Medicare program; catastrophic outpatient drug benefit, home intravenous drug therapy benefit, and screening mammography services--withdrawal--HCFA. Withdrawal of proposed rules

This notice announces the withdrawal of several proposed regulation documents that would have implemented certain provisions of the Medicare Catastrophic Coverage Act of 1988 by establishing new outpatient drug and home intravenous drug therapy benefits, expanding immunosuppressive drug coverage, and providing limited coverage for screening mammography services under Medicare part B. This notice implements section 201 of the Medicare Catastrophic Coverage Repeal Act of 1989 (Pub. L. 101-234, enacted December 13, 1989).     

Medicare program; changes to maintenance of effort requirements (section 421 of the Medicare Catastrophic Coverage Act)--HCFA. Notice

This notice announces the effect on employers of the repeal of section 421 (Maintenance of Effort Provision) of the Medicare Catastrophic Coverage Act of 1988 (MCCA). The enactment of Public Law 101-234 (Medicare Catastrophic Coverage Repeal Act of 1989) on December 13, 1989 repealed many of the provisions of MCCA and restored the Medicare benefit levels to those available prior to January 1, 1989. Consequently, employers are relieved of their Maintenance of Effort responsibilities effective January 1, 1990.     

Medicare program, fiscal year 1990; mid-year changes to the inpatient hospital prospective payment system--HCFA. Final rule with comment period

This final rule with comment implements several provisions of the Omnibus Budget Reconciliation Act of 1989 that affect Medicare payment for inpatient hospitals and that, in general, take effect on April 1, 1990. This final rule also responds to comments received concerning the changes we made in 1989 in implementing provisions of the Medicare Catastrophic Coverage Act of 1988 concerning adjustments applicable to prospective payment hospitals and to the target amounts of hospitals and units excluded from the prospective payment system due to the elimination of the day limitation on covered inpatient hospital days. We are making additional changes in these provisions to take into account the Medicare Catastrophic Coverage Repeal Act of 1989, and changes in the law made by the Family Support Act of 1988, which clarified the criteria for adjusting target amounts and changed the date for implementing that provision.     

Medicare program; changes to the inpatient hospital prospective payment system and fiscal year 1991 rates--HCFA. Final rule

We are revising the Medicare inpatient hospital prospective payment system to implement necessary changes arising from legislation and our continuing experience with the system. In addition, in the Addendum to this final rule, we are describing changes in the amounts and factors necessary to determine prospective payment rates for Medicare inpatient hospital services. In general, these changes are applicable to discharges occurring on or after October 1, 1990. We also set forth rate-of-increase limits for hospitals and hospital units excluded from the prospective payment system. This final rule also responds to comments received concerning changes to hospital payments made in an April 20, 1990 final rule with comment. These changes include mid-year changes to the inpatient hospital prospective payment system that implemented provisions of the Omnibus Budget Reconciliation Act of 1989; and adjustments applicable to prospective payment hospitals and to the target amounts of hospitals and units excluded from the prospective payment system due to the elimination of the day limitation on covered inpatient hospital days made by the Medicare Catastrophic Coverage Act of 1988 and later repealed by provisions in the Medicare Catastrophic Repeal Act of 1989. The April 20, 1990 final rule with comment also incorporated changes to these provisions made by the Family Support Act of 1988, which clarified the criteria for adjusting the target amounts and implementation date. In addition, this final rule clarifies the documentation requirements necessary to support the cost allocation of teaching physicians and the allowability of costs for rotating residents in determining payment for the direct costs of an approved graduate medical education program. This clarification is being made as a result of a September 29, 1989 final rule that made changes in Medicare policy concerning payment for the direct graduate medical education costs of providers associated with approved residency programs in medicine, osteopathy, dentistry, and podiatry.     

Medicare program; self-implementing coverage and payments provisions: 1990 legislation--HCFA. Final rule with comment period

This rule updates Medicare regulations to add or conform them to certain self-implementing provisions on coverage of services and payment requirements under the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). OBRA '90 was enacted November 5, 1990 and the cited changes to the statute are already in effect. Certain related self-implementing provisions of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89), and the Medicare Catastrophic Coverage Act (MCCA) of 1988, are included as necessary for consistency and clarity of the OBRA '90 provisions.     

Medicare program; monthly supplementary medical insurance premium beginning January 1, 1990--HCFA. Notice

This notice announces the monthly premium rate, as changed by the Omnibus Budget Reconciliation Act of 1989 and the Medicare Catastrophic Coverage Repeal Act of 1989, for aged (age 65 or over) and disabled (under age 65) enrollees in the Medicare Supplementary Medical Insurance (SMI) program for calendar year 1990. The 1990 SMI premium will be $28.60. This notice also announces the repeal of the monthly catastrophic coverage premium for aged and disabled enrollees.     

Health care programs: fraud and abuse; amendments to OIG exclusion and CMP authorities resulting from Public Law 100-93--HHS. Final rule

This final rule implements the OIG sanction and civil money penalty provisions established through section 2 and other conforming amendments in the Medicare and Medicaid Patient and Program Protection Act of 1987, along with certain additional provisions contained in the Consolidated Omnibus Budget Reconciliation Act of 1985, the Omnibus Budget Reconciliation Act (OBRA) of 1987, the Medicare Catastrophic Coverage Act of 1988, OBRA of 1989, and OBRA of 1990. Specifically, these regulations are designed to protect program beneficiaries from unfit health care practitioners, and otherwise to improve the anti-fraud provisions of the Department's health care programs under titles V, XVIII, XIX and XX of the Social Security Act.     

Medicare program; self-implementing coverage and payments provisions: 1990 legislation--HCFA. Confirmation of final rule

This document confirms our revisions to Medicare regulations published on August 12, 1992 (57 FR 36006). The revisions conformed the regulations to certain self-implementing provisions on coverage of services and payment requirements. The provisions were included under the Omnibus Budget Reconciliation Act of 1990, the Omnibus Budget Reconciliation Act of 1989 and the Medicare Catastrophic Coverage Act of 1983. We also respond to the comments we received on the revisions to the regulations.     

Medicare program; uniform electronic cost reporting system for hospitals--HCFA. Final rule with comment period

This final rule with comment period implements the provisions of section 4007(b) of the Omnibus Budget Reconciliation Act of 1987, as amended by section 411(b)(6) of the Medicare Catastrophic Coverage Act of 1988, which require the Secretary to place into effect a standardized electronic cost reporting system for all hospitals under the Medicare program. Under this final rule with comment period, all hospitals are required to submit their cost reports, for hospital cost reporting periods beginning on or after October 1, 1989, in a uniform electronic format. The Secretary may grant a delay or a waiver of this requirement where implementation could result in financial hardship for a hospital.     

Medicare program; fee schedules for the services of certified registered nurse anesthetists--HCFA. Final rule

We are revising the Medicare regulations to allow certified registered nurse anesthetists (CRNAs) to receive Medicare payment for the anesthesia services and related care they furnish. In addition, this final rule sets forth the fee schedules under which payment is made for the services of CRNAs, except for the services of CRNAs in certain rural hospitals who are paid on a reasonable cost basis. This rule, which is effective for services furnished on or after January 1, 1989, implements section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 4084 of the Omnibus Budget Reconciliation Act of 1987, section 411(i)(3) of the Medicare Catastrophic Coverage Act of 1988, section 608(c) of the Family Support Act of 1988, and sections 6106, 6107 and 6132 of the Omnibus Budget Reconciliation Act of 1989. This final rule does not reflect the changes concerning the calculation of payment rates contained in section 1833(1)(4) of the Social Security Act, as enacted by section 4160 of the Omnibus Budget Reconciliation Act of 1990. Those changes apply to services furnished on or after January 1, 1991. Thus, the changes to the payment calculation provisions described and published below are applicable only to services furnished in calendar years 1989 and 1990.     

Medicare and Medicaid programs; OBRA '87 conforming amendments--HCFA. Final rule with comment period

These regulations amend certain sections of Medicare and Medicaid rules to reflect 15 self-executing provisions of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) and changes made by sections 102, 103, and 211(b) of the Medicare Catastrophic Coverage Act of 1988 (MCCA), section 608(d)(3)(G) of the Family Support Act of 1988 (Pub. L. 100-485), and sections 6113 and 6301 of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). They also clarify related rules. The amendments are needed to make HCFA rules consistent with current provisions of law and to ensure that users of the regulations are not confused by outdated provisions or unclear language. This document also makes technical amendments, primarily to correct internal cross-references, make nomenclature changes, and revise an outdated definition.     

Medicaid program; home and community-based services and respiratory care for ventilator-dependent individuals--HCFA. Final rule with comment period

This final rule with comment period expands coverage of Medicaid home and community-based services under the waiver provisions of section 1915(c) of the Social Security Act. This final rule also adds coverage of respiratory care services as an optional benefit under State Medicaid plans. These revisions and additions incorporate changes made by the Consolidated Omnibus Budget Reconciliation Act of 1985 and the Omnibus Budget Reconciliation Act of 1986 and respond to the public comments that we received as a result of the June 1, 1988, publication of a proposed rule. This final rule with comment period also incorporates self-implementing provisions of the Omnibus Budget Reconciliation Act of 1987, the Medicare Catastrophic Coverage Act of 1988, the Technical and Miscellaneous Revenue Act of 1988, and the Omnibus Budget Reconciliation Act of 1990 concerning home and community-based services, and makes other technical changes not specifically related to these statutes.     

Medicaid program; eligibility and coverage requirements--HCFA. Final rule with comment period

These regulations amend the requirements for coverage of certain groups of individuals under Medicaid and the requirements for determining Medicaid eligibility. The regulations relate to coverage of individuals in optional categorically needy groups; aged, blind and disabled individuals in States that use more restrictive requirements for Medicaid than those under the Supplemental Security Income (SSI) program; individuals receiving optional State supplementary payments; individuals under age 21 who are not receiving AFDC; individuals who are ineligible for cash assistance under the Social Security Act because of requirements that do not apply under Medicaid; and medically needy groups. In addition, the regulations revise the methodologies for determining income and resource eligibility under Medicaid, including financial responsibility of relatives, and for determining financial eligibility of medically needy groups, including determining medically needy income levels. These regulations interpret provisions of the Tax Equity and Fiscal Responsibility Act of 1982, as amended by several acts, including, most recently, the Omnibus Budget Reconciliation Act of 1987, the Medicare Catastrophic Coverage Act of 1988, the Family Support Act of 1988, the Omnibus Budget Reconciliation Act of 1989, and the Omnibus Budget Reconciliation Act of 1990. We are also making some administrative changes to achieve more efficient operation of the Medicaid Program.     

Medicare and Medicaid; eligibility for premium hospital insurance; state buy-in agreements--HCFA. Final rule with comment period

These rules-- 1. Set forth the requirements and procedures for certain individuals under age 65 to enroll and become entitled to Medicare Part A benefits through payment of monthly premiums; 2. Revise the rules on State buy-in for Medicare benefits to provide that-- After 1988, a State may, at any time, request a buy-in agreement or a modification of an existing agreement, including a modification under which the State may enroll a pay Part B premiums on behalf of a new buy-in coverage group--Qualified Medicare Beneficiaries (QMBs); and After 1989, a State may request and obtain a modification of an existing agreement, under which the State may also enroll QMB's in Part A and pay Part A premiums on their behalf. These amendments are necessary to conform HCFA rules to changes made by section 9010 of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), section 301 of the Medicare Catastrophic Coverage Act of 1988 (MCCA), and sections 6012 and 6013 of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). The purposes of the amendments are-- 1. To make it possible for certain disabled individuals to become entitled to Medicare Part A benefits that require payment of a monthly premium. The provisions apply to an individual under age 65 who loses entitlement to Medicare Part A without premiums because his or her earnings exceed the limit imposed for entitlement to social security disability benefits, on which Medicare Part A entitlement was based; and 2. To make available to States, for payment of premiums for QMBs, the administrative and cost efficiencies of the State buy-in procedures.     

Medicare and Medicaid programs; survey, certification and enforcement of skilled nursing facilities and nursing facilities--HCFA. Final rule

This final rule implements certain provisions of the Omnibus Budget Reconciliation Act of 1987, as further amended by subsequent 1988, 1989, and 1990 legislation. These provisions make significant changes in the process of surveying skilled nursing facilities under Medicare and nursing facilities under Medicaid and in the process for certifying that these facilities meet the Federal requirements for participation in the Medicare and Medicaid programs. They also set forth a number of alternative remedies which may be imposed on facilities that do not comply with the Federal participation requirements (instead of or in addition to termination), and specify remedies for State survey agencies that do not meet surveying requirements.     

Medicare program; home health agencies: conditions of participation--HCFA. Final rule

This final rule responds to the major comments we received on an interim final rule that was published on August 14, 1989 (54 FR 33354). That interim final rule added requirements to the current conditions of participation for home health agencies (HHAs). Specifically, the rule specified requirements for protecting and promoting patient rights; training and competency evaluation of home health aides; notifying State entities responsible for the licensing or certification of HHAs of changes in ownership of the agency or management of the agency; including an individual's plan of care as part of the individual's clinical records; and operating and furnishing services in compliance with applicable Federal, State, and local laws and regulations and with accepted professional standards and principles that apply to professionals furnishing home health services. Most of the provisions of the rule implemented section 930 of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499), section 4021 of the Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203), and section 411(d) of the Medicare Catastrophic Coverage Act of 1988 (Pub. L. 100-360). This final rule implements changes, based on our review and consideration of the public comments, concerning patient notification of changes in payment liability, requirements for evaluators and instructors of home health aides, in-service training, and supervisory visits, and clarifies other home health issues.     

Medicaid program; home and community-based services waivers for individuals age 65 or older--HCFA. Interim final rule with comment period

This interim final rule amends current Medicaid regulations to permit States to offer, under a Secretarial waiver, a wide array of home and community-based services to individuals age 65 or older who are determined, but for the provision of these services, to be likely to require the level of care furnished in a skilled nursing facility (SNF) or intermediate care facility (ICF) (nursing facility (NF) effective October 1, 1990). The rule allows Federal payment for these and other long term care services, up to an amount specified in section 1915(d)(5)(B) of the Social Security Act, subject to HCFA's approval of the States' requests for waivers and certain assurances made by the States. Once granted, waivers are in effect for 3 years, unless terminated by the State with notice to the Secretary, and are renewable for periods of 5 years. Periodic evaluation, assessment, and review of the care furnished under the waivers is required. This rule implements section 4102 of the Omnibus Budget Reconciliation Act of 1987, as modified by section 411(k) of the Medicare Catastrophic Coverage Act of 1988, section 8432 of the Technical and Miscellaneous Revenue Act of 1988, and section 4741(b) of the Omnibus Budget Reconciliation Act of 1990. This rule is being issued in final and, for the most part, without a delay in the effective date for the reasons explained in section IV, "Waiver of Proposed Rulemaking and Delay in the Effective Date."     

The Medicare Catastrophic Coverage Act of 1988 and its impact on employer-sponsored retiree medical plans.

The Medicare Catastrophic Coverage Act of 1988 (MECCA) significantly enlarges the scope of federally funded health care benefits for elderly Americans. Since Medicare's inception in 1965, several inadequacies have become apparent, especially the absence of coverage for catastrophic illnesses. Now MECCA inhibits the potential financial ruin of elderly Americans faced with overwhelming, extended medical costs. The Act is budget-neutral and can reduce employers' Social Security payroll tax costs. However, the costs and complications of the maintenance-of-effort provision refunds and potential employee resistance to raised Medicare premiums, which could force some beneficiaries to cancel Part B participation and increase reliance on employer-sponsored plans, do pose problems for employers. Options and alternatives to these new opportunities and concerns are detailed herein.     

Medicaid program; eligibility of aliens for Medicaid--HCFA. Final rule

This regulation revises current Medicaid rules applicable to aliens who meet eligibility requirements as categorically needy or medically needy. It establishes that aliens lawfully admitted for permanent residence or permanently residing in the United States under color of law may be eligible for all Medicaid services. It clarifies and identifies certain categories of persons permanently residing in the United States under color of law. It also identifies those aliens who may be eligible only for limited services as a result of recent legislation. These revisions conform our regulations to changes made by the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509), and the Immigration Reform and Control Act of 1986 (Pub. L. 99-603), and the Medicare Catastrophic Coverage Act of 1988 (Pub. L. 100-360).