Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6475 

action is not a significant regulatory 

action under Executive Order 12866. 

I. National Technology Transfer and 

Advancement Act (NTTAA) 

In addition, since this action does not 

involve any technical standards, 

NTTAA section 12(d) (15 U.S.C. 272 

note), does not apply to this action. 

J. Executive Order 12898 

This action does not entail special 

considerations of environmental justice 

related issues as delineated by 

Executive Order 12898, entitled 

‘‘Federal Actions to Address 

Environmental Justice in Minority 

Populations and Low-Income 

Populations’’ (59 FR 7629, February 16, 

1994). 

XI. Congressional Review Act (CRA) 

Pursuant to the Congressional Review 

Act (5 U.S.C. 801 et seq.), EPA will 

submit a report containing this rule and 

other required information to the U.S. 

Senate, the U.S. House of 

Representatives, and the Comptroller 

General of the United States prior to 

publication of the rule in the Federal 

Register. This action is not a ‘‘major 

rule’’ as defined by 5 U.S.C. 804(2). 

List of Subjects 

40 CFR Part 9 

Environmental protection, Reporting 

and recordkeeping requirements. 

40 CFR Part 721 

Environmental protection, Chemicals, 

Hazardous substances, Reporting and 

recordkeeping requirements. 

Dated: January 20, 2014. 

Maria J. Doa, 

Director, Chemical Control Division, Office 

of Pollution Prevention and Toxics. 

Therefore, 40 CFR parts 9 and 721 are 

amended as follows: 

PART 9—[AMENDED] 

■ 1. The authority citation for part 9 

continues to read as follows: 

Authority: 7 U.S.C. 135 et seq., 136–136y; 

15 U.S.C. 2001, 2003, 2005, 2006, 2601–2671; 

21 U.S.C. 331j, 346a, 348; 31 U.S.C. 9701; 33 

U.S.C. 1251 et seq., 1311, 1313d, 1314, 1318, 

1321, 1326, 1330, 1342, 1344, 1345(d) and 

(e), 1361; E.O. 11735, 38 FR 21243, 3 CFR, 

1971–1975 Comp. p. 973; 42 U.S.C. 241, 

242b, 243, 246, 300f, 300g, 300g-1, 300g-2, 

300g-3, 300g-4, 300g-5, 300g-6, 300j-1, 300j2, 300j-3, 300j-4, 300j-9, 1857 et seq., 6901– 

6992k, 7401–7671q, 7542, 9601–9657, 11023, 

11048. 

■ 2. In § 9.1, add the following section 

in numerical order under the 

undesignated center heading 

‘‘Significant New Uses of Chemical 

Substances’’ to read as follows: 

§ 9.1 OMB approvals under the Paperwork 

Reduction Act. 

* * * * * 

40 CFR citation OMB Control No. 

*****

Significant New Uses of Chemical 

Substances 

*****

721.10423 2070–0012 

*****

* * * * * 

PART 721—[AMENDED] 

■ 3. The authority citation for part 721 

continues to read as follows: 

Authority: 15 U.S.C. 2604, 2607, and 

2625(c). 

■ 4. Add § 721.10423 to subpart E to 

read as follows: 

§ 721.10423 Complex strontium aluminate, 

rare earth doped (generic). 

(a) Chemical substances and 

significant new uses subject to reporting. 

(1) The chemical substances identified 

generically as complex strontium 

aluminate, rare earth doped (PMNs P– 

12–22, P–12–23, P–12–24, P–12–25, and 

P–12–26) are subject to reporting under 

this section for the significant new uses 

described in paragraph (a)(2) of this 

section. 

(2) The significant new uses are: 

(i) Industrial, commercial, and 

consumer activities. A significant new 

use of the substance is a use other than 

manufacture, processing, or use where 

no more than 5 percent of particles are 

less than 10 microns. 

(ii) [Reserved] 

(b) Specific requirements. The 

provisions of subpart A of this part 

apply to this section except as modified 

by this paragraph. 

(1) Recordkeeping. Recordkeeping 

requirements as specified in 

§ 721.125(a), (b), (c), and (i) are 

applicable to manufacturers, importers, 

and processors of this substance. 

(2) Limitations or revocation of 

certain notification requirements. The 

provisions of § 721.185 apply to this 

section. 

[FR Doc. 2014–02223 Filed 2–3–14; 8:45 am] 

BILLING CODE 6560–50–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 424 

[CMS–6046–N] 

Medicare, Medicaid, and Children’s 

Health Insurance Programs: 

Announcement of New and Extended 

Temporary Moratoria on Enrollment of 

Ambulances and Home Health 

Agencies in Designated Geographic 

Locations 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Extension and establishment of 

temporary moratoria. 

SUMMARY: This document announces the 

imposition of temporary moratoria on 

the enrollment of new ambulance 

suppliers and home health agencies in 

designated geographic locations to 

prevent and combat fraud, waste, and 

abuse. 

DATES: Effective January 30, 2014. 

FOR FURTHER INFORMATION CONTACT: 

August Nemec, (410) 786–0612. News 

media representatives must contact 

CMS’ Public Affairs Office at (202) 690– 

6145 or email them at press@

cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. CMS’ Authority To Impose 

Temporary Enrollment Moratoria 

Under the Patient Protection and 

Affordable Care Act (Pub. L. 111–148), 

as amended by the Health Care and 

Education Reconciliation Act of 2010 

(Pub. L. 111–152) (collectively known as 

the Affordable Care Act), the Congress 

provided the Secretary with new tools 

and resources to combat fraud, waste, 

and abuse in Medicare, Medicaid, and 

the Children’s Health Insurance 

Program (CHIP). Section 6401(a) of the 

Affordable Care Act added a new 

section 1866(j)(7) to the Social Security 

Act (the Act) to provide the Secretary 

with authority to impose a temporary 

moratorium on the enrollment of new 

Medicare, Medicaid or CHIP providers 

and suppliers, including categories of 

providers and suppliers, if the Secretary 

determines a moratorium is necessary to 

prevent or combat fraud, waste, or abuse 

under these programs. Section 6401(b) 

of the Affordable Care Act added 

specific moratorium language applicable 

to Medicaid at section 1902(kk)(4) of the 

Act, requiring States to comply with any 


tkelley on DSK3SPTVN1PROD with RULES
6476 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

1The Secretary has delegated to CMS authority to 

administer Titles XVIII, XIX, and XXI of the Act. 

For more information, see the September 6, 1984 

Federal Register (49 FR 35247) and the December 

16, 1997 Federal Register (62 FR 65813). 

2Although section 6501 of Affordable Care Act 

does not specifically state that individuals or 

entities that have been terminated under Medicare 

or Medicaid must also be terminated from CHIP, 

CMS has required CHIP, through federal regulation, 

to take similar action regarding termination of a 

provider that is also terminated or had its billing 

privileges revoked under Medicare or any State 

Medicaid plan. 

moratorium imposed by the Secretary 

unless the state determines that the 

imposition of such moratorium would 

adversely impact Medicaid 

beneficiaries’ access to care. Section 

6401(c) of the Affordable Care Act 

amended section 2107(e)(1) of the Act to 

provide that all of the Medicaid 

provisions in sections 1902(a)(77) and 

1902(kk) are also applicable to CHIP. 

In the February 2, 2011 Federal 

Register (76 FR 5862), CMS published a 

final rule with comment period titled, 

‘‘Medicare, Medicaid, and Children’s 

Health Insurance Programs; Additional 

Screening Requirements, Application 

Fees, Temporary Enrollment Moratoria, 

Payment Suspensions and Compliance 

Plans for Providers and Suppliers,’’ 

which implemented section 1866(j)(7) of 

the Act by establishing new regulations 

at 42 CFR 424.570. Under 

§ 424.570(a)(2)(i) and (iv), CMS, or CMS 

in consultation with the Department of 

Health and Human Services’ Office of 

Inspector General (HHS–OIG) or the 

Department of Justice (DOJ), or both, 

may impose a temporary moratorium on 

newly enrolling Medicare providers and 

suppliers if CMS determines that there 

is a significant potential for fraud, 

waste, or abuse with respect to a 

particular provider or supplier type or 

particular geographic locations or both. 

At § 424.570(a)(1)(ii), CMS stated that it 

would announce any temporary 

moratorium in a Federal Register 

document that includes the rationale for 

the imposition of such moratorium. This 

document fulfills that requirement. 

In accordance with section 

1866(j)(7)(B) of the Act, there is no 

judicial review under sections 1869 and 

1878 of the Act, or otherwise, of the 

decision to impose a temporary 

enrollment moratorium. A provider or 

supplier may use the existing appeal 

procedures at 42 CFR part 498 to 

administratively appeal a denial of 

billing privileges based on the 

imposition of a temporary moratorium, 

however the scope of any such appeal 

would be limited solely to assessing 

whether the temporary moratorium 

applies to the provider or supplier 

appealing the denial. Under 

§ 424.570(c), CMS denies the enrollment 

application of a provider or supplier if 

the provider or supplier is subject to a 

moratorium. If the provider or supplier 

was required to pay an application fee, 

the application fee will be refunded if 

the application was denied as a result of 

the imposition of a temporary 

moratorium (see § 424.514(d)(2)(v)(C)). 

B. Determination of the Need for a 

Moratorium 

In imposing these enrollment 

moratoria, CMS considered both 

qualitative and quantitative factors 

suggesting a high risk of fraud, waste, or 

abuse. CMS relied on law enforcement’s 

longstanding experience with ongoing 

and emerging fraud trends and activities 

through civil, criminal, and 

administrative investigations and 

prosecutions. CMS’ determination of 

high risk fraud in these provider and 

supplier types within these geographic 

locations was then confirmed by CMS’ 

data analysis, which relied on factors 

the agency identified as strong 

indicators of fraud risk. 

Because fraud schemes are highly 

migratory and transitory in nature, 

many of CMS’ program integrity 

authorities and anti-fraud activities are 

designed to allow the agency to adapt to 

emerging fraud in different locations. 

The laws and regulations governing 

CMS’ moratoria authority give us 

flexibility to use any and all relevant 

criteria for future moratoria, and CMS 

may rely on additional or different 

criteria as the basis for future moratoria. 

1. Application to Medicaid and the 

Children’s Health Insurance Program 

(CHIP) 

The February 2, 2011 final rule also 

implemented section 1902(kk)(4) of the 

Act, establishing new Medicaid 

regulations at § 455.470. Under 

§ 455.470(a)(1) through (3), the 

Secretary 1 may impose a temporary 

moratorium, in accordance with 

§ 424.570, on the enrollment of new 

providers or provider types after 

consulting with any affected State 

Medicaid agencies. The State Medicaid 

agency will impose a temporary 

moratorium on the enrollment of new 

providers or provider types identified 

by the Secretary as posing an increased 

risk to the Medicaid program unless the 

state determines that the imposition of 

a moratorium would adversely affect 

Medicaid beneficiaries’ access to 

medical assistance and so notifies the 

Secretary. The final rule also 

implemented section 2107(e)(1)(D) of 

the Act by providing, at § 457.990 of the 

regulations, that all of the provisions 

that apply to Medicaid under sections 

1902(a)(77) and 1902(kk) of the Act, as 

well as the implementing regulations, 

also apply to CHIP. 

Section 1866(j)(7) of the Act 

authorizes imposition of a temporary 

enrollment moratorium for Medicare, 

Medicaid, and/or CHIP, ‘‘if the Secretary 

determines such moratorium is 

necessary to prevent or combat fraud, 

waste, or abuse under either such 

program.’’ While there may be 

exceptions, CMS believes that generally, 

a category of providers or suppliers that 

poses a risk to the Medicare program 

also poses a similar risk to Medicaid 

and CHIP. Many of the new anti-fraud 

provisions in the Affordable Care Act 

reflect this concept of ‘‘reciprocal risk’’ 

in which a provider that poses a risk to 

one program poses a risk to the other 

programs. For example, section 6501 of 

the Affordable Care Act titled, 

‘‘Termination of Provider Participation 

under Medicaid if Terminated Under 

Medicare or Other State Plan,’’ which 

amends section 1902(a)(39) of the Act, 

requires State Medicaid agencies to 

terminate the participation of an 

individual or entity if such individual 

or entity is terminated under Medicare 

or any other State Medicaid plan.2

Additional provisions in title VI, 

Subtitles E and F of the Affordable Care 

Act also support the determination that 

categories of providers and suppliers 

pose the same risk to Medicaid as to 

Medicare. Section 6401(a) of the 

Affordable Care Act required us to 

establish levels of screening for 

categories of providers and suppliers 

based on the risk of fraud, waste, and 

abuse determined by the Secretary. 

Section 6401(b) of the Affordable Care 

Act required State Medicaid agencies to 

screen providers and suppliers based on 

the same levels established for the 

Medicare program. This reciprocal 

concept is also reflected in the Medicare 

moratoria regulations at 

§ 424.570(a)(2)(ii) and (iii), which 

permit CMS to impose a Medicare 

moratorium based solely on a state 

imposing a Medicaid moratorium. 

Therefore, CMS has determined that 

there is a reasonable basis for 

concluding that a category of providers 

or suppliers that poses a risk to 

Medicare also poses a similar risk to 

Medicaid and CHIP, and that a 

moratorium in all of these programs is 

necessary to effectively combat this risk. 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6477 

3The HEAT Medicare Strike Force operates in 

Miami, FL; Los Angeles, CA: Detroit, MI; Houston, 

TX; Brooklyn, NY; Southern Louisiana (the Strike 

Force in Southern Louisiana started in Baton Rouge 

and now operates in New Orleans as well); Tampa, 

FL; Chicago, IL; and Dallas, TX. 

4Testimony of the Inspector General, ‘‘Preventing 

Health Care Fraud: New Tools and Approaches to 

Combat Old Challenges.’’ See http://www.hhs.gov/ 

asl/testify/2011/03/t20110302i.html. 

5MedPAC, March 2013, ‘‘Report to Congress: 

Medicare Payment Policy, Chapter 9 home health 

services.’’ http://www.medpac.gov/documents/

Mar13_entirereport.pdf. 

6MedPAC, June 2013, ‘‘Chapter 7, Mandated 

Report: Medicare payment for ambulance services.’’ 

http://www.medpac.gov/chapters/Jun13_Ch07.pdf. 

7MedPAC, March 2013, ‘‘Report to Congress: 

Medicare Payment Policy, Chapter 9 home health 

services.’’ http://www.medpac.gov/documents/

Mar13_entirereport.pdf. 

2. Consultation With Law Enforcement 

In consultation with the HHS–OIG 

and the Department of Justice (DOJ), 

CMS identified two provider and 

supplier types in five geographic 

locations that warrant a temporary 

enrollment moratorium. CMS reached 

this determination based in part on the 

federal government’s experience with 

the Health Care Fraud Prevention and 

Enforcement Action Team (HEAT), a 

joint effort between DOJ and HHS to 

prevent fraud, waste, and abuse in the 

Medicare and Medicaid programs. The 

Medicare Fraud Strike Force teams are 

a key component of HEAT and operate 

in nine locations nationwide.3 Each 

HEAT Medicare Fraud Strike Force 

team combines the programmatic and 

administrative action capabilities of 

CMS, the analytic and investigative 

resources of the FBI and HHS–OIG, and 

the prosecutorial resources of DOJ’s 

Criminal Division’s Fraud Section and 

the United States Attorney’s Offices. 

The Strike Force teams use advanced 

data analysis techniques to identify high 

billing levels in health care fraud 

hotspots so that interagency teams can 

target emerging or migrating schemes 

along with chronic fraud by criminals 

masquerading as health care providers 

or suppliers. The locations of the Strike 

Force teams are identified by analyzing 

where Medicare claims data reveal 

aberrant billing patterns and 

intelligence data analysis suggests that 

fraud may be occurring. The presence of 

a Strike Force team within or near a 

particular geographic area is one factor 

that CMS considered in identifying the 

locations subject to the moratoria 

announced in this document. 

As a part of ongoing antifraud efforts, 

the HHS–OIG and CMS have learned 

that some fraud schemes are viral, 

meaning they replicate rapidly within 

communities, and that health care fraud 

also migrates—as law enforcement 

cracks down on a particular scheme, the 

criminals may redesign the scheme or 

relocate to a new geographic area.4 As 

a result, CMS has determined that it is 

necessary to extend these moratoria 

beyond the target counties to bordering 

counties, unless otherwise noted, to 

prevent potentially fraudulent providers 

and suppliers from enrolling in a 

neighboring county with the intent of 

providing services in a moratoriumtargeted area. CMS will monitor the 

surrounding counties, as well as the 

entirety of each affected state, by 

reviewing claims utilization and 

activity, for indicia of activity designed 

to evade these moratoria. Throughout 

the duration of these moratoria, CMS 

will continue to consult with law 

enforcement, to assess and address the 

spread of any significant risk of fraud 

beyond the moratoria locations. 

3. Data Analysis 

CMS analyzed its own data to 

determine the extent to which it 

confirms the specific provider and 

supplier types within geographic 

locations recommended by law 

enforcement as having a significant 

potential for fraud, waste or abuse, and 

therefore warranting the imposition of 

enrollment moratoria. CMS identified 

all counties across the nation with 

200,000 or more Medicare beneficiaries 

(‘‘comparison counties’’), and analyzed 

certain key metrics, which we believe to 

be strong indicators of potential fraud 

risk. These metrics included factors 

such as the number of providers or 

suppliers per 10,000 Medicare fee-forservice (FFS) beneficiaries and the 

compounded annual growth rate in 

provider or supplier enrollments. CMS 

also reviewed the 2012 FFS Medicare 

payments to providers and suppliers in 

the target locations based on the average 

amount spent per beneficiary who used 

services furnished by the targeted 

provider and supplier types. 

The four locations subject to the 

temporary enrollment moratoria for 

home health agencies (HHAs) are 

counties that contain or are adjacent to 

HEAT Medicare Fraud Strike Force 

locations and are also consistently 

ranked near the top for the identified 

metrics among counties with at least 

200,000 Medicare beneficiaries in 2012. 

See Table 1 of this document for a 

summary of the moratoria locations and 

some of the metrics examined. 

4. Beneficiary Access To Care 

Beneficiary access to care in 

Medicare, Medicaid, and CHIP is of 

critical importance to CMS and its state 

partners, and CMS carefully evaluated 

access for the five target moratorium 

locations. To determine if the moratoria 

would create an access to care issue for 

Medicaid and CHIP beneficiaries in the 

targeted locations and surrounding 

counties, CMS consulted with the 

appropriate State Medicaid Agencies 

and with the appropriate State 

Department of Emergency Medical 

Services. All of CMS’ state partners 

were supportive of CMS analysis and 

proposals, and together with CMS, have 

determined that these moratoria will not 

create access to care issues for Medicaid 

or CHIP beneficiaries. 

In order to determine if the moratoria 

would create an access to care issue for 

Medicare beneficiaries, CMS reviewed 

its own data regarding the number of 

providers and suppliers in the target 

and surrounding counties, and 

confirmed that there are no reports to 

CMS of access to care issues for these 

provider and supplier types. This 

conclusion is also supported by recent 

reports issued by the Medicare Payment 

Advisory Commission (MedPAC), an 

independent Congressional agency 

established by the Balanced Budget Act 

of 1997 to advise Congress on issues 

affecting the Medicare program. 

MedPAC has a Congressional mandate 

to monitor beneficiaries’ access to care 

and publishes its review of Medicare 

expenditures annually. Based on 

MedPAC’s March 2013 report (finding 

no access issues to Medicare home 

health services 5), and its June 2013 

report (finding no access issues to 

Medicare ambulance services 6), CMS 

does not believe these moratoria will 

cause an access to care issue for 

Medicare beneficiaries. 

In the March 2013 report, MedPAC 

also recommended that CMS use its 

authorities under current law to 

examine providers with aberrant 

patterns of utilization for possible fraud 

and abuse. With regard to home health 

services, MedPAC stated that a 

moratorium on the enrollment of new 

HHAs would prevent new agencies from 

entering markets that may already be 

saturated.7 CMS will continuously 

monitor for reductions in the number of 

HHA providers and Part B ambulance 

suppliers, as well as beneficiary 

complaints, and will continue 

consultation with the states, for any 

indication of a potential access to care 

issue. 

5. When a Temporary Moratorium Does 

Not Apply 

Under § 424.570(a)(1)(iii), a temporary 

moratorium does not apply to changes 

in practice locations, changes to 

provider or supplier information such as 

phone number, address, or changes in 

ownership (except changes in 


tkelley on DSK3SPTVN1PROD with RULES
6478 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

8HHS and DOJ, ‘‘Health Care Fraud and Abuse 

Control Program Annual Report for Fiscal Year 

2012.’’ See http://oig.hhs.gov/publications/docs/

hcfac/hcfacreport2012.pdf. 9Office of Inspector General Report, ‘‘CMS and 

Contractor Oversight of Home Health Agencies.’’ 

(OEI–04–11–00220). See https://oig.hhs.gov/oei/

reports/oei-04-11-00220.pdf. The HHS–OIG defines 

an ‘‘HHA fraud-prone area’’ as those that are—(1) 

Strike Force Cities; (2) Strike Force cities where 

individuals have been charged with billing 

potentially fraudulent home health services; and (3) 

located in a state that had a high percentage of 

HHAs with questionable billing identified by the 

HHS–OIG. 

10 Department of Justice, ‘‘US Intervenes in False 

Claims Act Lawsuit Against Fla. Home Health Care 

Company and Its Owner.’’ See http://

www.justice.gov/opa/pr/2013/July/13-civ-717.html. 

11CMS’s data shows that there are 31 counties 

that have at least 200,000 Medicare beneficiaries. 

For the home health analysis, 27 ‘‘comparison 

counties’’ are used. Besides Broward, three other 

counties were excluded from the comparison 

counties. New York County, NY, is excluded due 

to unique local conditions, such as that location’s 

high density, its compact geography, its high real 

estate costs, and the fact that very few HHAs that 

serve the large number of beneficiaries in that 

location are actually located within New York 

County. We believe that this outlier would have 

biased the average by making it artificially low, and 

could potentially over-represent the difference in 

ratios between the target county and the 

comparison counties. Miami-Dade County, FL and 

Cook County, IL are also excluded because CMS 

already determined that the data and other factors 

indicated a risk of fraud in those counties, and 

imposed HHA moratoria there on July 30, 2013, 

which are being extended by way of this document. 

12The areas with the highest ratio of providers to 

Medicare FFS beneficiaries are: Miami-Dade 

County, FL; Dallas County, TX; Harris County, TX; 

and Oakland County, MI. 

ownership of HHAs that require initial 

enrollments under § 424.550). Also, in 

accordance with § 424.570(a)(1)(iv), the 

moratorium does not apply to an 

enrollment application that a CMS 

contractor has already approved, but has 

not yet entered into the Provider 

Enrollment Chain and Ownership 

System (PECOS) at the time the 

moratorium is imposed. 

6. Lifting a Temporary Moratorium 

In accordance with § 424.570(b), a 

temporary enrollment moratorium 

imposed by CMS will remain in effect 

for 6 months. If CMS deems it 

necessary, the moratorium may be 

extended in 6-month increments. CMS 

will evaluate whether to extend or lift 

the moratorium before the end of the 

initial 6-month period and, if 

applicable, any subsequent moratorium 

periods. If one or more of the moratoria 

announced in this document are 

extended, CMS will publish document 

of such extensions in the Federal 

Register. 

As provided in § 424.570(d), CMS 

may lift a moratorium at any time if the 

President declares an area a disaster 

under the Robert T. Stafford Disaster 

Relief and Emergency Assistance Act, if 

circumstances warranting the 

imposition of a moratorium have abated, 

if the Secretary has declared a public 

health emergency, or if in the judgment 

of the Secretary, the moratorium is no 

longer needed. 

Once a moratorium is lifted, the 

provider or supplier types that were 

unable to enroll because of the 

moratorium will be designated to CMS’ 

high screening level under 

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

for 6 months from the date the 

moratorium was lifted. 

II. Imposition of Home Health 

Moratoria—Geographic Locations 

Under its authority at 

§ 424.570(a)(2)(i) and (iv), CMS is 

implementing temporary moratoria on 

the Medicare enrollment of HHAs in the 

geographic locations discussed in this 

section. Under regulations at §§ 455.470 

and 457.990, these moratoria will also 

apply to the enrollment of HHAs in 

Medicaid and CHIP. 

A. Moratorium on Enrollment of HHAs 

in the Florida County of Broward 

CMS has determined that there are 

factors in place that warrant the 

imposition of a temporary Medicare 

enrollment moratorium for HHAs in 

Broward County (which contains the 

City of Fort Lauderdale, FL). Florida has 

divided the state into 11 home health 

‘‘licensing districts,’’ that prevent an 

HHA from providing services outside its 

own licensing district. Broward is the 

only county in its licensing district. In 

this instance, it is not necessary to 

extend the moratorium to the other 

counties that border Broward because of 

the state’s home health licensing rules 

that prevent providers enrolling in these 

counties from serving beneficiaries in 

Broward. CMS has also consulted with 

the State Medicaid Agency and 

reviewed available data, and determined 

that the moratorium will also apply to 

Medicaid and CHIP. 

Beginning on the effective date of this 

document, no new HHAs will be 

enrolled into Medicare, Medicaid or 

CHIP with a practice location in the 

Florida county of Broward, unless their 

enrollment application has already been 

approved, but not yet entered into 

PECOS or the State Provider/Supplier 

Enrollment System at the time the 

moratorium is imposed. 

1. Consultation With Law Enforcement 

Consistent with § 424.570(a)(2)(iv), 

CMS has consulted with both the HHS– 

OIG and DOJ regarding the imposition 

of a moratorium on new HHAs in 

Broward County. Both HHS–OIG and 

DOJ agree that a significant potential for 

fraud, waste, or abuse exists with 

respect to HHAs in the affected 

geographic location. Miami-Dade, which 

is adjacent to Broward, is a Strike Force 

location. CMS has identified these 

counties as the target of program 

integrity special projects, and 

beneficiaries that reside in these 

counties are the recipients of monthly 

Medicare Summary Notices due to the 

high risk of fraud in these counties.8

The HHS–OIG has previously identified 

Florida as a state that had a high 

percentage of HHAs with questionable 

billing.9 There has also been 

considerable Strike Force and law 

enforcement activity in this area of the 

country. In FYs 2012 and 2013, the U.S. 

Attorney’s Office for the Southern 

District of Florida charged 113 

defendants in 51 HHA cases, 55 

individuals pled guilty, and there have 

been 8 trial convictions, including cases 

that involved conduct in Broward. In 

addition to criminal prosecutions, the 

government has also pursued civil fraud 

enforcement, such as its intervention in 

July 2013 in a whistleblower lawsuit 

against a home health care company in 

Fort Lauderdale, alleging that the 

company was engaged in a multimillion dollar kickback scheme.10 CMS 

program integrity contractors are also 

actively investigating HHAs in this area. 

2. Data Analysis 

a. Medicare Data Analysis 

CMS’ data show that in 2012, there 

were 31 U.S. counties nationally, 

including Broward, with at least 

200,000 Medicare beneficiaries. CMS 

excluded Broward County, FL, New 

York County, NY, Miami-Dade County, 

FL and Cook County, IL, and used the 

remaining 27 counties as ‘‘comparison 

counties.’’ 11 In the comparison 

counties, there was an average of 5.9 

HHAs per 10,000 Medicare FFS 

beneficiaries. In Broward County, there 

were 11.2 HHAs per 10,000 Medicare 

FFS beneficiaries. This means that the 

ratio of HHAs to Medicare FFS 

beneficiaries was 89.8 percent greater in 

Broward County than in the comparison 

counties. Broward had the fifth highest 

ratio of providers, behind locations all 

also subject to moratoria on HHA 

enrollment.12

CMS’ data show that in 2012, HHAs 

in Broward County were receiving 

payments of $6,432 per average 

Medicare home health user per year, 

compared to HHAs in the comparison 

counties, which received payments of 

$5,387. Payments to HHAs in Broward 

were 19 percent greater than the average 

for the comparison counties. Broward 

had the sixth highest payments to 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6479 

13The areas with the highest payments providers 

to Medicare FFS are: Miami-Dade County, FL; 

Harris County, TX; Dallas County, TX; Tarrant 

County, TX; and Cook County, IL. 

14CMS used 2011 data from the Medicaid 

Statistical Information System (MSIS) because it 

was the most recent data available for all three 

states in this document. 

15Office of Inspector General Report, ‘‘CMS and 

Contractor Oversight of Home Health Agencies.’’ 

(OEI–04–11–00220). See https://oig.hhs.gov/oei/

reports/oei-04-11-00220.pdf. 

16 DOJ, ‘‘Local Home Health Agency Owners are 

sentenced for Roles in Nearly $1.3 million Health 

Care Fraud Conspiracy.’’ See http://

www.justice.gov/usao/txn/PressRelease/2013/

FEB2013/feb21opurum_george_agatha_hcf_

sen.html. 

17 DOJ, ‘‘Owners of Texas Home Health Services 

Company Pleads Guilty, Admits Role in $374 

million fraud scheme.’’ See http://www.fbi.gov/

dallas/press-releases/2012/owner-of-texas-homehealth-services-company-pleads-guilty-admits-rolein-374-million-fraud-scheme. 

18HHS and DOJ, ‘‘Health Care Fraud and Abuse 

Control Program Annual Report for Fiscal Year 

2012.’’ See http://oig.hhs.gov/publications/docs/

hcfac/hcfacreport2012.pdf. 

19See footnote 11 for explanation of the 3 

additional counties that were excluded for purposes 

of the HHA comparison county analysis. 

HHAs, behind locations all also subject 

to the moratoria on HHA enrollment.13

b. Medicaid Data Analysis 

As discussed previously in section 

I.B.1. of this document, CMS believes 

that generally, a category of providers or 

suppliers that poses a risk to the 

Medicare program also poses a similar 

risk to Medicaid and CHIP. In addition, 

the data also show a significantly higher 

annual utilization of Medicaid home 

health services in Broward County 

compared to the entire state. CMS 

compared Broward County against the 

rest of the state rather than against 

comparison counties nationally because 

Medicaid policies are not necessarily 

uniform across different states. In 

2011 14 in Broward County, Medicaid 

paid HHAs an average of $281,609 per 

provider per year, or 95 percent more 

than the average of $144,704 that 

Medicaid paid to HHAs in the rest of the 

state. 

3. Beneficiary Access to Care 

Based upon CMS’ consultation with 

the State Medicaid agency, CMS has 

concluded that imposing this temporary 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Broward at this time. 

Accordingly, under §§ 455.470 and 

457.990, this moratorium will apply to 

the enrollment of HHAs in Medicaid 

and CHIP, unless the State later 

determines that imposition of the 

moratorium will adversely impact 

beneficiary access to care and so notifies 

CMS under § 455.470(a)(3). 

CMS reviewed Medicare data for the 

target county, and found that there are 

no problems with access to HHAs in 

Broward. Additionally, as described in 

section I.B.4. of this document, MedPAC 

has not reported any problems with 

Medicare beneficiary access to home 

health care. While CMS has determined 

there are no access to care issues for 

Medicare beneficiaries, nevertheless, the 

agency will continuously monitor these 

locations under a moratorium for 

changes such as an increase in 

beneficiary complaints to ensure that no 

access to care issues arise in the future. 

B. Moratorium on Enrollment of HHAs 

in the Texas Counties of Dallas, Collin, 

Denton, Ellis, Kaufman, Rockwall, and 

Tarrant 

CMS has determined there are factors 

in place that warrant the imposition of 

a temporary enrollment moratorium for 

HHAs in Dallas County, TX (which 

contains the City of Dallas), as well as 

the six surrounding Texas counties— 

Collin, Denton, Ellis, Kaufman, 

Rockwall, and Tarrant. CMS has 

determined that it is necessary to extend 

this moratorium to the surrounding 

counties to prevent potentially 

fraudulent HHAs from enrolling in a 

neighboring county to avoid the 

moratorium. CMS has consulted with 

the State Medicaid agency and reviewed 

available data and determined that this 

moratorium will also apply to Medicaid 

and CHIP. 

Beginning on the effective date of this 

document, no new HHAs will be 

enrolled into Medicare, Medicaid or 

CHIP with a practice location in the 

Texas Counties of Dallas, Collin, 

Denton, Ellis, Kaufman, Rockwall, and 

Tarrant unless their enrollment 

application has already been approved 

but not yet entered into PECOS or the 

State Provider/Supplier Enrollment 

System at the time the moratorium is 

imposed. 

1. Consultation With Law Enforcement 

Consistent with § 424.570(a)(2)(iv), 

CMS has consulted with both the HHS– 

OIG and DOJ regarding the imposition 

of a moratorium on new HHAs in Dallas 

County, TX and the surrounding 

counties. Both HHS–OIG and DOJ agree 

that a significant potential for fraud, 

waste, or abuse exists with respect to 

HHAs in the affected geographic 

locations. The HHS–OIG has previously 

identified Dallas, TX as an HHA fraudprone area because it is a Strike Force 

location where individuals have been 

charged with billing potentially 

fraudulent home health services, and is 

located in a State that had a high 

percentage of HHAs with questionable 

billing identified by the OIG.15 There 

has also been considerable Strike Force 

and law enforcement activity in this 

area of the country. Since February 

2011, the Strike Force has filed 4 home 

health fraud cases, and charged 18 

individuals that have resulted in 7 

guilty pleas in Dallas county TX. For 

example, in February 2013, two owners 

of a Dallas, TX home health care agency, 

were sentenced to 37 months in federal 

prison for their roles in a nearly $1.3 

million health care fraud conspiracy.16

In October 2012, a Dallas, TX area home 

health services company owner 

admitted his role in a $374 million 

home health fraud scheme in which he 

and others conspired to bill Medicare 

for unnecessary services that were never 

performed.17 In February 2012, a 

Federal grand jury indicted a Dallas, TX 

area doctor and owner of an association 

of health care providers, along with five 

others, in a $374 million home health 

care fraud scheme, the largest fraud case 

ever indicted in terms of the amount of 

loss charged against a single doctor.18

2. Data Analysis 

a. Medicare Data Analysis 

CMS’ data show that in 2012, there 

were 31 U.S. counties nationally, 

including Dallas, TX, with at least 

200,000 Medicare beneficiaries. CMS 

excluded Dallas County, TX and three 

other counties as explained previously 

and used the remaining 27 counties as 

‘‘comparison counties.’’ 19 In 2012, there 

was an average of 5.2 HHAs per 10,000 

FFS beneficiaries in the comparison 

counties. In Dallas County, TX, there 

were 24.4 HHAs per 10,000 Medicare 

FFS beneficiaries. This means that the 

ratio of HHAs to FFS beneficiaries was 

369 percent greater in Dallas County, TX 

than in the comparison counties. Only 

Miami-Dade County, FL had a higher 

ratio of HHAs to Medicare FFS 

beneficiaries compared to the 

comparison counties. 

CMS’ data show that in 2012, HHAs 

in Dallas County, TX were receiving 

payments of $7,336 per average home 

health user per year, compared to HHAs 

in the comparison counties, which 

received payments of $5,312. Payments 

to HHAs in Dallas County, TX were 38 

percent higher than the average for 

HHAs in the comparison counties in 

2012. Only payments in the counties of 

Miami-Dade, FL and Harris, TX (which 

contains the City of Houston) were 

higher in 2012. 


tkelley on DSK3SPTVN1PROD with RULES
6480 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

20CMS used 2011 data from the Medicaid 

Statistical Information System (MSIS) because it 

was the most recent data available for all three 

states in this document. 

21Office of Inspector General Report, ‘‘CMS and 

Contractor Oversight of Home Health Agencies.’’ 

(OEI–04–11–00220). See https://oig.hhs.gov/oei/

reports/oei-04-11-00220.pdf. 

22 Department of Justice, ‘‘Houston-area Doctor 

Sentenced to 63 months in Prison for Role in $17.3 

Million Medicare Fraud Scheme.’’ See http://

www.justice.gov/opa/pr/2013/March/13-crm313.html. 

23HHS and DOJ, ‘‘Health Care Fraud and Abuse 

Control Program Annual Report for Fiscal Year 

2012.’’ See http://oig.hhs.gov/publications/docs/

hcfac/hcfacreport2012.pdf. 

24See footnote 11 for explanation of the 3 

additional counties that were excluded for purposes 

of the HHA comparison county analysis. 

b. Medicaid Data Analysis 

As discussed previously in section 

I.B.1. of this document, CMS believes 

that generally, a category of providers or 

suppliers that poses a risk to the 

Medicare program also poses a similar 

risk to Medicaid and CHIP. In addition, 

the data also show a significantly higher 

annual utilization of Medicaid home 

health services in Dallas County, TX 

compared to the entire state. CMS 

compared Dallas County, TX against the 

rest of the state rather than against 

comparison counties nationally because 

Medicaid policies are not necessarily 

uniform across different states. In 

2011 20 in Dallas County, TX Medicaid 

spent an average of $3,236 per home 

health user per year, or 35 percent more 

than the average $2,404 per home health 

user that Medicaid spent in the rest of 

the state. 

3. Beneficiary Access 

Based upon CMS’ consultation with 

the State Medicaid agency, CMS has 

concluded that imposing this temporary 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Dallas, TX or the 

surrounding counties at this time. 

Accordingly, under §§ 455.470 and 

457.990, this moratorium will apply to 

the enrollment of HHAs in Medicaid 

and CHIP, unless the State later 

determines that imposition of the 

moratorium will adversely impact 

beneficiary access to care and so notifies 

CMS under § 455.470(a)(3). 

CMS reviewed Medicare data for the 

target and surrounding counties, and 

found that there are no problems with 

access to HHAs in Dallas, TX or 

surrounding counties. Additionally, as 

described in section I.B.4 of this 

document, MedPAC has not reported 

any problems with Medicare beneficiary 

access to home health care. While CMS 

has determined there are no access to 

care issues for Medicare beneficiaries, 

nevertheless, the agency will 

continuously monitor these locations 

under a moratorium for changes, such as 

an increase in beneficiary complaints, to 

ensure that no access to care issues arise 

in the future. 

C. Moratorium on Enrollment of HHAs 

in the Texas Counties of Harris, 

Brazoria, Chambers, Fort Bend, 

Galveston, Liberty, Montgomery, and 

Waller 

CMS has determined that the 

imposition of a temporary enrollment 

moratorium for HHAs that enroll in 

Medicare, Medicaid or CHIP in Harris 

County, TX (which contains the City of 

Houston) is warranted, and is extending 

the moratorium to the seven 

surrounding counties—Brazoria, 

Chambers, Fort Bend, Galveston, 

Liberty, Montgomery, and Waller. CMS 

has determined that it is necessary to 

extend this moratorium to the 

surrounding counties to prevent 

potentially fraudulent HHAs from 

enrolling in a neighboring county to 

avoid the moratorium. CMS has also 

consulted with the State Medicaid 

Agency and reviewed available data and 

has determined that the moratorium 

will also apply to Medicaid and CHIP. 

Beginning on the effective date of this 

document, no new HHAs will be 

enrolled into Medicare, Medicaid or 

CHIP with a practice location in the 

Texas Counties of Harris, Brazoria, 

Chambers, Fort Bend, Galveston, 

Liberty, Montgomery or Waller unless 

their enrollment application has already 

been approved, but not yet entered into 

PECOS or the State Provider/Supplier 

Enrollment System at the time the 

moratorium is imposed. 

1. Consultation With Law Enforcement 

Consistent with § 424.570(a)(2)(iv), 

CMS has consulted with both the HHS– 

OIG and DOJ regarding the imposition 

of a moratorium on new Medicare, 

Medicaid or CHIP HHAs in Harris 

County, TX and surrounding counties. 

Both the HHS–OIG and DOJ agree that 

a significant potential for fraud, waste or 

abuse exists with respect to HHAs in the 

affected geographic locations. The HHS– 

OIG has previously identified Houston 

as an HHA fraud-prone area because it 

is a Strike Force location where 

individuals have been charged with 

billing potentially fraudulent home 

health services, and is located in a State 

that had a high percentage of HHAs 

with questionable billing identified by 

the OIG.21 There has also been 

considerable Strike Force and law 

enforcement activity in this area of the 

country. Since June 2010, the HEAT 

Strike Force has filed 7 cases in 

Houston, TX alleging home health 

fraud, and 16 individuals have been 

charged in connection with these cases 

resulting in 9 guilty pleas and 3 trial 

conviction. For example, in March 2013, 

a physician was sentenced to 63 months 

in prison for his role in a $17.3 million 

Medicare home health care fraud 

scheme.22 In June 2012, former coowners of a home health care company 

were sentenced to 9 years in prison for 

their participation in a $5.2 million 

fraud scheme.23

2. Data Analysis 

a. Medicare Data Analysis 

CMS’ data show that in 2012, there 

were 31 U.S. counties nationally, 

including Harris County, TX with at 

least 200,000 Medicare beneficiaries. 

CMS excluded Harris County, TX and 

three other counties as explained 

previously and used the remaining 27 

counties as ‘‘comparison counties.’’ 24 In 

the comparison counties in 2012, there 

was an average of 5.2 HHAs per 10,000 

Medicare FFS beneficiaries. In Harris 

County, TX, there were 19.6 HHAs per 

10,000 Medicare FFS beneficiaries. This 

means that the ratio of HHAs to 

Medicare FFS beneficiaries was 277 

percent greater in Harris County, TX 

than in the comparison counties. Harris 

County, TX had the third highest ratio 

of HHAs to Medicare FFS beneficiaries 

compared to the comparison counties, 

behind Miami-Dade, FL and Dallas, TX 

counties. 

CMS’ data show that in 2012, HHAs 

in Harris County, TX were receiving 

payments of $7,631 per average home 

health user per year, compared to HHAs 

in the comparison counties, which 

received payments of $5,253. Payments 

to HHAs in Dallas County, TX were 45 

percent higher than the average for 

HHAs in comparison counties in 2012, 

second only to Miami-Dade, FL. 

b. Medicaid Data Analysis 

As discussed previously in section 

I.B.1. of this document, CMS believes 

that generally, a category of providers or 

suppliers that poses a risk to the 

Medicare program also poses a similar 

risk to Medicaid and CHIP. In addition, 

the data also show a significantly higher 

annual utilization of Medicaid home 

health services in Harris County, TX 

compared to the entire state. CMS 

compared Harris County, TX against the 

rest of the state rather than against 

comparison counties nationally because 

Medicaid policies are not necessarily 

uniform across different states. In 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6481 

25CMS used 2011 data from the Medicaid 

Statistical Information System (MSIS) because it 

was the most recent data available for all three 

states in this document. 

26Office of Inspector General Report, ‘‘CMS and 

Contractor Oversight of Home Health Agencies.’’ 

(OEI–04–11–00220). See https://oig.hhs.gov/oei/

reports/oei-04-11-00220.pdf. 

27 DOJ, ‘‘Detroit Area Home Health Agency 

Owner Sentenced to 60 Months for Role in $13 

Million Health Care Fraud Scheme.’’ See http://

www.justice.gov/opa/pr/2013/May/13-crm544.html. 

28Federal Bureau of Investigation, ‘‘Detroit Home 

Health Company Employee Pleads Guilty to Role in 

Medicare Fraud Scheme.’’ See http://www.fbi.gov/

detroit/press-releases/2013/detroit-home-healthcompany-employee-pleads-guilty-to-role-inmedicare-fraud-scheme. 

29 DOJ, ‘‘Detroit-Area Home Health Agency Office 

Manager Convicted in $5.8 million Medicare Fraud 

Scheme.’’ See http://www.justice.gov/opa/pr/2013/

April/13-crm-443.html. 

30 DOJ, ‘‘Forty-Four Individuals Indicted in 

Health Care Fraud and Drug Distribution Scheme.’’ 

See http://www.justice.gov/usao/mie/news/2013/

2013_3_20_stayreal.html. 

31See footnote 11 for explanation of the 3 

additional counties that were excluded for purposes 

of the HHA comparison county analysis. 

32CMS used 2011 data from the Medicaid 

Statistical Information System (MSIS) because it 

was the most recent data available for all three 

states in this document. 

2011 25 in Harris County, TX Medicaid 

spent an average of $4,251 per home 

health user per year, or 83 percent more 

than the average of $2,324 per home 

health user that Medicaid spent in the 

rest of the state. 

3. Beneficiary Access 

Based upon CMS’ consultation with 

the State Medicaid agency, CMS has 

concluded that imposing this temporary 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Harris County, TX or the 

surrounding counties at this time. 

Accordingly, under §§ 455.470 and 

457.990, this moratorium will apply to 

the enrollment of HHAs in Medicaid 

and CHIP, unless the State later 

determines that imposition of the 

moratorium will adversely impact 

beneficiary access to care and so notifies 

CMS under § 455.470(a)(3). 

CMS reviewed Medicare data for the 

target and surrounding counties, and 

found that there are no problems with 

access to HHAs in Harris County, TX or 

surrounding counties. Additionally, as 

described in section I.B.4. of this 

document, MedPAC has not reported 

any problems with Medicare beneficiary 

access to home health care. While CMS 

has determined there are no access to 

care issues for Medicare beneficiaries, 

nevertheless, the agency will 

continuously monitor these locations 

under a moratorium for changes such as 

an increase in beneficiary complaints to 

ensure that no access to care issues arise 

in the future. 

D. Moratorium on Enrollment of HHAs 

in the Michigan Counties of Wayne, 

Macomb, Monroe, Oakland, and 

Washtenaw 

CMS has determined there are factors 

in place that warrant the imposition of 

a temporary enrollment moratorium for 

HHAs in Wayne County, MI (which 

contains the City of Detroit), as well as 

the four surrounding counties; Macomb, 

Monroe, Oakland, and Washtenaw. CMS 

has determined that it is necessary to 

extend this moratorium to the 

surrounding counties to prevent 

potentially fraudulent HHAs from 

enrolling in a neighboring county to 

avoid the moratorium. CMS has also 

consulted with the State Medicaid 

agency and reviewed available data and 

determined that the temporary 

moratorium will also apply to Medicaid 

and CHIP. 

Beginning on the effective date of this 

document, no new HHAs will be 

enrolled into Medicare, Medicaid or 

CHIP with a practice location in the 

Michigan Counties of Wayne, Macomb, 

Monroe, Oakland, and Washtenaw 

unless their enrollment application has 

already been approved but not yet 

entered into PECOS or the State 

Provider/Supplier Enrollment System at 

the time the moratorium is imposed. 

1. Consultation With Law Enforcement 

Consistent with § 424.570(a)(2)(iv), 

CMS has consulted with both the HHS– 

OIG and DOJ regarding the imposition 

of a moratorium on new HHAs in 

Wayne County, MI and the surrounding 

counties. Both HHS–OIG and DOJ agree 

that a significant potential for fraud, 

waste, or abuse exists with respect to 

HHAs in the affected geographic 

locations. The HHS–OIG has previously 

identified Detroit has an HHA fraudprone area because it is a Strike Force 

location where individuals have been 

charged with billing potentially 

fraudulent home health services, and is 

located in a State that had a high 

percentage of HHAs with questionable 

billing identified by the OIG.26 There 

has been considerable Strike Force and 

law enforcement activity in this area of 

the country. Since January 2010, the 

Strike Force filed 14 home health fraud 

cases, and charged 84 individuals that 

have resulted in 44 guilty pleas and 6 

trial convictions. For example, in May 

2013, a Detroit-area home health care 

agency owner was sentenced to 60 

months in prison for causing the 

submission of over $1 million in false 

and fraudulent billing to Medicare as 

part of a $13.8 million health care fraud 

conspiracy.27 In April 2013, an 

employee of a Detroit medical service 

company pled guilty for her role in a 

$24 million home health care fraud 

scheme.28 Also in April 2013, a federal 

jury in Detroit convicted the office 

manager of a home health agency for her 

participation in a $5.8 million Medicare 

fraud scheme.29 As of March 2013, 44 

individuals were charged in a health 

care fraud and drug distribution scheme 

that centered on an allegation that three 

home health agency owners would 

provide kickbacks, bribes, and other 

illegal benefits to physicians to induce 

them to write prescriptions for patients 

with Medicare, Medicaid, and private 

insurance.30

2. Data Analysis 

a. Medicare Data Analysis 

CMS data show that in 2012, there 

were 31 U.S. counties nationally, 

including Wayne County, MI with at 

least 200,000 Medicare beneficiaries. 

CMS excluded Wayne County, MI and 

three other counties as explained 

previously and used the remaining 27 

counties as ‘‘comparison counties.’’ 31 In 

2012, there was an average of 5.9 HHAs 

per 10,000 Medicare FFS beneficiaries 

in the comparison counties. In Wayne 

County, MI there were 7.1 HHAs per 

10,000 Medicare FFS beneficiaries. This 

means that the ratio of HHAs to FFS 

beneficiaries was 19 percent greater in 

Wayne County, MI than in the 

comparison counties. 

b. Medicaid Data Analysis 

As discussed previously in section 

I.B.1. of this document, CMS believes 

that generally, a category of providers or 

suppliers that poses a risk to the 

Medicare program also poses a similar 

risk to Medicaid and CHIP. 

Additionally, the data also show a 

significantly higher annual utilization of 

Medicaid home health services in 

Wayne County, MI compared to the 

entire state. CMS compared Wayne 

County, MI against the rest of the state 

rather than to comparison counties 

nationally because Medicaid policies 

are not necessarily uniform across 

different states. In 2011 32 in Wayne 

County, MI Medicaid paid HHAs an 

average of $26,981 per provider per 

year, or 24 percent more than the 

average of $21,842 that Medicaid paid 

HHAs in the rest of the state. 

3. Beneficiary Access 

Based upon CMS’ consultation with 

the State Medicaid agency, CMS has 

concluded that imposing this temporary 

moratorium will not create an access to 

care issue for Medicaid or CHIP 


tkelley on DSK3SPTVN1PROD with RULES
6482 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

33Medicare Claims Processing Manual, CMS Pub. 

No. 100–04, Chapter 15, ‘‘Ambulance.’’ See 

http://www.cms.gov/Regulations-and-Guidance/

Guidance/Manuals/downloads/clm104c15.pdf. 

34Medicare Program Integrity Manual, Chapter 

15, Medicare Enrollment. See http://www.cms.gov/ 

Regulations-and-Guidance/Guidance/Manuals/

downloads/pim83c15.pdf. 

35HHS and DOJ, ‘‘Health Care Fraud and Abuse 

Control Program Annual Report for Fiscal Year 

2012.’’ See http://oig.hhs.gov/publications/docs/

hcfac/hcfacreport2012.pdf. 36 DOJ, ‘‘Owner of Brotherly Love Ambulance 

Pleads Guilty to $2 million Health Care Fraud 

Scheme.’’ See http://www.justice.gov/usao/pae/

News/2013/Apr/kuranplea_release.htm. 37 DOJ, ‘‘Seven Charged in Health Care Fraud 

Scheme.’’ See http://www.justice.gov/usao/pae/

News/2013/Apr/pennchoice_release.htm. 

38CMS’ data shows that there are 31 counties that 

have at least 200,000 Medicare beneficiaries. 

Besides Philadelphia, for the ambulance analysis, 2 

additional locations were excluded leaving 28 

‘‘comparison counties’’. New York County is 

excluded due to unique local conditions, such as 

New York’s high density, its compact geography, 

and its high real estate costs. We believe that this 

outlier would have biased the average by making it 

artificially low, and could potentially overrepresent the difference in ratios between the target 

county and the comparison counties. Harris County, 

Texas is also excluded because CMS already 

determined that the data and other factors indicated 

a risk of ambulance fraud in that county, and 

imposed a moratorium on July 30, 2013, which is 

being extended in this document. 

beneficiaries in Wayne County, MI or 

the surrounding counties at this time. 

Accordingly, under §§ 455.470 and 

457.990, this moratorium will apply to 

the enrollment of HHAs in Medicaid 

and CHIP, unless the State later 

determines that imposition of the 

moratorium will adversely impact 

beneficiary access to care and so notifies 

CMS under § 455.470(a)(3). 

CMS reviewed Medicare data for the 

target and surrounding counties, and 

found that there are no problems with 

access to HHAs in Wayne County, MI or 

surrounding counties. Additionally, as 

described in section I.B.4. of this 

document, MedPAC has not reported 

any problems with Medicare beneficiary 

access to home health care. While CMS 

has determined there are no access to 

care issues for Medicare beneficiaries, 

nevertheless, the agency will 

continuously monitor these locations 

under a moratorium for changes such as 

an increase in beneficiary complaints to 

ensure that no access to care issues arise 

in the future. 

III. Imposition of Ambulance 

Moratorium—Geographic Area 

Under its authority at 

§ 424.570(a)(2)(i) and (iv), CMS is 

implementing a temporary moratorium 

on the Medicare Part B enrollment of 

ambulance suppliers in the geographic 

area discussed in this section. The 

moratorium does not apply to providerbased ambulances, which are owned 

and/or operated by a Medicare provider 

(or furnished under arrangement with a 

provider) such as a hospital, critical 

access hospital, skilled nursing facility, 

comprehensive outpatient rehabilitation 

facility, home health agency, or hospice 

program,33 and are not required to 

enroll separately as a supplier in 

Medicare Part B.34

Under regulations at §§ 455.470 and 

457.990, this moratorium will also 

apply to the enrollment of ambulance 

service providers in Medicaid and CHIP. 

The moratorium does not apply to air 

ambulances attempting to enroll in 

Medicare, Medicaid or CHIP. 

A. Moratorium on Enrollment of 

Ambulances in the Pennsylvania 

Counties of Philadelphia, Bucks, 

Delaware, and Montgomery, and the 

New Jersey Counties of Burlington, 

Camden, and Gloucester 

CMS has determined that there are 

factors in place that warrant the 

imposition of a temporary enrollment 

moratorium for ambulance suppliers 

that enroll in Medicare Part B and 

ambulance providers in Medicaid and 

CHIP in Philadelphia County, PA 

(which contains the City of 

Philadelphia), as well as the six 

surrounding counties—the 

Pennsylvania counties of Bucks, 

Delaware, and Montgomery, and the 

New Jersey counties of Burlington, 

Camden, and Gloucester. CMS has 

determined that it is necessary to extend 

this moratorium to the surrounding 

counties to prevent potentially 

fraudulent ambulance suppliers from 

enrolling in a neighboring county to 

avoid the moratorium. CMS has 

consulted with the Pennsylvania and 

New Jersey State Medicaid Agencies 

and reviewed available data, and has 

determined that this moratorium will 

apply equally to enrollment of 

ambulance suppliers in Medicaid and 

CHIP. 

Beginning on the effective date of this 

document, no new ambulance suppliers 

will be enrolled into Medicare, 

Medicaid or CHIP with a practice 

location in the Pennsylvania Counties of 

Philadelphia, Bucks, Delaware, and 

Montgomery, and the New Jersey 

Counties of Burlington, Camden, and 

Gloucester unless their enrollment 

application has already been approved 

but not yet entered into PECOS or the 

State Enrollment System at the time the 

moratorium is imposed. The 

moratorium does not apply to air 

ambulance suppliers or providers 

attempting to enroll in Medicare, 

Medicaid or CHIP. 

1. Consultation With Law Enforcement 

Consistent with § 424.570(a)(2)(iv), 

CMS has consulted with both the HHS– 

OIG and DOJ regarding the imposition 

of a moratorium on new ambulance 

suppliers in Philadelphia, PA and 

surrounding counties. Both the HHS– 

OIG and DOJ agree that a significant 

potential for fraud, waste and abuse 

exists with respect to ambulance 

suppliers in the affected geographic 

locations. The HHS–OIG previously 

found that the Medicare ambulance 

transport benefit may be highly 

vulnerable to abuse in locations with 

high utilization, such as Philadelphia, 

PA and surrounding locations DOJ 

prosecuted an operator of an ambulance 

service company, indicted in June 2012, 

for submitting more than $5.4 million in 

false claims to Medicare for medically 

unnecessary transportation of patients 

by ambulance.35 Additionally, in April 

2013, the owner of a Philadelphia 

ambulance supplier pled guilty to a 

health care fraud scheme that involved 

billing Medicare for ambulance services 

that were not medically necessary, that 

were not actually provided, or that were 

induced by illegal kickbacks.36 Also in 

April 2013, seven people were charged 

in a $3.6 million health care scheme for 

unnecessary ambulance rides in 

Philadelphia.37

2. Data Analysis 

a. Medicare Data Analysis 

CMS’ data show that in 2012, there 

were 31 U.S. counties nationally, 

including Philadelphia, PA, with at 

least 200,000 Medicare beneficiaries. 

CMS excluded Philadelphia County, 

PA, New York County, NY and Harris 

County, TX and used the remaining 28 

counties as ‘‘comparison counties.’’ 38 In 

2012, there was an average of 1.4 

ambulance suppliers per 10,000 

Medicare FFS beneficiaries in the 

comparison counties. In Philadelphia 

County, PA there were 4.8 ambulance 

suppliers per 10,000 Medicare FFS 

beneficiaries. This means that the ratio 

of ambulance suppliers to FFS 

beneficiaries was 243 percent greater in 

Philadelphia County, PA than in the 

comparison counties, the third highest 

ratio compared to comparison counties. 

CMS’ data show that the compounded 

average annual growth rate of 

ambulance suppliers in Philadelphia 

County, PA, is 15 times higher 

compared to the comparison counties’ 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6483 

39CMS used 2011 data from the Medicaid 

Statistical Information System (MSIS) because it 

was the most recent data available for all three 

states in this document. 

40http://www.justice.gov/opa/pr/2013/

September/13-crm-1071.html. 

41http://www.justice.gov/opa/pr/2013/

September/13-crm-985.html. 

42http://www.justice.gov/opa/pr/2013/

September/13-crm-1077.html. 

43http://www.fbi.gov/miami/press-releases/2013/

health-care-clinic-owners-plead-guilty-in-miamifor-roles-in-8-million-health-care-fraud-scheme. 

annual growth rate of 1 percent, the 

second highest growth rate compared to 

comparison counties. 

CMS’ data show that in 2012, 

ambulance suppliers in Philadelphia 

County, PA were receiving payments of 

$1,314 per average ambulance user per 

year, compared to ambulance suppliers 

in comparison counties, which received 

payments of $803. Payments to 

ambulance suppliers were 64 percent 

higher than the average for comparison 

counties, and the third highest 

compared to comparison counties. 

b. Medicaid Data Analysis 

As discussed previously in section 

I.B.1. of this document, CMS believes 

that generally, a category of providers or 

suppliers that poses a risk to the 

Medicare program also poses a similar 

risk to Medicaid and CHIP. In addition, 

the data also show a significantly higher 

annual utilization of Medicaid 

ambulance services in Philadelphia 

County, PA compared to the entire state. 

CMS compared Philadelphia County, 

PA against the rest of the state rather 

than to comparison counties nationally 

because Medicaid policies are not 

necessarily uniform across different 

states. In 2011 39 in Philadelphia 

County, PA Medicaid paid ambulances 

an average of $18,254 per provider per 

year, or 130 percent more than the 

average of $7,922 that Medicaid paid 

ambulances in the rest of the state. 

3. Beneficiary Access 

After consulting with the 

Pennsylvania and New Jersey State 

Medicaid agencies and the Pennsylvania 

and New Jersey State Departments of 

Health Emergency Medical Services, 

and reviewing available data, CMS has 

concluded that imposing this temporary 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Philadelphia County, 

PA or the surrounding counties at this 

time. Accordingly, under §§ 455.470 

and 457.990, this moratorium will apply 

to the enrollment of ambulance 

providers in Medicaid and CHIP, unless 

either or both states later determine(s) 

that imposition of the moratorium will 

adversely impact beneficiary access to 

care and so notify(ies) CMS under 

§ 455.470(a)(3). 

CMS reviewed Medicare data for the 

target and surrounding counties, and 

found that there are no problems with 

access to ambulance suppliers in 

Philadelphia County, PA or surrounding 

counties. Additionally, as described in 

section I.B.4. of this document, MedPAC 

has not reported any problems with 

Medicare beneficiary access to 

ambulance services. While CMS has 

determined that this temporary 

moratorium will not create an access to 

care issue for Medicare beneficiaries in 

Philadelphia County, PA or the 

surrounding counties at this time, 

nevertheless, the agency will 

continuously monitor these locations 

under a moratorium for changes, such as 

any increase in beneficiary complaints, 

to ensure that no access to care issues 

arise in the future. 

IV. Extension of Home Health 

Moratoria—Geographic Locations 

In accordance with § 424.570(b), CMS 

may deem it necessary to extend the 

moratoria in 6-month increments. Under 

its authority at § 424.570(b), CMS is 

extending the temporary moratoria on 

the Medicare enrollment of HHAs in the 

geographic locations discussed in this 

section. Under regulations at §§ 455.470 

and 457.990, this moratorium also 

applies to the enrollment of HHAs in 

Medicaid and CHIP. At § 424.570(b), 

CMS stated it would publish a Federal 

Register document announcing any 

extension, and this document fulfills 

that requirement. 

A. Moratorium on Enrollment of HHAs 

in the Florida Counties of Miami-Dade 

and Monroe 

In the July 31, 2013 Federal Register 

(78 FR 46340), CMS published a 

document announcing the imposition of 

a temporary moratorium on the 

enrollment of new HHAs in the Florida 

counties of Miami-Dade and Monroe, as 

well as the qualitative and quantitative 

factors that supported CMS’ 

determination of a need for the 

moratorium. CMS consulted with both 

the HHS–OIG and DOJ regarding the 

extension of the moratorium on new 

HHAs in Miami-Dade and Monroe 

counties, and both HHS–OIG and DOJ 

agree that a significant potential for 

fraud, waste and abuse continues to 

exist in this geographic area. Law 

enforcement agencies continue to 

investigate and prosecute significant 

fraudulent activity relating to home 

health services in these counties. For 

example, five Miami residents were 

arrested for their roles in a $48 million 

home health scheme on September 25, 

2013,40 and three home health recruiters 

pled guilty for their role in the same $48 

million scheme 41 on September 4 and 

26, 2013.42 Additionally, two MiamiDade County, FL health care clinic 

owners pled guilty in connection with 

an $8 million health care fraud scheme 

involving a now-defunct home health 

care company on August 13, 2013.43

As stated in the July 31, 2013 Federal 

Register document, CMS’ data showed 

that Miami-Dade County had the highest 

ratio of HHAs to Medicare FFS 

beneficiaries compared to comparison 

counties, as well as the highest 

payments to HHAs compared to 

comparison counties. During the first 60 

days of the moratorium, CMS revoked 

the billing privileges of 14 HHAs, and 

deactivated the billing privileges of 7 

HHAs in Miami-Dade, FL. CMS has also 

performed other actions, such as 

payment suspensions and revocation of 

provider/supplier numbers for HHAs in 

this target area. 

As provided in § 424.570(d), CMS 

may lift a moratorium at any time if the 

President declares an area a disaster 

under the Robert T. Stafford Disaster 

Relief and Emergency Assistance Act, if 

circumstances warranting the 

imposition of a moratorium have abated, 

if the Secretary has declared a public 

health emergency or, if in the judgment 

of the Secretary, the moratorium is no 

longer needed. Neither Miami-Dade 

County nor Monroe County has been the 

site of a recent disaster or public health 

emergency. Additionally, the 

circumstances warranting the 

imposition of the moratorium have not 

yet abated, and CMS has determined 

that the moratorium is still needed as 

we monitor the indicators described and 

continue with administrative actions 

such as payment suspensions and 

revocation of provider/supplier 

numbers. 

Based upon CMS’ consultation with 

the State Medicaid Agency, CMS has 

concluded that extending this 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Miami-Dade, FL or the 

surrounding county at this time. CMS 

also reviewed Medicare data for the 

target and surrounding county and 

found there are no problems with access 

to HHAs. Additionally, as described in 

section I.B.4. of this document, MedPAC 

has not reported any problems with 

Medicare beneficiary access to home 

health care. While CMS has determined 

there are no access to care issues for 

Medicare beneficiaries, nevertheless, the 


tkelley on DSK3SPTVN1PROD with RULES
6484 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

44https://oig.hhs.gov/fraud/enforcement/

criminal/. 

45http://www.justice.gov/usao/iln/pr/chicago/

2012/pr0925_01.pdf. 

46http://www.fbi.gov/chicago/press-releases/

2013/mobile-doctors-chicago-ceo-and-doctorarrested-on-federal-health-care-fraud-charges. 

47http://www.yourhoustonnews.com/deer_park/

news/owner-of-texas-based-ambulance-serviceconvicted-of-health-care/article_49a3ed6e-355e5478-aa99-8d383071d1dc.html. 

agency will continue to monitor these 

locations. 

As a result of the law enforcement 

consultation and consideration of the 

factors and activities described, CMS 

has determined that the temporary 

enrollment moratorium will be 

extended for 6 months to combat fraud 

in this area. 

B. Moratorium on Enrollment of HHAs 

in the Illinois Counties of Cook, DuPage, 

Kane, Lake, McHenry and Will 

In the July 31, 2013 Federal Register 

(78 FR 46340), CMS published a 

document announcing the imposition of 

a temporary moratorium on the 

enrollment of new HHAs in the Illinois 

Counties of Cook, DuPage, Kane, Lake, 

McHenry and Will, as well as the 

qualitative and quantitative factors that 

supported CMS’ determination of a need 

of the moratorium. 

CMS consulted with both the HHS– 

OIG and DOJ regarding the extension of 

the moratorium on new HHAs in Cook 

and surrounding counties, and both 

HHS–OIG and DOJ agree that a 

significant potential for fraud, waste and 

abuse continues to exist in this 

geographic area. We have found that law 

enforcement activities continue. For 

example, a Chicago resident was 

arrested in connection with an 

indictment in an alleged $12 million 

home health fraud scheme on October 

29, 2013.44 In another example, nine 

defendants were indicted in a Chicago 

home health kickback scheme on 

September 26, 2013.45 The CEO of a 

Chicago home health company was 

arrested and $2.6 million in alleged 

fraud proceeds from various bank 

accounts were seized on August 27, 

2013. A physician who was also 

involved in this same scheme was 

arrested.46

As stated in the July 31, 2013 Federal 

Register document, CMS’ data showed 

that the growth rate in Cook County was 

double the national average of 

comparison counties, and that payments 

to HHAs were some of the highest 

nationally compared to the comparison 

counties. CMS has performed 

administrative actions, including 

investigations, referrals to law 

enforcement and payment suspensions 

on HHAs in this target area. 

As provided in § 424.570(d), CMS 

may lift a moratorium at any time if the 

President declares an area a disaster 

under the Robert T. Stafford Disaster 

Relief and Emergency Assistance Act, if 

circumstances warranting the 

imposition of a moratorium have abated, 

if the Secretary has declared a public 

health emergency, or if in the judgment 

of the Secretary, the moratorium is no 

longer needed. Cook and the 

surrounding counties have not been the 

site of a recent disaster or public health 

emergency. Additionally, the 

circumstances warranting the 

imposition of the moratorium have not 

yet abated, and CMS has determined 

that the moratorium is still needed as 

we monitor the indicators described and 

continue with administrative actions 

such as payment suspensions and 

revocations of provider/supplier 

numbers. 

Based upon CMS’ consultation with 

the State Medicaid Agency, CMS 

concluded that extending this 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Cook or the surrounding 

counties at this time. CMS also 

reviewed Medicare data for the target 

and surrounding counties and found 

there are no problems with access to 

HHAs. Additionally, as described in 

section I.B.4. of this document, MedPAC 

has not reported any problems with 

Medicare beneficiary access to home 

health care. While CMS has determined 

there are no access to care issues for 

Medicare beneficiaries, nevertheless, the 

agency will continue to monitor these 

locations. 

As a result of the law enforcement 

consultation and consideration of the 

factors and activities described, CMS 

has determined that this temporary 

enrollment moratorium will be 

extended for 6 months to combat fraud 

in this area. 

V. Extension of Ambulance Moratoria— 

Geographic Area 

A. Moratorium on the Enrollment of 

Ambulance Suppliers and Providers in 

the Texas Counties of Harris, Brazoria, 

Chambers, Fort Bend, Galveston, 

Liberty, Montgomery and Waller 

In the July 31, 2013 Federal Register 

(78 FR 46340), CMS published a 

document announcing the imposition of 

this temporary moratorium on the 

enrollment of new ambulance suppliers 

and providers in the Texas Counties of 

Harris, Brazoria, Chambers, Fort Bend, 

Galveston, Liberty, Montgomery and 

Waller, as well as the qualitative and 

quantitative factors that supported CMS’ 

determination of a need of the 

moratorium. 

CMS consulted with both the HHS– 

OIG and DOJ regarding the extension of 

the moratorium on new ambulances in 

Harris County, TX and surrounding 

counties, and both HHS–OIG and DOJ 

agree that a significant potential for 

fraud, waste and abuse continues to 

exist in this geographic area. For 

example, the owner of a Houston-based 

ambulance company was convicted of 

multiple counts of health care fraud on 

October 30, 2013.47

As stated in the July 31, 2013 Federal 

Register document, CMS’ data showed 

that Harris County, TX had the highest 

ratio of ambulance suppliers to 

Medicare beneficiaries compared to the 

comparison counties, as well as having 

the highest number of providers not 

continuously billing since 2008—a 

strong indicator of churn (churn is a 

term used to describe the switching 

between provider numbers when a 

provider number is identified as being 

involved in fraud and abuse)— 

compared to the comparison counties. 

In the first 60 days of the moratorium, 

CMS has revoked the billing privileges 

of 15 ambulance suppliers. 

As provided in § 424.570(d), CMS 

may lift a moratorium at any time if the 

President declares an area a disaster 

under the Robert T. Stafford Disaster 

Relief and Emergency Assistance Act, if 

circumstances warranting the 

imposition of a moratorium have abated, 

if the Secretary has declared a public 

health emergency, or if in the judgment 

of the Secretary, the moratorium is no 

longer needed. Harris County, TX and 

the surrounding counties have not been 

the site of a recent disaster or public 

health emergency. Additionally, the 

circumstances warranting the 

imposition of a moratorium have not yet 

abated, and CMS has determined that 

the moratorium is still needed as we 

monitor the indicators described and 

continue with administrative actions 

such as payment suspensions and 

revocations of provider/supplier 

numbers. 

Based upon CMS’ consultation with 

the State Medicaid Agency, CMS 

concluded that extending this 

moratorium will not create an access to 

care issue for Medicaid or CHIP 

beneficiaries in Harris County, TX or the 

surrounding counties at this time. CMS 

also reviewed Medicare data for the 

target and surrounding counties and 

found there are no problems with access 

to ambulance services. Additionally, as 

described in section I.B.4. of this 

document, MedPAC has not reported 

any problems with Medicare beneficiary 


tkelley on DSK3SPTVN1PROD with RULES
Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 6485 

access to ambulance services. While 

CMS has determined there are no access 

to care issues for Medicare beneficiaries, 

nevertheless, the agency will continue 

to monitor these locations. 

As a result of the law enforcement 

consultation and consideration of the 

factors and activities described, CMS 

has determined that the temporary 

enrollment moratorium will be 

extended for 6 months to combat fraud 

in these areas. 

VI. Summary of the Moratoria 

Locations 

CMS is executing its authority under 

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

2107(e)(1)(D) of the Act to implement a 

moratorium in the following counties 

for these providers and suppliers: 

TABLE 1—NEW HOME HEALTH AGENCY MORATORIA

City and State Counties Law enforcement activity Medicare data 

(2012) 

Medicaid data 

(2011) 

Fort Lauderdale, FL ........... Broward ............................. Adjacent to HEAT MiamiDade Strike Force Location.Ratio of HHAs to Medicare 

FFS Beneficiaries was 

92 percent higher than 

Comparison Counties.

HHAs were paid 95 percent more per year compared to the rest of the 

state. 

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

Monroe 

Oakland 

Washtenaw 

Wayne 

HEAT Strike Force Location.Compounded annual 

growth was almost double the national average.

HHAs were paid 24 percent more per year compared to the rest of the 

state. 

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

Dallas 

Denton 

Ellis 

Kaufman 

Rockwall 

Tarrant 

HEAT Strike Force Location.Ratio of HHAs to Medicare 

FFS Beneficiaries was 

365 percent higher than 

Comparison Counties.

Spent 35 percent more per 

home health user compared to the rest of the 

state. 

Houston, TX ...................... Brazoria Chambers ...........

Fort Bend Galveston 

Harris 

Liberty Montgomery 

Waller 

HEAT Strike Force Location.Ratio of HHAs to Medicare 

FFS Beneficiaries was 

276 percent higher than 

Comparison Counties.

Spent 83 percent more per 

home health user compared to the rest of the 

state. 

TABLE 2—NEW AMBULANCE MORATORIUM

City and State Counties Law enforcement activity Medicare data 

(2012) 

Medicaid data 

(2011) 

Philadelphia, PA ................ Bucks (PA) ........................

Delaware (PA) 

Montgomery (PA) 

Philadelphia (PA) 

Burlington (NJ) 

Camden (NJ) 

Gloucester (NJ) 

........................................... Ratio of Ambulance Suppliers to Medicare FFS 

Beneficiaries was 232 

percent higher than 

Comparison Counties.

Ambulances paid 130 percent more per year compared to the rest of the 

state. 

VII. Regulatory Impact Statement 

CMS has examined the impact of this 

document as required by Executive 

Order 12866 on Regulatory Planning 

and Review (September 30, 1993), 

Executive Order 13563 on Improving 

Regulation and Regulatory Review 

(January 18, 2011), the Regulatory 

Flexibility Act (RFA) (September 19, 

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

the Social Security Act, section 202 of 

the Unfunded Mandates Reform Act of 

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

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

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

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). A regulatory impact analysis 

(RIA) must be prepared for major 

regulatory actions with economically 

significant effects ($100 million or more 

in any 1 year). This document will 

prevent the enrollment of new home 

health providers and ambulance 

suppliers in Medicare, and ambulance 

providers in Medicaid and CHIP. 

Though savings may accrue by denying 

enrollments, the monetary amount 

cannot be quantified. After the 

imposition of the moratoria on July 30, 

2013, 231 HHAs and 7 ambulance 

companies in all geographic areas 

affected by the moratoria had their 

applications denied. We have found the 

number of applications that are denied 

after 60 days declines dramatically, as 

most providers and suppliers will not 

submit applications during the 

moratoria period. Therefore, this 

document does not reach the economic 

threshold and thus is not considered a 

major action. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most 

hospitals and most other providers and 

suppliers are small entities, either by 

nonprofit status or by having revenues 

of $7.0 million to $35.5 million in any 

one year. Individuals and states are not 

included in the definition of a small 

entity. CMS is not preparing an analysis 

for the RFA because it has determined, 

and the Secretary certifies, that this 


tkelley on DSK3SPTVN1PROD with RULES
6486 Federal Register / Vol. 79, No. 23 / Tuesday, February 4, 2014 / Rules and Regulations 

document will not have a significant 

economic impact on a substantial 

number of small entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if an action may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, CMS defines a small rural 

hospital as a hospital that is located 

outside of a Metropolitan Statistical 

Area for Medicare payment regulations 

and has fewer than 100 beds. CMS is not 

preparing an analysis for section 1102(b) 

of the Act because it has determined, 

and the Secretary certifies, that this 

document will not have a significant 

impact on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

regulatory action whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2013, that 

threshold is approximately $141 

million. This document will have no 

consequential effect on state, local, or 

tribal governments or on the private 

sector. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed regulatory action (and 

subsequent final action) that imposes 

substantial direct requirement costs on 

state and local governments, preempts 

state law, or otherwise has Federalism 

implications. Since this document does 

not impose any costs on state or local 

governments, the requirements of 

Executive Order 13132 are not 

applicable. 

In accordance with the provisions of 

Executive Order 12866, the Office of 

Management and Budget reviewed this 

document. 

Authority: Sections 1102 and 1871 of the 

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

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

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

Dated: January 27, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–02166 Filed 1–30–14; 4:15 pm] 

BILLING CODE 4120–01–P 

DEPARTMENT OF COMMERCE 

National Oceanic and Atmospheric 

Administration 

50 CFR Part 660 

[Docket No. 130717633–4069–02] 

RIN 0648–XC772 

Fisheries Off West Coast States; 

Coastal Pelagic Species Fisheries; 

Annual Specifications 

AGENCY: National Marine Fisheries 

Service (NMFS), National Oceanic and 

Atmospheric Administration (NOAA), 

Commerce. 

ACTION: Final rule. 

SUMMARY: NMFS issues this final rule to 

implement the annual catch limit (ACL), 

acceptable biological catch (ABC), 

annual catch target (ACT) and 

associated annual reference points for 

Pacific mackerel in the U.S. exclusive 

economic zone (EEZ) off the Pacific 

coast for the fishing season of July 1, 

2013, through June 30, 2014. This final 

rule is implemented according to the 

Coastal Pelagic Species (CPS) Fishery 

Management Plan (FMP). The 2013/

2014 ACL for Pacific mackerel is 52,358 

metric tons (mt). The ACT, which will 

be the directed fishing harvest target, is 

39,268 mt. If the fishery attains the ACT, 

the directed fishery will close, reserving 

the difference between the ACL and 

ACT (which is 13,089 mt) as a set aside 

for incidental landings in other CPS 

fisheries and other sources of mortality. 

This final rule is intended to conserve 

and manage the Pacific mackerel stock 

off the U.S. West Coast. 

DATES: Effective March 6, 2014, through 

June 30, 2014. 

FOR FURTHER INFORMATION CONTACT: 

Joshua Lindsay, West Coast Region, 

NMFS, (562) 980–4034. 

SUPPLEMENTARY INFORMATION: During 

public meetings each year, the estimated 

biomass for Pacific mackerel is 

presented to the Pacific Fishery 

Management Council’s (Council) CPS 

Management Team (Team), the 

Council’s CPS Advisory Subpanel 

(Subpanel) and the Council’s Scientific 

and Statistical Committee (SSC), where 

the biomass and the status of the 

fisheries are reviewed and discussed. 

The biomass estimate is then presented 

to the Council along with the calculated 

overfishing limit (OFL), acceptable 

biological catch (ABC), annual catch 

limit (ACL) and annual catch target 

(ACT) recommendations and comments 

from the Team, Subpanel and SSC. 

Following review by the Council and 

after hearing public comment, the 

Council adopts a biomass estimate and 

makes its catch level recommendations 

to NMFS. 

The final rule will implement the 

2013/2014 ACL, ACT and other annual 

catch reference points, including OFL 

and an ABC that takes into 

consideration uncertainty surrounding 

the current estimate of biomass, for 

Pacific mackerel in the U.S. EEZ off the 

Pacific coast. The CPS FMP and its 

implementing regulations require NMFS 

to set these annual catch levels for the 

Pacific mackerel fishery based on the 

annual specification framework in the 

FMP. For the 2013/2014 fishing season 

the ACL is set equal to the result of the 

ABC calculation. This formula is: 

ABC = Biomass * Buffer * FMSY * 

Distribution with the parameters 

described as follows: 

1. Biomass. The estimated stock 

biomass of Pacific mackerel for the 

2013/2014 management season is 

272,932 mt. 

2. Buffer. Used to addresses 

uncertainty in the OFL. For the 2013/

2014 fishing season the buffer value is 

0.913496. This is based on the Council’s 

recommendation of a P* of 0.45 and the 

SSC recommended sigma of 0.72. The 

sigma for this year is double that used 

for previous years due to a higher level 

of uncertainty in the biomass estimate. 

3. FMSY. The fishing mortality rate at 

maximum sustainable yield (MSY) is set 

to 0.30. 

4. Distribution. The average portion 

(currently 70%) of the total Pacific 

mackerel biomass that is estimated to be 

in the U.S. EEZ off the Pacific coast. 

At the June 2013 Council meeting, the 

Council recommended management 

measures for the Pacific mackerel 

fishery. These management measures 

and catch specifications are based on 

the control rules established in the CPS 

FMP and a biomass estimate of 272,932 

mt (the result of a full stock assessment 

that was completed in 2011 and 

updated based on a projection estimate 

for 2013). This biomass estimate was 

reviewed and approved by the SSC as 

the best available science for use in 

management. 

In this final rule, based on 

recommendations from the Council’s 

SSC and other advisory bodies, the 

Council recommended and NOAA 

Fisheries (NMFS) is implementing, an 

OFL of 57,316 mt, an ABC of 52,358 mt, 

an ACL 52,358 and an ACT of 39,268 mt 

for the 2013/2014 Pacific mackerel 

fishing season. The Pacific mackerel 

fishing season runs from July 1 to June 

30 of the following year. 

Amendment 13 (‘‘ACL’’ amendment) 

to the CPS FMP established a framework 


tkelley on DSK3SPTVN1PROD with RULES