Medicare Program; Schedule of Limits for Skilled Nursing Facility Inpatient Routine Service Costs

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]

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