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[Federal Register Volume 76, Number 1 (Monday, January 3, 2011)]
[Notices]
[Pages 148-159]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-32979]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2321-N]
RIN 0938-AQ44

Medicaid Program; Final FY 2009 and Preliminary FY 2011 
Disproportionate Share Hospital Allotments, and Final FY 2009 and 
Preliminary FY 2011 Institutions for Mental Diseases Disproportionate 
Share Hospital Limits

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces the final Federal share disproportionate 
share hospital (DSH) allotments for Federal FY (FY) 2009 and the 
preliminary Federal share DSH allotments for FY 2011. This notice also 
announces the final FY 2009 and the preliminary FY 2011 limitations on 
aggregate DSH payments that States may make to institutions for mental 
disease and other mental health facilities. In addition, this notice 
includes background information describing the methodology for 
determining the amounts of States' FY DSH allotments.

DATES: Effective Date: This notice is effective March 4, 2011. The 
final allotments and limitations set forth in this notice are effective 
for the fiscal years specified.

FOR FURTHER INFORMATION CONTACT: Richard Strauss, (410) 786-2019.

SUPPLEMENTARY INFORMATION:

I. Background

A. Disproportionate Share Hospital Allotments for Federal FY 2003

    Under section 1923(f)(3) of the Social Security Act (the Act), 
States' Federal fiscal year (FY) 2003 disproportionate share hospital 
(DSH) allotments were calculated by increasing the amounts of the FY 
2002 allotments for each State (as specified in the chart, entitled 
``DSH Allotment (in millions of dollars)'', contained in section 
1923(f)(2) of the Act) by the percentage change in the Consumer Price 
Index for all Urban Consumers (CPI-U) for the prior fiscal year. The 
allotment, determined in this way, is subject to the limitation that an 
increase to a State's DSH allotment for a FY cannot result in the DSH 
allotment exceeding the greater of the State's DSH allotment for the 
previous FY or 12 percent of the State's total medical assistance 
expenditures for the allotment year (this is referred to as the 12 
percent limit).
    Most States' actual FY 2002 allotments were determined in 
accordance with the provisions of section 1923(f)(4) of the Act which 
allowed for a special DSH calculation rule for FY 2001 and FY 2002. 
However, as indicated previously, the calculation of States' FY 2003 
allotments was not based on the actual FY 2002 DSH allotments; rather, 
section 1923(f)(3) of the Act requires that the States' FY 2003 
allotments be determined using the amount of the States' FY 2002 
allotments specified in the chart in section 1923(f)(2) of the Act. The 
exception to this is the calculation of the FY 2003 DSH allotments for 
certain ``Low-DSH States'' (defined in section 1923(f)(5) of the Act). 
Under the Low-DSH State provision, there is a special calculation 
methodology for the Low-DSH States only. Under this methodology, the FY 
2003 allotments were determined by increasing States' actual FY 2002 
DSH allotments, rather than their FY 2002 allotments specified in the 
chart in section 1923(f)(2) of the Act, by the percentage change in the 
CPI-U for the previous fiscal year.

B. DSH Allotments for FY 2004

    Section 1001(a) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted on December 
8, 2003) amended section 1923(f)(3) of the Act to provide for a 
``Special, Temporary Increase In Allotments On A One-Time, Non-
Cumulative Basis.'' Under this provision, States' FY 2004 DSH 
allotments were determined by increasing their FY 2003 allotments by 16 
percent, and the FY DSH allotment amounts so determined were not 
subject to the 12 percent limit.

C. DSH Allotments for Non-Low DSH States for FY 2005, and FYs 
Thereafter

    Under the methodology contained in section 1923(f)(3)(C) of the 
Act, as amended by section 1001(a)(2) of the MMA, the non-Low-DSH 
States' DSH allotments for FY 2005 and subsequent FYs continue at the 
same level as the States' DSH allotments for FY 2004 until a ``fiscal 
year specified'' occurs. The fiscal year specified is the first FY for 
which the Secretary estimates that a State's DSH allotment equals (or 
no longer exceeds) the DSH allotment as would have been determined 
under the statute in effect before the enactment of the MMA. We 
determine whether the fiscal year specified has occurred under a 
special parallel process. Specifically, under this parallel process, a 
``parallel'' DSH allotment is determined for FYs after 2003 by 
increasing the State's DSH allotment for the previous FY by the 
percentage change in the CPI-U for the prior FY, subject to the 12 
percent limit. This is the methodology as would otherwise have been 
applied under section 1923(f)(3)(A) of the Act, notwithstanding the 
application of the provisions of MMA. The fiscal year specified, is the 
FY in which the parallel DSH allotment calculated under this special 
parallel process equals or exceeds the FY 2004 DSH allotment, as 
determined under the MMA provisions. Once the fiscal year specified 
occurs for a State, that State's FY DSH allotment will be calculated by 
increasing the State's previous actual FY DSH allotment (which would be 
equal to the FY 2004 DSH allotment) by the percentage change in the 
CPI-U for the previous FY, subject to the 12 percent limit. The 
following example illustrates how the FY DSH allotment would be 
calculated for FYs after FY 2004.

    Example--In this example, we are determining the parallel FY 
2009 DSH allotment. A State's actual FY 2003 DSH allotment is $100 
million. Under the MMA, this State's actual FY 2004 DSH allotment 
would be $116 million ($100 million increased by 16 percent). The 
State's DSH allotment for FY 2005 and subsequent FYs would continue 
at the $116 million FY 2004 DSH allotment for FYs following FY 2004 
until the fiscal year specified occurs. Under the separate parallel 
process, we determine

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whether the fiscal year specified has occurred by calculating the 
State's DSH allotments in accordance with the statute in effect 
before the enactment of the MMA. Under this special process, we 
continue to determine the State's parallel DSH allotment for each FY 
by increasing the State's parallel DSH allotment for the previous FY 
(as also determined under the special parallel process) by the 
percentage change in the CPI-U for the previous FY, and subject to 
the 12 percent limit. Assume for purposes of this example that, in 
accordance with this special parallel process, the State's parallel 
FY 2008 DSH allotment was determined to be $115 million and the 
percentage change in the CPI-U for FY 2008 (the previous FY) 
relevant for the calculation of the FY 2009 DSH allotment was 4.4 
percent. That is, the percentage change for the CPI-U for FY 2008, 
the year before FY 2009, was 4.4 percent. Therefore, the State's 
special parallel process FY 2009 DSH allotment amount would be 
calculated by increasing the special parallel process FY 2008 DSH 
allotment amount of $115 million by 4.4 percent; this results in a 
parallel process DSH allotment process amount for FY 2009 of $120.06 
million. Since $120.06 million is greater than $116 million (the 
actual FY 2004 DSH allotment calculated under the MMA), we would 
determine that FY 2009 is the fiscal year specified (the first year 
that the FY 2004 allotment equals or no longer exceeds the parallel 
process allotment). Since FY 2009 is the fiscal year specified, we 
would then determine the State's FY 2009 allotment by increasing the 
State's actual FY 2008 DSH allotment ($116 million) by the 
percentage change in the CPI-U for FY 2008 (4.4 percent). Therefore, 
the State's FY 2009 DSH allotment would be $121.104 million ($116 
million increased by 4.4 percent); for purposes of the calculation 
in this example, the application of the 12 percent limit has no 
effect. Furthermore, for FY 2009 and thereafter, the State's DSH 
allotment would be calculated under the provisions of section 
1923(f)(3)(A) of the Act by increasing the State's previous FY's DSH 
allotment by the percentage change in the CPI-U for the previous FY, 
subject to the 12 percent limit.
    However, as amended by section 1001(b)(4) of the MMA, section 
1923(f)(5)(B) of the Act also contains criteria for determining 
whether a State is a Low-DSH State, beginning with FY 2004. This 
provision is described in section I.D.

D. DSH Allotments for Low-DSH States for FY 2004 and FYs Thereafter

    Section 1001(b)(1) of the MMA amended section 1923(f)(5) of the Act 
regarding the calculation of the FY DSH allotments for ``Low-DSH'' 
States for FY 2004 and subsequent fiscal years. Specifically, under 
section 1923(f)(5)(B) of the Act, as amended by section 1001(b)(4) of 
the MMA, a State is considered a Low-DSH State for FY 2004 if its total 
DSH payments under its State plan for FY 2000 (including Federal and 
State shares) as reported to CMS as of August 31, 2003, are greater 
than 0 percent and less than 3 percent of the State's total FY 2000 
expenditures under its State plan for medical assistance. For States 
that meet the Low-DSH criteria, their FY 2004 DSH allotments are 
calculated by increasing their FY 2003 DSH allotments by 16 percent. 
Therefore, for FY 2004, Low-DSH States' FY DSH allotments are 
calculated in the same way as the DSH allotments for regular States, 
which under section 1923(f)(3) of the Act, get the special temporary 
increase for FY 2004.
    Furthermore, for States meeting the MMA's Low-DSH definition, the 
DSH allotments for FYs 2005 through 2008 will continue to be determined 
by increasing the previous FY's DSH allotment by 16 percent. The Low-
DSH States' DSH allotments for FYs 2004 through 2008 are not subject to 
the 12 percent limit. The Low-DSH States' DSH allotments for FYs 2009 
and subsequent FYs are calculated by increasing those States' DSH 
allotments for the prior FY by the percentage change in the CPI-U for 
that prior fiscal year. For FYs 2009 and thereafter, the DSH allotments 
so determined would be subject to the 12 percent limit.

E. Institutions for Mental Diseases DSH Limits for FYs 1998 and 
Thereafter

    Under section 1923(h) of the Act, Federal financial participation 
(FFP) is not available for DSH payments to institutions for mental 
diseases (IMDs) and other mental health facilities that are in excess 
of State-specific aggregate limits. Under this provision, this 
aggregate limit for DSH payments to IMDs and other mental health 
facilities is the lesser of a State's FY 1995 total computable (State 
and Federal share) IMD and other mental health facility DSH 
expenditures applicable to the State's FY 1995 DSH allotment (as 
reported on the Form CMS-64 as of January 1, 1997), or the amount equal 
to the product of the State's current year total computable DSH 
allotment and the applicable percentage.
    Each State's IMD limit on DSH payments to IMDs and other mental 
health facilities was calculated by first determining the State's total 
computable DSH expenditures attributable to the FY 1995 DSH allotment 
for mental health facilities and inpatient hospitals. This calculation 
was based on the total computable DSH expenditures reported by the 
State on the Form CMS-64 as mental health DSH and inpatient hospital 
DSH as of January 1, 1997. We then calculate an ``applicable 
percentage.'' The applicable percentage for FY 1998 through FY 2000 
(1995 IMD DSH percentage) is calculated by dividing the total 
computable amount of IMD and mental health DSH expenditures applicable 
to the State's FY 1995 DSH allotment by the total computable amount of 
all DSH expenditures (mental health facility plus inpatient hospital) 
applicable to the FY 1995 DSH allotment. For FY 2001 and thereafter, 
the applicable percentage is defined as the lesser of the applicable 
percentage as calculated above (for FYs 1998 through 2001) or 50 
percent for FY 2001; 40 percent for FY 2002; and 33 percent for each 
subsequent fiscal year.
    The applicable percentage is then applied to each State's total 
computable FY DSH allotment for the current fiscal year. The State's 
total computable FY DSH allotment is calculated by dividing the State's 
Federal share DSH allotment for the FY by the State's Federal medical 
assistance percentage (FMAP) for that fiscal year.
    In the final step of the calculation of the IMD DSH Limit, the 
State's total computable IMD DSH limit for the FY is set at the lesser 
of the product of a State's current FY total computable DSH allotment 
and the applicable percentage for that FY, or the State's FY 1995 total 
computable IMD and other mental health facility DSH expenditures 
applicable to the State's FY 1995 DSH allotment as reported on the Form 
CMS-64.
    The MMA legislation did not amend the Medicaid statute with respect 
to the calculation of the IMD DSH limit.

F. Publication in the Federal Register of Preliminary and Final Notice 
for DSH Allotments and IMD DSH Limits

    In general, we initially determine States' DSH allotments and IMD 
DSH limits for a FY using estimates of medical assistance expenditures, 
including DSH expenditures in their Medicaid programs. These estimates 
are provided by States each year on the August quarterly Medicaid 
budget reports (Form CMS-37) before the FY for which the DSH allotments 
and IMD DSH limits are being determined. Also, as part of the basic 
determination of preliminary DSH allotments for a FY, we use the 
available CPI-U percentage increase that is available before the 
beginning of the FY for which the allotment is being determined to 
determine the preliminary FY DSH allotment. For example, in determining 
the preliminary FY 2011 DSH allotment, we would apply the CPI-U 
percentage increase for FY 2010 that was available just before the 
beginning of FY 2011 on October 1, 2010.
    The DSH allotments and IMD DSH limits determined using these 
estimates and CPI-U percentage increases

[[Page 150]]

available before the beginning of the FY are referred to as 
``preliminary.'' Only after we receive States' reports of the actual 
related medical assistance expenditures through the quarterly 
expenditure report (Form CMS-64), and the final historic CPI-U 
percentage increases for the prior FY, which occurs after the end of 
the FY, are the ``final'' DSH Allotments and IMD DSH limits determined.
    The notice published in the Federal Register on December 19, 2008 
(73 FR 77704), included the announcement of the preliminary FY 2009 DSH 
allotments (based on estimates), and the preliminary FY 2009 IMD DSH 
limits (since they were based on the preliminary DSH allotments for FY 
2009). A correction notice published in the Federal Register on January 
26, 2009 (74 FR 4439) provided a correction to the chart of preliminary 
FY 2009 DSH allotments published in the December 19, 2008 Federal 
Register. Finally, the notice published in the Federal Register on 
April 23, 2010 (75 FR 21314), included the announcement of the revised 
preliminary FY 2009 DSH allotments to reflect increases in the amount 
of the States' DSH allotments for FY 2009 and FY 2010 pursuant to the 
enactment on February 17, 2009 of the American Recovery and 
Reinvestment Act of 2009 (section 5002 of Pub. L. 111-5) and revisions 
to the CPI-U percentage increase for FY 2008, and the revised 
preliminary FY 2009 IMD DSH limits (since they were based on the 
revised preliminary DSH allotments for FY 2009).
    This notice announces the final FY 2009 DSH allotments and the 
final FY 2009 IMD DSH limits (since these are now based on the actual 
expenditures for that fiscal year), the preliminary FY 2011 DSH 
allotments (based on expenditure estimates), and the preliminary IMD 
DSH limits for FY 2011 (since they are based on the preliminary DSH 
allotments for FY 2011). This notice does not include the final FY 2010 
DSH allotments or the final FY 2010 IMD DSH limits, since the 
associated actual expenditures for FY 2010 are not available at this 
time.

G. DSH Allotment Provisions for Certain States

1. DSH Allotments for the State of Tennessee
    Section 1923(f)(6)(A) of the Act, as amended by section 404 of 
Public Law 109-432 (enacted on December 20, 2006), section 204 of 
Public Law 110-173 (enacted on December 29, 2007), section 202 of 
Public Law 110-275 (enacted on July 15, 2008), section 616 of Public 
Law 111-3 (enacted on February 4, 2009), and most recently as amended 
by Section 1054 of Public Law 111-152 (enacted on March 30, 2010) 
provides for the determination of a DSH allotment for the State of 
Tennessee for each of FYs 2007 through FY 2011, for 2 periods 
encompassing FY 2012, and for FY 2013. In accordance with this 
provision, Tennessee's DSH allotment for each of FYs 2007 through 2011 
is the greater of $280 million and the FY 2007 Federal medical 
assistance percentage of the DSH payment adjustments reflected in the 
State's TennCare Demonstration Project for the demonstration year 
ending in 2006. In accordance with this provision, the State's Federal 
share DSH allotment for each of FYs 2007 through 2011 is $305,451,928. 
Furthermore, Tennessee's DSH allotment for the period October 1, 2011 
through December 31, 2011 (the first quarter of FY 2012) is one-fourth 
of this amount; that is, $76,362,982. Section 1923(f)(6)(A)(ii) of the 
Act further limits the amount of Federal funds that are available for 
DSH payments that Tennessee may make in each of the FYs 2007 through 
2011, and for the first quarter of FY 2012 to 30 percent of the DSH 
allotment. In this regard, the limit on the DSH payments that the State 
of Tennessee may make is effectively $91,635,578 (30 percent of 
$305,451,928) for each FY 2007 through FY 2011, and $22,908,895 (30 
percent of $76,362,982) for the period October 1, 2011 through December 
31, 2011 (the first quarter of FY 2012. The statute also provides for 
additional allotments for Tennessee for the period January 1, 2011 
through September 30, 2012 (quarters 2 through 4 of FY 2012) and for 
all of FY 2013; future Federal Register notices will describe the 
determination of the amounts of DSH allotments for Tennessee for FY 
2012 and FY 2013.
2. DSH Allotments for the State of Hawaii
    Section 1923(f)(6)(B) of the Act, as amended by section 404 of 
Public Law 109-432, section 204 of Public Law 110-173, section 202 of 
Public Law 110-275, section 616 of Public Law 111-3 (enacted on 
February 4, 2009) most recently as amended by Section 10201(e)(1) of 
Public Law 111-148 (enacted on March 23, 2010) provides for a DSH 
allotment for the State of Hawaii for each of FYs 2007 through 2011, 
for 2 periods encompassing FY 2012, and certain other provisions 
providing for a DSH allotment for FY 2013. In accordance with the 
statute, Hawaii's DSH allotment each year for FY 2007 through FY 2011 
is $10 million. Furthermore, for the period October 1, 2011 through 
December 31, 2011 (the first quarter of FY 2012) Hawaii's DSH allotment 
is $2.5 million, and for the period January 1, 2012 through September 
30, 2012 Hawaii's DSH allotment is $7.5 million. Future Federal 
Register notices will describe the determination of the amounts of DSH 
allotments for Hawaii for FY 2012 and FY 2013.

H. DSH Allotments for FY 2009 and FY 2010 Under the Recovery Act

    Section 5002 of the Recovery Act added a new section 1923(f)(3)(E) 
of the Act; this new section provides for a temporary increase in 
States' DSH allotments only for FY 2009 and FY 2010.
1. Revised Preliminary DSH Allotments for FY 2009
    States' preliminary FY 2009 DSH allotments were previously 
published in the Federal Register on January 26, 2009. However, section 
5002 of the Recovery Act enacted after the publication of the 
preliminary FY 2009 DSH allotments provided for an increase in States' 
DSH allotments from what were previously determined and published in 
the Federal Register on January 26, 2009. The Recovery Act provided 
fiscal relief to States during the recent national economic downturn. 
In that regard, section 1923(f)(3)(E)(i)(I) of the Act, as created by 
section 5002 of the Recovery Act, requires that, in general, States' 
DSH allotments for FY 2009 be equal to 102.5 percent of the FY 2009 
allotments that would otherwise have been determined; this provision 
does not apply to certain States as discussed in section G. above.
    As described in section F. above, we typically publish States' 
preliminary DSH allotments based on expenditure estimates and CPI-U 
percentage increases available before the FY for which the preliminary 
DSH allotment is being determined. The preliminary DSH allotments are 
subsequently finalized after the FY is over and when the applicable 
inputs for determining the DSH allotments (that is, the applicable 
expenditures and the CPI-U percentage increase for the previous FY) are 
final.
    Due to the Recovery Act temporary increase for FY 2009, in this 
notice we revised the preliminary FY 2009 DSH allotments previously 
published to reflect updated States' expenditures, and more 
significantly, to reflect an updated and increased CPI-U percentage 
increase. As described above, States' DSH allotments are determined by 
increasing the previous FY allotment by the applicable CPI-U

[[Page 151]]

percentage increase. In particular, when we previously calculated the 
preliminary FY 2009 allotments, the applicable CPI-U percentage 
increase for FY 2008 (used for determining the FY 2009 DSH allotment), 
which was available before the beginning of FY 2009, was 4.0 percent. 
However, subsequent to our initial determination of the preliminary FY 
2009 DSH allotments, the historical applicable CPI-U percentage 
increase for FY 2008 became available; that actual CPI-U increase for 
FY 2008 is 4.4 percent. In order to ensure that the full increase in 
DSH allotments for FY 2009 is available to States during FY 2009, we 
revised the preliminary FY 2009 DSH allotments prior to the end of FY 
2009 to reflect both the updated increase in the applicable CPI-U 
percentage increase for FY 2008 and the 2.5 percent increase in States' 
FY 2009 DSH allotments as required under the Recovery Act.
    The final FY 2009 allotments contained in this Federal Register 
notice reflect the final CPI-U percentage increase for FY 2008 and the 
actual expenditures in Medicaid for FY 2009.
2. Preliminary DSH Allotments for FY 2011
    Sections 1923(f)(3)(E) of the Act, as amended by Section 5002 of 
the Recovery Act, in general (with the exceptions for certain States 
described above) provided for a 2.5 percent increase in States' FY 2009 
DSH allotments and for States' FY 2010 DSH allotments to be determined 
as the higher of:
     102.5 percent of the DSH allotment for FY 2009, as 
determined under the Recovery Act provision, or
     The FY 2010 DSH allotment as would otherwise be calculated 
without the application of the Recovery Act provision.
    The final FY 2009 DSH allotments contained in this Federal Register 
notice and the preliminary FY 2010 DSH allotment for States (as 
published in the Federal Register on April 23, 2010, 75 FR 21314) were 
determined in accordance with the law, as amended by the Recovery Act.
    As indicated, the Recovery Act DSH allotment provisions apply only 
for FY 2009 and FY 2010; that is, States' DSH allotments for FY 2011 
are determined as DSH allotments were determined prior to the enactment 
of the Recovery Act.
3. Effect of the Recovery Act DSH Provision on Calculation of the 
States' IMD DSH Limits for FY 2009 and FY 2010, and Determination of 
Such Limits for FY 2011
    Section E above described the determination of States' IMD DSH 
limits for FYs beginning FY 1998 and after, as determined under section 
1923(h) of the Act. Section 5002 of the Recovery Act did not amend 
section 1923(h) of the Act. Accordingly, States' preliminary IMD DSH 
limits for FY 2009 and FY 2010, the FYs for which the Recovery Act 
provisions are applicable, were determined as under the existing 
provisions. As described in section E above, States' DSH allotments are 
an element of the determination of the IMD DSH limit. Therefore, the 
DSH allotments for FY 2009 and FY 2010, as determined under the 
Recovery Act provisions, were used in calculating States' Final FY 2009 
(as contained in this Federal Register notice) and States' preliminary 
FY 2010 (as previously published in the Federal Register on April 23, 
2010, 75 FR 21314) IMD DSH limits. This is the same application of 
States' DSH allotments for purposes of determining States' IMD DSH 
limits as was applied under section 1923(h) of the Act, regardless of 
the Recovery Act provision.

II. Provisions of the Notice

A. Calculation of the Final FY 2009 Federal Share State DSH Allotments, 
and the Preliminary FY 2011 Federal Share State DSH Allotments

1. Final FY 2009 Federal Share State DSH Allotments
    Chart 1 of the Addendum to this notice provides the States' final 
FY 2009 DSH allotments as discussed above in section I.H.1 of this 
notice. As discussed in that section of this notice, the revised 
preliminary FY 2009 DSH allotments were previously published in the 
Federal Register on April 23, 2010. As described above and in previous 
Federal Register notices in determining non-Low DSH States' DSH 
allotments for FYs after FY 2004 under section 1923(f)(3)(C) of the Act 
for DSH allotments, we determined States' DSH allotments under a 
``parallel'' process. Under the parallel process, for each FY for each 
State, we have been determining whether the fiscal year specified (as 
defined in section 1923(f)(3)(D) of the Act) has occurred. Under 
section 1923(f)(3)(D) of the Act, the fiscal year specified is 
determined separately for each State and ``is the first FY for which 
the Secretary estimates that the DSH allotment for that State will 
equal (or no longer exceed) the DSH allotment for that State under the 
law as in effect before the date of enactment'' of MMA. The process in 
effect before the enactment in MMA is the process described in section 
1923(f)(3)(A) of the Act; under this process each States' DSH allotment 
since FY 2003 is increased by the CPI-U increase for the prior FY and 
the result is then compared to the State's FY 2004 DSH allotment, as 
determined under section 1923(f)(3)(C)(i) of the Act (under which the 
States' FY 2003 DSH allotments were increased by 16 percent). The 
fiscal year specified for a State is the FY when the FY 2004 allotment 
is no longer greater than the parallel process DSH allotment.
    We are reiterating the parallel process provision because we 
determined that FY 2009 was the fiscal year specified for all non-Low 
DSH States (except Louisiana). Therefore, as indicated in section 
1923(f)(3)(C)(ii) of the Act, the Final FY 2009 DSH allotment for all 
non-Low DSH States (except Louisiana) is equal to the prior FY 2008 DSH 
allotment increased by the CPI-U increase for FY 2008 (4.4 percent). 
Chart 1 contains the final FY 2009 DSH allotments. For the non-Low DSH 
States for which the FY 2009 is the fiscal year specified, the FY 2010 
and subsequent FY DSH allotments are calculated by increasing the prior 
FY DSH allotment by the CPI-U increase for the prior fiscal year.
    For Low-DSH States, the FY 2009 DSH allotment is calculated using 
the same methodology as for the non-Low DSH States for which the fiscal 
year specified has occurred. That is, for FY 2009 and following FYs, 
the DSH allotment for Low-DSH States is calculated by increasing the 
prior FY DSH allotment by the percentage change in the CPI-U for the 
prior fiscal year.
    The preliminary FY 2009 allotments were initially determined using 
the States' August 2008 expenditure estimates submitted by the States 
on the Form CMS-37, and the percentage increase in the CPI-U for the 
previous FY that was available before the beginning of FY 2009. As 
discussed in section I.H.1 above, based on the updated CPI-U percentage 
increase for FY 2008 (from 4.0 percent to 4.4 percent), and the 
enactment of section 5002 of the Recovery Act (which provides that 
States' FY 2009 DSH allotments are equal to 102.5 percent of these 
allotments as would otherwise be determined for the FY), we revised the 
preliminary FY 2009 DSH allotments, which were published in the Federal 
Register on April 23, 2010. States' final FY 2009 DSH allotments as 
contained in

[[Page 152]]

this Federal Register were determined based on States' four quarterly 
Medicaid expenditure reports (Form CMS-64) for FY 2009 received 
following the end of FY 2009 and the final applicable percentage 
increase to CPI-U for the previous FY 2008.
2. Calculation of the Preliminary FY 2011 Federal Share State DSH 
Allotments
    Chart 2 of the Addendum to this notice provides the preliminary FY 
2011 DSH allotments determined in accordance with the section 
1923(f)(3) of the Act, as described in section I.H.2. As described in 
that section of this notice, the Recovery Act provisions which 
increased States' DSH allotments for FY 2009 and FY 2010 are not 
applicable for determining States' FY 2011 DSH allotments. States' 
final FY 2011 DSH allotments will be published in the Federal Register 
following receipt of the States' four quarterly Medicaid expenditure 
reports (Form CMS-64) for FY 2010 following the end of FY 2011.

B. Calculation of the Final FY 2009 and Preliminary FY 2011 IMD DSH 
Limits

    As discussed in section I.E. and I.H.3 above of this notice, 
section 1923(h) of the Act specifies the methodology to be used to 
establish the limits on the amount of DSH payments that a State can 
make to IMDs and other mental health facilities. FFP is not available 
for IMD or DSH payments that exceed the IMD limits. In this notice, we 
are publishing the final FY 2009 IMD DSH Limit and the preliminary FY 
2011 IMD DSH Limit determined in accordance with the provisions 
discussed above, and for FY 2009, reflecting the DSH allotments for the 
FY determined under the provisions of section 1923(f)(3)(E) of the Act, 
as amended by section 5002 of the Recovery Act.
    Charts 3 and 4 of the Addendum to this notice detail each State's 
final IMD DSH Limit for FY 2009 and the preliminary IMD DSH Limit for 
FY 2011, respectively, determined in accordance with section 1923(h) of 
the Act.

III. 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).

IV. Regulatory Impact Statement

    We have examined the impact of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 1993), 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 Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). This notice 
does reach the $100 million economic threshold and thus is considered a 
major rule under the Congressional Review Act.
    There are no changes between the revised preliminary and final FY 
2009 DSH allotments and FY 2009 IMD DSH limits.
    The preliminary FY 2011 DSH allotments being published in this 
notice are about $365 million less than the preliminary FY 2010 DSH 
allotments published in the Federal Register on April 23, 2010 (75 FR 
21314). These decreases are a direct result of the application of the 
provisions of section 1923(f)(3) of the Act in the calculation of 
States' DSH allotments, and in particular the provisions of section 
1923(f)(3)(E) of the Act as amended by the Recovery Act (which provided 
for a temporary increase in States' DSH allotments for FY 2009 and FY 
2010 during the specified recession period) do not apply with respect 
to the FY 2011 and following FY DSH allotments.
    The preliminary FY 2011 IMD DSH Limits being published in this 
notice are about $23 million less than the preliminary FY 2010 IMD DSH 
Limits published in Federal Register on April 23, 2010 (75 FR 21314). 
This is because the DSH allotment for a FY is a factor in the 
determination of the IMD DSH limit for the FY, and since the 
preliminary FY 2011 DSH allotments were decreased as compared to the 
preliminary FY 2010 DSH allotments, the associated FY 2011 IMD DSH 
limits for some States were also decreased.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses, if a rule has a significant impact on a 
substantial number 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 $34.5 million in any one year. Individuals 
and States are not included in the definition of a small entity. We are 
not preparing an analysis for the RFA because the Secretary has 
determined that this notice will not have significant economic impact 
on a substantial number of small entities. Specifically, the effects of 
the various controlling statutes on providers are not impacted by a 
result of any independent regulatory impact and not this notice. The 
purpose of the notice is to announce the latest distributions as 
required by the statute.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule 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, we define a small rural 
hospital as a hospital that is located outside of a Core-Based 
Statistical Area for Medicaid payment regulations and has fewer than 
100 beds. We are not preparing analysis for section 1102(b) of the Act 
because the Secretary has determined that this notice will not have a 
significant impact on the operations of a substantial number of small 
rural hospitals.
    The Medicaid statute (including as most recently amended by the 
Recovery Act) specifies the methodology for determining the amounts of 
States' DSH allotments and IMD DSH limits; and as described previously, 
results in increases in States' DSH allotments and IMD DSH limits for 
the FYs referred to. The statute applicable to these allotments and 
limits does not apply to the determination of the amounts of DSH 
payments made to specific DSH hospitals; rather, these allotments and 
limits represent an overall limit on the total of such DSH payments. In 
this regard, we do not believe that this notice will have a significant 
economic impact on a substantial number of small entities.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending

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in any 1 year of $100 million in 1995 dollars, updated annually for 
inflation. In 2010, that threshold is approximately $135 million. This 
notice will have no consequential effect on State, local, or Tribal 
governments, in the aggregate, or on the private sector.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. Since this notice does not impose any costs on State or 
local governments, the requirements of E.O. 13132 are not applicable.

Alternatives Considered

    The methodologies for determining the States' fiscal year DSH 
allotments and IMD DSH Limits, as reflected in this notice, were 
established in accordance with the methodologies and formula for 
determining States' allotments as specified in statute. This notice 
does not put forward any further discretionary administrative policies 
for determining such allotments.

Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in the table below, we 
have prepared an accounting statement showing the classification of the 
estimated expenditures associated with the provisions of this notice. 
This table provides our best estimate of the change (decrease) in the 
Federal share of States' Medicaid DSH payments resulting from the 
application of the provisions of the Medicaid statute relating to the 
calculation of States' FY DSH allotments and the increase in the FY DSH 
allotments from FY 2010 to FY 2011.

 Table--Accounting Statement: Classification of Estimated Expenditures,
                         From FY 2010 to FY 2011
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  -$365.
From Whom To Whom?........................  Federal Government to
                                             States.
------------------------------------------------------------------------

    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

Addendum

    This addendum contains the charts 1 through 4 (preceded by 
associated keys) that are referred to in the preamble of this notice.
    Key to Chart 1. Final DSH Allotments for FY 2009.

       Key to Chart 1--Final DSH Allotments for Fiscal Year: 2009
    [The Final FY 2009 DSH Allotments for the NON-Low DSH States are
  presented in the top section of this chart, and the Final FY 2009 DSH
Allotments for the Low-DSH States are presented in the bottom section of
                              this chart.]
------------------------------------------------------------------------
                Column                             Description
------------------------------------------------------------------------
Column A..............................  State.
Column B..............................  1923(f)(3)(D) Test Met. This
                                         column indicates whether the
                                         ``FY Specified'' has occurred
                                         with respect to Non-Low DSH
                                         States, determined in
                                         accordance with section
                                         1923(f)(3)(D) of the Act.
                                         ``YES'' indicates the FY
                                         Specified has occurred; ``NOT
                                         MET'' indicates that the FY
                                         Specified has not occurred; and
                                         ``na'' indicates that this
                                         provision is not applicable.
                                         This provision is not
                                         applicable for Low-DSH States
                                         indicated in the bottom portion
                                         of chart 2.
Columns C-L...........................  For all States, the entries in
                                         Columns C through K present the
                                         determination of the final FY
                                         2009 DSH allotments as would be
                                         calculated without the
                                         application of section
                                         1923(f)(3)(E) of the Act as
                                         amended by section 5002 of
                                         ARRA. For all States, the
                                         entries in Column M present the
                                         calculation of the final FY
                                         2009 DSH Allotments, determined
                                         in accordance with the
                                         provisions of section 5002 of
                                         ARRA.
                                        For Non-Low DSH States indicated
                                         in the top portion of Chart 2,
                                         entries in Columns C through K
                                         are only for States meeting the
                                         ``FY Specified'' test (``YES''
                                         in Column B). For States not
                                         meeting the test indicated in
                                         Column B, these Columns
                                         indicate ``NA'', and for States
                                         for which such test is not
                                         applicable, these Columns
                                         indicate ``na''. For Low DSH
                                         States, entries are in the
                                         bottom portion of Chart 2.
Column C..............................  FY 2009 FMAPS. This column
                                         contains the States' FY 2009
                                         Federal Medical Assistance
                                         Percentages.
Column D..............................  FY 2008 DSH Allotment For States
                                         Meeting Test. This column
                                         contains the States' prior FY
                                         2008 DSH Allotments.
Column E..............................  FY 2008 Allotments X (1 +
                                         Percentage Increase in CPI-U):
                                         1.044. This column contains the
                                         amount in Column D increased by
                                         1 plus the percentage increase
                                         in the CPI-U for the prior FY
                                         (4.4 percent).
Column F..............................  FY 2009 TC MAP Exp. Incl. DSH.
                                         This column contains the amount
                                         of the States' actual FY 2009
                                         total computable medical
                                         assistance expenditures
                                         including DSH expenditures.
Column G..............................  FY 2009 TC MAP Exp. Net of DSH.
                                         This column contains the amount
                                         of the States' actual FY 2009
                                         total computable DSH
                                         expenditures.
Column H..............................  FY 2009 TC MAP Exp. Net of DSH.
                                         This column contains the amount
                                         of the States' actual FY 2009
                                         total computable medical
                                         assistance expenditures net of
                                         DSH expenditures, calculated as
                                         the amount in Column F minus
                                         the amount in Column G.
Column I..............................  12% AMOUNT. This column contains
                                         the amount of the ``12 percent
                                         limit'' in Federal share,
                                         determined in accordance with
                                         the provisions of section
                                         1923(f)(3) of the Act.
Column J..............................  Greater of FY 2008 Allotment or
                                         12% Limit. This column contains
                                         the greater of the State's
                                         prior FY (FY 2008) DSH
                                         allotment or the amount of the
                                         12% Limit, determined as the
                                         maximum of the amount in Column
                                         D or Column I.
Column K..............................  FY 2009 DSH Allotment PRE-ARRA.
                                         This column contains the
                                         States' FY 2009 DSH allotments
                                         as would be determined prior to
                                         ARRA, determined as the minimum
                                         of the amount in Column J or
                                         Column E. For Non-Low DSH
                                         States that have not met the
                                         ``FY Specified'' test (entry in
                                         Column B is ``NOT MET''), the
                                         amount in Column K is equal to
                                         the State's FY 2004 DSH
                                         allotment. For States for which
                                         the entry in Column B is
                                         ``na'', the amount in Column K
                                         is determined in accordance
                                         with the provisions of section
                                         1923(f)(6) of the Act.
Column L..............................  FY 2009 DSH Allotment Under
                                         ARRA. This column contains the
                                         State's FY 2009 DSH allotment
                                         as determined in accordance
                                         with section 5002 of ARRA, and
                                         calculated as the amount in
                                         Column K multiplied by 1.025.
Column M..............................  Final FY 2009 DSH Allotment
                                         Under ARRA. (Max of Col K or
                                         L.) This column contains the
                                         State's final FY 2009 DSH
                                         allotment as determined in
                                         accordance with section
                                         1923(f)(3)(E) of the Act as
                                         amended by section 5002 of
                                         ARRA, and determined as the
                                         maximum of the amount in Column
                                         K or L.
------------------------------------------------------------------------

[[Page 154]]

    Key to Chart 2. Preliminary DSH Allotments for FY 2011.

    Key to Chart 2--Preliminary DSH Allotments for Fiscal Year: 2011
 [The Preliminary FY 2011 DSH Allotments for the NON-Low DSH States are
 presented in the top section of this chart, and the Preliminary FY 2011
    DSH Allotments for the Low-DSH States are presented in the bottom
                         section of this chart.]
------------------------------------------------------------------------
                Column                             Description
------------------------------------------------------------------------
Column A..............................  State.
Column B..............................  1923(f)(3)(D) Test Met. This
                                         column indicates whether the
                                         ``FY Specified'' has occurred
                                         with respect to Non-Low DSH
                                         States, determined in
                                         accordance with section
                                         1923(f)(3)(D) of the Act.
                                         ``YES'' indicates the FY
                                         Specified has occurred; ``NOT
                                         MET'' indicates that the FY
                                         Specified has not occurred; and
                                         ``na'' indicates that this
                                         provision is not applicable.
                                         This provision is not
                                         applicable for Low-DSH States
                                         indicated in the bottom portion
                                         of chart 3.
Columns C-K...........................  For all States, the entries in
                                         Columns B through K present the
                                         determination of the
                                         preliminary FY 2011 DSH
                                         allotments as would be
                                         calculated without the
                                         application of section 5002 of
                                         ARRA since such provisions were
                                         only applicable for FY 2009 and
                                         FY 2010.
                                        For Non-Low DSH States indicated
                                         in the top portion of Chart 2,
                                         entries in Columns C through J
                                         are only for States meeting the
                                         ``FY Specified'' test (``YES''
                                         in Column B). For States not
                                         meeting the test indicated in
                                         Column B, these Columns
                                         indicate ``NA'', and for States
                                         for which such test is not
                                         applicable, these Columns
                                         indicate ``na''. For Low DSH
                                         States, entries are in the
                                         bottom portion of Chart 2.
Column C..............................  FY 2011 FMAPS. This column
                                         contains the States' FY 2011
                                         Federal Medical Assistance
                                         Percentages.
Column D..............................  FY 2010 DSH Allotment For States
                                         Meeting Test. This column
                                         contains the States' prior FY
                                         2010 DSH Allotments as would be
                                         determined without the
                                         application of section 5002 of
                                         ARRA.
Column E..............................  FY 2010 Allotments X (1 +
                                         Percentage Increase in CPI-U):
                                         1.018.
                                        This column contains the amount
                                         in Column D increased by 1 plus
                                         the percentage increase in the
                                         CPI-U for the prior FY (1.8
                                         percent).
Column F..............................  FY 2011 TC MAP Exp. Incl. DSH.
                                         This column contains the amount
                                         of the States' projected FY
                                         2011 total computable medical
                                         assistance expenditures
                                         including DSH expenditures.
Column G..............................  FY 2011 TC DSH Expenditures.
                                         This column contains the amount
                                         of the States' projected FY
                                         2011 total computable DSH
                                         expenditures.
Column H..............................  FY 2011 TC MAP Exp. Net of DSH.
                                        This column contains the amount
                                         of the States' projected FY
                                         2011 total computable medical
                                         assistance expenditures net of
                                         DSH expenditures, calculated as
                                         the amount in Column F minus
                                         the amount in Column G.
Column I..............................  12% AMOUNT. This column contains
                                         the amount of the ``12 percent
                                         limit'' in Federal share,
                                         determined in accordance with
                                         the provisions of section
                                         1923(f)(3) of the Act.
Column J..............................  Greater of FY 2010 Allotment or
                                         12% Limit. This column contains
                                         the greater of the State's
                                         prior FY (FY 2010) DSH
                                         allotment or the amount of the
                                         12% Limit, determined as the
                                         maximum of the amount in Column
                                         D or Column I.
Column K..............................  FY 2011 DSH Allotment. This
                                         column contains the States' FY
                                         2011 DSH allotments as would be
                                         determined without the
                                         application of the provisions
                                         of section 5002 of ARRA,
                                         determined as the minimum of
                                         the amount in Column J or
                                         Column E. For Non-Low DSH
                                         States that have not met the
                                         ``FY Specified'' test (entry in
                                         Column B is ``NOT MET''), the
                                         amount in Column K is equal to
                                         the State's FY 2004 DSH
                                         allotment. For States for which
                                         the entry in Column B is
                                         ``na'', the amount in Column K
                                         is determined in accordance
                                         with the provisions of section
                                         1923(f)(6) of the Act.
------------------------------------------------------------------------

    Key to Chart 3. Final IMD DSH Limit for FY 2009.

            Key to Chart 3--Final IMD DSH Limit for FY: 2009
  [Key to the Chart of the Final FY 2009 IMD Limitations.--The Final FY
   2009 IMD DSH Limits for the regular States are presented in the top
  section of this chart and the final FY IMD DSH Limits for the Low-DSH
        States are presented in the bottom section of the chart.]
------------------------------------------------------------------------
                Column                             Description
------------------------------------------------------------------------
Column A..............................  State.
Column B..............................  Inpatient Hospital Services FY
                                         95 DSH Total Computable. This
                                         column contains the States'
                                         total computable FY 1995
                                         inpatient hospital DSH
                                         expenditures as reported on the
                                         Form CMS-64.
Column C..............................  IMD and Mental Health Services
                                         FY 95 DSH Total Computable.
                                         This column contains the total
                                         computable FY 1995 mental
                                         health facility DSH
                                         expenditures as reported on the
                                         Form CMS-64 as of January 1,
                                         1997.
Column D..............................  Total Inpatient & IMD & Mental
                                         Health FY 95 DSH Total
                                         Computable, Col B + C. This
                                         column contains the total
                                         computation of all inpatient
                                         hospital DSH expenditures and
                                         mental health facility DSH
                                         expenditures for FY 1995 as
                                         reported on the Form CMS-64 as
                                         of January 1, 1997
                                         (representing the sum of Column
                                         B and Column C).
Column E..............................  Applicable Percentage Col C/D.
                                         This column contains the
                                         ``applicable percentage''
                                         representing the total
                                         computable FY 1995 mental
                                         health facility DSH
                                         expenditures divided by total
                                         computable all inpatient
                                         hospital and mental health
                                         facility DSH expenditures for
                                         FY 1995 (the amount in Column C
                                         divided by the amount in Column
                                         D). Per section
                                         1923(h)(2)(A)(ii)(III) of the
                                         Act, for FYs after FY 2002, the
                                         applicable percentage can be no
                                         greater than 33 percent.
Column F..............................  FY 2009 Allotment in FS Under
                                         ARRA. This column contains the
                                         States' final FY 2009 DSH
                                         allotments as determined under
                                         ARRA.
Column G..............................  FY 2009 FMAP. This column
                                         contains the States' FY 2009
                                         FMAPs.
Column H..............................  FY 2009 DSH Allotments in TC.
                                         Col. F/G. This column contains
                                         the FY 2009 total computable
                                         DSH Allotment (determined as
                                         the amount in Column F divided
                                         by the amount in Column G).
Column I..............................  Col E * Col H in TC. This column
                                         contains the applicable percent
                                         of FY 2008 total computable DSH
                                         allotment (calculated as the
                                         amount in Column E multiplied
                                         by the amount in Column H).

[[Page 155]]

 
Column J..............................  FY 2009 TC IMD DSH Limit. Lesser
                                         of Col. C or I. This column
                                         contains the FY 2009 TC IMD DSH
                                         Limit equal to the lesser of
                                         the amount in Column C or
                                         Column I.
Column K..............................  FY 2009 IMD DSH Limit in FS U/
                                         ARRA. Col. G x J. This column
                                         contains the FY 2009 Federal
                                         share IMD DSH limit determined
                                         by converting the total
                                         computable FY 2009 IMD DSH
                                         Limit from Column J into a
                                         Federal share amount by
                                         multiplying it by the FY 2009
                                         FMAP in Column G.
------------------------------------------------------------------------

    Key to Chart 4. Preliminary IMD DSH Limit for FY 2011.

         Key to Chart 4--Preliminary IMD DSH Limit for FY: 2011
  [Key to the Chart of the FY 2011 IMD Limitations--The preliminary FY
 2011 IMD DSH Limits for the Non-Low DSH States are presented in the top
section of this chart and the preliminary FY 2011 IMD DSH Limits for the
    Low-DSH States are presented in the bottom section of the chart.]
------------------------------------------------------------------------
                Column                             Description
------------------------------------------------------------------------
Column A..............................  State.
Column B..............................  Inpatient Hospital Services FY
                                         95 DSH Total Computable. This
                                         column contains the States'
                                         total computable FY 1995
                                         inpatient hospital DSH
                                         expenditures as reported on the
                                         Form CMS-64.
Column C..............................  IMD and Mental Health Services
                                         FY 95 DSH Total Computable.
                                         This column contains the total
                                         computable FY 1995 mental
                                         health facility DSH
                                         expenditures as reported on the
                                         Form CMS-64 as of January 1,
                                         1997.
Column D..............................  Total Inpatient & IMD & Mental
                                         Health FY 95 DSH Total
                                         Computable, Col. B + C. This
                                         column contains the total
                                         computation of all inpatient
                                         hospital DSH expenditures and
                                         mental health facility DSH
                                         expenditures for FY 1995 as
                                         reported on the Form CMS-64 as
                                         of January 1, 1997
                                         (representing the sum of Column
                                         B and Column C).
Column E..............................  Applicable Percent Col. C/D.
                                         This column contains the
                                         ``applicable percentage''
                                         representing the total
                                         Computable FY 1995 mental
                                         health facility DSH
                                         expenditures divided by total
                                         computable all inpatient
                                         hospital and mental health
                                         facility DSH expenditures for
                                         FY 1995 (the amount in Column C
                                         divided by the amount in Column
                                         D) Per section
                                         1923(h)(2)(A)(ii)(III) Of the
                                         Act, for FYs after FY 2002, the
                                         applicable Percentage can be no
                                         greater than 33 percent.
Column F..............................  FY 2011 Federal Share DSH
                                         Allotment. This column contains
                                         the States' preliminary FY 2011
                                         DSH allotments.
Column G..............................  FY 2011 FMAP. This column
                                         contains the States' FY 2010
                                         FMAPs.
Column H..............................  FY 2011 DSH Allotments in Total
                                         Computable Col. F/G. This
                                         column contains States' FY 2011
                                         total computable DSH allotment
                                         (determined as Column F/Column
                                         G).
Column I..............................  Col E * Col H in TC. This column
                                         contains the applicable percent
                                         of FY 2010 total computable DSH
                                         allotment (calculated as the
                                         percentage in Column E
                                         multiplied by the amount in
                                         Column H).
Column J..............................  FY 2011 TC IMD DSH Limit. Lesser
                                         of Col. C or I. This column
                                         contains the FY 2011 TC IMD DSH
                                         Limit equal to the lesser of
                                         the amount in Column C or
                                         Column I.
Column K..............................  FY 2011 IMD DSH Limit in Federal
                                         Share, Col. G x J. This column
                                         contains the FY 2011 Federal
                                         share IMD DSH limit determined
                                         by converting the total
                                         computable FY 2011 IMD DSH
                                         Limit from Column J into a
                                         Federal share amount by
                                         multiplying it by the FY 2011
                                         FMAP in Column G.
------------------------------------------------------------------------

BILLING CODE 4120-01-P

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(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: October 20, 2010.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: November 17, 2010.
Kathleen Sebelius,
Secretary.
[FR Doc. 2010-32979 Filed 12-30-10; 8:45 am]
BILLING CODE 4120-01-C
```