44752 Federal Register / Vol. 74, No. 167 / Monday, August 31, 2009 / Rules and Regulations 

buildings. The United States 

Department of the Treasury (Treasury) 

awards Section 1602 funds to State 

housing credit agencies in an amount 

equal to their low-income housing grant 

election amount which may not exceed 

a portion of the States’ low-income 

housing tax credit ceiling for 2009. 

Section 1602(d) of the Act requires 

that State housing credit agencies return 

to the Treasury funds not used to make 

subawards before January 1, 2011. The 

Terms and Conditions promulgated by 

the Treasury to govern the program 

require that any funds not disbursed 

before January 1, 2011, be returned to 

the Treasury. Upon further 

consideration Treasury has determined 

that this requirement is overly 

restrictive and may preclude funding of 

otherwise eligible projects that may not 

reach final completion by the end of 

2010. This rule therefore changes this 

requirement. Under this rule set forth at 

31 CFR part 32, State housing credit 

agencies are required to return to the 

Treasury any funds not used to make 

subawards by December 31, 2010. 

However, once a subaward has been 

made, a State can continue to disburse 

funds for the subaward through 

December 31, 2011, provided the project 

is at least 30 percent complete by the 

end of 2010. 

II. Procedural Analyses 

Administrative Procedures Act 

This rule is being issued without prior 

public notice and comment because 

under 5 U.S.C. 553(b) and (d)(3) good 

cause exists to determine that prior 

notice and comment rulemaking is 

unnecessary and contrary to the public 

interest. The policy being implemented 

through this rule impacts procedural 

requirements imposed on State housing 

credit agencies that receive funds from 

the Federal government under Section 

1602 and does not adversely affect the 

rights of the public. Additionally, delay 

in the effective date of this rule is 

contrary to the public interest because 

without clarity regarding the time 

period within which State housing 

credit agencies may disburse funds 

under the program, State housing credit 

agencies are unable to make decisions 

regarding which projects to fund 

thereby delaying the construction or 

rehabilitation of low-income housing. 

Request for Comment on Plain Language 

Executive Order 12866 requires each 

agency in the Executive branch to write 

regulations that are simple and easy to 

understand. We invite comment on how 

to make the interim rule clearer. For 

example, you may wish to discuss: (1) 

Whether we have organized the material 

to suit your needs; (2) whether the 

requirements of the rules are clear; or (3) 

whether there is something else we 

could do to make these rules easier to 

understand. 

Regulatory Planning and Review 

The rule is a ‘‘significant regulatory 

action’’ as defined in Executive Order 

12866. Accordingly, the rule has been 

reviewed by the Office of Management 

and Budget. 

Regulatory Flexibility Act Analysis 

Because no notice of rulemaking is 

required, the provisions of the 

Regulatory Flexibility Act (5 U.S.C. 601 

et seq.) do not apply. 

List of Subjects in 31 CFR Part 32 

Low-income housing tax credits. 

■ For the reasons set forth in the 

preamble, we add 31 CFR Part 32 to 

read as follows: 

PART 32—PAYMENTS IN LIEU OF 

LOW INCOME HOUSING TAX CREDITS 

Sec. 

32.1. Timing of disbursements. 

Authority: Public Law 111–5. 

§ 32.1 Timing of disbursements. 

(a) State housing credit agencies that 

receive funds under section 1602 of 

Division B of the American Recovery 

and Reinvestment Tax Act of 2009 must 

make subawards to subawardees to 

finance the construction or acquisition 

and rehabilitation of low-income 

housing no later than December 31, 

2010. Any funds that are not used to 

make subawards by December 31, 2010, 

must be returned to the Treasury by 

January 1, 2011. 

(b) The requirement in subsection (a) 

above does not prevent State housing 

credit agencies from continuing to 

disburse funds to subawardees after 

December 31, 2010 provided: 

(1) A subaward has been made to the 

subawardee on or before December 31, 

2010; 

(2) The subawardee has, by the close 

of 2010, paid or incurred at least 30 

percent of the subawardee’s total 

adjusted basis in land and depreciable 

property that is reasonably expected to 

be part of the low-income housing 

project; and 

(3) Any funds not disbursed to the 

subawardee by December 31, 2011, must 

be returned to the Treasury by January 

1, 2012. 

Dated: August 19, 2009. 

Gary Grippo, 

Acting Fiscal Assistant Secretary. 

[FR Doc. E9–20903 Filed 8–28–09; 8:45 am] 

BILLING CODE 4810–25–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 199 

[DoD–2008–HA–0007; RIN 0720–AB21] 

TRICARE; Reimbursement of Critical 

Access Hospitals (CAHs) 

AGENCY: Office of the Secretary, 

Department of Defense. 

ACTION: Final rule. 

SUMMARY: This rule implements the 

statutory provisions that TRICARE 

payment methods for institutional care 

be determined to the extent practicable 

in accordance with the same 

reimbursement rules as those that apply 

to payments to providers of services of 

the same type under Medicare. This 

final rule implements a reimbursement 

methodology similar to that furnished to 

Medicare beneficiaries for services 

provided by critical access hospitals 

(CAHs). 

DATES: Effective Date: This rule is 

effective December 1, 2009. 

FOR FURTHER INFORMATION CONTACT: Ms. 

Martha M. Maxey, TRICARE 

Management Activity, Medical Benefits 

and Reimbursement Branch, telephone 

(303) 676–3627. 

SUPPLEMENTARY INFORMATION: 

I. Introduction and Background 

Hospitals are authorized TRICARE 

institutional providers under 10 U.S. 

Code 1079(j)(2) and (4). Under 10 U.S.C. 

1079(j)(2), the amount to be paid to 

hospitals, skilled nursing facilities 

(SNFs), and other institutional providers 

under TRICARE, ‘‘shall be determined 

to the extent practicable in accordance 

with the same reimbursement rules as 

apply to payments to providers of 

services of the same type under 

Medicare.’’ Under 32 CFR 

199.14(a)(1)(ii)(D)(1) through (9) it 

specifically lists those hospitals that are 

exempt from the DRG-based payment 

system. CAHs are not listed as exempt, 

thereby making them subject to the 

DRG-based payment system. CAHs are 

not listed as excluded, because at the 

time this regulatory provision was 

written, CAHs were not a recognized 

entity. 

Legislation enacted as part of the 

Balanced Budget Act (BBA) of 1997 


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Federal Register / Vol. 74, No. 167 / Monday, August 31, 2009 / Rules and Regulations 44753 

authorized states to establish State 

Medicare Rural Hospital Flexibility 

Programs, under which certain facilities 

participating in Medicare could become 

CAHs. CAHs represent a separate 

provider type with their own Medicare 

conditions of participation as well as a 

separate payment method of 101 percent 

of reasonable costs. Since that time, a 

number of hospitals have taken the 

necessary steps to be designated as 

CAHs by the Centers for Medicare & 

Medicaid Services (CMS). The statutory 

authority requires TRICARE to apply the 

same reimbursement rules as apply to 

payments to providers of services of the 

same type under Medicare to the extent 

practicable. Therefore, if practicable, 

TRICARE has the requirement through 

the publication of a proposed and final 

rule to exempt critical access hospitals 

from the DRG-based payment system 

and adopt a reimbursement method 

similar to Medicare principles for these 

hospitals. 

Currently under TRICARE, with the 

exception of Alaska, CAHs are subject to 

the TRICARE DRG-based payment 

system for inpatient care. For outpatient 

care, CAHs are reimbursed based on 

billed charges for facility charges. In 

Alaska, under a demonstration project, 

CAHs are reimbursed the lesser of the 

billed charge or 101 percent of 

reasonable costs for inpatient and 

outpatient care. The 101 percent of 

reasonable costs is calculated by 

multiplying the billed charge of each 

claim by the hospital’s cost-to-charge 

(CCR) ratio, and then adding 1 percent 

to that amount. Based on the above 

statutory mandate, TRICARE is 

proposing to adopt this same 

reimbursement methodology for all 

CAHs, with one substantive change. 

TRICARE will not apply the ‘‘lesser of 

cost or charges’’ provision. We found 

approximately 15 percent of CAHs have 

inpatient CCRs of 1.0 or more and 2 

percent have outpatient CCRs greater 

than 1.0. In order to reimburse the vast 

majority of hospitals for all their costs 

in an administratively feasible manner, 

TRICARE will identify CCRs that are 

outliers using the method used by 

Medicare to identify outliers in its 

outpatient prospective payment system 

(OPPS) reimbursement methods. 

Specifically, Medicare classifies CCR 

outliers as values that fall outside of 

three standard deviations from the 

geometric mean. Applying this method 

to the CAH data, those limits will be 

considered the threshold limits on the 

CCR for reimbursement purposes. 

II. Public Comments 

The TRICARE Reimbursement of 

CAHs proposed rule (73 FR 17271) was 

published on May 5, 2008, providing a 

30-day public comment period. Five 

timely items of correspondence were 

received containing multiple comments 

on the proposed rule which resulted in 

one substantive change in TRICARE’s 

reasonable cost methodology, (i.e., 

removal of the lesser of cost or charges 

provision). 

Following is a summary of the public 

comments and our responses: 

Comment: Several commenters 

requested DoD adopt the exact Medicare 

CAH payment methodology of 101 

percent of their allowable and 

reasonable costs, not being subject to the 

‘‘lesser of cost or charges’’ reasonablecost principle. To comply with the 

statutory requirement regarding hospital 

reimbursement, these commenters urge 

the Secretary to adopt Medicare’s exact 

methodology for determining CAH 

reimbursement for inpatient and 

outpatient care. 

Response: Based on the comments 

received, TRICARE is removing the 

‘‘lesser of cost or charges’’ provision 

from its final rule. We found that 

approximately 15 percent of CAHs have 

inpatient CCRs of 1.0 or more but that 

only 2 percent of CAHs have outpatient 

CCRs greater than 1.0. In order to 

reimburse the vast majority of hospitals 

for all their costs in an administratively 

feasible manner, TRICARE will identify 

CCRs that are outliers using the method 

used by Medicare to identify outliers in 

its OPPS reimbursement methods. 

Specifically, Medicare classifies CCR 

outliers as values that fall outside of 

three standard deviations from the 

geometric mean. Applying this method 

to the CAH data, those limits will be 

considered the threshold limits on the 

CCR for reimbursement purposes. For 

FY09, this calculation resulted in an 

inpatient CCR cap of 2.12 and 

outpatient CCR cap of 1.23; these will be 

re-calculated each year with the CCR 

update. Thus, for FY09, TRICARE will 

pay the lesser of 2.12 × billed charges or 

101 percent of costs (using the hospital’s 

CCR and billed charges) for inpatient 

services and the lesser of 1.23 × billed 

charges or 101 percent of costs for 

outpatient services. We believe this 

approach captures the bulk of CAHs’ 

costs. 

Comment: Several commenters state 

the proposed rule fails to address 

interim payments and cost settlement. 

Medicare may make interim payments 

to CAHs during a fiscal year based on 

costs generally estimated from a prior 

year’s cost report. After a fiscal year 

ends, Medicare reaches a ‘‘settlement’’ 

with CAHs to align payment with actual 

costs, which may be higher or lower 

than estimated. If interim payments 

were lower than actual costs, Medicare 

pays the CAH the difference; if 

payments were higher, the CAH repays 

Medicare. Therefore, both interim 

payments and cost settlement help 

ensure that CAHs are reimbursed in a 

timely manner at the appropriate level. 

Without such mechanisms, hospitals 

could endure a significant amount of 

uncertainty about whether they will be 

able to cover their costs, which may 

affect their ability to provide quality 

patient care. These commenter’s urge 

the Secretary to make interim payments 

to and reach cost settlement with CAHs 

and to do so in the same manner as 

Medicare. 

Response: Since TRICARE is a 

relatively small payer, and hospitals do 

not file cost reports with TRICARE, it is 

not administratively feasible for 

TRICARE to issue interim payments or 

conduct retroactive cost settlements. 

TRICARE will be using historical data to 

pay claims, i.e., we are using FY 2006 

cost report data to calculate CCRs to 

process and pay claims for services 

provided in 2009. We acknowledge the 

data is a few years old, and some 

hospitals will be paid a little more one 

year and a little less another year, but 

over time we believe that the payments 

will be roughly equal to the hospital’s 

costs. TRICARE does not need to make 

interim payments because hospitals will 

be paid as each claim is processed 

(using the CCR approach). Due to 

varying fiscal year end dates, database 

development by CMS, etc., it is not 

possible to use more recent data. 

We have analyzed the impact of the 

rule on CAHs that have a high 

percentage of their discharges for 

TRICARE patients. We examined all the 

CAHs that served TRICARE patients in 

October 2008–March 2009 period and 

found that 11 CAHs had 5 percent or 

more of their discharges from TRICARE. 

We then calculated the change in 

TRICARE payments that would occur 

due to this rule. We found that the 

impact was under $1,000 for two of 

these hospitals, indicating that the rule 

would have a significant impact on only 

9 of the 11 hospitals. For these 9 

hospitals, we calculated the change in 

TRICARE payments relative to 

estimated total hospital revenues and 

found that 3 would have had slight 

declines in overall hospital revenues 

due to the rule and that 6 would have 

had increases. The range of change in 

total hospital revenues was from ¥2.4 

percent to +9.1 percent. The median 

change in total hospital revenues was 

estimated to be an increase of 2.9 

percent and the average was an increase 

of 3.2 percent. 


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44754 Federal Register / Vol. 74, No. 167 / Monday, August 31, 2009 / Rules and Regulations 

Comment: One commenter urges DoD 

to conduct a thorough review of the 

Alaska demonstration project— 

including contacting each of the twelve 

CAHs that are licensed in Alaska to 

discuss any difficulties experienced 

under the demonstration. 

Response: The opportunity to provide 

comments on the proposed 

reimbursement methodology for CAHs, 

currently being tested in Alaska, was 

provided through the publication of the 

proposed rule. We did receive one item 

of correspondence from one of the 

Health Systems in Alaska and their 

comments are addressed in this final 

rule. In addition, over the course of the 

demonstration, we have been contacted 

by some of the CAHs participating in 

the demonstration and have worked 

with them directly to resolve any 

problems. 

Comment: One commenter urged DoD 

to establish an election option regarding 

payment for outpatient services that is 

identical to established Medicare 

regulations found at 42 CFR Section 

413.70(b)(3). The change would also 

align the TRICARE reimbursement 

methodology in the proposed rule with 

Medicare reimbursement principles as 

required under the statute. 

Response: The statutory provision in 

10 United States Code 1079(j)(2) states 

that TRICARE payment methods for 

institutional care shall be determined to 

the extent practicable in accordance 

with the same reimbursement rules as 

those that apply to payments to 

providers of services of the same type 

under Medicare. While it is practicable 

to adopt a similar payment methodology 

to Medicare’s to pay CAHs 101 percent 

of reasonable costs, it is not practicable 

for TRICARE to implement an election 

option identical to Medicare due to the 

complexity of identifying what each 

hospital has elected and keeping up 

with the changes in the elections and 

implementing special claims processing 

procedures to accommodate these 

elections. TRICARE is not equipped to 

handle these types of elections. 

Comment: One commenter states that 

while the policy should be 

automatically effective on a prospective 

basis, the Secretary should allow CAHs 

the option to request retroactive 

reimbursement for all previous years for 

which they were classified as CAHs. 

Response: TRICARE does not have the 

regulatory authority to allow retroactive 

reimbursement prior to the effective 

date of the new reimbursement 

methodology for CAHs. 

Comment: One commenter requests 

TRICARE clarify in the final rule how 

the CAH reimbursement methodology 

will be implemented. They state the 

proposed rule was not specific and left 

many questions unanswered such as: 

• How will facility specific cost to 

charge ratios be computed? 

• What data elements will be used 

from the Medicare cost report? 

• How often will rates be determined? 

• When will rates be updated? 

• Will there be retroactive settlements 

if rates are changed mid-year after the 

filing of the prior year’s Medicare cost 

report? 

• Will there be retroactive settlements 

after the year’s Medicare cost report is 

audited and final settled? 

• Will there be any retroactive 

settlements or is the entire payment 

system prospective? 

Response: There are ongoing changes 

to the Medicare cost report; therefore, 

we think it is more appropriate to 

include the method for calculating the 

CCRs and the data elements used from 

the Medicare cost report in the Critical 

Access Hospital policy in Chapter 15, 

Section 1 of the TRICARE 

Reimbursement Manual (TRM). The 

TRM can be accessed at http:// 

manuals.tricare.osd.mil/. The rates will 

be calculated and updated on a yearly 

basis. As stated above, TRICARE will 

not conduct any retroactive settlements. 

Comment: Several commenters state 

that for many CAHs, their TRICARE 

patient volume is small enough that 

setting rates on a prospective basis 

updated once per year will be sufficient 

to ensure reasonable reimbursement. 

However, for those CAHs that have a 

higher TRICARE patient volume, they 

suggest a process be established where 

CAHs on their own initiative, may 

request a retroactive settlement after the 

end of a cost reporting period, by 

providing TRICARE with a copy of their 

Medicare cost report. A short 

computation form, similar to the current 

capital reimbursement form, could be 

developed to compute such a retroactive 

settlement. 

Response: We agree with the 

commenter’s first statement. In addition, 

we believe our revised approach on 

removing the ‘‘lesser of cost or charges’’ 

provision from the final rule will ease 

hospitals concerns about receiving 

reasonable reimbursement. As stated 

above, we have analyzed the impact of 

the rule on CAHs that have a high 

percentage of their discharges for 

TRICARE patients and for the period 

October 2008—March 2009 we found 

that 11 of approximately 1275 CAHs 

had 5 percent or more of their 

discharges from TRICARE. Of the 11, 

the impact was under $1,000 for two of 

the hospitals. For the remaining 9 

hospitals, we calculated the change in 

TRICARE payments relative to 

estimated total hospital revenues and 

found that 3 would have had slight 

declines in overall hospital revenues 

due to the rule and that 6 would have 

had increases. The range of change in 

total hospital revenues was from ¥2.4 

percent to +9.1 percent. The median 

change in total hospital revenues was 

estimated to be an increase of 2.9 

percent and the average was an increase 

of 3.2 percent. As stated above, 

TRICARE will be using historical data to 

pay claims and over time we believe 

that the payments will reimburse the 

vast majority of hospitals for all their 

costs. 

III. Regulatory Procedures 

Executive Order 12866, ‘‘Regulatory 

Planning and Review’’ 

Section 801 of Title 5, U.S.C., and 

Executive Order (E.O.) 12866 requires 

certain regulatory assessments and 

procedures for any major rule or 

significant regulatory action, defined as 

one that would result in an annual effect 

of $100 million or more on the national 

economy or which would have other 

substantial impacts. It has been certified 

that this rule is not an economically 

significant rule; however, it is a 

regulatory action which has been 

reviewed by the Office of Management 

and Budget as required under the 

provisions of E.O. 12866. 

Sec. 202, Public Law 104–4, ‘‘Unfunded 

Mandates Reform Act’’ 

It has been certified that this rule does 

not contain a Federal mandate that may 

result in the expenditure by State, local 

and tribal governments, in aggregate, or 

by the private sector, of $100 million or 

more in any one year. 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (5 U.S.C. 601) 

The Regulatory Flexibility Act (RFA) 

requires each Federal agency prepare, 

and make available for public comment, 

a regulatory flexibility analysis when 

the agency issues a regulation which 

would have a significant impact on a 

substantial number of small entities. 

This rule will not significantly affect a 

substantial number of small entities. 

Public Law 96–511, ‘‘Paperwork 

Reduction Act’’ (44 U.S.C. Chapter 35) 

This rule will not impose any 

additional information collection 

requirements on the public under the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 3501–3511). Existing information 

collection requirements of the 

TRICARE, cleared under OMB Control 

Number 0720–0013, and Medicare 

programs will be utilized. 


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Federal Register / Vol. 74, No. 167 / Monday, August 31, 2009 / Rules and Regulations 44755 

Executive Order 13132, ‘‘Federalism’’ 

This rule has been examined for its 

impact under E.O. 13132. It does not 

contain policies that have federalism 

implications that would have 

substantial direct effects on the States, 

on the relationship between the national 

Government and the States, or on the 

distribution of power and 

responsibilities among the various 

levels of government; therefore, 

consultation with State and local 

officials is not required. 

List of Subjects in 32 CFR Part 199 

Claims, Dental health, Health care, 

Health insurance, Individuals with 

disabilities, Military personnel. 

■ Accordingly, 32 CFR Part 199 is 

amended as follows: 

PART 199—[AMENDED] 

■ 1. The authority citation for Part 199 

continues to read as follows: 

Authority: 5 U.S.C. 301; 10 U.S.C. Chapter 

55. 

■ 2. In § 199.2, paragraph (b) is amended 

by adding a definition for ‘‘CAHs’’ in 

alphabetical order to read as follows: 

§ 199.2 Definitions. 

* * * * * 

(b) * * * 

CAHs. A small facility that provides 

limited inpatient and outpatient 

hospital services primarily in rural areas 

and meets the applicable requirements 

established by § 199.6(b)(4)(xvi). 

* * * * * 

■ 3. Section 199.6 is amended by adding 

new paragraph (b)(4)(xvi). 

§ 199.6 TRICARE—authorized providers. 

(b) * * * 

(4) * * * 

(xvi) CAHs. CAHs must meet all 

conditions of participation under 42 

CFR 485.601 through 485.645 in relation 

to TRICARE beneficiaries in order to 

receive payment under the TRICARE 

program. If a CAH provides inpatient 

psychiatric services or inpatient 

rehabilitation services in a distinct part 

unit, these distinct part units must meet 

the conditions of participation in 42 

CFR 485.647, with the exception of 

being paid under the inpatient 

prospective payment system for 

psychiatric facilities as specified in 42 

CFR 412.1(a)(2) or the inpatient 

prospective payment system for 

rehabilitation hospitals or rehabilitation 

units as specified in 42 CFR 412(a)(3). 

* * * * * 

■ 4. Section 199.14 is amended by: 

■ a. Redesignating paragraphs (a)(3) 

through (a)(5) as (a)(4) through (a)(6), 

respectively; 

■ b. Revising newly redesignated 

paragraph (a)(4) introductory text and 

the first sentence of paragraph (d)(1); 

and 

■ c. Adding new paragraphs 

(a)(1)(ii)(D)(10), (a)(3), and (a)(6)(iii) and 

(iv). 

The revisions and additions read as 

follows: 

§ 199.14 Provider reimbursement 

methods. 

(a) * * * 

(1) * * * 

(ii) * * * 

(D) * * * 

(10) CAHs. Effective December 1, 

2009, any facility which has been 

designated and certified as a CAH as 

contained in 42 CFR Part 485.606 is 

exempt from the CHAMPUS DRG-based 

payment system. 

* * * * * 

(3) Reimbursement for inpatient 

services provided by a CAH. For 

admissions on or after December 1, 

2009, inpatient services provided by a 

CAH, other than services provided in 

psychiatric and rehabilitation distinct 

part units, shall be reimbursed at 101 

percent of reasonable cost. This does not 

include any costs of physician services 

or other professional services provided 

to CAH inpatients. Inpatient services 

provided in psychiatric distinct part 

units would be subject to the 

CHAMPUS mental health per diem 

payment system. Inpatient services 

provided in rehabilitation distinct part 

units would be subject to billed charges 

or set rates. 

(4) Billed charges and set rates. The 

allowable costs for authorized care in all 

hospitals not subject to the CHAMPUS 

Diagnosis Related Group-based payment 

system, the CHAMPUS mental health 

per diem system, or the reasonable cost 

method for CAHs, shall be determined 

on the basis of billed charges or set 

rates. Under this procedure the 

allowable costs may not exceed the 

lower of: 

* * * * * 

(6) * * * 

(iii) Outpatient Services Subject to 

CAH Reasonable Cost Method. For 

services on or after December 1, 2009, 

outpatient services provided by a CAH, 

shall be reimbursed at 101 percent of 

reasonable cost. This does not include 

any costs of physician services or other 

professional services provided to CAH 

outpatients. 

(iv) CAH Ambulance Services. 

Effective for services provided on or 

after December 1, 2009, payment for 

ambulance services furnished by a CAH 

or an entity that is owned and operated 

by a CAH is the reasonable costs of the 

CAH or the entity in furnishing those 

services, but only if the CAH or the 

entity is the only provider or supplier of 

ambulance services located within a 35- 

mile drive of the CAH or the entity as 

specified under 42 CFR part 

413.70(b)(5)(ii). 

* * * * * 

(d) * * * 

(1) In general. CHAMPUS pays 

institutional facility costs for 

ambulatory surgery on the basis of 

prospectively determined amounts, as 

provided in this paragraph, with the 

exception of ambulatory surgery 

procedures performed in hospital 

outpatient departments or in CAHs, 

which are to be reimbursed in 

accordance with the provisions of 

paragraph (a)(6)(ii) or (a)(6)(iii) 

respectively, of this section. * * * 

* * * * * 

Dated: August 21, 2009. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. E9–20682 Filed 8–28–09; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Coast Guard 

33 CFR Part 165 

[Docket No. USCG–2009–0646] 

RIN 1625–AA00 

Safety Zone; Upper Mississippi River, 

Mile 427.2 to 427.6, Keithsburg, IL 

AGENCY: Coast Guard, DHS. 

ACTION: Temporary final rule. 

SUMMARY: The Coast Guard is 

establishing a temporary safety zone for 

all waters of the Upper Mississippi 

River, mile 427.2 to 427.6, extending the 

entire width of the river near 

Keithsburg, Illinois. This safety zone is 

needed to protect persons and vessels 

from safety hazards associated with a 

fireworks display occurring over a 

portion of the Upper Mississippi River. 

Entry into this zone is prohibited unless 

specifically authorized by the Captain of 

the Port Upper Mississippi River or a 

designated representative. 

DATES: This rule is effective from 8 p.m. 

until 10:30 p.m. CDT on September 5, 

2009. 

ADDRESSES: Documents indicated in this 

preamble as being available in the 


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