Category Archives: Reduction in Medicaid Payments
Attention Medicaid Providers: Potential SPA Decreases PCS Rates By 60 Cents Per 15 Minutes
The North Carolina State Medicaid Plan (State Plan) is constantly revised. The result of its constant revisions make for an 1800+ page, jumbled mess of plans, rules, amendments, and effective dates that make the State Plan as much fun to read as reading every volume of the Encyclopedia Britannica in Japanese with the aid of a Japanese translation dictionary.
First of all, what the heck is the State Plan? Basically, a State Plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. It “assures” the federal government that we, here in NC, will follow the State Plan because the federal government has “blessed” our State Plan. Whenever we need to change the State Plan, we file an amendment. In circumstances that call for much greater deviation from the State Plan, we can apply for a Waiver…or an exception.
On or about August 15, 2013, the Department of Health and Human Services (DHHS) issued a Public Notice “providing notice of its intent to amend the Medicaid State Plan for the purpose of defining the reimbursement methodology of Personal Care Services as directed by Section 10.9F of Session Law 2013-306 (House Bill 492). “
Personal Care Services (PCS) are Medicaid-covered, in-home services to recipients “who have a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.” See DHHS Website.
In a letter dated September 30, 2013, and signed by Sec. Aldona Wos, DHHS sent what is called a SPA or a State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS), in part, asking to be allowed to change the PCS unit rate from $3.88 to $3.28.
$3.88 to $3.28…
It may not sound like a huge decrease in pay to you, but a 60 cent drop per unit will be extremely harmful to providers who provide PCS services and, ultimately Medicaid recipients because less providers will be willing to serve the population.
One PCS unit is 15 minutes. There are 4 units in an hour. A 60 cent/unit cut to the rate will result in a $2.40 hourly cut.
Providers who employ staff who provide PCS are not paying staff upwards of $20/hour. Oh, no, most PCS providers make, maybe, $7-9.
Think about it…a small business provider of PCS (Let’s call it ABC Provider) employs 5-10 staff to provide PCS to recipients. ABC Provider has to pay its overhead (lease, office supplies, salaries of execs) plus pay the hourly wages of the PCS staff, and, supposedly, still make a profit…otherwise why even work?
For one hour of PCS, prior to a rate reduction, ABC Provider grosses $15.52/hour. Obviously, a portion of the $15.52 must go to overhead. ABC Provider pays her staff $9.00/hour. So ABC Provider nets $6.52/hour to pay for overhead. After 1000 man-hours, maybe ABC Provider can pays its rent and its utility bill. BTW: In order to reach 1000 man hours, it would take a person to work 41.66 days, 24 hours/day. Or it could take 10 staff working 10 hours/day for 2 weeks…just for the provider to make $6520 to pay bills…we aren’t even talking about profit…
After the rate reduction?
$2.40 has to be recouped somehow. Does the provider’s profit margin shrink or does the employee’s hourly rate decrease? Maybe a little of both.
According to the September 30, 2013, Sec. Wos letter, NC DHHS requested a retroactive date for the PCS rate reduction to July 1, 2013, or, in the alternative, October 1, 2013.
What? Retroactive reduced rates? Would DHHS recoup payments already made?
As of the day of this blog, I have not found out whether CMS approved the SPA sent to CMS September 30, 2013. I looked on CMS’ website. So if anyone reading has information as to whether CMS approved, is approving, denied, or is denying the rate reduction, I, as well as other people, would be much obliged for the information.
Study Shows the ACA Will Not Lead Physicians to REDUCE the Number of Medicaid Recipients, Supply and Demand, and Get Me My Pokemon Cards!
A recent “study” by Lippincott, Williams, and Wilkins is entitled “Doctors Likely to accept New Medicaid Patients as Coverage Expands.” (I may or may not have belly laughed when I read that title). See my blog “Medicaid Expansion: Bad for the Poor.”
The beginning of the article reads, “The upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept, suggests a study in the November issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.”
The study was published October 16, 2013. (BTW: From what I can discern from the article, the title actually means that physicians will be forced to accept more Medicaid patients because there will not be additional physicians accepting Medicaid). Odd title.
According to this study, the ACA will not cause doctors to reduce the number of Medicaid patients. What does this study NOT say? Nothing indicates that the ACA, which will allow millions more of Americans to become eligible for Medicaid, will cause MORE physicians to accept Medicaid. Nor does the study state that the ACA will cause physicians to accept MORE Medicaid recipients.
Am I the only person who understands supply and demand?
Anyone remember the 1999 Toys.R.Us.com debacle? On-line shopping was just heating up. I was in law school, and I, as well as millions of others, ordered Christmas presents on-line from Toys R Us. I ordered a bunch of Pokemon trading cards for a nephew…remember those? Me either…I just bought them for my nephew. Toys R Us promised delivery by December 10th.
Toys R Us was, apparently, a very popular store that year, because Toys R Us is unable to package and ship orders in time to meet the December 10th deadline. Nor could Toys R Us meet the deadline of Christmas. Employees were working through the weekends. About two days before Christmas, and just in time to create last-minute havoc during Christmas time, Toys R Us sends out thousands of emails saying, “We’re sorry.”
Obviously, Toys R Us was slammed by the media, and thousands of consumers were highly ticked off…including me.
I had to go to the mall (a place to which I detest going) on Christmas Eve (the worst day to shop of the entire year, except Black Friday, which I also avoid) to get my nephew a present.
Toys R Us learned its lesson. It outsourced its shipping to Amazon.com, which, obviously, has the whole shipping thing down pat.
Hypothetical:
50 million people are currently eligible for (and receive) Medicaid services (these numbers are purely fictional, as I do not know the real numbers…I basically estimated 1 million per state, which, I am sure, is an underestimation). Say there are 3.5 million physicians that accept Medicaid (70,000/state, which is probably a high estimation, when we are considering only physicians and not health care providers, generally).
Our hypothetical yields 14.28 Medicaid recipients per physician. Or a ratio of 14.28:1.
Media state that, if NC expanded Medicaid, that 587,000 more North Carolinians would be eligible for Medicaid if NC expanded Medicaid.
Using NC as a state average, 29.35 million more people would be eligible for Medicaid if all states expanded Medicaid (obviously not all states are expanding Medicaid, but, in my hypothetical, all states are expanding Medicaid). This equals a total of 79.35 million people in America on Medicaid.
But….no additional physicians….
Because, remember, according to the Lippincott study, the upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept. But the ACA does not lead more physicians to accept Medicaid or physicians to accept more Medicaid patients.
This brings the ratio to 22.67:1. 8 1/2 new patients per one physican…and, BTW, that one physician may not be accepting new Medicaid patients or may not have the capacity to accept more Medicaid patients. It’s a Toys R Us disaster!!! No one is getting their Pokemon trading cards!!!
Why not? Why won’t the ACA lead more physicians to accept Medicaid? Why won’t the ACA lead physicians to accept more Medicaid recipients?
Didn’t the ACA INCREASE Medicaid reimbursement rates? Wouldn’t higher reimbursement rates lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients??? I mean, didn’t you hear Obama tout that Medicaid rates would be increased to Medicare rates? I know I did.
One average, Medicaid pays approximately 66% of Medicare reimbursement rates. Obviously, every state differs as to the Medicaid reimbursement rate.
The ACA, however, slashes the Medicare budget by 716 million from 2013 to 2022. The cuts are across-the-board changes in Medicare reimbursement formulas for a variety of Medicare providers, including hospitals, nursing homes, home health agencies, and hospice agencies. Furthermore, the ACA creates the Independent Payment Advisory Board (IPAB), which is intended to determine additional Medicare reimbursement rate cuts. IPAB will be creating a new Medicare spending target; it will be comprised of 15 unelected bureaucrats. The board will be able to make suggestions to Congress to reign in Medicare spending, and one of the biggest tools the IPAB has is cutting physician reimbursement rates.
It’s the old smoke and mirrors trick…We will raise Medicaid rates to Medicare rates…pssst, decrease the Medicare rate so we can meet our own promise!!
While I am extremely happy to hear that, at least according to the Lippincott study, the ACA will not lead physicians to reduce the number of Medicaid patients they accept, I am concerned that the ACA will not lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients.
In fact, the study states that “[t]he data suggested that changes in Medicaid coverage did not significantly affect doctors’ acceptance of new Medicaid patients. “[P]hysicians who were already accepting (or not accepting) Medicaid patients before changes in Medicaid coverage rates continue to do so,” Drs Sabik and Gandhi write. I bet the Drs. did not ask, “Would you continue to accept Medicaid, if you knew that your practice would endure more audits, post-payment reviews, possible prepayment reviews, and, in general, suspensions of reimbursements if anyone alleges Medicaid fraud, irrespective of the truth?”
Which tells me…hello…more Medicaid recipients, not more doctors!! Even if the physicians already accepting Medicaid COULD accept additional Medicaid recipient patients, each physician only has a certain amount of capacity. To my knowledge, the ACA did not increase the number of hours in a day. Supply and demand, people!!
Where are my Pokemon cards???!!!
More Financial Pressure on Hospitals By 2013’s Legislative Medicaid Budget
Representative David Price spoke as the Keynote Speaker at the North Carolina Society of Health Care Attorneys annual meeting yesterday morning. Since Representative Price was actually up in Washington D.C. during the shutdown, it was very interesting to hear him speak. His opinion, as one would expect from his ideology, was that the shutdown was idiotic and unnecessary.
What I found interesting was how he described the relationships between congressmen and women today versus in the 90s. Remember, he has represented NC in Washington for more than one decade. He described the relationships, even across party lines, as more cordial in the 90s than today’s relationships. I wonder why our legislative body has become more segregated.
In the afternoon session, Linwood Jones from the North Carolina Hospital Association spoke about recent legislative action. This legislature was not good to hospitals. As Linwood described the legislative session this year…”It was all about Medicaid.” (I know you were wondering how the NC Society of Health Care Attorneys annual meeting was going to be germane to Medicaid). According to Mr. Jones, the Medicaid budget was the primary factor in almost all budget cuts. And what entities get most of Medicaid funding?
Duh…Hospitals. Hospitals are the biggest providers in the state, and, in some areas, the biggest employers.
Our Medicaid budget is approximately $13 billion.
Remember…36 million a day is what we spend on Medicaid in NC.
How much of that $13 billion Medicaid budget goes to hospitals? According to Kaiser Family Foundation, 25.7% for inpatient care. Or $3.341 billion annually. Or $9.252 million a day!!
Including outpatient care? 38.7% Or $5.031 billion annually. Or $13.932 million a day!!
According to the handy-dandy Wikipedia website, North Carolina has 126 hospitals in 83 counties. For those of you who never went to 6th grade in North Carolina, we have 100 counties in NC. (In the 6th grade, if you grew up here, you learn all about North Carolina geography, which apparently didn’t stick, because I still get lost).
That is $13.932 million dollars a day going to 126 hospitals in NC. That is a lot of money!!!
Does Medicaid matter to hospitals?
Heck, yes!! Remember, a hospital cannot turn anyone away, including Medicaid recipients and uninsured. Add the fact that the mentally ill in NC are not getting medically necessary services because our managed care organizations (MCOs) have monetary incentives to NOT provide the expensive mental health services; PLUS the fact that Medicaid reimbursements are painfully low, which leads to many physicians not accepting Medicaid, and you get the sad sum of Medicaid recipients ending up in emergency rooms of hospitals.
Don Dalton, a spokesman for the Hospital Association, said that statewide about 46 percent of hospitals’ revenue comes from Medicaid. (See Rose Hoban’s article).
But, hospitals don’t make a huge profit. Especially on Medicaid recipients.
On average, Medicaid reimburses hospitals 80% of the actual cost for hospital services.
But this year, the General Assembly created a budget in which the 80% will be reduced to 70%.
Medicaid reimbursements were already bad. But now, the Medicaid reimbursements will be 10% worse. Subtract 10% from the $13.932 million dollars a day…
This is not a good thing for hospitals nor Medicaid recipients.
When Representative Price was speaking, a woman raised her hand with a question/vignette. She said that she and her friends had gotten on the health care exchange (Obamacare) (Healthcare.gov) website and “shopped” for health insurance. She said that all the people who signed up for health care exchange (because it is mandated and there is a penalty for not having insurance) had their premiums increase anywhere from 300%-800%. Although Rep. Price made a good point, that they all should have contacted Blue Cross Blue Shield (BCBS) and asked why BCBS dropped that particular insurance plan. Nonetheless, the woman harped on the fact that Obama had promised, “You like your insurance? You can keep it! You like your doctor? You can keep him/her!” (I added the “her.”)
So, here we are…with low Medicaid reimbursements to begin with, high medical costs, and the General Assembly reducing the Medicaid rates for hospitals by 10%.
Incentive to accept Medicaid recipients? I think not…but hospitals have no choice.
Physicians and other Medicaid providers have the choice as to whether to accept Medicaid patients, but hospitals? No choice there. Hospitals must accept Medicaid recipients. Mandatory!!!
In my opinion, the very first step toward fixing the Medicaid system is RAISING Medicaid reimbursement rates.
Sound counterintuitive? Yes, I agree it sounds counterintuitive. But think about Medicaid like this:
If you agree with me that Medicaid is an entitlement and that the Medicaid budget is way too high, but that all Medicaid recipients deserve quality health care…if you agree with all that…
And you also agree with me that it is drastically more expensive for Medicaid recipients to go to the emergency room (ER) for health issues that could be solved in a family physicians’ office…if you agree with all that…
Then we would save Medicaid dollars by increasing (drastically) the Medicaid reimbursements. If doctors had a monetary incentive to accept Medicaid, then more doctors would accept Medicaid (Logic 101). If more doctors accept Medicaid, then more Medicaid recipients have the ability to go see a doctor. If more recipients have more office visits then ER visits drop. If more unnecessary ER visits drop, then the State pays less money to the hospitals, which is an extremely higher rate (even with the 10% reduction) than a higher Medicaid reimbursement to physicians. Cut the $13.932 million a day to hospitals, not by decreasing the reimbursement rate, but by fewer Medicaid recipient going to the ER…instead have the recipients receive quality care outside the hospital, thus saving money…
Get it?
By reducing the Medicaid reimbursements to hospitals, the legislature did decrease the Medicaid budget, but not in a way that intelligently attempts to fix the system. The same amount of Medicaid recipients will be going to hospitals. Since the hospitals cannot turn anyone away, reducing reimbursements to hospitals merely hurts the hospitals.
Want to decrease the Medicaid budget? Increase Medicaid reimbursements (drastically) to Medicaid providers. More providers accepting Medicaid means more recipients receiving quality care and NOT checking into the ER….
Money saved intelligently. Too bad the legislature didn’t ask my opinion prior to slashing Medicaid reimbursement rates.
Adult Medicaid Group Homes: Forgotten Again?
In the wake of such tragedies such as the Colorado movie theatre last July, the Sikh temple in Wisconsin in August, Minneapolis in September, then the unthinkable massacre at the Connecticut elementary school in December, and, of course, the Boston bombing in April, you would think that mental health would be a top priority.
Instead, politicians across America are advocating gun laws. Without commenting on gun control (as this is a Medicaid blog), mental health seems to be getting placed on the back-burner.
In the North Carolina budget passed by the Senate last week, mental health, in particular, group homes for adults with severe mental illnesses, again, was forgotten. Whether on purpose or by accident, I have no idea. But the fact remains a large part of metal health simply was not contemplated in the budget.
I am sure most of you remember the comedy of errors that occurred at the beginning of the year when the criteria for personal care services (PCS) was revised. Basically in January 2013, the criteria to receive PCS became more stringent.
According to DMA, effective January 1, 2013, PCS “is available to individuals who has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.”
Prior to January 1, 2013, individuals who qualified for Medicaid special room and board assistance were automatically granted approval to receive PCS funding regardless of need. This applied for both in-home and facility-based services.
Due to the more stringent 2013 criteria, thousands of adults in group homes in NC who depended on Medicaid were no longer eligible. Former Gov. Perdue was forced to shimmy around funds in order to keep these disabled adults from losing their homes. The whole debacle created terror and stress for those disabled adults whose residences were threatened, for the families of the threatened disabled adults, for the group home executives who did not want to evict these disabled adults, and for any mental health advocate or person with empathy toward the mentally ill.
The trainwreck of the adult PCS group homes only occurred 4-ish months ago.
Yet, lawmakers, seemingly, failed to address the recurrent problem of funding for group homes for adults with severe mental illnesses, who are no longer eligible for PCS, in last week’s budget passed by Senate.
Wednesday afternoon (if you work downtown, then you know what I am talking about) a group of protesters rallied outside the General Assembly clad in blue shirts, holding signs saying, “Save Group Homes!” and “Disaster Relief! Save my Home!,” and some simply said, “Help!”
The Senate’s budget failed to provide funds for approximately 1,450 people living in 6-person group homes. Each group home resident currently receives $16.14 a day, or about $6,000 a year, from the state program. The fear is that group homes are so underfunded as it is that any amount, no matter how small, of decreased funds would drive the group homes out of business, forcing residents onto the street.
In general, group homes are not huge money-makers for the owners. The workers at a group home make approximately $9-10/hour. Group homes must be staffed 24/hours/day and 365/days/year. The group homes must use the state-funded money to staff the home, keep up the maintenance of the home, feed all the residents and care for all the residents, plus all overhead (i.e., electricity, heat/air conditioning, any extras for the residents, such as TVs or cable, blankets, etc.). Plus group homes must provide a small, monthly stipend for the residents in order for the residents purchase medicine (co-pays) and personal hygiene products.
Logically there must be SOME profit in group homes in order for anyone to want to run a group home. But the profit is minimal.
Similar to the low Medicaid reimbursement rates to physicians, causing physicians to not accept Medicaid, any sort of cut to group home funding (including the residents not qualifying for PCS due to the new criteria and without special funding to cover the difference), group homes will inevitably close. You simply cannot expect a person to keep a group home open when no profit is made. Just as if you cannot expect a doctor to accept Medicaid patients if no profit is made.
So, is the State of North Carolina saving money by not providing additional funding to those PCS recipients who no longer qualify for PCS? Hey, the Medicaid budget goes down, right? But what happens to those adults with severe mental illnesses when, because of the lack of PCS funds, the group homes either close or turn out those residents who no longer qualify for PCS?
In a perfect world, I guess the families of the adult Medicaid recipients would take them in and all would be fine. But I gather there is a reason that these recipients are in a group home and not with family.
No, since this is not a perfect world, most of these adults with severe mental illnesses, without a group home, would be homeless and, eventually, if not immediately, would be hospitalized at a much higher price that a group home.
So these adult Medicaid recipients are stable in a group home. Well-cared for. Most likely, have relationships with the staff and other residents. But because of the new PCS criteria and the fact that the NC budget does not provide funding for Medicaid residents that no longer qualify for the PCS funding, we will uproot the adults with severe mental illness, send them into the world, expect them to be ok, and, then, later, pay much more money to the hospitals that are forced to take in these Medicaid recipients due to whatever issues caused the hospitalization.
Hmmmm….at least the Medicaid budget is lower.
New CMS Proposal Will Reduce Hospitals’ DSH Allotments: Less Incentive for Hospitals to Treat the Uninsured
The Centers of Medicare and Medicaid (CMS) put forth a new proposal setting forth aggregate reductions to state Medicaid disproportionate share hospital (DSH) allotments from 2014 – 2020.
First of all, what is DSH? (DSH) are payments to hospitals that serve a significantly disproportionate number of low-income patients; eligible hospitals are referred to as DSH hospitals. (Click here for a link to DSH hospitals in NC). States receive an annual DSH allotment to cover the costs of DSH hospitals that provide care to low-income patients that are not paid by other payors, such as Medicare and Medicaid. For example, in fiscal year 2011, North Carolina received $295,314,187.00 in DSH allotments. Almost 300 billion in allotments would make any hospital less reluctant to treat the uninsured.
Think of DSH this way, in North Carolina, according to a recent article in the News and Observer, we have approximately 1.5 million uninsured in NC, roughly 1 out of every 5 NC residents. When a person without health insurance gets sick, they cannot go to the doctor (since they do not have doctor because of not having insurance). Instead, the uninsured are forced to go to the emergency room.
Now think of hospitals as a business, which is what they are. We all would like to think that hospitals are there for everyone. That everyone is welcome in a hospital. (At least, I would like to think that). However, the reality is that hospitals are a business. Each procedure, each test, each exam costs a certain amount of money. If the person receiving the service cannot pay, what incentive does a hospital have to continue to service the person?
Well, there ARE federal requirements to treat. For example, under the Emergency Medical Treatment and Labor Act (EMTALA), part of the 1985 Consolidated Omnibus Reconciliation Act (COBRA), a hospital cannot turn away or unnecessarily discharge any uninsured person with an emergency condition. Anyone who shows up in a hospital emergency room will be screened to determine the severity of his or her condition. If the condition is deemed an emergency, the hospital is obligated to stabilize the patient. But for non-emergency conditions, what incentives do hospitals have to continue treatment for non-emergency condition? Hence, the DSH payments.
Going back to CMS’ proposed DSH reductions, the thought process behind these aggregate reductions is (in my opinion): Because of Medicaid expansion under the Affordable Care Act (ACA), more people with be insured by Medicaid and less uninsured people will be admitting themselves into ERs. In other words, if a state opted to expand Medicaid, then, supposedly, more people are insured; thus the hospitals need less DSH.
But what about the states that did not opt to expand Medicaid (i.e., North Carolina)?
CMS’ proposal sets forth 5 factors to determine each state’s DSH allotments. Whether the state expanded Medicaid will be considered. The proposal states, in pertinent part:
“Consequently, hospitals in states implementing the new coverage group [Medicaid expansion] that serve Medicaid patients may experience a deeper reduction in DSH payments than they would if all states were to implement the new coverage group.”
Here are the official statutory factors:
- Factor 1 – Low DSH Adjustment Factor (LDF)
- Factor 2 – Uninsured Percentage Factor (UPF)
- Factor 3 – High Volume of Medicaid Inpatients Factor (HMF)
- Factor 4 – High Level of Uncompensated Care Factor (HUF)
- Factor 5 – Section 1115 Budget Neutrality Factor (BNF)
The proposal also provides an illustrative chart of potential reductions. Here’s the warning: “Table 1 and the values contained therein are provided only for purposes of illustrating the application of the DHRM and the associated DSH reduction factors described in this proposed rule to determine each states’ DSH allotment reduction for FY 2014. Note that these values do not represent the final DSH reduction amounts for FY 2014.”
Here’s the illustrative chart: (which can also be found here since the below picture is so small…or I need new contacts)
So how much will North Carolina hospitals’ DSH allotments go down under this CMS proposal?
According to the Kaiser Foundation, North Carolina’s hospitals’ DSH payments will be reduced by $500 million in FY 2014, $600 million in FYs 2015-2016, $1.8 billion in FY 2017, $5 billion in FY2018, $5.6 billion in FY2019, and $4 billion in FY 2020.
Possible consequences?
Hospitals Treat Less Uninsured: It is only logical that if a hospital will no longer be allotted as much money to treat uninsured patients, the hospitals will want to treat less uninsured. One possible way a hospital could legally limit the number of uninsured is to determine less conditions as an “emergency condition.” Obviously, what constitutes an “emergency condition” has some subjective wiggle-room.
Less Hospitals Opt to be DSH Hospitals: If the amount of money is so greatly reduced so as NOT to provide an incentive for a hospital to treat uninsured, some hospitals may opt to not meet the standard of a DSH hospital.
More Transfers for the Uninsured: If hospitals are not receiving the incentive to treat uninsured, hospitals may transfer the uninsured patients to other hospitals in instances in which the hospital would not transfer an insured patient.
You can provide your comments to CMS regarding this proposed DSH reduction.
Send comments to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2367-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850
