44702 Federal Register / Vol. 79, No. 148 / Friday, August 1, 2014 / Rules and Regulations 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 424 

[CMS–6059–N] 

Medicare, Medicaid, and Children’s 

Health Insurance Programs: 

Announcement of the Extended 

Temporary Moratoria on Enrollment of 

Ambulance Suppliers and Home Health 

Agencies in Designated Geographic 

Locations 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Extension of temporary 

moratoria. 

SUMMARY: This document announces the 

extension of temporary moratoria on the 

enrollment of new ambulance suppliers 

and home health agencies (HHAs) in 

specific locations within designated 

metropolitan areas in Florida, Illinois, 

Michigan, Texas, Pennsylvania, and 

New Jersey to prevent and combat fraud, 

waste, and abuse. 

DATES: Effective Date: July 29, 2014. 

FOR FURTHER INFORMATION CONTACT: 

August Nemec, (410) 786–0612. 

News media representatives must 

contact CMS’ Public Affairs Office at 

(202) 690–6145 or email them at press@

cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. CMS’ Imposition of Temporary 

Enrollment Moratoria 

Section 6401(a) of the Affordable Care 

Act added a new section 1866(j)(7) to 

the Social Security Act (the Act) to 

provide the Secretary with authority to 

impose a temporary moratorium on the 

enrollment of new Medicare, Medicaid 

or CHIP providers and suppliers, 

including categories of providers and 

suppliers, if the Secretary determines a 

moratorium is necessary to prevent or 

combat fraud, waste, or abuse under 

these programs. For a more detailed 

explanation of these authorities, please 

see the July 31, 2013 notice (78 FR 

46339) or February 4, 2014 extension 

and establishment of a temporary 

moratoria document (hereinafter 

referred to as the February 4, 2014 

moratoria document) (79 FR 6475). 

Based on this authority and our 

regulations at § 424.570, we have 

implemented two phases of the 

moratoria to date. In the notice issued 

on July 31, 2013 (78 FR 46339), we 

imposed moratoria on the enrollment of 

home health agencies in Miami-Dade 

County, Florida and Cook County, 

Illinois and surrounding counties and 

on the enrollment of ground ambulance 

suppliers in the Harris County, Texas 

area and surrounding counties. Then, in 

the document published on February 4, 

2014 (79 FR 6475), we imposed 

moratoria on the enrollment of home 

health agencies in Broward County, 

Florida, Dallas County, Texas and 

Wayne County, Michigan and 

surrounding counties and on the 

enrollment of ground ambulance 

suppliers in Philadelphia, PA and 

surrounding counties. 

B. Determination of the Need for 

Extending a Moratorium 

In extending these enrollment 

moratoria, CMS considered both 

qualitative and quantitative factors 

suggesting a high risk of fraud, waste, or 

abuse. CMS relied on law enforcement’s 

longstanding experience with ongoing 

and emerging fraud trends and activities 

through civil, criminal, and 

administrative investigations and 

prosecutions. CMS’ determination of a 

high risk of fraud, waste, or abuse in 

these provider and supplier types 

within these geographic locations was 

then confirmed by CMS’ data analysis, 

which relied on factors the agency 

identified as strong indicators of risk. 

(For a more detailed explanation of this 

determination process and of these 

authorities, see the July 31, 2013 notice 

(78 FR 46339) or February 4, 2014 

moratoria document (79 FR 6475)). 

1. Consultation With Law Enforcement 

In consultation with the HHS–OIG 

and the Department of Justice (DOJ), 

CMS identified two provider and 

supplier types in nine geographic 

locations that warrant a temporary 

enrollment moratorium. For a more 

detailed discussion of this consultation 

process, see the July 31, 2013 notice (78 

FR 46339) or February 4, 2014 moratoria 

document (79 FR 6475). 

2. Beneficiary Access to Care 

Beneficiary access to care in 

Medicare, Medicaid, and CHIP is of 

critical importance to CMS and its state 

partners, and CMS carefully evaluated 

access for the target moratorium 

locations. Prior to imposing and 

extending these moratoria, CMS 

consulted with the appropriate State 

Medicaid Agencies and with the 

appropriate State Department of 

Emergency Medical Services to 

determine if the moratoria would create 

an access to care issue for Medicaid and 

CHIP beneficiaries in the targeted 

locations and surrounding counties. All 

of CMS’ state partners were supportive 

of CMS analysis and proposals, and 

together with CMS, determined that 

these moratoria will not create access to 

care issues for Medicaid or CHIP 

beneficiaries. CMS also reviewed 

Medicare data for these areas and found 

there are no current problems with 

access to HHAs or ground ambulance 

suppliers. 

3. Lifting a Temporary Moratorium 

In accordance with § 424.570(b), a 

temporary enrollment moratorium 

imposed by CMS will remain in effect 

for 6 months. (For a more detailed 

explanation of how CMS can lift a 

temporary moratorium, see the July 31, 

2013 notice (78 FR 46339) or February 

4, 2014 moratoria document (79 FR 

6475).) If CMS deems it necessary, the 

moratorium may be extended in 6- 

month increments. CMS will evaluate 

whether to extend or lift the moratorium 

before any subsequent moratorium 

periods. If one or more of the moratoria 

announced in this document are 

extended or lifted, CMS will publish a 

document to that effect in the Federal 

Register. 

Once a moratorium is lifted, the 

provider or supplier types that were 

unable to enroll because of the 

moratorium will be designated to CMS’ 

high screening level under 

§ 424.518(c)(3)(iii) and § 455.450(e)(2) 

for 6 months from the date the 

moratorium was lifted. 

II. Extension of Home Health and 

Ambulance Moratoria—Geographic 

Locations 

As noted earlier, we previously 

imposed moratoria on the enrollment of 

new HHAs in Broward county, MiamiDade and Monroe and their surrounding 

counties in Florida, the Illinois counties 

of Cook, DuPage, Kane, Lake, McHenry, 

and Will, the Michigan counties of 

Macomb, Monroe, Oakland Washtenaw, 

and Wayne and the Texas counties of 

Brazoria, Chambers, Collin, Fort Bend, 

Galveston, Dallas, Harris, Liberty, 

Denton, Ellis, Kauffman, Montgomery, 

Rockwall, Tarrant, and Waller. Further, 

we previously imposed moratoria on the 

enrollment of new ground ambulance 

suppliers in the Texas Counties of 

Brazoria, Chambers, Fort Bend, 

Galveston, Harris, Liberty, Montgomery, 

and Waller and the Pennsylvania 

counties of Bucks, Delaware, 

Montgomery; and Philadelphia and the 

New Jersey counties of Burlington, 

Camden, and Gloucester. These 

moratoria became effective upon 

publication in the Federal Register of a 

notice on July 31, 2013 (78 FR 46340) 


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Federal Register / Vol. 79, No. 148 / Friday, August 1, 2014 / Rules and Regulations 44703 

and a moratoria document on February 

4, 2014 (79 FR 6475). 

In accordance with § 424.570(b), CMS 

may deem it necessary to extend 

previously-imposed moratoria in 6- 

month increments. Under its authority 

at § 424.570(b), CMS is extending the 

temporary moratoria on the Medicare 

enrollment of HHAs and ground 

ambulance suppliers in the geographic 

locations discussed herein. Under 

regulations at § 455.470 and § 457.990, 

these moratoria also apply to the 

enrollment of HHAs and ground 

ambulance suppliers in Medicaid and 

CHIP. Under § 424.570(b), CMS is 

required to publish a document in the 

Federal Register announcing any 

extension of a moratorium, and this 

extension of moratoria document fulfills 

that requirement. 

CMS consulted with both the HHS– 

OIG and DOJ regarding the extension of 

the moratoria on new HHAs and ground 

ambulance suppliers in all of the 

moratoria counties, and both HHS–OIG 

and DOJ agree that a significant 

potential for fraud, waste, and abuse 

continues to exist in these geographic 

areas. The circumstances warranting the 

imposition of the moratoria have not yet 

abated, and CMS has determined that 

the moratoria are still needed as we 

monitor the indicators and continue 

with administrative actions such as 

payment suspensions and revocations of 

provider/supplier numbers. (For more 

information regarding the monitored 

indicators, see section I.B. of the 

February 4, 2014 moratoria document 

(79 FR 6475).) 

Based upon CMS’ consultation with 

the relevant State Medicaid Agencies, 

CMS has concluded that extending 

these moratoria will not create an access 

to care issue for Medicaid or CHIP 

beneficiaries in the affected counties at 

this time. CMS also reviewed Medicare 

data for these areas and found there are 

no current problems with access to 

HHAs or ground ambulance suppliers. 

Nevertheless, the agency will continue 

to monitor these locations to ensure that 

no access to care issues arise in the 

future. 

Based upon our consultation with law 

enforcement and consideration of the 

factors and activities described 

previously, CMS has determined that 

the temporary enrollment moratoria 

should be extended for an additional 6 

months. 

III. Summary of the Moratoria 

Locations 

CMS is executing its authority under 

sections 1866(j)(7), 1902(kk)(4), and 

2107(e)(1)(D) of the Act to extend these 

moratoria in the following counties for 

these providers and suppliers: 

TABLE 1—HHA MORATORIA

State City/metro area Counties 

FL ..... Fort Lauderdale ..... Broward. 

FL ..... Miami ..................... Monroe. 

Dade. 

IL ...... Chicago .................. Cook. 

DuPage. 

Kane. 

Lake. 

McHenry. 

Will. 

MI ..... Detroit .................... Macomb. 

Monroe. 

Oakland. 

Washtenaw. 

Wayne. 

TX ..... Dallas ..................... Collin. 

Dallas. 

Denton. 

Ellis. 

Kaufman. 

Rockwall. 

Tarrant. 

TX ..... Houston ................. Brazoria. 

Chambers. 

Fort Bend. 

Galveston. 

Harris. 

Liberty. 

Montgomery. 

Waller. 

TABLE 2—PART B AMBULANCE

MORATORIA

State City/metro area Counties 

PA/NJ Philadelphia ........... Bucks. 

Burlington 

(NJ). 

Camden (NJ). 

Delaware. 

Gloucester 

(NJ). 

Montgomery. 

Philadelphia. 

TX ..... Houston ................. Brazoria. 

Chambers. 

Fort Bend. 

Galveston. 

Harris. 

Liberty. 

Montgomery. 

Waller. 

IV. Collection of Information 

Requirements 

This document does not impose 

information collection and 

recordkeeping requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

V. Regulatory Impact Statement 

CMS has examined the impact of this 

document as required by Executive 

Order 12866 on Regulatory Planning 

and Review (September 30, 1993), 

Executive Order 13563 on Improving 

Regulation and Regulatory Review 

(January 18, 2011), the Regulatory 

Flexibility Act (RFA) (September 19, 

1980, Pub. L. 96–354), section 1102(b) of 

the Social Security Act, section 202 of 

the Unfunded Mandates Reform Act of 

1995 (March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 

direct 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 

regulatory actions with economically 

significant effects ($100 million or more 

in any 1 year). This document will 

prevent the enrollment of new home 

health providers and ambulance 

suppliers in Medicare, and new home 

health providers and ambulance 

suppliers in Medicaid and CHIP. 

Though savings may accrue by denying 

enrollments, the monetary amount 

cannot be quantified. After the 

imposition of the moratoria on July 30, 

2013, 231 HHAs and 7 ambulance 

companies in all geographic areas 

affected by the moratoria had their 

applications denied. We have found the 

number of applications that are denied 

after 60 days declines dramatically, as 

most providers and suppliers will not 

submit applications during the 

moratoria period. Therefore, this 

document does not reach the economic 

threshold and thus is not considered a 

major action. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most 

hospitals and most other providers and 

suppliers are small entities, either by 

nonprofit status or by having revenues 

of $7.0 million to $35.5 million in any 

one year. Individuals and states are not 

included in the definition of a small 

entity. CMS is not preparing an analysis 

for the RFA because it has determined, 

and the Secretary certifies, that this 

document will not have a significant 


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44704 Federal Register / Vol. 79, No. 148 / Friday, August 1, 2014 / Rules and Regulations 

economic impact on a substantial 

number of small entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if an action may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, CMS defines a small rural 

hospital as a hospital that is located 

outside of a Metropolitan Statistical 

Area for Medicare payment regulations 

and has fewer than 100 beds. CMS is not 

preparing an analysis for section 1102(b) 

of the Act because it has determined, 

and the Secretary certifies, that this 

document will not have a significant 

impact on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

regulatory action whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2014, that 

threshold is approximately $141 

million. This document will have no 

consequential effect on state, local, or 

tribal governments or on the private 

sector. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed regulatory action (and 

subsequent final action) that imposes 

substantial direct requirement costs on 

state and local governments, preempts 

state law, or otherwise has Federalism 

implications. Since this document does 

not impose any costs on state or local 

governments, the requirements of 

Executive Order 13132 are not 

applicable. 

In accordance with the provisions of 

Executive Order 12866, the Office of 

Management and Budget reviewed this 

document. 

Authority: Sections 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh) and 44 U.S.C. Chapter 35; Sec. 1103 

of the Social Security Act (42 U.S.C. 1302). 

Dated: July 2, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–18174 Filed 7–29–14; 4:15 pm] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Federal Emergency Management 

Agency 

44 CFR Part 67 

[Docket ID FEMA–2014–0002] 

Final Flood Elevation Determinations 

AGENCY: Federal Emergency 

Management Agency, DHS. 

ACTION: Final rule. 

SUMMARY: Base (1% annual-chance) 

Flood Elevations (BFEs) and modified 

BFEs are made final for the 

communities listed below. The BFEs 

and modified BFEs are the basis for the 

floodplain management measures that 

each community is required either to 

adopt or to show evidence of being 

already in effect in order to qualify or 

remain qualified for participation in the 

National Flood Insurance Program 

(NFIP). 

DATES: The date of issuance of the Flood 

Insurance Rate Map (FIRM) showing 

BFEs and modified BFEs for each 

community. This date may be obtained 

by contacting the office where the maps 

are available for inspection as indicated 

in the table below. 

ADDRESSES: The final BFEs for each 

community are available for inspection 

at the office of the Chief Executive 

Officer of each community. The 

respective addresses are listed in the 

table below. 

FOR FURTHER INFORMATION CONTACT: Luis 

Rodriguez, Chief, Engineering 

Management Branch, Federal Insurance 

and Mitigation Administration, Federal 

Emergency Management Agency, 500 C 

Street SW., Washington, DC 20472, 

(202) 646–4064, or (email) 

Luis.Rodriguez3@fema.dhs.gov. 

SUPPLEMENTARY INFORMATION: The 

Federal Emergency Management Agency 

(FEMA) makes the final determinations 

listed below for the modified BFEs for 

each community listed. These modified 

elevations have been published in 

newspapers of local circulation and 

ninety (90) days have elapsed since that 

publication. The Deputy Associate 

Administrator for Mitigation has 

resolved any appeals resulting from this 

notification. 

This final rule is issued in accordance 

with section 110 of the Flood Disaster 

Protection Act of 1973, 42 U.S.C. 4104, 

and 44 CFR part 67. FEMA has 

developed criteria for floodplain 

management in floodprone areas in 

accordance with 44 CFR part 60. 

Interested lessees and owners of real 

property are encouraged to review the 

proof Flood Insurance Study and FIRM 

available at the address cited below for 

each community. The BFEs and 

modified BFEs are made final in the 

communities listed below. Elevations at 

selected locations in each community 

are shown. 

National Environmental Policy Act. 

This final rule is categorically excluded 

from the requirements of 44 CFR part 

10, Environmental Consideration. An 

environmental impact assessment has 

not been prepared. 

Regulatory Flexibility Act. As flood 

elevation determinations are not within 

the scope of the Regulatory Flexibility 

Act, 5 U.S.C. 601–612, a regulatory 

flexibility analysis is not required. 

Regulatory Classification. This final 

rule is not a significant regulatory action 

under the criteria of section 3(f) of 

Executive Order 12866 of September 30, 

1993, Regulatory Planning and Review, 

58 FR 51735. 

Executive Order 13132, Federalism. 

This final rule involves no policies that 

have federalism implications under 

Executive Order 13132. 

Executive Order 12988, Civil Justice 

Reform. This final rule meets the 

applicable standards of Executive Order 

12988. 

List of Subjects in 44 CFR Part 67 

Administrative practice and 

procedure, Flood insurance, Reporting 

and recordkeeping requirements. 

Accordingly, 44 CFR part 67 is 

amended as follows: 

PART 67—[AMENDED] 

■ 1. The authority citation for part 67 

continues to read as follows: 

Authority: 42 U.S.C. 4001 et seq.; 

Reorganization Plan No. 3 of 1978, 3 CFR, 

1978 Comp., p. 329; E.O. 12127, 44 FR 19367, 

3 CFR, 1979 Comp., p. 376. 

§ 67.11 [Amended] 

■ 2. The tables published under the 

authority of § 67.11 are amended as 

follows: 


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