Robert Monroe-IL

Thank you for the opportunity to comment on the regulatory changes as required by the MMSEA. I will try to be brief in my comments. LTCH / Satellite Moratorium Exception. The exception allow LTCHs under development as of December 29, 2007 to obtain LTCH designation if there is "a binding written agreement with an outside, unrelated party for the actual construction, renovation, lease or demolition for a long term care hospital;" and "Has expended, before December 29, 2007, at least 10 percent (or, if less, $2.5 million) of the estimated cost of the project" (for the actual construction, renovation, lease or demolition). It is not clear who must spend the funds. For instance, an LTCH company may enter a lease with an acute care hospital and the acute care hospital contracts with a construction company to reconfigure the space for an LTCH. The 10 percent threshold may be passed by the acute hospital's spending but not necessarily the entity that will operate the LTCH. There are multiple ways to finance an LTCH and multiple parties that may have expended sums on or before December 29, 2007. The MMSEA is intended to protect those that have expended funds toward LTCH development. Please confirm that using such common financing practices will not result in a penalty toward these common financing arrangements. There is also a question as to determining the "estimated cost of the project" as related to leases. If an LTCH company enters a 10-year lease prior to December 29, 2007, does the "estimated cost of the project" include 10 years of lease payments? If so, it would seem that LTCH operators that spent the same amount of funds could be treated differently as a result of one having a shorter lease term than the other. An LTCH operator may also enter a lease after December 29, 2007 but have a development agreement with an acute hospital lessor prior to that date. The lessor may have incurred significant costs for development prior to December 29, 2007 with the lease being entered afterword at the conclusion of expenses. Is the lease, in this instance, a component of the "estimated cost of the project?" Application of 25% Rule. I work with a grandfathered HWH (412.22(f)) which has a grandfathered LTCH satellite facility. It is unclear whether 412.534 or 412.536 would apply to the LTCH or the satellite. 412.534 should not be applicable to the grandfathered HWH and it is difficult to see how 412.536 could be applicable to the satellite facility if it is not to be applied to grandfathered HWHs. Any clarity provided in this area would be appreciated. Thank you for your consideration of these issues. Robert L. Monroe