Medicare program; revision of the procedures for requesting exceptions to cost limits for skilled nursing facilities and elimination of reclassifications--HCFA. Proposed rule

This proposed rule would revise the procedures for granting exceptions to the cost limits for skilled nursing facilities (SNFs) and retain the current procedures for exceptions to the cost limits for home health agencies (HHAs). It also would remove the provision allowing reclassifications for all providers.     

Questions concerning the process of requesting exceptions from the skilled nursing facility cost limits

The new PRM provisions provide helpful guidance to SNFs in submitting requests for exceptions to cost limits. However, they also make the process more rigid and create procedural traps for the unwary. Accordingly, SNFs are advised to study the PRM sections to assure that their exception requests contain the required information. However, they should not feel bound by the limits in the PRM. When submitting requests, SNFs should think creatively about why their facilities are atypical and how to best quantify their higher costs. They should then protect their rights by including these more creative theories or calculations in the materials they submit to the intermediaries.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); reimbursement of providers, claims filing, and participating provider program--Office of the Secretary, DoD. Final rule

This final rule implements provisions of the Department of Defense Appropriations Act, 1993, section 9011, which limits increases in maximum allowable payments to physicians and other individual professional providers (including clinical laboratories), authorizes reductions in such amounts for overpriced procedures, provides special procedures to assure beneficiary access to care, and establishes limits on balance billing by providers. Also, the final rule implements a provision of the National Defense Authorization Act for Fiscal Year 1992 that requires providers to file claims on behalf of CHAMPUS beneficiaries, builds into the CHAMPUS Regulation provisions that have been in effect for several years regarding the Participating Provider Program, and implements a new approach for CHAMPUS reimbursement for ambulatory surgery.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); program for persons with disabilities; basic program--DoD. Final rule

This final rule simplifies the administration of benefits under the CHAMPUS Program for the Handicapped (PFTH) and changes the name of this benefit to Program for Persons with Disabilities (PFPWD); adds occupational therapists in independent practice to the list of authorized individual professional providers; provides criteria for cost-sharing certain procedures when data is transferred electronically from the patient's home to a medical practitioner; defines and limits plans recognized as supplemental insurance under CHAMPUS; and adopts the Federal Claims Collection Act and the Federal Claims Collection Standards by reference.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); reimbursement of individual health providers--Department of Defense. Final rule

This final rule implements the provisions of the Defense Appropriations Act for Fiscal Year 1991, Public Law 101-511, section 8012, which limits increases in maximum allowable payments to physicians and other individual health care providers and authorizes reductions in such amounts for overpriced procedures.     

Supplemental standards of ethical conduct and financial disclosure requirements for employees of the Department of Health and Human Services. Interim final rule with request for comments

The Department of Health and Human Services, with the concurrence of the Office of Government Ethics (OGE), is amending the HHS regulation that supplements the OGE Standards of Ethical Conduct. This interim final rule specifies additional procedural and substantive requirements that are necessary to address ethical issues at the National Institutes of Health (NIH) and updates nomenclature, definitions, and procedures applicable to other components of the Department. The rule: Revises the definition of a significantly regulated organization for the Food and Drug Administration (FDA); Updates the organization titles of designated separate agencies; Amends the gift exception for native artwork and craft items received from Indian tribes or Alaska Native organizations; Aligns the FDA prohibited holdings limit with the de minimis holdings exemption in OGE regulations; Revises prior approval procedures for outside activities; and, subject to certain exceptions: Prohibits NIH employees from engaging in certain outside activities with supported research institutions, health care providers or insurers, health-related trade or professional associations, and biotechnology, pharmaceutical, medical device, and other companies substantially affected by the programs, policies, or operations of the NIH; Bars NIH employees who file a public or confidential financial disclosure report from holding financial interests in substantially affected organizations; Subjects NIH non-filer employees to a monetary cap on holdings in such organizations; Specifies for NIH employees prior approval procedures for and limitations on the receipt of certain awards from outside sources; and Imposes a one-year disqualification period during which NIH employees are precluded from official actions involving an award donor. In addition, the Department is adding a new supplemental part to expand financial disclosure reporting requirements for certain outside activities and to ensure that prohibited financial interests are identified.     

Medicare program; adjustments to cost limits for skilled nursing facility inpatient routine service costs--HCFA. Proposed notice

This notice proposes to eliminate an adjustment that we make to the Medicare cost limits for skilled nursing facility (SNF) routine services if the final rate of change in the market basket index for a calendar year that we use to set the limits differs from the estimated rate of change in the index by at least 0.3 percentage points. Elsewhere in this issue of the Federal Register is a separate final notice with comment period that explains the methodology we use to develop the cost limits and sets forth the cost limits applicable to cost reporting periods occurring on or after October 1, 1997.     

Pharmaceutical Reimbursement Board; maximum allowable cost (MAC) limits and announcement of public hearing--HCFA. Proposed notice

The Pharmaceutical Reimbursement Board (PRB) proposes maximum allowable cost limits on the drugs specified below and announces a public hearing with regard to these proposed MAC limits.     

Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after October 1, 1997--HCFA. Notice with comment period

This notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after October 1, 1997. These limits replace the per visit limits that were set forth in our July 1, 1996 notice with comment period (61 FR 34344) and supersede those set forth in our July 1, 1997 notice with comment period (61 FR 35608). This notice also provides, in accordance with the Balanced Budget Act of 1997, that there be no changes in the home health per visit limits for cost reporting periods beginning on or after July 1, 1997 and before October 1, 1997 (that is, the cost limits set forth in our July 1, 1996 notice will apply to cost reporting periods beginning during this time period); that the establishment of the cost per visit limitations for cost reporting periods beginning on or after October 1, 1997 be based on 105 percent of the median of the labor-related and nonlabor per visit costs for freestanding home health agencies; that there be no updates in the home health costs limits (including no adjustments for changes in the wage index or other updates) for cost reporting periods beginning on or after July 1, 1994 and before July 1, 1996; and the wage index value that is applied to the labor portion of the per visit limitations be based on the geographic area in which the home health service is furnished.     

Medicare program: schedule of limits for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period

This final notice with comment period provides that there will be no changes in the skilled nursing facility (SNF) cost limits for cost reporting periods beginning during Federal fiscal years 1994 and 1995 and that the add-on for administrative and general costs of hospital-based SNFs is eliminated. This notice announces provisions of the Omnibus Budget Reconciliation Act of 1993 that affect the schedule of limits on SNF routine service costs for which payment may be made under the Medicare program and explains the effects of these provisions on the methodology used in calculating the SNF cost limits.     

TRICARE: the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); specialized treatment services (STS) program--DoD. Notice

This notice is to advise interested parties that Naval Hospital Jacksonville (NAVHOSPJAX), Florida, has been designated a regional Specialized Treatment Services facility (STSF) for total joint replacement. The application for this STSF designation was submitted by NAVHOSPJAX and approved by the Assistant Secretary of Defense (Health Affairs). The Lead Agent for TRICARE Region 3 will oversee that the STSF maintains the quality and standards required for specialized treatment services. This designation covers the following Diagnostic Related Groups: 209--Major Joint and Limb Reattachment Procedures of Lower Extremity 491--Major Joint and Limb Reattachment Procedures of Upper Extremity DoD beneficiaries who reside in the NAVHOSPJAX STS Catchment Area must be evaluated by NAVHOSPJAX before receiving TRICARE/CHAMPUS cost sharing for procedures that fall under the above Diagnostic Related Groups, in accordance with TRICARE/CHAMPUS Nonavailability Statement policy. Travel and lodging for the patient and, if stated to be medically necessary by a referring physician, for a nonmedical attendant, will be reimbursed by NAVHOSPJAX in accordance with the provision of the Joint Federal Travel Regulation. Although evaluation in person is preferred, it is possible to conduct the evaluation telephonically if the patient is unable to travel to NAVHOSPJAX. If the procedures cannot be performed at NAVHOSPJAX, Humana Military Healthcare Services will provide a medical necessity review prior to issuance of a Nonavailability Statement or other similar authorizations. The NAVHOSPJAX STSF Catchment Area includes zip codes within TRICARE Region 3 that fall within a 200-mile radius South and West of NAVHOSPJAX.     

Verification of eligibility for public benefits--INS. Proposed rule

This rule amends the Immigration and Naturalization Service ("Service") regulations by establishing a new part requiring certain entities that provide Federal public benefits (with certain exceptions) to verify, by examining alien applicants' evidence of alien registration and by using a Service automated verification system that the applicants are eligible for the benefits under welfare reform legislation. The rule also sets forth procedures by which a State or local government can verify whether an alien applying for a State or local public benefit is a qualified alien, a nonimmigrant, or an alien paroled into the United States for less than 1 year, for purposes of determining whether the alien is eligible for the benefit. In addition, the rule establishes procedures for verifying the U.S. nationality of individuals applying for benefits in a fair and nondiscriminatory manner.     

Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1989--HCFA. Final notice

This final notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program. This revised schedule of limits applies to cost reporting periods beginning on or after July 1, 1989 and before July 1, 1991. As required by section 6222 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239), the revised schedule of limits incorporates the hospital wage index in effect for cost reporting periods beginning prior to July 1, 1989.     

Medicare program; schedule of limits for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period

This final notice with comment period sets forth an updated schedule of limits on skilled nursing facility routine service costs for which payment may be made under the Medicare program. Section 1888(a) of the Social Security Act requires that for cost reporting periods beginning on or after October 1, 1992, and every two years thereafter, the Secretary update the per diem cost limits for skilled nursing facility routine service costs.     

Medicare program; schedule of limits on home health agency costs per visit--HCFA. Notice with comment period

This notice with comment period sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after July 1, 1993. These limits replace the per-visit limits that were set forth in our July 8, 1993 notice with comment period (58 FR 36748). This notice also provides, in accordance with the provisions of the Omnibus Budget Reconciliation Act of 1993 (OBRA '93), that there will be no changes in the home health agency (HHA) cost limits for cost reporting periods beginning on or after July 1, 1994, and before July 1, 1996. In addition, this notice responds to public comments on the July 8, 1993 notice with comment period, which originally set forth the HHA cost limits for cost reporting periods beginning on or after July 1, 1993, and on the January 6, 1994 notice with comment period (59 FR 760), which announced the elimination of the hospital based add-on effective for cost reporting periods beginning on or after October 1, 1993.     

The Israeli Model for Managing The National List of Health Services in an Era of Limited Resources

In order to attain financial stability, equality, and quality of care, Israel placed its basic health insurance system under strict government regulation in the National Health Insurance Act (NHIA) of 1994. The act creates the National List of Health Services (NLHS), which outlines the minimal health services (including drugs and medical devices) that the four pre–exiting Sick Funds must supply to their members free of charge or for a relatively small defined co–payment
This article analyzes the mechanisms that update the NLHS to ensure the quality of health services provided to all citizens with respect to the constant developments in health technologies both for medical procedures and diagnosis, and for drugs.
The article's main conclusion is that Israel offers a unique model for explicit rationing. The process of updating the list of services leads to clear decision making at a national level, one which offers new technologies to all citizens by public funding each year within the limits of an allocated and defined budget. However, the Israeli model is far from perfect, especially as the act does not establish a defined mechanism for allocating an annual budget for updating the list. Therefore, the act cannot assure a health care system with the stability and certainty it requires.     

Quality mammography standards. Department of Health and Human Services (HHS), Public Health Service (PHS), Food and Drug Administration (FDA). Direct final rule

The Food and Drug Administration (FDA) is amending its regulations governing mammography. The amendments are intended to incorporate changes required by the Mammography Quality Standards Reauthorization Act (MQSRA). Elsewhere in this issue of the Federal Register, FDA is publishing a companion proposed rule under FDA's usual procedures for notice and comment to provide a procedural framework to finalize the rule in the event that the agency withdraws the direct final rule.     

Medicare program; update of the reasonable compensation equivalent limits for services furnished by physicians--HCFA. Notice

This notice sets forth updated payment limits on the amount of allowable compensation for services furnished by physicians to providers that are not covered by the prospective payment system or per resident payments for graduate medical education. These services are paid by Medicare on a reasonable cost basis. The revised reasonable compensation equivalent limits are based on updated economic index data and replace the limits that were published in the Federal Register on February 20, 1985 (50 FR 7123).     

Medicare program; schedules of limits and prospectively determined payment rates for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period

This final notice with comment period sets forth an updated schedule of limits on skilled nursing facility (SNF) routine service costs for which payment may be made under the Medicare program and sets forth an updated schedule of payment rates for low Medicare volume SNFs that elect to receive prospectively determined payment rates for routine service costs. Section 1888(a) of the Social Security Act (the Act) requires that the Secretary update the per diem cost limits for SNF routine service costs for cost reporting periods beginning on or after October 1, 1995, and every 2 years thereafter. In addition, section 1888(d)(4) of the Act requires the Secretary to establish and publish prospectively determined payment rates at least 90 days prior to the beginning of the Federal fiscal year (FY) to which such rates are to be applied.     

Health insurance without provider influence: the limits of cost containment

In our previous paper, we showed that market forces can play a significant role in controlling health care costs and that a considerable amount of cost containment effort was pursued by third-party insurers in Oregon in the 1930s and 1940s. Although physicians were able to thwart this cost-control effort, a 1986 Supreme Court decision, FTC v. Indiana Federation of Dentists, found that a boycott of insurers by dentists violated Section 5 of the Federal Trade Commission Act. Further investigation of recent developments, including the recent Wickline v. California decision, indicates that the primary barriers to cost containment today are not obstructive tactics by providers or provider-controlled health insurance plans. Rather, the primary barriers are increases in the development and diffusion of new technology and society's apparent preference for paying for new tests and procedures regardless of economic efficiency.