[Federal Register: January 6, 2004 (Volume 69, Number 3)]
[Notices]
[Page 661-665]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr06ja04-87]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-1373-N]
RIN 0938-AN00
Medicare Program; Notice of One-Time Appeal Process for Hospital
Wage Index Classification
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: In accordance with section 508(a) of the Medicare Prescription
Drug, Improvement and Modernization Act of 2003, this notice
establishes a one-time appeal process by which a hospital may appeal
the wage index classification otherwise applicable to the hospital.
DATES: Effective Date: This notice is effective January 1, 2004.
Deadline for Submission of Appeal Requests: Appeal requests will be
considered if the Medicare Geographic Classification Review Board
receives them, at the appropriate address, no later than 5 p.m. EDT on
February 15, 2004.
Applicability: Geographic redesignations granted under this process
are applicable to discharges occurring during the 3-year period
beginning with discharges on or after April 1, 2004 and before April 1,
2007.
FOR FURTHER INFORMATION CONTACT: Stephen Phillips, (410) 786-4548.
SUPPLEMENTARY INFORMATION:
I. Background
Under section 1886(d)(10) of the Act, the Medicare Geographic
Classification Review Board (MGCRB) considers applications by hospitals
for geographic reclassification for purposes of payment under the
inpatient prospective payment system (IPPS). Hospitals can elect to
reclassify for the wage index or the standardized amount, or both, and
as individual hospitals or as groups. Generally, hospitals must be
proximate to the labor market area to which they are seeking
reclassification and must demonstrate characteristics similar to
hospitals located in that area. Hospitals must apply for
reclassification to the MGCRB. The MGCRB issues its decisions by the
end of February for reclassifications to become effective for the
following fiscal year (beginning October 1). The regulations applicable
to reclassifications by the MGCRB are located in Sec. Sec. 412.230
through 412.280.
Section 1886(d)(10)(D)(v) of the Act provides that, beginning with
FY 2001, an MGCRB decision on a hospital reclassification for purposes
of the wage index is effective for 3 fiscal years, unless the hospital
elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of
the Act provides that the MGCRB must use the 3 most recent years'
average hourly wage data in evaluating a hospital's reclassification
application for FY 2003 and any succeeding fiscal year.
Section 304(b) of Public Law (Pub. L.) 106-554 provides that the
Secretary must establish a mechanism under which a statewide entity may
apply to have all of the geographic areas in the State treated as a
single geographic area for purposes of computing and applying a single
wage index, for reclassifications beginning in FY 2003. The
implementing regulations for this provision are located at Sec.
412.235.
Section 1886(d)(8)(B) of the Act permits a hospital located in a
rural county adjacent to one or more urban areas to be designated as
being located in the Metropolitan Statistical Areas (MSA) to which the
greatest number of workers in the county commute if--(1) the rural
county would otherwise be considered part of an urban area under the
standards published in the Federal Register for designating MSAs (and
for designating New England County Metropolitan Areas (NECMAs)), and
(2) if the commuting rates used in determining outlying counties (or,
for New England, similarly recognized areas) were determined on the
basis of the aggregate number of resident workers who commute to (and,
if applicable under the standards, from) the central county or counties
of all contiguous MSAs (or NECMAs). Hospitals that meet these criteria
are deemed urban for purposes of the standardized amounts and for
purposes of assigning the wage index.
On June 6, 2003, the Office of Management and Budget (OMB) issued
OMB Bulletin No. 03-04, announcing revised definitions of MSAs and new
definitions of Micropolitan Statistical Areas and Combined Statistical
Areas. The new definitions recognize 49 new Metropolitan Statistical
Areas and 565 new Micropolitan Statistical Areas, as well as
extensively revising the construct of many of the existing Metropolitan
Areas. We are in the process of evaluating these new MSA
[[Page 662]]
definitions. At this time, however, we have not adopted these revised
MSA definitions for purposes of the wage index. Therefore, references
to MSAs (and, by inference, NECMAs) in this notice refer to the MSAs
currently used for the wage index, those in place prior to the new
definitions announced in June 2003 by OMB.
II. Provisions of the Notice
Section 508(a) of the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (MPDIMA) (Pub. L. 108-173) provides that, by
January 1, 2004, the Secretary must establish by instruction or
otherwise, a process for hospitals to appeal their wage index
classification. This notice establishes that process.
A. One-Time Appeal Process Requirements
Under this process, a qualifying hospital may appeal the wage index
classification otherwise applicable to the hospital and apply for
reclassification to another area of the State in which the hospital is
located (or, at the discretion of the Secretary, to an area within a
contiguous State). Such reclassifications are applicable to discharges
occurring during the 3-year period beginning April 1, 2004 and ending
March 31, 2007.
The process requirements under section 508(a)(2) and (a)(3) of Pub.
L. 108-173 are as follows:
[sbull] A hospital must file an appeal request no later than
February 15, 2004.
[sbull] The MGCRB will consider the request of any qualifying
hospital to change its geographic classification for purposes of
determining the hospital's area wage index. The MGCRB will issue a
decision on the requests. There shall be no further administrative
review or judicial appeal of the MGCRB's decision.
[sbull] If the MGCRB determines that the hospital is a qualifying
hospital, the hospital shall be reclassified to the selected area
within the State where the hospital is located (or, at the discretion
of the Secretary, to an area within a contiguous State). The approved
reclassification will be effective for 3 years beginning with
discharges occurring on April 1, 2004.
Under section 508(c) of Pub. L. 108-173, a ``qualifying hospital''
is defined as a subsection (d) hospital (as defined in section
1886(d)(1)(B) of the Act) that--
[sbull] Does not qualify for a change in wage index classification
under paragraphs (8) or (10) of section 1886(d) of the Act on the basis
of requirements relating to distance or commuting. Current distance and
commuting criteria for individual hospitals seeking reclassification
are set forth in Sec. 412.230(b) of the regulations. Rural referral
center and sole community hospital distance requirements are at Sec.
412.230(a)(3)(ii). Generally, hospitals must demonstrate a close
proximity to the labor market area to which they are seeking
reclassification. The proximity criteria are met if--(1) for an urban
hospital the distance from the hospital to the area to which the
hospital is reclassifying is no more than 15 miles; and (2) for a rural
hospital, the distance from the hospital to the area to which the
hospital is reclassifying is no more than 35 miles (Sec.
412.230(b)(1)) or; at least 50 percent of the hospital's employees
reside in the area (Sec. 412.230(b)(2)). Rural referral centers and
sole community hospitals are required to reclassify to the urban or
another rural area closest to the hospital. (Sec. 412.230(a)(3)(ii));
and,
[sbull] Meets such other criteria, such as quality, as the
Secretary may specify by instruction or otherwise.
Section 508(b) specifies that approved requests under this process
must not affect the wage index computation for any area or any other
hospital and shall not be budget neutral. The provisions of this
section shall not affect payment for discharges occurring after the end
of the 3-year period, which ends March 31, 2007. Finally, as specified,
the total additional expenditures of this section shall not exceed $900
million.
Under Sec. 412.273(b), a hospital may terminate an approved 3-year
reclassification for purposes of the wage index within 45 days of
publication of CMS's annual notice of proposed rulemaking concerning
changes and updates to the IPPS for the fiscal year for which the
termination is to apply. That is, a hospital may terminate its wage
index reclassification during either the first, second, or third year
of that reclassification. In order to terminate a reclassification
under this one-time process, a hospital should follow the process at
Sec. 412.273(b). Terminations will be effective with discharges during
the following Federal fiscal year (beginning October 1). Hospitals
whose applications under the one-time process are approved will not be
able to terminate such a reclassification prior to October 1, 2004.
B. One-Time Appeal Process Criteria
All hospitals seeking reclassification under this one-time process
must submit an application consistent with the process described in
section II.D. of this notice. Hospitals that have submitted an
application under the routine MGCRB application process must still
submit a separate application for consideration by the MGCRB under this
process. The MGCRB must approve a request, from any subsection (d)
hospital, for geographic reclassification for purposes of wage index
under this process if both of the following criteria are met (see
section II.C. of this notice for a discussion of the rationale for the
criteria). For purposes of applying these criteria, average hourly
wages (AHW) refers to the 3-year average AHWs published in the August
1, 2003 final rule (68 FR 45345) for hospitals (Table 2) and MSAs and
rural areas (Tables 3A and 3B, respectively), as corrected in the
October 6, 2003 Federal Register (68 FR 57732). As noted above,
references to MSAs refer to the MSA definitions currently employed for
the wage index, those in place prior to OMB's announcement of revised
MSAs in June 2003. Note that both of the following criteria must be met
in all reclassifications under this process:
1. A hospital meets neither the distance requirement set forth in
Sec. 412.230(b)(1) nor the commuting requirement set forth in Sec.
412.230(b)(2) (or fails to meet Sec. 412.230(a)(3)(ii) in the case of
a rural referral center or sole community hospital) to be reclassified
into the MSA for which the request under the process established by
this notice is submitted.
2. The hospital does not otherwise qualify for reclassification
effective for discharges on or after October 1, 2004 (except in the
case of criteria 2(b) and 2(g) below), under the reclassification
process at 42 CFR part 412 subpart L, and one of the following criteria
is met:
a. The hospital is an urban hospital located in a State with fewer
than 10 people per square mile. The hospital may only reclassify under
the process established by this notice to another MSA within its State
(Based on the 2000 Census data, only urban hospitals in the States of
Montana, North Dakota, South Dakota, and Wyoming meet this criteria.)
b. The hospital is currently (for FY 2004) reclassified into
another MSA and the hospital's 3-year AHW is at least 108 percent of
the AHW of the hospitals geographically located in the MSA to which the
hospital is currently reclassified. The hospital may only reclassify
under this process to an MSA within the hospital's State that has an
area AHW nearest to, but not less than, the hospital's AHW. If there is
no such MSA, the hospital will receive a wage index calculated based
upon its own AHW. If a hospital that otherwise would be reclassified
effective for discharges on or after October 1, 2004 is approved
[[Page 663]]
for reclassification under this one-time appeal process based upon this
criterion, any other reclassifications shall be considered to have been
terminated effective for discharges on or after April 1, 2004.
c. The hospital is currently (for FY 2004) reclassified by the
MGCRB to another MSA but, upon applying to the MGCRB for FY 2005, is
ineligible for reclassification because its AHW is now less than 84
percent (but greater than 82 percent) of the AHW of the hospitals
geographically located in the MSA to which the hospital applied for
reclassification for FY 2005. The hospital may only reclassify under
this process to an MSA within its State with an FY 2004 wage index
value that is nearest to the FY 2004 wage index the hospital currently
receives.
d. The hospital was part of an urban county group reclassification
application to the MGCRB for FY 2004 or FY 2005 in accordance with
Sec. 412.234, but the application did not meet the standardized amount
criteria set forth in Sec. 412.234(c). Individual hospitals that were
part of the urban county group reclassification application may
reclassify under this process only to the MSA specified in the group
application.
e. The hospital is located in an MSA that experiences at least a 6
percent decrease in its FY 2004 wage index compared to its FY 2003 wage
index; and a hospital with an AHW at least 10 percent higher than the
MSA's AHW that reclassified into the MSA during FY 2003 has
reclassified elsewhere for FY 2004. The hospital may only reclassify
under this process to an MSA within its State with an FY 2004 area wage
index value that is nearest to what it would have received if the
hospital that previously reclassified into the MSA had continued to
reclassify into the MSA for FY 2004.
f. One of the following criteria are met:
(1) The hospital is located in an MSA that is adjacent to an MSA
(or urban county) that was reclassified under section 152 of the
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999,
Pub. L. 106-113 and the hospital's FY 2004 wage index is at least 10
percent less than the FY 2004 wage index of the adjacent MSA (or urban
county) that was reclassified under section 152 of Pub. L. 106-113.
(2) The hospital is located in an MSA that is adjacent to an MSA
identified in sections 153 or 154(a) of Pub. L. 106-113, and the
hospitals' FY 2004 wage index is at least 10 percent less than the FY
2004 wage index of the adjacent MSA identified in section 153 or 154(a)
of Pub. L. 106-113.
In both cases, the hospital may only reclassify under this process
to the adjacent MSA (or urban county) identified in the applicable
section of Pub. L. 106-113.
g. The hospital received reclassification by act of Congress that
expired on September 30, 2003. The hospital may only reclassify under
this process to the MSA to which it was reclassified by act of
Congress, unless it would not qualify to reclassify under this process
into such MSA because it fails to meet criterion 1 above. If the later
situation applies, the hospital may reclassify to another MSA in its
State, where it would meet criterion 1 above, with a FY 2004 wage index
that most closely approximates the FY 2004 wage index of the area to
which the hospital was reclassified by statute. Nothing in this
criterion shall be viewed as superseding the reclassifications extended
by section 508(f) of Pub. L. 108-173.
h. After decisions by the MGCRB based on hospitals meeting criteria
2(a) through 2(g) above, as well as our implementation of section
508(f) of Pub. L. 108-173, the MGCRB may approve a hospital to be
reclassified if the hospital's 3-year AHW is at least 106 percent of
the 3-year AHW of the hospitals geographically located in the area in
which the hospital is located. The MGCRB will reclassify a hospital
under this process to the MSA within the hospital's State (in the case
of a rural hospital, or the nearest Statewide rural area of a
contiguous State) that has an area 3-year AHW nearest to the hospital's
3-year AHW. However, to be classified to that area, the hospital's 3-
year AHW must be at least 82 percent of the 3-year AHW of the area to
which it would be reclassified. The requests submitted under this
criterion will be considered and approved by the MGCRB in rank order.
Ranking will be based on the percentage difference between the
hospital's 3-year AHW and the 3-year AHW of the area where the hospital
is geographically located. A hospital application received under
criterion 2(h) will receive a 2.5 percentage point increase in its
ranking for each of the following two criteria that are met--
(1) The hospital has either:
[sbull] By January 23, 2004, submitted performance data on any of
the 10 measures that were in the National Voluntary Hospital Reporting
Initiative on November 15, 2003 meeting the sample size specifications
of either the Joint Commission on Accreditation of Healthcare
Organizations or CMS, or
[sbull] Pledged in a form dated before December 15, 2003 to submit
such data; or
(2) The hospital is a rural hospital.
For example, an urban hospital with a 3-year AHW that is 110
percent higher than the 3-year AHW for the area where it is located
would be ranked as though its 3-year AHW were 112.5 percent if that
hospital had submitted quality data by January 23, 2004. If the
hospital were a rural hospital, it would be ranked as though its 3-year
AHW were 115 percent of its area's 3-year AHW. Hospitals applying in
accordance with criterion 2(h) will only be approved after the MGCRB
decides upon all applications meeting the criteria specified in 2(a)
through 2(g) and section 508(f) of Pub. L. 108-173.
C. Rationale for Criteria
Criteria 2(a) through 2(g) above are designed to assist categories
of hospitals that fall just beyond the current reclassification
criteria. Although we generally believe our current reclassification
process appropriately balances the requirement at section 1886(d)(3)(E)
of the Act to adjust payments to reflect the ``relative hospital wage
level in the geographic area of the hospital compared to the national
average hospital wage level'' and the provisions for geographic
reclassification at section 1886(d)(8) and (10) of the Act, section 508
of Pub. L. 108-173 was intended to address, on a one-time basis,
situations that do not meet the established criteria. Specific
rationale for each criterion follows:
a. In States with low population densities, employees are likely to
commute greater distances to work. Dispersed urban areas are therefore
more likely to compete for employees than are urban areas in more
densely populated States. We established the population density and
number of MSAs based on our analysis indicating these criteria best
captured such a Statewide urban labor market situation. We did not
include rural hospitals under this criterion because we already employ
Statewide rural labor markets.
b. This criterion recognizes that some reclassified hospitals have
an AHW much higher even than a nearby MSA into they have already
reclassified. We believe it is appropriate to provide some relief for
these situations under this one-time appeals process. Because, in some
cases, the AHW of hospitals meeting this criterion are likely to exceed
those of any labor market area within the State, we are providing under
this one-time appeal process that a hospital qualifying under this
criterion may receive a wage index based on its own
[[Page 664]]
AHW if there is no MSA AHW at least equal to the hospital's AHW.
c. This criterion recognizes anomalous situations where previously
reclassified urban hospitals would meet the lower criterion for rural
hospitals to reclassify, but, for FY 2005, fail to meet the urban
hospital wage comparability criterion.
d. This criterion recognizes situations where hospitals have been
denied reclassification because they failed to meet the standardized
amount criterion, even though the hospital would have received no
benefit from a standardized amount reclassification because section 501
of Pub. L. 108-173 eliminated the differential in the standardized
amounts.
e. This criterion would protect hospitals from the negative impact
on an MSA's wage index resulting from a hospital with a significantly
higher AHW that no longer reclassifies into the MSA. The wage index
decrease standard and the AHW difference standard are designed to focus
this criterion upon situations where the reclassification elsewhere of
a particular hospital has a truly negative impact on the MSA's wage
index.
f. This criterion would alleviate large disparities in wage indexes
resulting from statutory reclassifications. It is limited to adjacent
MSAs because these are the labor market areas most impacted by the
statutory reclassifications (that is, rather than Statewide rural labor
market areas).
g. These statutory reclassifications would have expired on
September 30, 2003 but were extended by section 508(f) of Pub. L. 108-
173 and would otherwise expire on September 30, 2004. Because of the
special circumstances of these hospitals as recognized by Congress, we
believe it is appropriate to allow them to reclassify under this one-
time appeal process. However, like other hospitals, these hospitals
must meet criterion 1 in order to be considered qualifying hospitals
under the statute. Therefore, if a hospital would not meet criterion 1
with regard to the MSA to which Congress reclassified it, then the
hospital must reclassify to another MSA in its State where it would
meet criterion 1 and with a FY 2004 wage index that most closely
approximates the FY 2004 wage index of the area to which Congress
reclassified it.
h. This criterion would permit other hospitals that are not
currently reclassified to be reclassified based upon the relationship
between their AHW and the AHW of the area where they are geographically
located. We believe it is appropriate to give priority to hospitals
whose AHW exceeds the area's AHW by the largest percentage and
demonstrate a significant disparity (that is at least 106 percent of
the AHW of the area in which they are located) between the hospital's
current AHW and the area AHW. Furthermore, rural hospitals tend to have
lower AHWs in general than urban hospitals. Therefore, we believe it is
appropriate to provide a bonus under this criterion to rural hospitals.
Finally, we believe in light of Congress' mention of the submission of
quality data in section 508(c)(2), and the importance for the future of
health care quality to have performance measures that allow the
Government to evaluate quality, it is appropriate to give preferential
treatment to hospitals that have submitted these data.
D. One-Time Appeal Request Procedure
We are providing that a hospital seeking reclassification under
section 508 of Pub. L. 108-173 must submit a request in writing by
February 15, 2004, to the MGCRB, with a copy to CMS. The request must
be mailed. Facsimile or other electronic means are not acceptable.
The request must contain the following information:
[sbull] The hospital's name and street address.
[sbull] The hospital's Medicare provider number.
[sbull] For all communications regarding the appeals request,
provide the name, title, and telephone number of a contact person.
[sbull] Name of the area/county (include the MSA/identification
number) where the hospital is located.
[sbull] Name of the area/county (refer to the criteria) where the
hospital wishes to be reclassified.
[sbull] A statement of which criterion is applicable.
A hospital's appeal request must be received by the MGCRB no later
than 5 p.m. EDT on February 15, 2004. The request must be typed or
clearly printed in ink.
Hospitals must mail or deliver an original copy of their appeal
request to the MGCRB's at the following address: Medicare Geographic
Classification Review Board, 2520 Lord Baltimore Drive, Suite L,
Baltimore, Maryland 21244-2670.
Hospitals must simultaneously send an informational copy of their
completed appeal request to the following address: Centers for Medicare
and Medicaid Services, Center for Medicare Management, Hospital and
Ambulatory Policy Group, Division of Acute Care, Attention: One-Time
Appeals Process, Mail Stop C4-08-06, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Hospitals may want to send their application by a delivery method
that guarantees a signed receipt, which indicates delivery and date of
delivery of their appeal request to the MGCRB. The MGCRB and CMS
addresses listed above are applicable for both United States mail and
courier service delivery.
III. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
[sbull] The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
[sbull] The accuracy of our estimate of the information collection
burden.
[sbull] The quality, utility, and clarity of the information to be
collected.
[sbull] Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
However, the collection requirements associated with section II.B.
of this notice are currently approved under OMB PRA approval number
0938-0573, ``Medicare Geographic Classification Review Board,'' with a
current expiration date of October 31, 2005. In addition, we believe
that any information collected subsequent to an administrative action,
such as an appeal of a geographic classification, are exempt from the
PRA as stipulated under 5 CFR 1320.4(a)(2).
Consequently, this document does not impose any new information
collection and recordkeeping requirements that would require a review
by the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 35).
IV. Waiver of the Delay in Effective Date
Section 903 of Pub. L. 108-173 amended section 1871(e)(1) of the
Act to specify that a substantive change shall not become effective
before the end of the 30-day period that begins on the date that the
Secretary has issued or published the substantive change. Section 903
of Pub. L. 108-173 also states the substantive change can take
[[Page 665]]
effect on a date that precedes the 30-day period if the Secretary finds
that waiver of this period is necessary to comply with statutory
requirements, or is contrary to the public interest. In addition, it
specifies that the issuance or publication must include a brief
statement of the reasons for such finding.
This notice meets the waiver criteria described in section
1871(e)(1)(B)(ii) of the Act, since section 508 of Pub. L. 108-173
requires the Secretary to establish a one-time appeal process by
January 1, 2004 and directs that the appeals be ``filed as soon as
possible after the date of enactment of the Act.'' In order for the
process to be established and for appeals to be filed as soon as
possible, the process must be in effect, and there can be no delay in
the effective date.
V. Regulatory Impact Statement
We have examined the impact of this rule as required by Executive
Order 12866 (September 1993, Regulatory Planning and Review), and
Executive Order 13132.
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects, distributive impacts, and equity). A regulatory impact
analysis (RIA) must be prepared for major rules with economically
significant effects ($100 million or more in any 1 year). This notice
would increase payments to hospitals by up to $900 million, and thus is
considered a major rule.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. Since this notice does not impose any costs on State or
local governments, the requirements of E.O. 13132 are not applicable.
We estimate the impact of this provision will be to increase
payments to hospitals by up to $900 million. As noted above, section
508 of Pub. L. 108-173 specifies that the aggregate amount of
additional expenditures resulting from the application of this section
shall not exceed $900 million. Section 508(f) requires that hospitals
previously reclassified by an act of Congress, but such
reclassification expired effective with discharges on or after October
1, 2003, shall have their reclassifications reinstated effective April
1, 2004 through September 30, 2004. The extra payments for these
reclassification extensions under section 508(f) are also subject to
the $900 million limit.
We estimate the increased payments under section 508(f) will total
approximately $33 million. The higher payments associated with
reclassifications under this one-time appeals process are not expected
to exceed a total of $867 million (during the 3-year period covered by
the provision).
In accordance with the provisions of Executive Order 12866, this
notice was reviewed by the Office of Management and Budget.
Authority: Section 508(a) of the Public Law 108-173.
(Catalog of Federal Domestic Assistance Program No. 93.773
Medicare--Hospital Insurance Program; and No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: December 19, 2003.
Dennis G. Smith,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: December 29, 2003.
Tommy G. Thompson,
Secretary.
[FR Doc. 03-32337 Filed 12-31-03; 2:18 pm]
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