82 FR 46138 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices; Correction
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Federal Register Volume 82, Issue 191 (October 4, 2017)
Centers for Medicare & Medicaid Services
Federal Register Volume 82, Issue 191 (October 4, 2017)
| Page Range | 46138-46163 | |
| FR Document | 2017-21325 |
[Federal Register Volume 82, Number 191 (Wednesday, October 4, 2017)] [Rules and Regulations] [Pages 46138-46163] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2017-21325] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405, 412, 413, 414, 416, 486, 488, 489, and 495 [CMS-1677-CN] RIN-0938-AS98 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices; Correction AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Final rule; correction. ----------------------------------------------------------------------- SUMMARY: This document corrects technical and typographical errors in the final rule that appeared in the August 14, 2017, issue of the Federal Register, which will amend the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2018. DATES: This correction is effective October 1, 2017. FOR FURTHER INFORMATION CONTACT: Donald Thompson, (410) 786-4487. SUPPLEMENTARY INFORMATION: I. Background In FR Doc. 2017-16434 of August 14, 2017 (82 FR 37990) there were a number of technical and typographical errors that are identified and corrected by the Correction of Errors section of this correcting document. The provisions in this correcting document are effective as if they had been included in the document that appeared in the August 14, 2017 Federal Register. Accordingly, the corrections are effective October 1, 2017. II. Summary of Errors A. Summary of Errors in the Preamble On page 37990, we are making a conforming correction, removal of the reference to part 488, based on the removal of the regulations text for Sec. 488.5 described in section II.B. of this correcting document. On pages 38067 and 38068, we are correcting technical errors in our discussion and summary of and response to public comment regarding ICD- 10-PCS procedure codes describing procedures involving percutaneous insertion of intraluminal or monitoring device. Specifically, we erroneously referred to a count of 28 procedure codes describing procedures involving the percutaneous insertion of intraluminal and monitoring devices into central nervous system and other cardiovascular body parts rather than 18 procedure codes. Of the 28 codes listed in Table 6P.4b associated with the proposed rule, 10 procedure codes were duplicative, and erroneously included in the table and in the total number of codes referenced in the preamble. As indicated in the final rule, after consideration of the public comments we received, we maintained the designation of 15 procedure codes identified by the commenters. For this reason, we are also correcting Table 6P.4b associated with the final rule (as discussed in section II.E. of this correcting document) to reflect the 3 distinct procedure codes for which we finalized a change in designation, including to remove the listings of ICD-10-PCS procedure codes 00H032Z (Insertion of Monitoring Device into Brain, Percutaneous Approach) and 00H632Z (Insertion of Monitoring Device into Cerebral Ventricle, Percutaneous Approach), which we finalized to maintain as O.R. procedures for FY 2018, and are making conforming changes to the corresponding count of codes listed in that table as indicated on page 38068. Consistent with these corrections, we are also correcting the description of the proposal on page 38067 of the final rule. As a result of the corrections to Table 6P.4b associated with the final rule and the conforming corrections on pages 38067 and 38068, we have made conforming changes to the ICD-10 MS-DRG Definitions Manual Version 35 and ICD-10 MS-DRG Grouper Software Version 35 for FY 2018 to reflect the O.R. designation of ICD-10-PCS procedure codes 00H032Z (Insertion of Monitoring Device into Brain, Percutaneous Approach) and 00H632Z (Insertion of Monitoring Device into Cerebral Ventricle, Percutaneous Approach), as finalized on page 38068 of the final rule for FY 2018. In addition, after publication of the FY 2018 IPPS/LTCH PPS final rule, we became aware that the logic for the ICD-10 MS-DRG Definitions Manual Version 35 and the ICD-10 MS-DRG Grouper and Medicare Code Editor (MCE) Version 35 Software erroneously designated the following ICD-10-PCS procedure code as a non-O.R. procedure rather than as an O.R. procedure as finalized on page 38072 of the final rule for FY 2018: 0BCC8ZZ (Extirpation of matter from right upper lung lobe, via natural or artificial opening endoscopic). Therefore, we also made changes to the ICD-10 MS-DRG Definitions Manual Version 35 and the ICD- 10 MS-DRG Grouper and MCE Version 35 Software to correctly reflect the O.R. designation for this procedure code for FY 2018. We recalculated the FY 2018 MS-DRG relative weights (and associated statistics, such as average length of stay (ALOS)) as a result of the corrections to the logic for the ICD-10 MS-DRG Grouper Version 35 Software discussed above. In addition, since the MS-LTC-DRGs used under the LTCH PPS for FY 2018 are the same as the MS DRGs used under the IPPS for FY 2018 (and as such use the same ICD-10 MS-DRG Grouper Version 35 Software), we also recalculated the FY 2018 MS-LTC-DRG relative weights (and associated statistics, such as geometric ALOS) for the same reasons. On page 38119, we made a technical error in describing which ICD- 10-PCS procedure codes will be used to identify cases involving ZINPLAVATM that are eligible for new technology add-on payments in FY 2018. Specifically, cases involving ZINPLAVATM that are eligible for new technology add-on payments will be identified by either of the ICD-10-PCS procedure codes listed in the final rule (XW033A3 or XW043A3) (rather than requiring the combination of both ICD-10-PCS procedure codes). On pages 38132 and 38137, in our discussion of the wage indexes, we provided incorrect values for the FY 2018 national average hourly wage (unadjusted for occupational mix) and the FY 2018 occupational mix adjusted national average hourly wage due to inadvertent errors related to the wage data collected from the Medicare cost reports of six hospitals (CMS Certification Numbers (CCNs) 240010, 420033, 420037, 420038, 420078, and 420102). On page 38144, we made an inadvertent error in the mailing address [[Page 46139]] for the Medicare Geographic Review Board (MGCRB). On page 38195, in our discussion regarding disproportionate share hospitals (DSHs), we made errors in the June 2017 Office of the Actuary's estimate for FY 2018 Medicare DSH payments. On page 38225, we made typographical errors in our description of several Hospital Readmissions Reduction Program (HRRP) measures. On page 38249, in our response to a comment, we advertently referenced the MORT-30-PN measure, instead of the PN Payment measure. On page 38257 through 38259, in our discussion of the Hospital Value-Based Purchasing (HVBP) Program, we made several typographical and technical errors to references and dates. On pages 38309 and 38310, we are correcting the MS-LTC-DRG normalization factor and the MS-LTC DRG budget neutrality factor based on the recalculation of the MS-LTC-DRG relative weights due to the corrections to the MS-DRG Grouper Software Version 35 described previously. (Because the MS-LTC-DRGs used under the LTCH PPS are the same as the MS-DRGs used under the IPPS, the corrections to the MS-DRG Grouper Software Version 35 described previously affect the MS-LTC-DRGs groupings by extension.) On pages 38426, 38434, 38440, and 38458, in our discussion of the LTCH Quality Reporting Program (QRP), we made technical and typographical errors including an error in our description of a quality measure. B. Summary of Errors in the Regulations Text On page 38516, we inadvertently retained regulations language from the proposed rule at Sec. 488.5(a)(21), regarding accrediting organizations, after stating in the preamble of the final rule that we had decided not to adopt such language. In addition, on page 38509, we inadvertently retained a description of subjects set out in 42 CFR part 488 in the ``List of Subjects.'' We are correcting these errors by removing the description of subjects, amendatory instructions, and regulations text for part 488. On page 38516, in the regulations text provisions for Sec. 495.4 (definitions for the Electronic Health Record (EHR) Incentive Program), we inadvertently omitted the definition of certified electronic health record technology (CEHRT) for 2018. On page 38517, in the regulations text provisions for Sec. 495.24, we inadvertently omitted an EHR measure change for eligible professionals (EPs) in Sec. 495.24(d)(6)(i)(B)(1)(iv). C. Summary of Errors in the Addendum As discussed in section II.A. of this correcting document, we are making corrections to the logic for the ICD-10 MS-DRG Grouper Version 35 Software for three ICD-10-PCS procedure codes (0BCC8ZZ, 00H032Z and 00H632Z) that had been erroneously designated as non-O.R. procedures rather than as O.R. procedures as finalized for FY 2018. As a result, we have recalculated the FY 2018 MS-DRG relative weights after applying the changes in the Version 35 MS-DRG groupings to the FY 2016 MedPAR data used for the final rule. The FY 2018 MS-DRG relative weights are used to calculate the MS- DRG reclassification and recalibration budget neutrality factor when comparing total payments using FY 2017 MS-DRG relative weights to total payments using the FY 2018 MS-DRG relative weights. Additionally, the FY 2018 MS-DRG relative weights are used when determining total payments for purposes of all other budget neutrality factors and the final outlier threshold, which are discussed in this section II.C. of this correcting document. As discussed in section II.E. of this correcting document, we made several technical errors with regard to the calculation of Factor 3 of the uncompensated care payment methodology. Factor 3 is used to determine the total amount of the uncompensated care payment a hospital is eligible to receive for a fiscal year. This amount is then used to calculate the amount of the interim uncompensated care payments a hospital receives per discharge. Per discharge uncompensated care payments are included when determining total payments for purposes of all of the budget neutrality factors and the final outlier threshold. As a result, the revisions made to address these technical errors regarding the calculation of Factor 3 directly affected the calculation of total payments and required the recalculation of all the budget neutrality factors and the final outlier threshold. Because of the errors in the wage data for the six hospitals (CCNs 240010, 420033, 420037, 420038, 420078, and 420102), as discussed in section II.A. of this correcting document, we recalculated the FY 2018 national average hourly wages unadjusted for occupational mix and adjusted for occupational mix which resulted in the recalculation of the final FY 2018 IPPS wage indexes and the geographic adjustment factors (GAFs) (which are computed from the wage index). The final FY 2018 IPPS wage data are used in the calculation of the wage index budget neutrality adjustment when comparing total payments using the final FY 2017 IPPS wage index data to total payments using the final FY 2018 IPPS wage index data. Additionally, the final FY 2018 IPPS wage index data are used when determining total payments for purposes of the rest of the budget neutrality factors (except for the MS-DRG reclassification and recalibration budget neutrality factor) and the final outlier threshold. In addition, the final FY 2018 IPPS wage index data are used to calculate the FY 2018 LTCH PPS wage index values, certain budget neutrality factors, and the LTCH PPS standard Federal payment rate in the FY 2018 IPPS/LTCH PPS final rule. Due to the correction of the combination of errors listed previously (recalculation of the MS-DRG relative weights, revisions to Factor 3 of the uncompensated care methodology and correction to the final FY 2018 IPPS wage index data), we recalculated all IPPS budget neutrality adjustment factors, the fixed-loss cost threshold, the final wage indexes (and GAFs), and the national operating standardized amounts and capital Federal rate. Therefore, we made conforming changes to the following:On page 38522 and 38532, the MS-DRG reclassification and recalibration budget neutrality factor. On page 38522, the wage index budget neutrality adjustment. On page 38522, the reclassification hospital budget neutrality adjustment. On page 38523, the rural and imputed floor budget neutrality adjustment. On page 38527, the calculation of the outlier fixed-loss cost threshold, the national outlier adjustment factors, total operating Federal payments, total operating outlier payments, and percentage of capital outlier payments. On page 38529, the table titled ``Changes From FY 2017 Standardized Amounts to the FY 2018 Standardized Amounts''. On pages 38532 and 38534 through 38535, in our discussion of the determination of the Federal hospital inpatient capital related prospective payment rate update, due to the recalculation of the MS-DRG relative weights and GAFs we have made conforming corrections to the increase in the capital Federal rate, the capital outlier payment adjustment (budget neutrality) factor, the GAF/DRG budget neutrality adjustment factors, the capital Federal rate, and the outlier threshold (as discussed previously), along with [[Page 46140]] certain statistical figures (for example, percent change) in the accompanying discussions. Also, as a result of these errors, on page 38535, we have made conforming corrections in the tables showing the comparison of factors and adjustments for the FY 2017 capital Federal rate and FY 2018 capital Federal rate and the proposed FY 2018 capital Federal rate and final FY 2018 capital Federal rate. On pages 38537 and 38539, we are correcting the area wage level budget neutrality factor and making a conforming change to the FY 2018 LTCH PPS standard Federal payment rate due to corrections to the wage data discussed previously. On page 38544, we are making conforming corrections to the fixed- loss amount for FY 2018 LTCH PPS standard Federal payment rate discharges and the high-cost outlier (HCO) threshold determined in absence of the required changes under the 21st Century Cures Act due to corrections in the MS-LTC-DRG data discussed previously. On page 38545, we are making conforming corrections to the fixed- loss amount for site neutral discharges due to corrections in the IPPS rates and factors discussed previously. On pages 38546 and 38547, we are making conforming corrections to the figures used in the example of computing the adjusted LTCH PPS Federal prospective payment for FY 2018. On page 38548, we have made conforming corrections to the following: National adjusted operating standardized amounts and capital standard Federal payment rate (which also include the rates payable to hospitals located in Puerto Rico) in Tables 1A, 1B, 1C, and 1D as a result of the conforming corrections to certain budget neutrality factors and the outlier threshold (as described previously). LTCH PPS standard Federal payment rate in Table 1E as a result of the correction to area wage level budget neutrality factor (as discussed previously). Also, on page 38548, in Table 1E, we are correcting a technical error in our terminology by replacing ``Standard Federal Rate'' with `Standard Federal Payment Rate''. D. Summary of Errors in the Appendices On pages 38552 through 38560 and 38572 through 38574 in our regulatory impact analyses, we made conforming corrections to the factors, values, and tables and accompanying discussion of the changes in operating and capital IPPS payments for FY 2018 and the effects of certain budget neutrality factors as a result of the technical errors that lead to conforming changes in our calculation of the operating and capital IPPS budget neutrality factors, outlier threshold, final wage indexes, operating standardized amounts, and capital Federal rate (as described in sections II.A. and II.C. of this correcting document). In particular, we made changes to the following tables. On pages 38552 through 38554, the table titled ``Table I.--Impact Analysis of Changes to the IPPS for Operating Costs for FY 2018''. On pages 38557 through 38558, the table titled ``FY 2018 IPPS Estimated Payments Due To Rural and Imputed Floor With National Budget Neutrality''. On pages 38559 and 38560, the table titled ``Table II-- Impact Analysis of Changes for FY 2018 Acute Care Hospital Operating Prospective Payment System [Payments per Discharge]''. On pages 38572 through 38574, the table titled ``Table III--Comparison of Total Payments Per Case [FY 2017 Payments Compared to FY 2018 Payments]''. On pages 38561 through 38564, we are correcting the discussion of the ``Effects of the Changes to Medicare DSH and Uncompensated Care Payments for FY 2018'' for purposes of the Regulatory Impact Analysis in Appendix A of the FY 2018 IPPS/LTCH PPS final rule in light of the corrections discussed in sections II.D. and II.E. of this correcting document. On pages 38576 and 38578 through 38579, we made conforming corrections to the area wage level budget neutrality factor and the LTCH PPS standard Federal payment rate as described in section II.C. of this correcting document. On page 38579, we are making conforming corrections to ``Table IV.--Impact of Payment Rate and Policy Changes to LTCH PPS Payments for Standard Payment Rate Cases for FY 2018.'' We are also correcting technical errors in the terminology used in the title and column headings of Table IV by ensuring the use of ``Standard Federal Payment Rate''. On page 38585, we made conforming corrections to the estimated increase in capital payments in FY 2018 compared to FY 2017. E. Summary of Errors in and Corrections to Files and Tables Posted on the CMS Web Site We are correcting the errors in the following IPPS tables that are listed on pages 38547 and 38548 of the FY 2018 IPPS/LTCH PPS final rule and are available on the Internet on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page.html. The tables that are available on the Internet have been updated to reflect the revisions discussed in this correcting document. Table 2--Case-Mix Index and Wage Index Table- FY 2018. The wage data errors related to the six hospitals required the recalculation of the FY 2018 national average hourly wages unadjusted for occupational mix and adjusted for occupational mix which resulted in recalculating the FY 2018 wage indexes. Also, the recalculation of the MS-DRG relative weights, the revisions to Factor 3 of the uncompensated care payment methodology and recalculation of the FY 2018 wage index necessitated the recalculation of the rural and imputed floor budget neutrality factor (as discussed in section II.C. of this correcting document). Therefore, we are correcting the values in the column titled ``FY 2018 Wage Index'' for all hospitals. Additionally, for the six hospitals for which we inadvertently used the incorrect wage data (as discussed in section II.A. of this correcting document), we are correcting the average hourly wages in the columns titled ``Average Hourly Wage FY 2018'' and ``3-Year Average Hourly Wage (2016, 2017, 2018)''. Table 3.--Wage Index Table by CBSA-FY 2018. The wage data errors related to the six hospitals required the recalculation of the FY 2018 national average hourly wage adjusted for occupational mix which resulted in recalculating the FY 2018 wage indexes. Also, the recalculation of the MS-DRG relative weights, the revisions to Factor 3 of the uncompensated care payment methodology, and recalculation of the FY 2018 wage index necessitated the recalculation of the rural and imputed floor budget neutrality factor (as discussed in section II.C. of this correcting document). Therefore, we are making corresponding changes to the wage indexes and GAFs of all CBSAs listed in Table 3. Specifically, we are correcting the values and flags in the columns titled ``Wage Index'', ``Reclassified Wage Index'', ``GAF'', ``Reclassified GAF'', ``Pre-Frontier and/or Pre-Rural or Imputed Floor Wage Index'' and ``Eligible for Rural or Imputed Floor Wage Index''. Additionally, for the two CBSAs (24860 and 40340) where the six hospitals for which we inadvertently used the incorrect wage data are located (as discussed in section II.A. of this correcting document), we are correcting the average hourly wages in the [[Page 46141]] columns titled ``FY 2018 Average Hourly Wage'' and ``3-Year Average Hourly Wage (2016, 2017, 2018)''. As we described previously, we inadvertently used the incorrect wage data for the following hospitals: CCNs 240010, 420033, 420037, 420038, 420078 and 420102. Table 5.--List of Medicare Severity Diagnosis-Related Groups (MS- DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay--FY 2018. We are correcting this table to reflect the recalculation of the FY 2018 MS-DRG relative weights and associated statistics as a result of the corrections to the logic for the ICD-10 MS-DRG Grouper Version 35 Software discussed in section II.A. of this correcting document. Specifically, we are correcting the values in the columns titled ``Weights'', ``Geometric mean LOS'', and ``Arithmetic mean LOS''. Table 6P.--ICD-10-CM and ICD-10-PCS Code Designations, MCE and MS- DRG Changes--FY 2018. As discussed in section II.A of this correcting document, we are correcting the list of the ICD-10-PCS procedure codes in Table 6P.4b to reflect the three ICD-10-PCS procedure codes relating to the percutaneous insertion of intraluminal or monitoring devices that are finalized as non-O.R. procedures for FY 2018. Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2016 MedPAR Update--March 2017 GROUPER V35.0 MS- DRGs. We are correcting this table to reflect the recalculation of the FY 2018 MS-DRG relative weights and associated statistics as a result of the corrections to the logic for the ICD-10 MS-DRG Grouper Version 35 Software discussed in section II.A. of this correcting document. Table 10--New Technology Add-On Payment Thresholds for Applications for FY 2019. We are correcting the thresholds in this table as a result of the corrections to the operating standardized amounts discussed in section II.C. of this correcting document. Table 18.--Final FY 2018 Medicare DSH Uncompensated Care Payment Factor 3. We are correcting this table to reflect revisions to the Factor 3 calculations for purposes of determining uncompensated care payments for the FY 2018 IPPS/LTCH PPS final rule for the following reasons: To apply our finalized policy of double weighting the 2013 Factor 3 instead of developing a 2014 Factor 3 using uncompensated care cost data from Worksheet S-10 for several all-inclusive rate providers. To reflect mergers where data for the merged hospital were not combined with the data for the surviving hospital for purposes of calculating Factor 3 for the FY 2018 IPPS/LTCH PPS Final Rule. To correct the Factor 3 that was computed for a hospital whose FY 2014 cost report in the March 2017 extract of Healthcare Cost Report Information System (HCRIS) inadvertently omitted amended uncompensated care cost data reported on an amended Worksheet S-10 that had been received timely per CR 9648 issued on July, 15, 2016, and that was inadvertently omitted from the hospital's 2014 cost report when it was uploaded into HCRIS. To correct the Factor 3 that was computed for a hospital that only had Factor 3 values for two cost reporting periods, but whose Factor 3 was inadvertently calculated by dividing by three cost reporting periods when averaging the Factor 3 values. To correct the misapplication of our new hospital policy, where hospitals with a CMS Certification Number (CCN) established after October 1, 2013, but before October 1, 2014, were inadvertently considered subject to that policy when calculating Factor 3. As stated in the FY 2018 IPPS/LTCH PPS final rule (82 FR 38212), only those hospitals with a CCN established after October 1, 2014, are considered new and subject to the new hospital policy when calculating Factor 3 for FY 2018. We are revising Factor 3 for all hospitals to correct these errors. We are also revising the amount of the total uncompensated care payment calculated for each DSH-eligible hospital. The total uncompensated care payment that a hospital receives is used to calculate the amount of the interim uncompensated care payments the hospital receives per discharge. Per discharge uncompensated care payments are included when determining total payments for purposes of all of the budget neutrality factors and the final outlier threshold. As a result, these corrections to the uncompensated care payments impacted the calculation of all the budget neutrality factors as well as the outlier fixed-loss cost threshold for outlier payments. These corrections will be reflected in Table 18 and the Medicare DSH Supplemental Data File. In section II.D. of this correcting document, we have made corresponding revisions to the discussion of the ``Effects of the Changes to Medicare DSH and Uncompensated Care Payments for FY 2018'' for purposes of the Regulatory Impact Analysis in Appendix A of the FY 2018 IPPS/LTCH PPS final rule to reflect the corrections discussed previously. We are also correcting the errors in the following LTCH PPS tables that are listed on page 38548 of the FY 2018 IPPS/LTCH PPS final rule and are available on the Internet on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/LongTermCareHospitalPPS/index.html under the list item for regulation number CMS-1677-F. The tables that are available on the Internet have been updated to reflect the revisions discussed in this correcting document. Table 11.--MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and Short-Stay Outlier (SSO) Threshold for LTCH PPS Discharges Occurring from October 1, 2017 through September 30, 2018. We are correcting this table to reflect the recalculation of the FY 2018 MS- LTC-DRG relative weights and associated statistics as a result of the corrections to the logic for the Version 35 Grouper Software discussed in section II.A. of this correcting document. Table 12A.--LTCH PPS Wage Index for Urban Areas for Discharges Occurring from October 1, 2017 through September 30, 2018. We are correcting this table to reflect the revisions to the LTCH PPS wage index values discussed in section II.C. of this correcting document. Table 12B.--LTCH PPS Wage Index for Rural Areas for Discharges Occurring from October 1, 2017 through September 30, 2018. We are correcting this table to reflect the revisions to the LTCH PPS wage index values discussed in section II.C. of this correcting document. We also note that we have made conforming changes to the ICD-10 MS- DRG Definitions Manual Version 35 for consistency with the ICD-10 MS- DRG Grouper and Medicare Code Editor (MCE) Version 35 Software. First, the ICD-10-CM diagnosis code P05.18 (Newborn small for gestational age, 2000-2499 grams) was displayed in the ICD-10 MS-DRG Definitions Manual Version 35 as grouping to both MS-DRGs 793 (Full Term Neonate with Major Problems) and 795 (Normal Newborn). The correct MS-DRG assignment for diagnosis code P05.18 is only MS-DRG 795; therefore, corrections were made to the ICD-10 MS-DRG Definitions Manual Version 35 to reflect the correct MS-DRG assignment. Second, the following 9 diagnosis codes were not included in the major problem list in the MS-DRG Definitions Manual: K56.600 (Partial intestinal obstruction, unspecified as to cause); K56.601 (Complete intestinal obstruction, unspecified as to cause); [[Page 46142]] K56.609 (Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction); K56.690 (Other partial intestinal obstruction); K56.691(Other complete intestinal obstruction); K56.699 (Other intestinal obstruction unspecified as to partial versus complete obstruction); K91.30 (Postprocedural intestinal obstruction, unspecified as to partial versus complete); K91.31 (Postprocedural partial intestinal obstruction); and K91.32 (Postprocedural complete intestinal obstruction). We made corrections to add these 9 diagnosis codes to the major problems list for MS-DRG 793 under Major Diagnostic Category (MDC) 15 (Newborns & Other Neonates with Conditions Originating in Perinatal Period) in the ICD-10 MS-DRG Definitions Manual Version 35. III. Waiver of Proposed Rulemaking and Delay in Effective Date We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C. 553(b)). However, we can waive this notice and comment procedure if the Secretary finds, for good cause, that the notice and comment process is impracticable, unnecessary, or contrary to the public interest, and incorporates a statement of the finding and the reasons therefore in the notice. Section 553(d) of the APA ordinarily requires a 30-day delay in the effective date of final rules after the date of their publication in the Federal Register. This 30-day delay in effective date can be waived, however, if an agency finds for good cause that the delay is impracticable, unnecessary, or contrary to the public interest, and the agency incorporates a statement of the findings and its reasons in the rule issued. We believe that this correcting document does not constitute a rule that would be subject to the APA notice and comment or delayed effective date requirements. This correcting document corrects technical and typographic errors in the preamble, regulations text, addendum, payment rates, tables, and appendices included or referenced in the FY 2018 IPPS/LTCH PPS final rule but does not make substantive changes to the policies or payment methodologies that were adopted in the final rule. As a result, this correcting document is intended to ensure that the information in the FY 2018 IPPS/LTCH PPS final rule accurately reflects the policies adopted in that final rule. In addition, even if this were a rule to which the notice and comment procedures and delayed effective date requirements applied, we find that there is good cause to waive such requirements. Undertaking further notice and comment procedures to incorporate the corrections in this document into the final rule or delaying the effective date would be contrary to the public interest because it is in the public's interest for providers to receive appropriate payments in as timely a manner as possible, and to ensure that the FY 2018 IPPS/LTCH PPS final rule accurately reflects our policies. Furthermore, such procedures would be unnecessary, as we are not altering our payment methodologies or policies, but rather, we are simply implementing correctly the policies that we previously proposed, received comment on, and subsequently finalized. This correcting document is intended solely to ensure that the FY 2018 IPPS/LTCH PPS final rule accurately reflects these payment methodologies and policies. Therefore, we believe we have good cause to waive the notice and comment and effective date requirements. Correction of Errors In FR Doc. 2017-16434 of August 14, 2017 (82 FR 37990), we are making the following corrections: A. Corrections of Errors in the Preamble 1. On page 37990, first column, line 8 (Part headings), the figures ``486, 488, 489, and 495'' are corrected to read ``486, 489, and 495''. 2. On page 38067-- a. Second column, last partial paragraph, line 1, the figure ``28'' is corrected to read ``18''. b. Third column-- (1) First partial paragraph-- (a) Line 7, the phrase ``28 ICD-10-PCS'' is corrected to read ``28 (18 discrete) ICD-10-PCS''. (b) Line 15, the phrase ``O.R. procedures. We invite public'' is corrected to read ``O.R. procedures. (We note that Table 6P.4b. associated with the proposed rule listed 28 rather than 18 ICD-10-PCS codes because we inadvertently included 10 duplicate codes. However only 18 discrete ICD-10-PCS codes were listed in that table.) We invite public''. (2) First full paragraph-- (a) Line 3, the figure ``28'' is corrected to read ``18''. (b) Line 9, the figure ``28'' is corrected to read ``18''. 3. On page 38068, top half of the page (between the untitled tables) first column-- a. First paragraph, line 5, the figure ``28'' is corrected to read ``18''. b. Second paragraph, line 4, the figure ``13'' is corrected to read ``3''. 4. On page 38119, third column, first partial paragraph, lines 25 and 26, the phrase ``XW033A3 and XW043A3.'' is corrected to read ``XW033A3 or XW043A3.'' 5. On page 38132-- a. Second column, first paragraph, last line, the figure ``$42.1027'' is corrected to read ``$42.0795''. b. Third column, first partial paragraph, line 4, the figure $42.1027'' is corrected to read ``$42.0795''. 6. On page 38137, third column-- a. First full paragraph, last line, the figure $42.0564'' is corrected to read ``$42.0332''. b. Last full paragraph, last line, the figure $42.0564'' is corrected to read ``$42.0332''. 7. On page 38144, first column, first partial paragraph, lines 8 through 10, the phrase ``2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244- 2670.'' is corrected to read ``1508 Woodlawn Drive, Suite 100, Baltimore, MD 21207.''. 8. On page 38195-- a. Top of the page, third column, first full paragraph, line 19, the figure ``$15.533'' is corrected to read ``$15.553''. b. Bottom of the page in the table titled ``FACTORS APPLIED FOR FY 2015 THROUGH FY 2018 TO ESTIMATE MEDICARE DSH EXPENDITURES USING 2014 BASELINE'' last row (FY 2018), last column (Estimated DSH payment), the entry ``15.533'' is corrected to read ``15.553''. 9. On page 38225-- a. First column, last bulleted paragraph, lines 3 through 5, the phrase ``(AMI-Version 8.0, HF-Version 8.0, Pneumonia-Version 8.0, COPD- Version 4.0, and Stroke-Version 4.0: 2016'' is corrected to read ``(AMI-Version 9.0, HF-Version 9.0, Pneumonia-Version 9.0, COPD-Version 5.0, and Stroke-Version 5.0: 2016''. b. Second column; first bulleted paragraph, lines 2 through 4, the phrase ``(THA and/or TKA-Version 4.0, CABG-Version 2.0: 2016'' is corrected to read ``(THA and/or TKA-Version 5.0, CABG-Version 3.0: 2016)''. 10. On page 38249, second column, last paragraph, lines 23 and 24, the parenthetical phrase ``(for example, the MORT-30-PN measure)'' is corrected to read ``(for example, PN Payment measure)''. 11. On page 38257, third column, footnote paragraph (footnote 69), last line, the date ``Mar 1997'' is corrected to read ``Mar 1977''. 12. On page 38258, first column, third paragraph-- [[Page 46143]] a. Lines 8 and 9, the reference ``(78 FR 50074;'' is corrected to read ``(79 FR 50074;''. b. Line 9, the reference ``80 FR 49588).'' is corrected to read ``80 FR 49558).''. 13. On page 38259, first column, first partial paragraph, line 14, the date ``June 0'' is corrected to read ``June 30''. 14. On page 38309, third column, first full paragraph, line 29 the figure ``1.28590'' is corrected to read ``1.28593''. 15. On page 38310, first column-- a. First full paragraph, line 29, the figure ``0.9907845'' is corrected to read ``0.9907437''. b. Second full paragraph-- (1) Line 5, the figure ``1.28590'' is corrected to read ``1.28593''. (2) Line 6, the figure ``0.9907845'' is corrected to read ``0.9907437''. 16. On page 38426-- a. First column, second full paragraph, line 21, the phrase ``an Application of Percent'' is corrected to read ``Application of Percent''. b. Third column, third full paragraph, line 10, the phrase ``criteria; however should'' is corrected to read ``criteria. However, the measure should''. 17. On page 38434, in the first column, second paragraph-- a. Line 29, the phrase ``Stage 3 or 4 ulcers.'' is corrected to read ``Stage 3 or 4 pressure ulcers.''. b. Line 31, the phrase ``Stage 1 and 2 ulcers decreased'' is corrected to read ``Stage 1 and 2 pressure ulcers decreased''. c. Line 32, the phrase '' of Stage 3 and 4 ulcers'' is corrected to read ``of Stage 3 and 4 pressure ulcers''. 18. On page 38440, third column, last paragraph-- a. Lines 10 and 11, the phrase ``That nearly one third'' is corrected to read ``The fact that nearly one third''. b. Lines 16 and 17, the phrase ``LTCH, and also indicates'' is corrected to read ``LTCH. It also indicates''. 19. On page 38458, third column, second full paragraph-- a. Lines 21 through 23, the phrase (measure name) ``Functional Outcome Measure: Change in Mobility Among Patients Requiring Ventilator Support (NQF #2632).'' is corrected to read ``Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital (LTCH) Patients Requiring Ventilator Support (NQF #2632).''. b. Lines 31 through 34, the phrase (measure name) ``Functional Outcome Measure: Change in Mobility Among Patients Requiring Ventilator Support (NQF #2632)'' is corrected to read ``Functional Outcome Measure: Change in Mobility Among Long-Term Care Hospital (LTCH) Patients Requiring Ventilator Support (NQF #2632).'' 20. On page 38509, second column, eighth full paragraph (List of subjects 42 CFR 488), the paragraph is corrected by removing the paragraph. B. Correction of Errors in the Regulations Text 1. On page 38516, in the first column, remove the part heading for part 488 and remove amendatory instructions 34 and 35 in their entirety. Sec. 495.4 [Corrected] 2. On page 38516, in the second column, after amendatory instruction 39a, add amendatory instruction a2 to read-- ``a2. In the definition of ``Certified electronic health record technology (CEHRT)'': i. In paragraph (1)(iii), removing the phrase ``for 2018 subsequent years'' and adding in its place the phrase ``for 2019 and subsequent years''; and ii. In the introductory text of paragraph (2), removing the phrase ``For 2018 and subsequent years,'' and adding in its place the phrase ``For 2019 and subsequent years,''.'' Sec. 495.24 [Corrected] 3. On page 38517, second column, sixth full paragraph, amendatory instruction 41d is corrected and amendatory instructions 41e and f are correctly added to read as follows: ``d. Revising the paragraph (d) heading. e. In paragraph (d)(6)(i)(B)(1)(iv) by removing the phrase ``For an EHR reporting period in 2017 only, an EP'' and adding in its place the phrase ``For an EHR reporting period in 2017 and 2018, an EP''. f. Revising paragraphs (d)(6)(i)(B)(2)(i) and (ii), (d)(6)(ii)(B)(1)(iv), and (d)(6)(ii)(B)(2)(i) and (ii).'' C. Correction of Errors in the Addendum 1. On page 38522 -- a. Second column, first full paragraph-- (1) Line 3, the figure ``0.997432'' is corrected to read ``0.997439''. (2) Line 8, the figure ``0.997432'' is corrected to read ``0.997439''. b. Third column-- (1) First full paragraph, line 9, the figure ``1.001148'' is corrected to read ``1.000882''. (2) Last paragraph, line 11 the figure ``0.988008'' is corrected to read ``0.987985''. 2. On page 38523, second column, first partial paragraph, line 2, the figure ``0.993348'' is corrected to read ``0.993324''. 3. On page 38527, lower two-thirds of the page (after the first untitled table), third column-- a. First partial paragraph-- (1) Line 4, the figure ``$26,601'' is corrected to read ``$26,537''. (2) Line 5, the figure ``85,942,484,975'' is corrected to read ``$90,203,348,168''. (3) Line 6, the figure ``$4,618,707,285'' is corrected to read ``$4,600,554,656''. (4) Line 17, the figure ``$26,601'' is corrected to read ``$26,537''. b. First full paragraph, line 13, the figure ``5.16'' is corrected to read ``5.17''. c. Following the third full paragraph, the untitled table is corrected to read as follows: ------------------------------------------------------------------------ Operating standardized Capital federal amounts rate ------------------------------------------------------------------------ National.............................. 0.948998 0.948259 ------------------------------------------------------------------------ 4. On page 38529, top of the page, the table titled ``CHANGES FROM FY 2017 STANDARDIZED AMOUNTS TO THE FY 2018 STANDARDIZED AMOUNTS'', is corrected to read as follows: [[Page 46144]] Changes From FY 2017 Standardized Amounts to the FY 2018 Standardized Amounts ---------------------------------------------------------------------------------------------------------------- Hospital submitted Hospital did NOT Hospital did NOT Hospital submitted quality data and submit quality submit quality quality data and is NOT a data and is a data and is NOT a is a meaningful meaningful EHR meaningful EHR meaningful EHR EHR user user user user ---------------------------------------------------------------------------------------------------------------- FY 2018 Base Rate after removing: 1. FY 2017 Geographic If Wage Index is If Wage Index is If Wage Index is If Wage Index is Reclassification Budget Greater Than Greater Than Greater Than Greater Than Neutrality (0.988136). 1.0000: 1.0000: 1.0000: 1.0000: 2. FY 2017 Operating Outlier Labor (68.3%): Labor (68.3%): Labor (68.3%): Labor (68.3%): Offset (0.948998). $3,993.72. $3,993.72. $3,993.72. $3,993.72. 3. FY 2017 2-Midnight Rule Nonlabor Nonlabor Nonlabor Nonlabor One-Time Prospective (30.4%): (30.4%): (30.4%): (30.4%): Increase (1.006). $1,853.60. $1,853.60. $1,853.60. $1,853.60. 4. FY 2017 Labor Market If Wage Index is If Wage Index is If Wage Index is If Wage Index is Delineation Wage Index less Than or less Than or less Than or less Than or Transition Budget Equal to 1.0000: Equal to 1.0000: Equal to 1.0000: Equal to 1.0000: Neutrality Factor (0.999997). Labor (62%): Labor (62%): Labor (62%): Labor (62%): $3,625.34. $3,625.34. $3,625.34. $3,625.34. Nonlabor (38%): Nonlabor (38%): Nonlabor (38%): Nonlabor (38%): $2,221.98. $2,221.98. $2,221.98. $2,221.98. FY 2018 Update Factor........... 1.0135............ 0.99325........... 1.00675........... 0.9865. FY 2018 MS-DRG Recalibration 0.997439.......... 0.997439.......... 0.997439.......... 0.997439. Budget Neutrality Factor. FY 2018 Wage Index Budget 1.000882.......... 1.000882.......... 1.000882.......... 1.000882. Neutrality Factor. FY 2018 Reclassification Budget 0.987985.......... 0.987985.......... 0.987985.......... 0.987985. Neutrality Factor. FY 2018 Operating Outlier Factor 0.948998.......... 0.948998.......... 0.948998.......... 0.98998. Adjustment for FY 2018 Required 1.004588.......... 1.004588.......... 1.004588.......... 1.004588. under Section 414 of Pub. L. 114-10 (MACRA) and Section 15005 of Pub. L. 114-255. National Standardized Amount for Labor: $3,806.04.. Labor: $3,729.99.. Labor: $3,780.69.. Labor: $3,704.65. FY 2018 if Wage Index is Nonlabor: Nonlabor: Nonlabor: Nonlabor: Greater Than 1.0000; Labor/Non- $1,766.49. $1,731.20. $1,754.73. $1,719.43. Labor Share Percentage (68.3/ 31.7). National Standardized Amount for Labor: $3,454.97.. Labor: $3,385.94.. Labor: $3,431.96.. Labor: $3,362.93. FY 2018 if Wage Index is less Nonlabor: Nonlabor: Nonlabor: Nonlabor: Than or Equal to 1.0000; Labor/ $2,117.56. $2,075.25. $2,103.46. $2,061.15. Non-Labor Share Percentage (62/ 38). ---------------------------------------------------------------------------------------------------------------- 5. On page 38532, lower two-thirds of the page (after the untitled table)-- a. First column, second full paragraph, line 13, the figure ``0.997432'' is corrected to read ``0.997439''. b. Third column, second full paragraph, line 6, the figure ``1.61'' is corrected to read ``1.60''. 6. On page 38534-- a. First column-- (1) First full paragraph-- (a) Line 8, the figure ``5.16'' is corrected to read ``5.17''. (b) Line 12, the figure ``0.9484'' is corrected to read ``0.9483''. (2) Second full paragraph-- (a) Lines 5 and 6, the phrase ``outlier adjustment of 0.9484 is a 1.04 percent change'' is corrected to read ``outlier adjustment of 0.9483 is a 1.03 percent change''. (b) Line 10, the figures ``1.0104 (0.9484/0.9386)'' are corrected to read ``1.0103(0.9483/0.9386)''. (c) Line 12, the figure ``1.04'' is corrected to read ``1.03''. (3) Fourth full paragraph-- (a) Line 13, the figure ``0.9994'' is corrected to read ``0.9995''. (b) Line 16, the figure ``0.9844'' is corrected to read ``0.99845''. b. Second column-- (1). First partial paragraph, line 8, the figure ``0.9837'' is corrected to read ``0.9838''. (2). Third full paragraph-- (a) Line 1, the figure ``0.9986'' is corrected to read ``0.9987''. (b) Line 3, the figure ``0.9994'' is corrected to read ``0.9995''. c. Third column-- (1). First full paragraph-- (a) Line 4, the figure ``1.61'' is corrected to read ``1.60''. (b) Line 15, the figure ``$453.97'' is corrected to read ``$453.95''. [[Page 46145]] (c) Second bulleted paragraph, last line, the figure ``0.9986'' is corrected to read ``0.9987''. (d) Third bulleted paragraph, last line, the figure ``0.9484'' is corrected to read ``0.9483''. (e) Last paragraph-- (1) Line 15, the figure ``0.14'' is corrected to read ``0.13''. (2) Line 18, the figure ``1.04'' is corrected to read ``1.03''. 7. On page 38535-- a. Top of page-- (1) Second column, first partial paragraph, last line, the figure ``1.61'' is corrected to read ``1.60''. (2) The table titled ``COMPARISON OF FACTORS AND ADJUSTMENTS: FY 2017 CAPITAL FEDERAL RATE AND FY 2018 CAPITAL FEDERAL RATE'' is corrected to read as follows: Comparison of Factors and Adjustments: FY 2017 Capital Federal Rate and FY 2018 Capital Federal Rate ---------------------------------------------------------------------------------------------------------------- Percent change FY 2017 FY 2018 Change \3\ ---------------------------------------------------------------------------------------------------------------- Update Factor \1\............................... 1.0090 1.0130 1.0130 1.30 GAF/DRG Adjustment Factor \1\................... 0.9990 0.9987 0.9987 -0.13 Outlier Adjustment Factor \2\................... 0.9386 0.9483 1.0103 1.03 Removal of One-Time 2-Midnight Policy Adjustment 1.0060 1/1.006 0.9940 -0.60 Factor......................................... Capital Federal Rate............................ $446.79 $453.95 1.0160 1.60 ---------------------------------------------------------------------------------------------------------------- \1\ The update factor and the GAF/DRG budget neutrality adjustment factors are built permanently into the capital Federal rates. Thus, for example, the incremental change from FY 2017 to FY 2018 resulting from the application of the 0.9987 GAF/DRG budget neutrality adjustment factor for FY 2018 is a net change of 0.9987 (or -0.13 percent). \2\ The outlier reduction factor is not built permanently into the capital Federal rate; that is, the factor is not applied cumulatively in determining the capital Federal rate. Thus, for example, the net change resulting from the application of the FY 2018 outlier adjustment factor is 0.9483/0.9386 or 1.0103 (or 1.03 percent). \3\ Percent change may not sum due to rounding. b. Middle of page, the table titled ``COMPARISON OF FACTORS AND ADJUSTMENTS: PROPOSED FY 2018 CAPITAL FEDERAL RATE AND FINAL FY 2018 CAPITAL FEDERAL RATE'' is corrected to read as follows: Comparison of Factors and Adjustments: Proposed FY 2018 Capital Federal Rate and Final FY 2018 Capital Federal Rate ---------------------------------------------------------------------------------------------------------------- Proposed FY 2018 Final FY 2018 Change Percent change ---------------------------------------------------------------------------------------------------------------- Update Factor \1\............................... 1.0120 1.0130 1.0010 1.10 GAF/DRG Adjustment Factor \1\................... 0.9992 0.9987 0.9985 -0.05 Outlier Adjustment Factor \2\................... 0.9434 0.9483 1.0052 0.52 Removal of One-Time 2-Midnight Policy Adjustment 1/1.006 1/1.006 0.0000 0.00 Factor......................................... Capital Federal Rate............................ $451.37 $453.95 1.0057 0.57 ---------------------------------------------------------------------------------------------------------------- c. Lower third of the page, first column, second full paragraph, last line, the figure, ``$26,601'' is corrected to read ``$26,537''. 8. On page 38537-- a. First column last paragraph-- (1) Line 22, the figure ``1.0006434'' is corrected to read ``1.0002704''. (2) Line 35, the figure ``$41,430.56'' is corrected to read ``$41,415.11''. (3) Line 36, the figure ``1.0006434'' is corrected to read ``1.0002704''. b. Second column, first partial paragraph-- (1) Line 5, the figure ``40,610.16'' is corrected to read ``$40,595.02''. (2) Line 6, the figure ``1.0006434'' is corrected to read ``1.0002704''. 9. On page 38539, second column, fourth full paragraph-- a. Line 6, the figure ``1.0006434'' is corrected to read ``1.0002704''. b. Line 11, the figure ``1.0006434'' is corrected to read ``1.0002704''. 10. On page 38544-- a. First column-- (1) First partial paragraph-- (a) Line 6, the figure ``27,382'' is corrected to read ``27,381''. (b) Last line, the figure ``27,382'' is corrected to read ``27,381''. (2) First full paragraph-- (a) Line 4, the figure ``27,382'' is corrected to read ``27,381''. (b) Line 27, the figure ``27,240'' is corrected to read ``27,239''. (3) Second column, first partial paragraph, line 25, the figure ``27,382'' is corrected to read ``27,381''. 10. On page 38545-- a. Second column, second full paragraph-- (1) Line 14, the figure, ``$26,601'' is corrected to read ``$26,537''. (2) Last line, the figure, ``$26,601'' is corrected to read ``$26,537''. b. Third column, second full paragraph, line 3, the figure, ``$26,601'' is corrected to read ``$26,537''. 11. On page 38546, third column-- a. Second full paragraph, line 27, the figure ``$41,430.56'' is corrected to read ``$41,415.11''. b. Last paragraph, line 7, the figure ``1.0547'' is corrected to read ``1.0553''. 12. On page 38547, top of the page-- a. Second column, partial paragraph-- (1) Line 2, the figure ``$41,430.56'' is corrected to read ``$41,415.11''. (2) Line 3, the figure ``1.0547'' is corrected to read ``1.0553''. b. Third column, partial paragraph, line 5, the figure ``$41,449.71'' is corrected to read ``$41,450.13''. c. Untitled table, the table is corrected to read as follows: ------------------------------------------------------------------------ ------------------------------------------------------------------------ LTCH PPS Standard Federal Payment Rate.................. $41,415.11 Labor-Related Share..................................... x 0.662 Labor-Related Portion of the LTCH PPS Standard Federal = $27,416.80 Payment Rate........................................... Wage Index (CBSA 16974)................................. x 1.0553 [[Page 46146]] Wage-Adjusted Labor Share of LTCH PPS Standard Federal = $28,932.95 Payment Rate........................................... Nonlabor-Related Portion of the LTCH PPS Standard + $13,998.31 Federal Payment Rate ($41,415.11 x 0.338).............. Adjusted LTCH PPS Standard Federal Payment Amount....... = $42,931.26 MS-LTC-DRG 189 Relative Weight.......................... x 0.9655 Total Adjusted LTCH PPS Standard Federal Payment Rate... = $41,450.13 ------------------------------------------------------------------------ 13. On page 38548-- a. Middle of the page, (1) The table titled ``TABLE 1A.--NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR [(68.3 PERCENT LABOR SHARE/31.7 PERCENT NONLABOR SHARE IF WAGE INDEX IS GREATER THAN 1)--FY 2018''] is corrected to read as follows: Table 1A--National Adjusted Operating Standardized Amounts, Labor/Nonlabor [(68.3 percent labor share/31.7 percent nonlabor share if wage index is greater than 1)--FY 2018] -------------------------------------------------------------------------------------------------------------------------------------------------------- Hospital submitted quality data and is Hospital submitted quality data and Hospital did NOT submit quality data Hospital did NOT submit quality data a meaningful EHR user (update = 1.35 is not a meaningful EHR user (update and is a meaningful EHR user (update and is NOT a meaningful EHR user percent) = -0.675 percent) = 0.675 percent) (update = -1.35 percent) -------------------------------------------------------------------------------------------------------------------------------------------------------- Labor Nonlabor Labor Nonlabor Labor Nonlabor Labor Nonlabor -------------------------------------------------------------------------------------------------------------------------------------------------------- $3,806.04 $1,766.49 $3,729.99 $1,731.20 $3,780.69 $1,754.73 $3,704.65 $1,719.43 -------------------------------------------------------------------------------------------------------------------------------------------------------- (2) The table titled ``TABLE 1B.--NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR [(62 PERCENT LABOR SHARE/38 PERCENT NONLABOR SHARE IF WAGE INDEX IS LESS THAN OR EQUAL TO 1)--FY 2018]'' is corrected to read as follows: Table 1B--National Adjusted Operating Standardized Amounts, Labor/Nonlabor [(62 percent labor share/38 percent nonlabor share if wage index is less than or equal to 1)--FY 2018] -------------------------------------------------------------------------------------------------------------------------------------------------------- Hospital submitted quality data and is Hospital submitted quality data and Hospital did NOT submit quality data Hospital did NOT submit quality data a meaningful EHR user (update = 1.35 is not a meaningful EHR user (update and is a meaningful EHR user (update and is NOT a meaningful EHR user percent) = -0.675 percent) = 0.675 percent) (update = -1.35 percent) -------------------------------------------------------------------------------------------------------------------------------------------------------- Labor Nonlabor Labor Nonlabor Labor Nonlabor Labor Nonlabor -------------------------------------------------------------------------------------------------------------------------------------------------------- $3,454.97 $2,117.56 $3,385.94 $2,075.25 $3,431.96 $2,103.46 $3,362.93 $2,061.15 -------------------------------------------------------------------------------------------------------------------------------------------------------- (3) The table titled ``TABLE 1C.--ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR HOSPITALS IN PUERTO RICO, LABOR/NONLABOR [(NATIONAL: 62 PERCENT LABOR SHARE/38 PERCENT NONLABOR SHARE BECAUSE WAGE INDEX IS LESS THAN OR EQUAL TO 1);--FY 2018]'' is corrected to read as follows: Table 1C--Adjusted Operating Standardized Amounts For Hospitals In Puerto Rico, Labor/Nonlabor [(National: 62 percent labor share/38 percent nonlabor share because wage index is less than or equal to 1);--FY 2018] ---------------------------------------------------------------------------------------------------------------- Rates if wage index is greater than 1 Rates if wage index is less than -------------------------------------------- or equal to 1 Standardized amount --------------------------------- Labor Nonlabor Labor Nonlabor ---------------------------------------------------------------------------------------------------------------- National \1\...................... Not Applicable...... Not Applicable...... $3,454.97 $2,117.56 ---------------------------------------------------------------------------------------------------------------- \1\ For FY 2018, there are no CBSAs in Puerto Rico with a national wage index greater than 1. b. Bottom of the page-- (1) The table titled ``TABLE 1D.--CAPITAL STANDARD FEDERAL PAYMENT RATE [FY 2018]'' is corrected to read as follows: Table 1D--Capital Standard Federal Payment Rate [FY 2018] ------------------------------------------------------------------------ Rate ------------------------------------------------------------------------ National............................................... $453.95 ------------------------------------------------------------------------ (2) The table titled ``TABLE 1E.--LTCH PPS STANDARD FEDERAL PAYMENT RATE [FY 2018]'' is corrected to read as follows: [[Page 46147]] Table 1E--LTCH PPS Standard Federal Payment Rate [FY 2018] ------------------------------------------------------------------------ Reduced update Full update (1 * (-1.0 percent) percent) ------------------------------------------------------------------------ Standard Federal Payment Rate......... $41,415.11 $40,595.02 ------------------------------------------------------------------------ D. Corrections of Errors in the Appendices 1. On pages 38552 through 38554, the table and table notes for the table titled ``TABLE I.--IMPACT ANALYSIS OF CHANGES TO THE IPPS FOR OPERATING COSTS FOR FY 2018'' are corrected to read as follows: BILLING CODE 4120-01-P [[Page 46148]] [GRAPHIC] [TIFF OMITTED] TR04OC17.000 [[Page 46149]] [GRAPHIC] [TIFF OMITTED] TR04OC17.001 [[Page 46150]] [GRAPHIC] [TIFF OMITTED] TR04OC17.002 [[Page 46151]] [GRAPHIC] [TIFF OMITTED] TR04OC17.003 BILLING CODE 4120-01-C [[Page 46152]] 2. On page 38555, a. Second column, second full paragraph-- (1) Line 6, the figure ``0.997432'' is corrected to read ``0.997439''. (2) Line 14, the figure ``0.2'' is corrected to read ``0.1''. b. Third column, first full paragraph, line 26, the figure ``1.001148'' is corrected to read ``1.000882''. 3. On page 38556, lower half of the page-- a. First column, third full paragraph, line 6, the figure ``0.988008'' is corrected to read ``0.987985''. b. Third column-- (1) First full paragraph, line 8, the figure ``0.993348'' is corrected to read ``0.993324''. (2) Last paragraph, line 5, the figure ``0.993348'' is corrected to read ``0.993324''. 4. On page 38557, top of the page, first column, first partial paragraph, line 20, the figure ``$44 million'' is corrected to read ``$43 million''. 5. On pages 38557 and 38558, the table titled ``FY 2018 IPPS ESTIMATED PAYMENTS DUE TO RURAL AND IMPUTED FLOOR WITH NATIONAL BUDGET NEUTRALITY'' is corrected to read as follows: FY 2018 IPPS Estimated Payments Due to Rural and Imputed Floor With National Budget Neutrality ---------------------------------------------------------------------------------------------------------------- Percent change in payments Number of due to hospitals that application of State Number of will receive rural floor Difference (in hospitals the rural or and imputed $ millions) imputed floor floor with budget neutrality (1) (2) (3) (4) ---------------------------------------------------------------------------------------------------------------- Alabama......................................... 84 3 -0.3 -5 Alaska.......................................... 6 4 1.4 3 Arizona......................................... 57 38 0.4 7 Arkansas........................................ 44 1 -0.3 -4 California...................................... 299 177 1.2 134 Colorado........................................ 47 4 0.4 5 Connecticut..................................... 30 7 0.1 2 Delaware........................................ 6 6 1.8 8 Washington, DC.................................. 7 0 -0.4 -2 Florida......................................... 171 17 -0.2 -16 Georgia......................................... 103 0 -0.3 -9 Hawaii.......................................... 12 0 -0.3 -1 Idaho........................................... 14 0 -0.2 -1 Illinois........................................ 127 3 -0.4 -17 Indiana......................................... 85 0 -0.3 -8 Iowa............................................ 34 0 -0.3 -3 Kansas.......................................... 53 0 -0.3 -3 Kentucky........................................ 66 0 -0.3 -5 Louisiana....................................... 94 2 -0.3 -5 Maine........................................... 17 0 -0.4 -2 Massachusetts................................... 57 36 1.3 43 Michigan........................................ 94 0 -0.3 -14 Minnesota....................................... 49 0 -0.3 -6 Mississippi..................................... 60 0 -0.3 -4 Missouri........................................ 74 0 -0.2 -6 Montana......................................... 13 4 0 0 Nebraska........................................ 24 0 -0.3 -2 Nevada.......................................... 23 0 -0.4 -3 New Hampshire................................... 13 9 3.7 20 New Jersey...................................... 64 17 -0.1 -4 New Mexico...................................... 25 0 -0.2 -1 New York........................................ 154 11 -0.3 -23 North Carolina.................................. 84 0 -0.3 -10 North Dakota.................................... 6 0 -0.2 -1 Ohio............................................ 128 6 -0.3 -12 Oklahoma........................................ 84 4 -0.2 -3 Oregon.......................................... 34 5 -0.3 -3 Pennsylvania.................................... 150 3 -0.4 -17 Puerto Rico..................................... 52 10 0.2 0 Rhode Island.................................... 11 10 5.0 19 South Carolina.................................. 56 0 -0.3 -5 South Dakota.................................... 17 0 -0.2 -1 Tennessee....................................... 91 3 -0.3 -8 Texas........................................... 310 4 -0.3 -22 Utah............................................ 31 1 -0.3 -2 Vermont......................................... 6 0 -0.2 0 Virginia........................................ 73 1 -0.3 -7 Washington...................................... 48 3 -0.2 -5 West Virginia................................... 29 3 -0.1 -1 [[Page 46153]] Wisconsin....................................... 66 8 -0.2 -3 Wyoming......................................... 10 0 -0.1 0 ---------------------------------------------------------------------------------------------------------------- 6. On pages 38559 and 38560, the table titled ``TABLE II.--IMPACT ANALYSIS OF CHANGES FOR FY 2018 ACUTE CARE HOSPITAL OPERATING PROSPECTIVE PAYMENT SYSTEM (PAYMENTS PER DISCHARGE)'' is corrected to read as follows: Table II--Impact Analysis of Changes for FY 2018 Acute Care Hospital Operating Prospective Payment System [Payments per discharge] ---------------------------------------------------------------------------------------------------------------- Estimated Estimated Number of average FY average FY FY 2018 hospitals 2017 payment 2018 payment changes per discharge per discharge (1) (2) (3) (4) ---------------------------------------------------------------------------------------------------------------- All Hospitals................................... 3,292 $11,867 $12,024 1.3 By Geographic Location: Urban hospitals............................. 2,492 12,207 12,379 1.4 Large urban areas........................... 1,340 12,881 13,061 1.4 Other urban areas........................... 1,152 11,477 11,642 1.4 Rural hospitals............................. 800 8,911 8,930 0.2 Bed Size (Urban): 0-99 beds................................... 648 9,730 9,813 0.8 100-199 beds................................ 763 10,248 10,404 1.5 200-299 beds................................ 441 11,079 11,245 1.5 300-499 beds................................ 426 12,366 12,538 1.4 500 or more beds............................ 214 15,011 15,224 1.4 Bed Size (Rural): 0-49 beds................................... 318 7,523 7,486 -0.5 50-99 beds.................................. 282 8,487 8,372 -1.4 100-149 beds................................ 117 8,896 8,966 0.8 150-199 beds................................ 44 9,292 9,410 1.3 200 or more beds............................ 39 10,514 10,679 1.6 Urban by Region: New England................................. 114 13,125 13,303 1.4 Middle Atlantic............................. 315 13,819 13,967 1.1 South Atlantic.............................. 404 10,783 10,952 1.6 East North Central.......................... 385 11,537 11,727 1.6 East South Central.......................... 147 10,245 10,375 1.3 West North Central.......................... 160 11,915 12,107 1.6 West South Central.......................... 378 10,948 11,134 1.7 Mountain.................................... 162 12,824 12,898 0.6 Pacific..................................... 375 15,634 15,867 1.5 Puerto Rico................................. 52 8,851 8,947 1.1 Rural by Region: New England................................. 20 12,091 12,166 0.6 Middle Atlantic............................. 53 8,891 8,812 -0.9 South Atlantic.............................. 125 8,274 8,269 -0.1 East North Central.......................... 115 9,224 9,144 -0.9 East South Central.......................... 154 7,900 7,987 1.1 West North Central.......................... 97 9,736 9,794 0.6 West South Central.......................... 154 7,539 7,587 0.6 Mountain.................................... 58 10,620 10,718 0.9 Pacific..................................... 24 12,466 12,517 0.4 By Payment Classification: Urban hospitals............................. 2,373 12,148 12,320 1.4 [[Page 46154]] Large urban areas........................... 1,354 12,867 13,047 1.4 Other urban areas........................... 1,019 11,200 11,362 1.4 Rural areas................................. 919 10,568 10,656 0.8 Teaching Status: Nonteaching................................. 2,204 9,850 9,967 1.2 Fewer than 100 residents.................... 839 11,372 11,535 1.4 100 or more residents....................... 249 17,228 17,461 1.4 Urban DSH: Non-DSH..................................... 551 10,357 10,456 1.0 100 or more beds............................ 1,543 12,512 12,689 1.4 Less than 100 beds.......................... 370 8,960 9,102 1.6 Rural DSH: SCH......................................... 257 9,526 9,578 0.5 RRC......................................... 293 11,384 11,568 1.6 100 or more beds............................ 34 10,297 10,339 0.4 Less than 100 beds.......................... 244 7,035 6,764 -3.9 Urban teaching and DSH: Both teaching and DSH....................... 863 13,579 13,766 1.4 Teaching and no DSH......................... 92 11,410 11,522 1.0 No teaching and DSH......................... 1,050 10,217 10,374 1.5 No teaching and no DSH...................... 368 9,854 10,000 1.5 Special Hospital Types: RRC......................................... 263 11,165 11,360 1.8 SCH......................................... 316 10,774 10,820 0.4 SCH and RRC................................. 131 11,265 11,362 0.9 Type of Ownership: Voluntary................................... 1,914 12,058 12,212 1.3 Proprietary................................. 863 10,392 10,554 1.6 Government.................................. 513 12,810 12,980 1.3 Medicare Utilization as a Percent of Inpatient Days: 0-25........................................ 554 14,910 15,115 1.4 25-50....................................... 2,149 11,728 11,890 1.4 50-65....................................... 485 9,617 9,695 0.8 Over 65..................................... 103 7,591 7,444 -1.9 FY 2018 Reclassifications by the Medicare Geographic Classification Review Board: All Reclassified Hospitals.................. 858 11,661 11,830 1.5 Non-Reclassified Hospitals.................. 2,434 11,956 12,108 1.3 Urban Hospitals Reclassified................ 590 12,202 12,396 1.6 Urban Nonreclassified Hospitals............. 1,858 12,210 12,381 1.4 Rural Hospitals Reclassified Full Year...... 268 9,339 9,399 0.7 Rural Nonreclassified Hospitals Full Year... 485 8,422 8,379 -0.5 All Section 401 Reclassified Hospitals:..... 166 12,504 12,677 1.4 Other Reclassified Hospitals (Section 47 8,122 8,165 0.5 1886(d)(8)(B))............................. ---------------------------------------------------------------------------------------------------------------- 7. On pages 38561 through 38564 in the section titled ``Effects of the Changes to Medicare DSH and Uncompensated Care Payments for FY 2018'' (which begins with the phrase ``As discussed in section V.G of the preamble'' and ends with the phrase ``hospitals are projected to receive large increases'') the section is corrected to read as follows: ``5. Effects of the Changes to Medicare DSH and Uncompensated Care Payments for FY 2018. As discussed in section V.G. of the preamble of this final rule, under section 3133 of the Affordable Care Act, hospitals that are eligible to receive Medicare DSH payments will receive 25 percent of the amount they previously would have received under the statutory formula for Medicare DSH payments under section 1886(d)(5)(F) of the Act. The remainder, equal to an estimate of 75 percent of what formerly would have been paid as Medicare DSH payments (Factor 1), reduced to reflect changes in the percentage of uninsured individuals and additional statutory adjustments (Factor 2), is available to make additional payments to each hospital that qualifies for Medicare DSH payments and that has uncompensated care. Each hospital eligible for Medicare DSH payments will receive an additional payment based on its estimated share of the total amount of uncompensated care for all hospitals eligible for Medicare DSH payments. The uncompensated care payment methodology has redistributive effects based on the proportion of a hospital's uncompensated care relative to the uncompensated care for all hospitals eligible for Medicare DSH payments (Factor 3). [[Page 46155]] For FY 2018, we are establishing a Factor 2 of 58.01 percent determined using the uninsured estimates produced by CMS' Office of the Actuary (OACT) as part of the development of the National Health Expenditure Accounts (NHEA). Although we are continuing to use low- income insured patient days as a proxy for uncompensated care, for the first time, we are using these data in combination with data on uncompensated care costs from Worksheet S-10 in the calculation of Factor 3. The uncompensated care payment methodology has redistributive effects based on the proportion of a hospital's uncompensated care relative to the total uncompensated care for all hospitals eligible for Medicare DSH payments. The change to Medicare DSH payments under section 3133 of the Affordable Care Act is not budget neutral. In this final rule, we are establishing the amount to be distributed as uncompensated care payments to DSH eligible hospitals, which for FY 2018 is $6,766,695,163.56. This figure represents 75 percent of the amount that otherwise would have been paid for Medicare DSH payment adjustments adjusted by a Factor 2 of 58.01 percent. For FY 2017, the amount available to be distributed for uncompensated care was $5,977,483,146.86, or 75 percent of the amount that otherwise would have been paid for Medicare DSH payment adjustments adjusted by a Factor 2 of 55.36 percent. To calculate Factor 3 for FY 2018, we used an average of data computed using Medicaid days from hospitals' 2012 and 2013 cost reports from the March 2017 update of the HCRIS database, uncompensated care costs from hospitals' 2014 cost reports from the same extract of HCRIS, Medicaid days from 2012 cost report data submitted to CMS by IHS hospitals, and SSI days from the FY 2014 and FY 2015 SSI ratios. For each eligible hospital, we calculated an individual Factor 3 for cost reporting years FYs 2012, 2013, and 2014. We then added the individual amounts and divided the sum by the number of cost reporting periods with data to calculate an average Factor 3 for FY 2018. For purposes of this final rule, as we proposed, we used the most recent data from the March 2017 update of the HCRIS database for the Medicaid days component of the Factor 3 calculation as well as for the Worksheet S-10 uncompensated care cost component. The FY 2018 policy of using data from hospitals' FY 2012, FY 2013, and FY 2014 cost reporting years to determine Factor 3 is based on our FY 2017 final policy (81 FR 56943 through 56973), which is in contrast to the methodology used in FY 2016, when we used Medicaid days from the more recent of a hospital's full year 2012 or 2011 cost report from the March 2015 update of the HCRIS database, Medicaid days from 2012 cost report data submitted to CMS by IHS hospitals, and SSI days from the FY 2013 SSI ratios to calculate Factor 3. In addition, as explained in section V.G.4.c. of the preamble of this final rule, we are making several additional modifications to the Factor 3 methodology: (1) To annualize Medicaid data and uncompensated care data if a hospital's cost report does not equal 12 months of data; (2) to apply a scaling factor to the uncompensated care payment amount calculated for each DSH eligible hospital so that total uncompensated care payments are consistent with the estimated amount available to make uncompensated care payments for FY 2018; (3) to apply statistical trims to the CCRs on Worksheet S-10 that are considered anomalies to ensure reasonable CCRs are used to convert charges to costs for purposes of determining uncompensated care costs; (4) to calculate Factor 3 for Puerto Rico hospitals, all-inclusive rate providers, and Indian Health Service and Tribal hospitals by substituting data regarding low-income insured days for FY 2013 for the Worksheet S-10 data on uncompensated care costs from FY 2014 cost reports; and (5) to determine the ratio of uncompensated care costs relative to total operating costs on the hospital's 2014 cost report (as of March 2017), and in cases where the ratio of uncompensated care costs relative to total operating costs exceeds 50 percent, to determine the ratio of uncompensated care costs to total operating costs from the hospital's 2015 cost report (as of March 2017) and apply that ratio to the hospital's total operating costs from its 2014 cost report to determine uncompensated care costs for FY 2014. We also are continuing the policies that were finalized in the FY 2015 IPPS/LTCH PPS final rule (79 FR 50020 through 50022) to address several specific issues concerning the process and data to be employed in determining Factor 3 in the case of hospital mergers for FY 2018 and subsequent years, as well as continuing the policies finalized in the FY 2017 IPPS/LTCH PPS final rule concerning the methodology for calculating each hospital's relative share of uncompensated care, such as combining data from multiple cost reports beginning in the same fiscal year and calculating Factor 3 based on an average of the three individual Factor 3s for FYs 2012, 2013, and 2014, determined by adding the Factor 3 values for these years, and dividing by the number of cost reporting periods with data. To estimate the impact of the combined effect of changes in Factors 1 and 2, as well as the changes to the data used in determining Factor 3, on the calculation of Medicare DSH payments, including both empirically justified Medicare DSH payments and uncompensated care payments, we compared total DSH payments estimated in the FY 2017 IPPS/ LTCH PPS final rule to total DSH payments estimated in this FY 2018 IPPS/LTCH PPS final rule. For FY 2017, for each hospital, we calculated the sum of: (1) 25 percent of the estimated amount of what would have been paid as Medicare DSH in FY 2017 in the absence of section 3133 of the Affordable Care Act; and (2) 75 percent of the estimated amount of what would have been paid as Medicare DSH payments in the absence of section 3133 of the Affordable Care Act, adjusted by a Factor 2 of 55.36 percent and multiplied by a Factor 3 calculated as described in the FY 2017 IPPS/LTCH PPS final rule. For FY 2018, we calculated the sum of: (1) 25 percent of the estimated amount of what would be paid as Medicare DSH payments in FY 2018 absent section 3133 of the Affordable Care Act; and (2) 75 percent of the estimated amount of what would be paid as Medicare DSH payments absent section 3133 of the Affordable Care Act, adjusted by a Factor 2 of 58.01 percent and multiplied by a Factor 3 calculated using the methodology described previously. Our analysis included 2,438 hospitals that are projected to be eligible for DSH in FY 2018. It did not include hospitals that had terminated their participation in the Medicare program as of July 1, 2017, Maryland hospitals, and SCHs that are expected to be paid based on their hospital specific rates. In addition, data from merged or acquired hospitals were combined under the surviving hospital's CCN, and the non-surviving CCN was excluded from the analysis. The estimated impact of the changes to Factors 1, 2, and 3 across all hospitals projected to be eligible for DSH payments in FY 2018, by hospital characteristic, is presented in the following table. [[Page 46156]] Modeled Disproportionate Share Hospital Payments for Estimated FY 2018 DSHs by Hospital Type: Model DSH $ (in Millions) From FY 2017 to FY 2018 ---------------------------------------------------------------------------------------------------------------- FY 2017 final FY 2018 final Dollar Number of rule estimated rule estimated difference: FY Percent change estimated DSHs DSH $ (in DSH $ (in 2017-FY 2018 ** (FY 2018) millions) millions) (in millions) (1) (2) (3) (4) (5) ---------------------------------------------------------------------------------------------------------------- Total........................... 2,438 $9,553 $10,630 $1,077 11.3 By Geographic Location: Urban Hospitals............. 1,938 9,113 10,110 996 10.9 Large Urban Areas........... 1,043 5,717 6,377 660 11.5 Other Urban Areas........... 895 3,396 3,733 336 9.9 Rural Hospitals............. 500 439 520 80 18.3 Bed Size (Urban): 0 to 99 Beds................ 342 185 241 57 30.7 100 to 249 Beds............. 843 2,154 2,386 233 10.8 250+ Beds................... 753 6,775 7,482 707 10.4 Bed Size (Rural): 0 to 99 Beds................ 371 190 238 48 25.2 100 to 249 Beds............. 115 193 221 28 14.6 250+ Beds................... 14 56 60 5 8.2 Urban by Region: New England................. 91 387 415 29 7.4 Middle Atlantic............. 241 1,570 1,643 73 4.7 South Atlantic.............. 316 1,724 2,037 314 18.2 East North Central.......... 322 1,252 1,372 120 9.6 East South Central.......... 131 566 618 53 9.3 West North Central.......... 103 439 488 48 11.0 West South Central.......... 257 1,165 1,448 283 24.3 Mountain.................... 121 448 497 49 11.0 Pacific..................... 316 1,448 1,463 15 1.0 Puerto Rico................. 40 116 129 13 10.9 Rural by Region: New England................. 12 16 21 5 32.0 Middle Atlantic............. 25 33 32 -1 -3.9 South Atlantic.............. 86 92 115 23 25.2 East North Central.......... 68 44 58 13 29.9 East South Central.......... 136 141 150 9 6.2 West North Central.......... 30 19 23 4 22.1 West South Central.......... 111 72 95 23 32.1 Mountain.................... 27 15 20 5 32.2 Pacific..................... 5 7 6 -1 -11.4 By Payment Classification: Urban Hospitals............. 1,928 9,106 10,101 994 10.9 Large Urban Areas........... 1,043 5,717 6,377 660 11.5 Other Urban Areas........... 885 3,389 3,724 334 9.9 Rural Hospitals............. 510 447 529 82 18.5 Teaching Status: Nonteaching................. 1,526 2,955 3,276 321 10.9 Fewer than 100 residents.... 669 3,213 3,501 288 9.0 100 or more residents....... 243 3,384 3,853 468 13.8 Type of Ownership: Voluntary................... 1,434 5,971 6,533 563 9.4 Proprietary................. 552 1,650 1,662 12 0.7 Government.................. 452 1,932 2,434 502 30.0 Medicare Utilization Percent: Missing or Unknown.......... 15 1 15 14 2147.4 0 to 25..................... 425 2,972 3,365 393 13.2 25 to 50.................... 1,642 6,218 6,829 611 9.8 50 to 65.................... 310 352 408 57 16.1 Greater than 65............. 46 11 13 2 17.4 ---------------------------------------------------------------------------------------------------------------- Source: Dobson [bond] DaVanzo analysis of 2012-2014 Hospital Cost Reports. * Dollar DSH calculated by [0.25 * estimated section 1886(d)(5)(F) payments] + [0.75 * estimated section 1886(d)(5)(F) payments * Factor 2 * Factor 3]. When summed across all hospitals projected to receive DSH payments, DSH payments are estimated to be $9,553 million in FY 2017 and $10,630 million in FY 2018. ** Percentage change is determined as the difference between Medicare DSH payments modeled for the FY 2018 IPPS/ LTCH PPS final rule (column 3) and Medicare DSH payments modeled for the FY 2017 IPPS/LTCH PPS final rule (column 2) divided by Medicare DSH payments modeled for the FY 2017 final rule (column 2) times 100 percent. Changes in projected FY 2018 DSH payments from DSH payments in FY 2017 are primarily driven by (1) changes to Factor 1, which increased from $10.797 billion to $11.665 billion; (2) changes to Factor 2, which increased [[Page 46157]] from 55.36 percent to 58.01 percent; (3) changes to the data used to determine Factor 3; and (4) changes to the number of DSH-eligible hospitals within a given hospital type. The impact analysis found that, across all projected DSH eligible hospitals, FY 2018 DSH payments are estimated at approximately $10.630 billion, or an increase of approximately 11.3 percent from FY 2017 DSH payments (approximately $9.553 billion). While these changes result in a net increase in the amount available to be distributed in uncompensated care payments, DSH payments to select hospital types are expected to decrease. This redistribution of DSH payments is caused by changes in the data used to determine Factor 3 and changes in the number of DSH-eligible hospitals within a given hospital type. As seen in the above table, percent changes in DSH payments of less than 11.3 percent indicate that hospitals within the specified category are projected to experience a smaller increase in DSH payments, on average, compared to the universe of projected FY 2018 DSH hospitals. Conversely, percent changes in DSH payments that are greater than 11.3 percent indicate a hospital type is projected to have a larger increase than the overall percent change on average, a larger increase than the overall percent change. The variation in the distribution of DSH payments by hospital characteristic is largely dependent on the change in a given hospital's number of Medicaid days and SSI days for purposes of the low-income insured days proxy between FY 2017 and FY 2018, as well as on its uncompensated care costs as reported on its FY 2014 Worksheet S-10. Many rural hospitals, grouped by geographic location, payment classification, and bed size, are projected to experience a larger increase in DSH payments than their urban counterparts. Overall, rural hospitals are projected to receive an 18.3 percent increase in DSH payments, and urban hospitals are projected to receive a 10.9 percent increase. However, only smaller and medium-sized rural hospitals are projected to receive increases in DSH payments that are, on average, higher than the 11.3 percent change across all hospitals that are projected to be eligible for DSH in FY 2018. Rural hospitals that have 0-99 beds are projected to experience a 25.2 percent payment increase, those with 100-249 beds are projected to receive a 14.6 percent increase, and larger rural hospitals with 250+ beds are projected to experience an 8.2 percent payment increase. This trend is somewhat consistent with urban hospitals, in which the smallest urban hospitals (0- 99 beds) are projected to receive an increase in DSH payments of 30.7 percent. Medium sized hospitals (100-250 beds) and larger hospitals (250+ beds) are projected to receive increases of 10.8 and 10.4 percent in DSH payments, respectively, which are relatively consistent with the overall average. By region, projected DSH payment increases for urban hospitals are smaller than the overall percent change in the New England, Middle Atlantic, East North Central, East South Central, and Pacific regions. Hospitals in the South Atlantic and West South Central regions are projected to receive increases in DSH payments that are, on average, larger than the 11.3 percent change across all hospitals projected to be eligible for DSH in FY 2018. Increases in the West North Central, Mountain, and Puerto Rico regions are generally consistent with the overall average percent increase of 11.3 percent. Regionally, rural hospitals are projected to receive a wider range of increases. Rural hospitals in the Middle Atlantic and Pacific regions are expected to receive a decrease in DSH payments, while those in the East South Central region are projected to receive an increase in DSH payments smaller than the 11.3 overall percent change. Increases are projected to be substantially larger than the overall average in many regions, including New England, South Atlantic, East North Central, West North Central, West South Central, and Mountain. Nonteaching hospitals and teaching hospitals with fewer than 100 residents are projected to receive smaller increases than the overall percent change, at 10.9 and 9.0 percent respectively. Conversely, teaching hospitals with 100 or more residents are projected to receive, on average, larger increases than the overall percent change of 11.3 percent, with a projected increase of 13.8 percent. Voluntary hospitals are expected to receive a 9.4 percent increase, which is somewhat smaller than the overall percent change, while proprietary hospitals are expected to receive almost no change in DSH payments. Government hospitals are projected to receive a larger than average 30.0 percent increase. Hospitals with 25 to 50 percent Medicare utilization are projected to receive increases in DSH payments slightly below the overall average at 9.8 percent, while all other hospitals are projected to receive larger increases.'' 8. On page 38572 top of the page-- a. First column, fourth bulleted paragraph-- (1) Line 4, the figure ``0.9986'' is corrected to read ``0.9987'' (2) Line 5, the figure ``0.9484'' is corrected to read ``0.9483'' b Second column, first full paragraph-- (1) Line 8, the figure ``0.9484'' is corrected to read ``0.9483'' (2) Line 9, the figure ``1.04'' is corrected to read ``1.03''. c. Third column-- (1) First partial paragraph-- (a) Line 1, the figure ``2.9'' is corrected to read ``3.0'' (b) Line 4, the figure 2.0'' is corrected to read ``1.9''. (2) First full paragraph - (a) Line 4, the figure ``3.7'' is corrected to read ``3.8''. (b) Line 9, the figure ``5.2'' is corrected to read ``5.3''. (c) Line 12, the figure ``1.9'' is corrected to read ``2.0''. (3) Second full paragraph-- (a) Line 7, the figure ``2.3'' is corrected to read ``2.2''. (b) Lines 10 and 11, the phrase ``3.2 percent.'' is corrected to read ``3.2 percent and 3.3 percent, respectively.''. (4) Last paragraph-- (a) Line 14, the figure ``1.6'' is corrected to read ``1.7''. (b) Line 27, the figure ``6.6'' is corrected to read ``6.5''. 9. On pages 38572 through 38574, the table titled ``TABLE III.-- COMPARISON OF TOTAL PAYMENTS PER CASE [FY 2017 PAYMENTS COMPARED TO FY 2018 PAYMENTS]'' is corrected to read as follows: BILLING CODE 4120-01-P [[Page 46158]] [GRAPHIC] [TIFF OMITTED] TR04OC17.004 [[Page 46159]] [GRAPHIC] [TIFF OMITTED] TR04OC17.005 BILLING CODE 4120-01-C 10. On page 38576-- a. First column, last paragraph, line 4, the figure ``$41,430.56'' is corrected to read ``$41,415.11''. b. Second column-- (1) First partial paragraph-- (a) Line 1, the figure ``1.0006434'' is corrected to read ``1.0002704''. (b) Line 12, the figure ``$40,610.16'' is corrected to read ``$40,595.02''. (2) Second full paragraph, line 14, the figure ``1.0006434'' is corrected to read ``1.0002704''. 11. On page 38578, second column, second full paragraph-- a. Line 21, the figure ``$41,430.56'' is corrected to read ``$41,415.11''. b. Line 22, the figure ``$40,610.16'' is corrected to read ``$40,595.02''. 12. On page 38579-- a. Top of the page, the table title and the table titled ``TABLE IV: IMPACT OF PAYMENT RATE AND POLICY CHANGES TO LTCH PPS PAYMENTS FOR STANDARD PAYMENT RATE CASES FOR FY 2018 [Estimated FY 2017 payments compared to estimated FY 2018 payments]'' are corrected to read as follows: BILLING CODE 4120-01-P [[Page 46160]] [GRAPHIC] [TIFF OMITTED] TR04OC17.006 [[Page 46161]] [GRAPHIC] [TIFF OMITTED] TR04OC17.007 [[Page 46162]] [GRAPHIC] [TIFF OMITTED] TR04OC17.008 b. Lower fourth of the page, third column, partial paragraph, line 5, the figure ``1.0006434'' is corrected to read ``1.0002704''. 13. On page 38585, middle of the page, first column, first paragraph-- [[Page 46163]] a. Lines 34, the figure ``2.7'' is corrected to read ``2.5''. b. Line 38, the figure ``$226'' is corrected to read ``$227''. Dated: September 29, 2017. Ann C. Agnew, Executive Secretary to the Department, Department of Health and Human Services. [FR Doc. 2017-21325 Filed 9-29-17; 4:15 pm] BILLING CODE 4120-01-C
![46138 Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations
[FR Doc. 2017–21246 Filed 10–3–17; 8:45 am] II. Summary of Errors finalized on page 38068 of the final rule
BILLING CODE 6560–50–P for FY 2018.
A. Summary of Errors in the Preamble
In addition, after publication of the
On page 37990, we are making a FY 2018 IPPS/LTCH PPS final rule, we
conforming correction, removal of the became aware that the logic for the ICD–
DEPARTMENT OF HEALTH AND reference to part 488, based on the
HUMAN SERVICES 10 MS–DRG Definitions Manual Version
removal of the regulations text for 35 and the ICD–10 MS–DRG Grouper
Centers for Medicare & Medicaid § 488.5 described in section II.B. of this and Medicare Code Editor (MCE)
Services correcting document. Version 35 Software erroneously
On pages 38067 and 38068, we are designated the following ICD–10–PCS
correcting technical errors in our procedure code as a non-O.R. procedure
42 CFR Parts 405, 412, 413, 414, 416,
discussion and summary of and rather than as an O.R. procedure as
486, 488, 489, and 495
response to public comment regarding finalized on page 38072 of the final rule
[CMS–1677–CN] ICD–10–PCS procedure codes for FY 2018: 0BCC8ZZ (Extirpation of
describing procedures involving matter from right upper lung lobe, via
RIN–0938–AS98 percutaneous insertion of intraluminal natural or artificial opening
or monitoring device. Specifically, we endoscopic). Therefore, we also made
Medicare Program; Hospital Inpatient erroneously referred to a count of 28
Prospective Payment Systems for changes to the ICD–10 MS–DRG
procedure codes describing procedures
Acute Care Hospitals and the Long- Definitions Manual Version 35 and the
involving the percutaneous insertion of
Term Care Hospital Prospective ICD–10 MS–DRG Grouper and MCE
intraluminal and monitoring devices
Payment System and Policy Changes Version 35 Software to correctly reflect
into central nervous system and other
and Fiscal Year 2018 Rates; Quality the O.R. designation for this procedure
cardiovascular body parts rather than 18
Reporting Requirements for Specific code for FY 2018.
procedure codes. Of the 28 codes listed
Providers; Medicare and Medicaid in Table 6P.4b associated with the We recalculated the FY 2018 MS–
Electronic Health Record (EHR) proposed rule, 10 procedure codes were DRG relative weights (and associated
Incentive Program Requirements for duplicative, and erroneously included statistics, such as average length of stay
Eligible Hospitals, Critical Access in the table and in the total number of (ALOS)) as a result of the corrections to
Hospitals, and Eligible Professionals; codes referenced in the preamble. As the logic for the ICD–10 MS–DRG
Provider-Based Status of Indian Health indicated in the final rule, after Grouper Version 35 Software discussed
Service and Tribal Facilities and consideration of the public comments above. In addition, since the MS–LTC–
Organizations; Costs Reporting and we received, we maintained the DRGs used under the LTCH PPS for FY
Provider Requirements; Agreement designation of 15 procedure codes 2018 are the same as the MS DRGs used
Termination Notices; Correction identified by the commenters. For this under the IPPS for FY 2018 (and as such
reason, we are also correcting Table use the same ICD–10 MS–DRG Grouper
AGENCY: Centers for Medicare & Version 35 Software), we also
Medicaid Services (CMS), HHS. 6P.4b associated with the final rule (as
discussed in section II.E. of this recalculated the FY 2018 MS–LTC–DRG
ACTION: Final rule; correction. relative weights (and associated
correcting document) to reflect the 3
distinct procedure codes for which we statistics, such as geometric ALOS) for
SUMMARY: This document corrects the same reasons.
technical and typographical errors in finalized a change in designation,
including to remove the listings of ICD– On page 38119, we made a technical
the final rule that appeared in the error in describing which ICD–10–PCS
August 14, 2017, issue of the Federal 10–PCS procedure codes 00H032Z
(Insertion of Monitoring Device into procedure codes will be used to identify
Register, which will amend the cases involving ZINPLAVATM that are
Medicare hospital inpatient prospective Brain, Percutaneous Approach) and
00H632Z (Insertion of Monitoring eligible for new technology add-on
payment systems (IPPS) for operating payments in FY 2018. Specifically,
and capital related costs of acute care Device into Cerebral Ventricle,
Percutaneous Approach), which we cases involving ZINPLAVATM that are
hospitals to implement changes arising eligible for new technology add-on
from our continuing experience with finalized to maintain as O.R. procedures
for FY 2018, and are making conforming payments will be identified by either of
these systems for FY 2018. the ICD–10–PCS procedure codes listed
changes to the corresponding count of
DATES: This correction is effective codes listed in that table as indicated on in the final rule (XW033A3 or
October 1, 2017. page 38068. Consistent with these XW043A3) (rather than requiring the
FOR FURTHER INFORMATION CONTACT: corrections, we are also correcting the combination of both ICD–10–PCS
Donald Thompson, (410) 786–4487. description of the proposal on page procedure codes).
SUPPLEMENTARY INFORMATION: 38067 of the final rule. As a result of the On pages 38132 and 38137, in our
corrections to Table 6P.4b associated discussion of the wage indexes, we
I. Background with the final rule and the conforming provided incorrect values for the FY
In FR Doc. 2017–16434 of August 14, corrections on pages 38067 and 38068, 2018 national average hourly wage
2017 (82 FR 37990) there were a number we have made conforming changes to (unadjusted for occupational mix) and
of technical and typographical errors the ICD–10 MS–DRG Definitions the FY 2018 occupational mix adjusted
that are identified and corrected by the Manual Version 35 and ICD–10 MS– national average hourly wage due to
Correction of Errors section of this DRG Grouper Software Version 35 for inadvertent errors related to the wage
sradovich on DSK3GMQ082PROD with RULES
correcting document. The provisions in FY 2018 to reflect the O.R. designation data collected from the Medicare cost
this correcting document are effective as of ICD–10–PCS procedure codes reports of six hospitals (CMS
if they had been included in the 00H032Z (Insertion of Monitoring Certification Numbers (CCNs) 240010,
document that appeared in the August Device into Brain, Percutaneous 420033, 420037, 420038, 420078, and
14, 2017 Federal Register. Accordingly, Approach) and 00H632Z (Insertion of 420102).
the corrections are effective October 1, Monitoring Device into Cerebral On page 38144, we made an
2017. Ventricle, Percutaneous Approach), as inadvertent error in the mailing address
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![46140 Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations
certain statistical figures (for example, factors as a result of the technical errors Medicare/Medicare-Fee-for-Service-
percent change) in the accompanying that lead to conforming changes in our Payment/AcuteInpatientPPS/FY2018-
discussions. calculation of the operating and capital IPPS-Final-Rule-Home-Page.html. The
Also, as a result of these errors, on IPPS budget neutrality factors, outlier tables that are available on the Internet
page 38535, we have made conforming threshold, final wage indexes, operating have been updated to reflect the
corrections in the tables showing the standardized amounts, and capital revisions discussed in this correcting
comparison of factors and adjustments Federal rate (as described in sections document.
for the FY 2017 capital Federal rate and II.A. and II.C. of this correcting Table 2—Case-Mix Index and Wage
FY 2018 capital Federal rate and the document). Index Table- FY 2018. The wage data
proposed FY 2018 capital Federal rate In particular, we made changes to the errors related to the six hospitals
and final FY 2018 capital Federal rate. following tables. required the recalculation of the FY
On pages 38537 and 38539, we are • On pages 38552 through 38554, the 2018 national average hourly wages
correcting the area wage level budget table titled ‘‘Table I.—Impact Analysis unadjusted for occupational mix and
neutrality factor and making a of Changes to the IPPS for Operating adjusted for occupational mix which
conforming change to the FY 2018 Costs for FY 2018’’. resulted in recalculating the FY 2018
LTCH PPS standard Federal payment • On pages 38557 through 38558, the wage indexes. Also, the recalculation of
rate due to corrections to the wage data table titled ‘‘FY 2018 IPPS Estimated the MS–DRG relative weights, the
discussed previously. Payments Due To Rural and Imputed revisions to Factor 3 of the
On page 38544, we are making Floor With National Budget Neutrality’’. uncompensated care payment
conforming corrections to the fixed-loss • On pages 38559 and 38560, the methodology and recalculation of the
amount for FY 2018 LTCH PPS standard table titled ‘‘Table II—Impact Analysis FY 2018 wage index necessitated the
Federal payment rate discharges and the of Changes for FY 2018 Acute Care recalculation of the rural and imputed
high-cost outlier (HCO) threshold Hospital Operating Prospective Payment floor budget neutrality factor (as
determined in absence of the required System [Payments per Discharge]’’. discussed in section II.C. of this
changes under the 21st Century Cures • On pages 38572 through 38574, the correcting document). Therefore, we are
Act due to corrections in the MS–LTC– table titled ‘‘Table III—Comparison of correcting the values in the column
DRG data discussed previously. Total Payments Per Case [FY 2017 titled ‘‘FY 2018 Wage Index’’ for all
On page 38545, we are making Payments Compared to FY 2018 hospitals. Additionally, for the six
conforming corrections to the fixed-loss Payments]’’. hospitals for which we inadvertently
amount for site neutral discharges due On pages 38561 through 38564, we used the incorrect wage data (as
to corrections in the IPPS rates and are correcting the discussion of the discussed in section II.A. of this
factors discussed previously. ‘‘Effects of the Changes to Medicare correcting document), we are correcting
On pages 38546 and 38547, we are DSH and Uncompensated Care the average hourly wages in the
making conforming corrections to the Payments for FY 2018’’ for purposes of columns titled ‘‘Average Hourly Wage
figures used in the example of the Regulatory Impact Analysis in FY 2018’’ and ‘‘3-Year Average Hourly
computing the adjusted LTCH PPS Appendix A of the FY 2018 IPPS/LTCH Wage (2016, 2017, 2018)’’.
Federal prospective payment for FY PPS final rule in light of the corrections Table 3.—Wage Index Table by
2018. discussed in sections II.D. and II.E. of CBSA–FY 2018. The wage data errors
On page 38548, we have made this correcting document. related to the six hospitals required the
conforming corrections to the following: On pages 38576 and 38578 through recalculation of the FY 2018 national
• National adjusted operating 38579, we made conforming corrections average hourly wage adjusted for
standardized amounts and capital to the area wage level budget neutrality occupational mix which resulted in
standard Federal payment rate (which factor and the LTCH PPS standard recalculating the FY 2018 wage indexes.
also include the rates payable to Federal payment rate as described in Also, the recalculation of the MS–DRG
hospitals located in Puerto Rico) in section II.C. of this correcting document. relative weights, the revisions to Factor
Tables 1A, 1B, 1C, and 1D as a result of On page 38579, we are making 3 of the uncompensated care payment
the conforming corrections to certain conforming corrections to ‘‘Table IV.— methodology, and recalculation of the
budget neutrality factors and the outlier Impact of Payment Rate and Policy FY 2018 wage index necessitated the
threshold (as described previously). Changes to LTCH PPS Payments for recalculation of the rural and imputed
• LTCH PPS standard Federal Standard Payment Rate Cases for FY floor budget neutrality factor (as
payment rate in Table 1E as a result of 2018.’’ We are also correcting technical discussed in section II.C. of this
the correction to area wage level budget errors in the terminology used in the correcting document). Therefore, we are
neutrality factor (as discussed title and column headings of Table IV making corresponding changes to the
previously). by ensuring the use of ‘‘Standard wage indexes and GAFs of all CBSAs
Also, on page 38548, in Table 1E, we Federal Payment Rate’’. listed in Table 3. Specifically, we are
are correcting a technical error in our On page 38585, we made conforming correcting the values and flags in the
terminology by replacing ‘‘Standard corrections to the estimated increase in columns titled ‘‘Wage Index’’,
Federal Rate’’ with ‘Standard Federal capital payments in FY 2018 compared ‘‘Reclassified Wage Index’’, ‘‘GAF’’,
Payment Rate’’. to FY 2017. ‘‘Reclassified GAF’’, ‘‘Pre-Frontier and/
or Pre-Rural or Imputed Floor Wage
D. Summary of Errors in the Appendices E. Summary of Errors in and Corrections Index’’ and ‘‘Eligible for Rural or
On pages 38552 through 38560 and to Files and Tables Posted on the CMS Imputed Floor Wage Index’’.
sradovich on DSK3GMQ082PROD with RULES
38572 through 38574 in our regulatory Web Site Additionally, for the two CBSAs (24860
impact analyses, we made conforming We are correcting the errors in the and 40340) where the six hospitals for
corrections to the factors, values, and following IPPS tables that are listed on which we inadvertently used the
tables and accompanying discussion of pages 38547 and 38548 of the FY 2018 incorrect wage data are located (as
the changes in operating and capital IPPS/LTCH PPS final rule and are discussed in section II.A. of this
IPPS payments for FY 2018 and the available on the Internet on the CMS correcting document), we are correcting
effects of certain budget neutrality Web site at https://www.cms.gov/ the average hourly wages in the
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![Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations 46143
a. Lines 8 and 9, the reference ‘‘(78 FR a. Lines 21 through 23, the phrase amendatory instructions 41e and f are
50074;’’ is corrected to read ‘‘(79 FR (measure name) ‘‘Functional Outcome correctly added to read as follows:
50074;’’. Measure: Change in Mobility Among ‘‘d. Revising the paragraph (d)
b. Line 9, the reference ‘‘80 FR Patients Requiring Ventilator Support heading.
49588).’’ is corrected to read ‘‘80 FR (NQF #2632).’’ is corrected to read e. In paragraph (d)(6)(i)(B)(1)(iv) by
49558).’’. ‘‘Functional Outcome Measure: Change removing the phrase ‘‘For an EHR
13. On page 38259, first column, first in Mobility Among Long-Term Care reporting period in 2017 only, an EP’’
partial paragraph, line 14, the date Hospital (LTCH) Patients Requiring and adding in its place the phrase ‘‘For
‘‘June 0’’ is corrected to read ‘‘June 30’’. Ventilator Support (NQF #2632).’’. an EHR reporting period in 2017 and
14. On page 38309, third column, first b. Lines 31 through 34, the phrase 2018, an EP’’.
full paragraph, line 29 the figure (measure name) ‘‘Functional Outcome f. Revising paragraphs (d)(6)(i)(B)(2)(i)
‘‘1.28590’’ is corrected to read Measure: Change in Mobility Among and (ii), (d)(6)(ii)(B)(1)(iv), and
‘‘1.28593’’. Patients Requiring Ventilator Support
15. On page 38310, first column— (d)(6)(ii)(B)(2)(i) and (ii).’’
(NQF #2632)’’ is corrected to read
a. First full paragraph, line 29, the ‘‘Functional Outcome Measure: Change C. Correction of Errors in the Addendum
figure ‘‘0.9907845’’ is corrected to read in Mobility Among Long-Term Care
‘‘0.9907437’’. 1. On page 38522 —
Hospital (LTCH) Patients Requiring a. Second column, first full
b. Second full paragraph—
(1) Line 5, the figure ‘‘1.28590’’ is Ventilator Support (NQF #2632).’’ paragraph—
corrected to read ‘‘1.28593’’. 20. On page 38509, second column, (1) Line 3, the figure ‘‘0.997432’’ is
(2) Line 6, the figure ‘‘0.9907845’’ is eighth full paragraph (List of subjects 42 corrected to read ‘‘0.997439’’.
corrected to read ‘‘0.9907437’’. CFR 488), the paragraph is corrected by
(2) Line 8, the figure ‘‘0.997432’’ is
16. On page 38426— removing the paragraph.
corrected to read ‘‘0.997439’’.
a. First column, second full B. Correction of Errors in the b. Third column—
paragraph, line 21, the phrase ‘‘an Regulations Text (1) First full paragraph, line 9, the
Application of Percent’’ is corrected to
1. On page 38516, in the first column, figure ‘‘1.001148’’ is corrected to read
read ‘‘Application of Percent’’.
b. Third column, third full paragraph, remove the part heading for part 488 ‘‘1.000882’’.
line 10, the phrase ‘‘criteria; however and remove amendatory instructions 34 (2) Last paragraph, line 11 the figure
should’’ is corrected to read ‘‘criteria. and 35 in their entirety. ‘‘0.988008’’ is corrected to read
However, the measure should’’. ‘‘0.987985’’.
§ 495.4 [Corrected] 2. On page 38523, second column,
17. On page 38434, in the first
column, second paragraph— 2. On page 38516, in the second first partial paragraph, line 2, the figure
a. Line 29, the phrase ‘‘Stage 3 or 4 column, after amendatory instruction ‘‘0.993348’’ is corrected to read
ulcers.’’ is corrected to read ‘‘Stage 3 or 39a, add amendatory instruction a2 to ‘‘0.993324’’.
4 pressure ulcers.’’. read— 3. On page 38527, lower two-thirds of
b. Line 31, the phrase ‘‘Stage 1 and 2 ‘‘a2. In the definition of ‘‘Certified the page (after the first untitled table),
ulcers decreased’’ is corrected to read electronic health record technology third column—
‘‘Stage 1 and 2 pressure ulcers (CEHRT)’’: a. First partial paragraph—
decreased’’. i. In paragraph (1)(iii), removing the (1) Line 4, the figure ‘‘$26,601’’ is
c. Line 32, the phrase ’’ of Stage 3 and phrase ‘‘for 2018 subsequent years’’ and corrected to read ‘‘$26,537’’.
4 ulcers’’ is corrected to read ‘‘of Stage adding in its place the phrase ‘‘for 2019
(2) Line 5, the figure ‘‘85,942,484,975’’
3 and 4 pressure ulcers’’. and subsequent years’’; and
is corrected to read ‘‘$90,203,348,168’’.
18. On page 38440, third column, last ii. In the introductory text of
paragraph (2), removing the phrase ‘‘For (3) Line 6, the figure ‘‘$4,618,707,285’’
paragraph—
a. Lines 10 and 11, the phrase ‘‘That 2018 and subsequent years,’’ and adding is corrected to read ‘‘$4,600,554,656’’.
nearly one third’’ is corrected to read in its place the phrase ‘‘For 2019 and (4) Line 17, the figure ‘‘$26,601’’ is
‘‘The fact that nearly one third’’. subsequent years,’’.’’ corrected to read ‘‘$26,537’’.
b. Lines 16 and 17, the phrase ‘‘LTCH, b. First full paragraph, line 13, the
and also indicates’’ is corrected to read § 495.24 [Corrected] figure ‘‘5.16’’ is corrected to read ‘‘5.17’’.
‘‘LTCH. It also indicates’’. 3. On page 38517, second column, c. Following the third full paragraph,
19. On page 38458, third column, sixth full paragraph, amendatory the untitled table is corrected to read as
second full paragraph— instruction 41d is corrected and follows:
Operating Capital
standardized federal
amounts rate
National .................................................................................................................................................................... 0.948998 0.948259
4. On page 38529, top of the page, the FY 2018 STANDARDIZED AMOUNTS’’,
table titled ‘‘CHANGES FROM FY 2017 is corrected to read as follows:
sradovich on DSK3GMQ082PROD with RULES
STANDARDIZED AMOUNTS TO THE
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![46146 Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations
Wage-Adjusted Labor Share of LTCH PPS Standard Federal Payment Rate ................................................................................... = $28,932.95
Nonlabor-Related Portion of the LTCH PPS Standard Federal Payment Rate ($41,415.11 x 0.338) ............................................... + $13,998.31
Adjusted LTCH PPS Standard Federal Payment Amount .................................................................................................................. = $42,931.26
MS–LTC–DRG 189 Relative Weight ................................................................................................................................................... × 0.9655
Total Adjusted LTCH PPS Standard Federal Payment Rate .............................................................................................................. = $41,450.13
13. On page 38548— STANDARDIZED AMOUNTS, LABOR/ SHARE IF WAGE INDEX IS GREATER
a. Middle of the page, NONLABOR [(68.3 PERCENT LABOR THAN 1)—FY 2018’’] is corrected to
(1) The table titled ‘‘TABLE 1A.— SHARE/31.7 PERCENT NONLABOR read as follows:
NATIONAL ADJUSTED OPERATING
TABLE 1A—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR
[(68.3 percent labor share/31.7 percent nonlabor share if wage index is greater than 1)—FY 2018]
Hospital submitted quality data Hospital submitted quality data Hospital did NOT submit quality Hospital did NOT submit quality
and is a meaningful EHR user and is not a meaningful EHR user data and is a meaningful EHR data and is NOT a meaningful
(update = 1.35 percent) (update = ¥0.675 percent) user EHR user
(update = 0.675 percent) (update = ¥1.35 percent)
Labor Nonlabor Labor Nonlabor Labor Nonlabor Labor Nonlabor
$3,806.04 $1,766.49 $3,729.99 $1,731.20 $3,780.69 $1,754.73 $3,704.65 $1,719.43
(2) The table titled ‘‘TABLE 1B.— NONLABOR [(62 PERCENT LABOR THAN OR EQUAL TO 1)—FY 2018]’’ is
NATIONAL ADJUSTED OPERATING SHARE/38 PERCENT NONLABOR corrected to read as follows:
STANDARDIZED AMOUNTS, LABOR/ SHARE IF WAGE INDEX IS LESS
TABLE 1B—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR
[(62 percent labor share/38 percent nonlabor share if wage index is less than or equal to 1)—FY 2018]
Hospital submitted quality data Hospital submitted quality data Hospital did NOT submit quality Hospital did NOT submit quality
and is a meaningful EHR user and is not a meaningful EHR user data and is a meaningful EHR data and is NOT a meaningful
(update = 1.35 percent) (update = ¥0.675 percent) user EHR user
(update = 0.675 percent) (update = ¥1.35 percent)
Labor Nonlabor Labor Nonlabor Labor Nonlabor Labor Nonlabor
$3,454.97 $2,117.56 $3,385.94 $2,075.25 $3,431.96 $2,103.46 $3,362.93 $2,061.15
(3) The table titled ‘‘TABLE 1C.— LABOR/NONLABOR [(NATIONAL: 62 1);—FY 2018]’’ is corrected to read as
ADJUSTED OPERATING PERCENT LABOR SHARE/38 PERCENT follows:
STANDARDIZED AMOUNTS FOR NONLABOR SHARE BECAUSE WAGE
HOSPITALS IN PUERTO RICO, INDEX IS LESS THAN OR EQUAL TO
TABLE 1C—ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR HOSPITALS IN PUERTO RICO, LABOR/NONLABOR
[(National: 62 percent labor share/38 percent nonlabor share because wage index is less than or equal to 1);—FY 2018]
Rates if wage index is greater than 1 Rates if wage index is less
than or equal to 1
Standardized amount
Labor Nonlabor Labor Nonlabor
National 1 ........................................ Not Applicable ................................ Not Applicable ................................ $3,454.97 $2,117.56
1 For FY 2018, there are no CBSAs in Puerto Rico with a national wage index greater than 1.
b. Bottom of the page— TABLE 1D—CAPITAL STANDARD PAYMENT RATE [FY 2018]’’ is
(1) The table titled ‘‘TABLE 1D.— FEDERAL PAYMENT RATE corrected to read as follows:
CAPITAL STANDARD FEDERAL [FY 2018]
PAYMENT RATE [FY 2018]’’ is
corrected to read as follows: Rate
sradovich on DSK3GMQ082PROD with RULES
National ................................. $453.95
(2) The table titled ‘‘TABLE 1E.—
LTCH PPS STANDARD FEDERAL
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![Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations 46147
TABLE 1E—LTCH PPS STANDARD FEDERAL PAYMENT RATE
[FY 2018]
Reduced
Full update update *
(1 percent) (¥1.0
percent)
Standard Federal Payment Rate ............................................................................................................................. $41,415.11 $40,595.02
D. Corrections of Errors in the ‘‘TABLE I.—IMPACT ANALYSIS OF OPERATING COSTS FOR FY 2018’’ are
Appendices CHANGES TO THE IPPS FOR corrected to read as follows:
1. On pages 38552 through 38554, the BILLING CODE 4120–01–P
table and table notes for the table titled
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![Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations 46153
FY 2018 IPPS ESTIMATED PAYMENTS DUE TO RURAL AND IMPUTED FLOOR WITH NATIONAL BUDGET NEUTRALITY—
Continued
Percent
change in
Number of payments due
hospitals that to application
Number of Difference
State will receive the of rural floor
hospitals (in $ millions)
rural or and imputed
imputed floor floor with
budget
neutrality
(1) (2) (3) (4)
Wisconsin ......................................................................................................... 66 8 ¥0.2 ¥3
Wyoming .......................................................................................................... 10 0 ¥0.1 0
6. On pages 38559 and 38560, the ACUTE CARE HOSPITAL OPERATING (PAYMENTS PER DISCHARGE)’’ is
table titled ‘‘TABLE II.—IMPACT PROSPECTIVE PAYMENT SYSTEM corrected to read as follows:
ANALYSIS OF CHANGES FOR FY 2018
TABLE II—IMPACT ANALYSIS OF CHANGES FOR FY 2018 ACUTE CARE HOSPITAL OPERATING PROSPECTIVE PAYMENT
SYSTEM
[Payments per discharge]
Estimated Estimated
average average
Number of FY 2017 FY 2018 FY 2018
hospitals changes
payment per payment per
discharge discharge
(1) (2) (3) (4)
All Hospitals ..................................................................................................... 3,292 $11,867 $12,024 1.3
By Geographic Location:
Urban hospitals ......................................................................................... 2,492 12,207 12,379 1.4
Large urban areas .................................................................................... 1,340 12,881 13,061 1.4
Other urban areas .................................................................................... 1,152 11,477 11,642 1.4
Rural hospitals .......................................................................................... 800 8,911 8,930 0.2
Bed Size (Urban):
0–99 beds ................................................................................................. 648 9,730 9,813 0.8
100–199 beds ........................................................................................... 763 10,248 10,404 1.5
200–299 beds ........................................................................................... 441 11,079 11,245 1.5
300–499 beds ........................................................................................... 426 12,366 12,538 1.4
500 or more beds ..................................................................................... 214 15,011 15,224 1.4
Bed Size (Rural):
0–49 beds ................................................................................................. 318 7,523 7,486 ¥0.5
50–99 beds ............................................................................................... 282 8,487 8,372 ¥1.4
100–149 beds ........................................................................................... 117 8,896 8,966 0.8
150–199 beds ........................................................................................... 44 9,292 9,410 1.3
200 or more beds ..................................................................................... 39 10,514 10,679 1.6
Urban by Region:
New England ............................................................................................ 114 13,125 13,303 1.4
Middle Atlantic .......................................................................................... 315 13,819 13,967 1.1
South Atlantic ........................................................................................... 404 10,783 10,952 1.6
East North Central .................................................................................... 385 11,537 11,727 1.6
East South Central ................................................................................... 147 10,245 10,375 1.3
West North Central ................................................................................... 160 11,915 12,107 1.6
West South Central .................................................................................. 378 10,948 11,134 1.7
Mountain ................................................................................................... 162 12,824 12,898 0.6
Pacific ....................................................................................................... 375 15,634 15,867 1.5
Puerto Rico ............................................................................................... 52 8,851 8,947 1.1
Rural by Region:
New England ............................................................................................ 20 12,091 12,166 0.6
Middle Atlantic .......................................................................................... 53 8,891 8,812 ¥0.9
South Atlantic ........................................................................................... 125 8,274 8,269 ¥0.1
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East North Central .................................................................................... 115 9,224 9,144 ¥0.9
East South Central ................................................................................... 154 7,900 7,987 1.1
West North Central ................................................................................... 97 9,736 9,794 0.6
West South Central .................................................................................. 154 7,539 7,587 0.6
Mountain ................................................................................................... 58 10,620 10,718 0.9
Pacific ....................................................................................................... 24 12,466 12,517 0.4
By Payment Classification:
Urban hospitals ......................................................................................... 2,373 12,148 12,320 1.4
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![46154 Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations
TABLE II—IMPACT ANALYSIS OF CHANGES FOR FY 2018 ACUTE CARE HOSPITAL OPERATING PROSPECTIVE PAYMENT
SYSTEM—Continued
[Payments per discharge]
Estimated Estimated
average average
Number of FY 2018
FY 2017 FY 2018
hospitals changes
payment per payment per
discharge discharge
(1) (2) (3) (4)
Large urban areas .................................................................................... 1,354 12,867 13,047 1.4
Other urban areas .................................................................................... 1,019 11,200 11,362 1.4
Rural areas ............................................................................................... 919 10,568 10,656 0.8
Teaching Status:
Nonteaching .............................................................................................. 2,204 9,850 9,967 1.2
Fewer than 100 residents ......................................................................... 839 11,372 11,535 1.4
100 or more residents .............................................................................. 249 17,228 17,461 1.4
Urban DSH:
Non-DSH .................................................................................................. 551 10,357 10,456 1.0
100 or more beds ..................................................................................... 1,543 12,512 12,689 1.4
Less than 100 beds .................................................................................. 370 8,960 9,102 1.6
Rural DSH:
SCH .......................................................................................................... 257 9,526 9,578 0.5
RRC .......................................................................................................... 293 11,384 11,568 1.6
100 or more beds ..................................................................................... 34 10,297 10,339 0.4
Less than 100 beds .................................................................................. 244 7,035 6,764 ¥3.9
Urban teaching and DSH:
Both teaching and DSH ............................................................................ 863 13,579 13,766 1.4
Teaching and no DSH .............................................................................. 92 11,410 11,522 1.0
No teaching and DSH .............................................................................. 1,050 10,217 10,374 1.5
No teaching and no DSH ......................................................................... 368 9,854 10,000 1.5
Special Hospital Types:
RRC .......................................................................................................... 263 11,165 11,360 1.8
SCH .......................................................................................................... 316 10,774 10,820 0.4
SCH and RRC .......................................................................................... 131 11,265 11,362 0.9
Type of Ownership:
Voluntary ................................................................................................... 1,914 12,058 12,212 1.3
Proprietary ................................................................................................ 863 10,392 10,554 1.6
Government .............................................................................................. 513 12,810 12,980 1.3
Medicare Utilization as a Percent of Inpatient Days:
0–25 .......................................................................................................... 554 14,910 15,115 1.4
25–50 ........................................................................................................ 2,149 11,728 11,890 1.4
50–65 ........................................................................................................ 485 9,617 9,695 0.8
Over 65 ..................................................................................................... 103 7,591 7,444 ¥1.9
FY 2018 Reclassifications by the Medicare Geographic Classification Re-
view Board:
All Reclassified Hospitals ......................................................................... 858 11,661 11,830 1.5
Non-Reclassified Hospitals ....................................................................... 2,434 11,956 12,108 1.3
Urban Hospitals Reclassified .................................................................... 590 12,202 12,396 1.6
Urban Nonreclassified Hospitals .............................................................. 1,858 12,210 12,381 1.4
Rural Hospitals Reclassified Full Year ..................................................... 268 9,339 9,399 0.7
Rural Nonreclassified Hospitals Full Year ................................................ 485 8,422 8,379 ¥0.5
All Section 401 Reclassified Hospitals: .................................................... 166 12,504 12,677 1.4
Other Reclassified Hospitals (Section 1886(d)(8)(B)) .............................. 47 8,122 8,165 0.5
7. On pages 38561 through 38564 in hospitals that are eligible to receive payments and that has uncompensated
the section titled ‘‘Effects of the Changes Medicare DSH payments will receive 25 care. Each hospital eligible for Medicare
to Medicare DSH and Uncompensated percent of the amount they previously DSH payments will receive an
Care Payments for FY 2018’’ (which would have received under the statutory additional payment based on its
begins with the phrase ‘‘As discussed in formula for Medicare DSH payments estimated share of the total amount of
section V.G of the preamble’’ and ends under section 1886(d)(5)(F) of the Act. uncompensated care for all hospitals
with the phrase ‘‘hospitals are projected The remainder, equal to an estimate of eligible for Medicare DSH payments.
to receive large increases’’) the section 75 percent of what formerly would have The uncompensated care payment
sradovich on DSK3GMQ082PROD with RULES
is corrected to read as follows: been paid as Medicare DSH payments methodology has redistributive effects
‘‘5. Effects of the Changes to Medicare (Factor 1), reduced to reflect changes in based on the proportion of a hospital’s
DSH and Uncompensated Care the percentage of uninsured individuals uncompensated care relative to the
Payments for FY 2018. and additional statutory adjustments uncompensated care for all hospitals
As discussed in section V.G. of the (Factor 2), is available to make eligible for Medicare DSH payments
preamble of this final rule, under additional payments to each hospital (Factor 3).
section 3133 of the Affordable Care Act, that qualifies for Medicare DSH
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![46156 Federal Register / Vol. 82, No. 191 / Wednesday, October 4, 2017 / Rules and Regulations
MODELED DISPROPORTIONATE SHARE HOSPITAL PAYMENTS FOR ESTIMATED FY 2018 DSHS BY HOSPITAL TYPE: MODEL
DSH $ (IN MILLIONS) FROM FY 2017 TO FY 2018
Number of FY 2017 final FY 2018 final Dollar
estimated rule estimated rule estimated difference: FY Percent
DSHs DSH DSH 2017–FY 2018 change **
(FY 2018) $ (in millions) $ (in millions) (in millions)
(1) (2) (3) (4) (5)
Total ..................................................................................... 2,438 $9,553 $10,630 $1,077 11.3
By Geographic Location:
Urban Hospitals ............................................................ 1,938 9,113 10,110 996 10.9
Large Urban Areas ....................................................... 1,043 5,717 6,377 660 11.5
Other Urban Areas ....................................................... 895 3,396 3,733 336 9.9
Rural Hospitals ............................................................. 500 439 520 80 18.3
Bed Size (Urban):
0 to 99 Beds ................................................................. 342 185 241 57 30.7
100 to 249 Beds ........................................................... 843 2,154 2,386 233 10.8
250+ Beds .................................................................... 753 6,775 7,482 707 10.4
Bed Size (Rural):
0 to 99 Beds ................................................................. 371 190 238 48 25.2
100 to 249 Beds ........................................................... 115 193 221 28 14.6
250+ Beds .................................................................... 14 56 60 5 8.2
Urban by Region:
New England ................................................................ 91 387 415 29 7.4
Middle Atlantic .............................................................. 241 1,570 1,643 73 4.7
South Atlantic ................................................................ 316 1,724 2,037 314 18.2
East North Central ........................................................ 322 1,252 1,372 120 9.6
East South Central ....................................................... 131 566 618 53 9.3
West North Central ....................................................... 103 439 488 48 11.0
West South Central ...................................................... 257 1,165 1,448 283 24.3
Mountain ....................................................................... 121 448 497 49 11.0
Pacific ........................................................................... 316 1,448 1,463 15 1.0
Puerto Rico ................................................................... 40 116 129 13 10.9
Rural by Region:
New England ................................................................ 12 16 21 5 32.0
Middle Atlantic .............................................................. 25 33 32 ¥1 ¥3.9
South Atlantic ................................................................ 86 92 115 23 25.2
East North Central ........................................................ 68 44 58 13 29.9
East South Central ....................................................... 136 141 150 9 6.2
West North Central ....................................................... 30 19 23 4 22.1
West South Central ...................................................... 111 72 95 23 32.1
Mountain ....................................................................... 27 15 20 5 32.2
Pacific ........................................................................... 5 7 6 ¥1 ¥11.4
By Payment Classification:
Urban Hospitals ............................................................ 1,928 9,106 10,101 994 10.9
Large Urban Areas ....................................................... 1,043 5,717 6,377 660 11.5
Other Urban Areas ....................................................... 885 3,389 3,724 334 9.9
Rural Hospitals ............................................................. 510 447 529 82 18.5
Teaching Status:
Nonteaching .................................................................. 1,526 2,955 3,276 321 10.9
Fewer than 100 residents ............................................. 669 3,213 3,501 288 9.0
100 or more residents .................................................. 243 3,384 3,853 468 13.8
Type of Ownership:
Voluntary ....................................................................... 1,434 5,971 6,533 563 9.4
Proprietary .................................................................... 552 1,650 1,662 12 0.7
Government .................................................................. 452 1,932 2,434 502 30.0
Medicare Utilization Percent:
Missing or Unknown ..................................................... 15 1 15 14 2147.4
0 to 25 ........................................................................... 425 2,972 3,365 393 13.2
25 to 50 ......................................................................... 1,642 6,218 6,829 611 9.8
50 to 65 ......................................................................... 310 352 408 57 16.1
Greater than 65 ............................................................ 46 11 13 2 17.4
Source: Dobson | DaVanzo analysis of 2012–2014 Hospital Cost Reports.
* Dollar DSH calculated by [0.25 * estimated section 1886(d)(5)(F) payments] + [0.75 * estimated section 1886(d)(5)(F) payments * Factor 2 *
Factor 3]. When summed across all hospitals projected to receive DSH payments, DSH payments are estimated to be $9,553 million in FY 2017
and $10,630 million in FY 2018.
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** Percentage change is determined as the difference between Medicare DSH payments modeled for the FY 2018 IPPS/LTCH PPS final rule
(column 3) and Medicare DSH payments modeled for the FY 2017 IPPS/LTCH PPS final rule (column 2) divided by Medicare DSH payments
modeled for the FY 2017 final rule (column 2) times 100 percent.
Changes in projected FY 2018 DSH 2017 are primarily driven by (1) changes $10.797 billion to $11.665 billion; (2)
payments from DSH payments in FY to Factor 1, which increased from changes to Factor 2, which increased
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from 55.36 percent to 58.01 percent; (3) for DSH in FY 2018. Rural hospitals that increase of 13.8 percent. Voluntary
changes to the data used to determine have 0–99 beds are projected to hospitals are expected to receive a 9.4
Factor 3; and (4) changes to the number experience a 25.2 percent payment percent increase, which is somewhat
of DSH-eligible hospitals within a given increase, those with 100–249 beds are smaller than the overall percent change,
hospital type. The impact analysis projected to receive a 14.6 percent while proprietary hospitals are expected
found that, across all projected DSH increase, and larger rural hospitals with to receive almost no change in DSH
eligible hospitals, FY 2018 DSH 250+ beds are projected to experience payments. Government hospitals are
payments are estimated at an 8.2 percent payment increase. This projected to receive a larger than
approximately $10.630 billion, or an trend is somewhat consistent with average 30.0 percent increase. Hospitals
increase of approximately 11.3 percent urban hospitals, in which the smallest with 25 to 50 percent Medicare
from FY 2017 DSH payments urban hospitals (0– 99 beds) are utilization are projected to receive
(approximately $9.553 billion). While projected to receive an increase in DSH increases in DSH payments slightly
these changes result in a net increase in payments of 30.7 percent. Medium sized below the overall average at 9.8 percent,
the amount available to be distributed in hospitals (100–250 beds) and larger while all other hospitals are projected to
uncompensated care payments, DSH hospitals (250+ beds) are projected to receive larger increases.’’
payments to select hospital types are receive increases of 10.8 and 10.4 8. On page 38572 top of the page—
expected to decrease. This percent in DSH payments, respectively, a. First column, fourth bulleted
redistribution of DSH payments is which are relatively consistent with the paragraph—
caused by changes in the data used to overall average. (1) Line 4, the figure ‘‘0.9986’’ is
determine Factor 3 and changes in the By region, projected DSH payment corrected to read ‘‘0.9987’’
number of DSH-eligible hospitals within increases for urban hospitals are smaller (2) Line 5, the figure ‘‘0.9484’’ is
a given hospital type. than the overall percent change in the corrected to read ‘‘0.9483’’
As seen in the above table, percent New England, Middle Atlantic, East b Second column, first full
changes in DSH payments of less than North Central, East South Central, and paragraph—
11.3 percent indicate that hospitals Pacific regions. Hospitals in the South (1) Line 8, the figure ‘‘0.9484’’ is
within the specified category are Atlantic and West South Central regions corrected to read ‘‘0.9483’’
projected to experience a smaller are projected to receive increases in (2) Line 9, the figure ‘‘1.04’’ is
increase in DSH payments, on average, DSH payments that are, on average, corrected to read ‘‘1.03’’.
compared to the universe of projected larger than the 11.3 percent change c. Third column—
FY 2018 DSH hospitals. Conversely, across all hospitals projected to be (1) First partial paragraph—
percent changes in DSH payments that eligible for DSH in FY 2018. Increases (a) Line 1, the figure ‘‘2.9’’ is corrected
are greater than 11.3 percent indicate a in the West North Central, Mountain, to read ‘‘3.0’’
hospital type is projected to have a and Puerto Rico regions are generally (b) Line 4, the figure 2.0’’ is corrected
larger increase than the overall percent consistent with the overall average to read ‘‘1.9’’.
change on average, a larger increase percent increase of 11.3 percent. (2) First full paragraph –
than the overall percent change. The Regionally, rural hospitals are projected (a) Line 4, the figure ‘‘3.7’’ is corrected
variation in the distribution of DSH to receive a wider range of increases. to read ‘‘3.8’’.
payments by hospital characteristic is Rural hospitals in the Middle Atlantic
(b) Line 9, the figure ‘‘5.2’’ is
largely dependent on the change in a and Pacific regions are expected to
corrected to read ‘‘5.3’’.
given hospital’s number of Medicaid receive a decrease in DSH payments,
(c) Line 12, the figure ‘‘1.9’’ is
days and SSI days for purposes of the while those in the East South Central
corrected to read ‘‘2.0’’.
low-income insured days proxy between region are projected to receive an
(3) Second full paragraph—
FY 2017 and FY 2018, as well as on its increase in DSH payments smaller than
(a) Line 7, the figure ‘‘2.3’’ is corrected
uncompensated care costs as reported the 11.3 overall percent change.
to read ‘‘2.2’’.
on its FY 2014 Worksheet S–10. Increases are projected to be
Many rural hospitals, grouped by (b) Lines 10 and 11, the phrase ‘‘3.2
substantially larger than the overall
geographic location, payment percent.’’ is corrected to read ‘‘3.2
average in many regions, including New
classification, and bed size, are percent and 3.3 percent, respectively.’’.
England, South Atlantic, East North
projected to experience a larger increase (4) Last paragraph—
Central, West North Central, West South
in DSH payments than their urban Central, and Mountain. (a) Line 14, the figure ‘‘1.6’’ is
counterparts. Overall, rural hospitals are Nonteaching hospitals and teaching corrected to read ‘‘1.7’’.
projected to receive an 18.3 percent hospitals with fewer than 100 residents (b) Line 27, the figure ‘‘6.6’’ is
increase in DSH payments, and urban are projected to receive smaller corrected to read ‘‘6.5’’.
hospitals are projected to receive a 10.9 increases than the overall percent 9. On pages 38572 through 38574, the
percent increase. However, only smaller change, at 10.9 and 9.0 percent table titled ‘‘TABLE III.—COMPARISON
and medium-sized rural hospitals are respectively. Conversely, teaching OF TOTAL PAYMENTS PER CASE [FY
projected to receive increases in DSH hospitals with 100 or more residents are 2017 PAYMENTS COMPARED TO FY
payments that are, on average, higher projected to receive, on average, larger 2018 PAYMENTS]’’ is corrected to read
than the 11.3 percent change across all increases than the overall percent as follows:
hospitals that are projected to be eligible change of 11.3 percent, with a projected BILLING CODE 4120–01–P
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a. Lines 34, the figure ‘‘2.7’’ is identified and corrected in section IV., the corrected wage data for the six
corrected to read ‘‘2.5’’. Correction of Errors. The provisions in hospitals required the recalculation of
b. Line 38, the figure ‘‘$226’’ is this correcting document are effective as the final FY 2018 SNF PPS wage
corrected to read ‘‘$227’’. if they had been included in the indexes. Additionally, as discussed on
Dated: September 29, 2017. document that appeared in the August page 36543 of the FY 2018 SNF PPS
4, 2017, Federal Register (hereinafter final rule, section 1888(e)(4)(G)(ii) of the
Ann C. Agnew,
referred to as the FY 2018 SNF PPS final Act requires that we apply the wage
Executive Secretary to the Department,
rule). Accordingly, the corrections are index in a manner that does not result
Department of Health and Human Services.
effective October 1, 2017. in aggregate payments under the SNF
[FR Doc. 2017–21325 Filed 9–29–17; 4:15 pm]
PPS that are greater or less than would
BILLING CODE 4120–01–C II. Summary of Errors otherwise be made if the wage index
A. Summary of Errors in the Preamble adjustment had not been made. To
achieve this, we apply a budget
DEPARTMENT OF HEALTH AND As discussed in the FY 2018 SNF PPS
neutrality factor to the unadjusted SNF
HUMAN SERVICES final rule (82 FR 36539), in developing
PPS federal per diem base rates. Due to
the wage index to be applied to skilled
Centers for Medicare & Medicaid the recalculation and subsequent
nursing facilities (SNFs) under the SNF
Services revision of the final FY 2018 SNF PPS
prospective payment system (PPS), we
wage indexes, it was necessary to
use the updated, pre-reclassified
42 CFR Parts 409, 411, 413, 424, and recalculate the FY 2018 SNF PPS wage
hospital inpatient prospective payment
488 index budget neutrality factor as well.
system (IPPS) wage data, exclusive of
Revising the wage index budget
the occupational mix adjustment. For
[CMS–1679–CN] neutrality factor causes a change in the
FY 2018, the updated, unadjusted, pre- unadjusted SNF PPS federal per diem
RIN 0938–AS96 reclassified IPPS wage data used under rates (provided in Tables 2 and 3 of the
the SNF PPS are for hospital cost FY 2018 SNF PPS final rule (82 FR
Medicare Program; Prospective reporting periods beginning on or after
Payment System and Consolidated 36535)), which then causes changes in
October 1, 2013, and before October 1, the case-mix adjusted SNF PPS rates
Billing for Skilled Nursing Facilities for 2014 (FY 2014 cost report data), as
FY 2018, SNF Value-Based Purchasing (provided in Tables 4 and 5 in the FY
discussed in the FY 2018 IPPS final rule 2018 SNF PPS final rule (82 FR 36537
Program, SNF Quality Reporting (82 FR 38130). In calculating the wage through 36538), as well as the labor
Program, Survey Team Composition, index under the FY 2018 IPPS final rule, adjusted SNF PPS rates (provided in
and Correction of the Performance we made inadvertent errors related to Tables 6 and 7 of the FY 2018 SNF PPS
Period for the NHSN HCP Influenza the wage data collected from the final rule (82 FR 36541 through 36543).
Vaccination Immunization Reporting Medicare cost reports of six hospitals Finally, due to the recalculated wage
Measure in the ESRD QIP for PY 2020; which are located in CBSAs 24860 and indexes, we recalculated the impact
Correction 40340. Specifically, we used incorrect analysis provided in Table 26 of the FY
AGENCY: Centers for Medicare & wage data for these six hospitals to 2018 SNF PPS final rule (82 FR 36629).
Medicaid Services (CMS), HHS. calculate the final FY 2018 IPPS wage The corrections to these errors are found
indexes, the geographic adjustment in section IV. of this document.
ACTION: Final rule; correction. factor (GAF) (which is computed from
the wage index), as well as certain other B. Summary of Errors in and Corrections
SUMMARY: This document corrects
IPPS factors and adjustments. to Tables Posted on the CMS Web Site
technical errors in the final rule that
appeared in the August 4, 2017 Federal These errors are identified, discussed We are correcting the wage indexes in
Register, which will update the and corrected in the Medicare Program; Tables A and B setting forth the wage
payment rates used under the Hospital Inpatient Prospective Payment indexes for urban (Table A) and non-
prospective payment system (PPS) for Systems for Acute Care Hospitals and urban (Table B) areas based on CBSA
skilled nursing facilities (SNFs) for the Long Term Care Hospital labor market areas, which are available
fiscal year (FY) 2018. Prospective Payment System and Policy exclusively on the CMS Web site at
Changes and Fiscal Year 2018 Rates; http://www.cms.gov/Medicare/
DATES: This correction is effective Quality Reporting Requirements for
October 1, 2017. Medicare-Fee-for-Service-Payment/
Specific Providers; Medicare and SNFPPS/WageIndex.html. These tables
FOR FURTHER INFORMATION CONTACT: John Medicaid Electronic Health Record have been updated to reflect the
Kane, (410) 786–0557. (EHR) Incentive Program Requirements revisions discussed in this correcting
SUPPLEMENTARY INFORMATION: for Eligible Hospitals, Critical Access document.
Hospitals, and Eligible Professionals; We are republishing the wage indexes
I. Background
Provider-Based Status of Indian Health in Tables A and B accordingly on the
In FR Doc. 2017–16256 (82 FR 36530), Services and Tribal Facilities and CMS Web site at http://www.cms.gov/
the final rule entitled ‘‘Medicare Organizations; Cost Reporting and Medicare/Medicare-Fee-for-Service-
Program; Prospective Payment System Provider Requirements; Agreement Payment/SNFPPS/WageIndex.html.
and Consolidated Billing for Skilled Termination Notices; Correction (CMS–
Nursing Facilities for FY 2018, SNF 1677–CN) that appears elsewhere in this III. Waiver of Proposed Rulemaking
Value-Based Purchasing Program, SNF issue of the Federal Register. and Delayed Effective Date
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Quality Reporting Program, Survey As discussed above, we use the We ordinarily publish a notice of
Team Composition, and Correction of updated, pre-reclassified, unadjusted proposed rulemaking in the Federal
the Performance Period for the NHSN IPPS wage data in developing the wage Register to provide a period for public
HCP Influenza Vaccination index used under the SNF PPS. Due to comment before the provisions of a rule
Immunization Reporting Measure in the the technical errors described above, the take effect in accordance with section
ESRD QIP for PY 2020’’, there were a published FY 2018 SNF PPS wage 553(b) of the Administrative Procedure
number of technical errors that are indexes were incorrect. Thus, the use of Act (APA) (5 U.S.C. 553(b)). However,
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Document Created: 2018-10-25 09:55:44
Document Modified: 2018-10-25 09:55:44
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Rules and Regulations | |
| Action | Final rule; correction. | |
| Dates | This correction is effective October 1, 2017. | |
| Contact | Donald Thompson, (410) 786-4487. | |
| FR Citation | 82 FR 46138 | |
| CFR Citation | 42
CFR
405 42 CFR 412 42 CFR 413 42 CFR 414 42 CFR 416 42 CFR 486 42 CFR 488 42 CFR 489 42 CFR 495 |
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