fifth Amended and Restated Bylaws, attached as Exhibit 5G. Specifically, the Exchange proposes to (i) expand the prohibition contained in Section 2 of Article XI of the Exchange Bylaws; and (ii) add a definition of “Trading Permit Holder” to Article I.
Currently, Section 2 of Article XI of the Exchange Bylaws prohibits directors of BGM or BGM Holdings who are not also directors, officers, staff, counsel or advisors of the Exchange from participating in any meetings of the Exchange's board of directors (or any committee thereof) pertaining to the self-regulatory function of the Exchange (including disciplinary matters). This provision refers to BGM and BGM Holdings because they are currently the only direct and indirect owners of the Exchange. However, following the Transaction, the Exchange will be owned indirectly by CBOE V and CBOE Holdings (in addition to its direct ownership by BGM Holdings). Therefore, the Exchange is proposing to remove the reference to BGM and insert references to CBOE V and CBOE Holdings, so that CBOE V and CBOE Holdings will both be covered by this prohibition. The Exchange believes that this amendment will protect the independence of the Exchange's self-regulatory activities.
In addition, as noted above, the CBOE Holdings Charter currently prohibits certain persons from owning or exercising voting rights over certain percentages of ownership of CBOE Holdings. The CBOE Holdings Charter permits the board of directors of CBOE Holdings to waive the limitation on the exercise of voting rights in excess of 20 percent of the then outstanding votes entitled to be cast on such matter only if, among other things, “for so long as [CBOE Holdings] directly or indirectly controls any Regulated Securities Exchange Subsidiary, neither such Person nor any of its Related Persons is a `Trading Permit Holder' (as defined in the Bylaws of any Regulated Securities Exchange Subsidiary as they may be amended from time to time).”
The Exchange does not issue “trading permits,” but admits members. The Exchange believes the provisions of the CBOE Holdings Charter that refer to Trading Permit Holders of its Regulated Securities Exchange Subsidiaries should apply equally to members of the Exchange once it becomes a Regulated Securities Exchange Subsidiary of CBOE Holdings. As a result, the Exchange proposes to add clause (ff) to Article I of the Exchange Bylaws, providing that
Pursuant to Exchange Rule 2.3, in order to be eligible for membership in the Exchange, a registered broker or dealer is currently required to be a member of at least one other national securities association or national securities exchange. However, membership in the Exchange's affiliated national securities exchanges, BYX, EDGA or EDGX, is not sufficient for purposes of eligibility for Exchange membership. The Exchange adopted this because the Bats Exchanges have historically not functioned as the designated examining authority for any of its members, and the Exchange wanted to be sure that any member would be appropriately supervised by another national securities association or national securities exchange that has the capacity to function as the member's designated examining authority.
As a result of the Transaction, the Exchange will additionally become affiliated with the CBOE Exchanges. As with the Bats Exchanges, C2 does not currently serve as the designated examination authority for any of its members. CBOE, however, does act as the designated examining authority for certain of its members. Therefore, the Exchange proposes to amend Exchange Rule 2.3 to specify that a registered broker or dealer will be eligible for membership only if it is a member of a national securities association or national securities exchange other than or in addition to the following affiliates of the Exchange: BYX, EDGA, EDGX and C2.
In addition, to ensure there is no confusion with respect to the possibility that a broker or dealer could qualify for membership in the Exchange based solely on membership in CBOE Futures or any other national securities exchange notice-registered with the Commission pursuant to Section 6(g) of the Act
Exchange Rule 2.10 provides that, without prior approval of the Commission, neither the Exchange, nor any of its affiliates, shall directly or indirectly acquire or maintain an ownership interest in a member of the Exchange. This restriction is intended to address potential conflicts of interest that could result from affiliation between the Exchange and a member. Notwithstanding this general restriction, Exchange Rule 2.10 provides that it does not prohibit a member or its affiliate from acquiring or holding an equity interest in BGM that is permitted by the ownership and voting limitations contained in the BGM Charter and the BGM Bylaws. In addition, Exchange Rule 2.10 states that it does not prohibit a member from being or becoming an affiliate of the Exchange, or an affiliate of any affiliate of the Exchange, solely by reason of such member or any officer, director, manager, managing member, partner or affiliate of such member being or becoming either (a) a Director of the Exchange pursuant to the Bylaws of the Exchange, or (b) a Director of the Exchange serving on the Board of Directors of BGM. The Exchange proposes to replace the references to BGM in Rule 2.10 with references to CBOE Holdings to reflect the fact that following the Transaction, CBOE Holdings will replace BGM as the ultimate parent holding company of the Exchange. In addition to these changes, the Exchange proposes to replace all references in Rule 2.10 to “By-Laws” with “Bylaws” in order to maintain consistency with the actual documents referred to and EDGA and EDGX Rules 2.10. The proposed amendments to Exchange Rule 2.10 are set forth in Exhibit 5H.
The Exchange believes that the Proposed Rule Change is consistent with the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange, and, in particular, with the requirements of Section 6(b) of the Act.
The Proposed Rule Change is designed to enable the Exchange to continue to have the authority and ability to effectively fulfill its self-regulatory duties pursuant to the Act and the rules promulgated thereunder. In particular, the Proposed Rule Change includes in the CBOE Holdings Charter and CBOE Holdings Bylaws, like the BGM Charter and BGM Bylaws, various provisions intended to protect and maintain the integrity of the self-regulatory functions of the Exchange upon Closing. For example, the CBOE Holdings Charter, as described above, is drafted to preserve the independence of the Exchange's self-regulatory function and carry out its regulatory responsibilities under the Act. In addition, the CBOE Holdings Charter imposes limitations similar to the BGM Ownership Limitation and BGM Voting Limitation to preclude undue influence over or interference with the Exchange's self-regulatory functions and fulfillment of its regulatory duties under the Act.
Moreover, notwithstanding the Proposed Rule Change, including the change to the indirect ownership of the Exchange, the Commission will continue to have regulatory authority over the Exchange, as is currently the case, as well as jurisdiction over the Exchange's direct and indirect parent companies with respect to activities related to the Exchange.
The Exchange also believes that the Proposed Rule Change furthers the objectives of Section 6(b)(5) of the Act
In addition, as discussed further in the Exchange's Statement on Burden on Competition below, the Exchange expects that the Transaction will foster further innovation while facilitating efficient, transparent and well-regulated markets for issuers and investors, removing impediments to, and perfecting the mechanism of a free and open market and a national market system. The Transaction will benefit investors and the securities market as a whole by, among other things, enhancing competition among securities venues and reducing costs.
Furthermore, the Exchange is not proposing any significant changes to its existing operational and trading structure in connection with the change in ownership; the Exchange will operate in essentially the same manner upon Closing as it operates today. Therefore, the Exchange believes that it will continue to satisfy the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange. The changes that the Exchange is proposing to the Exchange Rules are designed to reflect the prospective affiliation with CBOE Holdings and the CBOE Exchanges. The Exchange believes that the proposed change to its Rules is consistent with the requirements of the Act and the rules and regulations thereunder.
The Exchange does not believe that the Proposed Rule Change would result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act. Indeed, the Exchange believes that the Proposed Rule Change will enhance competition among trading venues, as the Exchange believes that the Transaction will result in various synergies and efficiencies. For example, the Transaction will allow the Bats Exchanges and the CBOE Exchanges to utilize a single technology platform, which the Exchange expects will reduce Bats Exchanges' and the CBOE Exchanges' combined costs, creating the opportunity to further reduce costs to their respective members and other constituents. The potential use of a single technology platform may also reduce investors' costs of connecting to and using the Bats Exchanges and the CBOE Exchanges, including through the combination of data centers and market data services. Combining the expertise of the CBOE Exchanges' personnel with the expertise of the Bats Exchanges' personnel will also facilitate ongoing innovation, including through new product creation and platform improvements.
The Exchange notes that the Bats Exchanges and the CBOE Exchanges generally operate with different business models, target different customer bases and primarily focus on different asset classes, limiting any concern that the Transaction could burden competition. Therefore, the Exchange expects that the Transaction will benefit investors, issuers, shareholders and the market as a whole. The Exchange will continue to conduct regulated activities (including operating and regulating its market and members) of the type it currently conducts, but will be able to do so in a more efficient manner to the benefit of its members. These efficiencies will pass through to the benefit of investors and issuers, promoting further efficiencies, competition and capital formation, placing no burden on competition not necessary or appropriate in furtherance of the Act.
Furthermore, the Exchange's conclusion that the Proposed Rule Change would not result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act is consistent with the Commission's prior conclusions about similar combinations involving multiple exchanges in a single corporate family.
The Exchange has not solicited or received written comments on the Proposed Rule Change.
Within 45 days of the date of publication of this notice in the
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”)
The Exchange proposes to adopt Rules 9556 and 9800, which were previously adopted as a pilot the term of which has since expired, and to make related changes to the 9100, 9200, 9300, 9550, and 9800 Rule Series.
The text of the proposed rule change is available on the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
The Exchange is proposing to adopt new Rules 9556 and 9800, which were previously adopted as a pilot the term of which has since expired, and to make related changes to the 9100, 9200, 9300, 9550, and 9800 Rule Series. In May 2003, the Commission approved, on a pilot basis, a rule change to adopt NASD Rules 9556 and 9800 that gave NASD, now known as FINRA, authority to issue temporary cease and desist orders and made explicit NASD's ability to impose permanent cease and desist orders as a remedy in disciplinary cases.
On June 23, 2009, the Exchange's Rule 9556 and 9800 pilot programs expired, at which time those rules and certain references thereto became obsolete, notwithstanding that they remained in the rulebook. The FINRA pilot program, however, continued and was approved on July 14, 2009 on a permanent basis.
Neither the Exchange nor FINRA, acting on behalf of the Exchange pursuant to agreement, have [sic] used the cease and desist authority under Rules 9556 and 9800 during the time that the rules were effective. Nonetheless, the Exchange believes that, in addition to maintaining similar disciplinary rules, adoption of Rules 9556 and 9800 is important to the Exchange's disciplinary program. The authority under these rules will provide the Exchange and FINRA, operating on behalf of the Exchange, with a mechanism to take appropriate remedial action against a member or an associated person that has engaged (or is engaging) in violative conduct that could cause continuing harm to the investing public if not addressed expeditiously, such as dissipation or conversion of assets. It must be emphasized, however, that the cease and desist provisions contain numerous procedural protections for respondents to ensure that the proceedings are fair. Consequently, the Exchange believes that adoption of these rules is important to its regulatory program, notwithstanding that it anticipates exercising the authority provided by the rules sparingly.
The Exchange is proposing to delete Rules 9556 and 9800 (and related references in other rules
In 2011, FINRA amended Rules 9552(b), 9553(b), 9554(b), 9555(b), and 9556(b), all of which concern service of notice.
In 2015, FINRA made significant changes to its temporary and permanent cease and desist rules.
FINRA amended FINRA Rule 9840(a)(1) to change the evidentiary standard applied by Hearing Panels in issuing a temporary cease and desist order. Specifically, FINRA changed the standard for issuing a temporary cease and desist order from “by a preponderance of the evidence that the alleged violation specified in the notice has occurred” to a “showing of a likelihood of success on the merits.” FINRA noted that it believed that the “preponderance of the evidence” standard set too high an evidentiary threshold for this critical investor-protection tool, and noted that it is the identical standard for proving a violation in the underlying disciplinary proceeding that must be pursued at the same time.
FINRA also made a corresponding amendment to FINRA Rule 9840(a)(2). Prior to the amendment, FINRA Rule 9840(a)(2) provided that a temporary cease and desist order shall be imposed if the Hearing Panel finds that the violative conduct or continuation thereof is likely to result in significant dissipation or conversion of assets or other significant harm to investors prior to the completion of the underlying proceeding. The 2015 rule change modified this requirement to apply to the “alleged” violative conduct or continuation thereof, to be consistent with the proposed change to the evidentiary standard.
FINRA also made amendments to FINRA Rule 9556, which sets forth expedited procedures for enforcing violations of FINRA-issued temporary and permanent cease and desist orders. FINRA was concerned that their [sic] existing expedited procedures may permit cease and desist orders to be circumvented without any real threat of a sanction.
• A FINRA Rule 9556(h) proceeding could be initiated only if the respondent has previously been served, under FINRA Rule 9556(a), with a notice for failing to comply with any provision of the same temporary or permanent cease and desist order;
• FINRA's prosecuting department would initiate a FINRA Rule 9556(h) proceeding by filing a petition with FINRA's Office of Hearing Officers (and serving the respondent) that seeks the imposition of sanctions for the violation (rather than issuing a notice to the respondent);
• FINRA's prosecuting department would seek the imposition of any fitting sanction at the outset of the FINRA Rule 9556(h) proceeding (in contrast to other FINRA Rule 9556 expedited proceedings, where the recipient of a notice is not subject to the imposition of any fitting sanction unless such recipient opts for a hearing);
• a hearing is required in a FINRA Rule 9556(h) proceeding;
• the hearing for a FINRA Rule 9556(h) proceeding must be held in a condensed time frame (ten business days after a respondent is served the petition, versus other Rule 9556 proceedings which require a respondent to request a hearing within seven business days after service of a notice instituting a proceeding and require hearings to be held within 14 days after a request for a hearing is filed);
• a FINRA Rule 9556(h) proceeding is presided over by a Hearing Officer,
• the Hearing Officer may issue default decisions in FINRA Rule 9556(h) proceedings.
Under amended FINRA Rule 9556(h)(4), the FINRA department that filed the petition can withdraw it without prejudice and shall be permitted to refile a petition based on allegations concerning the same facts and circumstances that are set forth in the withdrawn petition. FINRA noted that this provision provides it the flexibility to withdraw the petition where, for instance, the respondent evidences a good faith intent to comply with the temporary or permanent cease and desist order without the need to adjudicate the petition, while preserving FINRA's right to refile the petition if the respondent fails to do so.
FINRA also made the rules that govern service of documents in temporary cease and desist proceedings and the eight different types of expedited proceedings under the Rule 9550 Series more consistent.
FINRA clarified its rules concerning the process for imposing permanent cease and desist orders in disciplinary proceedings. FINRA noted that when it obtained the authority to impose temporary cease and desist orders, it also obtained the authority to impose permanent cease and desist orders.
FINRA also expanded the pool of persons eligible to serve on hearing panels to include those who may serve on hearing panels for disciplinary matters, as provided under FINRA Rules 9231(b) and 9559(d)(2).
The Exchange is proposing to, likewise, expand the categories of individuals eligible to participate as Hearing Panelists. Like FINRA, the Exchange is harmonizing the categories of eligible individuals with the criteria under Rules 9231(b) and 9559(d)(2).
FINRA's proposed changes also eased other administrative burdens created by the shortened time frame of a temporary cease and desist proceeding. Those proposed changes were aimed at improving Hearing Panels' and parties' ability to prepare for hearings and giving Hearing Officers some needed flexibility. For example, under FINRA Rule 9830(a) prior to the 2015 amendments a Hearing Officer was not able to extend a hearing date in a temporary cease and desist proceeding unless all parties consented to the extension. The requirement to obtain the parties' consent was problematic in instances whereby the Office of Hearing Officers, rather than one of the parties, had a need for an extension, such as when it encounters difficulty in quickly appointing a Hearing Panel. To address this problem, FINRA amended its Rule 9830(a) to allow hearing deadlines to be extended by the Chief Hearing Officer or Deputy Chief Hearing Officer for good cause shown.
FINRA also made similar amendments to the process by which extensions are obtained to the deadlines for issuing decisions in temporary cease and desist proceedings and responding to requests to modify, set aside, limit, or suspend a temporary cease and desist order. Before the amendments to FINRA Rule 9840(a), the Hearing Panel's deadline for issuing its written decision could not be extended, even where there was good cause, without the consent of the parties. Likewise, prior to amending FINRA Rule 9850, a Hearing Panel's deadline for responding to an application to have a temporary cease and desist order modified, set aside, limited, or suspended could not be extended, even where there was a good cause, without the consent of the Parties. To allow a Hearing Panel some flexibility where there is a need for additional time to prepare its decision or respond to a FINRA Rule 9850 request (
To further address the burdens created by the short time frame of temporary cease and desist proceedings, FINRA amended its rules to: (i) Require FINRA's prosecuting department to file a memorandum of points and authorities with the notice initiating a temporary cease and desist proceeding; and (ii) permit the Hearing Officer to order a party to furnish to all other parties and the Hearing Panel such information as deemed appropriate, including any or all of the pre-hearing submissions described in FINRA Rule 9242(a). FINRA noted that requiring its prosecuting department to file a memorandum of points and authorities at the initiation of the proceeding provides more context to the allegations and set [sic] forth legal authorities on which the notice seeking a temporary cease and desist order is premised.
FINRA also proposed Rule 9840(e), which is a delivery requirement that requires a member firm that is the subject of a temporary cease and desist order to provide a copy of the order to its associated persons, within one business day of receiving it. Considering the significant nature of the harm that a temporary cease and desist order is aimed at stopping, FINRA believed that there is a heightened need to ensure that the persons who may act on behalf of the member firm are made aware of the contents of a temporary cease and desist order imposed against the member firm and the delivery requirement furthers that goal.
FINRA's rule change clarified the following additional three issues: (1) How settlements may be approved in temporary cease and desist proceedings; (2) which Hearing Panel has jurisdiction to preside over applications filed under FINRA Rule 9850 to modify, set aside, limit or suspend temporary cease and desist orders that are filed after a
With respect to the first issue, new FINRA Rule 9810(c) established that, if the parties agree to the terms of a proposed temporary cease and desist order, the Hearing Officer has the authority to approve and issue the order. On the second issue, amended FINRA Rule 9850 provided that the Hearing Panel that presided over the temporary cease and desist order proceeding shall retain jurisdiction to review a FINRA Rule 9850 application unless at the time the application is filed a Hearing Panel has already been appointed in the underlying disciplinary proceeding commenced under FINRA Rule 9211, in which case the Hearing Panel appointed in the disciplinary proceeding has jurisdiction. As to the third issue, amended FINRA Rule 9840(b) and new Rule 9291(a) established that when a temporary or permanent cease and desist order is imposed against a member firm, it also applies to any successor of the member firm.
Finally, FINRA amended certain provisions of FINRA Rule 9120. FINRA amended FINRA Rule 9120(s), “Hearing Panel,” to include an Adjudicator that is constituted under Rule 9231 to conduct a disciplinary proceeding governed by the Rule 9800 Series. The Exchange is adopting this amendment in its Rule 9120(s).
FINRA also amended FINRA Rule 9120(t), “Interested Staff,” to: (1) Insert “or petition” under paragraph (2)(A) of the rule, thus expanding the definition to include FINRA staff that filed a petition in a proceeding under the Rule 9520 Series or Rule 9550 Series; and (2) include a new paragraph (4) to list FINRA staff that are defined as Interested Staff in a proceeding under the FINRA Rule 9800 Series. The Exchange is also adopting the amendment to its Rule 9120(t) “Interested Staff,” but is expanding the definition to also include BX Regulation employees who directly participated in the authorization of the notice that initiates a temporary cease and desist proceeding, or directly participated in an examination, investigation, prosecution, or litigation related to a specific temporary cease and desist proceeding, under new paragraphs (t)(4)(C) and (D) of the rule.
FINRA also amended FINRA Rule 9120(w), “Panelists,” to include references to Panelists in the Rule 9550 Series, and the Rule 9800 Series within the definition provided by the rule. The Exchange is adopting this amendment in Rule 9120(z). FINRA also amended Rule 9120(z) “Respondent” to define a Respondent in a proceeding governed by the Rule 9800 Series to mean a FINRA member or associated person that has been served a notice initiating a cease and desist proceeding. The Exchange is adopting this amendment in Rule 9120(bb) “Respondent.”
The Exchange believes that the changes made by FINRA in 2011 and 2015, as described above, improve the cease and desist authority as well as the service provisions. Consequently, the Exchange is proposing to adopt the changes, as described above, as its own.
The Exchange is also proposing to make other non-substantive changes to its rules to correct misuse of the word “FINRA,” which were introduced erroneously when the Exchange adopted the rules. Specifically, the Exchange is proposing to amend Rule 9555(g) to remove reference to FINRA and replace it with reference to the Exchange to make clear that it is BX's departments that should be contacted. The Exchange is also replacing references to FINRA's rules under new Rule 9810 with references to analogous rules of BX. Specifically, BX is replacing reference to FINRA Rule 2010 with reference to Equity Rule 2110, reference to FINRA Rule 2020 with reference to Equity Rule 2120, and FINRA Rule 4330 with reference to Equity Rule 2150.
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
The Exchange also believes that the proposed rule is consistent with Section 6(b)(6) of the Act,
The Exchange believes that the proposed rule change is consistent with these provisions because the proposed changes are based on the cease and desist authority that FINRA has adopted, which the Exchange believes furthers the objectives of the Act by providing it with ability to stop violative conduct that is likely to cause dissipation or conversion of assets or other significant harm to investors, and on other changes to its related rules that clarify, harmonize, and improve its disciplinary process.
The proposed rule change will improve the Exchange's capacity to enforce compliance with applicable laws and rules by its members and persons associated with members and improving [sic] the Exchange's capability to prevent fraudulent and manipulative acts and practices. Thus, this authority is a vitally important tool to have to protect market participants.
The Exchange acknowledges that, when used, the cease and desist authority proposed herein would significantly impact a respondent. The Exchange, however, notes that the proposed rules incorporate numerous procedural protections for respondents to ensure that the proceedings initiated under these rules are fair, including
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The changes are being proposed to provide an important regulatory tool to the Exchange and FINRA, acting on its behalf, which will protect investors when violative conduct is being taken by a member or person associated with a member, and time is of the essence to prevent harm, or further harm, to investors.
The proposed change does not impose a burden on competition among participants or other venues because it will only be used in circumstances where investor harm is imminent or is occurring. Thus, to the extent a burden on competition results from use of the authority provided by the proposed rules, such burden is necessary to protect investors, which is consistent with the purposes of the Act.
No written comments were either solicited or received.
Because the foregoing proposed rule change does not: (i) Significantly affect the protection of investors or the public interest; (ii) impose any significant burden on competition; and (iii) become operative for 30 days from the date on which it was filed, or such shorter time as the Commission may designate, if consistent with the protection of investors and the public interest, the proposed rule change has become effective pursuant to Section 19(b)(3)(A)(iii) of the Act
The Exchange has asked the Commission to waive the 30-day operative delay so that the proposal may become operative upon filing. The Exchange has stated that it is requesting this waiver so that the Exchange could apply, at the earliest time possible, the authority to issue temporary cease and desist orders and explicit authority to impose permanent cease and desist orders as a remedy in disciplinary cases. The Exchange explained that although it does not anticipate that it will be necessary to use this authority, when its cease and desist authority is needed, the Exchange must be able to move swiftly to prevent or stop investor harm. The Commission believes that waiving the 30-day operative delay is consistent with the protection of investors and the public interest because this waiver will enable the Exchange to utilize the temporary or permanent cease and desist authority described herein without delay in the unlikely event that circumstances arise that warrant its use. For this reason, the Commission hereby waives the 30-day operative delay and designates the proposed rule change as operative upon filing.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in furtherance of the purposes of the Act. If the Commission takes such action, the Commission shall institute proceedings to determine whether the proposed rule should be approved or disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Brent J. Fields, Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (the “Act”),
The Exchange filed a proposed rule change (the “Proposed Rule Change”) in connection with the proposed corporate transaction (the “Transaction”), as described in more detail below, involving its ultimate parent company, Bats Global Markets, Inc. (“BGM”), CBOE Holdings, Inc. (“CBOE Holdings”), and two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”). CBOE Holdings is the parent company of Chicago Board Options Exchange, Incorporated (“CBOE”) and C2 Options Exchange, Incorporated (“C2”), each a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act,
Upon completion of the mergers described below that effectuate the Transaction (the “Closing”), the business of BGM will be carried on by CBOE V. CBOE V, rather than BGM, will be the direct parent company of Direct Edge LLC (“Direct Edge”), which is the direct parent company of the Exchange. As a result, CBOE Holdings will become the ultimate parent company of Direct Edge and of the Exchange.
To effectuate the Transaction, the Exchange seeks to obtain the Commission's approval of: (i) The resolutions of BGM's board of directors (the “BGM Board”) waiving certain provisions of the Amended and Restated Certificate of Incorporation of BGM (the “BGM Charter”) and making certain related determinations regarding CBOE Holdings and the impact of the Transaction on the Exchange (the “Resolutions”); (ii) the CBOE Holdings Second Amended and Restated Certificate of Incorporation (the “CBOE Holdings Charter”) and the CBOE Holdings Third Amended and Restated Bylaws (the “CBOE Holdings Bylaws”); (iii) the Certificate of Formation of CBOE V (the “CBOE V Certificate”) and the Limited Liability Company Operating Agreement of CBOE V (the “CBOE V Operating Agreement”); (iv) the proposed amendments to the Amended and Restated Limited Liability Company Operating Agreement of Direct Edge (the “Direct Edge Operating Agreement”); (v) the proposed amendments to the Fifth Amended and Restated Bylaws of the Exchange (the “Exchange Bylaws”); and (vi) the proposed amendments to EDGX Rules 2.3, 2.10 and 2.12 (the “Exchange Rules”).
The text of the proposed rule change is available at the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in Sections A, B, and C below, of the most significant parts of such statements.
The Exchange submits this Proposed Rule Change to seek the Commission's approval of the organizational and governance documents of the Exchange and its current and proposed future parent companies, and related actions that are necessary in connection with the Closing of the Transaction, as described below.
Other than as described herein and set forth in Exhibits 5A through 5H, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and members) in the manner currently conducted, and will not make any changes to its regulated activities in connection with the Transaction. Except as set forth in this Proposed Rule Change, the Exchange is not proposing any amendments to its trading and regulatory rules at this time. If the Exchange determines to make any such changes, it will seek the approval of the Commission to the extent required by the Act, and the Commission's rules thereunder, and the Rules of the Exchange.
The Exchange, Bats BZX Exchange, Inc. (“BZX”), Bats BYX Exchange, Inc. (“BYX”) and Bats EDGA Exchange, Inc. (“EDGA,” and together with the Exchange, BZX and BYX, the “Bats Exchanges”) are each Delaware corporations that are national securities exchanges registered with the Commission pursuant to Section 6(a) of the Act.
The Exchange and EDGA are each direct, wholly owned subsidiaries of Direct Edge, a Delaware limited liability company that is a direct, wholly owned subsidiary of BGM. BZX and BYX are direct, wholly owned subsidiaries of Bats Global Markets Holdings, Inc. (“BGM Holdings”), a Delaware corporation that is a direct, wholly owned subsidiary of BGM. In addition to certain other subsidiaries not registered with the Commission in any capacity, BGM Holdings also owns 100 percent of the equity interest in Bats Trading, Inc. (“Bats Trading”), a Delaware corporation that is a broker-dealer registered with the Commission that provides routing services outbound from, and in certain instances inbound to, each Bats Exchange. BGM, a Delaware corporation, is a publicly traded company listed on BZX.
CBOE Holdings, a Delaware corporation, is a publicly traded company listed on The NASDAQ Stock Market. CBOE Holdings owns 100 percent of the equity interest in the CBOE Exchanges.
In contemplation of the Transaction, CBOE Holdings formed two additional entities, CBOE Corporation, a Delaware corporation, and CBOE V, a Delaware limited liability company, each of which are direct, wholly owned subsidiaries of CBOE Holdings. Each of CBOE Corporation and CBOE V currently have no material assets or conduct any operations.
On September 25, 2016, BGM, CBOE Holdings, CBOE Corporation and CBOE V entered into an Agreement and Plan of Merger (the “Merger Agreement”). Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things:
(i) CBOE Corporation will be merged with and into BGM, whereupon the separate existence of CBOE Corporation will cease and BGM will be the surviving company (the “Merger”);
(ii) by virtue of the Merger and without any action required on the part of BGM, CBOE Corporation or any holder of BGM or CBOE Corporation stock, each share of BGM common stock (whether voting or non-voting) issued and outstanding (with the exception of shares owned by CBOE Holdings, BGM or any of their respective subsidiaries and certain shares held by persons that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings and/or cash, at the election of the holder of such share of BGM common stock (the “Merger Consideration”), and each share of CBOE Corporation issued and outstanding will be converted into one share of BGM, such that BGM will become a wholly owned subsidiary of CBOE Holdings; and
(iii) immediately following the Merger, BGM will be merged with and into CBOE V, whereupon the separate existence of BGM will cease and CBOE V will be the surviving company (the “Subsequent Merger”).
Upon the Closing, the Direct Edge Operating Agreement, the Exchange Bylaws and the Exchange Rules will be amended to take into account the post-Closing corporate structure, described below.
As a result of the Transaction, BGM will cease to exist and the business of BGM will be carried on by CBOE V, which is a wholly owned subsidiary of CBOE Holdings.
The BGM Charter provides that (i) no Person,
However, the BGM Charter provides that each of the BGM Ownership Limitation and the BGM Voting Limitation may be waived (except with respect to Exchange Members and their Related Persons) pursuant to a resolution duly adopted by the BGM Board if, in connection with taking such action, the BGM Board states in such resolution that it is the determination of the BGM Board that the waiver:
• Will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder;
• is otherwise in the best interests of BGM, its stockholders, and each Bats Exchange;
• will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder; and
• shall not be effective until it is filed with and approved by the Commission.
In addition, notwithstanding the above, the BGM Charter provides
As described above, as a result of the Merger (and prior to its separate existence ceasing as a result of the Subsequent Merger), BGM will become a wholly owned subsidiary of CBOE Holdings, such that CBOE Holdings will possess ownership and voting rights in BGM in excess of the Ownership Limitation and the Voting Limitation. In addition, as a result of the Subsequent Merger, BGM will merge with and into CBOE V, terminating the BGM Charter and becoming an entity whose ownership and voting is held entirely by CBOE Holdings, in excess of the BGM Ownership Limitation and the BGM Voting Limitation that would otherwise apply.
The BGM Board therefore determined that in order to effect the Transaction, a waiver of the BGM Ownership Limitation and the BGM Voting Limitation with respect to CBOE Holdings would be required. To do so, the BGM Board adopted the Resolutions, attached as Exhibit 5A, making certain determinations with respect to CBOE Holdings and the Transaction that are necessary to waive the BGM Ownership Limitation and BGM Voting Limitation. Specifically, the BGM Board determined that:
• The acquisition of the proposed ownership by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• the acquisition or exercise of the proposed voting rights by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• neither CBOE Holdings nor any of its Related Persons is subject to “statutory disqualification” within the meaning of Section 3(a)(39) of the Act;
• neither CBOE Holdings nor any of its Related Persons is an Exchange Member.
The Exchange has reviewed such Resolutions and requests that the Commission approve such Resolutions. The Exchange believes that the Commission should approve the Resolutions, as the Transaction will not impair the ability of any Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, or the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder. The Bats Exchanges will continue to operate and regulate their markets and members as they have done prior to the Transaction. Thus, each Bats Exchange will continue to enforce the Act, the Commission's rules thereunder, and each Exchange's own rules, in the manner it does today. Further, the Commission will continue to have plenary regulatory authority over the Bats Exchanges, as is currently the case with these entities.
The Exchange also notes that the Resolutions reflect the determination by the BGM Board that the Transaction and CBOE Holdings' resulting ownership and voting rights in BGM following the Merger, and CBOE V's ownership and voting rights following the Subsequent Merger, are otherwise in the best interests of BGM, its stockholders and the Bats Exchanges. The Bats Exchanges will be ultimately held by an entity, CBOE Holdings, that already owns other national securities exchanges and is subject to governance documents that similarly restrict concentration of ownership and voting rights.
As described in more detail below, the Exchange is also requesting approval of the adoption of the CBOE Holdings Charter and the CBOE Holdings Bylaws. The CBOE Holdings Charter includes a number of provisions relating to the Commission's regulatory oversight that have a similar effect as those in the BGM Charter, including the BGM Ownership Limitation and the BGM Voting Limitation. Therefore, notwithstanding the Resolutions and the Transaction, provisions similar (and, in some cases, more stringent) to the BGM Ownership Limitation and the BGM Voting Limitation will remain in place with respect to potential future transactions involving the ultimate parent company of the Bats Exchanges. This means that the Exchange ownership structure will continue to provide the Commission with appropriate oversight tools to ensure that the Commission will have the ability to enforce the Act with respect to the Exchange, its direct and indirect parent companies, and its directors, officers, employees and agents to the extent they are involved in the activities of the Exchange, and protect the independence of the Exchange's self-regulatory activities.
The Exchange therefore requests that the Commission approve the Resolutions, attached as Exhibit 5A.
CBOE Holdings currently holds a direct ownership interest in the CBOE Exchanges. The Commission has previously approved the CBOE Holdings Charter and the CBOE Holdings Bylaws (collectively, the “CBOE Holdings Organizational Documents”), attached as Exhibits 5B and 5C, respectively.
In connection with the Transaction, upon the Closing, CBOE Holdings will become the indirect owner (through CBOE V and Direct Edge) of the Exchange and EDGA and the indirect owner (through CBOE V and BGM Holdings) of BZX, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity).
The CBOE Holdings Organizational Documents include various provisions relating to any “Regulated Securities Exchange Subsidiary,” which is defined as any national securities exchange controlled, directly or indirectly, by CBOE Holdings. Upon the Closing, the Exchange will be covered by the
The Exchange believes that the CBOE Holdings Organizational Documents will protect and maintain the integrity of the self-regulatory functions of the Exchange and facilitate the ability of the Exchange and the Commission to carry out their regulatory and oversight obligations under the Act, as the CBOE Organizational Documents do with respect to the CBOE Exchanges.
In addition, the CBOE Organizational Documents contain provisions, including those with respect to the following, that are similar to those contained in the BGM Charter and BGM's Amended and Restated Bylaws (the “BGM Bylaws”), which the Commission has previously found to be consistent with the Act:
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Effective as of the Closing of the Transaction, CBOE V will hold direct ownership of (i) Direct Edge, which will continue to hold direct ownership of the Exchange and EDGA and (ii) BGM Holdings, which will continue to hold direct ownership of BZX, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity). However, unlike BGM currently, CBOE V will not be the ultimate holding company under the post-Closing corporate structure, but rather will be an intermediate holding company owned by CBOE Holdings. The Exchange believes that the CBOE V Operating Agreement contains provisions relating to its indirect ownership of one or more national securities exchanges, including such exchanges' regulatory functions and Commission oversight, that are appropriate for an intermediate holding company in the ownership chain of a national securities exchange. Many of the provisions of the CBOE V Operating Agreement relating to these matters are similar to the organizational documents of Direct Edge, which currently is, and following the Subsequent Merger will be, similarly situated as an intermediate holding company of the Exchange. The Commission has previously found the Direct Edge organizational documents to be consistent with the Act.
Although CBOE V will not carry out any regulatory functions, the Exchange notes that its activities with respect to the operation of the Bats Exchanges must be consistent with, and must not interfere with, the self-regulatory obligations of each Bats Exchange. The CBOE V Operating Agreement therefore includes certain provisions that are designed to maintain the independence of the Bats Exchanges' self-regulatory functions, enable the Bats Exchanges to operate in a manner that complies with the federal securities laws, including the objectives of Sections 6(b)
The CBOE V Certificate, attached as Exhibit 5D, includes the following provisions required under Delaware law: (i) The full name of CBOE V as “CBOE V, LLC”, and (ii) the name and address of CBOE V's registered office in the State of Delaware and the name of CBOE V's registered agent at such address.
As the Exchange believes is customary for limited liability companies formed in the State of Delaware, other substantive provisions governing the ownership, operation and management of CBOE V are set forth in the CBOE V Operating Agreement, discussed below.
With respect to ownership and control of CBOE V, the CBOE V Operating Agreement, attached as Exhibit 5E, specifically provides that CBOE V's sole member is CBOE Holdings, until the CBOE V Operating Agreement is amended (subject to Commission approval, as described below).
The CBOE V Operating Agreement also contains several provisions designed to protect the independence of the self-regulatory functions of the Bats Exchanges. The CBOE V Operating Agreement requires that, for so long as CBOE V, directly or indirectly, controls any Exchange Subsidiary, CBOE Holdings, as the sole member of CBOE V, and officers, employees and agents of CBOE V must give due regard to the preservation of independence of the self-regulatory functions of such Exchange Subsidiary, as well as to its obligations to investors and the general public, and not interfere with the effectuation of any decisions by the board of directors of an Exchange Subsidiary relating to its regulatory functions (including disciplinary matters) or which would interfere with the ability of such Exchange Subsidiary to carry out its responsibilities under the Act.
The CBOE V Operating Agreement also would require that CBOE V comply with the U.S. federal securities laws and rules and regulations thereunder and cooperate with the Commission and each Exchange Subsidiary, as applicable, pursuant to and to the extent of their respective regulatory authority.
Furthermore, to the fullest extent permitted by law, CBOE V and its officers, directors, employees and agents will be deemed to irrevocably submit to the jurisdiction of the U.S. federal courts, the Commission, and each Exchange Subsidiary, as applicable, for purposes of any suit, action, or proceeding pursuant to the U.S. federal securities laws or the rules or
The proposed CBOE V Operating Agreement also contains a number of provisions designed to ensure that the Exchange will have sufficient access to the books and records of CBOE V as they relate to any Exchange Subsidiary. Pursuant to the CBOE V Operating Agreement, to the extent they are related to the operation or administration of an Exchange Subsidiary, the books, records, premises, officers, agents, and employees of CBOE V are deemed to be the books, records, premises, officers, agents and employees of such Exchange Subsidiary for the purposes of, and subject to oversight pursuant to, the Act.
The proposed CBOE V Operating Agreement also provides that, to the fullest extent permitted by law, all books and records of any Exchange Subsidiary reflecting confidential information pertaining to the self-regulatory function of such Exchange Subsidiary (including disciplinary matters, trading data, trading practices and audit information) that comes into the possession of CBOE V, shall be retained in confidence by CBOE V, CBOE V's officers, employees and agents and CBOE Holdings, and not used for any non-regulatory purposes.
In addition, the CBOE V Operating Agreement provides that for so long as CBOE V controls, directly or indirectly, any Exchange Subsidiary, before any amendment to or repeal of any provision of the CBOE V Operating Agreement will be effective, those changes must be submitted to the board of directors of each Exchange Subsidiary, and if the same must be filed with, or filed with and approved by, the Commission before the changes may be effective under Section 19 of the Act
The Direct Edge Operating Agreement currently provides that the sole member of Direct Edge is BGM. However, as a result of the Transaction, CBOE V will become the sole member of Direct Edge. The Exchange proposes to amend the Direct Edge Operating Agreement to reflect this change, as set forth in Exhibit 5F.
In connection with the Transaction, the Exchange proposes to amend and restate its Fifth Amended and Restated Bylaws and adopt the amended Exchange Bylaws as its Sixth Amended and Restated Bylaws, attached as Exhibit 5G. Specifically, the Exchange proposes to (i) expand the prohibition contained in Section 2 of Article XI of the Exchange Bylaws and (ii) add a definition of “Trading Permit Holder” to Article I.
Currently, Section 2 of Article XI of the Exchange Bylaws prohibits directors of BGM or Direct Edge who are not also directors, officers, staff, counsel or advisors of the Exchange from participating in any meetings of the Exchange's board of directors (or any committee thereof) pertaining to the self-regulatory function of the Exchange (including disciplinary matters). This provision refers to BGM and Direct Edge because they are currently the only direct and indirect owners of the Exchange. However, following the Transaction, the Exchange will be owned indirectly by CBOE V and CBOE Holdings (in addition to its direct ownership by Direct Edge). Therefore, the Exchange is proposing to remove the reference to BGM and insert references to CBOE V and CBOE Holdings, so that CBOE V and CBOE Holdings will both be covered by this prohibition. The Exchange believes that this amendment will protect the independence of the Exchange's self-regulatory activities.
In addition, as noted above, the CBOE Holdings Charter currently prohibits certain persons from owning or exercising voting rights over certain percentages of ownership of CBOE Holdings. The CBOE Holdings Charter permits the board of directors of CBOE Holdings to waive the limitation on the exercise of voting rights in excess of 20 percent of the then outstanding votes entitled to be cast on such matter only if, among other things, “for so long as [CBOE Holdings] directly or indirectly controls any Regulated Securities Exchange Subsidiary, neither such Person nor any of its Related Persons is a `Trading Permit Holder' (as defined in the Bylaws of any Regulated Securities Exchange Subsidiary as they may be amended from time to time).”
The Exchange does not issue “trading permits,” but admits members. The Exchange believes the provisions of the CBOE Holdings Charter that refer to Trading Permit Holders of its Regulated Securities Exchange Subsidiaries should apply equally to members of the Exchange once it becomes a Regulated Securities Exchange Subsidiary of CBOE Holdings. As a result, the Exchange proposes to add clause (ff) to Article I of the Exchange Bylaws, providing that “ `Trading Permit Holder' shall have the same meaning as Exchange Member.” This will ensure that the Exchange's members will be considered Trading Permit Holders of a Regulated Securities Exchange Subsidiary for purposes of the CBOE Holdings Charter.
Pursuant to Exchange Rule 2.3, in order to be eligible for membership in the Exchange, a registered broker or dealer is currently required to be a member of at least one other national securities association or national securities exchange. However, membership in the Exchange's affiliated national securities exchanges, BZX, BYX or EDGA, is not sufficient for purposes of eligibility for Exchange membership. The Exchange adopted this because the Bats Exchanges have historically not functioned as the designated examining authority for any of its members, and the Exchange wanted to be sure that any member would be appropriately supervised by another national securities association or national securities exchange that has
As a result of the Transaction, the Exchange will additionally become affiliated with the CBOE Exchanges. As with the Bats Exchanges, C2 does not currently serve as the designated examination authority for any of its members. CBOE, however, does act as the designated examining authority for certain of its members. Therefore, the Exchange proposes to amend Exchange Rule 2.3 to specify that a registered broker or dealer will be eligible for membership only if it is a member of a national securities association or national securities exchange other than or in addition to the following affiliates of the Exchange: BZX, BYX, EDGA and C2.
In addition, to ensure there is no confusion with respect to the possibility that a broker or dealer could qualify for membership in the Exchange based solely on membership in CBOE Futures or any other national securities exchange notice—registered with the Commission pursuant to Section 6(g) of the Act
Exchange Rule 2.10 provides that, without prior approval of the Commission, neither the Exchange, nor any of its affiliates, shall directly or indirectly acquire or maintain an ownership interest in a member of the Exchange. This restriction is intended to address potential conflicts of interest that could result from affiliation between the Exchange and a member. Notwithstanding this general restriction, Exchange Rule 2.10 provides that it does not prohibit a member or its affiliate from acquiring or holding an equity interest in BGM that is permitted by the ownership and voting limitations contained in the BGM Charter and the BGM Bylaws. In addition, Exchange Rule 2.10 states that it does not prohibit a member from being or becoming an affiliate of the Exchange, or an affiliate of any affiliate of the Exchange, solely by reason of such member or any officer, director, manager, managing member, partner or affiliate of such member being or becoming either (a) a director of the Exchange pursuant to the Bylaws of the Exchange, or (b) a director of the Exchange serving on the board of directors of BGM. The Exchange proposes to replace the references to BGM in Rule 2.10 with references to CBOE Holdings to reflect the fact that following the Transaction, CBOE Holdings will replace BGM as the ultimate parent holding company of the Exchange.
Exchange Rule 2.10 also clarifies that it does not prohibit the Exchange from being an affiliate of its routing broker-dealer Direct Edge ECN LLC d/b/a DE Route (“DE Route”) or of EDGA, BZX, BYX, or Bats Trading, each of which are affiliated with the Exchange. The Exchange proposes to remove the reference to DE Route to reflect the fact that Bats Trading previously replaced DE Route as the Exchange's routing broker-dealer.
Exchange Rule 2.12 provides that the Exchange, on behalf of BGM, shall establish and maintain procedures and internal controls reasonably designed to ensure that Bats Trading does not develop or implement changes to its systems on the basis of nonpublic information obtained as a result of its affiliation with the Exchange until such information is available generally to similarly situated members of the Exchange in connection with the provision of inbound order routing to the Exchange. The Exchange proposes to replace the reference to BGM with a reference to “the holding company indirectly owning the Exchange and Bats Trading.” This change would reflect the fact that BGM would no longer be the ultimate holding company of the Exchange following the Transaction and would also make this language consistent with the language used in Rule 2.12 of the BZX and BYX rulebooks. The proposed amendments to Exchange Rule 2.12 are set forth in Exhibit 5H.
The Exchange believes that the Proposed Rule Change is consistent with the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange, and, in particular, with the requirements of Section 6(b) of the Act.
The Proposed Rule Change is designed to enable the Exchange to continue to have the authority and ability to effectively fulfill its self-regulatory duties pursuant to the Act and the rules promulgated thereunder. In particular, the Proposed Rule Change includes in the CBOE Holdings Charter and CBOE Holdings Bylaws, like the BGM Charter and BGM Bylaws, various provisions intended to protect and maintain the integrity of the self-regulatory functions of the Exchange upon Closing. For example, the CBOE Holdings Charter, as described above, is drafted to preserve the independence of the Exchange's self-regulatory function and carry out its regulatory responsibilities under the Act. In addition, the CBOE Holdings Charter imposes limitations similar to the BGM Ownership Limitation and BGM Voting Limitation to preclude undue influence over or interference with the Exchange's self-regulatory functions and fulfillment of its regulatory duties under the Act.
Moreover, notwithstanding the Proposed Rule Change, including the change to the indirect ownership of the Exchange, the Commission will continue to have regulatory authority over the Exchange, as is currently the case, as well as jurisdiction over the Exchange's direct and indirect parent companies with respect to activities related to the Exchange.
The Exchange also believes that the Proposed Rule Change furthers the objectives of Section 6(b)(5) of the Act
In addition, as discussed further in the Exchange's Statement on Burden on Competition below, the Exchange expects that the Transaction will foster further innovation while facilitating efficient, transparent and well-regulated markets for issuers and investors, removing impediments to, and perfecting the mechanism of a free and open market and a national market system. The Transaction will benefit investors and the securities market as a whole by, among other things, enhancing competition among securities venues and reducing costs.
Furthermore, the Exchange is not proposing any significant changes to its existing operational and trading structure in connection with the change in ownership; the Exchange will operate in essentially the same manner upon Closing as it operates today. Therefore, the Exchange believes that it will continue to satisfy the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange. The changes that the Exchange is proposing to the Exchange Rules are designed to reflect the prospective affiliation with CBOE Holdings and the CBOE Exchanges. The Exchange believes that the proposed change to its Rules is consistent with the requirements of the Act and the rules and regulations thereunder.
The Exchange does not believe that the Proposed Rule Change would result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act. Indeed, the Exchange believes that the Proposed Rule Change will enhance competition among trading venues, as the Exchange believes that the Transaction will result in various synergies and efficiencies. For example, the Transaction will allow the Bats Exchanges and the CBOE Exchanges to utilize a single technology platform, which the Exchange expects will reduce Bats Exchanges' and the CBOE Exchanges' combined costs, creating the opportunity to further reduce costs to their respective members and other constituents. The potential use of a single technology platform may also reduce investors' costs of connecting to and using the Bats Exchanges and the CBOE Exchanges, including through the combination of data centers and market data services. Combining the expertise of the CBOE Exchanges' personnel with the expertise of the Bats Exchanges' personnel will also facilitate ongoing innovation, including through new product creation and platform improvements.
The Exchange notes that the Bats Exchanges and the CBOE Exchanges generally operate with different business models, target different customer bases and primarily focus on different asset classes, limiting any concern that the Transaction could burden competition. Therefore, the Exchange expects that the Transaction will benefit investors, issuers, shareholders and the market as a whole. The Exchange will continue to conduct regulated activities (including operating and regulating its market and members) of the type it currently conducts, but will be able to do so in a more efficient manner to the benefit of its members. These efficiencies will pass through to the benefit of investors and issuers, promoting further efficiencies, competition and capital formation, placing no burden on competition not necessary or appropriate in furtherance of the Act.
Furthermore, the Exchange's conclusion that the Proposed Rule Change would not result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act is consistent with the Commission's prior conclusions about similar combinations involving multiple exchanges in a single corporate family.
The Exchange has not solicited or received written comments on the Proposed Rule Change.
Within 45 days of the date of publication of this notice in the
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”),
The Exchange proposes to amend Commentary .14 to Rule 4770 (Compliance with Regulation NMS Plan to Implement a Tick Size Pilot) to provide the SEC with notice of its efforts to re-program its systems to eliminate a re-pricing functionality for certain orders in Test Group Three securities in connection with the Regulation NMS Plan to Implement a Tick Size Pilot Program (“Plan” or “Pilot”).
The text of the proposed rule change is set forth below. Proposed new language is underlined; deleted text is in brackets.
(a) through (d) No Change.
.01-.13 No change.
.14 Until [October 31, 2016]
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, the Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the Exchange Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
On September 7, 2016, the Exchange filed with the Securities and Exchange Commission (“SEC” or “Commission”) a proposed rule change (“Proposal”) to adopt paragraph (d) to Exchange Rule 4770 to describe changes to system functionality necessary to implement the Plan. The Exchange also proposed amendments to Rule 4770(a) and (c) to clarify how the Trade-at exception may be satisfied. The SEC published the Proposal in the
In SR-BX-2016-050, BX had initially proposed a re-pricing functionality for Price to Comply Orders, Non-Displayed Orders, and Post-Only Orders entered through the OUCH and FLITE protocols in Group Three securities.
In that amendment, BX noted that this change would only impact the treatment of Price to Comply Orders, Non-Displayed Orders, and Post-Only orders that are submitted through the OUCH and FLITE protocols in Test Group Three Pilot Securities, as these types of Orders that are currently submitted to BX through the RASH or FIX protocols are already subject to this re-pricing functionality and will remain subject to this functionality under the Pilot.
In the Amendment, BX further noted that its systems are currently programmed so that Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities may be adjusted repeatedly to reflect changes to the NBBO and/or the best price on the BX book. BX stated that it is re-programming its systems to remove this functionality for Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities. In the Amendment, BX stated that it anticipated that this re-programming shall be completed no later than November 30, 2016. If it appears that this functionality will remain operational by October 17, 2016, BX indicated that it would file a proposed rule change with the SEC and will provide notice to market participants sufficiently in advance of that date to provide effective notice. The rule change and the notice to market participants will describe the current operation of the BX systems in this regard, and the timing related to the re-programming.
On October 17, 2016, BX filed a proposal to extend the date by which it would complete the re-programing of its systems to eliminate the re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols.
Subsequent to the approval of SR-BX-2016-050, BX become aware that this re-pricing functionality also applies to Price to Display Orders that are entered through the OUCH and FLITE protocols in Test Group Three Securities, and included those Orders as part of SR-BX-2016-054 accordingly. Price to Display Orders will be treated in the same manner as Price to Comply Orders under the re-pricing functionality.
At this time, BX is still determining how to modify its systems to eliminate the current re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols. BX is therefore submitting this proposal to extend the date by which the current re-pricing functionality will be eliminated. BX anticipates that the re-programming to eliminate the current re-pricing functionality shall be completed on or before November 14, 2016.
Therefore, the current treatment of Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols in Test Group Three securities shall be as follows:
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, a Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the BX Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
BX also believes that the proposal is consistent with the Act because the re-pricing functionality will not significantly impact the data gathered pursuant to the Pilot. BX notes that this re-pricing functionality only affects Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols for Test Group Three securities until the re-pricing functionality is eliminated, and only becomes relevant when an Order in a Test Group Three security would cross a Protected Quotation of another market center. BX has analyzed data relating to the frequency with which Orders in Test Group Three securities are entered with a limit price that would cross a Protected Quotation of another market center, and believes that the re-pricing functionality will be triggered infrequently once Test Group Three becomes fully operational.
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The purpose of this proposal is to provide the SEC and market participants with notice of BX's efforts to remove its re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols, consistent with its statements in SR-BX-2016-050 and SR-BX-2016-054.
No written comments were either solicited or received.
Because the foregoing proposed rule change does not: (i) Significantly affect the protection of investors or the public interest; (ii) impose any significant burden on competition; and (iii) become operative for 30 days from the date on which it was filed, or such shorter time as the Commission may designate, it has become effective pursuant to Section 19(b)(3)(A)(iii) of the Act
A proposed rule change filed under Rule 19b-4(f)(6) normally does not become operative prior to 30 days after the date of filing. Rule 19b-4(f)(6)(iii), however, permits the Commission to designate a shorter time if such action is consistent with the protection of investors and the public interest. The Exchange requests that the Commission waive the 30-day operative delay contained in Rule 19b-4(f)(6)(iii) so that this proposed change will be in operative as of October 31, 2016, the date that Test Group Three securities are fully implemented and are subject to the quoting and trading restrictions of the Plan and, therefore, the relevant language in Rule 4770.
The Commission believes that waiving the 30-day operative delay is consistent with the protection of investors and the public interest because it will allow the Exchange to implement the proposed rules immediately thereby preventing delays in the implementation of the Plan. The Commission notes that the Pilot started implementation on October 3, 2016, Test Group Three securities were fully phased into the Pilot on October 31, 2016, and waiving the 30-day operative delay would ensure that the rules of the Exchange would be in place during implementation. Therefore, the Commission hereby waives the 30-day operative delay and designates the proposed rule change to be operative upon filing with the Commission.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in furtherance of the purposes of the Act. If the Commission takes such action, the Commission shall institute proceedings to determine whether the proposed rule should be approved or disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (the “Act”),
The Exchange proposes to amend Rule 5050 to provide for the listing and trading on the Exchange of RealDay
In its filing with the Commission, the self-regulatory organization included statements concerning the purpose of, and basis for, the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The self-regulatory organization has prepared summaries, set forth in Sections A, B, and C below, of the most significant aspects of such statements.
The Exchange proposes to amend its rules to provide for the listing and trading on the Exchange of a new type of standardized option product on the SPDR® S&P 500® Exchange Traded Fund (“ETF”) (this security is known by its symbol “SPY”) called RealDay
RealDay Options are a propriety product that are designed and exclusively licensed by the RealDay Options Corporation.
Initially, RealDay Options will only be listed on SPY but the Exchange may seek to list RealDay Options on additional securities in the future,
RealDay Options will be P.M. cash-settled and have European-style exercise provisions.
RealDay Options are P.M.-settled due to the nature of the product. Specifically, RealDay Options are designed to cover a single trading day due to the fact they are only active for one trading day. The only way to ensure that the option covers one trading day is to have it be P.M.-settled, as opposed to A.M.-settlement where additional factors may have an effect on the settlement price. Specifically, A.M.-settled options use the opening price for settlement which means they will price in after-hours news and events and therefore do not cover only one trading day. If RealDay Options were A.M.-settled, they would not cover only a single trading day because the settlement price would include events occurring after the close, which is not the intended goal of RealDay Options. Additionally, the Exchange notes that standard options in SPY are already P.M.-settled.
Although RealDay Options are designed to cover one trading day, they will be listed at least two weeks prior to their expiration but no greater than nine (9) months prior to their expiration.
The numerical value of the strike prices for RealDay Options will not be known until the close of trading on the last trading day before expiration, although the strike intervals and strike price setting formula will be fixed from inception.
The Exchange may, in its sole discretion, determine to not list in-the-money (“ITM”) put or call options for any of the seven (7) strike prices.
As is the case with other options that the Exchange lists, the Exchange may add additional strike prices after the initial listing of a RealDay Option, provided that the Exchange does not list more than the seven strike prices as described above. For example, if the Exchange lists a RealDay Option at the beginning of March with only the strike price equal to the Strike Setting Price that expires on June 29, 2017, the Exchange could list up to six additional strike prices at the beginning of June for the same expiration.
The strike price formula will be used after the close of trading on the last trading day before expiration in order to calculate the numerical values of the strike prices. Specifically, the strike prices will be determined by multiplying the Strike Setting Price by the Strike Multiplier. Additionally, the strike prices will have fixed strike intervals of 0.50%; therefore the Exchange's general strike price interval rules shall not apply to RealDay Options.
On Tuesday, SPY's closing price is 180.15, which will be the Strike Setting Price. RealDay Options on SPY expiring on the next trading day, Wednesday, may have the following strike prices computed by multiplying the Strike Setting Price by the Strike Multiplier.
If SPY does not open for trading on the trading day before the options expiration date, then the last available closing price for SPY will be the Strike Setting Price. For Example, if a RealDay Option is expiring on Friday but SPY does not open for trading on Thursday, which is the last trading day before the expiration date, the Strike Setting Price used for the RealDay Option expiring on Friday will be the closing price of SPY from Wednesday, provided that SPY is open for trading on Wednesday.
The Exchange is proposing to list RealDay Options on SPY with the symbol “SPYZ.” During the anticipatory period, the strike prices will be listed as the Strike Multiplier, since the numerical value of the strike price is not yet known. The table below illustrates how this will work.
The Exchange believes that using three decimal places will minimize the potential for investor confusion.
After the close of trading on the last trading day before expiration, the decimal will be converted into the numerical strike price by multiplying the Strike Setting Price by the Strike Multiplier.
Although the Exchange will have some discretion in determining the exact number of strike prices that can be listed, the Exchange will follow additional procedures
These unique strike price features are designed to minimize excessive quoting traffic that would come from listing standard options that expire every trading day and are listed at least two weeks prior to their expiration. If the Exchange were to list standard options on an underlying security that expire every trading day, there would be an enormous increase in quoting trading traffic due to the sheer number of strike prices that would have to be listed for each series. This is in part due to the fact that the price of the underlying security will fluctuate between when a standard option is listed and its expiration date. For example, on March 1, 2016 there were 127 strike prices listed for the weekly SPY option expiring on March 4, 2016 and 232 strike prices listed for the standard SPY option expiring on March 18, 2016. The number of strike prices further increases as the options expiration date
The exercise and settlement price will be calculated based on the closing price of SPY on the trading day of expiration. The exercise-settlement amount is equal to the difference between the settlement price and the exercise price of the option multiplied by 100. Exercise will result in the delivery of cash on the business day following expiration.
On Monday, a trader purchased a 1.005 (0.50%) call for expiration on Thursday. The Strike Multiplier is 1.005. When he purchased the call he did not know the numerical value of the strike price, only that he will get a call option whose strike price is fixed at 0.50% above the close of SPY on Wednesday. On Wednesday, SPY closed at 177.43 (the Strike Setting Price). All RealDay strike prices for expiration on Thursday are determined as follows:
Since the trader purchased the RealDay SPY 1.005 call, the strike price is now set at 178.32. Upon the close on Thursday, if SPY has risen above 178.32, the option expires in the money. Assume that SPY closes at 178.75 on Thursday, the call option purchased by the trader will be $0.43 in the money (178.75 − 178.32 = 0.43), and the trader will receive $43.00 (100 * 0.43).
If SPY does not open for trading on the trading day of expiration, then the last available closing price for SPY will be used to determine the settlement price of the expiring RealDay Options. Specifically, if SPY does not open for trading, at the close of trading on expiration, RealDay Options will have an exercise price that is equal to the closing price from the last trading day before expiration. This will result in all RealDay Options expiring either ATM, OTM, or ITM; depending on whether an ATM, OTM, or ITM option was purchased. This is due to the nature of options that are designed to have an active period of one trading day. For example, if a trader purchases an ATM RealDay call option, which is equal to the closing price of SPY from the last trading day before expiration (1.000 call), and SPY does not open for trading on the expiration day of that RealDay Options, then the call option purchased by the trader would expire ATM. This is because the exercise price would be equal to the closing price which, in this case, is equal to the closing price from the last trading day before expiration, since SPY did not open for trading on the expiration day. This is the same procedure used for standard options. Specifically, when an option does not open for trading on an expiration date, the last available closing price is used for settlement purposes.
The contract specifications for RealDay Options are set forth in Exhibit 3-1. RealDay Options will be European-style and P.M. cash-settled. As mentioned above, the Exchange believes that having a P.M. settlement is the best way to adequately represent the goal of RealDay Options, which are designed to cover one trading day. The Exchange does not believe that having a P.M. settlement will raise any issues since the market for SPY is so large that any attempt to alter the closing price would be extremely difficult and would subject the manipulator to regulatory scrutiny. As previously mentioned, BOX is only proposing to list RealDay Options on SPY, the most actively traded ETF in the U.S. Due to the vast liquidity and diversity in market participants trading SPY, any attempt to manipulate the closing price of SPY would be near impossible to accomplish. Additionally, the Exchange has surveillance measures in place to monitor such behavior. RealDay Options will overlie 100 shares of SPY in the same manner as standard options on SPY. The Exchange's standard trading hours for SPY options will apply to trading in RealDay Options.
With respect to margin requirements
The minimum trading increments for RealDay Options will be the same as the minimum trading increments applicable to standard options on SPY.
The Exchange proposes that the position limits for RealDay Options will be the same as the position limits for standard options on SPY.
Section 4000 of the Exchange's rules is designed to protect public customer trading and shall apply to trading in RealDay Options. Specifically, Rules 4020(a) and (b) prohibit Order Flow Providers (“OFP”)
The Exchange has an adequate surveillance program in place for RealDay Options and intends to apply the same program procedures that it applies to the Exchange's other options products. The Exchange does not believe that it will have any issues with the surveillance of RealDay Options. Although there are certain differences with RealDay Options as compared to standard options, the Exchange believes its current surveillance procedures will adequately monitor RealDay Options. Additionally, the Exchange is also a member of the Intermarket Surveillance Group (“ISG”) under the Intermarket Surveillance Group Agreement dated June 20, 1994. The ISG members work together to coordinate surveillance and investigative information sharing in the stock and options markets.
Per the proposed rule change, RealDay Options will be settled using a calculation based on the daily closing prices of SPY. The Exchange believes that manipulating the settlement price will be difficult based on the size of the market for SPY. As discussed above, the Exchange is only proposing to list RealDay Options on SPY, which is the most actively traded ETF in the United States. The vast liquidity of the equities markets ensures a multitude of market participants at any given time. Due to the high level of participation among market makers that can enter quotes in SPY, the Exchange believes it would be very difficult for a single participant to alter the closing price in any significant way without exposing the would-be manipulator to regulatory scrutiny and financial costs. This is especially true for SPY given the vast amount of liquidity in the ETF.
The Exchange believes that there is no additional risk of manipulation of RealDay Options as compared to other P.M.-settled options. RealDay Options will be listed on the most actively traded ETF and should dispel any concerns of manipulation. Due to the vast liquidity in SPY and the diverse group of market participants that trade SPY, any potential manipulator would be subject to regulatory scrutiny.
The Exchange represents that it has the necessary system capacity to support additional quotations and messages that will result from the listing and trading of RealDay Options. The Exchange believes that by limiting the listing of RealDay Options to only seven (7) strike prices per expiration, the Exchange will minimize the system capacity required to list them. Additionally, the Exchange believes that having the discretion to not list ITM call or put options will further minimize the required system capacity.
Rule 9b-1 under the Act establishes a disclosure framework for standardized options that are traded on a national securities exchange and cleared through a registered clearing agency.
The Exchange believes that RealDay Options will be a useful tool for all market participants. The unique strike price setting structure and the fact that RealDay Options may expire every trading day will allow investors to hedge single day events, including the release of an economic report or a company's earnings release (“event days”). Although the Exchange believes that these event days will be more active as compared to the non-event days, the Exchange still believes that investors will see value, including obtaining exposure to implied volatility, as described in greater detail below, and trade RealDay Options expiring on non-event days. Additionally, market participants can capture interday realized volatility when they are bundled as consecutive at-the-money straddles.
Additionally, the Exchange believes that market participants will find value in trading RealDay Options during both the anticipatory period and active period. During the anticipatory period investors can trade RealDay Options in order to get exposure to implied volatility and during the active period RealDay Options will act and be traded in the same manner as standard options. Market participants can obtain exposure to implied volatility by initiating a position and then liquidating it prior to the expiration day.
The Exchange believes that Market Makers will be able to price and quote RealDay Options effectively. Since RealDay Options will not have their strike prices set until the day before expiration, the Exchange believes that the models Market Makers use to price and quote RealDay Options will be simpler than the models they use for standard options. Specifically, Market Makers will not have to account for price movements in SPY or time to expiration; basically Market Makers will just have to deal with implied volatility when pricing RealDay Options.
As proposed, the proposal would become effective on a pilot program basis for a period of twelve months.
The Exchange proposes to submit a pilot program report to the Commission two months prior to the expiration date of the Pilot Program (the “pilot report”). The pilot report would contain an analysis of volume, open interest, and trading patterns. The analysis would examine trading in RealDay Options. In addition, for certain series, the pilot report would provide analysis of price volatility and trading activity in additional option series. In addition to the pilot report, the Exchange would provide the Commission with periodic interim reports while the pilot is in effect that would contain some, but not all, of the information contained in the pilot report. The pilot report would be provided to the Commission on a confidential basis.
The pilot report would contain the following volume and open interest data for RealDay Options:
(1) Daily contract trading volume aggregated for all trades, for all option series with less than 31 days until expiration;
(2) daily contract trading volume aggregated by expiration date, for all option series with less than 31 days until expiration;
(3) daily contract trading volume for each individual series;
(4) daily open interest aggregated for all series, for all option series with less than 31 days until expiration;
(5) daily open interest aggregated for all series by expiration date, for all option series with less than 31 days until expiration;
(6) daily open interest for each individual series;
(7) statistics on the distribution of trade sizes;
(8) type of market participant trading (
(9) 5-minute returns, level changes, and trading volume for the S&P 500 Index, VIX, SPY, IVV, and expiring RealDay options between open and close for the first and second Wednesday of the month that is a trading day and trading days when standard SPY options expire.
In addition to the pilot report, the Exchange would periodically provide the Commission with interim reports of the information listed in items (1) through (9) above as required by the Commission while the pilot is in effect. These interim reports would also be provided on a confidential basis.
The Exchange also proposes to amend Rule 5050(a). Specifically, the Exchange proposes to amend the rule to state that the Exchange will fix a specific expiration date and exercise price for RealDay Options, as provided in proposed Rule 5050(f).
The Exchange believes that its proposal is consistent with Section 6(b) of the Act
The Exchange believes the proposed rule change will further the Exchange's goal of introducing new and innovative products to the marketplace. The Exchange believes that listing RealDay Options will provide an opportunity for investors to hedge, or speculate on, the market risk associated with single day events. The proposed rule change will allow the Exchange to list options that will allow traders to manage risk associated with certain events, such as a company's earnings or the release of an economic report. The Exchange believes that RealDay Options will give traders an unprecedented ability to hedge against single day events. As the Exchange previously noted, the concept of a delayed start options is not a new proposal. Specifically, CBOE has rules covering delayed start options.
Finally, the Exchange represents that it has an adequate surveillance program in place to detect manipulative trading in RealDay Options. The Exchange believes that by initially limiting RealDay Options to only SPY, it will reduce the chances of manipulation due to the robust market and liquidity in SPY. The Exchange also represents that it has the necessary systems capacity to support the new options series; and as stated in the filing, the Exchange has rules in place designed to protect public customer trading.
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The Exchange notes that the proposed rule change will facilitate the listing and trading of a novel option product that will enhance competition among market participants, to the benefit of investors and the marketplace.
The Exchange has neither solicited nor received comments on the proposed rule change.
Within 45 days of the date of publication of this notice in the
(A) by order approve or disapprove the proposed rule change, or
(B) institute proceedings to determine whether the proposed rule change should be disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street, NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”),
The Exchange submits this rule filing in connection with a proposed corporate transaction (the “Transaction”) involving its ultimate parent company, CBOE Holdings, Inc. (“CBOE Holdings”), two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”), and Bats Global Markets, Inc. (“BGM”). BGM is the ultimate parent company of Bats BZX Exchange, Inc. (“Bats BZX”), Bats BYX Exchange, Inc. (“Bats BYX”), Bats EDGX Exchange, Inc. (“Bats EDGX”), and Bats EDGA Exchange, Inc. (“Bats EDGA” and, together with Bats BZX, Bats BYX, and Bats EDGX, the “Bats Exchanges”). Upon completion of the Transaction (the “Closing”), CBOE Holdings will become the ultimate parent of the Bats Exchanges.
On September 25, 2016, CBOE Holdings, CBOE Corporation, CBOE V, and BGM entered into an Agreement and Plan of Merger, as it may be amended from time to time (the “Merger Agreement”). In connection with the Transaction, the Exchange seeks the Commission's approval of a provision in the Merger Agreement regarding the composition of the CBOE Holdings Board of Directors (“CBOE Holdings Board”) upon the Closing. There are no
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
The Exchange submits this filing for Commission approval of a provision in the Merger Agreement regarding the composition of the CBOE Holdings Board upon Closing. Other than as described herein, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and Trading Permit Holders) in essentially the same manner it conducts them today, and will not make any changes to its regulated activities in connection with the Transaction. The Exchange is not proposing any amendments to its trading and regulatory rules or organizational and governance documents at this time. If the Exchange determines to make any such changes, it will submit rule filings to the Commission proposing such changes to the extent required by the Act and the rules and regulations thereunder.
Each of C2 and Chicago Board Options Exchange, Incorporated (“CBOE” and, together with the Exchange, the “CBOE Exchanges”) is a Delaware corporation that is a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act.
Each Bats Exchange is a Delaware corporation that is a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act.
Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things, each share of BGM common stock (whether voting or non-voting) issued and outstanding (other than shares owned by CBOE Holdings, BGM or any of their respective subsidiaries, and certain shares held by BGM stockholders that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings common stock, an amount of cash, or a combination of both, at the election of the holder of such share of BGM common stock. BGM will ultimately merge with and into CBOE Holdings' wholly owned subsidiary CBOE V, at which time the separate existence of BGM will cease and CBOE V will be the surviving company.
As a result of the Transaction, CBOE Holdings will be the ultimate parent of the Bats Exchanges, each of which will continue to operate separately. CBOE Holdings will continue to be a publicly owned company and the ultimate parent of the CBOE Exchanges, each of which will continue to operate separately.
In connection with the Transaction, CBOE Holdings agreed in the Merger Agreement to take all requisite actions so, as of the Closing, the CBOE Holdings Board will include three individuals designated by BGM who (1) are serving as BGM directors immediately prior to the Closing and (2) comply with the policies (including clarifications of the policies provided to BGM) of the Nominating and Governance Committee of the CBOE Holdings Board as in effect on the date of the Merger Agreement and previously provided to BGM (each of whom will be appointed to the CBOE Holdings Board as of the Closing). The CBOE Holdings Board currently consists of 14 directors.
The Exchange believes the proposed rule change is consistent with the Act and the rules and regulations thereunder applicable to the Exchange and, in particular, the requirements of Section 6(b) of the Act.
The proposed rule change is consistent with CBOE Holdings' organizational and governing documents previously filed with the Commission.
The Exchange is proposing no changes to its existing operational and trading structure in connection with the Transaction. Upon Closing, the Exchange will operate in essentially the same manner as it operates today. Therefore, the Exchange believes it will continue to satisfy the requirements of the Act and the rules and regulations thereunder applicable to a national securities exchange.
The Exchange does not believe the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The proposed rule change relates to the corporate governance of CBOE Holdings—specifically a change in composition of the CBOE Holdings Board in connection with a corporate transaction—and not the operations of the Exchange. This is not a competitive filing and, therefore, imposes no burden on competition.
The Exchange neither solicited nor received comments on the proposed rule change.
Within 45 days of the date of publication of this notice in the
A. By order approve or disapprove such proposed rule change, or
B. institute proceedings to determine whether the proposed rule change should be disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”),
The Exchange proposes to amend Commentary .14 to Rule 3317 (Compliance with Regulation NMS Plan to Implement a Tick Size Pilot) to provide the SEC with notice of its efforts to re-program its systems to eliminate a re-pricing functionality for certain orders in Test Group Three securities in connection with the Regulation NMS Plan to Implement a Tick Size Pilot Program (“Plan” or “Pilot”).
The text of the proposed rule change is set forth below. Proposed new language is underlined; deleted text is in brackets.
(a) through (d) No Change.
.01-.13 No change.
.14 Until [October 31, 2016]
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, the Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the Exchange Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
On September 7, 2016, the Exchange filed with the Securities and Exchange Commission (“SEC” or “Commission”) a proposed rule change (“Proposal”) to adopt paragraph (d) and Commentary .12 to Exchange Rule 3317 to describe changes to system functionality necessary to implement the Plan. The Exchange also proposed amendments to Rule 3317(a) and (c) to clarify how the Trade-at exception may be satisfied. The SEC published the Proposal in the
In SR-Phlx-2016-92, Phlx had initially proposed a re-pricing functionality for Price to Comply Orders, Non-Displayed Orders, and Post-Only Orders entered through the OUCH and FLITE protocols in Group Three securities.
In that amendment, Phlx noted that this change would only impact the treatment of Price to Comply Orders, Non-Displayed Orders, and Post-Only orders that are submitted through the OUCH and FLITE protocols in Test Group Three Pilot Securities, as these types of Orders that are currently submitted to Phlx through the RASH or FIX protocols are already subject to this re-pricing functionality and will remain subject to this functionality under the Pilot.
In the Amendment, Phlx further noted that its systems are currently programmed so that Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities may be adjusted repeatedly to reflect changes to the NBBO and/or the best price on the Phlx book. Phlx stated that it is re-programming its systems to remove this functionality for Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities. In the Amendment, Phlx stated that it anticipated that this re-programming shall be completed no later than November 30, 2016. If it appears that this functionality will remain operational by October 17, 2016, Phlx indicated that it would file a proposed rule change with the SEC and will provide notice to market participants sufficiently in advance of that date to provide effective notice. The rule change and the notice to market participants will describe the current operation of the Phlx systems in this regard, and the timing related to the re-programming.
On October 17, 2016, Phlx filed a proposal to extend the date by which it would complete the re-programing of its systems to eliminate the re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols.
At this time, Phlx is still determining how to modify its systems to eliminate the current re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols. Phlx is therefore submitting this proposal to extend the date by which the current re-pricing functionality will be eliminated. Phlx anticipates that the re-programming to eliminate the current re-pricing functionality shall be completed on or before November 14, 2016.
Therefore, the current treatment of Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, a Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the Phlx Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
Phlx also believes that the proposal is consistent with the Act because the re-pricing functionality will not significantly impact the data gathered pursuant to the Pilot. Phlx notes that this re-pricing functionality only affects Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols for Test Group Three securities until the re-pricing functionality is eliminated, and only becomes relevant when an Order in a Test Group Three security would cross a Protected Quotation of another market center. Phlx has analyzed data relating to the frequency with which Orders in Test Group Three securities are entered with a limit price that would cross a Protected Quotation of another market center, and believes that the re-pricing functionality will be triggered infrequently once Test Group Three becomes fully operational.
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The purpose of this proposal is to provide the SEC and market participants with notice of Phlx's efforts to remove its re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols, consistent with its statements in SR-Phlx-2016-92 and SR-Phlx-2016-106.
No written comments were either solicited or received.
Because the foregoing proposed rule change does not: (i) Significantly affect the protection of investors or the public interest; (ii) impose any significant burden on competition; and (iii) become operative for 30 days from the date on which it was filed, or such shorter time as the Commission may designate, it has become effective pursuant to Section 19(b)(3)(A)(iii) of the Act
A proposed rule change filed under Rule 19b-4(f)(6) normally does not become operative prior to 30 days after the date of filing. Rule 19b-4(f)(6)(iii), however, permits the Commission to designate a shorter time if such action is consistent with the protection of investors and the public interest. The Exchange requests that the Commission waive the 30-day operative delay contained in Rule 19b-4(f)(6)(iii) so that this proposed change will be in operative as of October 31, 2016, the date that Test Group Three securities are fully implemented and are subject to the quoting and trading restrictions of the Plan and, therefore, the relevant language in Rule 3317.
The Commission believes that waiving the 30-day operative delay is consistent with the protection of investors and the public interest because it will allow the Exchange to implement the proposed rules immediately thereby preventing delays in the implementation of the Plan. The Commission notes that the Pilot started implementation on October 3, 2016, Test Group Three securities were fully phased into the Pilot on October 31, 2016, and waiving the 30-day operative delay would ensure that the rules of the Exchange would be in place during implementation. Therefore, the Commission hereby waives the 30-day operative delay and designates the proposed rule change to be operative upon filing with the Commission.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”),
The Exchange proposes to amend Nasdaq Rule 7014, Market Quality Incentive Programs, to modify the volume threshold for the method under which members may currently qualify for the Nasdaq Growth Program (“Program”). The Exchange also proposes to add another method through which members may qualify for the Program, and to modify the manner in which a member's Growth Baseline is updated.
The text of the proposed rule change is available on the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
The Exchange proposes to amend Nasdaq Rule 7014, Market Quality Incentive Programs, to modify the volume threshold for the method under which members may currently qualify for the Program. The Exchange also proposes to add another method through which members may qualify for the Nasdaq Growth Program (“Program”), and to modify the manner in which a member's Growth Baseline is updated.
Nasdaq recently introduced the Nasdaq Growth Program.
Rule 7014 defines the Growth Baseline as the member's shares of liquidity provided in all securities through one or more of its Nasdaq Market Center MPIDs as a percentage of Consolidated Volume during the last month a member qualified for the Program. If a member has not qualified for a credit under the Program, its August 2016 share of liquidity provided in all securities through one or more of its Nasdaq Market Center MPIDs as a percent of Consolidated Volume will be used to establish a baseline.
As noted above, Nasdaq is proposing to modify the volume requirement that members must satisfy in order to qualify for the Program under the current method. Nasdaq also proposes to add another method through which members may qualify for the Program. Nasdaq is therefore re-numbering Rule 7014(j)(ii) as Rule 7014(j)(ii)(A) and (B) accordingly.
Accordingly, Rule 7014(j)(ii)(A) will now state that, in order to be eligible for the rebate, the member must increase its shares of liquidity provided through one or more of its Nasdaq Market Center MPIDs as a percent of Consolidated Volume by 20% versus the member's Growth Baseline. Nasdaq notes that the purpose of the Program is to increase participation on the Exchange by incentivizing members to transact more volume on the Exchange. Nasdaq believes that changing the volume requirement from 25% to 20% will make it easier for members to qualify for the Program, thereby creating a greater incentive for members to increase their activity on the Exchange.
New Rule 7014(j)(ii)(B) provides that a member may qualify for the Program if it met the criteria set forth in Rule 7014(j)(ii)(A) in the preceding month and maintained or increased its shares of liquidity provided through one or more of its Nasdaq Market Center MPIDs as a percent of Consolidated Volume compared to the preceding month.
Previously, a member would have been required to increase its shares of liquidity by 25% (now 20%) each month versus the member's Growth Baseline in order to qualify for the Program. Assuming the member satisfied the criteria set forth in Rule 7014(j)(ii)(A) in the previous month, Rule 7014(j)(ii)(B) will allow a member to continue to qualify for the program as long as it maintains or increases its shares of liquidity in the current month. Since Rule 7014(j)(ii)(B) requires that the member met the criteria in Rule 7014(j)(ii)(A) in the preceding month, a member would not be able to use Rule 7014(j)(ii)(B) in successive months.
Third, Nasdaq proposes to modify the calculation of a member's baseline. As noted above, the Growth Baseline is defined as the member's shares of liquidity provided in all securities through one or more of its Nasdaq Market Center MPIDs as a percent of Consolidated Volume during the last month a member qualified for the Nasdaq Growth Program. If a member has not qualified for a credit under the Program, its August 2016 share of liquidity provided in all securities through one or more of its Nasdaq Market Center MPIDs as a percent of Consolidated Volume will be used to establish a baseline. Once the member qualifies for the Program, the August 2016 baseline is replaced by the volume of that qualifying month, which becomes the member's updated baseline.
Nasdaq is proposing to add language to the definition of the Growth Baseline to reflect the fact that a member's baseline will only be updated when a member qualifies for the rebate under Rule 7014(j)(ii)(A). A member may only qualify for the rebate under Rule 7014(j)(ii)(A) if it increases its volume by 20% over its baseline, whereas a member would qualify for the rebate under Rule 7014(j)(ii)(B) if it maintained or increased its volume in comparison to the previous month. Nasdaq believes that adjusting the member's baseline when the growth of the member's monthly volume meets or exceeds 20% is appropriate because this is a clearly defined threshold. Nasdaq also notes that members cannot qualify for the rebate under Rule 7014(j)(ii)(B) in successive months, so Nasdaq does not anticipate a scenario where a member qualifies for a rebate for several months without having its baseline adjusted accordingly.
The following example illustrates the proposed changes:
• In August 2016, the firm's shares of liquidity as a percentage of Consolidated Volume is 0.03%. This is the firm's Growth Baseline.
• In September 2016, the firm's shares of liquidity as a percentage of Consolidated Volume is 0.035%. The member does not qualify for an applicable rebate, and the member's Growth Baseline remains 0.03% (its August 2016 volume).
• In October 2016, the firm's shares of liquidity as a percentage of Consolidated Volume is 0.04%. Since the firm has increased its volume by more than 20% in comparison to its Growth Baseline, the firm qualifies for the credit. Since the firm has qualified for the credit, its Growth Baseline is now 0.04%.
• In November 2016, the firm's shares of liquidity as a percentage of Consolidated Volume is 0.041%. Although the firm did not increase its volume by 20% in comparison to its Growth Baseline, it still qualifies for the credit, since Rule 7014(j)(ii)(B) allows a member to continue to qualify for the Program if it met the criteria in Rule 7014(j)(ii)(A) in the previous month, and if it maintains or increases its shares of liquidity in the current month. Since the firm qualified for the credit under Rule 7014(j)(ii)(B), the Growth Baseline does not update.
• A member may only qualify for the rebate under Rule 7014(j)(ii)(B) if it satisfied the criteria of Rule 7014(j)(ii)(A) in the preceding month. In order to be eligible for the December 2016 rebate, the firm would therefore have to increase its volume by more than 20% in comparison to its Growth Baseline (which is October 2016).
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
The Exchange notes that the amount of the credits provided under the Program is unchanged.
In amending Rule 7014(j)(ii)(A) so that members may qualify for the Program by increasing their volume in a given month by 20% over their baseline, Nasdaq also notes that this proposed change merely changes the member's trading volume necessary to qualify for the program under Rule 7014(j)(ii)(A), and does not otherwise differentiate among members who may qualify for the Program.
Nasdaq also believes that Rule 7014(j)(ii)(B) is equitably allocated and not unfairly discriminatory. In adopting Rule 7014(j)(ii)(B), Nasdaq is providing all members that otherwise qualify for the Program with an alternate way in which they may qualify for the Program's rebate in a given month by permitting members to either maintain or increase their volume in comparison to the preceding month. Given, however, that the purpose of the Program is to increase a member's trading activity on the Exchange, Nasdaq believes that it is equitable and not unfairly discriminatory to only permit members to qualify for the rebate in this manner if they have qualified for the rebate in the preceding month under Rule 7014(j)(ii)(A) (increasing their volume by 20% or more in comparison to the Growth Baseline). Similarly, the member will be required to satisfy the criteria in Rule 7014(j)(ii)(A) in order to qualify for the rebate in the following month, which means that it will be required to increase its volume by 20% in comparison to its Growth Baseline. Nasdaq believes this requirement is equitable and not unfairly discriminatory because it furthers the aims of the Program by encouraging increased volume on the Exchange. Nasdaq also notes that these requirements will apply equally to all members.
Nasdaq believes that updating a member's Growth Baseline when the member has qualified for the rebate pursuant to Rule 7014(j)(ii)(A) by increasing its volume by 20% over its previous Growth Baseline is equitable and not unfairly discriminatory because this is a clearly defined threshold that applies equally to all members that qualify for the rebate under Rule 7014(j)(ii)(A). Nasdaq also notes that members cannot qualify for the rebate under Rule 7014(j)(ii)(B) in successive months, so Nasdaq does not anticipate a scenario where a member qualifies for a rebate for several months without having its baseline adjusted accordingly.
Finally, Nasdaq notes that participation in the Program is voluntary, and that the proposed changes apply to all members that otherwise qualify for the Program,
The proposed rule change will not result in a burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act, as amended.
Because competitors are free to modify their own fees and credits in response, and because market participants may readily adjust their order routing practices, the Exchange believes that the degree to which fee changes in this market may impose any burden on competition is extremely limited. In addition, the Exchange believes that the competition among exchanges and other venues will help to drive price improvement and overall execution quality higher for end retail investors.
In this instance, participation in the Program is voluntary. The proposed changes will lower the volume threshold for the current method of qualifying for the Program, and will provide members with another way in which they may qualify for the Program. These changes will apply equally to all members who otherwise qualify for the Program. Similarly, the proposed method of updating the Growth Baseline will be uniformly applied across members.
In sum, if the change proposed herein is unattractive to market participants, it is likely that the Exchange will lose market share as a result. Accordingly, the Exchange does not believe that the proposed change will impair the ability of members or competing order execution venues to maintain their competitive standing in the financial markets.
No written comments were either solicited or received.
The foregoing rule change has become effective pursuant to Section 19(b)(3)(A)(ii) of the Act.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in furtherance of the purposes of the Act. If the Commission takes such action, the Commission shall institute proceedings to determine whether the proposed rule should be approved or disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”)
The Exchange proposes to adopt Rules 9556 and 9800, which were previously adopted as a pilot the term of which has since expired, and to make related changes to the 9100, 9200, 9300, 9550, and 9800 Rule Series.
The text of the proposed rule change is available on the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
The Exchange is proposing to adopt new Rules 9556 and 9800, which were previously adopted as a pilot the term of which has since expired, and to make related changes to the 9100, 9200, 9300, 9550, and 9800 Rule Series. In May 2003, the Commission approved, on a pilot basis, a rule change to adopt NASD Rules 9556 and 9800 that gave NASD, now known as FINRA, authority to issue temporary cease and desist orders and made explicit NASD's ability to impose permanent cease and desist orders as a remedy in disciplinary cases.
On June 23, 2009, the Exchange's Rule 9556 and 9800 pilot programs expired, at which time those rules and certain references thereto became obsolete, notwithstanding that they remained in the rulebook. The FINRA pilot program, however, continued and was approved on July 14, 2009 on a permanent basis.
Neither the Exchange nor FINRA, acting on behalf of the Exchange pursuant to agreement, have [sic] used the cease and desist authority under Rules 9556 and 9800 during the time that the rules were effective. Nonetheless, the Exchange believes that, in addition to maintaining similar disciplinary rules, adoption of Rules 9556 and 9800 is important to the Exchange's disciplinary program. The authority under these rules will provide the Exchange and FINRA, operating on behalf of the Exchange, with a mechanism to take appropriate remedial action against a member or an associated person that has engaged (or is engaging) in violative conduct that could cause continuing harm to the investing public if not addressed expeditiously, such as dissipation or conversion of assets. It must be emphasized, however, that the cease and desist provisions contain numerous procedural protections for respondents to ensure that the proceedings are fair. Consequently, the Exchange believes that adoption of these rules is important to its regulatory program, notwithstanding that it anticipates exercising the authority provided by the rules sparingly.
The Exchange is proposing to delete Rules 9556 and 9800 (and related references in other rules
In 2011, FINRA amended Rules 9552(b), 9553(b), 9554(b), 9555(b), and 9556(b), all of which concern service of notice.
In 2015, FINRA made significant changes to its temporary and permanent cease and desist rules.
FINRA amended FINRA Rule 9840(a)(1) to change the evidentiary standard applied by Hearing Panels in issuing a temporary cease and desist order. Specifically, FINRA changed the standard for issuing a temporary cease and desist order from “by a preponderance of the evidence that the alleged violation specified in the notice has occurred” to a “showing of a likelihood of success on the merits.” FINRA noted that it believed that the “preponderance of the evidence” standard set too high an evidentiary threshold for this critical investor-protection tool, and noted that it is the identical standard for proving a violation in the underlying disciplinary proceeding that must be pursued at the same time.
FINRA also made a corresponding amendment to FINRA Rule 9840(a)(2). Prior to the amendment, FINRA Rule 9840(a)(2) provided that a temporary cease and desist order shall be imposed if the Hearing Panel finds that the violative conduct or continuation thereof is likely to result in significant dissipation or conversion of assets or other significant harm to investors prior to the completion of the underlying proceeding. The 2015 rule change modified this requirement to apply to the “alleged” violative conduct or continuation thereof, to be consistent with the proposed change to the evidentiary standard.
FINRA also made amendments to FINRA Rule 9556, which sets forth expedited procedures for enforcing violations of FINRA-issued temporary and permanent cease and desist orders. FINRA was concerned that their [sic] existing expedited procedures may permit cease and desist orders to be circumvented without any real threat of a sanction.
• a FINRA Rule 9556(h) proceeding could be initiated only if the respondent has previously been served, under FINRA Rule 9556(a), with a notice for failing to comply with any provision of the same temporary or permanent cease and desist order;
• FINRA's prosecuting department would initiate a FINRA Rule 9556(h) proceeding by filing a petition with FINRA's Office of Hearing Officers (and serving the respondent) that seeks the imposition of sanctions for the violation (rather than issuing a notice to the respondent);
• FINRA's prosecuting department would seek the imposition of any fitting sanction at the outset of the FINRA Rule 9556(h) proceeding (in contrast to other FINRA Rule 9556 expedited proceedings, where the recipient of a notice is not subject to the imposition of any fitting sanction unless such recipient opts for a hearing);
• a hearing is required in a FINRA Rule 9556(h) proceeding;
• the hearing for a FINRA Rule 9556(h) proceeding must be held in a condensed time frame (ten business days after a respondent is served the petition, versus other Rule 9556 proceedings which require a respondent to request a hearing within seven business days after service of a notice instituting a proceeding and require hearings to be held within 14 days after a request for a hearing is filed);
• a FINRA Rule 9556(h) proceeding is presided over by a Hearing Officer,
• the Hearing Officer may issue default decisions in FINRA Rule 9556(h) proceedings.
Under amended FINRA Rule 9556(h)(4), the FINRA department that filed the petition can withdraw it without prejudice and shall be permitted to refile a petition based on allegations concerning the same facts and circumstances that are set forth in the withdrawn petition. FINRA noted that this provision provides it the flexibility to withdraw the petition where, for instance, the respondent evidences a good faith intent to comply with the temporary or permanent cease and desist order without the need to adjudicate the petition, while preserving FINRA's right to refile the petition if the respondent fails to do so.
FINRA also made the rules that govern service of documents in temporary cease and desist proceedings and the eight different types of expedited proceedings under the Rule 9550 Series more consistent.
FINRA clarified its rules concerning the process for imposing permanent cease and desist orders in disciplinary proceedings. FINRA noted that when it obtained the authority to impose temporary cease and desist orders, it also obtained the authority to impose permanent cease and desist orders.
FINRA also expanded the pool of persons eligible to serve on hearing panels to include those who may serve on hearing panels for disciplinary matters, as provided under FINRA Rules 9231(b) and 9559(d)(2).
The Exchange is proposing to, likewise, expand the categories of individuals eligible to participate as Hearing Panelists. Like FINRA, the Exchange is harmonizing the categories of eligible individuals with the criteria under Rules 9231(b) and 9559(d)(2).
FINRA's proposed changes also eased other administrative burdens created by the shortened time frame of a temporary cease and desist proceeding. Those proposed changes were aimed at improving Hearing Panels' and parties' ability to prepare for hearings and giving Hearing Officers some needed flexibility. For example, under FINRA Rule 9830(a) prior to the 2015 amendments a Hearing Officer was not able to extend a hearing date in a temporary cease and desist proceeding unless all parties consented to the extension. The requirement to obtain the parties' consent was problematic in instances whereby the Office of Hearing Officers, rather than one of the parties, had a need for an extension, such as when it encounters difficulty in quickly appointing a Hearing Panel. To address this problem, FINRA amended its Rule 9830(a) to allow hearing deadlines to be extended by the Chief Hearing Officer or Deputy Chief Hearing Officer for good cause shown.
FINRA also made similar amendments to the process by which extensions are obtained to the deadlines for issuing decisions in temporary cease and desist proceedings and responding to requests to modify, set aside, limit, or suspend a temporary cease and desist order. Before the amendments to FINRA Rule 9840(a), the Hearing Panel's deadline for issuing its written decision could not be extended, even where there was good cause, without the consent of the parties. Likewise, prior to amending FINRA Rule 9850, a Hearing Panel's deadline for responding to an application to have a temporary cease and desist order modified, set aside, limited, or suspended could not be extended, even where there was a good cause, without the consent of the Parties. To allow a Hearing Panel some flexibility where there is a need for additional time to prepare its decision or respond to a FINRA Rule 9850 request (
To further address the burdens created by the short time frame of temporary cease and desist proceedings, FINRA amended its rules to: (i) Require FINRA's prosecuting department to file a memorandum of points and authorities with the notice initiating a temporary cease and desist proceeding; and (ii) permit the Hearing Officer to order a party to furnish to all other parties and the Hearing Panel such information as deemed appropriate, including any or all of the pre-hearing submissions described in FINRA Rule 9242(a). FINRA noted that requiring its prosecuting department to file a memorandum of points and authorities at the initiation of the proceeding provides more context to the allegations and set [sic] forth legal authorities on which the notice seeking a temporary cease and desist order is premised.
FINRA also proposed Rule 9840(e), which is a delivery requirement that requires a member firm that is the subject of a temporary cease and desist order to provide a copy of the order to its associated persons, within one business day of receiving it. Considering the significant nature of the harm that a temporary cease and desist order is aimed at stopping, FINRA believed that there is a heightened need to ensure that the persons who may act on behalf of the member firm are made aware of the contents of a temporary cease and desist order imposed against the member firm and the delivery requirement furthers that goal.
FINRA's rule change clarified the following additional three issues: (1) How settlements may be approved in temporary cease and desist proceedings; (2) which Hearing Panel has jurisdiction to preside over applications filed under FINRA Rule 9850 to modify, set aside, limit or suspend temporary cease and desist orders that are filed after a Hearing Panel has already been appointed in the underlying disciplinary proceeding; and (3) whether temporary and permanent cease and desist orders imposed against a firm also apply to successors of that firm.
With respect to the first issue, new FINRA Rule 9810(c) established that, if the parties agree to the terms of a proposed temporary cease and desist order, the Hearing Officer has the authority to approve and issue the order. On the second issue, amended FINRA Rule 9850 provided that the Hearing Panel that presided over the temporary cease and desist order proceeding shall retain jurisdiction to review a FINRA Rule 9850 application unless at the time the application is filed a Hearing Panel has already been appointed in the underlying disciplinary proceeding commenced under FINRA Rule 9211, in which case the Hearing Panel appointed in the disciplinary proceeding has jurisdiction. As to the third issue, amended FINRA Rule 9840(b) and new Rule 9291(a) established that when a temporary or permanent cease and desist order is imposed against a member firm, it also applies to any successor of the member firm.
Finally, FINRA amended certain provisions of FINRA Rule 9120. FINRA amended FINRA Rule 9120(s), “Hearing Panel,” to include an Adjudicator that is constituted under Rule 9231 to conduct a disciplinary proceeding governed by the Rule 9800 Series. The Exchange is adopting this amendment in its Rule 9120(s).
FINRA also amended FINRA Rule 9120(t), “Interested Staff,” to: (1) Insert “or petition” under paragraph (2)(A) of the rule, thus expanding the definition to include FINRA staff that filed a petition in a proceeding under the Rule 9520 Series or Rule 9550 Series; and (2) include a new paragraph (4) to list FINRA staff that are defined as Interested Staff in a proceeding under the FINRA Rule 9800 Series. The Exchange is also adopting the amendment to its Rule 9120(t) “Interested Staff,” but is expanding the definition to also include Nasdaq Regulation employees who directly participated in the authorization of the notice that initiates a temporary cease and desist proceeding, or directly participated in an examination, investigation, prosecution, or litigation related to a specific temporary cease and desist proceeding, under new paragraphs (t)(4)(C) and (D) of the rule.
FINRA also amended FINRA Rule 9120(w), “Panelists,” to include references to Panelists in the Rule 9550 Series, and the Rule 9800 Series within the definition provided by the rule. The Exchange is adopting this amendment in Rule 9120(z). FINRA also amended Rule 9120(z) “Respondent” to define a Respondent in a proceeding governed by the Rule 9800 Series to mean a FINRA member or associated person that has been served a notice initiating a cease and desist proceeding. The Exchange is adopting this amendment in Rule 9120(bb) “Respondent.”
The Exchange believes that the changes made by FINRA in 2011 and 2015, as described above, improve the cease and desist authority as well as the service provisions. Consequently, the Exchange is proposing to adopt the changes, as described above, as its own.
The Exchange is also proposing to make other non-substantive changes to its rules to correct misuse of the word “FINRA,” which were introduced erroneously when the Exchange adopted the rules. Specifically, the Exchange is proposing to amend Rule 9555(g) to remove reference to FINRA and replace it with reference to Nasdaq to make clear that it is Nasdaq's departments that should be contacted. The Exchange is also replacing references to FINRA's rules under new Rule 9810 with references to analogous rules of Nasdaq. Specifically, Nasdaq is replacing reference to FINRA Rule 2010 with reference to Nasdaq Rule 2010A, reference to FINRA Rule 2020 with reference to Nasdaq Rule 2120, and FINRA Rule 4330 with reference to Nasdaq Rule 2150.
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
The Exchange also believes that the proposed rule is consistent with Section 6(b)(6) of the Act,
The Exchange believes that the proposed rule change is consistent with these provisions because the proposed changes are based on the cease and desist authority that FINRA has adopted, which the Exchange believes furthers the objectives of the Act by providing it with ability to stop violative conduct that is likely to cause dissipation or conversion of assets or other significant harm to investors, and on other changes to its related rules that clarify, harmonize, and improve its disciplinary process.
The proposed rule change will improve the Exchange's capacity to enforce compliance with applicable laws and rules by its members and persons associated with members and improving [sic] the Exchange's capability to prevent fraudulent and manipulative acts and practices. Thus, this authority is a vitally important tool to have to protect market participants.
The Exchange acknowledges that, when used, the cease and desist authority proposed herein would significantly impact a respondent. The Exchange, however, notes that the proposed rules incorporate numerous procedural protections for respondents to ensure that the proceedings initiated under these rules are fair, including notice and an opportunity to be heard before a neutral tribunal. Moreover, the Exchange anticipates using the authority provided by these rules sparingly.
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The changes are being proposed to provide an important regulatory tool to the Exchange and FINRA, acting on its behalf, which will protect investors when violative conduct is being taken by a member or person associated with a member, and time is of the essence to prevent harm, or further harm, to investors.
The proposed change does not impose a burden on competition among participants or other venues because it will only be used in circumstances where investor harm is imminent or is occurring. Thus, to the extent a burden on competition results from use of the authority provided by the proposed rules, such burden is necessary to protect investors, which is consistent with the purposes of the Act.
No written comments were either solicited or received.
Because the foregoing proposed rule change does not: (i) Significantly affect the protection of investors or the public interest; (ii) impose any significant burden on competition; and (iii) become operative for 30 days from the date on which it was filed, or such shorter time as the Commission may designate, if consistent with the protection of investors and the public interest, the proposed rule change has become effective pursuant to Section 19(b)(3)(A)(iii) of the Act
The Exchange has asked the Commission to waive the 30-day operative delay so that the proposal may become operative upon filing. The Exchange has stated that it is requesting this waiver so that the Exchange could apply, at the earliest time possible, the authority to issue temporary cease and desist orders and explicit authority to impose permanent cease and desist orders as a remedy in disciplinary cases. The Exchange explained that although it does not anticipate that it will be necessary to use this authority, when its cease and desist authority is needed, the Exchange must be able to move swiftly to prevent or stop investor harm. The Commission believes that waiving the 30-day operative delay is consistent with the protection of investors and the public interest because this waiver will enable the Exchange to utilize the temporary or permanent cease and desist authority described herein without delay in the unlikely event that circumstances arise that warrant its use. For this reason, the Commission hereby waives the 30-day operative delay and designates the proposed rule change as operative upon filing.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in furtherance of the purposes of the Act. If the Commission takes such action, the Commission shall institute proceedings to determine whether the proposed rule should be approved or disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Brent J. Fields, Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (the “Act”),
The Exchange filed a proposed rule change (the “Proposed Rule Change”) in connection with the proposed corporate transaction (the “Transaction”), as described in more detail below, involving its ultimate parent company, Bats Global Markets, Inc. (“BGM”), CBOE Holdings, Inc. (“CBOE Holdings”), and two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”). CBOE Holdings is the parent company of Chicago Board Options Exchange, Incorporated (“CBOE”) and C2 Options Exchange, Incorporated (“C2”), each a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act,
Upon completion of the mergers described below that effectuate the Transaction (the “Closing”), the business of BGM will be carried on by CBOE V. CBOE V, rather than BGM, will be the direct parent company of Direct Edge LLC (“Direct Edge”), which is the direct parent company of the Exchange. As a result, CBOE Holdings will become the ultimate parent company of Direct Edge and of the Exchange.
To effectuate the Transaction, the Exchange seeks to obtain the Commission's approval of: (i) The resolutions of BGM's board of directors (the “BGM Board”) waiving certain provisions of the Amended and Restated Certificate of Incorporation of BGM (the “BGM Charter”) and making certain related determinations regarding CBOE Holdings and the impact of the Transaction on the Exchange (the “Resolutions”); (ii) the CBOE Holdings Second Amended and Restated Certificate of Incorporation (the “CBOE Holdings Charter”) and the CBOE Holdings Third Amended and Restated Bylaws (the “CBOE Holdings Bylaws”); (iii) the Certificate of Formation of CBOE V (the “CBOE V Certificate”) and the Limited Liability Company Operating Agreement of CBOE V (the “CBOE V Operating Agreement”); (iv) the proposed amendments to the Amended and Restated Limited Liability Company Operating Agreement of Direct Edge (the “Direct Edge Operating Agreement”); (v) the proposed amendments to the Fifth Amended and Restated Bylaws of the Exchange (the “Exchange Bylaws”); and (vi) the proposed amendments to EDGA Rules 2.3, 2.10 and 2.12 (the “Exchange Rules”).
The text of the proposed rule change is available at the Exchange's Web site at
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in Sections A, B, and C below, of the most significant parts of such statements.
The Exchange submits this Proposed Rule Change to seek the Commission's approval of the organizational and governance documents of the Exchange and its current and proposed future parent companies, and related actions that are necessary in connection with the Closing of the Transaction, as described below.
Other than as described herein and set forth in Exhibits 5A through 5H, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and members) in the manner currently conducted, and will not make any changes to its regulated activities in connection with the Transaction. Except as set forth in this Proposed Rule Change, the Exchange is not proposing any amendments to its trading and regulatory rules at this time. If the Exchange determines to make any such changes, it will seek the approval of the Commission to the extent required by the Act, and the Commission's rules thereunder, and the Rules of the Exchange.
The Exchange, Bats BZX Exchange, Inc. (“BZX”), Bats BYX Exchange, Inc. (“BYX”) and Bats EDGX Exchange, Inc. (“EDGX,” and together with the Exchange, BZX and BYX, the “Bats Exchanges”) are each Delaware corporations that are national securities exchanges registered with the Commission pursuant to Section 6(a) of the Act.
The Exchange and EDGX are each direct, wholly owned subsidiaries of Direct Edge, a Delaware limited liability company that is a direct, wholly owned subsidiary of BGM. BZX and BYX are direct, wholly owned subsidiaries of Bats Global Markets Holdings, Inc. (“BGM Holdings”), a Delaware corporation that is a direct, wholly owned subsidiary of BGM. In addition
CBOE Holdings, a Delaware corporation, is a publicly traded company listed on The NASDAQ Stock Market. CBOE Holdings owns 100 percent of the equity interest in the CBOE Exchanges.
In contemplation of the Transaction, CBOE Holdings formed two additional entities, CBOE Corporation, a Delaware corporation, and CBOE V, a Delaware limited liability company, each of which are direct, wholly owned subsidiaries of CBOE Holdings. Each of CBOE Corporation and CBOE V currently have no material assets or conduct any operations.
On September 25, 2016, BGM, CBOE Holdings, CBOE Corporation and CBOE V entered into an Agreement and Plan of Merger (the “Merger Agreement”). Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things:
(i) CBOE Corporation will be merged with and into BGM, whereupon the separate existence of CBOE Corporation will cease and BGM will be the surviving company (the “Merger”);
(ii) by virtue of the Merger and without any action required on the part of BGM, CBOE Corporation or any holder of BGM or CBOE Corporation stock, each share of BGM common stock (whether voting or non-voting) issued and outstanding (with the exception of shares owned by CBOE Holdings, BGM or any of their respective subsidiaries and certain shares held by persons that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings and/or cash, at the election of the holder of such share of BGM common stock (the “Merger Consideration”), and each share of CBOE Corporation issued and outstanding will be converted into one share of BGM, such that BGM will become a wholly owned subsidiary of CBOE Holdings; and
(iii) immediately following the Merger, BGM will be merged with and into CBOE V, whereupon the separate existence of BGM will cease and CBOE V will be the surviving company (the “Subsequent Merger”).
Upon the Closing, the Direct Edge Operating Agreement, the Exchange Bylaws and the Exchange Rules will be amended to take into account the post-Closing corporate structure, described below.
As a result of the Transaction, BGM will cease to exist and the business of BGM will be carried on by CBOE V, which is a wholly owned subsidiary of CBOE Holdings.
The BGM Charter provides that (i) no Person,
However, the BGM Charter provides that each of the BGM Ownership Limitation and the BGM Voting Limitation may be waived (except with respect to Exchange Members and their Related Persons) pursuant to a resolution duly adopted by the BGM Board if, in connection with taking such action, the BGM Board states in such resolution that it is the determination of the BGM Board that the waiver:
• will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder;
• is otherwise in the best interests of BGM, its stockholders, and each Bats Exchange;
• will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder; and
• shall not be effective until it is filed with and approved by the Commission.
In granting such a waiver, the BGM Board has the discretion to impose on the Person and its Related Persons, such conditions and restrictions that it deems necessary, appropriate or desirable in furtherance of the objectives of the Act and the rules and regulations promulgated thereunder, and the governance of each Bats Exchange.
In addition, notwithstanding the above, the BGM Charter provides
As described above, as a result of the Merger (and prior to its separate existence ceasing as a result of the Subsequent Merger), BGM will become a wholly owned subsidiary of CBOE Holdings, such that CBOE Holdings will possess ownership and voting rights in BGM in excess of the Ownership Limitation and the Voting Limitation. In addition, as a result of the Subsequent Merger, BGM will merge with and into CBOE V, terminating the BGM Charter and becoming an entity whose ownership and voting is held entirely by CBOE Holdings, in excess of the BGM Ownership Limitation and the BGM Voting Limitation that would otherwise apply.
The BGM Board therefore determined that in order to effect the Transaction, a waiver of the BGM Ownership Limitation and the BGM Voting Limitation with respect to CBOE Holdings would be required. To do so, the BGM Board adopted the Resolutions, attached as Exhibit 5A, making certain determinations with respect to CBOE Holdings and the Transaction that are necessary to waive the BGM Ownership Limitation and BGM Voting Limitation. Specifically, the BGM Board determined that:
• The acquisition of the proposed ownership by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• the acquisition or exercise of the proposed voting rights by CBOE Holdings in BGM will not impair the ability of each Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, is otherwise in the best interests of BGM, its stockholders and the Bats Exchanges, and will not impair the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder;
• neither CBOE Holdings nor any of its Related Persons is subject to “statutory disqualification” within the meaning of Section 3(a)(39) of the Act;
• neither CBOE Holdings nor any of its Related Persons is an Exchange Member.
The Exchange has reviewed such Resolutions and requests that the Commission approve such Resolutions. The Exchange believes that the Commission should approve the Resolutions, as the Transaction will not impair the ability of any Bats Exchange to carry out its functions and responsibilities as an “exchange” under the Act and the rules and regulations promulgated thereunder, or the ability of the Commission to enforce the Act and the rules and regulations promulgated thereunder. The Bats Exchanges will continue to operate and regulate their markets and members as they have done prior to the Transaction. Thus, each Bats Exchange will continue to enforce the Act, the Commission's rules thereunder, and each Exchange's own rules, in the manner it does today. Further, the Commission will continue to have plenary regulatory authority over the Bats Exchanges, as is currently the case with these entities.
The Exchange also notes that the Resolutions reflect the determination by the BGM Board that the Transaction and CBOE Holdings' resulting ownership and voting rights in BGM following the Merger, and CBOE V's ownership and voting rights following the Subsequent Merger, are otherwise in the best interests of BGM, its stockholders and the Bats Exchanges. The Bats Exchanges will be ultimately held by an entity, CBOE Holdings, that already owns other national securities exchanges and is subject to governance documents that similarly restrict concentration of ownership and voting rights.
As described in more detail below, the Exchange is also requesting approval of the adoption of the CBOE Holdings Charter and the CBOE Holdings Bylaws. The CBOE Holdings Charter includes a number of provisions relating to the Commission's regulatory oversight that have a similar effect as those in the BGM Charter, including the BGM Ownership Limitation and the BGM Voting Limitation. Therefore, notwithstanding the Resolutions and the Transaction, provisions similar (and, in some cases, more stringent) to the BGM Ownership Limitation and the BGM Voting Limitation will remain in place with respect to potential future transactions involving the ultimate parent company of the Bats Exchanges. This means that the Exchange ownership structure will continue to provide the Commission with appropriate oversight tools to ensure that the Commission will have the ability to enforce the Act with respect to the Exchange, its direct and indirect parent companies, and its directors, officers, employees and agents to the extent they are involved in the activities of the Exchange, and protect the independence of the Exchange's self-regulatory activities.
The Exchange therefore requests that the Commission approve the Resolutions, attached as Exhibit 5A.
CBOE Holdings currently holds a direct ownership interest in the CBOE Exchanges. The Commission has previously approved the CBOE Holdings Charter and the CBOE Holdings Bylaws (collectively, the “CBOE Holdings Organizational Documents”), attached as Exhibits 5B and 5C, respectively.
In connection with the Transaction, upon the Closing, CBOE Holdings will become the indirect owner (through CBOE V and Direct Edge) of the Exchange and EDGX and the indirect owner (through CBOE V and BGM Holdings) of BZX, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity).
The CBOE Holdings Organizational Documents include various provisions relating to any “Regulated Securities Exchange Subsidiary,” which is defined as any national securities exchange controlled, directly or indirectly, by CBOE Holdings. Upon the Closing, the Exchange will be covered by the definition of Regulated Securities Exchange Subsidiary for purposes of the CBOE Holdings Organizational Documents. As a result, no amendments to the CBOE Holdings Organizational Documents will be necessary to reflect CBOE Holdings' indirect ownership of the Exchange.
The Exchange believes that the CBOE Holdings Organizational Documents will protect and maintain the integrity of the self-regulatory functions of the Exchange and facilitate the ability of the Exchange and the Commission to carry out their regulatory and oversight obligations under the Act, as the CBOE Organizational Documents do with respect to the CBOE Exchanges.
In addition, the CBOE Organizational Documents contain provisions, including those with respect to the following, that are similar to those contained in the BGM Charter and BGM's Amended and Restated Bylaws (the “BGM Bylaws”), which the Commission has previously found to be consistent with the Act:
•
•
•
•
•
•
•
As stated above, the Exchange believes that the foregoing provisions will assist the Exchange in fulfilling its self-regulatory obligations and in administering and complying with the requirements of the Act.
Effective as of the Closing of the Transaction, CBOE V will hold direct ownership of (i) Direct Edge, which will continue to hold direct ownership of the Exchange and EDGX and (ii) BGM Holdings, which will continue to hold direct ownership of BZX, BYX and Bats Trading (and certain other subsidiaries not registered with the Commission in any capacity). However, unlike BGM currently, CBOE V will not be the ultimate holding company under the post-Closing corporate structure, but rather will be an intermediate holding company owned by CBOE Holdings. The Exchange believes that the CBOE V Operating Agreement contains provisions relating to its indirect ownership of one or more national securities exchanges, including such exchanges' regulatory functions and Commission oversight, that are appropriate for an intermediate holding company in the ownership chain of a national securities exchange. Many of the provisions of the CBOE V Operating Agreement relating to these matters are similar to the organizational documents of Direct Edge, which currently is, and following the Subsequent Merger will be, similarly situated as an intermediate holding company of the Exchange. The Commission has previously found the Direct Edge organizational documents to be consistent with the Act.
Although CBOE V will not carry out any regulatory functions, the Exchange notes that its activities with respect to the operation of the Bats Exchanges must be consistent with, and must not interfere with, the self-regulatory obligations of each Bats Exchange. The CBOE V Operating Agreement therefore includes certain provisions that are designed to maintain the independence of the Bats Exchanges' self-regulatory functions, enable the Bats Exchanges to operate in a manner that complies with the federal securities laws, including the objectives of Sections 6(b)
The CBOE V Certificate, attached as Exhibit 5D, includes the following provisions required under Delaware law: (i) the full name of CBOE V as “CBOE V, LLC”, and (ii) the name and address of CBOE V's registered office in the State of Delaware and the name of CBOE V's registered agent at such address.
As the Exchange believes is customary for limited liability companies formed in the State of Delaware, other substantive provisions governing the ownership, operation and management of CBOE V are set forth in the CBOE V Operating Agreement, discussed below.
With respect to ownership and control of CBOE V, the CBOE V Operating Agreement, attached as Exhibit 5E, specifically provides that CBOE V's sole member is CBOE Holdings, until the CBOE V Operating Agreement is amended (subject to Commission approval, as described below).
The CBOE V Operating Agreement also contains several provisions designed to protect the independence of the self-regulatory functions of the Bats Exchanges. The CBOE V Operating Agreement requires that, for so long as CBOE V, directly or indirectly, controls any Exchange Subsidiary, CBOE Holdings, as the sole member of CBOE V, and officers, employees and agents of CBOE V must give due regard to the preservation of independence of the self-regulatory functions of such Exchange Subsidiary, as well as to its obligations to investors and the general public, and not interfere with the effectuation of any decisions by the board of directors of an Exchange Subsidiary relating to its regulatory functions (including disciplinary matters) or which would interfere with the ability of such Exchange Subsidiary
The CBOE V Operating Agreement also would require that CBOE V comply with the U.S. federal securities laws and rules and regulations thereunder and cooperate with the Commission and each Exchange Subsidiary, as applicable, pursuant to and to the extent of their respective regulatory authority.
Furthermore, to the fullest extent permitted by law, CBOE V and its officers, directors, employees and agents will be deemed to irrevocably submit to the jurisdiction of the U.S. federal courts, the Commission, and each Exchange Subsidiary, as applicable, for purposes of any suit, action, or proceeding pursuant to the U.S. federal securities laws or the rules or regulations thereunder arising out of, or relating to, the activities of such Exchange Subsidiary.
The proposed CBOE V Operating Agreement also contains a number of provisions designed to ensure that the Exchange will have sufficient access to the books and records of CBOE V as they relate to any Exchange Subsidiary. Pursuant to the CBOE V Operating Agreement, to the extent they are related to the operation or administration of an Exchange Subsidiary, the books, records, premises, officers, agents, and employees of CBOE V are deemed to be the books, records, premises, officers, agents and employees of such Exchange Subsidiary for the purposes of, and subject to oversight pursuant to, the Act.
The proposed CBOE V Operating Agreement also provides that, to the fullest extent permitted by law, all books and records of any Exchange Subsidiary reflecting confidential information pertaining to the self-regulatory function of such Exchange Subsidiary (including disciplinary matters, trading data, trading practices and audit information) that comes into the possession of CBOE V, shall be retained in confidence by CBOE V, CBOE V's officers, employees and agents and CBOE Holdings, and not used for any non-regulatory purposes.
In addition, the CBOE V Operating Agreement provides that for so long as CBOE V controls, directly or indirectly, any Exchange Subsidiary, before any amendment to or repeal of any provision of the CBOE V Operating Agreement will be effective, those changes must be submitted to the board of directors of each Exchange Subsidiary, and if the same must be filed with, or filed with and approved by, the Commission before the changes may be effective under Section 19 of the Act
The Direct Edge Operating Agreement currently provides that the sole member of Direct Edge is BGM. However, as a result of the Transaction, CBOE V will become the sole member of Direct Edge. The Exchange proposes to amend the Direct Edge Operating Agreement to reflect this change, as set forth in Exhibit 5F.
In connection with the Transaction, the Exchange proposes to amend and restate its Fifth Amended and Restated Bylaws and adopt the amended Exchange Bylaws as its Sixth Amended and Restated Bylaws, attached as Exhibit 5G. Specifically, the Exchange proposes to (i) expand the prohibition contained in Section 2 of Article XI of the Exchange Bylaws and (ii) add a definition of “Trading Permit Holder” to Article I.
Currently, Section 2 of Article XI of the Exchange Bylaws prohibits directors of BGM or Direct Edge who are not also directors, officers, staff, counsel or advisors of the Exchange from participating in any meetings of the Exchange's board of directors (or any committee thereof) pertaining to the self-regulatory function of the Exchange (including disciplinary matters). This provision refers to BGM and Direct Edge because they are currently the only direct and indirect owners of the Exchange. However, following the Transaction, the Exchange will be owned indirectly by CBOE V and CBOE Holdings (in addition to its direct ownership by Direct Edge). Therefore, the Exchange is proposing to remove the reference to BGM and insert references to CBOE V and CBOE Holdings, so that CBOE V and CBOE Holdings will both be covered by this prohibition. The Exchange believes that this amendment will protect the independence of the Exchange's self-regulatory activities.
In addition, as noted above, the CBOE Holdings Charter currently prohibits certain persons from owning or exercising voting rights over certain percentages of ownership of CBOE Holdings. The CBOE Holdings Charter permits the board of directors of CBOE Holdings to waive the limitation on the exercise of voting rights in excess of 20 percent of the then outstanding votes entitled to be cast on such matter only if, among other things, “for so long as [CBOE Holdings] directly or indirectly controls any Regulated Securities Exchange Subsidiary, neither such Person nor any of its Related Persons is a `Trading Permit Holder' (as defined in the Bylaws of any Regulated Securities Exchange Subsidiary as they may be amended from time to time).”
The Exchange does not issue “trading permits,” but admits members. The Exchange believes the provisions of the CBOE Holdings Charter that refer to Trading Permit Holders of its Regulated Securities Exchange Subsidiaries should apply equally to members of the
Pursuant to Exchange Rule 2.3, in order to be eligible for membership in the Exchange, a registered broker or dealer is currently required to be a member of at least one other national securities association or national securities exchange. However, membership in the Exchange's affiliated national securities exchanges, BZX, BYX or EDGX, is not sufficient for purposes of eligibility for Exchange membership. The Exchange adopted this because the Bats Exchanges have historically not functioned as the designated examining authority for any of its members, and the Exchange wanted to be sure that any member would be appropriately supervised by another national securities association or national securities exchange that has the capacity to function as the member's designated examining authority.
As a result of the Transaction, the Exchange will additionally become affiliated with the CBOE Exchanges. As with the Bats Exchanges, C2 does not currently serve as the designated examination authority for any of its members. CBOE, however, does act as the designated examining authority for certain of its members. Therefore, the Exchange proposes to amend Exchange Rule 2.3 to specify that a registered broker or dealer will be eligible for membership only if it is a member of a national securities association or national securities exchange other than or in addition to the following affiliates of the Exchange: BZX, BYX, EDGX and C2.
In addition, to ensure there is no confusion with respect to the possibility that a broker or dealer could qualify for membership in the Exchange based solely on membership in CBOE Futures or any other national securities exchange notice-registered with the Commission pursuant to Section 6(g) of the Act
Exchange Rule 2.10 provides that, without prior approval of the Commission, neither the Exchange, nor any of its affiliates, shall directly or indirectly acquire or maintain an ownership interest in a member of the Exchange. This restriction is intended to address potential conflicts of interest that could result from affiliation between the Exchange and a member. Notwithstanding this general restriction, Exchange Rule 2.10 provides that it does not prohibit a member or its affiliate from acquiring or holding an equity interest in BGM that is permitted by the ownership and voting limitations contained in the BGM Charter and the BGM Bylaws. In addition, Exchange Rule 2.10 states that it does not prohibit a member from being or becoming an affiliate of the Exchange, or an affiliate of any affiliate of the Exchange, solely by reason of such member or any officer, director, manager, managing member, partner or affiliate of such member being or becoming either (a) a director of the Exchange pursuant to the Bylaws of the Exchange, or (b) a director of the Exchange serving on the board of directors of BGM. The Exchange proposes to replace the references to BGM in Rule 2.10 with references to CBOE Holdings to reflect the fact that following the Transaction, CBOE Holdings will replace BGM as the ultimate parent holding company of the Exchange.
Exchange Rule 2.10 also clarifies that it does not prohibit the Exchange from being an affiliate of its routing broker-dealer Direct Edge ECN LLC d/b/a DE Route (“DE Route”) or of EDGX, BZX, BYX, or Bats Trading, each of which are affiliated with the Exchange. The Exchange proposes to remove the reference to DE Route to reflect the fact that Bats Trading previously replaced DE Route as the Exchange's routing broker-dealer.
Exchange Rule 2.12 provides that the Exchange, on behalf of BGM, shall establish and maintain procedures and internal controls reasonably designed to ensure that Bats Trading does not develop or implement changes to its systems on the basis of nonpublic information obtained as a result of its affiliation with the Exchange until such information is available generally to similarly situated members of the Exchange in connection with the provision of inbound order routing to the Exchange. The Exchange proposes to replace the reference to BGM with a reference to “the holding company indirectly owning the Exchange and Bats Trading.” This change would reflect the fact that BGM would no longer be the ultimate holding company of the Exchange following the Transaction and would also make this language consistent with the language used in Rule 2.12 of the BZX and BYX rulebooks. The proposed amendments to Exchange Rule 2.12 are set forth in Exhibit 5H.
The Exchange believes that the Proposed Rule Change is consistent with the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange, and, in particular, with the requirements of Section 6(b) of the Act.
The Proposed Rule Change is designed to enable the Exchange to continue to have the authority and ability to effectively fulfill its self-regulatory duties pursuant to the Act and the rules promulgated thereunder. In particular, the Proposed Rule Change includes in the CBOE Holdings Charter and CBOE Holdings Bylaws, like the BGM Charter and BGM Bylaws, various provisions intended to protect and maintain the integrity of the self-
Moreover, notwithstanding the Proposed Rule Change, including the change to the indirect ownership of the Exchange, the Commission will continue to have regulatory authority over the Exchange, as is currently the case, as well as jurisdiction over the Exchange's direct and indirect parent companies with respect to activities related to the Exchange.
The Exchange also believes that the Proposed Rule Change furthers the objectives of Section 6(b)(5) of the Act
In addition, as discussed further in the Exchange's Statement on Burden on Competition below, the Exchange expects that the Transaction will foster further innovation while facilitating efficient, transparent and well-regulated markets for issuers and investors, removing impediments to, and perfecting the mechanism of a free and open market and a national market system. The Transaction will benefit investors and the securities market as a whole by, among other things, enhancing competition among securities venues and reducing costs.
Furthermore, the Exchange is not proposing any significant changes to its existing operational and trading structure in connection with the change in ownership; the Exchange will operate in essentially the same manner upon Closing as it operates today. Therefore, the Exchange believes that it will continue to satisfy the requirements of the Act and the rules and regulations thereunder that are applicable to a national securities exchange. The changes that the Exchange is proposing to the Exchange Rules are designed to reflect the prospective affiliation with CBOE Holdings and the CBOE Exchanges. The Exchange believes that the proposed change to its Rules is consistent with the requirements of the Act and the rules and regulations thereunder.
The Exchange does not believe that the Proposed Rule Change would result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act. Indeed, the Exchange believes that the Proposed Rule Change will enhance competition among trading venues, as the Exchange believes that the Transaction will result in various synergies and efficiencies. For example, the Transaction will allow the Bats Exchanges and the CBOE Exchanges to utilize a single technology platform, which the Exchange expects will reduce Bats Exchanges' and the CBOE Exchanges' combined costs, creating the opportunity to further reduce costs to their respective members and other constituents. The potential use of a single technology platform may also reduce investors' costs of connecting to and using the Bats Exchanges and the CBOE Exchanges, including through the combination of data centers and market data services. Combining the expertise of the CBOE Exchanges' personnel with the expertise of the Bats Exchanges' personnel will also facilitate ongoing innovation, including through new product creation and platform improvements.
The Exchange notes that the Bats Exchanges and the CBOE Exchanges generally operate with different business models, target different customer bases and primarily focus on different asset classes, limiting any concern that the Transaction could burden competition. Therefore, the Exchange expects that the Transaction will benefit investors, issuers, shareholders and the market as a whole. The Exchange will continue to conduct regulated activities (including operating and regulating its market and members) of the type it currently conducts, but will be able to do so in a more efficient manner to the benefit of its members. These efficiencies will pass through to the benefit of investors and issuers, promoting further efficiencies, competition and capital formation, placing no burden on competition not necessary or appropriate in furtherance of the Act.
Furthermore, the Exchange's conclusion that the Proposed Rule Change would not result in any burden on competition that is not necessary or appropriate in furtherance of the purposes of the Act is consistent with the Commission's prior conclusions about similar combinations involving multiple exchanges in a single corporate family.
The Exchange has not solicited or received written comments on the Proposed Rule Change.
Within 45 days of the date of publication of this notice in the
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”),
The Exchange proposes to amend Commentary .14 to Rule 4770 (Compliance with Regulation NMS Plan to Implement a Tick Size Pilot) to provide the SEC with notice of its efforts to re-program its systems to eliminate a re-pricing functionality for certain orders in Test Group Three securities in connection with the Regulation NMS Plan to Implement a Tick Size Pilot Program (“Plan” or “Pilot”).
The text of the proposed rule change is set forth below. Proposed new language is underlined; deleted text is in brackets.
(a) through (d) No Change.
.01-.13 No change.
.14 Until [October 31, 2016]
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, the Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the Nasdaq Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
On September 7, 2016, The Nasdaq Stock Market LLC (“Nasdaq” or “Exchange”) filed with the Securities and Exchange Commission (“SEC” or “Commission”) a proposed rule change (“Proposal”) to adopt paragraph (d) and Commentary .12 to Exchange Rule 4770 to describe changes to system
In SR-NASDAQ-2016-126, Nasdaq had initially proposed a re-pricing functionality for Price to Comply Orders, Non-Displayed Orders, and Post-Only Orders entered through the OUCH and FLITE protocols in Group Three securities.
In that amendment, Nasdaq noted that this change would only impact the treatment of Price to Comply Orders, Non-Displayed Orders, and Post-Only orders that are submitted through the OUCH and FLITE protocols in Test Group Three Pilot Securities, as these types of Orders that are currently submitted to Nasdaq through the RASH, QIX or FIX protocols are already subject to this re-pricing functionality and will remain subject to this functionality under the Pilot.
In the Amendment, Nasdaq further noted that its systems are currently programmed so that Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities may be adjusted repeatedly to reflect changes to the NBBO and/or the best price on the Nasdaq book. Nasdaq stated that it is re-programming its systems to remove this functionality for Price to Comply Orders, Non-Displayed Orders and Post-Only Orders entered through the OUCH and FLITE protocols in Test Group Three Securities. In the Amendment, Nasdaq stated that it anticipated that this re-programming shall be completed no later than November 30, 2016. If it appeared that this functionality would remain operational by October 17, 2016, Nasdaq indicated that it would file a proposed rule change with the SEC and will provide notice to market participants sufficiently in advance of that date to provide effective notice. The rule change and the notice to market participants would describe the current operation of the Nasdaq systems in this regard, and the timing related to the re-programming.
On October 17, 2016, Nasdaq filed a proposal to extend the date by which it would complete the re-programing of its systems to eliminate the re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols.
Subsequent to the approval of SR-NASDAQ-2016-126, Nasdaq become aware that this re-pricing functionality also applies to Price to Display Orders that are entered through the OUCH and FLITE protocols in Test Group Three Securities, and included those Orders as part of SR-NASDAQ-2016-143 accordingly. Price to Display Orders will be treated in the same manner as Price to Comply Orders under the re-pricing functionality.
At this time, Nasdaq is still determining how to modify its systems to eliminate the current re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols. Nasdaq is therefore submitting this proposal to extend the date by which the current re-pricing functionality will be eliminated. Nasdaq anticipates that the re-programming to eliminate the current re-pricing functionality shall be completed on or before November 14, 2016.
Therefore, the current treatment of Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols in Test Group Three securities shall be as follows:
Following entry, and if market conditions allow, a Price to Comply Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Comply Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Price to Display Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO until such time as the Price to Display Order is able to be ranked and displayed at its original entered limit price.
Following entry, and if market conditions allow, a Non-Displayed Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO up (down) to the Order's limit price.
Following entry, and if market conditions allow, a Post-Only Order in a Test Group Three Pilot Security will be adjusted repeatedly in accordance with changes to the NBBO or the best price on the Nasdaq Book, as applicable until such time as the Post-Only Order is able to be ranked and displayed at its original entered limit price.
The Exchange believes that its proposal is consistent with Section 6(b) of the Act,
Nasdaq also believes that the proposal is consistent with the Act because the re-pricing functionality will not significantly impact the data gathered pursuant to the Pilot. Nasdaq notes that this re-pricing functionality only affects Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols for Test Group Three securities until the re-pricing functionality is eliminated, and only becomes relevant when an Order in a Test Group Three security would cross a Protected Quotation of another market center. Nasdaq has analyzed data relating to the frequency with which Orders in Test Group Three securities are entered with a limit price that would cross a Protected Quotation of another market center, and believes that the re-pricing functionality will be triggered infrequently once Test Group Three becomes fully operational.
The Exchange does not believe that the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The purpose of this proposal is to provide the SEC and market participants with notice of Nasdaq's efforts to remove its re-pricing functionality in Test Group Three securities for Price to Comply Orders, Price to Display Orders, Non-Displayed Orders, and Post-Only Orders that are entered through the OUCH or FLITE protocols, consistent with its statements in SR-NASDAQ-2016-126 and SR-NASDAQ-2016-143.
No written comments were either solicited or received.
Because the foregoing proposed rule change does not: (i) Significantly affect the protection of investors or the public interest; (ii) impose any significant burden on competition; and (iii) become operative for 30 days from the date on which it was filed, or such shorter time as the Commission may designate, it has become effective pursuant to Section 19(b)(3)(A)(iii) of the Act
A proposed rule change filed under Rule 19b-4(f)(6) normally does not become operative prior to 30 days after the date of filing. Rule 19b-4(f)(6)(iii), however, permits the Commission to designate a shorter time if such action is consistent with the protection of investors and the public interest. The Exchange requests that the Commission waive the 30-day operative delay contained in Rule 19b-4(f)(6)(iii) so that this proposed change will be in operative as of October 31, 2016, the date that Test Group Three securities are fully implemented and are subject to the quoting and trading restrictions of the Plan and, therefore, the relevant language in Rule 4770.
The Commission believes that waiving the 30-day operative delay is consistent with the protection of investors and the public interest because it will allow the Exchange to implement the proposed rules immediately thereby preventing delays in the implementation of the Plan. The Commission notes that the Pilot started implementation on October 3, 2016, Test Group Three securities were fully phased into the Pilot on October 31, 2016, and waiving the 30-day operative delay would ensure that the rules of the Exchange would be in place during implementation. Therefore, the Commission hereby waives the 30-day operative delay and designates the proposed rule change to be operative upon filing with the Commission.
At any time within 60 days of the filing of the proposed rule change, the Commission summarily may temporarily suspend such rule change if it appears to the Commission that such action is: (i) Necessary or appropriate in the public interest; (ii) for the protection of investors; or (iii) otherwise in furtherance of the purposes of the Act. If the Commission takes such action, the Commission shall institute proceedings to determine whether the proposed rule should be approved or disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
Notice is hereby given that pursuant to the Paperwork Reduction Act of 1995 (“PRA”) (44 U.S.C. 3501
Rule 602 of Regulation NMS, Dissemination of Quotations in NMS securities, contains two related collections. The first collection of information is found in Rule 602(a).
It is anticipated that twenty respondents, consisting of nineteen national securities exchanges and one national securities association, will collectively respond approximately 2,184,303,485,488 times per year pursuant to Rule 602(a) at 18.22 microseconds per response, resulting in a total annual burden of approximately 11,640 hours. It is anticipated that no respondents will have a reporting burden pursuant to Rule 602(b).
Thus, the aggregate third-party disclosure burden under Rule 602 is 11,640 hours annually which is comprised of 11,640 hours relating to Rule 602(a) and 0 hours relating to Rule 602(b).
Compliance with Rule 602 of Regulation NMS is mandatory and the information collected is made available to the public.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information under the PRA unless it displays a currently valid OMB control number.
The public may view background documentation for this information collection at the following Web site:
Pursuant to Section 19(b)(1) of the Securities Exchange Act of 1934 (“Act”)
The Exchange submits this rule filing in connection with a proposed corporate transaction (the “Transaction”) involving its ultimate parent company, CBOE Holdings, Inc. (“CBOE Holdings”), two wholly owned subsidiaries of CBOE Holdings, CBOE Corporation and CBOE V, LLC (“CBOE V”), and Bats Global Markets, Inc. (“BGM”). BGM is the ultimate parent company of Bats BZX Exchange, Inc. (“Bats BZX”), Bats BYX Exchange, Inc. (“Bats BYX”), Bats EDGX Exchange, Inc. (“Bats EDGX”), and Bats EDGA Exchange, Inc. (“Bats EDGA” and, together with Bats BZX, Bats BYX, and Bats EDGX, the “Bats Exchanges”). Upon completion of the Transaction (the “Closing”), CBOE Holdings will become the ultimate parent of the Bats Exchanges.
On September 25, 2016, CBOE Holdings, CBOE Corporation, CBOE V, and BGM entered into an Agreement and Plan of Merger, as it may be amended from time to time (the “Merger Agreement”). In connection with the Transaction, the Exchange seeks the Commission's approval of a provision in the Merger Agreement regarding the composition of the CBOE Holdings Board of Directors (“CBOE Holdings Board”) upon the Closing. There are no
In its filing with the Commission, the Exchange included statements concerning the purpose of and basis for the proposed rule change and discussed any comments it received on the proposed rule change. The text of these statements may be examined at the places specified in Item IV below. The Exchange has prepared summaries, set forth in sections A, B, and C below, of the most significant aspects of such statements.
The Exchange submits this filing for Commission approval of a provision in the Merger Agreement regarding the composition of the CBOE Holdings Board upon Closing. Other than as described herein, the Exchange will continue to conduct its regulated activities (including operating and regulating its market and Trading Permit Holders) in essentially the same manner it conducts them today, and will not make any changes to its regulated activities in connection with the Transaction. The Exchange is not proposing any amendments to its trading and regulatory rules or organizational and governance documents at this time. If the Exchange determines to make any such changes, it will submit rule filings to the Commission proposing such changes to the extent required by the Act and the rules and regulations thereunder.
Each of CBOE and C2 Options Exchange, Incorporated (“C2” and, together with the Exchange, the “CBOE Exchanges”) is a Delaware corporation that is a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act.
Each Bats Exchange is a Delaware corporation that is a national securities exchange registered with the Commission pursuant to Section 6(a) of the Act.
Pursuant to and subject to the terms of the Merger Agreement, at the Closing, among other things, each share of BGM common stock (whether voting or non-voting) issued and outstanding (other than shares owned by CBOE Holdings, BGM or any of their respective subsidiaries, and certain shares held by BGM stockholders that are entitled to and properly demand appraisal rights) will be converted into the right to receive a particular number of shares of CBOE Holdings common stock, an amount of cash, or a combination of both, at the election of the holder of such share of BGM common stock. BGM will ultimately merge with and into CBOE Holdings' wholly owned subsidiary CBOE V, at which time the separate existence of BGM will cease and CBOE V will be the surviving company.
As a result of the Transaction, CBOE Holdings will be the ultimate parent of the Bats Exchanges, each of which will continue to operate separately. CBOE Holdings will continue to be a publicly owned company and the ultimate parent of the CBOE Exchanges, each of which will continue to operate separately.
In connection with the Transaction, CBOE Holdings agreed in the Merger Agreement to take all requisite actions so, as of the Closing, the CBOE Holdings Board will include three individuals designated by BGM who (1) are serving as BGM directors immediately prior to the Closing and (2) comply with the policies (including clarifications of the policies provided to BGM) of the Nominating and Governance Committee of the CBOE Holdings Board as in effect on the date of the Merger Agreement and previously provided to BGM (each of whom will be appointed to the CBOE Holdings Board as of the Closing). The CBOE Holdings Board currently consists of 14 directors.
The Exchange believes the proposed rule change is consistent with the Act and the rules and regulations thereunder applicable to the Exchange and, in particular, the requirements of Section 6(b) of the Act.
The proposed rule change is consistent with CBOE Holdings' organizational and governing documents previously filed with the Commission.
The Exchange is proposing no changes to its existing operational and trading structure in connection with the Transaction. Upon Closing, the Exchange will operate in essentially the same manner as it operates today. Therefore, the Exchange believes it will continue to satisfy the requirements of the Act and the rules and regulations thereunder applicable to a national securities exchange.
The Exchange does not believe the proposed rule change will impose any burden on competition not necessary or appropriate in furtherance of the purposes of the Act. The proposed rule change relates to the corporate governance of CBOE Holdings—specifically a change in composition of the CBOE Holdings Board in connection with a corporate transaction—and not the operations of the Exchange. This is not a competitive filing and, therefore, imposes no burden on competition.
The Exchange neither solicited nor received comments on the proposed rule change.
Within 45 days of the date of publication of this notice in the
A. by order approve or disapprove such proposed rule change, or
B. institute proceedings to determine whether the proposed rule change should be disapproved.
Interested persons are invited to submit written data, views, and arguments concerning the foregoing, including whether the proposed rule change is consistent with the Act. Comments may be submitted by any of the following methods:
• Use the Commission's Internet comment form (
• Send an email to
• Send paper comments in triplicate to Secretary, Securities and Exchange Commission, 100 F Street NE., Washington, DC 20549-1090.
For the Commission, by the Division of Trading and Markets, pursuant to delegated authority.
The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions of OMB-approved information collections.
SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.
Or you may submit your comments online through
I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than January 17, 2017. Individuals can obtain copies of the collection instruments by writing to the above email address.
Federal Aviation Administration (FAA), U.S. Department of Transportation (DOT).
Nineteenth RTCA SC-227 Standards of Navigation Performance Navigation Information on Electronic Maps.
The FAA is issuing this notice to advise the public of a meeting of Nineteenth RTCA SC-227 Standards of Navigation Performance Navigation Information on Electronic Maps.
The meeting will be held Monday through Thursday, December 05-08, 2016 09:00 a.m.-05:00 p.m.
The meeting will be held at: RTCA Headquarters, 1150 18th Street NW., Suite 910, Washington, DC 20036.
Claudia Chaudhari at
Pursuant to section 10(a)(2) of the Federal Advisory Committee Act (Pub. L. 92-463, 5 U.S.C., App.), notice is hereby given for a meeting of the Nineteenth RTCA SC-227 Standards of Navigation Performance Navigation Information on Electronic Maps. The agenda will include the following:
All other times will be designated for Working Groups.
Attendance is open to the interested public but limited to space availability. With the approval of the chairman, members of the public may present oral statements at the meeting. Persons wishing to present statements or obtain information should contact the person listed in the
Federal Aviation Administration (FAA), U.S. Department of Transportation (DOT).
Second RTCA SC-236 Joint Plenary with EUROCAE WG-96.
The FAA is issuing this notice to advise the public of a meeting of Second RTCA SC-236 Joint Plenary with EUROCAE WG-96.
The meeting will be held December 5-7, 2016, 9:00 a.m.-5:00 p.m.
The meeting will be held at: Texas A&M University, College Station, Texas.
Rebecca Morrison at
Pursuant to section 10(a) (2) of the Federal Advisory Committee Act (Pub. L. 92-463, 5 U.S.C., App.), notice is hereby given for a meeting of the Second RTCA SC-236 Joint Plenary with EUROCAE WG-96. The agenda will include the following:
Attendance is open to the interested public but limited to space availability. With the approval of the chairman, members of the public may present oral statements at the meeting. Persons wishing to present statements or obtain information should contact the person listed in the
Federal Motor Carrier Safety Administration (FMCSA), DOT.
Notice of renewal of exemptions; request for comments.
FMCSA announces its decision to renew the exemptions from
Each group of renewed exemptions are effective from the dates stated in the discussions below. Comments must be received on or before December 15, 2016.
You may submit comments bearing the Federal Docket Management System (FDMS) numbers: [Docket No. FMCSA-1998-3637; FMCSA-2000-7006; FMCSA-2000-7165; FMCSA-2000-8203; FMCSA-2001-10578; FMCSA-2002-12294; FMCSA-2004-18885; FMCSA-2008-0106; FMCSA-2008-0231; FMCSA-2008-0266; FMCSA-2010-0082; FMCSA-2010-0161; FMCSA-2010-0187; FMCSA-2010-0201; FMCSA-2011-0324; FMCSA-2012-0105; FMCSA-2012-0215; FMCSA-2014-0005; FMCSA-2014-0006; FMCSA-2014-0007; FMCSA-2014-0010; FMCSA-2014-0011; FMCSA-2014-0296; FMCSA-2014-0297], using any of the following methods:
•
•
•
•
Ms. Christine A. Hydock, Chief, Medical Programs Division, Medical Programs Division, 202-366-4001,
Under 49 U.S.C. 31136(e) and 31315, FMCSA may renew an exemption from the vision requirements in 49 CFR 391.41(b)(10), which applies to drivers of CMVs in interstate commerce, for a two-year period if it finds “such exemption would likely achieve a level of safety that is equivalent to or greater than the level that would be achieved absent such exemption.” The procedures for requesting an exemption (including renewals) are set out in 49 CFR part 381.
This notice addresses 38 individuals who have requested renewal of their exemptions in accordance with FMCSA procedures. FMCSA has evaluated these 38 applications for renewal on their merits and decided to extend each exemption for a renewable two-year period. Each individual is identified according to the renewal date.
The exemptions are extended subject to the following conditions: (1) That each individual has a physical examination every year (a) by an ophthalmologist or optometrist who attests that the vision in the better eye continues to meet the requirements in 49 CFR 391.41(b)(10), and (b) by a medical examiner who attests that the individual is otherwise physically qualified under 49 CFR 391.41; (2) that each individual provides a copy of the ophthalmologist's or optometrist's report to the medical examiner at the time of the annual medical examination; and (3) that each individual provide a copy of the annual medical certification to the employer for retention in the driver's qualification file and retains a copy of the certification on his/her person while driving for presentation to a duly authorized Federal, State, or local enforcement official. Each exemption will be valid for two years unless rescinded earlier by FMCSA. The exemption will be rescinded if: (1) The person fails to comply with the terms and conditions of the exemption; (2) the exemption has resulted in a lower level of safety than was maintained before it was granted; or (3) continuation of the exemption would not be consistent with the goals and objectives of 49 U.S.C. 31136(e) and 31315.
Under 49 U.S.C. 31315(b)(1), an exemption may be granted for no longer than two years from its approval date and may be renewed upon application for additional two year periods. The following group(s) of drivers will receive renewed exemptions effective in the month of November and are discussed below.
As of November 9, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 36 individuals have satisfied the conditions for obtaining a renewed exemption from the vision requirements (63 FR 196; 63 FR 30285; 65 FR 20245; 65 FR 33406; 65 FR 57230; 65 FR 57234; 65 FR 66293; 66 FR 53826; 66 FR 66966; 67 FR 46016; 67 FR 57266; 67 FR 57267; 67 FR 67234; 68 FR 69434; 69 FR 51346; 69 FR 52741; 69 FR 53493; 69 FR 62741; 69 FR 62742; 70 FR 74102; 71 FR 50970; 71 FR 53489; 71 FR 62147; 71 FR 62148; 73 FR 35196; 73 FR 36955; 73 FR 46973; 73 FR 48270; 73 FR 48275; 73 FR 51336; 73 FR 51689; 73 FR 54888; 73 FR 61925; 73 FR 63047; 73 FR 74565; 75 FR 25919; 75 FR 36779; 75 FR 39725; 75 FR 39729; 75 FR 44051; 75 FR 47883; 75 FR 50799; 75 FR 52061; 75 FR 52062; 75 FR 52063; 75 FR 54958; 75 FR 59327; 75 FR 61833; 75 FR 63257; 75 FR 64396; 75 FR 66423; 75 FR 70078; 77 FR 7657; 77 FR 22059; 77 FR 27852; 77 FR 38384; 77 FR 39379; 77 FR 40946; 77 FR 46153; 77 FR 48590; 77 FR 52381; 77 FR 52388; 77 FR 52389; 77 FR 60010; 77 FR 64582; 77 FR 64583; 77 FR 64841; 77 FR 68199; 77 FR 68200; 79 FR 27681; 79 FR
The drivers were included in one of the following dockets: Docket Nos. FMCSA-1998-3637; FMCSA-2000-7006; FMCSA-2000-7165; FMCSA-2000-8203; FMCSA-2001-10578; FMCSA-2002-12294; FMCSA-2004-18885; FMCSA-2008-0106; FMCSA-2008-0231; FMCSA-2008-0266; FMCSA-2010-0082; FMCSA-2010-0161; FMCSA-2010-0187; FMCSA-2010-0201; FMCSA-2011-0324; FMCSA-2012-0105; FMCSA-2012-0215; FMCSA-2014-0005; FMCSA-2014-0006; FMCSA-2014-0007; FMCSA-2014-0010; FMCSA-2014-0011; FMCSA-2014-0296. Their exemptions are effective as of November 9, 2016, and will expire on November 9, 2018.
As of November 22, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 2 individuals have satisfied the conditions for obtaining a renewed exemption from the vision requirements (79 FR 63211; 80 FR 2471):
The drivers were included in one of the following dockets: Docket No. FMCSA-2014-0297. Their exemptions are effective as of November 22, 2016, and will expire on November 22, 2018.
Each of the 38 applicants listed in the groups above has requested renewal of the exemption and has submitted evidence showing that the vision in the better eye continues to meet the requirement specified at 49 CFR 391.41(b)(10) and that the vision impairment is stable. In addition, a review of each record of safety while driving with the respective vision deficiencies over the past two years indicates each applicant continues to meet the vision exemption requirements.
These factors provide an adequate basis for predicting each driver's ability to continue to drive safely in interstate commerce. Therefore, FMCSA concludes that extending the exemption for each renewal applicant for a period of two years is likely to achieve a level of safety equal to that existing without the exemption.
FMCSA will review comments received at any time concerning a particular driver's safety record and determine if the continuation of the exemption is consistent with the requirements at 49 U.S.C. 31136(e) and 31315. However, FMCSA requests that interested parties with specific data concerning the safety records of these drivers submit comments by December 15, 2016.
FMCSA believes that the requirements for a renewal of an exemption under 49 U.S.C. 31136(e) and 31315 can be satisfied by initially granting the renewal and then requesting and evaluating, if needed, subsequent comments submitted by interested parties. As indicated above, the Agency previously published notices of final disposition announcing its decision to exempt these 38 individuals from the vision requirement in 49 CFR 391.41(b)(10). The final decision to grant an exemption to each of these individuals was made on the merits of each case and made only after careful consideration of the comments received to its notices of applications. The notices of applications stated in detail the qualifications, experience, and medical condition of each applicant for an exemption from the vision requirements. That information is available by consulting the above cited
Interested parties or organizations possessing information that would otherwise show that any, or all, of these drivers are not currently achieving the statutory level of safety should immediately notify FMCSA. The Agency will evaluate any adverse evidence submitted and, if safety is being compromised or if continuation of the exemption would not be consistent with the goals and objectives of 49 U.S.C. 31136(e) and 31315, FMCSA will take immediate steps to revoke the exemption of a driver.
You may submit your comments and material online or by fax, mail, or hand delivery, but please use only one of these means. FMCSA recommends that you include your name and a mailing address, an email address, or a phone number in the body of your document so that FMCSA can contact you if there are questions regarding your submission.
To submit your comment online, go to
We will consider all comments and material received during the comment period. FMCSA may issue a final rule at any time after the close of the comment period.
To view comments, as well as any documents mentioned in this preamble, go to
Federal Motor Carrier Safety Administration (FMCSA), DOT.
Notice of renewal of exemptions; request for comments.
FMCSA announces its decision to renew the exemptions of 117 individuals from its rule prohibiting persons with insulin-treated diabetes mellitus (ITDM) from operating commercial motor vehicles (CMVs) in interstate commerce. FMCSA has statutory authority to exempt individuals from this rule if the exemptions granted will not compromise safety. The Agency has concluded that granting these exemption renewals will provide a level of safety that is equivalent to or greater than the level of safety maintained without the exemptions for these CMV drivers.
Each group of renewed exemptions are effective from the dates stated in the discussions below. Comments must be received on or before December 15, 2016.
You may submit comments bearing the Federal Docket Management System (FDMS) numbers: Docket No. FMCSA-2010-0247; FMCSA-2012-0128; FMCSA-2012-0217; FMCSA-2012-0219; FMCSA-2014-0021, using any of the following methods:
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Ms. Christine A. Hydock, Chief, Medical Programs Division, 202-366-4001,
Under 49 U.S.C. 31136(e) and 31315, FMCSA may renew an exemption from the Federal Motor Carrier Safety Regulations 2-year period if it finds “such exemption would likely achieve a level of safety that is equivalent to or greater than the level that would be achieved absent such exemption.” The statute also allows the Agency to renew exemptions at the end of the 2-year period. The 117 individuals listed in this notice have recently become eligible for a renewed exemption from the diabetes prohibition in 49 CFR 391.41(b)(3), which applies to drivers of CMVs in interstate commerce. The drivers remain in good standing with the Agency, have maintained their required medical monitoring and have not exhibited any medical issues that would compromise their ability to safely operate a CMV during the previous 2-year exemption period.
This notice addresses 117 individuals who have requested renewal of their exemptions in accordance with FMCSA procedures. These 117 drivers remain in good standing with the Agency, have maintained their required medical monitoring and have not exhibited any medical issues that would compromise their ability to safely operate a CMV during the previous 2-year exemption period. Therefore, FMCSA has decided to extend each exemption for a renewable two-year period. Each individual is identified according to the renewal date.
The exemptions are renewed subject to the following conditions: (1) That each individual submit a quarterly monitoring checklist completed by the treating endocrinologist as well as an annual checklist with a comprehensive medical evaluation; (2) that each individual reports within 2 business days of occurrence, all episodes of severe hypoglycemia, significant complications, or inability to manage diabetes; also, any involvement in an accident or any other adverse event in a CMV or personal vehicle, whether or not it is related to an episode of hypoglycemia; (3) that each individual submit an annual ophthalmologist's or optometrist's report; and (4) that each individual provide a copy of the annual medical certification to the employer for retention in the driver's qualification file, or keep a copy in his/her driver's
Under 49 U.S.C. 31315(b)(1), an exemption may be granted for no longer than two years from its approval date and may be renewed upon application for additional two year periods. The following groups of drivers received renewed exemptions in the month of October and are discussed below.
As of October 8, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following individual, Gary B. Bland (GA), has satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (75 FR 52813; 75 FR 64394). The driver was included in Docket No. FMCSA-2010-0247. The exemption is effective as of October 8, 2016, and will expire on October 8, 2018.
As of October 10, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 8 individuals have satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (77 FR 48587; 77 FR 61655).
The drivers were included in Docket No. FMCSA-2012-0217. Their exemptions are effective as of October 10, 2016, and will expire on October 10, 2018.
As of October 19, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 14 individuals have satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (75 FR 52813; 75 FR 64394).
The drivers were included in Docket No. FMCSA-2010-0247. Their exemptions are effective as of October 19, 2016, and will expire on October 19, 2018.
As of October 21, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 71 individuals have satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (79 FR 56107; 79 FR 73946):
The drivers were included in Docket No. FMCSA-2014-0021. Their exemptions are effective as of October 21, 2016, and will expire on October 21, 2018.
As of October 22, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 16 individuals have satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (77 FR 52384; 77 FR 64585).
The drivers were included in Docket No. FMCSA-2012-0128. Their exemptions are effective as of October 22, 2016, and will expire on October 22, 2018.
As of October 31, 2016, and in accordance with 49 U.S.C. 31136(e) and 31315, the following 7 individuals have satisfied the renewal conditions for obtaining an exemption from the rule prohibiting drivers with ITDM from driving CMVs in interstate commerce (77 FR 56258; 77 FR 65929).
The drivers were included in Docket No. FMCSA-2012-0219. Their
Each of the 117 drivers in the aforementioned groups qualifies for a renewal of the exemption. They have maintained their required medical monitoring and have not exhibited any medical issues that would compromise their ability to safely operate a CMV during the previous 2-year exemption period.
These factors provide an adequate basis for predicting each driver's ability to continue to drive safely in interstate commerce. Therefore, FMCSA concludes that extending the exemption for each of the 117 drivers for a period of two years is likely to achieve a level of safety equal to that existing without the exemption. The drivers were included in docket numbers FMCSA-2010-0247; FMCSA-2012-0128; FMCSA-2012-0217; FMCSA-2012-0219; FMCSA-2014-0021.
FMCSA will review comments received at any time concerning a particular driver's safety record and determine if the continuation of the exemption is consistent with the requirements at 49 U.S.C. 31136(e) and 31315. However, FMCSA requests that interested parties with specific data concerning the safety records of these drivers submit comments by December 15, 2016.
FMCSA believes that the requirements for a renewal of an exemption under 49 U.S.C. 31136(e) and 31315 can be satisfied by initially granting the renewal and then requesting and evaluating, if needed, subsequent comments submitted by interested parties. As indicated above, the Agency previously published notices of final disposition announcing its decision to exempt these 117 individuals from rule prohibiting persons with ITDM from operating CMVs in interstate commerce in 49 CFR 391.41(b)(3). The final decision to grant an exemption to each of these individuals was made on the merits of each case and made only after careful consideration of the comments received to its notices of applications. The notices of applications stated in detail the medical condition of each applicant for an exemption from rule prohibiting persons with ITDM from operating CMVs in interstate commerce. That information is available by consulting the above cited
Interested parties or organizations possessing information that would otherwise show that any, or all, of these drivers are not currently achieving the statutory level of safety should immediately notify FMCSA. The Agency will evaluate any adverse evidence submitted and, if safety is being compromised or if continuation of the exemption would not be consistent with the goals and objectives of 49 U.S.C. 31136(e) and 31315, FMCSA will take immediate steps to revoke the exemption of a driver.
You may submit your comments and material online or by fax, mail, or hand delivery, but please use only one of these means. FMCSA recommends that you include your name and a mailing address, an email address, or a phone number in the body of your document so that FMCSA can contact you if there are questions regarding your submission.
To submit your comment online, go to
We will consider all comments and material received during the comment period. FMCSA may issue a final determination at any time after the close of the comment period.
To view comments, as well as any documents mentioned in this preamble, go to
Department of Veterans Affairs.
Notice of tribal consultation.
The Department of Veterans Affairs (VA), Veterans Health Administration (VHA) will facilitate a Tribal Consultation on VHA's effort to improve continuity of care and health care access for Veterans by consolidating multiple community care programs, previously known as non-VA care, into one standard program with standard rates. In October 2015, VA submitted to Congress the
Comments must be received by VA on or before November 30, 2016.
Written comments should be submitted by email at
Majed Ibrahim, VA Office of Community Care, VHA at (562) 400-3134 (this is not a toll-free number), or by email at
VA is seeking consultation and comments on the following questions:
(1) What would be the impact of transitioning from the existing reimbursement agreement structure, which requires each tribe to enter into an individual reimbursement agreement with VA, to a standard arrangement for reimbursement of direct care services provided to eligible Veterans managed by a third party administrator for VA?
(2) Would tribal health programs be interested in expanding direct care services under this new structure to include reimbursements for care provided to all Veterans enrolled in VA health care, regardless of whether they are eligible for health care funded by Indian Health Service (IHS) or not?
(3) Would tribal health programs be interested in receiving standard reimbursement rates based on Medicare rates plus a feasible percentage of those rates to minimize improper payments and comply with industry standards?
(4) Would tribal health programs be interested in extending existing reimbursement agreements between VA and tribal health programs through December 2018 and ensuring any new reimbursement agreements between VA and tribal health programs extend through December 2018, as VA works in collaboration with tribes and other VA stakeholders on implementing a consolidated community care program?
Tribal leaders and/or their designated representatives and other interested parties are invited to attend and provide comments during the in-person consultation and/or submit written comments.
Centers for Medicare & Medicaid Services (CMS), HHS.
Final rule.
This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.
These regulations are effective on January 1, 2017.
Jessica Bruton, (410) 786-5991, for issues related to identification of potentially misvalued services and any physician payment issues not identified below.
Gail Addis, (410) 786-4522, for issues related to diabetes self-management training.
Jaime Hermansen, (410) 786-2064, for issues related to moderate sedation coding and anesthesia services.
Roberta Epps, (410) 786-4503, for issues related to PAMA section 218(a) policy and the transition from traditional x-ray imaging to digital radiography.
Ann Marshall, (410) 786-3059, for primary care issues related to chronic care management (CCM), burden reduction, telehealth services and evaluation and management services.
Emily Yoder, (410) 786-1804, for issues related to resource intensive services, telehealth services and other primary care issues.
Lindsey Baldwin, (410) 786-1694, for primary care issues related to behavioral health integration services.
Geri Mondowney, (410) 786-4584, and Donta Henson, (410) 786-1947, for issues related to geographic practice cost indices.
Michael Soracoe, (410) 786-6312, for issues related to the target and phase-in provisions, the practice expense methodology, impacts, conversion factor, and the valuation of pathology and surgical procedures.
Pamela West, (410) 786-2302, for issues related to therapy.
Patrick Sartini, (410) 786-9252, for issues related to malpractice RVUs, radiation treatment, mammography and other imaging services.
Kathy Bryant, (410) 786-3448, for issues related to collecting data on resources used in furnishing global services.
Donta Henson, (410) 786-1947, for issues related to ophthalmology services.
Corinne Axelrod, (410) 786-5620, for issues related to rural health clinics or federally qualified health centers.
Simone Dennis, (410) 786-8409, for issues related to FQHC-specific market basket.
JoAnna Baldwin, (410) 786-7205, or Sarah Fulton, (410) 786-2749, for issues related to appropriate use criteria for advanced diagnostic imaging services.
Robin Usi, (410) 786-0364, for issues related to open payments.
Sean O'Grady, (410) 786-2259, or Julie Uebersax, (410) 786-9284, for issues related to release of pricing data from Medicare Advantage bids and release of medical loss ratio data submitted by Medicare Advantage organizations and Part D sponsors.
Sara Vitolo, (410) 786-5714, for issues related to prohibition on billing qualified Medicare beneficiary individuals for Medicare cost-sharing.
Michelle Peterman, (410) 786-2591, for issues related to Accountable Care Organization (ACO) participants who report PQRS quality measures separately.
Katie Mucklow, (410) 786-0537 or John Spiegel, (410) 786-1909, for issues related to Provider Enrollment Medicare Advantage Program.
Jen Zhu, (410) 786-3725, Carlye Burd, (410) 786-1972, or Nina Brown, (410) 786-6103, for issues related to Medicare Diabetes Prevention Program model expansion.
Rabia Khan or Terri Postma, (410) 786-8084 or
Kimberly Spalding Bush, (410) 786-3232, or Fiona Larbi, (410) 786-7224, for issues related to Value-based Payment Modifier and Physician Feedback Program.
Lisa Ohrin Wilson, (410) 786-8852, or Gabriel Scott, (410) 786-3928, for issues related to physician self-referral updates.
In addition, because of the many organizations and terms to which we refer by acronym in this final rule, we are listing these acronyms and their corresponding terms in alphabetical order below:
The PFS Addenda along with other supporting documents and tables referenced in this final rule are available through the Internet on the CMS Web site at
Throughout this final rule, we use CPT codes and descriptions to refer to a variety of services. We note that CPT codes and descriptions are copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable Federal Acquisition Regulations (FAR) and Defense Federal Acquisition Regulations (DFAR) apply.
This major final rule revises payment polices under the Medicare Physician Fee Schedule (PFS) and makes other policy changes related to Medicare Part B payment. These changes will be applicable to services furnished in CY 2017. In addition, this final rule includes the following provisions: Payment policy changes for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs); expansion of the Medicare Diabetes Prevention Program model; policy changes related to the Medicare Shared Savings Program; and release of pricing data submitted to CMS by Medicare Advantage (MA) organizations; and medical loss ratio reports submitted by MA plans and Part D plans. These additional policies are addressed in section III. of this final rule.
The statute requires us to establish payments under the PFS based on national uniform relative value units (RVUs) that account for the relative resources used in furnishing a service. The statute requires that RVUs be established for three categories of resources: Work, practice expense (PE); and malpractice (MP) expense; and, that we establish by regulation each year's payment amounts for all physicians' services paid under the PFS, incorporating geographic adjustments to reflect the variations in the costs of furnishing services in different geographic areas. In this major final rule, we establish RVUs for CY 2017 for the PFS, and other Medicare Part B payment policies, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes summaries of public comments and final policies regarding:
• Potentially Misvalued Codes.
• Telehealth Services.
• Establishing Values for New, Revised, and Misvalued Codes.
• Target for Relative Value Adjustments for Misvalued Services.
• Phase-in of Significant RVU Reductions.
• Chronic Care Management (CCM) and Transitional Care Management (TCM) Supervision Requirements in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
• FQHC-Specific Market Basket.
• Appropriate Use Criteria for Advanced Diagnostic Imaging Services.
• Reports of Payments or Other Transfers of Value to Covered Recipients: Solicitation of Public Comments.
• Release of Part C Medicare Advantage Bid Pricing Data and Part C and Part D Medical Loss Ratio (MLR) Data.
• Prohibition on Billing Qualified Medicare Beneficiary Individuals for Medicare Cost-Sharing.
• Recoupment or Offset of Payments to Providers Sharing the Same Taxpayer Identification Number.
• Accountable Care Organization (ACO) Participants Who Report Physician Quality Reporting System (PQRS) Quality Measures Separately.
• Medicare Advantage Provider Enrollment.
• Expansion of the Diabetes Prevention Program (DPP) Model.
• Medicare Shared Savings Program.
• Value-Based Payment Modifier and the Physician Feedback Program.
• Physician Self-referral Updates.
• Designated Health Services.
The statute requires that annual adjustments to PFS RVUs may not cause annual estimated expenditures to differ by more than $20 million from what they would have been had the adjustments not been made. If adjustments to RVUs would cause expenditures to change by more than $20 million, we must make adjustments to preserve budget neutrality. These adjustments can affect the distribution of Medicare expenditures across specialties. In addition, several changes in this final rule will affect the specialty distribution of Medicare expenditures. When considering the combined impact of work, PE, and MP RVU changes, the projected payment impacts would be small for most specialties; however, the impact would be larger for a few specialties.
We have determined that this major final rule is economically significant. For a detailed discussion of the economic impacts, see section VI. of this final rule.
Since January 1, 1992, Medicare has paid for physicians' services under section 1848 of the Social Security Act (the Act), “Payment for Physicians' Services.” The PFS relies on national relative values that are established for work, PE, and MP, which are adjusted for geographic cost variations. These values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. The concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239, enacted on December 19, 1989) (OBRA '89), and the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508, enacted on November 5, 1990) (OBRA '90). The final rule published on November 25, 1991 (56 FR 59502) set forth the first fee schedule used for payment for physicians' services.
We note that throughout this major final rule, unless otherwise noted, the term “practitioner” is used to describe both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for services furnished to Medicare beneficiaries.
The work RVUs established for the initial fee schedule, which was implemented on January 1, 1992, were developed with extensive input from the physician community. A research team at the Harvard School of Public Health developed the original work RVUs for most codes under a cooperative agreement with the Department of Health and Human Services (HHS). In constructing the code-specific vignettes used in determining the original physician work RVUs, Harvard worked with panels of experts, both inside and outside the federal government, and obtained input from numerous physician specialty groups.
As specified in section 1848(c)(1)(A) of the Act, the work component of physicians' services means the portion
Initially, only the work RVUs were resource-based, and the PE and MP RVUs were based on average allowable charges. Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 103-432, enacted on October 31, 1994), amended section 1848(c)(2)(C)(ii) of the Act and required us to develop resource-based PE RVUs for each physicians' service beginning in 1998. We were required to consider general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expenses) comprising PEs. The PE RVUs continue to represent the portion of these resources involved in furnishing PFS services.
Originally, the resource-based method was to be used beginning in 1998, but section 4505(a) of the Balanced Budget Act of 1997 (Pub. L. 105-33, enacted on August 5, 1997) (BBA) delayed implementation of the resource-based PE RVU system until January 1, 1999. In addition, section 4505(b) of the BBA provided for a 4-year transition period from the charge-based PE RVUs to the resource-based PE RVUs.
We established the resource-based PE RVUs for each physicians' service in a final rule, published on November 2, 1998 (63 FR 58814), effective for services furnished in CY 1999. Based on the requirement to transition to a resource-based system for PE over a 4-year period, payment rates were not fully based upon resource-based PE RVUs until CY 2002. This resource-based system was based on two significant sources of actual PE data: The Clinical Practice Expert Panel (CPEP) data; and the AMA's Socioeconomic Monitoring System (SMS) data. (These data sources are described in greater detail in the CY 2012 final rule with comment period (76 FR 73033).
Separate PE RVUs are established for services furnished in facility settings, such as a hospital outpatient department (HOPD) or an ambulatory surgical center (ASC), and in nonfacility settings, such as a physician's office. The nonfacility RVUs reflect all of the direct and indirect PEs involved in furnishing a service described by a particular HCPCS code. The difference, if any, in these PE RVUs generally results in a higher payment in the nonfacility setting because in the facility settings some costs are borne by the facility. Medicare's payment to the facility (such as the outpatient prospective payment system (OPPS) payment to the HOPD) would reflect costs typically incurred by the facility. Thus, payment associated with those facility resources is not made under the PFS.
Section 212 of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113, enacted on November 29, 1999) (BBRA) directed the Secretary of Health and Human Services (the Secretary) to establish a process under which we accept and use, to the maximum extent practicable and consistent with sound data practices, data collected or developed by entities and organizations to supplement the data we normally collect in determining the PE component. On May 3, 2000, we published the interim final rule (65 FR 25664) that set forth the criteria for the submission of these supplemental PE survey data. The criteria were modified in response to comments received, and published in the
In the CY 2007 PFS final rule with comment period (71 FR 69624), we revised the methodology for calculating direct PE RVUs from the top-down to the bottom-up methodology beginning in CY 2007. We adopted a 4-year transition to the new PE RVUs. This transition was completed for CY 2010. In the CY 2010 PFS final rule with comment period, we updated the practice expense per hour (PE/HR) data that are used in the calculation of PE RVUs for most specialties (74 FR 61749). In CY 2010, we began a 4-year transition to the new PE RVUs using the updated PE/HR data, which was completed for CY 2013.
Section 4505(f) of the BBA amended section 1848(c) of the Act to require that we implement resource-based MP RVUs for services furnished on or after CY 2000. The resource-based MP RVUs were implemented in the PFS final rule with comment period published November 2, 1999 (64 FR 59380). The MP RVUs are based on commercial and physician-owned insurers' malpractice insurance premium data from all the states, the District of Columbia, and Puerto Rico. For more information on MP RVUs, see section II.B.2. of this final rule.
Section 1848(c)(2)(B)(i) of the Act requires that we review RVUs no less often than every 5 years. Prior to CY 2013, we conducted periodic reviews of work RVUs and PE RVUs independently. We completed five-year reviews of work RVUs that were effective for calendar years 1997, 2002, 2007, and 2012.
Although refinements to the direct PE inputs initially relied heavily on input from the RUC Practice Expense Advisory Committee (PEAC), the shifts to the bottom-up PE methodology in CY 2007 and to the use of the updated PE/HR data in CY 2010 have resulted in significant refinements to the PE RVUs in recent years.
In the CY 2012 PFS final rule with comment period (76 FR 73057), we finalized a proposal to consolidate reviews of work and PE RVUs under section 1848(c)(2)(B) of the Act and reviews of potentially misvalued codes under section 1848(c)(2)(K) of the Act into one annual process.
In addition to the five-year reviews, beginning for CY 2009, CMS and the RUC have identified and reviewed a number of potentially misvalued codes on an annual basis based on various identification screens. This annual review of work and PE RVUs for potentially misvalued codes was supplemented by the amendments to section 1848 of the Act, as enacted by section 3134 of the Affordable Care Act, that require the agency to periodically
As described in section VI.C. of this final rule, in accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs cause expenditures for the year to change by more than $20 million, we make adjustments to ensure that expenditures did not increase or decrease by more than $20 million.
To calculate the payment for each service, the components of the fee schedule (work, PE, and MP RVUs) are adjusted by geographic practice cost indices (GPCIs) to reflect the variations in the costs of furnishing the services. The GPCIs reflect the relative costs of work, PE, and MP in an area compared to the national average costs for each component.
RVUs are converted to dollar amounts through the application of a CF, which is calculated based on a statutory formula by CMS's Office of the Actuary (OACT). The formula for calculating the Medicare fee schedule payment amount for a given service and fee schedule area can be expressed as:
Section 1848(b)(2)(B) of the Act specifies that the fee schedule amounts for anesthesia services are to be based on a uniform relative value guide, with appropriate adjustment of an anesthesia conversion factor, in a manner to ensure that fee schedule amounts for anesthesia services are consistent with those for other services of comparable value. Therefore, there is a separate fee schedule methodology for anesthesia services. Specifically, we establish a separate conversion factor for anesthesia services and we utilize the uniform relative value guide, or base units, as well as time units, to calculate the fee schedule amounts for anesthesia services. Since anesthesia services are not valued using RVUs, a separate methodology for locality adjustments is also necessary. This involves an adjustment to the national anesthesia CF for each payment locality.
Section 220(d) of the Protecting Access to Medicare Act of 2014 (Pub. L. 113-93, enacted on April 1, 2014) (PAMA) added a new subparagraph (O) to section 1848(c)(2) of the Act to establish an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. If the estimated net reduction in expenditures for a year is equal to or greater than the target for that year, the provision specifies that reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS. The provision specifies that the amount by which such reduced expenditures exceed the target for a given year shall be treated as a reduction in expenditures for the subsequent year for purposes of determining whether the target for the subsequent year has been met. The provision also specifies that an amount equal to the difference between the target and the estimated net reduction in expenditures, called the target recapture amount, shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. The PAMA amendments originally made the target provisions applicable for CYs 2017 through 2020 and set the target for reduced expenditures at 0.5 percent of estimated expenditures under the PFS for each of those 4 years.
Subsequently, section 202 of the Achieving a Better Life Experience Act of 2014 (Division B of Pub. L. 113-295, enacted December 19, 2014) (ABLE) accelerated the application of the target, amending section 1848(c)(2)(O) of the Act to specify that target provisions apply for CYs 2016, 2017, and 2018; and setting a 1 percent target for reduced expenditures for CY 2016 and a 0.5 percent target for CYs 2017 and 2018. The implementation of the target legislation was finalized in the CY 2016 PFS final rule with comment period, and revisions are discussed in section II.G. of this final rule.
Section 1848(c)(7) of the Act, as added by section 220(e) of the PAMA, specified that for services that are not new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs for the previous year, the applicable adjustments in work, PE, and MP RVUs shall be phased in over a 2-year period. Section 220(e) of the PAMA required the phase-in of RVU reductions of 20 percent or more to begin for 2017. Section 1848(c)(7) of the Act was later amended by section 202 of the ABLE Act to require instead that the phase-in must begin in CY 2016. The implementation of the phase-in legislation was finalized in the CY 2016 PFS final rule with comment period and revisions in this year's rulemaking are discussed in section II.H. of this final rule.
Practice expense (PE) is the portion of the resources used in furnishing a service that reflects the general categories of physician and practitioner expenses, such as office rent and personnel wages, but excluding malpractice expenses, as specified in section 1848(c)(1)(B) of the Act. As required by section 1848(c)(2)(C)(ii) of the Act, we use a resource-based system for determining PE RVUs for each physicians' service. We develop PE RVUs by considering the direct and indirect practice resources involved in furnishing each service. Direct expense categories include clinical labor, medical supplies, and medical equipment. Indirect expenses include administrative labor, office expense, and all other expenses. The sections that follow provide more detailed information about the methodology for translating the resources involved in furnishing each service into service-specific PE RVUs. We refer readers to the CY 2010 PFS final rule with comment period (74 FR 61743 through 61748) for a more detailed explanation of the PE methodology.
We determine the direct PE for a specific service by adding the costs of the direct resources (that is, the clinical staff, medical supplies, and medical equipment) typically involved with furnishing that service. The costs of the resources are calculated using the refined direct PE inputs assigned to each CPT code in our PE database, which are generally based on our review of recommendations received from the RUC and those provided in response to public comment periods. For a detailed explanation of the direct PE methodology, including examples, we refer readers to the Five-Year Review of Work Relative Value Units under the PFS and Proposed Changes to the Practice Expense Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final rule with comment period (71 FR 69629).
We use survey data on indirect PEs incurred per hour worked in developing the indirect portion of the PE RVUs. Prior to CY 2010, we primarily used the practice expense per hour (PE/HR) by specialty that was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). The AMA administered a new survey in CY 2007 and CY 2008, the Physician Practice Expense Information Survey (PPIS). The PPIS is a multispecialty, nationally representative, PE survey of both physicians and nonphysician practitioners (NPPs) paid under the PFS using a survey instrument and methods highly consistent with those used for the SMS and the supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 physician specialty and health care professional groups. We believe the PPIS is the most comprehensive source of PE survey information available. We used the PPIS data to update the PE/HR data for the CY 2010 PFS for almost all of the Medicare-recognized specialties that participated in the survey.
When we began using the PPIS data in CY 2010, we did not change the PE RVU methodology itself or the manner in which the PE/HR data are used in that methodology. We only updated the PE/HR data based on the new survey. Furthermore, as we explained in the CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnitude of payment reductions for some specialties resulting from the use of the PPIS data, we transitioned its use over a 4-year period from the previous PE RVUs to the PE RVUs developed using the new PPIS data. As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), the transition to the PPIS data was complete for CY 2013. Therefore, PE RVUs from CY 2013 forward are developed based entirely on the PPIS data, except as noted in this section.
Section 1848(c)(2)(H)(i) of the Act requires us to use the medical oncology supplemental survey data submitted in 2003 for oncology drug administration services. Therefore, the PE/HR for medical oncology, hematology, and hematology/oncology reflects the continued use of these supplemental survey data.
Supplemental survey data on independent labs from the College of American Pathologists were implemented for payments beginning in CY 2005. Supplemental survey data from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), representing independent diagnostic testing facilities (IDTFs), were blended with supplementary survey data from the American College of Radiology (ACR) and implemented for payments beginning in CY 2007. Neither IDTFs, nor independent labs, participated in the PPIS. Therefore, we continue to use the PE/HR that was developed from their supplemental survey data.
Consistent with our past practice, the previous indirect PE/HR values from the supplemental surveys for these specialties were updated to CY 2006 using the Medicare Economic Index (MEI) to put them on a comparable basis with the PPIS data.
We also do not use the PPIS data for reproductive endocrinology and spine surgery since these specialties currently are not separately recognized by Medicare, nor do we have a method to blend the PPIS data with Medicare-recognized specialty data.
Previously, we established PE/HR values for various specialties without SMS or supplemental survey data by crosswalking them to other similar specialties to estimate a proxy PE/HR. For specialties that were part of the PPIS for which we previously used a crosswalked PE/HR, we instead used the PPIS-based PE/HR. We continue previous crosswalks for specialties that did not participate in the PPIS. However, beginning in CY 2010, we changed the PE/HR crosswalk for portable X-ray suppliers from radiology to IDTF, a more appropriate crosswalk because these specialties are more similar to each other for work time.
For registered dietician services, the resource-based PE RVUs have been calculated in accordance with the final policy that crosswalks the specialty to the “All Physicians” PE/HR data, as adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) and discussed in more detail in the CY 2011 PFS final rule with comment period (75 FR 73183). We have incorporated the available utilization data for interventional cardiology, which became a recognized Medicare specialty during 2014. We finalized the use of a proxy PE/HR value for interventional cardiology in the CY 2016 final rule with comment period (80 FR 70892), as there are no PPIS data for this specialty, by crosswalking the PE/HR from Cardiology, since the specialties furnish similar services in the Medicare claims data.
To establish PE RVUs for specific services, it is necessary to establish the direct and indirect PE associated with each service.
The relative relationship between the direct cost portions of the PE RVUs for any two services is determined by the relative relationship between the sum of the direct cost resources (that is, the clinical staff, medical supplies, and medical equipment) typically involved with furnishing each of the services. The costs of these resources are calculated from the refined direct PE inputs in our PE database. For example, if one service has a direct cost sum of $400 from our PE database and another service has a direct cost sum of $200, the direct portion of the PE RVUs of the first service would be twice as much as the direct portion of the PE RVUs for the second service.
Section II.A.2.b. of this final rule describes the current data sources for specialty-specific indirect costs used in our PE calculations. We allocated the indirect costs to the code level on the basis of the direct costs specifically associated with a code and the greater of either the clinical labor costs or the work RVUs. We also incorporated the survey data described earlier in the PE/HR discussion. The general approach to developing the indirect portion of the PE RVUs is as follows:
• For a given service, we used the direct portion of the PE RVUs calculated as previously described and the average percentage that direct costs represent of total costs (based on survey data) across the specialties that furnish the service to determine an initial indirect allocator. That is, the initial indirect allocator is
• Next, we added the greater of the work RVUs or clinical labor portion of the direct portion of the PE RVUs to this initial indirect allocator. In our example, if this service had a work RVU of 4.00 and the clinical labor portion of the direct PE RVU was 1.50, we would add 4.00 (since the 4.00 work RVUs are greater than the 1.50 clinical labor portion) to the initial indirect allocator of 6.00 to get an indirect allocator of 10.00. In the absence of any further use of the survey data, the relative relationship between the indirect cost portions of the PE RVUs for any two services would be determined by the relative relationship between these indirect cost allocators. For example, if one service had an indirect cost allocator of 10.00 and another service had an indirect cost allocator of 5.00, the indirect portion of the PE RVUs of the first service would be twice as great as the indirect portion of the PE RVUs for the second service.
• Next, we incorporated the specialty-specific indirect PE/HR data into the calculation. In our example, if, based on the survey data, the average indirect cost of the specialties furnishing the first service with an allocator of 10.00 was half of the average indirect cost of the specialties furnishing the second service with an indirect allocator of 5.00, the indirect portion of the PE RVUs of the first service would be equal to that of the second service.
For procedures that can be furnished in a physician's office, as well as in a facility setting, where Medicare makes a separate payment to the facility for its costs in furnishing a service, we establish two PE RVUs: Facility, and nonfacility. The methodology for calculating PE RVUs is the same for both the facility and nonfacility RVUs, but is applied independently to yield two separate PE RVUs. In calculating the PE RVUs for services furnished in a facility, we do not include resources that would generally not be provided by physicians when furnishing the service. For this reason, the facility PE RVUs are generally lower than the nonfacility PE RVUs.
Diagnostic services are generally comprised of two components: A professional component (PC) and a technical component (TC). The PC and TC may be furnished independently or by different providers, or they may be furnished together as a “global” service. When services have separately billable PC and TC components, the payment for the global service equals the sum of the payment for the TC and PC. To achieve this, we use a weighted average of the ratio of indirect to direct costs across all the specialties that furnish the global service, TCs, and PCs; that is, we apply the same weighted average indirect percentage factor to allocate indirect expenses to the global service, PCs, and TCs for a service. (The direct PE RVUs for the TC and PC sum to the global.)
For a more detailed description of the PE RVU methodology, we refer readers to the CY 2010 PFS final rule with comment period (74 FR 61745 through 61746). We also direct interested readers to the file called “Calculation of PE RVUs under Methodology for Selected Codes” which is available on our Web site under downloads for the CY 2017 PFS final rule at
First, we create a setup file for the PE methodology. The setup file contains the direct cost inputs, the utilization for each procedure code at the specialty and facility/nonfacility place of service level, and the specialty-specific PE/HR data calculated from the surveys.
Sum the costs of each direct input.
Create indirect allocators.
We use an average of the 3 most recent years of available Medicare claims data to determine the specialty mix assigned to each code. As we stated in the CY 2016 final rule with comment period (80 FR 70894), we believe that the 3-year average will mitigate the need to use dominant or expected specialty instead of the claims data. Because we incorporated CY 2015 claims data for use in the CY 2017 proposed rates, we believe that the finalized PE RVUs associated with the CY 2017 PFS final rule provide a first opportunity to determine whether service-level overrides of claims data are necessary. Currently, in the development of PE RVUs we apply only the overrides that also apply to the MP RVU calculation. Since the proposed PE RVUs include a new year of claims into the 3-year average for the first time, we solicited comment on the proposed CY 2017 PFS rates and whether or not the incorporation of a new year of utilization data into a 3-year average mitigates the need for alternative service-level overrides such as a claims-based approach (dominant specialty) or stakeholder-recommended approach
For most services the indirect allocator is: Indirect PE percentage * (direct PE RVUs/direct percentage) + work RVUs.
There are two situations where this formula is modified:
• If the service is a global service (that is, a service with global, professional, and technical components), then the indirect PE allocator is: Indirect percentage (direct PE RVUs/direct percentage) + clinical labor PE RVUs + work RVUs.
• If the clinical labor PE RVUs exceed the work RVUs (and the service is not a global service), then the indirect allocator is: Indirect PE percentage (direct PE RVUs/direct percentage) + clinical labor PE RVUs.
(
For presentation purposes, in the examples in the download file called “Calculation of PE RVUs under Methodology for Selected Codes”, the formulas were divided into two parts for each service.
• The first part does not vary by service and is the indirect percentage (direct PE RVUs/direct percentage).
• The second part is either the work RVU, clinical labor PE RVU, or both depending on whether the service is a global service and whether the clinical PE RVUs exceed the work RVUs (as described earlier in this step).
Apply a scaling adjustment to the indirect allocators.
Calculate the indirect practice cost index.
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•
•
•
•
We also make adjustments to volume and time that correspond to other payment rules, including special multiple procedure endoscopy rules and multiple procedure payment reductions (MPPRs). We note that section 1848(c)(2)(B)(v) of the Act exempts certain reduced payments for multiple imaging procedures and multiple therapy services from the BN calculation under section 1848(c)(2)(B)(ii)(II) of the Act. These MPPRs are not included in the development of the RVUs.
For anesthesia services, we do not apply adjustments to volume since we use the average allowed charge when simulating RVUs; therefore, the RVUs as calculated already reflect the payments as adjusted by modifiers, and no volume adjustments are necessary. However, a time adjustment of 33 percent is made only for medical direction of two to four cases since that is the only situation where a single practitioner is involved with multiple beneficiaries concurrently, so that counting each service without regard to the overlap with other services would overstate the amount of time spent by the practitioner furnishing these services.
•
The equipment cost per minute is calculated as:
Stakeholders have often suggested that particular equipment items are used less frequently than 50 percent of the time in the typical setting and that CMS should reduce the equipment utilization rate based on these recommendations. We appreciate and share stakeholders' interest in using the most accurate assumption regarding the equipment utilization rate for particular equipment items. However, we believe that absent robust, objective, auditable data regarding the use of particular items, the 50 percent assumption is the most appropriate within the relative value system. We welcome the submission of data that illustrates an alternative rate.
We continue to investigate potential avenues for determining equipment maintenance costs across a broad range of equipment items.
This section focuses on specific PE inputs. The direct PE inputs are included in the CY 2017 direct PE input database, which is available on our Web site under downloads for the CY 2017 PFS final rule at
Prior to the CY 2015 PFS rulemaking cycle, the RUC provided a recommendation regarding the PE inputs for digital imaging services. Specifically, the RUC recommended that we remove supply and equipment items associated with film technology from a previously specified list of codes since these items were no longer typical resource inputs. The RUC also recommended that the Picture Archiving and Communication System (PACS) equipment be included for these imaging services since these items are typically used in furnishing imaging services. However, since we did not receive any invoices for the PACS system prior to that year's proposed rule, we were unable to determine the appropriate pricing to use for the inputs. For CY 2015, we finalized our proposal to remove the film supply and equipment items, and to create a new equipment item as a proxy for the PACS workstation as a direct expense (79 FR 67561-67563). We used the price associated with ED021 (computer, desktop, w-monitor) to price the new item, ED050 (PACS Workstation Proxy), pending receipt of invoices to facilitate pricing specific to the PACS workstation. Subsequent to establishing payment rates for CY 2015, we received information from several stakeholders regarding pricing for items related to the digital acquisition and storage of images. We received invoices from one stakeholder that facilitated a proposed price update for the PACS workstation in the CY 2016 PFS proposed rule, and we updated the price for the PACS workstation to $5,557 in the CY 2016 PFS final rule with comment period (80 FR 70899).
In addition to the workstation used by the clinical staff for acquiring the images and furnishing the technical component (TC) of the services, a stakeholder also submitted more detailed information regarding a workstation used by the practitioner interpreting the image in furnishing the professional component (PC) of many of these services.
As we stated in the CY 2015 PFS final rule with comment period (79 FR 67563), we generally believe that workstations used by these practitioners are more accurately considered indirect costs associated with the PC of the service. However, we understand that the professional workstations for interpretation of digital images are similar in principle to some of the previous film inputs incorporated into the global and technical components of the codes, such as the view box equipment. Given that the majority of these services are reported globally in the nonfacility setting, we believe it is appropriate to include these costs as direct inputs for the associated HCPCS codes. Based on our established
We stated in the CY 2016 PFS final rule with comment period that the costs of the professional workstation may be analogous to costs related to the use of film previously incorporated as direct PE inputs for these services. We also solicited comments on whether including the professional workstation as a direct PE input for these codes would be appropriate, given that the resulting PE RVUs would be assigned to the global and technical components of the codes. Commenters responded by indicating their approval of the concept of a professional PACS workstation used for interpretation of digital images. We received invoices for the pricing of a professional PACS workstation, as well as additional invoices for the pricing of a mammography-specific version of the professional PACS workstation. The RUC also included these new equipment items in its recommendations for the CY 2017 PFS rulemaking cycle.
Based on our analysis of submitted invoices, we proposed to price the professional PACS workstation (ED053) at $14,616.93. We did not propose a change in price for the current technical PACS workstation (ED050), which will remain at a price of $5,557.00.
The price of the professional PACS workstation is based upon individual invoices submitted for the cost of a PC Tower ($1531.52), a pair of 3 MP monitors ($10,500.00 in total), a keyboard and mouse ($84.95), a UPS power backup devices for TNP ($1098.00), and a switch for PACS monitors/workstations ($1402.46).
We proposed to add the professional PACS workstation to many CPT codes in the 70000 series that use the current technical PACS workstation (ED050) and include professional work for which such a workstation would be used. We did not propose to add the equipment item to add-on codes since the base codes would include minutes for the item. We also did not propose to add the item to codes that are therapeutic in nature, as the professional PACS workstation is intended for use in diagnostic services. We therefore did not propose to add the item to codes in the Radiation Therapy section (77261 through 77799) or the Nuclear Medicine Cardiology section (78414-78499). We also did not propose to add the item to image guidance codes where the dominant provider is not a radiologist (77002, 77011, 77071, 77077, and 77081) according to the most recent year of claims data, since we believe a single workstation would be more typical in those cases. We identified approximately 426 codes to which we proposed to add a professional PACS workstation. Please see Table 4 for the full list of affected codes.
For the professional PACS workstation, we proposed to assign equipment time equal to the intraservice work time plus half of the preservice work time associated with the codes, since the work time generally reflects the time associated with the professional interpretation. We proposed half of the preservice work time for the professional PACS workstation because we do not believe that the practitioner would typically spend all of the preservice work period using the equipment. For older codes that do not have a breakdown of physician work time by service period, and only have an overall physician work time, we proposed to use half the total work time as an approximation of the intraservice work time plus one half of the preservice work time. In our review of services that contained an existing PACS workstation and had a breakdown of physician work time, we found that half of the total time was a reasonable approximation for the value of intraservice work time plus one half of preservice work time where no such breakdown existed. We also considered using an equipment time formula of the physician intraservice time plus 1 minute (as a stand-in for the physician preservice work time). We solicited public comment on the most accurate equipment time formula for the professional PACS workstation.
We solicited public comment on the proposed list of codes that would incorporate the professional PACS workstation. We were interested in public comment on the codes for which a professional PACS workstation should be included, and whether one of these professional workstations should be included for codes outside the 70000 series. In cases within the 70000 series where radiologists are not the typical specialty reporting the code, such as CPT codes 77002 and 77011, we asked whether it would be appropriate to add one of the professional PACS workstations to these services.
The following is a summary of the comments we received on the proposed addition of the professional PACS workstation, the pricing of the workstation, the list of codes that would incorporate the professional PACS workstation, and the equipment minutes to assign to the workstation.
• We did not add the professional PACS workstation to any code that currently lacks a technical PACS workstation (ED050) or lacks a work RVU. We continue to believe that procedures which do not include a technical workstation, or do not have physician work, would not require a professional workstation.
• We did not add the professional PACS workstation to add-on codes. Because the base codes include equipment minutes for the workstation, we continue to believe it would be duplicative to add additional equipment time for the professional PACS workstation in the add-on code.
• We agree with commenters that because the clinical utility of the PACS workstation is not necessarily limited to diagnostic services, there may be therapeutic codes where it would be reasonable to assume its use to be typical. We believe that in these specific cases, the use of the professional PACS workstation has been established to be typical for the code in question by the specialties furnishing the service, as a result of the evidence provided in the comments submitted in response to our proposal. We have added the workstation to many of the therapeutic codes requested by commenters, specifically codes listed outside the 70000 series, where use of the professional PACS station is typical.
• Within the 70000 series, we reviewed each of the codes submitted by commenters. Most of these codes did not fall within one of the categories where we proposed to add the professional PACS workstation in the proposed rule: They lacked a technical PACS workstation, they were add-on codes, or they were diagnostic procedures for which radiology is not the dominant specialty providing the service. We continue to believe that the professional PACS workstation should not be added to codes that do not fall into these categories, since we believe that the image must be captured in order to for it to be interpreted, that the use of the PACS workstation in the base code reported with add-on codes would accurately capture the associated resources used, and that the PACS professional workstation is only typically used by radiologists. Based on comments, we are adding the professional workstation to only one code in the 70000 series, CPT code 73562, as it includes a technical PACS workstation, is not an add-on code, and is typically furnished by radiologists.
• For codes in the 80000 and 90000 series, we are concerned about whether it is appropriate to include the technical PACS workstation into many of these services. PACS workstations were created for imaging purposes, but many of these services that include a technical PACS workstation do not appear to make use of imaging. Although we are not removing the technical PACS workstation from these codes at this time, we do not believe that a professional PACS workstation should be added to these procedures. We will consider the inclusion of both PACS workstations for future rulemaking.
For older codes where there is no breakdown of work time values by service period, we do not agree with commenters that the professional PACS workstation should use the total work time. The comments do not provide a
Finally, we believe that there is a difference in the pattern of equipment usage for the professional PACS workstation between diagnostic and therapeutic codes. Generally, the intraservice work for diagnostic imaging codes describes the review of images, while the intraservice work for therapeutic services describes a broader range of activities. Therefore, although we used an equipment formula of half the preservice physician work time and the full intraservice physician work time for the diagnostic procedures, we do not believe that this same time formula would be appropriate for therapeutic procedures since the professional PACS workstation would not be in use during the intraservice portion of these services. Therefore, we will use an equipment time formula of half the preservice physician work time and half the postservice physician work time for the therapeutic codes to which we are adding a professional PACS workstation, which we believe is more consistent with the descriptions of work for the codes in question. Consistent with our ongoing efforts to improve payment accuracy for these costs, we seek recommendations from the RUC and other stakeholders on a more precise allocation methodology for equipment minutes for these procedures.
After consideration of comments received, we are finalizing our proposal to add a professional PACS workstation (ED053) to the equipment database and price it at the proposed rate of $14,616.93. We are dividing the codes that will contain a professional PACS workstation into diagnostic and therapeutic categories. For diagnostic codes, we are assigning equipment minutes equal to half the preservice physician work time and the full intraservice physician work time. For the relatively smaller group of diagnostic codes with no service period time breakdown, we are assigning equipment time equal to half of the total physician work time. For therapeutic codes, we are assigning equipment minutes equal to half the preservice physician work time and half the postservice physician work time for the second group. There are no therapeutic codes on our current list which lack a service period time breakdown. The following table lists all of the codes that include a professional PACS workstation for CY 2017, along with the equipment minutes for the workstation.
As we noted in the CY 2015 PFS final rule (79 FR 67640-67641), we continue to make improvements to the direct PE input database to provide the number of clinical labor minutes assigned for each task for every code in the database instead of only including the number of
In the following paragraphs, we address a series of issues related to clinical labor tasks, particularly relevant to services currently being reviewed under the misvalued code initiative.
In CY 2015 PFS rulemaking, we noted that the RUC recommendation regarding inputs for digital imaging services indicated that, as each code is reviewed under the misvalued code initiative, the clinical labor tasks associated with digital technology (instead of film) would need to be addressed. When we reviewed that recommendation, we did not have the capability of assigning standard clinical labor times for the hundreds of individual codes since the direct PE input database did not previously allow for comprehensive adjustments for clinical labor times based on particular clinical labor tasks. Therefore, consistent with the recommendation, we proposed to remove film-based supply and equipment items but maintain clinical labor minutes that were assigned based on film technology.
As noted in the paragraphs above, we continue to improve the direct PE input database by specifying for each code the minutes associated with each clinical labor task. Once completed, this work would allow adjustments to be made to minutes assigned to particular clinical labor tasks related to digital technology that occur in multiple codes, consistent with the changes that were made to individual supply and equipment items. In the meantime, we believe it would be appropriate to establish standard times for clinical labor tasks associated with all digital imaging services for purposes of reviewing individual services at present, and for possible broad-based standardization once the changes to the direct PE input database facilitate our ability to adjust time across services. During the CY 2016 PFS rulemaking cycle, we proposed appropriate standard minutes for five different clinical labor tasks associated with services that use digital imaging technology. In the CY 2016 PFS final rule with comment period (80 FR 70901), we finalized appropriate standard minutes for four of those five activities, which are listed in Table 5.
We did not finalize standard minutes for the activity “Technologist QC's images in PACS, checking for all images, reformats, and dose page.” We agreed with commenters that this task may require a variable length of time depending on the number of images to be reviewed. We stated that it may be appropriate to establish several different standard times for this clinical labor task for a low/medium/high quantity of images to be reviewed, in the same fashion that the clinical labor assigned to clean a surgical instrument package has two different standard times depending on the use of a basic pack (10 minutes) or a medium pack (30 minutes). We solicited public comment and feedback on this subject, with the anticipation of including a proposal in the CY 2017 proposed rule.
We received many comments suggesting that this clinical labor activity should not have a standard time value. Commenters stated that the number of minutes varies significantly for different imaging modalities; and the time is not simply based on the quantity of images to be reviewed, but also the complexity of the images. The commenters recommended that time for this clinical labor activity should be assigned on a code by code basis. We agree with the commenters that the amount of clinical labor needed to check images in a PACS workstation may vary depending on the service. However, we do not believe that this precludes the possibility of establishing standards for clinical labor tasks as we have done in the past by creating multiple standard times, for example, those assigned to cleaning different kinds of scopes. We continue to believe that the use of clinical labor standards provides greater consistency among codes that share the same clinical labor tasks and can improve relativity of values among codes. We proposed to establish a range of appropriate standard minutes for the clinical labor activity, “Technologist QCs images in PACS, checking for all images, reformats, and dose page.” These standard minutes will be applied to new and revised codes that make use of this clinical labor activity when they are reviewed by us for valuation. We proposed 2 minutes as the standard for the simple case, 3 minutes as the standard for the intermediate case, and 4 minutes as the standard for the complex case. We proposed the simple case of 2 minutes as the standard for the typical procedure code involving routine use of imaging. These values are based upon a review of the existing minutes assigned for this clinical labor activity; we have determined that 2 minutes is the
The following is summary of the comments we received regarding the ongoing standardization of clinical labor tasks, and our specific proposal regarding the clinical labor task, “Technologist QCs images in PACS, checking for all images, reformats, and dose page.”
After considering the comments received, we are finalizing a range of appropriate standard minutes for the clinical labor activity, “Technologist QCs images in PACS, checking for all images, reformats, and dose page” as follows: Simple (2 min); intermediate (3 min), complex (4 min) and highly complex (5 min). We are also finalizing our criteria for determining the simple and intermediate categories as proposed.
As with the clinical labor tasks associated with digital imaging, many of the currently assigned times for the specialized clinical labor tasks associated with pathology services are not consistent across codes. In reviewing past RUC recommendations for pathology services, we have not identified information that supports the judgment that the same tasks take significantly more or less time depending on the individual service for which they are performed, especially given the high degree of specificity with which the tasks are described. We continue to believe that, in general, a clinical labor task will tend to take the same amount of time to perform for one individual service as the same clinical labor task when it is performed in a clinically similar service.
Therefore, we developed standard times for clinical labor tasks that we have used in finalizing direct PE inputs in recent years, starting in the CY 2012 PFS final rule with comment period (76 FR 73213). These times were based on our review and assessment of the current times included for these clinical labor tasks in the direct PE input database. We proposed in the CY 2016 PFS proposed rule to establish standard times for a list of 17 clinical labor tasks related to pathology services, and solicited public feedback regarding our proposed standards. Many commenters stated in response to our proposal that they did not support the standardization of clinical labor activities across pathology services. Commenters stated that establishing a single standard time for each clinical labor task was infeasible due to the differences in batch size or number of blocks across different pathology procedures. Several commenters indicated that it might be possible to standardize across codes with the same batch sizes, and urged us to consider pathology-specific details, such as batch size and block number, in the creation of any future standard times for clinical labor tasks related to pathology services.
As we stated in the CY 2016 PFS proposed rule, we developed the proposed standard times based on our review and assessment of the current times included for these clinical labor tasks in the direct PE input database. We believe that, generally speaking, clinical labor tasks with the same description are comparable across different pathology procedures. We believe this to be true based on the comparability of clinical labor tasks in
We also stated our belief that many of the clinical labor activities for which we proposed to establish standard times were tasks that do not depend on number of blocks or batch size. Clinical labor activities such as “Clean room/equipment following procedure” and “Dispose of remaining specimens” would typically remain standard across different services without varying by block number or batch size, with the understanding that additional time may be required above the standard value for a clinical labor task that is part of an unusually complex or difficult service. As a result, we ultimately finalized standard times for 6 of the 17 proposed clinical labor activities in the CY 2016 final rule with comment period (80 FR 70902). We have listed the finalized standard times in Table 6. We are taking no further action on the remaining 11 clinical labor activities in this final rule, pending further action by the RUC (see below).
We remain committed to the process of establishing standard clinical labor times for tasks associated with pathology services. This may include establishing standards on a per-block or per-batch basis, as we indicated during the previous rulemaking cycle. However, we are aware that the PE Subcommittee of the RUC is currently working to standardize the pathology clinical labor activities they use in making their recommendations. We believe the RUC's efforts to narrow the current list of several hundred pathology clinical labor tasks to a more manageable number through the consolidation of duplicative or highly similar activities into a single description may serve PFS relativity and facilitate greater transparency in PFS ratesetting. We also believe that the RUC's standardization of pathology clinical labor tasks would facilitate our capacity to establish standard times for pathology clinical labor tasks in future rulemaking. Therefore, we did not propose any additional changes to clinical labor tasks associated with pathology services.
During our routine reviews of direct PE input recommendations, we have regularly found unexplained inconsistencies involving the use of scopes and the video systems associated with them. Some of the scopes include video systems bundled into the equipment item, some of them include scope accessories as part of their price, and some of them are standalone scopes with no other equipment included. It is not always clear which equipment items related to scopes fall into which of these categories. We have also frequently found anomalies in the equipment recommendations, with equipment items that consist of a scope and video system bundle recommended, along with a separate scope video system. Based on our review, the variations do not appear to be consistent with the different code descriptions.
To promote appropriate relativity among the services and facilitate the transparency of our review process, during review of recommended direct PE inputs for the CY 2017 PFS proposed rule, we developed a structure that separates the scope and the associated video system as distinct equipment items for each code. Under this approach, we proposed standalone prices for each scope, and separate prices for the video systems that are used with scopes. We would define the scope video system as including: (1) A monitor; (2) a processor; (3) a form of digital capture; (4) a cart; and (5) a printer. We believe that these equipment components represent the typical case for a scope video system. Our model for this system is the “video system, endoscopy (processor, digital capture, monitor, printer, cart)” equipment item (ES031), which we proposed to re-price as part of this separate pricing approach. We obtained current pricing invoices for the endoscopy video system as part of our investigation of these issues involving scopes, which we proposed to use for this re-pricing. We understand that there may be other accessories associated with the use of scopes; we proposed to separately price any scope accessories, and individually evaluate their inclusion or exclusion as direct PE inputs for particular codes as usual under our current policy based on whether they are typically used in furnishing the services described by the particular codes.
We also proposed standardizing refinements to the way scopes have been defined in the direct PE input database. We believe that there are four general types of scopes: Non-video scopes; flexible scopes; semi-rigid scopes, and rigid scopes. Flexible scopes, semi-rigid scopes, and rigid scopes would typically be paired with one of the video scope systems, while the non-video scopes would not. The
We proposed these changes only for the reviewed codes that make use of scopes; this applies to the codes in the Flexible Laryngoscope family (CPT codes 31572, 31573, 31574, 31575, 31576, 31577, 31578, 31579) (see section II.L) and the Laryngoplasty family (CPT codes 31551, 31552, 31553, 31554, 31580, 31584, 31587, 31591, 31592) (see section II.L) along with updated prices for the equipment items related to scopes utilized by these services. We also solicited comment on this separate pricing structure for scopes, scope video systems, and scope accessories, which we could consider proposing to apply to other codes in future rulemaking.
The following is a summary of the comments we received on this separate pricing structure for scopes, scope video systems, and scope accessories.
We look forward to receiving recommendations from the upcoming RUC PE Subcommittee regarding scopes and related scope equipment items. We note that in order for these recommendations to be considered for CY 2018 rulemaking, we would need to receive these recommendations by the same February deadline for the submission of recommendations on code valuations.
For the other four components of the video system, we are finalizing the prices as proposed. The invoices submitted for these components indicate that they are different forms of equipment with different product IDs and different prices. For example, our price for the processor comes from a “Video Processor with keyboard & video cable” (CV-180) as opposed to the newly submitted invoice for a “Viscera Elite Video System” (OTV-S190). These are two distinct equipment items, and we do not have any data to indicate that the equipment on the newly submitted invoices is more typical in its use than the equipment that we are currently using to price the endoscopy video system.
Therefore, we are finalizing the price of the endoscopy video system at $33,391.00, based on component prices of $9,000.00 for the processor, $18,346.00 for the digital capture device, $2,000.00 for the monitor, $2,295.00 for the printer, and $1,750.00 for the cart.
When we reviewed the invoices for the channeled and non-channeled flexible video rhinolaryngoscopes (ES064 and ES063 respectively), we found that the product numbers indicated that these were different equipment items than the scopes that we priced in the proposed rule. As we mentioned for the pricing of the endoscopy video system, we have no data to indicate that use of these particular rhinolaryngoscopes would be typical, as opposed to the rhinolaryngoscopes that we proposed to use to establish prices in the proposed rule. As a result, we are maintaining our current prices for these scopes pending the submission of additional information.
We similarly found that the invoices with recommended price increases for the endoscope, rigid, sinoscopy (ES013) from the current price of $2,414.17 to $4,024.00 and for the videoscope, colonoscopy (ES033) from $23,650.00 to $37,273.00 related to different equipment items that we do not believe are a better reflection of the typical case than the item we currently use. We did not propose to make price changes for these scopes, and we have not incorporated these equipment items into the new scope classification system. As we stated previously, we are currently limiting the scope changes to the CPT codes under review for CY 2017 and their associated equipment items. We will consider pricing changes for the rest of the scopes and associated scope equipment as part of the broader scope reclassification and pricing effort in future rulemaking.
We received invoices for a series of equipment items listed as “other capital inputs not included in CMS estimate” as part of this collection of invoices. Since these equipment items were not included in the original recommendations or our proposed valuations for the Flexible Laryngoscope and Laryngoplasty families of codes, we are not adding them to our equipment database at this time. We will consider the addition of these equipment items as part of the broader recommendations from the RUC PE Subcommittee on the scope classification project.
We did not receive an invoice or other data to support a change in the pricing of the fiberscope, flexible, rhinolaryngoscopy (ES020).
After consideration of comments received, we are finalizing our proposals as detailed in the proposed rule, with the updated prices for the endoscopy video system and the stroboscopy system.
Subsequent to the publication of the CY 2016 PFS final rule with comment period, stakeholders alerted us to several clerical inconsistencies in the direct PE database. We proposed to correct these inconsistencies as described below and reflected in the CY 2017 direct PE input database displayed on our Web site under downloads for the CY 2017 PFS proposed rule at
For CY 2017, we proposed the following technical corrections:
• For CPT codes 72081-72084, a stakeholder informed us that the equipment time for the PACS workstation (ED050) should be equal to the clinical labor during the service period; the equipment time formula we used for these codes for CY 2016 erroneously included 4 minutes of preservice clinical labor. We agree with the stakeholder that the PACS workstation should use the standard equipment time formula for a PACS workstation for these codes. As a result, we proposed to refine the ED050 equipment time to 21 minutes for CPT code 72081, 36 minutes for CPT code 72082, 44 minutes for CPT code 72083, and 53 minutes for CPT code 72084 to reflect the clinical labor time associated with these codes. This same commenter also indicated that a number of clinical labor activities had been entered in the database in the incorrect service period for CPT codes 37215, 50432, 50694, and 72081. These clinical labor activities were incorrectly listed in the “postservice” period instead of the “service post” period. We proposed to make these technical corrections as well so that the minutes are assigned to the appropriate service period within the direct PE input database.
• Another stakeholder alerted us that ileoscopy CPT codes 44380, 44381 and 44382 did not include the direct PE input equipment item called the Gomco suction machine (EQ235) and indicated that this omission appeared to be inadvertent. We agreed that it was. We have included the item EQ235 in the final direct PE input database for CPT code 44380 at a time of 29 minutes, for CPT code 44381 at a time of 39 minutes, and CPT code 44382 at a time of 34 minutes.
The PE RVUs displayed in Addendum B on our Web site were calculated with the inputs displayed in the CY 2017 direct PE input database.
Several of the PE worksheets included in the RUC recommendations for CY 2016 contained time for the equipment item “xenon light source” (EQ167). Because there appeared to be two special light sources already present (the fiberoptic headlight and the endoscope itself) in the services for which this equipment item was recommended by the RUC, we believed that the use of only one of these light sources would be typical and proposed to remove the xenon light equipment time. In the CY 2016 PFS final rule with comment period, we restored the xenon light (EQ167) and removed the fiberoptic headlight (EQ170) with the same number of equipment minutes for CPT codes 30300, 31295, 31296, 31297, and 92511.
We received comments expressing approval for the restoration of the xenon light. However, the commenters also stated that the two light sources were not duplicative, but rather, both a headlight and a xenon light source are required concurrently for otolaryngology procedures when scopes are utilized. The commenters requested that the fiberoptic headlight be restored to these codes.
We agreed with the commenters that the use of both light sources would be typical for these procedures. Therefore, we proposed in the CY 2017 proposed rule to add the fiberoptic headlight (EQ170) to CPT codes 30300, 31295, 31296, 31297, and 92511 at the same number of equipment minutes as the xenon light (EQ167).
After consideration of comments received, we are finalizing our proposal to add the fiberoptic headlight (EQ170) to CPT codes 30300, 31295, 31296, 31297, and 92511 at the same number of equipment minutes as the xenon light (EQ167).
In the CY 2011 PFS final rule with comment period (75 FR 73205), we finalized a process to act on public requests to update equipment and supply price and equipment useful life inputs through annual rulemaking, beginning with the CY 2012 PFS proposed rule. For CY 2017, we proposed the following price updates for existing direct PE inputs:
Several commenters wrote to discuss the price of the Antibody Estrogen Receptor monoclonal (SL493). We received information including three invoices with new pricing information regarding the SL493 supply. We proposed to use this information to propose for the supply item SL493 a price of $14.00 per test, which is the average price based on the invoices that we received in total for the item.
We also proposed to update the price for two supplies in response to the submission of new invoices. The proposed price for “antigen, venom” supply (SH009) reflects an increase from $16.67 to $20.14 per milliliter, and the proposed price for “antigen, venom, tri-vespid” supply (SH010) reflects an increase from $30.22 to $44.05 per milliliter.
We proposed to remove the laser tip, diffuser fiber supply (SF030) and replace it with the laser tip, bare (single use) supply (SF029) for CPT code 31572 (formerly placeholder code 317X1). We did not propose a price change for the SF030 supply.
We routinely accept public submission of invoices as part of our process for developing payment rates for new, revised, and potentially misvalued codes. Often these invoices are submitted in conjunction with the RUC-recommended values for the codes. For CY 2017, we note that some stakeholders have submitted invoices for new, revised, or potentially misvalued codes after the February deadline established for code valuation recommendations. To be considered for a given year's proposed rule, we generally need to receive invoices by the same February deadline. In similar fashion, we generally need to receive invoices by the end of the comment period for the proposed rule in order to consider them for supply and equipment pricing in the final rule for that calendar year. Of course, we consider invoices submitted as public comments during the comment period following the publication of the proposed rule when relevant for services with values open for comment, and will consider any other invoices received after February and/or outside of the public comment process as part of our established annual process for requests to update supply and equipment prices as finalized in the CY 2011 final rule with comment period (75 FR 73205).
We recognize that this change would be unanticipated, but we do not believe there is a straightforward, transparent way to offset the change since the statutory provision requires that we maintain the direct inputs for the PE RVUs. We note that this change is unique among the radiation therapy and related imaging codes where the maintenance of inputs has generally resulted in payment rate stability for these services.
Section 1848(c) of the Act requires that each service paid under the PFS be composed of three components: Work, PE, and malpractice (MP) expense. As required by section 1848(c)(2)(C)(iii) of the Act, beginning in CY 2000, MP RVUs are resource based. Malpractice RVUs for new codes after 1991 were extrapolated from similar existing codes or as a percentage of the corresponding work RVU. Section 1848(c)(2)(B)(i) of the Act also requires that we review, and if necessary adjust, RVUs no less often than every 5 years. In the CY 2015 PFS final rule with comment period, we implemented the third review and update of MP RVUs. For a comprehensive discussion of the third review and update of MP RVUs see the CY 2015 proposed rule (79 FR 40349 through 40355) and final rule with comment period (79 FR 67591 through 67596).
To determine MP RVUs for individual PFS services, our MP methodology is comprised of three factors: (1) Specialty-level risk factors derived from data on specialty-specific MP premiums incurred by practitioners, (2) service level risk factors derived from Medicare claims data of the weighted average risk factors of the specialties that furnish each service, and (3) an intensity/complexity of service adjustment to the service level risk factor based on either the higher of the work RVU or clinical labor RVU. Prior to CY 2016, MP RVUs were only updated once every 5 years, except in the case of new and revised codes.
As explained in the CY 2011 PFS final rule with comment period (75 FR
In the CY 2016 PFS final rule with comment period (80 FR 70906 through 70910), we finalized a policy to begin conducting annual MP RVU updates to reflect changes in the mix of practitioners providing services (using Medicare claims data), and to adjust MP RVUs for risk for intensity and complexity (using the work RVU or clinical labor RVU). We also finalized a policy to modify the specialty mix assignment methodology (for both MP and PE RVU calculations) to use an average of the 3 most recent years of data instead of a single year of data. We stated that under this approach, the specialty-specific risk factors would continue to be updated through notice and comment rulemaking every 5 years using updated premium data, but would remain unchanged between the 5-year reviews.
For CY 2016, we did not propose to discontinue our current approach for determining MP RVUs for new/revised codes. For the new and revised codes for which we proposed work RVUs and PE inputs, we also published the proposed MP crosswalks used to determine their MP RVUs. We address comments regarding valuation of new and revised codes in section II.L of this final rule, which makes clear the codes with interim final values for CY 2016 had newly proposed values for CY 2017, all of which were again open for comment. The MP crosswalks for new and revised codes with interim final values were established in the CY 2016 PFS final rule with comment period; we proposed these same crosswalks in the CY 2017 PFS proposed rule.
The proposed CY 2017 GPCI update (eighth update), discussed in section II.E of this final rule, reflects updated MP premium data, collected for the purpose of proposing updates to the MP GPCIs. Although we could have used the updated MP premium data obtained for the purposes of the proposed eighth GPCI update to propose updates to the specialty risk factors used in the calculation of MP RVUs, this would not be consistent with the policy we previously finalized in the CY 2016 PFS final rule with comment period. In that rule, we indicated that the specialty-specific risk factors would continue to be updated through notice and comment rulemaking every 5 years using updated premium data, but would remain unchanged between the 5-year reviews. Additionally, consistent with the statutory requirement at section 1848(e)(1)(C) of the Act, only one half of the adjustment to MP GPCIs would be applied for CY 2017 based on the new MP premium data. As such, we did not think it would be appropriate to propose to update the specialty risk factors for CY 2017 based on the updated MP premium data that is reflected in the proposed CY 2017 GPCI update. Therefore, we did not propose to update the specialty-risk factors based on the new premium data collected for the purposes of the 3-year GPCI update for CY 2017 at this time. However, we solicited comment on whether we should consider doing so, perhaps as early as for 2018, prior to the fourth review and update of MP RVUs that must occur no later than CY 2020.
The following is summary of the comments we received on whether we should consider updating the specialty-risk factors based on the new premium data collected for the purposes of the 3-year GPCI update, perhaps as early as for 2018, prior to the fourth review and update of MP RVUs that must occur no later than CY 2020.
Several conditions must be met for Medicare to make payments for telehealth services under the PFS. The service must be on the list of Medicare telehealth services and meet all of the following additional requirements:
• The service must be furnished via an interactive telecommunications system.
• The service must be furnished by a physician or other authorized practitioner.
• The service must be furnished to an eligible telehealth individual.
• The individual receiving the service must be located in a telehealth originating site.
When all of these conditions are met, Medicare pays a facility fee to the originating site and makes a separate payment to the distant site practitioner furnishing the service.
Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include professional consultations, office visits, office psychiatry services, and any additional service specified by the Secretary, when furnished via a telecommunications system. We first implemented this statutory provision, which was effective October 1, 2001, in the CY 2002 PFS final rule with comment period (66 FR 55246). We established a process for annual updates to the list of Medicare telehealth services as required by section 1834(m)(4)(F)(ii) of the Act in the CY 2003 PFS final rule with comment period (67 FR 79988).
As specified at § 410.78(b), we generally require that a telehealth service be furnished via an interactive telecommunications system. Under § 410.78(a)(3), an interactive telecommunications system is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.
Telephones, facsimile machines, and stand-alone electronic mail systems do not meet the definition of an interactive telecommunications system. An interactive telecommunications system is generally required as a condition of payment; however, section 1834(m)(1) of the Act allows the use of asynchronous “store-and-forward” technology when the originating site is part of a federal telemedicine demonstration program in Alaska or Hawaii. As specified in § 410.78(a)(1), asynchronous store-and-forward is the transmission of medical information from an originating site for review by the distant site physician or practitioner at a later time.
Medicare telehealth services may be furnished to an eligible telehealth individual notwithstanding the fact that the practitioner furnishing the telehealth service is not at the same location as the beneficiary. An eligible telehealth individual is an individual enrolled under Part B who receives a telehealth service furnished at a telehealth originating site.
Practitioners furnishing Medicare telehealth services are reminded that these services are subject to the same non-discrimination laws as other services, including the effective communication requirements for persons with disabilities of section 504 of the Rehabilitation Act and language access for persons with limited English proficiency, as required under Title VI of the Civil Rights Act of 1964. For more information, see
Practitioners furnishing Medicare telehealth services submit claims for telehealth services to the MACs that process claims for the service area where their distant site is located. Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth service to an eligible telehealth individual be paid an amount equal to the amount that the practitioner would have been paid if the service had been furnished without the use of a telecommunications system.
Originating sites, which can be one of several types of sites specified in the statute where an eligible telehealth individual is located at the time the service is being furnished via a telecommunications system, are paid a facility fee under the PFS for each Medicare telehealth service. The statute specifies both the types of entities that can serve as originating sites and the geographic qualifications for originating sites. With regard to geographic qualifications, § 410.78(b)(4) limits originating sites to those located in rural health professional shortage areas (HPSAs) or in a county that is not included in a metropolitan statistical area (MSA).
Historically, we have defined rural HPSAs to be those located outside of MSAs. Effective January 1, 2014, we modified the regulations regarding originating sites to define rural HPSAs as those located in rural census tracts as determined by the Federal Office of Rural Health Policy of the Health Resources and Services Administration (HRSA) (78 FR 74811). Defining “rural” to include geographic areas located in rural census tracts within MSAs allows for broader inclusion of sites within HPSAs as telehealth originating sites. Adopting the more precise definition of “rural” for this purpose expands access to health care services for Medicare beneficiaries located in rural areas. HRSA has developed a Web site tool to provide assistance to potential originating sites to determine their geographic status. To access this tool, see the CMS Web site at
An entity participating in a federal telemedicine demonstration project that has been approved by, or received funding from, the Secretary as of December 31, 2000 is eligible to be an originating site regardless of its geographic location.
Effective January 1, 2014, we also changed our policy so that geographic status for an originating site would be established and maintained on an annual basis, consistent with other telehealth payment policies (78 FR 74400). Geographic status for Medicare telehealth originating sites for each calendar year is now based upon the status of the area as of December 31 of the prior calendar year.
For a detailed history of telehealth payment policy, see 78 FR 74399.
As noted previously, in the CY 2003 PFS final rule (67 FR 79988), we established a process for adding services to or deleting services from the list of Medicare telehealth services. This process provides the public with an ongoing opportunity to submit requests for adding services. Under this process, we assign any qualifying request to make additions to the list of telehealth services to one of two categories. Revisions to criteria that we use to review requests in the second category were finalized in the CY 2012 PFS final rule (76 FR 73102). The two categories are:
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Some examples of clinical benefit include the following:
• Ability to diagnose a medical condition in a patient population without access to clinically appropriate in-person diagnostic services.
• Treatment option for a patient population without access to clinically appropriate in-person treatment options.
• Reduced rate of complications.
• Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due to reduced rate of recurrence of the disease process).
• Decreased number of future hospitalizations or physician visits.
• More rapid beneficial resolution of the disease process treatment.
• Decreased pain, bleeding, or other quantifiable symptom.
• Reduced recovery time.
For the list of telehealth services, see the CMS Web site at
Under our existing policy, we add services to the telehealth list on a category 1 basis when we determine that they are similar to services on the existing telehealth list for the roles of, and interactions among, the beneficiary, physician (or other practitioner) at the distant site and, if necessary, the telepresenter. As we stated in the CY 2012 final rule with comment period (76 FR 73098), we believe that the category 1 criteria not only streamline our review process for publicly requested services that fall into this category, but also expedite our ability to identify codes for the telehealth list that resemble those services already on this list.
We received several requests in CY 2015 to add various services as Medicare telehealth services effective for CY 2017. The following presents a discussion of these requests, and our decisions regarding additions to the CY 2017 telehealth list. Of the requests received, we found that four services were sufficiently similar to ESRD-related services currently on the telehealth list to qualify on a category 1 basis. Therefore, we proposed to add the following services to the telehealth list on a category 1 basis for CY 2017:
• CPT codes 90967 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age; 90968 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age; 90969 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age); and 90970 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older).
As we indicated in the CY 2015 final rule with comment period (80 FR 41783), for the ESRD-related services (CPT codes 90963-90966) added to the telehealth list for CY 2016, the required clinical examination of the catheter access site must be furnished face-to-face “hands on” (without the use of an interactive telecommunications system) by a physician, CNS, NP, or PA. This requirement also applies to CPT codes 90967-90970.
While we did not receive a specific request, we also proposed to add two advance care planning services to the telehealth list. We have determined that these services are similar to the annual wellness visits (HCPCS codes G0438 & G0439) currently on the telehealth list:
• CPT codes 99497 (advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), or surrogate); and 99498 (advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (list separately in addition to code for primary procedure)).
• 99217 (observation care discharge day management (this code is to be utilized to report all services provided to a patient on discharge from “observation status” if the discharge is on other than the initial date of “observation status.” To report services to a patient designated as “observation status” or “inpatient status” and discharged on the same date, use the codes for observation or inpatient care services [including admission and discharge services, 99234-99236 as appropriate.]));
• 99218 (initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the problem(s) requiring admission to “observation status” are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99219 (initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the problem(s) requiring admission to “observation status” are of moderate severity.
• 99220 (initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the problem(s) requiring admission to “observation status” are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99224 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: Problem focused interval history; problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the patient is stable, recovering, or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99225 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99226 (subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99234 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99235 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit);
• 99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these three key components: A comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit);
The request to add these observation services referenced various studies supporting the use of observation units. The studies indicated that observation units provide safe, cost effective care to patients that need ongoing evaluation and treatment beyond the emergency department visit by having reduced hospital admissions, shorter lengths of stay, increased safety and reduced cost. Additional studies cited indicated that observation units reduce the work load on emergency department physicians, and reduce emergency department overcrowding.
In the CY 2005 PFS proposed rule (69 FR 47510), we considered a request but did not propose to add the observation CPT codes 99217-99220 to the list of Medicare telehealth services on a category two basis for the reasons described in that rule. The most recent request did not include any information that would cause us to question the previous evaluation under the category one criterion, which has not changed, regarding the significant differences in patient acuity between these services and services on the telehealth list. While the request included evidence of the general benefits of observation units, it did not include specific information demonstrating that the services described by these codes provided clinical benefit when furnished via telehealth, which is necessary for us to consider these codes on a category two basis. Therefore, we did not propose to add these services to the list of approved telehealth services.
• 99281 (emergency department visit for the evaluation and management of a patient, which requires these three key components: A problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the presenting problem(s) are self-limited or minor);
• 99282 (emergency department visit for the evaluation and management of a patient, which requires these three key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the presenting problem(s) are of low to moderate severity);
• 99283 (emergency department visit for the evaluation and management of a patient, which requires these three key components: An expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the presenting problem(s) are of moderate severity);
• 99284 (emergency department visit for the evaluation and management of a patient, which requires these three key components: A detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function); and
• 99285 (emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and mental status: A comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function).
In the CY 2005 PFS proposed rule (69 FR 47510), we considered a request but did not propose to add the emergency department visit CPT codes 99281-99285 to the list of Medicare telehealth services for the reasons described in that rule.
The current request to add the emergency department E/M services stated that the codes are similar to outpatient visit codes (CPT codes 99201-99215) that have been on the telehealth list since CY 2002. As we noted in the CY 2005 PFS final rule, while the acuity of some patients in the emergency department might be the same as in a physician's office; we believe that, in general, more acutely ill patients are more likely to be seen in the emergency department, and that difference is part of the reason there are separate codes describing evaluation and management visits in the Emergency Department setting. The practice of emergency medicine often requires frequent and fast-paced patient reassessments, rapid physician interventions, and sometimes the continuous physician interaction with ancillary staff and consultants. This work is distinctly different from the pace, intensity, and acuity associated with visits that occur in the office or outpatient setting. Therefore, we did not propose to add these services to the list of approved telehealth services on a category one basis.
The requester did not provide any studies supporting the clinical benefit of managing emergency department patients with telehealth which is necessary for us to consider these codes on a category two basis. Therefore, we did not propose to add these services to the list of approved telehealth services on a category two basis.
Many requesters of additions to the telehealth list urged us to consider the potential value of telehealth for providing beneficiaries access to needed expertise. We note that if clinical guidance or advice is needed in the emergency department setting, a consultation may be requested from an appropriate source, including consultations that are currently included on the list of telehealth services.
• 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes); and 99292 (critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for primary service).
We previously considered and rejected adding these codes to the list of Medicare telehealth services in the CY 2009 PFS final rule (74 FR 69744) on a category 1 basis because, due to the acuity of critically ill patients, we did not believe critical care services are similar to any services on the current list of Medicare telehealth services. In that rule, we said that critical care services must be evaluated as category 2 services. Because we considered critical care services under category 2, we needed to evaluate whether these are services for which telehealth can be an adequate substitute for a face-to-face encounter, based on the category 2 criteria at the time of that request. We had no evidence suggesting that the use of telehealth could be a reasonable surrogate for the face-to-face delivery of this type of care.
The American Telemedicine Association (ATA) submitted a new request for CY 2016 that cited several studies to support adding these services on a category 2 basis. To qualify under category 2, we would need evidence that the service furnished via telehealth is still described accurately by the requested code and produces a clinical benefit for the patient via telehealth. However, in reviewing the information provided by the ATA and a study titled, “Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System,” published July 2014 in
This year, requesters cited additional studies to support adding critical care services to the Medicare telehealth list on a category 2 basis. Eight of the studies dealt with telestroke and one with teleneurology. Telestroke is an approach that allows a neurologist to provide remote treatment to vascular stroke victims. Teleneurology offers consultations for neurological problems from a remote location. It may be initiated by a physician or a patient, for conditions such as headaches, dementia, strokes, multiple sclerosis and epilepsy.
However, according to the literature, the management of stroke via telehealth requires more than a single practitioner and is distinct from the work described by the above E/M codes, 99291 and 99292. One additional study cited involved pediatric patients, while another noted that the Department of Defense has used telehealth to provide critical care services to hospitals in Guam for many years. Another reference study indicated that consulting intensivists thought that telemedicine consultations were superior to telephone consultations. In all of these cases, we believe the evidence demonstrates that interaction between these patients and distant site practitioners can have clinical benefit.
However, we are persuaded by the requests that we recognize the potential benefit of critical care consultation services that are furnished remotely. We note that there are currently codes on the telehealth list that could be reported when consultation services are furnished to critically ill patients. In consideration of these public requests, we recognize that there may be greater resource costs involved in furnishing these services relative to the existing telehealth consultation codes. We also agree with the requesters that there may be potential benefits of remote care by specialists for these patients. For these reasons, we think it would be advisable to create a coding distinction between telehealth consultations for critically ill patients, for example stroke patients, relative to telehealth consultations for other hospital patients. Such a coding distinction would allow us to recognize the additional resource costs in terms of time and intensity involved in furnishing such services, under the conditions where remote, intensive consultation is required to provide access to appropriate care for the critically ill patient. We recognize that the current set of E/M codes, including current CPT codes 99291 and 99292, may not adequately describe such services because current E/M coding presumes that the services are occurring in-person, in which case the expert care would be furnished in a manner described by the current codes for critical care.
Therefore, we proposed to make payment through new HCPCS codes G0508 and G0509, initial and subsequent, used to describe critical care consultations furnished via telehealth. This new coding would provide a mechanism to report an intensive telehealth consultation service, initial or subsequent, for the critically ill patient, such as a stroke patient, under the circumstance when a qualified health care professional has in-person responsibility for the patient but the patient benefits from additional services from a distant-site consultant specially trained in providing critical care services. We proposed limiting these services to once per day per patient. Like the other telehealth consultations, these services would be valued relative to existing E/M services.
More details on the new coding (G0508 and G0509) and valuation for these services are discussed in section II.L. of this final rule and the final RVUs for this service are included in Addendum B of this final rule, including a summary of the public comments we received and our responses to the comments. Like the other telehealth consultation codes, we proposed that these services would be added to the telehealth list and would be subject to the geographic and other statutory restrictions that apply to telehealth services.
• 96101 (psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology,
• 96102 psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology,
• 96118 Neuropsychological testing (
• 96119 Neuropsychological testing (
Requesters indicated that there is nothing in the Minnesota Multiphasic Personality Inventory (MMPI), the Rorschach inkblot test, the Wechsler Adult Intelligence Scale (WAIS), the Halstead-Reitan Neuropsychological Battery and Allied Procedures, or the Wisconsin Card Sorting Test (WCST), that cannot be done via telehealth nor is different than neurological tests done for Parkinson's disease, seizure medication side effects, gait assessment, nor any of the many neurological examinations done via telehealth with the approved outpatient office visit and inpatient visit CPT codes currently on the telehealth list. As an example, requesters indicated that the MPPI is administered by a computer, which generates a report that is interpreted by the clinical psychologist, and that the test requires no interaction between the clinician and the patient.
We previously considered the request to add these codes to the Medicare telehealth list in the CY 2015 final rule with comment period (79 FR 67600). We decided not to add these codes, indicating that these services are not similar to other services on the telehealth list because they require close observation of how a patient responds. We noted that the requesters did not submit evidence supporting the clinical benefit of furnishing these services via telehealth so that we could evaluate them on a category 2 basis. While we acknowledge that requesters believe that some of these tests require minimal, if any, interaction between the clinician and patient, we disagree. We continue to believe that successful completion of the tests listed as examples in these codes require the clinical psychologist to closely observe the patient's response, which cannot be performed via telehealth. Some patient responses, for example, sweating and fine tremors, may be missed when the patient and examiner are not in the same room. Therefore, we did not propose to add these services to the list of Medicare telehealth services for CY 2017.
• 92507 (treatment of speech, language, voice, communication, and auditory processing disorder; individual); and, 92508 (treatment of speech, language, voice, communication, and auditory processing disorder; group, 2 or more individuals); 92521 (evaluation of speech fluency (
The statute defines who is an authorized practitioner of telehealth services. Physical therapists, occupational therapists and speech-language pathologists are not authorized practitioners of telehealth under section 1834(m)(4)(E) of the Act, as defined in section 1842(b)(18)(C) of the Act. Because the above services are predominantly furnished by physical therapists, occupational therapists and speech-language pathologists, we do not believe it would be appropriate to add them to the list of telehealth services at this time. One requester suggested that we can add telehealth practitioners without legislation, as evidenced by the addition of nutritional professionals. However, we do not believe we have such authority and note that nutritional professionals are included as practitioners in the definition at section 1834(b)(18)(C)(vi) of the Act, and thus, are within the statutory definition of telehealth practitioners. Therefore, we did not propose to add these services to the list of Medicare telehealth services for CY 2017.
In summary, we proposed to add the following codes to the list of Medicare telehealth services beginning in CY 2017 on a category 1 basis:
• ESRD-related services 90967 through 90970. The required clinical examination of the catheter access site must be furnished face-to-face “hands on” (without the use of an interactive telecommunications system) by a physician, CNS, NP, or PA.
• Advance care planning (CPT codes 99497 and 99498).
• Telehealth Consultations for a Patient Requiring Critical Care Services (G0508 and G0509).
The following is summary of the comments we received regarding the proposed addition of services to the list of Medicare telehealth services:
We are also finalizing our proposal to make payment for these critical care consultation services through new codes G0508 and G0509, initial and subsequent, used to describe critical care consultations furnished via telehealth. More details on the new coding and valuation for these services are discussed in section II.L. of this final rule and the final RVUs for this service are included in Addendum B of this final rule. Like the other telehealth consultation codes, we proposed and are finalizing that these services would be added to the telehealth list and would be subject to the geographic and other statutory restrictions that apply to telehealth services.
A few commenters disagreed with our decision not to add psychological and neuropsychological testing services. Commenters cited general benefits, such as increased access to care, improved health outcomes, and as a remedy to address provider shortages. One commenter maintained that the requested codes are similar to many
We remind stakeholders that if consultative telehealth services are required for patients where emergency department or observation care services would ordinarily be reported, multiple codes describing consultative services are currently on the telehealth list and can be used to bill for such telehealth services.
We have received multiple requests from various stakeholders to establish a POS code to identify services furnished via telehealth. These requests have come from other payers, but may also be related to confusion concerning whether to use the POS where the distant site physician is located or the POS where the patient is located. The process for establishing POS codes is managed by the POS Workgroup within CMS, is available for use by all payers, and is not contingent upon Medicare PFS rulemaking. We noted in the CY 2017 proposed rule (81 FR 46184) that, if such a POS code were created, in order to make it valid for use in Medicare, we would have to determine the appropriate payment rules associated with the code. Therefore, we proposed how a POS code for telehealth would be used under the PFS with the expectation that, if such a code is available, it would be used as early as January 1, 2017. We proposed that the physicians or practitioners furnishing telehealth services would be required to report the telehealth POS code to indicate that the billed service is furnished as a telehealth service from a distant site. As noted below, since the publication of the CY 2017 proposed rule, the telehealth POS code has been created.
Our requirement for physicians and practitioners to use the telehealth POS code to report that telehealth services were furnished from a distant site would improve payment accuracy and consistency in telehealth claims submission. Currently, for services furnished via telehealth, we have instructed practitioners to report the POS code that would have been reported had the service been furnished in person. However, some practitioners use the POS where they are located when the service is furnished, while others use the POS corresponding to the patient's location.
Under the PFS, the POS code determines whether a service is paid using the facility or non-facility practice expense relative value units (PE RVUs). The facility rate is paid when a service is furnished in a location where Medicare is making a separate facility payment to an entity other than the physician or practitioner that is intended to reflect the facility costs associated with the service (clinical staff, supplies and equipment). We note that in accordance with section 1834(m)(2)(B) of the Act, the payment amount for the telehealth facility fee paid to the originating site is a national fee, paid without geographic or site of service adjustments that generally are made for payments to different kinds of Medicare providers and suppliers. In the case of telehealth services, we believe that facility costs (clinical staff, supplies, and equipment) associated with furnishing the service would generally be incurred by the originating site, where the patient is located, and not by the practitioner at the distant site. The statute requires Medicare to pay a fee to the site that hosts the patient. This is analogous to the circumstances under which the facility PE RVUs are used to pay for services under the PFS. Therefore, we proposed to use the facility PE RVUs to pay for telehealth services reported by physicians or practitioners with the telehealth POS code. We note that there are only three codes on the telehealth list with a difference greater than 1.0 PE RVUs between the facility PE RVUs and the non-facility PE RVUs. We did not anticipate that this proposal would result in a significant change in the total payment for the majority of services on the telehealth list. Moreover, many practitioners already use a facility POS when billing for telehealth services (those that report the POS of the originating site where the beneficiary is located). The policy to use the telehealth POS code for telehealth services would not affect payment for
The POS code for telehealth would not apply to originating sites billing the facility fee. Originating sites are not furnishing a service via telehealth since the patient is physically present in the facility. Accordingly, the originating site would continue to use the POS code that applies to the type of facility where the patient is located.
We also proposed a change to § 414.22(b)(5)(i)(A) that addresses the PE RVUs used in different settings. These revisions would improve clarity regarding our current policies. Specifically, we proposed to amend this section to specify that the facility PE RVUs are paid for practitioner services furnished via telehealth under § 410.78. In addition, we proposed a change to resolve any potential ambiguity and clarify that payment under the PFS is made at the facility rate (facility PE RVUs) when services are furnished in a facility setting paid by Medicare, including in off-campus provider based departments. As proposed, the regulation reflected the policy being proposed, for CY 2017 only, to pay the physician the nonfacility rate for services furnished in an off-campus provider based department that was not excepted under section 603 of the Bipartisan Budget Act of 2015. Finally, to streamline the existing regulation, we also proposed to delete § 414.32 of our regulation that refers to the calculation of payments for certain services prior to 2002.
The following is summary of the comments we received regarding the proposal to use a POS code for services furnished via telehealth:
• Whether the POS code would replace the GT modifier.
• Whether the description of telehealth as a service furnished via an interactive audio and video telecommunications system applies to the POS code as it does to the GT modifier.
• How to ensure proper payment when the distant site practitioner is at a facility, but the patient is not.
One commenter remarked that use of a POS code should not be the basis for reducing payments and that many codes would experience a significant payment change. The commenter noted that a 1.0 RVU reduction would result in a $36 payment reduction for the service. One commenter stated CMS should propose budget neutral PE and originating site fees, based on data, for CY 2018. One commenter noted that there are no facility PE RVUs for several codes.
There is utilization data for 56 of the 81 codes on the telehealth list. For these codes, 20 are not paid differently based on site of service, and 27 codes are paid differently by fewer than 0.5 RVUs. There are only three codes on the telehealth list with a difference greater than 1.0 PE RVUs between the facility PE RVUs and the non-facility PE RVUs.
Concerning psychotherapy and psychological testing services, we note that for the vast majority of psychiatric services the difference between the two rates is very small. For example, the difference between the facility and non-facility national rates for 45 minutes of psychotherapy is 0.02 RVUs per service: Less than $1.00. The differences between the facility PE RVUs and non-facility PE RVUS ranges from 0.01-0.03 RVUs for nine of the psychological testing codes on the Medicare telehealth list, and 0.12 RVUs lower for two other codes. We do not consider these reductions significant, nor do we have any evidence that practice expense costs are greater for furnishing such services via telehealth than for furnishing a face-to-face service. Commenters provided no evidence that practice expense costs for services furnished via telehealth are greater, due to the requirement for HIPAA-compliant equipment, than for furnishing in-person services, even in the facility setting.
There are a few HCPCS codes on the telehealth list that do not have a calculated facility PE RVU. For these services, the non-facility PE RVUs would serve as a proxy, and therefore, there would be no payment change for these codes.
Finally, we note that the originating site facility fee is established by statute (section 1834(m)(2)(B) of the Act) and is not affected by this proposal.
We note that we believe that payment using the facility PE RVUs for telehealth services is consistent our belief that the direct practice expense costs are generally incurred at the location of the beneficiary and not by the distant site practitioner. After reviewing the current list of telehealth services in the context of the comments, we continue to believe this is accurate.
After consideration of the public comments received, we are finalizing our proposal to use the POS code for telehealth and to use the facility PE RVUs to pay for telehealth service reported by physicians or practitioners with the telehealth POS code for CY 2017. However, we understand commenters' concerns and will consider the concerns regarding use of the facility payment rate as we monitor utilization of telehealth services. We will welcome information from stakeholders regarding any potential unintended consequences of the payment policy. We will also consider the applicability of the facility rate to any codes newly added to the list of telehealth services.
We have updated the POS code list on our Web site at
We are finalizing proposed revisions to our regulation at § 414.22(b)(5)(i)(A) that addresses the PE RVUs used in different settings as described above, except that we are not finalizing the proposed change that would have resulted in the payment of the nonfacility rate for services furnished in off-campus provider based departments that are not excepted under Section 603 of the Bipartisan Budget Act of 2015 since we are finalizing that payments to such non-excepted PBDs will be made under the PFS. In a separate interim final rule with comment period issued in conjunction with the CY 2017 OPPS/ASC final rule with comment period (see Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Certain Off-Campus Outpatient Departments of a Provider; Hospital Value-Based Purchasing (VBP) Program; Establishment of Physician Fee Schedule Payment Rates for Nonexcepted Items and Services Billed by Applicable Departments of a Hospital), we are finalizing other payment policies for nonexcepted items and services furnished by such non-excepted off-campus provider based departments. Accordingly, physicians furnishing services in such provider-based departments will continue to be paid the facility rate. We are also finalizing the proposal to delete § 414.32 of our regulation that refers to the calculation of payments for certain services prior to 2002.
We remind the public that we are currently soliciting requests to add services to the list of Medicare telehealth services. To be considered during PFS rulemaking for CY 2018, these requests must be submitted and received by December 31, 2016. Each request to add a service to the list of Medicare telehealth services must include any supporting documentation the requester wishes us to consider as we review the request. For more information on submitting a request for an addition to the list of Medicare telehealth services, including where to mail these requests, we refer readers to the CMS Web site at
Section 1834(m)(2)(B) of the Act establishes the Medicare telehealth originating site facility fee for telehealth services furnished from October 1, 2001 through December 31, 2002, at $20.00. For telehealth services furnished on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased by the percentage increase in the MEI as defined in section 1842(i)(3) of the Act. The originating site facility fee for telehealth services furnished in CY 2016 is $25.10. The MEI increase for 2017 is 1.2 percent and is based on the most recent historical update through 2016Q2 (1.6 percent), and the most recent historical MFP through calendar year 2015 (0.4 percent). Therefore, for CY 2017, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge or $25.40. The Medicare telehealth originating site facility fee and the MEI increase by the applicable time period is shown in Table 6.
Section 1848(c)(2)(B) of the Act directs the Secretary to conduct a periodic review, not less often than every 5 years, of the RVUs established under the PFS. Section 1848(c)(2)(K) of the Act requires the Secretary to periodically identify potentially misvalued services using certain criteria and to review and make appropriate adjustments to the relative values for those services. Section 1848(c)(2)(L) to the Act also requires the Secretary to develop a process to validate the RVUs of certain potentially misvalued codes under the PFS, using the same criteria used to identify potentially misvalued codes, and to make appropriate adjustments.
As discussed in section II.B. of this final rule, each year we develop appropriate adjustments to the RVUs taking into account recommendations provided by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), the Medicare Payment Advisory Commission (MedPAC), and others. For many years, the RUC has provided us with recommendations on the appropriate relative values for new, revised, and potentially misvalued PFS services. We review these recommendations on a code-by-code basis and consider these recommendations in conjunction with analyses of other data, such as claims data, to inform the decision-making process as authorized by the law. We may also consider analyses of work time, work RVUs, or direct PE inputs using other data sources, such as Department of Veteran Affairs (VA), National Surgical Quality Improvement Program (NSQIP), the Society for Thoracic Surgeons (STS), and the Physician Quality Reporting System (PQRS) databases. In addition to considering the most recently available data, we also assess the results of physician surveys and specialty recommendations submitted to us by the RUC for our review. We also consider information provided by other stakeholders. We conduct a review to assess the appropriate RVUs in the context of contemporary medical practice. We note that section 1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and other techniques to determine the RVUs for physicians' services for which specific data are not available and requires us to take into account the results of consultations with organizations representing physicians who provide the services. In accordance with section 1848(c) of the Act, we determine and make appropriate adjustments to the RVUs.
In its March 2006 Report to the Congress (
As MedPAC noted in its March 2009 Report to Congress (
• Codes that have experienced the fastest growth.
• Codes that have experienced substantial changes in practice expenses.
• Codes that describe new technologies or services within an appropriate time period (such as 3 years) after the relative values are initially established for such codes.
• Codes which are multiple codes that are frequently billed in conjunction with furnishing a single service.
• Codes with low relative values, particularly those that are often billed multiple times for a single treatment.
• Codes that have not been subject to review since implementation of the fee schedule.
• Codes that account for the majority of spending under the physician fee schedule.
• Codes for services that have experienced a substantial change in the hospital length of stay or procedure time.
• Codes for which there may be a change in the typical site of service since the code was last valued.
• Codes for which there is a significant difference in payment for the same service between different sites of service.
• Codes for which there may be anomalies in relative values within a family of codes.
• Codes for services where there may be efficiencies when a service is furnished at the same time as other services.
• Codes with high intra-service work per unit of time.
• Codes with high practice expense relative value units.
• Codes with high cost supplies.
• Codes as determined appropriate by the Secretary.
Section 1848(c)(2)(K)(iii) of the Act also specifies that the Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services. In addition, the Secretary may conduct surveys, other data collection activities, studies, or other analyses, as the Secretary determines to be appropriate, to facilitate the review and appropriate adjustment of potentially misvalued services. This section also authorizes the use of analytic contractors to identify and analyze potentially misvalued codes, conduct surveys or collect data, and make recommendations on the review and appropriate adjustment of potentially misvalued services. Additionally, this section provides that the Secretary may coordinate the review and adjustment of
To fulfill our statutory mandate, we have identified and reviewed numerous potentially misvalued codes as specified in section 1848(c)(2)(K)(ii) of the Act, and we plan to continue our work examining potentially misvalued codes in these areas over the upcoming years. As part of our current process, we identify potentially misvalued codes for review, and request recommendations from the RUC and other public commenters on revised work RVUs and direct PE inputs for those codes. The RUC, through its own processes, also identifies potentially misvalued codes for review. Through our public nomination process for potentially misvalued codes established in the CY 2012 PFS final rule with comment period, other individuals and stakeholder groups submit nominations for review of potentially misvalued codes as well.
Since CY 2009, as a part of the annual potentially misvalued code review and Five-Year Review process, we have reviewed over 1,671 potentially misvalued codes to refine work RVUs and direct PE inputs. We have assigned appropriate work RVUs and direct PE inputs for these services as a result of these reviews. A more detailed discussion of the extensive prior reviews of potentially misvalued codes is included in the CY 2012 PFS final rule with comment period (76 FR 73052 through 73055). In the CY 2012 PFS final rule with comment period, we finalized our policy to consolidate the review of physician work and PE at the same time (76 FR 73055 through 73958), and established a process for the annual public nomination of potentially misvalued services.
In the CY 2013 PFS final rule with comment period, we built upon the work we began in CY 2009 to review potentially misvalued codes that have not been reviewed since the implementation of the PFS (so-called “Harvard-valued codes”). In CY 2009, we requested recommendations from the RUC to aid in our review of Harvard-valued codes that had not yet been reviewed, focusing first on high-volume, low intensity codes (73 FR 38589). In the fourth Five-Year Review (76 FR 32410), we requested recommendations from the RUC to aid in our review of Harvard-valued codes with annual utilization of greater than 30,000. In the CY 2013 PFS final rule with comment period, we identified specific Harvard-valued services with annual allowed charges that total at least $10,000,000 as potentially misvalued. In addition to the Harvard-valued codes, in the CY 2013 PFS final rule with comment period we finalized for review a list of potentially misvalued codes that have stand-alone PE (codes with physician work and no listed work time and codes with no physician work that have listed work time).
In the CY 2016 PFS final rule with comment period, we finalized for review a list of potentially misvalued services, which included eight codes in the neurostimulators analysis-programming family (CPT 95970-95982). We also finalized as potentially misvalued 103 codes identified through our screen of high expenditure services across specialties.
Section 1848(c)(2)(L) of the Act requires the Secretary to establish a formal process to validate RVUs under the PFS. The Act specifies that the validation process may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre-, post-, and intra-service components of work. The Secretary is directed, as part of the validation, to validate a sampling of the work RVUs of codes identified through any of the 16 categories of potentially misvalued codes specified in section 1848(c)(2)(K)(ii) of the Act. Furthermore, the Secretary may conduct the validation using methods similar to those used to review potentially misvalued codes, including conducting surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the validation of RVUs of services.
In the CY 2011 PFS proposed rule (75 FR 40068) and CY 2012 PFS proposed rule (76 FR 42790), we solicited public comments on possible approaches, methodologies, and data sources that we should consider for a validation process. A summary of the comments along with our responses are included in the CY 2011 PFS final rule with comment period (75 FR 73217) and the CY 2012 PFS final rule with comment period (73054 through 73055).
We contracted with two outside entities to develop validation models for RVUs.
Given the central role of time in establishing work RVUs and the concerns that have been raised about the current time values used in rate setting, we contracted with the Urban Institute to develop empirical time estimates based on data collected from several health systems with multispecialty group practices. The Urban Institute collected data by directly observing the delivery of services and through the use of electronic health records for services selected by the contractor in consultation with CMS and is using this data to produce objective time estimates. We expect the final Urban Institute report will be made available on the CMS Web site later this year.
The second contract is with the RAND Corporation, which used available data to build a validation model to predict work RVUs and the individual components of work RVUs, time and intensity. The model design was informed by the statistical methodologies and approach used to develop the initial work RVUs and to identify potentially misvalued procedures under current CMS and RUC processes. RAND consulted with a technical expert panel on model design issues and the test results. The RAND report is available under downloads on the Web site for the CY 2015 PFS final rule with comment period at
After posting RAND's report on the models and results on our Web site, we received comments indicating that the models did not adequately address global surgery services due to the lack of available data on included visits. Therefore, we modified the RAND contract to include the development of G-codes that could be used to collect data about post-surgical follow-up visits on Medicare claims to meet the requirements in section 1848(c)(8)(B) of the Act regarding collection of data on global services. Our discussion related to this data collection requirement is in section II.D.6. Also, the data from this project would provide information that would allow the time for these services to be included in the model for validating RVUs.
Because routine E/M is included in the valuation of codes with 0-, 10-, and 90-day global periods, Medicare only makes separate payment for E/M services that are provided in excess of those considered included in the global procedure. In such cases, the physician would report the additional E/M service with Modifier 25, which is defined as a significant, separately identifiable E/M service performed by the same physician on the day of a procedure above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. Modifier 25 allows physicians to be paid forE/M services that would otherwise be denied as bundled.
In reviewing misvalued codes, both CMS and the RUC have often considered how frequently particular codes are reported with E/M codes to account for potential overlap in resources. Some stakeholders have expressed concern with this policy especially with regard to the valuation of 0-day global services that are typically billed with a separate E/M service with the use of Modifier 25. For example, when we established our valuation of the osteopathic manipulative treatment (OMT) services, described by CPT codes 98925-98929, we did so with the understanding that these codes are usually reported withE/M codes.
For our CY 2017 proposal (81 FR 46187), we investigated Medicare claims data for CY 2015 and found that 19 percent of the codes that described 0-day global services were billed over 50 percent of the time with an E/M with Modifier 25. Since routine E/M is included in the valuation of 0-day global services, we believed that the routine billing of separate E/M services may have indicated a possible problem with the valuation of the bundle, which is intended to include all the routine care associated with the service.
In the proposed rule (81 FR 46187), we stated that reviewing the procedure codes typically billed with an E/M with Modifier 25 may be one avenue to appropriate valuation for these services. Therefore, we developed and proposed a screen for potentially misvalued codes that identified 0-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary. We included a list of codes with total allowed services greater than 20,000. There are 83 codes that met the proposed criteria for the screen and were proposed as potentially misvalued. We also sought comment regarding additional ways to address appropriate valuations for all services that are typically billed with an E/M with Modifier 25.
The following is the summary of the comments we received.
Commenters overwhelmingly opposed any change to billing policies or standard valuation for 0-day services that are billed with an E/M with Modifier 25.
Because we recognize that the primary purpose in displaying lists of misvalued codes in rulemaking has been to seek recommendations regarding appropriate valuation from stakeholders, including the RUC, for 2017 we are only identifying the services for which we believe there might be the kind of misvaluation the RUC and the medical specialty societies recognize. Based on the comments from these organizations, we believe that for codes reviewed in the past 5 years, the RUC has already addressed that kind of misvaluation. In other words, commenters have made clear that external review of these services is likely to be limited to clear overlap in resource costs, but will not address the broader concerns we have about developing rates for services that include routine E/M when evaluation and management is also routinely separately reported. As a result, we will continue to consider that issue for future rulemaking. We note that we are required under statute to improve the valuation of the 10- and 90-day global periods, and therefore, we will consider this issue in that context, as well.
In the CY 2004 PFS final rule with comment period (68 FR 63216), we established new Level II HCPCS G-codes for end-stage renal disease (ESRD) services and established payment for those codes through monthly capitation payment (MCP) rates. For ESRD center-based patients, payment for the G-codes varied based on the age of the beneficiary and the number of face-to-face visits furnished each month (for example, 1 visit, 2-3 visits and 4 or more visits). We believed that many physicians would provide 4 or more visits to center-based ESRD patients and a small proportion will provide 2-3 visits or only one visit per month. Under the MCP methodology, to receive the highest payment, a physician would have to provide at least four ESRD-related visits per month. However, payment for home dialysis MCP services only varied by the age of beneficiary. Although we did not initially specify a frequency of required visits for home dialysis MCP services, we stated that we expect physicians to provide clinically appropriate care to manage the home dialysis patient.
The CPT Editorial Panel created new CPT codes to replace the G-codes for monthly ESRD-related services, and we accepted the new codes for use under the PFS in CY 2009. The CPT codes created were 90963-90966 for monthly ESRD-related services for home dialysis patient and CPT codes 90967-90970 for dialysis with less than a full month of services.
In a GAO report titled “END-STAGE RENAL DISEASE Medicare Payment Refinements Could Promote Increased Use of Home Dialysis” dated October 2015,
In the report, the GAO noted that CMS intended for the existing payment structure to create an incentive for physicians to prescribe home dialysis, because the monthly payment rate for managing the dialysis care of home patients, which requires a single in-person visit, was approximately equal to the rate for managing and providing two to three visits to ESRD center-based patients. However, GAO found that, in 2013, the rate of $237 for managing home patients was lower than the average payment of $266 and maximum payment of $282 for managing ESRD center-based patients. The GAO stated that this difference in payment rates may discourage physicians from prescribing home dialysis.
Physician associations and other physicians GAO interviewed stated that the visits with home patients are often longer and more comprehensive than in-center visits; this is in part because physicians may conduct visits with individual home patients in a private setting, but they may be able to more easily visit multiple in-center patients on a single day as they receive dialysis. The physician associations GAO interviewed also said that they may spend a similar amount of time outside of visits to manage the care of home patients and that they are required to provide at least one visit per month to perform a complete assessment of the patient.
It is important to note that, as stated in the CY 2011 PFS final rule with comment period (75 FR 73296), we believe that furnishing monthly face-to-face visits is an important component of high quality medical care for ESRD patients being dialyzed at home and generally would be consistent with the current standards of medical practice. However, we also acknowledged that extenuating circumstances may arise that make it difficult for the MCP physician (or NPP) to furnish a visit to a home dialysis patient every month. Therefore, we allow Medicare contractors the discretion to waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case-by-case basis, for example, when the MCP physician's (or NPP's) notes indicate that the MCP physician (or NPP) actively and adequately managed the care of the home dialysis patient throughout the month.
The GAO recommended, and we agreed, that CMS examine Medicare policies for monthly payments to physicians to manage the care of dialysis patients and revise them if necessary to ensure that these policies are consistent with our goal of encouraging the use of home dialysis among patients for whom it is appropriate. Therefore, we proposed to identify CPT codes 90963 through 90970 as potentially misvalued codes based on the volume of claims submitted for these services relative to those submitted for facility ESRD services.
The following is summary of the comments we received.
In the proposed rule (81 FR 46190), we stated that stakeholders had raised concerns about potential inconsistencies with the inputs and the prices related to endoscopic procedures in the direct PE database. Upon review, we noted that there are 45 different pieces of endoscope related-equipment and 25 different pieces of endoscope related-supplies that are currently associated with these services. Relative to other kinds of equipment items in the direct PE input, these items are much more varied and used for many fewer services. Given the frequency with which individual codes can be reviewed and the importance of standardizing inputs for purposes of maintaining relativity across PFS services, we believed that this unusual degree of variation was likely to result in code misvaluation. To facilitate efficient review of this particular kind of misvaluation, and because we believed that stakeholders would prefer the opportunity to contribute to such standardization, we requested that stakeholders like the AMA RUC review and make recommendations on the appropriate endoscopic equipment and supplies typically provided in all endoscopic procedures for each anatomical body region, along with their appropriate prices.
The following is summary of the comments we received.
In the proposed rule (81 FR 46190), we identified a potential inconsistency in instances where there are direct PE inputs included in the facility postservice period even though post-operative visit is not included in a service. We identified 13 codes affected by this issue and stated that we were unclear if the discrepancy was caused by inaccurate direct PE inputs or inaccurate post-operative data in the work time file. We requested that stakeholders including the AMA RUC review these discrepancies and provide their recommendations on the appropriate direct PE inputs for the codes.
The following is summary of the comments we received.
In the proposed rule (81 FR 46190), we stated that stakeholders had urged CMS to create new coding describing the insertion and removal of drug delivery implants for buprenorphine hydrochloride, formulated as a 4 rod, 80 mg, long acting subdermal drug implant for the treatment of opioid addiction. The stakeholders suggested that current coding describing insertion and removal of drug delivery implants was too broad and that new coding was needed to account for specific additional resource costs associated with particular treatment. We identified existing CPT codes 11981 (Insertion, non-biodegradable drug delivery implant), 11982 (Removal, non-biodegradable drug delivery implant), and 11983 (Removal with reinsertion, non-biodegradable drug delivery implant) as potentially misvalued codes and sought comment and information regarding whether the current resource inputs in work and practice expense for the codes appropriately accounted for variations in the service relative to which devices and related drugs are inserted and removed.
The following is summary of the comments we received.
The CPT manual identifies more than 400 diagnostic and therapeutic procedures (listed in Appendix G) for which the CPT Editorial Panel has determined that moderate sedation is an inherent part of furnishing the procedure. In developing RVUs for these services, we include the relative resources associated with moderate sedation in the valuation since the CPT codes include moderate sedation as an inherent part of the procedure. Therefore, practitioners only report the procedure code when furnishing the service. Endoscopic procedures constitute a significant portion of the services identified in Appendix G. In the CY 2015 PFS proposed rule (79 FR 40349), we noted that it appeared that practice patterns for endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures, meaning that the relative resources associated with sedation were no longer incurred by the practitioner reporting the Appendix G procedure. We indicated that, in order to reflect apparent changes in medical practice, we were considering establishing a uniform approach to the appropriate valuation of all Appendix G services for which moderate sedation is no longer inherent, rather than addressing the issue at the procedure level as individual codes are revalued. We solicited public comment on approaches to the appropriate valuation of these services.
In the CY 2016 PFS proposed rule (80 FR 41707), we again solicited public comment and recommendations on approaches to address the appropriate valuation of moderate sedation related to Appendix G services. Following our comment solicitation, the CPT Editorial Panel created CPT codes for separately reporting moderate sedation services in association with the elimination of Appendix G from the CPT manual for CY 2017. This coding change would provide for payment for moderate sedation services only in cases where they are furnished. In addition to providing recommended values for the new codes used to separately report moderate sedation, the RUC provided a methodology for revaluing all services previously identified in Appendix G, without moderate sedation, in order to make appropriate corresponding adjustments for the procedural services. The RUC recommended this methodology to address moderate sedation valuation generally instead of recommending that it be addressed as individual codes are reviewed. The RUC's recommended methodology would remove work RVUs for moderate sedation from Appendix G codes based on a code-level assessment of whether the procedures are typically furnished to straightforward patients or more difficult patients. Based on its recommended methodology, the RUC recommended removal of fewer RVUs from each of the procedural services than it recommended for valuing the moderate sedation services. If we were to use the RUC-recommended values for both the moderate sedation codes and the Appendix G procedural codes without refinement, overall payments for these procedures, when moderate sedation is furnished, would increase relative to the current payment.
We direct readers to section II.L. of this final rule, which includes more detail regarding our valuation of the new moderate sedation codes, our methodology for revaluation of the procedural codes previously identified in Appendix G, and discussion and responses to the public comments we received regarding our proposal. We believe that the RVUs assigned under the PFS should reflect the overall relative resources of PFS services, regardless of how many codes are used to report the services. Therefore, our methodology for valuation of Appendix G procedural services maintains current resource assumptions for the procedures when furnished with moderate sedation and redistributes the RVUs associated with moderate sedation (previously
We also noted in the CY 2017 PFS proposed rule that stakeholders presented information to CMS regarding specialty group survey data for physician work. The stakeholders shared survey results for physician work involved in furnishing moderate sedation that demonstrated a significant bimodal distribution between procedural services furnished by gastroenterologists (GI) and procedural services furnished by other specialties. Since we believe that gastroenterologists furnish the highest volume of services previously identified in Appendix G, and services primarily furnished by gastroenterologists prompted the concerns that led to our identification of changes in medical practice and potentially duplicative payment for these codes, we have addressed the variations between GI and other specialties in our review of the new moderate sedation CPT codes and their recommended values. We again direct readers to section II.L. of this final rule where we discuss our establishment of an endoscopy-specific moderate sedation G-code that augments the new CPT codes for moderate sedation, the public comments we received, and our finalized valuations reflecting the differences in the physician survey data between GI and other specialties.
Under the PFS, certain services, such as surgery, are valued and paid for as part of global packages that include the procedure and the services typically furnished in the periods immediately before and after the procedure. For each of these global packages, we establish a single PFS payment that includes payment for particular services that we assume to be typically furnished during the established global period. There are three primary categories of global packages that are labeled based on the number of post-operative days included in the global period: 0-day; 10-day; and 90-day. The 0-day global packages include the surgical procedure and the pre-operative and post-operative services furnished by the physician on the day of the service. The 10-day global packages include these services and, in addition, visits related to the procedure during the 10 days following the day of the procedure. The 90-day global packages include the same services as the 0-day global codes plus the pre-operative services furnished one day prior to the procedure and post-operative services during the 90 days immediately following the day of the procedure. Section 40.1 of Chapter 12 of the Claims Processing Manual (Pub. 100-04) defines the global surgical package to include the following services related to the surgery when furnished during the global period by the same physician or another practitioner in the same group practice:
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In the CY 2015 PFS proposed and final rules we extensively discussed the problems with accurate valuation of 10- and 90-day global packages. Our concerns included the fact that we do not use actual data on services furnished to update the rates, questions regarding the accuracy of our current assumptions about typical services, whether we will be able to adjust values on a regular basis to reflect changes in the practice of medicine and health care delivery, and how our global payment policies affect what services are actually furnished (79 FR 67582 through 67585). In finalizing a policy to transform all 10- and 90-day global codes to 0-day global codes in CY 2017 and CY 2018, respectively, to improve the accuracy of valuation and payment for the various components of global packages, including pre- and post-operative visits and the procedure itself, we stated that we were adopting this policy because it is critical that PFS payment rates be based upon RVUs that reflect the relative resources involved in furnishing the services. We also stated our belief that transforming all 10- and 90-day global codes to 0-day global packages would:
• Increase the accuracy of PFS payment by setting payment rates for individual services that more closely reflect the typical resources used in furnishing the procedures;
• Avoid potentially duplicative or unwarranted payments when a beneficiary receives post-operative care from a different practitioner during the global period;
• Eliminate disparities between the payment for E/M services in global periods and those furnished individually;
• Maintain the same-day packaging of pre- and post-operative physicians' services in the 0-day global packages; and
• Facilitate the availability of more accurate data for new payment models and quality research.
Section 523(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) added section 1848(c)(8)(A) of the Act, which prohibits the Secretary from implementing the policy, described above, that would have transformed all 10-day and 90-day global surgery packages to 0-day global packages.
Section 1848(c)(8)(B) of the Act, which was also added by section 523(a) of the MACRA, requires us to collect data to value surgical services. Section 1848(c)(8)(B)(i) of the Act requires us to develop, through rulemaking, a process to gather information needed to value surgical services from a representative sample of physicians, and requires that the data collection begin no later than January 1, 2017. The collected information must include the number and level of medical visits furnished during the global period and other items and services related to the surgery and furnished during the global period, as appropriate. This information must be reported on claims at the end of the global period or in another manner specified by the Secretary. Section 1848(c)(8)(B)(ii) of the Act requires that,
Section 1848(c)(8)(C) of the Act, which was also added by section 523(a) of the MACRA, requires that, beginning in CY 2019, we must use the information collected as appropriate, along with other available data, to improve the accuracy of valuation of surgical services under the PFS.
As noted above, section 1848(c)(8)(C) of the Act mandates that we use the collected data to improve the accuracy of valuation of surgery services beginning in 2019. We described in the CY 2015 PFS final rule (79 FR 67582 through 67591) the limitations and difficulties involved in the appropriate valuation of the global packages, especially when the resources and the related values assigned to the component services are not defined. To gain input from stakeholders on implementation of this data collection, we sought comment on various aspects of this task in the CY 2016 proposed rule (80 FR 41707 through 41708). We solicited comments from the public regarding the kinds of auditable, objective data (including the number and type of visits and other services furnished during the post-operative period by the practitioner furnishing the procedure) needed to increase the accuracy of the valuation and payment for 10- and 90-day global packages. We also solicited comment on the most efficient means of acquiring these data as accurately and efficiently as possible. For example, we sought information on the extent to which individual practitioners or practices may currently maintain their own data on services furnished during the post-operative period, and how we might collect and objectively analyze those data and use the results for increasing the accuracy of the values beginning in CY 2019.
We received many comments in response to the comment solicitation in the CY 2016 proposed rule regarding potential methods of valuing the individual components of the global surgical package. A large number of comments expressed strong support for our proposal to hold an open door forum or town hall meetings with the public. In response, we held a national listening session on January 20, 2016. Prior to the listening session, the topics for which guidance was being sought were sent electronically to those who registered for the session and made available on our Web site. The topics were:
• Capturing the types of services typically furnished during the global period.
• Determining the representative sample for the claims-based data collection.
• Determining whether we should collect data on all surgical services or, if not, which services should be sampled.
• Potential for designing data collection elements to interface with existing infrastructure used to track follow-up visits within the global period.
• Consideration of using the 5 percent withhold until required information is furnished to encourage reporting.
The 658 participants in the national listening session provided valuable information on this task. A written transcript and an audio recording of this session are available at
Resource-based valuation of individual physicians' services is a critical foundation for Medicare payment to physicians. It is essential that the RVUs under the PFS be based as closely and accurately as possible on the actual resources used in furnishing specific services to make appropriate payment and preserve relativity among services. For global surgical packages, this requires using objective data on all of the resources used to furnish the services that are included in the package. Not having such data for some components may significantly skew relativity and create unwarranted payment disparities within the PFS.
The current valuations for many services valued as global packages are based upon the total package as a unit rather than by determining the resources used in furnishing the procedure and each additional service/visit and summing the results. As a result, we do not have the same level of information about the components of global packages as we do for other services. To value global packages accurately and relative to other procedures, we need accurate information about the resources—work, PEs and malpractice—used in furnishing the procedure, similar to what is used to determine RVUs for all services. In addition we need the same information on the post-operative services furnished in the global period (and pre-operative services the day before for 90-day global packages). Public comments about our CY 2015 proposal to value all global services as 0-day global services and pay separately for additional post-operative services when furnished indicated that there were no reliable data available on the value of the underlying procedure that did not also incorporate the value of the post-operative services, reinforcing our view that more data are needed across the board.
While we believe that most of the services furnished in the global period are visits for follow-up care, we do not have accurate information on the number and level of visits typically furnished because those billing for global services are not required to submit claims for post-operative visits. A May 2012 Office of Inspector General (OIG) report, titled Cardiovascular Global Surgery Fees Often Did Not Reflect the Number of Evaluation and Management Services Provided (
Claims data plays a major role in PFS ratesetting. Specifically, Medicare claims data are a primary driver in the allocation of indirect PE RVUs and MP RVUs across the codes used by
In addition to the lack of information about the number and level of visits actually furnished, the current global valuations rely on crosswalks to E/M visits, based upon the assumption that the resources, including work, used in furnishing pre- and post-operative visits are similar to those used in furnishing E/M visits. We are unaware of any studies or surveys that verify this assertion. Although we generally value the visits included in global packages using the same direct PE inputs as are used for E/M visits, for services for which the RUC recommendations include specific PE inputs in addition to those typically included for E/M visits, we generally use the additional inputs in the global package valuation. In contrast, when a visit included in a global package would use fewer resources than a comparable E/M service, the RUC generally does not include recommendations to decrease the PE inputs of the visit included in the global package, and we have not generally made comparable reductions. Another inconsistency with our current global package valuation approach is that even though we effectively assume that the E/M codes are appropriate for valuing pre- and post-operative services, the indirect PE inputs used for calculating payments for global services are based upon the specialty mix furnishing the global service, not the specialty mix of the physicians furnishing the E/M services, resulting in a different valuation for the E/M services contained in global packages than for separately billable E/M services. There is a critical need to obtain complete information if we are to value global packages accurately and in a way that preserves relativity across the fee schedule.
In response to the requirement of section 1848(c)(8)(B)(i) of the Act that we develop, through rulemaking, a process to gather information needed to value surgical services, we proposed a rigorous data collection effort to provide us the data needed to accurately value the 4,200 codes with a 10- or 90-day global period. Using our authority under sections 1848(c)(2)(M) and (c)(8)(B)(i) of the Act, we proposed to gather the data needed to determine how to best structure global packages with post-operative care that is typically delivered days, weeks or months after the procedure and whether there are some procedures for which accurate valuation for packaged post-operative care is not possible. Finally, we indicated that these data would provide useful information to assess the resources used in furnishing pre- and post-operative care in global periods. To accurately do so, we need to know the volume and costs of the resources typically used.
We proposed a three-pronged approach to collect timely and accurate data on the frequency of and the level of pre- and post-operative visits and the resources involved in furnishing the pre-operative visits, post-operative visits, and other services for which payment is included in the global surgical payment. By analyzing these data, we would not only have the most comprehensive information available on the resources used in furnishing these services, but also would be able to determine the appropriate packages for such services. Specifically, the proposal included:
• A requirement for claims-based reporting about the number and level of pre- and post-operative visits furnished for 10- and 90-day global services.
• A survey of a representative sample of practitioners about the activities involved in and the resources used in providing a number of pre- and post-operative visits during a specified, recent period of time, such as two weeks.
• A more in-depth study, including direct observation of the pre- and post-operative care delivered in a small number of sites, and a separate survey module for practitioners practicing in ACOs.
The information collected and analyzed through the activities would be the first comprehensive look at the volume and level of services in a global period, and the activities and inputs involved in furnishing global services. The data from these activities would ultimately inform our revaluation of global surgical packages as required by statute.
To expand awareness of the proposal for data collection, we held a national listening session in which CMS reviewed the proposal for participants. Subsequent to this national listening session, we held a town hall meeting at the CMS headquarters in which participants, in person and virtual, shared their views on the proposal with CMS. The transcript from these town halls is available on the CMS Web site with the CY 2017 final rule downloads.
As described in this section of the final rule, section 1848(c)(8)(B)(i) of the Act requires us to develop, through rulemaking, a process to gather information needed to value surgical services from a representative sample of physicians. The statute requires that the collected information include the number and level of medical visits furnished during the global period and other items and services related to the surgery and furnished during the global period, as appropriate.
In addition, section 1848(c)(2)(M) of the Act, which was added to the Act by section 220 of the PAMA, authorizes the Secretary to collect or obtain information on resources directly or indirectly related to furnishing services for which payment is made under the PFS. Such information may be collected or obtained from any eligible professional or any other source. Information may be collected or obtained from surveys of physicians, other suppliers, providers of services, manufacturers, and vendors. That section also authorizes the Secretary to collect information through any other mechanism determined appropriate. When using information gathered under this authority, the statute requires the Secretary to disclose the information source and discuss the use of such information in the determination of relative values through notice and comment rulemaking.
As described in this section of the final rule, to gain information to assist CMS in determining the appropriate packages for global services and to revalue those services, CMS needs more information on the resources used in furnishing such services. Through the claims-based data collection and the study we are finalizing in this final rule, we would have better information about the actual number of services furnished to Medicare beneficiaries to use in valuation for these codes than has been typically available, such as from RUC surveys that reflect practitioner's estimates of the number of services typically furnished. We anticipate that such efforts would inform how to more regularly collect data on the resources used in furnishing physicians' services. To the extent that such mechanisms prove valuable, they may be used to collect data for valuing other services. To achieve this significant data collection, we proposed to collect data under the authority of both section 1848(c)(8)(B) and (c)(2)(M) of the Act.
We proposed a claims-based data collection that would have required all those providing 10- or 90-day global services to report on services furnished during the global period using a series of G-codes specially created for this purpose, beginning January 1, 2017.
In response to the comments submitted on the proposal, we are finalizing a claims-based data collection that differs from this proposal in the following significant ways:
• CPT code 99024 will be used for reporting post-operative services rather than the proposed set of G-codes. Reporting will not be required for pre-operative visits included in the global package or for services not related to patient visit.
• Reporting will be required only for services related to codes reported annually by more than 100 practitioners and that are reported more than 10,000 times or have allowed charges in excess of $10 million annually.
• Practitioners are encouraged to begin reporting post-operative visits for procedures furnished on or after January 1, 2017, but the mandatory requirement to report will be effective for services related to global procedures furnished on or after July 1, 2017.
• Only practitioners who practice in groups with 10 or more practitioners in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island will be required to report. Practitioners who only practice in smaller practices or in other geographic areas are encouraged to report data, if feasible.
Given that the data collection will be limited to only some states, a subset of global services, and only to those who practice in larger practices the information collected through claims for global packages services will not parallel the claims data that are available in pricing other PFS services. However, we believe that the information collected through this data collection will be a significant improvement over the information currently available to value these services and will be supplemented with information obtained through other mechanisms.
In the following sections, we discuss the comments on each element of our data collection proposal, our responses and our final decision.
A key element of claims-based reporting is using codes that appropriately reflect the services furnished. In response to the comment solicitation in the CY 2016 PFS proposed rule and the input received via the January 2016 listening session, we received numerous recommendations for the information to be reported on claims. The most frequently recommended approach was for practitioners to report the existing CPT code for follow-up visits included in the surgical package (CPT 99024—Postoperative follow-up visit, normally included in the surgical package, to indicate that an E/M service was performed during a postoperative period for a reason(s) related to the original procedure). Others suggested using this code for outpatient visits and using length of stay data to estimate the number of inpatient visits during the global period. In response to our concerns that CPT code 99024 would provide only the number of visits and not the level of visits as required by the statute, one commenter suggested using modifiers in conjunction with CPT code 99024 to indicate the level of the visit furnished. Others recommended using existing CPT codes for E/M visits to report post-operative care. One commenter suggested that CMS analyze data from a sample of large systems and practices that are using electronic health records that require entry of some CPT code for every visit to capture the number of post-operative visits. After noting that the documentation requirements and PEs required for post-operative visits differ from those of E/M visits outside the global period, one commenter encouraged us to develop a separate series of codes to capture the work of the post-operative services and to measure, not just estimate, the number and complexity of visits during the global period.
Other commenters opposed the use of a new set of codes or the use of modifiers to report post-operative visits. Commenters also noted several issues for us to consider in developing data collection mechanisms, including that many post-operative services do not have CPT codes to bill separately, that surgeons perform a wide range of collaborative care services, and that patient factors, including disease severity and comorbidities, influence what post-operative care is furnished.
To assist us in determining appropriate coding for claims-based reporting, we added a task to the RAND validation contract for developing a model to validate the RVUs in the PFS, which was awarded in response to a requirement in the Affordable Care Act. Comments that we received on the validation report suggested the models did not adequately address global surgery services due to the lack of available data on visits included in the global package. Therefore, we modified the validation contract to include the development of G-codes that could be used to collect data about post-surgical follow-up visits on Medicare claims for valuing global services under MACRA so that this time could be included in the model for validating RVUs.
To inform its work on developing coding for claims-based reporting, the contractor conducted interviews with surgeons and other physicians/non-physician practitioners (NPP) who provide post-operative care. A technical expert panel (TEP), convened by the contractor, reviewed the findings of the interviews and provided input on how to best capture care provided in the post-operative period on claims.
In summarizing the input from the interviews and the TEP, the contractor indicated that several considerations were important in developing a claims-based method for capturing post-operative services. First, a simple system to facilitate reporting was needed. Since it was reported that a majority of post-operative visits are straightforward, the contractor found that a key for any proposed system is identifying the smaller number of complex post-operative visits. Another consideration was not using the existing CPT E/M structure to capture postoperative care because of concerns that E/M codes are inadequately designed to capture the full scope of post-operative care and that using such codes might create confusion. Another consideration was that the TEP was most enthusiastic about a set of codes that used site of care, time, and complexity to report visits. The contractor also believed it was important to distinguish—particularly in the inpatient setting—between circumstances where a surgeon is providing primary versus secondary management of a patient. Finally, a mechanism for reporting the postoperative care occurs outside of in-person visits and by clinical staff was needed. The report noted that in the inpatient setting in particular, surgeons spend considerable time reviewing test results and coordinating care with other practitioners.
After reviewing various approaches, a set of time-based, post-operative visit codes that could be used for reporting care provided during the post-operative period was recommended.
The recommended codes distinguish services by the setting of care and whether they are furnished by a physician/NPP or by clinical staff. All codes are intended to be reported in 10-minute increments. A copy of the report
We proposed the following no-pay codes be used for reporting on claims the services actually furnished but not paid separately because they are part of global packages.
Our proposal included three codes for reporting inpatient pre- and post-operative visits that distinguish the intensity involved in furnishing the services. Under this proposal, visits that involve any combination or number of the services listed in Table 10, which were recommended by the contractor as those in a typical visit, would be reported using GXXX1. Based on the findings from the interviews and the TEP, the report indicated that the vast majority of inpatient post-operative visits would be expected to be reported using GXXX1.
Under our proposal, inpatient pre- and post-operative visits that are more complex than typical visits but do not qualify as critical illness visits would be coded using GXXX2 (Inpatient visit, complex, per 10 minutes, included in surgical package). To report this code, the practitioner would be required to furnish services beyond those included in a typical visit and have documentation that indicates what services were provided that exceeded those included in a typical visit. In the proposed rule, we noted some circumstances that might merit the use of the complex visit code are secondary management of a critically ill patient where another provider such as an intensivist is providing the primary management, primary management of a particularly complex patient such as a patient with numerous comorbidities or high likelihood of significant decline or death, management of a significant complication, or complex procedures outside of the operating room (For example, significant debridement at the bedside).
The highest level of inpatient pre- and post-operative visits, critical illness visits (GXXX3—Inpatient visit, critical illness, per 10 minutes, included in surgical package) would be reported when the physician is providing primary management of the patient at a level of care that would be reported using critical care codes if it occurred outside of the global period. This involves acute impairment of one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition.
Similar to how time is now counted for the existing CPT critical care codes, we proposed that all time spent engaged in work directly related to the individual patient's care would count toward the time reported with the inpatient visit codes; this includes time spent at the immediate bedside or elsewhere on the floor or unit, such as time spent with the patient and family members, reviewing test results or imaging studies, discussing care with other staff, and documenting care.
For the three codes in our proposal that would be used for reporting post-operative visits in the office or other outpatient settings, codes, time would be defined as the face-to-face time with patient, which reflects the current rules for time-based outpatient codes.
Like GXXX1, GXXX5 (Office or other outpatient visit, typical, per 10 minutes, included in surgical package) would be used for reporting any combination of activities in Table 10 under our proposal.
We proposed only face-to-face time spent by the practitioner with the patient and their family members would count toward the time reported with the office visit codes.
Services that are furnished via phone, the internet, or other electronic means outside the context of a face-to-face visit would be reported using GXXX7 when furnished by a practitioner and GXXX8 when provided by clinical staff under our proposal. We proposed that practitioners would not report these services if they are furnished the day before, the day of, or the day after a visit as we believe these would be included in the pre- and post-service activities in the typical visit. However, we proposed that these codes be used to report non-face-to-face services provided by clinical staff prior to the primary procedure since global surgery codes are typically valued with assumptions regarding pre-service clinical labor time. Given that some practitioners have indicated that services they furnish commonly include activities outside the face-to-face service, we believed it was important to capture information about those activities in both the pre- and post-service periods. We also believed these requirements to report on clinical
In addition, we proposed for services furnished via interactive telecommunications that meet the requirements of a Medicare telehealth service visit, the appropriate global service G-code for the services would be reported with the GT modifier to indicate that the service was furnished “via interactive audio and video telecommunications systems.”
After considering the contractor report, the comments in response to the comment solicitation in the CY 2016 proposed rule and other stakeholder input that we have received, and our needs for data to fulfill our statutory mandate and to value surgical services appropriately, we proposed this new set of codes because we believe it provides us the most robust data upon which to determine the most appropriate way and amounts to pay for PFS surgical services. We noted that these proposed codes would provide data of the kind that can reasonably collected through claims data and that reflect what we believe are key issues in the valuation of post-operative care—where the service is provided, who furnishes the service, its relative complexity, and the time involved in the service.
We solicited public comments about all aspects of these codes, including the nature of the services described, the time increment, and any other areas of interest to stakeholders. We noted particular interest in any pre- or post-operative services furnished that could not be appropriately captured by these codes. We solicited comments on whether the proposed codes were appropriate for collecting data on pre-operative services. We also sought comment on any activities that should be added to the list of activities in Table 10 to reflect typical pre-operative visit activities.
In making the proposal for G-codes, we noted that many stakeholders had expressed strong support for the use of CPT code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a post-operative period for a reason(s) related to the original procedure) to collect data on post-operative care. In response to stakeholders noting that practitioners are familiar with this existing CPT code and the burden on practitioners would be minimized by only having to report that a visit occurred, not the level of the visit, we noted that we did not believe that this code alone would provide the information that we need for valuing surgical services nor do we believe it alone can meet the statutory requirement that we collect data on the number and level of visits. Given the strong support for the use of CPT code 99024, we solicited comments specifically on how we could use this code to capture the statutorily required data on the number and level of visits and the data that we would need to value global services in the future.
We also discussed in the proposed rule our concern that using CPT code 99024 with modifiers to indicate to which of the existing levels of E/M codes the visit corresponds may not accurately capture what drives greater complexity in post-operative visits. We noted that as outlined in the contractor's report, E/M billing requirements are built upon complexity in elements such as medical history, review of systems, family history, social history, and how many organ systems are examined. In the context of a post-operative visit, many of these elements may be irrelevant. The contractor's report also notes that there was significant concern from interviewees and the expert panel about documentation that is required for reporting E/M codes. Specifically, they stated that documentation requirements for surgeons to support the relevant E/M visit code would place undue administrative burden on surgeons given that many surgeons currently use minimal documentation when they provide a postoperative visit. We also noted that to value surgical packages accurately we need to understand the activities involved in furnishing post-operative care and as discussed above, we lack information that would demonstrate that activities involved in post-operative care are similar to those in E/M services. In addition, the use of modifiers to report levels of services is more difficult to operationalize than using unique HCPCS codes. However, we sought comments on whether, and if so, why, practitioners would find it easier to report CPT code 99024 with modifiers corresponding to the proposed G-code levels rather than the new G-codes, as proposed. We also sought comment on whether practitioners would find it difficult to use this for pre-operative visits since the CPT code descriptor specifically defines it as a “post-operative follow-up” service.
We also sought comment on whether time of visits could alone be a proxy for the level of visit. If pre- and post-operative care varies only by the time the practitioner spends on care so that time could be a proxy for complexity of the service, then we could use the reporting of CPT code 99024 in 10-minute increments to meet the statutory requirement of collecting claims-based data on the number and level of visits. In addition to comments on whether time is an accurate proxy for level of visit, we solicited comment on the feasibility and desirability of reporting CPT code 99024 in 10-minute increments.
The following is a summary of the comments that we received on our proposal to use G-codes for reporting the services furnished during the pre- and post-operative periods of 10- and 90-day global services.
Three organizations commented that it was appropriate to collect time data, but recommended that we do so based upon 15-minute increments as these were more familiar to physicians than the proposed 10-minue increments. In addition, some other groups, including MedPAC, agreed that data on time was needed for valuations.
Some commenters expressed specific concern about the documentation burden that would come from using these codes. On the other hand, other commenters suggested that providers of visits during the global surgical services should be held to the same documentation standards as providers of E/M services. One stated that the “administrative burden on surgeons should be no different and certainly no less than that on non-surgeons when it comes to documenting a visit with a patient. If many surgeons currently use minimal documentation when they provide a post-operative visit that is no excuse for expecting the same inadequate level of documentation going forward. To require anything less than the same level of documentation for all clinicians providing E/M services would be irresponsible and unfair and would defeat the very purpose of documenting the actual types and extent of these services in the post-operative period.”
Most commenters disagreed that time could be a proxy for the complexity of the visit and objected to reporting time for the same reasons discussed above. These commenters did not agree that CPT code 99024 could be reported in time units as a proxy for collecting the required information about the level of visits.
Three organizations disagreed, however, stating that time is a sufficient proxy for work relativity in post-operative visits and that the number units of CPT code 99024 could reflect the complexity involved. These commenters recommended reporting data in 15-minute intervals, rather than the proposed 10-minute increments, stating that physicians are familiar with 15-minute increments and thus the use of 15-minute increments would greatly reduce the administrative burden. They recommended that CMS clearly define how time is to be reported and suggested that the 8-minute rule is already a familiar concept that could be used.
Many commenters suggested that other approaches, such as a survey, clinical registries, or on-line portals be used to collect data on level of visits.
Several commenters stated that CMS should not collect data on the level of visits based on these commenters' perspective that there is no problem with the level of visits currently used in the valuation of global packages. One commenter pointed out that only 1 percent of all established patient office visits used in valuing 10-day and 90-day global surgery packages have a visit level above a CPT code 99213. Another commenter suggested that the survey be used to collect data on the level of visits. Others suggested that RUC surveys be used to measure level of visits.
In addition to the statutory reference to collecting data on the level of visits, we believe that code valuations can be more accurate with more complete information. While we continue to believe that data only on the number of visits furnished would not provide data on both the number and level of visits needed for valuation of services, data on the number of visits alone is an important input in valuing global packages and having accurate data on the number of visits could be a useful first step in analyzing the global packages.
After considering the comments, we are finalizing a requirement to report post-operative visits furnished during 10- and 90-day global periods. However, rather than using the proposed set of G-codes for this reporting, we are requiring that CPT code 99024 be used to report such visits. We will not, at this time, require time units or modifiers to distinguish levels of visits to be reported. Since this code is specifically limited to post-operative care, we are only requiring reporting of post-operative visits. We expect that the reporting of this information through Medicare claims will provide us with information about the actual number of visits furnished during the post-operative periods for many services reported using global codes. Because the number of visits is a major factor in valuation of global services, we believe that examination of such information, when available, can improve the accuracy of the global codes. The use of a simple code that practitioners are familiar with should facilitate the submission of accurate information. We expect practitioners to note the visit in the medical chart documenting the post-operative visit.
Since CPT code 99024 will only provide data on the number of visits and no data on the level or resources used in furnishing the visit, we believe this is only the first step in gathering the data required by Section 1848(c)(8). The proposed G-codes could have provided information to better understand the resources used in furnishing services during global periods and in valuation of such services assuming that they could be accurately reported. However, widespread concerns from groups representing the practitioners that would be reporting these services, including concerns about the burdens regarding and the inability of physicians to track time and the need to learn a new 8-code coding system, persuade us that we should pursue less burdensome ways of obtaining information. We will assess whether these methods will lead to the collection of necessary data, including data on time and intensity, of these services.
As suggested by commenters, we will explore whether the data collected from the survey that we are conducting, which is discussed later in this preamble, can provide information on the level of visits and other resources needed to value surgical services accurately. Stakeholders should be aware that since this a new approach for collecting data, and one that has not been used previously, we are concerned that additional or different reporting will be necessary to collect data on the number and level of visits and other information needed to value surgical services as required by Section 1848(c)(8).
We proposed that the G-codes detailed above would be reported for services related to and within 10- and 90-day global periods for procedures furnished on or after January 1, 2017. Services related to the procedure furnished following recovery and otherwise within the relevant global period would be required to be reported. These codes would be included on claims filed through the usual process. Through this mechanism, we would collect all of the information reported on a claim for services, including information about the practitioner, service furnished, date of service, and the units of service. By not imposing special reporting requirements on these codes, we proposed to allow practitioners the flexibility to report the services on a rolling basis as they are furnished or to report all of the services on one claim once all have been furnished, as long as the filed claims meet the requirements for filing claims.
We did not propose any special requirements for inclusion of additional data on claims that could be used for linking the post-operative care furnished to a particular service. To use the data reported on post-operative visits for analysis and valuation, we proposed to link the data reported on post-operative care to the related procedure using date of service, practitioner, beneficiary, and diagnosis. While we believed this approach to matching would allow us to accurately link the preponderance of G-codes to the related procedure, we sought comment on the extent to which post-operative care may not be appropriately linked to related procedures whether we should consider using additional variables to link these aspects of the care, and whether additional data should be required to be reported to enable a higher percentage of matching.
The following is summary of the comments we received on our proposal to require reporting on pre- and post-operative care associated with all procedures with 10- and 90-day global periods.
Having specific data on all procedures would provide specific information for each service that Medicare pays for using a global period. In assessing the likely benefit of the additional data as compared to the burden of reporting based on the comments we received, we agree with commenters that collecting the data from high volume/high cost procedures could provide adequate information to improve the accuracy of valuation of global packages overall. Even if all practitioners reported data on all procedures, it is likely that we would not receive enough data on low-volume services for the data to be reliable for use in valuations. There are more than 1,500 services that are furnished less than 100 times per year. Because of this, data that we could collect on these services would be extremely limited. We also find that data on services with low volumes are not reliable due to variability from year to year. Since we often value related services by extrapolating data on one service to other services in the family, with adjustments as necessary to reflect variations in the procedure, the data gathered on high-volume services could similarly be used to value low-volume services in the same family. As a result we, believe that the data on high-volume services can improve the accuracy of values for all 10- and 90-day services.
After consideration of the comments, we are implementing a requirement for reporting on services that are furnished by more than 100 practitioners and are either furnished more than 10,000 times or have allowed charges of more than $10 million annually as recommended by the RUC and many other commenters. Under this policy, we estimate that we would collect data on about 260 codes that describe approximately 87 percent of all furnished 10- and 90-day global services and about 77 percent of all Medicare expenditures for 10- and 90-day global services under the PFS. Given that this data would provide information on the codes describing the vast majority of 10- and 90-day global services and expenditures, it will provide significant data for valuation. For 2017, we will use the CY 2014 claims data to determine the codes for which reporting is required and display the list on the CMS Web site. In subsequent years, we will update the list to reflect more recent claims data and publish a list of codes prior to the beginning of the reporting year. The services for which reporting is required will include successor codes to those deleted or modified since CY 2014 for which reporting would have been required if the code had not been deleted or modified.
The following is summary of the comments we received on our proposal to require claims-based reporting for services related to procedures furnished on or after January 1, 2017.
After consideration of comments, we are encouraging practitioners to begin reporting data on post-operative services for procedures furnished on or after January 1, 2017. However, the requirement to report will become mandatory for post-operative services related to procedures furnished on or after July 1, 2017 rather than as of January 1, 2017, as proposed. This delay will not negatively impact the use value of the collected data since we expect that data received early in the year might be less complete than data submitted once practitioners adjusted to the requirements. Also, by allowing time for practitioners to adjust EHR and billing software, to test such systems and to train staff, we think the quality of the data will be enhanced by providing flexibility with regard to the effective date of the requirement. Finally, because we are limiting required reporting to high-volume codes, meaningful data for CY 2017 should be available from 6 months of reporting. Our systems can now accept the post-operative visit data so practitioners can begin submitting such claims at any time.
We sought comment on whether special provisions are needed to capture the pre- and post-operative services provided by residents in teaching settings. If the surgeon is present for the key portion of the visit, should the surgeon report the joint time spent by the resident and surgeon with the patient? If the surgeon is not present for the key portion of the visit, should the resident report the service? If we value services without accounting for services provided by residents that would otherwise be furnished by the surgeon in non-teaching settings, subsequent valuations based upon the data we collect may underestimate the resources used, particularly for the types of surgeries typically furnished in teaching facilities. However, there is also a risk of overvaluing services if the reporting includes services that are provided by residents when those services would otherwise be furnished by a physician other than the surgeon, such as a hospitalist or intensivist, and as such, should not be valued in the global package.
After consideration of the comments, we are finalizing a requirement that teaching physicians will be subject to the reporting requirements in the same way that other physicians are. Such physicians should report CPT code 99024 only when the services furnished would meet the general requirements for reporting services and should use the GC or GE modifier as appropriate.
In both the comments on the CY 2016 proposed rule and in input from the January 2016 national listening session, there was a great deal of discussion regarding the challenges that we are likely to encounter in obtaining adequate data to support appropriate valuation. Some indicated that a broad sample and significant cooperation from physicians would be necessary to understand what is happening as part of the global surgical package. One commenter suggested that determining a representative sample would be difficult and, due to the variability related to the patient characteristics, it would be easier to have all practitioners report. Many suggested that we conduct an extensive analysis across surgical specialties with a sample that is representative of the entire physician community and covers the broad spectrum of the various types of physician practice to avoid problems that biased or inadequate data collection would cause. Suggestions of factors to account for in selecting a sample include specialty, practice size (including solo practices), practice setting, volume of claims, urban, rural, type of surgery, and type of health care delivery systems. Another commenter pointed out that small sample sizes may lead to unreliable data. Some commenters stated that requiring all practitioners to report this information is unreasonable and would be an insurmountable burden. A participant acknowledged that it would be difficult for practitioners to report on only certain procedures, while another stated that this would not be an administrative burden.
After considering the input of stakeholders on the CY 2016 proposed rule and at the January 2016 national listening session discussed above, we proposed that any practitioner who furnishes a procedure that is a 10- or 90-day global service report the pre- and post-operative services furnished on a claim using the proposed G-codes. We agreed with stakeholders that it would be necessary to obtain data from a broad, representative sample. However, as we struggled to develop a nationally representative sampling approach that would result in statistically reliable and valid data, it became apparent that we do not have adequate information about how post-operative care is delivered, how it varies and, more specifically, what drives variation in post-operative care to develop a sampling frame. In its work to develop the coding used for its study, the contractor found a range of opinions on what drives variation in post-operative care. (The report is available on the CMS Web site under downloads for the CY 2017 PFS proposed rule with comment period at
In addition to concerns about achieving a statistically representative sample of all practitioners nationally, we noted in the proposed rule significant operational concerns with limiting data collection to a subset of practitioners or a subset of services. These include how to gain sufficient information on practitioners to stratify the sample, how to identify the
We also noted in the proposed rule that the more robust the reported data, the more accurate our ultimate valuations can be. We stated that given the importance of data on visits in accurate valuations for global packages, collecting data on all pre- and post-operative visits in the global period is the best way to accurately value surgical procedures with global packages.
We recognized that reporting would require submission of additional claims by those practitioners furnishing global services, but indicated that we believed the benefits of accurate data for valuation of services merited the imposition of this requirement. By using the claims system to report the data, we believed the additional burden would be minimized and referred to stakeholder reports that many practitioners are already required by their practice or health care system to report a code for each visit for internal control purposes and some of these systems already submit claims for these services, which are denied. We noted that requiring only some physicians to report this information, or requiring reporting for only some codes, could actually be more burdensome to physicians than requiring this information from all physicians on all services because of the additional steps necessary to determine whether a report is required for a particular service and adopting a mechanism to assure that data is collected and reported when required. Moreover, we stated that the challenges with implementing a limited approach at the practice level as compared to a requirement for all global services would result in less reliable data being reported.
We noted that as we analyzed the data collected and made decisions about valuations, we would reassess the data needed and what should be required from whom. Through the data collected under our proposal, we indicated that we would have the information to assess whether the post-operative care furnished varies by factors such as specialty, geography, practice setting, and practice size, and thus, the information needed for a sample selection to be representative.
While section 1848(c)(8)(B) of the Act requires us to collect data from a representative sample of physicians on the number and level of visits provided during the global period, we stated that it does not prohibit us from collecting data from a broad set of practitioners. In addition, section 1848(c)(2)(M) of the Act authorizes the collection of data from a wide range of physicians. Given the benefits of more robust data, including avoiding sample bias, obtaining more accurate data, and facilitating operational simplicity, we noted that we believed collecting data on all post-operative care initially is the best way to undertake an accurate valuation of surgical services in the future.
The following is a summary of the comments that we received on our proposal to require all practitioners furnishing 10- or 90-day global services to submit claims for the pre- and post-operative services furnished.
One commenter stated that requiring every practitioner to report these codes will be in many ways less representative than a targeted sample, explaining that given the limited time for education, only large, technologically rich practices will have the ability to properly report these services. The commenter noted that this will leave many, smaller or rural practices without the proper education and robust billing systems in place to adequately, if at all, report these G-codes. The commenter also noted that smaller, rural practices have smaller patient populations, which can often be older and sicker than the typical patient seen in a large practice and by creating a complex system that favors one type of practice, the collected data is more likely to be biased rather than representative. Another commenter suggested that a small number of representative practices could provide us with the same level of accuracy as collected data from all physicians.
We do not agree with commenters that state that we do not have the statutory authority to require reporting by all practitioners furnishing certain services. We point commenters to section 1848(c)(2)(M) of the Act, which authorizes the collection of data to use in valuing PFS services. We continue to believe that section 1848(c)(8) of the Act requires us to collect data that is representative. We also continue to believe that requiring all practitioners to report is more likely to be representative than a sample given our lack of information about what drives variation in post-operative care. However, after considering the information presented by commenters regarding the difficulties that would be placed on many physicians by the proposal, we believe that requiring reporting by all practitioners for CY 2017 may present unforeseen, alternative impediments to the sample being nationally representative of all practitioners, such as practitioners being unable to report data accurately due to constraints of time, finances or technical ability.
Several commenters suggested broadly sampling using the characteristics that are frequently used for health care sampling generally, such as geographic areas, urban and rural, practice types, practice sizes, specialties and academic and non-academic. One commenter recommended that we select a sample using geographical data to identify a sample including practices of all sizes. The commenter suggested, for example, that large hospital-based practices often have practice patterns that are different from the majority of the practicing physicians in suburban and rural areas. Another commenter stated that we should not only collect data from MSAs but also from rural and less urban areas.
One commenter suggested that we consider phasing in the requirement, perhaps starting with larger groups. The commenter stated that through one of these approaches we could avoid “burdening providers with unfunded work that has not yet been tested.”
One commenter suggested that we use a geographic sampling approach similar to that one used for Comprehensive Care for Joint Replacement (CJR) model or the episode payment models proposed for cardiac and surgical hip/femur fraction and modify it to choose a geographic sampling unit of MSAs and non-MSAs.
However, instead of sampling by practice or practitioner or type of service, a geographic approach to sampling (for example, sampling all practitioners in a selected state) could help to alleviate the need to stratify the sample on a long list of criteria. By using broad geographical areas from varied areas of the country, we believe our sample will capture data from practitioners who practice in a variety of settings, single and multispecialty practices, urban and rural, a variety of medical specialties, and practitioners operating in both academic and non-academic institutions. Surgeons interviewed for the G-code development suggested that post-operative care might vary across these dimensions. A geographic approach could also mitigate some of the practical operational barriers. For example, we believe that by having all practitioners in the practice participate in reporting, we avoid concerns about incomplete data when a required reporter furnishes a procedure and another practitioner in the practice furnishes the post-operative visits. A geographic approach also makes it easier to educate practitioners on data collection requirements.
After consideration of the comments, we are finalizing a requirement for reporting that only applies to practitioners in selected states. In addition, those practicing only in small practices are excluded from required reporting. Those not required to report can do so voluntarily and we encourage them to do so.
As we noted in the proposed rule, we do not have adequate data on what drives variations in the delivery of pre- and post-operative care to design a sampling methodology that is certain to be representative. We also believe that submission by all practitioners would be consistent with our extensive use of claims data for other PFS services. Additionally, we understand the statute directs us to gather data from more than a select group of practitioners based on any particular attributes, such as gathering data only from “efficient” practices, consistent with longstanding recommendations from MedPAC regarding limiting data collection. We also believed that there were significant operational impairments to data reporting by a limited sample of physicians. In consideration of these factors, we proposed to require reporting by all physicians to make sure that the data we obtained reflected all services furnished. In light of the comments regarding the burden that would be created by requiring reporting by all physicians and the data that was actually needed for valuation, we think that reporting by a subset of practitioners could provide us valuable information on the number of visits typically furnished in global periods. This data could enhance the information we currently use to establish values for these services. While we acknowledge that we believe the data under this less burdensome approach will provide less information than necessary for optimal valuation for these services, we believe that the information on the number of actual visits from a subset of practitioners is preferable to the information on which we currently rely, which is the results of survey data reflecting respondents' assessment of the number of visits considered to be typical.
One commenter suggested that we could develop a geographic sample using a similar approach used by the Center for Medicare and Medicaid Innovation for the Comprehensive Care for Joint Replacement (CJR) or other proposed episode payment models, with an adjustment that would make certain we received data from rural, as well as urban areas. We reviewed these approaches and concluded that such an approach for sample selection could maximize the variability of the sample, mitigate some of our concerns, and provide a robust set of data for consideration.
Commenters suggested a sample should include geographic diversity. Studies show that health care delivery patterns often vary between geographic areas and while we have no specific information that the number of post-operative visits varies by geographic areas, it seems prudent to gather data from a variety of geographic areas to determine if there is such variation and
To make sure that we had states of a variety of sizes, we ranked states according to the number of Medicare beneficiaries in each state. We chose the number of Medicare beneficiaries to reflect the general need for Medicare services. We divided states into four groups: The top 5 states in terms of the number of Medicare beneficiaries (group 1); 6th through 15th largest states in terms Medicare beneficiaries (group 2); the 16th through 25th largest states in terms of Medicare beneficiaries (group 3); and all remaining states (26 including the District of Columbia, group 4). The states in each group are:
• Group 1—California, Florida, New York, Pennsylvania & Texas.
• Group 2—Georgia, Illinois, Massachusetts, Michigan, New Jersey, North Carolina, Ohio, Tennessee, Virginia, and Washington.
• Group 3—Alabama, Arizona, Indiana, Kentucky, Louisiana, Maryland, Minnesota, Missouri, Wisconsin, and South Carolina.
• Group 4—Alaska, Arkansas, Colorado, Connecticut, District of Columbia, Delaware, Hawaii, Idaho, Iowa, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Oregon, Rhode Island, South Dakota, Utah, Vermont, West Virginia and Wyoming.
We also recorded the Census region for each state using the Census Bureau's nine regions (New England, Middle Atlantic, South Atlantic, East South Central, West South Central, East North Central, West North Central, Mountain, and Pacific). Puerto Rico and other territories were excluded.
To ensure a mix of states in terms of size (measured by number of Medicare beneficiaries), we selected 1 state at random from group 1, followed by 2 states each at random from groups 2 and 3, and lastly 4 states from group four. After each random selection, we eliminated the remaining states in the same Census region from the remaining groups for which selection was pending to maximize geographic variation in the selection of states. In the event that this process resulted in fewer than 9 selected states (for example if none of the three Middle Atlantic states—all in Group 1 and 2—were selected in the first three picks), the last selection(s) were made randomly from states in the remaining Census region from which selections previously had not been made.
Practitioners located in the following states who meet the criteria for required reporting will be required to report the data discussed in this section of the final rule:
• Florida.
• Kentucky.
• Louisiana.
• Nevada.
• New Jersey.
• North Dakota.
• Ohio.
• Oregon.
• Rhode Island.
In response to comment about the burden of our proposed requirement and the concern that the burden would result in the submission of data of poor quality, we are exempting practitioners who only practice in practices with fewer than 10 practitioners from the reporting. Based upon the comments, we believe larger practices are more likely to currently require practitioners to track all visits and often use CPT code 99024 to do so. Moreover, larger practices are more likely to have coding and billing staff that can more easily adapt to this claims-based requirement. The combination of experience with reporting CPT code 99024 and the staff and resource base to devote to developing the infrastructure for such reporting will result in greater accuracy from such practitioners. By excluding practitioners who only practice in practices with fewer than 10 practitioners, we estimate that about 45 percent of practitioners will not be required to report. In defining small practices, we reviewed other programs. We chose 10 practitioners as the threshold for reporting as practices of this size are large enough to support coding and billing staff, which will make this reporting less burdensome. Also, this is the same threshold used by the value-based modifier program for its phase-in of a new requirement because of concerns about the burden of small practices.
For this purpose, we define practices as a group of practitioners whose business or financial operations, clinical facilities, records, or personnel are shared by two or more practitioners. For the purposes of this reporting requirement, such practices do not necessarily need to share the same physical address; for example, if practitioners practice in separate locations but are part of the same delivery system that shares business or financial operations, clinical facilities, records, or personnel, all practitioners in the delivery system would be included when determining if the practice includes at least 10 practitioners. Because qualified non-physician practitioners may also furnish procedures with global periods, the exception for reporting post-operative visits applies only to practices with fewer than ten physicians and qualified non-physician practitioners regardless of specialty. We are including all practitioners and specialties in the count because the exception policy uses practice size as a proxy for the likely ability of the practice to meet the reporting requirements without undue administrative burden. We recognize that physicians and qualified non-physician practitioners furnish services under a variety of practice arrangements. In determining whether a practitioner qualifies for the exception based on size of the practice, all physicians and qualified non-physician practitioners that furnish services as part of the practice should be included. This would include all practitioners, regardless of whether they are furnishing services under an employment model, a partnership model, or an independent contractor model under which they practice as a group and share facility and other resources but continue to bill Medicare independently instead of reassigning benefits. We also recognize that practice size can fluctuate over the year and anticipate that practices will determine their eligibility for the exception based
Although this policy excludes a significant number of practitioners, a majority of the global procedures furnished will be included in the reporting requirements and thus we will have data on a majority of services.
Several commenters also expressed concern that data from small practices be included to have complete information. If those practicing in small practices are motivated to report and either have the infrastructure to do so in place or the resources to develop such infrastructure, then, taken together, these attributes would minimize concerns with accuracy of data from small practices. Accordingly, we are encouraging, but not requiring, small practices to report the visits. As we collect data, we will explore mechanisms to appropriately use the voluntarily submitted claims data. Analysis of this and other data we are able to procure will allow us to assess whether the number of post-operative visits varies based upon the size of practice. To the extent that it does and that we do not have adequate data on the practice patterns in small practices from voluntarily submitted data and other sources, we will reconsider for future notice and comment rulemaking the exemption of practitioners in small practices from the reporting requirements.
The claims data received from practitioners in these states will provide more information about the number of visits typically provided in post-operative periods than is available from any other source. Through analysis of this data, we hope to learn more about what drives variations in the delivery of post-operative care. Many of the characteristics that were suggested by commenters, such as size of practice, type of practice, geographic, urban/rural, academic, hospital based, specialty, etc., will be able to be evaluated using the claims data. Moreover, we hope to be able to stratify the data received based upon comparisons to the national characteristics so that the submitted claims data can contribute to improved valuation of PFS services.
In summary, our claims-based data collection policy requires that, for procedures furnished on or after July 1, 2017, practitioners who practice in practices that includes of 10 or more practitioners in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island will be required to report on claims data on post-operative visits furnished during the global period of a specified procedure using CPT code 99024. The specified procedures are those that are furnished by more than 100 practitioners and either are nationally furnished more than 10,000 times annually or have more than $10 million in annual allowed charges. The final list of codes subject to required reporting will be available on the CMS Web site. Although required reporting begins for global procedures furnished on or after July 1, 2017, we encourage all practitioners to begin reporting for procedures furnished on or after January 1, 2017, if feasible. Similarly, we encourage those practicing in practices with fewer than 10 practitioners to report data if they can do so.
We agreed with commenters on the CY 2016 proposed rule and at the listening session that we need more information than is currently provided on claims and that we should utilize a number of different data sources and collection approaches to collect the data needed to assess and revalue global surgery services. In addition to the claims-based reporting, we proposed to survey a large, national sample of practitioners and their clinical staff in which respondents would report information about approximately 20 discrete pre-operative and post-operative visits and other global services like care coordination and patient training. This sample would be stratified based upon specialty and geography, as well as by physician volume (procedures billed) and practice setting. The proposed survey would produce data on a large sample of pre-operative and post-operative visits and is being designed so that we could analyze the data collected in conjunction with the claims-based data that we would be collecting. We expect to obtain data from approximately 5,000 practitioners.
We noted that, if our proposal was finalized, RAND would develop and conduct this survey. RAND would also assist us in collecting and analyzing data for this survey and the claims-based data. While the primary data collection would be via a survey instrument, semi-structured interviews would be conducted and direct observations of post-operative visits would occur in a small number of pilot sites to inform survey design, validate survey results, and collect information that is not conducive to survey-based reporting.
Our proposed sampling approach would sample practitioners rather than specific procedures or visits to streamline survey data collection and minimize respondent burden. Specifically, we will use a random sample from a frame of practitioners who billed Medicare for more than a minimum threshold of surgical procedures with a 10- or 90-day global period (for example, 200 procedures) in the most recent available prior year of claims data. The sampling frame would provide responses from approximately 5,000 practitioners, stratified by specialty, geography, and practice type. Based upon preliminary analysis, we believe this number of participants will allow us to collect information on post-operative care following the full range of CPT level-2 surgical procedure code groups. For many common types of post-operative visits, we anticipate a standard deviation of the time distribution at around 9 minutes. To achieve a 95 percent confidence intervals with a width of 2 minutes, we would need 311 reported post-operative visits per procedure/procedure group. The most comprehensive approach would be to sample sufficient practitioners to observe 311 post-operative visits for each HCPCS procedure, but this approach would be cost- and time-prohibitive. Since post-operative care following similar procedures may involve similar activities and times even if there are differences in the number of visits, we proposed to sample differentially by specialty to maximize our ability to estimate attributes of post-operative care for the largest range of procedures.
Sample sizes for each specialty will be determined on the basis of number of procedures billed by the specialty and number of practitioners billing, assuming a uniform distribution of procedures across the year, an average of 2 post-operative visits by each patient and an equal distribution of procedures across practitioners within a specialty. If the procedure represented only 5 percent of total billed procedures for the specialty, we could expect only one of 20 visits sampled and reported by each practitioner would be for the particular procedure, and thus we would need to sample 311 practitioners within the specialty to achieve the target precision level on estimated post-operative visit time.
We propose targeting 311 reporting practitioners from each specialty which is the only specialty contributing at least 5 percent of billings for any one
We did not propose that respondents report on the entire period of post-operative care for individual patients, as a 90-day follow-up window (for surgeries currently with a 90-day global period) is too long to implement practically in this study setting and would be more burdensome to practitioners. Instead, we proposed to collect information on a range of different post-operative services resulting from surgeries furnished by the in-sample practitioner prior to or during a fixed reporting period.
Practitioners will be asked to describe 20 post-operative visits furnished to Medicare beneficiaries or other patients during the reporting period. The information collected through the survey instrument, which will be developed based upon direct observation and discussions in a small number of pilot sites, will include contextual information to describe the background for the post-operative care, including, for example:
• Procedure codes(s) and date of service for procedure upon which the global period is based.
• Procedure place of service.
• Whether or not there were complications during or after the procedure.
• The number in sequence of the follow-up visit (for example, the first visit after the procedure).
The survey instrument will also collect information on the visit in question including, for example:
• Which level of visit using existing billing codes.
• Specific face-to-face and non-face-to-face activities furnished on the day of the visit.
• The total time spent on face-to-face and non-face-to-face activities on the day of the visit.
• Direct practice expense items used during the visit, for example supplies like surgical dressings and clinical staff time.
Finally, the instrument will ask respondents to report other prior or anticipated care furnished to the patient by the practice outside of the context of a post-operative visit, for example non-face-to-face services.
The survey approach will complement the claims data collection by collecting detailed information on the activities, time, intensity, and resources involved in delivering global services. The resulting visit-level survey data would allow us to explore in detail the variation in activities, time, intensity, and resources associated with global services within and between physicians and procedures, and would help to validate the information gathered through claims. A summary of the work that RAND would be doing is available on the CMS Web site under downloads for the CY 2017 PFS proposed rule with comment period at
The following is a summary of the comments that we received on our proposal to conduct a survey of practitioners furnishing 10- and 90-day global services to obtain information about the face-to-face activities and other activities included in post-operative care.
After consideration of the comments, we are finalizing our proposal to conduct a survey of practitioners to gain information on post-operative activities to supplement our claims-based data collection as proposed. We expect that the survey will be in the field mid-2017.
Using the authority we are provided under sections 1848(c)(8) and
Given the importance of the proposed survey effort, making sure that we get valid data is critical. By eliminating the bias that would be associated with using only data reported voluntarily, we stated that we expected to get more accurate and representative data. In addition to the potential bias inherent in voluntary surveys, we expressed concern that relying on voluntary data reporting would limit the adequacy of the volume of data we obtain, would require more effort to recruit participants, and may make it impossible to obtain data for valuation for CY 2019 as required by the statute.
Based on our previous experience with requesting voluntary cooperation in data collection activity, voluntary participation poses a significant challenge in collection and use of data. Specifically, the Urban Institute's work (under contract with us) to validate work RVUs by conducting direct observation of the time it took to furnish certain elements of services paid under the physician fee schedule provides evidence of this challenge. (See
Section 1848(a)(9) of the Act authorizes us, through rulemaking, to withhold payment of up to 5 percent of the payment for services on which the practitioner is required to report under section 1848(c)(8)(B)(i) of the Act until the practitioner has completed the required reporting. Some commenters opposed the imposition of this payment consequence for failure to report, and others stated that it was too large a penalty. While withholding a portion of payment would encourage practitioners to report the required information, we did not propose to implement this option for CY 2017. We stated that requiring physicians to report the information on claims, combined with the incentive to report complete information so that revaluations of payment rates for global services are based on accurate data, would result in compliance with the reporting requirements. However, we noted that if we find that compliance with required claims-based reporting is not acceptable, we would consider in future rulemaking imposing up to a 5 percent payment withhold as authorized by the statute.
Consistent with the requirements of section 1848(c)(2)(M) of the Act, should the data collected under this requirement be used to determine RVUs, we will disclose the information source and discuss the use of such information in such determination of relative values through future notice and comment rulemaking.
The following is a summary of the comments we received on our proposal to require reporting in the claims-based survey and participation in the survey.
After considering the comments, we are finalizing our proposal to require participation in the claims-based reporting. It should be noted, however, due to our modifying the requirement to apply only to those identified as part of the geographic sample, on selected procedures, using one code, and exempting those practicing in groups with fewer than 10 practitioners, as discussed above, the impact of the requirement is significantly reduced overall, including for the subset of practitioners who will have to report under the finalized requirements.
We are not implementing the statutory provision that authorizes a 5 percent withhold of payment for the global services until claims are filed for the post-operative care, if required. We reiterate that should we find that compliance with required claims-based reporting limits confidence in the use of the information for improving the accuracy of payments for the global codes, we would consider in future rulemaking imposing up to a 5 percent payment withhold as authorized by the statute.
We are particularly interested in knowing whether physicians and practices affiliated with ACOs expend greater time and effort in providing post-operative global services in keeping with their goal of improving care coordination for their assigned beneficiaries. ACOs are organizations in which practitioners and hospitals voluntarily come together to provide high-quality and coordinated care for their patients. Because such organizations share in the savings realized by Medicare, their incentive is to minimize post-operative visits while maintaining high quality post-operative care for patients. In addition, we believe that such organizations offer us the opportunity to gain more in-depth information about delivery of surgical services.
We proposed to collect data on the activities and resources involved in delivering services in and around surgical events in the ACO context by surveying a small number of ACOs (Pioneer and Next Generation ACOs). Similar to the approach of the more general practitioner survey, this effort would begin with an initial phase of primary data collection using a range of methodologies in a small number of ACOs; development, piloting, and validation of an additional survey module specific to ACOs. A survey of practitioners participating in approximately 4 to 6 ACOs using the
The following is summary of the comments we received about our proposal for data ACO data collection.
After consideration of the comments received, we are finalizing our proposal for data collection in ACOs. We recognize and will continue to consider the concerns raised by commenters as we implement this project.
We recognize that the some of the data collection activities being undertaken vary from how information is currently gathered to support PFS valuations for global surgery services. However, we believe the proposed claims-based data collection is generally consistent with how claims data is reported for other kinds of services paid under the PFS. We believe that the authority and requirements included in the statute through the MACRA and PAMA were intended to expand and enhance data that might be available to enhance the accuracy of PFS payments. In the proposed rule, we indicated that because these are new approaches to collecting data and in an area—global surgery—where very little data has previously been collected, we cannot describe exactly how this information would be used in valuing services. What is clear is that the claims-based data would provide information parallel to the kinds of claims-data used in developing RVUs for other PFS services and that by collecting these data, we would know far more than we do now about how post-operative care is delivered and gain insight to support appropriate packaging and valuation. We would include any revaluation proposals based on these data in subsequent notice and comment rulemaking.
Even though we did not make a proposal regarding how future re-valuations would use the data collected under these proposals, we received several comments on such revaluations. The following is summary of the comments we received regarding use of the data we obtain through this three-pronged data collection activity in future re-valuations.
In recent years, we have undertaken ongoing efforts to support primary care and patient-centered care management within the PFS as part of HHS' broader efforts to achieve better care, smarter spending and healthier people through delivery system reform. We have recognized the need to improve payment accuracy for these services over several years, especially beginning in the CY 2012 PFS proposed rule (76 FR 42793) and continuing in each subsequent year of rulemaking. In the CY 2012 proposed rule, we acknowledged the limitations of the current code set that describes evaluation and management (E/M) services within the PFS. For example, E/M services represent a high proportion of PFS expenditures, but have not been recently revalued to account for significant changes in the disease burden of the Medicare patient population and changes in health care practice that are underway to meet the current population's health care needs. These trends in the Medicare population and health care practice have been widely recognized in the provider community and by health services researchers and policymakers alike.
This has resulted in minimal service variation for ongoing primary care, care management and coordination, and cognitive services relative to other PFS services, and in potential misvaluation of E/M services under the PFS (76 FR 42793). Some stakeholders believe that there is substantial misvaluation of physician work within the PFS, and that the current service codes fail to capture the range and intensity of nonprocedural physician activities (E/M services) and the “cognitive” work of certain specialties (
Recognizing the inverse for specialties that furnish other kinds of services, MedPAC has noted that the PFS allows some specialties to more easily increase the volume of services they provide, and therefore, their revenue from Medicare relative to other specialties, particularly those that spend most of their time providing E/M services. (MedPAC March 2015 Report to the Congress, available at
In recent years, we have been engaged in an ongoing incremental effort to update and improve the relative value of primary care, care management/coordination, and cognitive services within the PFS by identifying gaps in appropriate payment and coding. These efforts include changes in payment and coding for a broad range of PFS services. This effort is particularly vital in the context of the forthcoming transition to the Quality Payment Program that includes the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) incentives under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015), since MIPS and many APMs will adopt and build on PFS coding, RVUs and PFS payment as their foundation.
In CY 2013, we began by focusing on post-discharge care management and transition of beneficiaries back into the community, establishing new codes to pay separately for transitional care management (TCM) services. Next we finalized new coding and separate payment beginning in CY 2015 for chronic care management (CCM) services provided by clinical staff. In the CY 2016 PFS proposed rule (80 FR 41708 through 41711), we solicited public comments on three additional policy areas of consideration: (1) Improving payment for the professional work of care management services through coding that would more accurately describe and value the work of primary care and other cognitive specialties for complex patients (for example, monthly timed services including care coordination, patient/caregiver education, medication management, assessment and integration of data, care planning); (2) establishing separate payment for collaborative care, particularly, how we might better value and pay for robust inter-professional consultation between primary care physicians and psychiatrists (developing codes to describe and provide payment for the evidence-based psychiatric collaborative care model (CoCM)), and between primary care physicians and other (non-mental health) specialists; and (3) assessing whether current PFS payment for CCM services is adequate and whether we should reduce the administrative burden associated with furnishing and billing these services.
We received substantial feedback on this comment solicitation, which we summarized in the CY 2017 PFS proposed rule and used to develop the following coding and payment proposals for CY 2017 (81 FR 46200 through 46215, and 46263 through 46265):
• Separate payment for existing codes describing prolonged E/M services without direct patient contact by the physician (or other billing practitioner), and increased payment for prolonged E/M services with direct patient contact by the physician (or other billing practitioner) adopting the RUC-recommended values.
• New coding and payment mechanisms for behavioral health integration (BHI) services including substance use disorder treatment, specifically three codes to describe services furnished as part of the psychiatric CoCM and one code to address other BHI care models.
• Separate payment for complex CCM services, reduced administrative burden for CCM, and an add-on code to the visit during which CCM is initiated (the CCM initiating visit) to reflect the work of the billing practitioner in assessing the beneficiary and establishing the CCM care plan.
• A new code for cognition and functional assessment and care planning, for treatment of cognitive impairment.
• An adjustment to payment for routine visits furnished to beneficiaries for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary.
We noted that the development of coding for these and other kinds of services across the PFS is typically an iterative process that responds to changes in medical practice and may be best refined over several years, with PFS rulemaking and the development of CPT codes as important parts of that process. We noted with interest that the CPT Editorial Panel and AMA/RUC restructured the former Chronic Care Coordination Workgroup to establish a
To facilitate separate payment for these services furnished to Medicare beneficiaries during CY 2017, we proposed to make payment through the use of three G-codes (G0502, G0503, and G0504—see below) that parallel the new CPT codes, as well as a fourth G-code (G0507—see below) to describe services furnished using other models of BHI in the primary care setting. We intended for these to be temporary codes and would consider whether to adopt and establish values for the new CPT codes under our standard process, potentially for CY 2018. We anticipated continuing the multi-year process of implementing initiatives designed to improve payment for, and recognize long-term investment in, primary care, care management and cognitive services, and patient-centered services. While we recognized that there may be some overlap in the patient populations for the proposed new codes, we noted that time spent by a practitioner or clinical staff could not be counted more than once for any code (or assigned to more than one patient), consistent with PFS coding conventions. We expressed continued consideration of additional codes for CCM services that would describe the time of the physician or other billing practitioner. We also expressed interest in whether there should be changes under the PFS to reflect additional models of inter-professional collaboration for health conditions, in addition to those we proposed for BHI.
We proposed to pay under the PFS for services described by new coding as follows (please note that the descriptions included for G0502, G0503, and G0504 are from
• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
++ Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;
++ Initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan;
++ Review by the psychiatric consultant with modifications of the plan if recommended;
++ Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
++ Tracking patient follow-up and progress using the registry, with appropriate documentation;
++ Participation in weekly caseload consultation with the psychiatric consultant;
++ Ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;
++ Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;
++ Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.
• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503).
• G0507: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.
• G0505: Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.
• G0506: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service).
• G0501: Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management visit (Add-on code, list separately in addition to primary procedure).
Regarding the majority of these proposals, the public comments were broadly supportive, some viewing our proposals as a temporary solution to an underlying need to revalue E/M services, especially outpatient E/M. Several commenters recommended that CMS utilize the global surgery data collection effort or another major research initiative to distinguish and revalue different kinds of E/M work.
In public comments on the CY 2016 PFS proposed rule, many commenters recommended that CMS should establish separate payment for non-face-to-face prolonged E/M service codes that we currently consider to be “bundled” under the PFS (CPT codes 99358, 99359). The CPT descriptors are:
• CPT code 99358 (Prolonged evaluation and management service before and/or after direct patient care, first hour); and
• CPT code 99359 (Prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (List separately in addition to code for prolonged service).
Commenters believed that separate payment for these existing CPT codes would provide a means for physicians and other billing practitioners to receive payment that more appropriately accounts for time that they spend providing non-face-to-face care. We agreed that these codes would provide a means to recognize the additional resource costs of physicians and other billing practitioners, when they spend an extraordinary amount of time outside of an E/M visit performing work that is related to that visit and does not involve direct patient contact (such as extensive medical record review, review of diagnostic test results or other ongoing care management work). We also believed that doing so in the context of the ongoing changes in health care practice to meet the current population's health care needs would be beneficial for Medicare beneficiaries and consistent with our overarching goals related to patient-centered care.
These non-face-to-face prolonged service codes are broadly described (although they include only time spent personally by the physician or other billing practitioner) and have a relatively high time threshold (the time counted must be an hour or more beyond the usual service time for the primary or “companion” E/M code that is also billed). They are not reported for time spent in care plan oversight services or other non-face-to-face services that have more specific codes and no upper time limit in the CPT code set. We believed this made these codes sufficiently distinct from the other codes we proposed for CY 2017 as part of our primary care/cognitive care/care management initiative described in this section of our final rule. Accordingly, we proposed to recognize CPT codes 99358 and 99359 for separate payment under the PFS beginning in CY 2017. We noted that time could not be counted more than once towards the provision of CPT codes 99358 or 99359 and any other PFS service. We addressed their valuation in the valuation section of the CY 2017 proposed rule.
Through a drafting error, we stated in the proposed rule that we would require these services to be furnished on the same day by the same physician or other billing practitioner as the companion E/M code. We intended to propose conformity with CPT guidance that requires that time counted towards the codes describe services furnished during a single day directly related to a discrete face-to-face service that may be provided on a different day, provided that the services are directly related to those furnished in a face-to-face visit.
We also solicited public comment on our interpretation of existing CPT guidance governing concurrent billing or overlap of CPT codes 99358 and 99359 with complex CCM services (CPT codes 99487 and 99489) and TCM services (CPT codes 99495 and 99496). Specifically CPT provides, “Do not report 99358, 99359 during the same month with 99487-99489. Do not report 99358, 99359 when performed during the service time of codes 99495 or 99496.” Complex CCM services and TCM services are similar to the non-face-to-face prolonged services in that they include substantial non-face-to-face work by the billing physician or other practitioner. The TCM and CCM codes similarly focus on a broader episode of patient care that extends beyond a single day, although they have a monthly service period and the prolonged service codes do not. We sought public input on the intersection of the non-face-to-face prolonged service codes with CCM and TCM services, and with the proposed add-on code to the CCM initiating visit G0506 (Comprehensive assessment of and care planning for patients requiring CCM services). We also solicited comment regarding how distinctions could be made between time associated with prolonged services and the time bundled into other E/M services, particularly pre- and post-service times, which would continue to be bundled with the other E/M service codes. For all of these services, we expressed concern that there would potentially be program integrity risks as the same or similar non-face-to-face activities could be undertaken to meet the billing requirements for a number of codes. We solicited public comment to help us identify the full extent of program integrity considerations, as well as options for mitigating program integrity risks.
Some commenters believed there might be some overlap between the proposed non-face-to-face prolonged service codes and the post-service work of G0505 (Cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient). Some commenters believed there is a discrepancy between our proposal to allow G0505 to be a companion code to prolonged services, and CPT's intent that G0505 should only be billed on the same day as another E/M visit if they are unrelated.
MedPAC commented that the companion E/M codes should be revalued instead of providing separate payment for prolonged services associated with the companion codes. However, if we finalize as proposed, MedPAC recommended that we clarify what situations the prolonged codes are appropriate for, beyond average times. Another commenter recommended an alternative policy instead of the non-face-to-face prolonged service codes, namely several modifiers and add-on codes to E/M services, associated with increased work RVUs. A typical time for the primary service would not need to be established. This coding schema would focus on visits actively treating patients with four or more chronic conditions; patients with three or more chronic problems introducing an acute problem during their visit; unexpected abnormal studies; and electronic communication after visits with the patient, lab, and other clinicians. One commenter drew a distinction between prolonged service work and care management services, where care management does not include extensive review of medical records, review of diagnostic tests and further discussion with a caregiver.
Second, the public comments elucidate that it is difficult to assess potential overlap between prolonged services and many other codes because the included services, service periods and timeframes are not aligned. For example, most services paid under the PFS are valued based on assumptions regarding the typical pre-service, intra-service and post-service time, but do not have required thresholds for time spent. It is difficult to distinguish the times associated with these services from the times for codes that include time requirements in their descriptor. It is also difficult to distinguish the time and other work included in codes that generally describe services furnished during one day (prolonged services and E/M visits) with codes that describe time and work over substantially different service periods (such as the calendar month services like CCM or BHI services) or add-on codes with no pre or post-service time (such as G0506). In addition, because portions of many services are likely describing work that is furnished “incident to” a physician's or practitioner's services, the time and effort of the billing practitioner may not be the only relevant time and effort to consider. Moreover, the comments reflect a desire and intent on the part of stakeholders to alter the prolonged service codes in the near future, which would, in turn, alter their intersection with the codes proposed in this section of our 2017 rule and many other codes. The public comments also reflect a lack of consensus regarding appropriate medical practice and reporting patterns for prolonged services in relation to the services described by the CCM, TCM, proposed G0505 and proposed G0506 codes.
Having considered this feedback, we have decided to finalize our proposal for separate payment of the non-face-to-face prolonged service codes (CPT 99358, 99359) and adopt the CPT code descriptors and prefatory language for reporting these services. We stress that we intend these codes to be used to report extended non-face-to-face time that is spent by the billing physician or other practitioner (not clinical staff) that is not within the scope of practice of clinical staff, and that is not adequately identified or valued under existing codes or the 2017 finalized new codes. We appreciate the commenters' suggestion to display the typical times associated with relevant services. We have posted a file that notes the times assumed to be typical for purposes of PFS rate-setting. That file is available on our Web site under downloads for the CY 2017 PFS final rule at
Based on our analysis of comments, we do not believe there is significant overlap between CPT codes 99358 and 99359 and the CCM codes (CPT 99487, 99489, 99490) or our finalized BHI service codes (G0502, G0503, G0504, G0507 discussed below). The work of the billing practitioner in the provision of non-complex CCM and the BHI services is related to the direction of ongoing care management and coordination activities of other individuals, compared to the work of 99358 and 99359 which is described as personally performed and directly related to a face-to-face service. On that basis, we do not believe that there is significant overlap in the description of services or the valuation.
The potential intersection of CPT codes 99358 and 99359 with the complex CCM codes is harder to assess because complex CCM explicitly includes medical decision-making of moderate to high complexity by the billing practitioner, which is not performed by clinical staff. The complex CCM codes, however, only measure or count the time of clinical staff. Similarly, TCM includes moderate to high complexity medical decision-making during the service period as well as a level 4 or 5 face-to-face visit, even though clinical staff may perform a number of other aspects of the service. For CY 2017, for administrative simplicity, we are adopting the CPT provision (and finalizing as proposed) that complex CCM cannot be reported during the same month as non-face-to-face prolonged services, CPT codes 99358 and 99359 (by a single practitioner). Similarly, we are adopting the CPT provision that non-face-to-face prolonged services, CPT codes 99358 and 99359 may not be reported when performed during the service time of TCM (CPT codes 99495 and 99496) (by a single practitioner). We interpret the CPT provision to mean that CPT codes 99358 and 99359 cannot be reported during the TCM 30-day service period, by the same practitioner who is reporting the TCM.
Regarding potential intersection of CPT codes 99358 and 99359 with proposed G0505 (Cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient), we are finalizing our proposal that G0505 be designated as a
Regarding intersection of CPT codes 99358 and 99359 with G0506, we note that G0506 is already an add-on code to another E/M service (the CCM initiating visit, which can be the AWV/IPPE or a qualifying face-to-face E/M visit). We are providing in section II.E.4.a that at this time (beginning in CY 2017), G0506 will be a code that is only billable one time, at the outset of CCM services. We agree with commenters that it would be unusual for physicians to spend enough time with a given beneficiary on a given day to warrant reporting all three codes (the initiating visit code, G0506, and a prolonged service code). We also believe that a simpler approach is preferable at this time (two related codes for CCM initiation, instead of possibly three). Therefore our final policy for CY 2017 is that prolonged services (whether face-to-face or non-face-to-face) cannot be reported in addition to G0506 in association with a companion E/M code that also qualifies as the CCM initiating visit. In association with the CCM initiating visit, a billing practitioner may choose to report either prolonged services or G0506 (if requirements to bill both prolonged services and G0506 are met), but cannot report both a prolonged service code and G0506.
In the CY 2016 PFS final rule with comment period (80 FR 70920), we stated that we believe the care and management for Medicare beneficiaries with behavioral health conditions often requires extensive discussion, information-sharing and planning between a primary care physician and a specialist. In CY 2016 rulemaking, we described that in recent years, many randomized controlled trials have established an evidence base for an approach to caring for patients with behavioral health conditions called the psychiatric Collaborative Care Model (CoCM). We sought information to assist us in considering refinements to coding and payment to address this model in particular. The psychiatric CoCM is one of many models for behavioral health integration or BHI, a term that refers broadly to collaborative care that integrates behavioral health services principally with primary care, but that may also integrate behavioral health care with inpatient and other clinical care. BHI is a team-based approach to care that focuses on integrative treatment of patients with medical and mental or behavioral health conditions. In the CY 2017 proposed rule (81 FR 46203 through 46205), we proposed four new G-codes for BHI services: Three describing the psychiatric CoCM specifically, and one generally describing related models of care.
A specific model for BHI, psychiatric CoCM typically is provided by a primary care team consisting of a primary care provider and a care manager who works in collaboration with a psychiatric consultant, such as a psychiatrist. Care is directed by the primary care team and includes structured care management with regular assessments of clinical status using validated tools and modification of treatment as appropriate. The psychiatric consultant provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. As we previously noted, several resources have been published that describe the psychiatric CoCM in greater detail and assess the impact of the model, including pieces from the University of Washington (
After consideration of the comments, we proposed in the CY 2017 PFS proposed rule to begin making separate payment for services furnished using the psychiatric CoCM, beginning January 1, 2017. We were aware that the CPT Editorial Panel, recognizing the need for new coding for services under this model of care, had approved three codes to describe the psychiatric collaborative care that is consistent with this model, but the codes would not be ready in time for valuation in CY 2017. Current CPT coding does not accurately describe or facilitate appropriate payment for the treatment of Medicare beneficiaries under this model of care. For example, under current Medicare payment policy, there is no payment made specifically for regular monitoring of patients using validated clinical rating scales or for regular psychiatric caseload review and consultation that does not involve face-to-face contact with the patient. We believed that these resources are directly involved in furnishing ongoing care management services to specific patients with specific needs, but they are not appropriately recognized under current coding and payment mechanisms. Because PFS valuation is based on the relative resource costs of the PFS services furnished to Medicare beneficiaries, we believed that appropriate coding for these services for CY 2017 will facilitate accurate payment for these and other PFS services. Therefore, we proposed separate payment for services under the psychiatric CoCM using three new G-codes, as detailed below: G0502, G0503, and G0504, which would parallel the CPT codes that are being created to report these services.
The proposed code descriptors were as follows (from
• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of
++ Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;
++ Initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan;
++ Review by the psychiatric consultant with modifications of the plan if recommended;
++ Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
++ Tracking patient follow-up and progress using the registry, with appropriate documentation;
++ Participation in weekly caseload consultation with the psychiatric consultant;
++ Ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;
++ Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;
++ Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.
• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503).
We stated that we intend these to be temporary codes and would consider whether to adopt and establish values for the associated new CPT codes under our standard process once those codes are active.
We proposed that these services would be furnished under the direction of a treating physician or other qualified health care professional during a calendar month. These services would be furnished when a patient has a diagnosed psychiatric disorder that requires a behavioral health care assessment; establishing, implementing, revising, or monitoring a care plan; and provision of brief interventions. The diagnosis could be either pre-existing or made by the billing practitioner. These services would be reported by the treating physician or other qualified health care professional and include the services of the treating physician or other qualified health care professional, the behavioral health care manager (see description below) who would furnish services incident to services of the treating physician or other qualified health care professional, and the psychiatric consultant (see description below) whose consultative services would be furnished incident to services of the treating physician or other qualified health care professional. We proposed that beneficiaries who are appropriate candidates for care reported using the psychiatric CoCM codes could have newly diagnosed conditions, need help in engaging in treatment, have not responded to standard care delivered in a non-psychiatric setting, or require further assessment and engagement prior to consideration of referral to a psychiatric care setting. Beneficiaries would be treated for an episode of care, defined as beginning when the behavioral health care manager engages in care of the beneficiary under the appropriate supervision of the billing practitioner and ending with:
• The attainment of targeted treatment goals, which typically results in the discontinuation of care management services and continuation of usual follow-up with the treating physician or other qualified healthcare professional; or
• Failure to attain targeted treatment goals culminating in referral to a psychiatric care provider for ongoing treatment; or
• Lack of continued engagement with no psychiatric collaborative care management services provided over a consecutive 6-month calendar period (break in episode).
The treating physician or other qualified health care professional would direct the behavioral health care manager and continue to oversee the beneficiary's care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed. Medically necessary E/M and other services could be reported separately by the treating physician or other qualified health care professional, or other physicians or practitioners, during the same calendar month. Time spent by the treating physician or other qualified health care professional on activities for services reported separately could not be included in the services reported using G0502, G0503, and G0504. We proposed that the behavioral health care manager would be a member of the treating physician or other qualified health care professional's clinical staff with formal education or specialized training in behavioral health (which could include a range of disciplines, for example, social work, nursing, and psychology) who provides care management services, as well as an assessment of needs, including the administration of validated rating scales,
We proposed that the behavioral health care manager may or may not be a professional who meets all the requirements to independently furnish and report services to Medicare. If otherwise eligible, then that individual
The psychiatric consultant involved in the “incident to” care furnished under this model would be a medical professional trained in psychiatry and qualified to prescribe the full range of medications. The psychiatric consultant would advise and make recommendations, as needed, for psychiatric and other medical care, including psychiatric and other medical diagnoses, treatment strategies including appropriate therapies, medication management, medical management of complications associated with treatment of psychiatric disorders, and referral for specialty services, that are communicated to the treating physician or other qualified health care professional, typically through the behavioral health care manager. The psychiatric consultant would not typically see the patient or prescribe medications, except in rare circumstances, but could and should facilitate a referral to a psychiatric care provider when clinically indicated.
In the event that the psychiatric consultant furnished services to the beneficiary directly in the calendar month described by other codes, such as E/M services or psychiatric evaluation (CPT codes 90791 and 90792), those services could be reported separately by the psychiatric consultant. Time spent by the psychiatric consultant on activities for services reported separately could not be included in the services reported using G0502, G0503, and G0504.
We also noted that, although the psychiatric CoCM has been studied extensively in the setting of specific behavioral health conditions (for example, depression), we received persuasive comments in response to the CY 2016 proposed rule recommending that we not specify particular diagnoses required for use of the codes for several reasons, including that: There may be overlap in behavioral health conditions; there are concerns that there could be modification of diagnoses to fit within payment rules which could skew the accuracy of submitted diagnosis code data; and for many patients for whom specialty care is not available, or who choose for other reasons to remain in primary care, primary care treatment will be more effective if it is provided within a model of integrated care that includes care management and psychiatric consultation.
In response to the public comment regarding whether we should require a diagnosed psychiatric disorder (as opposed to a subclinical or undiagnosed condition), we are clarifying that as described, the services require that there must be a presenting psychiatric or behavioral health condition(s) that, in the clinical judgment of the treating physician or other qualified health professional, warrants “referral” to the behavioral health care manager for further assessment and treatment through provision of psychiatric CoCM services. “Referral” is placed in quotes because the behavioral health care manager may be located in the same practice as the treating physician or other qualified health professional, who in any event provides ongoing oversight and continues to treat the beneficiary. However, the referring diagnosis (or diagnoses) may be either pre-existing or made by the treating physician or other qualified health professional, and we are not establishing any specific list of eligible or included diagnoses or conditions. The treating physician or other qualified health professional may not be qualified or able to fully diagnose all relevant psychiatric or behavioral health condition(s) prior to referring the beneficiary for psychiatric CoCM services. If in the course of providing psychiatric CoCM services, it becomes clear that the referring condition(s) or other diagnoses cannot be addressed by psychiatric CoCM services, then we understand that the beneficiary should be referred for other psychiatric treatment or should continue usual follow-up care with the treating practitioner, because the episode of psychiatric CoCM services ends if there is failure to attain targeted treatment goals after or despite changes in treatment, as indicated. Beneficiaries receiving care reported using the psychiatric CoCM codes may, but are not required to have comorbid chronic or other medical condition(s) that are being managed by the treating practitioner.
Regarding psychiatric CoCM services furnished to inpatients or beneficiaries in long-term care settings such as nursing or custodial care facilities, we note that the forthcoming CPT codes are not limited to office or other outpatient or domiciliary services. Moreover, our goal is to separately identify and pay for psychiatric CoCM services furnished to beneficiaries in any appropriate setting of care, whether inpatient or outpatient, in recognition of the associated time and service complexity. Care of beneficiaries who are admitted to a facility, are in long-term care, or are transitioning among settings during the month may be more complex than the care of other types of patients. While there is some overlap between psychiatric CoCM and CCM services, they are distinct services with differing patient populations, as discussed elsewhere in this section of our final rule. Therefore, we have valued the psychiatric CoCM services in both facility and non-facility settings (see section II.L on valuation). We are not limiting the time that can be counted towards the monthly time requirement to bill the psychiatric CoCM code(s) to time that is spent in the care of an outpatient or a beneficiary residing in the community. However, we also stress that G0502, G0503 and G0504 can only be reported by a treating physician or other qualified health care professional when he or she has directed the psychiatric CoCM service for the duration of time that he or she is reporting it, and has a qualifying relationship with individuals providing the service under his or her direction and control. Also, time and effort that is spent managing care transitions for CCM or TCM patients and that is counted towards reporting TCM or CCM services, cannot also be counted towards reporting any transitional care management activities reported under a BHI service code(s), either the psychiatric CoCM codes or the code describing other BHI services. We welcome additional input from stakeholders regarding appropriate (or inappropriate) sites of service for G0502, G0503 and G0504.
We note that for CY 2017, the facility PE RVU for psychiatric CoCM services will include the indirect PE allocated based on the work RVUs, but no direct PE (which is explicitly comprised of other labor, equipment and supplies). This is because historically, the PFS facility rate for a given professional service assumes that the billing practitioner is not bearing a significant resource cost in labor by other individuals, equipment or supplies. We generally assume that those costs are instead borne by the facility, and are adequately accounted for in a separate payment made to the facility to account for these costs and other costs incurred by the facility for the beneficiary's facility stay. For BHI services and similar care management services such as CCM, we have been considering whether this approach to PFS valuation is optimal because the PFS service, in significant part, may be provided by the behavioral health care manager, clinical staff, or even other physicians under the employment of the billing practitioner or under contract to the billing practitioner. These individuals may provide much of the PFS service remotely, and are not necessarily employees or staff of the facility. Indeed, the BHI services are defined in terms of activities performed by individual(s) other than the billing practitioner and who may not be affiliated with or located within the facility, even though as we discuss below the billing practitioner must also perform certain work. For this type of PFS service, there may be more direct practice expense borne by the billing practitioner even though the beneficiary is located, for part or all of the month, in a facility receiving institutional payment. We plan to consider these issues further in the future.
We understand that adoption of EHRs may be lower among behavioral health practitioners
The delivery of the psychiatric CoCM depends, in part, on continuity of care between a given patient and the assigned behavioral health care manager. Also it requires collaboration, integration and ongoing data flow between the behavioral health care manager and the treating practitioner the behavioral health care manager is supporting, as well as with the psychiatric consultant who is usually remotely located under the psychiatric CoCM model of care. As previously discussed, the psychiatric CoCM is an integrative model of care, and in considering our proposal we were concerned that allowing the behavioral health care manager to be located remotely would compromise their ability to collaborate, communicate, and timely treat and share information with the beneficiary and the rest of the care team. We are aware of many care
The fact that we proposed and are finalizing general supervision for the psychiatric CoCM codes as we did for CCM services (see section II.E.3.b) does not mean that general supervision alone suffices to meet the requirements of the psychiatric CoCM for continuity, collaboration and integration among the care team members, including the beneficiary. General supervision means that the service is furnished under the overall direction and control of the practitioner billing the service, but without the presence of the practitioner being required during the performance of the service. This definition does not directly govern where individual(s) providing the service on an incident to basis are located, whether on site or remote. Rather, it governs the location and informs the involvement of the billing practitioner.
For payment purposes, we are assigning general supervision to the psychiatric CoCM codes because we do not believe it is clinically necessary that the professionals on the team who provide services other than the treating practitioner (namely, the behavioral health care manager and the psychiatric consultant) must have the billing practitioner immediately available to them at all times, as would be required under a higher level of supervision. However, general supervision sets the minimum standard for supervision and does not, by itself, meet the requirements we are setting for billing new codes G0502, G0503 and G0504. While certain aspects of psychiatric CoCM services might be furnished under general supervision, we do not believe the general supervision requirement adequately describes the nature of the relationship and interactions of the respective team members for services furnished using the psychiatric CoCM or the codes we are creating to describe those services. Moreover it only directly addresses the physical location of the billing practitioner, not the behavioral health care manager, necessarily.
After considering the public comments, we are not finalizing our proposal that the behavioral health care manager must be a member of the treating physician or other qualified health care professional's clinical staff. As some of the psychiatric CoCM services can be contracted out to a third party (subject to rules discussed below), the contracted individuals are not necessarily employees of the treating practitioner.
Regarding the face-to-face provision of services by the behavioral health care manager, we are requiring that the behavioral health care manager must be available to provide services on a face-to-face basis, but not that face-to-face services must be provided. We are not finalizing the proposed requirement that the behavioral health care manager must be located on site, in order to allow for after-hours or appropriate remote provision of services. However, to ensure clinical integration with the treating practitioner and familiarity and continuity with the beneficiary, which are characteristic of services furnished under the psychiatric CoCM model of care, we are requiring that the behavioral health care manager must have a collaborative, integrated relationship with the rest of the care team members, and be able to perform all of the required elements of the psychiatric CoCM services delineated for the behavioral health care manager. The behavioral health care manager must have the ability to engage the beneficiary outside of regular clinic hours as necessary to perform their duties under the CoCM model, and have a continuous relationship with the beneficiary. This does not mean the behavioral health care manager is necessarily an employee of or always physically located within the practice, nor does it require provision of behavioral health care manager services to the beneficiary on site. The behavioral health care manager may provide his or her services from a remote location that is remote from the billing practitioner or remote from the beneficiary, subject to incident to rules and regulations in 42 CFR 410.26, if he or she has a qualifying relationship with the rest of the care team including the beneficiary, and is available to provide services face-to-face.
We will monitor this issue going forward, not just for the psychiatric CoCM but also for the general BHI service code (G0507) we are finalizing, as well as for TCM and CCM services. As we discuss in the final rule section on CCM below, we are continuing to consider whether outsourcing certain aspects of these services to a third party fragments care, leads to insufficient involvement and oversight of the billing practitioner or results in services that do not actually represent or facilitate continuous, seamless transitional care and other required aspects of these services. We will continue to consider how to best define the continuity of care that is required for services furnished and billed under all of these codes, and whether arrangements for remote provision of services whether by a case management company or another entity increases rather than reduces service fragmentation. Advances in health information technology provide opportunities for remote connectivity and interoperability that may assist and be useful, if not necessary, for reducing care fragmentation. However, remote provision of services by entities having only a loose association with the treating practitioner can detract from continuous, patient-centered care, whether or not those entities employ certified or other electronic technology.
We note that while time spent by the treating practitioner is not explicitly counted for in codes G0502, G0503 and G0504, these codes are valued to include work performed directly by the treating practitioner. The treating practitioner directs the behavioral health care manager and continues to oversee the patient's care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed. We are finalizing as proposed that some of these services may be separately billable. However, we wish to emphasize that the treating practitioner must remain involved in ongoing oversight, management, collaboration and reassessment as appropriate to bill the psychiatric CoCM codes.
Evaluation and management services (such as face-to-face E/M visits) may be separately billed during the service period or on the same day as the psychiatric CoCM services, provided time is not counted twice towards the same code.
We recognize that the psychiatric CoCM is prescriptive and that much of its demonstrated success may be attributable to adherence to a set of elements and guidelines of care. We are finalizing the code set discussed above to pay accurately for care furnished using this specific model of care, given its widespread adoption and recognized effectiveness. However, we note that PFS coding, in general, does not dictate how physicians practice medicine and believe that it should, instead, reflect the practice of medicine. We also recognize that there are primary care practices that are incurring, or may incur, resource costs inherent to treatment of patients with similar conditions based on BHI models of care other than the psychiatric CoCM that may benefit beneficiaries with behavioral health conditions (see, for example, the approaches described at
To recognize the resource costs associated with furnishing such BHI services to Medicare beneficiaries, we also proposed to make payment using a new G-code that describes care management for beneficiaries with behavioral health conditions under other models of care. We believe that the resources associated with such care are not currently adequately recognized under the PFS. The proposed code was G0507 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month). We noted that we would expect this code to be refined over time as we receive more information about other BHI models being used and how they are implemented.
We sought stakeholder input on whether we should consider different increments of time for this code, such as a base code plus an add-on code comprised of additional 20 minute increments. We recognized that BHI services furnished under the proposed code may range in resource costs. We believed that appropriate payment for these services would further the refinement and implementation of BHI models of care, and that having utilization data would inform future refinement of the proposed code's valuation.
Many commenters recommended that CMS provide more of a framework or description of included services and provider types without being unduly burdensome. Some commenters recommended service elements similar to the CCM service elements (continuity of care with a designated member of the care team; a written care plan; a comprehensive assessment of behavioral health or psychiatric and other medical conditions as well as any functional and psychosocial needs, updated as necessary; routine evaluation of patient progress using a tracking system; services should be documented in the medical record and available to other treating professionals). These
Regarding included elements of the general BHI service (G0507), we agree with the commenters that we should be more specific in our definition of this service. We wish to provide greater specificity without being overly prescriptive, since a range of activities may be included in BHI models of care other than the psychiatric CoCM. We believe we should include a core set of service elements that are similar to core elements of the psychiatric CoCM, especially a systematic process for initial assessment and routine follow up evaluation, revising the treatment approach or methods for patients who are not progressing or whose status changes; facilitating and coordinating behavioral health expertise and treatment; and designating a member of the care team with whom the beneficiary has a continuous relationship. We may revisit the included services in future years, but for CY 2017 the required service elements for the general BHI service (G0507) will be:
• Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;
• Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;
• Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
• Continuity of care with a designated member of the care team.
Accordingly, the final code descriptor will be, G0507: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
• Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;
• Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;
• Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
• Continuity of care with a designated member of the care team.
We are aware of a number of validated rating scales that are available for use for a number of conditions addressed by BHI models of care, such as those described by the Kennedy Forum (see
Regarding diagnosis, we believe we should specify similar diagnostic criteria for G0507 and the psychiatric CoCM services (G0502, G0503 and G0504). Accordingly we are providing that beneficiaries who are appropriate candidates for services billed under G0507 will have an identified psychiatric or behavioral health condition(s) that requires a behavioral health care assessment, behavioral health care planning, and provision of interventions. Eligible beneficiaries must present with a condition(s) that in the treating practitioner's clinical judgment, warrants the services included in G0507. The presenting condition(s) may be pre-existing or newly diagnosed by the treating practitioner, and may be refined as treatment progresses. Beneficiaries receiving services reported under G0507 may, but are not required to have comorbid chronic or other medical condition(s) that are being managed by the treating practitioner. We are not limiting billing and payment for G0507 to a specified set of behavioral health conditions, because there may be overlap in behavioral health conditions; if we specified only certain diagnoses, practitioners might modify diagnoses to fit within payment rules; and for many beneficiaries for whom specialty care is not available, or who choose for other reasons to remain within primary care, their behavioral health condition(s) can be addressed using a model of integrated care.
Regarding rules for clinical staff, we are clarifying that services included in the code G0507 may be provided directly by the treating practitioner or provided by other qualifying individuals (whom we term “clinical staff”) under his or her direction, during the calendar month service period. Unlike the psychiatric CoCM codes, for G0507 there is not necessarily a specific individual designated as a “behavioral health care manager” with formal or specialized education in providing the services (although there could be). Similarly, there is not necessarily a psychiatric or other behavioral health specialist consultant (although there could be), and we note that G0507 is not valued to explicitly account for such a consultant. We will apply the same definition of the term “clinical staff” that we have applied for CCM to G0507, namely, the CPT definition of this term, subject to the incident to rules and regulations and applicable state law, licensure and scope of practice at 42 CFR 410.26. For G0507, then, we note that the term “clinical staff” will encompass or include a psychiatric or other behavioral health specialist consultant, if the treating practitioner obtains consultative expertise. Clinical staff that provide included services do not have to be employed by the treating practitioner or located on site, necessarily, and may or may not be a professional who is permitted to independently furnish and report services to Medicare. Time spent by administrative or clerical staff cannot be counted towards the time required to bill G0507.
G0507 is valued to include minimal work by the treating practitioner; the bulk of the valuation is based on clinical staff time (see section II.L on valuation). However, we want to emphasize that the
Evaluation and management services, such as face-to-face E/M visits, may be separately billed during the service period or on the same day as G0507, provided time is not counted twice towards the same code.
For payment purposes, we are categorizing this service as a designated care management service assigned general supervision for purposes of “incident to” billing, because we do not believe it is clinically necessary for the individuals on the team who provide services other than the treating practitioner (namely, clinical staff) to have the treating practitioner immediately available to them at all times, as would be required under a higher level of supervision. However, general supervision sets the minimum standard for supervision and does not, by itself, meet the requirements we are setting for billing new code G0507. While certain aspects of G0507 might be furnished under general supervision, we do not believe the general supervision requirement adequately describes the nature of the relationship and interactions of the respective team members for services furnished using BHI models of care or the codes we are creating to describe those services. Moreover the general supervision requirement only directly addresses the physical location of the treating practitioner, not the location of clinical staff, necessarily.
However, we understand that adoption of EHRs may be lower among behavioral health practitioners
We believe the format of the care plan(s) is less important than having a process whereby feedback and expertise from all relevant practitioners and providers, whether internal or external to the billing practice, are integrated into the beneficiary's treatment plan and goals; that this plan be regularly assessed and revisited by the practitioner who is assuming an overall care management role for the beneficiary in a given month; that the patient is engaged in the care planning process; and that the care planning be documented in the medical record (as with any required element of any PFS service). We have framed the care planning service element for G0507 accordingly, “Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes.”
We received similar comments supporting the addition of psychiatric collaborative care services to the PFS, and other evidence-based models in a variety of primary care-based treatment settings. However, these commenters supported the inclusion of social workers at all levels of licensures as reimbursable providers of these services.
Since the BHI initiating visit that is required to bill G0507 is not within the scope of practice of a psychologist or social worker (see below), psychologists and social workers will not be able to report G0507 directly (although a psychiatrist may be able to do so). Psychologists and social workers may provide care management services included in G0507 incident to the services of another (billing) practitioner. They may also provide services that are separately billable during the service period. We appreciate the commenters' support for team-based care, and we recognize the substantial role of various types of mental health professionals within a primary care team. We are interested in receiving additional input from stakeholders as to whether and why behavioral health care management services by a social worker, psychologist or similarly qualified professional should be reportable in its own right, rather than incident to the services of a practitioner authorized to bill Medicare for a BHI initiating visit. Consistent with our recent approaches to making proposals under PFS notice and comment rulemaking, we could consider adopting new coding under a different construct that was not defined as BHI, if stakeholders provided sufficient input on how to design, define and value the services. We would also consider such changes if adopted by the CPT Editorial Panel, per our usual process. BHI integrates behavioral health expertise into evaluation and management care. Therefore G0507 is designed to include services that require the oversight and involvement of a practitioner who can perform evaluation and management services, including facilitation of any needed pharmacotherapy, referral for specialty care, and overall management of the beneficiary's treatment in relation to primary care treatment. We note that G0507 would not be independently billed by psychologists or social workers, though from our understanding of various models of BHI, these professionals seem likely to be participants in team-based care for beneficiaries receiving these services.
Similar to CCM services (see section II.E.4), we proposed to require an initiating visit for all of the BHI codes (G0502, G0503, G0504 and G0507) that would be billable separate from the BHI services themselves. We proposed that the same services that can serve as the initiating visit for CCM services (see section II.E.4.a. of this final rule) could serve as the initiating visit for the proposed BHI codes. The initiating visit would establish the beneficiary's relationship with the billing practitioner (most aspects of the BHI services would be furnished incident to the billing practitioner's professional services), ensure the billing practitioner assesses the beneficiary prior to initiating care management processes, and provide an opportunity to obtain beneficiary consent (discussed below). We solicited public comment on the types of services that are appropriate for an initiating visit for the BHI codes, and within what timeframe the initiating visit should be conducted prior to furnishing BHI services.
As discussed above, we are interested in receiving input from stakeholders regarding circumstances other than BHI in which behavioral health care management services by a psychologist, social worker or similarly qualified professional should be reportable in its own right, rather than incident to the services of a practitioner authorized to bill Medicare for a BHI initiating visit.
Commenters to the CY 2016 PFS proposed rule indicated that they did not believe a specific patient consent for BHI services is necessary and indicated that requiring special informed consent
We recognized that special informed consent could also be helpful in cases when a particular service is limited to being billed by a single practitioner for a particular beneficiary. We did not believe that there are circumstances where it would reasonable for multiple practitioners to be reporting these codes during the same month. However, we did not propose a formal limit at this time. We solicited comment on whether such a limitation would be beneficial or whether there are circumstances under which a beneficiary might reasonably receive BHI services from more than one practitioner during a given month.
The public comments were supportive of our proposal for a broad consent that could be verbally obtained but must be documented in the medical record, and we are finalizing as proposed. At this time, we do not believe a single consent process for both BHI and CCM is advisable. It is not clear how frequently BHI and CCM would or should be furnished concurrently. BHI and CCM are distinct, separate services, having significant differences in time thresholds, the nature of the services, types of individuals providing the services, and payment and cost sharing amounts. Therefore, at this time, we are maintaining separate consent processes for CCM and BHI, as provided in the respective sections of this final rule. Also, as discussed in section II.E.4 on CCM, CCM and BHI may be billed during the same service period.
It remains unclear whether it would be reasonable and necessary for more than one practitioner (whether in the same practice or different practices) to bill BHI services for a given beneficiary for a given service period, given the lack of public response and input on this issue. It may depend on the conditions(s) being treated and whether specialty care, other than psychiatric or behavioral health specialty care, and primary care are both involved. We are not proposing a formal limit at this time, but we stress that BHI services can only be reported by a treating physician or other qualified health care professional when he or she has obtained the required beneficiary consent, directed the BHI services he or she reports for the duration of time reported, and has a qualifying relationship with individuals providing the reported services under his or her direction and control. We would not expect a single practitioner to furnish care to a given beneficiary under more than one BHI model of care during a given month. Therefore a single practitioner must choose whether to report psychiatric CoCM code(s) (G0502, G0503, and G0504 as applicable) or the general BHI code (G0507) for a given month for a given beneficiary. We remind stakeholders that time cannot be counted more than once towards any code(s), all services must be medically reasonable and necessary, and that beneficiary cost sharing and advance consent apply. We will be monitoring the claims data and studying the utilization patterns. We will continue to assess appropriate reporting patterns, and we expect that potential coding changes by the CPT Editorial Panel may inform this issue.
Beginning in CY 2017, we are providing separate payment for a range of BHI services. Specifically, we are providing payment for psychiatric CoCM services under the following codes:
• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
++ Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;
++ Initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan;
++ Review by the psychiatric consultant with modifications of the plan if recommended;
++ Entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.
• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:
++ Tracking patient follow-up and progress using the registry, with appropriate documentation;
++ Participation in weekly caseload consultation with the psychiatric consultant;
++ Ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;
++ Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant;
++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;
++ Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.
• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503).
These psychiatric CoCM services are reported by the treating physician or other qualified health care professional for services furnished during a calendar month service period. These services may be furnished when a beneficiary has a psychiatric or behavioral health condition(s) that in the treating physician or other qualified health care professional's clinical judgment, requires a behavioral health care assessment; establishing, implementing, revising, or monitoring a care plan; and provision of brief interventions. The diagnosis or diagnoses may be pre-existing or made by the treating physician or other qualified health care professional, and may be refined over time. The psychiatric CoCM services may be furnished to beneficiaries with any psychiatric or behavioral health condition(s) that is being treated by the physician or other qualified health care professional, including substance use disorders. Beneficiaries receiving psychiatric CoCM services may, but are not required to have comorbid chronic or other medical condition(s) that are being managed by the treating practitioner.
Psychiatric CoCM services include the services of the treating physician or other qualified health care professional, the behavioral health care manager (see description below) who provides services incident to services of the treating physician or other qualified health care professional, and the psychiatric consultant (see description below) whose consultative services are furnished incident to services of the treating physician or other qualified health care professional. Time spent by administrative or clerical staff cannot be counted towards the time required to bill the psychiatric CoCM service codes.
Beneficiaries receiving psychiatric CoCM services may have newly diagnosed conditions, need help in engaging in treatment, have not responded to standard care delivered in a non-psychiatric setting, or require further assessment and engagement prior to consideration of referral to a psychiatric care setting. Beneficiaries are treated for an episode of care, defined as beginning when the behavioral health care manager engages in care of the beneficiary under the appropriate supervision of the billing practitioner and ending with:
• The attainment of targeted treatment goals, which typically results in the discontinuation of care management services and continuation of usual follow-up with the treating physician or other qualified healthcare professional; or
• Failure to attain targeted treatment goals culminating in referral to a psychiatric care provider for ongoing treatment; or
• Lack of continued engagement with no psychiatric collaborative care management services provided over a consecutive 6-month calendar period (break in episode).
The treating physician or other qualified health care professional directs the behavioral health care manager and continues to oversee the beneficiary's care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed. The treating physician or other qualified health care professional must remain involved in ongoing oversight, management, collaboration and reassessment as appropriate to bill the psychiatric CoCM codes.
The behavioral health care manager has formal education or specialized training in behavioral health (which could include a range of disciplines, for example, social work, nursing, and psychology). The behavioral health care manager provides care management services, as well as an assessment of needs, including the administration of validated rating scales;
The behavioral health care manager must have a collaborative, integrated relationship with the rest of the care team members, and be able to perform all of the required elements of the service delineated for the behavioral health care manager. The behavioral health care manager must have the ability to engage the beneficiary outside of regular clinic hours as necessary to perform the behavioral health care manager's duties under the psychiatric CoCM model, and must have a continuous relationship with the beneficiary. The behavioral health care manager may or may not be a
The psychiatric consultant is a medical professional trained in psychiatry and qualified to prescribe the full range of medications. The psychiatric consultant advises and makes recommendations, as needed, for psychiatric and other medical care, including psychiatric and other medical diagnoses, treatment strategies including appropriate therapies, medication management, medical management of complications associated with treatment of psychiatric disorders, and referral for specialty services, that are communicated to the treating physician or other qualified health care professional, typically through the behavioral health care manager. The psychiatric consultant does not typically see the beneficiary or prescribe medications, except in rare circumstances, but can and should facilitate referral for direct provision of psychiatric care when clinically indicated. The psychiatric consultant is subject to the incident to rules and regulations and applicable state law, licensure and scope of practice (see 42 CFR 410.26).
Beginning in CY 2017, we are providing separate payment for BHI services furnished under models of care other than the psychiatric CoCM model, under HCPCS code G0507: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
• Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;
• Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;
• Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
• Continuity of care with a designated member of the care team.
G0507 is reported by the treating physician or other qualified health care professional for services furnished during a calendar month service period. This service may be furnished when the beneficiary has a psychiatric or behavioral health condition(s) that in the treating physician or other qualified health care professional's clinical judgment, requires a behavioral health care assessment, behavioral health care planning, and provision of interventions. The presenting condition(s) may be pre-existing or newly diagnosed by the treating physician or other qualified health care professional, and may be refined over time. Beneficiaries receiving services reported under G0507 may have any psychiatric or behavioral health condition(s) that is being treated by the physician or other qualified health care professional, including substance use disorders. Beneficiaries receiving services reported under G0507 may, but are not required to have comorbid chronic or other medical condition(s) that are being managed by the treating practitioner.
Services reported under G0507 may be provided directly by the treating physician or other qualified health care professional, or provided by clinical staff under his or her direction, during a calendar month service period. For G0507, there is not necessarily a specific individual designated as a “behavioral health care manager” with formal or specialized education in providing the services (although there could be). Similarly, there is not necessarily a psychiatric or other behavioral health specialist consultant (although there could be) and we note that G0507 is not valued to explicitly account for expert consultation. For G0507, the term “clinical staff” means the CPT definition of this term, subject to the incident to rules and regulations and applicable state law, licensure and scope of practice at 42 CFR 410.26. For G0507, then, we note that the term “clinical staff” will encompass or include any psychiatric or other behavioral health specialist consultant that may provide consultative services. Clinical staff providing services are not required to be employed by the treating practitioner or located on site, and these individuals may or may not be a professional permitted to independently furnish and report services to Medicare. Time spent by administrative or clerical staff cannot be counted towards the time required to report G0507. We emphasize that the physician or other qualified health care professional must direct the service, continue to oversee the beneficiary's care, and perform ongoing management, collaboration and reassessment. If the service (or part thereof) is provided incident to services of the treating practitioner, whether on site or remotely, the clinical staff providing services must have a collaborative, integrated relationship with the treating practitioner. They must also have a continuous relationship with the beneficiary.
For all of the BHI service codes (G0502, G0503, G0504 and G0507), we are requiring an initiating visit that is billable separate from the BHI services themselves. The same services that qualify as initiating visits for CCM services can serve as the initiating visit for BHI services (certain face-to-face E/M services including the face-to-face visit required for TCM services, and the AWV or IPPE). The BHI initiating visit establishes the beneficiary's relationship with the treating practitioner (BHI services may be furnished incident to the treating practitioner's professional services); ensures that the treating practitioner assesses the beneficiary prior to initiating care management processes; and provides an opportunity to obtain beneficiary consent (consent may also be obtained outside of the BHI initiating visit, as long as it is obtained prior to commencement of BHI services).
For all of the BHI service codes, we are also requiring prior beneficiary consent, recognizing that applicable rules continue to apply regarding privacy. The consent will include permission to consult with relevant specialists including a psychiatric consultant, and inform the beneficiary that cost sharing will apply to in-person and non-face-to-face services provided. Consent may be verbal (written consent is not required) but must be documented in the medical record.
For payment purposes, we are assigning general supervision to all of the BHI service codes (G0502, G0503, G0504 and G0507). However we note that general supervision does not, by itself, comprise a qualifying relationship between the treating practitioner and other individuals providing BHI services under the incident to relationship. Also we note that we valued BHI services in both facility and non-facility settings. BHI services may be furnished to beneficiaries in any setting of care. Time that is spent furnishing BHI services to a beneficiary who is an inpatient or in any other facility setting during service provision or for any part of the service period may be counted towards reporting a BHI code(s). We refer the reader to our discussion above on this matter, as well as reporting by specialty, intersection with other services, and potential reporting by more than one practitioner for a given beneficiary within a service period. A single practitioner must choose whether to report psychiatric CoCM code(s) (G0502, G0503, and
Beginning in CY 2015, we implemented separate payment for CCM services under CPT code 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month, with the following required elements:
• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
• Comprehensive care plan established, implemented, revised, or monitored).
In the CY 2015 final rule with comment period, we finalized a proposal to make separate payment for CCM services as one initiative in a series of initiatives designed to improve payment for, and encourage long-term investment in, care management services (79 FR 67715). In particular, we sought to address an issue raised to us by the physician community, which stated that the care management included in many of the existing E/M services, such as office visits, does not adequately describe the typical non-face-to-face care management work required by certain categories of beneficiaries (78 FR 43337). We began to re-examine how Medicare should pay under the PFS for non-face-to-face care management services that were bundled into the PFS payment for face-to-face E/M visits, being included in the pre- and post-encounter work (78 FR 43337). In proposing separate payment for CCM, we acknowledged that, even though we had previously considered non-face-to-face care management services as bundled into the payment for face-to-face E/M visits, the E/M office/outpatient visit CPT codes may not reflect all the services and resources required to furnish comprehensive, coordinated care management for certain categories of beneficiaries. We stated that we believed that the resources required to furnish complex chronic care management services to beneficiaries with multiple (that is, two or more) chronic conditions were not adequately reflected in the existing E/M codes. Medical practice and patient complexity required physicians, other practitioners and their clinical staff to spend increasing amounts of time and effort managing the care of comorbid beneficiaries outside of face-to-face E/M visits, for example, complex and multidisciplinary care modalities that involve regular physician development and/or revision of care plans; subsequent report of patient status; review of laboratory and other studies; communication with other health care professionals not employed in the same practice who are involved in the patient's care; integration of new information into the care plan; and/or adjustments of medical therapy.
Therefore, in the CY 2014 PFS final rule with comment period, we established a separate payment under the PFS for CPT code 99490 (78 FR 43341 through 43342). We sought to include a relatively broad eligible patient population within the code descriptor, established a moderate payment amount, and established bundled payment for concurrently new CPT codes that were reserved for beneficiaries requiring “complex” CCM services (base CPT code 99487 and its add-on code 99489) (79 FR 67716 through 67719). We stated that we would evaluate the services reported under CPT code 99490 to assess whether the service is targeted to the right population and whether the payment amount is appropriate (79 FR 67719). We remind stakeholders that CMS did not limit the eligible population to any particular list of chronic conditions other than the language in the CPT code descriptor. Accordingly, one or more of the chronic conditions being managed through CCM services could be chronic mental health or behavioral health conditions or chronic cognitive disorders, as long as the chronic conditions meet the eligibility language in the CPT code descriptor for CCM services and the billing practitioner meets all of Medicare's requirements to bill the code including comprehensive, patient-centered care planning for all health conditions.
In finalizing separate payment for CPT code 99490, we considered whether we should develop standards to ensure that physicians and other practitioners billing the service would have the capability to fully furnish the service (79 FR 67721). We sought to make certain that the newly payable PFS code(s) would provide beneficiary access to appropriate care management services that are characteristic of advanced primary care, such as continuity of care; patient support for chronic diseases to achieve health goals; 24/7 patient access to care and health information; receipt of preventive care; patient, family and caregiver engagement; and timely coordination of care through electronic health information exchange. Accordingly, we established a set of scope of service elements and payment rules in addition to or in lieu of those established in CPT guidance (in the CPT code descriptor and CPT prefatory language), that the physician or nonphysician practitioner must satisfy to fully furnish CCM services and report CPT code 99490 (78 FR 74414 through 74427, 79 FR 67715 through 67730, and 80 FR 14854). We established requirements to furnish a preceding qualifying visit, obtain advance written beneficiary consent, use certified electronic health record (EHR) technology to furnish certain elements of the service, share the care plan and clinical summaries electronically, document specified activities, and other items summarized in Table 11 of our CY 2017 proposed rule. For the CCM service elements for which we required use of a certified EHR, the billing practitioner must use, at a minimum, technology meeting the edition(s) of certification criteria that is acceptable for purposes of the EHR Incentive Programs as of December 31st of the calendar year preceding each PFS payment year. (For the CY 2017 PFS payment year, this would mean technology meeting the 2014 edition of certification criteria).
These elements and requirements for separately payable CCM services are extensive and generally exceed those required for payment of codes describing procedures, diagnostic tests, or other E/M services under the PFS. In addition, both CPT guidance and Medicare rules specify that only a single practitioner who assumes the care management role for a given beneficiary can bill CPT code 99490 per service period (calendar month). Because the new CCM service closely overlapped with several Medicare demonstration models of advanced primary care (the Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration and the Comprehensive Primary Care Initiative (CPCI)), we provided that practitioners participating in one of these two initiatives could not be paid for CCM services furnished to a beneficiary attributed by the initiative to their practice (79 FR 67729).
Given the non-face-to-face nature of CCM services, we also sought to ensure that beneficiaries would receive advance notice that Part B cost sharing applies since we currently have no legislative authority to “waive” cost sharing for this service. Also since only one practitioner can bill for CCM each service period, we believed the
Since the establishment of CPT code 99490 for separate payment of CCM services, in a number of forums and in public comments to the CY 2016 PFS final rule (80 FR 70921), many practitioners have stated that the service elements and billing requirements are burdensome, redundant and prevent them from being able to provide the services to beneficiaries who could benefit from them. Stakeholders have stated that CPT code 99490 is underutilized because it is underpaid relative to the resources involved in furnishing the services, especially given the extensive Medicare rules for payment, and they have suggested a number of potential changes to our current payment rules. Stakeholders continue to believe that many of the CCM payment rules are duplicative, and to recommend that we reduce the rules and expand CCM coding and payment to distinguish among different levels of patient complexity. We also note that section 103 of the MACRA requires CMS to assess and report to Congress (no later than December 31, 2017) on access to CCM services by underserved rural and racial and ethnic minority populations and to conduct an outreach/education campaign that is underway.
The professional claims data for CPT code 99490 show that utilization is steadily increasing but may remain low considering the number of eligible Medicare beneficiaries. To date, approximately 513,000 unique Medicare beneficiaries received the service an average of four times each, totaling $93 million in total payments. Since CPT code 99490 describes a minimum of 20 minutes of clinical staff time spent furnishing CCM services during a month and does not have an upper time limit, and since we currently do not separately pay the other codes in the CCM family of CPT codes (which would provide us with utilization data on the number of patients requiring longer service times during a billing period), we do not know how often beneficiaries required more than 20 minutes of CCM services per month. We also do not know their complexity relative to one another, other than meeting the acuity criteria in the CPT code descriptor. Initial information from practitioner interviews conducted as part of our CCM evaluation efforts indicates that practitioners overwhelmingly meet and exceed the 20-minute threshold time for billing CCM. Typically, these practitioners reported spending between 45 minutes and an hour per month on CCM services for each patient, with times ranging between 20 minutes and several hours per month. CCM beneficiaries tend to exhibit a higher disease burden, are more likely to be dually eligible for Medicare and Medicaid, and are older than the general Medicare fee-for-service population.
In light of this stakeholder feedback and our mandate under MACRA section 103 to encourage and report on access to CCM services, we proposed several changes in the payment rules for CCM services. Our primary goal, and our statutory mandate, is to pay as accurately as possible for services furnished to Medicare beneficiaries based on the relative resources required to furnish PFS services, including CCM services. In so doing, we also expect to facilitate beneficiaries' access to reasonable and necessary CCM services that improve health outcomes. First, for CY 2017 we proposed to more appropriately recognize and pay for the other codes in the CPT family of CCM services (CPT codes 99487 and 99489 describing complex CCM), consistent with our general practice to price services according to their relative ranking within a given family of services. We direct the reader to section II.L of this final rule for a discussion of valuation for base CPT code 99487 and its add-on CPT code 99489. The CPT code descriptors are:
• CPT code 99487—Complex chronic care management services, with the following required elements:
++ Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
++ Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
++ Establishment or substantial revision of a comprehensive care plan;
++ Moderate or high complexity medical decision making;
++ 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
• CPT code 99489—Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
As CPT provides, less than 60 minutes of clinical staff time in the service period could not be reported separately, and similarly, less than 30 minutes in addition to the first 60 minutes of complex CCM in a service period could not be reported. We would require 60 minutes of services for reporting CPT code 99487 and 30 additional minutes for each unit of CPT code 99489.
We proposed to adopt the CPT provision that CPT codes 99487, 99489 and 99490 may only be reported once per service period (calendar month) and only by the single practitioner who assumes the care management role with a particular beneficiary for the service period. That is, a given beneficiary would be classified as eligible to receive either complex or non-complex CCM during a given service period, not both, and only one professional claim could be submitted to the PFS for CCM for that service period by one practitioner.
Except for differences in the CPT code descriptors, we proposed to require the same CCM service elements for CPT codes 99487, 99489 and 99490. In other words, all the requirements in Table 11 of our proposed rule would apply, whether the code being billed for the service period is CPT code 99487 (plus CPT code 99489, if applicable) or CPT code 99490. These three codes would differ in the amount of clinical staff service time provided; the complexity of medical decision-making as defined in the E/M guidelines (determined by the problems addressed by the reporting practitioner during the month); and the nature of care planning that was performed (establishment or substantial revision of the care plan for complex CCM versus establishment, implementation, revision or monitoring of the care plan for non-complex CCM). Billing practitioners could consider identifying beneficiaries who require complex CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT
We proposed several changes to our current scope of service elements for CCM, and proposed that the same scope of service elements, as amended, would apply to all codes used to report CCM services beginning in 2017 (
As provided in the CY 2014 PFS final rule with comment period (78 FR 74425) and subregulatory guidance (available at
We continued to believe that we should require an initiating visit in advance of furnishing CCM services, separate from the services themselves, because a face-to-face visit establishes the beneficiary's relationship with the billing practitioner and most aspects of the CCM services are furnished incident to the billing practitioner's professional services. The initiating visit also ensures collection of comprehensive health information to inform the care plan. We continued to believe that the types of face-to-face services that qualify as an initiating visit for CCM are appropriate. We did not propose to change the kinds of visits that can qualify as initiating CCM visits. However, we proposed to require the initiating visit only for new patients or patients not seen within one year instead of for all beneficiaries receiving CCM services. We believed this would allow practitioners with existing relationships with patients who have been seen relatively recently to initiate CCM services without furnishing a potentially unnecessary E/M visit. We solicited public comment on whether a period of time shorter than one year would be more appropriate.
We believe that the proposed one-year timeframe for the single, CCM initiating visit is appropriate for CY 2017, so we are finalizing as proposed. We will require the CCM initiating visit only for new patients or patients not seen within the year prior to commencement of CCM (instead of for all beneficiaries receiving CCM services). We will continue to consider in future years whether a different timeframe is warranted. The goal of our final policy is to allow practitioners with existing relationships with beneficiaries who have been seen relatively recently to initiate CCM services (for the first time) without furnishing a potentially unnecessary E/M visit. Regarding subsequent visits (after CCM services begin), practitioners are already permitted to furnish and separately bill subsequent E/M visits (or AWVs) for beneficiaries receiving CCM services. If a face-to-face reassessment is reasonable and necessary and furnished by the billing practitioner, then he or she may bill an appropriate code describing the face-to-face assessment of a beneficiary to whom they have previously furnished CCM services.
We also proposed for CY 2017 to create a new add-on G-code that would improve payment for services that qualify as initiating visits for CCM services. The code would be billable for beneficiaries who require extensive face-to-face assessment and care planning by the billing practitioner (as opposed to clinical staff), through an add-on code to the initiating visit, G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service)).
We proposed that when the billing practitioner initiating CCM personally
The code G0506 would account specifically for additional work of the billing practitioner in personally performing a face-to-face assessment of a beneficiary requiring CCM services, and personally performing CCM care planning (the care planning could be face-to-face and/or non-face-to-face) that is not already reflected in the initiating visit itself (nor in the monthly CCM service code). We believed G0506 might be particularly appropriate to bill when the initiating visit is a less complex visit (such as a level 2 or 3 E/M visit), although G0506 could be billed along with higher level visits if the billing practitioner's effort and time exceeded the usual effort described by the initiating visit code. It could also be appropriate to bill G0506 when the initiating visit addresses problems unrelated to CCM, and the billing practitioner does not consider the CCM-related work he or she performs in determining what level of initiating visit to bill. We believed that this proposal would more appropriately recognize the relative resource costs for the work of the billing practitioner in initiating CCM services, specifically for extensive work assessing the beneficiary and establishing the CCM care plan that is reasonable and necessary, and that is not accounted for in the billed initiating visit or in the unit of the CCM service itself that is billed for a given service period. In addition, we believed this proposal would help ensure that the billing practitioner personally performs and meaningfully contributes to the establishment of the CCM care plan when the patient's complexity warrants it.
As we stated in the CY 2017 proposed rule, we were very interested in coding that was presented to the CPT Editorial Panel, but not adopted, to create code(s) that would separately identify and account for monthly CCM work by the billing practitioner. Such coding may be a better means of separately identifying and valuing the subsequent work of the billing practitioner after CCM is initiated. We want to establish policies that help ensure that the billing practitioner is not merely handing the beneficiary off to a remote care manager under general supervision while no longer remaining involved in their care. We believe that the practitioner billing CCM services should be actively re-assessing the beneficiary's chronic conditions, reviewing whether treatment goals are being met, updating the care plan, performing any medical decision-making that is not within the scope of practice of clinical staff, performing any necessary face-to-face care, and performing other related work. However, it would be more straightforward to separately identify this CCM-related work under code(s) that in their own right describe it, instead of add-on codes to very broadly drawn E/M codes where it becomes difficult to assess the relationship between the two services. Also for beneficiaries receiving complex CCM, some of this work is explicitly included in the complex CCM service codes (
We note that despite the role of the billing practitioner in the initiation and provision of CCM services provided by clinical staff, non-complex CCM (CPT code 99490) is described based on the time spent by clinical staff. Complex CCM (CPT codes 99487 and 99489) similarly counts only clinical staff time, although it also includes complex medical decision-making by the billing practitioner. This raises issues regarding appropriate valuation in the facility setting that we will continue to consider in future rulemaking. The facility PE RVU for CCM includes indirect PE (which is an allocation based on physician work), but no direct PE (which would be comprised of other labor, supplies and equipment). This is because historically, the PFS facility rate assumes that the billing practitioner is not bearing a significant resource cost in labor by other individuals, equipment or supplies. Medicare assumes that those costs are instead borne by the facility and adequately accounted for in a separate payment made to the facility. The PFS non-facility rate generally does include such costs, assuming that the billing practitioner bears the resource costs in clinical and other staff labor, supplies and equipment.
For CCM, we have been considering whether this approach to valuation remains appropriate, because the service, in whole or in significant part, is provided by clinical staff under the direction of the billing practitioner. These individuals may provide the service or part thereof remotely, and are not necessarily employees or staff of the facility. Under this construct, there may be more direct practice expense borne by the billing practitioner that should be separately identified and valued over and above any institutional payment to the facility for its staff and infrastructure. We plan to explore these issues in future rulemaking and consider other approaches to valuation that would recognize the accurate relative resource costs to the billing practitioner for CCM and similar services furnished to beneficiaries who remain or reside in a facility setting during some or all of the service period.
Consistent with general coding guidance, we proposed that the work that is reported under G0506 (including time) could not also be reported under or counted towards the reporting of any other billed code, including any of the monthly CCM services codes. The care plan that the practitioner must create to bill G0506 would be subject to the same requirements as the care plan included in the monthly CCM services, namely, it must be an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an
We received a number of comments regarding the relationship between proposed G0506, G0505 (Cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient), prolonged non-face-to-face services, and BHI. We address these comments in the sections of this final rule regarding G0505, prolonged non-face-to-face services and BHI services (sections II.E.5, II.E.2 and II.E.3). In brief, we are not allowing G0506 and G0505 to be billed the same day (by a single practitioner). G0506 will not be an add-on code for the BHI initiating visit or BHI services. G0506 will be a one-time service code for CCM initiation, and the billing practitioner must choose whether to report either G0506 or prolonged services in association with CCM initiation (if requirements to bill both are met).
The CCM and BHI service codes differ substantially in potential diagnosis and comorbidity, the expected duration of the condition(s) being treated, the kind of care planning performed (comprehensive care planning versus care planning focused on behavioral/mental health issues), service elements and who performs them, and the interventions the beneficiary needs and receives apart from the CCM and BHI services themselves. The BHI codes include a more focused process than CCM for the clinical integration of primary care and behavioral health/psychiatric care, and for continual reassessment and treatment progression to a target or goal outcome that is specific to mental and behavioral health or substance abuse issues. However there is no explicit BHI service element for managing care transitions or systematic assessment of receipt of preventive services; there is no requirement to perform comprehensive care planning for all health issues (not just behavioral health issues); and there are different emphases on medication management or medication reconciliation, if applicable. In deciding which code(s) to report for services furnished to a beneficiary who is eligible for both CCM and BHI services, practitioners should consider which service elements were furnished during the service period, who provided them, how much time was spent, and should select the code(s) that most accurately and specifically identifies the services furnished without duplicative time counting. Practitioners should generally select the more specific code(s) when an alternative code(s) potentially includes the services provided. We are not precluding use of the CCM codes to report, or count, behavioral health care management if it is provided as part of a broader CCM service by a practitioner who is comprehensively overseeing all of the beneficiary's health issues, even if there are no imminent non-behavioral health needs. However, such behavioral care management activities could not also be counted towards reporting a BHI code(s). If a BHI service code more specifically describes the service furnished (service time and other relevant aspects of the service being equal), or if there is no focus on the health of the beneficiary outside of a narrower set of behavioral health issues, then it is more appropriate to report the BHI code(s) than the CCM code(s). Similarly, it may be more appropriate for certain specialists to bill BHI services than CCM services, since specialists are more likely to be managing the beneficiary's behavioral health needs in relation to a narrow subset of medical condition(s). CCM and BHI services can only be billed the same month for the same beneficiary if all the requirements to bill each service are separately met. We will monitor the claims data, and we welcome further stakeholder input to inform appropriate reporting rules.
We proposed several revisions to the scope of service elements of 24/7 Access to Care, Continuity of Care, Care Plan and Managing Transitions. We continued to believe these elements are important aspects of CCM services, but that we should reduce the requirements for the use of specified electronic health information technology (IT) in their provision. In sum, we proposed to retain a core requirement to use a certified electronic health record (EHR), but allow fax to count for electronic transmission of clinical summaries and the care plan; no longer require access to the electronic care plan outside of normal business hours to those providing CCM services; and remove standards for clinical summaries in managing care transitions.
We sought to improve alignment with CPT provisions by removing the requirement for the care plan to be available remotely to individuals providing CCM services after hours. Studies have shown that after-hours care is best implemented as part of a larger practice approach to access and continuity (see for example, the peer-review article available at
We recognized that some models of care require more significant investment in practice infrastructure than others, for example resources in staffing or health information technology. In addition, we believed there is room to reduce the administrative complexity of our current payment rules for CCM services to accommodate a range of potential care models. In re-examining what should be included in the CCM scope of service elements for 24/7 Access to Care and Continuity of Care, we believed the CPT language adequately and more appropriately describes the services that should, at a minimum, be included in these service elements. Therefore, we proposed to adopt the CPT language for these two elements. For 24/7 Access to Care, the scope of service element would be to provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week. We believed the CPT language more accurately reflects the potential role of clinical staff or call-sharing services in addressing after-hours care needs than our current language does. In addition, the 24/7 access would be for “urgent” needs
We recognized that health information systems that include remote access to the care plan or the full EHR after hours, or a feedback loop that communicates back to the primary care physician and others involved in the beneficiary's care regarding after-hours care or advice provided, are extremely helpful (
This proposal reflected our understanding that flexibility in how practices can provide the requisite 24/7 access to care, as well as continuity of care and management of care transitions, for their CCM patients could facilitate appropriate access to these services for Medicare beneficiaries. This proposal was not intended to undermine the significance of standardized communication methods as part of effective care. Instead, we recognized that other CMS initiatives (such as MIPS and APMs under the Quality Payment Program) may be better mechanisms to incentivize increased interoperability of health information systems than conditions of payment assigned to particular services under the PFS. We also anticipated that improved accuracy of payment for care management services and reduced administrative burden associated with billing for them would contribute to practitioners' capacity to invest in the best tools for managing the care of Medicare beneficiaries.
For Continuity of Care, we currently require the ability to obtain successive routine appointments “with the practitioner or a designated member of the care team,” while CPT only references successive routine appointments “with a designated member of the care team.” We do not believe there is any practical difference between these two phrases and therefore proposed to omit the words “practitioner or” from our requirement. The billing practitioner is a member of the CCM care team, so the CPT language already allows for successive routine appointments either with the billing practitioner or another appropriate member of the CCM care team.
Based on review of extensive public comment and stakeholder feedback, we had also come to believe that we should not require individuals providing the beneficiary with the required 24/7 access to care for urgent needs to have access to the care plan as a condition of CCM payment. As discussed above, we believed that in general, provision of effective after-hours care of the beneficiary would require access to the care plan, if not the full EHR. However, we have heard from rural and other practices that remote access to the care plan is not always necessary or possible because urgent care needs after-hours are often referred to a practitioner or care team member who established the care plan or is familiar with the beneficiary. In some instances, the care plan does not need to be available to address urgent patient needs after business hours. In addition, we have not required the use of any certified or non-certified health information technology in the provision of any other PFS services (including various other care management services). We were concerned that imposing EHR-related requirements at the service level as a condition of PFS payment could distort the relative valuation of services priced under the fee schedule. Therefore, we proposed to change the CCM service element to require timely electronic sharing of care plan information within and outside the billing practice, but not necessarily on a 24/7 basis, and to allow transmission of the care plan by fax.
We acknowledged that it is best for practitioners and providers to have access to care plan information any time they are providing services to beneficiaries who require CCM services. This proposal was not intended to undermine the significance of electronic communication methods other than fax transmission in providing effective, continuous care. On the contrary, we believed that fax transmission, while commonly used, is much less efficient and secure than other methods of communicating patient health information, and we encouraged practitioners to adopt and use electronic technologies other than fax for transmission and exchange of the CCM care plan. We continued to believe the best means of exchange of all relevant patient health information is through standardized electronic means. However, we recognized that other CMS initiatives (such as MIPS and APMs under the Quality Payment Program) may be better mechanisms to incentivize increased interoperability of health information systems than conditions of payment assigned to particular services under the PFS. We believed our proposal would still allow timely availability of health information within and outside the practice for purposes of providing CCM, and would simplify the rules governing provision of the service and improve access to the service. The proposed revisions would better align the service with appropriate CPT prefatory language, which may reduce unnecessary administrative complexity for practitioners in navigating the differences between CPT guidance and Medicare rules.
The CCM scope of service element Management of Care Transitions includes a requirement for the creation and electronic transmission and exchange of continuity of care documents referred to as “clinical summaries” (see Table 11 of the CY 2017 PFS proposed rule). We patterned our requirements regarding clinical summaries after the EHR Incentive Program requirement that an eligible professional who transitions their patient to another setting of care or provider of care, or refers their patient to another provider of care, should provide a summary care record for each transition of care or referral. This clinical summary includes demographics, the medication list, medication allergy list, problem list, and a number of other data elements if the
Based on review of extensive public comment and stakeholder feedback, we had come to believe that we should not require the use of any specific electronic technology in managing a beneficiary's care transitions as a condition of payment for CCM services. Instead, we proposed more simply to require the billing practitioner to create and exchange/transmit continuity of care document(s) timely with other practitioners and providers. To avoid confusion with the requirements of the EHR Incentive Programs, and since we would no longer require standardized content for the CCM continuity of care document(s), we would refer to them as continuity of care documents instead of clinical summaries. We would no longer specify how the billing practitioner must transport or exchange these document(s), as long as it is done timely and consistent with the Care Transitions Management scope of service element. We welcomed public input on how we should refer to these document(s), noting that CPT does not provide model language specific to CCM services. The proposed term “continuity of care document(s)” draws on CPT prefatory language for TCM services, which CPT provides may include “obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care document).”
Again, this proposal was not intended to undermine the significance of a standardized, electronic format and means of exchange (other than fax) of all relevant patient health information, for achieving timely, seamless care across settings especially after discharge from a facility. On the contrary, we believed that fax transmission, while commonly used, is much less efficient and secure than other methods of communicating patient health information, and we encourage practitioners to adopt and use electronic technologies other than fax for transmission and exchange of continuity of care documents in providing CCM services. We continued to believe the best means of exchange of all relevant patient health information is through standardized electronic means. However, as we discussed above regarding the CCM care plan, we have not applied similar requirements to other PFS services specifically (including various other care management services) and had concerns about how doing so may create disparities between these services and others under the PFS. We also recognized that other CMS initiatives (such as MIPS and APMs under the Quality Payment Program) may be better mechanisms to incentivize increased interoperability of health information systems than conditions of payment assigned to particular services under the PFS.
However, we appreciate the commenters' feedback that relaxing the health IT use requirements may be of particular concern in situations where CCM is outsourced to a third party, reducing clinical integration. As we discuss in the section of this final rule on BHI services (section II.E.3.b), health IT holds significant promise for remote connectivity and interoperability that may assist and be useful (if not necessary) for reducing care fragmentation. However, we agree that remote provision of services by entities having only a loose association with the treating practitioner can detract from continuous, patient-centered care, whether or not those entities employ certified or other electronic technology. We will continue to consider the potential impacts of remote provision of CCM and similar types of services by third parties. We wish to emphasize for CCM, as we did for BHI services, that while the CCM codes do not explicitly count time spent by the billing practitioner, they are valued to include work performed by the billing practitioner, especially complex CCM. We emphasize that the practitioner billing for CCM must remain involved in ongoing oversight, management, collaboration and reassessment as appropriate to bill CCM services. If there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing CCM and the billing practitioner, we do not believe that the CCM service elements are actually being furnished and therefore, in such cases, the practitioner should not bill for CCM.
Finally, we note that activities undertaken as part of participation in MIPS or an APM under the Quality Payment Program may support the ability of a practitioner to meet our final requirements for the continuity of care document(s) and the electronic care plan.
As we stated in the CY 2017 proposed rule, the policy changes for CCM health IT use are not intended to undermine the importance of interoperability or electronic data exchange. These changes are driven by concerns that we have not applied similar requirements to other PFS services specifically, including various other care management services, and that such requirements create disparities between CCM services and other PFS services. We believe that other CMS initiatives may be better mechanisms to incentivize increased use and interoperability of health information systems than conditions of payment assigned to particular services under the PFS. We anticipate that these CCM policy changes will improve practitioners' capacity to invest in the best tools for managing the care of Medicare beneficiaries.
We proposed to simplify the current requirement to provide the beneficiary with a written or electronic copy of the care plan, by instead adopting the CPT language specifying more simply that a copy of the care plan must be given to the patient or caregiver. While we believe beneficiaries should and must be provided a copy of the care plan, and that practitioners may choose to provide the care plan in hard copy or electronic form in accordance with patient preferences, we do not believe it is necessary to specify the format of the care plan that must be provided as a condition of CCM payment. Additionally, we recognize that there may be times that sharing the care plan with the caregiver (in a manner consistent with applicable privacy and security rules and regulations) may be appropriate.
We continue to believe that obtaining advance beneficiary consent to receive CCM services is important to ensure the beneficiary is informed, educated about CCM services, and is aware of applicable cost sharing. We also believe that querying the beneficiary about whether another practitioner is already providing CCM services helps to reduce the potential for duplicate provision or billing of the services. However, we believe the consent process could be simplified, and that it should be left to the practitioner and the beneficiary to decide the best way to establish consent. Therefore, we proposed to continue to require billing practitioners to inform the beneficiary of the currently required information (that is, inform the beneficiary of the availability of CCM services; inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month; and inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month)). However, we proposed to specify that the practitioner could document in the beneficiary's medical record that this information was explained and note whether the beneficiary accepted or declined CCM services instead of obtaining a written agreement.
We also proposed to remove the language requiring beneficiary authorization for the electronic communication of his or her medical information with other treating providers as a condition of payment for CCM services, because under federal regulations that implement the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164.506), a covered entity is permitted to use or disclose protected health information for purposes of treatment without patient authorization. Moreover, if such disclosure is electronic, the HIPAA Security Rule requires secure transmission (45 CFR 164.312(e)). In previous regulations we have reminded practitioners that for all electronic sharing of beneficiary information in the provision of CCM services, HIPAA Privacy and Security Rule standards apply in the usual manner (79 FR 67728).
We have heard from practitioners that the requirements to document certain
We are finalizing changes to the CCM scope of service elements discussed above that will apply for both complex and non-complex CCM services beginning in CY 2017. The final CY 2017 service elements for CCM are summarized in Table 11. We believe these changes will retain elements of the CCM service that are characteristic of the changes in medical practice toward advanced primary care, while eliminating redundancy, simplifying provision of the services, and improving access to the services. For payment of complex CCM services beginning in CY 2017, we are adopting the CPT code descriptors for CPT codes 99487 and 99489 as well as the service elements in Table 11. We are providing separate payment for complex CCM (CPT 99487, 99489) using the RUC-recommended payment inputs for those services. We may reconsider the role of health information technology in CCM service provision in future years. We anticipate that improved accuracy of payment for CCM services, and reduced administrative burden associated with billing CCM services, will contribute to practitioners' capacity to invest in the best tools for managing the care of Medicare beneficiaries.
For CY 2017 we proposed a G-code that would provide separate payment to recognize the work of a physician (or other appropriate billing practitioner) in assessing and creating a care plan for beneficiaries with cognitive impairment, such as from Alzheimer's disease or dementia, at any stage of impairment, G0505 (Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home). We understand that a similar code was recently approved by the CPT Editorial Panel and is scheduled to be included in the CY 2018 CPT code set. We intended for G0505 to be a temporary code, perhaps for only one year, to be replaced by the CPT code in CT 2018. We will consider whether to adopt and establish relative value units for the new CPT code under our standard process, presumably for CY 2018.
We reviewed the list of service elements that were considered by the CPT Editorial Panel, and proposed the following as required service elements of G0505:
• Cognition-focused evaluation including a pertinent history and examination.
• Medical decision making of moderate or high complexity (defined by the E/M guidelines).
• Functional assessment (for example, Basic and Instrumental Activities of Daily Living), including decision-making capacity.
• Use of standardized instruments to stage dementia.
• Medication reconciliation and review for high-risk medications, if applicable.
• Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized instrument(s).
• Evaluation of safety (for example, home), including motor vehicle operation, if applicable.
• Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.
• Advance care planning and addressing palliative care needs, if applicable and consistent with beneficiary preference.
• Creation of a care plan, including initial plans to address any neuropsychiatric symptoms and referral to community resources as needed (for example, adult day programs, support groups); care plan shared with the patient and/or caregiver with initial education and support.
The proposed valuation of G0505 (discussed in section II.E.1) assumed that this code would include services that are personally performed by the physician (or other appropriate billing practitioner, such as a nurse practitioner or physician assistant) and would significantly overlap with services described by certain E/M visit codes, advance care planning services, and certain psychological or psychiatric service codes that are currently separately payable under the PFS. Accordingly, we proposed that G0505 must be furnished by the physician (or other appropriate billing practitioner) and could not be billed on the same date of service as CPT codes 90785 (Psytx complex interactive), 90791 (Psych diagnostic evaluation), 90792 (Psych diag eval w/med srvcs), 96103 (Psycho testing admin by comp), 96120 (Neuropsych tst admin w/comp), 96127 (Brief emotional/behav assmt), 99201-99215 (Office/outpatient visits new), 99324-99337 (Domicil/r-home visits new pat), 99341-99350 (Home visits new patient), 99366-99368 (Team conf w/pat by hc prof), 99497 (Advncd care plan 30 min), 99498 (Advncd care plan addl 30 min)), since these codes all reflect face-to-face services furnished by the physician or other billing practitioner for related separately billable services that overlap substantially with G0505. In addition, we proposed to prohibit billing of G0505 with other care planning services, such as care plan oversight services (CPT code 99374), home health care and hospice supervision (G0181, G0182), or our proposed add-on code for comprehensive assessment and care planning by the billing practitioner for patients requiring CCM services (GPPP7). We solicited comment on whether there are circumstances where multiple care planning codes could be furnished without significant overlap. We proposed to specify that G0505 may serve as a companion or primary E/M code to the prolonged service codes (those that are currently separately paid, and those we proposed to separately pay beginning in 2017), but were interested in public input on whether there is any overlap among these services. We solicited comment on how to best delineate the post-service work for G0505 from the work necessary to provide the prolonged services code.
We did not believe the services described by G0505 would significantly overlap with proposed or current medically necessary CCM services (CPT codes 99487, 99489, 99490); TCM services (CPT codes 99495, 99496); or the proposed behavioral health integration service codes (HCPCS codes GPPP1, GPPP2, GPPP3, GPPPX). Therefore, we proposed that G0505 could be billed on the same date-of-service or within the same service period as these codes (CPT codes 99487, 99489, 99490, 99495, 99496, and HCPCS codes GPPP1, GPPP2, GPPP3, and GPPPX). There may be overlap in the patient population eligible to receive these services and the population eligible to receive the services described by G0505, but we believed there would be sufficient differences in the nature and extent of the assessments, interventions and care planning, as well as the qualifications of individuals providing the services, to allow concurrent billing for services that are medically reasonable and necessary. We solicited public comment on potential overlap between G0505 and other codes currently paid under the PFS, as well as the other primary care/cognitive services addressed in this section of the final rule.
• Expand scope of service elements related to medication management.
• Include occupational therapy in the scope of service element pertaining to community resources.
• Rewrite “Creation of a care plan, including initial plans to address any neuropsychiatric symptoms and referral to community resources as needed (for example, adult day programs, support groups); care plan shared with the patient and/or caregiver with initial education and support” to include “identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness and availability of caregiver to voluntarily take on caregiving tasks.”
• Make sure that non-paid or informal caregivers are included in care planning and provide resources and support for care givers so as to improve care givers ability to provide care for the beneficiary.
• Require the inclusion of caregiver names in care plan and patients medical record, require that caregivers be assessed for stress and depressive symptoms, as well as care giver skill and education needs.
• State that consultations with the caregiver are permissible under HIPAA and that such conversations may be necessary in the development of a care plan.
• Specify that any advance care planning is consistent with beneficiary preference and addresses any palliative care needs of the patient, and include establishment of durable power of attorney.
• Clarify that diagnosis of dementia is not part of the scope of service by deleting “cognition focused evaluation including pertinent history” from the scope of service.
• Clarify that “functional assessment” is separate from decision making assessments, and that this is a non-legal assessment of competency.
• Stipulate that other decision makers should be identified.
• Consider deleting “use of standardized instruments to stage dementia” because the care plan is the most important aspect of the service and many standardized instruments are not very effective at staging.
• Clarify that the care plan address both medical and non-medical issues, and includes follow-up scheduling for monitoring and evaluation.
• Provide a copy of the written care plan to the patient.
• Refer to the care plan as a “person-centered care plan.”
• Include evaluation of medical problems including review of lab or imaging tests, review of co-morbidities, especially those which are dependent on self-care, evaluation the risk of falls and recommendations for fall prevention, evaluation of possible elder abuse, and documentation of financial issues, as part of the scope of service.
We estimate that about 7 percent of all Medicare beneficiaries have a potentially disabling mobility-related diagnosis (the Medicare-only prevalence is 5.5 percent and the prevalence for Medicare-Medicaid dual eligible beneficiaries is 11 percent), using 2010 Medicare (and for dual eligible beneficiaries, Medicaid) claims data.
When a beneficiary with a mobility-related disability goes to a physician or other practitioner's office for an E/M visit, the resources associated with providing the visit can exceed the resources required for the typical E/M visit. An E/M visit for a patient with a mobility-related disability can require more physician and clinical staff time to provide appropriate care because the patient may require skilled assistance throughout the visit to carefully move and adjust his/her body. Furthermore, an E/M visit for a patient with a mobility-related disability commonly requires specialized equipment such as a wheel chair accessible scale, floor and overhead lifts, a movable exam table, padded leg supports, a stretcher and transfer board. The current E/M visit payment rates, based on an assumption of “typical” resources involved in furnishing an E/M visit to a “typical” patient, do not accurately reflect these additional resources associated with furnishing appropriate care to many beneficiaries with mobility-related disabilities.
When furnishing E/M services to beneficiaries with mobility-related disabilities, practitioners face difficult choices in deciding whether to take the extra time necessary and invest in the required specialized equipment for these visits even though the payment rate for the service does not account for either expense; potentially providing less than optimal care for a beneficiary whose needs exceed the standard appointment block of time in the standard equipped exam room reflected in the current E/M visit payment rate; or declining to accept appointments altogether for beneficiaries who require additional time and specialized equipment.
Each of these scenarios is potentially problematic. The first two scenarios suggest that the quality of care for this beneficiary population might be compromised by assumptions under the PFS regarding relative resource costs in furnishing services to this population. The third scenario reflects an obvious access problem for these beneficiaries. To improve payment accuracy and help ameliorate potential disparity in access and quality for beneficiaries with mobility-related disabilities, we proposed to create a new add-on G-code, effective for CY 2017, to describe the additional services furnished in conjunction with E/M services to beneficiaries with disabilities that impair their mobility:
G0501: Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management service visit (Add-on code, list separately in addition to primary procedure).
Effective January 1, 2017, we proposed that this add-on code could be billed with new and established patient office/outpatient E/M codes (CPT codes 99201 through 99205, and 99212 through 99215), as well as transitional care management codes (CPT codes 99495 and 99496), when the additional resources described by the code are medically necessary and used in the provision of care. In addition to seeking comment on this proposal, we are also sought comment on other HCPCS codes that may be appropriate base codes for this proposed add-on code, including those describing preventive visits and services. We reminded potential commenters that the rationale for this proposal is based in large part on the broad use and lack of granularity in coding for E/M services relative to other PFS services in conjunction with the additional resources used.
We received many thoughtful comments on this proposal and thank commenters for their input. Comments received are summarized below.
Generally, commenters noted that they appreciate CMS' efforts to address health disparities based on disability, and some then supported this proposal as a first step in providing medically necessary services to patients with disabilities, while others recommended that CMS not finalize the proposal and raised legal, access, and equity concerns.
Although there was near universal agreement among commenters regarding problems in health care disparities and barriers to access among individuals with disabilities, there was disagreement about whether establishing payment for code G0501 as proposed was a good solution to help solve these problems. While we believe that improving the payment accuracy of physicians' services is necessary and appropriate, and can help to address the underlying access issues for individuals with disabilities, we also acknowledge that implementation of new or revised payments can result in unanticipated, and potentially undesirable, consequences. Before implementing payment for code G0501, we plan to further analyze and address the concerns raised by commenters. As such, we are not finalizing payment for code G0501 at this time. We appreciate commenters' insights, and our commitment to promoting better primary care for people with disabilities remains strong. Over the next 6 months we will engage with interested beneficiaries, advocates, and practitioners to continue to explore improvements in payment accuracy for care of people with disabilities. We intend to discuss this issue again in future rulemaking.
While we are not finalizing separate payment for code G0501 for CY 2017, we are including the code in the CY 2017 code set as G0501. The HCPCS code G0501 will not be payable under the Medicare PFS for CY 2017, though practitioners will be able to report the code, should they be inclined to do so.
When furnishing care to a beneficiary with a mobility-related disability, the current E/M visit payment rates may not fully reflect the associated resource costs that are being incurred by practitioners. We recognize that there are other populations for which payment adjustment may be appropriate. Our proposal regarding beneficiaries with mobility-related disabilities reflected the discrete nature of the additional resource costs for this population, the clear lack of differentiation in resource costs regarding particular kinds of frequently-furnished services, and the broad recognition of access problems. We recognize that some physician practices may frequently furnish services to particular populations for which the relative resource costs are similarly systemically undervalued and we sought comment regarding other circumstances where these dynamics can be discretely observed.
Our current regulations in 42 CFR 410.26(b) provide for an exception to assign general supervision to CCM services (and similarly, for the non-face-to-face portion of TCM services), because these are generally non-face-to-face care management/care coordination services that would commonly be provided by clinical staff when the billing practitioner (who is also the supervising practitioner) is not physically present; and the CPT codes are comprised solely (or in significant part) of non-face-to-face services provided by clinical staff. A number of codes that we proposed to establish for separate payment in CY 2017 under our initiative to improve payment accuracy for primary care and care management are similar to CCM services, in that a critical element of the services is non-face-to-face care management/care coordination services provided by clinical staff or other qualified individuals when the billing practitioner may not be physically present. Accordingly, we proposed to amend 42 CFR 410.26(a)(3) and 410.26(b) to better define general supervision and to assign general supervision not only to CCM services and the non-face-to-face portion of TCM services, but also to proposed codes G0502, G0503, G0504, G0507, CPT code 99487, and CPT code 99489. Instead of adding each of these proposed codes assigned general supervision to the regulation text on an individual basis, we proposed to revise our regulation under 42 CFR 410.26(b)(1) to assign general supervision to the non-face-to-face portion of designated care management services, and we would designate the applicable services through notice and comment rulemaking.
We did not receive any public comments on our proposed regulation text. However we received a number of comments regarding a related proposal to require behavioral health care managers to be located on site. Also for psychiatric CoCM services (G0502, G0503 and G0504), we are finalizing a requirement that the behavioral health care manager is available to perform his or her duties face-to-face and non-face-to-face with the beneficiary. We address these issues at length in the BHI section of this final rule (section II.E.3). Since we are assigning general supervision to psychiatric CoCM behavioral health care manager services that may be provided face-to-face with the beneficiary, we are omitting the phrase “non-face-to-face portion of” in “the non-face-to-face portion of designated care management services.” Accordingly, the final amended regulation text in 42 CFR 410.26(b) assigns general supervision to “designated care management services” that we will designate through notice and comment rulemaking. The services that we are newly designating (finalizing) for general supervision in this final rule are G0502, G0503, G0504, G0507, CPT code 99487 and CPT code 99489. We had initially proposed adding a cross-reference to the existing definition of “general supervision” in current regulations at § 410.32(b)(3)(i), but to better describe general supervision in the context of these services, we are specifying at § 410.26(a)(3) that general supervision means the service is furnished under the physician's (or other practitioner's)
RHCs and FQHCs have been authorized to bill for CCM services since January 1, 2016, and are paid based on the Medicare PFS national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim. The RHC and FQHC requirements for billing CCM services have generally followed the requirements for practitioners billing under the PFS, with some adaptations based on the RHC and FQHC payment methodologies.
To assure that CCM requirements for RHCs and FQHCs are not more burdensome than those for practitioners billing under the PFS, we proposed revisions for CCM services furnished by RHCs and FQHCs similar to the revisions proposed under the section above entitled, “Reducing Administrative Burden and Improving Payment Accuracy for Chronic Care Management (CCM) Services” for RHCs and FQHCs. Specifically, we proposed to:
• Require that CCM be initiated during an AWV, IPPE, or comprehensive E/M visit only for new patients or patients not seen within one year. This would replace the requirement that CCM could only be initiated during an AWV, IPPE, or comprehensive E/M visit where CCM services were discussed.
• Require 24/7 access to a RHC or FQHC practitioner or auxiliary personnel with a means to make contact with a RHC or FQHC practitioner to address urgent health care needs regardless of the time of day or day of week. This would replace the requirement that CCM services be available 24/7 with health care practitioners in the RHC or FQHC who have access to the patient's electronic care plan to address his or her urgent chronic care needs, regardless of the time of day or day of the week.
• Require timely electronic sharing of care plan information within and outside the RHC or FQHC, but not necessarily on a 24/7 basis, and expands the circumstances under which transmission of the care plan by fax is allowed. This would replace the requirement that the electronic care plan be available on a 24/7 basis to all practitioners within the RHC or FQHC whose time counts towards the time requirement for the practice to bill the CCM code, and removes the restriction on allowing the care plan to be faxed only when the receiving practitioner or provider can only receive clinical summaries by fax.
• Require that in managing care transitions, the RHC or FQHC creates, exchanges, and transmits continuity of care document(s) in a timely manner with other practitioners and providers. This would replace the requirements that clinical summaries must be created and formatted according to certified EHR technology, and the requirement for electronic exchange of clinical summaries by a means other than fax.
• Require that a copy of the care plan be given to the patient or caregiver. This would remove the description of the format (written or electronic) and allows the care plan to be provided to the caregiver when appropriate (and in a manner consistent with applicable privacy and security rules and regulations).
• Require that the RHC or FQHC practitioner documents in the beneficiary's medical record that all the elements of beneficiary consent (for example, that the beneficiary was informed of the availability of CCM services; only one practitioner can furnish and be paid for these services during a calendar month; the beneficiary may stop the CCM services at any time, effective at the end of the calendar month, etc.) were provided, and whether the beneficiary accepted or declined CCM services. This would replace the requirement that RHCs and FQHCs obtain a written agreement that these elements were discussed, and removes the requirement that the beneficiary provide authorization for the electronic communication of his or her medical information with other treating providers as a condition of payment for CCM services.
• Require that communication to and from home- and community-based providers regarding the patient's psychosocial needs and functional deficits be documented in the patient's medical record. This would replace the requirement to document this patient health information in a certified EHR format.
We noted that we did not propose an additional payment adjustment for patients who require extensive assessment and care planning as part of the initiating visit, as payments for RHC and FQHC services are not adjusted for length or complexity of the visit.
We stated that we believe these proposed changes would keep the CCM requirements for RHCs and FQHCs consistent with the CCM requirements for practitioners billing under the PFS, simplify the provision of CCM services by RHCs and FQHCs, and improve access to these services without compromising quality of care, beneficiary privacy, or advance notice and consent.
We received 31 comments on the proposed revisions to the CCM requirements for RHCs and FQHCs. The following is a summary of the comments we received:
After considering the comments, we are finalizing as proposed the revisions to the requirements for CCM services furnished by RHCs and FQHCs.
Section 1861(s)(2)(S) of the Act specifies that medical and other health services include DSMT services as defined in section 1861(qq) of the Act. DSMT services are intended to educate beneficiaries in the successful self-management of diabetes. DSMT includes, as applicable, instructions in self-monitoring of blood glucose; education about diet and exercise; an insulin treatment plan developed specifically for the patient who is insulin-dependent; and motivation for patients to use the new skills for self-management (see 42 CFR 410.144(a)(5)). DSMT services are reported under HCPCS codes G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) and G0109 (Diabetes outpatient self- management training services, group session (2 or more), per 30 minutes). The benefit, as specified at 42 CFR 410.141, consists of 1 hour of individual and 9 hours of group training unless special circumstances warrant more individual training or no group session is available within 2 months of the date the training is ordered.
Section 1861(qq) of the Act specifies that DMST services are furnished by a certified provider, defined as a physician or other individual or entity that also provides, in addition to DSMT, other items or services for which payment may be made under Medicare. The physician, individual or entity that furnishes the training also must meet certain quality standards. The physician, individual or entity can meet standards established by us or standards originally established by the National Diabetes Advisory Board and subsequently revised by organizations who participated in their establishment, or can be recognized by an organization that represents individuals with diabetes as meeting standards for furnishing the services.
We require that all those who furnish DSMT services be accredited as meeting quality standards by a CMS-approved national accreditation organization (NAO). In accordance with § 410.144, a CMS-approved NAO may accredit an individual, physician or entity to meet one of three sets of DSMT quality standards: CMS quality standards; the National Standards for Diabetes Self-Management Education Programs (National Standards); or the standards of an NAO that represents individuals with diabetes that meet or exceed our quality standards. Currently, we recognize the American Diabetes Association and the American Association of Diabetes Educators as approved NAOs, both of whom follow National Standards. Medicare payment for outpatient DSMT services is made in accordance with 42 CFR 414.63.
An article titled “Use of Medicare's Diabetes Self-Management Training Benefit” was published in
In the CY 2017 PFS proposed rule (81 FR 45215), we identified issues that the
Section 1848(c)(2)(O) of the Act establishes an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. Under section 1848(c)(2)(O)(ii) of the Act, if the estimated net reduction in expenditures for a year as a result of adjustments to the relative values for misvalued codes is equal to or greater than the target for that year, reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS in accordance with the existing budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. The provision also specifies that the amount by which such reduced expenditures exceeds the target for a given year shall be treated as a net reduction in expenditures for the succeeding year, for purposes of determining whether the target has been met for that subsequent year. Section 1848(c)(2)(O)(iv) of the Act defines a target recapture amount as the difference between the target for the year and the estimated net reduction in expenditures under the PFS resulting from adjustments to RVUs for misvalued codes. Section 1848(c)(2)(O)(iii) of the Act specifies that, if the estimated net reduction in PFS expenditures for the year is less than the target for the year, an amount equal to the target recapture amount shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. Under section 1848(c)(2)(O)(v) of the Act, the target that applies to calendar years (CYs) 2017 and 2018 is calculated as 0.5 percent of the estimated amount of expenditures under the PFS for the year.
In CY 2016 PFS rulemaking, we proposed and finalized a methodology to implement this statutory provision.
Because the annual target is calculated by measuring changes from one year to the next, for CY 2016, we considered how to account for changes in values that are best measured over 3 years, instead of 2 years. As we described in the CY 2016 final rule with comment period (80 FR 70932), our general valuation process for potentially misvalued, new, and revised codes was to establish values on an interim final basis for a year in the PFS final rule with comment period. Then, during the 60-day period following the publication of the final rule with comment period, we would accept public comment about those valuations. In the final rule with comment period for the subsequent year, we would consider and respond to public comments received on the interim final values, and make any appropriate adjustments to values based on those comments. Under that process for revaluing new, revised, and misvalued codes, we believe the overall change in valuation for many codes would best be measured across values for 3 years: between the original value in the first year; the interim final value in the second year; and the finalized value in the third year. However, the target calculation for a year would only be comparing changes in RVUs between 2 years and not among 3 years, so the contribution of a particular change towards the target for any single year would be measured against only the preceding year without regard to the overall change that takes place over 3 years.
For recent years, interim final values for misvalued codes (year 2) have generally reflected reductions relative to original values (year 1), and for most codes, the interim final values (year 2) are maintained and finalized (year 3). However, when values for particular codes have changed between the interim final (year 2) and final values (year 3) based on public comment, the general tendency has been that codes increase in the final value (year 3) relative to the interim final value (year 2), even in cases where the final value (year 3) represents a decrease from the original value (year 1). Therefore, for these codes, the year 2 changes compared to year 1 would risk over-representing the overall reduction, while the year 3 to year 2 changes would represent an increase in value. We noted that if there were similar targets in every PFS year, and a similar number of misvalued code changes made on an interim final basis, the incongruence in measuring what is really a 3-year change in 2-year increments might not be particularly problematic since each year's calculation would presumably include a similar number of codes measured between years 1 and 2 and years 2 and 3.
However, including changes that take place over 3 years generated challenges in calculating the target for CY 2016. Because there was no target for CY 2015, any reductions that occurred on an interim final basis for CY 2015 were not counted toward achievement of a target. If we had then included any upward adjustments made to these codes based on public comment as “misvalued code” changes for CY 2016, we would effectively be counting the service-level increases for 2016 (year 3) relative to 2015 (year 2) against achievement of the target without any consideration to the service-level changes relative to 2014 (year 1), even in cases where the overall change in valuation was negative.
Therefore, we proposed and finalized the decision to exclude code-level input changes for CY 2015 interim final values from the calculation of the CY 2016 misvalued code target since the misvalued change occurred over multiple years, including years not applicable to the misvalued code target provision.
For the CY 2017 final rule, we will be finalizing values (year 3) for codes that were interim final in CY 2016 (year 2). Unlike codes that were interim final for CY 2015, the codes that are interim final for CY 2016 were included as misvalued codes and will fall within the range of years for which the misvalued code target provision applies. Thus, overall changes in values for these codes would
As such, we proposed to include changes in values of the CY 2016 interim final codes toward the CY 2017 misvalued code target. We believe that this is consistent with the approach that we finalized in the CY 2016 PFS final rule with comment period. The changes in values of CY 2015 interim final codes were not counted towards the misvalued code target in CY 2016 since the valuation change occurred over multiple years, including years not applicable to the misvalued code target provision. However, both of the changes in valuation for the CY 2016 interim final codes, from year 1 to year 2 (CY 2015 to CY 2016) and from year 2 to year 3 (CY 2016 to CY 2017), have taken place during years that occur within the misvalued code target provision. We therefore believe that any adjustments made to these codes based on public comment should be considered towards the achievement of the target for CY 2017, just as any changes in valuation for these same CY 2016 interim final codes previously counted towards the achievement of the target for CY 2016.
We solicited comments regarding this proposal. We also reminded commenters that we revised our process for revaluing new, revised and misvalued codes so that we will be proposing and finalizing values for most of the misvalued codes during a single calendar year. After this year, there will be far fewer instances of interim final codes and changes that are best measured over 3 years.
We refer readers to the regulatory impact analysis section of this final rule for the net reduction in expenditures relative to the 0.5 percent target for CY 2017, and the resulting adjustment required to be made to the conversion factor. Additionally, we refer readers to the public use file that provides a comprehensive description of how the target is calculated, as well as the estimated impact by code family on the CMS Web site under the supporting data files for the CY 2017 PFS final rule at
The following is summary of the comments we received regarding the target for relative value adjustments for misvalued services.
We did not receive any public comments on our proposal to include changes in values of the CY 2016 interim final codes toward the CY 2017 misvalued code target.
After consideration of comments received, we are finalizing our proposal to count any adjustments to interim final codes towards the misvalued code target when both first and second year changes can be counted towards a misvalued codes target.
Section 1848(c)(7) of the Act specifies that for services that are not new or revised codes, if the total RVUs for a service for a year would otherwise be decreased by an estimated 20 percent or more as compared to the total RVUs for the previous year, the applicable adjustments in work, PE, and MP RVUs shall be phased in over a 2-year period. In the CY 2016 PFS rulemaking, we proposed and finalized a methodology to implement this statutory provision. To determine which services are described by new or revised codes for purposes of the phase-in provision, we apply the phase-in to all services that are described by the same, unrevised code in both the current and update year, and exclude codes that describe different services in the current and update year.
Because the phase-in of significant reductions in RVUs falls within the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act, we estimate the total RVUs for a service prior to the budget-neutrality redistributions that result from implementing phase-in values. In implementing the phase-in, we consider a 19 percent reduction as the maximum 1-year reduction for any service not described by a new or revised code. This approach limits the year one reduction for the service to the maximum allowed amount (that is, 19 percent), and then phases in the remainder of the reduction.
The statute provides that the applicable adjustments in work, PE, and MP RVUs shall be phased in over a 2-year period when the RVU reduction for a code for a year is estimated to be equal to or greater than 20 percent. Since CY 2016 was the first year in which we applied the phase-in transition, CY 2017 will be the first year in which a single code could be subject to RVU reductions greater than 20 percent for 2 consecutive years.
Under our finalized policy, the only codes that are not subject to the phase-in are those that are new or revised, which we defined as those services that are not described by the same, unrevised code in both the current and update year, or by the same codes that describe different services in the current and update year. Since CY 2016 was the first year for which the phase-in provision applied, we did not address how we would handle codes with values that had been partially phased in during the first year, but that have a remaining phase-in reduction of 20 percent or greater.
The significant majority of codes with reductions in RVUs that are greater than 20 percent in year one would not be likely to meet the 20 percent threshold in a consecutive year. However, in a few cases, significant changes (for example, in the input costs included in the valuation of a service) could produce reductions of 20 percent or greater in consecutive years.
As stated in the CY 2017 PFS proposed rule, we believed that a consistent methodology regarding the phase-in transition should be applied to these cases. We proposed to reconsider
The list of codes subject to the phase-in and the associated proposed RVUs that result from this methodology is available on the CMS Web site under downloads for the CY 2017 PFS final rule at
The following is summary of the comments we received regarding the phase-in of significant RVU reductions.
After consideration of comments received, we are finalizing the policy as proposed.
Section 1848(e)(1)(A) of the Act requires us to develop separate Geographic Practice Cost Indices (GPCIs) to measure relative cost differences among localities compared to the national average for each of the three fee schedule components (that is, work, PE, and malpractice (MP)). The PFS localities are discussed in section II.E.3. of this final rule. Although the statute requires that the PE and MP GPCIs reflect the full relative cost differences, section 1848(e)(1)(A)(iii) of the Act requires that the work GPCIs reflect only one-quarter of the relative cost differences compared to the national average. In addition, section 1848(e)(1)(G) of the Act sets a permanent 1.5 work GPCI floor for services furnished in Alaska beginning January 1, 2009, and section 1848(e)(1)(I) of the Act sets a permanent 1.0 PE GPCI floor for services furnished in frontier states (as defined in section 1848(e)(1)(I) of the Act) beginning January 1, 2011. Additionally, section 1848(e)(1)(E) of the Act provided for a 1.0 floor for the work GPCIs, which was set to expire on March 31, 2015. Section 201 of the MACRA amended the statute to extend the 1.0 floor for the work GPCIs through CY 2017 (that is, for services furnished no later than December 31, 2017).
Section 1848(e)(1)(C) of the Act requires us to review and, if necessary, adjust the GPCIs at least every 3 years. Section 1848(e)(1)(C) of the Act requires that, if more than 1 year has elapsed since the date of the last previous GPCI adjustment, the adjustment to be applied in the first year of the next adjustment shall be half of the adjustment that otherwise would be made. Therefore, since the previous GPCI update was implemented in CY 2014 and CY 2015, we proposed to phase in 1/2 of the latest GPCI adjustment in CY 2017.
We have completed a review of the GPCIs and proposed new GPCIs in this final rule. We also calculate a geographic adjustment factor (GAF) for each PFS locality. The GAFs are a weighted composite of each area's work, PE and malpractice expense GPCIs using the national GPCI cost share weights. While we do not actually use GAFs in computing the fee schedule payment for a specific service, they are useful in comparing overall areas costs and payments. The actual effect on payment for any actual service would deviate from the GAF to the extent that the proportions of work, PE and MP RVUs for the service differ from those of the GAF.
As noted above, section 201 of the MACRA extended the 1.0 work GPCI floor for services furnished through December 31, 2017. Therefore, the proposed CY 2017 work GPCIs and summarized GAFs reflect the 1.0 work floor. Additionally, as required by sections 1848(e)(1)(G) and 1848(e)(1)(I) of the Act, the 1.5 work GPCI floor for Alaska and the 1.0 PE GPCI floor for frontier states are permanent, and therefore, applicable in CY 2017. See Addenda D and E to this final rule for the CY 2017 GPCIs and summarized GAFs available on the CMS Web site under the supporting documents section of the CY 2017 PFS final rule located at
The proposed updated GPCI values were calculated by a contractor. There are three GPCIs (work, PE, and MP), and all GPCIs are calculated relative to the national average for each measure. Additionally, each of the three GPCIs relies on its own data source(s) and methodology for calculating its value as described below. Additional information on the CY 2017 GPCI update may be found in our contractor's draft report, “Draft Report on the CY 2017 Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which is available on our Web site. It is located under the supporting documents section for the CY 2017 PFS final rule located at
The work GPCIs are designed to reflect the relative costs of physician labor by Medicare PFS locality. As required by statute, the work GPCI reflects one quarter of the relative wage differences for each locality compared to the national average.
To calculate the work GPCIs, we use wage data for seven professional specialty occupation categories, adjusted to reflect one-quarter of the relative cost differences for each locality compared to the national average, as a proxy for physicians' wages. Physicians' wages are not included in the occupation categories used in calculating the work GPCI because Medicare payments are a key determinant of physicians' earnings. Including physician wage data in calculating the work GPCIs would potentially introduce some circularity to the adjustment since Medicare payments typically contribute to or influence physician wages. That is, including physicians' wages in the physician work GPCIs would, in effect, make the indices, to some extent, dependent upon Medicare payments.
The work GPCI updates in CYs 2001, 2003, 2005, and 2008 were based on professional earnings data from the 2000 Census. However, for the CY 2011 GPCI update (75 FR 73252), the 2000 data were outdated and wage and earnings data were not available from the more recent Census because the “long form” was discontinued. Therefore, we used the median hourly earnings from the 2006 through 2008 Bureau of Labor Statistics (BLS) Occupational Employment Statistics (OES) wage data as a replacement for the 2000 Census data. The BLS OES data meet several criteria that we consider to be important for selecting a data source for purposes of calculating the GPCIs. For example, the BLS OES wage and employment data are derived from a large sample size of approximately 200,000 establishments of varying sizes nationwide from every metropolitan area and can be easily accessible to the public at no cost. Additionally, the BLS OES is updated regularly, and includes a comprehensive set of occupations and industries (for example, 800 occupations in 450 industries). For the CY 2014 GPCI update, we used updated BLS OES data (2009 through 2011) as a replacement for the 2006 through 2008 data to compute the work GPCIs.
Because of its reliability, public availability, level of detail, and national scope, we believe the BLS OES data continue to be the most appropriate source of wage and employment data for use in calculating the work GPCIs (and as discussed in section II.E.2.b the employee wage component and purchased services component of the PE GPCI). Therefore, for the proposed CY 2017 GPCI update, we used updated BLS OES data (2011 through 2014) as a replacement for the 2009 through 2011 data to compute the work GPCIs.
The PE GPCIs are designed to measure the relative cost difference in the mix of goods and services comprising practice expenses (not including malpractice expenses) among the PFS localities as compared to the national average of these costs. Whereas the physician work GPCIs (and as discussed later in this section, the MP GPCIs) are comprised of a single index, the PE GPCIs are comprised of four component indices (employee wages; purchased services; office rent; and equipment, supplies and
For the previous update to the GPCIs (implemented in CY 2014) we used 2009 through 2011 BLS OES data to calculate the employee wage and purchased services indices for the PE GPCI. As discussed in section II.E.2.a., because of its reliability, public availability, level of detail, and national scope, we continue to believe the BLS OES is the most appropriate data source for collecting wage and employment data. Therefore, in calculating the proposed CY 2017 GPCI update, we used updated BLS OES data (2011 through 2014) as a replacement for the 2009 through 2011 data for purposes of calculating the employee wage component and purchased service index component of the PE GPCI.
The MP GPCIs measure the relative cost differences among PFS localities for the purchase of professional liability insurance (PLI). The MP GPCIs are calculated based on insurer rate filings of premium data for $1 million to $3 million mature claims-made policies (policies for claims made rather than services furnished during the policy term). For the CY 2014 GPCI update (seventh update) we used 2011 and 2012 malpractice premium data (78 FR 74382). The proposed CY 2017 MP GPCI update reflects 2014 and 2015 premium data. Additionally, the proposed CY 2017 MP GPCI update reflects several proposed technical refinements to the MP GPCI methodology as discussed later in section 5.
For CY 2017 GPCIs, we proposed to continue to use the current cost share weights for determining the PE GPCI values and locality GAFs. We refer readers to the CY 2014 PFS final rule with comment period (78 FR 74382 through 74383), for further discussion regarding the 2006-based MEI cost share weights revised in CY 2014 that were also finalized for use in the CY 2014 (seventh) GPCI update.
The GPCI cost share weights for CY 2017 are displayed in Table 12.
Section 10324(c) of the Affordable Care Act added a new subparagraph (I) under section 1848(e)(1) of the Act to establish a 1.0 PE GPCI floor for physicians' services furnished in frontier states effective January 1, 2011. In accordance with section 1848(e)(1)(I) of the Act, beginning in CY 2011, we applied a 1.0 PE GPCI floor for physicians' services furnished in states determined to be frontier states. In general, a frontier state is one in which at least 50 percent of the counties are “frontier counties,” which are those that have a population per square mile of less than 6. For more information on the criteria used to define a frontier state, we refer readers to the FY 2011 Inpatient Prospective Payment System (IPPS) final rule (75 FR 50160 through 50161). There are no changes in the states identified as Frontier States for the CY 2017 final rule. The qualifying states are: Montana, Wyoming, North Dakota, South Dakota, and Nevada. In accordance with statute, we would apply a 1.0 PE GPCI floor for these states in CY 2017.
As explained above in the background section, the periodic review and adjustment of GPCIs is mandated by section 1848(e)(1)(C) of the Act. At each update, the proposed GPCIs are published in the PFS proposed rule to provide an opportunity for public comment and further revisions in response to comments prior to implementation. As discussed later in this section, we are finalizing the GPCIs as proposed (except where we correct technical errors). The final CY 2017 updated GPCIs for the first and second year of the 2-year transition, along with the GAFs, are displayed in Addenda D and E to this final rule available on our Web site under the supporting documents section of the CY 2017 PFS final rule Web page at
The current PFS locality structure was developed and implemented in 1997. There are currently 89 total PFS localities; 34 localities are statewide areas (that is, only one locality for the entire state). There are 52 localities in the other 16 states, with 10 states having 2 localities, 2 states having 3 localities, 1 state having 4 localities, and 3 states having 5 or more localities. The combined District of Columbia, Maryland, and Virginia suburbs; Puerto Rico; and the Virgin Islands are the remaining three localities of the total of 89 localities. The development of the current locality structure is described in detail in the CY 1997 PFS final rule (61 FR 34615) and the subsequent final rule with comment period (61 FR 59494). We note that the localities generally represent a grouping of one or more constituent counties.
Prior to 1992, Medicare payments for physicians' services were made under the reasonable charge system. Payments were based on the charging patterns of physicians. This resulted in large differences in payment for physicians' services among types of services, geographic payment areas, and physician specialties. Recognizing this, the Congress replaced the reasonable
Payment localities originally were established under the reasonable charge system by local Medicare carriers based on their knowledge of local physician charging patterns and economic conditions. These localities changed little between the inception of Medicare in 1967 and the beginning of the PFS in 1992. Shortly after the PFS took effect, we undertook a study in 1994 that culminated in a comprehensive locality revision that was implemented in 1997 (61 FR 59494).
The revised locality structure reduced the number of localities from 210 to the current 89, and the number of statewide localities increased from 22 to 34. The revised localities were based on locality resource cost differences as reflected by the GPCIs. For a full discussion of the methodology, see the CY 1997 PFS final rule with comment period (61 FR 59494). The current 89 fee schedule areas are defined alternatively by state boundaries (for example, Wisconsin), metropolitan areas (for example, Metropolitan St. Louis, MO), portions of a metropolitan area (for example, Manhattan), or rest-of-state areas that exclude metropolitan areas (for example, Rest of Missouri). This locality configuration is used to calculate the GPCIs that are in turn used to calculate payments for physicians' services under the PFS.
As stated in the CY 2011 PFS final rule with comment period (75 FR 73261), changes to the PFS locality structure would generally result in changes that are budget neutral within a state. For many years, before making any locality changes, we have sought consensus from among the professionals whose payments would be affected. In recent years, we have also considered more comprehensive changes to locality configuration. In 2008, we issued a draft comprehensive report detailing four different locality configuration options (
The following is a summary of the comments we received regarding the proposed CY 2017 GPCI update.
After consideration of the public comments received regarding the proposed CY 2017 GPCI data update, we are finalizing as proposed.
Section 220(h) of the PAMA added a new section 1848(e)(6) to the Act, that modifies the fee schedule areas used for payment purposes in California beginning in CY 2017.
Currently, the fee schedule areas used for payment in California are based on the revised locality structure that was implemented in 1997 as previously discussed. Beginning in CY 2017, section 1848(e)(6)(A)(i) of the Act requires that the fee schedule areas used for payment in California must be Metropolitan Statistical Areas (MSAs) as defined by the Office of Management and Budget (OMB) as of December 31 of the previous year; and section 1848(e)(6)(A)(ii) of the Act requires that all areas not located in an MSA must be treated as a single rest-of-state fee schedule area. The resulting modifications to California's locality structure would increase its number of localities from 9 under the current locality structure to 27 under the MSA-based locality structure.
However, section 1848(e)(6)(D) of the Act defines transition areas as the fee schedule areas for 2013 that were the rest-of-state locality, and locality 3, which was comprised of Marin County, Napa County, and Solano County. Section 1848(e)(6)(B) of the Act specifies that the GPCI values used for payment in a transition area are to be phased in over 6 years, from 2017 through 2021, using a weighted sum of the GPCIs calculated under the new MSA-based locality structure and the GPCIs calculated under the current PFS locality structure. That is, the GPCI values applicable for these areas during this transition period are a blend of what the GPCI values would have been under the current locality structure, and what the GPCI values would be under the MSA-based locality structure. For example, in the first year, CY 2017, the applicable GPCI values for counties that were previously in rest-of-state or locality 3 and are now in MSAs are a blend of 1/6 of the GPCI value calculated for the year under the MSA-based locality structure, and 5/6 of the GPCI value calculated for the year under the current locality structure. The proportions shift by 1/6 in each subsequent year so that, by CY 2021, the applicable GPCI values for counties within transition areas are a blend of 5/6 of the GPCI value for the year under the MSA-based locality structure, and 1/6 of the GPCI value for the year under the current locality structure. Beginning in CY 2022, the applicable GPCI values for counties in transition areas are the values calculated under the new MSA-based locality structure. For the sake of clarity, we reiterate that this incremental phase-in is only applicable to those counties that are in transition areas that are now in MSAs, which are only some of the counties in the 2013 California rest-of state locality and locality 3.
Additionally, section 1848(e)(6)(C) of the Act establishes a hold harmless for transition areas beginning with CY 2017 whereby the applicable GPCI values for a year under the new MSA-based locality structure may not be less than what they would have been for the year under the current locality structure. There are a total of 58 counties in California, 50 of which are in transition areas as defined in section 1848(e)(6)(D) of the Act. Therefore, 50 counties in California are subject to the hold harmless provision. The other 8 counties, which are metropolitan counties that are not defined as transition areas, are not held harmless for the impact of the new MSA-based locality structure, and may therefore potentially experience slight decreases in their GPCI values as a result of the provisions in section 1848(e)(6) of the Act, insofar as the locality in which they are located now newly includes data from adjacent counties that decreases their GPCI values relative to those that would have applied had the new data not been incorporated. Therefore, the GPCIs for these eight counties under the MSA-based locality structure may be less than they would have been under the current GPCI structure. The eight counties that are not within transition areas are: Orange; Los Angeles; Alameda; Contra Costa; San Francisco; San Mateo; Santa Clara; and Ventura counties.
We emphasize that while transition areas are held harmless from the impact of the GPCI changes using the new MSA-based locality structure, because we proposed other updates for CY 2017 as part of the eighth GPCI update, including the use of updated data, transition areas would still be subject to impacts resulting from those other updates. Table 13 illustrates using GAFs, for CY 2017, the isolated impact of the MSA-based locality changes and hold-harmless for transition areas required by section 1848(e)(6) of the Act, the impact of the use of updated data for GPCIs, and the combined impact of both of these changes.
Additionally, for the purposes of calculating budget neutrality and consistent with the PFS budget neutrality requirements as specified under section 1848(c)(2)(B)(ii)(II) of the Act, we proposed to start by calculating the national GPCIs as if the current localities are still applicable nationwide; then for the purposes of payment in California, we override the GPCI values with the values that are applicable for California consistent with the requirements of section 1848(e)(6) of the Act. This approach is consistent with the implementation of the GPCI floor provisions that have previously been implemented—that is, as an after-the-fact adjustment that is implemented for purposes of payment after both the GPCIs and PFS budget neutrality have already been calculated.
As discussed above, under section 1848(e)(6) of the Act, counties that were previously in the rest-of-state locality or locality 3 and are now in MSAs would have their GPCI values under the new MSA-based locality structure phased in gradually, in increments of one-sixth over 6 years. Section 1848(e)(1)(C) of the Act requires that, if more than 1 year has elapsed since the date of the last previous GPCI adjustment, the adjustment to be applied in the first year of the next adjustment shall be 1/2 of the adjustment that otherwise would be made. While section 1848(e)(6)(B) of the Act establishes a blended phase-in for the MSA-based GPCI values, it does not explicitly state whether or how that provision is to be reconciled with the requirement at section 1848(e)(1)(C) of
As previously stated, the resulting modifications to California's locality structure increase its number of localities from 9 under the current locality structure to 27 under the MSA-based locality structure. However, both the current localities and the MSA-based localities are comprised of various component counties, and in some localities only some of the component counties are subject to the blended phase-in and hold harmless provisions required by section 1848(e)(6)(B) and (C) of the Act. Therefore, the application of these provisions may produce differing GPCI values among counties within the same fee schedule area under the MSA-based locality structure. For example, the MSA-based San Jose-Sunnyvale-Santa Clara locality, is comprised of 2 constituent counties—San Benito County, and Santa Clara County. San Benito County is in a transition area (2013 rest-of-state), while Santa Clara County is not. Hence, although the counties are in the same MSA, the requirements of section 1848(e)(6)(B) and (C) of the Act may produce differing GPCI values for each county. To address this issue, we proposed to assign a unique locality number to the counties that would be impacted in the aforementioned manner. As a result, although the modifications to California's locality structure increase the number of localities from 9 under the current locality structure to 27 under the MSA-based locality structure, for purposes of payment, the actual number of localities under the MSA-based locality structure would be 32 to account for instances where unique locality numbers are needed as described above. Additionally, while the fee schedule area names are consistent with the MSAs designated by OMB, we proposed to maintain 2-digit locality numbers to correspond to the existing fee schedule areas. Pursuant to the implementation of the new MSA-based locality structure for California, the total number of PFS localities would increase from 89 to 112. Table 14 displays the current fee schedule areas in California, and Table 15 displays the MSA-based fee schedule areas in California required by section 1848(e)(6) of the Act. Additional information on the California locality update may be found in our contractor's draft report, “Draft Report on the CY 2017 Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which is available on the CMS Web site. It is located under the supporting documents section of the CY 2017 PFS final rule located at
We received few comments regarding the California locality update to the fee schedule areas used for payment under section 220(h) of PAMA.
After consideration of the public comments received regarding the proposed California payment locality implementation plan, we are finalizing as proposed.
In calculating GPCIs within U.S. states, we use county-level wage data from the Bureau of Labor Statistics (BLS) Occupational Employment Statistics Survey (OES), county-level residential rent data from the American Community Survey (ACS), and malpractice insurance premium data from state departments of insurance. In calculating GPCIs for the U.S. territories, we currently use three distinct methodologies—one for Puerto Rico, another for the Virgin Islands, and a third for the Pacific Islands (Guam, American Samoa, and Northern Marianas Islands). These three methodologies were adopted at different times based primarily on the data that were available at the time they were adopted. At present, because Puerto Rico is the only territory where county-level BLS OES, county-level ACS, and malpractice premium data are available, it is the only territory for which we use territory-specific data to calculate GPCIs. For the Virgin Islands, because county-level wage and rent data are not available, and insufficient malpractice premium data are available, CMS has set the work, PE, and MP GPCI values for the Virgin Islands payment locality at the national average of 1.0 even though, like Puerto Rico, the Virgin Islands is its
As noted above, currently Puerto Rico is the only territory for which we calculate GPCIs using the territory-specific information relative to data from the U.S. States. For several years stakeholders in Puerto Rico have raised concerns regarding the applicability of the proxy data in Puerto Rico relative to their applicability in the U.S. states. We believe that these concerns may be consistent across island territories, but lack of available, appropriate data has made it difficult to quantify such variation in costs. For example, some stakeholders previously indicated that shipping and transportation expenses increase the cost of acquiring medical equipment and supplies in islands and territories relative to the mainland. While we have previously attempted to locate data sources specific to geographic variation in such shipping costs, we found no comprehensive national data source for this information (we refer readers to 78 FR 74387 through 74388 for the detailed discussion of this issue). Therefore, we have not been able to quantify variation in costs specific to island territories in the calculation of the GPCIs.
For all the island territories other than Puerto Rico, the lack of comprehensive data about unique costs for island territories has had minimal impact on GPCIs because we have used either the Hawaii GPCIs (for the Pacific territories) or used the unadjusted national averages (for the Virgin Islands). In an effort to provide greater consistency in the calculation of GPCIs given the lack of comprehensive data regarding the validity of applying the proxy data used in the States in accurately accounting for variability of costs for these island territories, we proposed to treat the Caribbean Island territories (the Virgin Islands and Puerto Rico) in a consistent manner. We proposed to do so by assigning the national average of 1.0 to each GPCI index for both Puerto Rico and the Virgin Islands. We did not propose any changes to the GPCI methodology for the Pacific Island territories (Guam, American Samoa, and Northern Marianas Islands) where we already consistently assign the Hawaii GPCI values for each of the three GPCIs. Additional information on the Proposed Update to the Methodology for Calculating GPCIs in the U.S. Territories may be found in our contractor's draft report, “Draft Report on the CY 2017 Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which is available on our Web site. It is located under the supporting documents section of the CY 2017 PFS final rule located at
The following is a summary of the comments we received regarding the proposed update to the methodology for calculating GPCIs in the U.S. territories.
After consideration of the public comments received regarding our proposal to treat the Caribbean Island territories (the Virgin Islands and Puerto Rico) in a consistent manner, by assigning the national average of 1.0 to each GPCI index for both Puerto Rico and the Virgin Islands, we are finalizing as proposed.
In the process of calculating MP GPCIs for the purposes of this final rule, we identified several technical refinements to the methodology that yield improvements over the current method. We also proposed refinements that conform to our proposed methodology for calculating the GPCIs for the U.S. Territories described above. Specifically, we proposed modifications to the methodology to account for missing data used in the calculation of the MP GPCI. Under the methodology used in the CY 2014 GPCI update (78 FR 74380 through 74391), we first calculated the average premiums by insurer and specialty, then imputed premium values for specialties for which we did not have specific data, before adjusting the specialty-specific premium data by market share weights. We proposed to revise our methodology to instead calculate the average premiums for each specialty using issuer market share for only available companies. This proposed methodological improvement would reduce potential bias resulting from large amounts of imputation, an issue that is prevalent for insurers that only write policies for ancillary specialties for which premiums tend to be low. The current method would impute the low premiums for ancillary specialties across the remaining specialties, and generally greater imputation leads to less accuracy. Additional information on the MP GPCI methodology, and the proposed refinement to the MP GPCI methodology may be found in our contractor's draft report, “Draft Report on the CY 2017 Update of the Geographic Practice Cost Index for the Medicare Physician Fee Schedule,” which is available on our Web site. It is located under the supporting documents section of the CY 2017 PFS final rule located at
We did not receive any comments regarding the proposed technical refinements to the MP GPCI methodology, and we are finalizing as proposed.
Section 502(a)(1) of Division O, Title V of the Consolidated Appropriations Act, 2016 (Pub. L. 114-113) amended section 1848(b) of the Act by adding new paragraph (b)(9). Effective for services furnished on or after January 1, 2017, section 1848(b)(9)(A) of the Act reduces by 20 percent the payment amounts under the PFS for the technical component (TC) (including the TC portion of a global services) of imaging services that are X-rays taken using film. The reduction is made prior to any other adjustment under this section and without application of this new paragraph.
Section 1848(b)(9) of the Act allows for the implementation of the payment reduction through appropriate mechanisms which may include use of modifiers. In accordance with section 1848(c)(2)(B)(v)(X), the adjustments under section 1848(b)(9)(A) of the Act are exempt from budget neutrality.
To implement this provision, in the CY 2017 PFS proposed rule (81 FR 46224), we proposed to establish a new modifier to be used on claims that include imaging services that are X-rays (including the imaging portion of a service) taken using film. Since the display of the proposed rule, modifier FX has been established for that purpose. Effective January 1, 2017, the modifier must be used on claims for X-rays that are taken using film. The use of this modifier will result in a 20 percent reduction for the X-ray service, as specified under section 1848(b)(9)(A) of the Act.
The proposed rule preamble stated that the applicable HCPCS codes describing imaging services that are X-ray services could be found on the PFS Web site. However, we did not intend this to indicate that we would be developing or displaying an exhaustive list of applicable codes. Instead, we intended to refer to the several lists of PFS imaging codes, including those that describe imaging services that are X-rays.
After consideration of the public comments we received, we are finalizing the establishment of new modifier “FX” to be reported on claims for imaging services that are X-rays that are taken using film.
Beginning January 1, 2017, claims for imaging services that are X-rays taken using film must include the modifier “FX.”
The use of this modifier will result in a 20 percent reduction for the X-ray service, as specified under section 1848(b)(9)(A) of the Act.
Effective January 1, 2012, we implemented an MPPR of 25 percent on the professional component (PC) of advanced imaging services. The reduction applies when multiple imaging procedures are furnished by the same physician (or physician in the same group practice) to the same patient, in the same session, on the same day. Full payment is made for the PC of the highest priced procedure. Payment for the PC of subsequent services is reduced by 25 percent.
Section 502(a)(2)(A) of Division O, Title V of the Consolidated Appropriations Act, 2016 (Pub. L. 114-113, enacted on December 18, 2015) added a new section 1848(b)(10) of the Act which revises the payment reduction from 25 percent to 5 percent, effective January 1, 2017. Section 502(a)(2)(B) added a new subclause at section 1848(c)(2)(B)(v)(XI) which exempts the reduced expenditures attributable to the revised 5 percent MMPR on the PC of imaging from the PFS budget neutrality provision. We proposed to implement these provisions for services furnished on or after January 1, 2017. We refer readers to section VI.C of this final rule regarding the necessary adjustment to the proposed PFS conversion factor to account for the mandated exemption from PFS budget neutrality.
We note that the lists of services for the upcoming calendar year that are subject to the MPPR on diagnostic cardiovascular services, diagnostic imaging services, diagnostic ophthalmology services, and therapy services; and the list of procedures that meet the definition of imaging under section 5102(b) of the Deficit Reduction Act (DRA), and therefore, are subject to the OPPS cap, are displayed in the public use files for the PFS proposed and final rules for each year. The public use files for CY 2017 are available on our Web site under downloads for the CY 2017 PFS final rule with comment period at
Establishing valuations for newly created and revised CPT codes is a routine part of maintaining the PFS. Since inception of the PFS, it has also been a priority to revalue services regularly to make sure that the payment rates reflect the changing trends in the practice of medicine and current prices for inputs used in the PE calculations. Initially, this was accomplished primarily through the 5-year review process, which resulted in revised work RVUs for CY 1997, CY 2002, CY 2007, and CY 2012, and revised PE RVUs in CY 2001, CY 2006, and CY 2011. Under the 5-year review process, revisions in RVUs were proposed and finalized via rulemaking. In addition to the 5-year reviews, beginning with CY 2009, CMS and the RUC have identified a number of potentially misvalued codes each year using various identification screens, as discussed in section II.D.4 of this final rule. Historically, when we received RUC recommendations, our process had been to establish interim final RVUs for the potentially misvalued codes, new codes, and any other codes for which there were coding changes in the final rule for a year. Then, during the 60-day period following the publication of the final rule, we accepted public comment about those valuations. For services furnished during the calendar year following the publication of interim final rates, we paid for services based upon the interim final values established in the final rule. In the final rule with comment period for the subsequent year, we considered and responded to public comments received on the interim final values, and typically made any appropriate adjustments and finalized those values.
In the CY 2015 PFS final rule with comment period, we finalized a new process for establishing values for new, revised and potentially misvalued codes. Under the new process, we include proposed values for these services in the proposed rule, rather than establishing them as interim final in the final rule with comment period. Beginning with the CY 2017 proposed rule, the new process is applicable to all codes, except for new codes that describe truly new services. For CY 2017, we proposed new values in the CY 2017 proposed rule for the vast majority of new, revised, and potentially misvalued codes for which we received complete RUC recommendations by February 10, 2016. To complete the transition to this new process, for codes where we established interim final values in the CY 2016 PFS final rule with comment period, we reviewed the comments received during the 60-day public comment period following release of the CY 2016 PFS final rule with comment period, and re-proposed
We considered public comments received during the 60-day public comment period for the proposed rule before establishing final values in this final rule. As part of our established process we will adopt interim final values only in the case of wholly new services for which there are no predecessor codes or values and for which we do not receive recommendations in time to propose values. For CY 2017, we are not aware of any new codes that describe such wholly new services. Therefore, we are not establishing any code values on an interim final basis. However, we remind stakeholders that we continually review stakeholder information regarding the valuation of codes under the potentially misvalued code initiative and, under our existing process, could consider proposing any particular changes as early as CY 2018 rulemaking.
We conduct a review of each code identified in this section and review the current work RVU (if any), RUC-recommended work RVU, intensity, time to furnish the preservice, intraservice, and postservice activities, as well as other components of the service that contribute to the value. Our review of recommended work RVUs and time inputs generally includes, but is not limited to, a review of information provided by the RUC, HCPAC (Health Care Professionals Advisory Committee), and other public commenters, medical literature, and comparative databases, as well as a comparison with other codes within the PFS, consultation with other physicians and health care professionals within CMS and the federal government, as well as Medicare claims data. We also assess the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters and the rationale for the recommendations. In the CY 2011 PFS final rule with comment period (75 FR 73328 through 73329), we discussed a variety of methodologies and approaches used to develop work RVUs, including survey data, building blocks, crosswalks to key reference or similar codes, and magnitude estimation (see the CY 2011 PFS final rule with comment period for more information). When referring to a survey, unless otherwise noted, we mean the surveys conducted by specialty societies as part of the formal RUC process. The building block methodology is used to construct, or deconstruct, the work RVU for a CPT code based on component pieces of the code.
Components used in the building block approach may include preservice, intraservice, or postservice time and post-procedure visits. When referring to a bundled CPT code, the building block components could be the CPT codes that make up the bundled code and the inputs associated with those codes. Magnitude estimation refers to a methodology for valuing work that determines the appropriate work RVU for a service by gauging the total amount of work for that service relative to the work for a similar service across the PFS without explicitly valuing the components of that work. In addition to these methodologies, we have frequently utilized an incremental methodology in which we value a code based upon its incremental difference between another code or another family of codes. The statute specifically defines the work component as the resources in time and intensity required in furnishing the service. Also, the published literature on valuing work has recognized the key role of time in overall work. For particular codes, we refine the work RVUs in direct proportion to the changes in the best information regarding the time resources involved in furnishing particular services, either considering the total time or the intraservice time.
Several years ago, to aid in the development of preservice time recommendations for new and revised CPT codes, the RUC created standardized preservice time packages. The packages include preservice evaluation time, preservice positioning time, and preservice scrub, dress and wait time. Currently there are six preservice time packages for services typically furnished in the facility setting, reflecting the different combinations of straightforward or difficult procedure, straightforward or difficult patient, and without or with sedation/anesthesia. Currently, there are three preservice time packages for services typically furnished in the nonfacility setting, reflecting procedures without and with sedation/anesthesia care.
We have developed several standard building block methodologies to value services appropriately when they have common billing patterns. In cases where a service is typically furnished to a beneficiary on the same day as an E/M service, we believe that there is overlap between the two services in some of the activities furnished during the preservice evaluation and postservice time. Our longstanding adjustments have reflected a broad assumption that at least one-third of the work time in both the preservice evaluation and postservice period is duplicative of work furnished during the E/M visit.
Accordingly, in cases where we believe that the RUC has not adequately accounted for the overlapping activities in the recommended work RVU and/or times, we adjust the work RVU and/or times to account for the overlap. The work RVU for a service is the product of the time involved in furnishing the service multiplied by the intensity of the work. Preservice evaluation time and postservice time both have a long-established intensity of work per unit of time (IWPUT) of 0.0224, which means that 1 minute of preservice evaluation or postservice time equates to 0.0224 of a work RVU.
Therefore, in many cases when we remove 2 minutes of preservice time and 2 minutes of postservice time from a procedure to account for the overlap with the same day E/M service, we also remove a work RVU of 0.09 (4 minutes × 0.0224 IWPUT) if we do not believe the overlap in time has already been accounted for in the work RVU. The RUC has recognized this valuation policy and, in many cases, now addresses the overlap in time and work when a service is typically furnished on the same day as an E/M service.
We note that many commenters and stakeholders have expressed concerns with our ongoing adjustment of work RVUs based on changes in the best information we have regarding the time resources involved in furnishing individual services. We are particularly concerned with the RUC's and various specialty societies' objections to our approach given the significance of their recommendations to our process for valuing services and since much of the information we have used to make the adjustments is derived from their survey process. As explained in the CY 2016 PFS final rule with comment period (80 FR 70933), we recognize that adjusting work RVUs for changes in time is not always a straightforward process, so we apply various methodologies to identify several potential work values for individual codes. However, we want to reiterate that we are statutorily obligated to consider both time and intensity in establishing work RVUs for PFS services.
We have observed that for many codes reviewed by the RUC, final recommended work RVUs appear to be incongruous with recommended assumptions regarding the resource costs in time. This is the case for a significant portion of codes for which we have recently established or proposed work RVUs that are based on
In so doing, rather than ignoring the RUC-recommended value, we are using the recommended values as a starting reference and then applying one of these several methodologies to account for the reductions in time that we believe have not otherwise been reflected in the RUC-recommended value. When we believe that such changes in time have already been accounted for in the RUC recommendation, then we do not make such adjustments. Likewise, we do not arbitrarily apply time ratios to current work RVUs to calculate proposed work RVUs. We use the ratios to identify potential work RVUs and consider these work RVUs as potential options relative to the values developed through other options.
We clarify that we are not implying that the decrease in time as reflected in survey values must equate to a one-to-one or linear decrease in newly valued work RVUs. Instead, we believe that, since the two components of work are time and intensity, absent an obvious or explicitly stated rationale for why the relative intensity of a given procedure has increased, significant decreases in time should be reflected in decreases to work RVUs. If the RUC recommendation has appeared to disregard or dismiss the changes in time, without a persuasive explanation of why such a change should not be accounted for in the overall work of the service, then we generally use one of the aforementioned referenced methodologies to identify potential work RVUs, including the methodologies intended to account for the changes in the resources involved in furnishing the procedure.
Several commenters, including the RUC, in general have objected to our use of these methodologies and deemed our actions in adjusting the recommended work RVUs as inappropriate. We received several specific comments regarding this issue in response to the CY 2016 PFS final rule with comment period and those comments are summarized below.
Regarding the validity of comparing new times to the old times, we, too, hope that time estimates have improved over many years especially when many years have elapsed since the last time the service in question was valued. However, we also believe that our operating assumption regarding the validity of the pre-existing values as a point of comparison is critical to the integrity of the relative value system as currently constructed. Pre-existing times are a very important element in the allocation of indirect PE RVUs by specialty, and had the previously recommended times been overestimated, the specialties that furnish such services would be benefitting from these times in the allocation of indirect PE RVUs. As long time observers of the RUC process, we also recognize that the material the RUC uses to develop overall work recommendations includes the data from the surveys about time. We have previously stated concerns regarding the validity of much of the RUC survey data. However, we believe additional kinds of concern would be warranted if the RUC itself were operating under the assumption that its pre-existing data were typically inaccurate.
We understand stakeholders' concerns regarding how best to consider changes in time in improving the accuracy of work RVUs and have considered all of the issues raised by commenters. In conjunction with our review of recommended code values for CY 2017, we conducted a preliminary analysis to identify general tendencies in the relationship between changes in time and changes in work RVUs for CY 2014 and CY 2015. We looked at services for which there were no coding changes to simplify the analysis. The intent of this preliminary analysis was to examine commenters' beliefs that CMS is only considering time when making refinements to RUC recommended work values. For CY 2014, we found that in the aggregate, the average difference between the RUC recommended intraservice time and existing intraservice time was −17 percent, but the average difference between the RUC recommended work RVU and existing work RVU was only −4 percent. However, the average difference between the CMS refined work RVU and existing work RVU was −7 percent. For CY 2015, the average difference between the RUC recommended intraservice time and existing intraservice time was −17 percent, but the average difference between the RUC recommended work RVU and existing work RVU was 1 percent, and the average difference between the CMS refined work RVU and existing work RVU was −6 percent. This preliminary analysis demonstrates that we are not making refinements solely in consideration of time, if that were the case, the changes in the work RVU values that we adopted would be comparable to the changes in the time that we adopted, but that is not the case.
We believe that we should account for efficiencies in time when the recommended work RVU does not account for those efficiencies, otherwise relativity across the PFS can be significantly skewed over periods of time. For example, if when a code is first valued, a physician was previously able to do only 5 procedures per day, but due to new technologies, the same physician can now do 10 procedures per day, resource costs in time have empirically been lessened, and we believe that relative reduction in resources involved in furnishing that service should be accounted for in the assignment of work RVUs for that service, since the statute explicitly identifies time as one of the two components of work. Of course, if more resource intensive technology has allowed for the increased efficiency in furnishing the procedure, then the nonfacility PE RVUs for the service should also be adjusted to account for this change. Additionally, we believe it may be that the intensity per minute of the procedure may have changed with the greater efficiency in time. Again, that is why we do not generally reduce work RVUs in strict proportion to changes in time. We understand that intensity is not entirely linear, and that data related to time as obtained in the RUC survey instrument may improve over time, and that the number of survey respondents may improve over time. However, we also understand time as a tangible resource cost in furnishing PFS services, and a cost that by statute, is one of the two kinds of resources to be considered as part of the work RVU.
Therefore, in the proposed rule, we stated that we were interested in receiving comments on whether, within the statutory confines, there are alternative suggestions as to how changes in time should be accounted for when it is evident that the survey data and/or the RUC recommendation regarding the overall work RVU does not reflect significant changes in the resource costs of time for codes describing PFS services. We solicited comment on potential alternatives, including the application of the reverse building block methodology, to making the adjustments that would recognize overall estimates of work in the context of changes in the resource of time for particular services.
The following is a summary of the comments we received in response to our solicitation regarding potential alternatives, including the application of the reverse building block methodology, to making the adjustments that would recognize overall estimates of work in the context of changes in the resource of time for particular services.
Another commenter stated that it appreciates that CMS provided
We also disagree that we ignore the statutory requirement to consider time and intensity in the valuation of services. Based on the assessments of CMS medical officers and other reviewers, as well as upon consideration of the survey results, and the rationales in the recommendations, we make determinations about the overall work valuations. We acknowledge that the degree to which intensity varies among different procedures is a relatively subjective assessment, and we understand that sometimes stakeholders
We thank the commenters for their feedback. We did not receive any comments regarding specific potential alternatives to making the adjustments that would recognize overall estimates of work in the context of changes in the resource of time for particular services as requested. However, we appreciate the commenters' sharing their concerns and suggestions and will continue to consider them as we continue examining the valuation of services, and as we explore the best way to address these issues.
Consistent with the policy finalized in the CY 2016 PFS final rule with comment period, we have retained the Refinement Panel process for use with codes with interim final values where additional input by the panel is likely to add value as a supplement to notice and comment rulemaking. Because there are no codes with interim final values in this final rule, the refinement panel is not necessary for CY 2017. We note that many commenters requested inclusion of codes with proposed values for a refinement panel. While these requests are not consistent with our established process, given the number of requests we received, we are addressing them here. Many commenters appear to believe that that the purpose of the refinement panel process was to serve as a kind of “appeals” or reconsideration process outside of notice and comment rulemaking and that we have effectively eliminated a useful appeals process. We understand that the refinement panel has been perceived as an appeals process by many stakeholders. However, as we have previously clarified, the purpose of the refinement panel process was to assist us in reviewing the public comments on CPT codes with interim final work RVUs and to consider more fully the interests of the specialty societies who provide input on RVU work time and intensity with the budgetary and redistributive effects that could occur if we accepted extensive increases in work RVUs across a broad range of services. From our perspective, the objective of the refinement panel has long been to provide a needed venue for stakeholders to present any new clinical information that was not available at the time of the RUC valuation for interim final values in order that we arrive at the most appropriate final valuation, especially since the initial values for such codes were generally established approximately 2 months prior to being used for Medicare payment. In recent years, we have continually observed that the material presented to the refinement panel largely raised and discussed issues and perspective already included as part of the RUC meetings and considered by us.
We believe that our new process, in which we propose the vast majority of code values in the proposed rule for public comment on those proposed values prior to their taking effect, provides stakeholders and the public with several opportunities to present data or information that might affect code valuation. We believe that this is generally consistent with the purpose of the rulemaking process and reflects our efforts to increase transparency and accountability to the public. We also note that we continue to seek new information that is relevant to valuation of particular services, including those with values recently finalized, for use in future rulemaking. We believe that notice and comment rulemaking provides the most appropriate means for valuing services under the PFS. We note that in several instances in this final rule, thoughtful and informative comments have helped us to finalize values for CY 2017 that we believe are improved from those we had proposed. In many cases, these changes reflect the RUC-recommended value. Therefore, we urge commenters to review this information and continue to consider how we might continue to improve the notice and comment rulemaking process rather than establish a process outside of notice and comment rulemaking.
Table 27 contains a list of codes for which we proposed work RVUs; this includes all RUC recommendations received by February 10, 2016, and
On an annual basis, the RUC provides us with recommendations regarding PE inputs for new, revised, and potentially misvalued codes. We review the RUC-recommended direct PE inputs on a code by code basis. Like our review of recommended work RVUs, our review of recommended direct PE inputs generally includes, but is not limited to, a review of information provided by the RUC, HCPAC, and other public commenters, medical literature, and comparative databases, as well as a comparison with other codes within the PFS, consultation with physicians and health care professionals within CMS and the federal government, as well as Medicare claims data. We also assess the methodology and data used to develop the recommendations submitted to us by the RUC and other public commenters and the rationale for the recommendations. When we determine that the RUC's recommendations appropriately estimate the direct PE inputs (clinical labor, disposable supplies, and medical equipment) required for the typical service, are consistent with the principles of relativity, and reflect our payment policies, we use those direct PE inputs to value a service. If not, we refine the recommended PE inputs to better reflect our estimate of the PE resources required for the service. We also confirm whether CPT codes should have facility and/or nonfacility direct PE inputs and refine the inputs accordingly.
Our review and refinement of RUC-recommended direct PE inputs includes many refinements that are common across codes, as well as refinements that are specific to particular services. Table 28 details our finalized refinements of the RUC's direct PE recommendations at the code-specific level. In this final rule, we address several refinements that are common across codes, and refinements to particular codes are addressed in the portions of this section that are dedicated to particular codes. We note that for each refinement, we indicate the proposed impact on direct costs for that service. We note that, on average, in any case where the impact on the direct cost for a particular refinement is $0.32 or less, the refinement has no impact on the proposed PE RVUs. This calculation considers both the impact on the direct portion of the PE RVU, as well as the impact on the indirect allocator for the average service. We also note that nearly half of the proposed refinements listed in Table 28 result in changes under the $0.32 threshold and are unlikely to result in a change to the proposed RVUs.
We also note that the final direct PE inputs for CY 2017 are displayed in the CY 2017 direct PE input database, available on the CMS Web site under the downloads for the CY 2017 final rule at
Some direct PE inputs are directly affected by revisions in work time. Specifically, changes in the intraservice portions of the work time and changes in the number or level of postoperative visits associated with the global periods result in corresponding changes to direct PE inputs. The direct PE input recommendations generally correspond to the work time values associated with services. We believe that inadvertent discrepancies between work time values and direct PE inputs should be refined or adjusted in the establishment of proposed direct PE inputs to resolve the discrepancies.
Prior to CY 2010, the RUC did not generally provide CMS with recommendations regarding equipment time inputs. In CY 2010, in the interest of ensuring the greatest possible degree of accuracy in allocating equipment minutes, we requested that the RUC provide equipment times along with the other direct PE recommendations, and we provided the RUC with general guidelines regarding appropriate equipment time inputs. We continue to appreciate the RUC's willingness to provide us with these additional inputs as part of its PE recommendations.
In general, the equipment time inputs correspond to the service period portion of the clinical labor times. We have clarified this principle over several years of rulemaking, indicating that we consider equipment time as the time within the intraservice period when a clinician is using the piece of equipment plus any additional time that the piece of equipment is not available for use for another patient due to its use during the designated procedure. For those services for which we allocate cleaning time to portable equipment items, because the portable equipment does not need to be cleaned in the room where the service is furnished, we do not include that cleaning time for the remaining equipment items, as those items and the room are both available for use for other patients during that time. In addition, when a piece of equipment is typically used during follow-up post-operative visits included in the global period for a service, the equipment time would also reflect that use.
We believe that certain highly technical pieces of equipment and equipment rooms are less likely to be used during all of the preservice or postservice tasks performed by clinical labor staff on the day of the procedure (the clinical labor service period) and are typically available for other patients even when one member of the clinical staff may be occupied with a preservice or postservice task related to the procedure. We also note that we believe these same assumptions would apply to inexpensive equipment items that are used in conjunction with and located in a room with non-portable highly technical equipment items since any items in the room in question would be available if the room is not being occupied by a particular patient. For additional information, we refer readers to our discussion of these issues in the CY 2012 PFS final rule with comment period (76 FR 73182) and the CY 2015 PFS final rule with comment period (79 FR 67639).
In general, the preservice, intraservice, and postservice clinical labor minutes associated with clinical labor inputs in the direct PE input database reflect the sum of particular tasks described in the information that accompanies the RUC-recommended direct PE inputs, commonly called the “PE worksheets.” For most of these described tasks, there are a standardized number of minutes, depending on the type of procedure, its typical setting, its global period, and the other procedures with which it is typically reported. The RUC sometimes recommends a number of minutes either greater than or less
In general, clinical labor tasks fall into one of the categories on the PE worksheets. In cases where tasks cannot be attributed to an existing category, the tasks are labeled “other clinical activity.” We believe that continual addition of new and distinct clinical labor tasks each time a code is reviewed under the misvalued code initiative is likely to degrade relativity between newly reviewed services and those with already existing inputs. This is because codes more recently reviewed would be more likely to have a greater number of clinical labor tasks as a result of the general tendency to increase the number of clinical labor tasks. To mitigate the potential negative impact of these additions, we review these tasks to determine whether they are fully distinct from existing clinical labor tasks, typically included for other clinically similar services under the PFS, and thoroughly explained in the recommendation. For those tasks that do not meet these criteria, we do not accept these newly recommended clinical labor tasks.
In some cases, the PE worksheets included with the RUC recommendations include items that are not clinical labor, disposable supplies, or medical equipment or that cannot be allocated to individual services or patients. We have addressed these kinds of recommendations in previous rulemaking (78 FR 74242), and we do not use items included in these recommendations as direct PE inputs in the calculation of PE RVUs.
The RUC generally recommends the use of supply and equipment items that already exist in the direct PE input database for new, revised, and potentially misvalued codes. Some recommendations, however, include supply or equipment items that are not currently in the direct PE input database. In these cases, the RUC has historically recommended that a new item be created and has facilitated our pricing of that item by working with the specialty societies to provide us copies of sales invoices. For CY 2017, we received invoices for several new supply and equipment items. Tables 30 and 31 detail the invoices received for new and existing items in the direct PE database. As discussed in section II.A. of this final rule, we encourage stakeholders to review the prices associated with these new and existing items to determine whether these prices appear to be accurate. Where prices appear inaccurate, we encourage stakeholders to provide invoices or other information to improve the accuracy of pricing for these items in the direct PE database during the 60-day public comment period for this final rule. We expect that invoices received outside of the public comment period would be submitted by February 10th of the following year for consideration in future rulemaking, similar to our new process for consideration of RUC recommendations.
We remind stakeholders that due to the relativity inherent in the development of RVUs, reductions in existing prices for any items in the direct PE database increase the pool of direct PE RVUs available to all other PFS services. Tables 30 and 31 also include the number of invoices received, as well as the number of nonfacility allowed services for procedures that use these equipment items. We provide the nonfacility allowed services so that stakeholders will note the impact the particular price might have on PE relativity, as well as to identify items that are used frequently, since we believe that stakeholders are more likely to have better pricing information for items used more frequently. A single invoice may not be reflective of typical costs and we encourage stakeholders to provide additional invoices so that we might identify and use accurate prices in the development of PE RVUs.
In some cases, we do not use the price listed on the invoice that accompanies the recommendation because we identify publicly available alternative prices or information that suggests a different price is more accurate. In these cases, we include this in the discussion of these codes. In other cases, we cannot adequately price a newly recommended item due to inadequate information. Sometimes, no supporting information regarding the price of the item has been included in the recommendation. In other cases, the supporting information does not demonstrate that the item has been purchased at the listed price (for example, vendor price quotes instead of paid invoices). In cases where the information provided on the item allows us to identify clinically appropriate proxy items, we might use existing items as proxies for the newly recommended items. In other cases, we have included the item in the direct PE input database without any associated price. Although including the item without an associated price means that the item does not contribute to the calculation of the proposed PE RVU for particular services, it facilitates our ability to incorporate a price once we obtain information and are able to do so.
Generally speaking, our proposed inputs did not include clinical labor minutes assigned to the service period because the cost of clinical labor during the service period for a procedure in the facility setting is not considered a resource cost to the practitioner since Medicare makes separate payment to the facility for these costs. We address proposed code-specific refinements to clinical labor in the individual code sections.
We note that the public use files for the PFS proposed and final rules for each year display both the services subject to the MPPR lists on diagnostic cardiovascular services, diagnostic imaging services, diagnostic ophthalmology services and therapy services and the list of procedures that meet the definition of imaging under section 1848(b)(4)(B) of the Act, and therefore, are subject to the OPPS cap for the upcoming calendar year. The public use files for CY 2017 are available on the CMS Web site under downloads for the CY 2017 PFS final rule at
The final CY 2017 malpractice crosswalk table is displayed in the public use files for the PFS final rule. The public use files for CY 2017 are available on the CMS Web site under downloads for the CY 2017 PFS final rule at
CPT codes 00740 and 00810 are used to report anesthesia furnished in conjunction with lower gastrointestinal (GI) procedures. In the CY 2016 PFS proposed rule (80 FR 41686), we discussed that in reviewing Medicare claims data, a separate anesthesia service is typically reported more than 50 percent of the time that various colonoscopy procedures are reported. We discussed that given the significant change in the relative frequency with which anesthesia codes are reported with colonoscopy services, we believed the relative values of the anesthesia services should be reexamined. We proposed to identify CPT codes 00740 and 00810 as potentially misvalued and sought public comment regarding valuation for these services.
The RUC recommended maintaining the base unit value of 5 as an interim base value for both CPT code 00740 and 00810 on an interim basis, due to their concerns about the specialty societies' surveys. The RUC suggested that the typical patient vignettes used in the surveys for both CPT codes 00740 and 00810 were not representative of current typical practice and recommended that the codes be resurveyed with updated vignettes. We stated in the CY 2017 proposed rule that we believed it premature to propose any changes to the valuation of CPT codes 00740 and 00810, continued to believe that these services are potentially misvalued, and sought additional input from stakeholders for consideration during future rulemaking.
One commenter stated that CMS' perception that these codes are misvalued is related to the distinction between screening, diagnostic, and therapeutic endoscopies. The commenter further stated that there are no differences in the clinical risk and anesthesia preparation regardless of the indication for these procedures and suggested that the current base unit value of 5 units for CPT codes 00740 and 00810 is appropriate and should be maintained. Another commenter stated that the frequency of use of separate anesthesia services concurrent with colonoscopy procedures is not due to any potential misvaluation, but rather due to changes in Medicare coverage and payment policies that encourage Medicare beneficiaries to undergo screening colonoscopies.
In the CY 2016 PFS final rule with comment period, we established the RUC-recommended work value as interim final for CPT codes 10035 and 10036. We also made standard refinements to remove duplicative clinical labor and utilize standard equipment time formulas for the PACS workstation proxy (ED050).
In the CY 2017 proposed rule, we proposed to maintain our previous refinement to 0 minutes for this clinical labor task for CPT codes 10035 and 10036. We also proposed to maintain the interim final work RVUs for CPT codes 10035 and 10036.
We did not receive any comments in response to our proposed valuation on CPT codes 10035 and 10036 and we are finalizing the clinical labor task and work RVUs as proposed.
We identified CPT code 11730 through a screen of high expenditures by specialty. The HCPAC recommended a work RVU of 1.10. We believed the recommendation for this service overestimates the work involved in performing this procedure, specifically given the decrease in physician intraservice and total time concurrently recommended by the HCPAC. We believed that a work RVU of 1.05, which corresponds to the 25th percentile of the survey results, more accurately represents the time and intensity of furnishing the service. To further support the validity of the use of the 25th percentile of the survey, we identified two crosswalk codes, CPT code 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa), with a work RVU of 1.00, and CPT code 50389 (Removal of nephrostomy tube, requiring fluoroscopic guidance), with a work RVU of 1.10, both of which have identical intraservice times, similar total times and similar intensity. We noted that our proposed work RVU of 1.05 for CPT code 11730 falls halfway between the work RVUs for these two crosswalk codes. CPT code 11730 may be reported with add-on CPT code 11732 to report performance of the same procedure for each additional nail plate procedure.
Since CPT code 11732 was not reviewed by the HCPAC for CY 2017, we proposed a new work value to maintain the consistency of this add-on code with the base code, CPT code 11730. We proposed to remove 2 minutes from the physician intraservice time to maintain consistency with the HCPAC-recommended reduction of 2 minutes from the physician intraservice time period for the base code. We are using a crosswalk from the value for CPT code 77001 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)), which has similar physician intraservice and total time values; therefore, we proposed a
We proposed to use the HCPAC-recommended direct PE inputs for CPT code 11730. We proposed to apply some of the HCPAC-recommended refinements for CPT code 11730 to CPT code 11732, including the removal of the penrose drain (0.25 in × 4 in), lidocaine 1%-2% inj (Xylocaine), applicator (cotton-tipped, sterile) and silver sulfadiazene cream (Silvadene), as well as the reduction of the swab-pad, alcohol from 2 to 1. In addition, we proposed not to include the recommended supply items “needle, 30g, and syringe, 10-12ml” since other similar items are present, and we believe inclusion of these additional supply items would be duplicative. For clinical labor, we proposed to assign 8 minutes to “Assist physician in performing procedure” to maintain a reduction that is proportionate to that recommended for CPT code 11730. For the supply item “ethyl chloride spray,” we believed that the listed input price of $4.40 per ounce overestimates the cost of this supply item, and we solicited comment on the accuracy of this supply item price. Finally, we proposed to add two equipment items as was done in the base code, basic instrument pack and mayo stand, and proposed to adjust the times for all pieces of equipment to eight minutes to reflect the clinical service period time.
In CY 2014, CPT code 20245 was identified by the RUC's 10-Day Global Post-Operative Visits Screen.
For CY 2017, the RUC recommended a work RVU of 6.50 for CPT code 20245, including a change in global period from 10 to 0 days. We disagreed with this value given the significant reductions in the intraservice time, total time, and the change in the office visits assuming the change in global period. The intraservice and total times were decreased by approximately 33 and 53 percent respectively; while the elimination of three post-operative visits (one CPT code 99214 and two CPT code 99213 visits) alone would reduce the overall work RVU by at least 38 percent under the reverse building block methodology. We also note that the RUC-recommended work RVU of 6.50 only represents a 27 percent reduction relative to the previous work RVU of 8.95. To develop a work RVU for this service, we used a crosswalk from CPT code 19298 (Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance), since we believe the codes share similar intensity and total time and the same intraservice time of 60 minutes. Therefore, for CY 2017, we proposed a work RVU of 6.00 for CPT code 20245.
The RUC also noted the current time of CPT code 20245 was based on a survey of 35 individuals more than 15 years ago and due to the previous flawed survey, the resulting IWPUT was almost zero. Given these discrepancies, the surveyed time of 60 minutes better reflects an appropriate level of intensity and complexity (IWPUT= 0.071) for this service relative to other 0-day global procedures.
Another commenter stated concern that the values proposed by CMS have been arrived at using methodologies that are not consistent with the RUC-recommended values, and therefore, are not appropriately relative to other similar services.
Although the total times for CPT codes 19298 and 20245 are not identical, we continue to believe it is a more accurate comparison than the additional codes submitted by the RUC, which have 22-29 minutes less total time.
We note that according to the most recent survey, respondents lowered the work RVU of the 25th percentile, which we typically accept, from 6.06 RVUs to 4.94 RVUs when the code was revalued with a 0-day global period.
For CY 2017, we are finalizing the work RVU of 6.00 for CPT code 20245.
For CY 2016, the CPT Editorial Panel converted two Category III codes to Category I codes describing the insertion of an interlaminar/interspinous process stability device (CPT codes 22867 and 22869) and developed two corresponding add-on codes (CPT codes 22868 and 22870). The RUC recommended a work RVU of 15.00 for CPT code 22867, 4.00 for CPT code 22868, 7.39 for CPT code 22869, and 2.34 for CPT code 22870.
We believe that the RUC recommendations for CPT codes 22867 and 22869 overestimate the work involved in furnishing these services. We believe that a crosswalk to CPT code 36832 (Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)), which has a work RVU of 13.50 is a more accurate comparison. CPT code 36832 is similar in total time, work intensity, and number of visits to CPT code 22867. This crosswalk is supported by the ratio between total time and work in the key reference service, CPT code 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar). Therefore, we proposed a work RVU of 13.50 for CPT code 22867. For CPT code 22869, we believed that CPT code 29881 (Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed) is an appropriate crosswalk based on clinical similarity, as well as intensity and total time. CPT code 29881 has a work RVU of 7.03; therefore, we proposed a work RVU of 7.03 for CPT code 22869. We proposed the RUC-recommended work RVU for CPT codes 22868 and 22870 without refinement.
With regard to CPT code 22869, we disagree that the RUC crosswalk to CPT code 29880 is a closer comparison than CPT code 29881. The intraservice time for the newly created CPT code 22869 (43 minutes) is between that of the RUC recommended crosswalk CPT code 29880 (45 minutes) and the CMS crosswalk CPTcode 29881 (40 minutes). Total time for CPT code 29881, however, is identical to total time for CPT code 22869 (194 minutes), whereas the RUC recommended crosswalk CPT code 29880 has a higher total time (199 minutes). We continue to believe, therefore, that our crosswalk is appropriate and we are finalizing the proposed work RVU of 7.03 for CPT code 22869.
For CY 2016, the CPT Editorial Panel established three new Category I add-on codes and deleted one code to provide a more detailed description of the placement and attachment of biomechanical spinal devices. For CPT code 22853, the RUC recommended a work RVU of 4.88. For CPT codes 22854 and 22859, the RUC-recommended work RVUs are 5.50 and 6.00, respectively.
In reviewing the code descriptors, descriptions of work and vignettes associated with CPT codes 22854 and 22859, we concluded that the two procedures, in addition to having identical work time, contain many clinical similarities and do not have quantifiable differences in overall intensity. Therefore, we proposed the RUC-recommended work RVU of 5.50 for both CPT code 22854 and CPT code 22859. We believe that the RUC-recommended work RVU of 4.88 for CPT code 22853 overestimates the work in the procedure relative to the other codes in the family. We proposed a work RVU of 4.25 for CPT code 22853 based a crosswalk from CPT code 37237 (Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)), which is similar in time and intensity to the work described by CPT code 22853.
In addition to the survey results and RUC recommendations, we reviewed the descriptors of these codes and agree with commenters who found them vague and unclear. We share the concern of stakeholders who indicated that the lack of differentiation in the codes may lead to inconsistent use and reporting.
Given the disagreement between the RUC and survey respondents regarding the order and level of intensity of these services, along with confusion about the code descriptors, we find that valuing the services of 22854 and 22859 differently from each another is difficult to justify. Therefore, we are finalizing our proposed work RVU of 5.50 for CPT code 22859.
In the CY 2016 PFS final rule with comment period, we established an interim final work RVU of 9.56 for CPT code 26356 after considering both its similarity in time to CPT code 25607 (Open treatment of distal radial extra-articular fracture) and the recommended reduction in time relative to the current times assumed for this procedure. We established an interim final work RVU of 10.53 for CPT code 26357 based on a direct crosswalk from CPT code 27654 (Repair, secondary, Achilles tendon, with or without graft), as we believed that this work RVU better reflected the changes in time for this procedure. For the last code in the family, we established an interim final work RVU of 12.13 for CPT code 26358, based on the RUC-recommended increment of 1.60 work RVUs relative to CPT code 26357.
In the CY 2017 proposed rule, we proposed to maintain the current direct PE inputs for all three codes.
The following is a summary of the comments we received regarding our proposed valuation of the Repair Flexor Tendon codes:
After consideration of comments received, we are finalizing our proposed valuation of the Repair Flexor Tendon codes.
For CY 2017, the CPT Editorial Panel deleted CPT codes 27193 and 27194 and replaced them with new CPT codes 27197 and 27198. The RUC recommended a work RVU of 5.50 for CPT code 27193, and a work RVU of 9.00 for CPT code 27198. We proposed to change the global period for these services from 90 days to 0 days because these codes typically represent emergent procedures with which injuries beyond pelvic ring fractures are likely to occur; we believe it is typical that multiple practitioners would be involved in providing post-operative care and it is likely that a practitioner furnishing a different procedure is more likely to be providing the majority of post-operative care. If other practitioners are typically furnishing care in the post-surgery period, we believe that the six post-service visits included in CPT code 27197, and the seven post-service visits included in CPT code 27198, would likely not occur. This is similar to our CY 2016 review and valuation of CPT codes 21811 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs), 21812 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs), and 21813 (Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs). In our valuation of those codes, we determined that a 0-day, rather than a 90-day global period was preferable, in part because those codes describe rib fractures that would typically occur along with other injuries, and the patient would likely already be receiving post-operative care because of the other injuries. We believe that the same rationale applies here. To establish a work RVU for CPT code 27197, we proposed crosswalking this code to CPT code 65800 (Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous), due to its identical intraservice time and similar total time, after removing the work associated with postoperative visits, and its similar level of intensity. Therefore, we proposed a work RVU of 1.53 for CPT code 27197. For CPT code 27198, we proposed crosswalking this code to CPT code 93452 (Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed) which has an identical intraservice time and similar total time, after removing the work associated with post-operative visits from CPT code 27198. We proposed a work RVU of 4.75 for CPT code 27198.
The RUC identified CPT code 28293 as a 90-day global service with more than 6 office visits and CPT codes 28290-28299 as part of the family of services. In October 2015, the CPT Editorial Panel created two new CPT codes (28291, 28295), deleted CPT codes 28290, 28293, and 28294 and revised CPT codes 28289, 28292, 28296,
For CPT codes 28289, 28292, 28296, 28297, 28298, and 28299, the RUC recommended and we proposed work RVUs of 6.90, 7.44, 8.25, 9.29, 7.75, and 9.29 respectively. For CPT code 28291, the RUC recommended a work RVU of 8.01 based on the 25th percentile of the survey. We believed the recommendation for this service overestimates the overall work involved in performing this procedure given the decrease in intraservice time, total time, and post-operative visits when compared to deleted predecessor CPT code 28293. Due to similarity in intraservice and total times, we believed a direct crosswalk of the work RVUs for CPT code 65780 (Ocular surface reconstruction; amniotic membrane transplantation, multiple layers) to CPT code 28291 more accurately reflects the time and intensity of furnishing the service. Therefore, for CY 2017, we proposed a work RVU of 7.81 for CPT code 28291.
For CPT code 28295, the RUC recommended a work RVU of 8.57 based on the 25th percentile of the survey. We believed the recommendation for this service overestimates the work involved in performing this procedure given the similarity in the intensity of the services and identical intraservice and total times as CPT code 28296. Therefore, we proposed a direct RVU crosswalk from CPT code 28296 to CPT code 28295. For CY 2017, we proposed a work RVU of 8.25 for CPT code 28295.
The RUC acknowledged that the deleted CPT code 28293 had 30 minutes more intra-service time and a higher work RVU of 11.48 compared to the recommended work RVU of 8.01 for CPT code 28291. However, the RUC stated the differences in the physician work, time, intensity and the actual new service as described in CPT code 28291 were appropriately accounted for in its recommendation.
The RUC also stated disagreement with the proposed crosswalk of work RVUs from CPT code 28291 to CPT code 65780. The RUC stated it compared the family and relative ranking and believed CPT code 28291 was more complex and intense than CPT code 28298. The relative difference in work and complexity was reviewed and correctly ranked by the survey respondents at the 25th percentile, which corresponds with the RUC-recommended value.
One commenter stated that CPT code 28293 was deleted and a new CPT code was established because the two procedures were no longer synonymous. Also, the slight decrease in the intraoperative intensity with the new value is barely measurable, and therefore, the commenter does not agree with CMS that a work RVU of 7.81 is a more accurate valuation.
One commenter stated that CPT code 28295 is more intense than CPT code 28296 because CPT code 28295 requires separate areas of dissection. With CPT code 28296, the osteotomy and soft tissue procedure are performed at the same anatomic location. The commenter stated this nuance in complexity is the rationale for separate codes and is similar to the rationale for separate cervical versus lumbar spine codes or artery versus vein codes for vascular work.
In the CY 2016 PFS final rule with comment period (80 FR 70914), we identified CPT code 31500 as potentially misvalued. The specialty societies surveyed this code, and after reviewing the survey responses (which included increases in time) the RUC recommended a work RVU of 3.00 for CPT code 31500. After reviewing the RUC's recommendation, we proposed a work RVU of 2.66, based on a direct crosswalk to CPT code 65855 (Trabeculoplasty by laser surgery), which has similar intensity and service times.
After we identified CPT codes 31575 and 31579 as potentially misvalued (80 FR 70912-70914), the RUC referred the entire flexible laryngoscopy family of codes back to the CPT Editorial Panel for revision and the addition of several codes representing new technology within this family of services. At the May 2015 CPT meeting, the CPT Editorial Panel added three new codes to describe laryngoscopy with ablation or destruction of lesion and therapeutic injection. Based on the survey results, the time resources involved in furnishing the procedures described by this code family experienced a significant reduction in the intraservice period, yet the recommended work RVUs were not similarly reduced. Therefore, in reviewing the recommended values for this family of codes we looked for a rationale for increased intensity and absent such rationale, proposed to adjust the recommend work RVUs to account for significant changes in time.
For CPT code 31575, we disagreed with the RUC-recommended work RVU of 1.00, and we instead proposed a work RVU of 0.94. We looked at the total time ratio for CPT code 31575, which is decreasing from 28 minutes to 24 minutes, and applied this ratio of 0.86 times the current work RVU of 1.10 to derive our proposed work RVU of 0.94. We supported this value for CPT code 31575 through a crosswalk to CPT code 64405 (Injection, anesthetic agent; greater occipital nerve), which shares 5 minutes of intraservice time and also has a work RVU of 0.94.
We agreed with the RUC that CPT code 31575 serves as the base code for the rest of the Flexible Laryngoscopy family. As a result, we proposed to
Regarding the direct PE inputs, we proposed to use refined clinical labor time for “Obtain vital signs” for CPT codes 31577 and 31579 from 3 minutes to 2 minutes. We believe that this extra clinical labor time is duplicative, as these codes are typically performed with a same day E/M service. Each procedure is only allotted a maximum of 5 minutes for obtaining vital signs, and since 3 minutes are already included in the E/M code, we proposed to reduce the time to 2 minutes for these services. Similarly, we proposed to remove the 3 minutes of clinical labor time for “Clean room/equipment by physician staff” from CPT codes 31575, 31577, and 31579. These procedures are typically reported with a same day E/M service, making the clinical labor minutes for cleaning the room in these procedure codes duplicative of the time already included in the E/M codes.
For CPT code 31572, we proposed to remove the “laser tip, diffuser fiber” supply (SF030) and replace it with the “laser tip, bare (single use)” supply (SF029) already present in our direct PE database. We believe that the invoice for SF030 submitted with the RUC recommendation is not current enough to establish a new price for this supply; as a result, we substituted the SF029 supply for this input. We welcomed the submission of new invoices to accurately price the diffuser fiber with laser tip.
We also proposed to make significant changes to the prices of several of the supplies and equipment related to Flexible Laryngoscopy, as well as to the prices of scopes more broadly. We proposed to set the price of the disposable biopsy forceps supply (SD318) at $26.84, based on the submission of an invoice with a price of $536.81 for a unit size of 20. In our search for additional information regarding scope inputs, we obtained a quote from a vendor listing the current price for several equipment items related to the use of scopes. Since we believe that the prices in vendor quotes would typically be equal to or higher than prices actually paid by practitioners, we are updating the prices in our direct PE database to reflect this new information. As part of this process, we proposed to increase the price of the “light source, xenon” (EQ167) from $6,723.33 to $7,000 to reflect current pricing information. We also proposed to adjust the price of the “fiberscope, flexible, rhinolaryngoscopy” (ES020) from $6,301.93 to $4,250.00.
In accordance with the wider proposal that we made involving the use of scope equipment, we proposed to separate the scopes used in these procedures from the scope video systems. In the course of researching different kinds of scopes, we obtained vendor pricing for two different types of scopes used in these procedures. We proposed to price the “rhinolaryngoscope, flexible, video, non-channeled” (ES063) at $8,000 and the “rhinolaryngoscope, flexible, video, channeled” (ES064) at $9,000 in accordance with our vendor quotes. We proposed to use the non-channeled scope for CPT codes 31575, 31579, and 31574 and the channeled scope for CPT codes 31576, 31577, 31578, 31572, and 31573 in accordance with the RUC-recommended video systems that stipulated channeled versus non-channeled scope procedures.
We believe that the “Video-flexible laryngoscope system” listed in the recommendations is not a new form of equipment, but rather constitutes a version of the existing “video system, endoscopy” equipment (ES031). We did not add a new equipment item to our direct PE database; instead, we proposed to use the submitted invoices to update the price of the ES031 endoscopy video system. As the equipment code for ES031 indicates, we proposed to define the endoscopy video system as containing a processor, digital capture, monitor, printer, and cart. We proposed to price ES031 at $15,045.00; this reflected a price of $2,000.00 for the monitor, $9,000.00 for the processor, $1,750.00 for the cart, and $2,295.00 for the printer. These prices were obtained from our vendor invoice, with the exception of the printer, which is a crosswalk to the “video printer, color (Sony medical grade)” equipment (ED036).
We did not agree that there is a need for multiple different video systems for this collection of Flexible Laryngoscopy codes based on our understanding of the clinical differences among the codes. In keeping with this understanding, we proposed to use the same existing “video system, endoscopy” equipment (ES031) for the remaining codes in the family that included RUC recommendations for new equipment items named “Video-flexible channeled laryngoscope system” and “Video-flexible laryngoscope stroboscopy system.” For CPT codes 31576, 31577, 31578, 31572, and 31573, we proposed to replace the Video-flexible channeled laryngoscope system with the existing endoscopy video system (ES031) along with a channeled flexible video rhinolaryngoscope (ES064). For CPT code 31579, we proposed to rename the RUC-recommended “Video-flexible laryngoscope stroboscopy system” to the shortened “stroboscopy system” (ES065) and assign it a price of $19,100.00. This reflected the price of the StrobeLED Stroboscopy system included on the submitted invoice. We proposed to treat the stroboscopy system as a scope accessory, which was included along with the “video system, endoscopy” equipment (ES031) and the “rhinolaryngoscope, flexible, video, non-channeled” (ES063) for CPT code 31579. When the price of the scope, the scope video system, and the stroboscopy system were summed together, the total proposed equipment price was $42,145.00.
We proposed to refine the recommended equipment times for several equipment items to conform to changes in clinical labor time. These are: The fiberoptic headlight (EQ170), the suction and pressure cabinet (EQ234), the reclining exam chair with headrest (EF008), and the basic instrument pack (EQ137). We proposed to use the standard equipment time formula for scope accessories for the endoscopy video system (ES031) and the stroboscopy scope accessory system (ES065). We also proposed to refine the equipment time for the channeled and non-channeled flexible video rhinolaryngoscopes to use the standard equipment time formula for scopes. For this latter pair of two new equipment items, this proposal resulted in small increases to their respective equipment times.
The following is a summary of the comments we received regarding our proposed valuation of the Flexible Laryngoscopy codes:
We note as well that there were many comments addressing our proposal to reclassify scope equipment, as well as the proper pricing of the scope equipment utilized in this family of codes. These comments are summarized with responses in the PE section of this final rule (II.A).
After consideration of comments received, we are finalizing the work RVUs of the codes in the Flexible Laryngoscopy family at the proposed values. We are also finalizing the proposed direct PE inputs, with the exception of the refinement to the “Clean room/equipment by physician staff” clinical labor detailed above.
CPT code 31588 (Laryngoplasty, not otherwise specified (
For CPT code 31584, the RUC recommended a work RVU of 20.00. We believed that the 25th percentile of the survey, which is a work RVU of 17.58, better represents the time and intensity involved with furnishing this service based on a comparison with and assessment of the overall intensity of other codes with similar instraservice and total time. This value is also supported by a crosswalk code of CPT code 42844 (Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (
We reviewed the two additional codes that commenters recommended as comparisons. We note that CPT code 43280 (work RVU of 18.1) was most recently valued in 1997 and that for low-volume code CPT code 37660, physician intensity is considerably higher than that for CPT code 31584, suggesting a poor reference for comparing the work involved in furnishing the service. For these reasons, we do not believe this code is an appropriate comparison for CPT code 31584 and we are finalizing our work RVU of 17.58 for CPT code 31584.
For CPT code 31591, the RUC recommended a work RVU of 15.60. We believed that the 25th percentile of the survey, which is a work RVU of 13.56, better represents the time and intensity involved with furnishing this service based on a comparison of the overall intensity of other codes with similar instraservice and total time. The 25th percentile of the survey is additionally bracketed by two crosswalk codes that we estimate have slightly lower and slighter higher overall intensities, CPT code 36819 (Arteriovenous anastomosis, open; by upper arm basilic vein transposition), which has a work RVU of 13.29, and CPT code 49654 (Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible), which has a work RVU of 13.76; both of these codes have identical intraservice time and similar total time. Therefore, we proposed a work RVU of 13.56 for CPT code 31591.
Additionally, the RUC forwarded invoices provided by a medical specialty society for the video-flexible laryngoscope system used in these services. We discussed our proposed changes to the items included in equipment item ES031 (video system, endoscopy) in the CY 2017 proposed rule (81 FR 46247). Consistent with those proposed changes, we proposed to add a Nasolaryngoscope, non-channeled, to the list of equipment items used for CPT codes 31580, 31584, 31587, 31551-31554, 31591, and 31592, along with the modified equipment item ES031.
The CPT Editorial Panel deleted category III CPT code 0281T (Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation) and created new CPT code 33340 to describe percutaneous transcatheter closure of the left atrial appendage with implant. The RUC recommended a work RVU of 14.00. We proposed a work RVU of 13.00 for CPT code 33340, which is the minimum survey result. Based on our clinical judgment and that the key reference codes discussed in the RUC recommendations have higher intraservice and total service times than the median survey results for CPT code 33340, we stated in the CY 2017 proposed rule that we believe a work RVU of 13.00 would more accurately represent the work value for this service.
The CPT Editorial Panel created new codes to describe valvuloplasty procedures and deleted existing CPT code 33400 (Valvuloplasty, aortic valve; open, with cardiopulmonary bypass). New CPT code 33390 represents a simple valvuloplasty procedure and new CPT code 33391 describes a more complex valvuloplasty procedure. We proposed to use the RUC-recommended values for CPT code 33390. For CPT code 33391, the RUC recommended a work RVU of 44.00, the 25th percentile survey result. The RUC estimated that approximately 70 percent of the services previously reported using CPT code 33400 would be reported using CPT code 33391, with 30 percent reported using new CPT code 33390. Therefore, the typical service previously reported with CPT code 33400 ought to now be reported with CPT code 33391. Compared to deleted CPT code 33400, the survey results for CPT code 33391 showed similar median intraservice times and decreased total times. Therefore, we proposed a work RVU of 41.50 for CPT code 33391, which is the current value of CPT code 33400. Given that the typical service should remain consistent between the two codes, we stated that we believe the work RVUs should remain consistent as well.
At the October 2015 CPT meeting, the CPT Editorial Panel established two Category I codes for reporting venous mechanochemical ablation, CPT codes 36473 and 36474. We proposed the RUC-recommended work RVU of 3.50 for CPT code 36473. For CPT code 36474, we proposed a work RVU of 1.75 and stated that we believed the RUC-recommended work RVU of 2.25 does not accurately reflect the typical work involved in furnishing this procedure. The specialty society survey showed that this add-on code has half the work of the base code (CPT code 36473). This value is supported by the ratio between work and time in the key reference service (CPT code 36476: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)).
The RUC-recommended direct PE inputs for CPT codes 36473 and 36474 included inputs for an ultrasound room (EL015). Based on the clinical nature of these procedures, we stated in our proposal that we do not believe that an ultrasound room would typically be used to furnish these procedures. We proposed to remove inputs for the ultrasound room and subsequently include a portable ultrasound (EQ250), power table (EF031), and light (EF014). The RUC also recommended that the ultrasound machine be allocated clinical staff time based on the PACS workstation formula. We stated that we did not believe that an ultrasound machine would be used like a PACS workstation, as images are generated and reviewed in real time. Therefore, we proposed to remove all direct PE inputs associated with the PACS workstation.
In January 2015, a CPT/RUC workgroup identified the following CPT codes as being frequently reported together in various combinations: 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel), 35476 (Transluminal balloon angioplasty, percutaneous; venous), 36147 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report), 36148 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention), 37236 (Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery), 37238 (Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein), 75791 (Angiography, arteriovenous shunt (
For CPT code 36901, we proposed a work RVU of 2.82 instead of the RUC-recommended work RVU of 3.36. When we compared CPT code 36901 against other codes in the RUC database, we found that the RUC-recommended work RVU of 3.36 would be the highest value in the database among the 32 0-day global codes with 25 minutes of intraservice time. Generally speaking, we are particularly skeptical of RUC-recommended values for newly “bundled” codes that appear not to recognize the full resource overlap between predecessor codes. Since the recommended values would establish a new highest value when compared to other services with similar time, we believed it likely that the recommended value for the new code does not reflect the efficiencies in time. Of course, were there compelling evidence for this valuation accompanying the recommendation, we would consider such information. We also noted that the reference code selected by the survey participants, CPT code 36200 (Introduction of catheter, aorta), has a higher intraservice time and total time, but a lower work RVU of 3.02 We believe that there are more accurate CPT codes that can serve as a reference for CPT code 36901. As a result, we proposed to crosswalk CPT code 36901 to CPT code 44388 (Colonoscopy through stoma; diagnostic). CPT code 44388 has a work RVU of 2.82, and we believe it is a more accurate crosswalk for valuation due to its similar overall intensity and shared intraservice time of 25 minutes with 36901 and similar total time of 65 minutes.
We proposed a work RVU of 4.24 for CPT code 36902 instead of the RUC-recommended work RVU of 4.83. The RUC-recommended work RVU is based upon a direct crosswalk to CPT code 43253 (Esophagogastroduodenoscopy, flexible, transoral), which shares the same 40 minutes of intraservice time with CPT code 36902. However, CPT code 43253 has significantly longer total time than CPT code 36902, 104 minutes against 86 minutes, which we believe reduces its utility for comparison. We instead proposed to crosswalk the work RVU for CPT code 36902 from CPT code 44408 (Colonoscopy through stoma), which has a work RVU of 4.24. In addition to our assessment that the two codes share similar intensities, CPT code 44408 also shares 40 minutes of intraservice time with CPT code 36902 but has only 95 minutes of total time and matches the duration of the procedure under review more closely than the RUC-recommended crosswalk to CPT code 43253. We also note that the RUC-recommended work increment between CPT codes 36901 and 36902 was 1.47, and by proposing a work RVU of 4.24 for CPT code 36902, we would maintain a very similar increment of 1.42. As a result, we proposed a work RVU of 4.24 for CPT code 36902, based on this direct crosswalk to CPT code 44408. For CPT code 36903, we proposed a work RVU of 5.85 instead of the RUC-recommended work RVU of 6.39. The RUC-recommended value is based on a direct crosswalk to CPT code 52282 (Cystourethroscopy, with insertion of permanent urethral stent). Like the previous pair of RUC-recommended crosswalk codes, CPT code 52282 shares the same intraservice time of 50 minutes with CPT code 36903, but has substantially longer total time (120 minutes against 96 minutes) which we believe limits its utility as a crosswalk. We proposed a work RVU of 5.85 based on maintaining the RUC-recommended work RVU increment of 3.03 as compared to CPT code 36901 (proposed at a work RVU of 2.82), the base code for this family of related procedures. We also point to CPT code 44403 (Colonoscopy through stoma; with endoscopic mucosal resection) as a reference point for this value. CPT code
We proposed a work RVU of 6.73 instead of the RUC-recommended work RVU of 7.50 for CPT code 36904. Our proposed value comes from a direct crosswalk from CPT code 43264 (Endoscopic retrograde cholangiopancreatography), which shares the same intraservice time of 60 minutes with CPT code 36904 and has a higher total time. We also looked to the intraservice time ratio between CPT codes 36901 and 36904; this works out to 60 minutes divided by 25 minutes, for a ratio of 2.4, and a suggested work RVU of 6.77 (derived from 2.4 times CPT code 36901's work RVU of 2.82). This indicates that our proposed work RVU of 6.73 maintains relativity within the Dialysis Circuit family. As a result, we proposed a work RVU of 6.73 for CPT code 36904, based on a direct crosswalk to CPT code 43264.
We proposed a work RVU of 8.46 instead of the RUC-recommended work RVU of 9.00 for CPT code 36905. We looked at the intraservice time ratio between CPT codes 36901 and 36905 as one potential method for valuation, which is a 1:3 ratio (25 minutes against 75 minutes) for this case. This means that one potential value for CPT code 36905 would be triple the work RVU of CPT code 36901, or 2.82 times 3, which results in a work RVU of 8.46. We also investigated preserving the RUC-recommended work RVU increment between CPT code 36901 and 36905, which was an increase of 5.64. When this increment is added to the work RVU of 2.82 for CPT code 36901, it also resulted in a work RVU of 8.46 for CPT code 36905. Therefore, we proposed a work RVU of 8.46 for CPT code 36905, based on both the intraservice time ratio with CPT code 36901 and the RUC-recommended work increment with the same code.
For CPT code 36906, we proposed a work RVU of 9.88 instead of the RUC-recommended work RVU of 10.42. We based the proposed value upon the RUC-recommended work RVU increment between CPT codes 36901 and 36906, which is 7.06. When added to the work RVU of 2.82 for CPT code 36901, the work RVU for CPT code 36906 would be 9.88. We are supporting this value through the use of two crosswalks that both share the same 90 minutes of intraservice time with 36906. These are CPT code 31546 (Laryngoscopy, direct, with submucosal removal of non-neoplastic lesion(s) of vocal cord) at a work RVU of 9.73 and CPT code 61623 (Endovascular temporary balloon arterial occlusion, head or neck) at a work RVU of 9.95.
The final three codes in the Dialysis Circuit family are all add-on codes, which make comparisons difficult to the global 0-day codes that make up the rest of the family. We proposed a work RVU of 2.48 instead of the RUC-recommended work RVU of 3.00 for CPT code 36907. Due to the difficulty of comparing CPT code 36907 with the non-add-on codes in the rest of the Dialysis Circuit family, we looked instead to compare the value to the add-on codes in the Open and Percutaneous Transluminal Angioplasty family of codes (CPT codes 37246-37249). As we stated previously, both of these groups of new codes are being constructed from the same set of frequently reported together codes. We reviewed these two families of codes together to maintain relativity across the two families, and so that we could compare codes that shared the same global period.
We proposed the RUC-recommended work RVUs for all four codes in the Open and Percutaneous Transluminal Angioplasty family of codes. As a result, we compared CPT code 36907 with the RUC-recommended work RVU of 2.97 for CPT code 37249, which is also an add-on code. These procedures should be clinically very similar, since both of them are performing percutaneous transluminal angioplasty on a central vein, and both of them are add-on procedures. We looked at the intraservice time ratio between these two codes, which was a comparison between 25 minutes for CPT code 36907 against 30 minutes for CPT code 37249. This produces a ratio of 0.83, and a proposed work RVU of 2.48 for CPT code 36907 when multiplied with the RUC-recommended work RVU of 2.97 for CPT code 37249. We noted as well that the intensity was markedly higher for CPT code 36907 as compared to CPT code 37249 when using the RUC-recommended work values, which did not make sense since CPT code 36907 would typically be a clinically less intense procedure. Using the intraservice time ratio results in the two codes having exactly the same intensity. As a result, we therefore proposed a work RVU of 2.48 for CPT code 36907, based on this intraservice time ratio with the RUC-recommended work RVU of CPT code 37249.
For CPT code 36908, we disagree with the RUC-recommended work RVU of 4.25, and we instead proposed a work RVU of 3.73. We did not consider the RUC work value of 4.25 to be accurate for CPT code 36908, as this was higher than our proposed work value for CPT code 36902 (4.24), and we did not believe that an add-on code should typically have a higher work value than a similar non-add-on code with the same intraservice time. We identified two appropriate crosswalks for valuing CPT code 36908: CPT code 93462 (Left heart catheterization by transseptal puncture through intact septum or by transapical puncture) and CPT code 37222 (Revascularization, endovascular, open or percutaneous, iliac artery). Both of these codes share the same intraservice time as CPT code 36908, and both of them also have the same work RVU of 3.73, which results in these codes also sharing the same intensity since they are all add-on codes. We therefore proposed a work value of 3.73 for CPT code 36908, based on a direct crosswalk to CPT codes 93462 and 37222.
Finally, we proposed a work RVU of 3.48 for CPT code 36909 instead of the RUC-recommended work RVU of 4.12. The RUC-recommended value comes from a direct crosswalk from CPT code 38746 (Thoracic lymphadenectomy by thoracotomy). We compared the RUC-recommended work RVU for this procedure to other add-on codes with 30 minutes of intraservice time and found that the recommended work RVU of 4.12 would overestimate the overall intensity of this service relative to those with similar times. In reviewing the range of these codes, we believed that a more appropriate crosswalk is to CPT code 61797 (Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator)) at a work RVU of 3.48. We believed that this value is more accurate when compared to other add-on procedures with 30 minutes of intraservice time across the PFS. As a result, we proposed a work RVU of 3.48 for CPT code 36909 based on a direct crosswalk from CPT code 61797.
We proposed to use the RUC-recommended direct PE inputs for these nine codes with several refinements. We did not propose to include the recommended additional preservice clinical labor for CPT codes 36904, 36905, and 36906. The preservice work description is identical for all six of the global 0-day codes in this family; there is no justification given in the RUC recommendations as to why the second three codes need additional clinical labor time beyond the minimal preservice clinical labor assigned to the
We proposed to refine the L037D clinical labor for “Prepare and position patient/monitor patient/set up IV” from 5 minutes to 3 minutes for CPT codes 36901-36906. The RUC recommendation included a written justification for additional clinical labor time beyond the standard 2 minutes for this activity, stating that the extra time is needed to prepare the patient's arm for the procedure. We agreed that extra time may be needed for this activity as compared to the default standard of 2 minutes; however, we proposed to assign 1 extra minute for preparing the patient's arm, resulting in a total of 3 minutes for this task. We did not believe that 3 extra minutes would be typically needed for arm positioning.
We proposed to remove the “kit, for percutaneous thrombolytic device (Trerotola)” supply (SA015) from CPT codes 36904, 36905, and 36906. We believed that this thrombolytic device kit and the “catheter, thrombectomy-Fogarty” (SD032) provide essentially the same supply, and the use of only one of them would be typical in these procedures. We believed that each of these supplies can be used individually for thrombectomy procedures. We proposed to remove the SA015 supply and retain the SD032 supply, and we solicited additional comment and information regarding the use of these two supplies.
We also proposed to remove the recommended supply item “covered stent (VIABAHN, Gore)” (SD254) and replace it with the “stent, vascular, deployment system, Cordis SMART” (SA103) for CPT codes 36903 and 36906. The Cordis SMART vascular stent was previously used in the past for CPT code 37238, which is the deleted code for transcatheter placement of an intravascular stent that CPT codes 36903 and 36906 are replacing. We did not have a stated rationale as to the need for this supply substitution, and therefore, we did not believe it would be appropriate to replace the current items with a significantly higher-priced item without additional information.
We also proposed to refine the quantity of the “Hemostatic patch” (SG095) from 2 to 1 for CPT codes 36904, 36905, and 36906. This supply was not included in any of the deleted base codes out of which the new codes are being constructed, and while we agreed that the use of a single hemostatic patch has become common clinical practice, we did not agree that CPT codes 36904-36906 would typically require a second patch. As a result, we proposed to refine the SG095 supply quantity from 2 to 1 for CPT codes 36904-36906, which also matches the supply quantity for CPT codes 36901-36903.
Included in the RUC recommendation for the Dialysis Circuit family of codes were a series of invoices for a “ChloraPrep applicator (26 ml)” supply. We solicited comments regarding whether the Betadine solution has been replaced by a Chloraprep solution in the typical case for these procedures. We also solicited comments regarding whether the “ChloraPrep applicator (26 ml)” detailed on the submitted invoices is the same supply as the SH098 “chlorhexidine 4.0% (Hibiclens)” applicator currently in the direct PE database.
Finally, we also solicited comments about the use of guidewires for these procedures. We requested feedback about which guidewires would be typically used for these procedures, and which guidewires are no longer clinically necessary.
The following is a summary of the comments we received regarding our proposed valuation of the Dialysis Circuit codes. Due to the large number of comments we received for this code family, we will first summarize the comments related to general code valuation, followed by the comments related to specific work RVUs, and finally the comments related to direct PE inputs.
We note that a change in overall RVUs for particular services, regardless of the magnitude of the change, may reflect improved accuracy. For example, comparing the summed total RVU of CPT codes 36147, 36148, 36870, and 37238 against the total RVU of CPT code 36906 is an accurate method to describe the services taking place under the coding schema effective for 2016 and 2017, respectively. Through the bundling of these frequently reported services, it is reasonable to expect that the new coding system will achieve savings via elimination of duplicative assumption of the resources involved in furnishing particular servicers. For example, a practitioner would not be carrying out the full preservice work four separate times for CPT codes 36147, 36148, 36870, and 37238, but preservice times were assigned to each of the codes under the old coding. We believe the new coding assigns a more accurate preservice time and thus reflects efficiencies in resource costs that existed regardless of how the services were previously reported.
We are also seeking information on how to reconcile situations where we have multiple sets of recommendations from the RUC and from other PFS stakeholders, both for this specific case and for the situation more broadly, given the need to maintain relativity among PFS services.
The following comments address the proposed work valuation of individual codes in the family.
The following comments address the proposed direct PE inputs for the Dialysis Circuit family of codes.
After consideration of comments received, we are finalizing the work RVUs for the Dialysis Circuit codes as proposed. We are also finalizing the proposed direct PE inputs, with the refinements detailed above.
In January 2015, a CPT/RUC workgroup identified the following CPT codes as being frequently reported together in various combinations: 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or
At the October 2015 CPT Editorial Panel meeting, the panel approved the creation of four new codes and deletion of 13 existing codes used to describe bundled percutaneous transluminal angioplasty services. The Open and Percutaneous Transluminal Angioplasty family of codes overlaps with the Dialysis Circuit family of codes (CPT codes 36901-36909), as they are both being constructed from the same set of frequently reported together codes. We reviewed these two families of codes concurrently to maintain relativity between these clinically similar procedures based upon the same collection of deleted codes. After consideration of these materials, we proposed to accept the RUC-recommended work RVU for CPT codes 37246, 37247, 37248, and 37249.
For the clinical labor direct PE inputs, we proposed to use the RUC-recommend inputs with several refinements. Our proposed inputs refined the recommended clinical labor time for “Prepare and position patient/monitor patient/set up IV” from 5 minutes to 3 minutes for CPT codes 37246 and 37248. The RUC recommendation included a written justification for additional clinical labor time beyond the standard 2 minutes for this activity, stating that the extra time was needed to move leads out of X-ray field, check that X-ray is not obstructed and that there is no risk of collision of X-ray equipment with patient. As we wrote for the same clinical labor activity in the Dialysis Circuit family, we agreed that extra time might be needed for this activity as compared to the default standard of 2 minutes; however, we assigned 1 extra minute for the additional positioning tasks, resulting in a total of 3 minutes for this task. We did not believe that 3 extra minutes would be typically needed for preparation of the X-ray. The equipment times for the angiography room (EL011) and the PACS workstation (ED050) were also refined to reflect this change in clinical labor.
We proposed to remove the “drape, sterile, femoral” supply (SB009) and replace it with a “drape, sterile, fenestrated 16in x 29in” supply (SB011) for CPT codes 37246 and 37248. The two base codes out of which these new codes are being constructed, CPT codes 35471 and 35476, both made use of the SB011 fenestrated sterile drape supply, and there was no rationale provided for the switch to the SB009 femoral sterile drape in the two new codes. We solicited comment on the use of sterile drapes for these procedures, and what rationale there was to support the use of the SB009 femoral sterile drape as typical for these new procedures.
The following is a summary of the comments we received regarding our proposed valuation of the Open and Percutaneous Transluminal Angioplasty codes.
After consideration of comments received, we are finalizing the proposed work RVUs for the four codes in the family. We are also finalizing the proposed direct PE inputs, with the refinement to the sterile femoral drape detailed above.
For CY 2016, the CPT Editorial Panel established CPT code 43210 to describe trans-oral esophagogastric fundoplasty. The RUC recommended a work RVU of 9.00 and for CY 2016, we established an interim final work RVU of 7.75 for CPT code 43210. We noted that a work RVU of 7.75, which corresponds to the 25th
The following is a summary of the comments we received regarding our proposed valuation of CPT code 43210:
In October 2015, the CPT Editorial Panel created two new codes to describe laparoscopic implantation and removal of a magnetic bead sphincter augmentation device used for treatment of gastroesophageal reflux disease (GERD). The RUC noted that the specialty societies conducted a targeted survey of the 145 physicians who have been trained to furnish these services and who are the only physicians who have performed these procedures. They noted that only 18 non-conflicted survey responses were received despite efforts to follow up and that nine physicians had no experience in the past 12 months with the procedure. The RUC agreed with the specialty society that the expertise of those responding was sufficient to consider the survey; however, neither the RUC nor the specialty society used the survey results as the primary basis for their recommended value.
For CPT code 43284, the RUC recommended a work RVU of 10.13. We compared this code to CPT code 43180 (Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (
For CPT code 43285, the RUC recommended a work RVU of 10.47. We used the increment between the RUC-recommended work RVU for this code and CPT code 43284 (0.34 RVUs) to develop our proposed work RVU of 9.37 for CPT code 43285.
For CPT code 43285, commenters noted that although CPT code 47562 (the RUC-recommended crosswalk) requires more intraservice time than the aggregate survey median time for CPT code 43285, the median intraservice time may be understated because of the number of people without experience, and suggested that the total time for CPT codes 43285 and 47562 is nearly identical and both require similar work and intensity. Commenters stated that only 18 non-conflicted survey responses were received despite the efforts of the specialty societies, and that nine physicians had no experience with the procedure in the past 12 months. Commenters also noted that the RUC recommendations used the specialty society survey times, but provided a crosswalk for work RVU valuation.
Many commenters expressed additional concerns about the specialty society survey data, indicating that the survey median and 25th percentile work RVUs were inconsistent with the total physician work for services reported with CPT codes 43284 and 43285. Commenters stated that to accept the results of the survey is to essentially state that the opinions of inexperienced surgeons is adequate to determine the value of a surgical procedure and lacked input from surgeons experienced in performing the procedure. Commenters suggested that CMS maintain carrier pricing for services reported with CPT codes 43284 and 43285 while the specialty societies conduct new surveys that include data from surgeons experienced with the procedures. Some commenters suggested that the work of CPT codes 43284 and/or 43285 is more similar to fundoplication procedures reported with CPT code 43280 (a work RVU of 18.10). Other commenters suggested valuations for these procedures ranging from 14 to 17 work RVUs, stating that the services reported with CPT codes 43284 and 43285 were slightly less complicated than fundoplication procedures, but more complex than the valuations reflected in the survey results, RUC recommendations, and CMS proposed values.
This group of fourteen codes was reviewed by the RUC at the April 2015 meeting. We established interim final values for this group of codes during the CY 2016 PFS rulemaking cycle, and subsequently received updated RUC recommendations from the October 2015 meeting for the CY 2017 PFS rulemaking cycle. Our proposals for these codes incorporated both the updated RUC recommendations, as well as public comments received as part of the interim final status of these procedures.
We received several comments regarding the CMS refinements to the work values for this family of codes in the CY 2016 final rule with comment period. The relevance of many of these comments has been diminished by the new series of RUC recommendations for work values that we received as a result of the October 2015 meeting. Given that we proposed the updated RUC-recommended work RVUs for CPT codes 47531, 47532, 47533, 47534, 47535, 47536, 47537, 47538, 47539, 47540, 47542, 47543, and 47544, we solicited additional comments relative to these proposed values. We agreed that the second round of physician surveys conducted for the October 2015 RUC meeting more accurately captured the work and time required to perform these procedures. The one exception was CPT code 47541; the survey times for this procedure were identical as conducted for the April and October 2015 RUC meetings, yet the RUC recommendation increased from a work RVU of 5.61 in April to a work RVU of 7.00 in October. Given that the time values for the procedure remained unchanged between the two surveys, we do not understand why the work RVU would have increased by nearly 1.50 in the intervening months. Since this code also has an identical intraservice time (60 minutes) and total time (121 minutes) as CPT code 47533, we do not agree that it should be valued at a substantially higher rate compared to a medically similar procedure within the same code family. We therefore proposed to crosswalk the work value of CPT code 47541 to the work value of CPT code 47533, and we proposed a work RVU of 5.63 for both procedures.
We also note that many of the codes in the Percutaneous Biliary Procedures family were previously included in Appendix G, and were valued under the assumption that moderate sedation was typically performed on the patient. As part of the changes for services previously valued with moderate sedation as inherent, we are removing a portion of the work RVU and preservice work time from CPT codes 47532, 47533, 47534, 47535, 47536, 47538, 47539, 47540, and 47541. For example, we proposed a work value for CPT code 47541 with a 0.25 reduction from 5.63 to 5.38, and a 10 minute reduction in its preservice work time from 33 minutes to 23 minutes, to reflect the work that will now be reported separately using the new moderate sedation codes. CPT codes 47542, 47533, and 47544 also were valued with moderate sedation; however, as add-on codes, they are not subject to alterations in their work RVUs or work times since the moderate sedation code with work RVUs and work time (99152) will only be billed once for each base-code and not additionally with the add-on codes. These changes are reflected in Appendix B and the work time file posted to the web; see section II.D for more details.
For the direct PE inputs, we did not propose to include the recommended L051A clinical labor for “Sedate/apply anesthesia” and the L037D for “Assist Physician in Performing Procedure” for CPT codes 47531 and 47537. As we wrote in the CY 2016 final rule with comment period (80 FR 71053), we believe that this clinical labor describes activities associated with moderate sedation, and moderate sedation is not typical for these procedures. We also proposed to refine the L037D clinical labor for “Clean room/equipment by physician staff” from 6 minutes to 3 minutes for all of the codes in this family. Three minutes is the standard for this clinical labor activity, and we continued to maintain that the need for additional clinical labor time for this cleaning activity would not be typical for these procedures.
We also proposed to remove the recommended supply item “stone basket” (SD315) from CPT code 47543 and add it to CPT code 47544. Based on the code descriptors, we believed that the stone basket was intended to be included in CPT code 47544 and was erroneously listed under CPT code 47543. We solicited comments from the public to help clarify this issue.
We noted again that many of the codes in the Percutaneous Biliary Procedures family were previously included in Appendix G, and as part of the change in moderate sedation reporting, we removed some of the recommended direct PE inputs related to moderate sedation from CPT codes 47532, 47533, 47534, 47535, 47536, 47538, 47539, 47540, and 47541. We removed the L051A clinical labor time for “Sedate/apply anesthesia”, “Assist Physician in Performing Procedure (CS)”, and “Monitor pt. following moderate sedation”. We also removed the conscious sedation pack (SA044) supply, and some or all of the equipment time for the stretcher (EF018), the mobile instrument table (EF027), the 3-channel ECG (EQ011), and the IV infusion pump (EQ032). These changes are reflected in the public use files posted to the web; see section II.D for more details.
The following is a summary of the comments we received regarding our proposed valuation of the Percutaneous Biliary Procedures codes.
For the 15 minutes of assist physician time, the commenter did not provide a justification for why an additional staff member would be needed or what the staff member would be doing. CPT codes 47531 and 47537 already contain two clinical staff members, one technician to assist the physician and another technician to acquire images, plus a circulator. The other codes in the Percutaneous Biliary Procedures family previously had a third RN clinical staff member to administer the sedation to the patient, before moderate sedation was split off into its own separate procedure codes. However, CPT codes 47531 and 47537 do not typically require sedation, and we do not agree that this additional clinical staff member would be required to perform the procedures.
After consideration of comments received, we are finalizing our proposed work RVUs for the Percutaneous Biliary Procedures family of codes, with the one change to a work RVU of 6.75 for CPT code 47541. We are finalizing our proposed direct PE inputs without refinement.
For CY 2016, we established an interim final work RVU of 2.35 for CPT code 49185 based on a crosswalk from CPT code 62305 (Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (
Commenters also stated that the procedure reported with CPT code 49185 required a separate clinical labor staff type. The commenter noted that, due to the inclusion of this additional individual, the L037D clinical labor and additional gloves were appropriate to include in the procedure. The commenter did not provide any evidence for this claim.
Therefore, for CY 2017, we proposed a work RVU of 2.35 for CPT code 49185. We sought stakeholder feedback regarding why a different work RVU or crosswalk would more accurately reflect the resources involved in furnishing this service. We also proposed to maintain our direct PE refinements from the CY 2016 PFS final rule with comment period, but proposed to refine the direct practice expense inputs for the sclerosing solution (supply item SH062) from 300 mL to 10 mL, which is the highest level associated with other CPT codes utilizing sclerosing solution.
The following is a summary of the comments we received regarding our proposed valuation of CPT code 49185.
In the CY 2016 PFS final rule with comment period, we established as interim final the RUC-recommended work RVUs for all three codes. We did not receive any comments on the work values for these codes, and we proposed to maintain all three at their current work RVUs.
The RUC recommended the inclusion of “room, angiography” (EL011) for this family of codes. As we discussed in the CY 2016 PFS final rule with comment period, we did not believe that an angiography room would be used in the typical case for these procedures, and we therefore replaced the recommended equipment item “room, angiography” with equipment item “room, radiographic-fluoroscopic” (EL014) for all three codes on an interim final basis. We also stated our belief that since the predecessor procedure codes generally did not include an angiography room and we did not have a reason to believe that the procedure would have shifted to an angiography room in the course of this coding change, we did not believe that the use of an angiography room would be typical for these procedures.
We did not believe that these codes described the same clinical work either. CPT code 50387 is for the “Removal and replacement of externally accessible transnephric ureteral stent” while CPT code 50606 describes an “Endoluminal biopsy of ureter and/or renal pelvis”, CPT code 50705 refers to “Ureteral embolization or occlusion”, and CPT code 50706 details “Balloon dilation, ureteral stricture.” Additionally, the codes do not have the same global periods, which makes comparisons between CPT code 50387 and CPT codes 506060, 50705, and 50706 even more difficult. We noted that while the commenter stated that CPT code 50387 was provided as a reference for these procedures, 50387 is not listed as a reference for any of these three codes, or mentioned at all in the codes' respective summary of recommendations. However, we acknowledged that among the procedures that are provided as references, many of them included the use of an angiography room, such as CPT code 36227 (Selective catheter placement, external carotid artery) and CPT code 37233 (Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel). Therefore, we agreed that the use of the angiography room in these procedures, or at least some of its component parts, might be warranted.
We included all of the above components except the Provis Injector, as commenters indicated that its use would not be typical for these procedures. We welcomed additional comments regarding if these or other components were typically used in these Genitourinary procedures. We lacked pricing information for these components; we therefore proposed to include each of these components in the direct PE input database at a price of $0.00 and we solicited invoices from the public for their costs to be able to price these items for use in developing final PE RVUs for CY 2017.
We also noted that we believed that this issue illustrated a potentially broad problem with our use of equipment “rooms” in the direct PE input database. For most services, we only include equipment items that are used and unavailable for other uses due to their use during the services described by a particular code. However, for items included in equipment “rooms,” we allocate costs regardless of whether the individual items that comprise the room are actually used in the particular service.
To maintain relativity among different kinds of procedures, we were interested in obtaining more information specifying the exact resources used in furnishing services described by different codes. We hoped to address this subject in greater detail in future rulemaking.
The following is a summary of the comments we received regarding our proposed valuation of the Genitourinary codes:
Commenters did not generally agree with the CMS proposal to price all of the components of the angiography room at $0.00 pending invoices from the public regarding their individual cost. Commenters stated that the resource cost of the angiography room components was clearly not $0.00, since the equipment in total costs over $1.3 million. Commenters stated that it was
After consideration of comments received, we are finalizing our work values for the three Genitourinary codes as proposed. We are finalizing the proposed direct PE inputs as well, with the changes to the angiography room as detailed above.
We identified CPT code 51784 as potentially misvalued through a screen of high expenditure services by specialty. This family also includes CPT code 51785 (Needle electromyography studies (EMG) of anal or urethral sphincter, any technique) but was not included in this survey. Both services have 0-day global periods. The RUC recommended a work RVU of 0.75 for CPT code 51784. We believe that this service is more accurately valued without a global period, since that is more consistent with other diagnostic services, and specifically, with all the other diagnostic electromyography services. We proposed to eliminate the global period and proposed the RUC-recommended work RVU of 0.75 for CY 2017. We also proposed to change the global period for CPT code 51785 from 0-day to no global period, to be consistent with the global period for CPT code 51784. Additionally, we proposed to add CPT code 51785 to the list of potentially misvalued codes to update the value of the service considering the change in global period, and to maintain consistency with CPT code 51784.
Another commenter, while supporting our acceptance of the RUC-recommended work RVU for CPT code 51784, did not support adding CPT code 51785 to the potentially misvalued code list as that code was addressed recently when the new CPT codes were created for urodynamic testing procedures.
In the CY 2016 PFS final rule with comment period, CMS identified CPT code 52000 through the screen for high expenditure services. We stated in the CY 2017 proposed rule that the RUC-recommended work RVU of 1.75 for CPT code 52000 is higher than the work RVUs for all 0-day global codes with 10 minutes of intraservice time and we did not believe that the overall intensity of this service was greater than all of the other codes. Instead, we proposed that this code compares favorably to CPT code 58100 (Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)), which has a work RVU of 1.53, and has identical intraservice time and similar total time. Therefore, we proposed a work RVU of 1.53 for CPT code 52000, using a direct crosswalk to CPT code 58100.
In the CY 2016 PFS final rule with comment period, CMS identified CPT code 55700 as potentially misvalued based on the high expenditure by specialty screen.
The RUC subsequently reviewed this code for physician work and practice expense and recommended a work RVU of 2.50 based on the 25th percentile of the survey. We believed the RUC-recommended work RVU overestimates the work involved in furnishing this service given the reduction in total service time; specifically, the reduction in preservice and postservice times. The RUC recommendation also appears overvalued when compared to similar 0-day global services with 15 minutes of intraservice time and comparable total times. To develop a proposed work RVU, we crosswalked the work RVUs
In the CY 2016 PFS final rule with comment period, we established an interim final work RVU of 21.36 for CPT code 55866 based on a direct crosswalk to CPT code 55840 (Prostatectomy, retropubic radical, with or without nerve sparing). We stated that we believed these codes were medically similar procedures with nearly identical time values, and we did not believe that the difference in intensity between CPT code 55840 and CPT code 55866 was significant enough to warrant the RUC-recommended difference of 5.50 work RVUs. We also compared CPT code 55866 to the work RVU of 25.18 for CPT code 55845, and stated our belief that, in general, a laparoscopic procedure would not require greater resources than an open procedure.
The following is a summary of the comments we received regarding our proposed valuation of CPT code 55866:
In this case of the particular comment, we note the potential logical dissonance of the commenter urging us to adopt the RUC-recommended work value derived from the RUC survey by citing alternative data that calls into question the accuracy of the time data from the same RUC survey. In other words, we are troubled with the idea that we should consider survey data as valid for work while rejecting its validity for time, given that time is one of the two elements of overall work.
Despite these concerns, we agree that the study presents additional data indicating that there is a significant difference between the open and robotic-assisted forms of laparoscopic radical prostatectomy, and that the robotic form described by CPT code 55866 likely takes a longer time to perform. Based on this presentation of additional clinical evidence, we agree with the commenters that the recommended work RVU of 26.80 is a more appropriate value for this procedure.
After consideration of comments received, we are finalizing a work RVU of 26.80 for CPT code 55866.
During CY 2016 PFS rulemaking, we identified CPT code 58558 as a potentially misvalued code via the high expenditure specialty screen. CPT codes 58559-58563 were also included in the RUC's January 2016 review of this family of codes.
For CPT code 58555, the RUC recommended a work RVU of 3.07. We proposed that the 25th percentile survey result, a work RVU of 2.65, accurately reflects the resources involved in furnishing this service. We stated that this value is bracketed by two crosswalk codes, CPT code 43191 (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)), which has a work RVU of 2.49, and CPT code 31295 (Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (for example, balloon dilation), transnasal or via canine fossa), which has a work RVU of 2.70. CPT codes 43191 and 31295 have identical intraservice times and similar total times when compared with CPT code 58555.
For CPT code 58558, the RUC recommended a work RVU of 4.37. However, we believed that a direct crosswalk from CPT code 36221 (Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed), which has a work RVU of 4.17, and identical intraservice time, and similar total time, more accurately reflects the time and intensity of furnishing this service. Our proposed work RVU was additionally supported by using an increment between this code and the base code for this family, CPT code 58555. The increment between the RUC-recommended values for these two codes is 1.3. That increment added to the proposed work RVU of 2.65 for the base code, CPT code 58555, results in a work RVU of 3.95. Therefore, we proposed a work RVU of 4.17 RVUs for CPT code 58558.
For CPT code 58559, the RUC recommended a work RVU of 5.54. However, we believed that a direct crosswalk from CPT code 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated), which has a work RVU of 5.20, a similar intraservice
For CPT code 58560, the RUC recommended a work RVU of 6.15. We stated in the proposed rule that we believe that a direct crosswalk from CPT code 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic), which has a work RVU of 5.75 and which has more intraservice time and very similar total time, more accurately reflects the time and intensity of furnishing this service. Our proposal further supported this value by using an increment between CPT code 58560 and the base code for this family, CPT code 58555. We stated that the increment between the RUC recommended values for the two codes is 3.08. That increment added to the proposed value for the base code, CPT code 58555, would result in a work RVU of 5.73. Therefore, we proposed a work RVU of 5.75 for CPT code 58560.
For CPT code 58561, the RUC recommended a work RVU of 7.00. We stated in the proposed rule that we believe that a direct crosswalk from CPT code 35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel), which has a work RVU of 6.60 and which has similar intraservice and total times, more accurately reflected the time and intensity of furnishing this service. We also noted that our proposal was further supported by using an increment between CPT code 58561 and the base code for this family, CPT code 58555. The increment between the RUC recommended values for the two codes is 3.93. That increment added to the proposed value for the base code, CPT code 58555, would result in a work RVU of 6.58. Therefore, we proposed a work RVU of 6.60 for CPT code 58561.
For CPT code 58562, the RUC recommended a work RVU of 4.17. However, we believed that a direct crosswalk of the work RVUs for CPT code 15277 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children), which has a work RVU of 4.00 and which has identical intraservice time and similar total time, more accurately reflects the time and intensity of furnishing this service. The RUC also used this code as one of its supporting codes for its recommendation. This value is additionally supported by using an increment between CPT code 58562 and the base code for this family, CPT code 58555. The increment between the RUC recommended values for the two codes is 1.10. That increment added to the proposed value for the base code, CPT code 58555, results in a work RVU of 3.75. Therefore, we proposed a work RVU of 4.00 for CPT code 58562.
For CPT code 58563, the RUC recommended a work RVU of 4.62. However, we believed that a direct crosswalk of the work RVUs for CPT code 33962 (Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed)), which has a work RVU of 4.47 and that has identical intraservice time and similar total time, more accurately reflects the resources involved in furnishing this service. This value is additionally supported by using an increment between CPT code 58563 and the base code for this family, CPT code 58555. The increment between the RUC recommended values for the two codes is 1.55. That increment added to the proposed value for the base code, CPT code 58555), results in a work RVU of 4.20. We note that CPT code 58563 has the same instraservice time and the same total time as CPT code 58558; however, we agreed that the intensity would be slightly higher for this service. Therefore, we proposed a work RVU of 4.47 for CPT code 58562.
The RUC submitted invoices for two new equipment items used in furnishing CPT code 58558, the hysteroscopic fluid management system and the hysteroscopic resection system. We proposed to use these invoice prices for the hysteroscopic fluid management system, which totaled $14,698.38. The hysteroscopic resection system included the price of the hysteroscope, as well as other items necessary for tissue removal. However, we generally price endoscopes separately and not as a part of a system. To maintain consistency, we proposed not to include the hysteroscope from the Resection System. Instead, we proposed to update the equipment item “endoscope, rigid, hysteroscopy” (ES009) with the invoice price, $6,207.50. We did not propose to include the sterilization tray from the hysteroscopic resection system because we believe this tray has generally been characterized as an indirect practice expense. For the hysteroscopic resection system, we proposed to include the hysteroscopic tissue remover ($18,375), the sheath ($1,097.25), and the calibration device ($300), and created a new equipment item code, priced at $19,857.50 in the proposed direct PE input database. We did not propose to include the calibration device since the submitted price was not documented with a paid invoice.
• CPT code 58555, 2.65 work RVUs;
• CPT code 58558, 4.17 work RVUs;
• CPT code 58559, 5.20 work RVUs;
• CPT code 58560, 5.75 work RVUs;
• CPT code 58561, 6.60 work RVUs;
• CPT code 58562, 4.00 work RVUs; and
• CPT code 58563, 4.47 work RVUs.
• Supply item SD009: Canister, suction;
• Supply item SD031: Catheter, suction; and
• Equipment item EQ235: Suction machine (Gomco).
The commenter also included an additional invoice for the incision instrument. Based on this new information, we are renaming this new supply item, “hysteroscopic tissue removal device,” with a final price of $629.00, which is the simple average of the two invoice prices we have received for this supply item ($599 and $659 respectively). Additionally, we note that our proposed summary price for the hysteroscopic resection system was added incorrectly. The correct price is $19,772.25. We are also modifying the equipment title to ensure clarity of items included in the hysteroscopic resection system (control unit, footpiece, handpiece, sheath and calibration device).
For CY 2016, we established an interim final work RVU of 15.00 for CPT code 61645, 10.00 for CPT code 61650 and 4.25 for CPT code 61651. The RUC-recommended values for CPT codes 61645, 61650 and 61651 were 17.00, 12.00 and 5.50, respectively. We valued CPT code 61645 by applying the ratio between the RUC-recommended reference code, CPT code 37231 (revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed), to the work and time for CPT code 61645. We valued CPT code 61650 based on a crosswalk to CPT code 37221 (revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed), due to similar intensity and intraservice time. We valued CPT code 61651 based on a crosswalk to CPT code 37223 (revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (list separately in addition to the code for primary procedure)), due to similar intraservice time and intensity.
Both CPT codes 61645 and 61650 included postservice work time associated with a level 3 inpatient hospital visit. In the CY 2016 PFS final rule with comment period, we stated that we believe that for the typical patient, these services would be considered hospital outpatient services, not inpatient services. As a result, the intraservice time of the hospital observation care service was valued in the immediate postservice time. We refined the work time for CPT code 61645 by removing 55 minutes of work time associated with CPT code 99233, and added 30 minutes of time to the immediate postservice time. Therefore, the total time for CPT code 61645 was reduced to 241 minutes and the immediate postservice time increased to 83 minutes. We also removed the inpatient visit from CPT code 61650, which reduced the total time to 206 minutes and increased the postservice time to 75 minutes.
We do not believe that 0-day global codes should include post-operative visits; rather, if global codes require post-operative visits, they are more appropriately assigned 10- or 90-day global periods based on our current criteria. Our policy has been to remove the visit from the post-operative period and the associated minutes from the total time while adding 30 minutes to the immediate postservice period without necessarily making an adjustment to the work RVU (see the CY 2010 PFS proposed rule, 74 FR 33557; also see the CY 2011 PFS proposed rule, 75 FR 40072). We solicited comment on the inclusion of post-operative visits in valuation of codes with 0-day global periods. Both CPT codes 61645 and 61650 are assigned 0-day global periods, and the refinements we proposed reflected changes to more appropriately value these codes with 0-day global periods.
The following is a summary of the comments we received regarding our proposed valuations for the intracranial endovascular intervention family:
Regarding physician time for CPT codes 61645 and 61650, as we discussed in the proposed rule, we do not believe that 0-day global codes should include post-operative visits; rather, if global codes require post-operative visits, they are more appropriately assigned 10- or 90-day global periods based on our current criteria. Our policy has been to remove the visit from the post-operative period and the associated minutes from the total time while adding 30 minutes to the immediate postservice period without necessarily making an adjustment to the work RVU (see the CY 2010 PFS proposed rule, 74 FR 33557; also see the CY 2011 PFS proposed rule, 75 FR 40072).
Therefore, for CY 2017, we are finalizing a work RVU of 15.00 for CPT code 61645, a work RVU of 10.00 for CPT code 61650, and a work RVU of 4.25 for CPT code 61651.
We proposed the RUC-recommended work RVU for all eight of the codes in this family.
We proposed to remove the 10-12mL syringes (SC051) and the RK epidural needle (SC038) from all eight of the codes in this family. We stated that these supplies were duplicative, as they are included in the epidural tray (SA064). As an alternative, we raised the possibility of removing the epidural tray and replacing it with the individual supply components used in each procedure; we solicited public comment on either the inclusion of the epidural tray or its individual components for this family of codes.
The following is a summary of the comments we received regarding our proposed valuation of the Epidural Injection codes:
After consideration of comments received, we are finalizing the proposed work RVUs for the Epidural Injection codes. We are also finalizing the proposed direct PE inputs, with the addition of the 10-12mL syringes and the RK epidural needle detailed above.
For CY 2016, the CPT Editorial Panel created CPT code 62380 to describe the endoscopic decompression of neural elements. The RUC recommended a work RVU of 10.47 based on a crosswalk to CPT code 47562 (Laparoscopy, surgical; cholecystectomy) with a higher intraservice time than reflected in the survey data. Since we believe CPT codes 62380 and 47562 are similar in intensity, we believe using the same work RVU as the crosswalk code overestimates the work involved in furnishing CPT code 62380. Reference CPT code 49507 (Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated) has a work RVU of 9.09 and has similar intensity and an identical intraservice time compared to CPT code 62380. Therefore, we proposed a work RVU of 9.09 for CPT code 62380.
A few commenters expressed concerns about the structure of the CPT code descriptors and RUC-recommended valuations. Commenters suggested that the CPT Editorial Panel and the RUC did not take certain indications into account such as differences between the physician work required for endoscopic tubular microdiscectomy compared to lumbar spinal stenosis decompression and posterior cervical posterior laminoforaminotomy. Commenters indicated that the specialty society survey data was inadequate due to the inexperience of the survey respondents, with others suggesting that the survey times were not reflective of some practitioners' experience or patient complexity.
The commenters indicated that the current RUC recommendations for full endoscopic tubular endoscopic surgery are based on limited experience among survey respondents with lumbar microdiscectomy, and insufficient experience with lumbar spinal stenosis decompression and posterior cervical foraminotomy without fusion and are invalid for these indications. Commenters requested that the current CPT codes and valuations for full endoscopic lumbar spinal stenosis decompression and posterior cervical foraminotomy without fusion remain unchanged until further RUC survey data are examined. Some commenters suggested alternative crosswalks including CPT code 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic) with a work RVU of 23.37, CPT code 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) with a work RVU of 13.18, and CPT code 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (
We note that based on the RUC's utilization crosswalk, services that will be reported in CY 2017 with CPT code 62380 are currently reported using either CPT code 22899 (Unlisted procedure, spine) or CPT code 0275T (Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect guidance (
In CY 2015, the CPT Editorial Panel created three new codes to describe paravertebral block injections at single or multiple levels, as well as for continuous infusion for the administration of local anesthetic for post-operative pain control and thoracic and abdominal wall analgesia. For the CY 2016 PFS final rule with comment period, we established the RUC-recommended work RVUs of 1.75 and 1.10 as interim final for CPT codes 64461 and 64462, respectively. For CPT code 64463, we utilized a direct crosswalk from three other injection codes (CPT codes 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement), 64446 (Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement), and 64449 (Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)), which all had a work RVU of 1.81, as we believed this crosswalk more accurately reflected the work involved in furnishing this service.
The following is a summary of the comments we received regarding our proposed valuations for the Paravertebral Block Injection family:
The RUC identified CPT codes 64553 and 64555 as a site of service anomaly during the CY 2016 PFS rulemaking cycle. In the Medicare claims data, these services were typically reported in the nonfacility setting, yet the survey data were predicated on a facility-based procedure. We agreed with the RUC that these two codes should be referred to the CPT Editorial Panel to better define the services, in particular to investigate the possibility of establishing one code to describe temporary or testing implantation and another code to describe permanent implantation. We maintained the CY 2015 work RVUs and direct PE inputs for these two codes on an interim basis until receiving updated recommendations from the CPT Editorial Panel and the RUC.
Additionally, we were alerted to a discrepancy regarding the times for these codes in the CY 2016 work time file. Our proposed CY 2017 work time file addressed this discrepancy by reflecting the RUC recommended times of 155 minutes for CPT code 64553 and 140 minutes for CPT code 64555.
The following is a summary of the comments we received regarding our proposed valuation of the Implantation of Neuroelectrodes codes:
After consideration of comments, we are finalizing the proposed work RVUs and proposed direct PE inputs for CPT codes 64553 and 64555.
In CY 2015, the RUC identified CPT code 65780 as potentially misvalued through a misvalued code screen for 90-day global services that included more than 6 office visits. The RUC recommended a direct work RVU crosswalk from CPT code 27829 (Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed). After examining comparable codes, we determined the RUC-recommended work RVU of 8.80 for CPT code 65780 would likely overstate the work involved in the procedure given the change in intraservice and total times compared to the previous values. We believed that the ratio of the total times (230/316) applied to the work RVU (10.73) more accurately reflected the work involved in this procedure. Therefore, we established an interim final work RVU of 7.81 for CPT code 65780.
In the CY 2017 proposed rule, we proposed a work RVU of 7.81 for CPT code 65780.
We did not receive any comments in response to our proposed valuation on CPT code 65780; therefore, we are finalizing a work RVU of 7.81 as proposed.
In CY 2015, the RUC identified CPT code 65855 as potentially misvalued through the review of 10-day global services with more than 1.5 postoperative visits. The RUC noted that the code was changed from a 90-day to a 10-day global period when it was last valued in 2000. However, the descriptor was not updated to reflect that change. CPT code 65855 describes multiple laser applications to the trabecular meshwork through a contact lens to reduce intraocular pressure. The current practice is to perform only one treatment session during a 10-day period and then wait for the effect on the intraocular pressure. The descriptor for CPT code 65855 has been revised and removes the language “1 or more sessions” to clarify this change in practice.
The RUC recommended a work RVU of 3.00 for CPT code 65855. While the RUC-recommended value represents a reduction from the CY 2015 work RVU of 3.99, we stated that significant reductions in the intraservice time, the total time, and the change in the office visits represent a more significant change in the work resources involved in furnishing the typical service. The intraservice and total times were decreased by approximately 33 percent while the elimination of two postoperative visits (CPT code 99212) alone would reduce the overall work RVU by at least 24 percent under the reverse building block method. However, the RUC-recommended work RVU only represents a 25 percent reduction relative to the previous value. To identify potential work RVUs for this service, we calculated an intraservice time ratio between the CY 2015 intraservice time, 15 minutes, and the RUC-recommended intraservice time, 10 minutes, and applied this ratio to the current work RVU of 3.99 to arrive at a work RVU of 2.66 for CPT code 65855, which we established as interim final for CY 2016.
Comment on the CY 2016 PFS final rule with comment period: A few commenters, including the RUC, provided explanations as to how the RUC recommendation had already accounted for the reduction in physician intraservice time and post-operative visits. Some commenters disagreed with CMS' interim final values based on objections to CMS' use of time ratios in developing work RVUs for PFS services.
In the CY 2017 proposed rule, we proposed the RUC-recommended work RVU value of 3.00 for CPT code 65855.
We did not receive any comments in response to our proposed valuation on CPT code 65855; therefore, we are finalizing a work RVU of 3.00 as proposed.
The RUC identified CPT codes 66170 and 66172 as potentially misvalued through a screen for 90-day global codes that included more than six office visits. We believed the RUC-recommended work RVU of 13.94 for CPT code 66170 did not accurately account for the reductions in time. Specifically, the survey results indicated reductions of 25 percent in intraservice time and 28 percent in total time. These reductions suggested that the RUC-recommended work RVU for CPT code 66170 overstated the work involved in furnishing the service, since the recommended value only represented a reduction of approximately seven percent. We believed that applying the intraservice time ratio, the ratio between the CY 2015 intraservice time, 60 minutes, and the RUC-recommended intraservice time, 45 minutes, applied to the current work RVU, 15.02, resulted in a more appropriate work RVU of 11.27. Therefore, for CY 2016, we established an interim final work RVU of 11.27 for CPT code 66170.
For CPT code 66172, the RUC recommended a work RVU of 14.81. After comparing the RUC-recommended work RVU for this code to the work RVU for similar codes (for example, CPT code 44900 (Incision and drainage of appendiceal abscess, open) and CPT code 52647 (Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed))), we believed the RUC-recommended work RVU of 14.81 overstated the work involved in this procedure. For the same reasons and following the same valuation methodology utilized above, we applied the intraservice time ratio between the CY 2015 intraservice time and the survey intraservice time, 60/90, to the CY 2015 work RVU of 18.86. This resulted in a work RVU of 12.57 for CPT code 66172. Therefore, for CY 2016, we established an interim final work RVU of 12.57 for CPT code 66172.
The following is a summary of the comments we received regarding our proposed valuations for the Glaucoma Surgery family:
For CY 2015, the CPT Editorial Panel made several changes to CPT codes 67101 and 67105. These changes include revising the code descriptors to exclude “diathermy” and “with or without drainage of subretinal fluid” and removing the reference to “1 or more sessions.” The recommended global period also changed from 90 days to 10 days. For CPT code 67101, we proposed the RUC recommended work RVU of 3.50, which was based on the 25th percentile of the survey. For CPT code 67105, the RUC recommended a work RVU of 3.84 based on the 25th percentile of the survey. The RUC also stated that CPT code 67105 was a more intense procedure, and therefore, it should have a higher work RVU than CPT code 67101. Currently, CPT code 67101 has a higher work RVU than CPT code 67105 and according to the surveys, the intraservice and total times remain higher for CPT code 67101. We do not understand why the RUC believes that CPT code 67105 is more work than CPT code 67101. Therefore, we did not propose the RUC-recommended work RVU of 3.50 for CPT code 67105. We did not find evidence that CPT code 67105 is more intense than CPT code 67101 and accordingly, proposed a lower work RVU for CPT code 67105. To value CPT code 67105, we used the RVU ratio between CPT codes 67101 and 67105. We divided the current work RVU of 8.53 for CPT code 67105, by the current work RVU of 8.80 for CPT code 67101 and multiplied the quotient by the RUC-recommended work RVU of 3.50 for CPT code 67101 to arrive at a work RVU of 3.39. Therefore, for CY 2017, we proposed a work RVU of 3.39 for CPT code 67105.
CPT codes 67107, 67108, 67110, and 67113 were identified through the Relative Assessment Workgroup process under the 90-day global post-operative visit screen in CY 2015. The RUC recommended a work RVU of 16.00 for CPT code 67107, which corresponded to the 25th percentile of the survey. While the RUC recommendation represented a five percent reduction from the current work RVU of 16.71, we believed the RUC recommendation still overvalued the service given the 15 percent reduction in intraservice time and 25 percent reduction in total time.
We used the intraservice time ratio between the existing and new time values to identify an interim final work RVU of 14.06. We believed this value accurately reflected the work involved in this service and was comparable to other codes that have the same global period and similar intraservice time and total time. For CY 2016, we established an interim final work RVU of 14.06 for CPT code 67107. For CPT code 67108, the RUC recommended a work RVU of 17.13 based on the 25th percentile of the survey, which reflected a 25 percent reduction from the current work RVU. The survey results reflected a 53 percent reduction in intraservice time and a 42 percent reduction in total time. We believed the RUC-recommended work RVU overestimated the work, given the significant reductions in intraservice time and total time and does not maintain relativity among the codes in this family. To determine the appropriate value for this code and maintain relativity within the family, we preserved the 1.13 work RVU increment recommended by the RUC between this code and CPT code 67107
We also stated that generally we do not agree that a low IWPUT itself indicates overall misvaluation as the validity of the IWPUT as a measure of intensity depends on the accuracy of the assumptions regarding the number, level, and work RVUs attributable to visits for services in the post-operative global period for individual services.
We provided an example where a service with an unrealistic number or level of postoperative visits may have a very low derived intensity for the intra-service time. CPT codes 67107, 67108, and 67110 were referred to the CY 2016 multispecialty refinement panel per commenters' request. The outcome of the refinement panel was a median work RVU of 16.00, 17.13, and 10.25, respectively. After consideration of the comments and the results of the refinement panel, we proposed a work RVU of 16.00, 17.13, and 10.25 for CPT codes 67107, 67108, and 66110, respectively, for CY 2017.
The following is a summary of the comments we received regarding our proposed valuations for the Retinal Detachment Repair family:
For CPT codes 67107, 67108, 67110, and 67113, several commenters supported CMS' decision to propose the values recommended by the refinement panel and urged CMS to finalize these proposed values. A few commenters, including the RUC, brought to our attention discrepancies between our proposal for these codes and the work RVUs posted in Addendum B on the CMS Web site.
We appreciate commenters bringing to our attention the issue regarding conflicting information in the CY 2017 PFS proposed rule preamble text and the public use files published on the CMS Web site. We have corrected this discrepancy in this final rule and the public use files.
For CY 2017, we are finalizing a work RVU of 16.00, 17.13, 10.25 and 19.00 for CPT codes 67107, 67108, 66110 and 67113, respectively, in agreement with the refinement panel recommendations.
For CY 2016, we established the RUC-recommended work RVU of 3.00 as interim final for CPT code 74712. We established an interim final work RVU of 1.78 for CPT code 74713 based on a refinement of the RUC-recommended work RVU of 1.85 using the ratio of work to time for both codes. This proposed value also corresponds to the 25th percentile survey result.
Comment on the CY 2016 PFS final rule with comment period: Commenters stated that the work RVU of 1.78 for CPT code 74713 did not reflect the higher intensity inherent in the procedure's typical patient. The commenter explained that the typical patient is pregnant with twins and has a higher likelihood of complications related to congenital anomalies, as well as of ischemic brain injury with twin gestations. The commenter further stated that twin gestations are more difficult to image. Commenters requested that CPT code 74713 be referred to the multispecialty refinement panel.
Response in the CY 2017 PFS proposed rule: CPT code 74713 was referred to the CY 2016 multispecialty refinement panel. After considering the comments and the results of the refinement panel, we agreed with commenters that an RVU of 1.78 underestimated the work for CPT code 74713.
In the CY 2017 proposed rule, we proposed a work RVU of 1.85 for the service for CY 2017.
We did not receive any comments in response to our proposed valuation on CPT code 74713; therefore, we are finalizing the proposed work RVU.
For CY 2017, the CPT Editorial Panel created a new code, CPT code 76706, to describe abdominal aortic ultrasound screening, currently described by HCPCS code G0389. The specialties that surveyed CPT code 76706 for the RUC were vascular surgery and radiology, and the direct PE inputs recommended by the RUC included an ultrasound room. Based on an analysis of Medicare claims data, the dominant specialties furnishing the service are family practice and internal medicine. We believe that these specialties may more typically use a portable ultrasound device rather than an ultrasound room. Therefore, we proposed to accept the RUC-recommended work RVU of 0.55, and the RUC-recommended PE inputs for this service, but we solicited comment regarding whether or not it would be more accurate to substitute a portable ultrasound device or possibly a hand-held device for an ultrasound room for CPT code 76706. We note that while the phase-in of significant
One commenter states that abdominal aortic aneurysm screenings are performed on nonportable machines in either ambulatory or hospital settings, and therefore, an ultrasound room is appropriate.
In the CY 2015 PFS final rule with comment period, CMS indicated that while CPT codes 77002 and 77003 had been previously classified as stand-alone codes without global periods, we believe their vignettes and CPT Manual parentheticals are consistent with an add-on code as has been established for CPT code 77001. Therefore, the global periods for CPT codes 77002 and 77003 now reflect an add-on code global period with modifications to the vignettes and parentheticals.
For CPT code 77001, we proposed the RUC-recommended work RVU of 0.38. We stated that the RUC-recommended work RVUs for CPT codes 77002 and 77003 did not appear to account for the significant decrease in total times for these codes relative to the current total times. We noted that these three codes describe remarkably similar services and have identical intraservice and total times. Based on the identical times and notable similarity for all three of these codes, we proposed a work RVU of 0.38 for all three codes.
The following is a summary of the comments we received regarding our proposed valuation of the Fluoroscopic Guidance codes:
After consideration of comments received, we are finalizing the RUC-recommended work RVUs for all three codes in the family, which is an increase from the proposed work RVU of 0.38 to a work RVU 0.54 for CPT code
Section 104 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-554) required us to create separate codes with higher payment amounts for digital mammography compared to film mammography, which was the technology considered to be typical at the time. In addition, the statute required additional payment to be made when computer-aided detection (CAD) was used.
In CY 2002, we began valuing digital mammography services using three G-codes, G0202, G0204, and G0206 to describe screening mammography, unilateral diagnostic mammography, and bilateral diagnostic mammography, respectively. CMS implemented the requirements of BIPA section 104(d)(1), which applied to tests furnished in 2001, by using the work RVUs of the parallel CPT codes, but establishing a fixed PE RVU rather than using PE RVUs developed under the standard PE methodology. The fixed amount of PE RVUs for these codes has generally remained unchanged since implementation of the G-codes that specifically described digital imaging.
Most mammography services under Medicare have since been billed with these G-codes when digital mammography was used, and with CPT codes 77055, 77056, and 77057 when film mammography was used. The use of CAD has been reported with CPT codes 77051 and 77052. For CY 2017, the CPT Editorial Panel deleted CPT codes 77051, 77052, 77055, 77056, 77057 and created three new CPT codes, 77065, 77066, and 77067, to describe mammography services bundled with CAD. For CY 2017, the RUC recommended work RVUs of 0.81 for CPT code 77065, 1.00 for CPT code 77066, and 0.76 for CPT code 77067, as well as new PE inputs for use in developing resource-based PE RVUs based on our standard methodologies. The RUC recommended these inputs and only one medical specialty society provided us with a set of single invoices to price the equipment used in furnishing these services.
We reviewed these coding changes and proposed changes to valuation for these codes for CY 2017. The revised CPT coding mitigates the need for both separate G-codes and the CAD add-on codes. Based upon these coding changes and the RUC-recommended input values, overall Medicare payment for mammography services would be drastically reduced. This is particularly true for the technical component of these services, which could possibly be reduced up to 50 percent relative to the PE RVUs currently used for payment for these services.
Based on our initial review of the recommended inputs for the new codes, we believed that these changes would likely result in values more closely related to the relative resources involved in furnishing these services. However, we recognized that these services, particularly the preventive screenings, are of particular importance to the Medicare program and the health of Medicare beneficiaries. We were concerned that making drastic changes in coding and payment for these services could be disruptive in ways that could adversely impact beneficiary access to necessary services. We also recognized that unlike almost any other high-volume PFS service, the RVUs used for payment for many years have not been developed through the generally applicable PFS methodologies, and instead reflect the statutory directive under section 104 of the BIPA. Similarly, we recognized that the changes in both coding and valuation are significant changes for those who provide these services. Therefore, instead of proposing to simultaneously adopt the revised CPT coding and drastic reductions in overall payment rates, we believed it was advisable to propose to adopt the new coding, including the elimination of separate billing for CAD, for CY 2017 without proposing immediate implementation of the recommended resource inputs. We anticipated that we would consider the recommended inputs, including the pricing of the required equipment, as carefully as possible prior to proposing revised PE values through subsequent rulemaking.
Therefore, for CPT codes 77065, 77066, and 77067, we proposed to accept the RUC-recommended work RVUs, but to crosswalk the PE RVUs for the technical component of the current corresponding G-codes, as we sought further pricing information for these equipment items.
Since the publication of the proposed rule, we have determined that for several reasons related to claims processing systems, Medicare claims systems will be unable to process claims using CPT codes 77065, 77066, and 77067 for CY 2017. However, given the parallel structure of these new CPT codes, 77065, 77066, and 77067 to existing G-codes G0206, G0204, and G0202, we anticipate that the claims systems will be fully capable of processing the appropriate payment policies and prices discussed below for CPT codes 77065, 77066, and 77067 by using the existing G-codes. Therefore, for CY 2017, we will operationalize the new coding rules, including adoption of the new code descriptors for CPT codes 77065, 77066, and 77067 through use of the three current G-codes. For the purposes of discussion below, we discuss policies and payment rates for these three codes using the CPT numbers. Therefore, in the preamble discussion below, references to the G-codes refer to the descriptors, policies, and rates for CY 2016 and references to the new CPT codes refer to the 2017 descriptors, policies and rates that will be implemented through revisions to the current G-codes. We anticipate being able to adopt the CPT coding for CY 2018.
In addition to soliciting comment on this proposal, we also solicited input on rates for these services in the commercial market to help us understand the potential impacts of any future proposed revisions to PFS payment rates.
Finally, we noted that by proposing to adopt the new coding for CY 2017, any subsequent significant reduction in RVUs (greater than 20 percent) for the codes would be subject to the statutory phase-in under section 1848(c)(7).
To help us examine the resource inputs for these services, we solicited public comment on the list of items recommended as equipment inputs for mammography services. We also invited commenters to provide any invoices that would help with future pricing of these items.
We also received specialty society recommendations for a new Equipment Item, a physician PACS mammography workstation. We note that we discuss physician PACS workstation in section II.A of this rule. The items that comprise the physician PACS mammography workstation are listed in Table 19. We requested public comment as to the appropriateness of this list and if some items are indirect expenses or belong in other codes. We also invited commenters to provide any invoices that would help with future pricing of these items.
We also note that for CY 2015, the CPT Editorial Panel created CPT codes 77061, 77062, and 77063 to describe unilateral, bilateral, and screening digital breast tomosynthesis, respectively. CPT code 77063 is an add-on code to CPT code 77057, the CPT code for screening mammography. To be consistent with our use of G-codes for digital mammography, we did not implement two of these three CPT codes for Medicare purposes. We only adopted CPT code 77063 as an add-on code to HCPCS code G0202. Instead of adopting stand-alone CPT codes 77061 and 77062, we created a new code, G0279 Diagnostic digital breast tomosynthesis, as an add-on code to the diagnostic digital mammography HCPCS codes G0204 and G0206 and assigned it values based on CPT code 77063. Pending revaluation of the mammography codes using direct PE inputs, we proposed in CY 2017 to maintain the current coding structure for digital breast tomosynthesis with the technical change that HCPCS code G0279 be reported with CPT codes 77065 or 77066 as the replacement codes for HCPCS codes G0204 and G0206.
For CY 2017, we are finalizing the proposed work RVUs and PE RVUs associated with CPT codes 77067, 77066 and 77065 for use with HCPCS codes G0202, G0204, and G0206, respectively.
We identified CPT codes 77332, 77333, and 77334 through the high expenditures by specialty screen. These services represent an incremental increase of complexity from the simple to the intermediate to the complex in design of radiation treatment devices. The RUC recommended no change from the current work RVUs of 0.54 for CPT code 77332, 0.84 for CPT code 77333 and 1.24 for CPT code 77334. We believed the recommended work RVUs overstate the work involved in furnishing these services, as they do not sufficiently reflect the degree to which the RUC concurrently recommended a decrease in intraservice or total time. For CPT code 77332, we believed the RUC recommendation to maintain its current value despite a 34 percent decrease in total time appeared to ignore the change in time. Therefore, we proposed a value for this code based on a crosswalk from the value from CPT code 93287 (Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system), due to its identical intraservice time, similar total time, and similar level of intensity. We therefore proposed a work RVU of 0.45 for CPT code 77332. We further supported this valuation with CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported) upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes), which has similar physician time and intensity measurements and a work RVU of 0.45. As these codes are designed to reflect an incremental increase in work value from simple, to intermediate, and complex device designs, we used an incremental difference methodology to value CPT codes 77333 and 77334. We proposed a work RVU of 0.75 for CPT code 77333, maintaining its recommended increment from CPT code 77332. For CPT code 77334, we proposed a work RVU of 1.15, which would maintain its increment from CPT code 77332.
A commenter supported the use of incremental valuation methodology in theory but did not believe it is appropriately applied to these codes, because the commenter believes that the valuation of CPT code 77332, upon which the increments are based, is incorrect.
We identified CPT code 77470 through the high expenditures by specialty screen. We proposed the RUC-recommended work RVU of 2.03. However, we believe the description of service and vignette describe different and unrelated treatments being performed by the physician and clinical staff for a typical patient, and this presents a disparity between the work RVUs and PE RVUs. We solicited comment on information that would clarify this apparent disparity to help determine appropriate PE inputs. In addition, we solicited comment to determine if creating two G-codes, one that describes the work portion of this service, and one that describes the PE portion, may be a potentially more accurate method of valuing and paying for the service or services described by this code.
In the CY 2016 PFS final rule with comment period, we established an interim final value for CPT code 77790 without a work RVU, consistent with the RUC's recommendation. We did not use the RUC-recommended work RVU to establish the interim final values for CPT code 77778. We stated that the specialty society survey included a work time that was significantly higher than the RUC-recommended work time without a commensurate change in the work RVU. For CY 2016, we established the 25th percentile work RVU survey result of 8.00 as interim final for CPT code 77778 and 0 work RVUs for CPT code 77790.
Comment on the CY 2016 PFS final rule with comment period: Commenters agreed that the preservice survey times and the RUC-recommended survey times were inconsistent and explained that this inconsistency resulted from the RUC's use of preservice packages in developing recommendations. In addition, commenters stated that because the work associated with CPT code 77790 (including pre-time supervision, handling, and loading of radiation seeds into needles) was bundled into CPT code 77778, that the additional work should be reflected in the RVU for CPT code 77778. Commenters encouraged us to accept the RUC-recommended work RVU of 8.78 and requested that CPT code 77778 be referred to the refinement panel.
Response in the CY 2017 PFS proposed rule: We did not refer CPT code 77778 to the CY 2016 multispecialty refinement panel because commenters did not provide new clinical information. We continued to believe that, based on the reduction in total work time, an RVU of 8.00 accurately reflected the work involved in furnishing CPT code 77778.
In the CY 2017 proposed rule, we proposed a work RVU of 8.00 for CPT code 77778 and 0 work RVUs for CPT code 77790. We also sought comment on whether we should use time values based on preservice packages if the recommended work value was based on time values that were significantly different than those ultimately recommended.
The following is a summary of the comments we received regarding our proposed valuations for CPT codes 77778 and 77790:
Commenters did not agree with our decision not to accept the RUC-recommended work RVU of 8.78 and to propose for CY 2017 a work RVU of 8.00, considering the disparity between the survey total time and the RUC-recommended total time. According to the RUC, the survey respondents had accurately estimated the work RVU based on magnitude estimation while overestimating the relatively low intensity pre-service time involved in performing this service, and this explains the disparity between the survey time and the RUC-recommended total time. One commenter noted that the RUC significantly reduced the pre-time because it did not include work in supervising the ordering of the isotope. Several commenters stated that CMS routinely accepts and uses pre-service time packages as recommended by the RUC.
In general we are concerned with using recommended time values that are disconnected from recommended work RVUs, including in cases where the recommended work RVU may include elements of work that are not reflected in the assumptions in time, as appears to be the case for this code. We reiterate that we believe the statute directs us to establish work RVUs that reflect the relative resource costs in time and intensity, so we believe that there should be an identifiable relationship between time and work RVUs.
To align the time and work associated with this code, we proposed a reduction of the work RVU from 8.78 to 8.00 as we proposed. However, upon consideration of comments, we were persuaded that
While we are not finalizing a change in the time associated with this code since we proposed to use the RUC recommended value based on the pre-service package, we seek additional information regarding the best approach to valuing work when there is a clear disconnect between assumptions regarding time described by a code and the time recommended by the RUC. We understand that pre-service time packages can be a helpful tool in assigning estimates of time to particular codes relative to others on the PFS and that these times may be significantly different than those derived from survey results. However, since the RUC has repeatedly stated that its recommendations reflect the typical resources involved in furnishing PFS services, we believe it would be important for us to be able to identify cases where the recommended time values reflect the application of particular policies rather than the best estimate of the actual time involved in furnishing procedures.
In establishing CY 2016 interim final values, we accepted the RUC recommended work RVUs for CPT codes 78265 and 78266. We believed that the RUC-recommended RVU of 0.80 overestimated the work involved in furnishing CPT code 78264 and as a result, we established an interim final work RVU of 0.74 based on a crosswalk to CPT code 78226 (hepatobiliary system imaging, including gallbladder when present), due to similar intraservice times and intensities.
In the CY 2017 proposed rule, we proposed a value of 0.79 for CPT code 78264.
The following is a summary of the comments we received regarding our proposed valuation of the Colon Transit Imaging codes:
In the CY 2016 PFS final rule with comment period, we made a series of refinements to the recommended direct PE inputs for this family of codes. We removed the equipment time for the solvent recycling system (EP038) and the associated clinical labor described by the tasks “Recycle xylene from stainer” and “Order, restock, and distribute specimen containers and or slides with requisition forms” due to our belief that these were forms of indirect PE. This refinement applied to all seven codes in the family. We also noticed what appeared to be an error in the quantity of non-sterile gloves (SB022), impermeable staff gowns (SB027), and eye shields (SM016) assigned to CPT codes 88108 and 88112. The recommended value of these supplies was a quantity of 0.2, which we believed was intended to be a quantity of 2. We therefore refined the value of these supplies to 2 for CPT codes 88108 and 88112.
The following is a summary of the comments we received regarding our proposed valuation of the Cytopathology Fluids and Cytopathology Smears codes:
After consideration of comments, we are finalizing the proposed direct PE inputs for CPT codes 88104, 88106, 88108, 88112, 88160, 88161, and 88162.
The Flow Cytometry Interpretation family of codes is split into a pair of codes used to describe the technical component of flow cytometry (CPT codes 88184 and 88185) that do not have a work component, and a trio of codes (CPT codes 88187, 88188, and 88189) that do not have direct practice expense inputs, as they are professional component only services. CPT codes 88184 and 88185 were reviewed by the RUC in April 2014, and their CMS refined values were included in the CY 2016 PFS final rule with comment period. The full family of codes was reviewed again at the January 2016 RUC meeting, and new recommendations were submitted to CMS as part of the CY 2017 PFS rulemaking cycle.
We proposed the RUC-recommended work RVU of 0.74 for CPT code 88187, and the RUC-recommended work RVU of 1.70 for CPT code 88189. For CPT code 88188, we proposed a work RVU of 1.20 instead of the RUC-recommended work RVU of 1.40. We arrived at this value by noticing that there were no comparable codes with no global period in the RUC database with intraservice time and total time of 30 minutes that had a work RVU higher than 1.20. The RUC-recommended work RVU of 1.40 would go beyond the current maximum value and establish a new high, which is not consistent with our estimation of the overall intensity of this service relative to the others. As a result, we believe it is more accurate to crosswalk CPT code 88188 to the work value of the code with the current highest value, which is CPT code 88120 (Cytopathology, in situ hybridization (for example, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes) at a work RVU of 1.20. We believe that CPT code 88120 is crosswalk comparable code since it shares the identical intraservice time and total time of 30 minutes with CPT code 88188.
We also noted that the survey increment between CPT codes 88187 and 88188 at the RUC-recommended 25th percentile was 0.40 (between work RVUs of 1.00 and 1.40), and this increment of 0.40 when added to CPT code 88187's work RVU of 0.74 would arrive at a value of 1.14. In addition, the total time for CPT code 88188 decreases from 43 minutes to 30 minutes, which is a ratio of 0.70, and when this time ratio is multiplied by CPT code 88188's previous work value of 1.69, the result would be a new work RVU of 1.18. With this information in mind, we proposed a work RVU of 1.20 for CPT code 88188 as a result of a direct crosswalk to CPT code 88120.
For CPT codes 88184 and 88185, which describe the technical component of flow cytometry, we proposed to use the RUC-recommended inputs with a series of refinements. However, we believe that the coding for these two procedures may inhibit accurate valuation. CPT code 88184 describes the first marker for flow cytometry, while CPT code 88185 is an add-on code that describes each additional marker. We believe that it may be more accurate to have a single CPT code that describes the technical component of flow cytometry on a per patient case basis, as these two procedures are always performed together and it is difficult to determine the clinical labor, supplies, and equipment used in the typical case under the current coding structure. We solicited comments regarding the public interest in consolidating these two procedures into a single code used to describe the technical component of flow cytometry.
Absent such a change in coding, we proposed to refine the clinical labor time for “Instrument start-up, quality control functions, calibration, centrifugation, maintaining specimen tracking, logs and labeling” from 15 minutes to 13 minutes for CPT code 88184. We maintained that 13 minutes for this activity, which is the current time value, would be typical for the procedure, as CPT code 88182 also uses 13 minutes for the identical clinical labor task. We also proposed to refine the L054A clinical labor for “Load specimen into flow cytometer, run specimen, monitor data acquisition, and data modeling, and unload flow cytometer” from 10 minutes to 7 minutes using the same rationale, a comparison to CPT code 88182.
We proposed to maintain the clinical labor for “Print out histograms, assemble materials with paperwork to pathologists Review histograms and gating with pathologist” for CPT code 88184 at 2 minutes, as opposed to the RUC-recommended 5 minutes. A clinical labor time of 2 minutes is standard for this activity; we disagree with the RUC rationale that reviewing histograms and gating with the pathologist in this procedure is not similar to other codes. We also note that the review of histograms with a pathologist is not even described by CPT code 88184, which again refers to the technical component of flow cytometry, not the professional component. We also proposed to refine the L033A clinical labor time for “Clean room/equipment following procedure” from 2 minutes to 1 minute for CPT code 88184. We have established 1 minute in previous rulemaking (80 FR 70902) as the standard time for this clinical labor activity in the laboratory setting.
We proposed to maintain our removal of the clinical labor time for “Enter data into laboratory information system, multiparameter analyses and field data entry, complete quality assurance documentation” for both CPT code 88182 and CPT code 88184. As we stated in the CY 2016 PFS final rule with comment period (80 FR 70979), we have not recognized the laboratory information system as an equipment
We proposed to maintain the quantity of the “lysing reagent” supply (SL089) at 2 ml for CPT code 88185, as opposed to the RUC-recommended quantity of 3 ml. In our discussions with pathology specialists who perform flow cytometry, we were informed that the use of 50-55 ml of the lysing reagent would be typical for an entire patient case. The RUC recommendation similarly suggested a quantity of 46 ml or 48 ml per patient case. We were also told that the most typical number of markers used for flow cytometry is 24, consisting of 1 service of CPT code 88184 and 23 services of CPT code 88185. An investigation of our claims data confirmed this information, indicating that 24 markers is the most frequent per patient case for flow cytometry, and the use of more than 20 markers is typical. We believe that this data supports our refinement of the lysing reagent from a quantity of 3 ml to a quantity of 2 ml for CPT code 88185, which is also the current value for the procedure and the RUC-recommended value from the previous set of recommendations. For the typical case of 24 markers, our value would produce a total lysing reagent quantity of 51 ml (5 ml from the single service of CPT code 88184 and 46 ml from the 23 services of CPT code 88185), which matches with the amount required for a total per patient case. If we were to adopt the RUC recommendation, the total lysing reagent quantity would be 74 ml, which is well in excess of what we believe to be typical for these procedures.
We also proposed to refine the quantity of the “antibody, flow cytometry” supply (SL186) from quantity 1.6 to quantity 1, which is also the current value for the supply and the RUC-recommended value from the previous set of recommendations. We do not agree that more than one antibody would be typically used for each marker. We are reaffirming the previous RUC recommendation, and maintaining the current quantity of 1 antibody for each marker.
We did not agree with the recommended additional time for the “printer, dye sublimation (photo, color)” equipment (ED031). We proposed to maintain the equipment time at 2 minutes for CPT code 88184, and at 1 minute for CPT code 88185. As we stated in the CY 2016 PFS final rule with comment period (80 FR 70979), we proposed to assign equipment time for the dye sublimation printer to match the clinical labor time for “Print out histograms, assemble materials with paperwork to pathologists.” We do not believe that it would be typical for the printer to be in use longer than it takes to accomplish this clinical labor task.
The following is a summary of the comments we received regarding our proposed valuation of the Flow Cytometry Interpretation codes. Due to the large number of comments we received for this code family, we will first summarize the comments related to the coding structure of CPT codes 88184 and 88185, followed by the comments related to specific work RVUs, and finally the comments related to the direct PE inputs.
A few commenters supported the possibility of combining CPT codes 88184 and 88185 into a single code. One commenter stated that the current coding structure does not incentivize the use of less reagents, and actually penalizes labs that appropriately test fewer markers. According to this commenter, moving to a single code structure would be consistent with the vast majority of lab tests, would simplify billing processes, and may make development of more cost-effective panels financially desirable. The commenter supported further examination of a single CPT code and urged that current payment rates should be frozen while such examination occurs. Another commenter suggested a slightly different coding structure, one which would collapse the codes into a series of case rate codes that reflect the procedures: screening, classification, and monitoring. There was support from one additional commenter for a three code proposal designed to track this workflow.
With regards to non-add on codes, Table 21 lists all 13 codes in the RUC database with 30 minutes of intraservice time, fewer than 40 minutes of total time, and a global period of XXX:
As we stated previously, there are no codes with a work RVU higher than 1.20, which is where we proposed to value CPT code 88188. We acknowledge that there are global XXX codes with 30 minutes of intraservice time that have a work RVU greater than 1.20. However, all of these codes have at least 40 minutes of total time, which is 33 percent higher at a minimum than the total time for CPT code 88188. We believe that a crosswalk to CPT code 88120, which shares the identical time values as CPT 88188, is a more appropriate choice than codes that have substantially higher total time. In the particular case of CPT code 88188, we continue to believe that establishing a new maximum work value above 1.20 would not be consistent with our estimation of the overall intensity of this service relative to the others on the PFS.
The following comments address the proposed direct PE inputs for the Flow Cytometry family of codes.
After consideration of comments received, we are finalizing the proposed work RVUs for CPT code 88187, 88188, and 88189. We are also finalizing the proposed direct PE inputs, with the refinement to the dye sublimation printer detailed above.
CPT codes 88321, 88323, and 88325 were reviewed by the RUC in April 2014 for their direct PE inputs only, and the CMS refined values were included in the CY 2016 PFS final rule with comment period. The family of codes was reviewed again at the January 2016 RUC meeting for both work values and direct PE inputs, and new recommendations were submitted to CMS as part of the CY 2017 PFS rulemaking cycle.
In the CY 2016 PFS final rule with comment period, we finalized our proposal to remove many of the inputs for clinical labor, supplies, and equipment for CPT code 88325. The descriptor for this code did not state that slide preparation was taking place, and therefore, we refined the labor, supplies, and equipment inputs to align with the inputs recommended for CPT code 88321, which also does not include the preparation of slides. After further discussion with pathologists and consideration of comments received, we have been persuaded that slide preparation does take place in conjunction with the service described by CPT code 88325. In the RUC-recommended direct PE inputs from the January 2016 meeting, the labor, supplies, and equipment inputs related to slide preparation were added once again to CPT code 88325. We proposed to accept these restorations related to slide preparation without refinement.
Regarding the clinical labor direct PE inputs, we proposed to assign 1 minute of L037B clinical labor for “Complete workload recording logs. Collate slides and paperwork. Deliver to pathologist” for CPT codes 88323 and 88325. We are maintaining this at the current value for CPT code 88323, and adding this 1 minute to CPT code 88325 based on our new understanding that slide preparation is undertaken as part of the service described by this code. We proposed to remove the clinical labor for “Assemble and deliver slides with paperwork to pathologists” from all three codes, as we believe this clinical labor is redundant with the labor assigned for “Complete workload recording logs.” We similarly proposed to remove the clinical labor for “Clean equipment while performing service” from CPT codes 88323 and 88325, as we believe it to be redundant with the clinical labor assigned for “Clean room/equipment following procedure.”
We proposed to maintain the quantity of the “stain, hematoxylin” supply
We also proposed to update the use of the eosin solution (sometimes listed as “eosin y”) in our supply database. We believe that the eosin solution supply (SL063), which is measured in grams, reflects an older process of creating eosin stains by hand. This is in contrast to the eosin stain supply (SL201), which is measured in milliliters, and can be ordered in a state that is ready for staining immediately. We do not believe that the use of eosin solution would reflect typical lab practice today, with the readily availability for purchase of inexpensive eosin staining materials. We also note that in the CY 2016 PFS final rule with comment period, we removed 8 gm of the eosin solution and replaced it with 8 ml of the eosin stain, and this substitution was accepted without further change in the most recent set of RUC recommendations. As a result, we proposed to update the price of the eosin stain supply from $0.044 per ml to $0.068 per ml to reflect the current cost of the supply. We also proposed to use CPT codes 88323 and 88325 as a model, and replace the use of eosin solution with an equal quantity of eosin stain for the rest of the codes that make use of this supply. This applies to 15 other CPT codes: 88302 (Level II—Surgical pathology, gross and microscopic examination), 88304 (Level III—Surgical pathology, gross and microscopic examination), 88305 (Level IV—Surgical pathology, gross and microscopic examination), 88307 (Level V—Surgical pathology, gross and microscopic examination), 88309 (Level VI—Surgical pathology, gross and microscopic examination), 88364 (In situ hybridization (
The following is a summary of the comments we received regarding our proposed valuation of the Microslide Consultation codes.
After consideration of comments received, we are finalizing our proposed work RVUs for CPT code 88321, 88323, and 88325. We are also finalizing the proposed direct PE inputs, with the addition of 1 minute of clinical labor time as detailed above for CPT code 88321. We note as well that we are finalizing the replacement of eosin solution with eosin stain, as detailed in the PE section of this final rule (see section II.A. of this final rule).
In the CY 2014 PFS final rule with comment period (78 FR 74341), we assigned a status indicator of I (Not valid for Medicare purposes) to CPT codes 88342 and 88343 and instead created two G-codes, G0461 and G0462, to report immunohistochemistry services. We did this, in part, to avoid creating incentives for overutilization.
For CY 2015, the CPT coding was revised with the creation of two new CPT codes, 88341 and 88344, the revision of CPT code 88342 and the deletion of CPT code 88343. In the past for similar procedures in this family, the RUC recommended a work RVU for the add-on code (CPT code 88364) that was 60 percent of the work RVU for the base code (CPT code 88365). In the CY 2015 PFS final rule with comment period, we stated that the relative resources involved in furnishing an add-on service in this family would be reflected appropriately using the same 60 percent metric and subsequently established an interim final work RVU of 0.42 for CPT code 88341, which was 60 percent of the work RVU of 0.70 for the base CPT code 88342. In the CY 2016 PFS proposed rule, we revised the add-on codes from 60 percent to 76 percent of the base code and subsequently proposed a work RVU of 0.53 for CPT code 88341. However, we inadvertently published work RVUs for CPT code 88341 in Addendum B on the CMS Web site without explicitly discussing it in the preamble text. In the CY 2016 PFS final rule with comment period, we maintained the CY 2015 work RVU of 0.53 for CPT code 88341 as interim final for CY 2016 and requested public comment. Also, in the CY 2016 PFS final rule with comment period, we
The following is a summary of the comments we received regarding our proposed valuations for the Immunohistochemistry family:
The RUC stated the CY 2017 proposed work RVUs for CPT codes 88341 and 88350 do not represent the work involved in furnishing the procedure and present a rank order anomaly for other services. The RUC also stated that the services furnished by CPT codes 37252 and 37253, which we used to establish the relationship between the base code and the add-on code, are not medically comparable services to CPT codes 88341 and 88350. Additionally, the RUC stated each pathology service has individual intensities and complexities. Specifically, for additional immunohistochemistry services represented by add-on CPT codes 88341 and 88350, each antibody is evaluated separately on different slides and each additional service is separate and distinct.
Lastly, the RUC stated its approach of evaluating the actual work associated with each unique base and each unique add-on service is far more accurate, rational, and responsive to the specific circumstances than holding codes equal to a fixed discount from the base code. Applying ratio comparisons and fixed discounts to arrive at a work relative value will continue to create inter-specialty rank order anomalies of physician work RVUs.
Another commenter noted there were RUC surveys that evaluated physician work differentials between the base codes and the add-on codes for pathology services. The commenter offered CPT codes 88333 (Pathology consultation during surgery; cytologic examination (
As discussed in detail in previous proposed and final rules, we continue to believe the metric we use to value add-on codes relative to their base codes is appropriate and representative of the work involved and note that there is no rank order anomaly within this particular code family. In response to the commenter's statement that there should be no comparison of intravascular ultrasound services to any pathology service, we continue to believe any difference in work RVUs for codes describing different kinds of services should reflect the relative differences in time and intensity involved in furnishing the services. Therefore, we believe that it is imperative that we can compare the assumptions regarding overall work between any two codes, regardless of their characteristics.
We appreciate commenters' concerns regarding a standard discount, and we do not consider the use of a particular increment to establish a new standard. Instead, we reiterate that we believe that it is reasonable to estimate work RVUs for a base and an add-on code, and to recognize efficiencies between them, by looking at how similar efficiencies are reflected in work RVUs for other PFS services. We appreciate the commenters' concerns regarding the time ratio methodologies and have responded to these concerns about our methodology in section II.L of this final rule.
Therefore, for CY 2017 we are finalizing a work RVU of 0.56, 0.70, 0.70, and 0.59 for CPT codes 88341, 88342, 88344 and 88350, respectively.
For CY 2015, the CPT Editorial Panel revised the code descriptors for the in situ hybridization procedures, CPT codes 88365, 88367 and 88368, to specify “each separately identifiable probe per block.” Additionally, three new add-on codes (CPT codes 88364, 88369 and 88373) were created to specify “each additional separately identifiable probe per slide.” Some of the add-on codes in this family had RUC-recommended work RVUs that were 60 percent of the work RVU of the base procedure. We believed this accurately reflected the resources used in furnishing these add-on codes and
For CY 2016, the RUC re-reviewed these services due to the specialty society's initially low survey response rate. In our review of these codes, we noticed that the latest RUC recommendation was identical to the RUC recommendation provided for CY 2015. Therefore, we proposed to retain the CY 2015 work RVUs and work time for CPT codes 88367 and 88368 for CY 2016. For CPT code 88365 we finalized a work RVU of 0.88 for CY 2016. For CPT codes 88364 and 88369, we increased the work RVUs for both of these add-on codes from 0.53 to 0.67, which reflected 76 percent of the work RVUs of the base procedures for these services. However, we inadvertently omitted the rationale for this revision to the work RVUs in the preamble to CY 2016 proposed rule. Consequently, we maintained the CY 2015 interim final values of the work RVU of 0.67 for CPT codes 88464 and 88369 and sought comment on these values for CY 2016. For CPT code 88373 we finalized a work RVU of 0.43.
In the CY 2017 proposed rule, we proposed a work RVU of 0.58 for CPT code 88373.
The following is a summary of the comments we received regarding our proposed valuation of the Morphometric Analysis codes:
The RUC also stated that although some medical procedures and services may present efficiencies between base and add-on services, this is not the case for CPT codes 88364 and 88369, as each pathology service is individual so that any rational comparison of the physician work of intravascular ultrasound services with pathology services is impossible. The RUC also stated that no pathology add-on service can be presumed to have a discount in physician work from the base service.
Another commenter stated for CPT code 88373, it is irrational to assume that second and subsequent services designated by convention as “add-on” services require a reduction in resources relative to the corresponding initial service.
Another commenter noted that in the CY 2017 proposed rule, CMS incorrectly stated it was utilizing a RUC recommendation specific to these codes. According to the CY 2015 Final Rule (79 FR 67548), the codes on which CMS based its discount were CPT codes 88334, 88335, 88177, and 88172. The commenter states the distinction between the codes cited in the CY 2015 final rule, CPT codes 88334, 88335, 88177, 88172, and the new add-on codes, CPT codes 88364, 88369 and 88373, is that the discount factor is specific to services for which a diagnosis has already been furnished. For the new codes to which CMS applied this discount, no such corresponding interpretative diagnosis has been made.
The same commenter stated for morphometric codes, the pathologist is reviewing a second, unique and distinct probe with an entirely different signal than that of its base code, and the work involved with these add-on services requires the same level of intensity and time as their base codes.
The commenter also stated that pathology consultation and cytopathology evaluation codes were clinically different and are not valid proxies to identify efficiencies for the new add-on codes.
We also continue to believe that it is reasonable to recognize efficiencies between them a base and an add-on code. In reviewing the RUC-recommended base/add-on relationships between several pathology codes, we continue to believe the base/add-on code time relationships for pathology services are appropriate and have not been presented with any persuasive evidence or rationale that conflicts with the RUC-recommended relationships.
We agree with the commenter that the designation “add-on” does not automatically imply a reduction; however, in the case of these similar pathology services, we continue to believe using the same valuation metrics is valid. Therefore, for CY 2017, we are finalizing a work RVU of 0.70, 0.73, 0.88, 0.70 and 0.58 for CPT codes 88364, 88367, 88368, 88369 and 88373, respectively.
For CY 2016, we received a RUC recommendation of 0.27 work RVUs for CPT code 91200. After careful review of the recommendation, we established the RUC-recommended work RVU and direct PE inputs as interim final for CY 2016.
The following is a summary of the comments we received regarding our proposed valuation of CPT code 91200.
After consideration of comments received, we are finalizing our proposed work RVUs and direct PE inputs, with the price increase to the Fibroscan with printer equipment.
The CPT Editorial Panel developed three new codes (two base codes and one add-on code) to describe paravalvular leak closure procedures that were previously reported using an unlisted code. The RUC recommended a work RVU of 17.97 for CPT code 93591. We proposed a work RVU of 14.50 for CPT code 93591, a direct crosswalk from CPT code 37227. We stated in the CY 2017 proposed rule that we believe that a direct crosswalk to CPT code 37227 accurately reflected the time and intensity described in CPT code 93591 since CPT code 37227 also described a transcatheter procedure with similar service times.
To maintain relativity among the codes in this family, we proposed refinements to the recommended work RVUs for CPT code 93590. The RUC noted that the additional work associated with CPT code 93590 compared to CPT code 93591 was due to the addition of a transseptal puncture to access the mitral valve. The RUC identified a work RVU of 3.73 for a transseptal puncture. Therefore, for CPT code 93590, we proposed a work RVU of 18.23 by using our proposed work RVU of 14.50 for CPT code 93591 and adding the value of a transseptal puncture (3.73).
CPT code 93592 is an add-on code used to report placement of additional occlusion devices for percutaneous transcatheter paravalvular leak closure, performed in conjunction with either an initial mitral or aortic paravalvular leak closure. The RUC recommended a work RVU of 8.00 for this code. In the proposed rule, we stated that we considered applying the relative increment between CPT codes 93590 and 93591; however, we believed that a direct crosswalk to CPT code 35572, with a work RVU of 6.81, more accurately reflected the time and intensity of furnishing the service. Therefore, for CPT code 93592, we proposed a work RVU of 6.81.
For CPT code 93590, commenters, including the RUC, supported CMS' proposed use of the same building block methodology used in the RUC recommendations, by proposing to apply a work RVU of 3.73 to the base code value of 93591. However, commenters suggested that CMS apply the value of a transeptal puncture to the RUC-recommended value for CPT code 93591, and therefore, finalize the RUC-recommended work RVU of 21.70 for CPT code 93590.
For CPT code 93592, commenters, including the RUC, disagreed with CMS' proposed comparison of CPT code 93592 to CPT code 35572 (Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (
In February 2016, the RUC submitted recommendations for work and direct PE inputs for CPT codes 95812, 95813, and 95957. We proposed to use the RUC-recommended physician work and direct PE inputs for CPT code 95957 and to use the RUC-recommended work RVUs for CPT codes 95812 and 95813.
In the CY 2016 PFS final rule with comment period (80 FR 70886), we finalized direct PE input refinements for several clinical labor times for CPT codes 95812 and 95813. The RUC's February 2016 direct PE summary of recommendations indicated that the specialty society expert panel disagreed with CMS' refinements to clinical labor time for these two codes. The RUC recommended 62 minutes for clinical labor task “perform procedure” for CPT code 95812 and 96 minutes for the same clinical labor task for CPT code 95813, similar to the values recommended by the RUC in April 2014.
We proposed to maintain the CMS-refined CY 2016 PE inputs for clinical labor task “perform procedure” for CPT codes 95812 (50 minutes) and 95813 (80 minutes), since the RUC's PE summary of recommendations stated that CPT code 95812 required 50 minutes of clinical labor time for EEG recording, and CPT code 95813 required 80 minutes of clinical labor time for the same clinical labor task.
We did not receive any comments on our proposals for this family of codes. Therefore, for CY 2017, we are finalizing our proposed direct PE inputs for these codes without modifications. We are also finalizing for CY 2017 work RVUs of 1.08 for CPT code 95812, 1.63 for CPT code 95813, 1.98 for CPT code 95957.
CPT codes 95971 and 95972 were established as interim final following the CY 2016 final rule with comment period. For CY 2017, we proposed to maintain their work RVUs and direct PE inputs.
After consideration of comments received, we are finalizing our proposed work RVUs and proposed direct PE inputs for CPT codes 95971 and 95972.
In October 2015, the CPT Editorial Panel created two new PE-only CPT codes, 96160 (Administration of patient-focused health risk assessment instrument (
We noted that we believed that CPT code 96160 describes a service that is frequently reasonable and necessary in the treatment of illness or injury, such as when there has been a change in health status. However, when the service described by CPT code 96160 is explicitly included in another service being furnished, such as the Annual Wellness Visit (AWV), this code should not be billed separately, much like other codes that describe services included in codes with broader descriptions. We also noted that this service should not be billed separately if furnished as a preventive service as it would describe a non-covered service. However, we also solicited comment on whether this service may be better categorized as an add-on code and welcomed stakeholder input regarding whether or not there are circumstances when this service might be furnished as a stand-alone service.
• Assessment of maternal depression in the active care of infants,
• Assessment of parental mental health as part of evaluating a child's functioning,
• Assessment of caretaker conditions as indicated where atypical parent/child interactions are observed during care,
• Assessment of caregivers as part of care management for adults whose physical or cognitive status renders them incapable of independent living and dependent on another adult caregiver. Some examples might be intellectually disabled adults, seriously
Because commenters noted that these assessments were generally administered during E/M services, they were receptive to making both CPT codes 96160 and 96161 add-on codes to E/M services.
In developing our proposal regarding the payment disposition of this code, we noted that it singularly described a service administered to a caregiver. However, based on public comments, including the receptivity to our assignment of add-on code status, we understand that in actual practice, this service is integrated with E/M visits under particular circumstances. Consequently, we believe the appropriate payment status for the code should be determined by looking at the overall service as described by the two codes together. We agree with commenters, then, that there are circumstances where this service is an essential part of a service to a Medicare beneficiary. Therefore, we are assigning an active payment status to both codes for CY 2017. We are also establishing use of the RUC recommended values for these codes. We are also assigning an add-on code status to both of these services. As add-on codes, CPT codes 96160 and 96161 describe additional resource components of a broader service furnished to the patient that are not accounted for in the valuation of the base code.
For CY 2015, the CPT Editorial Panel established six new Category I codes to describe reflectance confocal microscopy (RCM) for imaging of skin. For CPT codes 96931 and 96933, the specialty society and the RUC agreed that the physician work required for both codes were identical, and therefore, should be valued the same. The RUC recommended a work RVU of 0.80 for CPT codes 96931 and 96933 based on the 25th percentile of the survey. Based on the similarity of the services being performed in CPT codes 96931 and 96933 and the identical intra-service times of 96931, 96933 and 88305, the key reference code from the survey, we believe a direct crosswalk from CPT code 88305 to CPT codes 96931 and 96933 would more accurately reflect the work involved in furnishing the procedure. Therefore, for CY 2017, we proposed a work RVU of 0.75 for CPT codes 96931 and 96933. In addition, we proposed removing 3 minutes of preservice time from CPT codes 96931 and 96933 since it is not included in CPT code 88305 and as a result, we did not believe it was appropriate in CPT codes 96931 and 96933.
For CPT codes 96934 and 96936, the specialty society and the RUC agreed that the physician work required for both codes were identical, and therefore, should be valued the same. In its recommendation, the RUC stated that it believed the survey respondents somewhat overestimated the work for CPT code 96934 with the 25th percentile yielding a work RVU of 0.79. Consequently, the RUC reviewed the survey results from CPT code 96936 and agreed that the 25th percentile work RVU of 0.76 accurately accounted for the work involved for the service. Therefore, the RUC recommended a work RVU of 0.76 for CPT codes 96934 and 96936.
We believe that the incremental difference between the RUC-recommended values for the base and add-on codes accurately captures the difference in work between the code pairs. However, because we valued the base codes differently than the RUC, we proposed values for the add-on codes that maintain the RUC's 0.04 increment instead of the RUC-recommended values. Therefore we proposed a work RVU of 0.71 for CPT codes 96934 and 96936.
We also proposed to reduce the preservice clinical labor for “Patient clinical information and questionnaire reviewed by technologist, order from physician confirmed and exam protocoled by physician” for CPT codes 96934 and 93936 as this work is performed in the two base CPT codes 93931 and 93933. We proposed to reduce the service period clinical labor for “Prepare and position patient/monitor patient/set up IV” from 2 to 1 minute for CPT codes 93934 and 93936 since we believed that less positioning time is needed with subsequent lesions. We proposed to refine the service period clinical labor for “Other Clinical Activity—Review imaging with interpreting physician” to zero minutes for CPT codes 96933 and 96936 as these are interpretation and report only codes and not image acquisition.
One commenter stated CMS incorrectly removed technician time for “Other Clinical Activity—Review imaging with interpreting physician” for CPT codes 96933 and 96936 noting the technician still must review the imaging with the interpreting physician and urged CMS to accept the RUC recommendations.
For CY 2017, the CPT Editorial Panel deleted four CPT codes (97001, 97002, 97003, and 97004) and created eight new CPT codes (97161-97168) to describe the evaluative procedures furnished by physical therapists and
The CPT Editorial Panel's creation of the new codes for PT and OT evaluative procedures grew out of a CPT workgroup that was originally convened in January 2012 when contemplating major revision of the Physical Medicine and Rehabilitation CPT section of codes in response to our nomination of therapy codes as potentially misvalued codes, including CPT code 97001 (and, as a result, all four codes in the family) in the CY 2012 PFS proposed rule.
In reviewing the eight new CPT codes for evaluative procedures, the HCPAC forwarded recommendations for work RVUs and direct PE inputs for each code. Currently, CPT codes 97001 and 97003 both have a work RVU of 1.20, and CPT codes 97002 and 97004 both have a work RVU of 0.60. These CPT codes have reflected the same work RVUs since CY 1998 when we accepted the HCPAC values during CY 1998 rulemaking.
In the CY 2017 PFS proposed rule, we noted that the HCPAC submitted work RVU recommendations for each of the six new PT and OT evaluation codes. These recommendations are intended to be work neutral relative to the valuation for the previous single evaluation code for PT and OT, respectively. However, that assessment for each family of codes is dependent on the accuracy of the utilization forecast for the different complexity levels within the PT or OT family. As used in this section, work neutrality is distinct from the budget neutrality that is applied broadly in the PFS. Specifically, work neutrality is intended to reflect that despite changes in coding, the overall amount of work RVUs for a set of services is held constant from one year to the next. For example, if a service is reported using a single code with a work RVU of 2.0 for one year but that same service would be reported using two codes, one for “simple” and another for “complex” in the subsequent year valued at 1.0 and 3.0 respectively, work neutrality could only be attained if exactly half the services were reported using each of the two new codes. If more than half of the services were reported using the “simple” code, then there would be fewer overall work RVUs. If more than half of the services were reported using the “complex” code, then there would be more overall work RVUs. Therefore, work neutrality can only be assessed with an understanding of the relative frequency of how often particular codes will be reported.
The HCPAC recommended a work RVU of 0.75 for CPT code 97161, a work RVU of 1.18 for CPT code 97162, and a work RVU of 1.5 for CPT code 97163. The PT specialty society projected that the moderate complexity evaluation code would be reported 50 percent of the time because it is the typical evaluation, and the CPT codes for the low and high complexity evaluations are each expected to be billed 25 percent of the time. The HCPAC-recommended work RVU of 1.18 for CPT code 97162 represents the survey median with 30 minutes of intraservice time, 10 minutes of preservice time, and 15 minutes postservice time. The HCPAC notes this work value is appropriately ranked between levels 2 and 3 of the E/M office visit codes for new patients.
The HCPAC recommended a work RVU of 0.88 for CPT code 97165, a work RVU of 1.20 for CPT code 97166, and a work RVU of 1.70 for CPT code 97167. For the OT codes, work neutrality would be achieved only with a projected utilization in which the low complexity evaluation is billed 50 percent of the time; the moderate complexity evaluation is billed 40 percent of the time, and the high complexity evaluation only billed 10 percent of the time. For purposes of calculating work neutrality, the HCPAC recommended assuming that the low complexity code will be most frequently reported even though the HCPAC-recommended work RVU of 1.20 and 45 minutes of intraservice time for moderate complexity code is identical to that of the current OT evaluation code. The HCPAC believes that the work RVU of 1.20 is appropriately ranked between 99202 and 99203, levels 2 and 3 for E/M office visits for new outpatients.
In our review of the HCPAC recommendations, we noted the work neutrality and the inherent reliance on the utilization assumptions. We considered the three complexity levels for the PT evaluations and the three complexity levels for the OT evaluations; and we also considered the evaluation services described by the codes as a whole. The varying work RVUs and the dependence on utilization for each complexity level to ensure work neutrality in the PT and OT code families make it difficult for us evaluate the HCPAC's recommended values or to predict with a high degree of certainty whether physical and occupational therapists will actually bill for these services at the same rate forecast by their respective specialty societies.
We were concerned that the coding stratification in the PT and OT evaluation codes may result in upcoding incentives, especially while physical and occupational therapists gain familiarity and expertise in the differential coding of the new PT and OT evaluation codes that now include the typical face-to-face times and new required components that are not enumerated in the current codes. We were also concerned that stratified payment rates may provide, in some cases, a payment incentive to therapists to upcode to a higher complexity level than was actually furnished to receive a higher payment.
We understood that there may be multiple reasons for the CPT Editorial Panel to stratify coding for OT and PT evaluation codes based on complexity. We also noted that the codes will be used by payers in addition to Medicare, and other payers may have direct interest in making such differential payment based on complexity of OT and PT evaluation. Given our concerns regarding appropriate valuation, work neutrality, and potential upcoding, however, we did not believe that making different payment based on the reported complexity for these services is, at current, advantageous for Medicare or Medicare beneficiaries.
Given the advantages inherent and public interest in using CPT codes once they become part of the code set, we proposed to adopt the new CPT codes for use in Medicare for CY 2017. However, given our concerns about appropriate pricing and payment for the stratified services, we proposed to price the services described by these stratified codes as a group instead of individually. To do that, we proposed to utilize the authority in section 220(f) of the Protecting Access to Medicare Act (PAMA), which revised section 1848(c)(2)(C) of the Act to authorize the Secretary to determine RVUs for groups of services, rather than determining RVUs at the individual service level. We believed that using this authority instead of proposing to make payment based on Medicare G-codes will preserve consistency in the code set
We proposed a work RVU of 1.20 for both the PT and the OT evaluation groups of services. We proposed this work RVU because we believed it best represents the typical PT and OT evaluation. This is the value recommended by the HCPAC for the OT moderate complexity evaluation and nearly the same work RVU for corresponding PT evaluation (1.18). Additionally, a work RVU of 1.20 is the long-standing value for the current evaluation codes, CPT codes 97001 and 97003, and thus, assures work neutrality without reliance on particular assumptions about utilization, which we believed was the intent of the HCPAC recommendation.
Because we proposed to use the same work RVU for the six evaluation codes, we are not addressing any additional concerns about the utilization assumptions recommended to us. Because we proposed the same work values for each code in the family, there will be no ratesetting impact to work neutrality. As such, we are not revising the utilization crosswalks as projected by the respective therapy specialties to achieve work neutrality. However, were we to value each code in the PT or OT evaluation families individually, we would seek objective data from stakeholders to support the utilization crosswalks, particularly those for the OT family in which the low-level complexity evaluation is depicted as typical and the high complexity is projected to be billed infrequently at 10 percent of the overall number of OT evaluations.
We proposed to use the direct PE inputs forwarded by the HCPAC (with the refinements described below) for the moderate complexity PT and OT evaluations in the development of PE RVUs for the PT and OT codes as a group of services. For the PT codes, we proposed to use the recommended inputs for the moderate complexity code for the direct PE inputs of all three codes based on its assumption as the typical service. Our proposed direct PE inputs reflect the recommended values minus 2 minutes of physical therapist assistant (PTA) time in the service period because we believe that PTA tasks to administer certain assessment tools are appropriately included as part of the physical therapist's work and the time of the PTA to explain and score self-reported outcome measures is not separately included in the clinical labor of other codes. We proposed to include the recommended four sheets of laser paper without an association to a specific equipment item, but we solicited comment regarding the paper's use.
For the OT evaluation codes, we considered proposing to use the direct PE inputs for the low complexity evaluation because the OT specialty organization believes it represents the typical OT evaluation service with a projected 50 percent utilization rate. However, we proposed to use the moderate-level direct inputs instead, because the direct PE for this level is based on a vignette that is valued with the same intraservice time, 45 minutes, as the current code, CPT code 97003. Consequently, we proposed to use the recommended direct PE inputs for the moderate complexity code for use in developing PE RVUs for this group of services.
Our proposed direct PE inputs reflect the recommended values minus 2 minutes of occupational therapist assistant (OTA) time in the service period because we believe that OTA tasks to administer certain assessment tools are appropriately included as part of the occupational therapist's work and the time of the OTA to explain and score self-reported outcome measures is not separately included in the clinical labor of other codes. We also rounded up the recommended 6.8 minutes to 7 minutes to represent the time the OTA assists the occupational therapist during the intraservice time period. For the Vision Kit equipment item, our proposed price reflects the submitted invoice that clearly defined a kit.
The recommendations the HCPAC sent to us for the PT and OT re-evaluation codes are not work neutral. For the new PT re-evaluation code, CPT code 97164, the HCPAC recommended a work RVU of 0.75 compared to the work RVU of 0.60 for CPT code 97002. This recommended work RVU falls between the 25th percentile of the survey and the survey's median value and was based on a direct crosswalk to CPT code 95992 for canalith repositioning with 20 minutes intraservice time and 10 minutes immediate postservice time. The HCPAC supported this 0.15 work RVU increase based on an anomalous relationship between PT services and E/M office visit codes for established patients, noting that physician E/M codes have historically been used as a relative comparison. The HCPAC stated its recommendation of a work RVU of 0.75 for CPT code 97164 appropriately ranks it between the key reference codes for this service, CPT codes 99212 and 99213, levels 2 and 3 E/M office-visit codes for established patients.
The HCPAC provided a work RVU of 0.80 for the OT re-evaluation code, CPT code 97168, based on the 25th percentile of the survey, which represents an increase over the current work RVU of 0.60 for CPT code 97004. This work value includes 30 minutes of intraservice time, 5 minutes preservice time, and 10 minutes immediate postservice time. The HCPAC noted that the increase in work compared to the PT re-evaluation code (0.75) is because the occupational therapist spends more time observing and assessing the patient and, in general, the OT patient typically has more functional and cognitive disabilities. The HCPAC recommendation notes that the 0.80 work RVU recommendation appropriately ranks it between the level 1 and 2 E/M office-visit codes for new patients.
The HCPAC's recommended increases to work RVUs for the PT and OT re-evaluation codes are not work neutral. We are unclear why the HCPAC did not maintain work neutrality for the OT and PT re-evaluation codes since maintaining work neutrality was important to the establishment of the six new evaluation codes. We proposed to maintain the overall work RVUs for these services by proposing a work RVU of 0.60 for CPT codes 97164 and 97168, consistent with the work RVUs for the deleted re-evaluation codes. We solicited comments from stakeholders on whether there are reasons that the re-evaluation codes should be revalued without regard to work neutrality.
We proposed the HCPAC-recommended direct PE inputs for CPT code 97164 with a reduction in time for the PTA by 1 minute (from 5 to 4) in the service period—the line for “Other Clinical Activity”—because the time to explain and score the self-reported outcome measure (for example, Oswestry) is not separately included in the clinical labor of other codes.
We proposed the HCPAC-recommended direct PE inputs for CPT code 97168 with a reduction in time for the OTA by 1 minute (from 3 to 2) in the service period—the line for “Other Clinical Activity”—for the same reason we proposed to reduce the corresponding line for PTAs—because the time to explain and score any patient-self-administered functional and other standardized outcome measure is not separately included in the clinical labor of other codes.
Because the new CPT code descriptors contain new coding requirements for each complexity level, we solicited comment from the PT and
The following is summary of the comments we received:
Because we proposed the same values, a few commenters were concerned that we failed to discuss the difference in the PT and OT evaluation services. These commenters told us that the HCPAC recommendations included higher work RVUs for the OT services because they reflected greater intraservice times from the surveys, and these times led, in part, to the HCPAC's belief that the typical patient receiving OT services is more complex and intense to treat than the patient receiving PT services. The HCPAC and the OT specialty society urged us to consider the increase in work RVUs for the OT evaluative services, indicating in their comments that while the HCPAC recommendations for the PT evaluations were work-neutral, those for the OT evaluations were not. The HCPAC requested that we consider the difference in PT services versus OT services.
Some commenters presumed that our proposal to value the work the same for each evaluation complexity level was temporary. Another commenter expressed hope that we did not intend to equally value the PT high complexity evaluation the same as the low complexity one in perpetuity. Several commenters requested that CMS describe our future plans to revisit these code sets and asked that the future proposal for these payment amounts be subject to public comment. One of these commenters that favored keeping the current code structure urged us not to adopt the new CPT codes until we are ready to differentiate payments based on the complexity of the provided service.
Some commenters told us that our lack of payment stratification for the three PT and three OT evaluation codes would likely prompt coding and billing behavioral change by some therapists and other providers of therapy services. One of these commenters claimed that assigning the same work RVU to each evaluation complexity level would cause some providers not to adhere to the new coding stratification which could result in inaccurate data on the levels being reported. Another commenter stated that the lack of payment stratification to reflect the therapist's time and expertise at each complexity level could signal to therapists that the accurate coding of evaluations is of diminished interest to CMS. Other commenters stated that the failure to recognize payment stratification between the complexity levels would be detrimental to patient care and the practice of therapy, for example, by reducing incentives for therapists to thoroughly evaluate patients with multiple and complex conditions who fall into the high complexity evaluation.
We understand commenters' concerns about the possibility that the absence of payment stratification in the complexity levels of the PT and OT evaluations could have an effect on some therapists' coding behavior in for these services in CY 2017. However, we are also concerned with the implication that financial incentives are the primary drivers for accurate coding for a significant number of therapists, and if that is the case, we believe that implementing stratified coding would likely encourage upcoding since that is consistent with the financial incentives. We believe that the implementation of these new PT and OT code sets carries with it an inherent change for the therapists furnishing the services since there will be three complexity levels to replace just one and each new code contains newly defined necessary components. We also believe that it is premature to predict how therapists will code and bill the new complexity levels before therapists gain familiarity with the new codes.
We received several comments from stakeholders in response to our statement in the proposed rule that we would request additional objective data to support the utilization crosswalks, especially for the OT codes, if we were to value the codes individually for the PT and OT evaluation complexity levels. In its comments, the OT specialty society explained that their frequency estimations of the three complexity levels were based on the most recent utilization frequency data from the 2014 Medicare utilization from the five percent sample file. The OT specialty society also stated that it defined the complexity levels using certain groups of diagnoses and patient types. The PT specialty society stated that because its survey process included a broad cross-section of therapists working in the various Medicare settings, it believed its utilization projections for the low, moderate and high complexity evaluation were representative. Many commenters told us because some therapists may not initially code the complexity levels correctly, that we would need to consider an entire year of utilization data to ensure its accuracy.
A few commenters say they will need a delay of six months, at a minimum, to train therapists, since all new descriptors include various required elements and the typical time for each PT and OT complexity level and the re-evaluation codes. The majority of commenters, though, indicated they would need a year for their educational efforts to be successful. In addition to therapists, a few commenters told us they would have to educate coders and billers in the use of the new CPT codes. A few commenters noted the time to implement these new codes into their billing systems was too short.
The PT and OT specialty societies each told us about their plans to educate their therapist members and nonmembers to ensure coding accuracy. Each therapy association has already begun this training, some of which will include webinars, self-paced online courses, frequently asked questions, documentation resources, published articles, etc.
Some commenters asked CMS to work with various stakeholders and to either establish guidelines or assist in educating therapists about the new codes through Open Door Forums, MLN articles, etc. Additionally, they also wanted to work with CMS on LCDs established by contractors. One commenter stated that CMS must provide clear guidance regarding the selection of the appropriate level of evaluation services provided by physical and occupational therapists and the associated documentation requirements to ensure consistency and appropriate reporting of these services.
Several commenters asked us to consider a one-year reprieve from the payment consequences of medical review and audit requirements that address lack of documentation to support the complexity level of the code billed.
We understand and appreciate that the PT and OT specialty societies are already underway in their educational efforts of therapists, as it has been our past experience with the implementation of other CPT codes and code sets that the leading educational role is assumed by the specialty societies responsible for the code changes.
One commenter supported increasing the work RVUs, but suggested that the PT and OT re-evaluation codes should be equally valued for the relative work, PE and MP RVUs. This same commenter contended that because the patients treated by the PT and OT disciplines for hand rehabilitation are the same; that is, have the same functional and cognitive deficits, the same time and expertise of both physical and occupational therapists is required to perform a thorough re-evaluation. The commenter recommended that both re-evaluations reflect the 30-minute typical time that is inherent to the OT re-evaluation code.
Several commenters reminded us that the work RVU recommendations forwarded to us were not considered work neutral because the HCPAC accepted the PT and OT specialty societies' beliefs as compelling evidence that the practice of PT and OT have each significantly changed over the past two decades.
Some commenters reasoned that we should accept the HCPAC-recommended work RVUs for these codes, in part, because the PT and OT specialty societies completed the RUC-HCPAC defined survey process, including time and intensity of the services.
Comments from the HCPAC, the PT and OT specialty societies, and a few other stakeholders provided the rationale that the practice of PT and OT has significantly changed since 1997, including the work of physical therapists and occupational therapists. Some of their rationale included: (a) advances in technology has created opportunities for additional types of treatment approaches; and, (b) the work RVUs for the PT and OT re-evaluation codes have not kept pace with the relativity of increases in work RVUs of comparable E/M codes that have historically been used as comparison: In 1997 the 0.60 work RVUs for CPT codes 97002 and 97004 was 90 percent of that for CPT code 99213; today, it is just 62 percent. Other rationales included ones often cited by commenters requesting increases in RVUs, including increased patient acuity and administrative and reporting burdens.
We would like to take this opportunity to remind physical and occupational therapists about our manual instructions regarding the reporting of a both the evaluation and re-evaluation codes (MBPM, Chapter 15, section 220). Of note, to be separately payable, the re-evaluation requires a
After considering the comments, in summary, we are finalizing our proposals to (a) accept the new CPT codes 97161-97168 for PT and OT evaluative procedures and (b) use the PAMA smoothing authority to value the PT and OT complexity level evaluations as groups of services rather than individually by assigning a work RVU of 1.2 to each complexity level. We are modifying our proposal for the valuation of the PT and OT re-evaluation codes and are finalizing a work RVU of 0.75 for each code. Lastly, we are finalizing the PE inputs as proposed.
It is important to note that CMS defines the codes for these evaluative services as “always therapy.” This means that they always represent therapy services regardless of who performs them and always require a therapy modifier, GP or GO, to signify that the services are furnished under a PT or OT plan of care, respectively. These codes will also be subject to the therapy MPPR and to statutory therapy caps.
Since 2010, in addition to the codes for evaluative services, CMS has periodically added codes that represent therapy services to the list of potentially misvalued codes. The current list of ten therapy codes was based on the statutory category “codes that account for the majority of spending under the physician fee schedule,” as specified in section 1848(c)(2)(K)(ii)(VII) of the Act. We understand that the therapy specialty organizations have pursued the development of coding changes through the CPT process for these modality and procedure services. While we understand that, in some cases, it may take several years to develop appropriate coding revisions, we are, in the meantime, seeking information regarding appropriate valuation for the existing codes. See Table 24.
A few commenters believe the codes on the potentially misvalued code list are already valued correctly as the PE inputs for many therapy codes, including those defined by 15-minute intervals, have already been adjusted by the PEAC/RUC/HCPAC to account for efficiencies when billed with other therapy codes. Several commenters cautioned that any review must also consider that all of these codes are already subject to a 50 percent MPPR reduction. One commenter believes the work of CPT code 97140 is undervalued compared to other codes since it requires the more skilled therapist using manual techniques to touch the patient.
In the CY 2015 PFS proposed rule (79 FR 40349), we noted that it appeared that practice patterns for endoscopic procedures were changing. Anesthesia services are increasingly being separately reported for endoscopic procedures, meaning that resource costs associated with sedation were no longer incurred by the practitioner reporting the procedure. Subsequently, in the CY 2016 PFS proposed rule (80 FR 41707), we solicited public comment and recommendations on approaches to address the appropriate valuation of moderate sedation related to the approximately 400 diagnostic and therapeutic procedures for which the CPT Editorial Panel has determined that moderate sedation is an inherent part of furnishing the service. The CPT Editorial Panel created separate codes for reporting moderate sedation services (see Table 25).
For the newly created moderate sedation CPT codes, we proposed to use the RUC-recommended work RVUs for CPT codes 99151, 99152, 99155, and 99157. We stated in the CY 2017 proposed rule that CPT codes 99151 and 99152 make a distinction between moderate sedation services furnished to patients younger than 5 years of age and patients 5 years or older, with CPT codes 99155 and 99156 making a similar distinction. The RUC recommendations included a work RVU increment of 0.25 between CPT codes 99151 and 99152. For CPT code 99156, we proposed a work RVU of 1.65 to maintain the 0.25 increment relative to CPT code 99155 (a RUC-recommended work RVU of 1.90) and maintain relativity among the CPT codes in this family. We proposed to use the RUC-recommended direct PE inputs for all six codes.
We stated in the CY 2017 proposed rule that when moderate sedation is reported for Medicare beneficiaries, we expect that it would most frequently be reported using the code that describes moderate sedation furnished by the same person who also performs the primary procedure for patients 5 years
• G0500: moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service (excluding biliary procedures) that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older.
We proposed to value HCPCS code G0500 at 0.10 work RVUs based on the median survey result for GI respondents in the survey data. We proposed that when moderate sedation services are furnished by the same practitioner reporting the GI endoscopy procedure, practitioners would report the sedation services using HCPCS code G0500 instead of CPT code 99152. In all other cases, we proposed that practitioners would report moderate sedation using one of the new moderate sedation CPT codes consistent with CPT guidance. This would include the full range of codes for those furnishing moderate sedation with the remaining (non-GI endoscopy) base procedures, as well as for the other circumstances during which moderate sedation is furnished along with a GI endoscopy (for example, to a patient under 5 years of age or for a biliary procedure, the endoscopist furnishing moderate sedation should not use HCPCS code G0500, but instead use the appropriate CPT code.
In addition to proposing work RVUs for the new codes used to separately report moderate sedation, we stated in the proposed rule that the RUC provided recommendations that valued the procedural services without moderate sedation. However, the RUC recommended removing fewer RVUs from the procedures than it recommended for valuing the moderate sedation services that were removed from the procedure codes. In other words, the RUC recommended that overall payments for these procedures should be increased now that practitioners would be required to report the sedation services that were previously included as inherent parts of the procedures. We stated in the proposed rule that we believe that if we were to use the RUC recommendations for revaluation of the procedural services without refinement, the RVUs currently attributable to the redundant payment for sedation services when anesthesia is separately reported would be used exclusively to increase overall payment for these services. We refer readers to section II.D.5. of this final rule, which includes a more extensive discussion of our general principle that overall resource costs for procedures that include moderate sedation do not inherently change based solely on changes in coding.
To account for the separate billing of moderate sedation services, we proposed to maintain current values for the procedure codes less the work RVUs associated with the most frequently reported corresponding moderate sedation code so that practitioners furnishing the moderate sedation services previously considered to be inherent in the procedure would have no change in overall work RVUs. Since we proposed 0.10 work RVUs for moderate sedation for the GI endoscopy procedures, we proposed a corresponding 0.10 reduction in work RVUs for these same procedures. For all other Appendix G procedures that currently include moderate sedation as an inherent part of the procedure, we proposed to remove 0.25 work RVUs from the current values.
We received 22 comments from medical professionals, ambulatory surgical centers (ASCs), manufacturers, and professional medical specialty societies representing radiation oncology, brachytherapy, colon and rectal surgeons, certified registered nurse anesthetists (CRNAs), pediatrics, cardiology, thorasic surgery, general surgery, gastroenterology, emergency medicine, interventional radiology, and vascular surgery. Commenters were generally supportive of CMS' proposals related to valuation of the new moderate sedation codes. A few commenters disagreed with our proposed refinements for one of the new moderate sedation CPT codes. While most commenters were supportive of CMS' proposal to use a methodology to revalue the procedural services without moderate sedation, some commenters suggested that we should revalue certain procedures differently (for example, apply a lower work RVU reduction or make no reduction). A few commenters were opposed to separate reporting of moderate sedation and suggested alternatives for CMS to consider. Our responses to commenters' specific issues are included below.
Therefore, for CY 2017, we are finalizing work RVUs for the moderate sedation codes as follows:
• Work RVU of 0.50 for CPT code 99151;
• Work RVU of 0.25 for CPT code 99152;
• Work RVU of 1.90 for CPT code 99155;
• Work RVU of 1.65 for CPT code 99156; and
• Work RVU of 1.25 for CPT code 99157.
We note that CPT code 99153 is a PE-only code and we are finalizing the proposed PE inputs for CPT code 99153, as well as finalizing the proposed PE inputs for all other codes in this family without modification.
• G0500: Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older. (additional time may be reported with 99153, as appropriate).
In summary, after consideration of the comments, we are finalizing our proposed modifications to maintain the current values for the procedure codes less the work RVUs associated with the most frequently reported corresponding moderate sedation code. Practitioners furnishing the moderate sedation services previously considered to be inherent in the procedure will have no change in overall work RVUs. Since we are finalizing a work RVU of 0.10 (HCPCS code G0500) for moderate sedation for the GI endoscopy procedures, we are finalizing a corresponding 0.10 reduction in work RVUs for the corresponding procedural services. For all other Appendix G procedures that currently include moderate sedation as an inherent part of the procedure, we are finalizing a 0.25 work RVU reduction from the current values.
Table 26 lists the CY 2016 work RVUs for each applicable service and our proposed and final CY 2017 refined work RVUs using the finalized revaluation methodology described above. Additionally, the table identifies the GI endoscopic services for which HCPCS code G0500 will be used to report moderate sedation services (available in the “downloads” section of the PFS Web site at
We previously received RUC recommendations for face-to-face and non-face-to-face prolonged E/M services. In response to the request for public comments in the CY 2016 PFS proposed rule about improving payment accuracy for cognitive services, commenters suggested that we consider making separate payment for CPT codes 99358 and 99359. As reflected in section II.E, we proposed to make separate payment for these services.
We also proposed values for services in this family of codes based on the RUC-recommended values, including for CPT code 99354, which would increase the current work RVU to 2.33. Likewise, we proposed to adopt the RUC-recommended work RVU of 2.10 for CPT code 99358 and 1.00 for CPT code 99359.
We received RUC recommendations for CPT codes 99487 and 99489 following the October 2012 RUC meeting, however we considered these services bundled and did not make separate payment. For CY 2017, we proposed to change the procedure status for CPT codes 99487 and 99489 from B (bundled) to A (active), see II.E, and proposed to adopt the RUC-recommended work RVUs of 1.00 for CPT code 99487 and 0.50 for CPT code 99489, as well as direct PE inputs consistent with the RUC recommendations.
We received no comments on the valuation of CPT codes 99487 and 99489; therefore, we are finalizing as proposed.
The College of American Pathologists and the American Society of Cytopathology formed an expert panel to make recommendations at the October 2015 RUC meeting to determine an appropriate work RVU for HCPCS code G0416, as they believed that the survey results were invalid. The panel made several arguments to the RUC in recommending a higher work RVU under the RUC's “compelling evidence” standard. These arguments were: (1) That incorrect assumptions were made in previous valuations; (2) the value of HCPCS code G0416 remained constant while the code descriptors changed over the years; and (3) the “anomalous relationship” between HCPCS code G0416 and CPT code 88305 (Level IV—Surgical pathology, gross and microscopic examination). The expert panel recommended a work RVU of 4.00 based on a crosswalk from CPT code 38240 (Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor). The RUC agreed with the recommendation of the expert panel.
We believed HCPCS code G0416 should not be valued as a direct crosswalk from CPT code 38240. Instead, since code G0416 describes services that would otherwise be reported using CPT code 88305 we believed that G0416 should be valued relative to CPT code 88305. To value HCPCS code G0416, we used the intra-service time ratio between HCPCS code G0416 and CPT code 88305 to arrive at a work RVU of 3.60. To further support this method, we noted that the IWPUT for HCPCS code G0416 with a work RVU of 3.60 is the same as CPT code 88305. Using the RUC-recommended RVU of 4.00 results in a higher IWPUT, and we did not believe there is a difference in work intensity between these codes. Therefore for CY 2017, we proposed a work RVU of 3.60 for HCPCS code G0416.
We believe the vignette for CPT code 88305 typically involves, by definition, two blocks and resulting slides. Based upon that rationale, CMS values each block (and resulting slides) as worth a work RVU of 0.375. Valuing the RVUs on a per block basis, then a sextant
As discussed in section II.E. of this final rule, we proposed to establish payment for services furnished to patients with mobility-related disabilities, through a new add-on G-code, to be billable with office/outpatient E/M and TCM codes. Based on our analysis of the resources typically involved in furnishing office visits to patients with these needs (especially including the typical additional practitioner and staff time), we believed that the physician work and time for HCPCS code G0501 was most accurately valued through a direct crosswalk from CPT code 99212 (Level 2 office or other outpatient visit for the evaluation and management of an established patient). Therefore, we proposed a work RVU of 0.48 and a physician time of 16 minutes for HCPCS code G0501. We sought comment on whether these work and time values accurately capture the additional physician work typically involved in furnishing services to patients with mobility impairments.
We believed that a direct crosswalk to the clinical staff time associated with CPT code 99212, which is 27 minutes of LN/LPN/MTA (L037D) accurately represented the additional clinical staff time required to furnish an outpatient office visit or TCM to a patient with a mobility-related disability. We also proposed to include as direct PE inputs 27 minutes for a stretcher (EF018) and a high/low table (EF028), and 27 minutes for new equipment inputs associated with the following: A patient lift system, wheelchair accessible scale, and padded leg support positioning system. These items were included in the CY 2017 proposed direct PE input database. We sought comments on whether these inputs are appropriate, and whether any additional inputs are typically used in treating patients with mobility impairments.
For CY 2017, we proposed to establish and make separate Medicare payment using four new HCPCS G-codes, G0502 (Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional), G0503 (Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional), G0504 (Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional), and G0507 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month) for collaborative care and care management for beneficiaries with behavioral health conditions, as detailed in section II.E of this final rule. To value HCPCS codes G0502, G0503, and G0504, we proposed to base the portion of the work RVU that accounts for the work of the treating physician or other qualified health care professional on a direct crosswalk to the proposed work values for the complex CCM codes, CPT codes 99487 and 99489. To value the portion of the work RVU that accounts for the psychiatric consultant, we estimated 10 minutes of psychiatric consultant time per patient per month and a work RVU of 0.42, based on the per minute work RVUs for the highest volume codes typically billed by psychiatrists, since the resource costs of the consultant's work is being paid to the primary practitioner. Since the behavioral health care manager in the services described by HCPCS codes G0502, G0503, and G0504 should have specialized training in behavioral health, we proposed a new clinical labor type for the behavioral health care manager, L057B, at $0.57 per minute, based on the rates for genetic counselors in the direct PE input database. We solicited comment on all aspects of these proposed valuations.
We welcome any information on the best way to account for the work, time, and practice expense resource costs associated with two physicians when one physician is typically incurring the resource costs of another. We are particularly interested in information regarding how CoCM might apply for beneficiaries receiving care in an institutional or inpatient setting.
We believe that the work associated with the billing practitioner would overall be greater than the work associated with the psychiatric consultant. The work of the billing practitioner includes services such as broader care management, direction of the care manager, and by “incident to” rules, the general supervision of other staff, while the psychiatric consultant primarily conducts review work. Therefore, in allocating differential portion of the work RVU to each practitioner, we believe the work RVU associated with the billing practitioner should be greater than the work RVU associated with the psychiatric consultant.
After considering these comments, we are finalizing total work RVUs of 1.70 for G0502, 1.53 for G0503, and 0.82 for G0504. These RVUs include 0.52 for the psychiatric consultant based on a crosswalk to the work per minute of a level three established patient office visit.
To value HCPCS code G0507, we proposed a work RVU of 0.61 based on a direct crosswalk from CPT code 99490 (Chronic care management services). We recognize that the services described by CPT code 99490 are distinct from those furnished under the CoCM and we believe that these also vary based on different kinds of BHI care. We note that there are relatively few existing codes that describe these kinds of services over a calendar month. We also believe that the resources associated with CPT code 99490 may vary based on the ways different practitioners furnish the service. Until we have more information about how the services described by G0507 are typically furnished, we believe valuation based on an estimate of the typical resources would be most appropriate. To account for the care manager minutes in the direct PE inputs for HCPCS code G0507, we proposed to use clinical labor type L045C, which is the labor type for social workers/psychologists and has a rate of $0.45 per minute.
After considering these comments, we are finalizing a total work RVU of 0.61 for G0507.
For CY 2017, we proposed to create and pay separately for new HCPCS code G0505 (Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history face-to-face obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home), see II.E for further discussion. Based on similarities between work intensity and time, we believe that the physician work and time for this code would be accurately valued by combining the work RVUs from CPT code 99204 (Level 4 office or other outpatient visit for the evaluation and
For direct PE inputs we proposed 70 total minutes of time for RN/LPN/MTA (L037D). We believed this was typical based on information from several specialty societies representing practitioners who typically furnish this service and report, it, when appropriate, using E/M codes. We solicited comment on these valuation assumptions and welcomed additional information on the work and direct PE associated with furnishing this service.
For CY 2017, we proposed to make payment for the resource costs of comprehensive assessment and care planning for patients requiring CCM services through HCPCS code G0506 as an add-on code to be billed with the initiating visit for CCM for patients that require extensive assessment and care planning (see section II.E). In valuing this code, we believed that a crosswalk to half the work and time values of HCPCS code G0181 (Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more) accurately accounts for the time and intensity of the work associated with furnishing this service over and above the work accounted for as part of the separately billed initiating visit. Therefore, we proposed a work RVU of 0.87 and 29 minutes of physician time. We also proposed 36 minutes for a RN/LPN/MTA (L037D) as the only direct PE input for this service.
As discussed in section II.C, we proposed use of new HCPCS G-codes, G0508 (Telehealth consultation, critical care, physicians typically spend 60 minutes communicating with the patient via telehealth (initial) and G0509 (Telehealth consultation, critical care, physicians typically spend 50 minutes communicating with the patient via telehealth (subsequent)), to report telehealth consultations for a patient requiring critical care services, such as a stroke patient. We noted that due to limited coding granularity for high-intensity cognitive services, in the PFS, we did not believe there is an intuitive crosswalk code for ideal estimation of the work and time values for G0508. In general, we believed that the overall work for G0508 is not as great as 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) but that the service involves more work than HCPCS code G0427 (Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth). We believe that G0508 is most accurately valued by a crosswalk to the work RVU and physician intra-service time of CPT code 38240 (Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor). Therefore, we proposed a work RVU of 4.0 and solicited comment on the accuracy of these assumptions. We did not believe that direct PE inputs would typically be involved with furnishing this service from the distant site. For G0509 we proposed a work RVU of 3.86 based on a crosswalk from G0427. We believed that G0427 has similar overall work intensity to G0509 and has a similar intraservice time. We also believed that no direct PE inputs would typically be associated with furnishing this service from the distant site.
• G0508: Telehealth consultation, critical care, physicians typically spend 60 minutes communicating with the patient and providers via telehealth (initial).
• G0509: Telehealth consultation, critical care, physicians typically spend 50 minutes communicating with the patient and providers via telehealth (subsequent).
Section 1833(g) of the Act requires application of annual per beneficiary limitations on the amount of expenses that can be considered as incurred expenses for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” There is one therapy cap for outpatient occupational therapy (OT) services and another separate therapy cap for physical therapy (PT) and speech-language pathology (SLP) services combined.
The therapy caps apply to outpatient therapy services furnished in all settings, including the previously exempted hospital setting (effective October 1, 2012), critical access hospitals (CAHs) (effective January 1, 2014), and Maryland hospitals paid under the Maryland All-Payer Model (effective January 1, 2016).
The therapy cap amounts under section 1833(g) of the Act are updated each year based on the Medicare Economic Index (MEI). Specifically, the annual caps are calculated by updating the previous year's cap by the MEI for the upcoming calendar year and rounding to the nearest $10.00. Increasing the CY 2016 therapy cap of $1,960 by the CY 2017 MEI of 1.2 percent and rounding to the nearest $10.00 results in a CY 2017 therapy cap amount of $1,980.
An exceptions process for the therapy caps has been in effect since January 1, 2006. Originally required by section 5107 of the Deficit Reduction Act of 2005 (DRA), which amended section 1833(g)(5) of the Act, the exceptions process for the therapy caps has been extended multiple times through subsequent legislation as described in the CY 2015 PFS final rule with comment period (79 FR 67730) and most recently extended by the MACRA. Our current authority to provide an exceptions process for therapy caps expires on December 31, 2017.
CMS tracks each beneficiary's incurred expenses annually and counts them towards the therapy caps by applying the PFS rate for each service less any applicable multiple procedure payment reduction (MPPR) amount. As required by section 1833(g)(6)(B) of the Act, added by section 603(b) of the American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240) and extended by subsequent legislation, the PFS-rate accrual process is applied to outpatient therapy services furnished by CAHs even though they are paid on a cost basis. As we explained in the CY 2016 PFS final rule, we use cost-based rates to track each beneficiary's incurred expenses amounts for the outpatient therapy services furnished by the Maryland hospitals paid under the Maryland All-Payer Model, currently being tested under the authority of section 1115A of the Act. After expenses incurred for the beneficiary's outpatient therapy services for the year have exceeded one or both of the therapy caps, therapy suppliers and providers use the KX modifier on claims for subsequent services to request an exception to the therapy caps. By using the KX modifier, the therapist is attesting that the services above the therapy caps are reasonable and necessary and that there is documentation of medical necessity for the services in the beneficiary's medical record. Claims for outpatient therapy services over the caps without the KX modifier are denied.
Since October 1, 2012, under section 1833(g)(5)(C) of the Act as amended by the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) (Pub. L. 112-96), we have been required to apply a manual medical review process to therapy claims when a beneficiary's incurred expenses for outpatient therapy services exceed a threshold amount of $3,700. Just as there are two separate therapy caps, there are two separate thresholds of $3,700, one for OT services and one for PT and SLP services combined; and incurred expenses are counted towards these thresholds in the same manner as the caps. Under section 1833(g)(5) of the Act, as amended by section 202(b) of the MACRA, not all claims exceeding the therapy thresholds are subject to a manual medical review process as they were before. Instead, since MACRA, we are permitted to do a more targeted medical review on these claims using factors specified in section 1833(g)(5)(E)(ii) of the Act as amended by section 202(b) of the MACRA, including targeting those therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers. The manual medical review process required under section 1833(g)(5)(C) of the Act expires at the same time as the exceptions process for therapy caps, on December 31, 2017. For information on the manual medical review process, go to
In the CY 2016 PFS final rule with comment period (80 FR 71080 through 71088), we finalized policies for payment of CCM services in RHCs and FQHCs. Payment for CCM services in RHCs and FQHCs was effective beginning on January 1, 2016, for RHCs and FQHCs that furnish a minimum of 20 minutes of qualifying CCM services during a calendar month to patients with multiple (two or more) chronic conditions that are expected to last at least 12 months or until the death of the patient, and that would place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Payment is made when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim, and the rate is based on the PFS national average non-facility payment rate. The requirement that RHC or FQHC services be furnished face-to-face was waived for CCM services furnished to a RHC or FQHC patient because CCM services are not required to be furnished face-to-face.
Medicare payment for TCM services furnished by a RHC or FQHC practitioner was effective January 1, 2013, consistent with the effective date of payment for TCM services under the PFS (77 FR 68978 through 68994; also, see CMS-Pub. 100-02, Medicare Benefit Policy Manual, chapter 13, section 110.4).
TCM services are billable only when furnished within 30 days of the date of the patient's discharge from a hospital (including outpatient observation or partial hospitalization), skilled nursing facility, or community mental health center. Communication (direct contact, telephone, or electronic) with the patient or caregiver must commence within 2 business days of discharge, and a face-to-face visit must occur within 14 days of discharge for moderate complexity decision making (CPT code 99495), or within 7 days of discharge for high complexity decision making (CPT code 99496). The TCM visit is billed on the day that the TCM visit takes place, and only one TCM visit may be paid per beneficiary for services furnished during that 30 day post-discharge period. If the TCM visit occurs on the same day as another billable visit, only one visit may be billed. TCM and CCM cannot be billed during the same time period for the same patient.
In the CY 2016 PFS final rule with comment period (80 FR 71087), we responded to comments requesting that we make an exception to the supervision requirements for auxiliary personnel furnishing CCM and TCM services incident to physician services in RHCs and FQHCs (80 FR 71087). Auxiliary personnel in RHCs and FQHCs furnish services incident to a RHC or FQHC visit and include nurses, medical assistants, and other clinical personnel who work under the direct supervision of a RHC or FQHC practitioner. The commenters suggested that the regulatory language be amended to be consistent with the provision in § 410.26(b)(5) for CCM and TCM services under the PFS, which states that services and supplies furnished incident to CCM and TCM services can be furnished under general supervision of the physician (or other practitioner) when they are provided by clinical staff. It further specifies that the physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based, but only the supervising physician (or other practitioner) may bill Medicare for incident to services. We responded that due to the differences between physician offices and RHCs and FQHCs in their models of care and payment structures, we believe that the direct supervision requirement for services furnished by auxiliary personnel is appropriate for RHCs and FQHCs, but that we would consider changing this in future rulemaking if RHCs and FQHCs found that requiring direct supervision presents a barrier to furnishing CCM services.
Since payment for CCM in RHCs and FQHCs began on January 1, 2016, some RHCs and FQHCs have informed us that, in their view, the direct supervision requirement for auxiliary personnel has limited their ability to furnish CCM services. Specifically, these RHCs and FQHCs have stated that the direct supervision requirement prevented them from entering into contracts with third party companies to provide CCM services, especially during hours that they were not open, and that they were unable to meet the CCM requirements within their current staffing and budget constraints.
To bill for CCM services, RHCs and FQHCs must ensure that there is access to care management services on a 24 hour a day, 7 day a week basis. This includes providing the patient with a means to make timely contact with RHC or FQHC practitioners who have access to the patient's electronic care plan to address his or her urgent chronic care needs. The RHC or FQHC must ensure the care plan is available electronically at all times to anyone within the RHC or FQHC who is providing CCM services.
Once the RHC or FQHC practitioner has initiated CCM services and the patient has consented to receiving this service, CCM services can be furnished by a RHC or FQHC practitioner, or by auxiliary personnel, as defined in § 410.26(a)(1), which includes nurses, medical assistants, and other personnel working under physician supervision who meet the requirements to provide incident to services. Auxiliary personnel in RHCs and FQHCs must furnish services under direct supervision, which requires that a RHC or FQHC practitioner be present in the RHC or FQHC and immediately available to furnish assistance and direction. The RHC or FQHC practitioner does not need to be present
Although many RHCs and FQHCs prefer to furnish CCM and TCM services utilizing existing personnel, some RHCs and FQHCs would like to contract with a third party to furnish aspects of their CCM and TCM services, but cannot do so because of the direct supervision requirement. Without the ability to contract with a third party, these RHCs and FQHCs have stated that they find it difficult to meet the CCM requirements for 24 hours a day, 7 days a week access to services.
To enable RHCs and FQHCs to effectively contract with third parties to furnish aspects of CCM and TCM services, we proposed to revise § 405.2413(a)(5) and § 405.2415(a)(5) to state that services and supplies furnished incident to CCM and TCM services can be furnished under general supervision of a RHC or FQHC practitioner. The proposed exception to the direct supervision requirement would apply only to auxiliary personnel furnishing CCM or TCM incident to services, and would not apply to any other RHC or FQHC services. The proposed revisions for CCM and TCM services and supplies furnished by RHCs and FQHCs are consistent with § 410.26(b)(5), which allows CCM and TCM services and supplies to be furnished by clinical staff under general supervision when billed under the PFS.
The following is a summary of the comments we received on revising the supervision requirements for RHCs and FQHCs to allow general supervision for auxiliary personnel furnishing CCM or TCM services.
After considering the comments, we are finalizing this policy to revise § 405.2413(a)(5) and § 405.2415(a)(5) to state that services and supplies furnished incident to CCM and TCM services can be furnished under general supervision of a RHC or FQHC practitioner.
Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-152) added section 1834(o) of the Act to establish a payment system for the costs of FQHC services under Medicare Part B based on prospectively set rates. In the Prospective Payment System (PPS) for FQHC Final Rule published in the May 2, 2014
Section 1834(o)(2)(B)(ii) of the Act requires that the payment for the first year after the implementation year be increased by the percentage increase in the MEI. Therefore, in CY 2016, the FQHC PPS base payment rate was increased by the MEI. The MEI was based on 2006 data from the American Medical Association (AMA) for self-employed physicians and was used in the PFS Sustainable Growth Rate (SGR) formula to determine the conversion factor for physician service payments. (See the CY 2014 PFS final rule (78 FR 74264) for a complete discussion of the 2006-based MEI). Section 1834(o)(2)(B)(ii) of the Act also requires that beginning in CY 2017, the FQHC PPS base payment rate is to be increased by the percentage increase in a market basket of FQHC goods and services, or if such an index is not available, by the percentage increase in the MEI.
For CY 2017, we proposed to create a 2013-based FQHC market basket. The market basket uses Medicare cost report (MCR) data submitted by freestanding FQHCs. In the discussion in the CY 2017 PFS proposed rule (81 FR 46378-46386) we provided an overview of the market basket and described the methodologies used to determine the cost categories, cost weights, and price proxies. In addition, we compared the growth rates of the proposed FQHC market basket to the growth rates of the MEI.
The 2013-based FQHC market basket is a fixed-weight, Laspeyres-type price index. A Laspeyres price index measures the change in price, over time, of the same mix of goods and services purchased in the base period. Any changes in the quantity or mix of goods and services (that is, intensity) purchased over time relative to a base period are not measured.
The index itself is constructed in three steps. First, a base period is selected (in this final rule, the base period is CY 2013), total base period costs are estimated for a set of mutually exclusive and exhaustive cost categories, and the proportion of total costs that each cost category represents is calculated. These proportions are called cost weights. Second, each cost category is matched to an appropriate price or wage variable, referred to as a price proxy. These price proxies are derived from publicly available statistical series that are published on a consistent schedule (preferably at least on a quarterly basis). Finally, the cost weight for each cost category is multiplied by the established price proxy index level. The sum of these products (that is, the cost weights multiplied by their price levels) for all cost categories yields the composite index level of the market basket for the given time period. Repeating this step for other periods produces a series of market basket levels over time. Dividing the composite index level of one period by the composite index level for an earlier period produces a rate of growth in the input price index over that timeframe.
As previously noted, the market basket is described as a fixed-weight index because it represents the change in price over time of a constant mix (quantity and intensity) of goods and services needed to furnish FQHC services. The effects on total costs resulting from changes in the mix of goods and services purchased subsequent to the base period are not measured. For example, a FQHC hiring more nurses to accommodate the needs of patients would increase the volume
In 2015, we began researching the possibility of creating a FQHC market basket that would be used in place of the MEI to update the FQHC PPS base payment rate annually. A FQHC market basket should reflect the cost structures of FQHCs while the MEI reflects the cost structures of self-employed physician offices. At the time of implementation of the FQHC PPS, a FQHC market basket had not been developed, and therefore, the law stipulated that the FQHC PPS base payment rate be updated by the MEI for the first year after implementation (CY 2016). In subsequent years, the FQHC PPS base payment rate should be annually updated by a FQHC market basket, if available.
The MEI cost weights were derived from data collected by the AMA on the Physician Practice Expense Information Survey (PPIS), since physicians, unlike other Medicare providers, are not required to complete and submit a Medicare Cost Report. FQHCs submit expense data annually on the Medicare Cost Report form CMS-222-92 (OMB NO: 0938-0107), “Independent Rural Health Clinic and Freestanding Federally Qualified Health Center Cost Report”; therefore, we were able to estimate relative cost weights specific to FQHCs. We define a “major cost weight” as one calculated using the Medicare cost reports (for example, FQHC practitioner compensation). However, the Medicare cost report data allows multiple methods for reporting detailed expenses, either in detailed cost center lines or more broadly reported in general categories of expenses. An alternative data source is used to disaggregate further residual costs that could not be classified into a major cost category directly using only the Medicare Cost Report data. We estimated the cost weights for each year 2009 through 2013 and found the cost weights from each year to be similar, which provided confidence in the derived cost weights.
We believe that the proposed methodologies for the FQHC market basket better reflect the cost structure of FQHC since it captures the scope of services that FQHCs furnish compared to the 2006-based MEI.
The 2013-based FQHC market basket consists of eight major cost categories, which were derived from the CY 2013 Medicare cost reports for freestanding FQHCs. These categories are FQHC-Practitioner Compensation, Other Clinical Compensation, Non-Health Compensation, Fringe Benefits, Pharmaceuticals, Fixed Capital, Moveable Capital, and an All Other (Residual) cost category. The All Other (Residual) cost category reflects the costs not captured in the other seven cost categories. The CY 2013 Medicare cost reports include all FQHCs whose cost reporting period began on or after January 1, 2013, and prior to or on December 31, 2013. We selected CY 2013 as the base year because the Medicare cost reports for that year were the most recent, complete set of Medicare cost report data available for FQHCs at the time of development of the cost share weights and proposed 2013-based FQHC market basket. As stated above, we compared the cost share weights from the MCR for CY 2009 through CY 2013 and the CY 2013 weights were consistent with the weights from prior years.
The resulting 2013-based FQHC market basket cost weights reflect Medicare allowable costs. We define Medicare allowable costs for freestanding FQHC facilities as: Worksheet A, Columns 1 and 2, cost centers lines 1 through 51 but excluding line 20, which is professional liability insurance (PLI). We excluded PLI costs from the total Medicare allowable costs because FQHCs that receive section 330 grant funds also are eligible to apply for medical malpractice coverage under Federally Supported Health Centers Assistance Act (FSHCAA) of 1992 (Pub. L. 102-501) and FSHCAA of 1995 (Pub. L. 104-73 amending section 224 of the Public Health Service Act).
Below we summarize how we derive the eight major cost category weights.
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Although a cost weight for these categories could be obtained directly from the costs reported in that cost center's respective line on the cost report form, some FQHCs reported significant costs in other (specify), or “free form,” lines which made it difficult to determine the accuracy of these costs. For example, some FQHCs reported costs only in the free form lines and not in the cost center specific lines, while other FQHCs reported costs in both the cost center specific lines and the free form lines. Since a majority of FQHCs used the free form lines, relying solely on the costs reported in the cost center specific lines for costs could lead to an inaccurate cost weights in the market basket. For example, if a FQHC reported all other healthcare costs in line 21 rather than breaking the healthcare costs into the detailed cost centers (lines 17 through 20.50), then the cost weight for medical supplies could be lower than it should be if we did not allocate the costs reported in the free form lines to medical supplies.
Section III.B.1.b explains the method used to allocate the residual costs to more detailed cost categories.
After we derived costs for the eight major cost categories for each FQHC using the Medicare cost report data as previously described, we addressed data outliers using the following steps. First, we divided the costs for each of the eight categories by total Medicare allowable costs for each FQHC. We then removed those FQHCs whose derived cost weights fell in the top and bottom 5 percent of provider specific derived cost weights. Five percent is the standard trim applied for all CMS market basket cost weights. After these outliers were removed, we summed the costs for each category across all remaining FQHCs. We then divided this by the sum of total Medicare allowable costs across all remaining FQHCs to obtain a cost weight for the 2013-based FQHC market basket for the given category. See Table 33 for the resulting cost weights for these major cost categories that we obtained from the Medicare cost reports.
The All Other Residual cost weight was derived from summing all expenses reported on the Medicare cost report Worksheet A, columns 1 and 2 for medical supplies (line 17), transportation (line 18), allowable GME pass through costs (line 20.50), facility
To further divide the “All Other” residual cost weight (20.1 percent) estimated from the CY 2013 Medicare cost report data into more detailed cost categories, we used the relative cost shares from the 2006-based MEI for nine detailed cost categories: Utilities; Miscellaneous Office Expenses; Telephone; Postage; Medical Equipment; Medical Supplies; Professional, Scientific, & Technical Services; Administrative & Facility Services; and Other Services. For example, the Utilities cost represents 7 percent of the sum of the 2006-based MEI “All Other” cost category weights; therefore, the Utilities cost weight would represent 7 percent of the 2013-based FQHC market basket's “All Other” cost category (20.066 percent), yielding a “final” Utilities cost weight of 1.4 percent in the 2013-based FQHC market basket (7 percent * 20.1 percent = 1.4 percent).
Table 34 shows the cost weight for each matching category from the 2006-based MEI, the percent each cost category represents of the 2006-baesd MEI “All Other” cost weight, and the resulting proposed 2013-based FQHC market basket cost weights for detailed cost categories.
FQHCs have liberty in how and where certain costs are reported on the Medicare cost report form CMS-222-92. We believe that, given the ambiguity in how the data are reported for these overhead cost centers on the FQHC cost report form, relying on the relative shares determined from the MEI is reasonable. We believe that the revised FQHC cost report form will allow us to better estimate the detailed cost weights for these categories directly. We expect all FQHCs to report PPS costs on the new form for cost report periods beginning after October 1, 2014. The following is a description of the types of expenses included in the FQHC detailed cost categories derived from the All Other (Residual) cost category:
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•
•
•
•
•
•
•
Table 35 shows the cost categories and weights for the 2013-based FQHC market basket. The resulting cost weights include combining the cost weights derived from the Medicare Cost Report Data (shown in Table 33), distributing the fringe benefits weight across the three compensation cost categories (shown in Table 32), and disaggregating the residual cost weight into detailed cost categories (shown in Table 34). Additionally, we compare the cost weights of the 2013-based FQHC market basket to the cost weights in the 2006-based MEI, where we have grouped the cost weights from the MEI to align with the FQHC cost categories.
Although the overall cost structure of the MEI, the index currently used to update the FQHC PPS base payment, is similar to the FQHC cost structure, there are a few key differences. First, though total compensation costs in the FQHC market basket and the MEI are each approximately 67-68 percent of total costs, non-health compensation accounts for a larger share of compensation costs in the FQHC setting than in the self-employed physician office. Likewise, physician compensation accounts for a larger percentage of costs in the MEI than FQHC practitioner compensation accounts for in the FQHC market basket. Second, the FQHC market basket includes a cost category for pharmaceuticals, while drug costs are excluded from the MEI. Drug costs are an expense in the FQHC PPS base payment rate since drugs and biologicals that are not usually self-administered, and certain Medicare-covered preventive injectable drugs are paid incident to a visit while drug costs are reimbursed separately under the PFS. Third, as mentioned previously, PLI expenditures are excluded from the FQHC market basket since most FQHC's PLI costs are covered under the FSHCAA, while in the MEI the PLI costs are a significant expense for self-employed physicians. Finally, fixed capital expenses, which include costs such as office rent and depreciation, are about half of the share in the FQHC market basket as they are in the MEI.
After establishing the 2013 cost weights for the FQHC market basket, an appropriate price proxy was selected for each cost category. The price proxies are chosen from a set of publicly available price indexes that best reflect the rate of price change for each cost category in the FQHC market basket. All of the proxies for the 2013-based FQHC market basket are based on indexes published by the Bureau of Labor Statistics (BLS) and are grouped into one of the following BLS categories:
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We evaluate the price proxies using the criteria of reliability, timeliness, availability, and relevance. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Timeliness implies that the proxy is published regularly, preferably at least once a quarter. Availability means that the proxy is publicly available. Finally, relevance means that the proxy is applicable and representative of the cost category weight to which it is applied. We believe the PPIs, CPIs, and ECIs selected meet these criteria.
Table 36 lists all price proxies for the 2013-based FQHC market basket. Below is a detailed explanation of the price proxies for each cost category; we note that many of the proxies for the 2013-based FQHC market basket are the same as those used for the 2006-based MEI.
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(12)
(13)
(14)
(15)
Table 36 lists the proposed price proxies for each cost category in the proposed FQHC market basket.
Section 1834(o)(2)(B)(ii) of the Act describes the methods for determining updates to FQHC PPS payment. After the first year of implementation, the FQHC PPS base payment rate must be increased by the percentage increase in the MEI. In subsequent years, the FQHC PPS base payment rate shall be increased by the percentage increase in a market basket of FQHC goods and services as established through regulations or, if not available, the MEI published in the PFS final rule.
The MEI published in the PFS final rule has a productivity adjustment. The MEI has been adjusted for changes in productivity since its inception. In the CY 2003 PFS final rule with comment period (67 FR 80019), we implemented a change in the way the MEI was adjusted to account for changes in productivity. In 2012, we convened the MEI Technical Panel to review all aspects of the MEI including and the productivity adjustment. For more information regarding the MEI Technical Panel, see the CY 2014 PFS final rule with comment period (78 FR 74264). The MEI Technical Panel concluded in Finding 5.1 that “such an adjustment continues to be appropriate. This adjustment prevents `double counting' of the effects of productivity improvements, which would otherwise be reflected in both (i) the increase in compensation and other input price proxies underlying the MEI, and (ii) the growth in the number of physician services performed per unit of input resources, which results from advances in productivity by individual physician practices.”
We proposed to include a productivity adjustment similar to the MEI in the FQHC market basket. We believe that applying a productivity adjustment is appropriate because this would be consistent with the MEI, which has an embedded productivity adjustment. We note that the MEI Technical Panel concluded that a productivity adjustment is appropriate for the MEI given the type of services performed in physician's offices. Specifically, the MEI Technical Panel report states that “The input price increases within the MEI are reflected in the price proxies, such as changes in wages and benefits. Wages increase, in part, due to the ability of workers to increase the amount of output per unit of input. Absent a productivity adjustment in the MEI, physicians would be receiving increased payments resulting both from their ability to increase their individual outputs and from the productivity gains already reflected in the wage proxies used in the index. The productivity adjustment used in the MEI ensures the productivity gains reflected in increased outputs are not double counted, or paid for twice. Currently, the productivity adjustment in the MEI is based on changes in economy-wide productivity based on the rationale that the price proxy for physician income reflects changes in economy-wide wages. Implicitly, this assumes physicians can achieve the same level of productivity as the average general wage earner.” We believe that the services performed in FQHC facilities are similar to those covered by physician visits, and therefore, a productivity adjustment is appropriate to avoid double counting of the effects of productivity improvements in the FQHC market basket.
We proposed to use the most recent estimate of the 10-year moving average of changes in annual private nonfarm business (economy-wide) multifactor productivity (MFP), which is the same measure of MFP used in the MEI. The BLS publishes the official measure of private nonfarm business MFP. (See
We note that MFP is derived by subtracting the contribution of labor and capital input growth from output growth. Since at the time of the proposed rule the 2015 MFP has not been published by BLS, we rely on a projection of MFP. The projection of MFP is currently produced by IHS Global Insight (IGI), a national economic forecasting firm with which CMS contracts to forecast the components of the market basket and MFP. A complete description of the MFP projection methodology is available at
Using IGI's first quarter 2016 forecast, the productivity adjustment for CY 2017 (the 10-year moving average of MFP for the period ending CY 2015) was projected to be 0.4 percent. If more recent data are subsequently available (for example, a more recent estimate of the market basket and MFP adjustment), we would use such data to determine the CY 2017 increase in the FQHC market basket in the final rule.
For CY 2017, we proposed to use the 2013-based FQHC market basket increase factor to update the FQHC PPS base payment rate. Consistent with CMS practice, we estimated the market basket update for the FQHC PPS based on the most recent forecast from IGI. Identical to the MEI, we proposed to use the update based on the most recent historical data available at the time of
Based on IGI's first quarter 2016 forecast with historical data through the fourth quarter of 2015, the projected proposed FQHC market basket increase factor for CY 2017 was 1.7 percent. This reflected a 2.1-percent increase of FQHC input prices and a 0.4-percent adjustment for productivity. We also proposed that if more recent data are subsequently available (for example, a more recent estimate of the market basket or MFP) we would use such data, to determine the CY 2017 update in the final rule.
For comparison, the 2006-based MEI was projected to be 1.3 percent in CY 2017; this estimate was based on IGI's first quarter 2016 forecast (with historical data through the fourth quarter of 2015). Table 37 compares the proposed 2013-based FQHC market basket updates and the proposed 2006-based MEI market basket updates for CY 2017.
For CY 2017, the proposed 2013-based FQHC market basket update (1.7 percent) is 0.4 percent higher than the 2006-based MEI (1.3 percent). The 0.4 percentage point difference stems mostly from the inclusion of pharmaceuticals in the FQHC market basket. This cost category and associated price pressures are not included in the MEI.
We proposed to update the FQHC PPS base payment rate by 1.7 percent for CY 2017 based on the 2013-based FQHC market basket. The FQHC market basket would more accurately reflect the actual costs and scope of services that FQHCs furnish compared to the 2006-based MEI. We invited public comment on all aspects of the FQHC market basket proposals.
We received 12 comments on the proposed FQHC market-basket. The following is a summary of the comments we received:
Additionally, only 17 FQHCs reported costs in line 4 (Visiting Nurse) of Worksheet A of the cost report, which is approximately 1.4 percent of all FQHCs that submitted cost reports. Had these costs been allocated to “FQHC Practitioner Compensation,” the proposed “FQHC Practitioner Compensation” cost share weight would essentially be unchanged (31.9 percent if we were to include the Visiting Nurse Compensation costs in that category compared to the proposed 31.7 percent). This small difference, based on a very small proportion of FQHC's who report this data, would not impact the growth rate of the FQHC market basket. Thus, we believe that changing our proposed classification of these expenses is not necessary at this time. We will consider this issue when we rebase and revise the FQHC market basket in the future using the revised cost report form.
After considering the public comments, we are finalizing the FQHC market basket, as proposed. We believe that the FQHC market basket, as proposed, more accurately reflects the actual costs and scope of services that FQHCs furnish relative to the MEI. We
Table 38 shows the final 2013-based FQHC Market Basket cost categories, cost weights, and price proxies.
We also proposed that we would use the most recent data available to determine the final FQHC market basket and MFP update for CY 2017. Based on IGI's third quarter 2016 forecast with historical data through the second quarter of 2016, the final FQHC market basket increase factor for CY 2017 is 1.8 percent. This reflects a 2.2 percent increase of FQHC input prices and a 0.4-percent adjustment for productivity. For comparison, the MEI increase factor for CY 2017 is 1.2 percent (a 1.6 percent MEI update and a 0.4 percent MFP adjustment); these updates reflect the most historical data available, with historical data through the second quarter of 2016.
Table 39 shows the final 2013-based FQHC market basket updates compared to the proposed 2013-based FQHC market basket updates for CY 2017.
Section 218(b) of the PAMA amended Title XVIII of the Act to add section 1834(q) of the Act directing us to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. The CY 2016 PFS final rule with comment period addressed the initial component of the new Medicare AUC program, specifying applicable AUC. In that rule we established evidence-based process and transparency requirements for the development of AUC, defined provider-led entities (PLEs) and established the process by which PLEs may become qualified to develop, modify or endorse AUC. The first list of qualified PLEs were posted on the CMS Web site at the end of June 2016 at which time their AUC libraries became specified AUC for purposes of section 1834(q)(2)(A) of the Act.
This rule proposed requirements and processes for specification of qualified clinical decision support mechanisms (CDSMs) under the Medicare AUC program; the initial list of priority clinical areas; and exceptions to the requirement that ordering professionals consult specified applicable AUC when ordering applicable imaging services.
AUC present information in a manner that links: A specific clinical condition or presentation; one or more services; and, an assessment of the appropriateness of the service(s). For purposes of this program, AUC are a set or library of individual appropriate use criteria. Each individual criterion is an evidence-based guideline for a particular clinical scenario. Each scenario in turn starts with a patient's presenting symptoms and/or condition. Evidence-based AUC for imaging can assist clinicians in selecting the imaging study that is most likely to improve health outcomes for patients based on their individual clinical presentation.
AUC need to be integrated as seamlessly as possible into the clinical workflow. CDSMs are the electronic portals through which clinicians would access the AUC during the patient workup. While CDSMs can be standalone applications that require direct entry of patient information, they may be more effective when they automatically incorporate information such as specific patient characteristics, laboratory results, and lists of co-morbid diseases from Electronic Health Records (EHRs) and other sources. Ideally, practitioners would interact directly with the CDSM through their primary user interface, thus minimizing interruption to the clinical workflow.
Consistent with definitions of CDSM by the Agency for Healthcare Research and Quality (AHRQ) (
In the CY 2016 PFS final rule with comment period, we included a discussion of the Medicare Imaging Demonstration (MID), which was required by section 135(b) of the MIPPA, in addition to independent experiences of implementing AUC by several healthcare systems and academic medical centers. Two key aspects of that discussion remain relevant to the CDSM component of this program. First, AUC, and the CDSMs through which clinicians access AUC, must be integrated into the clinical workflow and facilitate, not obstruct, evidence-based care delivery. For instance, a CDSM may be fully integrated with or part of a provider's Certified EHR system, partially integrated, or entirely outside of it. A CDSM that is external to a provider's primary user interface could utilize an application program interface (API), a set of protocols and tools specifying how software components should interact, to pull relevant information into the decision support application and provide support back to the primary interface. It could also provide decision support, based on the pulled EHR data, via a separate interface. By adhering to common interoperability standards, such as the national standards advanced through certified health IT (see 2015 edition of certification criteria available in the
Second, the ideal AUC is an evidence-based guide that starts with a patient's specific clinical condition or presentation (symptoms) and assists the clinician in the overall patient workup, treatment, and follow-up. Imaging would appear as key nodes within the clinical management decision tree.
Other options outside of certified EHR technology exist to access AUC through CDSMs. Stand-alone, internet-based CDSMs are available and, although they will not interact with EHR data, can nonetheless search for and present AUC relevant to a patient's presenting symptoms or condition.
In communicating an appropriateness rating to the ordering practitioner, some CDSMs provide a scale with numeric ratings, some output a red, yellow, or green light while others provide a dichotomous yes or no. At this time, we do not believe there is one correct approach to communicating the level of appropriateness to the ordering professional. However, section 1834(q)(4)(B) of the Act requires that information be reported on the claim form as to whether the service would or would not adhere to the specified AUC consulted through a particular CDSM, or whether the AUC was not applicable to
Other stakeholders believe, based on decades of experience rolling out AUC in the context of robust quality improvement programs that it is best to start with a CDSM that contains AUC for a few clinical areas where impact is large and evidence is strong. This would ensure that quality AUC are developed, and that clinicians and entire care teams could fully understand the AUC they are using, including when they do not apply to a particular patient.
As we stated in the CY 2016 PFS final rule with comment period, we believe there is merit to both approaches, and it has been suggested to us that the best approach may depend on the particular care setting. The second, “focused” approach may work better for a large health system that produces and uses its own AUC. The first, “comprehensive” approach may in turn work better for a smaller practice with broad image ordering patterns and fewer resources that wants to simply adopt and start using a complete AUC system developed elsewhere. We believe a successful program would allow flexibility, and under section 1834(q) of the Act, we foresee a number of sets of AUC developed by different PLEs, and an array of CDSMs from which clinicians may choose.
We established in the CY 2016 PFS final rule with comment period that we would identify priority clinical areas through rulemaking, and that these may be used in the determination of outlier ordering professionals (a future phase of the Medicare AUC program). The concept of priority clinical areas allows us to implement an AUC program that combines the focused and comprehensive approaches to implementation discussed above. Although potentially large volumes of AUC (as some PLEs have large libraries of AUC) would become specified across clinical conditions and advanced imaging technologies, we believe this rapid and comprehensive roll out of specified AUC should be balanced with a more focused approach when identifying outlier ordering professionals. We believe this will provide an opportunity for physicians and practitioners to become familiar with AUC in identified priority clinical areas prior to Medicare claims for those services being part of the input for calculating outlier ordering professionals.
As we describe earlier, CDSMs are the access point for ordering professionals to consult AUC. We believe the combination of the comprehensive and focused approaches should be applied to CDSM requirements as we consider a minimum floor of AUC that must be made available to ordering professionals through qualified CDSMs. AUC that reasonably address the entire clinical scope of priority clinical areas could establish a minimum floor of AUC to be included in qualified CDSMs, and the number of priority clinical areas could be expanded through annual rulemaking and in consultation with physicians and other stakeholders. This allows priority clinical areas to roll out judiciously, and build over time.
Section 218(b) of the PAMA added a new section 1834(q) of the Act entitled, “Recognizing Appropriate Use Criteria for Certain Imaging Services,” which directs the Secretary to establish a new program to promote the use of AUC. Section 1834(q)(3)(A) of the Act requires the Secretary to specify qualified CDSMs that could be used by ordering professionals to consult with specified applicable AUC for applicable imaging services.
There are four major components of the AUC program under section 1834(q) of the Act, each with its own implementation date: (1) Establishment of AUC by November 15, 2015 (section 1834(q)(2)); (2) identification of mechanisms for consultation with AUC by April 1, 2016 (section 1834(q)(3)); (3) AUC consultation by ordering professionals and reporting on AUC consultation by furnishing professionals by January 1, 2017 (section 1834(q)(4)); and (4) annual identification of outlier ordering professionals for services furnished after January 1, 2017 (section 1834(q)(5)). As we will discuss later in this preamble, we did not identify mechanisms for consultation by April 1, 2016 and will not have specified or published the list of qualified CDSMs by January 1, 2017; therefore, ordering professionals will not be required to consult CDSMs, and furnishing professionals will not be able to report information on the consultation, by this date.
In the CY 2016 PFS final rule with comment period, we addressed the first component under section 1834(q)(2) of the Act—the requirements and process for establishment and specification of applicable AUC, along with relevant aspects of the definitions under section 1834(q)(1) of the Act. This included defining the term PLE and finalizing requirements for the rigorous, evidence-based process by which a PLE would develop AUC, upon which qualification is based, as provided in section 1834(q)(2)(B) of the Act and in the CY 2016 PFS final rule with comment period. Using this process, once a PLE is qualified by CMS, the AUC that are developed, modified or endorsed by the qualified PLE are considered to be specified applicable AUC under section 1834(q)(2)(A) of the Act. We defined the term PLE to include national professional medical societies, health systems, hospitals, clinical practices and collaborations of such entities such as the High Value Healthcare Collaborative or the National Comprehensive Cancer Network. Qualified PLEs may collaborate with third parties that they believe add value to their development of AUC, provided such collaboration is transparent. We expect qualified PLEs to have sufficient infrastructure, resources, and the relevant experience to develop and maintain AUC according to the rigorous, transparent, and evidence-based processes detailed in the CY 2016 PFS final rule with comment period.
A timeline and process was established for PLEs to apply to become qualified and the first list of qualified PLEs was published at
The second major component of the Medicare AUC program is the specification of qualified CDSMs that could be used by ordering professionals for consultation with specified applicable AUC under section 1834(q)(3) of the Act. We envision a CDSM as an interactive tool that communicates AUC information to the user. Information regarding the clinical
Section 1834(q)(3)(A) of the Act states that the Secretary must specify qualified CDSMs in consultation with physicians, practitioners, health care technology experts, and other stakeholders. This paragraph authorizes the Secretary to specify mechanisms that could include: CDS modules within certified EHR technology; private sector CDSMs that are independent of certified EHR technology; and a CDSM established by the Secretary. The Secretary did not propose to establish a CDSM at this time.
All CDSMs must meet the requirements under section 1834(q)(3)(B) of the Act, which specifies that a mechanism must: Make available to the ordering professional applicable AUC and the documentation supporting the appropriateness of the applicable imaging service that is ordered; where there is more than one applicable appropriate use criterion specified for an applicable imaging service, indicate the criteria it uses for the service; determine the extent to which an applicable imaging service that is ordered is consistent with the applicable AUC; generate and provide to the ordering professional documentation to demonstrate that the qualified CDSM was consulted by the ordering professional; be updated on a timely basis to reflect revisions to the specification of applicable AUC; meet applicable privacy and security standards; and perform such other functions as specified by the Secretary (which may include a requirement to provide aggregate feedback to the ordering professional). Section 1834(q)(3)(C) of the Act specifies that the Secretary must publish an initial list of specified mechanisms no later than April 1, 2016, and that the Secretary must identify on an annual basis the list of specified qualified CDSMs.
As we explained in the CY 2016 PFS proposed rule and final rule with comment period, implementation of many aspects of the amendments made by section 218(b) of the PAMA requires consultation with physicians, practitioners, and other stakeholders, and notice and comment rulemaking. We continue to believe the PFS calendar year rulemaking process is the most appropriate and administratively feasible implementation vehicle. Given the timing of the PFS rulemaking process, we were not able to include proposals in the PFS proposed rule to begin implementation in the same year the PAMA was enacted, as we would have had to interpret and analyze the new statutory language, and develop proposed plans for implementation in under one month. As we did prior to the CY 2016 PFS proposed rule when we met extensively with stakeholders to gain insight and hear their comments and concerns about the AUC program, we used the time prior to the CY 2017 PFS proposed rule to meet with many of the same stakeholders but also a new group of stakeholders specifically related to CDSMs. In addition, we are continuing our stepwise approach to implementing this AUC program. The first phase of the AUC program (specifying AUC including defining what AUC are and specifying the process for developing them) was accomplished through last year's CY 2016 PFS final rule with comment period. For this second phase, we use the CY 2017 PFS rulemaking process as the vehicle to establish requirements for CDSMs, and the process to specify qualified CDSMs, in a transparent manner that allows for stakeholder and public involvement. Therefore, the final CDSM requirements and process for CDSMs to become qualified are included in this CY 2017 PFS final rule.
The third major component of the AUC program is in section 1834(q)(4) of the Act, Consultation with Applicable Appropriate Use Criteria. This section establishes, beginning January 1, 2017, the requirement for an ordering professional to consult with a qualified CDSM when ordering an applicable imaging service that would be furnished in an applicable setting and paid for under an applicable payment system; and for the furnishing professional to include on the Medicare claim information about the ordering professional's consultation with a qualified CDSM. The statute distinguishes between the ordering and furnishing professional, recognizing that the professional who orders an applicable imaging service is usually not the same professional who bills Medicare for that service when furnished. Section 1834(q)(4)(C) of the Act provides for certain exceptions to the AUC consultation and reporting requirements including in the case of certain emergency services, inpatient services paid under Medicare Part A, and ordering professionals who obtain an exception due to a significant hardship. Section 1834(q)(4)(D) of the Act specifies that the applicable payment systems for the AUC consultation and reporting requirements are the PFS, hospital outpatient prospective payment system, and the ambulatory surgical center payment systems.
Since a list of qualified CDSMs is not yet available and will not be available by January 1, 2017, we will not require ordering professionals to meet this requirement by that date.
The fourth component of the AUC program is in section 1834(q)(5) of the Act, Identification of Outlier Ordering Professionals. The identification of outlier ordering professionals under this paragraph facilitates a prior authorization requirement for outlier professionals beginning January 1, 2020, as specified under section 1834(q)(6) of the Act. Although we did not propose to implement these sections in the CY 2017 PFS proposed rule, we proposed below a list of priority clinical areas which may serve as part of the basis for identifying outlier ordering professionals.
We proposed to amend our regulations at § 414.94, “Appropriate Use Criteria for Certain Imaging Services.”
In § 414.94(b), we proposed to codify and add language to clarify some of the definitions provided in section 1834(q) of the Act, as well as define terms that were not defined in statute but for which a definition would be helpful for program implementation. In this section, we provide a description of the terms we proposed to codify to facilitate understanding and encouraged public comment on the AUC program.
We proposed to define CDSM under § 414.94(b) as an interactive, electronic tool for use by clinicians that communicates AUC information to the user and assists them in making the most appropriate treatment decision for a patient's specific clinical condition. A CDSM would incorporate specified
As prescribed in section 1834(q) of the Act and § 414.94(b) of our regulations, the Medicare AUC program imposes requirements only for applicable imaging services furnished in applicable settings. Further, as specified in section 1834(q)(4)(D) of the Act, we proposed to amend our regulation at § 414.94(b) to state that the applicable payment systems for the Medicare AUC program are the PFS under section 1848(b) of the Act, the prospective payment system for hospital outpatient department services under section 1833(t) of the Act, and the ambulatory surgical center payment systems under section 1833(i) of the Act. Applicable payment systems are relevant to implementation of section 1834(q)(4)(B) of the Act, entitled “Reporting by Furnishing Professionals.”
We remind readers that in PFS rulemaking for CY 2016 we defined applicable imaging service in § 414.94(b) as an advanced diagnostic imaging service as defined in 1834(e)(1)(B) of the Act for which the Secretary determines (i) One or more applicable appropriate use criteria apply; (ii) There are one or more qualified clinical decision support mechanisms listed; and (iii) One or more of such mechanisms is available free of charge.
The following is a summary of the comments we received on the definitions for CDSM and applicable payment system.
After considering the comments, we have made no changes to the definitions and are finalizing the language at § 414.94(b) as proposed.
We proposed to establish a new § 414.94(e)(5) to set forth the initial list of priority clinical areas.
To compile this proposed list, we performed an analysis of Medicare claims data using the CMS Chronic Conditions Data Warehouse (CCW) as the primary data source. The CCW contains 100 percent of Medicare claims for beneficiaries who are enrolled in the fee-for-service (FFS) program. Data were derived from the CCW's 2014 Part B non-institutional claim line file, which includes Part B services furnished during CY 2014. This is the main file containing final action claims data for non-institutional health care providers, including physicians, physician assistants, clinical social workers, nurse practitioners, independent clinical laboratories, and freestanding ambulatory surgical centers. The Part B non-institutional claim line file contains the individual line level information from the claim and includes Healthcare Common Procedure Coding System (HCPCS) code(s), diagnosis code(s) using the International Classification of Diseases, Ninth Revision (ICD-9), service dates, and Medicare payment amount. A publicly available version of this dataset can be downloaded from the CMS Web site at
In the CY 2016 PFS final rule with comment period, we stated that when identifying priority clinical areas we may consider factors such as incidence and prevalence of disease, the volume and variability of utilization of imaging services, the strength of evidence for their use, and applicability of the clinical area to the Medicare population and to a variety of care settings.
Using the 2014 Medicare claims data referenced above, we ranked ICD-9 codes by the frequency with which they were used as the primary indication for specific imaging procedures, which in turn were identified by the volume of individual Current Procedural Terminology (CPT) codes for which payments were made in 2014. We extracted the top 135 ICD-9 codes from this list and formed clinically-related categories. Next, we searched manually through an electronic list of all ICD-9 codes to find others that would plausibly fit into each clinical grouping. This process required subjective clinical judgment on whether a particular ICD-9 code should be included in a given clinical group. The top eight clinical groupings (by volume of procedures) are what we proposed as the initial list of priority clinical areas. The eight clinical areas account for roughly 40 percent of part B advanced diagnostic imaging services paid for by Medicare in 2014. We are aware that some stakeholders have suggested beginning the AUC program with no more than five priority clinical areas while others have suggested a far greater number. We believed the proposed eight priority clinical areas strike a reasonable balance that allows us to focus on a significant range and volume of advanced diagnostic imaging services.
We also considered extracting pulmonary embolism as a separate priority clinical area from the chest pain grouping based on stakeholder consultation and feedback. However, we decided not to identify pulmonary embolism separately, but asked for public comment on whether pulmonary embolism should be included as a stand-alone priority clinical area. Based on our consultations with physicians, practitioners and other stakeholders, as required by section 1834(q)(3)(A) of the Act, we attempted to be inclusive when grouping ICD-9 codes into cohesive clinical areas. As an example of how we derived the priority clinical area for low back pain, we grouped together 10 ICD-9 codes, incorporating six from the top 135 and four from the manual search of all ICD-9 codes. Included in this grouping are the ICD-9 codes for displacement of lumbar intervertebral disc without myelopathy (722.10), degeneration of lumbar of lumbosacral intervertebral disc (722.52), intervertebral disc disorder with myelopathy lumbar region (722.73), post-laminectomy syndrome of lumbar region (722.83), lumbago (724.2), sciatica (724.3), thoracic or lumbosacral neuritis or radiculitis unspecified (724.4), spinal stenosis, lumbar region, without neurogenic claudication (724.02), lumbosacral spondylosis without myelopathy (721.3), and spondylosis with myelopathy lumbar region (721.42) which resulted in 1,883,617 services. To see all of the priority clinical area groupings of diagnosis codes, a table is available on the CMS Web site at
Using the above methodology, we developed and proposed eight priority clinical areas. These reflect both the significance and the high prevalence of some of the most disruptive diseases in the Medicare population.
We also engaged the CMS Alliance to Modernize Healthcare (CAMH) Federally Funded Research and Development Center (FFRDC), the MITRE Corporation (MITRE), to begin developing efficient and effective processes for managing current and future health technology assessments. MITRE generated an independent report that presents a summary of findings from claims data from the Medicare population and their utilization of advanced imaging procedures. Coupled with our internal analysis, this report has assisted in identification of proposed priority clinical areas for the Medicare AUC program for advanced diagnostic imaging services. Analysis and methods for this report are available at
While this year we proposed priority clinical areas based on an analysis of claims data alone, we may use a different approach in future rulemaking cycles. As we specified in § 414.94(e) of our regulations, we may consider factors other than volume when proposing priority clinical areas including incidence and prevalence of disease, variability of use of particular imaging services, strength of evidence supporting particular imaging services and the applicability of a clinical area to a variety of care settings and to the Medicare population.
We encouraged public comments on this proposed initial list of priority clinical areas, including recommendations for other clinical areas that we should include among our list of priority clinical areas. In particular, we were interested in comments on the above methodology or alternate options; whether the proposed priority clinical areas are appropriate including information on the extent to which these proposed priority clinical areas may be represented by clinical guidelines or AUC in the future. Furthermore, we were interested in public comments, supported by published information, for varying levels of evidence that exist across, as well as within priority clinical areas.
The following is a summary of the comments we received on the list of priority clinical areas which may serve as part of the basis for identifying outlier ordering professionals.
Other commenters recommended eliminating suspected stroke, altered mental status, chest pain and abdominal pain, and creating a stand-alone priority clinical area for suspected pulmonary embolism. For abdominal pain, commenters were concerned that there were not high quality AUC available to cover such a vast clinical area. For suspected stroke, commenters were concerned that using this area for future outlier calculations would not be beneficial as advanced imaging for these patients may be exempt from this program under the emergency medical conditions exception. Commenters disagreed with both suspected stroke and altered mental status because both could fall under other priority clinical areas and they noted there was a lack of high quality AUC available to address them.
Some commenters encouraged and others discouraged CMS from considering alternative priority clinical areas. Some commenters generally asked CMS to refrain from considering other clinical areas beyond what is listed in the CY 2017 PFS proposed rule. Other commenters offered alternatives in both number and scope of priority clinical areas. Other commenters suggested including musculoskeletal (hip pain, knee pain, joint pain, shoulder pain, rotator cuff injury), other cancers (breast, prostate), right upper quadrant pain, solitary pulmonary nodule, pancreatitis, appendicitis, renal colic, suspected abdominal aortic dissection, CT for minor blunt head trauma, suspected cardiac ischemia, and hematuria. One commenter noted that the top ten conditions for which advanced imaging is requested included low back pain, headache, and cervical pain. Another commenter recommended that these priority clinical areas should be phased in at a rate of two per year, with examples of pulmonary embolism and low back pain (as areas where strength of evidence was particularly high), which echoed other general comments to more gradually expand the list of
We agree with commenters that chest pain is a general symptom and too broad for a focused priority clinical area. We further agree with commenters that supported creating a stand-alone priority clinical area for suspected pulmonary embolism, as discussed in detail below, and one for coronary artery disease. Chest pain may be a clinical symptom of underlying suspected pulmonary embolism and coronary artery disease. There is a solid evidence base from well designed, randomized controlled trials supporting specific protocols and guidelines that consider different signs, symptoms and history associated with working up a patient with suspected pulmonary embolism. There is also strong evidence from multiple large, randomized controlled trials to guide imaging for coronary artery disease. We note that, according to the American Heart Association Statistical Update, coronary artery disease is the leading cause of death among men and women in the United States. The evidence is less robust for many other causes of chest pain. Therefore, based on the above, we are removing chest pain as a priority clinical area and finalizing suspected pulmonary embolism and coronary artery disease as two distinct areas.
We recognize, along with commenters, that the proposed list of priority clinical areas did not include scenarios specific to musculoskeletal indications. As stated in the proposed rule, CMS also engaged MITRE to generate an independent report, which indicates that almost half a million advanced diagnostic imaging services were rendered to Medicare beneficiaries in 2014 for clinical presentations related to joint pain. Furthermore, we agree with commenters who suggested CMS consider additional clinical areas with a reasonably robust volume of literature on appropriate use and agree that the strength of evidence for imaging use and relevance to the Medicare population supports inclusion of hip pain and shoulder pain (to include suspected rotator cuff injury) in the final list of priority clinical areas.
In addition to commenters' support of inclusion of low back pain and headache in the list of priority clinical areas, we also note that the MID cites clinical research demonstrating that use of clinical decision support was associated with a decrease in the utilization of lumbar MRIs for low back pain and head MRIs for headache.
We are finalizing the proposed areas of low back pain and headache, as well as cancer of the lung (primary or metastatic, suspected or diagnosed).
We have removed altered mental status and abdominal pain based on the concerns expressed by commenters summarized above, including the lack of strong evidence to cover the breadth of each of these areas. Based on the commenters' concerns we may review these areas in the future, possibly narrowing their scope.
Regarding stroke, we acknowledge that evidence-based stroke protocols do exist, however, we believe that it is possible that an exception for emergency medical services may disproportionally apply to suspected stroke so there may be a concern for using this priority clinical area for future outlier calculations. Furthermore, there may be some overlap of the clinical areas of suspected stroke and headache. A strong level of evidence specific to headache is available and we believe headache is less likely to be impacted by the emergency medical services exception. Therefore, we are removing suspected stroke and retaining headache in the final list of priority clinical areas. We may consider adding suspected stroke through future rulemaking.
In response to public comments and as supported by the additional information above and further discussion below, we have modified the list of priority clinical areas by: (1) removing chest pain, abdominal pain (any locations and flank pain), suspected stroke and altered mental status; and (2) adding coronary artery disease (suspected or diagnosed), suspected pulmonary embolism, hip pain and shoulder pain (to include suspected rotator cuff injury). We are finalizing as proposed the priority clinical areas of headache (traumatic and non-traumatic), low back pain, cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain. The final list of priority clinical areas is as follows:
• Coronary artery disease (suspected or diagnosed).
• Suspected pulmonary embolism.
• Headache (traumatic and non-traumatic).
• Hip pain.
• Low back pain.
• Shoulder pain (to include suspected rotator cuff injury).
• Cancer of the lung (primary or metastatic, suspected or diagnosed).
• Cervical or neck pain.
Consistent with section 1834(q) of the Act, we are not AUC developers, and therefore, would not produce AUC tailored to the elderly population. However, § 414.94(c)(1) of our regulations requires qualified PLEs to utilize an evidentiary review process when developing or modifying AUC. This regulation further requires qualified PLEs to identify AUC that are relevant to priority clinical areas, and specifies that to be considered relevant, the AUC must reasonably address the entire clinical scope of the corresponding priority clinical areas. These requirements and the resulting fundamental process ensures that AUC are evidence-based to the extent feasible as required by section 1834(q)(1)(B) of the Act. Therefore, we expect that qualified PLEs will undertake evidence reviews of sufficient depth and quality to ensure that all relevant evidence-based publications in the peer-reviewed medical literature on trials, observational studies, and consensus statements are identified, considered and evaluated; and that such reviews are reproducible.
We do not agree with the suggestion to reduce the total number of priority clinical areas we proposed in CY 2017 rulemaking, and reiterate that ordering professionals must consult AUC for all applicable imaging services, not only those falling within a priority clinical area. Furthermore, we anticipate that additional priority clinical areas will be proposed in future rulemaking, and we believe that Medicare beneficiaries will benefit as ordering professionals become familiar with specified applicable AUC relevant to all advanced diagnostic imaging services.
Given the transition to ICD-10 in 2015 and changes in the list of priority clinical areas, as well as factors discussed above, we clarify that the supplemental table does not define the final list of priority clinical areas. We expect to address the role of ICD-10 diagnosis codes in claims based reporting, auditing and outlier identification for priority clinical areas with rulemaking next year. We note, however, that we believe that the list of priority clinical areas provides sufficient guidance to CDSMs as they decide whether to apply to be a qualified CDSM in the upcoming application cycle.
We acknowledge the alternative opinions of commenters seeking to modify the extent of diagnosis codes in one or more priority clinical areas. We hope to discuss further with physicians and other stakeholders the relevance of mapping ICD diagnosis codes to priority clinical areas as we move forward in formulating the claims reporting implementation strategy (discussed in more detail below) and strategies to avoid areas of concern for commenters. We clarify that ICD-9 diagnosis codes will not be used for claims reporting purposes in this program given the 2015 transition to ICD-10. We expect that the role of ICD-10 diagnosis codes for the purposes of claims based reporting, auditing and outlier identification will be addressed through rulemaking next year.
Some commenters also shared with CMS publications that suggested a lack of evidence-based AUC for clinical scenarios that could reasonably fall within one or more proposed priority clinical areas. In particular, one commenter believed that available appropriateness criteria do not address altered mental status. Commenters generally believed that clinical scenarios providing no appropriateness rating or contradictory recommendations from CDSMs based on AUC using lower grades of evidence or expert opinion would not result in significant modifications in ordering professional behavior. A commenter suggested CMS consider the safety margin inherent in the clinical area where imaging for acute stroke, for example, has a narrow safety margin while imaging for suspected rotator cuff injury has a wider safety margin. Many commenters identified situations when the available high-quality evidence does not cover the entire clinical scope of a priority clinical area. In these situations, a CDSM would either cover less than the entire clinical scope of a priority clinical area and only incorporate AUC based on high-quality evidence or cover the entire clinical scope and in doing so incorporate AUC based on low quality evidence and expert opinion. These commenters cautioned against requiring qualified CDSMs to incorporate specified applicable AUC that encompass the entire clinical scope given the potential for forcing consultation with AUC based on lower quality evidence. As an alternative, a few commenters encouraged CMS to separate priority clinical areas into those that have high quality AUC and those that do not.
We continue to believe that evidence grading is an essential component of the AUC development process for all clinical areas, including priority clinical areas. However, we acknowledge that different grading systems may be more appropriate for different clinical areas. As such, we will not require the use of specific grading mechanisms and leave that decision to qualified PLEs. We recognize that some AUC development processes could invite public comment and include a wide range of experts and stakeholders on the multidisciplinary AUC development team. However, we will not establish these as requirements, and instead require under § 414.94(c)(1) that qualified PLEs post AUC along with the process they use for developing and modifying AUC on their Web site in the public domain to allow for review by all stakeholders.
Regarding local adaptation, we believe it is important to fit AUC to local circumstances, while also ensuring a rigorous process for doing so. However, only AUC modified by qualified PLEs can become specified applicable AUC. Furthermore, qualified PLEs are required under our regulation at § 414.94(c)(v) to identify each appropriate use criterion or AUC subset that is relevant to a priority clinical area. Stakeholders should expect to see such delineations on the Web site of the qualified PLE.
We are not launching an educational campaign at this time because this program is only partially implemented. However, we believe that physicians and other practitioners, through continued dialogue with us, will continue to become more informed as implementation of this program proceeds, and we will continue to evaluate the programmatic and educational needs of ordering and furnishing professionals impacted by the AUC program over time.
In response to comments, we are finalizing a modified list of priority clinical areas under § 414.94(e)(5) of our regulations, making the following changes from the proposed list: (1) removed chest pain, abdominal pain (any locations and flank pain), suspected stroke and altered mental status; and (2) added coronary artery disease, (suspected or diagnosed), suspected pulmonary embolism, hip pain and shoulder pain (to include suspected rotator cuff injury). We are finalizing the proposed priority clinical areas of headache (traumatic and non-traumatic), low back pain, cancer of the lung (primary or metastatic, suspected or diagnosed), and cervical or neck pain without change.
We proposed to add a new § 414.94(g)(1) to our regulations to establish requirements for qualified CDSMs. Section 1834(q)(3)(A)(iii) of the Act provides relative flexibility for qualified CDSMs, and states that they may include mechanisms that are within certified EHR technology, private sector mechanisms that are independent from certified EHR technology or mechanisms that are established by the Secretary.
We believe that, at least initially, it is in the best interest of the program to establish CDSM requirements that are not prescriptive about specific IT standards. Rather, we proposed an approach that focuses on the functionality and capabilities of qualified CDSMs. The CDSM, EHR and health IT environments are constantly changing and improving and we want to allow room for growth and innovation. However, in the future, as more stakeholders and other entities including the ONC, AHRQ, and relevant standards development organizations come to consensus regarding standards for CDSMs, then we may consider pointing to such standards as a requirement for qualified CDSMs under this program. We believe standards would make it possible to achieve interoperability, allowing any CDSM to incorporate any standardized AUC and for sets of AUC to be easily interchangeable among various CDSMs. We will continue to work with the ONC and AHRQ to facilitate movement in this direction.
Recent work under the federally-sponsored Clinical Quality Framework (CQF) initiative has successfully developed an integrated approach that harmonizes standards for electronic clinical quality measurement with those that enable shareable clinical decision support artifacts (for example, AUC) using Fast Healthcare Interoperability Resources (FHIR). The CQF initiative is working to support semantically interoperable data exchange for (1) calling a service, sending patient data to a service for clinical decision support guidance and receiving clinical decision support guidance or quality measurement results in return, and (2) enabling a system to consume and internally execute decision support artifacts. The current implementation guide supports both approaches and could be used to successfully execute and share AUC as described in this program. As this standard is considered sufficiently mature for widespread adoption, the ONC may consider it for use in future editions of certification criteria for health IT. While the current regulation requires no specific standard, the CMS and ONC are supportive of this approach and additional information is available at
At § 414.94(g)(1), we proposed to codify in regulations the seven requirements for qualified CDSMs set forth in section 1834(q)(3)(B)(ii) of the Act. The statute requires qualified CDSMs to make available to the ordering professional specified applicable AUC and the supporting documentation for the applicable imaging service ordered. We do not interpret this requirement to mean that every qualified CDSM must make available every specified applicable AUC. In the CY 2016 PFS final rule with comment period, we allowed for the
Consistent with that approach, we proposed to add a requirement in § 414.94(g)(1)(iii) that qualified CDSMs must make available to ordering professionals, at a minimum, specified applicable AUC that reasonably encompass the entire clinical scope of all priority clinical areas. We encourage and expect some CDSMs, based on the needs of the professionals they serve, will choose to include a far more comprehensive set of AUC going above and beyond the minimum set as we understand many ordering professionals want such comprehensive access to AUC. When this Medicare AUC program is fully implemented, all ordering professionals must consult specified applicable AUC through a qualified CDSM for every applicable imaging service that would be furnished in an applicable setting and paid for under an applicable payment system in order for payment to be made for the service. However, when identifying the outlier ordering professionals who will be subject to prior authorization beginning in 2020, we anticipate focusing on consultation with specified applicable AUC within priority clinical areas rather than the universe of specified applicable AUC. The concept of priority clinical areas will allow us to implement an AUC program that combines two approaches to implementation allowing clinicians flexibility to either engage with a rapid rollout of comprehensive specified applicable AUC or adopt a focused approach to consulting AUC. Thus, they can choose their approach and select a CDSM and AUC set(s) that fit their needs and preferences, while being sure that each qualified CDSM will include AUC that address all priority clinical areas.
We further proposed to add a requirement in § 414.94(g)(1)(iv) of our regulations that qualified CDSMs must be able to incorporate specified applicable AUC from more than one qualified PLE. We believe this approach ensures that CDSMs can expand the AUC libraries they can provide access to represent AUC across all priority clinical areas (consistent with the requirements under proposed § 414.94(g)(1)(iii)). We do not necessarily expect that a single qualified PLE will develop AUC addressing every priority clinical area domain, especially since we believe that over time and through future rulemaking, the list of priority clinical areas will expand and cross additional clinical domains. Ensuring that qualified CDSMs are not limited in their technology to incorporating AUC from only one qualified PLE will help to ensure that ordering professionals will not be in a position of consulting a CDSM that cannot offer them access to AUC that address all priority clinical areas. As stakeholders continue to advance CDSM technology, we look forward to standards being developed and widely accepted so that AUC are incorporated in a standardized format across CDSM platforms. Increasing standardization in this area will move the industry closer to the goal of interoperability across CDSMs and EHRs.
We also proposed to add a requirement in § 414.94(g)(1)(i) that specified applicable AUC and related documentation supporting the appropriateness of the applicable imaging service ordered must be made available within the qualified CDSM. For example, the ordering professional would have immediate access to the full appropriate use criterion, citations supporting the criterion and a summary of key evidence supporting the criterion.
We proposed to add a requirement in § 414.94(g)(1)(ii), consistent with section 1834(q)(3)(B)(ii)(II) of the Act, that the qualified CDSM must clearly identify the appropriate use criterion consulted if the tool makes available more than one criterion relevant to a consultation for a patient's specific clinical scenario. We believe this is important since CDSMs that choose to incorporate a comprehensive AUC library may be offering the ordering professional access to AUC from multiple qualified PLEs. In such scenarios, it is important that the ordering professional knows which appropriate use criterion is being consulted and have the option to choose one over the other if more than one criterion accessible within the CDSM applies to the scenario.
We proposed to add a requirement in § 414.94(g)(1)(v), consistent with section 1834(q)(3)(B)(ii)(III) of the Act, that the qualified CDSM must provide to the ordering professional a determination, for each consultation, of the extent to which an applicable imaging service is consistent with specified applicable AUC or a determination of “not applicable” when the mechanism does not contain a criterion that would apply to the consultation. This determination would communicate the appropriateness of the applicable imaging service to the ordering professional. In addition to this determination, we also proposed that the CDSM provide the ordering professional with a determination of “not applicable” when the mechanism does not contain an appropriate use criterion applicable to that patient's specific clinical scenario.
We proposed to add a requirement in § 414.94(g)(1)(vi), consistent with section 1834(q)(3)(B)(ii)(IV) of the Act, that the qualified CDSM must generate and provide to the ordering professional certification or documentation that documents which qualified CDSM was consulted, the name and NPI of the ordering professional that consulted the CDSM and whether the service ordered would adhere to applicable AUC, whether the service ordered would not adhere to such criteria, or whether such criteria was not applicable for the service ordered. We proposed to require under § 414.94(g)(1)(vi)(A) that this certification or documentation must be issued each time an ordering professional consults the qualified CDSM. Since Medicare claims will be filed only for services that are rendered to beneficiaries, we will not see CDSM consultation information on the claim form specific to imaging services that are not ordered. We believe that for the CDSM to be able to provide meaningful feedback to ordering professionals, information regarding consultations that do not result in imaging is just as important as information on consultations that do result in an order for advanced imaging.
Thus, we proposed to require under § 414.94(g)(1)(vi)(B) that the documentation or certification provided by the qualified CDSM must include a unique consultation identifier. This would be a unique code issued by the CDSM that is specific to each consultation by an ordering professional. This type of unique code may serve as a platform for future collaboration and aggregation of consultation data across CDSMs. In addition, at some point in the future, this unique code may assist in more seamlessly bringing Medicare data together with CDSM clinical data to maximize quality improvement in clinical practices and to iteratively improve the AUC itself. We proposed in § 414.94(g)(1)(vii), consistent with section 1834(q)(3)(B)(ii)(V) of the Act, that the specified applicable AUC content within qualified CDSMs be
In addition, we proposed in § 414.94(g)(1)(vii)(B) that qualified CDSMs must make available for consultation specified applicable AUC that address any new priority clinical areas within 12 months of the priority clinical area being finalized by CMS. We believe this would allow the CDSM sufficient time to incorporate the AUC into the CDSM. Thus, any new priority clinical areas finalized, for example, in the CY 2018 PFS final rule that would be effective January 1, 2018, would need to be incorporated into a qualified CDSM by January 1, 2019. To accommodate this time frame, we would accept a not applicable determination from a CDSM for a consultation on a priority clinical area for dates of service through the 12-month period that ends, in this example, on January 1, 2019. We note that all qualified CDSMs that are approved by June 30, 2017, should be capable of supporting AUC for all priority clinical areas that are finalized in the CY 2017 PFS final rule.
We proposed to add a requirement in § 414.94(g)(1)(viii), consistent with section 1834(q)(3)(B)(ii)(VI) of the Act, that the qualified mechanism must meet privacy and security standards under applicable provisions of law. Potentially applicable laws may include the HIPAA Privacy and Security rules.
We proposed to add a requirement in § 414.94(g)(1)(ix), consistent with section 1834(q)(3)(B)(ii)(VII) of the Act, that qualified CDSMs must provide ordering professionals aggregate feedback in the form of an electronic report on an annual basis (at minimum) regarding their consultations with specified applicable AUC. Our intent is to require records to be retained in a manner consistent with the HIPAA Security Rule. To provide such feedback, and to make detailed consultation information available to ordering professionals, furnishing professionals (when they have authorized access to the CDSM), auditors and CMS, we proposed in § 414.94(g)(1)(x) that a qualified CDSM must maintain electronic storage of clinical, administrative and demographic information of each unique consult for a minimum of 6 years. We believe CDSMs could fulfill this requirement in a number of ways, including involving a third party in the storage of information, as well as for providing feedback to ordering professionals. We recognize that these requirements represent a minimum floor that clinicians may choose to expand their local QI programs.
In the event requirements under § 414.94(g)(1) are modified through rulemaking during the course of a qualified CDSM's 5-year approval cycle, we proposed in § 414.94(g)(1)(xi) that the CDSM would be required to comply with the modification(s) within 12 months of the effective date of the modification.
The following is a summary of the comments we received on CDSM qualifications and requirements.
As noted, we believe examples of CDSMs that seamlessly integrate with EHRs, including those that operate outside of certified EHR technology, such as those that operate in the cloud, will likely be most effective in meeting clinicians' needs. As the market continues to mature, we would expect to see expanded availability of easily affordable tools that fully integrate AUC guidance with an efficient, clinician-friendly workflow within the interface of the primary health IT system they use in providing and documenting care.
Specialists may seek to align themselves with a qualified CDSM that contains AUC more exhaustive in one area of medicine to reflect the imaging services that they order most often.
We continue to believe that all tools should contain the specified applicable AUC needed by the ordering professionals they serve, as well as contain specified applicable AUC related to the priority clinical areas, to ensure that when an ordering professional needs to consult AUC for an imaging service, they will not have to go outside their regular qualified CDSM for the consultation. We reiterate that we envision choices for qualified CDSMs that allow efficient access by ordering professionals to one or more specialty-focused specified applicable AUC sets along with more comprehensive specified applicable AUC sets. We believe the determination of which AUC sets are made accessible through a given CDSM should be demand-driven by ordering professionals, who would be choosing from a marketplace of options for both CDSMs and AUC, all of which meet basic CMS qualifications to ensure implementation of the statutory requirements established under section 218(b) of the PAMA.
To balance the requirement for the minimum floor, we believe it is important to reconsider the extent to which specified applicable AUC encompass the entire clinical scope of priority clinical areas. We agree that requiring the entire clinical scope may not yield consultation of the highest quality specified applicable AUC and that ordering professionals, particularly specialists, may not have a need for specified applicable AUC addressing the entire clinical scope of a priority clinical area. We do not expect this requirement to be met by AUC that address only a narrow clinical aspect of a priority clinical area. We believe addressing less than the entire clinical scope should still result in AUC that robustly fill priority clinical areas. To avoid forcing the development of AUC based on poor evidence just for the sake of having AUC we modified this language and expect it will enable qualified PLEs to confidently develop AUC that represent a high level of evidence. Therefore, we agree with commenters' suggestions that we keep the AUC floor but allow the requirement to be fulfilled if specified applicable AUC address less than the entire scope of the priority clinical areas and instead reasonably address the common and important clinical scenarios within each priority clinical area. We have included this modified language in § 414.94(g)(1)(iii) and § 414.94(g)(1)(vii)(C).
In future years, as greater consensus emerges around common standards for interfacing with, uploading or otherwise referencing content that is not already in the system being used, we expect incorporation of AUC from a wide range of sources to become easier. We encourage systems to build standards-based mechanisms to incorporate external AUC and anticipate that such an approach would facilitate meeting this requirement.
For example, if the system only contains AUC for “uncomplicated headache” but the patient has presented with “headache, fever, and altered mental status” the practitioner could make the determination that no applicable AUC exists for the patient under consideration and document this using a text box, check box, or drop-down menu. The documentation that the search did not match the existing AUC and that the practitioner agreed that the existing AUC was not applicable should be retained. Furthermore, manual intervention by the practitioner might not be required in all cases in which the use of AUC is not applicable. We expect that there would be a legitimate clinical reason for declaring a relevant AUC “not applicable” to the patient and that this reason would be documented. Likewise, we expect that when no applicable AUC exists relevant to the patient that would be similarly documented. CDSMs should not be designed to permit the use of “not applicable” overrides without a documented reason. Ideally, systems would evaluate scenarios in which AUC were not available on a regular basis so qualified PLEs can seek to fill in these gaps. We agree with commenters who believe the “not applicable” response should be able to occur in the background of some qualified CDSMs, such as a qualified CDSM integrated within an EHR system. We do not foresee any problems with this method so long as documentation is produced as a result and the needed information is available to be provided by the ordering professional to the furnishing professional.
To allow flexibility for situations in which the ordering professional plays a role in the determination of “not applicable,” as well as those in which such determination is completely automated within the CDSM, we have revised our proposals in § 414.94(g)(1)(v) to require qualified CDSMs only to determine the extent to which the applicable imaging service is consistent with specified applicable AUC with the removal of language requiring the tool to make a determination of “not applicable” when it does not contain a criterion that would apply to the consultation.
We have also revised our proposals in § 414.94(g)(1)(vi) to allow for qualified CDSMs that are embedded seamlessly into the EHR system to provide documentation or certification of CDSM consultation without stopping the workflow of the ordering professional. This minor change in language requires the qualified CDSM to develop the documentation or certification at the time of the order but will no longer explicitly state that it has to be provided directly to the ordering professional.
For consistency, we have made a similar change to § 414.94(g)(1)(vi)(A) to allow for the documentation or certification to be generated but not necessarily issued directly to the ordering professional. This may be important to avoid workflow disruptions when an ordering professional is working within their EHR environment and the qualified CDSM working in the background does not alert the ordering professional when they have placed an order that is appropriate.
We have further modified § 414.94(g)(1)(vi) to more clearly state the requirements that the certification or documentation must document which CDSM was consulted; the name and NPI of the ordering professional that consulted the CDSM; whether the service ordered would adhere to specified applicable AUC or whether the specified applicable AUC consulted was not applicable to the service ordered.
We are finalizing our proposals without change, but will continue to consult with other agencies and consider whether such standards may be specified in the future.
We are finalizing our proposals without change, but will continue to consult with other agencies and consider whether such standards may be specified in the future.
In response to public comments, we are finalizing the following requirements at § 414.94(g)(1):
• Make available specified applicable AUC and its related supporting documentation.
• Identify the appropriate use criterion consulted if the CDSM makes available more than one criterion relevant to a consultation for a patient's specific clinical scenario.
• Make available, at a minimum, specified applicable AUC that reasonably address common and important clinical scenarios within all priority clinical areas identified in paragraph (e)(5) of this section.
• Be able to incorporate specified applicable AUC from more than one qualified PLE.
• Determine, for each consultation, the extent to which the applicable imaging service is consistent with specified applicable AUC.
• Generate and provide a certification or documentation at the time of order that documents which qualified CDSM was consulted; the name and national provider identifier (NPI) of the ordering professional that consulted the CDSM; whether the service ordered would adhere to specified applicable AUC; whether the service ordered would not adhere to specified applicable AUC; or whether the specified applicable AUC consulted was not applicable to the service ordered. Certification or documentation must be generated each time an ordering professional consults a qualified CDSM and include a unique consultation identifier generated by the CDSM.
• Modifications to AUC within the CDSM must comply with the following timeline requirements: make available updated AUC content within 12 months from the date the qualified PLE updates AUC; and have a protocol in place to expeditiously remove AUC determined by the qualified PLE to be potentially dangerous to patients and/or harmful if followed; and make available for consultation within 12 months of a priority clinical area being finalized by CMS specified applicable AUC that reasonably address common and important clinical scenarios within any new priority clinical area.
• Meet privacy and security standards under applicable provisions of law.
• Provide to the ordering professional aggregate feedback regarding their consultations with specified applicable AUC in the form of an electronic report on at least an annual basis.
• Maintain electronic storage of clinical, administrative, and demographic information of each unique consultation for a minimum of 6 years.
• Comply with modification(s) to any requirements under paragraph (g)(1) of this section made through rulemaking within 12 months of the effective date of the modification.
• Notify ordering professionals upon de-qualification.
We proposed that CDSMs must apply to CMS to be specified as a qualified CDSM. We proposed that CDSM developers who believe their mechanisms meet the regulatory requirements must submit an application to us that documents adherence to each of the requirements to be a qualified CDSM.
We proposed to require in § 414.94(g)(2) that CDSM developers must submit applications to CMS for review that document adherence to each of the CDSM requirements. Applications to be specified as a qualified CDSM must be submitted by January 1 of a year to be reviewed within that year's review cycle. For example, as proposed the first applications would be accepted from the date of publication of the PFS final rule until January 1, 2017. A determination on whether the applicants are qualified would be made by June 30, 2017. Applications must be submitted electronically to
An example of our proposed timeline for applications and the approval cycle is as follows:
• Year 1 = July 2017 to June 2018.
• Year 2 = July 2018 to June 2019.
• Year 3 = July 2019 to June 2020.
• Year 4 = July 2020 to June 2021.
• Year 5 = July 2021 to June 2022 (reapplication is due by January 1, 2022).
We believe it is important for us to have the ability to remove from the list of specified qualified CDSMs a CDSM that we determine fails to adhere to any of the qualification requirements, including removal outside of the proposed 5-year cycle. We proposed to state under § 414.94(h) that, at any time, we may remove from the list of qualified CDSMs a CDSM that fails to meet the criteria to be a qualified CDSM or consider this information during the requalification process. Such determinations may be based on public comment or our own review and we may consult with the National Coordinator for Health Information Technology or her designee to assess whether a qualified CDSM continues to adhere to requirements.
We invited comments on how we could streamline and strengthen the approval process for CDSMs in future program years. For instance, CMS may consider a testing framework for CDSMs that would validate adherence to specific standards that enable seamless incorporation of AUC across CDSMs.
The following is a summary of the comments we received on the process for CDSMs to become qualified and determination of non-adherence.
We further agree with commenters that qualification should be available to CDSMs that demonstrate a commitment to meeting the requirements. CDSM applicants whose applications are received by March 1, 2017 but who are not able to provide evidence that all requirements are met at the time of application will have the opportunity to receive preliminary qualification. Applicants eligible for a preliminary qualification must demonstrate a commitment to meeting the requirements by including expected dates by which each requirement is expected to be met and information documenting how they intend to meet them. Applicants that meet most but not all of the requirements at the time of application will be considered only for preliminary qualification.
CDSMs that receive preliminary qualification must achieve full qualification before the implementation of the consultation and reporting requirements. As CDSMs move from preliminary qualification to full qualification upon meeting the requirements, CMS will update the information on the AUC Web site. For those who are not able to achieve full qualification by the time of program implementation, preliminary qualification will terminate and they will be eligible to reapply in the next annual application cycle. For CDSMs that received preliminary qualification and are later converted to full qualification status, their preliminary period will be included as part of their 5-year approval period.
We encourage CDSMs to strive to meet all requirements by the March 1, 2017 application submission deadline, or as soon thereafter as possible, in order to receive full qualification status. We believe this policy strikes a balance between providing sufficient time for CDSMs to prepare for full implementation, while also providing ordering professionals information on CDSMs' qualification status to assist them in making procurement decisions.
In response to the comments, we have added language to § 414.94(g)(2)(ii) delineating the process and requirements to include preliminary qualification. The first application cycle following the publication of this CY 2017 PFS final rule will be extended to March 1, 2017 for all CDSM applicants. As opposed to full qualification by which CDSMs have documented how all requirements are met at the time of application, preliminary qualification allows CDSMs to document, if not already met, how and when such requirements are reasonably expected to be met. The preliminary qualification period ends when we implement the consulting and reporting requirements under this program as specified in § 414.94(g)(2)(ii)(B). We have also added § 414.94(g)(1)(xii) to require qualified CDSMs to notify ordering professionals upon de-qualification.
Although we continue to aggressively move forward to implement this AUC program, ordering professionals will not be expected to consult AUC using qualified CDSMs by January 1, 2017. At the earliest, the first qualified CDSM(s) will be specified on June 30, 2017. We anticipate that some ordering professionals could be able to begin consulting AUC through qualified CDSMs very quickly as some may already be aligned with a qualified CDSM.
We expect that furnishing professionals will be required to begin reporting January 1, 2018. This timeframe is necessary to allow time for ordering practitioners who are not already aligned with a qualified CDSM to research and evaluate the qualified CDSMs so they may make an informed decision. While there will be further rulemaking next year, we are announcing this date because the agency expects physicians and other stakeholders/regulated parties to begin preparing themselves to begin reporting on that date. We will adopt procedures for capturing this information on claims forms and the timing of the reporting requirement through PFS rulemaking for CY 2018.
As we expect to implement the AUC consultation and reporting requirements under section 1834(q)(4)(A) and (B) of the Act on January 1, 2018, we requested feedback from the public to include a discussion of specific operational considerations that we should take into account and include in such rulemaking. For example, we noted that commenters could consider alternatives for reporting data on claims and for seeking exceptions, as discussed below. We also requested information on the barriers to implementation along this timeline that allows ordering and furnishing professionals to be prepared to consult AUC and report consultation information on the claims and whether separate rulemaking outside of the payment rule cycle would be preferred.
Under section 1834(q)(4)(B) of the Act, Medicare claims for applicable imaging services furnished in applicable settings can only be paid under the applicable payment systems if certain information is included on the claim including: which qualified CDSM was consulted by the ordering professional for the service; whether the service, based on the CDSM consultation, adheres to specified applicable AUC, does not adhere to specified applicable AUC or whether no criteria in the CDSM were applicable to the patient's clinical scenario; and, the national provider identifier (NPI) of the ordering professional. This section further allows payment for these services only if the claim contains such information beginning January 1, 2017. To develop and operationalize a meaningful solution to collecting new AUC consultation-related information on the claims, we must diligently evaluate our options taking into account the vast number of claims impacted and the limitations of the legacy claims processing system. Additionally, in the case of advanced imaging services, related claims are already required to append certain HCPCS modifiers and G codes for purposes of proper payments. In the recent implementation of section 218(a) of the PAMA, we established a HCPCS modifier for CT services rendered on machines that do not meet an equipment standard. It is important that we understand and evaluate how the additional requirements for AUC reporting would impact the information that is already required for advanced imaging services. Moving too quickly to satisfy the reporting requirement could inadvertently result in technical and operational problems that could cause delays in payments.
Section 1834(q)(4)(C) of the Act includes exceptions that allow claims to be paid even though they do not include the information about AUC consultation by the ordering professional. We believe
We are considering the mechanisms for appending the AUC consultation information to various types of Medicare claims and expect to develop requirements for appending such information in the CY 2018 PFS rulemaking process. We encouraged stakeholders interested in sharing feedback related to reporting and claims processing to do so as part of the comment period to inform this final rule. We were particularly interested in receiving feedback on, for example, whether the information should be collected using HCPCS level II G codes or HCPCS modifiers.
The following is summary of the comments we received on consultation by ordering professionals and reporting by furnishing professionals.
Some commenters noted that modifiers and G codes were not ideal solutions and provided alternate suggestions. Several commenters addressed use of the UB04/837i for reporting. Some noted that such proposals would not work when more than one test is performed on the same date of service because the form does not allow reporting by line item. Others noted that the UB04/837i form would allow providers to report individual line item services, but limited space on the form prevents specific line items from being linked to other information like an ordering professional, diagnosis code or authorization code to each item.
Many commenters recommended the use of a specific code issued by the CDSM that would include alphanumeric characters to represent each of the required elements for reporting. Commenters suggested that this code could be placed in field 23 (prior authorization field) of the 837P claim form. Another commenter recommended placing a unique identifier in field 19 of the 1500 form. Two other suggestions included placing the unique identifier on both the professional component and technical component (or OPPS) claims, identifying field 63 on the 837i form, or submitting a “dummy” claim with the unique identifier to accompany all claims for applicable imaging services furnished.
A commenter suggested that the reporting requirement should apply to providers who submit claims on a 155/837P because line item reporting is available. We also received a comment suggesting CMS could work with X12 to add the data to the claim more quickly through the K3 segment of the electronic claim, which is reserved for new data required under legislation and regulation. A commenter suggested that the reporting requirements use a framework allowing for regular feedback to ordering professionals regarding their ordering patterns. Another commenter suggested a simple attestation that such information would be available to CMS upon request. A commenter recommended that codes be modified to reflect additional costs of CDSM services.
We appreciate all information shared by commenters. We will use this feedback to inform CY 2018 rulemaking where we expect to establish the requirements for reporting under the AUC program.
Section 1834(q)(4)(C) of the Act provides for certain exceptions to the AUC consultation and reporting requirements under section 1834(q)(4)(B) of the Act. First, the statute provides for an exception under section 1834(q)(4)(C)(i) of the Act where an applicable imaging service is ordered for an individual with an emergency medical condition as defined in section 1867(e)(1) of the Act. We believe this exception is warranted because there can be situations in which a delay in action would jeopardize the health or safety of individuals. Though we believe they occur primarily in the emergency department, these emergent situations could potentially arise in other settings. Furthermore, we recognize that most encounters in an emergency department are not for an emergency medical condition as defined in section 1867(e)(1) of the Act.
We proposed to provide for an exception to the AUC consultation and reporting requirements under § 414.94(i)(1) for an applicable imaging service ordered for an individual with an emergency medical condition as defined in section 1867(e)(1) of the Act. For example, if a patient, originally determined by the clinician to have an emergency medical condition prior to ordering an applicable imaging service, is later determined not to have had an emergency medical condition at that time, the relevant claims for applicable imaging services would still qualify for an exception. To meet the exception for an emergency medical condition as defined in section 1867(e)(1) of the Act, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman's unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Orders for advanced imaging services for beneficiaries with an emergency medical condition as defined under section 1867(e)(1) of the Act are excepted from the requirement to consult AUC. We intend through the CY 2018 PFS proposed rule to propose more details around how this exception will be identified on the Medicare claim.
The second exception is under section 1834(q)(4)(ii) of the Act for applicable imaging services ordered for an inpatient and for which payment is made under Medicare Part A. We proposed to codify this exception in new § 414.94(i)(2). While we are including this exception consistent with statute, we note that if payment is made under Medicare Part A, the service would not be paid under an applicable payment system, such that the AUC consultation and reporting requirements under § 414.94 would never apply.
The third exception is under section 1834(q)(4)(iii) of the Act for applicable imaging services ordered by an ordering professional who the Secretary determines, on a case-by-case basis and subject to annual renewal, that consultation with applicable AUC would result in a significant hardship, such as in the case of a professional practicing in a rural area without sufficient Internet access. We proposed to codify this exception in new § 414.94(i)(3) by specifying that ordering professionals who are granted a significant hardship exception for purposes of the Medicare EHR Incentive Program payment adjustment under § 495.102(d)(4)(i), (ii), or (iii)(A) or (B) of our regulations would also be granted a significant hardship exception for purposes of the AUC consultation requirement. We proposed, to the extent technically feasible, that the year for which the eligible professional is excepted from the EHR Incentive Program payment adjustment is the same year that the ordering professional is excepted from the requirement to consult AUC through a qualified CDSM. We proposed not to adopt the Meaningful Use significant hardship exception under § 495.102(d)(4)(iv)(C) as an exception for purposes of the AUC consultation requirement. Therefore, ordering professionals with a primary specialty of anesthesiology, radiology or pathology will not be categorically excepted from AUC consultation requirements.
We believe there is substantial overlap between the eligible professionals that would seek a hardship exception under the EHR Incentive Program and those ordering professionals that would seek a hardship exception under the AUC program and, as such, this proposal would be administratively efficient. Using an existing program is the most efficient and expeditious manner to implement the significant hardship exception under the Medicare AUC program. We also believe it is the only administratively feasible option for a national significant hardship identification process that can be implemented by January 1, 2018, though we intend to revisit this option for years after 2018 as the current EHR Incentive Program payment adjustment is set to expire after the 2018 payment adjustment year as the Merit-Based Incentive Payment System takes effect. In addition, below we discuss considerations for a supplemental process to account for hardships for ordering professionals that are not eligible to apply for a significant hardship under the EHR Incentive Program (for example, non-physician practitioners) and ordering professionals that incur a significant hardship outside of the EHR Incentive Program application deadline.
The criteria for significant hardships under the EHR Incentive Program relate to insufficient internet connectivity, extreme and uncontrollable circumstances that prevent the EP from becoming a meaningful EHR user, practicing for less than 2 years, practicing at multiple locations with the inability to control the availability of Certified EHR Technology, lack of face-to-face or telemedicine interaction with patients or a primary specialty designation of anesthesiology, radiology or pathology. We believe that most of these criteria would be relevant to demonstrate a significant hardship for ordering professionals to consult AUC. Regarding hardship exceptions for certain specialty designations, based on Medicare claims data for advanced imaging services from the first 6 months of 2014, approximately 1.2 percent of those claims were for advanced imaging services that had been ordered by a professional with one of the three
We understand that there are differences between the purpose and timing of significant hardship exceptions for the EHR Incentive Program and the Medicare AUC program. Foremost, a significant hardship under the EHR Incentive Program is generally based on a hardship that occurred in a prior period, impacting meaningful EHR use that would affect payments in a subsequent calendar year. For example, a professional that submits an application in March 2017 and qualifies for the hardship exception under the EHR Incentive Program would be exempt from the EHR payment adjustment for calendar year 2018. Although significant hardship exceptions for the EHR payment adjustment year generally are based on the existence of a hardship in a prior period, we believe it would be appropriate for these professionals to also qualify for a significant hardship exception for purposes of the AUC consultation requirement during calendar year 2018. It is also our best, most efficient, administratively feasible means of determining significant hardships for ordering professionals for CY 2018.
We also recognize the possibility that an ordering professional could suffer a significant hardship during the AUC program year, and therefore, is immediately unable to consult AUC. In addition, while again we believe there is significant overlap, there may be circumstances where an ordering professional is not considered to be an eligible professional for purposes of the Medicare payment adjustmentsunder the EHR Incentive Program (for example, an ordering professional that is not a physician). We solicited feedback from commenters regarding processes that could be put in place to accommodate ordering professionals with primary specialties that categorically receive significant hardship exceptions under the EHR Incentive Program, real-time hardships that arise during a year, and ordering professionals that are not eligible to apply using the EHR Incentive Program significant hardship exception process and need to seek a significant hardship exception for the purposes of the AUC program. We believe this would involve only a small number of ordering professionals. To the extent technically feasible, some possibilities for implementing such hardship exceptions may include Medicare Administrative Contractors granting hardships on a case-by-case basis or establishing another mechanism to allow for self-attestation of a significant hardship for a defined period of time (for example, a calendar quarter or a calendar year). We intend to propose a process in the CY 2018 PFS proposed rule.
We invited the public to comment on our proposal for ordering professionals granted a hardship exception for the EHR Incentive Program for payment adjustment year 2018 to also be granted a hardship exception to the Medicare AUC program for those years. We proposed that the year the practitioner is excepted from the EHR Incentive Program payment adjustment is the same year that the practitioner would be excepted from consulting AUC.
The following is a summary of the comments we received on the proposed exceptions to consulting and reporting requirements:
We agree with the commenters that the agency need not create a separate process for granting a significant hardship exception where practitioner overlap is available but we understand that a separate process will need to be established to handle significant hardship requests from non-physician practitioners that order advanced imaging tests as they are not currently included in the EHR Incentive Program. However, we remind all commenters that we intend to revisit this option for years after 2018 as the current EHR Incentive Program payment adjustment is set to expire after the 2018 payment year as the Merit-Based Incentive Payment System takes effect.
In response to the comments, we have made no changes to the proposed exceptions and have finalized our proposals.
Section 1834(q) of the Act includes rapid timelines for establishing a Medicare AUC program for advanced diagnostic imaging services. The number of clinicians impacted by the scope of this program is massive as it will apply to every physician or other practitioner who orders or furnishes applicable imaging services. This crosses almost every medical specialty and could have a particular impact on primary care physicians since their scope of practice can be quite broad.
We continue to believe the best implementation approach is one that is diligent, maximizes the opportunity for public comment and stakeholder engagement, and allows for adequate advance notice to physicians and practitioners, beneficiaries, AUC developers, and CDSM developers. It is for these reasons we proposed to continue a stepwise approach, adopted through notice and comment rulemaking. We proposed this second component to the program to specify qualified CDSMs, identify the initial list of priority clinical areas, and establish requirements related to CDSMs, as well as consulting and reporting exceptions. However, we also recognize the importance of moving expeditiously to accomplish a fully implemented program. Under this proposal, the first list of qualified CDSMs will be posted no later than June 30, 2017, allowing ordering professionals to begin aligning themselves with a qualified CDSM. We expect that furnishing professionals will be required to begin reporting AUC information starting January 1, 2018, and will address this requirement through PFS rulemaking for CY 2018, including how to report that information on claims.
In summary, we proposed definitions of terms and processes necessary to implement the second component of the AUC program. We invited the public to submit comments on these proposals. We were particularly seeking comment on the proposed priority clinical areas and the requirements that must be met by CDSMs to become qualified. We believe the proposed requirements for qualified CDSMs will allow for flexibility so mechanisms can continue to reflect innovative concepts in decision support and develop customer-driven products to ultimately provide information to the ordering professional in such a manner that will maximize appropriate ordering of advanced diagnostic imaging while seamlessly integrating into workflow. As the stakeholders continue to move to a place of consensus-based standards deemed ready for deployment, we may become more prescriptive in future requirements for CDSMs. We also solicited comment on the exceptions to the requirements to consult applicable AUC using CDSMs.
The following is a summary of the other of the comments we received specific to the Medicare AUC program but not directly related to our proposals.
Some commenters opposed a strict application of all priority clinical areas for the purposes of outlier identification. Commenters requested that only ordering professionals with ordering patterns significantly misaligned with AUC be subject to prior authorization. Commenters also requested criteria used to make outlier determination be adjusted over time to allow for innovation in ordering. One commenter requested that ordering professionals not be subject to AUC consultation and prior authorization at the same time.
These additional comments will assist us in further building out the AUC program as we move into the next component for implementation in future rulemaking and have not resulted in any changes to our proposals. We have discussed above, throughout the preamble, our changes in response to public comment. We thank the public for their comments and appreciate the detailed feedback and recommendations from stakeholders. We believe the changes based on public comments have improved the identified priority clinical areas and the qualified CDSM requirements and process for qualification. We are finalizing without change the proposals for the determination of non-adherence and the exceptions under this program. We will continue to post information on our Web site for this program accessible at
In the February 8, 2013
In addition to the Open Payments final rule, we issued final regulations in the CY 2015 PFS final rule with comment period (79 FR 67758) that revised the Open Payments regulations. Specifically, we: (1) Deleted the definition of “covered device”; (2) removed the continuous medical education (CME) exclusion; (3) expanded the marketed name reporting requirements to biologicals and medical supplies; and (4) required stock, stock options, and any other ownership interests to be reported as distinct forms of payment.
Since the publication and implementation of the Open Payments Final Rule and the CY 2015 PFS, various stakeholders have provided feedback to us regarding a variety of aspects of the Open Payments program. As a result, we have identified areas of the rule that might benefit from revision or subregulatory clarification. To consider the views of all stakeholders,
Examples of subject matter areas for which we solicited public comments included: (1) Expansion of the nature of payment categories; (2) length of continued reporting obligations; (3) length of time in which Open Payments data remains relevant to users; (4) mandatory registration for applicable manufacturers and GPOs; (5) pre-vetting of payment information with physicians and teaching hospitals prior to submission; (6) definition of a teaching hospital; (7) new teaching hospital reporting elements; (8) option for early or continuous data submission; (9) the impact of mergers, acquisitions, and other business dealings on reporting; (10) clarification on the definitions of ownership and investment interest terms; and (11) definition of, and collection of data from, Physician Owned Distributors (PODs).
In response to our solicitation, we received 136 timely comments, 95 of which were deemed relevant to the solicitation in that they suggested matters to consider in future rulemaking and system enhancements. The majority of the comments focused on:
• Expanding or clarifying the nature of payment categories enumerated in § 403.904(e)(2).
• Changing the continued reporting obligation to a specific period of time, such as 5 years after the payment or transfer of value was made.
• Publishing or refreshing the Open Payments data so that it is accessible to stakeholders for an appropriate period of time, such as 5 years or the number of years in which an applicable manufacturer or GPO is required to report.
• Streamlining the Open Payments registration process and maintaining voluntary registration for those applicable manufacturers or GPOs that do not report.
• Requiring applicable manufacturers and GPOs to pre-vet financial information with physicians and teaching hospitals before it is reported to Open Payments.
• Clarifying the regulatory definition of a teaching hospital.
• Adding non-public data elements that allow additional detail about the specific recipient or department of a teaching hospital that received a payment or transfer of value.
• Expanding the timeframe in which the Open Payments program can accept data submissions from applicable manufacturers and GPOs, such as by implementing multiple submission windows.
• Implementing flexible reporting requirements so that applicable manufacturers and GPOs can properly and easily represent changes resulting from mergers, acquisitions, and other business dealings.
• Clarifying the definition of PODs and how Open Payments requirements apply to PODs.
These comments, submitted by a variety of parties, broadly supported our effort to engage the program's stakeholders before revising or creating new reporting requirements. We appreciate the commenters' views and recommendations and we will consider the public comments received in the future through possible rulemaking or publication of subregulatory guidance. No Open Payments program changes are being proposed or finalized within this final rule.
In the CY 2017 PFS proposed rule (81 FR 46162) we proposed to release certain data related to the bids submitted annually by Medicare Advantage Organizations (MAOs) and certain Medical Loss Ratio (MLR) data submitted annually by MAOs and Part D plan sponsors. In general, we proposed to release the data submitted by MAOs in the Medicare Advantage (MA) Bid Pricing Tool (BPT), subject to a 5-year delay; and to release data submitted by MAOs and Part D sponsors in accordance with MLR requirements, subject to an 18-month delay. In both cases, the proposed release is subject to specified exclusions.
The proposed rule included a discussion of both the statutory and regulatory authority for collecting bids, as well as an overview of how the information is collected. Each year, MAOs submit bids to CMS for participation in the Medicare Advantage program. Information from these bids is primarily collected through the MA BPT, which was developed by CMS. The data collected in the BPT demonstrates the actuarial bases of the plan bid. Each MA plan bid is an estimate of the plan's revenue requirement to cover plan benefits for a projected population, including benefit costs net of cost-sharing, non-benefit expenses, and gain/loss margin.
The following summary describes the types of data collected in the BPT, which we described in greater detail in the proposed rule at 81 FR 46397-99:
• Base period experience data.
• Trend assumptions.
• Manual rates and credibility assumptions.
• Projected allowed costs.
• Effective value of a plan's cost-sharing.
• Projected administrative expenses and information related to the plan's gain/loss margin.
• Plan-specific bid and benchmark, based on projected enrollment and risk scores.
• Beneficiary rebate and beneficiary premium for the plan.
• Rebate allocations to MA mandatory supplemental benefits and buy down of the Part D basic premium, the Part D supplemental premium, and/or the Part B premium.
• Actuarial pricing elements for any optional supplemental benefit packages.
In addition to these categories of data collected in the BPT, MAOs must submit supporting documentation to substantiate the actuarial basis of pricing and an actuarial certification of the bid.
We described the proposed regulatory changes to allow for the release of MA bid pricing data, along with the manner in which we proposed to make the release. We proposed to codify the requirements for release of MA bid pricing data by adding new § 422.272 to subpart F of part 422. We proposed to release to the public each year, after the first Monday in October, MA bid pricing data for MA plan bids that we accepted or approved for a contract year at least 5 years prior to the upcoming calendar year, subject to specific exclusions described in proposed § 422.272(c). We proposed to amend the regulation text at § 422.504 by adding a new paragraph (n)(2), which would require that an MAO acknowledge the release of MA bid pricing data as provided in § 422.272 as a mandatory contract provision; we also proposed certain technical changes to § 422.504(n). The proposed rule did not discuss these changes to § 422.504(n) in detail as part of the proposal to release MA bid data, but they were reflected in the proposed regulation text at 81 FR 46471. Specifically, we proposed to move the existing provisions regarding the release of summary CMS payment data at existing paragraph (n) to paragraph (n)(1) and to redesignate the existing paragraphs (n)(1)(i) through (iv) and (n)(2) as (n)(1)(i)(A) through (D) and (n)(1)(ii), respectively.
We also described the data that would be subject to exclusion from release. We proposed not to include any Part D bid pricing data, or any information pertaining to the Part D prescription drug bid amount for an MA plan offering Part D benefits. We also proposed to exclude any narrative information included in the MA BPT, MSA BPT, and ESRD-SNP BPT regarding base period factors, manual rates, cost-sharing methodology, optional supplemental benefits, or other topics for which narratives are required by us under § 422.254. We proposed to exclude supporting documentation that is provided outside of the BPT template. We proposed to exclude any information identifying Medicare beneficiaries or other individuals. Regarding other individuals, we explained that our proposal would exclude the names and contact information of certifying actuaries and MAO contacts from the releases. Finally, we proposed to exclude any bid review correspondence between us or our contractors and the MAO.
We detailed the rationale for the proposed releases. We discussed how the release of this data is in support of the Administration's commitment to transparency. We indicated that release of MA bid pricing data could support public research into the MA program that could support the agency's goals for the program, including the delivery of better healthcare. We also suggested the data release would promote public accountability of the program.
We also addressed past and ongoing attempts to achieve release of this data under the Freedom of Information Act, 5 U.S.C. 552 (FOIA). We have received several requests under the FOIA for the type of MA bid pricing data we proposed to release. Under the FOIA, we are required to make available any data released under the FOIA that the agency determines are likely to become the subject of subsequent requests, or that have been requested by three or more requesters. As a result of one such FOIA request, we have already released publicly a limited set of MA bid pricing data. This data, from 2011, is available at
We solicited comments on the scope of the proposed release of MA BPT worksheets and data elements. We were particularly interested in comments on whether the MA bid pricing data we proposed to release contains proprietary information, and if so, we requested detailed explanations of good cause for its redaction from public availability and suggestions for what safeguards might be implemented to appropriately protect those portions of the data. We noted that detailed explanations should contain specific examples which show how this information disclosure could cause substantial competitive harm to MAOs. Specific examples should have (1) cited the particular information proposed to be released and explained how that information differs from publicly available data; (2) pointed to the particular entity or entity type that could gain an unfair competitive advantage from the information release; and (3) fully explained the mechanism by which the release of that particular information would create an unfair competitive advantage for that particular entity. Similarly, we were interested in comments that our proposed scope for release was too narrow and unnecessarily protects data that is not confidential and should not be protected.
We also solicited comments on the proposed 5-year delay and its effect with respect to any competitive disadvantages to MAOs that could result from the disclosure of MA bid pricing data. We solicited comments on whether a shorter period would suffice to protect MAOs from competitive harm associated with the disclosure of confidential commercial information or if a longer period is necessary to adequately protect the information.
We received 30 comments from the public, some in support and some in opposition to our proposed release of MA bid pricing data. We reviewed these comments closely, and we appreciate the concerns identified in comments on our proposed release. These comments are addressed below.
As discussed in the proposed rule, we believe this disclosure is consistent with Presidential directives to make information available to the public, and with our goals of allowing public evaluation of the MA program, encouraging research into better ways to provide health care, and reporting to the public regarding federal expenditures and other statistics involving this program. Analysis of this data could inform future bidding and payment policies. Further, releasing MA bid pricing data, particularly in conjunction with information already released under § 422.504(n), will provide insight into the use of public funds for the MA program, providing appropriate transparency about the administration of the program.
We discussed the need to balance these goals with the need to protect the proprietary information of the MAOs that submit this bid pricing information to us. Our proposed time lag of 5 years prior to the upcoming calendar year was an important element in our decision to release the MA bid pricing data.
As part of our efforts to balance our mission to effectively administer federal health care programs and increase data transparency with MAOs' proprietary interests, we requested that commenters who oppose release of MA bid pricing data provide a “detailed explanation of good cause” for the redaction of some or all MA bid data from public release. As noted in section III.E.2.a of this final rule (“Summary of Proposed Rule”), we stated that detailed explanations should contain specific examples which show how this information disclosure could cause substantial competitive harm to MAOs. Specific examples should have (1) cited the particular information proposed to be released and explained how that information differs from publicly available data; (2) pointed to the particular entity or entity type that could gain an unfair competitive advantage from the information release;
We believe that commenters did not provide data analysis that met this requested standard of specificity to help us determine that release of the data as proposed would cause unfair competitive harm or negative consequences for the MA program. We did not receive specific examples that illustrated how the structure of a particular healthcare market (for example, a particular county or multi-county healthcare market), combined with universal access to certain 5-year-old data elements in the MA BPT, could create an unfair competitive advantage.
A number of commenters expressed concern about the use of MA bid pricing data to reverse-engineer provider payment rates, stating that this could cause competitive harm, especially in highly consolidated markets in which there are a limited number of providers for a specific service. A few commenters stated that a provider might determine whether its payment rates were higher or lower than the average in such a consolidated market (especially for MA bids for single-county MA plans) by comparing its negotiated rate to the average unit price reported in the BPT, in order to increase its leverage in future negotiations with the MAO.
We understand this concern and appreciate the sensitivity of the negotiations between private health plans and healthcare providers. We discuss these comments a greater length below. However, as discussed in more detail throughout this final rule, we believe that the 5-year delay in the release of MA bid pricing data would make any information about payment rates that could be obtained from an examination of plan bids stale and no longer commercially sensitive.
Finally, in 2013, we released certain 2009 actual costs (worksheet 1) from the 2011 MA bid pricing data, as required by the U.S. District Court for the District of Columbia in
In the absence of any evidence or analysis demonstrating that competitive harm would result from the proposed release of MA bid pricing data, and in consideration of the important policy goals that we believe will be served by publicly releasing MA bid pricing data, discussed above, we are finalizing our proposal to release MA bid pricing data after a 5-year delay, subject to certain specified exclusions.
Several commenters also described, at a general level, various methods for reverse engineering provider payment rates using certain information that MAOs submit in their bids. A few commenters stated that the release of an MA plan's average historical cost per unit could be used to calculate negotiated rates by service category and market, particularly where health care markets are highly concentrated.
We do not have access to these negotiated rates between an MAO and its contracted network of providers, so we cannot determine how closely an entry in the BPT may represent negotiated rates in provider contracts. Since payment figures in the MA BPTs are grouped into general service categories (such as “Inpatient Facility” and “Skilled Nursing Facility”) and represent average costs across multiple providers, beneficiaries, services, and sites of service, we believe that the BPT information is unlikely to give more than high-level insight into contractual negotiated rates.
Even if reverse engineering of provider rates were possible, the 5-year delay renders that information even less competitively useful or relevant. We do not believe that any commenters established that a provider who uses MA bid data to estimate the negotiated rate that a competitor was receiving 5 years earlier would be greatly advantaged by this information.
Delivery of health care is constantly evolving and MAOs are continually seeking ways to gain efficiency in providing care. For example, the number of providers, the cost of services, and utilization patterns associated with an MAO are very likely to change over a 5-year period; we believe that these changes—particularly
We selected a 5-year delay, in part, due to the requirements associated with projected margins in the bids submitted by MAOs, particularly when the margin is projected to be negative. MAOs with negative margins in their bids are expected to achieve profitability within 5 years (that is, bids should not have negative margins for more than 4 consecutive years). Absent the 5-year delay, we were concerned that the public might be able to use this margin rule to deduce competitively sensitive information from a plan's bids.
We also believe that 5 years is sufficient time for competitively sensitive bid data to become no longer competitively sensitive. The time lag represents a buffer between the development and implementation of pricing strategies that can be distilled from multiple years of data and the observed relationship and trend from 1 year to the next, and we believe that this buffer mitigates any competitive disadvantage that might otherwise result from the disclosure of multiple years of bid data. As an example, we noted that an MAO looking to enter a new market is significantly less likely to gain an unfair commercial advantage from being able to examine and trend 5-year-old bid pricing data than if the MAO were able to examine and trend more recent bid pricing data (81 FR 46400).
We continue to believe that the proposed exclusion of MA BPT narrative fields and supporting documentation is appropriate because MAOs provide information in narrative fields and supporting documentation that is commercially sensitive information in a way that the cost and enrollment estimates in the BPT are not. MA BPT narrative fields and supporting documentation can include sensitive information such as multi-year regional or national-level information on an MAO's approach to cost-sharing methodology or projection factors, which can provide insight into longer-term strategies, or they may include information on provider contracting, such as fee schedules or summaries of provider contract terms. Provider contract terms and actual fee schedules, for example, would be more competitively sensitive than the estimated provider payment rates that could be generated from 5-year-old bid figures at the broad service level categories in the MA BPT. In addition, we believe that supporting documentation could cause misinterpretation of the MA bid pricing data that we proposed to release. We proposed to release only the MA bid pricing data for MA plan bids that were accepted or approved by CMS. However, MAOs often upload multiple versions of each plan bid in response to our requests for further information or corrections. Given the volume of supporting documentation submitted by MAOs, it may be difficult for a member of the public to identify clearly which documents support the final accepted version of the bid. We proposed, and finalize here, that these documents will not be included in the data that we release under this rule.
We agree that more recent MA bid data is more competitively sensitive than bid data that is at least 5 years old, and we recognize that, even if the release of bid pricing data for a single, more recent year would not itself create a risk of substantial competitive harm, there could be an increased likelihood of substantial competitive harm resulting from the release of a more recent year's bid pricing data when that data can be analyzed in combination with publicly-released bid data for previous years and trended forward to predict current or future bids.
If a FOIA request is received, we will follow our ordinary FOIA procedures and not release data the agency determines are trade secrets, or commercial or financial information protected by Exemption 4 to the FOIA (5 U.S.C. 552(b)(4)). We also note that we do not view data releases made under the authority of the new § 422.272 as FOIA releases. These releases are discretionary disclosures of data to the public, rather than in response to a request under the FOIA. Section 422.272 permits the release of data, but does not require it. As noted in the proposed rule (81 FR 46396-97), we believe that these releases are consistent with the principles of transparency in government that underlie the FOIA and that regular release of this data might mitigate the number of FOIA requests and the associated need for repeated analyses of this data.
Specifically, regarding the comment that MA bid pricing data is proprietary and covered by Exemption 4 of the FOIA, we restate here that we are finalizing our proposal to expand the basis and scope of our regulations on MA bidding to incorporate section 1106(a) of the Act (42 U.S.C. 1306(a)), which authorizes disclosure of information filed with this agency in accordance with regulations adopted by
Finally, regarding the usefulness of currently available MA bid pricing data to researchers, one commenter pointed to research conducted by Dr. Brian Biles on behalf of the Commonwealth Fund, and his work to examine costs in MA. We believe that the data may be accessed again in the future for further research.
After consideration of the public comments received, we are choosing to finalize the proposed MA bid pricing data release, codified at § 422.272, and the proposed contractual acknowledgment of the release, codified at § 422.504(n)(2), without modification. We also finalize our proposal to amend § 422.504 by moving the existing provisions regarding the release of summary CMS payment data at existing paragraph (n) to paragraph (n)(1) and redesignating existing paragraphs (n)(1)(i) through (iv) and (n)(2) as (n)(1)(i)(A) through (D) and (n)(1)(ii), respectively. We appreciate the concerns raised by some commenters, and we believe that these concerns are addressed by our decision to delay our release of MA bid data by 5 years and to exclude certain information from release, as discussed above. We continue to believe that the release of MA bid pricing data is consistent with the Administration's directives regarding the transparency of program data, and will support public research that can potentially strengthen the program.
While we are not modifying any of the proposed exclusions, we note that we will withhold certain fields within the BPT where necessary to comply with our current cell size suppression policy. This policy stipulates that no cell (for example, admissions, discharges, patients, services, etc.) 10 or less may be displayed. For example, a plan with more than 11 enrollees may have fewer than 11 beneficiaries who receive benefits that fall under one of the BPT's service categories. The policy is designed and implemented in order to protect against disclosure of individually identifiable data as our analysis has indicated the potential to identify individuals where the information in the cell is based on 10 or fewer individuals. We interpret the regulation text in this final rule (that protects against and excludes from these disclosures “information that could be used to identify Medicare beneficiaries or other individuals”) to support this suppression policy. Further, to the extent that the suppression policy is revised in the future for these purposes to apply to cell sizes based on more than 10 individuals, we will apply that updated policy under this rule. In order for our release of MA bid pricing data to be consistent with our cell size suppression policy, we may determine that certain fields in the BPT should be withheld or redacted.
We proposed to amend § 422.250 on the basis and scope of the MA program to add a reference to section 1106 of the Act. As discussed in the proposed rule (81 FR 46396), section 1106(a) of the Act (42 U.S.C. 1306(a)) addresses requirements, including rulemaking, for the agency to release information filed with it by outside parties.
We received a few comments on the proposed technical change, summarized below with our response.
The presence of this rider was clearly discussed in the title of the proposed rule, and was also discussed in the Fact Sheet we released to the public at the time of the rule's display. We received many comments from across the industry, including a number of comments from MAOs and their trade associations. This further demonstrates that adequate notice was provided.
After consideration of the public comments we received on the proposed technical amendment, we are finalizing the amendment as proposed.
The proposed rule provided background on the Part C and Part D Medical Loss Ratio requirements, including the statutory and regulatory authority. An MLR is expressed as a percentage, generally representing the percentage of revenue used for patient care rather than for such other items as administrative expenses or profit. In the May 23, 2013 final rule (78 FR 31284), we codified the MLR requirements for MAOs and Part D sponsors in the regulations at 42 CFR part 422, subpart X, and part 423, subpart X, respectively.
For contracts beginning in 2014 or later, MAOs and Part D sponsors are required to report their MLRs and are subject to financial and other penalties for failure to meet the statutory requirement that they have an MLR of at least 85 percent (see § 422.2410 and § 423.2410). Section 1857(e)(4) of the Act requires several levels of sanctions for failure to meet the 85 percent minimum MLR requirement, including remittance of funds to CMS, a prohibition on enrolling new members, and ultimately contract termination.
Under the regulations at § 422.2410 and § 422.2460, with respect to MAOs, and § 423.2410 and § 423.2460, with respect to Part D sponsors, for each contract year, each MAO and Part D sponsor is required to submit a report to us, in a timeframe and manner that we specify, which includes the data needed to calculate and verify the MLR and remittance amount, if any, for each contract. For each contract year beginning in 2014 or later, MAOs and Part D sponsors are required to enter their MLR data and upload their MLR Reports to our Health Plan Management System (HPMS). The MLR Report is on our Web site at
In the proposed rule, we summarized the information collected in conjunction with the MLR requirement. We described the categories of information, including:
• Revenue.
• Claims.
• Federal and State Taxes and Licensing or Regulatory Fees.
• Health Care Quality Improvement Expenses.
• Non-claims Costs.
• Member Months.
We explained the proposed regulatory changes to provide for the release of Part C and Part D MLR data, along with the manner in which we proposed to make the release. We proposed to codify the new requirements for the release of Part C and Part D MLR data by adding new regulations at § 422.504 (related to contract terms) and § 422.2490 (related to the details of the MLR data release) of part 422, with respect to Part C MLR data, and § 423.505 (related to contract terms) and § 423.2490 (related to the details of the MLR data release) of part 423, with respect to Part D MLR data. We proposed to define Part C MLR data at § 422.2490(a), and Part D MLR data at § 423.2490(a), as the data the MAOs and Part D sponsors submit to us in their annual MLR Reports, as required under existing § 422.2460 and § 423.2460. At § 422.2490(b) and § 423.2490(b), we proposed certain exclusions to the definitions of Part C MLR data and Part D MLR data, respectively. We proposed at § 422.2490(c) and § 423.2490(c) to release the Part C MLR data and Part D MLR data, respectively, for each contract for each contract year, no earlier than 18 months after the end of the applicable contract year.
We proposed to amend the regulation text at § 422.504 by adding a new paragraph (n)(2), which would require that an MAO acknowledge the release of Part C MLR data as provided in § 422.2490 as a mandatory contract provision. We also proposed to amend the regulation text at § 423.505(o) by adding a new paragraph (o)(2), which would require that a Part D sponsor acknowledge the release of Part D MLR data as provided in § 423.2490 as a mandatory contract provision. We proposed certain technical changes to § 422.504(n) and to § 423.505(o). The proposed rule did not discuss these changes to § 422.504(n) and § 423.505(o) in detail as part of the proposal to release Part C and Part D MLR data, but they were reflected in the proposed regulation text at 81 FR 46471-72. Our proposed technical changes to § 422.504(n) are described in section III.E.2.a of this final rule (“Summary of Proposed Rule”). With respect to § 423.505(o), we proposed to move the existing provisions regarding the release of summary CMS payment data at existing paragraph (o) to paragraph (o)(1) and to redesignate the existing paragraphs (o)(1) through (5) as (o)(1)(i) through (v).
We also explained the rationale for the proposed data release. As with our release of MA bid pricing data, discussed in section III.E.2.b of this final rule (“Comments”), our release of Part C and Part D MLR data is consistent with Administration initiatives to improve federal management of information resources by increasing data transparency and access to federal datasets. We also noted in the proposed rule that we already publicly release MLR data that issuers of commercial health plans submit each year as required by section 2718 of the Public Health Service Act. This data is listed publicly at
Finally, we discussed our belief that Part C and Part D MLR data could be a valuable tool for consumers, researchers, and the public. We believe that the release of this data will facilitate public evaluation of the MA and Part D programs by providing insight into the efficiency of health insurers' operations. In addition, we believe that the release of certain MLR
We also believe that the availability of Part C and Part D MLR data will enhance the competitive nature of the MA and Part D programs. The proposed access to data will support potential new plan sponsors in evaluating their participation in the Part C and Part D programs and will facilitate the entry into new markets of existing plan sponsors. With knowledge of historical MLR data, new business partners might emerge, and better business decisions might be made by existing partners. As a result, we believe that releasing Part C and Part D MLR data as proposed is both important and appropriate for the effective operation of these programs.
Further, we believe that the release of Part C and Part D MLR data, as described in this final rule, strikes the appropriate balance between our goals for the release of Part C and Part D MLR data and safeguarding information that could be commercially sensitive or proprietary. Costs in the MLR numerator are aggregated across providers, beneficiaries, and sites of service. Costs and revenues are further aggregated across all plans under the contract. We do not believe that there is a realistic possibility that the MLR data we release could be disaggregated or reverse engineered to reveal commercially sensitive or proprietary information.
We described the data we proposed to exclude from the public release. We stated that we would exclude the following four categories of data from release: narrative information, plan-level information (Part C MLR data and Part D MLR data that we will release is aggregated at the contract level), any information identifying beneficiaries or other individuals, and any MLR review correspondence.
First, at proposed § 422.2490(b)(1) and § 423.2490(b)(1), we proposed to exclude from release any narrative information that MAOs and Part D sponsors submit to support the amounts that they include in their MLR Reports, such as descriptions of the methods used to allocate expenses. MAOs and Part D sponsors are required to describe the methods they used to allocate expenses, including incurred claims, quality improvement expenses, federal and state taxes and licensing or regulatory fees, and other non-claims costs. A detailed description of each expense element is provided, including how each specific expense meets the criteria for the type of expense in which it is categorized. MAOs and Part D sponsors may provide information that is pertinent to more than the individual MA or Part D contract for which the MLR Report is being submitted (see, for example, § 422.2420(d)(1)(ii) and § 423.2420(d)(1)(ii), which requires that expenditures that benefit multiple contracts, or contracts other than those being reported, be reported on a pro rata share), such as an MAO's or Part D sponsor's approach to setting payment rates in contracts with providers, or its strategies for investing in activities that improve health quality. We proposed to exclude this narrative information because we believe that it is more competitively sensitive than the contract-level figures that are used to populate the non-narrative fields in the MLR Report. We are concerned that MAOs and Part D sponsors would be reluctant to submit narrative descriptions that include information that they regard as proprietary or confidential if they know that it will be disclosed to the public, which could impair our ability to assess whether their allocation methods are appropriate.
Second, at proposed § 422.2490(b)(2) and § 423.2490(b)(2), we proposed to exclude from release any plan-level information that MAOs and Part D sponsors submit in their MLR Reports. Some of the plan-level data in MAO's and Part D sponsors' MLR Reports is also included in their plan bids as base period experience data, such as plan IDs, plan member months, and Medicaid per member per month gain/loss. As discussed in our proposal to release certain MA bid pricing data, we believe bid data would no longer be competitively sensitive after 5 years; however, we do not believe that bid data becomes no longer competitively sensitive within the 18-month timeframe for our proposed release of MLR data. Therefore, we proposed to exclude from release plan-level data that is included as base period experience data in plan bids. We also proposed to exclude the plan-level information submitted in MLR Reports because we do not regard it as relevant to the purposes of our proposed release of Part C and Part D MLR data, which include giving the public access to data that can be used to evaluate the efficiency of MAOs and Part D sponsors and providing enrollees with information that can be used to compare the relative value of health plans. For example, our proposed release excludes MAOs' and Part D sponsors' responses to questions in the MLR Report that ask whether each plan under a contract is a Special Needs Plan for beneficiaries who are dually eligible for both Medicare and Medicaid (D-SNP), or whether the plan's defined service area includes counties in one of the territories.
Third, at proposed § 422.2490(b)(3) and § 423.2490(b)(3), we proposed to exclude from release any information identifying Medicare beneficiaries or other individuals. This exclusion was proposed for the same reason we proposed to exclude similar information from MA bid submission data that will be released: we believe that it is important to protect the privacy of individuals identified in these submissions, particularly Medicare beneficiaries. We explained that, consistent with our longstanding data release policy for protecting individually identifiable information, if a data field in the MLR Report for an MA or Part D contract is calculated based on figures associated with fewer than 11 enrollees (or 132 member months, assuming each individual is counted for 12 months), we would suppress all the data from such fields in the public release file for that contract.
Regarding other individuals, we require that MAOs and Part D sponsors provide in their MLR Reports the names and contact information of individuals who can answer questions about the data submitted in an MLR Report. We proposed to exclude this information from release. We do not believe that the release of this information serves the purposes of our proposed release of certain MLR data, which are to provide the public with data that can be used to evaluate MA and Part D contracts' efficiency, and to provide beneficiaries with information that can be used to compare the relative value of Medicare plans. Further, release of this identifying and contact information appears to be an unnecessary intrusion into information about private individuals.
Fourth, at proposed § 422.2490(b)(4) and § 423.2490(b)(4), we proposed to exclude from release any MLR review correspondence. In the course of the MLR review process, our reviewers may engage in correspondence with MAOs and Part D sponsors in order to validate amounts included in their MLR Reports. Such correspondence may include
We proposed to release the MLR data specified in this rule for each MA and Part D contract on an annual basis no earlier than 18 months after the end of the contract year to which the MLR data applies. We proposed to follow the commercial MLR approach in making the data we receive in MLR Reports available to the public. For Part C and Part D MLR reporting, the data is due about 12 months after the end of the contract year. After we receive MAOs' and Part D sponsors' MLR Reports, we anticipate that it will take approximately 6 months for us to review and finalize the data submitted by MAOs and Part D sponsors.
We recognize that the 18-month time lag time for the release of Part C and Part D MLR data differs from the 5-year delay used for the release of MA bid pricing data (discussed in section III.E.2.a of this final rule (“Summary of Proposed Rule”)). This difference in the length of the delay that applies to each of these data releases reflects key differences between the MA bid pricing data that we proposed to release in accordance with § 422.272 and the Part C and Part D MLR data that we proposed to in accordance with § 422.2490 and § 423.2490. Most importantly, the Part C and Part D MLR data that we proposed to release is aggregated at the contract level, and we are excluding any plan-level data. The MA bid pricing data that we proposed to release includes plan-level information. We believe that contract-level information is sufficiently aggregated such that it would be difficult to obtain an unfair competitive advantage from its review. For example, we do not believe it is possible to reverse-engineer provider rates from contract-level information.
Finally, we proposed to amend § 422.2400, which identifies the basis and scope of the MLR regulations for MAOs, and § 423.2400, which identifies the basis and scope of the MLR regulations for Part D sponsors, to add a reference to section 1106 of the Act, which governs the release of information gathered in the course of administering our programs under the Act.
We solicited comment on the release of MLR data as outlined above. We also solicited comment on whether the Part C and Part D MLR data we proposed to release contain proprietary information, and if so, what safeguards might be appropriate to protect those data, such as recommended fields to be redacted, the minimum length of time that such data remains commercially sensitive, and any suggestions for publishing aggregations of Part C and Part D MLR data in lieu of publishing the MLR data as submitted by MAOs and Part D sponsors. We invited commenters to provide analysis and explanations to support comments that information should be protected for a longer—or shorter—period of time so that we could properly evaluate our proposal in adopting a final rule. Analysis and explanations were requested to (1) cite the particular information proposed to be released and explain how that information differs from publicly available data; (2) point to the particular entity or entity type that could gain an unfair competitive advantage from the information release; and (3) fully explain the mechanism by which the release of that particular information would create an unfair competitive advantage for that particular entity. We requested this level of detail in order to substantiate the positions taken by commenters and to better inform our rulemaking and decisions (81 FR 46403).
The following is summary of the comments we received on our proposed regulatory changes providing for the release of Part C and Part D MLR data.
However, to address concerns raised by commenters, we are expanding the data that would be subject to exclusion. First, we are revising our proposed exclusion of plan-level data at proposed § 422.2490(b)(2) and § 423.2490(b)(2) to state that we will not be releasing any MLR data submitted for contracts that consist of only one plan. Contract-level data for single-plan contracts is equivalent to plan-level data, which we regard as more competitively sensitive because it is at a lower level of aggregation. In expanding the exclusion at proposed § 422.2490(b)(2) and § 423.2490(b)(2) to include MLR data submitted for single-plan contracts, we are confirming our commitment not to release any plan-level MLR data. Second, we are excluding from release any MLR data for a contract in a contract year that the contract is determined to be non-credible, as defined in accordance with § 422.2440(d) for MA contracts and § 423.2440(d) for Part D contracts. Although, as we explain more fully below, we are adopting this new exclusion of non-credible contracts' MLR data for reasons other than the protection of proprietary information, we expect that this exclusion will address concerns about competitive harm for MAOs or Part D sponsors operating contracts with limited enrollment.
Currently, MA contracts are considered to be non-credible if they have fewer than 2,400 member months, and Part D contracts are considered non-credible if they have fewer than 4,800 member months. In the February 23, 2013 proposed rule (78 FR 12428, 12438-40), we explained our rationale for taking into account the number of enrollees under a contract when assessing Part C and Part D MLRs, stating, “To avoid requiring MA organizations and Part D sponsors to pay remittances due to random claim variation, rather than due to their underlying pricing and benefits structure, it is necessary to assess MLRs
We have proposed appropriate exclusions and safeguards to protect proprietary business strategies. Completely excluding other information would not be consistent with the Administration's commitment to transparency.
The presence of this rider was clearly discussed in the title of the rule and in the Fact Sheet that we released publicly at the time of the rule's display. We received 26 comments on our proposed release of Part C and Part D MLR data from across the industry, including a number of comments from MAOs, Part D sponsors, and their trade associations. This further demonstrates that adequate notice was provided.
We also proposed to amend § 422.2400, which identifies the basis and scope of the MLR regulations for MAOs, and § 423.2400, which identifies the basis and scope of the MLR regulations for Part D sponsors, to add a reference to section 1106 of the Act, which governs the release of information gathered in the course of administering our programs under the Act. After consideration of public comments received on the technical changes, we are finalizing these technical changes to § 422.2400 and § 423.2400 as proposed.
After reviewing the comments we received, we are choosing to finalize the proposed MLR data release with two modifications. First, we will revise the exclusion at § 422.2490(b)(2), with respect to Part C MLR data, and at § 423.2490(b)(2), with respect to Part D MLR data, to exclude from release any MLR data submitted for a single-plan contract. Second, we add a new exclusion at § 422.2490(b)(5), with respect to Part C MLR data, and at § 423.2490(b)(5), with respect to Part D MLR data, to exclude from release any MLR data submitted for a contract in a contract year for which the contract is determined to be non-credible, as defined in accordance with § 422.2440(d) for MA contracts and § 423.2440(d) for Part D contracts. We continue to believe that the release of MLR data is consistent with the Administration's directives regarding the transparency of program data, and we support public research that can potentially strengthen the program.
As we stated in the CY 2017 proposed rule, we remind all Medicare providers (including providers of services defined in section 1861 of the Act and physicians) that federal law prohibits them from collecting Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments, from beneficiaries enrolled in the Qualified Medicare Beneficiaries (QMB) program (a Medicaid program which helps certain low-income individuals with Medicare cost-sharing liability). In July 2015, we released a study finding that confusion and inappropriate balance billing persist notwithstanding laws prohibiting Medicare cost-sharing charges for QMB individuals, Access to Care Issues Among Qualified Medicare Beneficiaries (QMB) (“Access to Care”)
These findings underscore the need to re-educate providers about proper billing practices for QMB enrollees.
In 2013, approximately 7 million Medicare beneficiaries were enrolled in the QMB program. State Medicaid programs are liable to pay Medicare providers who serve QMB individuals for the Medicare cost-sharing. However, as permitted by federal law, states can limit provider payment for Medicare cost-sharing to the lesser of the Medicare cost-sharing amount, or the difference between the Medicare payment and the Medicaid rate for the service. Regardless, as stated in the CY 2017 proposed rule, Medicare providers must accept the Medicare payment and Medicaid payment (if any, and including any permissible Medicaid cost sharing from the beneficiary) as payment in full for services rendered to a QMB individual. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See sections 1902(n)(3), 1905(p), 1866(a)(1)(A), and 1848(g)(3) of the Act.)
Additionally, as we stated in the CY 2017 proposed rule, Medicare providers should take steps to educate themselves and their staff about QMB billing prohibitions and to exempt QMB individuals from impermissible Medicare cost-sharing billing and related collection efforts. For more information about these requirements, steps to identify QMB patients and ways to promote compliance, see
Given that original Medicare providers may also serve Medicare Advantage enrollees, we again note that the CY 2017 Medicare Advantage Call Letter reiterates the billing prohibitions applicable to dual eligible beneficiaries (including QMBs) enrolled in Medicare Advantage plans and the responsibility of plans to adopt certain measures to protect dual eligible beneficiaries from unauthorized charges under § 422.504(g). (See pages 181-183 at
Although we did not solicit comments on this statement of current law and policy, we appreciate the comments received, which included comments from national beneficiary advocacy organizations, and professional, insurance, and medical billing associations.
Medicare payments to providers and suppliers may be offset or recouped, in whole or in part, by a Medicare Administrator Contractor (MAC) if the MAC or CMS has determined that a provider or supplier has been overpaid. Historically, we have used the Medicare provider billing number or National Provider Identifier (NPI) to recoup overpayments from Medicare providers and suppliers until these debts were paid in full or eligible for referral to the Department of Treasury (Treasury) for further collection action under the Debt
On March 23, 2010, the Affordable Care Act (ACA) was enacted. Section 6401(a)(6) of the Affordable Care Act established a new section 1866(j)(6) of the Act. Section 1866(j)(6) of the Act allows the Secretary to make any necessary adjustments to the payments to an applicable provider of services or supplier to satisfy any amount due from an obligated provider of services or supplier. The statute defines an applicable provider of services or supplier (applicable provider) as a provider of services or supplier that has the same taxpayer identification number as the one assigned to the obligated provider of services or supplier. The statute defines the obligated provider of services or supplier (obligated provider) as a provider of services or supplier that owes a past-due overpayment to the Medicare program. For purposes of this provision, the applicable and obligated providers must share a TIN, but may possess a different billing number or National Provider Identifier (NPI) number than one another.
For example, a health care system may own a number of hospital providers and these providers may share the same TIN while having different NPI or Medicare billing numbers. If one of the hospitals in this system receives a demand letter for a Medicare overpayment, then that hospital (Hospital A) will be considered the obligated provider while its sister hospitals (Hospitals B and C) will be considered the applicable providers. This authority allows us to recoup the overpayment of the obligated provider, Hospital A, against any or all of the applicable providers, Hospitals B and C, with which it, Hospital A, shares a TIN.
If CMS or a Medicare contractor has decided to put into effect an offset or recoupment, then § 405.373(a) requires the Medicare contractor to notify the provider or supplier in writing of its intention to fully or partially offset or recoup payment and the reasons for the offset or recoupment. Currently, the written demand letter sent by the Medicare contractor to a provider or supplier serves as notification of the overpayment and intention to recoup or offset if the obligated provider, Hospital A, fails to repay the overpayment in a timely manner.
With the passage of section 1866(j)(6) of the Act, the requirements in § 405.373(a) could be interpreted to require the Medicare contractor to provide notification to both the obligated provider, Hospital A, and the applicable provider, Hospital B, of its intention to recoup or offset payment. Because we don't think it is necessary to provide separate notice to both the obligated provider and the applicable provider, we proposed to amend the notice requirement in § 405.373. Specifically, we proposed to create a new paragraph (f) in § 405.373 to state that § 405.373(a) does not apply in instances where the Medicare Administrative Contractor intends to offset or recoup payments to the applicable provider of services or supplier to satisfy an amount due from an obligated provider of services or supplier when the applicable and obligated provider of services or supplier share the same Taxpayer Identification Number.
Before the effective date of this rule, we intend to notify all potentially affected Medicare providers of the implementation of section 1866(j)(6) of the Act through Medicare Learning Network (MLN) or MLN Connects Provider eNews article(s). We also intend to update the current Internet Only Manual instructions including, the Medicare Financial Management Manual, and the addition of clarifying language in the demand letters issued to obligated providers. We believe these actions would provide adequate notice to providers and suppliers sharing a TIN, if they choose, provide the opportunity to implement a tracking system of Medicare overpayments on the corporate level for the affected providers. We also believe these actions are sufficient because of Treasury's analogous practice of offsetting using a TIN without furnishing notice to all potentially affected providers and suppliers. It has been a long standing practice for Treasury to offset federal payments using the TIN and Treasury currently does not issue a notice of intent to recoup or offset to applicable providers and suppliers when Treasury recoups CMS overpayments.
Additionally, in our review of § 405.373(a) and (b), we proposed to replace the terms intermediary and carrier with the term Medicare Administrative Contractor as intermediaries and carriers no longer exist.
The following is a summary of the comments we received on recoupment or offset of payments to providers sharing the same taxpayer identification number.
The Affordable Care Act gives the Secretary authority to incorporate reporting requirements and incentive payments from certain Medicare programs into the Shared Savings Program, and to use alternative criteria to determine if payments are warranted.
Current Shared Savings Program regulations at § 425.504(c) do not allow eligible professionals (EPs) billing through the Taxpayer Identification Number (TIN) of an Accountable Care Organization (ACO) participant to participate in PQRS outside of the Shared Savings Program, and these EPs and the ACO participants through which they bill may not independently report for purposes of the PQRS apart from the ACO. This policy was designed to ease reporting burden for individual EPs and group practices and promote integration of providers and suppliers within the ACO in order to help achieve the Shared Savings Program goals of improving quality and coordination of care. While over 98 percent of ACOs satisfactorily report their quality data annually, if an ACO fails to satisfy the PQRS reporting requirements, the individual EPs and group practices participating in that ACO will receive the PQRS payment adjustment along with the automatic VM downward payment adjustment.
We proposed to amend the regulation at § 425.504 to permit EPs that bill under the TIN of an ACO participant to report separately for purposes of the 2018 PQRS payment adjustment when the ACO fails to report on behalf of the EPs who bill under the TIN of an ACO participant. Specifically, we proposed to remove the requirement at § 425.504(c)(2) so that, for purposes of the reporting period for the 2018 PQRS payment adjustment (that is, January 1, 2016, through December 31, 2016), EPs who bill under the TIN of an ACO participant have the option of reporting separately as individual EPs or group practices. If the ACO fails to satisfactorily report on behalf of such EPs or group practices, we proposed to consider this separately reported data for purposes of determining whether the EPs or group practices are subject to the 2018 PQRS payment adjustment. We also proposed to amend § 425.504(c)(2) to apply only for purposes of the 2016 payment adjustment. We proposed revised requirements for the 2017 and 2018 PQRS payment adjustments under the Shared Savings Program at § 425.504(d). We refer readers to section III.K.1.e. of this final rule for a more detailed discussion of the proposed revisions to the requirements at § 425.504 and the policies that are being finalized in this final rule.
In the proposed rule, we noted that the registration deadline for participating in the PQRS Group Practice Reporting Option (GPRO) is June 30 of the applicable reporting period. Since affected EPs are not able to register for the PQRS GPRO by the applicable deadline for the 2018 PQRS payment adjustment, we proposed that such EPs would not need to register for the PQRS GPRO for the 2018 PQRS payment adjustment, but rather could mark the data as group-level data in their submission. Thus, we proposed to eliminate a registration process for groups submitting data using third party entities. When groups submit data utilizing third party entities, such as a qualified registry, qualified clinical data registry (QCDR), direct Electronic Health Record (EHR) product, or EHR data submission vendor, we are able to obtain group information from the third party entity and discern whether the data submitted represents a group-level submission or an individual-level submission once the data is submitted. In addition, we proposed that an affected EP may utilize the secondary reporting period either as an individual EP using one of the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options or as a group practice using one of the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options. We noted that this would exclude, for individual EPs, the claims reporting option and, for group practices, the Web Interface and certified survey vendor reporting options.
Furthermore, we recognized that certain EPs are similarly situated with regard to the 2017 PQRS payment adjustment, which will be applied beginning on January 1, 2017. We stated that we believe it is appropriate and consistent with our stated policy goals to afford these EPs the benefit of this proposed policy change. Accordingly, as noted above, we proposed to permit EPs that bill through the TIN of an ACO participant to report separately for purposes of the 2017 PQRS payment adjustment if the ACO failed to report on behalf of the EPs who bill under the TIN of an ACO participant. Specifically, we proposed to remove the requirements at § 425.504(c)(2) so that, for purposes of the reporting period for the 2017 PQRS payment adjustment, EPs who bill under the TIN of an ACO participant have the option of reporting separately as individual EPs or group practices. As noted in this final rule, we proposed to amend § 425.504(c)(2) to apply only for purposes of the 2016 payment adjustment. We proposed to include the revised requirements for the 2017 and 2018 PQRS payment adjustments under the Shared Savings Program at § 425.504(d). We refer readers to the discussion of this proposal and the final policies that we are adopting in section III.K.1.e. of this final rule.
The previously established reporting period for the 2017 PQRS payment adjustment is January 1, 2015, through December 31, 2015. To allow affected EPs that participate in an ACO to report separately for purposes of the 2017 PQRS payment adjustment, we proposed at § 414.90(j)(1)(ii) to establish a secondary PQRS reporting period for the 2017 PQRS payment adjustment for individual EPs or group practices who bill under the TIN of an ACO participant if the ACO failed to report on behalf of such individual EPs or group practices during the previously established reporting period for the 2017 PQRS payment adjustment. We proposed that this option would be limited to EPs that bill through the TIN of an ACO participant in an ACO that failed to satisfactorily report on behalf of its EPs and would not be available to EPs that failed to report for purposes of PQRS outside the Shared Savings Program.
In addition, we proposed that these affected EPs may utilize the secondary reporting period either as an individual EP using the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options or as a group practice using one of the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options. We noted that this would exclude, for individual EPs, the claims reporting option and, for group practices, the Web Interface and certified survey vendor reporting options.
We note that the registration deadline for the participating in the PQRS GPRO is June 30 of the applicable reporting period. Since the applicable deadline for the 2017 PQRS payment adjustment has passed, we proposed that such EPs would not need to register for the PQRS GPRO for the 2017 PQRS payment adjustment, but rather would be able to report as a group practice via the registry, QCDR, direct EHR product, or EHR data submission vendor reporting options. Therefore, we proposed at § 414.90(j)(4)(v) that sections
We also proposed that the secondary reporting period for the 2017 PQRS payment adjustment would coincide with the reporting period for the 2018 PQRS payment adjustment (that is, January 1, 2016 through December 31, 2016). In addition, for operational reasons and to minimize any additional burden on affected EPs (who are already required to report for CY 2016 for purposes of the 2018 PQRS payment adjustment), we proposed to assess the individual EP or group practice's 2016 data using the applicable satisfactory reporting requirements for the 2018 PQRS payment adjustment (including, but not limited to, the applicable PQRS measure set). We invited comment on any 2018 requirements that might need to be modified when applied for purposes of the 2017 PQRS payment adjustment.
As a result, individual EP or group practice 2016 data could be used with respect to the secondary reporting period for the 2017 PQRS payment adjustment or for the 2018 PQRS payment adjustment or for both payment adjustments if the ACO in which the affected EPs participate failed to report for purposes of the applicable payment adjustment. We explained that we believe this change to our program rules is necessary for affected individual EPs and group practices to be able to take advantage of the additional flexibility proposed for the Shared Savings Program (81 FR 46426 through 45427). If an affected individual EP or group practice decides to use the secondary reporting period for the 2017 PQRS payment adjustment, we explained that this EP or group practice should expect to receive a PQRS payment adjustment for services furnished in 2017 until CMS is able to determine that the EP or group practice satisfactorily reported for purposes of the 2017 PQRS payment adjustment. First, we would need to process the data submitted for 2016. Second, we would need to determine whether or not the individual EP or group practice met the applicable satisfactory reporting requirements for the 2018 PQRS payment adjustment. Third, we would need to update the individual EP or group practice's status so that the EP or group practice stops receiving a negative payment adjustment on claims for services furnished in 2017 and reprocess all claims that were previously paid. In addition, as discussed in the proposed rule, the EP or group practice would also avoid the automatic downward VM adjustment, but would not qualify for an upward adjustment since the ACO failed to report (81 FR 46446).
Since EPs and group practices taking advantage of this secondary reporting period for the 2017 PQRS payment adjustment will have missed the deadline for submitting an informal review request for the 2017 PQRS payment adjustment, we proposed that the informal review submission periods for these EPs or group practices would occur during the 60 days following the release of the PQRS feedback reports for the 2018 PQRS payment adjustment.
We requested comments on these proposals.
The following is summary of the comments we received on ACO participants who report PQRS quality measures separately.
We received a few comments for this section that are out of scope for this final rule. We received comments pertaining to the following: (1) Support for CMS' proposal that EPs participating in an ACO under the Shared Savings Program that satisfy the CQM reporting component of meaningful use for the Medicare EHR Incentive Program when the EP extracts data necessary for the ACO to satisfy the quality reporting requirements under the Shared Savings Program from CEHRT and when the ACO reports the ACO GPRO measures through the CMS Web Interface; (2) recommendation that under MIPS, CMS use the PQRS data (either submitted by the ACO or separately by the ACO participant) which would generate the highest score for the quality performance category; and (3) requested guidance in the final rule for EPs, such as rehabilitation therapists, who are currently subject to PQRS, but will not be subject to MIPS until 2021 at the earliest.
After consideration of the comments received regarding our proposed policies for EPs and group practices participating in ACOs that report PQRS quality measures separately from the ACO, we are finalizing the policies as proposed. At § 414.90(j)(1)(ii), we are finalizing our proposal to establish a secondary PQRS reporting period for the 2017 PQRS payment adjustment for individual EPs or group practices who bill under the TIN of an ACO participant if the ACO failed to report on behalf of such individual EPs or group practices during the previously established reporting period for the 2017 PQRS payment adjustment. This option is limited to EPs and group practices that bill through the TIN of an
The Medicare program is the primary payer of health care for approximately 54 million beneficiaries and enrollees. Section 1802(a) of the Act permits beneficiaries to obtain health services from any individual or organization qualified to participate in the Medicare program. Providers and suppliers furnishing items or services must comply with all applicable Medicare requirements stipulated in the Act and codified in the regulations. These requirements are meant to promote quality care while protecting the integrity of the program. As a major component of our fraud prevention activities, we have increased our efforts to prevent unqualified individuals or organizations from enrolling in Medicare.
The term “provider of services” is defined in section 1861(u) of the Act as a hospital, a critical access hospital (CAH), a skilled nursing facility (SNF), a comprehensive outpatient rehabilitation facility (CORF), a home health agency (HHA), or a hospice. The term “supplier” is defined in section 1861(d) of the Act as, unless context otherwise requires, a physician or other practitioner, facility or other entity (other than a provider of services) that furnishes items or services under title XVIII of the Act. Other supplier categories may include, for example, physicians, nurse practitioners, and physical therapists.
Providers and suppliers that fit into these statutorily defined categories may enroll in Medicare if they meet the proper screening and enrollment requirements. This final rule will require providers and suppliers in MA organization networks and other designated plans (hereafter including MA-PD plans, FDRs, PACE, Cost HMOs or CMPs, demonstration programs, pilot programs, locum tenens suppliers, and incident-to suppliers) to be enrolled in Medicare in an approved status. We generally refer to an “approved status” as a status whereby a provider or supplier is enrolled in, and is not revoked from, the Medicare program. For example, a provider or supplier that has submitted an application, but has not completed the enrollment process with their respective Medicare Administrative Contractor (MAC), is not enrolled in an approved status. The submission of an enrollment application does not deem a provider or supplier enrolled in an approved status. A provider or supplier that is currently revoked from Medicare is not in an approved status. Out-of network or non-contract providers and suppliers are not required to enroll in Medicare to meet the requirements of this final rule with respect to furnishing items and services to MA enrollees.
To receive payment for a furnished Medicare Part A or Part B service or item, or to order, certify, or prescribe certain Medicare services, items, and drugs, a provider or supplier must enroll in Medicare. The enrollment process requires the provider or supplier to complete, sign, and submit to its assigned Medicare contractor the appropriate Form CMS-855 enrollment application. The CMS-855 application form captures information about the provider or supplier that is needed for CMS or its contractors to screen the provider or supplier, verify the information provided, and determine whether the provider or supplier meets all Medicare requirements. This screening prior to enrollment helps to ensure that unqualified individuals and entities do not bill Medicare and that the Medicare Trust Funds are accordingly protected. Data collected and verified during the enrollment process generally includes, but is not limited to: (1) Basic identifying information (for example, legal business name, tax identification number); (2) state licensure information; (3) practice locations; and (4) information regarding ownership and management control.
We strive to further strengthen the provider and supplier enrollment process to prevent problematic providers and suppliers from entering the Medicare program. This includes, but is not limited to, enhancing our program integrity monitoring systems and revising our provider and supplier enrollment regulations in 42 CFR 424, subpart P, and elsewhere, as needed. With authority granted by the Act, including provisions in the Affordable Care Act, we have revised our provider and supplier enrollment regulations by issuing the following:
• In the February 2, 2011
++ A requirement that institutional providers and suppliers must submit application fees as part of the Medicare, Medicaid, and CHIP provider and supplier enrollment processes.
++ Establishment of Medicare, Medicaid, and CHIP provider and supplier risk-based enrollment screening categories and corresponding screening requirements.
++ Authority that enabled imposition of temporary moratoria on the enrollment of new Medicare, Medicaid, and CHIP providers and suppliers of a particular type (or the establishment of new practice locations of a particular type) in a geographic area.
• In the April 27, 2012
++ This requirement was expanded to include prescribers of Medicare Part D drugs in the final rule published in the May 23, 2014
Through improved processes and systems, since March 2011 we have:
• Saved over $927 million by revoking Medicare Part A and B providers and suppliers that did not comply with Medicare requirements;
• Avoided over $2.4 billion in costs by preventing further billing from revoked and deactivated Medicare Part A and B providers and suppliers;
• Deactivated more than 543,163 Medicare Part A and B providers and suppliers that did not meet Medicare enrollment standards;
• Revoked enrollment and billing privileges under § 424.535 for more than 34,888 Medicare Parts A and B providers and suppliers that did not meet Medicare enrollment standards, and
• Denied 4,949 applications for providers and suppliers in Medicare Parts A and B that did not meet Medicare enrollment standards within a recent 12-month period.
The public may review the Annual Report to Congress on the Medicare and Medicaid Integrity Programs each year for more information on program integrity efforts, including how we calculate savings to the Medicare and Medicaid programs. The Department of Health and Human Services (HHS), Office of Inspector General (OIG), Government Accountability Office (GAO), and other federal agencies routinely review Medicare's provider and supplier enrollment processes and systems, including a recent study stating that “as part of an overall effort to enhance program integrity and reduce fraud risk, effective enrollment-screening procedures are essential to ensure that ineligible or potentially fraudulent providers or suppliers do not enroll in the Medicare program.” (GAO-15-448) The enrollment screening authorities granted in the Affordable Care Act and used to prevent and detect ineligible or potentially fraudulent providers and suppliers from enrolling in the Medicare program are working to protect beneficiaries and the Medicare Trust Funds.
Under applicable provisions of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, Medicare began to pay health plans on a prospective risk basis for the first time. The Balanced Budget Act of 1997 (BBA) modified these provisions and established a new Part C of the Medicare program, known as Medicare+Choice (M+C), effective January 1999. As part of the M+C program, the BBA authorized us to contract with public or private organizations to offer a variety of health plan options for enrollees, including both traditional managed care plans (such as those offered by HMOs, as defined in section 1876 of the Act) and new options not previously authorized.
The M+C program was renamed the Medicare Advantage (MA) program under Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173), which was enacted on December 8, 2003. The MMA updated the choice of plans for enrollees under MA and changed how benefits are established and payments are made. In addition, Title I of the MMA established the Medicare prescription drug benefit (Part D) program and amended the MA program to allow most types of MA plans to offer prescription drug coverage.
All Medicare health plans, with the exception of PACE organizations, operating in geographic areas that we determine to have enough qualified providers and suppliers with which to contract in order for enrollees to have access to all Medicare Part A and Part B services, must develop a network of qualified providers and suppliers that meet our network adequacy standards. As a condition of contracting with us, the health plans' contracted network of providers and suppliers must be approved by us as part of application approval (§ 417.406). PACE organizations must furnish comprehensive medical, health, and social services that integrate acute and long-term care in at least the PACE center, the participant's home, or inpatient facilities, and must ensure accessible and adequate services to meet the needs of its participants.
Individuals receiving care through MA organizations are typically referred to as enrollees, while in other parts of the Medicare program, benefit recipients are referred to as beneficiaries. This rule does not change the proper meaning of either term; however, for ease of reading, the terms “beneficiary” and “enrollee” are used synonymously throughout the preamble of this final rule.
This final rule will require providers or suppliers that furnish health care items or services to a Medicare enrollee who receives his or her Medicare benefit through an MA organization to be enrolled in Medicare and be in an approved status. The term “MA organization” refers to both MA plans and also MA plans that provide drug coverage, otherwise known as MA-PD plans. This final rule creates consistency with the provider and supplier enrollment requirements for all other Medicare (Part A, Part B, and Part D) programs. We believe that this final rule is necessary to help ensure that Medicare enrollees receive items or services from providers and suppliers that are fully compliant with the requirements for Medicare enrollment and that are in an approved enrollment status in Medicare. This final rule will assist our efforts to prevent fraud, waste, and abuse and to protect Medicare enrollees by carefully screening all providers and suppliers, especially those that potentially pose an elevated risk to Medicare, to ensure that they are qualified to furnish Medicare items and services. Out-of-network or non-contract providers and suppliers are not required to enroll in Medicare to meet the requirements of this final rule.
We consider provider and supplier enrollment to be the gateway to the Medicare program and to beneficiaries. Requiring enrollment of those that wish to furnish items or services to MA beneficiaries gives us improved oversight of the providers and suppliers treating beneficiaries and the Medicare Trust Funds dollars spent on their care. However, Medicare has not historically had direct oversight over all providers and suppliers in MA organizations. We note that § 422.204 requires MA organizations to conduct screening of their providers. We believe that we, through our enrollment processes, can further ensure that only qualified providers and suppliers treat Medicare beneficiaries by conducting rigorous screening and rescreening of providers and suppliers that includes, for example, risk-based site visits and, in some cases, fingerprint-based background checks. We also have access to information and data not available to MA organizations, making oversight to ensure compliance with all federal and state requirements more robust. We also continually review provider and supplier enrollment information from multiple sources, such as judicial and law enforcement databases, state licensure databases, professional credentialing sources, and other systems of record. In short, we collect and carefully review and verify information prior to the provider's or supplier's enrollment and, of great importance, continue this monitoring throughout the period of enrollment. Section 422.204, on the other hand, neither requires MA organizations to, for instance, review a provider or supplier's final adverse action history (as defined in § 424.502), nor to verify a provider or supplier's practice location, ownership, or general identifying information.
We believe that MA organization enrollees should have the same protections against potentially unqualified or fraudulent providers and suppliers as those afforded to beneficiaries under the fee-for-service (FFS) and Part D programs. Indeed, Medicare beneficiaries and enrollees, the Medicare Trust Funds, and the program at large, are at risk when providers and suppliers that have not been adequately screened, furnish, order, certify, or prescribe Medicare services and items and receive Medicare payments. For instance, a network provider with a history of performing medically unnecessary tests, treatments, or procedures could threaten enrollees' welfare, as could a physician who routinely overprescribes dangerous drugs. Lack of sufficient oversight could also result in improper Medicare payments, harming the Medicare Trust Funds and taxpayers. Requiring enrollment allows us to have proper oversight of providers and suppliers, making it more difficult for these types of providers and suppliers to enroll in Medicare and remain enrolled in Medicare. Furthermore, it allows us to remove a enrolled provider or supplier that does not comply with our rules across Medicare (Part A, Part B, MA, and Part D).
Information regarding a provider or supplier's enrollment status is housed in our enrollment repository called the Provider Enrollment, Chain and Ownership System (PECOS). A link to that information is located on the CMS Web site. Initial data show a large percent of MA providers and suppliers are already enrolled in Medicare. We do not believe that this final rule will have a significant impact on MA organizations' ability to establish networks of contracted providers and suppliers that meet CMS' MA network requirements. However, we solicited industry comment on the potential impact of this final rule on MA organizations ability to establish or maintain an adequate networks of providers and suppliers. To clarify, this rule only requires the enrollment of providers and suppliers that are of a provider or supplier type eligible to enroll in Medicare. Categorically- eligible providers and suppliers unable to meet the specific enrollment requirements are not exempt from this rule. For example, if a clinical social worker cannot meet an education requirement as required by § 410.73, the clinical social worker cannot enroll because he or she fails to meet program requirements. Therefore, this clinical social worker may not provide items and services to beneficiaries that receive items and services through FFS, MA, MA-PD, PACE, and Cost plans, as well as demonstration and pilot programs, regardless of whether the provider or supplier is listed on a specific claim for payment.
We believe that preventing questionable providers or suppliers from participating in the MA program and removing existing unqualified providers and suppliers will help ensure that fewer enrollees are exposed to risks and potential harm, and that taxpayer monies are spent appropriately. Such a policy will also help comply with the GAO's recommendation that we improve our provider and supplier enrollment processes and systems to increase the protection of all beneficiaries and the Medicare Trust Funds. (GAO-15-448). The additional resources and oversight that we provide in our processes for enrolling providers and suppliers will enhance and complement the screening processes that MA organizations already are required to perform.
The following are the principal legal authorities for these provisions:
• Section 1856(b) of the Act provides that the Secretary shall establish by regulation other standards for Medicare+Choice organizations and plans consistent with, and to carry out, this part. In addition, section 1856(b) states that these standards supersede any state law or regulation (other than those related to licensing or plan solvency) for all MA organizations.
• Sections 1102 and 1871 of the Act, which provide general authority for the Secretary to prescribe regulations for the efficient administration of the Medicare program.
• Section 1866(j) of the Act, which provides specific authority with respect to the enrollment process for providers and suppliers in the Medicare program.
Given the foregoing and the need to safeguard the Medicare program and its enrollees, we are finalizing most provisions included in the proposed rule, with limited exceptions and explained herein.
Although existing regulations at § 422.204 address basic requirements for MA provider credentialing, we are finalizing the requirement in § 422.204(b)(5) to require plans to verify that they are compliant with the provider and supplier enrollment requirements. We believe this addition would help facilitate MA organizations' compliance.
In §§ 422.222, 417.478, 460.50, 460.70, and 460.71 we are finalizing the provisions requiring providers and suppliers to enroll in Medicare and be in an approved status in order to provide health care items or services to a Medicare enrollee who receives his or her Medicare benefit through an MA organization. This requirement would apply to network providers and suppliers; first-tier, downstream, and related entities (FDR); providers and suppliers participating in the Program of All-inclusive Care for the Elderly (PACE); suppliers in Cost HMOs or CMPs; providers and suppliers participating in demonstration programs; providers and suppliers in pilot programs; locum tenens suppliers; and incident-to suppliers. Based on a comment we received, we made a change from the proposed rule when
We are finalizing the provisions in § 422.510, § 422.752, § 460.40, and § 460.50 stating that organizations and programs that do not ensure that providers and suppliers comply with the provider and supplier enrollment requirements may be subject to sanctions and termination. Considering the serious risks to the Medicare program and enrollees from fraudulent or unqualified providers and suppliers, we believe that these are actions may be appropriate.
Current rules allow MA organizations to contract with different entities to provide services to beneficiaries. These contracted entities are referred to as first-tier, downstream, and related entities or FDRs, as defined in § 422.500. FDRs must enroll to comply with this rule.
PACE is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility, wherein a team of health care professionals works with participants and their families to make sure participants get the coordinated care they need. A participant enrolled in PACE must receive Medicare and Medicaid benefits solely through the PACE organization. To ensure consistency within our programs, we believe that our provider and supplier enrollment requirements should extend to this program.
Medicare Cost HMOs or CMPs are a type of Medicare health plan available in certain areas of the country. Some Cost HMOs or CMPs only provide coverage for Part B services. Cost HMOs or CMPs do not include Part D. These plans are either sponsored by employer or union group health plans or offered by companies that do not provide Part A services.
Demonstrations and pilot programs, also called research studies, are special projects that test improvements in Medicare coverage, payment, and quality of care. They usually operate only for a limited time for a specific group of people and may only be offered only in specific areas. Providers and suppliers in these programs would not be exempt from the requirements of this final rule.
In §§ 422.224 and 460.86, we are finalizing the prohibition on MA, PACE, the other designated programs and organizations from paying individuals or entities that are excluded by the OIG or revoked from the Medicare program. These provisions also require MA, PACE, the other designated programs and organizations to notify the enrollee and the excluded or revoked provider or supplier that payment shall not be made. We are not, however, finalizing a first time allowance for payment. Based on further analysis, we believe a first time payment allowance would violate existing statute. However, we believe that beneficiaries are adequately protected in these situations based upon regulatory protections afforded at 42 CFR 1001.1901(b) and § 424.555(b) that preclude OIG excluded individuals and entities, as well as revoked, deactivated, or Medicare enrollment denied providers or suppliers from recouping payment from beneficiaries. We continue to believe such excluded or revoked individuals and entities pose a significant risk to enrollees and the Medicare program and should not receive federal dollars, even if payment is made through an intermediary such as an MA organization. Based upon the inclusion of PACE in § 422.222 in the proposed rule, and our relocating the PACE requirement to part 460, the application of the prohibition to pay excluded and revoked providers and suppliers also needs to be separately designated. Therefore, in this final rule, the sections applicable to not paying excluded or revoked providers and suppliers is now designated in § 460.86.
In § 422.501(c)(2), we are finalizing language requiring MA organization applications to include documentation demonstrating that all applicable providers and suppliers are enrolled in Medicare in an approved status. We believe that this will assist CMS in the MA organization application process by requiring MA organizations to provide assurance that the designated providers and suppliers are properly screened and enrolled in Medicare.
In § 422.504(a)(6), we are finalizing language with respect to contract conditions. MA organizations must agree to comply with all applicable provider requirements in subpart E of this part, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers, and limits on physician incentive plans. In § 422.504(a)(6), we are finalizing the extension of this requirement to suppliers. In this same section, we also are finalizing the requirement for MA organizations to comply with the provider and supplier enrollment requirements referenced in § 422.222. We believe these revisions would help facilitate the MA organizations' compliance with § 422.222. In §§ 422.504(i)(2)(v), 417.484, 460.70, and 460.71, we are finalizing provisions that require MA organizations, Cost plans, and PACE organizations to require all FDRs and contracted entities to agree to comply with the provider and supplier enrollment provision.
Finally, the provisions are effective the first day of the next plan year that begins 2 years from the date of publication of the CY 2017 PFS final rule. For PACE organizations, these requirements will be effective the first day of the calendar year that is 2 years after the publication of this final rule.
We believe this would give all stakeholders sufficient time to prepare for these requirements. We are unable to impose new requirements on MA organizations mid-year, and therefore, must wait to make these rules effective.
The following is a summary of the comments we received on MA provider enrollment.
As discussed in the preamble, a recent GAO study stated that “as part of an overall effort to enhance program integrity and reduce fraud risk, effective enrollment-screening procedures are essential to ensure that ineligible or potentially fraudulent providers or suppliers do not enroll in the Medicare program.” (GAO-15-448) This study's recommendations did not specifically recommend MA provider and supplier enrollment; however, these new provisions are part of an overall plan to ensure standard screening for those providers and suppliers treating MA beneficiaries. Evidentiary support for improved care for beneficiaries can be seen by reviewing the Annual Report to Congress on the Medicare and Medicaid Integrity Programs, which gives more information on program integrity efforts and administrative actions. This report demonstrates statistical evidence of the judicial and administrative actions taken against providers and suppliers, such as, licensure suspensions, felony convictions, and Medicare revocations.
Our justification for broadening our enrollment requirements is based upon a desire for MA organization enrollees to have the same protections against potentially unqualified or fraudulent providers and suppliers as those afforded to beneficiaries under the FFS and Part D programs. We believe that robust screening is fundamentally important to promote quality of care. Medicare beneficiaries and enrollees, the Medicare Trust Funds, and the program at large, are at risk when providers and suppliers that have not been adequately screened furnish, order, certify, or prescribe Medicare services and items and receive Medicare payments. Requiring enrollment allows us to have proper oversight of providers and suppliers, making it more difficult for these types of providers and suppliers to enroll in Medicare and remain enrolled in Medicare. Furthermore, it allows us to remove a provider or supplier that does not comply with our rules across Medicare (Part A, Part B, MA, and Part D).
We believe the GAO report cited herein provides specific examples and evidence of our need to standardize the enrollment process and take advantage of the information available to Medicare that the MA organizations cannot access. We believe the enrollment file provides an efficient way for the plans to ensure that providers and suppliers are enrolled, which will minimize burden on plans.
This final rule finalizes our proposal to expand the duration and scope of the Diabetes Prevention Program (DPP) model test, which we refer to as the Medicare Diabetes Prevention Program (MDPP) expanded model.
We received approximately 700 timely pieces of correspondence containing multiple comments on the MDPP expanded model. We note that some of these public comments were outside of the scope of the proposed rule. Summaries of the public comments that are within the scope of the proposed rule and our responses to those public comments are set forth in the various sections of this final rule under the corresponding heading.
Commenters ranged from professional organizations, health plans, advocacy groups, individual physicians, and numerous individuals who have direct experience with the National Diabetes Prevention Program (National DPP), and expressed overwhelming support for this model expansion. Commenters raised key considerations as well.
Because the MDPP expanded model will be implemented through at least two rounds of rulemaking, we have chosen in this final rule to finalize aspects of this model expansion that will enable organizations to prepare for enrollment. This includes finalizing the framework for expansion and finalizing details of the MDPP benefit, beneficiary eligibility criteria, and MDPP supplier eligibility criteria and enrollment policies.
We are finalizing our proposal to expand the duration and scope of the DPP model test as proposed. We are also finalizing our proposal to designate MDPP services as “additional preventive services” as defined by section 1861(ddd) of the Act. We are finalizing our proposal to use the Secretary's waiver authority under section 1115A(d)(1) of the Act to waive two requirements of the benefit category of additional preventive services: the requirement in section 1861(ddd)(1)(B) of the Act that the services be recommended by a grade of A or B from the United States Preventive Services Task Force (USPSTF) and the requirement of section 1861(ddd)(2) of the Act that the Secretary make the determinations required under section 1861(ddd)(1) of the Act using the National Coverage Determination (NCD) process.
We are finalizing our proposal that the MDPP core benefit is 12 consecutive months and consists of at least 16 weekly core sessions over months 1-6 and at least six monthly core maintenance sessions over months 6-12, furnished regardless of weight loss. Eligible beneficiaries will have access to ongoing maintenance sessions after the MDPP core benefit if they achieve and maintain the required minimum weight loss of five percent. We are adding definitions of “maintenance session bundle” and “maintenance of weight loss” to help provide clarity. We are revising the definition of “CDC-approved core curriculum” to remove specific curriculum topic names. We are also revising the session duration requirement to specify that any session must have a duration of approximately one hour.
We are finalizing the beneficiary eligibility criteria and our referral policy as proposed.
We are finalizing the proposed high screening level for MDPP supplier enrollment, the requirement for coaches to obtain National Provider Identifiers (NPIs), and for DPP organizations to submit a roster of coach NPIs and other coach information upon applying for enrollment. We are modifying our proposal regarding the enrollment of existing Medicare providers or suppliers, and are requiring all DPP organizations, regardless of any existing enrollment in Medicare, to enroll in Medicare as MDPP suppliers in order to furnish and bill for MDPP services.
We are not finalizing our proposal that organizations that deliver DPP virtually or through remote technologies will be eligible to furnish MDPP services to future rulemaking. We intend to address policies related to the delivery of virtual MDPP services in future rulemaking. We are also not finalizing the definition of preliminary recognition. We intend to seek comment on recognition standards in future rulemaking.
We are also deferring certain policies, specifically related to payment, use of coach information during enrollment and monitoring, and other program integrity safeguards to future rulemaking. In particular, specific policies regarding monitoring and enforcement actions for supplier enrollment require future rulemaking. Because we are not implementing such requirements in this rule, we cannot begin any enrollment for organizations seeking to enroll as MDPP suppliers until after the next round of rulemaking is complete in 2017. We intend to begin supplier enrollment before the model expansion becomes effective on January 1, 2018. We intend for organizations to be able to apply to enroll as MDPP suppliers at the conclusion of the next round of rulemaking. We may issue subregulatory guidance to assist in this preparation before subsequent rulemaking is finalized. We will address public comments on sections of the proposed rule we sought comment on, including payment, quality reporting, and program integrity, in future rulemaking.
The MDPP expanded model will become effective nationwide beginning on January 1, 2018. We will continue to evaluate this expanded model test.
In January 2015, the Administration announced the vision of “Better Care, Smarter Spending, Healthier People” with emphases on improving the way
Diabetes affects more than 25 percent of Americans aged 65 or older
Fortunately, type 2 diabetes is typically preventable with appropriate lifestyle changes. The National DPP, administered by the Centers for Disease Control and Prevention (CDC), is an evidence-based intervention targeted to individuals with pre-diabetes, meaning those with blood sugar that is higher than normal but not yet in the diabetes range. The National DPP is a structured health behavior change program delivered in community and health care settings by trained community health workers or health professionals. The National DPP consists of 16 intensive core sessions of a CDC-approved curriculum in a group-based setting that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. After the 16 core sessions, monthly maintenance sessions help to ensure that the participants maintain healthy behaviors. The primary goal of the intervention is to reduce incidence of type 2 diabetes by achieving at least 5 percent average weight loss among participants. To learn more about the National DPP, please visit
In 2012, the Innovation Center awarded a Health Care Innovation Award (HCIA) to The Young Men's Christian Association (YMCA) of the USA (Y-USA) to test whether DPP services could be successfully furnished by non-physician, community-based organizations to Medicare beneficiaries diagnosed with pre-diabetes and therefore at high risk for development of type 2 diabetes (referred to hereafter as the DPP model test). The DPP model test has been conducted under the authority of section 1115A of the Act, which authorizes the Innovation Center to test innovative health care payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children's Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of patient care.
Between February 2013 and June 2015, the Y-USA, in partnership with 17 local YMCAs, the Diabetes Prevention and Control Alliance, and seven other non-profit organizations, enrolled a total of 7,804 Medicare beneficiaries into the model. Enrolled beneficiaries represented a diverse demographic across the eight states of Arizona, Delaware, Florida, Indiana, Minnesota, New York, Ohio, and Texas. According to the second year independent evaluation report of the DPP model test, Medicare beneficiaries demonstrated high rates of participation and sustained engagement in the Diabetes Prevention Program. Approximately 83 percent of recruited Medicare beneficiaries attended at least four core sessions and approximately 63 percent completed nine or more core sessions. The first and second independent evaluation reports are available on the Innovation Center's Web site at
Section 1115A(c) of the Act provides the Secretary of the U.S. Department of Health and Human Services (the Secretary) with the authority to expand (including implementation on a nationwide basis) through rulemaking the duration and scope of a model that is being tested under section 1115A(b) of the Act if the following findings are made, taking into account the evaluation of the model under section 1115A(b)(4) of the Act: (1) The Secretary determines that the model expansion is expected to either reduce spending without reducing quality of care or improve the quality of patient care without increasing spending; (2) the CMS Chief Actuary certifies that the expansion would reduce (or would not result in any increase in) net program spending; and (3) The Secretary determines that the expansion would not deny or limit the coverage or provision of benefits.
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The full Chief Actuary Certification is available at
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The following is a summary of the comments received and our responses.
The Chief Actuary also reviewed data from other sources besides the model evaluations in certifying the Pioneer Accountable Care Organization (ACO) Model, the first Innovation Center model determined eligible for expansion. In April 2015, the Chief Actuary certified that expansion of the Pioneer ACO Model, as it was tested in the model's first 2 years, would reduce net program spending. The Chief Actuary used historical evidence from the formal evaluation of the Pioneer ACO Model as well as the Chief Actuary's independent internal analysis of financial impacts. The Chief Actuary's certification of the Pioneer ACO Model is available at
The statute does not require that an expanded model test be identical to the initial model test. Indeed, section 1115A(c) of the Act authorizes the Secretary to expand (including implementation on a nationwide basis) the duration and the scope of a model being tested under subsection (b) or a demonstration project under section 1866C of the Act through rulemaking. The rulemaking requirement indicates that the expansion is to be subject to public comment, which, in turn, indicates that the expansion can and should be modified as appropriate to reflect the outcome of the rulemaking process. In addition, we expect that we will need to modify some design features in nearly all cases of expanded model tests, by virtue of the shift in duration or scope. For example, a nationwide expansion may require different policies and operations to manage large-scale provider enrollment or payment than does the initial model test. The Chief Actuary certified expansion of the DPP model test understanding that the expansion would include specific changes driven by policies and operations necessary in bringing the model to a national scale. As the expansion's full design is implemented in future rulemaking, the Chief Actuary will assess whether such expansion will reduce or not increase net program spending, and will update the certification as appropriate.
In general, evaluations of Innovation Center models address the impact of the models on use of services and the quality of care provided, relative to a comparison group, using CMS administrative data and relevant beneficiary experience data when available. Utilization measures can be used to monitor whether beneficiaries are receiving the services that would be expected given beneficiaries' health status. The comparison group generally consists of beneficiaries who are similar to the beneficiaries receiving services under the model, and are often matched on underlying health status and other important characteristics, including whether the beneficiary is part of another model test. We intend to apply additional information on the evaluation in the future. We will continue to assess whether the MDPP expanded model is expected to improve the quality of care without increasing spending, reduce spending without reducing the quality of care, or improve the quality of care and reduce spending, and we will terminate or modify the MDPP expanded model if the expanded model is not expected to meet these criteria.
We proposed to expand the duration and scope of the DPP model test under section 1115A(c) of the Act, and we proposed to refer to this expanded model as the MDPP. In this section of this final rule, we are finalizing a framework for the MDPP expanded model. We intend to engage in additional rulemaking in 2017, to establish additional requirements of the MDPP expanded model. We solicited comment on all of the proposals below and on other policy or operational issues that need to be considered in implementing this expansion.
We proposed to designate MDPP services as “additional preventive services” available under Medicare Part B. Section 1861(ddd) of the Act defines “additional preventive services” as services (other than screening or other preventive services or personalized prevention plan services described in other sections of the Act) that identify medical conditions or risk factors, and that the Secretary determines, using the National Coverage Determination (NCD) process, are (A) reasonable and necessary for the prevention or early detection of an illness or disability; (B) recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF); and (C) appropriate for individuals entitled to benefits under Part A or enrolled in Part B.
We believe that MDPP services are consistent with the types of additional preventive services that are appropriate
We proposed to use the Secretary's waiver authority under section 1115A(d)(1) of the Act to waive two requirements of the benefit category of additional preventive services. MDPP services do not meet the requirement in section 1861(ddd)(1)(B) of the Act in that MDPP services have not been recommended with a grade of A or B by the USPSTF, and thus a waiver of that requirement is necessary. We proposed to use the Secretary's waiver authority to waive this requirement with respect to MDPP services.
We proposed to waive the requirement of section 1861(ddd)(2) of the Act that the Secretary make the determinations required under section 1861(ddd)(1) of the Act using the NCD process. We proposed to waive this requirement because applying the NCD process to the MDPP model expansion is inappropriate, and thus the waiver is necessary. The creation of a new supplier class is necessary for coaches to furnish MDPP services, which the NCD process was not designed to address.
Since Medicare cost-sharing does not apply to additional preventive services, MDPP services would not be subject to Medicare cost-sharing.
We solicited comment on these proposals.
The following is a summary of the comments we received on designating MDPP services as additional preventive services and our responses.
Therefore, in our view, the Secretary is authorized to waive requirements of Title XI, Title XVIII, and sections 1902(a)(1), 1902(a)(13), 1902(m)(2)(A)(iii), and 1934 of the Act (other than subsections (b)(1)(A) and (c)(5) of such section) in connection with expanded model tests. As the MDPP model expansion is an expansion of the duration and scope of a model described in and tested under subsection (b), the Secretary may waive Medicare requirements as necessary for the purposes of the expanded model.
In particular, the specific USPSTF recommendation cited by commenters is for “adults aged 40 to 70 years who are overweight or obese who are seen in primary care settings,” which does not include Medicare beneficiaries over 70 who would be eligible for MDPP services or the furnishing of MDPP services by a community service organization.
While the USPSTF recommendation discussed by the commenters does not match with the elements of the MDPP model expansion, we do note that the recommendation supports the principle of the MDPP expanded model. In addition, we have spoken to the USPSTF about its recommendation and shared the findings of the evaluation of the model in case the USPSTF would like to reconsider its recommendation.
Similarly, we note that in 2014, the Community Preventive Services Task Force (CPSTF), a “sister entity” to the USPSTF that is focused on population-based interventions, issued a recommendation for
The MDPP expanded model necessitates the creation of a new supplier class that must be able to enroll in Medicare so that it may furnish MDPP services as of the effective date of the expanded model. We are establishing the new supplier class through rulemaking, in conjunction with the model expansion. Contrary to commenters' assertions, using the NCD process to designate MDPP services as additional preventive services would create significant timing challenges, given that we need to expand the model and establish the MDPP supplier class through rulemaking. If we were to use the NCD process to determine that MDPP services are additional preventive services, we would not be able to begin covering MDPP services on the date the NCD was issued, even if it were issued simultaneously with the effective date of a final rule establishing the supplier class. This is because in order to align the effective dates, we would have had to issue a final rule establishing the MDPP supplier class 60 days before we determined that MDPP services were covered by Medicare. Were we to instead issue an NCD simultaneously with the release of a final rule establishing a new supplier class, the benefit would be unavailable for a period of time after the NCD's effective date because of the 60-day delay in effectiveness of the final rule plus time needed thereafter to process MDPP supplier enrollment applications. Because we cannot allow MDPP suppliers to enroll specifically to provide a service that is not yet a Medicare service, we find that it is necessary for purposes of expanding the MDPP model to waive the requirements of section 1861(ddd)(2) of the Act. This rulemaking establishes MDPP services as additional preventive services that will become available after there is sufficient time to enroll MDPP suppliers to furnish those services, which allows us to avoid timing and logistics problems while also providing the public with the opportunity to comment in a manner similar to the NCD process.
We proposed that the expansion of the duration and scope of the DPP model test would become effective on a nationwide basis beginning on January 1, 2018. Expanding the DPP model test is a complex undertaking, which could be approached in different ways, such as expanding the scope of the DPP model test nationally in its first year of implementation or expanding the duration and scope using a phase-in approach. The phase-in approach could expand MDPP initially for a period of time in certain geographic markets or regions or among a subpopulation of MDPP suppliers, with the goal of addressing technical issues prior to broader expansion. We solicited comment on whether to expand the scope of the DPP model test nationally or use a phase-in approach, and if phased-in, what factors we should consider in the possible selection of initial phased-in MDPP suppliers.
MDPP services will be available to eligible beneficiaries beginning on January 1, 2018, subject to additional rulemaking on issues such as payment for the service. However, as a factual matter, eligible beneficiaries' access to MDPP services will increase over time as more organizations seek and receive CDC DPRP recognition, enroll in Medicare as MDPP suppliers, and therefore furnish MDPP services. As of October 2016, more than 1,000 organizations have pending or full recognition from the CDC DPRP to provide DPP services. As described in section III.J.7.a. of this final rule, these organizations will have to meet certain standards before becoming eligible to enroll as a Medicare supplier. This will provide a de facto phase in that will allow us to gain experience with the MDPP expanded model with fewer organizations initially who meet the supplier eligibility criteria, and more over time as supplier enrollment increases.
We proposed the MDPP core benefit to be 12-months of sessions using a CDC-approved DPP curriculum, consisting of at least 16 core sessions furnished over a range of 16 to 26 weeks (that is, the first 6 months) and at least 6 monthly core maintenance sessions over weeks 27-52 (second 6 months). We proposed that beneficiaries who complete the 12-month core benefit, and achieve and maintain a required minimum weight loss of 5 percent from the first core session, in accordance with the CDC Diabetes Prevention Recognition Program Standards and Operating Procedures (CDC DPRP Standards), would be eligible for monthly ongoing maintenance sessions for as long as the weight loss is maintained. The CDC DPRP Standards are available at
We proposed that during the first 6 months (weeks 1-26) of the MDPP core benefit, each of the 16 core sessions must address a different curriculum topic included on the list of 16 curriculum topics, ensuring all topics are addressed by the end of the 16 sessions. We proposed that the second 6 months (weeks 27-52) of the MDPP core benefit must include at least one core maintenance session furnished in each of the 6 months (for a minimum of six sessions), and all core maintenance sessions must address different topics. We proposed that ongoing maintenance sessions adhere to the same curriculum requirements as the core maintenance sessions.
We solicited comment on these proposals.
The following is a summary of the comments received and our responses.
Several commenters recommended allowing beneficiaries who did not achieve and maintain the required 5 percent weight loss to still be able to access the ongoing maintenance sessions. The commenters stated various reasons, including that weight loss of less than 5 percent is clinically relevant and also reduces type 2 diabetes risk; the evidence base suggests greater impact on onset of diabetes through re-enrolling beneficiaries who are regaining weight than through continuing the service for those who can maintain weight loss; weight regain is common due to metabolic adaptation or receding behavior changes; discontinuing the service for beneficiaries who do not lose weight will discourage them and increase their risk for diabetes; the opportunity to provide a safe environment of recovery for individuals who have a binge-eating disorder; and that the intervention will still reduce diabetes among beneficiaries who are unable to achieve or maintain weight loss. Additionally, commenters stated that exclusion from maintenance sessions for beneficiaries who do not achieve the required weight loss would be punitive, particularly for beneficiaries who need the additional support to achieve the desired weight loss goal. Some commenters suggested that MDPP expanded model risks perpetuating health inequities because low-income beneficiaries who need MDPP services the most struggle disproportionately to achieve the required weight loss and will not be able to access ongoing maintenance sessions.
One commenter suggested that CMS use an aggregate, not individual, 5 percent weight loss across a supplier's beneficiaries to align with the CDC DPRP Standards and promote ongoing maintenance session eligibility for populations that experience difficulty achieving the 5 percent weight loss due to socioeconomic or demographic factors. Another recommendation was to allow participants within 2 percentage points of the minimum weight loss to have their maintenance sessions covered to account for weight gain during extenuating circumstances (for example, falling ill or other circumstances that interfere with weight loss).
Several commenters recommended that access to ongoing maintenance sessions, and payments for maintenance session attendance, depend not on the 5 percent weight loss, but instead on attendance of monthly maintenance sessions. Other commenters suggested that payment should be linked to alternative measures rather than weight loss, such as A1C, waist measurement, and knowledge tests.
We acknowledge some commenters' desire for CMS to cover ongoing maintenance sessions for beneficiaries who do not achieve and maintain the required 5 percent weight loss. The requirement that eligible beneficiaries must maintain 5 percent weight loss is consistent with the weight loss goal tested in the DPP model test, and was factored into the Secretary's determination to expand the model and the Chief Actuary's certification that MDPP expansion would not result in an increase of Medicare spending. We are not changing the requirement that beneficiaries must maintain the 5 percent minimum weight loss in order to receive ongoing maintenance sessions. We acknowledge commenters' concerns regarding potential unintended consequences if the MDPP expanded model results in low-income or other disadvantaged populations having less access to ongoing maintenance sessions. We may consider making adjustments as appropriate if, through our monitoring and evaluation and through tribal consultation, we find that such adjustments are warranted to address disparities in access.
We disagree with a commenter's suggestion that we use an aggregate, not individual, 5 percent weight loss for ongoing maintenance session eligibility. We do not believe aggregate weight loss is an appropriate application for individuals' eligibility for ongoing maintenance sessions. We believe it is unfair to deny a beneficiary access to ongoing maintenance sessions if the beneficiary achieves 5 percent or more weight loss but happens to attend MDPP sessions with other beneficiaries who gain or do not lose the minimum weight. Aggregate weight loss can be arbitrary because there is no minimum or maximum number of beneficiaries per MDPP supplier, and there is no way to ensure equal access to the benefit. It decreases a beneficiary's incentive to meet the weight loss goal in order to access ongoing maintenance sessions and a suppliers' incentive to actively help each beneficiary to meet that weight loss goal, particularly if a few people lost a large percent of their weight. The goal of the DPP model test is at least 5 percent weight loss for each individual, which is expected to lead to a reduction in the incidence of diabetes. We do not have data to support an expanded model that does not require the achievement and maintenance of the minimum weight loss. We clarify that beneficiaries have access to the MDPP core benefit regardless of weight loss. This provides all eligible beneficiaries with access to 12 months of MDPP services, without cost-sharing, to achieve the target weight loss. We believe the incentive to achieve the target weight loss would be diluted for
One commenter recommended that we clarify whether beneficiaries must participate with the same coach or group of beneficiaries upon the transition from the core benefit to ongoing maintenance sessions. Another commenter recommended that CMS use different terminology for the ongoing maintenance sessions after the 12-month core benefit because it is confusing that the core maintenance sessions in the second 6 months are also called maintenance sessions.
In response to comments on the provision of services outside of MDPP, the MDPP model expansion only includes MDPP services. We note the distinction between core maintenance sessions and ongoing maintenance sessions is important in that core maintenance sessions are a part of the core benefit and are accessible to all eligible beneficiaries, while ongoing maintenance sessions require beneficiaries to maintain weight loss after the 12 month core benefit. As mentioned in section III.J.6. of this final rule, we defer questions of beneficiary attribution, such as how to address beneficiaries who switch suppliers upon the transition from the core benefit to ongoing maintenance sessions, to future rulemaking.
Commenters also suggested clarification on the curriculum topics that MDPP suppliers should follow for ongoing maintenance sessions, as the National DPP curriculum only specifies content for what is analogous to the MDPP core benefit. Other commenters recommended allowing MDPP suppliers to use the CDC-approved DPP curriculum in another language or making the curriculum more culturally sensitive. Commenters suggested changes to the curriculum, such as shifting the focus away from calorie counting, emphasizing physical activity and exercise goals, training coaches to handle emotional issues and offering oral hygiene sessions.
One commenter suggested we consider ways to embed the curriculum into the Diabetes Self-Management Training (DSMT) benefit.
For the ongoing maintenance session curriculum, we are requiring that MDPP suppliers use a CDC-approved curriculum. The purpose of ongoing maintenance sessions is to reinforce and revisit what was learned and practiced in the core benefit, so beneficiaries can maintain healthy behavioral changes and weight loss. Coaches can offer any of the curriculum topics except for the introductory sessions. We support the use of culturally sensitive curricula based on the MDPP supplier's population and furnishing MDPP services in languages other than English. If the CDC approves a curriculum that has adjustments to address language barriers or cultural differences, the MDPP supplier can use the curriculum. We remind organizations that the policies and procedures of approved curricula must ensure accessibility to persons with disabilities, persons with limited English proficiency, and other populations in compliance with HHS civil rights non-discrimination regulations, including those implementing section 504 of the Rehabilitation Act of 1973, Title VI of the Civil Rights Act, section 1557 of the Patient Protection and Affordable Care Act, and Title IX of the Education Amendments of 1972, as amended. More information is available at
We proposed that coverage of MDPP services would be available for beneficiaries who meet all of the following criteria: (1) Are enrolled in Medicare Part B; (2) have, as of the date of attendance at the first core session, a body mass index (BMI) of at least 25 if not self-identified as Asian or a BMI of at least 23 if self-identified as Asian. The CDC DPRP Standards have defined a lower BMI for self-identified Asian individuals based on data that show Asians develop abnormal glucose levels at a lower BMI; (3) have, within the 12 months prior to attending the first core session, a hemoglobin A1c (HgA1c) test with a value between 5.7 and 6.4 percent, or a fasting plasma glucose of 110-125 mg/dL, or a 2-hour post-glucose challenge of 140-199 mg/dL (oral glucose tolerance test); (4) have no previous diagnosis of type 1 or type 2 diabetes with the exception of a previous diagnosis of gestational diabetes; and (5) does not have end-stage renal disease (ESRD).
Several commenters also supported the lower BMI threshold for self-identified Asians.
We believe the requirement to obtain blood test results is important for maintaining program integrity, and use of risk questionnaires presents opportunities for invalid and unreliable data reporting. The DPP model test required blood test results as part of its eligibility criteria to show a beneficiary has pre-diabetes, and therefore we are requiring blood tests for MDPP eligibility. In considering how to expand the DPP model test, we relied on eligibility criteria that was either tested in the initial DPP model test and/or set forth by the American Diabetes Association or World Health Organization, and we do not intend to include additional eligibility criteria at this time.
Regarding comments about the timeframe of eligibility tests and required documentation: We did not propose specific requirements for how or where blood test results may be obtained as we do not want to create unnecessary obstacles for beneficiaries and MDPP suppliers. An MDPP supplier may administer an HgA1c finger prick to determine eligibility. We note that Medicare only covers the fasting plasma glucose test and the oral glucose tolerance test when the beneficiary has a referral from his or her primary care physician or qualifying provider. Similarly, we did not propose specific documentation methods beyond our proposal that MDPP suppliers maintain records that document each beneficiary's eligibility status. We will consider whether it is necessary or appropriate to establish specific documentation standards in future rulemaking.
We did not propose an eligibility policy for beneficiaries who receive a diagnosis of diabetes while receiving MDPP services. However, we agree with commenters that a protocol needs to be developed to ensure beneficiaries who are diagnosed with diabetes while receiving MDPP services are receiving the proper care for their condition. We intend to address this issue in future rulemaking.
We appreciate the commenters' interest in Medicaid coverage. However, this model expansion pertains only to Medicare beneficiaries, though we note that Medicaid beneficiaries who are also Medicare beneficiaries are eligible if they meet the MDPP beneficiary eligibility requirements. We encourage states to work with the Center for Medicaid & CHIP Services (CMCS) to discuss options to cover diabetes preventive services within the Medicaid program.
We proposed that beneficiaries who meet the beneficiary eligibility criteria would be able to receive MDPP services only once in their lifetime.
Commenters also requested clarity on how we may handle attribution if beneficiaries switch suppliers. One commenter believed there may be operational implications of managing this benefit across hundreds of suppliers should participants change suppliers or elect to withdraw from MDPP while it is underway and re-enroll at a later date. The commenter recommended that we issue guidelines on how MDPP suppliers should address changes, particularly with respect to beneficiary eligibility and billing and reimbursement.
We are finalizing the policy that eligible beneficiaries can participate in MDPP only once in their lifetimes. However, we acknowledge the commenters' concerns, and plan to address any exceptions to the once per lifetime restriction in future rulemaking as appropriate. As we did not propose to restrict eligible beneficiaries' choice of MDPP suppliers, we are confirming that they will be able to change suppliers at any time; however, because beneficiary attribution directly relates to payment, we will consider the comments on how to address attribution and its attendant effect on payment in developing proposals for future rulemaking.
The DPP currently allows community-referral such as by Y-USA and self-referral of patients, in addition to referral by physicians and other health care practitioners, if the patient presents DPP-qualifying blood test results that the DPP organization keeps on record. We proposed to similarly permit beneficiaries who meet our eligibility criteria to obtain MDPP services by self-referral, community-referral, or health care practitioner-referral.
The following is a summary of the comments received and our responses.
We proposed that any organization with preliminary or full CDC DPRP recognition would be eligible to apply for enrollment in Medicare as an MDPP supplier beginning on or after January 1, 2017. This proposal would promote timely enrollment of CDC-recognized organizations before the MDPP expanded model becomes effective on January 1, 2018. We proposed that MDPP suppliers would be subject to the enrollment regulations set forth in 42 CFR part 424, subpart P.
Organizations seeking to enroll in Medicare to become MDPP suppliers would be subject to screening under § 424.518. We proposed that potential MDPP suppliers be screened according to the high categorical risk category defined in § 424.518(c) because the MDPP expanded model allows organization types that are new to Medicare to enroll. We also believe that MDPP suppliers have some similarities to home health agencies, a provider screened according to the high categorical risk category, because non-licensed personnel may furnish MDPP services in a non-clinical setting, such as at Y-USA.
We proposed that existing Medicare providers and suppliers that wish to bill for MDPP services would have to inform us of that intention and satisfy all other requirements, such as preliminary or full CDC DPRP recognition, but would not need to enroll a second time. These existing Medicare providers and suppliers would be eligible to bill for MDPP services furnished on or after January 1, 2018. We also considered an alternative approach where existing Medicare providers and suppliers would have to submit a separate enrollment application (including any applicable enrollment application fee) and be separately screened to be eligible to bill for MDPP services. This alternative would enable all organizations furnishing MDPP services to have the same classification as MDPP suppliers and undergo the same application requirements. Under this option, should an entity have an issue related to their MDPP enrollment, for example, falsely attesting to beneficiary weight loss, CMS would have discretion to apply revocation to its MDPP enrollment, rather than affecting their broader enrollment in Medicare.
We proposed to require that all MDPP suppliers comply with applicable Medicare supplier enrollment, program integrity, and payment rules. These regulations include, but are not limited to, time limits for filing claims (§ 424.44), requirements to report and return overpayments (§ 401.305), and procedures for suspending, offsetting or recouping Medicare payments in certain situations (§ 405.371).
The following is a summary of the comments we received regarding supplier enrollment.
Many commenters who supported allowing these organizations to enroll in Medicare as MDPP suppliers recommended that the enrollment policies should be aligned as closely to CDC DPRP Standards as possible to avoid additional burden to organizations that are less familiar with Medicare rules and regulations.
For those who requested that we closely align MDPP supplier eligibility requirements to the DPP organization recognition requirements in the CDC DPRP Standards, an organization that obtains CDC DPRP recognition can become an MDPP supplier if they meet a few additional Medicare requirements.
We recognize the role that third party administrators may play in facilitating the enrollment process for DPP organizations. We intend to allow MDPP suppliers to utilize third-party administrators for the purposes of enrollment but will further consider how these entities may fit into the MDPP enrollment and policy framework in future rulemaking, as appropriate.
Commenters requested clarity regarding what supplier type an MDPP supplier would indicate on the Medicare enrollment application. Other commenters requested clarity on what taxonomy code suppliers would use when applying for their NPI.
We acknowledge commenters' questions regarding which provider taxonomy to include when applying for an NPI, as well as which supplier type MDPP organizations would denote when enrolling. We plan to issue additional details through guidance or future rulemaking as appropriate to help guide organizations in applying for an NPI. For the purposes of providing guidance in this final rule, we would like to note for DPP organizations that we believe the taxonomy code of Health Educator (174H00000X) could be appropriate for MDPP suppliers when applying for an NPI. As for supplier type to denote upon applying to enroll in Medicare, we intend to create a new supplier type, specific to MDPP suppliers, and may release an appropriate application form accordingly.
Other commenters disagreed with CMS' parallel between HHAs and MDPP, noting that the requirement to obtain CDC DPRP recognition establishes a higher level of program integrity than that faced by HHAs. One commenter noted that Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) suppliers and HHAs became classified as high categorical risk in response to reports issued by the HHS Office of Inspector General (HHS-OIG) and the Government Accountability Office (GAO).
Commenters also requested additional information on the requirements for high categorical risk screening. One commenter stated that for entities that are corporately owned or traded, requirements for regional, privately owned suppliers may not be appropriate given the different ownership structures that are not well captured by CMS's enrollment applications. A few commenters also noted that suppliers newly enrolled into Medicare for MDPP, and providers or suppliers with existing enrollment in Medicare who wish to furnish MDPP, should be screened at the same level.
We agree with commenters who noted that suppliers newly enrolling into Medicare for MDPP should be screened at the same level as those with existing enrollment in Medicare who wish to furnish MDPP services. We acknowledge the financial burden that enrolling may place on some community-based DPP organizations. It is not our intent to hinder smaller organizations' ability to enroll in Medicare. We do not, however, believe that a high screening level as opposed to limited or moderate would greatly affect participation given the minimal additional requirements the higher screening levels entail. The difference between limited and high categorical risk screening includes a site visit for each base of operations and fingerprinting of certain individuals within the organization. This site visit poses no cost to the supplier, and should not delay the enrollment process beyond the 45 to 60 day window. Fingerprints are required of all individuals with 5 percent or more ownership interest in the entity. Organizations would not be required to submit fingerprints from managing members, coaches, or other employees. The enrollment application fee a supplier pays to Medicare is the same regardless of screening level, therefore the only difference in cost to the supplier amounts to the cost of obtaining fingerprints of those with 5 percent or more direct or indirect ownership interest in the entity. We do not believe this additional cost of high screening is cost prohibitive for enrollment, even for smaller community-based organizations. We understand the commenter's concern that for entities that are corporately owned or traded, screening requirements and CMS's enrollment applications may be difficult or may not be applicable given the different ownership structures. We will not change our requirement to collect fingerprints from all individuals with a direct or indirect ownership interest, though we recognize that not all suppliers under this requirement will have individual owners who meet this criterion. However, when an individual has 5 percent or more direct or indirect ownership in a prospective MDPP supplier, whether private or publically traded, submitting a set of fingerprints would be required for enrollment into Medicare.
We refer those interested in learning more about the requirements associated with a high screening level to § 424.518. Given the nominal financial difference of obtaining fingerprints from 5 percent or more owners, we do not believe that application of the high screening level will be a barrier to organizations to enroll in Medicare as an MDPP supplier. Additionally, we expect that MDPP suppliers will revalidate at a moderate risk level, consistent with the revalidation policy of other high risk suppliers. We will address the screening level of MDPP suppliers seeking to revalidate in future rulemaking.
Some commenters noted that many existing health care providers are well suited to furnish MDPP services, but may lack familiarity with the CDC National DPP and the process to obtain CDC DPRP recognition. These commenters recommended that CMS provide education and outreach to these
Although many individual clinicians could serve as MDPP coaches, we note that entities, not individuals, receive CDC DPRP recognition. Furthermore, we would like to reiterate that entities enrolled in Medicare for the sole purpose of furnishing MDPP services would be eligible to submit claims only for MDPP services.
We agree that many health care entities may be well suited to furnish MDPP services but may lack familiarity with the CDC DPRP recognition process. We will further consider the recommendations to undertake targeted education and outreach efforts to build supplier capacity.
RHCs and FQHCs can enroll as MDPP suppliers if they otherwise meet the enrollment eligibility criteria, but we clarify that MDPP is not a RHC/FQHC service. However, a clinic that chooses to furnish MDPP services could exclude all costs related to furnishing MDPP services from its cost report and instead submit claims for MDPP services under its separate MDPP supplier enrollment. RHCs and FQHCs must ensure that there is no commingling of RHC or FQHC resources in the cost report used to furnish MDPP services. We understand that some clinics believe this will be burdensome, but only RHC or FQHC services can be billed on a UB-04 form.
For providers and suppliers with existing enrollment in Medicare, some commenters noted that they should not have to be held to the CDC DPRP Standards, but instead meet other requirements, as noted above. Other commenters expressed support for specific health care provider types that are well suited to furnish MDPP services.
A few commenters supported our alternative proposal that existing Medicare providers and suppliers separately enroll as MDPP suppliers and be separately screened to be eligible to bill for MDPP services. One commenter noted that consistency of procedures and guidelines among organizations furnishing MDPP services, regardless of whether they were new entrants to Medicare, would benefit the program to ensure the same requirements applied across all entities furnishing MDPP services.
Though requiring existing Medicare providers and suppliers to separately enroll as MDPP suppliers initially imposes an additional requirement, this is a standard procedure for current suppliers. Other types of Medicare providers, such as hospitals or clinics who wish to provide home health services, would similarly need to enroll as HHA suppliers and undergo screening requirements associated with HHAs. We also believe this requirement would ultimately protect existing Medicare providers from revocation action against their enrollment and ability to furnish services outside of MDPP. For example, should an existing provider furnishing MDPP services lose CDC DPRP recognition, the provider would be subject to revocation. If the provider were not enrolled separately as a MDPP supplier, the provider's Medicare enrollment would be subject to revocation action, not just the billing privileges associated with MDPP services. As discussed in section III.J.7.d. of this final rule, many commenters agreed with the proposal that loss of CDC DPRP recognition should result in revocation only of MDPP billing authorities, and not necessarily affect the existing provider or supplier's eligibility to furnish and bill for non-MDPP services. By requiring all prospective MDPP suppliers—regardless of whether they have existing enrollment in Medicare—to enroll as an MDPP supplier, CMS has the discretion to target any revocation action against the MDPP supplier enrollment alone, rather than affect the existing provider or supplier's other enrollment. It is important to note that revocation removes a provider or supplier's enrollment in Medicare, not just its billing privileges for a particular Medicare service. For example, if a hospital had an additional enrollment as an MDPP supplier and one of their coaches was fraudulently reporting weight loss that beneficiaries did not achieve, CMS would have the discretion
We acknowledge the concerns that requiring enrolled providers and suppliers to separately enroll as an MDPP suppler imposes a burden. However, we disagree that enrollment screening for the purposes of one supplier type would satisfy program integrity concerns for a different supplier type. Many program integrity checks specifically target the licensure and credentials of a particular supplier type that would not necessarily transfer to other suppliers. Similarly, we disagree with commenters who stated that the program integrity efforts and regulations on providers or suppliers with an existing, non-MDPP enrollment in Medicare would sufficiently address any program integrity related concerns with regards to MDPP services. MDPP services and the manner in which those services will be provided differ from other Medicare benefits and therefore require separate monitoring and regulation to ensure the program integrity.
We are finalizing the high screening level as proposed. We will continue to monitor enrollment efforts and program integrity, and should our policy merit adjustment, we may amend this decision in future rulemaking as necessary.
We are finalizing that MDPP suppliers are obligated to comply with all statutes and regulations that establish generally applicable requirements for Medicare suppliers. These regulations include, but are not limited to, time limits for filing claims (§ 424.44), requirements to report and return overpayments (§ 401.305), and procedures for suspending, offsetting or recouping Medicare payments in certain situations (§ 405.371). As explained in more detail in section III.J.7.c. of this final rule, we will not be able to begin supplier enrollment until enforcement activities are finalized during subsequent rulemaking in 2017, but we encourage DPP organizations to use this final rule to prepare for enrollment. This may include working towards CDC recognition, as detailed in III.J.7.b. of this final rule, obtaining NPIs, or obtaining claims processing software.
The final policies for MDPP supplier enrollment are set forth in § 424.59.
CDC grants pending recognition to an organization upon its approval of the organization's application and the organization's agreement to comply with requirements for use of a CDC-approved curriculum and for duration and frequency of sessions. CDC also establishes an effective date for each approved organization which is the first day of the month following their approval date. Organization must submit data every 12 months from their effective date. CDC grants full recognition after an organization with pending recognition has consistently furnished sessions with a CDC-approved curriculum, met CDC performance standards, and met CDC reporting requirements. CDC makes the first determination for full recognition 24 months after their effective date. Organizations not meeting full recognition at that time are reassessed at 36 months. Organizations that do not achieve full recognition within 36 months after their effective date will lose any recognition and must wait 12 months before reapplying.
In our proposal regarding eligibility of DPP organizations to enroll in Medicare, we proposed the use of an additional CDC recognition status: preliminary recognition.
We proposed that DPP organizations must have either preliminary or full CDC DPRP recognition in order to be eligible to enroll in Medicare as MDPP suppliers. We proposed that DPP organizations can attain preliminary CDC DPRP recognition upon meeting CDC DPRP performance standards and reporting requirements for 12 months after applying for recognition, and full recognition upon demonstrating program effectiveness for 24-36 months after applying for CDC DPRP recognition. We proposed that if an organization loses its CDC DPRP recognition status at any point, for example for not meeting CDC standards or failing to move from preliminary to full recognition within 36 months of their effective date, or withdraws from the CDC DPRP at any point, the organization would be subject to revocation of its Medicare billing privileges for MDPP services as provided by 42 CFR part 424, subpart P. Under the CDC DPRP Standards, an organization that loses its CDC DPRP recognition (and thus, under our proposal, would no longer be able to bill Medicare for MDPP services) must wait 12 months before reapplying for recognition. We proposed that DPP organizations would be eligible to re-enroll in Medicare as an MDPP supplier if, after reapplying for CDC DPRP recognition, the organization again achieves preliminary recognition.
The following is a summary of the comments we received and our responses.
A few commenters noted that CDC DPRP recognition is difficult to attain because it relies on average weight loss of 5 percent across the population of participants an organization serves, and if organizations fall a few decimal points short of that threshold, they can lose their recognition. Some commenters expressed the concern that beneficiary access may be disrupted if a supplier falls short of CDC DPRP Standards, therefore losing recognition and Medicare eligibility. Furthermore, commenters were concerned with the timelines the CDC DPRP Standards require for reapplication. Tribal organizations collectively requested CDC DPRP recognition be automatically granted to providers of the Special Diabetes Program for Indians.
We welcome consultation with tribes and tribal organizations as required by the CMS Tribal Consultation Policy,
Several commenters recommended that CMS clarify which performance standards and reporting requirements need to be met for 12 consecutive months to qualify for preliminary recognition. The commenters noted that they assume that an MDPP supplier would comply with the first year of CDC DPRP Standards for pending recognition status, starting at the effective date of the DPP organization's pending recognition. The commenters also noted that this means submitting data at 12 months from the effective date, but not achieving any particular outcomes at 12 months because current CDC DPRP Standards do not consider outcomes for achieving recognition until 24 months from the effective date. Several commenters recommended that we clarify whether an organization must submit 6 months or one year of data to obtain preliminary recognition. The commenters expressed their support that an organization offer DPP services for at least a year before qualifying for recognition as an MDPP supplier. A separate commenter suggested that CMS clarify that to obtain preliminary recognition, an organization must offer the CDC-approved curriculum within 6 months of the effective date of the organization's CDC DPRP application and submit at least 6 months of participant data at 12 months post-effective date of the application. Several commenters recommended removing the requirement to submit one year's worth of data before obtaining preliminary recognition.
One commenter noted that given the work and time required for DPP organizations to start providing DPP services, it may be difficult to obtain 12 months of reporting data immediately after the effective date of the DPP organization's pending recognition status. The commenter expressed concern that an organization that has met the standards and reporting requirements for 11 of the 12 months immediately following its application to participate in the DPRP should not have to reapply for preliminary recognition and start the 12-month process over again. Another commenter recommended that preliminary recognition performance standards focus on percent of weight loss achieved, as opposed to average weight loss, and maintenance of weight loss among participants.
Some commenters recommended that we allow organizations that have either pending recognition or full recognition from CDC to enroll as MDPP suppliers. The commenters noted that organizations obtain pending recognition from CDC after they agree to curriculum, duration, and intensity requirements. One commenter noted that the additional status of preliminary recognition adds a complicated layer of bureaucracy to the existing CDC DPRP, adds little value, and will likely delay enrollment of organizations in Medicare as MDPP suppliers due to lack of defined requirements for preliminary recognition. Several commenters suggested that we allow participation of DPP organizations with pending recognition until CDC standards for preliminary recognition status are established. One commenter requested that we explain why we proposed an additional recognition status, whether we can create new CDC DPRP recognition standards, and if so, how the new recognition standards will be incorporated into the CDC DPRP Standards.
One commenter recommended that only organizations with full CDC DPRP recognition may serve as MDPP suppliers in order to eliminate potential confusion caused by the preliminary recognition standard and preserve program integrity. The commenter suggested that we should only pay suppliers that have demonstrated their effectiveness as MDPP suppliers or their ability to establish and maintain the necessary infrastructure. Another commenter suggested that organizations with full recognition be paid at a higher rate than organizations with preliminary recognition.
Several commenters recommended that CMS adopt a grandfathering policy where organizations with 12 months of data may obtain preliminary recognition. A few commenters noted that the creation of the preliminary recognition definition risks having few or no MDPP suppliers with preliminary recognition by MDPP's scheduled effective date of January 1, 2018, thus delaying the implementation of MDPP. One commenter noted that the preliminary recognition status does not exist in CDC DPRP Standards, and that the preliminary recognition definition would be published in CDC DPRP Standards too late for MDPP suppliers to begin enrolling into Medicare in time to begin furnishing MDPP services on January 1, 2018. The commenter recommended that we require CDC to identify organizations with pending recognition that qualify for preliminary recognition no later than December 31, 2016 and require that CDC release interim guidance on standards or requirements for preliminary recognition no later than March or April 2017. The commenter notes that additional, minor clarifications may also be needed when the CDC issues updated CDC DPRP Standards in January 2018 to reflect early experience with the new preliminary recognition definition. One commenter believed it should be permitted to enroll as an MDPP supplier because it has one year of data, even though it lacks CDC DPRP recognition. Another commenter urged that we review its organization's data before 2018, and if it meets the standards for MDPP suppliers in 2017, that CMS reimburse the organization in 2017.
For this reason, we intend to use future rulemaking to propose interim standards for preliminary recognition, under CMS authority, that would bridge the gap until CDC preliminary recognition standards are established. We anticipate that our proposed interim preliminary recognition standards would be consistent with the principles described in the proposed rule. We intend to align our MDPP supplier enrollment policies with CDC recognition standards, as appropriate, as they are established. We will take the commenters' comments on preliminary recognition into account as we develop our proposal for interim CMS recognition standards. We do not intend to delay implementation of the MDPP expansion.
We proposed that certain DPP organizations that had not yet achieved full recognition could enroll in Medicare in acknowledgement that full recognition might take 36 months and require achievement of certain performance standards. We proposed this eligibility requirement for Medicare enrollment to allow an increased number of organizations that have demonstrated a capacity to provide DPP services to enroll in Medicare, thereby allowing access to MDPP services in a timely manner as of January 1, 2018. We continue to believe that it is appropriate to permit enrollment in Medicare prior to achievement of full CDC recognition in cases where there is demonstrated capacity to furnish DPP services, and as noted above, we intend to address this issue in future rulemaking. Therefore, we decline to permit DPP organizations that have only pending recognition to enroll in Medicare because such organizations may not have any demonstrated capacity to furnish DPP services. We are aware that most DPP organizations are currently in pending recognition status, and that CDC's definition for pending recognition currently includes a 6-month grace period before organizations are required to start offering DPP sessions. We are also aware that the current definition of full recognition requires organizations to meet certain standards for average weight loss and participation, and relative to those in pending status, few organizations have obtained full recognition. However, we believe it is important to ensure that prospective MDPP suppliers have demonstrated experience in actually furnishing DPP services, and therefore we do not believe it is appropriate to permit organizations to enroll in Medicare before they have submitted any performance data to CDC that allows CDC to assess their capacity to deliver DPP services.
We recognize the timing and nature of our proposal has caused some confusion, particularly because we intend to use CDC recognition status as a Medicare enrollment standard. We also agree with commenters that in general CDC should be responsible for recognizing DPP organizations, consistent with its recognition standards. However, as noted above, we intend to propose in future rulemaking interim CMS recognition standards that would permit DPP organizations that are seeking full CDC recognition and have demonstrated capacity to furnish DPP services to enroll in Medicare prior to January 1, 2018. We are considering performance criteria that we could propose as part of any interim CMS standards that we would use to permit DPP organizations that have not yet achieved full CDC recognition to enroll as MDPP suppliers before the CDC standards are updated. For example, we are considering proposing that DPP organizations with pending CDC recognition would be required to meet a performance standard threshold of 60 percent participant attendance in at least 9 core sessions in months 1-6 and 60 percent participant attendance in at least 3 core maintenance sessions in months 7-12. In addition, we intend to consider options to ensure program integrity and mitigate fraud and abuse during the preliminary recognition stage. We encourage interested parties to submit comments on any updates to CDC's DPRP Standards when CDC publishes them for public comment.
Finally, in response to commenters, we do not intend to propose differential payments based on whether the supplier has full recognition. We also do not intend to make payments for MDPP services prior to January 1, 2018. We will also propose details on the payment structure in future rulemaking.
We proposed to require personnel who would furnish MDPP services, referred to hereafter as “coaches,” to obtain a National Provider Identifier (NPI) to help ensure the coaches meet CMS program integrity standards. We also considered requiring that coaches enroll in the Medicare program in addition to obtaining an NPI, and we solicited comment on this approach. Another alternative policy we considered was to require DPP organizations to collect and submit information on the coaches who would furnish MDPP services, which could include identifying information such as first and last name and social security number (SSN). We proposed to require MDPP suppliers to submit the active and valid NPIs of all coaches who would furnish MDPP services on behalf of the MDPP supplier through a roster of coach identifying information. We proposed that if MDPP suppliers fail to provide active and valid NPIs of their coaches, or if the coaches fail to obtain or lose their active and valid NPIs, the MDPP supplier may be subject to compliance action or revocation of MDPP supplier status.
The following is a summary of the comments we received and our responses.
The majority of commenters indicated that organizations alone should enroll in Medicare as MDPP suppliers, though one commenter proposed that diabetes prevention coordinators, who oversee the coaches as outlined in the CDC DPRP Standards, should enroll. A few commenters recommended that coaches enroll, stating that this would ensure our ability to protect the integrity of the Medicare program and have direct oversight over coaches furnishing the benefit. Other commenters cited
Commenters who opposed the requirement for coaches to obtain NPIs largely expressed that only health care providers should obtain NPIs. Some commenters believed that MDPP coaches do not meet the definition of health care provider under 45 CFR 160.103, and therefore coaches should not be allowed to obtain an NPI. Other commenters questioned how coaches could obtain NPIs, particularly when registered nurses (RNs) and other credentialed professionals can neither obtain NPIs nor enroll as Medicare suppliers. Several commenters recommended that CMS extend those same proposals for coaches to RNs and other medical professionals who currently lack the ability to obtain an NPI. As an alternative to obtaining NPIs, a number of commenters proposed that coaches should have specialized training.
To commenters who did not believe that coaches would be eligible for an NPI, we note that 45 CFR part 162, subpart D specifies that health care providers, as defined in 45 CFR 160.103, may obtain NPIs. Among other things, a health care provider under 45 CFR 160.103 is a person or organization who furnishes health care in the normal course of business. Because 45 CFR 160.103 specifies that health care includes preventive services, we believe MDPP coaches provide health care and are therefore health care providers under 45 CFR 160.103 and eligible to obtain NPIs. We disagree that requiring coaches to obtain NPIs would impose an undue burden on coaches, even those who work as coaches part-time or as volunteers. Obtaining an NPI takes approximately 20 minutes and can be done easily online. We will further consider the impact of coach requirements for rural and tribal areas that lack reliable access to the internet and will consider adjusting policies in future rulemaking as appropriate.
Requests for CMS to address NPI issues and enrollment for other health care providers such as RNs are outside of the scope of this rulemaking for MDPP. Should RNs or other providers who currently lack an NPI decide to work as a coach, these individuals would be able to obtain an NPI on that basis for purposes of furnishing MDPP services.
Given the relatively low burden that obtaining NPIs places on coaches and important considerations for monitoring, evaluation, and program integrity, we will require every coach furnishing MDPP services on behalf of an MDPP supplier to obtain an active and valid NPI that will be submitted to Medicare on the supplier's updated roster of coaches. This roster of coach identifying information would be submitted alongside the MDPP supplier's enrollment application to be used for vetting and program integrity purposes. However, we did not propose specific standards for how we would use roster information in connection with MDPP supplier enrollment. We intend to propose such standards in future rulemaking, and will begin enrollment of MDPP suppliers once appropriate standards are in place.
Upon enrollment, MDPP suppliers must submit, and update within 30 days of any changes, a roster of coaches, including individuals' first and last
Many commenters supported specific practitioners to serve as coaches, such as Certified Diabetes Educators (CDEs). Other commenters recommended that coaches should have clinician oversight. Similarly, other commenters suggested that we require for coaches to have clinicians as affiliates who can serve as a medical resource. A few commenters stated that coaches should have some form of credentials, particularly given that participants may have medical questions about weight loss that extend beyond a CDC-approved curriculum, which credentialed professionals are better equipped to handle. A number of commenters specifically requested that we recognize the value that CDEs can have in the MDPP expanded model and specify the role that they play in the management of lifestyle changes.
While we received many comments suggesting additional requirements for coaches, a number of commenters also urged against adding additional requirements on coaches beyond CDC DPRP Standards.
Though we agree that CDEs, RNs, and other credentialed professions can be effective MDPP coaches, the DPP model test showed that trained, non-credentialed coaches can effectively deliver the program. Additionally, we do not believe that the literature supports this claim that coaches with credentials would result in better participant performance than non-credentialed individuals trained to be coaches.
We will further consider commenters' suggestions regarding mechanisms to ensure that coaches have received high quality training, whether we will require coach certification, the impact credentials may have on coaches, and the possibility of clinician affiliation or oversight as we monitor and evaluate the expanded model.
The final policies for coach requirements are set forth in § 424.59.
We proposed that all MDPP suppliers would be required to comply with the requirements of 42 CFR part 424. If an MDPP supplier has its Medicare enrollment revoked or deactivated for reasons unrelated to its loss of CDC DPRP recognition, that MDPP supplier would lose its ability to bill Medicare for MDPP services but would not automatically lose its CDC DPRP recognition. We proposed that existing Medicare providers and suppliers who lose CDC DPRP recognition would lose their Medicare billing privileges with respect to MDPP services, but may continue to bill for other non-MDPP Medicare services for which they are eligible to bill. We proposed that MDPP suppliers that have their Medicare billing privileges revoked or that lose billing privileges for MDPP may appeal these decisions in accordance with the procedures specified in 42 CFR part 405, subpart H, 42 CFR part 424, and 42 CFR part 498. We proposed to add a new § 424.59 to our regulations to specify the suppliers who would be eligible for Medicare enrollment and billing for MDPP services. We solicited comment on these proposals.
The following is a summary of the comments we received regarding these proposals and our responses.
The final revocation and appeal policies are set forth in § 424.59.
Currently, CDC-recognized DPP organizations deliver DPP services in-person or virtually via a telecommunications system or other remote technology. The majority of current DPP organizations furnish DPP services in-person, but an emerging body of literature
We planned to monitor administrative claims for virtual services to identify any unusual and/or adverse utilization of the MDPP services. We solicited comment on specific monitoring activities or program integrity safeguards with respect to virtual services, in addition to the time period in which such enhanced monitoring activities should occur.
We noted that MDPP services provided via a telecommunications system or other remote technology will not be part of current Medicare telehealth benefits and have no impact on how telehealth services are defined by Medicare. We recognize that the provision of MDPP services by such virtual methods may introduce additional risks for fraud and abuse, and we plan to address specific policies in future rulemaking to mitigate these risks. We thus solicited comment on whether there are quality or program integrity concerns regarding the use of virtual sessions, or whether they offer comparable or higher quality MDPP services when compared to in-person services. We solicited comment on strategies to strengthen program integrity and minimize the potential for fraud and abuse in virtual sessions.
The following is a summary of the comments we received regarding these proposals and our responses.
We proposed that in order to receive payment, MDPP suppliers would be required to submit claims to Medicare using standard claims forms and procedures. Claims would be submitted in batches that contain beneficiary Protected Health Information (PHI) and Personally Identifiable Information (PII), including the Health Insurance Claim Number (HICN). Most Medicare claims are submitted electronically except in limited situations. We provide a free software package called PC-ACE Pro32 that creates a patient database and allows organizations to electronically submit claims to Medicare Part A and B. We understand there are several other electronic claims submissions software packages available in the market for purchase. We encouraged current and prospective DPP organizations to investigate adopting these systems to enhance the efficiency of claims
We proposed to require MDPP suppliers to maintain a crosswalk between the beneficiary identifiers they submit to CMS for billing purposes and the beneficiary identifiers they provide CDC for beneficiary level-clinical data. We proposed that MDPP suppliers provide this crosswalk to the CMS evaluator on a regular basis.
We proposed that MDPP suppliers maintain records that contain detailed documentation of the services furnished to beneficiaries, including but not limited to the beneficiary's eligibility status, sessions attended, the coach furnishing the session attended, the date and place of service of sessions attended, and weight. We proposed that MDPP suppliers maintain these records within a larger medical record, or within a medical record that an MDPP supplier establishes for the purposes of administering MDPP. Consistent with the requirement in § 424.516(f) we proposed that these records be retained for 7 years from the date of service and that MDPP suppliers would provide CMS or a Medicare contractor access to these records upon request. We proposed to require MDPP suppliers to accurately track payments and resolve any discrepancies between claims and the beneficiary record within their medical record. We also proposed that MDPP suppliers would be required to maintain and handle any beneficiary PII and PHI in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), other applicable privacy laws, and CMS standards. We indicated that we would provide education and guidance to MDPP suppliers to mitigate the risk of data discrepancies and audits. We stated that we would address specific recordkeeping requirements and standards in future rulemaking as appropriate.
The following is a summary of the comments we received and our responses.
These commenters suggested clarifying the medical record requirement in such a way that would be economically feasible for community-based programs. Due to these concerns, a number of commenters suggested that we work with CDC or other entities to identify a low cost data and billing system. Other commenters went further to suggest that CMS work with CDC to streamline the two data reporting systems such that when coaches or suppliers input performance data on beneficiary sessions to CDC, the Medicare claim would automatically be generated. Others appreciated the reliance on existing claim forms and software and applauded CMS for not creating a new data submission system. A few commenters noted that given the cost burdens of adequate IT, data, and recordkeeping systems, many community-based programs are likely to use third party integrators. These commenters did not advocate for a specific role for these integrators. One commenter, however, requested that MDPP suppliers be permitted to partner with and use the IT system of a healthcare entity to maintain records and submit claims for Medicare payment. Lastly, one commenter suggested that MDPP suppliers be required to take HIPAA-compliant training due to concerns about non-medical professionals housing HIPAA-compliant information.
Although we understand it might be easier for suppliers to submit claims and performance data to one joint CMS-CDC data system, we believe that maintaining MDPP claims independent from CDC performance data would allow us to compare information submitted to CMS with those submitted to CDC to identify inconsistencies, as supported by certain commenters. Additionally, it is important to note that while all MDPP suppliers will be organizations that have CDC recognition, it is likely that not all organizations with CDC recognition will enroll in Medicare. Similarly, not all participants in the National DPP are Medicare beneficiaries. Thus, Medicare claims information will not be relevant to CDC's assessment of performance data. For the aforementioned reasons, we do not agree with commenters that a joint CDC-CMS data system would be appropriate. We appreciate that these recordkeeping requirements can impose burdens on MDPP suppliers, particularly those who have not previously had to comply with these types of recordkeeping requirements. While MDPP suppliers are responsible for complying with these requirements, MDPP suppliers can decide which resources to utilize in order to do so, including the use of a third party administrator or other entity.
We proposed to reimburse for MDPP services at the times and in the amounts set forth in the Table 41, with payment tied to the number of sessions attended and achievement of a minimum weight loss of 5 percent of baseline weight (body weight recorded during the beneficiary's first core session).
As proposed, Table 41 illustrates that payments would be heavily weighted toward achievement of weight loss over the 12-month core benefit, and no payments would be available after the first 6 months without achievement of
We are deferring finalizing the proposed reimbursement structure to future rulemaking. In response to our solicitation, we received many comments. We intend to address these comments in future rulemaking.
We recognize the potential for fraud and abuse by suppliers filing inaccurate claims and/or duplicative claims on the number of sessions attended or amount of weight loss achieved. We also recognize beneficiaries may move between MDPP suppliers, and we intend to address in future rulemaking as appropriate any requirements necessary to prevent duplication claims for MDPP services furnished by more than one MDPP supplier to the same beneficiary. We are also concerned about the potential for beneficiary inducement or coercion and the potential program risks posed by permitting a new type of organization to receive payment from Medicare for furnishing MDPP services. We also realize that there may be other risks to program integrity. We intend to develop policies to mitigate these risks and monitor the MDPP expansion, to ensure MDPP suppliers meet all applicable CMS program integrity and supplier enrollment standards, and will address them in future rulemaking, as necessary. We intend to develop system checks to identify when CMS may need to audit an MDPP supplier's records. We are considering ways to cross reference the data DPP organizations are currently required to report to the CDC to identify potential discrepancies with data submitted to CMS. We sought comment on such approaches. Finally, MDPP suppliers would be subject to audits and reviews performed by CMS program integrity and/or review or audit contractors in addition to program-specific audits. We sought comment on these approaches and others to mitigate these risks and strategies to ensure program integrity.
In response to our solicitation, we received many comments. We intend to address these comments in future rulemaking.
The CDC provides technical assistance to DPP organizations with CDC DPRP recognition to improve performance. We solicited comment on what additional technical assistance would be needed for providers and other organizations in order to expand the MDPP model.
In response to our solicitation, we received many insightful and informative public comments and will consider the input when developing our strategy for ensuring that organizations seeking to enroll in Medicare and furnish and bill for MDPP services have the information and guidance they need to do so.
We solicited comment on the quality metrics that should be reported by MDPP suppliers in addition to the reporting elements required on Medicare claims submissions outlined above (attendance and weight loss) or by the CDC DPRP. We solicited comment specifically on what quality metrics should be considered for public reporting (not for payment) to guide beneficiary choice of MDPP suppliers.
In response to our solicitation, we received many comments. We intend to address these comments in future rulemaking.
Under section 1899 of the Act, we established the Medicare Shared Savings Program (Shared Savings Program) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs. Eligible groups of providers and suppliers, including physicians, hospitals, and other health care providers, may participate in the Shared Savings Program by forming or participating in an Accountable Care Organization (ACO). The final rule establishing the Shared Savings Program appeared in the November 2, 2011
Additionally, on April 27, 2016, the Department of Health and Human Services (HHS) issued a proposed rule to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and establish a new Quality Payment Program (QPP) (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models (81 FR 28162) (QPP proposed rule)). On October 14, 2016, HHS issued a final rule to implement key provisions of the MACRA and establish a new QPP (QPP final rule with comment period). (The rule will appear in the November 4, 2016
Our intent in the CY 2017 PFS proposed rule was to propose further refinements to the Shared Savings Program rules, and we identified several policies that we proposed to update or revise. First, we discussed and proposed policies related to ACO quality reporting including proposed changes to the quality measures used to assess ACO quality performance, changes in the methodology used in our quality
Section 1899(b)(3)(A) of the Act requires the Secretary to determine appropriate measures to assess the quality of care furnished by ACOs, such as measures of clinical processes and outcomes; patient, and, wherever practicable, caregiver experience of care; and utilization such as rates of hospital admission for ambulatory sensitive conditions. Section 1899(b)(3)(B) of the Act requires ACOs to submit data in a form and manner specified by the Secretary on measures that the Secretary determines necessary for ACOs to report to evaluate the quality of care furnished by ACOs. Section 1899(b)(3)(C) of the Act requires the Secretary to establish quality performance standards to assess the quality of care furnished by ACOs, and to seek to improve the quality of care furnished by ACOs over time by specifying higher standards, new measures, or both for the purposes of assessing the quality of care. Additionally, section 1899(b)(3)(D) of the Act gives the Secretary authority to incorporate reporting requirements and incentive payments related to the PQRS, EHR Incentive Program and other similar initiatives under section 1848 of the Act. Finally, section 1899(d)(1)(A) of the Act states that an ACO is eligible to receive payment for shared savings, if they are generated, only after meeting the quality performance standards established by the Secretary.
In the November 2011 final rule and recent CY PFS final rules with comment period (77 FR 69301 through 69304; 78 FR 74757 through 74764; 79 FR 67907 through 67931; and 80 FR 71263 through 712710), we have established the quality performance standard that ACOs must meet to be eligible to share in savings that are generated. Through these previous rulemakings, we have worked to improve the alignment of quality performance measures, submission methods, and incentives under the Shared Savings Program and PQRS.
In the CY 2017 PFS proposed rule, we proposed several changes and other revisions to our policies related to the quality measures and the quality performance standard, including the following:
• Changes to the measure set used in establishing the quality performance standard;
• Changes to the methodology used to validate quality data submitted by the ACO along with penalties that may apply if the audit match rate is less than 90 percent;
• Revisions to the use of the terms “quality performance standard” and “minimum attainment level” in the regulation text;
• Revisions related to use of flat percentages to establish quality benchmarks; and
• Alignment with policies proposed in the QPP proposed rule.
Section 1899(b)(3)(C) of the Act states that the Secretary shall establish quality performance standards to assess the quality of care furnished by ACOs and seek to improve the quality of care furnished by ACOs over time by specifying higher standards, new measures, or both. In the November 2011 final rule, we established a quality performance standard consisting of 33 measures across four domains, including patient experience of care, care coordination/patient safety, preventive health, and at-risk population. In subsequent PFS final rules with comment period, we have made a number of updates to the set of measures that make up the quality performance standard. The quality measure set currently includes 34 quality measures.
Quality measures are submitted by the ACO through the CMS web interface, calculated by CMS from administrative and claims data, and collected via a patient experience of care survey based on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. The measures collected through the CMS web interface are also used to determine whether eligible professionals participating in an ACO avoid the PQRS and automatic Physician Value Modifier (VM) payment adjustments for 2015 and subsequent years. Currently, eligible professionals billing through the TIN of an ACO participant may avoid the downward PQRS payment adjustment when the ACO satisfactorily reports all of the ACO GPRO measures on their behalf using the CMS web interface. Beginning with the 2017 VM, ACO performance on the CMS web interface measures and all cause readmission measure will be used in calculating the quality component of the VM for groups and solo practitioners participating within an ACO (79 FR 67941 through 67947).
In the CY 2017 PFS proposed rule, we explained that our principal goal and rationale for selecting quality measures for ACOs has been to identify measures of success in the delivery of high-quality health care at the individual and population levels with a focus on outcomes and a preference for NQF-endorsed measures. We noted, however, that the statute does not limit us to using endorsed measures in the Shared Savings Program. As a result, we have also exercised our discretion to include certain measures that we believe to be high impact but that are not currently endorsed, including for example, ACO#11, which is currently titled Percent of PCPs Who Successfully Meet Meaningful Use Requirements.
Further, we described our continuing work with the measures community to ensure that the specifications for the measures used under the Shared Savings Program are up-to-date and reduce reporting burden. Importantly, we noted that the Core Quality Measures Collaborative was formed in 2014, as a collaboration between CMS, providers, and other stakeholders, with the goal of aligning quality measures for reporting across public and private stakeholders in order to reduce provider reporting burden. On February 16, 2016, the Core Quality Measures Collaborative recommended a core quality measure set that aligns and simplifies quality reporting across multiple payers (
In efforts to continue to align with other CMS initiatives and reduce provider confusion and the burden of reporting, we proposed modifications to the quality measure set that an ACO is required to report. Specifically, to align the Shared Savings Program quality measure set with the measures recommended by the Core Quality Measures Collaborative and proposed for reporting through the CMS web interface under the QPP proposed rule, we proposed to add, and in some cases to replace, existing quality measures with the following:
As we stated in the CY 2017 PFS proposed rule, by aligning the Shared Savings Program measures with the Core Quality Measures Collaborative recommendations and proposals under the QPP proposed rule, we hope to reduce the burden of provider data collection and reporting of measures that do not align across public and private quality reporting initiatives. Therefore, we proposed to retire or replace the following measures in order to reduce provider reporting burden by reducing the number of measures that must be reported and because these measures do not align with the core measure set recommendations from the Core Quality Measures Collaborative and the measures that we proposed for reporting through the CMS web interface in the QPP proposed rule:
• ACO-39 Documentation of Current Medications in the Medical Record.
• ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented.
• ACO-31 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD).
• ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy—for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%).
In addition to our proposals above to modify the quality measure set to align with the Core Quality Measures Collaborative and the proposed modifications to the measures reported through the CMS web interface under the QPP proposed rule, we proposed a few additional modifications as follows:
First, we proposed to retire the two AHRQ Ambulatory Sensitive Conditions Admission measures (ACO-9 and ACO-10). Although ACO-9 and ACO-10 address admissions for patients with heart failure, chronic obstructive pulmonary disease (COPD), and asthma, we introduced two all-cause, unplanned admission measures for heart failure and multiple chronic conditions (ACO-37 and ACO-38, respectively) in the 2015 PFS final rule (79 FR 67911-67912). We believe ACO-37 and ACO-38 report on a similar population with similar conditions as ACO-9 and ACO-10. Therefore, in order to continue our efforts to reduce redundancies within the Shared Savings Program measure set, we proposed to remove ACO-9 and ACO-10 from the measure set.
Second, although we proposed to remove ACO-9 and ACO-10, we stated that we continue to believe AHRQ's Prevention Quality Indicator (PQI)
The following is a summary of the comments we received on specific proposed changes to the quality measure set:
Table 42 lists the Shared Savings Program quality measure set that will be used to assess quality performance starting with the 2017 performance year including the new measures adopted in this final rule. Each measure that is indicated as a new measure will be assessed as a pay for reporting measure for the 2017 and 2018 performance years. After that, the measure will be assessed based on the phase-in schedule noted in Table 42.
As a result of these proposed measure changes, the four domains will include the following number of quality measures (See Table 43 for details.):
• Patient/Caregiver Experience of Care-8 measures
• Care Coordination/Patient Safety-10 measures
• Preventive Health-8 measures
• At Risk Population-5 measures (3 individual measures and a 2-component diabetes composite measure)
Table 43 provides a summary of the number of measures by domain and the total points and domain weights that will be used for scoring purposes under the changes to the quality measure set adopted in this final rule.
In the
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If at the conclusion of the third phase there is a discrepancy greater than 10 percent between the quality data reported and the medical records provided during the audit, the ACO will not be given credit for meeting the quality target for any measure(s) for which the mismatch rate exists.
As we explained in the proposed rule, since publication of the initial program rules in 2011, we have gained experience in conducting audits and believe that certain modifications to our rules should be made in order to increase the statistical rigor of the audit methodology, streamline audit operations, and more closely align the Quality Measures Validation audit used in Shared Savings Program audits with other CMS quality program audits including those performed in the Physician Quality Reporting Program and the Hospital Inpatient and Outpatient Quality Reporting programs. We therefore proposed four improvements to our audit process that would address the number of records to be reviewed per measure, the number of audit phases, the calculation of an audit match rate and the consequences if the audit match rate falls below 90 percent.
First, we proposed to increase the number of records audited per measure to achieve a high level of confidence that the true audit match rate is within
Second, we proposed to modify our regulations in order to conduct the quality validation audit in a single step rather than the current multi-phased process described at § 425.500(e)(2). We proposed to use a more streamlined approach in which all records selected for audit would be reviewed in a single step and some activities currently conducted in phase 3 would be removed from the audit process entirely while others would instead be addressed at the conclusion of the audit. During the proposed single step, we stated we would review all submitted medical records and calculate the match rate. We anticipated that the education we currently provide to ACOs and the opportunity for ACOs to explain the mismatches that occur in Phase 3 of the current process would continue, but would occur at the conclusion of the audit. We stated that under the proposal, there would not be an the opportunity for ACOs to correct and resubmit data for any measure with a >10 percent mismatch because we have learned through our experience with program operations that resubmission of CMS Web Interface measure data after the close of the CMS Web Interface is not feasible. Instead, we proposed that an ACO's quality score would be affected by an audit failure as described below, without requiring re-opening of the CMS Web Interface. We stated we believed that this single step process would allow us to maintain the desired level of confidence that the true audit match rate is within 5 percentage points of the calculated result and to complete the audit in a timely manner. Therefore, we proposed to remove the provision at § 425.500(e)(2) that requires 3 phases of medical record review. In so doing, we proposed to redesignate § 425.500(e)(3) as § 425.500(e)(2).
Third, we proposed to revise the redesignated provision at § 425.500(e)(2) in order to provide for an assessment of the ACO's overall audit match rate across all measures, instead of assessing the ACO's audit mismatch rate at the measure level. Specifically, we proposed to calculate an overall audit match rate which would be derived by dividing the total number of audited records that match the information reported in the Web Interface by the total number of records audited. This would be a change from the current audit performance calculation methodology, which calculates a measure specific mismatch rate. We stated that we believe making this change would be necessary to minimize the number of records that must be requested in order to achieve the desired level of statistical certainty as described in the first proposal discussed in this section. Our analysis suggests that we would have to request a much larger number of records (approximately 200 per measure) from the ACO during a quality validation audit of individual measures to achieve a 90 percent confidence interval for each measure. In addition, combining all records to calculate an overall audit match rate is less subject to variability based on the specific subset of measures chosen for audit each year and better aligns with the methodology used by other CMS quality program audits.
Fourth, we proposed to revise the redesignated provision at § 425.500(e)(2), to indicate that if an ACO fails the audit (that is, has an overall audit match rate of less than 90 percent), the ACO's overall quality score would be adjusted proportional to its audit performance. Currently, our regulation at § 425.500(e)(3) states that if, at the conclusion of the audit process there is a discrepancy greater than 10 percent between the quality data reported and the medical records provided, the ACO will not be given credit for meeting the quality target for any measures for which this mismatch rate exists. In light of our proposed modifications to the quality validation audit process above in which we proposed to assess and validate the ACO's performance overall rather than the ACO's performance on each measure, we explained that we believe a modification to this requirement would be necessary to reflect an overall adjustment. Therefore, we proposed to modify the provision at newly redesignated § 425.500(e)(2) to state that if an ACO fails the audit (that is, has an audit match rate of less than 90 percent), the ACO's overall quality score will be adjusted proportional to the ACO's audit performance. The audit-adjusted quality score would be calculated by multiplying the ACO's overall quality score by the ACO's audit match rate. For example, if an ACO's quality score is 75 percent and the ACO's audit match rate is 80 percent, the ACO's audit-adjusted quality score would be 60 percent. The audit-adjusted quality score would be the quality score that is used to determine the percentage of any earned savings that the ACO may share or the percentage of any losses for which the ACO is accountable.
Finally, we proposed to add a new requirement at § 425.500(e)(3) that in addition to the adjustment to the ACO's overall quality score, any ACO that has an audit match rate of less than 90 percent, may be required to submit a corrective action plan (CAP) under § 425.216 for CMS approval. In the CAP, the ACO may be required to explain the cause of its audit performance and how it plans to improve the accuracy of its quality reporting in the future. In addition, we explained that CMS maintains the right, as described in § 425.500(f), to terminate or impose other sanctions on any ACO that does not report quality data accurately, completely or timely.
We invited comment on the proposed improvements to the process used to validate ACO quality data reporting.
The following is a summary of the comments we received regarding the proposed improvements to the process used to validate ACO quality data reporting.
Additionally, we appreciate stakeholder input on our operational documents, such as the suggestion to create a single guidance document that addresses the specifications for and requirements of web interface measures reporting. Currently, educational materials about web interface measures are found in several documents. In response to earlier requests for the creation of a single document, we have been working closely with our colleagues who are responsible for the CMS web interface to develop educational documents that would streamline the information available to all web interface reporters, including ACOs. We intend to continue to work to improve these communications and materials to assist ACOs in their preparation for quality measures submission. However, we believe that information currently available to ACOs, in addition to the support we provide through our help desks, webinars, and other methods of communication as noted below, is sufficient to ensure ACOs' understanding of and compliance with quality measure submission requirements. We therefore will not delay implementation of the new streamlined audit process and will use it beginning in spring 2017 to validate data received from ACOs for the 2016 performance year.
Finally, we are finalizing our proposal to add a new requirement at § 425.500(e)(3) that an ACO that has an audit match rate of less than 90 percent may be required to submit a corrective action plan (CAP) under § 425.216 for CMS approval. In the CAP, the ACO would be required to explain the reasons for the low audit match rate and how it plans to improve the accuracy of its quality reporting in the future. In addition, we maintain the right, as described in § 425.500(f), to terminate or impose other sanctions on any ACO that does not report quality data accurately, completely or timely. We will apply these policies to the quality validation audits beginning in 2017 with the quality validation audits of quality reporting for the 2016 performance year.
In this section of the CY 2017 PFS proposed rule, we proposed several technical changes to the quality performance standard that an ACO must meet to be eligible to share in savings, as established in the November 2011 final rule. Part of the determination of whether an ACO has met the quality reporting standard in each year is dependent on the ACO meeting the minimum attainment level for certain measures. We discussed how the “minimum attainment” requirement has been implemented to date and proposed a modification that we believe is more consistent with our policies for assessing an ACO's performance over time. Finally, we proposed to move references to compliance actions from § 425.502(d)(2)(ii) to a more appropriate provision at § 425.316(c).
First, we proposed to make technical revisions to ensure stakeholder understanding of the definition of the quality performance standard. The quality performance standard is established under Subpart F for each performance year (§ 425.502(a)). For the first performance year of an ACO's first agreement period, the quality performance standard is defined as complete and accurate reporting of all quality measures. For each subsequent performance year, quality measures phase in to pay for performance, and although the ACO must continue to report all measures completely and accurately, the ACO will also be assessed on performance based on the quality performance benchmark and minimum attainment level of certain measures that are designated as pay for performance. The quality performance standard that applies to an ACO's final year in its first agreement period also applies to each year of an ACO's subsequent agreement period (§ 425.502(a)(3)) (79 FR 67925 through 67926). ACOs must meet or exceed the minimum quality performance standard in a given performance year to be eligible to receive payments for shared savings (§ 425.100(b)). Conversely, failure to meet the quality performance standard in a given performance year makes ACOs ineligible to share in savings, even if generated, and such ACOs may be subject to compliance actions.
In the proposed rule, we explained that our intent in the November 2011 final rule was to establish a single quality performance standard that would apply for each performance year in which an ACO participates in the program. Because the quality performance standard changes, depending on the performance year, the ACO may be subject to multiple quality performance standards over the course of its 3-year agreement period. We stated that we recognize that some of the language used in subsequent revisions to our regulations may have generated some confusion related to this issue. We clarified that while there are certain standards that must be met for each measure or in each domain, there is one overall quality performance standard that must be met in each performance year by an ACO. Therefore, we proposed to make conforming changes to the regulations text to remove references to the quality performance standard in contexts where it does not appear to apply to the overall quality performance standard (particularly §§ 425.316(c)(2), 425.502(a)(4), and 425.502(d)(1)). We proposed to retain certain references to multiple quality performance standards, such as the reference at § 425.100(b), because we believe the use of the plural is appropriate in certain contexts as the quality performance standard varies depending on the performance year in question.
Second, we addressed the concept of the minimum attainment level and its use in determining whether an ACO has met the quality performance standard. As noted above, beginning in the second year of an ACO's first agreement period, the quality performance standard is met by complete and accurate reporting on all measures, but also includes meeting the minimum attainment level on “certain” measures. As provided at § 425.502(b)(1), we designate a performance benchmark and minimum attainment level for each measure. Pursuant to § 425.502(b)(3), the minimum attainment level is set at 30 percent or the 30th percentile of the performance benchmark. In § 425.502(c)(1) through (c)(2), we state that performance below the minimum attainment level for a measure will receive zero points for that measure and performance equal to or greater than the minimum attainment level for a measure will receive points on a sliding scale based on the level of performance. Finally, § 425.502(d) outlines quality performance requirements for the four domains, stating that the ACO must report all measures in a domain and must score above the minimum attainment level determined by CMS on 70 percent of the measures in each domain. If the ACO fails to achieve the minimum attainment level on at least 70 percent of the measures in a domain, CMS will take compliance action. Additionally, the ACO must achieve the
Therefore, we proposed to take all measures into account when determining ACO performance at the domain level for purposes of compliance actions. Additionally, we stated that we believe compliance actions should be addressed at § 425.316 rather than in the quality reporting section, and therefore, we proposed to move the provisions governing the specific performance levels at which a compliance action would be triggered from § 425.502 to § 425.316.
The following is a summary of the comments we received regarding the proposed technical changes related to the quality performance standard and minimum attainment level.
• Revise introductory text at § 425.502(a) to clarify that the quality performance standard is the overall standard the ACO must meet to qualify to share in savings.
• Replace the word “certain” in § 425.502(a)(2) and (3) with “all,” so that the term “minimum attainment level” clearly applies to both pay for reporting and pay for performance measures.
• At § 425.502(a)(4), make modifications to remove the reference to the quality performance standard each time it appears to avoid causing confusion between the standards for individual measures and the overall quality performance standard.
• At § 425.502(b)(3), define “minimum attainment level” for both pay for reporting and pay for performance measures. We will set the minimum attainment level for pay for performance measures at the 30th percent or 30th percentile of the quality performance benchmark and for pay for reporting measures at the level of complete and accurate reporting.
• At § 425.502(c)(2), revise the regulation text to specify that only pay for performance measures are assessed on a sliding scale.
• At § 425.502(c)(5), add a provision to specify that pay for reporting measures earn the maximum number of
• Modify § 425.502(d) to refer generally to compliance actions that may be taken for failure to meet quality requirements, including low quality performance.
We are also modifying § 425.316(c)(1) and (c)(2) to address the specific levels of quality performance at which compliance action will be triggered and to reference the single quality performance standard that an ACO must meet in order to remain eligible to participate in the Shared Savings Program.
As explained in greater detail in the CY 2017 PFS proposed rule, we previously finalized a methodology to spread clustered measures when setting quality benchmarks to promote a clinically meaningful assessment of ACO quality. Specifically, we finalized a policy that CMS would set quality benchmarks using flat percentages for a clustered measure when the national FFS data results in the 60th percentile for the measure are equal to or greater than 80.00 percent. We noted that the methodology would not apply to measures whose performance rates are calculated as ratios, for example, measures such as the two ACO Ambulatory Sensitive Conditions Admissions and the All Condition Readmission measures. We subsequently finalized a policy to address “topped out” measures by setting benchmarks using flat percentages when the 90th percentile is equal to or greater than 95 percent. Although similar to the “cluster” policy finalized earlier, we included measures whose performance rates are calculated as ratios. We believed this policy was appropriate because measures calculated and reported as ratios may become topped out and we wanted to treat all topped out measures consistently.
Since these policies were adopted, we have determined that converting measures calculated and reported as ratios into benchmarks expressed as percentiles and percentages creates confusion in the interpretation of quality results and may yield results that are contrary to the intended purpose of using flat percentages. As a result, we proposed to no longer apply the flat percentage policy to performance measures calculated as ratios. In addition, we proposed two technical changes to address typographical errors in § 425.502(a)(1), which contains a duplicative reference to CMS, and in § 425.502(b)(2)(ii), which contains an extra “t” at the end of “percent.”
The following is a summary of the comments we received regarding the proposed technical change to the application of flat percentages for quality benchmarks.
The Affordable Care Act gives the Secretary authority to incorporate reporting requirements and incentive payments from certain Medicare programs into the Shared Savings Program, and to use alternative criteria to determine if payments are warranted. Specifically, section 1899(b)(3)(D) of the Act affords the Secretary discretion to incorporate reporting requirements and incentive payments related to the physician quality reporting initiative (PQRI), under section 1848 of the Act, including such requirements and such payments related to electronic prescribing, electronic health records, and other similar initiatives under section 1848, and permits the Secretary to use alternative criteria than would otherwise apply under section 1848 of the Act for determining whether to make such payments. Under this authority, in the November 2011 final rule establishing the Shared Savings Program, we incorporated certain reporting requirements and payment rules related to the PQRS into the Shared Savings Program at § 425.504 for “eligible professionals” (EPs) who bill under the TIN of an ACO participant within an ACO. Thus, the Shared Savings Program rules provide that EPs who bill under the TIN of an ACO participant within an ACO may only participate under their ACO participant TIN as a group practice under PQRS under the Shared Savings Program for purposes of qualifying for a PQRS incentive (prior to 2015) or avoiding the payment adjustment (starting in 2015). In other words, the current regulations prohibit ACO participant TINs and the EPs billing through those TINs from participating in PQRS outside of the Shared Savings Program such that these entities may not independently report for purposes of PQRS apart from the ACO.
An ACO, reporting on behalf of its EPs for purposes of PQRS, is required to satisfactorily submit through the CMS web interface all of the ACO GPRO measures that are part of the Shared Savings Program quality performance standard. Under § 425.504(c), for 2016 and subsequent years, if an ACO fails to satisfactorily report all of the ACO GPRO measures through the CMS web interface each EP who bills under the TIN of an ACO participant within the ACO will receive a downward adjustment, as described in § 414.90(e) for that year. In the 2017 PFS proposed rule, we noted that the current regulations do not provide any mechanism for these EPs to report separately or otherwise avoid the downward payment adjustment if the ACO fails to satisfactorily report on their behalf. We also summarized the reasons discussed in the November 2011 final rule for not allowing EPs who bill under the TIN of an ACO participant to report outside their ACO for purposes of PQRS.
Since publication of the November 2011 final rule, we have gained experience with these policies and program operations, and now believe there may be limited instances in which it would be appropriate to use data that is reported by these EPs outside their ACO for purposes of PQRS. Therefore, we proposed a change in policy in order to be able to accept and use data that is separately reported outside the ACO by EPs billing through the TIN of an ACO participant within an ACO for purposes of PQRS under limited circumstances for the final 2 years of PQRS before it sunsets and is replaced by the Quality Payment Program (QPP). We stated that we continue to believe that in most cases it is appropriate to assess EPs that
However, we went on to explain in the proposed rule that we believe that when an ACO does not satisfactorily report for purposes of PQRS, it may be appropriate to accept and use data that is reported outside the ACO. In order to be able to accept and use data reported outside the ACO for purposes of PQRS, we noted that we must modify the provision at § 425.504 prohibiting EPs that bill under the TIN of an ACO participant in an ACO from reporting separately for purposes of PQRS. We therefore proposed to modify § 425.504 to lift the prohibition on separate reporting for purposes of the 2017 and 2018 PQRS payment adjustment. We explained that we believe this change to our program rules was necessary for several reasons.
First, we stated that we believe it is necessary to protect EPs that participate in ACOs that fail to satisfactorily report all of the ACO GPRO measures. Although 98 percent of ACOs successfully complete required quality reporting annually, there have been a few instances where an ACO has failed to report all of the required measures, for example, where an ACO has terminated its participation in the Shared Savings Program and did not quality report on behalf of the EPs that bill under the TIN of an ACO participant at the end of the performance year as required under our close-out procedures. In other instances, some ACOs continued to participate in the Shared Savings Program but failed to complete quality reporting in a timely manner. In these instances, the lack of complete quality reporting by the ACO translated into a failure for the EPs within the ACO to receive a PQRS incentive (or to avoid the PQRS downward adjustment) for that year.
Second, PQRS has transitioned away from providing incentive payments to applying only downward payment adjustments to payments under the Medicare Physician Fee Schedule, making it even more important for EPs to ensure they comply with the reporting requirements for PQRS. Under the current rules, EPs who bill under the TIN of an ACO participant within an ACO must ultimately rely on the ACO to report on their behalf. These EPs are only able to encourage and facilitate ACO reporting, but lack the ability to ensure that the ACO satisfactorily reports in order to prevent application of the payment adjustment. The proposed change to allow EPs to report separately would provide them a mechanism over which they have direct control to ensure satisfactory reporting occurs. Additionally, we noted that because there are no more payment incentives under the PQRS, there is no longer any concern that an EP may inadvertently receive duplicative PQRS incentive payments from CMS. We address the specific issues and policies related to the use of data reported by EPs apart from an ACO for purposes of avoiding the PQRS payment adjustment for payment years 2017 and 2018 in section III.H. of this final rule.
Third, under the VM, groups and solo practitioners that bill under the TIN of an ACO participant are evaluated under a quality tiering methodology and could qualify for an upward payment adjustment if the ACO satisfactorily reports on their behalf. However, if the ACO does not satisfactorily report quality data as required under § 425.504 then groups and solo practitioners that bill under the TIN of an ACO participant fall into Category 2 for the VM and are subject to a downward payment adjustment. Our proposed and final policies for how quality data reported by EPs billing under the TINs of ACO participants that is reported apart from the ACO will be used for purposes of avoiding the VM downward payment adjustment for 2017 and 2018 are discussed in section III.L.3.b of this final rule.
For the reasons noted above, we stated that we believed it would be appropriate to retain the provisions under § 425.504 that require the ACO to report all of the ACO GPRO measures to satisfactorily report on behalf of the EPs who bill under the TIN of an ACO participant for purposes of the PQRS payment adjustment; however, we proposed to modify the provisions that prohibit EPs that bill under the TIN of an ACO participant from reporting apart from the ACO. Specifically, we proposed to add a redesignated and revised paragraph at § 425.504(d) to address the requirement that the ACO report on behalf of the eligible professionals who bill under the TIN of an ACO participant for purposes of the 2017 and 2018 PQRS payment adjustment. Under this revised provision the prohibition on separate quality reporting for purposes of the PQRS payment adjustment for 2017 and 2018 would be removed. We also proposed to make a technical change to § 425.504 to move existing § 425.504(d) to § 425.504(c)(5) because the intent of this provision was to parallel the language of § 425.504(b)(6) for purposes of the payment adjustment for 2016 and subsequent years. We reiterated our intent that data reported by an ACO would continue to be preferentially used for purposes of other CMS initiatives that rely on such data, including the PQRS and the VM. If an EP who bills under the TIN of an ACO participant chooses to report apart from the ACO, the EP's data may be used for purposes of PQRS and VM only when complete ACO reported data is not available. Additionally, we noted that under the Shared Savings Program, only the quality data reported by the ACO as required under § 425.500 would be used to assess the ACO's performance under the Shared Savings Program. In other words, quality data submitted separately from the ACO would not be considered under the Shared Savings Program. We requested comments on this proposal.
The following is a summary of the comments we received regarding our proposed changes to the reporting requirements under the Shared Savings Program related to PQRS.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015), amended title XVIII of the Act to repeal the Medicare sustainable growth rate (SGR) and strengthen Medicare access by improving physician payments and making other improvements. The statute established the Merit-Based Incentive Payment System (MIPS), a new program for certain Medicare-participating practitioners. MIPS consolidates components of three existing programs, the PQRS, the Physician Value Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for EPs. The statute also established incentives for participation in certain alternative payment models (APMs). On April 27, 2016, the Department of Health and Human Services (HHS) issued a proposed rule to implement key provisions of the MACRA and establish a new Quality Payment Program (QPP) (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models (81 FR 28162 through 28586) (the QPP proposed rule)). On October 19, 2016, HHS issued the final rule with comment period establishing the Quality Payment Program (QPP final rule with comment period). (The rule will publish in the November 4, 2016
• Establishes criteria for reporting under each of the 4 categories. For example, the QPP final rule with comment period establishes a policy for the quality performance category to use quality information submitted by the ACO through the CMS Web interface to assess each EC billing under the TIN of an ACO participant. To assess performance in the category of advancing care information performance category for ECs billing under the TIN of an ACO participant, we will aggregate EC-reported data to calculate an ACO score which will be applied to each participating EC. Under the QPP final rule with comment period, this reporting by ECs will be accomplished by each ACO participant TIN reporting on the advancing care information as specified in § 414.1375(b). We note that under the QPP final rule with comment period, ECs for whom a sufficient percentage of payments for covered professional services, or a sufficient percentage of patients, are attributable to services furnished through an Advanced APM for a year will be qualifying APM participants (QPs) for the year. In addition to earning a 5 percent APM Incentive Payment, QPs are exempt from the MIPS reporting requirements and payment adjustment for the year.
• Defines an Advanced APM as one that meets several criteria including requiring participants to use certified EHR technology (CEHRT). Under the QPP final rule with comment period, only Tracks 2 and 3 of the Shared Savings Program have the potential to meet all criteria necessary for designation as an Advanced APM. In order for Tracks 2 and 3 of the Shared Savings Program to meet the CEHRT requirement for Advanced APMs, the Shared Savings Program must hold ACOs accountable for their participating eligible clinicians' use of CEHRT by applying a penalty or reward based on the degree of use of CEHRT (such as the percentage of EPs that are using CEHRT or the care coordination or other activities performed using CEHRT).
In the 2017 PFS proposed rule, we reviewed the Shared Savings Program
• Revisions to §§ 425.504 and 425.506 to sunset Shared Savings Program alignment with PQRS and the EHR Incentive Program starting with quality reporting period 2017 (corresponding to payment year 2019).
• Addition of new paragraph § 425.506(e) and section § 425.508 to align with the proposed Quality Payment Program, including rules addressing annual assessment of the use of CEHRT by ECs participating in ACOs and for ACO reporting of certain quality measures to satisfy the quality performance category on behalf of the eligible clinicians who bill under the TIN of an ACO participant.
• Modifications to the EHR measure title and specifications necessary to align with the proposed QPP criteria for determining Advanced APM status, including scoring requirements for the limited circumstances when the measure is designated as pay for reporting.
The Shared Savings Program has established rules at §§ 425.504 and 425.506 incorporating reporting requirements related to PQRS and the EHR Incentive Program. The current provision at § 425.504(c), addresses the PQRS payment adjustment for 2016 and subsequent years. Under current Shared Savings Program rules, EPs who bill under the TIN of an ACO participant within an ACO may only participate under their ACO participant TIN as a group practice under the PQRS Group Practice Reporting Option for purposes of the PQRS payment adjustment under the Shared Savings Program. ACOs must submit all of the ACO GPRO measures to satisfactorily report on behalf of their eligible professionals for purposes of the PQRS payment adjustment. If an ACO does not satisfactorily report, each EP participating in the ACO receives a payment adjustment under PQRS. As discussed in this final rule, we are finalizing a policy that will allow EPs who bill under the TIN of an ACO participant within an ACO to report separately from their ACO for purposes of the PQRS payment adjustment for 2017 and 2018.
At § 425.506, we address alignment with the EHR Incentive Program. Specifically, at § 425.506(a), we state that ACOs, ACO participants, and ACO providers/suppliers are encouraged to develop a robust EHR infrastructure, which aligns with our eligibility criteria under § 425.112 that require ACOs to define care coordination processes, which may include the use of enabling technologies such as CEHRT. At § 425.506(b) and (c) we state that the quality measure regarding EHR adoption is measured based on a sliding scale and that it is weighted twice that of any other measure for scoring purposes and determining compliance with quality performance requirements for domains. To align with the EHR incentive program we state in § 425.506(d), that EPs participating in an ACO under the Shared Savings Program satisfy the CQM reporting component of meaningful use for the Medicare EHR Incentive Program when the EP extracts data necessary for the ACO to satisfy the quality reporting requirements under the Shared Savings Program from CEHRT and when the ACO reports the ACO GPRO measures through a CMS Web interface. EPs are responsible for meeting the rest of the EHR incentive program requirements apart from the ACO.
As noted above, the VM, PQRS and the EHR incentive programs are sunsetting and the last quality reporting period under these programs will be 2016, which will impact payments in 2018. Quality reporting under the QPP, as proposed and subsequently finalized, will begin in 2017 for payment year 2019. In order to align with the policies proposed in the QPP proposed rule (and that were subsequently finalized in the QPP final rule with comment period), we proposed to amend §§ 425.504 and 425.506 to indicate that these reporting requirements would apply to ACOs and their EPs through the 2016 performance year. Specifically, at § 425.504(c) we proposed to remove the phrase “for 2016 and subsequent performance years” each time it appears and add in its place the phrase “for 2016.” As discussed above, we proposed and are finalizing a technical change to redesignate paragraph (d) as paragraph (c)(5) and then to add new paragraph (d) to address the PQRS alignment rules for the 2017 and 2018 PQRS payment adjustment. Similarly, at § 425.506, we proposed to revise paragraph (d) to indicate that the last reporting year for the EHR Incentive Program is 2016.
In addition, in the CY 2017 PFS proposed rule, we proposed to require ACOs, on behalf of the ECs who bill under the TIN of an ACO participant, to report quality measures through the CMS Web interface in order to satisfy the QPP quality performance category. Currently, ACOs are required under § 425.504 to report certain quality measures on behalf of the EPs who bill under the TIN of an ACO participant for purposes of PQRS. Under the policy proposed in the QPP proposed and subsequently adopted in the QPP final rule with comment period, the quality data submitted to the CMS Web interface by ACOs will satisfy the quality performance category for ECs participating in the ACO. Therefore, in order to align with the QPP, we proposed to add a new paragraph at § 425.508(a) that parallels the current requirement at § 425.504 for reporting on behalf of EPs who bill under the TIN of an ACO participant for purposes of PQRS. Specifically, we proposed to require that ACOs, on behalf of ECs who bill under the TIN of an ACO participant, must submit all the ACO CMS Web interface measures required by the Shared Savings Program using a CMS Web interface, to meet reporting requirements for the quality performance category under MIPS. Because we proposed to maintain flexibility for EPs to report quality performance category data separately from the ACO for purposes of PQRS, we did not propose to include a provision that would restrict an EC from reporting outside the ACO for purposes of the QPP. While the intent of these proposals was to permit flexibility in reporting quality data, we reiterated that no quality data reported apart from the ACO would be considered for purposes of assessing the quality performance of the ACO under the Shared Savings Program.
The following is a summary of the comments we received regarding our proposals to sunset PQRS and EHR Incentive Program alignment and to align with the reporting requirements under the QPP.
To align with the reporting requirements under the QPP, we are finalizing our proposal to add a new provision at § 425.508 that parallels the current requirement at § 425.504 that ACOs report on behalf of EPs who bill under the TIN of an ACO participant for purposes of PQRS. Specifically, we are finalizing our proposal to require that ACOs, on behalf of ECs who bill under the TIN of an ACO participant, must submit all the CMS Web interface measures required by the Shared Savings Program using a CMS Web interface, to meet reporting requirements for the quality performance category under the QPP. As discussed elsewhere in this final rule, we are also finalizing a policy to maintain flexibility for EPs to report quality data separately from the ACO for purposes of PQRS and the VM, and therefore, are not including a provision that would restrict an EC from reporting outside the ACO for purposes of the QPP. While the intent of this policy is to permit flexibility in reporting quality data for purposes of the QPP, we reiterate that no quality data reported apart from the ACO will be considered for purposes of assessing the quality performance of the ACO under the Shared Savings Program.
In the QPP proposed rule (81 FR 28296) and in the subsequent QPP final rule with comment period, we outlined and defined the criteria for Advanced APMs, APMs through which ECs would have the opportunity to become Qualified Participants (QPs) as specified in section 1833(z)(3)(C) and (D) of the Act. First, under MACRA, for an APM to be considered an Advanced APM, it must meet three requirements: (1) Require participants to use certified EHR technology; (2) provide payment for covered professional services based on quality measures comparable to those used in the quality performance category of MIPS; and (3) either be a Medical Home Model expanded under section 1115A(c) of the Act or require the participants to bear more than a nominal amount of risk for monetary losses. In the rulemaking implementing the QPP, we established criteria for each of these requirements. As proposed and subsequently finalized, under the QPP, significant distinctions between the design of different tracks or options within an APM mean that certain tracks or options could meet the Advanced APM criteria while other tracks or options may not. Under the approach discussed in the QPP proposed rule and as subsequently adopted in the QPP final rule with comment period, while all Tracks of the Shared Savings Program would meet the criterion to provide for payment based on quality measures comparable to those used in the quality performance category of MIPS, only Tracks 2 and 3 meet the proposed financial risk standard to bear more than a nominal amount of risk for monetary losses.
In the rulemaking to establish the QPP, we adopted an alternative criterion that would allow all three tracks of the Shared Savings Program to satisfy the EHR criterion if ACOs are held accountable for their ECs' use of CEHRT. In the QPP final rule with comment period, we adopted a definition of CEHRT at § 414.1305 for purposes of MIPS and the APM incentive. We noted that section 1833(z)(3)(D)(i)(I) of the statute does not specify how the APM must require participants to use CEHRT in order to be an Advanced APM. For this reason, we stated that we believed it was reasonable to use discretion when determining the details of how APMs might meet this criterion. For purposes of the APM incentive under the QPP, we proposed and subsequently finalized a policy that an Advanced APM must require at least 50 percent of ECs who are enrolled in Medicare (or each hospital if hospitals are the APM participants) to use the certified health IT functions outlined in the definition of CEHRT to document and communicate clinical care with patients and other health care professionals. However, although the Shared Savings Program requires ACOs to encourage and promote the use of enabling technologies (such as EHRs) to coordinate care for assigned beneficiaries, the Shared Savings Program does not require a specific level of CEHRT use for participation in the program. Instead, the Shared Savings Program, as noted above, includes an assessment of EHR use as part of the quality performance standard which directly impacts the amount of shared savings/shared losses generated by the ACO. Therefore, in the rulemaking to establish the QPP, we proposed and subsequently finalized an alternative criterion available only to the Shared Savings Program. Specifically, we proposed and subsequently finalized an alternative criterion that would allow the Shared Savings Program to satisfy the EHR criterion to be an Advanced APM if it holds APM Entities accountable for their ECs' use of CEHRT by applying a financial penalty or reward based on the degree of CEHRT use (such as the percentage of ECs that use CEHRT or the engagement in care coordination or other activities using CEHRT). In the rulemaking for the QPP, we noted that the current EHR quality measure at ACO #11 assesses the degree to which certain ECs in the ACO successfully meet the requirements of the EHR Incentive Program, and we stated that “[s]uccessful reporting of the measure for a performance year gives the ACO points toward its overall quality score, which in turn affects the amount of shared savings or shared losses an ACO could earn or be liable for, respectively.” Finally, we stated that we believed the alternative criterion meets the statutory requirement because the alternative criterion builds on established Shared Savings Program rules and incentives that directly tie the level of CEHRT use to the ACO's financial reward which in turn has the effect of directly incentivizing ever-increasing levels of CEHRT use among participating clinicians.
In the CY 2017 PFS proposed rule, we proposed several modifications to our program rules in order to align with the policies proposed for the QPP.
First, we proposed to modify the title and specifications of the EHR quality measure (ACO #11). This measure is currently titled Percent of PCPs Who Successfully Meet Meaningful Use Requirements. Under the current Shared Savings Program rules, ACOs must report on and are held accountable for certain measures that make up the quality reporting standard. One of these measures, ACO #11, assesses the degree of CEHRT use by primary care physicians participating in the ACO and performance on this measure is weighted twice that of any other measure for scoring purposes. To calculate this measure, CMS collects information submitted by PCPs through the EHR Incentive Program and determines the rate of CEHRT use by PCPs participating in the ACO. Specifically, as explained in our guidance [
In the QPP proposed rule, we proposed that ECs participating in an ACO would satisfy the Advancing Care Information performance category under the MIPS by reporting meaningful use of EHRs apart from the ACO (81 FR 28247, Table 15). We subsequently finalized this policy in the QPP final rule with comment period. Similar to the process currently used under the Shared Savings Program to determine what practitioners have met criteria for meaningful use for the ACO #11 measure, we will access EC-reported data under the Advancing Clinical Information performance category to assess the ACO's overall use of CEHRT. Because the current EHR measure at ACO-11 only assesses the degree of use of CEHRT by primary care physicians participating in the ACO, in the CY 2017 PFS proposed rule we proposed to modify the EHR measure to align with the policy proposed for the QPP. Specifically, we proposed to change the specifications of the EHR measure in order to assess the ACO on the degree of CEHRT use by all providers and suppliers designated as ECs under the QPP that are participating in the ACO, rather than narrowly focusing on the degree of use of CEHRT of only the primary care physicians participating in the ACO. We stated that we believed this modification to the specifications for ACO #11 would better align with the QPP and ensure a subset of ACOs in the Shared Savings Program could qualify to be Advanced APM entities by participating in an Advanced APM. We also proposed to modify the title of the measure to remove the reference to PCPs. We stated that we believed the modification in the specifications of ACO #11 would be extensive and ECs would also have to gain familiarity with the reporting requirements under the QPP. We therefore proposed that this measure would be considered a newly introduced measure and set at the level of complete and accurate reporting for the first 2 reporting periods for which reporting of the measure is required according to our rules at § 425.502(a)(4). Thus, the measure would be pay for reporting for the 2017 and 2018 performance years. We further proposed to define requirements specific to this measure for the limited circumstances in which it is designated as pay for reporting. Specifically, we proposed to include the requirement at § 425.506(e)(1) that during years in which ACO #11 is designated as a pay for reporting measure, in order for us to determine that the ACO has met requirements for complete and accurate reporting, at least one EC, as that term is defined for purposes of the QPP, participating in the ACO must meet the reporting requirements under the Advancing Clinical Information performance category under the QPP. We stated that we believed this proposal would safeguard the ability of Tracks 2 and 3 to fully meet all criteria for designation as Advanced APMs by ensuring the letter and spirit of the statutory criteria are met, even in the limited circumstances when ACO #11 is designated as pay for reporting under the Shared Savings Program. Beginning in the 2019 performance year, we proposed that ACO #11 would be assessed according to the phase-in schedule indicated in Table 36 of the proposed rule (81 FR 46421-46422) which is consistent with the current phase-in schedule for the measure. We further proposed to add § 425.506(e)(2) reiterating our current requirement at § 425.506(b) that during pay for performance years, the quality measure regarding EHR adoption is measured based on a sliding scale. We stated that we did not intend our proposal to use this measure to assess the degree of CEHRT use by ECs participating in the ACO for purposes of meeting the CERHT criterion for Advanced APMs under the QPP to change the way we treat the measure under pay for performance now. Similar to the current method used by the Shared Savings Program to calculate the EHR measure, we stated that the data would continue to be derived using EC reported EHR data that is required and collected for purposes of MIPS. Additionally, we stated that we intended for the measure to remain double weighted. We proposed to retain the existing EHR measure requirements at § 425.506(a)-(c) and to modify § 425.506(d) to sunset the current EHR reporting requirement as discussed in the prior section.
We also stated that we did not believe that any additional modifications or exceptions to current Shared Savings Program rules (other than the ones proposed, specifically, that the measure specifications and title of ACO #11 be modified to include all ECs and not just PCPs, and the proposal for how an ACO would demonstrate complete and accurate reporting) must be made in order to be consistent with the spirit and intent of the statute and the Advanced APM criteria, as proposed in the QPP proposed rule. Rather, we stated that we believe the existing Shared Savings Program rules are sufficient to permit Tracks 2 and 3 to meet the criteria to be designated as Advanced APMs because the EHR quality measure will always be used to impact the amount of shared savings or losses of an ACO, regardless of whether it is designated as pay for performance or pay for reporting. We noted that the EHR measure has an especially significant impact on the overall quality scoring for an ACO because it is double-weighted compared to any other measure. In spite of this, we indicated that we were considering additional options regarding the treatment of the EHR measure under the Shared Savings Program in order to further enhance the importance of this measure and its impact on an ACO's quality performance score and to improve alignment with the intent of the policies proposed in the QPP proposed rule. Specifically, we were considering whether to finalize a policy that would require the EHR measure to be pay for performance in all performance years, including the first year of an ACO's first agreement period. Additionally, we were considering whether to finalize a policy that would require the EHR measure to remain pay for performance, even when a new EHR measure is introduced or there are significant modifications to the specifications for the measure. We noted that such modifications may require additional changes or alternative approaches to certain current Shared Savings Program rules related to quality benchmarking and scoring. We anticipated that if such modifications were made, they would only apply to the EHR measure and would not impact current scoring and benchmarking rules for other quality measures that make up the quality performance standard. We solicited comment on how best to conform to the intent and spirit of the QPP requirements to ensure that clinicians have assurance they are participating in an Advanced APM. We specifically solicited comment on our proposals and the alternatives considered.
Furthermore, we noted that the CMS Web interface measures, including those proposed in the QPP proposed rule, are consistent across CMS reporting programs. We stated that we do not believe it is beneficial to propose CMS Web interface measures for ACO quality reporting separately. Therefore, to avoid confusion and duplicative rulemaking, we proposed that any future changes to the CMS Web interface measures would be proposed and finalized through rulemaking for the QPP, and that such
The following is a summary of the comments we received regarding our proposals to align with QPP.
We note that under the QPP final rule with comment period, eligible clinicians who become QPs by participating in Advanced APMs will be exempt from reporting in the advancing care information performance category for purposes of MIPS. However, under § 425.500(c), ACOs must submit data on ACO quality performance measures according to the method of submission established by CMS. Thus, in the QPP final rule with comment period, we established a policy that all eligible clinicians participating in ACOs under all tracks of the Shared Savings Program must report for purposes of the advancing care information performance category according to the MIPS requirements found at § 414.1375(b) regardless of whether they are excluded from MIPS for the year by virtue of their participation in an Advanced APM, in order for the Shared Savings Program to assess the ACO's performance on ACO-11, as required by the Advanced APM CEHRT use criterion.
We appreciate the suggestion that the old measure (based on percent of primary care physician use of CEHRT) be retained in addition to establishing a new EHR measure that assesses EC use of CEHRT. We decline to retain the old measure at this time because the nature of the data being submitted to us is changing and primary care physicians are included in the new measure as a subset of the ECs participating in the ACO. Although we decline to hold ACOs accountable for both measures of CEHRT use at this time, we will continue to consider whether in the future it would be useful to calculate the percent of primary care physicians using CEHRT and share this information with ACOs.
Because the specifications for this measure are changing, we are finalizing our proposal to consider it a newly introduced measure and to set it at the level of complete and accurate reporting for the first 2 reporting periods for which reporting of the measures is required consistent with our existing rule at § 425.502(a)(4). Specifically the measure will be pay for reporting for all ACOs for the 2017 and 2018 performance years. We are also finalizing our proposal to include a requirement at § 425.506(e)(1) that during years in which ACO #11 is designated as a pay for reporting measure, in order for us to determine that an ACO has met requirements for complete and accurate reporting, at least one EC participating in the ACO must meet the reporting requirements under the Advancing Clinical Information performance category under the QPP. Beginning in the 2019 performance year, ACO #11 will be assessed according to the phase-in schedule noted in Table 42. We are finalizing our proposal to add § 425.506(e)(2) reiterating our current requirement at § 425.506(b) that during pay for performance years, assessment of EHR adoption will be measured based on a sliding scale.
Finally, we are finalizing a policy that any future changes to the CMS Web interface measures will be adopted through rulemaking for the QPP, and that such changes will be applicable to ACO quality reporting under the Shared Savings Program.
Under section 1899(c) of the Act, beneficiaries are required to be assigned to an ACO participating in the Shared Savings Program based on the beneficiary's utilization of primary care services rendered by physicians participating in the ACO. Medicare FFS beneficiaries do not enroll in the Shared Savings Program, and they retain the right to seek Medicare-covered services from any Medicare-enrolled provider or supplier of their choosing. No exclusions or restrictions based on health conditions or similar factors are applied in the assignment of Medicare FFS beneficiaries. Thus, a beneficiary's choice to receive primary care services furnished by physicians and certain non-physician practitioners that are ACO professionals in the ACO, determines the beneficiary's assignment to an ACO under the Shared Savings Program. As discussed in detail in the November 2011 Medicare Shared Savings Program final rule (76 FR 67851 through 67870), we finalized a claims-based hybrid approach (called preliminary prospective assignment with retrospective reconciliation) for assigning beneficiaries to an ACO. Under this approach, beneficiaries are preliminarily assigned to an ACO at the beginning of a performance year to help the ACO refine its care coordination activities, but final beneficiary assignment is determined at the end of each performance year based on where beneficiaries chose to receive a plurality of their primary care services during the performance year. We adopted this policy because we believe that the methodology balances beneficiary freedom to choose healthcare providers under FFS Medicare with the ACO's desire to have information about the FFS beneficiaries that are likely to be assigned at the end of the performance year. We believe this methodology accomplishes an appropriate balance because ACOs have the greatest opportunities to impact the quality and cost of the care of beneficiaries that choose to receive care from providers and suppliers participating in the ACO during the course of the year.
A beneficiary is eligible for assignment to an ACO under § 425.402 if the beneficiary had a primary care service with a physician who is an ACO professional, and thus, is eligible for assignment to the ACO under the statutory requirement to base assignment on utilization of primary care services furnished by physicians who are ACO professionals in the ACO. The beneficiary is then assigned to the ACO if the allowed charges for primary care services furnished to the beneficiary by all primary care physicians who are ACO professionals and non-physician ACO professionals in the ACO are greater than the allowed charges for such services provided by primary care physicians, nurse practitioners, physician assistants, and clinical nurse specialists who are ACO professionals in another ACO or not affiliated with any ACO and are identified by a Medicare-enrolled TIN. The second step of the assignment process considers the remainder of beneficiaries who have received at least one primary care service from an ACO physician with a specialty designation specified in § 425.402(c), but have received no services from a primary care physician, nurse practitioner, physician assistant, or clinical nurse specialist either inside or outside the ACO. These beneficiaries are assigned to the ACO if the allowed charges for primary care services furnished by physicians who are ACO professionals in the ACO with one of the specialty designations specified in § 425.402(c) are greater than the allowed charges for primary care services furnished by physicians with such specialty designations in another ACO or who are not affiliated with any ACO and are identified by a Medicare-enrolled TIN. The “two step” assignment process simultaneously maintains the requirement to focus on primary care services in beneficiary assignment, while recognizing the necessary and appropriate role of specialists and non-physician practitioners in providing primary care services, such as in areas with primary care physician shortages. We revised this two-step claims based methodology in the June 2015 Final Rule as discussed in detail in that final rule (80 FR 32743 through 32758) and finalized a policy that would exclude services provided by certain physician specialties from step 2 of the assignment process.
Additionally, in the June 2015 final rule, and in response to stakeholders' suggestions, we implemented an option for ACOs to participate in a new two-sided performance-based risk track, Track 3. Under Track 3, beneficiaries are
Because of uncertainty inherent in FFS Medicare where there is no beneficiary lock-in or enrollment, both patient advocacy groups and ACOs have expressed interest in and support for enhancing claims-based assignment of beneficiaries to ACOs by taking into account beneficiary attestation regarding the healthcare provider that they consider to be responsible for coordinating their overall care. Stakeholders believe that incorporating this information and giving beneficiaries the opportunity to voluntarily “align” with the ACO in which their primary healthcare provider participates will improve the patient centeredness of the assignment methodology, and possibly reduce year-to-year “churn” in beneficiary assignment lists.
The Center for Medicare & Medicaid Innovation (Innovation Center) began conducting a test of beneficiary attestation (which was referred to as voluntary alignment, a term that we will also use in the context of the Shared Savings Program) in the Pioneer ACO Model (see
The ACOs sent letters to beneficiaries during a specified period asking the beneficiaries to confirm whether a listed Pioneer Provider/Supplier was their “main doctor.” The Innovation Center imposed certain safeguards on the participating ACOs to protect against actions that could improperly influence a beneficiary's decision to complete the voluntary alignment form. The ACOs collected responses and turned them in to CMS in fall 2014, before the start of the 2015 performance year. Beneficiaries who confirmed a care relationship with the Pioneer Provider/Supplier listed on the form, and met all other eligibility criteria for alignment, were prospectively aligned to the Pioneer ACO for the upcoming performance year, regardless of whether or not the practitioners participating in the Pioneer ACO rendered the plurality of the beneficiary's primary care services during the alignment period. We refer to the procedures used under the Pioneer ACO Model as “the manual process.”
Beneficiary and ACO participation in and experience with voluntary alignment under the Pioneer ACO Model to date has been mixed. Initially, beneficiaries often seemed confused about the implications of attesting to a care relationship with a Pioneer Provider/Supplier, based on the letters they received from Pioneer ACOs. Beneficiaries, for example, were often unfamiliar with the name of the Pioneer ACO. Although most Pioneer ACOs initially expressed high interest in beneficiary attestation, only half participated. Those that did not participate cited cost/benefit concerns. To address concerns expressed by ACOs and beneficiaries, the beneficiary attestation process was updated for the Pioneer ACO Model for PY 2016, with letters sent to beneficiaries during the summer of 2015. The new beneficiary attestation process includes updated language in the letters to beneficiaries and the attestation form to reduce beneficiary confusion. The letters now include plainer language, refer to a specific healthcare provider (in addition to the ACO), and Pioneer Providers/Suppliers are permitted to discuss beneficiary attestation with beneficiaries and respond to questions. Other significant changes to the process are discussed in the proposed rule (81 FR 46432). We would note that for performance year five (Pioneer ACO contract year 2016), CMS changed the criteria to allow beneficiaries to voluntarily align into the performance year five aligned population if, among other requirements, the beneficiary had at least one paid claim for a Qualified E/M service, as defined in section 2.4 of Appendix C of the Pioneer ACO Agreement, furnished by a Pioneer Provider/Supplier on or after January 1, 2013. Based on some initial feedback, beneficiaries appear to be wary of the implications of designating a “main doctor” but are much more amenable to this type of information request when it comes from their physician or other practitioner, rather than from an ACO. However, information is not yet available on the impact or results of the modifications made to the beneficiary attestation process in the Pioneer ACO Model. The Next Generation ACO Model, which started operation on January 1, 2016, includes a beneficiary attestation policy similar to the updated manual process used under the Pioneer ACO Model. In order for a Medicare FFS beneficiary to be eligible to voluntarily align with a Next Generation ACO for performance year two (Next Generation ACO contract year 2017), the beneficiary must have had at least one paid claim for a qualified evaluation and management service on or after January 1, 2014, with an entity that was a Next Generation Participant during performance year one, among other requirements.
To date, the Innovation Center has done limited analyses of the updated voluntary alignment process for effects on beneficiary engagement. Early experience indicates that for the participating ACOs, the number of prospectively assigned beneficiaries per ACO increased by 0.2 to 2.7 percent relative to the number of beneficiaries who would have otherwise been assigned. However, there is not yet enough information to determine whether beneficiary attestation under the manual process has had an impact on increasing certainty that a beneficiary will continue to choose to receive primary care or other services from practitioners participating in an ACO.
We note that a similar manual process for sending letters to beneficiaries to provide them notice of their opportunity to opt out of claims data sharing was removed from the Shared Savings Program in the June 2015 final rule (see 80 FR 32743). This data sharing opt out process was removed because it was resource intensive and cumbersome for ACOs and CMS, and was confusing for beneficiaries. Instead, based on stakeholder comments, we finalized a process to provide beneficiaries the opportunity to decline claims data sharing directly by contacting the Medicare program (through 1-800-MEDICARE) rather than through the ACO. This more direct process started at the end of 2015 and so far appears to be working well, as it has not generated the number of complaints and concerns raised by the initial manual process.
In the CY 2017 PFS proposed rule, we proposed to incorporate beneficiary attestation into the assignment of beneficiaries to ACOs participating in the Shared Savings Program, to supplement and enhance the current claims-based algorithm driven methodology as described in more detail in this section of the final rule.
We indicated that we believed that it would be appropriate to implement, at a minimum, a voluntary alignment process under the Shared Savings Program that would be similar to the updated manual process we have implemented under the Pioneer ACO Model and that is used under the Next Generation ACO Model. Supplementing the current claims-based assignment process with a voluntary alignment process that incorporates beneficiary attestation about their “main doctor” could help ACOs to increase patient engagement, improve care management and health outcomes, and lower expenditures for beneficiaries, while also helping to assure that beneficiaries are assigned to ACOs based on their relationship with providers that they believe to be truly responsible for their overall care. However, based on the valuable knowledge and experience we have gained through these Innovation Center models, we also expressed our concern that the manual voluntary alignment process used for the Pioneer ACO Model and that is used under the Next Generation ACO Model is resource intensive for both ACOs and CMS.
Because of the limitations of the manual process, we proposed to implement an automated approach under which we could determine which healthcare provider a FFS beneficiary believes is responsible for coordinating their overall care (their “main doctor”) using information that is collected in an automated and standardized way directly from beneficiaries (through a system established by us, such as
We proposed to make such an automated mechanism available for beneficiaries to voluntarily align with the provider or supplier that they believe is responsible for coordinating their overall care starting early in 2017, making it possible for us to use beneficiary attestations for assigning beneficiaries to ACOs in all three tracks for the 2018 performance year. We indicated that voluntary alignment data would be accessed and incorporated in the beneficiary assignment process each time we run the assignment algorithm. Under the automated approach, beneficiaries would be able to change their attestation about their “main doctor” at any time; however, we noted there may be a lag in using the information to update an ACO's assignment list depending on the timing of the beneficiary's updated designation and the track under which the ACO is participating. For example, as described in more detail in the CY 2017 PFS proposed rule, we proposed for Track 3 to incorporate the beneficiary's designation annually prior to the start of the performance year at the time beneficiaries are prospectively assigned for that performance year.
Further, we proposed to incorporate voluntary alignment for ACOs in Tracks 1 and 2 on a quarterly basis. We stated that we believe this policy would be appropriate because it aligns with the current timing for updates to Track 1 and 2 ACO assignment lists. We also proposed that if a beneficiary voluntarily aligns with a provider or supplier whose services would be considered in assignment but who is not participating in an ACO as an ACO professional, the beneficiary would not be eligible for alignment to an ACO, even if the beneficiary would have otherwise been assigned to an ACO under our claims-based approach.
We further proposed that, if an automated voluntary alignment process is not operationally ready for implementation by spring 2017, we would implement a manual voluntary alignment process for Track 3 ACOs only that builds upon experience previously gained under the Pioneer ACO Model. We explained our view that it would be appropriate to initially limit the manual process to ACOs participating in the Shared Savings Program under Track 3 because the process and timing for sending letters to beneficiaries regarding voluntary alignment under the manual process was developed specifically for prospective alignment under the Pioneer and Next Generation ACO Models and for a limited number of ACOs. We indicated that we believe implementing such a manual process for the hundreds of ACOs in Track 1 and Track 2 whose beneficiaries are preliminarily prospectively assigned with retrospective reconciliation would result in operational challenges for ACOs and CMS and could have unintended consequences that could be confusing or harmful to beneficiaries. We therefore proposed that if an automated process is not available to allow beneficiaries to designate their primary healthcare provider in time for the information to be considered for beneficiary assignment for PY 2018, we would implement an alternative manual voluntary alignment process (similar to the updated process used under the Pioneer ACO Model and described in more detail in the CY 2017 PFS proposed rule) to allow beneficiaries to align with Track 3 ACOs for the 2018 performance year and until such time as an automated process is available.
Regardless of process (manual or automatic), we proposed to begin to incorporate beneficiary attestation into the assignment methodology for the Shared Savings Program, effective for assignment for the 2018 performance year. In brief, under the proposal, an eligible beneficiary would be assigned to an ACO based on the existing claims-based assignment process unless the beneficiary has designated a primary care physician as defined at § 425.20, a physician with a specialty designation included at paragraph (c) of § 425.402, or a nurse practitioner, physician
We stated that to maintain flexibility for ACOs, ACO participants, ACO providers/suppliers, ACO professionals, beneficiaries, and CMS, we would intend to provide further operational details regarding the voluntary alignment process and the applicable implementation timelines through subregulatory guidance and other outreach activities.
We solicited comments on this proposal, on the effective date, and on any other related issues that we should consider for the final rule to address issues related to voluntary alignment under the Shared Savings Program. In particular, we solicited comment on a variety of topics such as whether voluntary alignment is an appropriate mechanism for assigning beneficiaries retrospectively to an ACO, whether ACOs should be permitted to opt into or out of voluntary alignment, and whether we should exclude a beneficiary from an ACO's prospective assignment list for a performance year if later during the performance year the beneficiary voluntarily aligns with a healthcare provider that is not an ACO professional in the ACO. We also solicited input on how concerns about ACO avoidance of at risk beneficiaries might be addressed.
We also noted that under the proposed automated voluntary alignment process, a beneficiary's designation of a healthcare provider as responsible for coordinating their overall care would stay in effect until the beneficiary chose to make a subsequent change. We indicated that under the proposal we would rely on appropriate information shared with beneficiaries at the point of care to ensure the beneficiary's designation is kept up to date. We solicited comment on this issue and our proposal under the automated system to continue to use a beneficiary's designation of the healthcare provider responsible for coordinating their overall care until it is changed.
We also welcomed suggestions regarding the operational process, implementation timelines, and related issues regarding the process for beneficiaries to voluntarily align with an ACO, including how to strengthen ACOs' beneficiary engagement activities. We noted that although we proposed to establish a process under which beneficiaries may designate their “main doctor” who they consider responsible for coordinating their overall care, in establishing the operational processes for allowing beneficiaries to designate their “main doctor” we may not explicitly use the phrase “responsible for coordinating overall care” which we included in the proposed provision at § 425.402(e). Instead, we indicated that we may consider using other terminology based on focus group testing and/or other feedback from beneficiary representatives. We welcomed comments on what terminology would be preferable to ensure beneficiaries understand the significance of designating a provider or supplier as responsible for coordinating their overall care. We indicated we would consider such suggestions further as we develop program guidance and outreach activities for beneficiaries and ACOs.
The following is a summary of the comments we received regarding voluntary alignment under the Shared Savings Program.
Another commenter suggested there are many times where for a particular year the current claims-based assignment algorithm may not be an accurate reflection of the beneficiary's wishes and normal care pattern. Examples provided by this commenter of when the current algorithm could lead to inappropriate attribution were in cases where a beneficiary is dealing with an acute illness or condition requiring specialized evaluation and management services, is experiencing an extended time away from a primary residence, is a low health care utilizer where a single service plays a big role in determining the plurality of primary care services, or is switching primary care physicians when entering a skilled nursing facility (SNF). Commenters indicated that allowing beneficiaries to attest to the provider they believe is managing their care may also help increase beneficiary engagement in that care. A number of commenters expressed support for the proposal to exclude from alignment to an ACO any beneficiaries who voluntarily align with a healthcare provider who is not an ACO professional, as that respects the beneficiary's preference.
Another commenter expressed concerns that voluntary alignment under a retrospective assignment methodology (Tracks 1 and 2) could increase adverse incentives for ACOs to selectively encourage some beneficiaries
In brief, if a beneficiary designates an ACO professional that they believe is responsible for coordinating their overall care as their “main doctor”, the beneficiary will be assigned to the ACO in which that ACO professional is participating, as long as the ACO professional's specialty is used in assignment and the beneficiary has received at least one primary care service from a physician in that ACO and does not meet the criteria for exclusion. If these criteria are met, the beneficiary's selection of his or her “main doctor” and, ultimately, assignment to the ACO would take precedence over any assignment to an ACO based on claims. For example, if a beneficiary selects a physician in ACO 1 as his or her main doctor, the beneficiary's designation would take precedence over claims-based assignment, as long as the physician's specialty is used in assignment and the beneficiary received a primary care service from a physician in ACO 1. This will be the case even if the beneficiary would have otherwise been assigned to ACO 2 through claims-based assignment.
However, if a beneficiary designates a physician or practitioner in an ACO and the conditions for assignment are not met, then the claims-based assignment methodology will be used to determine the beneficiary's assignment. For example, if a beneficiary designates a physician in ACO 1, he or she could not be assigned to ACO 1 based on the attestation if he or she did not receive at least one primary care service from a physician in ACO 1. Similarly, if a beneficiary designates an ACO professional in ACO 1 whose services are not used in assignment, the claims-based assignment methodology would be used to determine whether the beneficiary will be assigned to ACO 1, another ACO, or to no ACE. Relatedly, if a beneficiary designates a practitioner with a specialty used in assignment and the practitioner is not affiliated with an ACO, then the beneficiary will not be eligible for assignment to an ACO, even if the beneficiary would have otherwise been assigned to an ACO through claims-based assignment.
Finally, we also clarify that consistent with § 425.400(a)(1), the assignment methodology described under § 425.402 also applies to benchmarking years. Accordingly, when determining beneficiary assignment for a benchmark year, we will incorporate beneficiary designations that were in place during the assignment window for the benchmarking year.
• We no longer intend to develop a manual voluntary alignment process as an alternative for ACOs participating in Track 3 in the event an automated process is not ready for performance year 2018, and instead will focus on developing and implementing an automated voluntary alignment process with the intent of incorporating beneficiary designations into the current claims-based assignment algorithm beginning with the 2018 performance year. If an automated system is not available during the assignment window for the 2018 performance year, then voluntary alignment would not be used for performance year 2018.
• We are modifying our proposed policy to incorporate new or revised beneficiary attestations and align such beneficiaries to ACOs in Tracks 1 and 2 on a quarterly basis and instead will incorporate these updates and align such beneficiaries prospectively for all tracks at the beginning of each performance and benchmark year, provided the beneficiary is eligible for assignment to the ACO in which their designated “main doctor” is participating.
• We are modifying § 425.402, paragraph (b), by removing the phrase “beneficiaries to an ACO:” and adding in its place the phrase “beneficiaries to an ACO based on available claims information.” This revision is necessary to ensure understanding that the procedure described under paragraph (b) is based on claims data, not on other data that may be available (such as voluntary alignment data).
We are also revising the regulations governing the assignment methodology to amend § 425.402(b) and add a new paragraph (e) to § 425.402. Beginning in performance year 2018, if a system is available to allow beneficiaries to designate a provider or supplier as responsible for coordinating their overall care and for CMS to process the designation electronically, beneficiaries that have voluntarily aligned with an ACO by designating an ACO professional whose services are used in assignment as responsible for coordinating their overall care will be added to the ACO's list of assigned beneficiaries, for a benchmark or performance year under the following conditions:
• The beneficiary must have had at least one primary care service during the assignment window as defined under § 425.20 with a physician who is an ACO professional in the ACO and who is a primary care physician as defined under § 425.20 of this subpart or who has one of the primary specialty designations included in § 425.402(c).
• The beneficiary must meet the assignment eligibility criteria established in § 425.401(a), and must not be excluded by the criteria at § 425.401(b). Such exclusion criteria shall apply to all tracks for purposes of alignment based on beneficiary designation information.
• The beneficiary must have designated an ACO professional who is a primary care physician as defined at § 425.20 of this part, a physician with a specialty designation included at § 425.402(c) of this subpart, or a nurse practitioner, physician assistant, or clinical nurse specialist as responsible for their overall care.
• The designation must be made in the form and manner and by a deadline determined by CMS.
In contrast, if a beneficiary designates a provider or supplier outside the ACO, who is a primary care physician as defined at § 425.20 of this part, a physician with a specialty designation included at § 425.402(c), or a nurse practitioner, physician assistant, or clinical nurse specialist, as responsible for coordinating their overall care, the beneficiary will not be added to the ACO's list of assigned beneficiaries for a performance year or benchmark year, even if the beneficiary would otherwise be included in the ACO's assigned beneficiary population under the assignment methodology in § 425.402(b).
Further, we are finalizing our proposal that the ACO and its ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions or services related to ACO activities are prohibited from providing or offering gifts or other remuneration to Medicare beneficiaries as inducements to influence a Medicare beneficiary's decision to designate or not designate an ACO professional under § 425.402(e). The ACO, ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions or services related to ACO activities must not directly or indirectly, commit any act or omission, nor adopt any policy that coerces or otherwise influences a Medicare beneficiary's decision to designate or not designate an ACO professional as responsible for coordinating their overall care, including but not limited to the following:
• Offering anything of value to the Medicare beneficiary as an inducement to influence the Medicare beneficiary's decision to designate or not to designate an ACO professional as responsible for coordinating their overall care. Any items or services provided in violation of this prohibition will not be considered to have a reasonable connection to the medical care of the beneficiary, as required under § 425.304(a)(2).
• Withholding or threatening to withhold medical services or limiting or threatening to limit access to care.
We will provide further operational details regarding the voluntary alignment process and the applicable
The Medicare SNF benefit is for beneficiaries who require a short-term intensive stay in a SNF, requiring skilled nursing, or skilled rehabilitation care, or both. Under section 1861(i) of the Act, beneficiaries must have a prior inpatient hospital stay of no fewer than 3 consecutive days in order to be eligible for Medicare coverage of inpatient SNF care. In the June 2015 final rule (80 FR 32804 through 32806), we provided ACOs participating in Track 3 with additional flexibility to attempt to increase quality and decrease costs by allowing these ACOs to apply for a waiver of the SNF 3-day rule for their prospectively assigned beneficiaries when they are admitted to certain “SNF affiliates,” that is, SNFs with whom the ACO has executed SNF affiliate agreements. (See § 425.612(a)(1)). Waivers are effective upon CMS notification of approval for the waiver or the start date of the ACO's participation agreement, whichever is later. (See § 425.612(c)). We stated in the June 2015 final rule that the SNF 3-day rule waiver would be effective for services furnished on or after January 1, 2017. Program requirements for this waiver are codified at § 425.612. These requirements are primarily based on criteria previously developed under the Pioneer ACO Model. Specifically, under § 425.612(a)(1), we waive the requirement in section 1861(i) of the Act for a 3-day inpatient hospital stay prior to a Medicare covered post-hospital extended care service for eligible beneficiaries prospectively assigned to ACOs participating in Track 3 that have been approved to implement the waiver that receive otherwise covered post-hospital extended care services furnished by an eligible SNF that has entered into a written agreement to partner with the ACO for purposes of this waiver. All other provisions of the statute and regulations regarding Medicare Part A post-hospital extended care services continue to apply.
We believe that clarity regarding whether a waiver applies to SNF services furnished to a particular beneficiary is important to help ensure compliance with the conditions of the waiver and also improve our ability to monitor waivers for misuse. Therefore, in the June 2015 final rule, we limited the waiver to ACOs in Track 3 because under the prospective assignment methodology used in Track 3, beneficiaries are assigned in advance to the ACO for the entire performance year (unless they meet any of the exclusion criteria under § 425.401(b) during the performance year), so it will be clearer to a Track 3 ACO whether the waiver applies to SNF services furnished to a particular beneficiary than it would be to an ACO in Track 1 or 2, where beneficiaries are assigned using a preliminary prospective assignment methodology with retrospective reconciliation (80 FR 32804). An ACO's use of the SNF 3-day rule waiver will be associated with a distinct and easily identifiable event, specifically, admission of a prospectively assigned beneficiary to a previously identified SNF affiliate without prior inpatient hospitalization or after an inpatient hospitalization of fewer than 3 days.
Based on our experiences under the Pioneer ACO Model, and in response to comments, we established certain requirements under § 425.612 for ACOs, ACO providers/suppliers, SNF affiliates, and beneficiaries with respect to the SNF 3-day rule waiver under the Shared Savings Program. All ACOs electing to participate in Track 3 will be offered the opportunity to apply for a waiver of the SNF 3-day rule for their prospectively assigned beneficiaries at the time of their initial application to participate in Track 3 of the program and annually thereafter while participating in Track 3. We began accepting the first SNF 3-day rule waiver applications from Track 3 ACOs this past summer.
To be eligible to receive covered services under the SNF 3-day rule waiver, a beneficiary must be prospectively assigned to the ACO for the performance year in which he or she is admitted to the SNF affiliate, may not reside in a SNF or other long-term care setting, must be medically stable and have an identified skilled nursing or rehabilitation need that cannot be provided as an outpatient, and must meet the other requirements set forth at § 425.612(a)(1)(ii).
For a SNF to be eligible to partner with ACOs for purposes of the waiver, the SNF must have an overall quality rating of 3 or more stars under the CMS 5 Star Quality Rating System, and must sign a written agreement with the ACO, which we refer to as the “SNF affiliate agreement,” that includes elements determined by CMS, including: A clear indication of the effective dates of the SNF affiliate agreement; agreement to comply with Shared Savings Program rules, including but not limited to those specified in the participation agreement between the ACO and CMS; agreement to validate beneficiary eligibility to receive covered SNF services under the waiver prior to admission; remedial processes and penalties for noncompliance with the terms of the waiver, and other requirements set forth at § 425.612(a)(1)(iii). The SNF affiliate agreement must include these elements to ensure that the SNF affiliate understands its responsibilities related to implementation of the SNF 3-day rule waiver.
We indicated in the June 2015 final rule that the SNF 3-day rule waiver would be effective no earlier than January 1, 2017; thereafter, the waiver will be effective upon CMS notification to the ACO of approval for the waiver or the start date of the ACO's participation agreement, whichever is later, and will not extend beyond the term of the ACO's participation agreement.
We also indicated in the June 2015 final rule that we established the timeline for implementation of the SNF 3-day rule waiver to allow for development of additional subregulatory guidance, including necessary education and outreach for ACOs, ACO participants, ACO providers/suppliers, and SNF affiliates. We noted that we would continue to evaluate the waiver of the SNF 3-day rule, including further lessons learned from Innovation Center models in which a waiver of the SNF 3-day rule is being tested. We indicated that in the event we determined that additional safeguards or protections for beneficiaries or other changes were necessary, such as to incorporate additional protections for beneficiaries into the ACO's participation agreement or SNF affiliate agreements, we would propose the necessary changes through future rulemaking.
In considering additional beneficiary protections that may be necessary to ensure proper use of the SNF 3-day rule waiver under the Shared Savings Program, we note that there are existing, well established payment and coverage policies for SNF services based on sections 1861(i), 1862(a)(1), and 1879 of the Act that include protections for beneficiaries from liability for certain non-covered SNF charges. These existing payment and coverage policies for SNF services continue to apply to SNF services furnished to beneficiaries assigned to ACOs participating in the Shared Savings Program, including services furnished pursuant to the SNF 3-day rule waiver. (For example, see the Medicare Claims Processing Manual, Chapter 30—Financial Liability Protections, section 70, available at
Since publication of the June 2015 final rule, we have continued to learn from implementation and refinement of the SNF 3-day rule waiver in the Pioneer ACO Model (see
First, one example of a scenario under which a beneficiary may be at financial risk relates to the quarterly exclusions from a Track 3 ACO's prospective assignment list. For example, assume a beneficiary was prospectively assigned to a Track 3 ACO that has been approved for the SNF 3-day rule waiver (a waiver-approved ACO), but during the first quarter of the year, the beneficiary's Part B coverage terminated and the beneficiary is therefore no longer eligible to be assigned to the ACO. As a result, the beneficiary would be excluded from the ACO's prospective assignment list because the beneficiary meets one or more of the exclusion criteria specified at § 425.401(b). That is, although SNF services are covered under Part A, not Part B, the beneficiary would be dropped from the ACO's prospective assignment list if during the performance year the beneficiary is no longer enrolled in Part B and thus no longer eligible to be assigned to the ACO. We are concerned about some very limited situations, such as when a beneficiary's Part B coverage terminates during a quarter when the beneficiary is also receiving SNF services. The beneficiary may be admitted to a SNF without a prior 3-day inpatient hospital stay after his or her Part B coverage ended, but before the beneficiary appears on a quarterly exclusion list. It is not operationally feasible for CMS to notify the ACO and for the ACO, in turn, to notify its SNF affiliates, ACO participants, and ACO providers/suppliers immediately of the beneficiary's exclusion. The lag in communication may then cause the SNF affiliate to unknowingly admit a beneficiary who no longer qualifies for the waiver without a prior 3-day inpatient hospital stay. Absent specific beneficiary protections, we are concerned that the beneficiary could be charged for such non-covered SNF services. We do not believe it would be appropriate for CMS to hold the beneficiary or the SNF affiliate financially liable for such services. We believe we should allow for a reasonable amount of time for CMS to communicate beneficiary exclusions to an ACO and for the ACO to communicate the exclusions to its SNF affiliates, ACO participants, and ACO providers/suppliers. Typically there would be no way for the SNF affiliate to verify in real-time that a beneficiary continues to be prospectively assigned to the ACO; the SNF affiliate must rely upon the assignment list and quarterly exclusion lists provided by CMS to the ACO and communicated by the ACO to its SNF affiliates, ACO participants, and ACO providers/suppliers. Further, the beneficiary does not receive a notification regarding his or her eligibility for the SNF 3-day rule waiver prior to receiving SNF services under the waiver, so beneficiaries are not able to check their own eligibility.
To address delays in communicating beneficiary exclusions from the prospective assignment list, the Pioneer ACO Model and Next Generation ACO Model provide for a 90-day grace period that functionally acts as an extension of beneficiary eligibility for the SNF 3-day rule waiver and permits some additional time for the ACO to receive quarterly exclusions lists from CMS and communicate beneficiary exclusions to its SNF affiliates. In the proposed rule, we stated that we believe it would be appropriate, in order to protect beneficiaries from potential financial liability related to the SNF 3-day rule waiver under the Shared Savings Program, to establish a similar 90-day grace period in the case of a beneficiary who was prospectively assigned to a waiver-approved ACO at the beginning of the performance year but is later excluded from assignment to the ACO.
Therefore, we explained that we believe it is necessary for purposes of carrying out the Shared Savings Program to allow formerly assigned beneficiaries to receive covered SNF services under the SNF 3-day rule waiver when the beneficiary is admitted to a SNF affiliate within a 90-day grace period following the date that CMS delivers the quarterly beneficiary exclusion list to an ACO. The equitable and efficient implementation of the SNF 3-day rule waiver is necessary to further support ACOs' efforts to increase quality and decrease costs under two-sided performance-based risk arrangements. (See 80 FR 32804 for a detailed discussion of the rationale for establishing the SNF 3-day rule waiver.) Based upon the experience in the Pioneer ACO Model, we believe it is not possible to adopt such a waiver without providing some protection for certain beneficiaries who were prospectively assigned to the ACO at the start of the year, but are subsequently excluded from assignment. Accordingly, we proposed to modify the waiver to include a 90-day grace period to allow sufficient time for CMS to notify the ACO of any beneficiary exclusions, and for the ACO then to inform its SNF affiliates, ACO participants, and ACO providers/suppliers of those exclusions.
More specifically, we proposed to modify the waiver under § 425.612(a)(1) to include a 90-day grace period that would permit payment for SNF services provided to beneficiaries who were initially on the ACO's prospective assignment list for a performance year but were subsequently excluded during the performance year. CMS would make payments for SNF services furnished to such a beneficiary under the terms of the SNF 3-day rule waiver if the following conditions are met:
• The beneficiary was prospectively assigned to a waiver-approved ACO at the beginning of the performance year
• The SNF affiliate services are furnished to a beneficiary admitted to the SNF affiliate within 90 days following the date that we deliver the quarterly exclusion list to the ACO.
• We would have otherwise made payment to the SNF affiliate for the services under the SNF 3-day rule waiver, but for the beneficiary's exclusion from the waiver-approved ACO's prospective assignment list.
We further noted that we anticipate that there would be very few instances where it would be appropriate for SNF services to qualify for payment under this 90-day grace period. This is because this waiver only allows for payment for claims that meet all applicable requirements except the requirement for a prior 3-day inpatient hospital stay. For example, assume that a beneficiary who had been assigned to a waiver-approved ACO was admitted to a SNF without a prior 3-day inpatient hospital stay after his or her enrollment in an MA Plan, but before the beneficiary appears on a quarterly exclusion list. In this case, these SNF services would not be covered under FFS because the waiver does not expand coverage to include services furnished to Medicare beneficiaries enrolled in MA Plans. Both beneficiaries and healthcare providers are expected to know that the beneficiary is covered under an MA plan and not FFS Medicare.
Second, we are concerned that there could be other more likely scenarios where a beneficiary could be charged for non-covered SNF services that were a result of an ACO's or SNF's inappropriate use of the SNF 3-day rule waiver. Specifically, we are concerned that a beneficiary could be charged for non-covered SNF services if a SNF affiliate were to admit a FFS beneficiary who is not prospectively assigned to the waiver-approved ACO, and payment for SNF services is denied for lack of a qualifying inpatient hospital stay.
We believe this situation could occur as a result of a breakdown in one or more of processes the ACO and SNF affiliate are required to have in place to implement the waiver. For example, the SNF affiliate and the admitting ACO provider/supplier may not verify that the beneficiary appears on the ACO's prospective assignment list prior to admission, as required under the SNF 3-day rule waiver (§ 425.612(a)(1)(iii)(B)(4)) and the terms of the SNF's affiliate agreement with the ACO. In this scenario, Medicare would deny payment of the SNF claim under existing FFS rules because the beneficiary did not have a qualifying inpatient hospital stay. We are concerned that, once the claim is rejected, the beneficiary may not be protected from financial liability, and thus could be charged by the SNF affiliate for these non-covered SNF services that were a result of an inappropriate attempt to use the waiver, potentially subjecting the beneficiary to significant financial liability. However, in this scenario, a SNF with a relationship to the ACO submitted the claim that was rejected for lack of a qualifying inpatient hospital stay, but that otherwise would have been paid by Medicare. In this circumstance, we proposed to assume the SNF's intent was to rely upon the SNF 3-day rule waiver, but the waiver requirements were not met. We believe it is reasonable to assume the SNF's intent was to use the SNF 3-day rule waiver because, as a SNF affiliate, the SNF should be well aware of the ability to use the SNF 3-day rule waiver and, by submitting the claim, demonstrated an expectation that CMS would pay for SNF services that would otherwise have been rejected for lack of a 3-day inpatient hospital stay. We believe that in this scenario, the rejection of the claim under the SNF 3-day rule waiver could easily have been avoided if the ACO, the admitting ACO provider/supplier, and the SNF affiliate had confirmed that the requirements for use of the SNF 3-day rule waiver were satisfied. Because each of these entities is in a better position to know the requirements of the waiver and ensure that they are met than the beneficiary is, we believe that the ACO and/or the SNF affiliate should be accountable for such rejections and the SNF affiliate should be prevented from attempting to charge the beneficiary for the non-covered SNF stay.
To address situations similar to this scenario where the beneficiary may be subject to financial liability due to an eligible SNF submitting a claim that is not paid only as a result of the lack of a qualifying inpatient hospital stay, the Next Generation ACO Model generally places the financial responsibility on the SNF, where the SNF knew or reasonably could be expected to have known that payment would not be made for the non-covered SNF services. In such cases, CMS makes no payment for the services and the SNF may not charge the beneficiary for the services and must return any monies collected from the beneficiary. Additionally, under the Next Generation ACO Model, the ACO must indemnify and hold the beneficiary harmless for payment for the services. We believe it is appropriate to propose to adopt a similar policy under the Shared Savings Program because, under § 425.612(a)(1)(iii)(B), to be a SNF affiliate, a SNF must agree to validate the eligibility of a beneficiary to receive covered SNF services in accordance with the waiver prior to admission to the SNF, and otherwise comply with the requirements and conditions of the Shared Savings Program. SNF affiliates are required to be familiar with the SNF 3-day rule and the terms and conditions of the SNF 3-day rule waiver for the Shared Savings Program, and should know to verify that a FFS Medicare beneficiary who is a candidate for admission has completed a qualifying hospital stay or that the admission meets the criteria under a waiver of the SNF 3-day rule that is properly in place. Additionally, ACOs and their SNF affiliates are required to develop plans that will govern communication and beneficiary evaluation and admission prior to use of the SNF 3-day rule waiver. In these circumstances, we believe it is reasonable that the ultimate responsibility and liability for a non-covered SNF admission should rest with the admitting SNF affiliate.
Therefore, to protect FFS beneficiaries from being charged in certain circumstances for non-covered SNF services related to the waiver of the SNF 3-day rule under the Shared Savings Program, potentially subjecting such beneficiaries to significant financial liability, we proposed to add certain beneficiary protection requirements in § 425.612(a)(1). These requirements would apply to SNF services furnished by a SNF affiliate that would otherwise have been covered except for the lack of a qualifying hospital stay preceding the admission to the SNF affiliate. Specifically, we proposed that we would make no payment to the SNF, and the SNF may not charge the beneficiary for the non-covered SNF services, in the event that a SNF that is a SNF affiliate of a Track 3 ACO that has been approved for the SNF 3-day rule waiver admits a FFS beneficiary who was never prospectively assigned to the waiver-approved ACO (or was assigned but later excluded and the 90 day grace period has lapsed), and the claim is rejected only for lack of a qualifying inpatient hospital stay.
In this situation, we proposed that we would apply the following rules:
• We would make no payment to the SNF affiliate for such services.
• The SNF affiliate must not charge the beneficiary for the expenses incurred for such services, and the SNF affiliate must return to the beneficiary any monies collected for such services.
• The ACO may be required to submit a corrective action plan to CMS for approval as specified at § 425.216(b) addressing what actions the ACO will take to ensure that the SNF 3-day rule waiver is not misused in the future. If after being given an opportunity to act upon the corrective action plan the ACO fails to come into compliance, approval to use the waiver will be terminated in accordance with § 425.612(d). We noted that in accordance with our existing program rules at §§ 425.216 and 425.218, CMS retains the authority to take corrective action, including terminating an ACO for non-compliance with program rules. A misuse of a waiver under § 425.612 would constitute non-compliance with program rules. Accordingly, we proposed to codify at new provision at § 425.612(d)(4) providing that misuse of a waiver under § 425.612 may result in CMS taking remedial action against the ACO under §§ 425.216 and 425.218, up to and including termination of the ACO from the Shared Savings Program.
We proposed that if the SNF submitting the claim is a SNF affiliate of a waiver-approved ACO, and the only reason for the rejection of the claim is lack of a qualifying inpatient hospital stay, then CMS would assume the SNF intended to rely upon the SNF 3-day rule waiver. We would not assume the SNF intended to rely upon the SNF 3-day rule waiver if the SNF is not a SNF affiliate of a waiver-approved ACO because the waiver is not available to SNFs more broadly. We explained that we believe intended reliance on the waiver is an important factor in determining whether the proposed additional beneficiary protections should apply. Outside the context of an intent to rely on the SNF 3-day rule waiver, we do not believe it would be necessary to include additional beneficiary protections under the Shared Savings Program because there is no reason for either the beneficiary or the SNF to expect that different coverage rules would apply to SNF services. In these other situations, the beneficiary protections generally applicable under traditional FFS Medicare, noted earlier in this section, continue to apply.
We solicited comments on these proposals. We noted that under our proposed beneficiary protection provision, a SNF affiliate would be prohibited from charging a beneficiary for non-covered SNF services even in cases where the beneficiary explicitly requested or agreed to being admitted to the SNF in the absence of a qualifying 3-day hospital stay if all other requirements for coverage are met. We therefore specifically solicited comment on whether it is reasonable to hold SNFs that are SNF affiliates responsible for all claims that are rejected solely as a result of lack of a qualifying inpatient hospital stay. We also solicited comment on whether the ACO rather than or in addition to the SNF affiliate, should be held liable for such claims and under what circumstances. We also solicited comment on our proposal to modify the waiver under § 425.612(a)(1) to include a 90-day grace period for beneficiaries prospectively assigned to a waiver-approved ACO at the start of the performance year but later excluded. We solicited comment on the proposed length of the grace period, and in particular whether the grace period should be less than 90 days, given our expectation that ACOs will share the quarterly beneficiary exclusion lists with their SNF affiliates, ACO participants, and ACO providers/suppliers in a timely manner. Finally, we solicited comment on any other related issues that we should consider in connection with these proposals to protect beneficiaries from significant financial liability for non-covered SNF services related to the waiver of the SNF 3-day rule under the Shared Savings Program.
The following is a summary of the comments we received on these proposals.
Further, we do not believe that it is necessary to include the suggested additional requirements for SNF affiliate agreements. The current requirements provide SNFs with the flexibility to address, in their SNF affiliate agreements with Track 3 ACOs, any concerns they may have about the processes used by ACOs to communicate which beneficiaries are eligible to receive covered SNF services under the waiver.
ACOs must create and implement a communication plan between the ACO and all of its SNF affiliates as required at § 425.612(a)(1)(i)(A)(1). In accordance with our SNF waiver guidance on the CMS Web site at
ACOs are also required to establish a beneficiary evaluation and admission plan for beneficiaries admitted to a SNF affiliate under the SNF 3-day rule waiver that is approved by the ACO medical director and the healthcare professional responsible for the ACO's quality improvement and assurance processes under § 425.112. Further, as part of their waiver application, ACOs are required to describe how they plan to evaluate and periodically update their plan (see section 6 of the guidance at
We believe these requirements adequately address the commenter's concerns about SNF affiliates' ability to verify beneficiaries' eligibility to receive covered SNF services under the SNF 3-day rule waiver. However, as we develop operational procedures and guidance documents, we will further consider whether it would be feasible to develop a mechanism that could permit SNF affiliates to verify, though a source other than the ACO, a beneficiary's eligibility to receive SNF services under the waiver.
We strongly believe it is important to ensure that beneficiaries have appropriate financial protections, including financial protection against misuse of the waiver prior to approving any SNF 3-day rule waiver applications from Track 3 ACOs. We also recognize that ACOs and their SNF affiliates could be reluctant to enter into a SNF affiliate agreement without there being clarity as to their potential responsibility for non-covered SNF services related to the waiver. For these reasons, we are also developing a process for Track 3 ACOs that have already applied for the SNF 3-day rule waiver for the 2017 performance year to confirm that they and their SNF affiliates agree to comply with all requirements related to the SNF 3-day rule waiver, including the new requirements we are adopting in this rulemaking. ACOs and SNF affiliates that do not agree to comply with all requirements will be ineligible to offer services under the SNF 3-day rule waiver. We note that this confirmation process may delay approval of ACOs' applications for the SNF 3-day rule waiver for the 2017 performance year; however, we do not anticipate approval will be delayed beyond the first quarter of 2017.
Section 1899(b)(2)(D) of the Act includes a requirement that a participating ACO must have a minimum of 5,000 Medicare FFS beneficiaries assigned to it. Currently, the regulations at § 425.110(b) indicate that if at any time during the performance year, an ACO's assigned population falls below 5,000, the ACO may be subject to the actions described in §§ 425.216 and 425.218; the regulations further indicate at § 425.110(b)(1) that while under a CAP, the ACO remains eligible for shared savings and losses and the MSR and MLR (if applicable) is set at a level consistent with the number of assigned beneficiaries. We have applied this rule in the past to perform financial reconciliation for ACOs that fell below 5,000 assigned beneficiaries. In these cases, the ACO was subject to a CAP and financial reconciliation was based on a variable MSR/MLR that was determined by the number of assigned beneficiaries. For example, we have calculated the ACO's MSR based on an expanded sliding scale that includes a range of 3,000 to 4,999 assigned beneficiaries with a corresponding MSR range of 5.0 to 3.9 percent.
However, ACOs under risk-based tracks are not limited to financial reconciliation under a variable MSR/MLR that is based on the number of assigned beneficiaries. In the June 2015 final rule (see 80 FR 32769-32771, and 32779-32780), we finalized a policy that provides ACOs under two-sided performance-based risk tracks with an opportunity to choose among several options for establishing their MSR/MLR. In addition to being able to choose a symmetrical MSR/MLR that varies based on the ACO's number of assigned beneficiaries, ACOs under two-sided performance-based risk tracks can also choose from a menu of non-variable MSR/MLR options (either a 0 percent MSR/MLR or a symmetrical MSR/MLR in a 0.5 percent increment between 0.5 through 2.0 percent).
We stated in the CY 2017 PFS proposed rule that we believe it is important to clarify the policy regarding situations where an ACO under a two-sided performance-based risk track has chosen a non-variable MSR/MLR at the start of the agreement period but has fallen below 5,000 assigned beneficiaries at the time of financial reconciliation. As discussed in detail in the June 2015 final rule, we continue to believe that ACOs under two-sided performance-based risk tracks are best positioned to determine the level of risk that they are prepared to accept. Therefore, we proposed to update the regulations at § 425.110(b)(1) to be consistent with the regulatory changes in the June 2015 final rule that permit ACOs under a two-sided performance-based risk track (Track 2 and Track 3) to choose their own MSR/MLR from a menu of options. Specifically, we proposed to update the regulations at § 425.110(b)(1) to indicate that in the event an ACO falls below 5,000 assigned beneficiaries at the time of financial reconciliation, the ACO participating under a two-sided risk track will be eligible to share in savings (or losses) and the MSR/MLR will be set at a level consistent with the choice of MSR/MLR that the ACO made at the start of the agreement period. If the Track 2 or Track 3 ACO selected a symmetrical MSR/MLR option based on a fixed percentage (for example, zero percent or a percentage between 0.5 and 2 percent) regardless of ACO size, then the current methodology for use of a variable MSR/MLR based on the ACO's number of assigned beneficiaries would not apply. For example, if at the beginning of the agreement period the ACO chose a 1.0 percent MSR/MLR and the ACO's assigned population falls below 5,000, the MSR/MLR will remain 1.0 percent for purposes of financial reconciliation while the ACO is under a CAP. Further, as we noted in earlier rulemaking, if the ACO has elected a variable MSR/MLR, the methodology for calculating the variable MSR/MLR under a two-sided model is consistent with the methodology for calculating the variable MSR that is required under the under the one-sided model (Track 1) (see 80 FR 32769 through 32771; 32779 through 32780). Under the one-sided shared savings model (Track 1), we have accounted for circumstances where an ACO's number of assigned beneficiaries falls below 5,000, by expanding the variable MSR range based on input from the CMS Office of the Actuary (OACT). Thus, in the case where a Track 2 or Track 3 ACO selects a variable MSR/MLR based on its number of assigned beneficiaries, and the ACO's number of assigned beneficiaries falls below 5,000, we proposed to continue to use an approach for determining the MSR/MLR range consistent with the approach for calculating the MSR range under the one-sided model.
The following is a summary of the comments we received on these proposals.
Section 1899(d)(1)(B)(i) of the Act specifies that the Secretary shall determine the appropriate percent by which an ACO's expenditures must be lower than its benchmark in order for the ACO to be eligible to share in savings to account for normal variation in expenditures under Title XVIII. Consistent with the statute, this percentage must be based upon the number of Medicare fee-for-service beneficiaries assigned to the ACO. As explained in the November 2011 final rule, we believe that the most appropriate policy concerning determination of the “appropriate percent” for the MSR would achieve a balance between the advantages of making incentives and rewards available to successful ACOs and prudent stewardship of the Medicare Trust Funds (76 FR 67927). Capping the MSR for Track 1 ACOs would not be consistent with the statute and our established policy for computing the MSR for Track 1 ACOs. Capping only the MSR but not the MLR for Track 2 or 3 ACOs would create an asymmetry that would make it easier for the ACO to share in savings but not in losses. To the extent that the commenter was recommending capping both the MSR and MLR for ACOs in Tracks 2 and 3 that choose a variable MSR/MLR, we believe this could be an approach worthy of consideration in future rulemaking because the approach would equalize the risk for the ACO and CMS.
ACOs frequently request that we take into account the claims billed by the TINs of practices that have been acquired by sale or merger for the purpose of meeting the minimum assigned beneficiary threshold, establishing a more accurate financial benchmark, and determining the prospective or preliminary prospective assignment list for the upcoming performance year. In response to these inquiries, we initially developed subregulatory guidance that allowed claims billed under the TIN of a merged or acquired entity to be considered in certain circumstances. In that guidance we indicated that the merged or acquired entity's TIN may no longer be used to bill Medicare. In the June 2015 final rule, we codified the policies outlined in this guidance allowing for consideration of claims billed under merged or acquired entities' TINs for purposes of beneficiary assignment and establishing the ACO's benchmark, provided certain requirements were met (§§ 425.204(g), 425.118(a)(2)). However, the regulation at § 425.204(g) indicates that an ACO may request that CMS consider, for purposes of beneficiary assignment and establishing the ACO's benchmark under § 425.602, claims billed by “Medicare-enrolled” entities' TINs that have been acquired through sale or merger by an ACO participant. Because the regulation at § 425.204(g) refers to such merged or acquired TINs as “Medicare-enrolled,” we have received inquiries from ACOs regarding whether such merged or acquired TINs must continue to be Medicare-enrolled after the merger or acquisition has been completed and the TINs are no longer used to bill Medicare.
We stated in the CY 2017 PFS proposed rule that it was not our intent to establish such a requirement. We stated we do not believe there would be a program purpose to require the TIN of a merged or acquired entity to maintain Medicare enrollment if it is no longer used to bill Medicare. Therefore, to address this issue, we proposed a technical change to § 425.204(g) to clarify that the merged/acquired TIN is not required to remain Medicare enrolled after it has been merged or acquired and is no longer used to bill Medicare.
The following is a summary of the comments we received on these proposals.
Section 1848(p) of the Act requires that we establish a value-based payment modifier (VM) and apply it to specific physicians and groups of physicians the Secretary determines appropriate starting January 1, 2015, and to all physicians and groups of physicians by January 1, 2017. On or after January 1, 2017, section 1848(p)(7) of the Act provides the Secretary discretion to apply the VM to eligible professionals (EPs) as defined in section 1848(k)(3)(B) of the Act. Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral. The VM and Physician Feedback program continue CMS' initiative to recognize and reward clinicians based on the quality and cost of care provided to their patients, increase the transparency of health care quality information and to assist clinicians and beneficiaries in improving medical decision-making and health care delivery. As stated in the CY 2016 PFS final rule with comment period (80 FR 71277), the MACRA was enacted on April 16, 2015. Under section 1848(p)(4)(B)(iii) of the Act, as amended by section 101(b)(3) of MACRA, the VM shall not be applied to payments for items and services furnished on or after January 1, 2019. Section 1848(q) of the Act, as added by section 101(c) of MACRA, establishes the Merit-based Incentive Payment System (MIPS) that shall apply to payments for items and services furnished on or after January 1, 2019.
In the CY 2013 PFS final rule with comment period, we discussed the goals of the VM and also established that specific principles should govern the implementation of the VM (77 FR 69307). We refer readers to that rule for a detailed discussion. In the CY 2013 PFS final rule with comment period (77 FR 69310), we finalized policies to phase-in the VM by applying it beginning January 1, 2015, to Medicare PFS payments to physicians in groups of 100 or more EPs. A summary of the existing policies that we finalized for the CY 2015 VM can be found in the CY 2014 PFS proposed rule (78 FR 43486 through 43488). Subsequently, in the CY 2014 PFS final rule with comment period (78 FR 74765 through 74787), we finalized policies to continue the phase-in of the VM by applying it starting January 1, 2016, to payments under the Medicare PFS for physicians in groups of 10 or more EPs. Then, in the CY 2015
As a general summary, we proposed to update the VM informal review policies and establish how the quality and cost composites under the VM would be affected for the CY 2017 and CY 2018 payment adjustment periods in the event that unanticipated program issues arise.
Section 1848(p)(10) of the Act provides that there shall be no administrative or judicial review under section 1869 of the Act, section 1878 of the Act, or otherwise of the following:
• The establishment of the VM.
• The evaluation of the quality of care composite, including the establishment of appropriate measures of the quality of care.
• The evaluation of the cost composite, including the establishment of appropriate measures of costs.
• The dates of implementation of the VM.
• The specification of the initial performance period and any other performance period.
• The application of the VM.
• The determination of costs.
These statutory requirements regarding limitations of review are reflected in § 414.1280. We previously indicated in the CY 2013 PFS final rule with comment period (77 FR 69326) that we believed an informal review mechanism is appropriate for groups of physicians to review and to identify any possible errors prior to application of the VM, and we established an informal inquiry process at § 414.1285.
In the CY 2016 PFS final rule with comment period (80 FR 71294 through 71295), for the CY 2017 and CY 2018 payment adjustment periods, we finalized a deadline of 60 days that would start after the release of the QRURs for the applicable performance period for a group or solo practitioner to request a correction of a perceived error related to the VM calculation. We also finalized the continuation of the process for accepting requests from groups and solo practitioners to correct certain errors made by CMS or a third-party vendor (for example, PQRS-qualified registry). We stated we would continue the approach of the initial corrections process to classify a TIN as “average quality” in the event we determine a third-party vendor error or CMS made an error in the calculation of the quality composite and the infrastructure was not available to allow for recomputation of the quality measure data. Additionally, we finalized that we would reclassify a TIN as Category 1 when PQRS determines on informal review that at least 50 percent of the TIN's EPs meet the criteria to avoid the PQRS downward payment adjustment for the relevant payment adjustment year. If the group was initially classified as Category 2, then we would not expect to have data for calculating their quality composite, in which case they would be classified as “average quality”; however, if the data is available in a timely manner, then we would recalculate the quality composite.
As we noted in the CY 2017 PFS proposed rule (81 FR 46443 through 46444), as a result of issues that we became aware of prior to and during the CY 2016 VM informal review process, we learned that re-running QRURs and recalculating the quality composite is not always practical or possible, given the diversity and magnitude of the errors, timing of when we become aware of an error, and practical considerations in needing to compute a final VM upward payment adjustment factor after the performance period has ended, based on the aggregate amount of downward payment adjustments. Furthermore, this approach can create uncertainty for groups and solo practitioners about their final VM payment adjustment making it difficult for them to plan and make forecasts.
Due to the volume and complexities of the informal review issues, the inconsistency of available PQRS data to calculate a TIN's quality composite, the case-by-case nature of the informal review process, and the condensed timeline to calculate an accurate VM upward payment adjustment factor, we expressed our belief that we needed to update the VM informal review policies and establish in rulemaking how the quality and cost composites under the VM would be affected if unanticipated issues were to arise (for example, the program issues described in the CY 2017 PFS proposed rule), errors made by a third-party such as a vendor, or errors in our calculation of the quality and/or cost composites). We noted that the intent of these proposals is not to provide relief for EPs and groups who fail to report under PQRS, but rather to provide a mechanism for addressing unexpected issues such as the data integrity issues discussed in the proposed rule.
We further noted that limiting the potential movement of TINs between VM quality tiers based on informal review may result in a more accurate adjustment factor calculation and provide greater predictability for the CMS' Office of the Actuary (OACT) in making assumptions around the adjustment factor including assumptions around the impact of outstanding informal reviews at the time of the calculations. We expressed our belief that our proposals would help groups and solo practitioners to better predict the outcome of their final VM adjustment and reduce uncertainty as we continue to improve our systems. We requested comment on all four of the scenarios we proposed. We provide a combined summary of comments received on the four scenarios later in this section of this final rule, following the individual descriptions of the scenarios proposed.
Table 44 summarizes our proposals.
As finalized in the CY 2016 PFS final rule with comment period, for the CY 2017 VM, Category 1 will include those groups that meet the criteria to avoid the CY 2017 PQRS payment adjustment as a group practice participating in the PQRS Group Practice Reporting Option (GPRO) in CY 2015 and groups that have at least 50 percent of the group's EPs meet the criteria to avoid the CY 2017 PQRS payment adjustment as individuals (80 FR 71280). Category 1 also includes those solo practitioners that meet the criteria to avoid the CY 2017 PQRS payment adjustment as individuals. Category 2 will include groups and solo practitioners that are subject to the CY 2017 VM and do not fall within Category 1 (79 FR 67939). We finalized a similar two-category approach for the CY 2018 VM based on participation in the PQRS by groups and solo practitioners in 2016 (80 FR 71280 through 71281).
In the CY 2017 PFS proposed rule, we proposed that, if a TIN were initially classified as Category 2, and subsequently, through the PQRS or VM informal review process, it was reclassified as Category 1, then we would classify the TIN's quality composite as “average quality,” instead of attempting to calculate the quality composite (81 FR 46444). We also proposed to calculate the TIN's cost composite using the quality-tiering methodology. If the TIN were classified as “high cost” based on its performance on the cost measures, then we proposed to reclassify the TIN's cost composite as “average cost.” If the TIN were classified as “average cost” or “low cost”, then we proposed that the TIN would retain the calculated cost tier designation. We noted that in the CY 2016 PFS final rule with comment period (80 FR 71280), we finalized a policy for the CY 2017 and 2018 payment adjustment periods that when determining whether a group would be included in Category 1, we would consider whether the 50 percent threshold had been met, regardless of whether the group registered to participate in the PQRS GPRO for the relevant performance period. We expressed our belief that this policy would allow groups that register for a PQRS GPRO, but fail as a group to meet the criteria to avoid the PQRS payment adjustment an additional opportunity for the quality data reported by individual EPs in the group to be taken into account for the purposes of applying the VM. We noted that consequently, because of this policy we anticipate that the number of TINs who could fall into Scenario 1 would be minimal; however, we believe it is necessary to have a policy in place, in the event that CMS determines on informal review that Category 2 TINs had been negatively impacted by a third-party vendor error or CMS made an error in the calculation of the quality composite. We proposed to apply these policies for the CY 2017 VM and CY 2018 VM.
Calculating a quality composite for a TIN that was initially classified as Category 2, then reclassified as Category 1 during the informal review process would be operationally complex, given a number of factors: The timeline for determining and applying the VM adjustments for all TINs subject to the VM; the volume of informal reviews; the need to calculate the VM upward payment adjustment factor as close to the beginning of the payment adjustment period as possible; and uncertainty about the availability of the PQRS quality data. Therefore, classifying the quality composite as “average quality” would offer a predictable decision for all informal reviews where a TIN changes classification from Category 2 to Category 1.
Our proposal to calculate the cost composite and assign “average cost” if the cost composite was initially classified as “high cost” would alleviate concerns from stakeholders that a TIN may receive a downward VM payment adjustment under the quality-tiering methodology as a result of being classified as average quality and high cost. Under our proposal discussed above, for TINs in Scenario 1, we would not consider a TIN's actual performance on the quality measures or calculate a quality composite score; rather, we would classify the TIN's quality composite as average quality for the reasons stated above. In this scenario, we do not believe that we should retain a TIN's “high cost” designation when the TIN's actual cost performance is not being compared to the TIN's actual quality performance, as it is possible the TIN might have scored high quality if actual performance had been considered. We believe that these proposals would help groups and solo practitioners who receive a favorable determination on informal review to better predict the outcome of their final VM adjustment and reduce uncertainty about the impact of the informal review. Additionally, it is important to note that groups or solo practitioners who submit an informal review request would not automatically be covered by the policy proposed for Scenario 1. In the CY 2017 PFS proposed rule, we stated that we would verify on informal review that the group or solo practitioner did submit complete and accurate data and did meet the criteria to avoid the PQRS payment adjustment to be included in Category 1.
As finalized in the CY 2016 PFS final rule with comment period, for the CY 2017 VM, Category 1 will include groups that have at least 50 percent of
• If the TIN's quality composite is initially classified as “low quality”, then we proposed to reclassify the TIN's quality composite as “average quality.” If the TIN's quality composite is initially classified as “average quality” or “high quality”, then we proposed that the TIN would retain that quality tier designation.
• We would maintain the cost composite that was initially calculated.
We proposed to apply these policies for the CY 2017 VM and CY 2018 VM. Under these policies, we would not recalculate the TIN's quality composite to include the additional EPs that were determined to have met the criteria to avoid the PQRS payment adjustment as individuals through the PQRS informal review process. As discussed under Scenario 1, recalculating the quality composite is operationally complex, and we may not have PQRS data for the additional EPs, because they were initially determined not to have met the criteria to avoid the PQRS payment adjustment. In addition, we seek to avoid a situation where by recalculating the quality composite, a TIN may be subject to a lower quality tier designation because a few EPs in the TIN independently pursued PQRS informal reviews. As stated above, we proposed to reclassify a TIN's quality composite as average quality if it is initially classified as “low quality” in order to avoid a situation where we do not have the PQRS quality data for those few EPs whose quality performance could have bumped the TIN up from a low quality designation as the EPs did not meet the criteria to avoid the PQRS payment adjustment during the initial determination. Additionally, it is important to note that TINs whose EPs submit an informal review request would not automatically be covered by the policy proposed for Scenario 2. We stated in the CY 2017 PFS proposed rule that we would verify on informal review that an EP did submit complete and accurate data and did meet the criteria to avoid the PQRS payment adjustment as an individual in order for the TIN to be included in Category 1.
In cases where there is a systematic issue with any of a Category 1 TIN's quality data that renders it unusable for calculating a TIN's quality composite, we proposed to classify the TIN's quality composite as average quality. For this proposal, we consider widespread quality data issues, as issues that impact multiple TINs and we are unable to determine the accuracy of the data submitted via these TINs (for example, the EHR and QCDR issues for the CY 2014 performance period as described in the CY 2017 PFS proposed rule (81 FR 46455). This proposal would offer a predictable designation for all TINs under this scenario.
We also proposed to calculate the TIN's cost composite using the quality-tiering methodology. If the TIN were classified as “high cost” based on its performance on the cost measures, then we proposed to reclassify the TIN's cost composite as “average cost.” If the TIN were classified as “average cost” or “low cost”, then we proposed that the TIN would retain the calculated cost tier designation. We proposed to apply these policies for the CY 2017 VM and CY 2018 VM.
As discussed under Scenario 1, our proposal to calculate the cost composite and assign “average cost” if the cost composite is initially classified as “high cost” would alleviate concerns from stakeholders that a TIN may receive a downward VM payment adjustment under the quality-tiering methodology as a result of being classified as average quality and high cost. Similarly, for TINs in Scenario 3, we would not consider a TIN's actual performance on the quality measures or calculate a quality composite score; rather, we would classify the TIN's quality composite as average quality for the reasons stated above. In this scenario, we do not believe that we should retain a TIN's high cost designation when the TIN's actual cost performance is not being compared to the TIN's actual quality performance, as it is possible the TIN might have scored high quality if actual performance had been considered. We would continue to show and designate these groups as high cost in their annual QRURs so they have the opportunity to understand and improve their performance, but under our proposal, we would classify their cost composite as average cost for purposes of determining their VM adjustment.
In the CY 2017 PFS proposed rule, we noted that we expect quality data issues to be significantly limited moving forward, due to newly-added front-end edits. Additionally, we noted that TINs are ultimately responsible for the data that are submitted by their third-party vendors and that we expect that TINs are holding their vendors accountable for accurate reporting. We noted that, while we understand that data submission requirements are evolving and that both vendors and CMS are developing capabilities for reporting and assessing performance, we are considering further policies to promote complete and accurate reporting by registries and other third-party entities that submit data on behalf of groups and EPs.
If we determine after the release of the Quality and Resource Use Reports (QRURs) that there is a widespread claims data issue that impacts the calculation of the quality and/or cost composites for Category 1 TINs, we propose to recalculate the quality and cost composites for affected TINs. For this proposal, we consider widespread claims data issues, as issues that impact multiple TINs and require the recalculation of the quality and/or cost composites (for example, the incomplete claims identification and specialty adjustment issues described in the CY 2017 PFS proposed rule (81 FR 46446)
After recalculating the composites, if the TIN's quality composite is classified as low quality, then we proposed to reclassify the quality composite as average quality, and if the TIN's cost composite is classified as high cost, we proposed to reclassify the cost composite as average cost. If the TIN is classified as average quality, high quality, average cost or low cost, then we proposed that the TIN would retain the calculated quality or cost tier designation. We made the proposals because, after a claims data issue is identified, it would take approximately 6 weeks to recalculate the composites and notify groups and solo practitioners about their recalculated VM. Given that the VM informal review period lasts for 60 days after the release of the QRURs and the timing of when we become aware of an error, we would likely not be able to notify groups and solo practitioners about their recalculated VM before the end of the informal review period. Further, we expressed our belief that the proposed policies are necessary to provide certainty for
We proposed to apply these policies for the CY 2017 VM and CY 2018 VM.
The following is a summary of the comments we received regarding these proposals.
In the CY 2015 PFS final rule with comment period (79 FR 67946), for groups and solo practitioners, as identified by their TIN, that participate in a Shared Savings Program ACO, we finalized the same policy that is generally applicable to groups and solo practitioners that fail to satisfactorily report or participate under PQRS and thus fall in Category 2 and are subject to an automatic downward adjustment under the VM in CY 2017. We stated that, consistent with the application of the VM to other groups and solo practitioners that report under PQRS, if the ACO does not successfully report quality data as required by the Shared Savings Program under § 425.504, all groups and solo practitioners participating in the ACO will fall in Category 2 for the VM, and therefore, will be subject to a downward payment adjustment. We finalized this policy for the 2017 payment adjustment period for the VM. In the CY 2016 PFS proposed rule (80 FR 41899), we proposed to continue this policy in the CY 2018 payment adjustment period for all groups and solo practitioners subject to the VM that participate in a Shared Savings Program ACO and finalized our proposal in the CY 2016 PFS final rule with comment period (80 FR 71285).
As discussed in sections III.H. and III.K.1.e. of this final rule, we proposed to remove the prohibition on EPs who are part of a group or solo practitioner that participates in a Shared Savings Program ACO, for purposes of PQRS reporting for the CY 2017 and CY 2018 payment adjustments, to report outside the ACO. As a result of this proposed policy, the EPs in groups and those who are solo practitioners would be allowed to report to the PQRS as a group (using one of the group registry, QCDR, or EHR reporting options) or individually (using the registry, QCDR, or EHR reporting option) outside of the ACO. This section addresses how we proposed to use the PQRS data reported by EPs outside of the ACO for the CY 2018 VM when the ACO does not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504.
For the CY 2018 payment adjustment period, if a Shared Savings Program ACO does not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504, then we proposed to use the
As finalized for the CY 2018 payment adjustment period (80 FR 71285), all groups and solo practitioners that participate in a Shared Savings Program ACO and fall in Category 2 will be subject to an automatic downward payment adjustment under the VM. In the CY 2017 PFS proposed rule, we proposed that, for groups and solo practitioners that participate in a Shared Savings Program ACO that did not successfully report quality data as required by the Shared Savings Program under § 425.504 and are in Category 1 as a result of reporting quality data to the PQRS outside of the ACO, we would classify their quality composite for the VM for the CY 2018 payment adjustment period as “average quality (81 FR 46447).” As finalized in the CY 2015 PFS final rule with comment period (79 FR 67943), the cost composite for groups and solo practitioners that participate in a Shared Savings Program ACO will be classified as “average cost.” Because we would not have the ACO's quality data for these groups and solo practitioners, we expressed our belief that it would be appropriate to use the quality data they reported to the PQRS outside the ACO to determine whether they avoided the PQRS payment adjustment and whether they would be in Category 1 or 2 for purposes of the VM, but not to calculate a quality composite using the quality-tiering methodology. As we stated previously, we continue to believe that it is appropriate to calculate a quality composite for groups and solo practitioners participating in the Shared Savings Program based on the ACO's quality data (79 FR 67944). We noted that the proposal was not intended to encourage groups and solo practitioners that participate in a Shared Savings Program ACO to report to the PQRS outside the ACO, but in the event the ACO does not successfully report quality data on behalf of their EPs for purposes of PQRS, to provide them with a safeguard that would allow them to avoid the PQRS payment adjustment and the automatic downward adjustment under the VM. We encourage groups and solo practitioners to continue to report through the ACO in order to promote clinical and financial integration within the ACO and for the Medicare beneficiaries they treat. For groups and solo practitioners that participate in a Shared Savings Program ACO that successfully reports quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504, we will calculate their VM for the CY 2018 payment adjustment period according to the policies established in the CY 2015 PFS final rule with comment period (79 FR 67941 to 67947 and 79 FR 67956 to 67957) and CY 2016 PFS final rule with comment period (80 FR 71283 to 71286 and 80 FR 71294). We solicited comment on these proposals and also proposed corresponding revisions to § 414.1210(b)(2).
As discussed in section III.H. of this final rule, to allow affected EPs that participate in an ACO to report separately for the CY 2017 PQRS payment adjustment, we proposed a secondary PQRS reporting period for EPs that were in an ACO that did not successfully report quality data on behalf of the EPs in the group and those who are solo practitioners. Specifically, we proposed that affected individual EPs or groups, who report under an ACO, may separately report outside the ACO either as individual EPs (using the registry, QCDR, or EHR reporting option) or using one of the group registry, QCDR, or EHR reporting options (note these EPs and groups would not need to register for one of these group reporting options, but rather could mark the data as group-level data in their submission) during a secondary PQRS reporting period for the CY 2017 PQRS payment adjustment if they were a participant in an ACO that did not successfully report quality data on their behalf during the established reporting period for the CY 2017 PQRS payment adjustment. We proposed the secondary PQRS reporting period for the CY 2017 PQRS payment adjustment would coincide with the reporting period for the CY 2018 PQRS payment adjustment (that is, January 1, 2016 through December 31, 2016).
This section addresses how we proposed to use, for purposes of the CY 2017 VM, the PQRS data reported by the EPs in the group and those who are solo practitioners outside of the ACO using the secondary PQRS reporting period when the ACO did not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504 for the CY 2017 PQRS payment adjustment. For the CY 2017 payment adjustment period, if a Shared Savings Program ACO did not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504 for the CY 2017 PQRS payment adjustment, then we propose to use the data reported to the PQRS by the EPs (as a group using one of the group registry, QCDR, or EHR reporting options or as individuals using the registry, QCDR, or EHR reporting option) under the participant TIN) outside of the ACO during the secondary PQRS reporting period to determine whether the TIN would fall in Category 1 or Category 2 under the VM. We proposed to apply the two-category approach finalized for the CY 2017 VM (79 FR 67938 to 67939 and as revised in 80 FR 71280 to 71281) based
As finalized for the CY 2017 payment adjustment period (79 FR 67946), all groups and solo practitioners that participate in a Shared Savings Program ACO and fall in Category 2 will be subject to an automatic downward payment adjustment under the VM. For groups and solo practitioners that participate in a Shared Savings Program ACO that did not successfully report quality data as required by the Shared Savings Program under § 425.504 and are in Category 1 as a result of reporting quality data to the PQRS outside of the ACO using the secondary PQRS reporting period, we propose to classify their quality composite for the VM for the CY 2017 payment adjustment period as “average quality” for the same reasons described above for the CY 2018 payment adjustment period. As finalized in the CY 2015 PFS final rule with comment period (79 FR 67943), the cost composite for groups and solo practitioners that participate in a Shared Savings Program ACO will be classified as “average cost.”
If EPs who are part of a group or are solo practitioners who participated in a Shared Savings Program ACO in 2015 that did not successfully report quality data on their behalf decide to use the secondary PQRS reporting period, it is important to note that such groups and solo practitioners should expect to be initially classified as Category 2 and receive an automatic downward adjustment under the VM for items and services furnished in CY 2017 until CMS is able to determine whether the group or solo practitioner met the criteria to avoid the PQRS payment adjustment as described above. First, we would need to process the data submitted for 2016. Second, we would need to determine whether or not the group or solo practitioner would be classified as Category 1 or Category 2 for the CY 2017 VM and notify the group or solo practitioner if there is a change in the VM status. Third, we would need to update the group or solo practitioner's status so that they will stop receiving an automatic downward adjustment under the VM for items and services furnished in CY 2017 and reprocess all claims that were previously paid. Since groups and solo practitioners taking advantage of this secondary reporting period for the 2017 VM will have missed the deadline for submitting an informal review request for the 2017 VM, we proposed the informal review submission periods for these groups and solo practitioners would occur during the 60 days following the release of the QRURs for the 2018 VM.
We requested comment on these proposals. We also proposed corresponding revisions to § 414.1210(b)(2).
The following is a summary of the comments we received regarding these proposals.
We appreciate the commenters' support of our proposal to use the PQRS data reported by EPs outside of the ACO for the CY 2017 and CY 2018 VM when the ACO does not successfully report quality data on behalf of its EPs and are finalizing the policies as proposed. We plan to communicate with the ACOs (and their participant TINs) that did not successfully report quality data on behalf of their EPs for purposes of PQRS for the CY 2017 PQRS payment adjustment to inform them about the reporting during the secondary PQRS reporting period. We encourage EPs to
For the CY 2018 payment adjustment period, we are finalizing that, if a Shared Savings Program ACO does not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504, then we will use the data reported to the PQRS by the EPs under the participant TIN (as a group (using one of the group registry, QCDR, or EHR reporting options) or as individuals (using the registry, QCDR, or EHR reporting option) outside of the ACO to determine whether the TIN would fall in Category 1 or Category 2 under the VM. We are also finalizing that we will apply the two-category approach finalized for the CY 2018 VM (80 FR 71280) based on participation in the PQRS by groups and solo practitioners to determine whether groups and solo practitioners that participate in a Shared Savings Program ACO, but report to the PQRS outside of the ACO, would fall in Category 1 or Category 2 under the VM. Thus, if groups that participate in a Shared Savings Program ACO in 2016 report quality data to the PQRS outside of the ACO and meet the criteria to avoid PQRS payment adjustment for CY 2018 as a group using one of the group registry, QCDR, or EHR reporting options or have at least 50 percent of the group's EPs meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals using the registry, QCDR, or EHR reporting option by reporting quality data to PQRS outside of the ACO, then they will be included in Category 1 for the CY 2018 VM. If solo practitioners that participate in a Shared Savings Program ACO in 2016 report quality data to the PQRS outside of the ACO and meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals using the registry, QCDR, or EHR reporting option, then they will also be included in Category 1. Category 2 will include those groups and solo practitioners subject to the CY 2018 VM that participate in a Shared Savings Program ACO and do not fall within Category 1.
For the CY 2017 payment adjustment period, we are finalizing that, if a Shared Savings Program ACO did not successfully report quality data on behalf of their EPs for purposes of PQRS as required by the Shared Savings Program under § 425.504 for the CY 2017 PQRS payment adjustment, then we will use the data reported to the PQRS by the EPs under the participant TIN (as a group using one of the group registry, QCDR, or EHR reporting options or as individuals using the registry, QCDR, or EHR reporting option) outside of the ACO during the secondary PQRS reporting period to determine whether the TIN would fall in Category 1 or Category 2 under the VM. We are also finalizing that we will apply the two-category approach finalized for the CY 2017 VM (79 FR 67938 to 67939 and as revised in 80 FR 71280 to 71281) based on participation in the PQRS by groups and solo practitioners to determine whether groups and solo practitioners that participate in a Shared Savings Program ACO, but report to the PQRS outside of the ACO, would fall in Category 1 or Category 2 under the VM. In section III.H. of this final rule, we finalized that we will assess the individual EP or group's 2016 data submitted outside the ACO and during the secondary PQRS reporting period against the reporting requirements for the CY 2018 PQRS payment adjustment. Therefore, we are also finalizing that groups that meet the criteria to avoid PQRS payment adjustment for CY 2018 as a group practice participating in the PQRS GPRO (using one of the group registry, QCDR, or EHR reporting options) or have at least 50 percent of the group's EPs meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals (using the registry, QCDR, or EHR reporting option), based on data submitted outside the ACO and during the secondary PQRS reporting period, will be included in Category 1 for the CY 2017 VM. We are also finalizing that solo practitioners that meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals using the registry, QCDR, or EHR reporting option, based on data submitted outside the ACO and during the secondary PQRS reporting period, will be included in Category 1 for the CY 2017 VM. Category 2 will include those groups and solo practitioners subject to the CY 2017 VM that participate in a Shared Savings Program ACO and do not fall within Category 1.
Therefore, we are finalizing as proposed that, for groups and solo practitioners that participate in a Shared Savings Program ACO that did not successfully report quality data as required by the Shared Savings Program under § 425.504 and are in Category 1 as a result of reporting quality data to the PQRS outside of the ACO, we will classify their quality composite for the VM for the CY 2018 payment adjustment period as “average quality.” We are also finalizing that for groups and solo practitioners that participate in a Shared Savings Program ACO that did not successfully report quality data as required by the Shared Savings Program under § 425.504 and are in Category 1 as a result of reporting quality data to the PQRS outside of the ACO using the secondary PQRS reporting period, we will classify their quality composite for the VM for the CY 2017 payment adjustment period as “average quality”.
As finalized in the CY 2015 PFS final rule with comment period (79 FR 67943), the cost composite for groups and solo practitioners that participate in a Shared Savings Program ACO will be
Since groups and solo practitioners taking advantage of the secondary PQRS reporting period for the CY 2017 PQRS payment adjustment will have missed the deadline for submitting an informal review request for the 2017 VM, we proposed the informal review submission periods for these groups and solo practitioners would occur during the 60 days following the release of the QRURs for the 2018 VM. We did not receive any comments on this proposal and are finalizing this policy as proposed.
Section 6204 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101- 239) (OBRA 1989), enacted on December 19, 1989, added section 1877 to the Act. Section 1877 of the Act, also known as the physician self-referral law: (1) Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership or compensation), unless an exception applies; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third party payer) for those referred services. The statute establishes a number of specific exceptions, and grants the Secretary the authority to create regulatory exceptions for financial relationships that pose no risk of program or patient abuse. Additionally, the statute mandates refunding any amount collected under a bill for an item or service furnished under a prohibited referral. Finally, the statute imposes reporting requirements and provides for sanctions, including civil monetary penalty provisions. Section 1877 of the Act became effective on January 1, 1992.
Section 4207(e) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508) (OBRA 1990), enacted on November 5, 1990, amended certain provisions of section 1877 of the Act to clarify definitions and reporting requirements relating to physician ownership and referrals and to provide an additional exception to the prohibition. Several subsequent laws further changed section 1877 of the Act. Section 13562 of the Omnibus Budget Reconciliation Act of 1993 (Pub. L. 103- 66) (OBRA 1993), enacted on August 10, 1993, expanded the referral prohibition to cover certain other “designated health services” in addition to clinical laboratory services, modified some of the existing statutory exceptions, and added new exceptions. Section 152 of the Social Security Act Amendments of 1994 (SSA 1994) (Pub. L. 103-432), enacted on October 31, 1994, amended the list of designated health services, changed the reporting requirements at section 1877(f) of the Act, and modified some of the effective dates established by OBRA 1993. Some provisions relating to referrals for clinical laboratory services were effective retroactively to January 1, 1992, while other provisions became effective on January 1, 1995.
The following discussion provides a chronology of our more significant and comprehensive rulemakings; it is not an exhaustive list of all rulemakings related to the physician self-referral law.
Following the passage of section 1877 of the Act, we proposed rulemakings in 1992 (related only to referrals for clinical laboratory services) (57 FR 8588) (the 1992 proposed rule) and 1998 (addressing referrals for all DHS) (63 FR 1659) (the 1998 proposed rule). We finalized the proposals from the 1992 proposed rule in 1995 (60 FR 41914) (the 1995 final rule), and issued final rules following the 1998 proposed rule in three stages. The first final rulemaking (Phase I) was published in the January 4, 2001
We issued additional final regulations after passage of the Affordable Care Act. In the CY 2011 PFS final rule with comment period (75 FR 73170), we codified a disclosure requirement established by the Affordable Care Act for the in-office ancillary services exception. We also issued regulations in the CY 2011 OPPS final rule with comment period (75 FR 71800), the CY 2012 OPPS final rule with comment period (76 FR 74122), and the CY 2015 OPPS final rule with comment period (79 FR 66770) that established or revised certain regulatory provisions concerning physician-owned hospitals to codify and interpret the Affordable Care Act's revisions to section 1877 of the Act. Finally, in the CY 2016 PFS final rule (80 FR 70886), we issued regulations to accommodate delivery and payment system reform, reduce burden, and to facilitate compliance. In that rulemaking, we established two new exceptions, clarified certain provisions of the physician self-referral law, updated regulations to reflect changes in terminology, and revised definitions related to physician-owned hospitals. One of the new exceptions, the exception for timeshare arrangements at § 411.357(y), includes a prohibition on certain per unit-of-service compensation formulas.
We have addressed the issue of unit-based compensation in several rulemakings. Sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act provide that, for an arrangement for the rental of office space or equipment to satisfy the relevant exceptions to the physician self-referral law, the rental charges over the term of the lease must be set in advance, be consistent with fair market value, and not be determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties. Interpreting this “volume or value” standard in the 1998 proposed rule, we proposed that compensation could be based on units of service (for example, “per-use” equipment rentals) provided that the units of service did not include services provided to patients who were referred by the physician receiving the payment. For example, a physician who owned a lithotripter could rent it to a hospital on a per-procedure basis,
After reviewing the public comments in response to the 1998 proposed rule, we finalized in Phase I significant revisions with respect to the scope of the volume or value standard. We revised our interpretation of the “volume or value” standard for purposes of section 1877 of the Act to permit, among other things, payments based on a unit of service, provided that the unit-based payment is fair market value and does not vary over time (66 FR 876 through 879). Importantly, we permitted unit-based compensation formulas, even when the physician receiving the payment has generated the payment through a DHS referral. To reach this position, we noted that page 814 of the House Conference Committee report (H. Rep. No. 213, 103rd Cong., 1st Sess. (1993)) stated, with respect to the statutory exceptions for the rental of office space and equipment in sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act, that the conferees “intend[ed] that rental charges for [office] space and equipment leases may be based on daily, monthly, or other time-based rates, or rates based on units of service furnished, so long as the amount of the time-based or units of service rates does not fluctuate during the contract period based on the volume or value of referrals between the parties to the lease or arrangement.” (66 FR 876). However, we stated our unequivocal belief that arrangements in which the lessor is compensated each time that the lessor refers a patient to the lessee for a service performed in the leased office space or using the leased equipment have an obvious potential for abuse and could incent overutilization (66 FR 878). We indicated that we would continue to monitor financial arrangements in the health care industry and would revisit particular regulatory decisions if we determine that there has been abuse or overutilization (66 FR 860).
In the CY 2008 PFS proposed rule (72 FR 38122), we stated that arrangements between a physician lessor and an entity lessee under which the physician lessor receives unit-of-service payments are inherently susceptible to abuse because the physician lessor has an incentive to profit from referring a higher volume of patients to the lessee. We proposed that space and equipment leases may not include per-click payments to a physician lessor for services rendered by an entity lessee to patients who are referred by a physician lessor to the entity (72 FR 38183). We also solicited comments on the question of whether we should prevent per-click payments in situations in which the physician is the lessee and a DHS entity is the lessor. The CY 2008 PFS proposed rule also included eight other significant proposed revisions to the physician self-referral regulations. Due to the large number of physician self-referral proposals, the significance of the provisions both individually and in concert with each other, and the volume of public comments received in response to the CY 2008 PFS proposed rule, we declined to finalize our proposals, including our proposal to prohibit certain per unit-of-service compensation formulas in arrangements for the rental of office space and equipment, in the CY 2008 PFS final rule (72 FR 66222).
After consideration of the public comments and our independent research, we finalized regulations prohibiting certain per-unit of service compensation formulas for determining office space and equipment rental charges in the FY 2009 IPPS final rule (73 FR 48434). Specifically, we revised § 411.357(a)(4) and (b)(4) to prohibit rental charges for the rental of office space or equipment that are determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee. In doing so, we relied on our authority in section 1877(e)(1)(A)(vi) and (B)(vi) of the Act, which permits the secretary to impose by regulation other requirements needed to protect against program or patient abuse. We also revised the exceptions at §§ 411.357(l) and (p) for fair market value compensation and indirect compensation arrangements, respectively, to include similar limitations on the formula for determining office space and equipment rental charges, as applicable. We did so using our authority at section 1877(b)(4) of the Act, as those exceptions were established using that authority (
On June 12, 2015, the D.C. Circuit (the Court) issued an opinion in
The text of the statute does not unambiguously preclude the Secretary from using her authority to add a requirement that bans per-click leases. To the contrary, the statutory text of the exception clearly provides the Secretary with the discretion to impose any additional requirements that she deems necessary “to protect against program or patient abuse.” (
The Court also concluded, however, that CMS's discussion of the House
As discussed above, in the FY 2009 IPPS final rule, we revised the exceptions for the rental of office space and equipment to include in each a requirement that the rental charges for the office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee. We explained that our decision to add this requirement was ultimately based on our authority under section 1877(e)(1)(B)(vi) of the Act to promulgate “other requirements” needed to protect against program or patient abuse. However, we also discussed certain legislative history contained in the House Conference Report addressing sections 1877(e)(1)(A)(iv) and 1877(e)(1)(B)(iv) of the Act, which establish requirements that rental charges over the term of a lease for office space or rental equipment be set in advance, be consistent with fair market value, and not be determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties. With respect to those statutory conditions, the language in the House Conference Report states that—
The conferees intend that charges for space and equipment leases may be based on daily, monthly, or other time-based rates, or rates based on units of service furnished, so long as the amount of time-based or units of service rates does not fluctuate during the contract period based on the volume or value of referrals between the parties to the lease or arrangement. (H.R. Rep. No. 103-213, at 814 (1993).)
In the FY 2009 IPPS final rule, we noted that CMS had previously concluded that this language indicated that Congress intended to permit leases that included per-click payments, even for patients referred by the physician lessor (66 FR 940), but stated that the language could also be interpreted as excluding from the office space and equipment lease exceptions those lease arrangements that include per-click payments for services provided to patients referred from one party to the other (73 FR 48716). Specifically, we stated that, where the total amount of rent (that is, the rental charges) over the term of the lease is directly affected by the number of patients referred by one party to the other, those rental charges can arguably be said to “take into account” or “fluctuate during the contract period based on” the volume or value of referrals between the parties. The Court found this revised interpretation to be an unreasonable reading of the language of the House Conference Report. The Court remanded § 411.357(b)(4)(ii)(B) to the Secretary for further proceedings consistent with its opinion, and directed that the Secretary should consider whether a ban on per-click equipment leases is consistent with the House Conference Report.
c. The CY 2017 PFS Proposed Rule: Re-proposal of Limitation on the Types of Per-unit of Service Compensation Formulas for Determining Office Space and Equipment Rental Charges
In the CY 2017 PFS proposed rule, we proposed certain requirements for arrangements involving the rental of office space or equipment. Specifically, using the same language in existing § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B), we proposed to include at § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B) a requirement that rental charges for the lease of office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee. We used the authority granted to the Secretary in sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to re-propose this requirement in the exceptions at § 411.357(a) and (b) for the rental of office space and equipment, respectively. We used the authority granted to the Secretary in section 1877(b)(4) of the Act to re-propose this requirement in the exceptions at § 411.357(l) and (p) for fair market value compensation and indirect compensation arrangements, respectively. For the reasons set forth below, we are finalizing without modification at § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B) a requirement that rental charges for the lease of office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
We emphasize that we did not propose and are not finalizing an absolute prohibition on rental charges based on units of service furnished. In general, per-unit of service rental charges for the rental of office space or equipment are permissible. We proposed to limit, and in this final rule are finalizing a limit on, the general rule by prohibiting per-unit of service rental charges where the lessor generates the payment from the lessee through a referral to the lessee for a service to be provided in the rented office space or using the rented equipment. Thus, under this final rule, per-unit of service rental charges for the rental of office space or equipment are permissible, but only in those instances where the referral for the service to be provided in the rented office space or using the rented equipment did not come from the lessor.
In accordance with the Court's opinion in
As the Court stated, the physician self-referral law gives the Secretary power to add requirements as needed to protect against program or patient abuse, even if Congress did not anticipate such abuses at the time of enactment of the statute. Specifically, although Congress may not have originally included a ban on per-click rental charges in office space and equipment lease arrangements, it “empowered the Secretary to make her own assessment of the needs of the Medicare program and regulate accordingly.” (
The Secretary's authority to impose requirements regarding the type of compensation formulas upon which office space and equipment rental charges may be based is not constrained by the House Conference Report. In the proposed rule, we acknowledged that the language in the House Conference Report states Congress' intent at the time of enactment of the physician self-referral law that sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act not be interpreted as prohibiting charges for the rental of office space or equipment that are based on units of service furnished. We did not purport to interpret this language as implying anything other than the conferees' understanding—at the time of enactment of the statute—that the statute as written did not prohibit rental charges based on units of service rates. But Congress also gave the Secretary the authority in sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to impose by regulation other requirements as needed to protect against program or patient abuse. Nowhere in the House Conference Report did Congress express an intent to limit the authority granted to the Secretary in sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act (as enacted). In fact, the House Conference Report was completely silent regarding sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act, leaving the express words of the statute to speak for themselves. As the Court noted—
The conference report . . . states only that rental charges “may” be based on units of service. The language is not obligatory. Instead, it simply indicates that, as written, the rental-charge clause [(section 1877(e)(1)(B)(iv) of the Act)] does not preclude per-click leases. But, as we have already explained, there is more to the statute than this clause, and to qualify for the exception, a rental agreement must comply with all six clauses, not merely the rental-charge clause alone. The final clause [(section 1877(e)(1)(B)(vi) of the Act)] gives the Secretary the authority to add further requirements. Nothing in the legislative history suggests a limit on this authority. We conclude that the statute does not unambiguously forbid the Secretary from banning per-click leases as she evaluates the needs of the Medicare system and its patients. (790 F.3d at 221-22 (
Moreover, as the Court further noted, a statement that unit of service-based rental charges are not precluded by sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act as they are written is not equivalent to a statement that the Secretary must continue to permit such charges as she reevaluates, in light of experience, the operation of the statute and the need to protect the Medicare program and its beneficiaries against abuse. (
In the proposed rule, we discussed the Secretary's broad authority under sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to impose conditions on arrangements for the rental of office space or equipment in order to protect against program or patient abuse. That authority is not limited by the express words of the statute as it is in other provisions of section 1877 of the Act. In agreement, the Court in
The Secretary's authority to limit the use of per-unit of service rental charges in arrangements for the rental of office space or equipment is particularly clear when the exceptions for the rental of office space and equipment are compared to other provisions in section 1877 of the Act. According to the Court in
[T]he statute elsewhere expressly permits charging per-click fees in other contexts, showing that Congress knew how to authorize such payment terms when it wanted to. In [section 1877(e)(7)(A) of the Act], Congress created an exception to the [physician self-referral law] that allows the continuation of certain group practice arrangements with a hospital. . . . The provision states that “[a]n arrangement between a hospital and a group under which designated health services are provided by the group but are billed by the hospital” is excepted from the ban on referrals if, among other things, “the compensation paid over the term of the agreement is consistent with fair market value and the compensation
As we did in 2007 when we first proposed to impose additional requirements for rental charges in arrangements for the rental of office space and equipment, and in 2008 when we finalized regulations incorporating
As we discussed in prior rulemakings, including the 1998 proposed rule, we stated in the proposed rule that a number of studies prior to the enactment of the physician self-referral law found that physicians who had financial relationships with entities to which they referred patients ordered more services than physicians without such financial relationships (63 FR 1661). We noted that studies conducted since that time, including recent studies by GAO, indicate that financial self-interest continues to affect physicians' medical decision making.
In the FY 2009 IPPS final rule, we discussed in detail our rationale for finalizing the limitation on per-unit of service rental charges in arrangements for the rental of office space or equipment. We noted primary concerns regarding the potential for overutilization, patient steering and other anti-competitive effects, and reduction in quality of care and patient outcomes, as well as concerns regarding the potential for increased costs to the Medicare program. For the reasons set forth in the FY 2009 IPPS final rule, some of which we restated in the proposed rule, we stated our belief that, in order to protect against program or patient abuse, it is necessary to impose additional requirements on arrangements for the rental of office space or equipment. Specifically, we stated that we believe that it is necessary to prohibit rental charges that are determined using a formula based on per-unit of service rental charges to the extent that such charges reflect services provided to patients referred by the lessor to the lessee of the office space or equipment.
In the CY 2017 PFS proposed rule, we noted that commenters responding to our proposal in the CY 2008 PFS proposed rule to impose additional requirements for office space and equipment lease arrangements provided compelling information regarding potential program or patient abuse. We were persuaded in 2008 to finalize requirements limiting per-unit of service rental charges in the exceptions applicable to the rental of office space or equipment, and stated our continued belief that these requirements continue to be necessary, due to our concerns that “per-click” lease arrangements in which the lessor makes referrals to the lessee that generate payments to the lessor—
• Create an incentive for overutilization of imaging services (as described by MedPAC in its comments to our proposal in the CY 2008 PFS proposed rule), as well as other services, including therapeutic services;
• Create an incentive for physicians to narrow their choice of treatment options to those for which they will realize a profit, even where the best course of action may be no treatment;
• Influence physicians to refer to the lessee instead of referring to another entity that utilizes the same or different (and perhaps more efficacious) technology to treat the patient's condition;
• Result in physicians steering patients to equipment they own, even if it means having the patient travel to a non-convenient site for services using the leased equipment; and
• Increase costs to the Medicare program when referring physicians pressure hospitals to use their leasing company despite not being the low cost provider.
We noted that, in the CY 2016 PFS final rule, we expressed our continued concern that, when physicians have a financial incentive to refer a patient to a particular entity, this incentive can affect utilization, patient choice, and competition. Physicians can overutilize by ordering items and services for patients that, absent a profit motive, they would not have ordered. A patient's choice is diminished when physicians steer patients to less convenient, lower quality, or more expensive providers of health care, just because the physicians are sharing profits with, or receiving remuneration from, the providers. And lastly, where referrals are controlled by those sharing profits or receiving remuneration, the medical marketplace suffers if new competitors cannot win business with superior quality, service, or price (80 FR 41926). We stated that, in establishing the exception at § 411.357(y) for timeshare arrangements, we determined it necessary to exclude from the exception any timeshare arrangements that incorporate compensation formulas based on: (1) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services provided while using the timeshare; or (2) per-unit of service fees, to the extent that such fees reflect services provided to patients referred by the party granting permission to use the timeshare to the party to which the permission is granted. We explained our belief that timeshare arrangements based on percentage compensation or per-unit of service compensation formulas present a risk of program or patient abuse because they may incentivize overutilization and patient steering. We noted in the CY 2016 PFS final rule, by way of example, that a per-patient compensation formula could incent the timeshare grantor to refer patients (potentially for unnecessary consultations or services) to the party using the timeshare because the grantor will receive a payment each time the premises, equipment, personnel, items, supplies, or services are used (80 FR 71331 through 71332). Similarly, we believe that arrangements utilizing rental charges for the rental of office space or equipment that are determined using a formula that rewards the lessor for each service the lessor refers to the lessee are susceptible to this and other abuse.
Finally, we noted in the CY 2017 PFS proposed rule that we are not alone in our concern regarding overutilization and steering of beneficiaries resulting from arrangements in which a physician's referral may provide future remuneration back to the physician. In two notable advisory opinions, OIG expressed its concern with per-unit of service compensation arrangements. Specifically, in Advisory Opinion 03-08, OIG stated that “`[p]er patient,' `per click,' `per order,' and similar payment arrangements with parties in a position, directly or indirectly, to refer or recommend an item or service payable by a federal health care program are disfavored under the anti-kickback statute. The principal concern is that such arrangements promote overutilization . . . .” In Advisory Opinion 10-23, OIG noted that the arrangement that was the subject of the opinion “involves a `per-click' fee structure, which is inherently reflective of the volume or value of services ordered and provided . . . .”
The following is a summary of the comments we received regarding our re-proposal.
One commenter commended us for keeping the integrity of the Medicare program in mind by re-proposing the per-click restrictions. This commenter and another noted that improper financial relationships risk wasting funds and could limit access to more appropriate treatment options. A third commenter encouraged us to “keep in place the relevant restriction on per-unit arrangements when payments are made to referral sources.” Another commenter acknowledged that a careful balance must be established between permitting physicians to lease office space or equipment to ensure access to patient care and avoiding potential risks of abuse of the Medicare program, and stated its appreciation that the restrictions we proposed on the formula for rental charges are reasonable and preserve the ability of physicians to lease office space and equipment from other physicians.
The commenter premised its objection to our proposal in two ways. First, the commenter asserted that we lacked the authority to re-propose the regulations because our determination to prohibit certain per-click rental charges cannot be reconciled with the House Conference Report. The commenter asserted that we did “not even try to reconcile a ban on per-click [compensation formulas] with the [House] Conference Report.” At the same time, the commenter asserted that the Court rejected our explanation that, given the authority granted to the Secretary under sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act, the House Conference Report does not constrain her authority to impose requirements regarding the type of compensation formulas upon which office space and equipment rental charges may be based.
Second, the commenter rejected our justification for re-proposing the prohibition on certain per-click compensation formulas for determining rental charges in arrangements for the rental of office space and equipment. Specifically, the commenter claimed that we cited no “industry developments” since the enactment of the physician self-referral law or since our Phase I regulations that “now warrant a prohibition on per-click [rental charge formulas]”; criticized our reliance on “concerns” and “belief[s]” informing our judgment that per-click rental charge arrangements create incentives for abuse and overutilization; and asserted that “only empirical data or evidence” can support a Secretarial determination under the physician self-referral law that additional conditions are needed to protect against program or patient abuse. The commenter acknowledged that the GAO studies and other studies, as well as an OIG advisory opinion, referenced in the CY 2017 PFS proposed rule “stand . . . for the general proposition that physician financial interests can affect the utilization of medical tests and procedures.” Nonetheless, the commenter asserted that the re-proposed regulations must be based on “recent” developments or “recent” studies showing abuse in per-click lease arrangements in order to stand.
We first address the commenter's assertion that a ban on per-click rental charges in arrangements for the lease of office space or equipment
We next address the commenter's assertion that our CY 2017 PFS rulemaking “did not even try to reconcile a ban on per-click [compensation formulas] with the [House] Conference Report.” The Court's directive to the Secretary was to “consider—with more care than she exercised [in the FY 2009 IPPS final rule]—whether a per-click ban on equipment leases is consistent with the 1993 Conference Report.” (
In accordance with the Court's opinion in
As the Court stated, the physician self-referral law gives the Secretary power to add requirements as needed to protect against program or patient abuse, even if Congress did not anticipate such abuses at the time of enactment of the statute. Specifically, although Congress may not have originally included a ban on per-click rental charges in office space and equipment lease arrangements, it “empowered the Secretary to make her own assessment of the needs of the Medicare program and regulate accordingly.” (
The Secretary's authority to impose requirements regarding the type of compensation formulas upon which office space and equipment rental charges may be based is not constrained by the House Conference Report. Clause (iv) in each of the statutory exceptions for the rental of office space and equipment (sections 1877(e)(1)(A) and (B) of the Act) provide that a physician may only make use of either exception if the rental charges over the term of the lease are set in advance, are consistent with fair market value, and are not determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties. In the 1998 proposed rule, we proposed to interpret the “volume or value” standard, which is common in many of the exceptions to the physician self-referral law and included in the exceptions for the rental of office space and equipment at sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act, respectively, as permitting only those per-click compensation formulas where the units of service did not include services provided to patients who were referred by the physician receiving the payment (63 FR 1714). In our Phase I interim final rule with comment period, we stated that, after reviewing the comments on our proposed interpretation of the “volume or value” standard, we were substantially revising the regulation with respect to the scope of that standard (66 FR 876). Most importantly, under our revised interpretation of the “volume or value” standard, we would permit time-based or unit-based compensation formulas, even when the physician receiving the rental payment generated the payment through a DHS referral. We noted that we reviewed the legislative history with respect to the exceptions for office space and equipment lease arrangements and concluded that Congress intended that sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act not be interpreted to prohibit time-based or unit-of-service-based compensation formulas, so long as the payment per unit is fair market value at inception and does not subsequently change during the lease term in any manner that takes into account DHS referrals.
The passage in the House Conference Report relevant to sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act reads in full—
The conferees intend that charges for space and equipment leases may be based on daily, monthly, or other time-based rates, or rates based on units of service furnished, so long as the amount of the time-based or units of service rates does not fluctuate during the
In the CY 2017 PFS proposed rule, we again acknowledged that the language in the House Conference Report states Congress' intent at the time of enactment of the physician self-referral law that sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act (the clauses that contain the “volume or value” standard in the exceptions for the rental of office space and equipment, respectively) not be interpreted as prohibiting charges for the rental of office space or equipment that are based on units of service furnished (81 FR 46451). Even so, the House Conference Report in no way limits any other provision, including clause (vi) of the exceptions for the rental of office space and equipment.
As in the proposed rule, we do not purport here to interpret this language as implying anything other than the conferees' understanding—at the time of enactment of the statute—that the statute as written did not prohibit rental charges based on unit-of-service rates. But Congress also gave the Secretary the authority in sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to impose by regulation other requirements as needed to protect against program or patient abuse, which could only happen
The conference report . . . states only that rental charges “may” be based on units of service. The language is not obligatory. Instead, it simply indicates that, as written, the rental-charge clause [(section 1877(e)(1)(B)(iv) of the Act)] does not preclude per-click leases. But, as we have already explained, there is more to the statute than this clause, and to qualify for the exception, a rental agreement must comply with all six clauses, not merely the rental-charge clause alone. The final clause [(section 1877(e)(1)(B)(vi) of the Act)] gives the Secretary the authority to add further requirements. Nothing in the legislative history suggests a limit on this authority. We conclude that the statute does not unambiguously forbid the Secretary from banning per-click leases as she evaluates the needs of the Medicare system and its patients. (790 F.3d at 221-22 (
Moreover, as the Court further noted, a statement that unit of service-based rental charges are not precluded by sections 1877(e)(1)(A)(iv) and (B)(iv) of the Act as they are written is not equivalent to a statement that the Secretary must continue to permit such charges as she reevaluates, in light of experience, the operation of the statute and the need to protect the Medicare program and its beneficiaries against abuse. (
The Secretary has broad authority under sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to impose conditions on arrangements for the rental of office space or equipment in order to protect against program or patient abuse. That authority is not limited by the express words of the statute as it is in other provisions of section 1877 of the Act. In agreement, the Court in
. . . Congress knew how to limit the Secretary's authority to impose additional requirements to the various exceptions [to the physician self-referral law]. In [section 1877(e)(2) of the Act], Congress excludes bona fide employment relationships from the definition of compensation arrangements. This provision states that the employment relationship must comply with various requirements, including that the pay not be determined “in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the referring physician.” This employment exception also allows the Secretary to impose “other requirements,” just as the equipment rental exception. But the statute then goes on to say that the listed requirements “shall not prohibit the payment of remuneration in the form of a productivity bonus based on services performed personally by the physician.” This language shows that Congress knew how to cabin the Secretary's authority to impose “other” requirements and that it knew how to further clarify what it meant by compensation that does not take into account the volume of business generated between parties. That Congress employed neither of these tools with reference to the [exceptions for the rental of office space or equipment] again supports reading the statute as giving the Secretary broad discretion as she regulates in this area. (790 F.3d at 221 (citations omitted).)
The Secretary's authority to limit the use of per-unit of service rental charges in arrangements for the rental of office space or equipment is particularly clear when the exceptions for the rental of office space and equipment are compared to other provisions in section 1877 of the Act. According to the Court in
[T]he statute elsewhere expressly permits charging per-click fees in other contexts, showing that Congress knew how to authorize such payment terms when it wanted to. In [section 1877(e)(7)(A) of the Act], Congress created an exception to the [physician self-referral law] that allows the continuation of certain group practice arrangements with a hospital. . . . The provision states that “[a]n arrangement between a hospital and a group under which designated health services are provided by the group but are billed by the hospital” is excepted from the ban on referrals if, among other things, “the compensation paid over the term of the agreement is consistent with fair market value and the compensation
In summary, as we stated in the FY 2009 IPPS final rule (73 FR 48716), the physician self-referral statute responds to the context of the times in which it was enacted (by addressing known risks of overutilization and, in particular, by creating exceptions for common business arrangements), and also incorporates sufficient flexibility to adapt to changing circumstances and developments in the health care industry. For example, in section 1877(b)(4) of the Act, Congress authorized the Secretary to protect additional beneficial arrangements by promulgating new regulatory exceptions. In addition, Congress included the means to address other fraud risks by inserting into many of the exceptions—and notably, for our purposes, in the lease exceptions—specific authority for the Secretary to add conditions as needed to protect against abuse. This design reflects a recognition that a fraud and abuse law with sweeping coverage over most of the health care industry could not achieve its purpose over the long term if it were frozen in time (73 FR 48716). It also demonstrates Congress' respect for regulatory expertise of the Secretary. The Secretary administers and oversees numerous federal health care programs, including Medicare and Medicaid, and interacts with numerous participants in
As we did in 2007 when we first proposed to impose additional requirements for rental charges in arrangements for the rental of office space and equipment, and in 2008 when we finalized regulations incorporating such additional requirements, we are relying in this final rule on the Secretary's clear authority in sections 1877(e)(1)(A)(vi) and (B)(vi) of the Act to finalize such other requirements needed to protect against program or patient abuse. With respect to our determination to include the same requirements at §§ 411.357(l) and (p), we have determined that the revisions to §§ 411.357(l) and (p) that we are finalizing here are necessary to meet the standard set forth in section 1877(b)(4) of the Act, which authorizes the Secretary to establish exceptions to the statute's referral and billing prohibitions only where the excepted financial relationships do not pose a risk of program or patient abuse.
We intend and believe that the reasoning set forth in this final rule fully addresses the basis for the D.C. Circuit's conclusion that the prior regulation of per-click compensation arrangements contained in the FY 2009 IPPS final rule was arbitrary and capricious. In
We next address the commenter's assertion that only recent empirical data or evidence can support a Secretarial determination under the physician self-referral law that additional conditions in the exceptions for the rental of office space and equipment are needed to protect against program or patient abuse, and that the agency may not rely on its concerns and beliefs when issuing regulations. As a preliminary matter, section 1877 of the Act does not require the agency to “clear a specific evidentiary hurdle prior to imposing additional restrictions for lease exceptions.” (
As we discussed in prior rulemakings, including the 1998 proposed rule, a number of studies prior to the enactment of the physician self-referral law found that physicians who had financial relationships with entities to which they referred patients ordered more services than physicians without such financial relationships (63 FR 1661). Studies conducted since that time, including recent studies by GAO, indicate that financial self-interest continues to affect physicians' medical decision making. We note that the commenter agreed that, as a general matter, “physician financial interests can affect the utilization of medical tests and procedures.” Nonetheless, the regulations finalized in this rulemaking at § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B) are based not merely on general propositions regarding financial self-interest, but on input from stakeholders and public comments to proposed rulemaking, as well as our own conclusions and those of our law enforcement partners regarding the risks of per-click compensation arrangements. Contrary to the commenter's contention that we cited “no industry developments since the [physician self-referral] law was enacted—or since the 2001 [Phase I] regulations,” we stated in the CY 2017 PFS proposed rule and repeat here that commenters responding to our proposal in the CY 2008 PFS proposed rule to impose additional requirements for office space and equipment lease arrangements provided compelling information regarding potential program or patient abuse. In addition, commenters responding to our proposal in the CY 2017 PFS proposed rule supported the continuation of the per-click bans finalized in the FY 2009 IPPS final rule. We note that, even in the absence of the information upon which we relied in the FY 2009 IPPS final rule and in this final rule (all of which was developed after the publication of the Phase I interim final rule with comment period), the commenter is incorrect that we are now prohibited from determining that additional conditions on certain per-click compensation formulas are needed to protect against program or patient abuse. It is axiomatic that “agencies are entitled to alter their policies `
In the FY 2009 IPPS final rule and the CY 2017 PFS proposed rule, we discussed in detail our rationale for the limitation on per-unit of service rental
For the reasons set forth in the FY 2009 IPPS final rule and the CY 2017 PFS proposed rule, some of which are restated below, we continue to believe that, in order to protect against program or patient abuse, it is necessary to impose additional requirements on arrangements for the rental of office space or equipment. Specifically, we believe that it is necessary to prohibit rental charges that are determined using a formula based on per-unit of service rental charges to the extent that such charges reflect services provided to patients referred by the lessor to the lessee of the office space or equipment.
We were persuaded to finalize in the FY 2009 IPPS final rule requirements limiting per-unit of service rental charges in the exceptions applicable to the rental of office space or equipment, and agree with the commenters to the CY 2017 PFS proposed rule that these requirements continue to be necessary, due to our concerns that “per-click” lease arrangements in which the lessor makes referrals to the lessee that generate payments to the lessor—
• Create an incentive for overutilization of imaging services (as described by MedPAC in its comments to our proposal in the CY 2008 PFS proposed rule), as well as other services, including therapeutic services;
• Create an incentive for physicians to narrow their choice of treatment options to those for which they will realize a profit, even where the best course of action may be no treatment;
• Influence physicians to refer to the lessee instead of referring to another entity that utilizes the same or different (and perhaps more efficacious) technology to treat the patient's condition;
• Result in physicians steering patients to equipment they own, even if it means having the patient travel to a non-convenient site for services using the leased equipment; and
• Increase costs to the Medicare program when referring physicians pressure hospitals to use their leasing company despite not being the low cost provider. (
We note also that, in the CY 2016 PFS final rule, we expressed our continued concern that, when physicians have a financial incentive to refer a patient to a particular entity, this incentive can affect utilization, patient choice, and competition. Physicians can overutilize by ordering items and services for patients that, absent a profit motive, they would not have ordered. A patient's choice is diminished when physicians steer patients to less convenient, lower quality, or more expensive providers of health care, just because the physicians are sharing profits with, or receiving remuneration from, the providers. And lastly, where referrals are controlled by those sharing profits or receiving remuneration, the medical marketplace suffers if new competitors cannot win business with superior quality, service, or price (80 FR 41926). In that rule, in establishing the exception at § 411.357(y) for timeshare arrangements, we determined it necessary to exclude from the exception any timeshare arrangements that incorporate compensation formulas based on: (1) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services provided while using the timeshare; or (2) per-unit of service fees, to the extent that such fees reflect services provided to patients referred by the party granting permission to use the timeshare to the party to which the permission is granted. We explained our belief that timeshare arrangements based on percentage compensation or per-unit of service compensation formulas present a risk of program or patient abuse because they may incentivize overutilization and patient steering. We noted, by way of example, that a per-patient compensation formula could incent the timeshare grantor to refer patients (potentially for unnecessary consultations or services) to the party using the timeshare because the grantor will receive a payment each time the premises, equipment, personnel, items, supplies, or services are used (80 FR 71331 through 71332). Similarly, we believe that arrangements utilizing rental charges for the rental of office space or equipment that are determined using a formula that rewards the lessor for each service the lessor refers to the lessee are susceptible to this and other abuse. Simply put, per-click lease arrangements create an incentive for overutilization because the physician knows that the more referrals he or she makes to the lessee, the more revenue that that physician will earn.
For all of these reasons, and because we believe that there is a continued need to protect the program and its beneficiaries against the potential abuses of per-click office space and equipment leases, we are finalizing without modification the re-proposed regulations at § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B), which include a requirement that the rental charges for the lease of office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
After considering the comments, for the reasons set forth above and in the CY 2017 proposed rule (81 FR 46448), we are finalizing without modification our proposal to include at § 411.357(a)(5)(ii)(B), (b)(4)(ii)(B), (l)(3)(ii), and (p)(1)(ii)(B) a requirement that the rental charges for the lease of office space or equipment are not determined using a formula based on per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
We proposed to revise § 411.372(a) by making a minor technical correction to change the instructions for submitting a request for an advisory opinion relating to physician referrals. We noted that the current language in this subsection directs a requesting party to submit its request to a physical address that is out of date. In an effort to expedite the receipt and processing of these requests, and to account for any future changes, we proposed to revise paragraph (a) to state that a party or parties must submit a request for an advisory opinion to CMS according to the instructions specified on the CMS Web site.
We noted that, at the time of the proposed rule, the correct address for such advisory opinion requests was: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Office of Financial Management, Division of Premium Billing and Collections, Mail Stop C3-09-27, Attention: Advisory Opinions, 7500 Security Boulevard, Baltimore, MD 21244-1850. However, we noted that this address is subject to change, per this technical correction, and that parties seeking to submit a request for an advisory opinion relating to physician referrals would need to refer to the instructions on the CMS Web site.
We received no comments regarding this technical correction and are finalizing it without modification.
Section 1877 of the Act prohibits a physician from referring a Medicare beneficiary for certain designated health services (DHS) to an entity with which the physician (or a member of the physician's immediate family) has a financial relationship, unless an exception applies. Section 1877 of the Act also prohibits the DHS entity from submitting claims to Medicare or billing the beneficiary or any other entity for Medicare DHS that are furnished as a result of a prohibited referral.
Section 1877(h)(6) of the Act and § 411.351 of our regulations specify that the following services are DHS:
• Clinical laboratory services.
• Physical therapy services.
• Occupational therapy services.
• Outpatient speech-language pathology services.
• Radiology services.
• Radiation therapy services and supplies.
• Durable medical equipment and supplies.
• Parenteral and enteral nutrients, equipment, and supplies.
• Prosthetics, orthotics, and prosthetic devices and supplies.
• Home health services.
• Outpatient prescription drugs.
• Inpatient and outpatient hospital services.
In § 411.351, we specify that the entire scope of four DHS categories is defined in a list of CPT/HCPCS codes (the Code List), which is updated annually to account for changes in the most recent CPT and HCPCS Level II publications. The DHS categories defined and updated in this manner are:
• Clinical laboratory services.
• Physical therapy, occupational therapy, and outpatient speech-language pathology services.
• Radiology and certain other imaging services.
• Radiation therapy services and supplies.
The Code List also identifies those items and services that may qualify for either of the following two exceptions to the physician self-referral prohibition:
• EPO and other dialysis-related drugs furnished in or by an ESRD facility (§ 411.355(g)).
• Preventive screening tests, immunizations, or vaccines (§ 411.355(h)).
The definition of DHS at § 411.351 excludes services for which payment is made by Medicare as part of a composite rate (unless the services are specifically identified as DHS and are themselves payable through a composite rate, such as home health and inpatient and outpatient hospital services). Effective January 1, 2011, EPO and dialysis-related drugs furnished in or by an ESRD facility (except drugs for which there are no injectable equivalents or other forms of administration), have been reimbursed under a composite rate known as the ESRD prospective payment system (ESRD PPS) (75 FR 49030). Accordingly, EPO and any dialysis-related drugs that are paid for under ESRD PPS are not DHS and are not listed among the drugs that could qualify for the exception at § 411.355(g) for EPO and other dialysis-related drugs furnished by an ESRD facility.
Drugs for which there are no injectable equivalents or other forms of administration were scheduled to be paid under ESRD PPS beginning January 1, 2014 (75 FR 49044). However, there have been several delays of the implementation of payment of these drugs under ESRD PPS. Most recently, on December 19, 2014, section 204 of the Achieving a Better Life Experience Act of 2014 (ABLE) (Pub. L. 113-295) was enacted and delayed the inclusion of these drugs under the ESRD PPS until 2025. Until that time, such drugs furnished in or by an ESRD facility are not paid as part of a composite rate and thus, are DHS. For purposes of the exception at § 411.355(g), only those drugs that are required for the efficacy of dialysis may be identified on the List of CPT/HCPCS Codes as eligible for the exception. As we have explained previously in the CY 2010 PFS final rule with comment period (75 FR 73583), we do not believe any of these drugs are required for the efficacy of dialysis. Therefore, we have not included any such drugs on the list of drugs that can qualify for the exception.
The Code List was last updated in Tables 50 and 51 of the CY 2016 PFS final rule with comment period (80 FR 71342).
We received one public comment relating to the Code List that became effective January 1, 2016.
The updated, comprehensive Code List effective January 1, 2017, is available on our Web site at
Additions and deletions to the Code List conform it to the most recent publications of CPT and HCPCS Level II and to changes in Medicare coverage policy and payment status.
Tables 45 and 46 identify the additions and deletions, respectively, to the comprehensive Code List that become effective January 1, 2017. Tables 45 and 46 also identify the additions and deletions to the list of codes used to identify the items and services that may qualify for the exception in § 411.355(g) (regarding dialysis-related outpatient prescription drugs furnished in or by an ESRD facility) and in § 411.355(h) (regarding preventive screening tests, immunizations, and vaccines).
Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. Chapter 35), we are required to publish a 30-day notice in the
To fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the PRA requires that we solicit comment on the following issues:
• The need for the information collection and its usefulness in carrying out the proper functions of our agency.
• The accuracy of our burden estimates.
• The quality, utility, and clarity of the information to be collected.
• Our effort to minimize the information collection burden on the affected public, including the use of automated collection techniques.
In the CY 2017 PFS proposed rule (81 FR 46456-46457) we solicited public comment on each of the section 3506(c)(2)(A)-required issues for the following information collection requirements. PRA-related comments were received as indicated below under section IV.B.2.
To derive average costs, we used data from the U.S. Bureau of Labor Statistics' May 2015 National Occupational Employment and Wage Estimates for all salary estimates. In this regard, Table 47 presents the mean hourly wage, the cost of fringe benefits (calculated at 100 percent of salary), and the adjusted hourly wage.
As indicated, we are adjusting our employee hourly wage estimates by a factor of 100 percent. This is necessarily a rough adjustment, both because fringe benefits and overhead costs vary significantly from employer to employer, and because methods of estimating these costs vary widely from study to study. Nonetheless, there is no practical alternative and we believe that doubling the hourly wage to estimate total cost is a reasonably accurate estimation method.
For individual EPs or group practices, who choose to separately report quality measures during the secondary PQRS reporting period for the 2017 PQRS payment adjustment, who bill under the TIN of an ACO participant if the ACO failed to report on behalf of such EPs or group practices during the previously established reporting period for the 2017 PQRS payment adjustment, we do not believe the individual EP or group practice incurs any additional burden. The associated reporting burden which is currently approved by OMB under control number 0938-1059 (CMS-10276) explains that the PQRS annual burden estimate was calculated separately for (1) individual eligible professionals and group practices using the claims (for eligible professionals only), (2) qualified registry and QCDR, (3) EHR-based reporting mechanisms, and (4) group practices using the GPRO. We estimated that ALL 1.25 million eligible professionals will participate in the PQRS in 2016 for purposes of meeting the criteria for satisfactory reporting (or, in lieu of satisfactory reporting, satisfactory participation in a QCDR) for the 2018 PQRS payment adjustment. This is a high estimate according to the 2014 PQRS Reporting Experience and Trends Report which found approximately 822,000 EPs participated in PQRS in 2014. Therefore, the additional EPs who choose to report separately from the ACOs have already been accounted for in the PQRS burden. We estimate there were approximately 1,947 EPs that are part of the 218 participant TINs that are under the 8 ACOs that failed to successfully report their 2015 quality data. There is no change in the reporting mechanisms or reporting criteria for PQRS. It is important to note that if the ACO fails to report on behalf of an EP or group practice and the EP or group practice does not utilize this secondary reporting period they may be subject to a downward adjustment.
We did not receive any comments pertaining to our position that the proposed rule would not set out any additional requirements or burden. Consequently, we are restating our position without change.
Consistent with section 1834(q) of the Act (as amended by section 218(b) of the PAMA), we have established specific requirements for clinical decision support mechanisms (CDSMs) that can be qualified CDSMs under § 414.94 as
Applications must be submitted electronically and demonstrate how the CDSM meets the requirements under § 414.94(g)(1). Specifically, applications must demonstrate how the CDSM: (1) Makes available specified applicable AUC and its related supporting documentation; (2) identifies the appropriate use criterion consulted if the CDSM makes available more than one criterion relevant to a consultation for a patient's specific clinical scenario; (3) makes available, at a minimum, specified applicable AUC that reasonably address common and important clinical scenarios within all priority clinical areas identified in § 414.94(e)(5); (4) is able to incorporate specified applicable AUC from more than one qualified PLE; (5) determines, for each consultation, the extent to which the applicable imaging service is consistent with a specified applicable AUC; (6) generates and provides a certification or documentation at the time of order each time an ordering professional consults a qualified CDSM that includes a unique consultation identifier that documents: Which qualified CDSM was consulted, the name and national provider identifier (NPI) of the ordering professional that consulted the CDSM, whether the service ordered would adhere to specified applicable AUC, whether the service ordered would not adhere to specified applicable AUC, or whether the specified applicable AUC consulted was not applicable to the service ordered; (7) updates AUC content within 12 months from the date the qualified PLE updates AUC; (8) has a protocol in place to expeditiously remove AUC determined by the qualified PLE to be potentially dangerous to patients and/or harmful if followed; (9) makes available specified applicable AUC that reasonably address common and important clinical scenarios within any new priority clinical area for consultation through the qualified CDSM within 12 months of the priority clinical area being finalized by CMS; (10) meets privacy and security standards under applicable provisions of law; (11) provides the ordering professional aggregate feedback regarding their consultations with specified applicable AUC in the form of an electronic report on at least an annual basis; (12) maintains electronic storage of clinical, administrative, and demographic information of each unique consultation for a minimum of 6 years; (13) complies with modification(s) to any requirements under § 414.94(g)(1) made through rulemaking within 12 months of the effective date of the modification; and (14) notifies ordering professionals upon de-qualification.
To be specified as a qualified CDSM by CMS, applicants must document adherence to the requirements in their application for CMS review and use the application process identified in § 414.94(g)(2) which includes: (1) Applications submitted by CDSMs documenting adherence to each requirement outlined in § 414.94(g)(1) must be received annually by January 1 except for the first round of applications following publication of the CY 2017 PFS Final Rule which will be due by March 1, 2017; (2) CDSMs with applications that document adherence to all requirements under § 414.94(g)(1) may receive full qualification and CDSMs with applications that cannot document adherence to each requirement must document how and when each requirement is reasonably expected to be met and may receive preliminary qualification; (3) the preliminary qualification period begins June 30, 2017 and ends when CMS implements sections 1834(q)(4)(A) and 1834(q)(4)(B) of the Act; (4) CDSMs with preliminary qualification that fail to meet all requirements by the end of the preliminary qualification period will not be automatically converted to qualified status; (5) all qualified CDSMs specified by CMS in each year will be included on the list of specified qualified CDSMs posted to the CMS Web site by June 30 of that year; (6) qualified CDSMs are specified by CMS as such for a period of 5 years; and (7) qualified CDSMs are required to re-apply during the 5th year after they are specified by CMS to maintain their status as qualified CDSMs and the applications must be received by CMS by January 1 of the 5th year after the most recent approval date. If a qualified CDSM is found to be non-adherent to the requirements identified above, CMS may terminate its qualified status or may consider this information during re-qualification.
The one-time burden associated with the requirements under § 414.94(g)(2) is the time and effort it will take each of the approximately 30 CDSM developers (as estimated by CMS, the Office of the National Coordinator (ONC), and the Agency for Healthcare Research and Quality (AHRQ)) that have interests in incorporating AUC consultation into their mechanisms' functionality to compile, review and submit documentation demonstrating adherence to the CDSM requirements. We anticipate 30 respondents based on the number of existing CDSMs that have expressed an interest in incorporating AUC for advanced diagnostic imaging, as well as our estimation of the number of CDSM developers that may be interested in incorporating AUC for advanced diagnostic imaging in the future as their mechanisms develop and evolve. Each respondent will voluntarily compile, review and submit documentation that demonstrates their adherence to the CDSM requirements listed above.
We estimate it will take 10 hours at $68.18/hr for a business operations specialist to compile, prepare and submit the required information, 2.5 hours at $86.72/hr for a computer system analyst to review and approve the submission, 2.5 hours at $135.58/hr for a computer and information systems manager to review and approve the submission, and 5 hours at $131.02/hr for a lawyer to review and approve the submission. In this regard, we estimate 20 hours per submission at a cost of $1,892.65. In aggregate, we estimate 600 hours (20 hr × 30 submissions) at $56,779.50 ($1,892.65 × 30 submissions).
After the anticipated initial 30 respondents, we expect less than 10 applicants to apply to become qualified CDSMs annually. Since we estimate fewer than 10 respondents, the information collection requirements and burden are exempt (5 CFR 1320.2(c)) from the requirements of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501
Given that qualified CDSMs must re-apply every 5 years, in years 6-10, we expect the initial 30 entities will re-apply. The ongoing burden for re-applying is expected to be half the burden of the initial application process. The CDSM developers will be able to make modifications to their original application which should result in a burden of 5 hours at $68.18/hr for a business operations specialist to compile, prepare and submit the required information, 1.25 hours at $86.72/hr for a computer system analyst to review and approve the submission, 1.25 hours at $135.58/hr for a computer and information systems manager to review and approve the submission, and 2.5 hours at $131.02/hr for a lawyer to review and approve the submission. Annually, we estimate 10 hours per submission at a cost of $946.33 per CDSM developer. In aggregate, we estimate 300 hours (10 hr × 30
In response to public comments, we added a new requirement under § 414.94(g)(1)(xii) whereby CDSMs are required to notify ordering professionals upon de-qualification. We estimate that 1 CDSM will be de-qualified each year. Because this disclosure is required of less than 10 entities, the PRA is not applicable.
The aforementioned requirements and burden will be submitted to OMB under control number 0938-1315 (CMS-10624).
As regulatory requirements become more complex, we will look to innovative technologies that minimize the burden on an organizations' budget and manpower. To this end, the CDSM functionality requirements identified in § 414.94(g)(1) will help practitioners meet the requirements of the AUC program. While the CDSM application process in § 414.94(g)(2) is a new burden under this program, the CDSM functionality requirements in § 414.94(g)(1) do not add burden as they are functions of the CDSM. These mechanisms function consistently with their voluntary and individualized design so the requirements in § 414.94(g)(1) are either part of a mechanism's functionality or not. If CDSM developers wish their CDSMs to become qualified under this program, they may choose to develop the functionality of their mechanisms consistent with these requirements to be qualified, but all CDSMs are not required to participate in this program. For example, a CDSM that does not incorporate AUC for any advanced diagnostic imaging services would likely choose not to seek to become qualified under this Medicare AUC program. As such, only CDSMs that wish to participate in the Medicare AUC for advanced diagnostic imaging services program are required to apply for qualification and, in choosing to seek qualification, CDSM developers would also choose to incorporate the requirements into their mechanism's functionality.
We received public comments (see below) regarding our proposed requirements and burden estimates. We considered the comments and are largely adopting the proposed provisions with minimal changes to improve clarity. Three areas where we have made more significant changes include: (1) Revising the proposed requirement for CDSMs to “reasonably encompass the entire clinical scope of all priority clinical areas” to now “reasonably address common and important clinical scenarios within all priority clinical areas;” (2) a new requirement that qualified CDSMs notify ordering professionals upon de-qualification; and (3) a new preliminary qualification period for CDSMs that apply for qualification during the first application period but do not fully meet all requirements under § 414.94(g)(1).
Specialists may seek to align themselves with a qualified CDSM that contains AUC more exhaustive in one area of medicine to reflect the imaging services that they order most often.
We continue to believe that all tools should contain the specified applicable AUC needed by the ordering professionals they serve, as well as contain specified applicable AUC related to the priority clinical areas to ensure that if the professional needs to order an imaging service then they will not have to go outside their regular qualified CDSM for the consultation. We reiterate that we envision having a given qualified CDSM allow efficient access to ordering professionals of one or more specialty-focused specified applicable AUC sets along with more comprehensive specified applicable AUC sets. We believe the determination of which AUC sets are made accessible through a given CDSM should be demand-driven by ordering professionals, who would be choosing from a marketplace of options for both CDSMs and AUC, all of which meet basic CMS qualifications to ensure implementation of the PAMA statutory requirements.
To balance the requirement for the minimum floor, we believe it is important to reconsider the extent to which specified applicable AUC encompass the entire clinical scope of priority clinical areas. We agree that requiring the entire clinical scope may not yield consultation of the highest quality specified applicable AUC and that ordering professionals, particularly specialists, may not require specified applicable AUC addressing the entire clinical scope of a priority clinical area. Therefore, we agree with commenters who suggested we keep the AUC floor but allow the requirement to be fulfilled if specified applicable AUC address less than the entire scope of the priority clinical areas and instead reasonably address the common and important clinical scenarios within each priority clinical area.
There are approximately 1.9 million providers and suppliers nationwide that are enrolled in Medicare. Through our analysis of currently available encounter data provided by MA organizations, we have found that some providers and suppliers that furnish items or services to MA organization enrollees are not enrolled in Medicare in an approved status. Based on preliminary data, we estimate that 64,000 MA providers and suppliers will have to enroll in Medicare under § 422.222 in order to treat enrollees.
About half of the approximately 64,000 unenrolled providers and suppliers, or 32,000, are individuals and the other half are organizations. We do not have data at this point to confirm the number of unenrolled individuals who are physicians as opposed to non-physician practitioners. For purposes of fulfilling the requirements of the PRA, we will project that one-half (16,000) are physicians and the other half (16,000) are practitioners.
Consistent with our prior time (per respondent) estimates, we project that it will take 3 hours at $194.66/hr for a physician and $93.30/hr for a non-physician practitioner to complete their individual enrollments. For organizations (office and administrative support personnel), we estimate it will take 6 hours at $34.94/hr, since organizational enrollees typically must submit more data than individual enrollees. For physicians, we estimate a total burden of 48,000 hours (16,000 applicants × 3 hours) at a cost of $9,343,680 (48,000 hr × $194.66/hr). For non-physician practitioners, we estimate 48,000 hours (16,000 applicants × 3 hours) at a cost of $4,478,400 (48,000 hr × $93.30/hr). For organizations, we estimate 192,000 hours (32,000 applicants × 6 hours) at a cost of $6,708,480 (192,000 hr × $34.94). In aggregate, we estimate 288,000 hours at $20,530,560.
When projected annually over OMB's maximum 3-year approval period, we estimate 96,000 hours at a cost of $6,843,520.
For physicians and non-physician practitioners, the requirements and annualized burden (32,000 hours) will be submitted to OMB under control number 0938-0685 (Form CMS-855I) because physicians and non-physician practitioners enroll via the Form CMS-855I. For organizations, the requirements and annualized burden of 64,000 hours (192,000 hours/3 years) will be submitted to OMB under control number 0938-0685 (21,333.3 hours for Form CMS-855A and 21,333.3 hours for Form CMS-855B) and control number 0938-1056 (21,333.3 hours for Form CMS-855S). The specific form to be completed will depend upon the provider or supplier type at issue. For instance, and consistent with current enrollment policy, certified providers and certain certified suppliers will complete the Form CMS-855A; group practices, ambulance suppliers, and certain other supplier types will complete the Form CMS-855B; suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) will complete the Form CMS-855S.
Please note that breakout of the organization burden (dividing 64,000 hours by 3 forms) is an estimate. Logistically, this is necessary for the purposes of submitting burden for approval. We have no way of estimating the number of providers/suppliers that will complete the individual forms. We welcomed comments on this issue to help us derive a more reliable breakout but received none. Nor did we receive comments pertaining to any other aspects of the proposed requirements or burden. Consequently, we are adopting our proposed requirements and burden estimates without change.
In the proposed rule, new § 422.272 proposed an annual public release of MA bid pricing data (with specified exceptions from release), which would occur after the first Monday in October and would contain MA bid pricing data that was approved by CMS for a contract year at least 5 years prior to the upcoming calendar year. Under Part C, MA organizations (MAOs) are required to submit bid data to CMS each year for MA plans they wish to offer in the upcoming contract year (calendar year), under current authority at § 422.254.
Proposed §§ 422.2490 (for Part C) and 423.2490 (for Part D) also provided for the public release of Part C and Part D MLR data for each contract year, which would occur no sooner than 18 months after the end of the contract year for which the MLR Report was submitted. Starting with contract year 2014, if an MAO or Part D sponsor fails to spend at least 85 percent of the revenue received under an MA or Part D contract on incurred claims and quality improvement activities, the MAO or Part D sponsor must remit to the Secretary the product of: (1) The contract's total revenue; and (2) the difference between 85 percent and the contract's MLR. For each contract year, each MAO and Part D sponsor must submit an MLR Report to CMS which includes the data needed by the MAO or Part D sponsor to calculate and verify the MLR and remittance amount, if any, for each contract. The proposed rule provided for the release of the Part C and Part D MLR data contained in the MLR Reports that we receive from MAOs and Part D sponsors, with specified exceptions to release.
We determined for the proposed rule that the proposed provisions on the release of MA bid pricing data and the release of Part C and Part D MLR data did not change any of the existing requirements regarding submission of bid data and MLR data by MAOs or Part D plan sponsors, nor did the proposed rule propose any new or revised reporting, recordkeeping, or third-party disclosure requirements. We noted that although the proposed provisions have no impact on respondent requirements or burden, the changes have been submitted to OMB for approval under control number 0938-0944 (CMS-10142) for MA bid pricing data and 0938-1232 (CMS-10476) for Part C and Part D MLR data.
We did not receive any comments on the proposed requirements or burden and are finalizing them without change.
Changes to §§ 422.501 and 422.510 involve only CMS contract changes and will not result in any external charges or operational costs to MA organizations. Many MA organizations already require Medicare enrollment for all their network providers and suppliers. So there will be no additional costs to most MA and MA-PD plans. The only tangible costs will be to those providers or suppliers that are not enrolled and those costs are estimated in section IV.B.3. of this final rule.
Section 1115A(d)(3) of the Social Security Act exempts the Center for Medicare and Medicaid Innovation (CMMI) model tests and expansions, including the Medicare Diabetes Prevention Program expansion, from the PRA. The section provides that Chapter 35 of title 44, United States Code, which includes such provisions as the PRA, shall not apply to the testing and evaluation of CMMI models or expansion of such models.
Section 1899(e) of the Act provides that chapter 35 of title 44 of the U.S. Code, which includes such provisions as the PRA, shall not apply to any information collection activities under the Shared Savings Program.
This rule references three information collection requirements that do not pertain to the amendments in the regulatory text. While the activities meet the PRA's definition of an information collection requirement, section 220 of the Protecting Access to Medicare Act (PAMA) of 2014 (Pub. L. 113-93) provides that the activities are exempt from the requirements of under the PRA. The exemption applies to information collected to ensure the accurate valuation of services under the Physician Fee Schedule which includes but is not limited to surveys of physicians, other suppliers, providers of services, manufacturers, and vendors; surgical logs, billing systems, or other practice or facility records; electronic health records; and, any other mechanism deemed appropriate by the Secretary.
The activities consist of the following:
Section II.D.2. of this final rule details our plans for a claims-based reporting program for global surgical services. Our claims-based data collection is applicable to 10- and 90-day global services furnished on or after January 1, 2017, which will set out: Who will be required to report, what they will be required to report, and how the reports will be submitted.
As discussed earlier in section II.D.6.e.(1) through (2) of this final rule, we intend to conduct a survey of practitioners to help us explore options and collect data with respect to assessing and revaluing the global surgery services.
In section II. D.6.e.(3) of this final rule, we intend to conduct a survey of ACOs on a number of issues surrounding pre- and post-operative surgical services. In addition to the PRA exemption as described above under PAMA, the survey is also exempt from the PRA under section 3022 of the Affordable Care Act which exempts collections associated with the Medicare Shared Savings Program.
We have submitted a copy of this rule's information collection and recordkeeping requirements to OMB for review and approval. The requirements are not effective until they have been approved by the OMB.
To obtain copies of the supporting statement and any related forms for the collections discussed above, please visit CMS' Web site at
We invite public comments on these potential information collection requirements. If you wish to comment, please identify the rule (CMS-1654-F) and submit your comments to the OMB desk officer via one of the following transmissions:
PRA-related comments must be received on/by December 2, 2016.
This final rule makes payment and policy changes under the Medicare PFS and makes required statutory changes under the MACRA, ABLE, PAMA, and the Consolidated Appropriations Act of 2016. This final rule also makes changes to payment policy and other related policies for Medicare Part B, Part D, and Medicare Advantage.
We examined the impact 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 (February 2, 2013), 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 rules with economically significant effects ($100 million or more in any 1 year). We estimate, as discussed in this section, that the PFS provisions included in this final rule would redistribute more than $100 million in 1 year. Therefore, we estimate that this rulemaking is “economically significant” as measured by the $100 million threshold, and hence also a major rule under the Congressional Review Act. Accordingly, we prepared an RIA that, to the best of our ability, presents the costs and benefits of the rulemaking. The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals, practitioners and most other providers
The RFA requires that we analyze regulatory options for small businesses and other entities. We prepare a regulatory flexibility analysis unless we certify that a rule would not have a significant economic impact on a substantial number of small entities. The analysis must include a justification concerning the reason action is being taken, the kinds and number of small entities the rule affects, and an explanation of any meaningful options that achieve the objectives with less significant adverse economic impact on the small entities.
Approximately 95 percent of practitioners, other providers, and suppliers are considered to be small entities, based upon the SBA standards. There are over 1 million physicians, other practitioners, and medical suppliers that receive Medicare payment under the PFS. Because many of the affected entities are small entities, the analysis and discussion provided in this section, as well as elsewhere in this final rule is intended to comply with the RFA requirements regarding significant impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare an RIA 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 for Medicare payment regulations and has fewer than 100 beds. We did not prepare an analysis for section 1102(b) of the Act because we determined, and the Secretary certified, that this final rule would 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 on state, local, or tribal governments or on the private sector 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. This final rule will impose no mandates on state, local, or tribal governments or on the private sector.
Executive Order 13132 establishes certain requirements that an agency must meet when it issues a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. Since this regulation does not impose any costs on state or local governments, the requirements of Executive Order 13132 are not applicable.
We prepared the following analysis, which together with the information provided in the rest of this preamble, meets all assessment requirements. The analysis explains the rationale for and purposes of this final rule; details the costs and benefits of the rule; analyzes alternatives; and presents the measures we would use to minimize the burden on small entities. As indicated elsewhere in this final rule, we are implementing a variety of changes to our regulations, payments, or payment policies to ensure that our payment systems reflect changes in medical practice and the relative value of services, and implementing statutory provisions. We provide information for each of the policy changes in the relevant sections of this final rule. We are unaware of any relevant federal rules that duplicate, overlap, or conflict with this final rule. The relevant sections of this final rule contain a description of significant alternatives if applicable.
Section 1848(c)(2)(B)(ii)(II) of the Act requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustments to preserve budget neutrality.
Our estimates of changes in Medicare expenditures for PFS services compare payment rates for CY 2016 with proposed payment rates for CY 2017 using CY 2015 Medicare utilization. The payment impacts in this final rule reflect averages by specialty based on Medicare utilization. The payment impact for an individual practitioner could vary from the average and would depend on the mix of services he or she furnishes. The average percentage change in total revenues would be less than the impact displayed here because practitioners and other entities generally furnish services to both Medicare and non-Medicare patients. In addition, practitioners and other entities may receive substantial Medicare revenues for services under other Medicare payment systems. For instance, independent laboratories receive approximately 83 percent of their Medicare revenues from clinical laboratory services that are paid under the Clinical Lab Fee Schedule.
The annual update to the PFS conversion factor (CF) was previously calculated based on a statutory formula; for details about this formula, we refer readers to the CY 2015 PFS final rule with comment period (79 FR 67741 through 67742). Section 101(a) of the MACRA repealed the previous statutory update formula and amended section 1848(d) of the Act to specify the update adjustment factors for calendar years 2015 and beyond. For CY 2017, the specified update is 0.5 percent before applying other adjustments.
Section 220(d) of the PAMA added a new paragraph at section 1848(c)(2)(O) of the Act to establish an annual target for reductions in PFS expenditures resulting from adjustments to relative values of misvalued codes. Under section 1848(c)(2)(O)(ii) of the Act, if the net reduction in expenditures for the year is equal to or greater than the target for the year, reduced expenditures attributable to such adjustments shall be redistributed in a budget-neutral manner within the PFS in accordance with the existing budget neutrality requirement under section 1848(c)(2)(B)(ii)(II) of the Act. Section 1848(c)(2)(O)(iii) of the Act specifies that, if the estimated net reduction in PFS expenditures for the year is less than the target for the year, an amount equal to the target recapture amount shall not be taken into account when applying the budget neutrality requirements specified in section 1848(c)(2)(B)(ii)(II) of the Act. We estimate the CY 2017 net reduction in expenditures resulting from adjustments to relative values of misvalued codes to be 0.32 percent. Since this amount does not meet the 0.5 percent target established by the Achieving a Better Life Experience Act of 2014 (ABLE) (Division B of Pub. L. 113-295, enacted December 19, 2014), payments under the fee schedule must be reduced by the difference between the target for the year and the estimated net reduction in expenditures, known as the target recapture amount. As a result, we estimate that the CY 2017 target
Effective January 1, 2012, we implemented an MPPR of 25 percent on the professional component (PC) of advanced imaging services. Section 502(a)(2)(A) of Division O, Title V of the Consolidated Appropriations Act of 2016 (Pub. L 114-113, enacted on December 18, 2015) added a new section 1848(b)(10) of the Act, which revises the MPPR on the professional component of imaging services from 25 percent to 5 percent, effective January 1, 2017. Section 502(a)(2)(B) of Division O, Title V of the Consolidated Appropriations Act of 2016 added a new subclause at section 1848(c)(2)(B)(v)(XI) which exempts the MPPR reductions attributable to the new 5 percent MPPR on the PC of imaging from the PFS budget neutrality provision. However, the provision does not exempt the change attributable to the 25 percent MPPR from PFS budget neutrality. Therefore, for CY 2017 we must calculate PFS rates in a manner that exempts the 5 percent MPPR from budget neutrality but ensures that the elimination of the 25 percent MPPR is included in PFS budget neutrality. We note that the application of the 25 percent MPPR has been applied in a budget neutral fashion to date.
The CY 2017 final PFS rates exclude the 5 percent MPPR for the professional component of imaging services by calculating the rates as if the discount does not occur, consistent with our approach to other discounts that occur outside of PFS budget neutrality. In order to implement the change from the 25 percent discount in 2016 to the 5 percent discount in 2017 within PFS budget neutrality, we measured the difference in total RVUs for the relevant services, assuming an MPPR of 25 percent and the total RVUs for the same services without an MPPR, and then applied that difference as an adjustment to the conversion factor to account for the increased expenditures attributable to the change, within PFS budget neutrality. This approach is consistent with the statutory provision that requires the 5 percent MPPR to be implemented outside of PFS budget neutrality.
To calculate the final conversion factor for this year, we multiplied the product of the current year conversion factor and the update adjustment factor by the target recapture amount, the budget neutrality adjustment and the imaging MPPR adjustment described in the preceding paragraphs. We estimate the CY 2017 PFS conversion factor to be 35.8887, which reflects the budget neutrality adjustment, the 0.5 percent update adjustment factor specified under section 1848(d)(18) of the Act, the adjustment due to the non-budget neutral 5 percent MPPR for the professional component of imaging services, and the −0.18 percent target recapture amount required under section 1848(c)(2)(O)(iv) of the Act and described above. We estimate the CY 2017 anesthesia conversion factor to be 22.0454, which reflects the same overall PFS adjustments.
We note that the proposed RVU budget neutrality adjustment was negative, due to the estimated overall increases in proposed RVUs relative to 2016. However, because we did not finalize the proposed changes to make separate payment for the additional resource costs involved in mobility impairment services, we are finalizing an overall decrease in RVUs relative to 2016. This results in an RVU budget neutrality adjustment that is positive.
Table 52 shows the payment impact on PFS services of the proposals contained in this final rule. To the extent that there are year-to-year changes in the volume and mix of services provided by practitioners, the actual impact on total Medicare revenues would be different from those shown in Table 52 (CY 2017 PFS Estimated Impact on Total Allowed Charges by Specialty). The following is an explanation of the information represented in Table 52.
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The most widespread specialty impacts of the final RVU changes are generally related to the changes to RVUs for specific services resulting from the Misvalued Code Initiative, including finalized RVUs for new and revised codes. Several specialties, including interventional radiology and independent labs, would experience significant decreases to overall payments for services that they frequently furnish as a result of revisions to the coding structure or the final inputs used to develop RVUs for the codes that describe particular services. Other specialties, including endocrinology and family practice, would experience significant increases to payments for similar reasons.
We note that the positive impact for CY 2017 several specialties is lower than it was in the proposed rule, especially for certain specialties disproportionately likely to have reported the proposed code related to mobility impairment services. Because we did not finalize that proposal, we do not anticipate that shift in payment for CY 2017. However, we note that we believe that many practitioners of those same specialties will likely report the several other new codes described in section F of this final rule. Based on the history with other, similar codes, we would anticipate significant changes in allowed charges for these specialties over a longer period of time thanis shown by the single year comparison that we believe is more generally relevant in displaying the impacts of changes in payment under the PFS.
We often receive comments regarding the changes in RVUs displayed on the specialty impact table, including comments received in response to the proposed rates for the current year. We remind stakeholders that although the estimated impacts are displayed at the specialty level, typically the changes are driven by the valuation of a relatively small number of new and/or potentially misvalued codes. The percentages in the table are based upon aggregate estimated PFS allowed charges summed across all services furnished by physicians, practitioners, and suppliers within a specialty to arrive at the total allowed charges for the specialty, and compared to the same summed total from the previous calendar year. They are therefore averages, and may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty.
Column F of Table 52 displays the estimated CY 2017 impact on total allowed charges, by specialty, of all the RVU changes. A table shows the estimated impact on total payments for selected high volume procedures of all of the changes is available under “downloads” on the CY 2017 PFS final rule Web site at
As discussed in section II.I. of this final rule, we added several new codes to the list of Medicare telehealth services. Although we expect these changes to increase access to care in rural areas, based on recent utilization of similar services already on the telehealth list, we estimate no significant impact on PFS expenditures from the additions relative to overall PFS expenditures.
Based upon statutory requirements, we proposed new GPCIs for each Medicare payment locality. The final GPCIs incorporate updated data and cost share weights as discussed in section II.I. The Act requires that updated GPCIs be phased in over two years. Addendum D shows the estimated effects of the revised GPCIs on area GAFs for the transition year (CY 2017) and the fully implemented year (CY 2018). The GAFs reflect the use of the updated underlying GPCI data, and the cost share weights remain unchanged from the previous (seventh) GPCI update. The GAFs are a weighted composite of each area's work, PE and malpractice expense GPCIs using the national GPCI cost share weights. Although we do not actually use the GAFs in computing the PFS payment for a specific service, they are useful in comparing overall areas costs and payments. The actual effect on payment for any actual service will deviate from the GAF to the extent that the proportions of work, PE and malpractice expense RVUs for the service differ from those of the GAF.
The most significant changes occur in 19 non-California payment localities, where the fully implemented (CY 2018) GAF moves up by more than 1 percent (14 payment localities) or down by more than 2 percent (5 payment localities). These changes, required by section 1848(e)(6) of the Act, are discussed in section II.I. of this final rule.
We are finalizing our proposal to revise § 405.2413(a)(5) and § 405.2415(a)(5) to state that services and supplies furnished incident to TCM and CCM services can be furnished under general supervision of a RHC or FQHC practitioner. This regulatory change was already made for CCM services furnished by practitioners billing the PFS, and changes to RHC and FQHC regulations have no impact on regulations for practitioners billing under the PFS. The impact of this change on RHCs and FQHCs in 2017 is negligible, as estimates are rounded to the nearest 5 million and 2017 was too small of an impact to have a notable effect on the estimate.
We are also finalizing our proposal to revise the CCM requirements for RHCs and FQHCs to be consistent with the proposed revisions to the CCM requirements for practitioners billing under the PFS. These revisions will allow RHCs and FQHCs to provide TCM and CCM services at the level that was projected when the programs were authorized, and therefore, no impact on spending is expected.
As discussed in section III.B of this final rule, we are finalizing our proposal to create a 2013-based FQHC market basket to update the FQHC PPS base payment rate. Table 53 shows the 5-year and 10-year fiscal cost estimates from switching from a MEI-adjusted base payment rate to a FQHC PPS market basket-adjusted base payment rate. This was determined by compiling data on historical FQHC spending, projecting it forward, and creating two separate baselines. The first baseline assumed an MEI price update and the second baseline assumed an FQHC specific market basket price update which was created by the Office of the Actuary within CMS. The utilization of services was held constant between the two
The clinical decision support mechanism (CDSM) requirements, as well as the application process that CDSM developers must comply with for their mechanisms to be specified as qualified under this program do not impact CY 2017 physician payments under the PFS.
We solicited comments to inform future rulemaking. We do not intend to finalize any requirements directly as a result of this final rule; so there is no impact to CY 2017 physician payments under the PFS.
Under section III.E. of the preamble of this final rule, we describe our proposal to revise the existing regulations by adding § 422.272 to provide for an annual public release of MA bid pricing data (with specified exceptions from release). We proposed that the annual release would occur after the first Monday in October and would contain MA bid pricing data that was accepted or approved by CMS for a contract year at least 5 years prior to the upcoming calendar year. We noted that under current authority at § 422.254, MA organizations (MAOs) are required to submit bid pricing data to CMS each year for MA plans they wish to offer in the upcoming contract year (calendar year).
In addition, we proposed to add § 422.2490 for Part C and § 423.2490 for Part D to provide for an annual public release of Part C and Part D medical loss ratio (MLR) data (with specified exceptions from release). This annual release would occur no sooner than 18 months after the end of the contract year for which MLR data was reported to us. Starting with contract year 2014, each MAO or Part D sponsor that fails to spend at least 85 percent of revenue received under an MA or Part D contract on incurred claims and quality improving activities must remit the difference to the government. Under current authority at § 422.2460 and § 423.2460, each year MAOs and Part D sponsors must submit an MLR Report to us, which includes the data needed by the MAO or Part D sponsor to calculate and verify the MLR and remittance amount, if any, for each contract.
We proposed to add regulatory language to permit our release of such data to the public. In the proposed rule, we determined that the proposed regulatory amendments do not impose any mandatory costs on the public or entities that seek to download and use the released data. We expect that this data will be available to the public from the CMS Web site (
We are restating information to inform providers to take steps to educate themselves and their staff about QMB billing prohibitions and to exempt QMB individuals from Medicare cost-sharing billing and related collection efforts. Therefore, there is no impact to CY 2017 physician payments under the PFS.
This final rule implements section 1866(j) of the Act which grants the Secretary the authority to make any necessary adjustments to the payments of an applicable provider of services or supplier who shares a TIN with an obligated provider of services or supplier that has an outstanding Medicare overpayment. The Secretary is authorized to adjust the payments of such applicable provider, regardless of whether that applicable provider is assigned a different Medicare billing number or National Provider Identifier (NPI) number from the obligated provider with the outstanding Medicare overpayment. The concept of offsetting or recouping payments of providers sharing a TIN to satisfy a Medicare overpayment is analogous to Treasury's current practice of offsetting against entities that share a TIN to collect Medicare overpayments. This final rule will help support our efforts to safeguard the Medicare Trust Funds by collecting its own overpayments more quickly and reducing the accounts receivable delinquency rates reported in the Treasury Report on Receivables. This final rule also helps the obligated provider because we will collect the overpayments more quickly; thus reducing the additional interest assessments that would continue on the provider's outstanding delinquent balance until paid in full. Therefore, there is no impact to CY 2017 physician payments under the PFS.
This final rule will require that providers and suppliers must be enrolled in Medicare in approved status
Virtually all of the quantifiable costs associated with this final rule involve the paperwork burden to providers and suppliers (see section IV. of this final rule). The estimates presented in this section do not address the potential financial benefits of this final rule from the standpoint of the rule's effectiveness in preventing or deterring certain providers from enrolling in or maintaining their enrollment in Medicare. We simply have no means of quantifying these benefits in monetary terms.
There are three main uncertainties associated with this final rule. First, we are uncertain as to the number of providers and suppliers that will be required to enroll in Medicare under § 422.222. Second, we cannot estimate the savings in fraud and abuse prevention that will accrue from this rule. Third, since we have no systematic method to know how many FDRs may be used by MA or MA-PD organizations to deliver services to Medicare beneficiaries, therefore, we cannot estimate the possible impact to FDRs.
We proposed to expand the Diabetes Prevention Program (DPP) Model in accordance with section 1115A(c) of the Act, and we proposed to refer to this expanded model as the Medicare Diabetes Prevention Program (MDPP). We proposed that MDPP would become effective January 1, 2018, and we would continue to test and evaluate MDPP as finalized. In the future, we will assess whether the nationwide implementation of the MDPP is continuing to either reduce Medicare spending without reducing quality of care or improve the quality of patient care without increasing spending, and could modify the nationwide MDPP as appropriate. In this final rule, we are finalizing the framework for expansion and finalizing details of the MDPP benefit, beneficiary eligibility criteria, and MDPP supplier eligibility criteria and enrollment policies. We will engage in additional rulemaking within the next year to address payment, delivery of virtual MDPP services, the preliminary recognition standard, use of coach information during enrollment and monitoring, and other program integrity safeguards. MDPP policies finalized in this rule and those proposed in future rulemaking will result in changes to our current financial projections and therefore affect economic impact estimates of MDPP. For these reasons, it is premature to provide an impact statement at this time. We intend to provide an impact statement in future rulemaking.
We are finalizing certain rules having to do with ACO quality reporting: (1) We are finalizing conforming changes to align with the policies adopted for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) in the QPP final rule with comment period including changes to the quality measure set; (2) we are finalizing a policy to streamline the quality validation audit process and, absent unusual circumstances, to use the results to modify an ACO's overall quality score; (3) we are finalizing revisions to references to the Quality Performance Standard and Minimum Attainment Level; (4) we are revising our policies regarding the application of flat percentages to provide that measures calculated as ratios are excluded from use of flat percentages when such benchmarks appear “clustered” or “topped out”; and (5) we are modifying our PQRS alignment rules to permit flexibility for EPs to report quality data to PQRS to avoid the PQRS and VM downward adjustments for 2017 and 2018 in cases where an ACO fails to report on their behalf. (The rule can be accessed at
We are also finalizing additional beneficiary protections when ACOs in Track 3 make use of the SNF 3-day rule waiver under the Shared Savings Program. Finally, we are finalizing certain technical changes and clarifications related to financial reconciliation for ACOs that fall below 5,000 assigned beneficiaries and related to our policies for consideration of claims billed by merged and acquired TINs.
Because the final policies are not expected to substantially change the quality reporting burden for ACOs participating in the Shared Savings Program and their ACO participants or financial calculations under the Shared Savings Program, we do not anticipate any impact for these final policies.
Section 1848(p) of the Act requires that we establish a value-based payment modifier (VM) and apply it to specific physicians and groups of physicians the Secretary determines appropriate starting January 1, 2015 and to all physicians and groups of physicians by January 1, 2017. Section 1848(p)(4)(C) of the Act requires the VM to be budget neutral. Budget-neutrality means that, in aggregate, the increased payments to high performing physicians and groups of physicians equal the reduced payments to low performing physicians and groups of physicians, as well as those physicians and groups of physicians that failed to avoid the PQRS payment adjustment as a group or as individuals.
In the CY 2015 PFS final rule with comment period (79 FR 67936 and 67941 through 67942), we established that, beginning with the CY 2017 payment adjustment period, the VM will apply to physicians in groups with two or more EPs and to physicians who are solo practitioners based on the applicable performance period, including physicians that participate in an ACO under the Shared Savings Program. In the CY 2014 PFS final rule with comment period (78 FR 74771 through 74772), we established CY 2015 as the performance period for the VM that will be applied to payments during CY 2017. In CY 2017, the VM will be waived for groups and solo practitioners, as identified by their TIN, if at least one EP who billed for Medicare PFS items and services under the TIN during 2015 participated in the Pioneer ACO Model or the Comprehensive Primary Care initiative in 2015 (80 FR 71288).
In the CY 2015 PFS final rule with comment period (79 FR 67938 through 67939), we adopted a two-category approach for the CY 2017 VM based on participation in the PQRS by groups and solo practitioners. Category 1 will include those groups that meet the criteria to avoid the PQRS payment adjustment for CY 2017 as a group
For groups and solo practitioners that participated in an ACO under the Shared Savings Program in CY 2015, they are considered to be Category 1 for the CY 2017 VM if the ACO in which they participated successfully reported on quality measures via the GPRO Web Interface in CY 2015 (79 FR 67946). As discussed in sections III.H. and III.K.1.e. of this final rule, we are finalizing our proposal to remove the prohibition on EPs who are part of a group or solo practitioner that participates in a Shared Savings Program ACO, for purposes of PQRS reporting for the CY 2017 and CY 2018 payment adjustments, to report outside the ACO. In section III.L.3.b. of this final rule, we are finalizing that for the CY 2017 payment adjustment period, if a Shared Savings Program ACO did not successfully report quality data as required by the Shared Savings Program under § 425.504 for the CY 2017 PQRS payment adjustment, then we will use the data reported to the PQRS by the EPs (as a group using one of the group registry, QCDR, or EHR reporting options or as individuals using the registry, QCDR, or EHR reporting option) under the participant TIN) outside of the ACO during the secondary PQRS reporting period to determine whether the TIN will fall in Category 1 or Category 2 under the VM. We are finalizing that groups that meet the criteria to avoid PQRS payment adjustment for CY 2018 as a group practice participating in the PQRS GPRO (using one of the group registry, QCDR, or EHR reporting options) or have at least 50 percent of the group's EPs meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals (using the registry, QCDR, or EHR reporting option), based on data submitted outside the ACO and during the secondary PQRS reporting period, will be included in Category 1 for the CY 2017 VM. We are also finalizing that solo practitioners that meet the criteria to avoid the PQRS payment adjustment for CY 2018 as individuals using the registry, QCDR, or EHR reporting option, based on data submitted outside the ACO and during the secondary PQRS reporting period, will be included in Category 1 for the CY 2017 VM and be classified as “average quality” and “average cost” under the quality-tiering methodology. Category 2 will include those groups and solo practitioners subject to the CY 2017 VM that participate in a Shared Savings Program ACO and do not fall within Category 1.
The CY 2017 VM payment adjustment amount for groups and solo practitioners in Category 2 is −4.0 percent for groups of physicians with 10 or more EPs and −2.0 percent for groups of physicians with between 2 to 9 EPs and physician solo practitioners.
In the CY 2015 PFS final rule with comment period (79 FR 67939 through 67941), we finalized that quality-tiering, which is the methodology for evaluating performance on quality and cost measures for the VM, will apply to all groups of physicians and physician solo practitioners in Category 1 for the VM for CY 2017. However, groups of physicians with between 2 to 9 EPs and physician solo practitioners will be subject only to upward or neutral adjustments derived under quality-tiering, while groups of physicians with 10 or more EPs will be subject to upward, neutral, or downward adjustments derived under quality-tiering. That is, groups of physicians with between 2 to 9 EPs and physician solo practitioners in Category 1 will be held harmless from any downward adjustments derived under quality-tiering for the CY 2017 VM.
Under the quality-tiering methodology, each group and solo practitioner's quality and cost composites will be classified into high, average, and low categories depending upon whether the composites are at least one standard deviation above or below the mean and statistically different from the mean. We will compare their quality of care composite classification with the cost composite classification to determine their VM adjustment for the CY 2017 payment adjustment period according to the amounts in Tables 54 and 55.
Under the quality-tiering methodology, for groups and solo practitioners that participated in a Shared Savings ACO that successfully reports quality data for CY 2015, the cost composite will be classified as
We are finalizing in section III.L.3.b. of this final rule, for groups and solo practitioners that participate in a Shared Savings Program ACO that did not successfully report quality data for CY 2015 and are in Category 1 as a result of reporting quality data to the PQRS outside of the ACO using the secondary PQRS reporting period, our proposal to classify their quality composite for the VM for the CY 2017 payment adjustment period as “average quality.” Their cost composite will be classified as “average cost” (79 FR 67943).
To ensure budget neutrality, we first aggregate the downward payment adjustments in Tables 54 and 55 for those groups and solo practitioners in Category 1 with the automatic downward payment adjustments of −2.0 percent or −4.0 percent for groups and solo practitioners subject to the VM that fall within Category 2. Using the aggregate downward payment adjustment amount, we then calculate the upward payment adjustment factor (x). We plan to incorporate assumptions about the number of physicians in groups and physician solo practitioners in the ACOs that did not successfully report their CY 2015 quality data whose status could potentially change from Category 2 to Category 1 if the group or solo practitioner satisfactorily report their 2016 data during the secondary PQRS reporting period. Additionally, as we had done when calculating the upward payment adjustment factor for the 2016 VM, we will also incorporate adjustments made for estimated changes in physician behavior (
On September 26, 2016, we made the 2015 Annual QRURs available to all groups and solo practitioners based on their performance in CY 2015. We also completed a preliminary analysis (based on results included in the 2015 Annual QRURs and prior to accounting for the informal review process) of the impact of the VM in CY 2017 on physicians in groups with 2 or more EPs and physician solo practitioners based on their performance in CY 2015. A summary of the results for groups and solo practitioners subject to the 2017 VM is presented below.
There are 208,832 groups and physician solo practitioners (as identified by their Taxpayer Identification Number (TIN)) consisting of 885,108 physicians whose physicians' payments under the Medicare PFS will be subject to the VM in the CY 2017 payment adjustment period. These counts include both TINs that participated in a Shared Savings Program ACO in CY 2015 and TINs that did not. Of all the physicians subject to the CY 2017 VM, approximately 65 percent of the physicians (577,959 physicians) are in TINs that met the criteria for inclusion in Category 1 and are subject to the quality-tiering methodology in order to calculate their CY 2017 VM; and approximately 35 percent of the physicians (307,149 physicians) are in TINs that are Category 2. Physicians in Category 2 TINs with between 1 to 9 EPs will be subject to an automatic −2.0 percent payment adjustment, while physicians in Category 2 TINs with 10 or more EPs will be subject to an automatic −4.0 percent payment adjustment under the VM during the CY 2017 payment adjustment period for failing to meet quality reporting requirements.
For physicians (428,461) that are in Category 1 TINs that did not participate in a Shared Savings Program ACO (61,445) in CY 2015, Tables 56 and 57 show the distribution of these physicians and TINs with between 1 to 9 EPs and 10 or more EPs, respectively, into the various quality and cost tiers. The results show that 2,351 TINs consisting of 12,026 physicians will receive an upward payment adjustment; 58,099 TINs consisting of 384,922 physicians will receive a neutral payment adjustment; and 995 TINs consisting of 31,513 physicians will receive a downward payment adjustment under the VM in CY 2017.
For physicians (149,498) that are in Category 1 TINs that participated in a Shared Savings Program ACO (12,500) in CY 2015, Table 58 shows the distribution of the 389 ACOs into the various quality tiers along with the number of physicians in the ACOs. The results show that physicians in participant TINs in 3 ACOs will receive an upward payment adjustment; physicians in participant TINs in 382 ACOs will receive a neutral payment adjustment; and physicians in participant TINS with 10 or more EPs in 4 ACOs will receive a downward payment adjustment under the VM in CY 2017. Physicians in ACO TINs are more likely to be in a Category 1 TIN compared to those in non-ACO TINs and are less likely to get the downward adjustment based on performance compared to those in Category 1 non-ACO TINs. Physicians in ACOs are also more likely to get either an average or upward adjustment under the VM compared to physicians overall. The VM is applied at the TIN-level, and the amount of the upward or downward adjustment will vary based on the size of the ACO's participant TIN.
The numbers presented above are preliminary numbers and may be subject to change as a result of the informal review process. In late 2016, after the conclusion of the informal review period, we will release updates to the number of TINs receiving upward, neutral, and downward adjustments, along with the adjustment factor for the CY 2017 VM on the CMS Web site at
The physician self-referral update provisions are discussed in section III.M of this final rule. We re-issued regulatory provisions prohibiting certain per-unit of service compensation formulas for determining rental charges in the exceptions for the rental of office space, rental of equipment, fair market value compensation, and indirect compensation arrangements. These provisions are necessary to protect against potential abuses such as overutilization and stifling patient choice. We believe that most parties comply with these regulatory provisions since they originally became effective on October 1, 2009, and the re-issued regulations text is identical to the existing regulations text. Therefore, we do not believe that the provisions will have a significant burden.
This final rule contains a range of policies, including some provisions related to specific statutory provisions. The preceding preamble provides descriptions of the statutory provisions that are addressed, identifies those policies when discretion has been exercised, presents rationale for our final policies and, where relevant, alternatives that were considered. For purposes of the payment impact on PFS services of the policies contained in this final rule, we presented the estimated impact on total allowed charges by specialty. The alternatives we considered, as discussed in the preceding preamble sections, will result in different final payment rates, and therefore, result in different estimates than those shown in Table 52 (CY 2017 PFS Estimated Impact on Total Allowed Charges by Specialty). For example, the estimated increases to primary care specialties would be lessened without the revised payment policies for certain care management and patient-specific services as described in section II.E. of this final rule with comment period. However, because PFS rates are based on relative value units, the final rates reflect all of the final changes and eliminate some of the proposed changes that might have multi-faceted impacts on the payment rates for other services.
There are a number of changes in this final rule that would have an effect on beneficiaries. In general, we believe that many of these changes, including those intended to improve accuracy in payment through revisions to the inputs used to calculate payments under the PFS, would have a positive impact and improve the quality and value of care provided to Medicare beneficiaries. In particular, we believe that improving payment for primary care and care management services based on more accurate assessment of patient needs and the resources involved in caring for them will benefit beneficiaries by improving care coordination and
Most of the aforementioned final policy changes could result in a change in beneficiary liability as relates to coinsurance (which is 20 percent of the fee schedule amount, if applicable for the particular provision after the beneficiary has met the deductible). To illustrate this point, as shown in our public use file Impact on Payment for Selected Procedures available on the CMS Web site at
As discussed in section III.B of this final rule, we proposed that beginning on January 1, 2017, the FQHC base rate would be updated using a FQHC-specific market basket instead of using the MEI to more accurately reflect changes in the cost of furnishing FQHC services. This would result in a higher payment to FQHCs, and since coinsurance is 20 percent of the lesser of the FQHC's charge for the specific payment code or the PPS rate, beneficiary coinsurance would also increase. The FQHC market basket cost estimates in Table 53 include a premium offset line which is the amount of cost that would be offset by the beneficiaries. The beneficiaries would pay approximately $5 million and $35 million over the 5 and 10 year projection windows.
As required by OMB Circular A-4 (available at
The analysis in the previous sections, together with the remainder of this preamble, provided an initial Regulatory Flexibility Analysis. The previous analysis, together with the preceding portion of this preamble, provides a Regulatory Impact Analysis. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget.
Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medical devices, Medicare, Reporting and recordkeeping requirements, Rural areas, X-rays.
Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, Reporting and recordkeeping requirements, Rural areas, X-rays.
Kidney diseases, Medicare, Physician Referral, Reporting and recordkeeping requirements.
Administrative practice and procedure, Biologics, Drugs, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping requirements.
Administrative practice and procedure, Grant programs-health, Health care, Health insurance, Health maintenance organizations (HMO), Loan programs-health, Medicare, Reporting and recordkeeping requirements.
Administrative practice and procedure, Health facilities, Health maintenance organizations (HMO), Medicare, Penalties, Privacy, Reporting and recordkeeping requirements.
Administrative practice and procedure, Emergency medical services, Health facilities, Health maintenance organizations (HMO), Medicare, Penalties, Privacy, Reporting and recordkeeping requirements.
Emergency medical services, Health facilities, Health professions, Medicare, Reporting and recordkeeping requirements.
Administrative practice and procedure, Health facilities, Health professions, Medicare, Reporting and recordkeeping requirements.
Aged, Health care, Health records, Medicaid, Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below:
Secs. 205(a), 1102, 1861, 1862(a), 1869, 1871, 1874, 1881, and 1886(k) of the Social Security Act (42 U.S.C. 405(a), 1302, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr and 1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C. 263a).
The revisions and addition read as follows:
(a)
(b)
(f)
(a) * * *
(5) Furnished under the direct supervision of a physician, except that services and supplies furnished incident to transitional care management and chronic care management services can be furnished under general supervision of a physician when these services or supplies are furnished by auxiliary personnel, as defined in § 410.26(a)(1) of this chapter.
(a) * * *
(5) Furnished under the direct supervision of a nurse practitioner, physician assistant, or certified nurse-midwife, except that services and supplies furnished incident to transitional care management and chronic care management services can be furnished under general supervision of a nurse practitioner, physician assistant, or certified nurse-midwife, when these services or supplies are furnished by auxiliary personnel, as defined in § 410.26(a)(1) of this chapter.
Secs. 1102, 1834, 1871, 1881, and 1893 of the Social Security Act (42 U.S.C. 1302. 1395m, 1395hh, and 1395ddd).
The addition and revision reads as follows:
(a) * * *
(3)
(b) * * *
(5) In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.
(a) Medicare Diabetes Prevention Program (MDPP) services will be available beginning on January 1, 2018.
(b)
(c)
(i) Are enrolled in Medicare Part B.
(ii) Have as of the date of attendance at the first core session a body mass index (BMI) of at least 25 if not self-identified as Asian and a BMI of at least 23 if self-identified as Asian.
(iii) Have, within the 12 months prior to attending the first core session, a hemoglobin A1c test with a value between 5.7 and 6.4 percent, a fasting plasma glucose of 110-125 mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test).
(iv) Have no previous diagnosis of type 1 or type 2 diabetes.
(v) Do not have end-stage renal disease (ESRD).
(2)
(ii)
(d)
(2) Ongoing maintenance sessions are available only if the MDPP eligible beneficiary has achieved maintenance of weight loss.
Secs. 1102, 1860D-1 through 1860D-42, 1871, and 1877 of the Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn).
(a) * * *
(5) * * *
(ii) * * *
(B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(b) * * *
(4) * * *
(ii) * * *
(B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(l) * * *
(3) * * *
(ii) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(p) * * *
(1) * * *
(ii) * * *
(B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(a)
Secs. 1102, 1871, and 1881(b)(l) of the Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(l)).
(b) * * *
(5) For services furnished in 2002 and subsequent years, the practice expense RVUs are based entirely on relative practice expense resources.
(i) * * *
(A)
(B)
(j) * * *
(1) * * *
(ii) Secondary Reporting Period for the 2017 PQRS payment adjustment for certain eligible professionals or group practices- Individual eligible professionals or group practices, who bill under the TIN of an ACO participant if the ACO failed to report data on behalf of such EPs or group practices during the previously established reporting period for the 2017 PQRS payment adjustment, may separately report during a secondary reporting period for the 2017 PQRS payment adjustment. The secondary reporting period for the 2017 PQRS payment adjustment for the affected individual eligible professionals or group practices is January 1, 2016 through December 31, 2016.
(4) * * *
(v) Paragraphs (j)(8)(ii), (iii), and (iv) of this section apply to individuals reporting using the secondary reporting period established under paragraph (j)(1)(ii) of this section for the 2017 PQRS payment adjustment.
(7) * * *
(viii) Paragraphs (j)(9)(ii), (iii), and (iv) of this section apply to group practices reporting using the secondary reporting period established under paragraph (j)(1)(ii) of this section for the 2017 PQRS payment adjustment.
(k) * * *
(4) * * *
(ii) Section 414.90(k)(5) applies to individuals and group practices reporting using the secondary reporting period established under paragraph (j)(1)(ii) of this section for the 2017 PQRS payment adjustment.
The additions read as follows:
(b) * * *
(i) The physician fee schedule established under section 1848(b) of the Act;
(ii) The prospective payment system for hospital outpatient department services under section 1833(t) of the Act; and
(iii) The ambulatory surgical center payment systems under section 1833(i) of the Act.
(e) * * *
(5) Priority clinical areas include the following:
(i) Coronary artery disease (suspected or diagnosed).
(ii) Suspected pulmonary embolism.
(iii) Headache (traumatic and non-traumatic).
(iv) Hip pain.
(v) Low back pain.
(vi) Shoulder pain (to include suspected rotator cuff injury).
(vii) Cancer of the lung (primary or metastatic, suspected or diagnosed).
(viii) Cervical or neck pain.
(g)
(1)
(i) Make available specified applicable AUC and its related supporting documentation.
(ii) Identify the appropriate use criterion consulted if the CDSM makes available more than one criterion relevant to a consultation for a patient's specific clinical scenario.
(iii) Make available, at a minimum, specified applicable AUC that reasonably address common and important clinical scenarios within all priority clinical areas identified in paragraph (e)(5) of this section.
(iv) Be able to incorporate specified applicable AUC from more than one qualified PLE.
(v) Determines, for each consultation, the extent to which the applicable imaging service is consistent with specified applicable AUC.
(vi) Generate and provide a certification or documentation at the time of order that documents which qualified CDSM was consulted; the name and national provider identifier (NPI) of the ordering professional that consulted the CDSM; whether the service ordered would adhere to specified applicable AUC; whether the service ordered would not adhere to specified applicable AUC; or whether the specified applicable AUC consulted was not applicable to the service ordered. Certification or documentation must:
(A) Be generated each time an ordering professional consults a qualified CDSM.
(B) Include a unique consultation identifier generated by the CDSM.
(vii) Modifications to AUC within the CDSM must comply with the following timeline requirements:
(A) Make available updated AUC content within 12 months from the date the qualified PLE updates AUC.
(B) A protocol must be in place to expeditiously remove AUC determined by the qualified PLE to be potentially dangerous to patients and/or harmful if followed.
(C) Specified applicable AUC that reasonably address common and important clinical scenarios within any new priority clinical area must be made available for consultation through the qualified CDSM within 12 months of the priority clinical area being finalized by CMS.
(viii) Meet privacy and security standards under applicable provisions of law.
(ix) Provide to the ordering professional aggregate feedback regarding their consultations with specified applicable AUC in the form of an electronic report on at least an annual basis.
(x) Maintain electronic storage of clinical, administrative, and demographic information of each unique consultation for a minimum of 6 years.
(xi) Comply with modification(s) to any requirements under paragraph (g)(1) of this section made through rulemaking within 12 months of the effective date of the modification.
(xii) Notify ordering professionals upon de-qualification.
(2)
(ii)
(B) For CDSM applicants seeking qualification in CY 2017, applications must be submitted by March 1, 2017; and
(
(
(
(
(iii) All qualified CDSMs specified by CMS in each year will be included on the list of specified qualified CDSMs posted to the CMS Web site by June 30 of that year; and
(iv) Qualified CDSMs are specified by CMS as such for a period of 5 years.
(v) Qualified CDSMs are required to re-apply during the fifth year after they are specified by CMS in order to maintain their status as qualified CDSMs. This application must be received by CMS by January 1 of the 5th year after the most recent approval date.
(h)
(i)
(1) Emergency services when provided to individuals with emergency medical conditions as defined in section 1867(e)(1) of the Act.
(2) For an inpatient and for which payment is made under Medicare Part A.
(3) Ordering professionals who are granted a significant hardship exception to the Medicare EHR Incentive Program payment adjustment for that year under § 495.102(d)(4) of this chapter, except for those granted such an exception under § 495.102(d)(4)(iv)(C) of this chapter.
(b) * * *
(2) * * *
(i) * * *
(B) For groups and solo practitioners that participate in a Shared Savings Program ACO that successfully reports quality data as required by the Shared Savings Program under § 425.504 of this chapter, the quality composite score is calculated under § 414.1260(a) using quality data reported by the ACO for the performance period through the ACO GPRO Web interface as required under § 425.504(a)(1) of this chapter or another mechanism specified by CMS and the ACO all-cause readmission measure. Groups and solo practitioners that participate in two or more ACOs during the applicable performance period receive the quality composite score of the ACO that has the highest numerical quality composite score. For the CY 2018 payment adjustment period, the CAHPS for ACOs survey also will be included in the quality composite score. For the CY 2017 and 2018 payment adjustment periods, for groups and solo practitioners who participate in a Shared Savings Program ACO that does not successfully report quality data as required by the Shared Savings Program under § 425.504 and who meet the requirements to avoid the PQRS payment adjustment for CY 2018 by reporting to the PQRS outside the ACO, the quality composite is classified as “average” under § 414.1275(b).
(C) For the CY 2017 payment adjustment period, the value-based payment modifier adjustment will be equal to the amount determined under § 414.1275 for the payment adjustment period, except that if the ACO (or groups and solo practitioners that participate in the ACO) does not successfully report quality data as described in paragraph (b)(2)(i)(B) of this section for the performance period, such adjustment will be equal to -4% for groups of physicians with 10 or more eligible professionals and equal to -2% for groups of physicians with two to nine eligible professionals and for physician solo practitioners. If the ACO has an assigned beneficiary population during the performance period with an average risk score in the top 25 percent of the risk scores of beneficiaries nationwide, and a group of physician or physician solo practitioner that participates in the ACO during the performance period is classified as high quality/average cost under quality-tiering for the CY 2017 payment adjustment period, the group or solo practitioner receives an upward adjustment of +3 × (rather than +2 ×) if the group has 10 or more eligible professionals or +2 × (rather than +1 ×) for a solo practitioner or the group has two to nine eligible professionals.
(D) For the CY 2018 payment adjustment period, the value-based payment modifier adjustment will be equal to the amount determined under § 414.1275 for the payment adjustment period, except that if the ACO (or groups and solo practitioners that participate in the ACO) does not successfully report quality data as described in paragraph (b)(2)(i)(B) of this section for the performance period, such adjustment will be equal to the downward payment adjustment amounts described at § 414.1270(d)(1). If the ACO has an assigned beneficiary population during the performance period with an average risk score in the top 25 percent of the risk scores of beneficiaries nationwide, and a group or solo practitioner that participates in the ACO during the performance period is classified as high quality/average cost under quality-tiering for the CY 2018 payment adjustment period, the group or solo practitioner receives an upward adjustment of +3 × (rather than +2 ×) if the group of physicians has 10 or more eligible professionals, +2 × (rather than +1 ×) for a physician solo practitioner or if the group of physicians has two to nine eligible professionals, or +2 × (rather than +1 ×) for a solo practitioner who is a nonphysician eligible professional or if the group consists of nonphysician eligible professionals.
(F) For groups and solo practitioners that participate in a Shared Savings Program ACO that successfully reports quality data as required by the Shared Savings Program under § 425.504 of this chapter, the same value-based payment modifier adjustment will be applied in the payment adjustment period to all groups based on size as specified under § 414.1275 and solo practitioners that
Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh), secs. 1301, 1306, and 1310 of the Public Health Service Act (42 U.S.C. 300e, 300e-5, and 300e-9), and 31 U.S.C. 9701.
(e) Sections 422.222 and 422.224 of this chapter which requires all providers or suppliers that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, to be enrolled in Medicare in an approved status and prohibits payment to providers and suppliers that are excluded or revoked. This includes locum tenens suppliers and, if applicable, incident-to suppliers.
(b) * * *
(3) All providers or suppliers that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, are enrolled in Medicare in an approved status.
Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
(a) * * *
(1) * * *
(i) 1106—Disclosure of information in possession of agency.
(b) * * *
(5) Ensures compliance with the provider and supplier enrollment requirements at § 422.222.
(a) Providers or suppliers that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, must be enrolled in Medicare and be in an approved status in Medicare in order to provide health care items or services to a Medicare enrollee who receives his or her Medicare benefit through an MA organization. This requirement applies to all of the following providers and suppliers:
(1) Network providers and suppliers.
(2) First-tier, downstream, and related entities (FDR).
(3) Providers and suppliers in Cost HMOs or CMPs, as defined in 42 CFR part 417.
(4) Providers and suppliers participating in demonstration programs.
(5) Providers and suppliers in pilot programs.
(6) Locum tenens suppliers.
(7) Incident-to suppliers.
(b) MA organizations that do not ensure that providers and suppliers comply with paragraph (a) of this section, may be subject to sanctions under § 422.750 and termination under § 422.510.
(a) An MA organization may not pay, directly or indirectly, on any basis, for items or services (other than emergency and urgently needed services as defined in § 422.113) furnished to a Medicare enrollee by any individual or entity that is excluded by the Office of the Inspector General (OIG) or is revoked from the Medicare program except as provided.
(b) If an MA organization receives a request for payment by, or on behalf of, an individual or entity that is excluded by the OIG or is revoked in the Medicare program, the MA organization must notify the enrollee and the excluded or revoked individual or entity in writing, as directed by contract or other direction provided by CMS, that payments will not be made. Payment may not be made to, or on behalf of, an individual or entity that is excluded by the OIG or is revoked in the Medicare program.
This subpart is based largely on section 1854 of the Act, but also includes provisions from sections 1853 and 1858 of the Act, and is also based on section 1106 of the Act. It sets forth the requirements for the Medicare Advantage bidding payment methodology, including CMS' calculation of benchmarks, submission of plan bids by Medicare Advantage (MA) organizations, establishment of beneficiary premiums and rebates through comparison of plan bids and benchmarks, negotiation and approval of bids by CMS, and the release of MA bid submission data.
(a)
(1) The pricing-related information described at § 422.254(a)(1); and
(2) The information required for MSA plans, described at § 422.254(e).
(b)
(c)
(1) For an MA plan bid that includes Part D benefits, the information described at § 422.254(b)(1)(ii), (c)(3)(ii), and (c)(7).
(2) Additional information that CMS requires to verify the actuarial bases of
(i) Narrative information on base period factors, manual rates, cost-sharing methodology, optional supplement benefits, and other required narratives.
(ii) Supporting documentation.
(3) Any information that could be used to identify Medicare beneficiaries or other individuals.
(4) Bid review correspondence and reports.
(d)
(c) * * *
(1) * * *
(iv) Documentation that all providers or suppliers in the MA or MA-PD plan that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, are enrolled in an approved status.
(2) The authorized individual must thoroughly describe how the entity and MA plan meet, or will meet, all the requirements described in this part, including providing documentation that all providers and suppliers referenced in § 422.222 are enrolled in Medicare in an approved status.
The revisions and addition read as follows:
(a) * * *
(6) To comply with all applicable provider and supplier requirements in subpart E of this part, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers, limits on physician incentive plans, and Medicare provider and supplier enrollment requirements.
(i) * * *
(2) * * *
(v) They will require all of their providers and suppliers to be enrolled in Medicare in an approved status consistent with § 422.222.
(n)
(i) For Part C, the following data—
(A) Average per member per month CMS payment amount for A/B (original Medicare) benefits for each MA plan offered, standardized to the 1.0 (average risk score) beneficiary.
(B) Average per member per month CMS rebate payment amount for each MA plan offered (or, in the case of MSA plans, the monthly MSA deposit amount).
(C) Average Part C risk score for each MA plan offered.
(D) County level average per member per month CMS payment amount for each plan type in that county, weighted by enrollment and standardized to the 1.0 (average risk score) beneficiary in that county.
(ii) For Part D plan sponsors, plan payment data in accordance with § 423.505(o) of this subchapter.
(2)
(a) * * *
(4) * * *
(xiii) Fails to meet provider and supplier enrollment requirements in accordance with §§ 422.222 and 422.224.
(a) * * *
(13) Fails to comply with §§ 422.222 and 422.224, that requires the MA organization to ensure providers and suppliers are enrolled in Medicare and not make payment to excluded or revoked individuals or entities.
This subpart is based on sections 1857(e)(4), 1860D-12(b)(3)(D), and 1106 of the Act, and sets forth medical loss ratio requirements for Medicare Advantage organizations, financial penalties and sanctions against MA organizations when minimum medical loss ratios are not achieved by MA organizations, and release of medical loss ratio data to entities outside of CMS.
(a)
(b)
(1) Narrative descriptions that MA organizations submit to support the information reported to CMS pursuant to the reporting requirements at § 422.2460, such as descriptions of expense allocation methods.
(2) Information that is reported at the plan level, such as the number of member months associated with each plan under a contract, including information submitted for a contract consisting of only one plan.
(3) Any information that could be used to identify Medicare beneficiaries or other individuals.
(4) MLR review correspondence.
(5) Any information for a contract for those contract years for which the contract is determined to be non-credible, as defined in accordance with § 422.2440(d).
(c)
Sections 1102, 1106, 1860D-1 through 1860D-42, and 1871 of the Social Security Act (42 U.S.C. 1302, 1306, 1395w-101 through 1395w-152, and 1395hh).
(o)
(i) The average per member per month Part D direct subsidy standardized to the 1.0 (average risk score) beneficiary for each Part D plan offered.
(ii) The average Part D risk score for each Part D plan offered.
(iii) The average per member per month Part D plan low-income cost sharing subsidy for each Part D plan offered.
(iv) The average per member per month Part D Federal reinsurance subsidy for each Part D plan offered.
(v) The actual Part D reconciliation payment data summarized at the Parent Organization level including breakouts of risk sharing, reinsurance, and low income cost sharing reconciliation amounts.
(2)
This subpart is based on sections 1857(e)(4), 1860D-12(b)(3)(D), and 1106 of the Act, and sets forth medical loss ratio requirements for Part D sponsors, financial penalties and sanctions against Part D sponsors when minimum medical loss ratios are not achieved by Part D sponsors and release of medical loss ratio data to entities outside of CMS.
(a)
(b)
(1) Narrative descriptions that Part D sponsors submit to support the information reported to CMS pursuant to the reporting requirements at § 423.2460, such as descriptions of expense allocation methods.
(2) Information that is reported at the plan level, such as the number of member months associated with each plan under a contract, including information submitted for a contract consisting of only one plan.
(3) Any information that could be used to identify Medicare beneficiaries or other individuals.
(4) MLR review correspondence.
(5) Any information for a contract for those contract years for which the contract is determined to be non-credible, as defined in accordance with § 423.2440(d).
(c)
Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
(a)
(1) At the time of enrollment has either preliminary or full CDC DPRP recognition.
(2) Has obtained and maintains an active and valid TIN and NPI at the organizational level.
(3) Has passed application screening at a high categorical risk level per § 424.518(c).
(4) All coaches who will be furnishing MDPP services on the entity's behalf have obtained and maintain active and valid NPIs.
(5) Submits a roster of all coaches who will be furnishing MDPP services on the entity's behalf that includes the coaches' first and last names, date of birth, SSN, and NPI.
(b)
(1) The records must contain documentation of the services furnished including evidence of the beneficiary's eligibility, specific session topics attended, the NPI of the coach who furnished the session attended, the date and place of service of sessions attended, and weight.
(2) MDPP suppliers are required to maintain and handle any beneficiary PII and PHI in compliance with HIPAA, other applicable privacy laws and CMS standards.
(3) The MDPP supplier must maintain a crosswalk between the beneficiary identifiers submitted to CMS for billing and the beneficiary identifiers submitted to CDC for beneficiary level-clinical data.
(4) The records must include an attestation from the supplier that the MDPP eligible beneficiary for which it is submitting a claim:
(i) Has attended 1, 4 or 9 core sessions, or
(ii) Has achieved the required minimum weight loss percentage specified in § 410.79 of this chapter, or
(iii) Has achieved maintenance of weight loss and attended core maintenance sessions, or
(iv) Has achieved maintenance of weight loss and attended ongoing maintenance sessions.
(c)
(1) Establishes and maintains all enrollment and program requirements under Title 42.
(2) Submits attestation as specified in paragraph (b) of this section.
(d)
(1) It loses its CDC DPRP recognition or withdraws from seeking CDC DPRP recognition.
(2) One of the revocation reasons specified in § 424.535 applies.
(e)
(2) An MDPP supplier that has had its MDPP supplier enrollment revoked may:
(i) Become eligible to bill for MDPP services again if it reapplies for CDC DPRP recognition, successfully achieves preliminary CDC DPRP recognition, and enrolls again Medicare as an MDPP supplier subject to paragraph (a) of this section.
(ii) Appeal in accordance with the procedures specified in 42 CFR part 405, subpart H, 42 CFR part 424, and 42 CFR part 498. References to suppliers in these sections apply to MDPP suppliers.
(b) * * *
(1) While under the CAP, the ACO remains eligible for shared savings and losses.
(i) For ACOs with a variable MSR and MLR (if applicable), the MSR and MLR (if applicable) will be set at a level consistent with the number of assigned beneficiaries.
(ii) For ACOs with a fixed MSR/MLR, the MSR/MLR will remain fixed at the level consistent with the choice of MSR and MLR that the ACO made at the start of the agreement period.
The addition reads as follows:
(e) For performance year 2018 and subsequent performance years, if a system is available to allow a beneficiary to designate a provider or supplier as responsible for coordinating their overall care and for CMS to process the designation electronically, CMS will supplement the claims-based assignment methodology described in this section with information provided by beneficiaries regarding the provider or supplier they consider responsible for coordinating their overall care. Such designations must be made in the form and manner and by a deadline determined by CMS.
(1) Notwithstanding the assignment methodology under paragraph (b) of this section, beneficiaries who designate an ACO professional participating in an ACO as responsible for coordinating their overall care are prospectively assigned to that ACO, regardless of track, annually at the beginning of each benchmark and performance year based on available data at the time assignment lists are determined for the benchmark and performance year.
(2) Beneficiaries will be added to the ACO's list of assigned beneficiaries if all of the following conditions are satisfied:
(i) The beneficiary must have had at least one primary care service during the assignment window as defined under § 425.20 with a physician who is an ACO professional in the ACO who is a primary care physician as defined under § 425.20 or who has one of the primary specialty designations included in paragraph (c) of this section.
(ii) The beneficiary meets the eligibility criteria established at § 425.401(a) and must not be excluded by the criteria at § 425.401(b). The exclusion criteria at § 425.401(b) apply for purposes of determining beneficiary eligibility for alignment to ACOs under all tracks based on the beneficiary's designation of an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section.
(iii) The beneficiary must have designated an ACO professional who is a primary care physician as defined at § 425.20, a physician with a specialty designation included at paragraph (c) of this section, or a nurse practitioner, physician assistant, or clinical nurse specialist as responsible for coordinating their overall care.
(iv) If a beneficiary has designated a provider or supplier outside the ACO who is a primary care physician as defined at § 425.20, a physician with a specialty designation included at paragraph (c) of this section, or a nurse practitioner, physician assistant, or clinical nurse specialist, as responsible for coordinating their overall care, the beneficiary will not be added to the ACO's list of assigned beneficiaries for a performance year under the assignment methodology in paragraph (b) of this section.
(3) The ACO, ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions and services related to ACO activities are prohibited from providing or offering gifts or other remuneration to Medicare beneficiaries as inducements for influencing a Medicare beneficiary's decision to designate or not to designate an ACO professional under paragraph (e) of this section. The ACO, ACO participants, ACO providers/suppliers, ACO professionals, and other individuals or entities performing functions and services related to ACO activities must not, directly or indirectly, commit any act or omission, nor adopt any policy that coerces or otherwise influences a Medicare beneficiary's decision to designate or not to designate an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section, including but not limited to the following:
(i) Offering anything of value to the Medicare beneficiary as an inducement to influence the Medicare beneficiary's decision to designate or not to designate an ACO professional as responsible for coordinating their overall care under paragraph (e) of this section. Any items or services provided in violation of paragraph (e)(3) will not be considered to have a reasonable connection to the medical care of the beneficiary, as required under § 425.304(a)(2).
(ii) Withholding or threatening to withhold medical services or limiting or threatening to limit access to care.
(e) * * *
(2) If, at the conclusion of the audit process the overall audit match rate between the quality data reported and the medical records provided under paragraph (e)(1) of this section is less than 90 percent, absent unusual circumstances, CMS will adjust the ACO's overall quality score proportional to the ACO's audit performance.
(3) If, at the conclusion of the audit process CMS determines there is an audit match rate of less than 90 percent, the ACO may be required to submit a CAP under § 425.216 for CMS approval.
The revisions and addition read as follows:
(a)
(b) * * *
(3) The minimum attainment level for pay for performance measures is set at 30 percent or the 30th percentile of the performance benchmark. The minimum attainment level for pay for reporting measures is set at the level of complete and accurate reporting.
(c) * * *
(5) Performance equal to or greater than the minimum attainment level for pay-for-reporting measures will receive the maximum available points.
(d) * * *
(2) * * *
(ii) CMS may take the compliance actions described in § 425.216 for ACOs exhibiting poor performance on a domain, as determined by CMS under § 425.316.
The addition reads as follows:
(d)
(2) Eligible professionals who bill under the TIN of an ACO participant within an ACO participate under their ACO participant TIN as a group practice under the Physician Quality Reporting System Group Practice Reporting Option of the Shared Savings Program for purposes of the Physician Quality Reporting System payment adjustment under the Shared Savings Program for 2017 and 2018.
(3) If an ACO, on behalf of eligible professionals who bill under the TIN of an ACO participant, does not satisfactorily report for purposes of the Physician Quality Reporting System payment adjustment for 2017 or 2018, each eligible professional who bills under the TIN of an ACO participant will receive a payment adjustment, as described in § 414.90(e) of this chapter, unless such eligible professionals have reported quality measures apart from the ACO in the form and manner required by the Physician Quality Reporting System.
(4) For eligible professionals subject to the Physician Quality Reporting System payment adjustment under the Medicare Shared Savings Program for 2017 or 2018, the Medicare Part B Physician Fee Schedule amount for covered professional services furnished during the program year is equal to the applicable percent of the Medicare Part B Physician Fee Schedule amount that would otherwise apply to such services under section 1848 of the Act, as described in § 414.90(e) of this chapter.
(5) The reporting period for a year is the calendar year from January 1 through December 31 that occurs 2 years prior to the program year in which the payment adjustment is applied, unless otherwise specified by CMS under the Physician Quality Reporting System.
The revision and addition read as follows:
(e) For 2017 and subsequent years, CMS will annually assess the degree of use of certified EHR technology by eligible clinicians billing through the TINs of ACO participants for purposes of meeting the CEHRT criterion necessary for Advanced Alternative Payment Models under the Quality Payment Program.
(1) During years in which the measure is designated as pay for reporting, in order to demonstrate complete and accurate reporting, at least one eligible clinician billing through the TIN of an ACO participant must meet the reporting requirements under the Advancing Clinical Information category under the Quality Payment Program.
(2) During years in which the measure is designated as pay for performance, the quality measure regarding EHR adoption will be measured based on a sliding scale.
(a)
(b) [Reserved]
The additions read as follows:
(a) * * *
(1) * * *
(iv) For a beneficiary who was included on the prospective assignment list under § 425.400(a)(3) for a performance year for a Track 3 ACO for which a waiver of the SNF 3-day rule has been approved under paragraph (a)(1) of this section, but who was subsequently excluded from the ACO's prospective assignment list, CMS makes payment for SNF services furnished to the beneficiary by a SNF affiliate if the following conditions are met:
(A) The beneficiary was prospectively assigned to the ACO at the beginning of the applicable performance year but was excluded in the most recent quarterly update to the prospective assignment list under § 425.401(b).
(B) The SNF services are furnished to a beneficiary who was admitted to a SNF affiliate within 90 days following the date that CMS delivers the quarterly exclusion list to the ACO.
(C) But for the beneficiary's exclusion from the ACO's prospective assignment list, CMS would have made payment to the SNF affiliate for such services under the waiver under paragraph (a)(1) of this section.
(v) The following beneficiary protections apply when a beneficiary receives SNF services without a prior 3-day inpatient hospital stay from a SNF affiliate that intended to provide services pursuant to a SNF 3-day rule waiver under paragraph (a)(1) of this section, but the beneficiary was not prospectively assigned to the ACO and was not in the 90 day grace period under paragraph (a)(1)(iv) of this section. The SNF affiliate services must be non-covered only because the SNF affiliate stay was not preceded by a qualifying hospital stay under section 1861(i) of the Act.
(A) A SNF is presumed to intend to provide services pursuant to the SNF 3-day rule waiver under paragraph (a)(1) of this section if the SNF submitting the claim is a SNF affiliate of an ACO for which such a waiver has been approved.
(B) CMS makes no payments for SNF services to a SNF affiliate of an ACO for which a waiver of the SNF 3-day rule has been approved when the SNF affiliate admits a FFS beneficiary who was never prospectively assigned to the ACO or was prospectively assigned but was later excluded and the 90 day grace period under paragraph (a)(1)(iv) of this section has lapsed.
(C) In the event that CMS makes no payment for SNF services furnished by a SNF affiliate as a result of paragraph (a)(1)(v)(B) of this section and the only reason the claim was non-covered is due to the lack of a qualifying inpatient stay, the following beneficiary protections will apply:
(d) * * *
(4) CMS reserves the right to take compliance action, including termination, against an ACO for noncompliance with program rules, including misuse of a waiver under this section, as specified at §§ 425.216 and 425.218.
Secs. 1102, 1871, 1894(f), and 1934(f) of the Social Security Act (42 U.S.C. 1302, 1395, 1395eee(f), and 1396u-4(f)).
(j) Employs or contracts with any provider or supplier that is a type of individual or entity that can enroll in Medicare in accordance with section 1861 of the Act, that is not enrolled in Medicare in an approved status.
(b) * * *
(1) * * *
(ii) The PACE organization failed to comply substantially with conditions for a PACE program or PACE organization under this part, or with terms of its PACE program agreement, including employing or contracting with any provider or supplier that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, that is not enrolled in Medicare in an approved status.
(a) * * *
(4) That are not enrolled in Medicare in an approved status, if the providers or suppliers are of the types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act.
(b) * * *
(1) * * *
(iv) Providers or suppliers that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, must be enrolled in Medicare and be in an
(b) * * *
(7) Providers or suppliers that are types of individuals or entities that can enroll in Medicare in accordance with section 1861 of the Act, must be enrolled in Medicare and be in an approved status in Medicare in order to provide health care items or services to a PACE participant who receives his or her Medicare benefit through a PACE organization.
(a) A PACE organization may not pay, directly or indirectly, on any basis, for items or services (other than emergency or urgently needed services as defined in § 460.100) furnished to a Medicare enrollee by any individual or entity that is excluded by the Office of the Inspector General (OIG) or is revoked from the Medicare program.
(b) If a PACE organization receives a request for payment by, or on behalf of, an individual or entity that is excluded by the OIG or is revoked in the Medicare program, the PACE organization must notify the enrollee and the excluded or revoked individual or entity in writing, as directed by contract or other direction provided by CMS, that payments will not be made. Payment may not be made to, or on behalf of, an individual or entity that is exclude by the OIG or is revoked in the Medicare program.
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 |