[Federal Register Volume 59, Number 4 (Thursday, January 6, 1994)]
[Notices]
[Pages 762-767]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-62]
[[Page Unknown]]
[Federal Register: January 6, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[BPD-795-NC]
RIN: 0938-AG56
Medicare Program; Schedule of Limits for Skilled Nursing Facility
Inpatient Routine Service Costs
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final notice with comment period.
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SUMMARY: 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.
DATES: Effective date: The provisions set forth in this notice are
effective for cost reporting periods beginning on or after October 1,
1993.
Comment date: Written comments will be considered if we receive
them at the appropriate address, as provided below, no later than 5
p.m. on [March 7, 1994].
ADDRESSES: Mail written comments (1 original and 3 copies) to the
following address:
Health Care Financing Administration Department of Health and Human
Services Attention: BPD-795-NC, P.O. Box 7571, Baltimore Maryland
21207-0517.
If you prefer, you may deliver your comments to one of the
following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Ave. SW.,
Washington DC 20201, or
Room 132, East High Rise Building 6325 Security Boulevard Baltimore
Maryland 21207.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-795-NC. Comments received timely will be available for
public inspection as they are received, beginning approximately three
weeks after publication of a document, in room 309-G of the
Department's offices at 200 Independence Avenue SW., Washington DC, on
Monday through Friday of each week from 8:30 a.m. to 5:00 p.m. (Phone:
202-690-7890).
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or MasterCard
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 783-3238 or by faxing to (202) 275-
6802. The cost for each copy (in paper or microfiche form) is $4.50. As
an alternative, you can view and photocopy the Federal Register
document at most libraries designated as U.S. Government Depository
Libraries and at many other public and academic libraries throughout
the country that receive the Federal Register.
FOR FURTHER INFORMATION CONTACT: Laurence Wilson, (410) 966-4603
SUPPLEMENTARY INFORMATION:
I. Background
Sections 1861(v)(1)(A) and 1888 of the Social Security Act (the
Act) authorize the Secretary to set limits on allowable costs incurred
by a provider of services for which payment may be made under Medicare.
These limits are based on estimates of the costs necessary for the
efficient delivery of needed health services. Implementing regulations
appear at 42 CFR 413.30. Section 1888 of the Act directs the Secretary
to set limits on per diem inpatient routine service costs for hospital-
based and freestanding skilled nursing facilities (SNFs) by urban or
rural area location. Section 4008(e)(2) of the Omnibus Budget
Reconciliation Act of 1990 (Pub. L. 101-508) amended section 1888(a) of
the Act to require the Secretary to update the per diem SNF cost limits
for cost reporting periods beginning on or after October 1, 1992, and
every 2 years thereafter.
Under the authority of section 1888 of the Act, we published a
final notice on October 7, 1992 (57 FR 46177) announcing a schedule of
limits for freestanding and hospital-based SNFs effective for cost
reporting periods beginning on or after October 1, 1992. The limits
were computed using data from cost reporting periods ending on or after
June 30, 1989, through May 31, 1990, for freestanding SNFs and from
cost reporting periods ending on or after October 31, 1988, through
September 30, 1989, for hospital-based SNFs.
The October 7, 1992 final notice contained provisions relating to:
(1) Separate group limits for labor-related and nonlabor-related
components of SNF per diem routine service costs;
(2) Adjustments to the cost limits by an area wage index developed
from hospital industry wages;
(3) A ``market basket'' index developed to reflect changes in the
price of goods and services purchased by SNFs;
(4) Application of the adjusted hospital wage index to wages,
employee benefits, health service costs, costs of business services,
and other miscellaneous expenses;
(5) Freestanding SNF cost limits set at 112 percent of the average
per diem labor-related and nonlabor-related costs;
(6) Hospital-based SNF cost limits set at the limit for
freestanding SNFs, plus 50 percent of the difference between the
freestanding limit and 112 percent of the average per diem routine
service costs of hospital-based SNFs, and an add-on for administrative
and general (A&G) costs;
(7) Cost-of-living adjustments for Alaska, Hawaii, Puerto Rico, and
the Virgin Islands;
(8) Exceptions to the cost limits;
(9) A classification system based on whether the SNF is hospital-
based or freestanding and whether it is located in an urban or rural
area.
In addition to the above provisions, the October 7, 1992 final
notice also provided for a per diem add-on to recognize the costs
incurred by SNFs in complying with the additional nursing home reform
requirements of section 1819 of the Act (including the costs of
conducting nurse aide training and competency evaluations). (Section
1861(v)(1)(E) of the Act provides for Medicare payment for costs
incurred by SNFs in complying with the requirements of section 1819 of
the Act.) The October 7, 1992 notice also included an add-on to the
cost limits to recognize the costs that SNFs may incur in meeting the
universal precaution requirements of the Occupational Safety and Health
Administration (OSHA). These requirements were described in a final
rule published by OSHA in the Federal Register on December 6, 1991 (54
FR 64004) that set forth a standard under section 6(b) of the
Occupational Safety and Health Act of 1970 (29 U.S.C. 655) to eliminate
or minimize occupational exposure to bloodborne pathogens.
II. Provisions of This Final Notice With Comment Period
A. No Changes in the Cost Limits
On August 10, 1993, the Omnibus Budget Reconciliation Act of 1993
(OBRA '93), Public Law 103-66, was enacted. Section 13503(a)(1) of OBRA
'93 requires that there be no changes in the SNF routine cost limits
(except as may be necessary to take into account the elimination of the
administrative and general add-on for hospital-based SNFs) for cost
reporting periods beginning during Federal fiscal years (FY) 1994 and
1995, that is, for cost reporting periods beginning on or after October
1, 1993, and before October 1, 1995. The effect of this provision is
that a SNF's latest routine cost limit for a period beginning on or
after October 1, 1992 and before October 1, 1993, as calculated under
the October 7, 1992 notice, without regard to any subsequent
adjustments under section 1888(c) of the Act such as exceptions, will
remain in effect until its cost reporting period beginning on or after
October 1, 1995. Accordingly, there will be no changes to a SNF's cost
limit for cost reporting periods beginning on or after October 1, 1993,
and before October 1, 1995, to account for inflation, updates of the
data, changes to the wage index or to MSA designations. Thus, in
computing a provider's cost limit for cost reporting periods beginning
on or after October 1, 1993 and before October 1, 1995, the cost
reporting period adjustment factors that were to apply for cost
reporting periods beginning on or after October 1, 1993, as set forth
in Table IV of the October 7, 1992 notice (57 FR 46188), will not be
used. Other components of the October 7, 1992 notice, specifically the
SNF Group Limits in Table I, and the wage indexes in Tables II and III
will continue to be used to compute the limits, with the exception in
Table I of the add-on for administrative and general costs of hospital-
based SNFs.
In the example below, a freestanding SNF in Dallas, Texas has a
cost reporting period beginning date of January 1, 1993. As calculated
under the October 7, 1992 notice, its cost limit for the 12-month
period beginning January 1, 1993 is $96.97. Under the provisions of
this notice, the cost limit of $96.97 will remain in effect for its 12-
month cost reporting periods beginning January 1, 1994 and January 1,
1995. As explained above, the cost reporting period adjustment factors
that would have been used under the October 7, 1992 notice for
calculating the limits for the SNF's new cost reporting periods
beginning January 1, 1994 and January 1, 1995, are not used.
Accordingly, the provider in this example will not have any change in
its cost limit until its cost reporting period beginning January 1,
1996.
Example--Calculation of Adjusted Limit for a Freestanding SNF
Located in Dallas, Texas (using the appropriate tables from the October
7, 1992 schedule of limits):
Labor-Related Component....................................................... $79.56 (Table I).
Wage Index.................................................................... x 0.9638 (Table II).
----------------
Adjusted Labor Component...................................................... $76.68
Nonlabor-Related Component.................................................... +17.08 (Table I).
Nursing Home Reform and OSHA Per Diem Add-On.................................. +1.98.
----------------
Limit Prior To Inflation Adjustment $95.74
Adjustment Factor............................................................. x 1.01286 (Table IV).
----------------
Inflation Adjusted Limit...................................................... $96.97
As noted above, for cost reporting periods beginning on or after
October 1, 1993 but before October 1, 1995, a SNF's cost limit will be
its latest routine cost limit for the period beginning on or after
October 1, 1992 and before October 1, 1993, as calculated under the
October 7, 1992 notice and without regard to any subsequent
adjustments, such as an exception to the limit. Thus, if the SNF in the
above example received an exception to its cost limit for its cost
reporting period beginning January 1, 1993, its cost limit for the cost
reporting period beginning January 1, 1994 would not include the
exception amount for the previous period. To receive an exception or
other adjustment to its cost limit, the SNF would need to submit a
request to its fiscal intermediary in accordance with the procedures
set forth in Sec. 413.30 of the regulations.
B. Periods Other Than 12 Months
The above methodology applies to providers with cost reporting
periods of 12 months in duration. If a facility's cost reporting period
is not 12 months in duration, a special adjustment factor is
calculated. This is necessary because inflation projections are
computed to the midpoint of a cost reporting period, and the adjustment
factors in Table IV are based on 12-month reporting periods. For cost
reporting periods of other than 12 months, the calculation must be made
based on the midpoint of the specific cost reporting period. The SNF's
intermediary obtains this adjustment factor from HCFA central office.
This methodology results in a different cost limit than if a 12-month
adjustment factor were used. However, since the provisions of OBRA '93
require no changes in the cost limit on or after October 1, 1993, the
limit calculated with the special adjustment factor will remain in
place for subsequent cost reporting periods beginning before October 1,
1995.
C. Providers Entering the Medicare Program
For providers entering the Medicare program on or after October 1,
1993 and before October 1, 1995, the applicable cost limit will be the
cost limit for the identical period beginning on or after October 1,
1992 through September 30, 1993. For example, if a provider enters the
Medicare program on September 1, 1994, with a 12-month cost reporting
period, its cost limit will be determined in the same manner as a cost
limit for a period beginning September 1, 1993 and ending August 30,
1994. If the provider's cost reporting period is a short period
beginning September 1, 1994 and ending December 31, 1994, the
provider's cost limit will be determined in the same manner as a cost
limit for a period beginning September 1, 1993 and ending December 31,
1993. In addition, whether the first period is a full 12-month period
or a period other than 12 months, the cost limit determined for the
first period will remain in effect until the provider's first cost
reporting period beginning on or after October 1, 1995.
D. Next Update of Limits
As discussed above, before the enactment of OBRA '93, section
1888(a) of the Act required that the SNF routine cost limits be updated
on October 1, 1992 and every 2 years thereafter. Section 13503(a)(1) of
OBRA '93 amended this section to delay the next update until October 1,
1995, and every 2 years thereafter. Accordingly, there will be no
changes to the routine cost limits published in the October 7, 1992
notice for inflation, changes in the wage index, geographic
designation, or for a more recent data base until October 1, 1995.
E. Add-On for Hospital-Based SNFs
Before the enactment of OBRA '93, section 1888(b) of the Act
provided for an add-on to recognize the cost differences between
hospital-based and freestanding SNFs attributable to excess overhead
allocations, that is, an add-on for the administrative and general
costs (A&G) of hospital-based SNFs. Section 13503(a)(3) of OBRA '93
amended this section of the Act to repeal the requirement that we
recognize cost differences attributable to excess overhead allocations.
Therefore, this notice implements that provision by eliminating the A&G
add-on for hospital-based SNFs. In addition, while section 13503(a)(1)
of OBRA '93 requires that there be no changes in the cost limits, as
explained above, it also states that the provision does not apply to
the elimination of the A&G add-on for hospital-based SNFs. Therefore,
effective for cost reporting periods beginning on or after October 1,
1993, we will no longer apply the administrative and general add-on for
hospital-based SNFs as shown in Table I of the October 7, 1992 schedule
of limits. The intermediary will continue to determine the cost limits
for hospital-based SNFs using the relevant instructions and Table I SNF
Group Limits, as described in the October 7, 1992 notice. However, for
cost reporting periods beginning on or after October 1, 1993, these
limits will be calculated without using the A&G add-on.
The example below uses information from Table I of the October 7,
1992 schedule of limits to calculate a cost limit for a hospital-based
SNF located in Scranton, Pennsylvania. The cost limit is for a cost
reporting period beginning October 1, 1993. However, as discussed
above, the A&G add-on for hospital-based SNFs is no longer applied, and
the cost limit effective October 1, 1992 remains in effect for the cost
reporting period beginning on or after October 1, 1993.
Example--Calculation of Adjusted Limit Effective October 1, 1993,
for a Hospital-Based SNF Located in Scranton, Pennsylvania:
Labor-Related Component Limit................................................. $112.22 (Table I).
Wage Index.................................................................... x 0.8952 (Table II).
----------------
Adjusted Labor Component.................................................. $100.46
Nonlabor-Related Component:
Limit................................................................. 23.79 (Table I).
Nursing Home Reform and OSHA Per Diem Add-on.......................... +1.98
----------------
Adjusted Limit........................................................ $126.23
F. Adjustments to the Routine Limits
Section 1888(c) of the Act provides for appropriate adjustments to
the SNF routine cost limits. These adjustments are set forth at
Sec. 413.30 and include: exemptions from the cost limits for new
providers; exceptions to the limits for atypical services and
extraordinary circumstances; and other provisions. Section 13503(a)(1)
of OBRA '93 mandates that the effect of allowing no changes in the SNF
routine cost limits for cost reporting periods beginning during FYs
1994 and 1995 not be considered in making adjustments to the routine
cost limits under the exceptions process. Therefore, effective for cost
reporting periods beginning on or after October 1, 1993, and before
October 1, 1995, a provider may request an exception only for costs
incurred above the amount that the limit would have been had the
provisions set forth in this notice regarding no changes in the cost
limits not been enacted. Accordingly, for the purpose of determining
the amount of an exception to the SNF routine cost limits under the
regulations at Sec. 413.30(f), the difference between the amount of a
provider's cost limit as determined by the provisions set forth in this
notice, and the amount that a provider's cost limit would have been
under the October 7, 1992 notice had the provisions described herein
not been enacted, is not subject to an exception to the routine cost
limits. We note that this provision does not apply to the A&G add-on
for hospital-based SNFs. That is, for cost reporting periods beginning
on or after October 1, 1993, the A&G add-on for hospital-based SNFs
will not be used in computing the amount that the hospital-based cost
limit would have been had the provisions requiring no changes in the
limits not been enacted. In addition, we note that this provision has
no effect on new provider exemptions to the SNF cost limits, as set
forth under Sec. 413.30(e)(2), since this exemption removes the
limitation on a SNF's routine costs.
The example below demonstrates the computation to determine the
amount not subject to an exception under the provisions set forth in
this notice. The provider's cost limit is computed for the cost
reporting period beginning January 1, 1993, in accordance with the
provisions set forth in this notice, and this limit remains in effect
until the cost reporting period beginning January 1, 1995. The provider
has requested an exception to its limit for the period beginning
January 1, 1994. Again, we use the information from the October 7, 1992
notice to calculate what the limit would have been had the OBRA '93
provisions requiring no changes in the limits not been enacted. The
difference of $5.04 between the actual limit and the amount the limit
would have been is the amount not subject to an exception.
Example--Calculation of Amount Not Subject to an Exception to the
Limits Freestanding SNF Located in Dallas, Texas:
Labor-Related Component....................................................... $79.56 (Table I).
Wage Index.................................................................... x 0.9638 (Table II).
----------------
Adjusted Labor Component...................................................... $76.68
Nonlabor-Related Component.................................................... +17.08 (Table I).
Nursing Home Reform and OSHA Per Diem Add-On.................................. +1.98
----------------
Limit Prior To Inflation Adjustment........................................... $95.74
Adjustment Factor (January 1, 1993)........................................... x 1.01286 (Table IV).
----------------
Inflation Adjusted Limit (Limit in Effect for January 1, 1993, January 1, $96.97
1994, January 1, 1995).
Adjustment Factor (January 1, 1994 for Exception Purposes Only)............... x 1.06553 (Table IV).
----------------
Inflation Adjusted Limit (January 1, 1994 for Exception Purposes Only)........ $102.01
Amount Not Subject to Exception ($102.01-$96.97).............................. $5.04
III. Impact Statement
Executive Order 12866 (E.O. 12866) requires us to prepare an
analysis for any rule that meets one of the E.O. 12866 criteria for a
``significant regulatory action''; that is, that may--
Have an annual effect on the economy of $100 million or
more or adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or State, local, or tribal governments or
communities;
Create a serious inconsistency or otherwise interfere with
an action taken or planned by another agency;
Materially alter the budgetary impact of entitlements,
grants, user fees, or loan programs or the rights and obligations of
recipients thereof; or
Raise a novel legal or policy issues arising out of legal
mandates, the President's priorities, or the principles set forth in
E.O. 12866.
In addition for final notices such as this, we generally prepare a
regulatory flexibility analysis that is consistent with the Regulatory
Flexibility Act (RFA) (5 U.S.C. 601 through 612) unless the Secretary
certifies that this notice will not have a significant economic impact
on a substantial number of small entities. For purposes of the RFA, all
SNFs are treated as small entities.
This final notice with comment period announces the provisions of
section 13503(a) of OBRA '93, which provides for a delay in the updates
of the limits on payments for routine SNF services through cost
reporting periods beginning before October 1, 1995, and provides for
the elimination of the A&G add-on for hospital-based SNFs effective for
cost reporting periods beginning on or after October 1, 1993. None of
the provisions of this notice interprets or extends requirements beyond
those set forth in OBRA '93.
Sections 13503(a)(1) and (3) of OBRA '93 will result in significant
Federal cost savings. The impact of these provisions is discussed
further below. This notice explains the revised methodology for
calculating the SNF limits that results from the provisions of OBRA
'93. We do not believe that merely reflecting these provisions in this
notice produces any effect that will meet any of the criteria of E.O.
12866 for a significant regulatory action or will have a significant
effect on a substantial number of small entities. Therefore, we have
determined and the Secretary certifies that neither an impact analysis
under E.O. 12866 nor a regulatory flexibility analysis under the RFA
are required.
To the extent that a legislative provision being announced by a
notice such as this may have a significant effect on beneficiaries or
providers or may be viewed as controversial, we believe that we should
address any potential concerns. In this instance, we believe it is
desirable to inform the public of our estimate of the substantial
budgetary effect of these statutory changes. We estimate that these
statutory provisions will result in the following savings to the
Medicare program:
Table 1.--Impact of Delay in the Update of SNF Limits and Elimination of
Add-on*
------------------------------------------------------------------------
Update Elimination
Fiscal year delay of add-on
------------------------------------------------------------------------
1994............................................ $30 $10
1995............................................ 120 10
1996............................................ 90 10
1997............................................ ......... 10
1998............................................ ......... 10
------------------------------------------------------------------------
*All figures are rounded to the nearest $10 million.
As illustrated in Table 2 below, the delay in updating the cost
limits until October 1, 1995, combined with the elimination of the A&G
add-on for hospital-based SNFs, will result in a small increase in the
number of SNFs exceeding the SNF limits in all categories, although we
cannot isolate the separate impact of these factors. Table 2 below
shows the combined impact of these changes.
Table 2.
------------------------------------------------------------------------
Exceeding old Exceeding new
Total SNFs limits limits
------------------------------------------------------------------------
Freestanding SNFs....... 5340 911 1209
Urban............... 4074 706 930
Rural............... 1266 205 279
Hospital-based SNFs..... 908 518 563
Urban............... 455 298 321
Rural............... 453 220 242
------------------------------------------------------------------------
We are unable to identify the effects of these provisions on
individual SNFs. However, we anticipate that overall SNF payments for
FY 1994 and FY 1995 will be approximately 1.2 percent and 2.3 percent
less, respectively, than they would have been in those years if the
OBRA '93 provisions were not in effect. Moreover, since Medicare does
not account for a high proportion of SNF utilization or revenue, we
estimate that the delay in updating the limits and the elimination of
the hospital-based add-on will not result in a significant number of
facilities' total revenues being increased or reduced by 3 percent or
more from the October 7, 1992 limits, adjusted for inflation. Thus, we
have determined that the economic impact on SNFs will not be
significant.
Section 1102(b) of the Act requires the Secretary to prepare a
regulatory impact analysis if a final notice such as this may have a
significant impact on the operations of a substantial number of small
rural hospitals. Such an analysis must conform to the provisions of
section 604 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital with fewer than 100 beds
located outside of a Metropolitan Statistical Area.
We have not prepared a rural impact statement since we have
determined and the Secretary certifies that this final notice will not
have a significant economic impact on the operations of a substantial
number of small rural hospitals.
IV. Other Required Information
A. Paperwork Reduction Act
This final notice with comment period does not impose information
collection requirements. Consequently, it need not be reviewed by the
Office of Management and Budget under the authority of the Paperwork
Reduction Act of 1980 (44 U.S.C. 3501 through 3511).
B. Waiver of Proposed Notice and 30-Day Delay in the Effective Date
In adopting notices such as this, we ordinarily publish a proposed
notice in the Federal Register with a 60-day period for public comment
as required under section 1871(b)(1) of the Act. We also normally
provide a delay of 30 days in the effective date for documents such as
this. However, we may waive these procedures if we find good cause that
prior notice and comment or a delay in the effective date are
impracticable, unnecessary, or contrary to the public interest.
As discussed above, before the enactment of OBRA '93, section
1888(a) of the Act required that the SNF routine cost limits be updated
for cost reporting periods beginning on or after October 1, 1992 and
every 2 years thereafter. However, section 13503(a)(1) of OBRA '93
specifies that there be no changes in the SNF cost limits for cost
reporting periods beginning during FYs 1994 and 1995, and section
13503(a)(2) of OBRA '93 amended section 1888 of the Act to delay the
next required update of the SNF limits until October 1, 1995. In
addition, section 13503(a)(3) of OBRA '93 amended section 1888(b) of
the Act to eliminate, effective for cost reporting periods beginning on
or after October 1, 1993, the add-on to the SNF cost limits to
recognize the higher administrative and general costs of hospital-based
SNFs.
In conformance with the clear direction of section 13503(a) of OBRA
'93, this notice announces the new SNF provisions and explains the
effects of these provisions on the methodology used in calculating the
SNF cost limits. We have made no changes in this methodology beyond
those directly required by OBRA '93, nor are there any other
discretionary aspects to this notice. Moreover, section 13503(a) of
OBRA '93 mandates that these provisions are effective beginning with
cost reporting periods beginning on or after October 1, 1993. Thus, we
have concluded that in this instance, it would be impracticable,
unnecessary, and contrary to the public interest to publish a proposed
notice or to provide for a 30-day delay in the effective date of this
notice. Therefore, we find good cause to waive publication of a
proposed notice and the 30-day delay in effective date. However, we are
providing a 60-day period for public comment, as indicated at the
beginning of this preamble.
C. Public Comments
Because of the large number of items of correspondence we normally
receive, we are not able to acknowledge or respond to them
individually. However, we will consider all comments that we receive by
the date and time specified in the ``Date'' section of the preamble to
this notice. If we make any changes to this notice, we will respond to
the comments in the preamble to the notice that incorporates the
changes.
Authority: (Sections 1102, 1814(b), 1861(v)(1), 1866(a), 1871,
and 1888 of the Social Security Act (42 U.S.C. 1302, 1395f(b),
1395x(v)(1), 1395cc(a), 1395hh, and 1395yy); section 6024 of Pub. L.
101-239 (42 U.S.C. 1395yy(note)); section 13503 of Pub. L. 103-66
(42 U.S.C. 1395yy(note)) and 42 CFR 413.30.)
(Catalog of Federal Domestic Assistance Program No. 93.773 Medicare-
Hospital Insurance Program)
Dated: November 23, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: November 28, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-62 Filed 1-5-94; 8:45 am]
BILLING CODE 4120-01-P
