Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 9629 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 411, 412, 416, 419, 422, 

423, and 424 

[CMS–1613–CN] 

RIN 0938–AS15 

Medicare and Medicaid Programs: 

Hospital Outpatient Prospective 

Payment and Ambulatory Surgical 

Center Payment Systems and Quality 

Reporting Programs; Physician-Owned 

Hospitals: Data Sources for Expansion 

Exception; Physician Certification of 

Inpatient Hospital Services; Medicare 

Advantage Organizations and Part D 

Sponsors: CMS-Identified 

Overpayments Associated With 

Submitted Payment Data; Corrections 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Correction of final rule. 

SUMMARY: This document corrects 

technical errors that appeared in the 

final rule with comment period 

published in the Federal Register on 

November 10, 2014, entitled ‘‘Medicare 

and Medicaid Programs: Hospital 

Outpatient Prospective Payment and 

Ambulatory Surgical Center Payment 

Systems and Quality Reporting 

Programs; Physician-Owned Hospitals: 

Data Sources for Expansion Exception; 

Physician Certification of Inpatient 

Hospital Services; Medicare Advantage 

Organizations and Part D Sponsors: 

CMS-Identified Overpayments 

Associated with Submitted Payment 

Data.’’ 

DATES: Effective Date: This document is 

effective February 24, 2015. 

Applicability Date: The corrections 

noted in this document and posted on 

the CMS Web site are applicable to 

payments for services furnished on or 

after January 1, 2015. 

FOR FURTHER INFORMATION CONTACT: 

David Rice, (410) 786–6004, hospital 

outpatient prospective payment system 

(OPPS) issues. 

Esther Markowitz, (410) 786–4595, 

ambulatory surgical center (ASC) 

payment issues. 

Marjorie Baldo, (410) 786–4617, OPPS 

issues related to status indicators (SI) 

and ambulatory payment classification 

(APC) changes. 

SUPPLEMENTARY INFORMATION: 

I. Background 

In FR Doc. 2014–26146 of November 

10, 2014 (79 FR 66770) (hereinafter 

referred to as the CY 2015 OPPS/ASC 

final rule with comment period), there 

were a number of technical errors that 

are discussed in the Summary of Errors, 

and further identified and corrected in 

the Correction of Errors section below. 

The provisions in this correction notice 

are applicable to payments for services 

furnished on or after January 1, 2015, 

and, therefore, are treated as if they had 

been included in the CY 2015 OPPS/ 

ASC final rule with comment period (79 

FR 66770) appearing in the November 

10, 2014 Federal Register. 

II. Summary of Errors and Corrections 

Posted on the CMS Web site 

A. Hospital Outpatient Prospective 

Payment System (OPPS) Corrections 

In the CY 2015 OPPS/ASC final rule 

with comment period, for the OPPS 

cancer hospital payment adjustment (79 

FR 66831 through 66832), we finalized 

a target payment-to-cost ratio (PCR) of 

0.89. This target PCR is equal to the 

weighted average PCR for the other 

OPPS hospitals included in this dataset 

(see 79 FR 66832 for more details on the 

hospitals included in this dataset). 

Under our longstanding policy, outlier 

payments are included in the 

calculation of the weighted average PCR 

(or ‘‘target PCR’’) for these hospitals. We 

have since determined that some outlier 

payments were not included in the cost 

report data we used to calculate the 

target PCR. We have corrected this error 

and included these outlier payments in 

the target PCR calculation, which results 

in a target PCR equal to 0.90 for each 

cancer hospital. 

In addition to identifying the error in 

calculating the target PCR because of 

missing outlier payments, we 

determined that certain outlier 

payments were similarly not included 

in our calculations for estimated cancer 

hospital PCRs. We have now corrected 

this error and included these outlier 

payments in determining the estimated 

cancer hospital PCRs. As a result of 

correcting these two technical errors, 

the estimated total cancer hospital 

payment adjustments, which are based 

on the difference between estimated 

cancer hospital PCRs and the target PCR 

is also being corrected in this notice. 

The revisions to the target PCR and 

estimated cancer hospital PCRs have 

decreased our estimate of total cancer 

hospital payment adjustments by $18.6 

million. 

OPPS cancer hospital payment 

adjustment payments are budget 

neutral; therefore, we are updating the 

budget neutrality adjustment to the 

OPPS conversion factor for the 

differential in estimated total cancer 

hospital payment adjustments of $18.6 

million. This additional $18.6 million 

increases the conversion factor from 

$74.144 to $74.173, which will slightly 

increase payment rates for most 

ambulatory payment classifications 

(APCs). These revised APC payment 

rates are reflected in the attached 

Addenda. 

We are also making technical 

corrections to certain healthcare 

common procedure coding system 

(HCPCS) codes that appeared in Table 

36—HCPCS Codes to Which the CY 

2015 Drug-Specific Packaging 

Determination Methodology Applies (79 

FR 66889). Specifically, we are 

correcting the CY 2015 OPPS status 

indicators (SI) for HCPCS codes J1070, 

J1080, J2271, J3120, and J3130 from ‘‘N’’ 

to ‘‘D’’ to accurately indicate that these 

codes were deleted on December 31, 

2014, and should not have appeared in 

Table 36. These codes were correctly 

assigned to OPPS SI ‘‘D’’ in the OPPS 

Addendum B that was released with the 

CY 2015 OPPS/ASC final rule. In 

addition, HCPCS codes J1440 and J1441 

were deleted on December 31, 2013, and 

should not have appeared in Table 36. 

HCPCS codes J1440 and J1441 were not 

listed in the OPPS Addendum B that 

was released with the CY 2015 OPPS/ 

ASC final rule. 

Also, in Addendum B of the CY 2015 

OPPS/ASC final rule with comment 

period, HCPCS code J7180 (Factor xiii 

anti-hem factor) was incorrectly 

assigned a status indicator ‘‘N’’. Because 

HCPCS code J7180 is a separately 

payable drug, we have corrected this 

error and assigned status indicator ‘‘K’’ 

and APC 1416. This correction is 

included in the revised OPPS 

Addendum B which is posted to the 

CMS Web site at http://www.cms.gov/

Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/

Hospital-Outpatient-Regulations-andNotices.html. 

B. Ambulatory Surgical Center (ASC) 

Payment System Corrections 

ASC payment rates are based on the 

OPPS relative payment weights for the 

majority of covered surgical procedures 

and covered ancillary services. For some 

items, such as device-intensive 

procedures, the ASC payment rates also 

take into account the OPPS conversion 

factor and payment rates. Therefore, 

corrections to the CY 2015 OPPS 

conversion factor and payment rates 

affect the CY 2015 ASC payment rates. 

To account for geographic wage 

variation, individual ASC payments are 

adjusted by applying the pre-floor and 

pre-reclassified inpatient prospective 

payment system (IPPS) hospital wage 


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9630 Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 

indexes to the labor-related share, 

which is 50 percent of the ASC payment 

amount. In other words, the wage index 

for an ASC is the pre-floor and prereclassified IPPS hospital wage index of 

the CBSA that maps to the CBSA where 

the ASC is located. The FY 2015 IPPS 

hospital wage indexes reflect new Office 

of Management and Budget (OMB) labor 

market area delineations; therefore, the 

CY 2015 final ASC wage indexes reflect 

the new OMB delineations. However, as 

described in the CY 2015 OPPS/ASC 

final rule (79 FR 66935 through 66937), 

we finalized a policy to apply a one-year 

blended wage index for all ASCs that 

will experience any decrease in their 

actual wage index exclusively due to the 

implementation of the new OMB 

delineations. Specifically, for ASCs 

where the CY 2015 ASC wage index 

with the CY 2015 Core-Based Statistical 

Areas (CBSAs) is lower than with the 

CY 2014 CBSAs, the CY 2015 ASC wage 

index is 50 percent of the ASC wage 

index based on the CY 2014 CBSA and 

50 percent of the ASC wage index based 

on the new CY 2015 CBSA. We have 

since determined that the transitional 

wage index for CY 2015 was calculated 

incorrectly. We have now recalculated 

the CY 2015 ASC wage index per the 

policy finalized in the CY 2015 OPPS/ 

ASC final rule with comment period. 

Due to these corrections, the final CY 

2015 ASC wage index budget neutrality 

adjustment changes from 0.9998, as 

originally published (79 FR 66939 and 

67023), to 0.9995. Using the final 

corrected wage index budget neutrality 

adjustment, the final CY 2015 ASC 

conversion factor changes from $44.071, 

as originally published (79 FR 66939, 

66940, and 67023), to $44.058. The final 

CY 2015 ASC conversion factor for 

ASCs that do not meet the requirements 

of the ASC Quality Reporting Program 

changes from $43.202, as originally 

published (79 FR 66939), to $43.189. 

The final CY 2015 ASC rates and 

indicators for certain office-based 

covered surgical procedures and certain 

covered ancillary services were 

impacted due to corrections to the final 

CY 2015 Medicare Physician Fee 

Schedule (MPFS) rates. We note that we 

expect to issue the CY 2015 MPFS 

corrections in a separate Federal 

Register document in the near future. 

For covered office-based surgical 

procedures, covered ancillary radiology 

services (except certain nuclear 

medicine procedures and radiology 

procedures that use contrast agents), 

and certain covered ancillary diagnostic 

tests, the payment rate is the lower of 

the amount calculated using the ASC 

standard ratesetting methodology and 

the MPFS nonfacility practice expense 

relative value unit-based amount 

effective January 1, 2015. The 

corrections discussed in the MPFS 

correcting document affected some of 

the final payment indicators and rates 

for these covered surgical procedures 

and covered ancillary services. As such, 

we have corrected these payment 

indicators and rates based upon the 

MPFS corrections discussed in the 

MPFS correcting document. As stated in 

the preamble and addenda to the CY 

2015 OPPS/ASC final rule with 

comment period (79 FR 66922, 66923, 

66931, 66934, and 66939), the ASC 

payment indicators and rates do not 

include the effect of the negative update 

to the MPFS payment rates effective 

April 1, 2015 under current law. 

Updates to the ASC rates and payment 

indicators effective April 1, 2015 will be 

included in the April 2015 quarterly 

ASC addenda posted on the CMS Web 

site. 

C. Summary of Errors and Corrections to 

the OPPS and ASC Addenda Posted on 

the CMS Web site 

1. OPPS Addenda Posted on the CMS 

Web site 

We are making several minor 

technical corrections to the OPPS 

addenda. First, as a result of the cancer 

hospital payment adjustment correction 

and subsequent budget neutrality 

adjustment corrections, we have 

updated Addenda A, B, and C to reflect 

corrected APC payment rates. 

Secondly, CPT codes 88342, 88344, 

and 88366, were incorrectly assigned to 

OPPS SI ‘‘E’’ and ‘‘N’’. Because these 

services may be separately payable in 

certain instances, we have corrected this 

error. Specifically, we are correcting the 

OPPS SI and APC assignments for CPT 

code 88342 to ‘‘Q1’’ and APC 0433; for 

CPT code 88344 to ‘‘Q1’’ and APC 0433; 

and for CPT code 88366 to ‘‘Q1’’ and 

APC 0342. We have updated OPPS 

Addendum B to reflect these corrected 

SIs. 

Further, the 24 codes listed below 

were assigned to incorrect OPPS SIs. 

The correct OPPS SIs are listed in the 

table below. Because these changes were 

too late to include in the January 2015 

Integrated Outpatient Code Editor 

(IOCE), they will be included in the 

April 2015 IOCE update retroactive to 

January 1, 2015. 

HCPCS code Short descriptor CY 2015 

OPPS SI 

CY 2015 

OPPS APC 

0356T .......... Insrt drug device for iop ................................................................................................................. Q1 0698 

86592 .......... Syphilis test non-trep qual ............................................................................................................. A ........................

86593 .......... Syphilis test non-trep quant ........................................................................................................... A ........................

86631 .......... Chlamydia antibody ........................................................................................................................ A ........................

86632 .......... Chlamydia igm antibody ................................................................................................................. A ........................

86780 .......... Treponema pallidum ...................................................................................................................... A ........................

87110 .......... Chlamydia culture .......................................................................................................................... A ........................

87270 .......... Chlamydia trachomatis ag if .......................................................................................................... A ........................

87320 .......... Chylmd trach ag eia ....................................................................................................................... A ........................

87341 .......... Hepatitis b surface ag eia .............................................................................................................. A ........................

87490 .......... Chylmd trach dna dir probe ........................................................................................................... A ........................

87491 .......... Chylmd trach dna amp probe ........................................................................................................ A ........................

87590 .......... N.gonorrhoeae dna dir prob ........................................................................................................... A ........................

87591 .......... N.gonorrhoeae dna amp prob ........................................................................................................ A ........................

87800 .......... Detect agnt mult dna direc ............................................................................................................. A ........................

87810 .......... Chylmd trach assay w/optic ........................................................................................................... A ........................

87850 .......... N. gonorrhoeae assay w/optic ....................................................................................................... A ........................

88380 .......... Microdissection laser ...................................................................................................................... N ........................

88381 .......... Microdissection manual .................................................................................................................. N ........................

88387 .......... Tiss exam molecular study ............................................................................................................ N ........................

93895 .......... Carotid intima atheroma eval ......................................................................................................... E ........................

G0461 ......... Immunohisto/cyto chem 1st st ....................................................................................................... D ........................

G0462 ......... Immunohisto/cyto chem add .......................................................................................................... D ........................

V2760 .......... Scratch resistant coating ................................................................................................................ E ........................


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Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 9631 

HCPCS code Short descriptor CY 2015 

OPPS SI 

CY 2015 

OPPS APC 

V2762 .......... Polarization, any lens ..................................................................................................................... E ........................

V2786 .......... Occupational multifocal lens .......................................................................................................... E ........................

V2797 .......... Vis item/svc in other code .............................................................................................................. E ........................

We are correcting the OPPS SI for CPT 

code 0356T to ‘‘Q1’’ since this is the SI 

assigned to APC 0698. In addition, we 

are correcting the OPPS SI for CPT 

codes 86592 through 87850 to ‘‘A’’ to 

indicate that these preventive services 

are paid separately in another Medicare 

payment system other than the OPPS. 

Further, we are correcting the OPPS SI 

for CPT codes 88380, 88381, and 88387 

to ‘‘N’’ to indicate that these services are 

packaged. We are also correcting the 

OPPS SI for CPT code 93895 to ‘‘E’’ to 

indicate that this service is non-covered. 

We are correcting the OPPS SI for 

HCPCS codes G0461 and G0462 to ‘‘D’’ 

to indicate that these codes were deleted 

on December 31, 2014. Also, we are 

correcting the OPPS SI for HCPCS codes 

V2760, V2762, V2786, and V2797 to ‘‘E’’ 

to indicate that these items are noncovered under the OPPS. 

To view the corrected CY 2015 OPPS 

payment rates that result from these 

technical corrections, we refer readers to 

the Addenda and supporting files that 

are posted on the CMS Web site at: 

http://www.cms.gov/Medicare/

Medicare-Fee-for-Service-Payment/

HospitalOutpatientPPS/index.html. 

Select ‘‘CMS–1613–CN’’ from the list of 

regulations. All corrected Addenda for 

this correcting document are contained 

in the zipped folder titled ‘‘2015 OPPS 

Final Rule Addenda’’ at the bottom of 

the page for CMS–1613–CN. 

2. Ambulatory Surgical Center (ASC) 

Payment System Addenda Posted on the 

CMS Web site 

As a result of the technical corrections 

described in Section II.B. and IV. of this 

correction notice, we have updated 

Addenda AA and BB to reflect the final 

corrected payment rates and indicators 

for CY 2015 for ASC covered surgical 

procedures and covered ancillary 

services. To view the corrected final CY 

2015 ASC payment rates and indicators 

that result from these technical 

corrections, we refer readers to the 

Addenda and supporting files that are 

posted on the CMS Web site at: http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/ASCPayment/ASCRegulations-and-Notices.html. Select 

‘‘CMS–1613–CN’’ from the list of 

regulations. All corrected ASC addenda 

for this correcting document are 

contained in the zipped folder entitled 

‘‘Addendum AA, BB, DD1, DD2, and 

EE’’ at the bottom of the page for CMS– 

1613–CN. The corrected final CY 2015 

ASC wage index file and updated public 

use files are also posted on this Web 

page. 

III. Waiver of Proposed Rulemaking, 

60-Day Comment Period, and Delay of 

Effective Date 

Under 5 U.S.C. 553(b) of the 

Administrative Procedure Act (APA), 

the agency is required to publish a 

notice of the proposed rule in the 

Federal Register before the provisions 

of a rule take effect. Similarly, section 

1871(b)(1) of the Act requires the 

Secretary to provide for notice of the 

proposed rule in the Federal Register 

and provide a period of not less than 60 

days for public comment. In addition, 

section 553(d) of the APA, and section 

1871(e)(1)(B)(i) of the Act mandate a 30- 

day delay in effective date after issuance 

or publication of a rule. Sections 

553(b)(B) and 553(d)(3) of the APA 

provide for exceptions from the notice 

and comment and delay in effective date 

APA requirements; in cases in which 

these exceptions apply, sections 

1871(b)(2)(C) and 1871(e)(1)(B)(ii) of the 

Act provide exceptions from the notice 

and 60-day comment period and delay 

in effective date requirements of the Act 

as well. Section 553(b)(B) of the APA 

and section 1871(b)(2)(C) of the Act 

authorize an agency to dispense with 

normal rulemaking requirements for 

good cause if the agency makes a 

finding that the notice and comment 

process are impracticable, unnecessary, 

or contrary to the public interest. In 

addition, both section 553(d)(3) of the 

APA and section 1871(e)(1)(B)(ii) of the 

Act allow the agency to avoid the 30- 

day delay in effective date where such 

delay is contrary to the public interest 

and an agency includes a statement of 

support. 

In our view, this correcting document 

does not constitute a rulemaking that 

would be subject to these requirements. 

This correcting document corrects 

technical errors in the preamble, 

addenda, payment rates, and tables 

included or referenced in the CY 2015 

OPPS/ASC final rule with comment 

period. The corrections contained in 

this document are consistent with, and 

do not make substantive changes to, the 

policies and payment methodologies 

that were adopted subjected to notice 

and comment procedures in the CY 

2015 OPPS/ASC final rule with 

comment period. As a result, the 

corrections made through this correcting 

document are intended to ensure that 

the CY 2015 OPPS/ASC final rule with 

comment period accurately reflects the 

policies adopted in that rule. 

Even if this were a rulemaking to 

which the notice and comment and 

delayed effective date requirements 

applied, we find that there is good cause 

to waive such requirements. 

Undertaking further notice and 

comment procedures to incorporate the 

corrections in this document into the 

CY 2015 OPPS/ASC final rule with 

comment period or delaying the 

effective date would be contrary to the 

public interest because it is in the 

public’s interest for providers and 

suppliers to receive appropriate 

payments in as timely a manner as 

possible, and to ensure that the CY 2015 

OPPS/ASC final rule with comment 

period accurately reflects our policies as 

of the date they take effect and are 

applicable. Further, such procedures 

would be unnecessary, because we are 

not altering the payment methodologies 

or policies, but rather, we are simply 

correctly implementing the policies that 

we previously proposed, received 

comment on, and subsequently 

finalized. This correcting document is 

intended solely to ensure that the CY 

2015 OPPS/ASC final rule with 

comment period accurately reflects 

these payment methodologies and 

policies. For these reasons, we believe 

we have good cause to waive the notice 

and comment and effective date 

requirements. 

IV. Correction of Errors 

In FR Doc. 2014–26146 of November 

10, 2014 (79 FR 66770), make the 

following corrections: 

Correction of Errors in the Preamble 

1. On page 66776, second column, 

second bullet, lines 11 and 17, the figure 

‘‘0.89’’ is corrected to read ‘‘0.90’’. 

2. On page 66777, third column, first 

paragraph under column heading (4), 

line 11, the figure ‘‘2.3’’ is corrected to 

read ‘‘2.4’’. 

3. On page 66825, 

a. Second column, 

(1) First partial paragraph, lines 6 

through 14, remove the last two 


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sentences of the paragraph and add the 

following sentence in its place: ‘‘The CY 

2015 estimated cancer hospital payment 

adjustments result in a budget neutral 

adjustment factor of 1.0004 to the 

conversion factor for the cancer hospital 

payment adjustment.’’ 

(2) Second full paragraph, 

(a) Line 17, the figure ‘‘$72.692’’ is 

corrected to read ‘‘$72.690’’. 

(b) Line 19, the figure ‘‘¥$1.484’’ is 

corrected to read ‘‘¥$1.483’’. 

b. Third column, 

(1) First full paragraph, line 13, the 

figure ‘‘$72.661’’ is corrected to read 

‘‘$72.690’’. 

(2) Last paragraph, line 10, the figure 

‘‘$74.144’’ is corrected to read 

‘‘$74.173’’. 

4. On page 66826, first column, first 

partial paragraph, 

(a) Line 2, the figure ‘‘1.0000’’ is 

corrected to read ‘‘1.0004’’. 

(b) Line 7, the figure ‘‘$74.144’’ is 

corrected to read ‘‘$74.173’’. 

5. On page 66832, 

a. First column, first partial 

paragraph, 

(1) Line 3, the figure ‘‘89’’ is corrected 

to read ‘‘90’’. 

(2) Lines 5 and 11, the figure ‘‘0.89’’ 

is corrected to read ‘‘0.90’’. 

b. Second column, 

(1) First partial paragraph, line 4, the 

figure ‘‘0.89’’ is corrected to read ‘‘0.90’’. 

(2) First full paragraph, lines 4 and 9, 

the figure ‘‘0.89 is corrected to read 

‘‘0.90’’. 

c. Third column, first partial 

paragraph, 

(1) Line 3, the figure ‘‘89’’ is corrected 

to read ‘‘90’’. 

(2) Lines 5 and 11, the figure ‘‘0.89’’ 

is corrected to read ‘‘0.90’’. 

d. Table 14—Estimated CY 2015 

Hospital-Specific Payment Adjustment 

For Cancer Hospitals To Be Provided At 

Cost Report Settlement, the table is 

corrected to read as follows: 

TABLE 14—ESTIMATED CY 2015 HOSPITAL-SPECIFIC PAYMENT ADJUSTMENT FOR CANCER HOSPITALS TO BE PROVIDED

AT COST REPORT SETTLEMENT

Provider No. Hospital name 

Estimated 

percentage 

increase in 

OPPS Payments 

for CY 2015 

050146 ......... City of Hope Comprehensive Cancer Center ....................................................................................................... 16.1 

050660 ......... USC Norris Cancer Hospital ................................................................................................................................. 23.2 

100079 ......... Sylvester Comprehensive Cancer Center ............................................................................................................. 12.7 

100271 ......... H. Lee Moffitt Cancer Center & Research Institute .............................................................................................. 20.5 

220162 ......... Dana-Farber Cancer Institute ................................................................................................................................ 47.3 

330154 ......... Memorial Sloan-Kettering Cancer Center ............................................................................................................. 42.4 

330354 ......... Roswell Park Cancer Institute ............................................................................................................................... 19.2 

360242 ......... James Cancer Hospital & Solove Research Institute ........................................................................................... 32.7 

390196 ......... Fox Chase Cancer Center .................................................................................................................................... 19.7 

450076 ......... M.D. Anderson Cancer Center .............................................................................................................................. 49.4 

500138 ......... Seattle Cancer Care Alliance ................................................................................................................................ 43.6 

6. On page 66889, Table 36—HCPCS 

Codes To Which The CY 2015 DrugSpecific Packaging Determination 

Methodology Applies, the table is 

corrected to read as follows: 

TABLE 36—HCPCS CODES TO WHICH THE CY 2015 DRUG-SPECIFIC PACKAGING DETERMINATION METHODOLOGY

APPLIES

CY 2015 

HCPCS code CY 2015 long descriptor CY 2015 SI 

C9257 ........... Injection, bevacizumab, 0.25 mg .............................................................................................................................. K 

J9035 ........... Injection, bevacizumab, 10 mg ................................................................................................................................. K 

J1020 ........... Injection, methylprednisolone acetate, 20 mg .......................................................................................................... N 

J1030 ........... Injection, methylprednisolone acetate, 40 mg .......................................................................................................... N 

J1040 ........... Injection, methylprednisolone acetate, 80 mg .......................................................................................................... N 

J1460 ........... Injection, gamma globulin, intramuscular, 1 cc ........................................................................................................ N 

J1560 ........... Injection, gamma globulin, intramuscular over 10 cc ............................................................................................... N 

J1642 ........... Injection, heparin sodium, (heparin lock flush), per 10 units .................................................................................... N 

J1644 ........... Injection, heparin sodium, per 1000 units ................................................................................................................. N 

J1840 ........... Injection, kanamycin sulfate, up to 500 mg .............................................................................................................. N 

J1850 ........... Injection, kanamycin sulfate, up to 75 mg ................................................................................................................ N 

J2270 ........... Injection, morphine sulfate, up to 10 mg .................................................................................................................. N 

J2788 ........... Injection, rho d immune globulin, human, minidose, 50 micrograms (250 i.u.) ....................................................... N 

J2790 ........... Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) .................................................... N 

J2920 ........... Injection, methylprednisolone sodium succinate, up to 40 mg ................................................................................. N 

J2930 ........... Injection, methylprednisolone sodium succinate, up to 125 mg ............................................................................... N 

J3471 ........... Injection, hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 usp units) ......................................... N 

J3472 ........... Injection, hyaluronidase, ovine, preservative free, per 1000 usp units .................................................................... N 

J7030 ........... Infusion, normal saline solution , 1000 cc ................................................................................................................ N 

J7040 ........... Infusion, normal saline solution, sterile (500 ml = 1 unit) ......................................................................................... N 

J7050 ........... Infusion, normal saline solution , 250 cc .................................................................................................................. N 

J7502 ........... Cyclosporine, oral, 100 mg ....................................................................................................................................... N 

J7515 ........... Cyclosporine, oral, 25 mg ......................................................................................................................................... N 

J8520 ........... Capecitabine, oral, 150 mg ....................................................................................................................................... K 


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Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 9633 

TABLE 36—HCPCS CODES TO WHICH THE CY 2015 DRUG-SPECIFIC PACKAGING DETERMINATION METHODOLOGY

APPLIES—Continued 

CY 2015 

HCPCS code CY 2015 long descriptor CY 2015 SI 

J8521 ........... Capecitabine, oral, 500 mg ....................................................................................................................................... K 

J9250 ........... Methotrexate sodium, 5 mg ...................................................................................................................................... N 

J9260 ........... Methotrexate sodium, 50 mg .................................................................................................................................... N 

7. On page 66917, third column, 

remove the first full paragraph and add 

the following paragraph in its place: 

‘‘For the new Category III CPT codes 

implemented in July 2014 through the 

quarterly update CR, as shown below in 

Table 43, we are not finalizing the ‘‘Z2’’ 

payment indicator that we proposed for 

CPT codes 0348T, 0349T, and 0350T or 

the ‘‘R2’’ payment indicator that we 

proposed for CPT code 0356T. For CY 

2015, these codes will be conditionally 

packaged under the OPPS when 

provided with a significant procedure 

(status indicator ‘‘Q1’’). With the 

exception of device removal procedures 

(as discussed in section XII.D.1.b. of this 

final rule with comment period), HCPCS 

codes that are conditionally packaged 

under the OPPS are always packaged 

(payment indicator ‘‘N1’’) under the 

ASC payment system. Therefore, the 

final CY 2015 ASC payment indicator 

for CPT codes 0348T, 0349T, 0350T, 

and 0356T is ‘‘N1’’ for CY 2015. 

8. On page 66918, Table 43—New 

Category III CPT Codes for Covered 

Surgical Procedures or Covered 

Ancillary Services Implemented in July 

2014, the table is corrected to read as 

follows: 

TABLE 43—NEW CATEGORY III CPT CODES FOR COVERED SURGICAL PROCEDURES OR COVERED ANCILLARY SERVICES

IMPLEMENTED IN JULY 2014 

CY 2014 

CPT code 

CY 2015 

CPT code CY 2015 long descriptor 

Final CY 2015 

ASC payment 

indicator 

0348T 0348T Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and 

lumbosacral, when performed) ........................................................................................................ N1 

0349T 0349T Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) ........................................................................................... N1 

0350T 0350T Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, 

proximal femur, knee and ankle, when performed) ......................................................................... N1 

0356T 0356T Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) 

into lacrimal canaliculus, each ......................................................................................................... N1 

N1 = Packaged service/item; no separate payment made. 

9. On page 66939, 

a. Second column, last paragraph, line 

10, the figure ‘‘0.9998’’ is corrected to 

read ‘‘0.9995’’. 

b. Third column, first partial 

paragraph, 

(1) Line 6, the figure ‘‘$44.071’’ is 

corrected to read ‘‘$44.058’’. 

(2) Line 11, the figure ‘‘0.9998’’ is 

corrected to read ‘‘0.9995’’. 

(3) Line 21, the figure ‘‘$43.202’’ is 

corrected to read ‘‘$43.189’’. 

(4) Line 26, the figure ‘‘0.9998’’ is 

corrected to read ‘‘0.9995’’. 

10. On page 66940, first column, 

second full paragraph, line 6, the figure 

‘‘$44.071’’ is corrected to read 

‘‘$44.058’’. 

11. On page 66962, second column, 

first full paragraph, 

a. Line 12, the figure ‘‘$72.661’’ is 

corrected to read ‘‘$72.690’’. 

b. Line 14, the figure ‘‘$74.144’’ is 

corrected to read ‘‘$74.173’’. 

12. On page 67019, 

a. Second column, first paragraph, 

(1) Line 3, the figure ‘‘(4,006)’’ is 

corrected to read ‘‘(4,007)’’. 

(2) Line 31, the figure ‘‘(3,871)’’ is 

corrected to read ‘‘(3,782)’’. 

b. Third column, remove the entire 

fourth paragraph, which begins with 

‘‘There is no difference in impact’’ and 

add the following paragraph in its place: 

‘‘The impacts reflect slightly smaller 

total cancer hospital payment 

adjustments as a result of the updated 

target PCR and updated estimated 

cancer hospital PCRs for 2015.’’ 

13. On page 67020, 

a. First column, first full paragraph 

under column 5 heading, 

(1) Line 10, the figures ‘‘3.4 and 4.2’’ 

are corrected to read ‘‘3.5 and 4.3’’ 

respectively. (2) Line 14, the figure 

‘‘3.2’’ is corrected to read ‘‘3.3’’. 

b. Second column, first partial 

paragraph, line 9, the figure ‘‘$74.144’’ 

is corrected to read ‘‘$74.173’’. 

c. Third column, 

(1) First partial paragraph, last line, 

the figure ‘‘2.3’’ is corrected to read 

‘‘2.4’’. 

(2) First full paragraph, line 11, the 

figures ‘‘0.9 to 2.1’’ are corrected to read 

‘‘1.0 to 2.2’’ respectively. 

(3) Second full paragraph, line 4, the 

figure ‘‘3.1’’ is corrected to read ‘‘3.2’’. 

(4) Last paragraph, 

(a) Line 7, the figure ‘‘1.7’’ is corrected 

to read ‘‘1.8’’. 

(b) Line 9, the figure ‘‘2.1’’ is 

corrected to read ‘‘2.2’’. 

14. On pages 67020 through 67022, 

Table 49—Estimated Impact of the CY 

2015 Changes for the Hospital 

Outpatient Prospective Payment 

System, the table is corrected to read as 

follows: 


tkelley on DSK3SPTVN1PROD with RULES
9634 Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 

TABLE 49—ESTIMATED IMPACT OF THE PROPOSED CY 2015 CHANGES FOR THE HOSPITAL OUTPATIENT PROSPECTIVE

PAYMENT SYSTEM

Number of 

hospitals 

APC 

recalibration 

(all changes) 

New wage 

index and 

provider 

adjustments 

All budget 

neutral 

changes 

(combined 

cols 2, 3) with 

market basket 

update 

All budget 

neutral 

changes and 

update 

(column 4) 

with frontier 

wage index 

adjustment 

All changes 

(1) (2) (3) (4) (5) (6) 

ALL FACILITIES * .................................... 4,007 0.0 0.0 2.2 2.3 2.3 

ALL HOSPITALS ..................................... 3,872 0.0 0.0 2.3 2.4 2.3 

(excludes hospitals permanently held 

harmless and CMHCs).

URBAN HOSPITALS ............................... 3,008 0.0 0.0 2.3 2.4 2.4 

LARGE URBAN (GT 1 MILL.) .......... 1,646 0.1 0.2 2.5 2.5 2.6 

OTHER URBAN (LE 1 MILL.) .......... 1,362 0.0 ¥0.1 2.1 2.3 2.1 

RURAL HOSPITALS ................................ 863 0.0 ¥0.3 1.9 2.2 1.9 

SOLE COMMUNITY ......................... 376 0.1 ¥0.2 2.2 2.6 2.2 

OTHER RURAL ................................ 487 ¥0.2 ¥0.3 1.7 1.7 1.6 

BEDS (URBAN): 

0–99 BEDS ....................................... 1,067 0.0 0.0 2.3 2.5 2.3 

100–199 BEDS ................................. 856 0.0 0.0 2.2 2.3 2.3 

200–299 BEDS ................................. 458 ¥0.1 0.1 2.3 2.4 2.3 

300–499 BEDS ................................. 410 ¥0.1 0.1 2.3 2.4 2.3 

500 + BEDS ...................................... 217 0.3 ¥0.1 2.5 2.4 2.5 

BEDS (RURAL): 

0–49 BEDS ....................................... 345 0.1 ¥0.2 2.2 2.4 2.2 

50–100 BEDS ................................... 315 0.3 ¥0.3 2.3 2.5 2.2 

101–149 BEDS ................................. 116 ¥0.3 ¥0.1 1.9 2.1 1.8 

150–199 BEDS ................................. 46 ¥0.4 ¥0.4 1.4 2.2 1.5 

200 + BEDS ...................................... 41 ¥0.3 ¥0.4 1.6 1.5 1.5 

VOLUME (URBAN): 

LT 5,000 Lines .................................. 544 ¥1.7 ¥0.3 0.3 0.5 0.5 

5,000–10,999 Lines .......................... 135 ¥0.8 ¥0.2 1.3 1.4 1.4 

11,000–20,999 Lines ........................ 117 ¥1.5 0.0 0.7 1.2 0.9 

21,000–42,999 Lines ........................ 228 ¥0.7 0.0 1.6 1.5 1.6 

42,999–89,999 Lines ........................ 526 ¥0.3 0.0 1.9 2.0 2.0 

GT 89,999 Lines ............................... 1,458 0.1 0.0 2.4 2.5 2.4 

VOLUME (RURAL): 

LT 5,000 Lines .................................. 34 ¥3.8 ¥0.3 ¥1.8 1.1 ¥2.0 

5,000–10,999 Lines .......................... 27 ¥1.8 ¥0.5 ¥0.1 1.1 0.0 

11,000–20,999 Lines ........................ 42 ¥1.1 ¥0.3 0.9 0.9 1.0 

21,000–42,999 Lines ........................ 161 0.2 ¥0.3 2.2 2.8 2.2 

GT 42,999 Lines ............................... 599 0.0 ¥0.3 2.0 2.2 1.9 

REGION (URBAN): 

NEW ENGLAND ............................... 152 1.1 0.2 3.5 3.5 3.5 

MIDDLE ATLANTIC .......................... 361 0.5 0.5 3.2 3.2 3.3 

SOUTH ATLANTIC ........................... 482 ¥0.2 ¥0.3 1.8 1.7 1.8 

EAST NORTH CENT. ....................... 473 0.1 ¥0.1 2.2 2.2 2.2 

EAST SOUTH CENT. ....................... 179 ¥0.9 ¥0.5 0.9 0.9 0.9 

WEST NORTH CENT. ...................... 194 0.0 ¥0.2 2.0 3.3 2.1 

WEST SOUTH CENT. ...................... 527 ¥0.7 ¥0.5 1.1 1.0 1.1 

MOUNTAIN ....................................... 203 0.0 ¥0.1 2.2 2.5 2.2 

PACIFIC ............................................ 389 0.3 1.1 3.7 3.6 3.7 

PUERTO RICO ................................. 48 ¥0.4 0.3 2.1 2.1 2.0 

REGION (RURAL): 

NEW ENGLAND ............................... 23 1.6 ¥0.1 3.7 3.6 3.7 

MIDDLE ATLANTIC .......................... 58 0.8 0.2 3.3 3.3 3.2 

SOUTH ATLANTIC ........................... 130 ¥0.6 ¥0.5 1.1 1.1 1.0 

EAST NORTH CENT ........................ 120 0.0 0.0 2.2 2.2 2.2 

EAST SOUTH CENT ........................ 165 ¥0.8 ¥0.5 1.0 1.0 0.9 

WEST NORTH CENT ....................... 101 0.2 ¥0.2 2.2 3.5 2.2 

WEST SOUTH CENT ....................... 181 ¥0.7 ¥0.8 0.8 0.7 0.7 

MOUNTAIN ....................................... 61 0.7 ¥0.4 2.5 4.3 2.7 

PACIFIC ............................................ 24 0.8 0.9 4.0 4.0 3.9 

TEACHING STATUS: 

NON-TEACHING .............................. 2,839 ¥0.2 0.0 2.0 2.1 2.0 

MINOR .............................................. 706 ¥0.2 ¥0.1 2.0 2.2 2.0 

MAJOR ............................................. 326 0.7 0.1 3.1 3.1 3.2 

DSH PATIENT PERCENT: 

0 ........................................................ 21 0.0 0.3 2.6 2.6 2.6 

GT 0–0.10 ......................................... 328 0.3 0.2 2.7 2.8 2.7 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 9635 

TABLE 49—ESTIMATED IMPACT OF THE PROPOSED CY 2015 CHANGES FOR THE HOSPITAL OUTPATIENT PROSPECTIVE

PAYMENT SYSTEM—Continued 

Number of 

hospitals 

APC 

recalibration 

(all changes) 

New wage 

index and 

provider 

adjustments 

All budget 

neutral 

changes 

(combined 

cols 2, 3) with 

market basket 

update 

All budget 

neutral 

changes and 

update 

(column 4) 

with frontier 

wage index 

adjustment 

All changes 

(1) (2) (3) (4) (5) (6) 

0.10–0.16 .......................................... 334 0.1 0.0 2.4 2.5 2.4 

0.16–0.23 .......................................... 680 0.1 0.0 2.3 2.4 2.3 

0.23–0.35 .......................................... 1,076 0.0 0.0 2.2 2.4 2.2 

GE 0.35 ............................................. 824 0.1 0.1 2.3 2.3 2.5 

DSH NOT AVAILABLE ** .................. 608 ¥3.6 0.0 ¥1.4 ¥1.3 ¥1.4 

URBAN TEACHING/DSH: 

TEACHING & DSH ........................... 938 0.2 0.0 2.5 2.6 2.5 

NO TEACHING/DSH ........................ 1,477 ¥0.2 0.1 2.1 2.2 2.1 

NO TEACHING/NO DSH .................. 18 ¥0.1 0.4 2.5 2.5 2.5 

DSH NOT AVAILABLE ** .................. 575 ¥3.3 0.1 ¥0.9 ¥0.9 ¥1.0 

TYPE OF OWNERSHIP: 

VOLUNTARY .................................... 2,006 0.1 0.0 2.4 2.5 2.4 

PROPRIETARY ................................ 1,322 ¥0.4 ¥0.1 1.7 1.9 1.8 

GOVERNMENT ................................ 543 ¥0.1 ¥0.1 2.1 2.1 2.2 

CMHCs ..................................................... 72 0.0 ¥0.5 1.8 1.8 1.3 

Column (1) shows the total number of hospitals and/or CMHCs. 

Column (2) shows the impact of all final CY 2015 OPPS APC policies and compares those to the CY 2014 OPPS. 

Column (3) shows the budget neutral impact of updating the wage index by applying the final FY 2015 hospital inpatient wage index, including 

all hold harmless policies and transitional wages. The final rural adjustment continues our current policy of 7.1 percent so the budget neutrality 

factor is 1. The budget neutrality adjustment for the cancer hospital adjustment is 1.004. 

Column (4) shows the impact of all budget neutrality adjustments and the addition of the proposed 2.2 percent OPD fee schedule update factor (2.9 percent reduced by 0.5 percentage points for the final productivity adjustment and further reduced by 0.2 percentage point in order to 

satisfy statutory requirements set forth in the Affordable Care Act). 

Column (5) shows the impact of all budget neutral changes and the non-budget neutral impact of applying the frontier State wage adjustment 

in CY 2015. 

Column (6) shows the additional adjustments to the conversion factor resulting from a change in the pass-through estimate, adding estimated 

outlier payments, and applying payment wage indexes. 

* These 4,007 providers include children and cancer hospitals, which are held harmless to pre-BBA amounts, and CMHCs. 

** Complete DSH numbers are not available for providers that are not paid under IPPS, including rehabilitation, psychiatric, and long-term care 

hospitals. 

15. On page 67022, second column, 

first full paragraph, 

a. Line 13, the figure ‘‘1.7’’ is 

corrected to read ‘‘1.8’’. 

b. Line 16, the figure ‘‘1.7’’ is 

corrected to read ‘‘1.8’’. 

c. Line 19, the figure ‘‘¥0.4’’ is 

corrected to read ‘‘¥0.5’’. 

16. On page 67023, second column, 

first partial paragraph, 

a. Line 12, the figure ‘‘0.9998’’ is 

corrected to read ‘‘0.9995’’. 

b. Last line, the figure ‘‘$44.071’’ is 

corrected to read ‘‘$44.058’’. 

17. On page 67024, third column (top 

third of the page above Table 50), first 

partial paragraph, line 1, replace ‘‘9’’ 

with ‘‘11’’. 

18. On pages 67024 through 67025, 

Table 51—Estimated Impact of the CY 

2015 Update to the ASC Payment 

System on Aggregate Payments for 

Selected Procedures, the table is 

corrected to read as follows: 

TABLE 51—ESTIMATED IMPACT OF THE CY 2015 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS

FOR SELECTED PROCEDURES

CPT/HCPCS code Short descriptor 

Estimated CY 

2014 ASC 

payments (in 

millions) 

Estimated CY 

2015 percent 

change 

(1) (2) (3) (4) 

66984 ......................... Cataract surg w/iol, 1 stage ............................................................................................. $1,131 ¥1 

43239 ......................... Upper GI endoscopy, biopsy ........................................................................................... 170 11 

45380 ......................... Colonoscopy and biopsy ................................................................................................. 167 7 

45385 ......................... Lesion removal colonoscopy ........................................................................................... 107 7 

66982 ......................... Cataract surgery, complex ............................................................................................... 93 ¥1 

64483 ......................... Inj foramen epidural l/s .................................................................................................... 90 0 

62311 ......................... Inject spine l/s (cd) .......................................................................................................... 79 0 

45378 ......................... Diagnostic colonoscopy ................................................................................................... 72 7 

66821 ......................... After cataract laser surgery ............................................................................................. 63 3 

64493 ......................... Inj paravert f jnt l/s 1 lev .................................................................................................. 47 0 

G0105 ........................ Colorectal scrn; hi risk ind ............................................................................................... 45 1 


tkelley on DSK3SPTVN1PROD with RULES
9636 Federal Register / Vol. 80, No. 36 / Tuesday, February 24, 2015 / Rules and Regulations 

TABLE 51—ESTIMATED IMPACT OF THE CY 2015 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS

FOR SELECTED PROCEDURES—Continued 

CPT/HCPCS code Short descriptor 

Estimated CY 

2014 ASC 

payments (in 

millions) 

Estimated CY 

2015 percent 

change 

(1) (2) (3) (4) 

64635 ......................... Destroy lumb/sac facet jnt ............................................................................................... 45 ¥5 

63650 ......................... Implant neuroelectrodes .................................................................................................. 41 4 

G0121 ........................ Colon ca scrn not hi rsk ind ............................................................................................ 41 1 

64590 ......................... Insrt/redo pn/gastr stimul ................................................................................................. 38 ¥1 

15823 ......................... Revision of upper eyelid .................................................................................................. 35 2 

63685 ......................... Insrt/redo spine n generator ............................................................................................ 34 29 

29827 ......................... Arthroscop rotator cuff repr ............................................................................................. 34 1 

64721 ......................... Carpal tunnel surgery ...................................................................................................... 32 ¥1 

29881 ......................... Knee arthroscopy/surgery ................................................................................................ 30 ¥1 

29824 ......................... Shoulder arthroscopy/surgery .......................................................................................... 27 1 

29880 ......................... Knee arthroscopy/surgery ................................................................................................ 25 ¥1 

43235 ......................... Uppr gi endoscopy diagnosis .......................................................................................... 23 10 

62310 ......................... Inject spine c/t .................................................................................................................. 23 0 

29823 ......................... Shoulder arthroscopy/surgery .......................................................................................... 22 1 

52000 ......................... Cystoscopy ...................................................................................................................... 22 1 

G0260 ........................ Inj for sacroiliac jt anesth ................................................................................................. 21 0 

45384 ......................... Lesion remove colonoscopy ............................................................................................ 21 7 

67042 ......................... Vit for macular hole ......................................................................................................... 21 1 

26055 ......................... Incise finger tendon sheath ............................................................................................. 19 ¥2 

Dated: February 18, 2015. 

C’Reda Weeden, 

Executive Secretary to the Department, 

Department of Health and Human Services. 

[FR Doc. 2015–03760 Filed 2–23–15; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 600 

[CMS–2391–FN] 

RIN 0938–ZB18 

Basic Health Program; Federal 

Funding Methodology for Program 

Year 2016 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final methodology. 

SUMMARY: This document provides the 

methodology and data sources necessary 

to determine federal payment amounts 

made in program year 2016 to states that 

elect to establish a Basic Health Program 

under the Affordable Care Act to offer 

health benefits coverage to low-income 

individuals otherwise eligible to 

purchase coverage through Affordable 

Insurance Exchanges. 

DATES: These regulations are effective 

on January 1, 2016. 

FOR FURTHER INFORMATION CONTACT: 

Christopher Truffer, (410) 786–1264; 

Stephanie Kaminsky (410) 786–4653. 

SUPPLEMENTARY INFORMATION: 

Table of Contents 

I. Background 

II. Summary of Proposed Provisions and 

Analysis of and Responses to Public 

Comments on the Proposed Methodology 

A. Background 

B. Overview of the Funding Methodology 

and Calculation of the Payment Amount 

C. Required Rate Cells 

D. Sources and State Data Considerations 

E. Discussion of Specific Variables Used in 

Payment Equations 

F. Adjustments for American Indians and 

Alaska Natives 

G. State Option to Use 2015 QHP 

Premiums for BHP Payments 

H. State Option To Include Retrospective 

State-Specific Health Risk Adjustment in 

Certified Methodology 

III. Provisions of the Final Methodology 

A. Overview of the Funding Methodology 

and Calculation of the Payment Amount 

B. Federal BHP Payment Rate Cells 

C. Sources and State Data Considerations 

D. Discussion of Specific Variables Used in 

Payment Equations 

E. Adjustments for American Indians and 

Alaska Natives 

F. State Option To Use 2015 QHP 

Premiums for BHP Payments 

G. State Option To Include Retrospective 

State-Specific Health Risk Adjustment in 

Certified Methodology 

IV. Collection of Information Requirements 

V. Regulatory Impact Statement 

A. Overall Impact 

B. Unfunded Mandates Reform Act 

C. Regulatory Flexibility Act 

D. Federalism 

Acronyms 

To assist the reader, the following 

acronyms are used in this document. 

DAV Change in Actuarial Value 

APTC Advance payment of the premium 

tax credit 

ARP Adjusted reference premium 

AV Actuarial value 

BHP Basic Health Program 

CCIIO CMS’ Center for Consumer 

Information and Insurance Oversight 

CDC Centers for Disease Control and 

Prevention 

CHIP Children’s Health Insurance Program 

CPI–U Consumer price index for all urban 

consumers 

CSR Cost-sharing reduction 

EHB Essential Health Benefit 

FPL Federal poverty line 

FRAC Factor for removing administrative 

costs 

IRF Income reconciliation factor 

IRS Internal Revenue Service 

IUF Induced utilization factor 

QHP Qualified health plan 

OTA Office of Tax Analysis [of the U.S. 

Department of Treasury] 

PHF Population health factor 

PTC Premium tax credit 

PTCF Premium tax credit formula 

PTF Premium trend factor 

RP Reference premium 

SBM State Based Marketplace 

TRAF Tobacco rating adjustment factor 

I. Background 

The Patient Protection and Affordable 

Care Act (Pub. L. 111–148, enacted on 

March 23, 2010), together with the 

Health Care and Education 

Reconciliation Act of 2010 (Pub. L. 111– 

152, enacted on March 30, 2010) 

(collectively referred as the Affordable 


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