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Code · REGISTER · 2008-02-22 · Peace Corps · Notices

Notices. Proposed rule

42,438 words·~193 min read·/register/2008/02/22/08-789

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

BILLING CODE 3510-22-S 73 36 Friday, February 22, 2008 Proposed Rules PEACE CORPS 22 CFR Part 309 RIN 0420-AA22 Debt Collection AGENCY: Peace Corps. ACTION: Proposed rule. SUMMARY: The Peace Corps is revising its current regulations on debt collection. The revisions will clarify and simplify Peace Corps' debt collection procedures and practices. It eliminates the tax refund offset provisions of the previous regulation, and consolidates the administrative and tax refund offset provisions into one section.
DATES: Comments must be received by March 24, 2008. ADDRESSES: Comments should be submitted to Tyler Posey, General Counsel, Office of the General Counsel, 8th Floor, 1111 20th Street, NW., Washington, DC 20526. FOR FURTHER INFORMATION CONTACT: Suzanne B. Glasow, Associate General Counsel, 202-692-2157. SUPPLEMENTARY INFORMATION: Section-by-Section Analysis Subpart A—General Provisions The subpart announces the general purpose and scope of the regulation, provides definitions and terms used in this regulation, and this regulation's interaction with other regulations and procedures.
Charges for interest, penalties and administrative expenses are addressed. Procedures for installment payments are provided. Authority to carry out the necessary duties for debt collection is delegated to the Chief Financial Officer. Subpart B—Collection Actions The subpart provides for aggressive collection efforts by the Peace Corps, and the timely turnover of past due collections to the Department of the Treasury. Procedures for written demand of payment and debtor review of the debt are provided.
Methods of debt collection are listed. Subpart C—Salary Offset The subpart provides for salary offset collection procedures. Coordination of salary offset of another Federal Agency is addressed. Notice requirements prior to salary offset are listed. Outside hearings prior to salary offset is addressed. Executive Order 12866 This regulation has been determined to be non-significant within the meaning of Executive Order 12866. Regulatory Flexibility Act The Peace Corps Director, in accordance with the Regulatory Flexibility Act, (5 U.S.C. 605) has reviewed this regulation and by approving it certifies that this regulation will not have a significant economic impact on a substantial number of small entities.
This regulation pertains to the administrative collection of individual debts owed to the Peace Corps, and does not affect acquisition, inter-Agency, or foreign claims. Unfunded Mandates Reform Act of 1995 This rule will not result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100,000,000 or more in any one year, and it will not significantly or uniquely affect small governments. Therefore, no actions were deemed necessary under the provisions of the Unfunded Mandates Reform Act of 1995.
List of Subjects in 22 CFR Part 303 Claims. For the reasons stated in the preamble, Peace Corps proposes to revise 22 CFR part 303, as set forth below: PART 309—DEBT COLLECTION Section Contents Subpart A—General Provisions Sec. 309.1 General purpose. 309.2 Scope. 309.3 Definitions. 309.4 Other procedures or actions. 309.5 Interest, penalties, and administrative costs. 309.6 Collection in installments. 309.7 Designation. Subpart B—Collection Actions 309.8 Application. 309.9 Notice—written demand for payment. 309.10 Review requirements. 309.11 Collection.
Subpart C—Salary Offset 309.12 Purpose. 309.13 Scope. 309.14 Coordinating offset with another Federal agency. 309.15 Notice requirements before offset. 309.16 Review. 309.17 Procedures for salary offset. 309.18 Voluntary repayment agreements as an alternative to salary offset. 309.19 Waiver. 309.20 Compromise. 309.21 Suspension of collection. 309.22 Termination of collection. 309.23 Discharge. 309.24 Bankruptcy. Authority: 31 U.S.C. 3701-3719; 5 U.S.C. 5514; 22 U.S.C. 2503(b); 31 U.S.C. 3720A; 31 CFR part 285; 5 CFR 550, subpart K.
Subpart A—General Provisions § 309.1 General purpose. This part prescribes the procedures to be used by the United States Peace Corps (Peace Corps) in the collection and/or disposal of non-tax debts owed to Peace Corps and to the United States. § 309.2 Scope.
(a)Applicability of Federal Claims Collection Standards (FCCS). Peace Corps hereby adopts the provisions of the Federal Claims Collections Standards (31 CFR parts 900-904) and, except as set forth in this part or otherwise provided by law, Peace Corps will conduct administrative actions to collect claims (including offset, compromise, suspension, termination, disclosure and referral) in accordance with the FCCS.
(b)This part is not applicable to:
(1)Peace Corps claims against another Federal agency, any foreign country or any political subdivision thereof, or any public international organization.
(2)Debts arising out of acquisitions contracts subject to the Federal Acquisition Regulation
(FAR)shall be determined, collected, compromised, terminated, or settled in accordance with those regulations (see 49 CFR part 32).
(3)Claims where the Peace Corps Director (or designee) determines that the achievement of the purposes of the Peace Corps Act, as amended, 22 U.S.C. 2501 et seq., or any other provision of law administered by the Peace Corps require a different course of action. § 309.3 Definitions. As used in this part (except where the context clearly indicates, or where the term is otherwise defined elsewhere in this part) the following definitions shall apply:
(a)*Administrative offset* means withholding funds payable by the United States to, or held by the United States for, a person to satisfy a debt owed by the person to the United States.
(b)*Administrative wage garnishment* means the process by which a Federal agency orders a non-Federal employer to withhold amounts from an employee's wages to satisfy a debt the employee owes to the United States.
(c)*Compromise* means that the creditor agency accepts less than the full amount of an outstanding debt in full satisfaction of the entire amount of the debt.
(d)*Debt* or *claim* means an amount of money which has been determined by an appropriate agency official to be owed to the United States from any person. As used in this part, the terms debt and claim are synonymous.
(e)*Debtor* means a person who owes the Federal Government money.
(f)*Delinquent debt* means any debt, which has not been paid by the date specified in an agency's initial written notification or in an applicable agreement, unless other satisfactory payment arrangements have been made.
(g)*Discharge* means the release of a debtor from personal liability for a debt. Further collection action is prohibited.
(h)*Disposable pay* has the same meaning as that term is defined in 5 CFR 550.1103.
(i)*Employee* means a current employee of the Peace Corps or other Federal agency, including a member of the Armed Forces or Reserve of the Armed Forces of the United States.
(j)*FCCS* means the Federal Claims Collection Standards jointly published by the Department of the Treasury and the Department of Justice at 31 CFR parts 900-904.
(k)*Person* means an individual, corporation, partnership, association, organization, State or local government, or any other type of entity other than a Federal agency, foreign government, or public international organization.
(l)*Salary offset* means the withholding of amounts from the current pay account of a Federal employee to satisfy a debt owed by that employee to the United States.
(m)*Suspension* means the temporary cessation of an active debt collection pending the occurrence of an anticipated event.
(n)*Termination* means the cessation of all active debt collection action for the foreseeable future.
(o)*Waiver* means the decision to forgo collection of a debt owed to the United States as permitted or required by law. § 309.4 Other procedures or actions.
(a)Nothing contained in this regulation is intended to require Peace Corps to duplicate administrative proceedings required by contract or other laws or regulations.
(b)Nothing in this regulation is intended to preclude utilization of informal administrative actions or remedies which may be available.
(c)Nothing contained in this regulation is intended to deter Peace Corps from demanding the return of specific property or from demanding the return of the property or the payment of its value.
(d)The failure of Peace Corps to comply with any provision in this regulation shall not serve as a defense to the debt. § 309.5 Interest, penalties, and administrative costs.
(a)Except as otherwise provided by statute, contract or excluded in accordance with FCCS, Peace Corps will assess:
(b)Interest on unpaid debts in accordance with 31 CFR 901.9.
(c)Penalty charges at a rate of 6 percent a year or such other rate as authorized by law on any portion of a claim that is delinquent for more than 90 days.
(d)Administrative charges to cover the costs of processing and handling delinquent debts.
(e)Late payment charges shall be computed from the date of mailing or hand delivery of the notice of the claim and interest requirements.
(f)When a debt is paid in partial or installment payments, amounts received shall be applied first to outstanding penalty and administrative cost charges, second to accrued interest, and then to outstanding principal.
(g)Waiver. Peace Corps will consider waiver of interest, penalties and/or administrative costs in accordance with the FCCS, 31 CFR 901.9(g). § 309.6 Collection in installments. Whenever feasible, and except as required otherwise by law, debts owed to the United States, together with interest, penalties, and administrative costs as required by this regulation, should be collected in one lump sum. This is true whether the debt is being collected under administrative offset, including salary offset, or by another method, including voluntary payment. However, if the debtor is financially unable to pay the indebtedness in one lump sum, payment may be accepted in regular installments. If Peace Corps agrees to accept payment in installment, it may require a legally enforceable written agreement from the debtor that specifies all of the terms of the arrangement and which contains a provision accelerating the debt in the event the debtor defaults. The size and frequency of the payments should bear a reasonable relation to the size of the debt and ability of the debtor to pay. If possible, the installment payments should be sufficient in size and frequency to liquidate the Government's claim within three years. § 309.7 Designation. The Chief Financial Officer is delegated authority and designated to perform all the duties for which the Director is responsible under the forgoing statutes and joint regulations. SUBPART B—COLLECTION ACTIONS § 309.8 Application.
(a)Peace Corps shall aggressively collect claims and debts in accordance with these regulations and applicable law.
(b)Peace Corps will transfer to the Department of the Treasury, Financial Management Service
(FMS)any past due, legally enforceable non-tax debt that has been delinquent for 180 days or more so that FMS may take appropriate action to collect the debt or take other appropriate action in accordance with applicable law and regulation.
(c)Peace Corps may transfer any past due, legally enforceable debt that has been delinquent for fewer than 180 days to FMS for collection in accordance with applicable law and regulation. (See 31 CFR part 285) § 309.9 Notice—written demand for payment.
(a)Upon determination that a debt is owed to Peace Corps or the United States, Peace Corps shall promptly hand deliver or send by first-class mail (to the debtor's most current address in the records of Peace Corps) at least one written notice (e.g., Bill of Collection or demand letter) informing the debtor of the consequences of failing to pay or otherwise resolve a Peace Corps debt, subject to paragraph
(c)of this section. Written demand under this subpart may be preceded by other appropriate actions under this part and or the FCCS, including but not limited to actions taken under the procedures applicable to administrative offset, including salary offset.
(b)The written notice shall inform the debtor of:
(1)The nature and amount of the debt, and the facts giving rise to the debt;
(2)The date by which payment should be made to avoid the imposition of interest, penalties, and administrative costs, and the enforced collection actions described in section 309.5 of this part;
(3)The applicable standards for imposing interest, penalties and administrative costs to delinquent debts;
(4)Peace Corps' willingness to discuss alternative payment arrangements and how the debtor may enter into a written agreement to repay the debt under terms acceptable to Peace Corps;
(5)The name, address, and telephone number of a contact person or office within Peace Corps;
(6)Peace Corps' intention to enforce collection if the debtor fails to pay or otherwise resolve the debt, by taking one or more of the following actions:
(i)Offset from Federal payments otherwise due to the debtor, including income tax refunds, salary, certain benefit payments, retirement, vendor payments, travel reimbursement and advances, and other Federal payments;
(ii)Referral to private collection agency;
(iii)Report to credit bureaus;
(iv)Administrative wage garnishment;
(v)Referral to Department of Justice for litigation action;
(vi)Referral to Financial Management Service of the Department of the Treasury for collection;
(vii)Other actions as permitted by the FCCS and applicable law.
(7)How the debtor may inspect and copy records related to the debt;
(8)The debtor's opportunity for an internal review of Peace Corps' determination that the debtor owes a debt or the amount of the debt;
(9)The debtor's right, if any, to request waiver of collection of certain debts, as applicable;
(10)Requirement that the debtor advise Peace Corps of any bankruptcy proceeding of the debtor.
(c)Peace Corps may omit from a notice to a debtor one or more of the provisions contained in paragraphs (b)(6) through (b)(10) of this section if Peace Corps determines that any provision is not legally required given the collection remedies to be applied to a particular debt, or which have already been provided by prior notice, applicable agreement, or contract. § 309.10 Review requirements.
(a)For purposes of this section, whenever Peace Corps is required to afford a debtor a review within the agency, Peace Corps shall provide the debtor with an opportunity for an internal review of the existence or the amount of the debt. For offset of current Federal salary under 5 U.S.C. 5514 for certain debts, debtors may also request an outside hearing. See subpart C of this part.
(b)Any request for a review must be in writing to the contact office by the payment due date stated in the initial notice sent under § 309.9(b) or other applicable provision. The debtor's request shall state the basis for the dispute and include any relevant documentation in support.
(1)Peace Corps will provide for an internal review of the debt by an appropriate agency official. The review may include examination of documents, internal discussions with relevant officials and discussion by letter or orally with the debtor, at Peace Corps' discretion.
(2)An oral hearing is not required when, in Peace Corps' determination, the matter can be decided on the documentary record. Peace Corps will provide a “paper hearing”, that is, a determination based upon a review of the written record unless Peace Corps makes a determination that a debt involves issues of credibility or veracity, at which point an oral hearing may be required. Unless otherwise required by law, such oral hearing shall not be a formal evidentiary hearing. § 309.11 Collection. Upon final determination of the existence and amount of a debt, unless other acceptable payment arrangements have been made or procedures under a specific statute apply, Peace Corps shall collect the debt by one or more of the methods described in § 309.9(b)(6)(i-vii) or as otherwise authorized by law and regulation.
(a)Administrative offset—
(1)Payments otherwise due the debtor from the United States shall be offset from the debt in accordance with 31 CFR 901.3. These may be funds under the control of Peace Corps or other Federal agencies. Collection may be through centralized offset by the Financial Management Service
(FMS)of the Department of the Treasury.
(2)Such payments include but are not limited to vendor payments, salary, retirement, lump sum payments due upon Federal employment separation, travel reimbursements, tax refunds, loans or other assistance. Offset of Federal salary payments will be in accordance with 5 U.S.C. 5514.
(3)Before administrative offset is instituted by another Federal agency or the FMS, Peace Corps shall certify in writing to that entity that the debt is past due and legally enforceable and that Peace Corps has complied with all applicable due process and other requirements as described in this part and other Federal law and regulations.
(b)Any other method authorized by law or regulation. SUBPART C—SALARY OFFSET § 309.12 Purpose. This subpart provides Peace Corps' policies and procedures for the collection by salary offset of a Federal employee's pay to satisfy certain past due debts owed the United States Government. § 309.13 Scope.
(a)The provisions of this section apply to collection by salary offset under 5 U.S.C. 5514 of debts owed to Peace Corps and debts owed to other Federal agencies by Peace Corps' employees. Peace Corps will make reasonable and lawful efforts to administratively collect amounts owed by employees prior to initiating salary offset action. This section does not apply to debts where collection by salary offset is explicitly provided for or prohibited by another statute (e.g., travel advances).
(b)References. The following statutes and regulations apply to Peace Corps' recovery of debts due the United States by salary offset:
(1)5 U.S.C. 5514, as amended, governing the installment collection of debts;
(2)31 U.S.C. 3716, governing the liquidation of debts by administrative offset;
(3)5 CFR part 550, subpart K, setting forth the minimum requirements for executive agency regulations on salary offset; and
(4)31 CFR parts 900 through 904, the Federal Claims Collection Standards.
(c)Nothing in this subpart precludes the compromise, suspension, or termination of collection actions where appropriate under the standards implementing the Federal Claims Collection Standards. § 309.14 Coordinating offset with another Federal agency.
(a)When Peace Corps is owed a debt by an employee of another agency, the other agency shall not initiate the requested offset until Peace Corps provides the agency with a written certification that the debtor owes Peace Corps a debt (including the amount and basis of the debt and the due date of payment) and that Peace Corps has complied with these regulations.
(b)When another agency is owed the debt, Peace Corps may use salary offset against one of its employees who is indebted to another agency, if requested to do so by that agency. Such request must be accompanied by a certification that the person owes the debt (including the amount and basis of the debt and the due date of payment) and that the agency has complied with its regulations as required by 5 U.S.C. 5514 and 5 CFR part 550, subpart K. § 309.15 Notice requirements before offset.
(a)Deductions under the authority of 5 U.S.C. 5514 shall not be made unless the creditor agency first provides the employee with written notice that he/she owes a debt to the Federal Government at least 30 calendar days before salary offset is to be initiated. When Peace Corps is the creditor agency this notice of intent to offset an employee's salary shall be hand-delivered or sent by certified mail to the most current address that is available. The written notice will state:
(1)That Peace Corps has reviewed the records relating to the claim and has determined that a debt is owed, its origin and nature, and the amount of the debt;
(2)The intention of Peace Corps to collect the debt by means of deduction from the employee's current disposable pay account until the debt and all accumulated interest is paid in full;
(3)The amount, frequency, approximate beginning date, and duration of the intended deductions;
(4)An explanation of the Peace Corps' policy concerning interest, penalties and administrative costs, including a statement that such assessments must be made unless excused in accordance with the FCCS (See § 309.5);
(5)The employee's right to inspect and copy all records of the Peace Corps pertaining to the debt claimed or to receive copies of such records if personal inspection is impractical;
(6)The right to a hearing conducted by a hearing official (an administrative law judge, or alternatively, an individual not under the supervision or control of the Peace Corps) with respect to the existence and amount of the debt claimed, or the repayment schedule, so long as a petition is filed by the employee as prescribed;
(7)If not previously provided, the opportunity (under terms agreeable to the Peace Corps) to establish a schedule for the voluntary repayment of the debt or to enter into a written agreement to establish a schedule for repayment of the debt in lieu of offset. The agreement must be in writing, signed by both the employee and the creditor agency, and documented in the creditor agency's files;
(8)The name, address and telephone number of an officer or employee of the Peace Corps who may be contacted concerning procedures for requesting a hearing;
(9)The method and time period for requesting a hearing;
(10)That the timely filing of a petition for a hearing as prescribed will stay the commencement of collection proceedings;
(11)The name and address of the office to which the petition should be sent;
(12)That the Peace Corps will initiate certification procedures to implement a salary offset, as appropriate, (which may not exceed 15 percent of the employee's disposable pay) not less than 30 calendar days from the date of delivery of the notice of debt, unless the employee files a timely petition for a hearing;
(13)That a final decision on the hearing (if one is requested) will be issued at the earliest practical date, but not later than 60 calendar days after the filing of the petition requesting the hearing, unless the employee requests and the hearing official grants a delay in the proceedings;
(14)That any knowingly false or frivolous statements, representations or evidence may subject the employee to:
(i)Disciplinary procedures appropriate under the Peace Corps Act or the Foreign Service Act, Peace Corps regulations, or any other applicable statutes or regulations;
(ii)Penalties under the False Claims Act, §§ 3729-3731 of title 31, United States Code, or any other applicable statutory authority; and
(iii)Criminal penalties under 18 U.S.C. sections 286, 287, 1001, and 1002 or any other applicable authority;
(15)Any other rights and remedies available to the employee under statutes or regulations governing the program for which the collection is being made;
(16)That unless there are applicable contractual or statutory provisions to the contrary, amounts paid on or deducted for the debt which are later waived or found not owed to the United States will be promptly refunded to the employee; and
(17)That proceedings with respect to such debt are governed by 5 U.S.C. 5514.
(b)Peace Corps is not required to provide prior notice to an employee when the following adjustments are made by Peace Corps to a Peace Corps employee's pay:
(1)Any adjustment to pay arising out of an employee's election of coverage or a change in coverage under a Federal benefits program requiring periodic deductions from pay if the amount to be recovered was accumulated over four pay periods or less;
(2)A routine adjustment of pay that is made to correct an overpayment of pay attributable to clerical or administrative errors or delays in processing pay documents, if the overpayment occurred within the four pay periods preceding the adjustment, and, at the time of such adjustment, or as soon thereafter as practical, the individual is provided written notice of the nature and the amount of the adjustment and point of contact for contesting the adjustment; or
(3)Any adjustment to collect a debt of $50 or less, if, at the time of such adjustment, or as soon thereafter as practical, the individual is provided written notice of the nature of the amount of the adjustment and a point of contact for contesting the adjustment. § 309.16 Review.
(a)Request for outside hearing. Except as provided in paragraph
(b)of this section, an employee who desires an outside hearing concerning the existence or amount of the debt or the proposed offset schedule must send a request to the office designated in the notice of intent. See § 309.15(a)(8). The request must be received by the designated office not later than 20 calendar days after the date of delivery of the notice as provided in § 309.15(a). The request must be signed by the employee and should identify and explain with reasonable specificity and brevity the facts, evidence and witnesses which the employee believes support his or her position. If the employee objects to the percentage of disposable pay to be deducted from each check, the request should state the objection and the reasons for it. The employee must also specify whether an oral hearing or a review of the documentary evidence is requested. If an oral hearing is desired, the request should explain why the matter cannot be resolved by review of the documentary evidence alone.
(b)Failure to submit timely.
(1)If the employee files a petition for a review after the expiration of the 20 calendar day period provided for in paragraph
(a)of this section, the designated office may accept the request if the employee can show that the delay was the result of circumstances beyond his or her control, or because of a failure to receive the notice of the filing deadline (unless the employee has actual knowledge of the filing deadline).
(2)An employee waives the right to a review, and will have his or her disposable pay offset in accordance with Peace Corps' offset schedule, if the employee fails to file a request for a hearing unless such failure is excused as provided in paragraph (b)(1) of this section.
(3)If the employee fails to appear at an oral hearing of which he or she was notified, unless the hearing official determines failure to appear was due to circumstances beyond the employee's control, his or her appeal will be decided on the basis of the documents then available to the hearing official.
(c)Representation at the hearing. The creditor agency may be represented by a representative of its choice. The employee may represent himself or herself or may be represented by an individual of his or her choice and at his or her expense.
(d)Review of Peace Corps records related to the debt.
(1)An employee who intends to inspect or copy creditor agency records related to the debt in accordance with § 309.15(a)(5) must send a letter to the official designated in the notice of intent to offset stating his or her intention. The letter must be sent within 20 calendar days after receipt of the notice.
(2)In response to a timely request submitted by the debtor, the designated official will notify the employee of the location and time when the employee may inspect and copy records related to the debt.
(3)If personal inspection is impractical, copies of such records shall be sent to the employee.
(e)Oral Hearing.
(1)If an employee timely files a request for an oral hearing under § 309.16(a), the matter will be conducted by a hearing official not under the supervision or control of Peace Corps.
(2)Procedure.
(i)After the employee requests a hearing, the hearing official shall notify the employee of the form of the hearing to be provided. If the hearing will be oral, notice shall set forth the date, time and location of the hearing. If the hearing will be paper, the employee shall be notified that he or she should submit arguments in writing to the hearing official by a specified date after which the record shall be closed. This date shall give the employee reasonable time to submit documentation.
(ii)An employee who requests an oral hearing shall be provided an oral hearing if the hearing official determines that the matter cannot be resolved by review of documentary evidence alone (e.g. when an issue of credibility or veracity is involved). The hearing is not an adversarial adjudication, and need not take the form of an evidentiary hearing.
(iii)If the hearing official determines that an oral hearing is not necessary, he or she will make a decision based upon a review of the available written record.
(iv)The hearing official must maintain a summary record of any hearing provided by this subpart. Witnesses who provide testimony will do so under oath or affirmation.
(3)Decision. The written decision shall include:
(i)A statement of the facts presented to support the origin, nature, and amount of the debt;
(ii)The hearing official's findings, analysis, and conclusions; and
(iii)The terms of any repayment schedules, or the date salary offset will commence, if applicable.
(4)Failure to appear. In the absence of good cause shown (e.g. excused illness), an employee who fails to appear at a hearing shall be deemed, for the purpose of this subpart, to admit the existence and amount of the debt as described in the notice of intent. The hearing official shall schedule a new hearing upon the request of the creditor agency representative when good cause is shown.
(5)A hearing official's decision is considered to be an official certification regarding the existence and amount of the debt for purposes of executing salary offset under 5 U.S.C. 5514 only. It does not supersede the finding by Peace Corps that a debt is owed and does not affect the Government's ability to recoup the debt through alternative collection methods under other appropriate methods. § 309.17 Procedures for salary offset. Unless otherwise provided by statute or contract, the following procedures apply to salary offset:
(a)Method. Salary offset will be made by deduction at one or more officially established pay intervals from the current pay account of the employee without his or her consent.
(b)Source. The source of salary offset is current disposable pay.
(c)Types of collection.
(1)Lump sum payment. Ordinarily debts will be collected by salary offset in one lump sum if possible. However, if the amount of the debt exceeds 15 percent of disposable pay for an officially established pay interval, the collection by salary offset must be made in installment deductions.
(2)Installment deductions.
(i)The size of installment deductions must bear a reasonable relation to the size of the debt and the employee's ability to pay. If possible, the size of the deduction will be that necessary to liquidate the debt in no more than 1 year. However, the amount deducted for any period must not exceed 15 percent of the disposable pay from which the deduction is made, except as provided by other regulations or unless the employee has agreed in writing to greater amount.
(ii)Installment payments of less than $25 per pay period will be accepted only in the most unusual circumstances.
(iii)Installment deductions will be made over a period of not greater than the anticipated period of employment. § 309.18 Voluntary repayment agreements as an alternative to salary offset.
(a)In response to a notice of intent, an employee may propose a written agreement to repay the debt as an alternative to salary offset. Any employee who wishes to repay a debt without salary offset shall submit in writing a proposed agreement to repay the debt. The proposal shall admit the existence of the debt and set forth a proposed repayment schedule. Any proposal under this paragraph must be received by the official designated in that notice within 20 calendar days after receipt of the notice of intent.
(b)When the Peace Corps is the creditor agency, in response to a timely proposal by the debtor the agency will notify the employee whether the employee's proposed written agreement for repayment is acceptable. It is within the agency's discretion to accept a repayment agreement instead of proceeding by offset.
(c)If the Peace Corps decides that the proposed repayment agreement is unacceptable, the employee will have 15 calendar days from the date he or she received notice of the decision to file a petition for a review.
(d)If the Peace Corps decides that the proposed repayment agreement is acceptable, the alternative arrangement must be in writing and signed by both the employee and a designated agency official. § 309.19 Waiver.
(a)Under certain circumstances, employees may have a statutory right to request a waiver of indebtedness. When an employee makes a request under a statutory right, further collection will be stayed pending an administrative determination on the request.
(b)Waiver of indebtedness is an equitable remedy and as such must be based on an assessment of the facts involved in the individual case under consideration. The burden is on the employee to demonstrate that the applicable waiver standard has been met. § 309.20 Compromise. Peace Corps may attempt to effect compromise in accordance with the standards set forth in the FCCS (31 CFR part 902). § 309.21 Suspension of collection. Suspension of collection action shall be made in accordance with the standards set forth in the FCCS (31 CFR 903.1-903.2). § 309.22 Termination of collection. Termination of collection action shall be made in accordance with the standards set forth in the FCCS (31 CFR 903.1 and 903.3-903.4). § 309.23 Discharge. Once a debt has been closed out for accounting purposes and collection has been terminated, the debt is discharged. Peace Corps will report discharged debt as income to the debtor to the Internal Revenue Service per 26 U.S.C. 6050P and 26 CFR 1.6050P-1. § 309.24 Bankruptcy. Peace Corps generally terminates collection activity on debts that have been discharged in bankruptcy unless otherwise provided for by bankruptcy law. The CFO will seek legal advice by the General Counsel's office if there is the belief that any claims or offset may have survived the discharge of a debtor. Dated: February 15, 2008. Tyler S. Posey, General Counsel. [FR Doc. E8-3268 Filed 2-21-08; 8:45 am] BILLING CODE 6015-01-P DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 440 [CMS-2232-P] RIN 0938-A048 Medicaid Program; State Flexibility for Medicaid Benefit Packages AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: This proposed rule would implement provisions of section 6044 of the Deficit Reduction Act of 2005, Pub. L. 109-171, which amends the Social Security Act by adding a new section 1937 related to the coverage of medical assistance under approved State plans. Under this new section, States have increased flexibility under an approved State plan to define the scope of covered medical assistance by offering coverage of benchmark or benchmark-equivalent benefit packages to certain Medicaid recipients. DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. March 24, 2008. ADDRESSES: In commenting, please refer to file code CMS-2232-P. Because of staff and resource limitations, we cannot accept comments by facsimile
(FAX)transmission. You may submit comments in one of four ways (no duplicates, please): 1. *Electronically.* You may submit electronic comments on specific issues in this regulation to *http://www.cms.hhs.gov/eRulemaking.* Click on the link “Submit electronic comments on CMS regulations with an open comment period.” (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.) 2. *By regular mail.* You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2232-P, P.O. Box 8016, Baltimore, MD 21244-8016. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. *By express or overnight mail.* You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2232-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 4. *By hand or courier.* If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number
(410)786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850. (Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. *Submission of comments on paperwork requirements.* You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the “Collection of Information Requirements” section in this document. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION CONTACT: Donna Schmidt,
(410)786-5532. SUPPLEMENTARY INFORMATION: *Submitting Comments:* We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-2232-P and the specific “issue identifier” that precedes the section on which you choose to comment. *Inspection of Public Comments:* All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: *http://www.cms.hhs.gov/eRulemaking.* Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments. Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951. I. Background Under title XIX of the Social Security Act (the Act), the Secretary is authorized to provide funds to assist States in furnishing medical assistance to needy individuals whose income and resources are insufficient to meet the costs of necessary medical services, including families with dependent children and individuals who are aged, blind, or disabled. To be eligible for funds under this program, States must submit a State plan, which must be approved by the Secretary. Programs under title XIX are jointly financed by Federal and State governments. Within broad Federal guidelines, each State determines the design of its program, eligible groups, benefit packages, payment levels for coverage and administrative and operating procedures. Before the passage of the Deficit Reduction Act (DRA), States were required to offer at minimum a standard benefit package to eligible populations identified in section 1902(a)(10)(A) of the Act (with some specific exceptions, for example, for certain pregnant women, who could be limited to pregnancy-related services). Under section 1902(a)(10)(A) of the Act, this standard benefit package had to include certain specific benefits identified in the definition of “medical assistance” at section 1905(a) of the Act. These identified benefits include inpatient and outpatient hospital services, physician services, medical and surgical services furnished by a dentist, rural health clinic services, federally qualified health center services, laboratory and X-ray services, nursing facility services, early and periodic screening, diagnostic and treatment services for individuals under age 21, family planning services to individuals of child-bearing age, nurse-midwife services, certified pediatric nurse practitioner, and certified family nurse practitioner services. Under section 1902(a)(10)(D) of the Act, the standard benefit package is also required to include home health services. Section 6044 of the Deficit Reduction Act of 2005
(DRA)(Pub. L. 109-171, enacted on February 8, 2006), amended the Act by adding a new section 1937 that allows States to amend their Medicaid State plans to provide for the use of benefit packages other than the standard benefit package, namely benchmark benefit packages or benchmark-equivalent packages, for certain populations. The statute delineates what benefit packages qualify as benchmark packages and what would constitute a benchmark-equivalent package. The statute also specifies those exempt populations that may not be included or mandated in the benchmark coverages. To be eligible for funds under this new provision, States must submit a State plan amendment, which must be approved by the Secretary. This proposed rule would incorporate and integrate into Centers for Medicare & Medicaid Services
(CMS)regulations the statutory framework for alternative benchmark packages. II. Provisions of the Proposed Rule [If you choose to comment on issues in this section, please include the caption “PROVISIONS OF THE PROPOSED RULE” at the beginning of your comments.] By creating section 1937 of the Act, we believe the Congress intended to provide States unprecedented flexibility within Medicaid State Plans to provide health benefits coverage. This authority, created by section 6044 of the DRA, allows States broad flexibility to develop innovative health coverage plans for Medicaid recipients. States may create more mainstream packages like those found in the private insurance market by implementing health benefit packages mirroring employer sponsored group health plans. These flexibilities give States new opportunities to provide benefit plans to meet the health care needs of Medicaid populations while maintaining the sustainability of the program. For the first time in the State plan, States may create innovative Medicaid programs that further strengthen and support the overall health care system. States now have the tools they need to provide person-centered care to maximize health outcomes for individuals. These tools may be used in conjunction with other title XIX and XXI authorities and other programs, to strategically align the Medicaid Program with today's healthcare environment to expand access to affordable mainstream coverage; to promote personal responsibility for health and accessing health care; and to improve quality and coordination of care. The enactment of this provision of the DRA gave States new options to create programs that are more aligned with the needs of today's Medicaid populations and the health care environment. States may use this flexibility to capitalize on the strengths of their existing health care systems by incorporating and building upon the private insurance market. Additionally, we encourage States to use these flexibilities to shape innovations in the health care marketplace. The authority under this provision creates great opportunities for States to focus the health care system on delivering person-centered health care for all individuals. States will be able to reconnect families receiving health care through Medicaid to the larger insurance system that serves most Americans and promote continuity of coverage. This in turn will strengthen the private market and assist in creating better access to health care in the State. Section 1937 of the Act gives States greater control over the administration of their Medicaid programs by moving innovative programs into State plans. This in turn, provides States with ease in leveraging the private market forces to provide care to Medicaid recipients in much the same way this care is provided to those with benefits through private insurance. We began issuing guidance about the new flexibilities available to States within months of the enactment of the DRA. For example, on March 31, 2006, we issued a State Medicaid Director letter providing guidance on the implementation of section 6044 of the DRA. This proposed rule is consistent with that guidance. Under section 1937 of the Act, a State may require that medical assistance to individuals, within one or more groups of individuals specified by the State, be provided through enrollment in a benchmark or benchmark-equivalent benefit coverage package. A State has the option to amend its State plan to provide benchmark or benchmark-equivalent coverage without regard to comparability, statewideness, freedom of choice, the assurance of transportation to medically necessary services and other requirements in order to tailor and provide the coverage to the individuals. The purpose of this section, as indicated in the title of section 6044 of the DRA, was to provide States with increased flexibility. In order to maximize that flexibility, we are proposing to interpret the statutory clause “notwithstanding any other provision of this title” to relieve States of the responsibility to assure transportation to and from providers, which is the regulatory requirement at 42 CFR 431.53 that is based on sections 1902(a)(4) and 1902)(a)(19) of the Act. The statute provides benchmark options available to States that are equivalent to those found in the private health insurance market. Generally, private health insurance plans do not offer non-emergency medical transportation as a benefit to enrollees. It would be a strong disincentive for States to offer benchmark coverage through private health insurance plans if States had to supplement benchmark benefit plans with additional transportation benefits. We are therefore proposing to exempt States that elect benchmark coverage from the transportation assurance requirement. This provides maximum flexibility to states and is consistent with the stated purpose of section 6044. *Populations Affected.* Benchmark or benchmark-equivalent coverage packages may only be offered to individuals whose eligibility is based on an eligibility category of the Act that would have been covered under the State's plan on or before the enactment of the DRA on February 8, 2006. We are interpreting the statutory term “eligibility category” in this rule to mean an eligibility category listed under section 1905(a) of the Act, in order to maximize State flexibility. All recipients within a covered category would be eligible to participate in a benchmark plan at the State's option, unless specifically exempted by statute as discussed below, even when the State makes modifications to the income and resource eligibility levels for a group or groups under such an eligibility category after February 8, 2006. A State may require recipients to obtain benefits by enrolling in benchmark or benchmark-equivalent coverage only if they are “full benefit eligibles.” A full benefit eligible is an individual who would otherwise be eligible to receive the standard full Medicaid benefit package under the approved Medicaid State plan, but does not include individuals determined eligible by the State for medical assistance under section 1902(a)(10)(C) of the Act, or by reason of section 1902(f) of the Act, or otherwise eligible based on a reduction of income based on costs incurred for medical or other remedial care (medically needy and spend-down populations). The statute also specifies other individuals who are also exempt from being required to enroll in benchmark or benchmark-equivalent benefit coverage. These individuals include: • A pregnant woman who is required to be covered under the State plan under section 1902(a)(10)(A)(i) of the Act; • A recipient qualifying for medical assistance under the State plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for Supplemental Security Income
(SSI)benefits under title XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of section 1902(e)(3) of the Act; • A recipient entitled to benefits under any part of Medicare; • A terminally ill recipient receiving benefits for hospice care under title XIX; • A recipient who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, and is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs; • A recipient who is medically frail or otherwise an individual with special medical needs (as described by the Secretary); • A recipient qualifying based on medical condition for medical assistance for long-term care services described in section 1917 (c)(1)(C) of the Act; • A recipient with respect to whom aid or assistance is made available under part B of title IV to children in foster care or with respect to whom adoption or foster care assistance is made available under part E of title IV, without regard to age; • A recipient qualifying for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of title IV (as in effect on or after welfare reform effective date defined in section 1931(i) of the Act); • Recipients eligible based on the diagnosis of breast or cervical cancer by virtue of the application of sections 1902(a)(10)(ii)(XVIII) and 1902(aa) of the Act; and • Recipients who receive limited services because they are eligible only under section 1902(a)(10)(A)(ii)(XII) of the Act because they are TB-infected, or because they are not qualified aliens (as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (Pub. L. 104-193, enacted on August 22, 1996) and receive only the care and services necessary for the treatment of an emergency medical condition in accordance with section 1903(v) of the Act. For purposes of the exempted populations under section 1937 of the Act, the Secretary is proposing in § 440.315(f) to define individuals with special medical needs to include those groups defined by Federal regulations at 42 CFR 438.50(d)(1) and §438.50(d)(3) of the managed care regulations. These groups are: dual eligibles and certain children under age 19 who are eligible for Supplemental Security Income (SSI); children eligible under section 1902(e)(3) of the Act/Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) children; individuals in foster care or other out of home placement; individuals receiving foster care or adoption assistance; or individuals receiving services through a family-centered, community-based, coordinated care system that receives grant funds under section 501(a)(1)(D) of title V, as defined by the State in terms of either program participation or special health care needs. There may be instances when an exempted individual may benefit from enrolling in a benchmark or benchmark-equivalent benefit package. States are permitted to offer these individuals a benchmark or benchmark-equivalent package, but may not require them to enroll in one. In any case in which a State offers an individual the option to enroll in a benchmark or benchmark-equivalent benefit package, the State must inform the individual that the enrollment is voluntary and that he or she may opt out at any time. In addition, the State must inform the individual of the benefits available under the benchmark or benchmark-equivalent benefit package, provide a comparison of how they differ from the benefits available under the regular Medicaid program, and must document that the individual was informed. Generally, we would expect that the benchmark or benchmark equivalent plan would have sufficient enrollment capacity for eligible individuals. However, there may be circumstances when it is beneficial for the State to limit enrollment or when the benchmark or benchmark-equivalent plan would not have the capacity to enroll all interested and eligible individuals. In these instances, the State would maintain selection criteria for such plans based on factors such as geography or date of application that are not related to health status. The State would provide otherwise available benefits to individuals under the State plan, which may include the option of enrolling in another benchmark or benchmark-equivalent plan. And, if applicable, the State would have a system under which recipients already enrolled in the benchmark or benchmark equivalent plan are given priority to continue enrollment if the plan does not have the capacity to accept all those seeking enrollment under the program. *Benefit Packages.* Under section 1937 of the Act, benchmark coverage is either Federal Employees Health Benefit Plan Equivalent Health Insurance Coverage; State Employee Coverage; a Health Maintenance Organization
(HMO)plan that has the largest insured commercial, non-Medicaid enrollment in the State; or Secretary approved coverage. Secretary approved coverage is any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population proposed to be provided this coverage. In determining the coverage available under a benchmark coverage package, we do not consider cost sharing to be a limitation on the coverage (even when the benchmark plan itself does so). Thus, for example, if the selected benchmark plan document indicates that it provides coverage for only half of the cost of mental health services, we view that as a coinsurance requirement rather than as a limitation on coverage. Cost sharing and premiums for recipients may not exceed cost sharing limits under the State's plan with respect to sections 1916 and 1916A of the Act. The State would assure that all out of pocket costs for the recipients do not exceed the applicable limits. However, benchmark and benchmark-equivalent benefit packages may include annual coverage limitations on the numbers and types of particular services. In determining whether a proposed health benefits coverage package should be Secretary approved because it provides appropriate health benefits coverage for the proposed population, we would require that States submit full descriptions of the proposed coverage, including comparisons to one of the benchmark plans or to the State's standard full Medicaid coverage package under section 1905(a) of the Act. In addition, the State would submit any other information that would be relevant to a determination that the proposed health benefits coverage would be appropriate for the proposed population. The scope of a Secretary-approved health benefits package will be limited to benefits within the scope of the categories available under a benchmark coverage package or the standard full Medicaid coverage under section 1905(a) of the Act. In determining Secretary approved coverage, a State may consider a benefit package for a specific population that excludes a certain category of service. For example, a State may utilize a Secretary approved package that is benchmarked to the State employees benefit package which does not include pregnancy-related services. This would be appropriate where the targeted population is a population group that does not require such category of service—for instance non-pregnant adults. If an individual within the targeted population group enrolled in the Secretary approved benefit was initially eligible through a category targeted for the Secretary approved coverage, but later qualified for Medicaid through a group excluded from mandatory enrollment (e.g., non-pregnant female enrolled in the Secretary approved benefit becomes pregnant and qualifies under the State plan under section 1902(a)(10)(A)(i)), such individual must have the opportunity to receive state plan services not available through the benchmark and must be given the choice to remain in the Secretary approved benchmark or revert to traditional Medicaid. In either event, the individual must be provided the State plan services not available through the benchmark through either wrap around coverage to the Secretary approved benefit or by virtue of reverting back to traditional Medicaid. A State may elect to offer one or more benchmark coverage options. The State may also specify in the State plan criteria establishing the benchmark options, if any, available for any specific group of recipients. For example, the State plan may identify groups of recipients who receive benefits through a Federal Employees Health Benefit Plan (FEHBP) benchmark coverage plan and may identify other groups who receive benefits through a State Employee Coverage benchmark coverage plan. A State may also elect to offer benchmark-equivalent benefit coverage. Coverage would be considered benchmark-equivalent coverage if it has an aggregate actuarial value equivalent to a benchmark plan described above, and it includes the following basic categories of service: inpatient and outpatient hospital services; physicians' surgical and medical services; laboratory and x-ray services; well-baby and well-child care, including age-appropriate immunizations; and other appropriate preventive services. In addition to the categories of services set forth above, benchmark-equivalent coverage may include coverage of additional health benefits in categories of services included in the benchmark package or described in section 1905(a) of the Act. If the benchmark coverage package used by the State as a basis for comparison in establishing the aggregate actuarial value of the benchmark-equivalent package includes the following four categories of services: prescription drugs; mental health services; vision services; and hearing services; then the actuarial value of the coverage for each of these categories of service in the benchmark-equivalent coverage package must be at least 75 percent of the actuarial value of the coverage for that category of service in the benchmark plan used for comparison by the State. If the benchmark coverage package does not cover one of the additional four categories of services, then the benchmark-equivalent coverage package may, but is not required to, include coverage for that category of service. As a condition of approval of benchmark-equivalent coverage, the State must provide an actuarial report with an actuarial opinion that the benchmark-equivalent coverage meets the actuarial requirements. Benchmark or benchmark-equivalent benefit coverage may be offered through employer sponsored health plans for individuals with access to private health insurance. For example, if an individual has access to employer sponsored coverage and that coverage is determined by the State to offer a benchmark or benchmark-equivalent benefit package (either alone or with the addition of wrap-around services covered separately under Medicaid), a State may elect to provide premium payments on behalf of the recipient to purchase the employer coverage. The State may also provide premium payments on behalf of the recipient to purchase private health insurance coverage. The premium payments would be considered medical assistance, the State could require the recipient to enroll in the group health plan, and the resulting coverage would comprise the Medicaid benefit. In addition, cost sharing for recipients should not exceed cost sharing limits under the State's plan with respect to sections 1916 and 1916A of the Act. The State must make available to recipients under age 19 who are covered under the State plan under section 1902(a)(10)(A) of the Act benefits consisting of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services which are medically necessary for that individual as defined in section 1905(r) of the Act. For those individuals who are enrolled in benchmark coverage, the individual must seek coverage through the benchmark plan before seeking wrap-around benefits from the State. As always, medical necessity as determined by the State guides the delivery of EPSDT services. A State must also assure that individuals in a benchmark or benchmark-equivalent plan have access, through that coverage or otherwise, to rural health clinic services and federally qualified health center
(FQHC)services. Under section 1937(a)(1)(C) of the Act, States have the option to provide additional or wrap-around services to the benchmark or benchmark-equivalent plans. The wrap-around services do not need to include all State plan services. However, the State plan must describe the populations covered and the procedures for assuring those services. We interpret the term “additional or wrap-around services” to mean health benefits that are of the same type as those covered under the benchmark or considered to be health benefits under the Medicaid statute. We propose in § 440.360 that additional or wrap-around services must be within the scope of categories of services covered under the benchmark plan, or described in section 1905(a) of the Act. Generally, we would expect that the benchmark or benchmark equivalent plan would have sufficient enrollment capacity for eligible individuals. However, because benchmark and benchmark equivalent plans are not bound by comparability, statewideness, freedom of choice, the assurance of transportation to medically necessary services and other requirements of title XIX of the Act, there may be a circumstance, particularly in rural areas, when a plan is not capable of enrolling all interested and eligible individuals. In this instance, the State must have a process for enrolling the individual in an alternate option. If applicable, the State must have a system under which recipients already enrolled in the benchmark or benchmark equivalent plan are given priority to continue enrollment if the plan does not have the capacity to accept all those seeking enrollment under the program. *Program Integrity.* We propose to establish in § 440.370 of this regulation that States are required to implement benchmark coverage in a cost effective and efficient manner. While section 1937 of the Act is premised with a provision that states notwithstanding any other provision of this title, we do not believe that the Congress intended to permit States to bypass efficiency and effectiveness rules that were tightened up in other sections of title XIX. Therefore, we are clarifying that States must deliver benchmark benefits in a manner that is cost effective and efficient. States may not use this provision to recycle funds or deliver services to the detriment of the Federal/State partnership. Benchmark or benchmark-equivalent coverage and any additional benefits must be provided in accordance with economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. In other words, if benchmark coverage is provided on a fee-for-service basis, the same upper payment limits would apply to each service as to these services under standard full Medicaid coverage. Similarly, the same procurement requirements, or other economy or efficiency principles would apply to this coverage as would apply to the purchase of managed care coverage as under the managed care rules at part 438 of our regulations. To achieve economy and efficiency, States may use a variety of delivery systems for benchmark and benchmark-equivalent coverage. States may furnish benefits using one or more of the following: a fee-for-service delivery system, a fee-for-service delivery system operated with a primary care case management system, a managed care delivery system, or through premium assistance. The State may use a selective procurement process to restrict the managed care entity or other provider from (or through) whom a recipient can obtain services, except in emergency situations. The selected provider must meet the reimbursement, quality and utilization standards under the State Plan. If a State chooses to selectively contract for the provider of the benchmark or benchmark equivalent plan services, it can do so without any waiver authority, but only to the extent that:
(1)The selected provider complies with the reimbursement, quality, and utilization standards under the State plan;
(2)the selection process does not discriminate among classes of providers on grounds unrelated to their demonstrated effectiveness and efficiency in providing the benchmark benefit package; and
(3)all providers are paid on a timely basis in the same manner as health care practitioners must be paid under § 447.45. To the extent that these conditions are met, the State does not need to obtain a waiver under the authority of section 1915(b)(4) of the Act in order to selectively contract. *Requirements Not Applicable.* In authorizing implementation of section 1937 of the Act “notwithstanding any other provision of this title,” we believe that the Congress intended to permit States to bypass the comparability, statewideness, freedom of choice, the assurance of transportation to medically necessary services and other requirements of title XIX of the Act in order for States to tailor benefit packages appropriate to specified groups of Medicaid recipients. We believe that the Congress intended for States to have a great amount of flexibility in crafting programs for those populations which may be mandated into a benchmark or benchmark-equivalent plan. We also believe that the Congress intended for those individuals to have health coverage which mirrored that of the coverage millions of Americans receive through employer sponsored plans in the private health insurance market. Therefore, we propose in § 440.375, § 440.380, § 440.385, and § 440.390 to provide States this flexibility by allowing them to amend their State plans to provide benchmark or benchmark-equivalent coverage without regard to comparability, statewideness, freedom of choice, the assurance of transportation to medically necessary services, and/or other requirements in order to tailor and provide benefits. *Changes to Regulations Text.* We propose to add a new subpart C beginning with § 440.300. Subpart C—Benchmark Packages: General Provisions Sections 440.300, 440.305, and 440.310 Basis, Scope, and Applicability At proposed § 440.300 (Basis), § 440.305 (Scope), and § 440.310 (Applicability), the regulations would reflect the new statutory authority for States to provide medical assistance to recipients, within one or more groups of Medicaid eligible recipients specified by the State, through enrollment in benchmark coverage or benchmark-equivalent coverage. A State may only require that individuals obtain benefits by enrolling in that coverage if they are a “full benefit eligible” whose eligibility is based on an eligibility category under section 1905(a) of the Act that would have been covered under the State's plan on or before February 8, 2006, and are not within exempted categories under the statute. The proposed regulatory definition of full benefit eligible individuals would include individuals who would otherwise be eligible to receive the standard full Medicaid benefit package under the approved Medicaid State plan, but would not include individuals within the statutory exceptions for individuals, who are determined eligible by the State for medical assistance under section 1902(a)(10)(C) of the Act, or by reason of section 1902(f) of the Act, or otherwise eligible based on a reduction of income based on costs incurred for medical or other remedial care (other medically needy and spend-down populations). Section 440.315 Exempt Individuals Proposed § 440.315 would reflect statutory limitations on mandatory enrollment of specified categories of individuals. A State may not require enrollment in a benchmark or benchmark-equivalent benefit plan by the following individuals: • The recipient who is a pregnant woman who is required to be covered under the State plan under section 1902(a)(10)(A)(i) of the Act. • The recipient who qualifies for medical assistance under the State plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for SSI benefits under title XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of section 1902(e)(3) of the Act. • The recipient who is entitled to benefits under any part of Medicare. • The recipient who is terminally ill and is receiving benefits for hospice care under title XIX. • The recipient who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, and is required, as a condition of receiving services in such institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs. • The recipient who is medically frail or otherwise an individual with special medical needs (as described by the Secretary in section 440.315(f)). For purposes of this section, we would propose that individuals with special needs includes those groups defined by Federal regulations at § 438.50(d)(1) and § 438.50(d)(3) of the managed care regulations (that is, dual eligibles and certain children under age 19 who are eligible for SSI; eligible under section 1902(e)(3) of the Act, TEFRA children; in foster care or other out of home placement; or receiving foster care or adoption assistance). We are not proposing a definition for medically frail populations but we invite public comments to assist us in defining this term in the final regulation. • The recipient who qualifies based on medical condition for medical assistance for long-term care services described in section 1917(c)(1)(C) of the Act. • The recipient who receives aid or assistance under part B of title IV for children in foster care or an individual with respect to whom adoption or foster care assistance is made available under part E of title IV, without regard to age. • The recipient who qualifies for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of title IV (as in effect on or after welfare reform effective date defined in section 1931(i) of the Act). This provision relates to those individuals who qualify for Medicaid solely on the basis of qualification under the Temporary Assistance for Needy Families
(TANF)rules (that is, the State links Medicaid eligibility to TANF eligibility). • The recipient is a woman who is receiving medical assistance by virtue of the application of sections 1902(a)(10)(ii)(XVIII) and 1902(a) of the Act. This provision relates to those individuals who are eligible for Medicaid based on the breast or cervical cancer eligibility provisions. • The recipient qualifies for medical assistance as a TB-infected individual on the basis of section 1902(a)(10)(A)(ii)(XII) of the Act. • The recipient is not a qualified alien (as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) and receives only care and services necessary for the treatment of an emergency medical condition in accordance with section 1903(v) of the Act. Section 440.320 State Plan Requirements: Optional Enrollment for Exempt Individuals At proposed § 440.320, we would allow States to offer exempt individuals specified in § 440.315 the option to enroll into a benchmark or benchmark-equivalent benefit plan. The State plan must identify in its State plan the exempt groups for which this coverage is available. There may be instances in which an exempted individual may benefit from enrolling in a benchmark or benchmark-equivalent benefit package. States are permitted to elect in the State plan to offer exempted individuals a benchmark or benchmark-equivalent package, but States may not require them to enroll in one. For example, in some States the State employee benchmark coverage may be more generous than the State Medicaid plan. Secretary-approved coverage may offer the opportunity for disabled individuals to obtain integrated coverage for acute care and community-based long-term care services. Additionally, States may be able to better integrate disease management programs to provide better coordinated care which targets the specific needs of individuals with special health needs. Section 440.325 State Plan Requirements: Coverage and Benefits At proposed § 440.325, we set forth the conditions under which a State may offer enrollment to exempt recipients specified in § 440.315. When a State offers exempt recipients the option to enroll in a benchmark or benchmark-equivalent benefit package, the State must inform the recipients that enrollment is voluntary and that the individual may opt out of the benchmark or benchmark-equivalent benefit package at any time and regain immediate eligibility for the standard full Medicaid program under the State plan. The State must inform the recipient of the benefits available under the benchmark or benchmark-equivalent benefit package and provide a comparison of how they differ from the benefits available under the standard full Medicaid program. The State must document in the individual's eligibility file that the individual was informed in accordance with this paragraph and voluntarily chose to enroll in the benchmark or benchmark-equivalent benefit package. At proposed § 440.325, a State would have the option to choose to specify the benchmark or benchmark-equivalent coverage packages offered under the State's Medicaid plan. A State may select one or all of the benchmark plans described in § 440.330 or establish benchmark-equivalent plans described in § 440.335, respectively. Section 440.330 Benchmark Health Benefits Coverage At proposed § 440.330, benchmark coverage is described as any one of the following: • Federal Employees Health Benefit Plan Equivalent Coverage (FEHBP—Equivalent Health Insurance Coverage). A benefit plan equivalent to the standard Blue Cross/Blue Shield preferred provider option service benefit plan that is described in and offered to Federal employees under 5 U.S.C. 8903(1). • State employee coverage. A health benefits plan that is offered and generally available to State employees in the State involved. • Health Maintenance Organization
(HMO)plan. A health insurance plan that is offered through an HMO (as defined in section 2791(b)(3) of the Public Health Service Act) that has the largest insured commercial, non-Medicaid enrollment in the State. • Secretary approved coverage. Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population proposed to be provided that coverage. States wishing to opt for Secretarial approved coverage should submit a full description of the proposed coverage and include a benefit-by-benefit comparison of the proposed plan to one or more of the three benchmark plans specified above or to the State's standard full Medicaid coverage package under section 1905(a) of the Act, as well as a full description of the population that would be receiving the coverage. In addition, the State should submit any other information that would be relevant to a determination that the proposed health benefits coverage would be appropriate for the proposed population. The scope of a Secretary-approved health benefits package will be limited to benefits within the scope of the categories available under a benchmark coverage package or the standard full Medicaid coverage package under section 1905(a) of the Act. A State may select one or more benchmark coverage plan options. The State may also specify the benchmark plan for any specific recipient. For example, one recipient may be enrolled in the FEHBP and another may be enrolled into State Employee Coverage at the option of the State. Section 440.335 Benchmark-Equivalent Health Benefits Coverage At proposed § 440.335, we would provide that if a State designs or selects a benchmark plan other than those specified in § 440.330, the State must provide coverage that is equivalent to benchmark coverage. Coverage that meets the following requirements will be considered to be benchmark-equivalent coverage: • Required Coverage. Benchmark-equivalent coverage includes benefits for items and services within each of the following categories of basic services and must include coverage for the following categories of basic services: + Inpatient and outpatient hospital services. + Physicians' surgical and medical services. + Laboratory and x-ray services. + “Well-baby” and “well-child” care, including age-appropriate immunizations. + Other appropriate preventive services, as designated by the Secretary. • Aggregate actuarial value equivalent to benchmark coverage. Benchmark-equivalent coverage must have an aggregate actuarial value, determined in accordance with proposed § 440.340 that is at least equivalent to coverage under one of the benchmark packages outlined in § 440.330. • Additional coverage. In addition to the categories of services set forth above, benchmark-equivalent coverage may include coverage for any additional services included in the benchmark plan or described in section 1905(a) of the Act. • Application of actuarial value for benchmark-equivalent coverage that includes prescription drugs, mental health, vision, and hearing services. Where the benchmark coverage package used by the State as a basis for comparison in establishing the aggregate actuarial value of the benchmark-equivalent package includes any or all of the following four categories of services: prescription drugs; mental health services; vision services; and hearing services; then the actuarial value of the coverage for each of these categories of service in the benchmark-equivalent coverage package must be at least 75 percent of the actuarial value of the coverage for that category of service in the benchmark plan used for comparison by the State. If the benchmark coverage package does not cover one of the four categories of services mentioned above, then the benchmark-equivalent coverage package may, but is not required to, include coverage for that category of service. Section 440.340 Actuarial Report for Benchmark-Equivalent Health Benefit Coverage In accordance with 1937(a)(3) of the Act, at proposed § 440.340, we would require a State as a condition of approval of benchmark-equivalent coverage, to provide an actuarial report, with an actuarial opinion that the benchmark-equivalent coverage meets the actuarial requirements of § 440.335. At proposed § 440.340, we would require the actuarial report to obtain approval for benchmark-equivalent health benefit coverage and to meet all the provisions of the statute. The actuarial report must state: • The actuary issuing the opinion is a member of the American Academy of Actuaries
(AAA)(and meets Academy standards for issuing an opinion). • The actuary used generally accepted actuarial principles and methodologies of the AAA, standard utilization and price factors and a standardized population representative of the population involved. • The same principles and factors were used in analyzing the value of different coverage (or categories of services) without taking into account differences in coverage based on the method of delivery or means of cost control or utilization used. • The report should also state if the analysis took into account the State's ability to reduce benefits because of the increase in actuarial value of health benefits coverage offered under the State plan that results from the limitations on cost sharing (with the exception of premiums) under that coverage. • The actuary preparing the opinion must select and specify the standardized set of utilization and pricing factors as well as the standardized population. • The actuary preparing the opinion must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State's result. Section 440.345 EPSDT Services Requirement At proposed § 440.345, we would require States to make available EPSDT services as defined in section 1905(r) of the Act that are medically necessary for those individuals under age 19 who are covered under the State plan. We expect that most benchmark or benchmark equivalent plans will offer the majority of EPSDT services. To the extent that any medically necessary EPSDT services are not covered through the benchmark or benchmark-equivalent plan, States are required to supplement the benchmark or benchmark-equivalent plan in order to ensure access to these services. Individuals mandated into a benchmark or benchmark-equivalent plan and entitled to have access to EPSDT services cannot opt out of the benchmark or benchmark equivalent plan just to receive these services. While individuals are required to have access to such medically necessary services first under the benchmark or benchmark-equivalent plan, the State may provide wrap-around or additional coverage for medically necessary services not covered under such plan. Any wrap-around benefits must be sufficient so that, in combination with the benchmark or benchmark-equivalent benefits package, an individual would have coverage for his or her medically necessary services consistent with the requirements under 1905(r) of the Act. The State plan must include a description of how wrap-around benefits or additional services will be provided to ensure that these recipients have access to full EPSDT services under 1905(r) of the Act. In addition, individuals must first seek coverage of EPSDT services through the benchmark or benchmark equivalent plan before seeking coverage of such through wrap-around benefits. Section 440.350 Employer Sponsored Insurance Health Plans At proposed § 440.350, the use of benchmark or benchmark-equivalent benefit coverage would be at the discretion of the State and may be used in conjunction with employer sponsored health plans as a coverage option for individuals with access to private health insurance. Additionally, the use of benchmark or benchmark-equivalent coverage may be used for individuals with access to private health insurance coverage. For example, if an individual has access to employer sponsored coverage and that coverage is determined by the State to be benchmark or benchmark-equivalent, a State may, at its option, provide premium payments on behalf of the recipient to purchase the employer coverage. Additionally, a State could create a benchmark or benchmark-equivalent plan combining employer sponsored insurance and wrap-around benefits to that employer sponsored insurance benefit package. The premium payments would be considered medical assistance and the State could require the recipient to enroll in the group health plan. Section 440.355 Payment of Premiums At proposed § 440.355, payment of premiums by the State, net of beneficiary contributions, to obtain benchmark or benchmark-equivalent benefit coverage on behalf of beneficiaries under this section will be treated as medical assistance under 1905(a) of the Act. Section 440.360 State Plan Requirement for Providing Additional Wrap-Around Services At proposed § 440.360, a State may at its option provide additional wrap-around services to the benchmark or benchmark-equivalent plans. The wrap-around services do not need to include all State plan services. However, the State plan must describe the populations covered and the payment methodology for assuring those services. Such additional or wrap-around services must be within the scope of categories of services covered under the benchmark plan, or described in section 1905(a) of the Act. Section 440.365 Coverage of Rural Health Clinic and Federally Qualified Health Center
(FQHC)Services At proposed § 440.365, a State that provides benchmark or benchmark-equivalent coverage to individuals must assure that the individual has access, through that coverage or otherwise, to rural health clinic services and FQHC services as defined in subparagraphs
(B)and
(C)of section 1905(a)(2) of the Act. Payment for these services must be made in accordance with the payment provisions of section 1902(bb) of the Act. Section 440.370 Cost Effectiveness At proposed § 440.370, benchmark or benchmark-equivalent coverage and any additional benefits must be provided in accordance with Federal upper payment limits, procurement requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. Section 440.375 Comparability At proposed § 440.375, a State may at its option amend its State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to comparability. Section 440.380 Statewideness At proposed § 440.380, a State may at its option amend its State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to statewideness. Section 440.385 Freedom of Choice At proposed § 440.385, a State may at its option amend its State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to freedom of choice. States may restrict recipients to obtaining services from (or through) selectively procured provider plans or practitioners that meet, accept, and comply with reimbursement, quality and utilization standards under the State Plan, to the extent that the restrictions imposed meet the following requirements: (+) Do not discriminate among classes of providers on grounds unrelated to their demonstrated effectiveness and efficiency in providing the benchmark benefit package. (+) Do not apply in emergency circumstances. (+) Require that all provider plans are paid on a timely basis in the same manner as health care practitioners must be paid under § 447.45 of the chapter. Section 440.390 Assurance of Transportation At proposed § 440.390, a State may at its option amend its State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to the assurance of transportation to medically necessary services requirement specified in section 42 CFR 431.53. III. Collection of Information Requirements While the following requirements are subject to the PRA, they are currently approved under OMB# 0938-0993 with an expiration date of October 31, 2009. Section 440.320 State Plan Requirements: Optional Enrollment for Exempt Individuals Section 440.320(a)requires a State to:
(1)Inform the individuals that the enrollment is voluntary and that the individual may opt out of the benchmark or benchmark-equivalent coverage at any time and regain immediate access to standard full Medicaid coverage under the State plan;
(2)Inform the exempt recipient of the benefits available under the benchmark or benchmark-equivalent benefit package and provide a comparison of how they differ from the benefits available under the standard full Medicaid program; and,
(3)Document in the exempt recipient's eligibility file that the recipient was informed in accordance with this section and voluntarily chose to enroll in the benchmark or benchmark-equivalent benefit package. Section 440.330 Benchmark Health Benefits Coverage Section 440.330(d) requires States wishing to opt for Secretarial-approved coverage to submit a full description of the proposed coverage and include a benefit-by-benefit comparison of the proposed plan to one or more of the three other benchmark plans specified. Section 440.340 Actuarial Report for Benchmark-Equivalent Coverage Section 440.340 requires a State trying to obtain approval for benchmark-equivalent health benefits coverage described in 440.335 to submit, as part of its State Plan Amendment, an actuarial report. The report must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State's result. Section 440.345 Requirement to Provide EPSDT Services Section 440.345(a)(2) requires a State to include a description in their State Plan of how the wrap-around benefits or additional services will be provided to ensure that recipients receive full EPSDT services. The description must describe the populations covered and the procedures for assuring those services. Section 440.350 Employer-Sponsored Insurance Health Plans Section 440.350(b) requires a State to set forth in the State plan the criteria it will use to identify individuals who would be required to enroll in an available group health plan to receive benchmark or benchmark-equivalent coverage. Section 440.360 State Plan Requirement for Providing Additional Wrap-Around Services This section requires States opting to provide additional services to the benchmark-equivalent plans, to describe the populations covered and the payment methodology for these services in their State plan. IV. Response to Comments Because of the large number of public comments we normally receive on **Federal Register** documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document. V. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act
(RFA)(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis
(RIA)must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We issued a State Medicaid Director's letter on March 31, 2006 providing guidance on the new flexibilities available to States as a result of the enactment of the Deficit Reduction Act of 2005. This proposed rule simply codifies that guidance. States have already begun implementing this provision well in advance of this proposed rule. As a result, while we anticipate that implementation of this flexibility would be economically significant, the significance is based on the changes authorized by statute and not based on discretionary policies contained in the rule itself. The impact of the rule would be limited to ensuring uniform policies for States that implement the flexibility afforded under section 1937 of the Social Security Act, as added by the Deficit Reduction Act of 2005. The aggregate amount of Federal savings is estimated to be $2.3 billion from FY 2006 through FY 2010. We have estimated the impact of this rule by analyzing the potential Federal savings related to lower per capita spending that may be achieved if States choose to enroll beneficiaries in eligible populations in plans that are less costly than projected Medicaid costs. To do this, we developed estimates based on the following assumptions: • The number of eligible beneficiaries and the Federal Medicaid costs of these beneficiaries are based on 2003 Medicaid Statistical Information System
(MSIS)data; • Projections of the number of eligible beneficiaries and their associated Federal Medicaid costs were made using assumptions from the President's Budget 2007, including enrollment growth rates and per capita spending growth rates; • The relative costs of the new plans allowed under this rule to current Medicaid spending were estimated based on reviews of Medicaid spending data and the plans described in this rule. Additionally, we have assumed that not all States would immediately use the options made available through this rule; therefore, we assume that State use of these plans would continue to increase through 2011. We assume that use in 2006 will be about 10% of 2011-level of use; 40% in 2007; 60% in 2008; 80% in 2009; and 90% in 2010.” These estimates assume that there will be a negligible impact on State administration costs. As States already have experience in dealing with alternative plan designs, including through waivers or managed care plans, we have assumed States are equipped to implement these plans and will be part of their normal administrative spending. These estimates are subject to a substantial amount of uncertainty and actual experience may be significantly different. The range of possible experience is greater than under most other rules for the following two reasons. First, this rule provides the option for States to use alternative plans; to the extent that States participate more or less than assumed here (both the number of States that participate and the extensiveness of States' use of these plans), Federal savings may be greater than or less than estimated. Second, this rule also provides a wide range of options for States in designing these plans; to the extent that States use plans that are relatively more or less costly than assumed here, Federal savings may be less than or greater than estimated. Estimated Annual Federal Savings Discounted at 0%, 3% and 7%—From FY 2006 to FY 2010 [In millions] Discount rate 2006 2007 2008 2009 2010 Total 2006-2010 0% $70 $280 $460 $660 $810 $2,280 3% 68 264 421 586 699 2,038 7% 65 245 375 504 578 1,767 We anticipate that States would phase in alternative benefit programs, and changes would not be fully realized until 2010. The majority of savings would be achieved through cost avoidance of future anticipated costs by providing appropriate benefits based on a population's health care needs, appropriate utilization of services, and through gains in efficiencies through contracting. States would be able to take greater advantage of marketplace dynamics within their State. We also anticipate that a number of States will use this flexibility to create programs that are more similar to their SCHIP programs. Because States are no longer tied to statewideness and comparability rules for non-disabled, non-aged, and non-blind populations, they would be able to offer individuals and families different types of plans consistent with their needs and available delivery systems. Estimated Annual State Savings Discounted at 0%, 3% and 7%—From FY 2006 to FY 2010 [In millions] Discount rate 2006 2007 2008 2009 2010 Total 2006-2010 0% $50 $210 $350 $500 $610 $1,720 3% 49 198 320 444 526 1,537 7% 47 183 286 381 435 1,332 The RFA requires agencies to analyze options for regulatory relief of small businesses. 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 $6.5 million to $30.5 million in any 1 year. Individuals and States are not included in the definition of a small entity. We have determined, and the Secretary certifies, that this provision applies to States only and would not affect small entities. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Core-Based Statistical Area and has fewer than 100 beds. We have determined, and the Secretary certifies, that this proposed rule would 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 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditures in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million, updated annually for inflation. That threshold level is currently approximately $127 million. Because this rule does not mandate State participation in using these benchmark plans, there is no obligation for the State to make any change to their Medicaid program. Therefore, there is no mandate for the State. We believe this proposed rule would not mandate expenditures in that amount. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. This proposed rule would not impose direct cost on States or local government or preempt State law. The rule would provide States the option to implement alternative Medicaid benefits through a Medicaid State plan amendment. B. Anticipated Effects Before section 6044 of the DRA became effective on March 31, 2006, State Medicaid programs generally were required to offer at minimum the same standard benefit package to each recipient, regardless of income, eligibility category, or geographic location. Some States offered alternative benefit packages to certain recipients under section 1115 demonstration waivers approved by the Centers for Medicare & Medicaid Services. This provision allows for similar program alternatives under the State plan without the constraints of a waiver. Moreover, Medicaid families would gain continuity in coverage as family members move together from Medicaid and the State Children's Health Insurance Program (SCHIP) to, eventually, private coverage. Today, because of the lack of flexibility in Medicaid, one child may be receiving Medicaid, another in SCHIP, and the parent has access to private coverage. With benefit flexibility in State Medicaid programs, families could enroll under the same plan, with the same providers and one set of administrative rules. Administrative simplification can help families maintain health insurance coverage and give them experience with private insurance coverage that would become important when their income rises above Medicaid and SCHIP eligibility levels and to mitigate the need for dependence. States with strong employer-based coverage may emphasize family coverage premium assistance. States may form larger pools by combining Medicaid recipients with their public employees. C. Alternatives Considered This rule proposes requirements for States to elect alternative Medicaid benefit programs through the adoption of a Medicaid State plan amendment. The proposed requirements in this rule were designed to maximize State flexibility while assuring that beneficiaries will get quality care that meets their needs. Under this rule, we would permit States to define the alternative benefit packages only by reference to the benchmark or benchmark-equivalent standard (with the exception of the EPSDT wrap-around benefits). We would also permit States to combine an alternative benefit package with alternative benefit delivery methods, such as through managed care, employer-based coverage, or selective contracting. An alternative might have been to require the State to document any deviation from otherwise applicable State plan requirements, much as is required under section 1115 demonstration waivers, 1915(b) waivers, 1915(c) waivers, or any combination thereof. We have not elected this alternative because it would be cumbersome for States, it would not be consistent with the statutory use of benchmark and benchmark-equivalent coverage as reference points for permissible benefit packages, and it would not improve the clarity of the State plan. Another alternative might have been to limit State flexibility under this provision to variation in the amount, duration and scope of benefits without providing authority for an integrated approach combining alternative benefits with alternative benefit delivery methods. We have not elected this alternative because an integrated approach allows greater State flexibility to tailor both benefits and delivery methods to the eligible groups of individuals being served. D. Accounting Statement As required by OMB Circular A-4 (available at ), *http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf),* in Table 15 below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the decrease in Medicaid payments as a result of the changes presented in this proposed rule. All savings are classified as transfers to the Federal Government, as well as to States. Table.—Accounting Statement: Classification of Estimated Savings, From FY 2006 to FY 2010 [In $ millions] Category Transfers Year Dollar Units Discount Rate Period Covered Annualized Monetized Transfers 7% 3% 0% 2006 −$430.8 −$445.0 −$456.0 2006-2010 From Whom To Whom? Federal Government to Beneficiaries, Providers Category Transfers Year 2006 2007 2008 2009 2010 Annualized Monetized Transfers −$70 −$280 −$460 −$660 −$810 From Whom To Whom? Federal Government to Beneficiaries, Providers Category Transfers Year Dollar Units Discount Rate Period Covered Annualized Monetized Transfers 7% 3% 0% 2006 −$324.9 −$335.7 −$344.0 2006-2010 From Whom to Whom? State Governments to Beneficiaries, Providers Category Transfers Year 2006 2007 2008 2009 2010 Annualized Monetized Transfers −$50 −$210 −$350 −$500 −$610 From Whom to Whom? State Governments to Beneficiaries, Providers *Column 1: Category* —Contains the description of the different impacts of the rule; it could include monetized, quantitative but not monetized, or qualitative but not quantitative or monetized impacts; it also may contain unit of measurement (such as, dollars). In this case, the only impact is the Federal annualized monetized impact of the rule. *Column 2: Primary Estimate* —Contains the quantitative or qualitative impact of the rule for the respective category of impact. Monetized amounts are generally shown in real dollar terms. In this case, the federalized annualized monetized primary estimate represents the equivalent amount that, if paid (saved) each year over the period covered, would result in the same net present value of the stream of costs (savings) estimated over the period covered. *Column 3: Year Dollar* —Contains the year to which dollars are normalized; that is, the first year that dollars are discounted in the estimate. *Column 4: Unit Discount Rate* —Contains the discount rate or rates used to estimate the annualized monetized impacts. In this case, three rates are used: 7 percent; 3 percent; 0 percent. *Column 5: Period Covered* —Contains the years for which the estimate was made. *Rows:* The rows contain the estimates associated with each specific impact and each discount rate used. *“From Whom to Whom?”* —In the case of a transfer (as opposed to a change in aggregate social welfare as described in the OMB Circular), this section describes the parties involved in the transfer of costs. In this case, the costs represent a reduction in Federal Government spending on behalf of beneficiaries. The table may also contain minimum and maximum estimates and sources cited. In this case, there is only a primary estimate and there are no additional sources for the estimate. *Estimated Savings* —The following table shows the discounted costs (savings) for each discount rate and for each year over the period covered. “Total” represents the net present value of the impact in the year the rule takes effect. These numbers represent the anticipated annual reduction in Federal Medicaid spending under this rule. E. Conclusion We project that the use of benchmark plans under this rule will save $2.3 billion from 2006-2010. These savings would arise as States use the plans described by this rule to manage the costs of their Medicaid program by modifying plan benefits for targeted beneficiaries. The actual savings will heavily depend on the number of States that ultimately implement these plans, the number of beneficiaries States cover with these plans, and the specific design and selection of benchmark plans. For reasons stated above, we are not preparing analyses for either the RFA or section 1102(b) of the Act because we have determined that this rule would not have a significant economic impact on a substantial number of small entities or a significant impact on the operations of a substantial number of small rural hospitals. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects in 42 CFR Part 440 Grant programs—health, Medicaid. For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as set forth below: PART 440—SERVICES: GENERAL PROVISIONS 1. The authority citation for part 440 continues to read as follows: Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 1302). 2. A new subpart C, consisting of § 440.300 through § 440.390, is added to part 440 to read as follows: Subpart C—Benchmark Benefit and Benchmark-Equivalent Coverage Sec. 440.300 Basis. 440.305 Scope. 440.310 Applicability. 440.315 Exempt individuals. 440.320 State plan requirements: Optional enrollment for exempt individuals. 440.325 State plan requirements: Coverage and benefits. 440.330 Benchmark health benefits coverage. 440.335 Benchmark-equivalent health benefits coverage. 440.340 Actuarial report for benchmark-equivalent coverage. 440.345 EPSDT services requirement. 440.350 Employer-sponsored insurance health plans. 440.355 Payment of premiums. 440.360 State plan requirement for providing additional wrap-around services. 440.365 Coverage of rural health clinic and federally qualified health center
(FQHC)services. 440.370 Cost-effectiveness. 440.375 Comparability. 440.380 Statewideness. 440.385 Freedom of choice. 440.390 Assurance of Transportation. Subpart C—Benchmark Benefit and Benchmark-Equivalent Coverage § 440.300 Basis. This subpart implements section 1937 of the Act, which authorizes States to provide for medical assistance to one or more groups of Medicaid-eligible recipients specified by the State under an approved State plan amendment through enrollment in coverage that provides benchmark or benchmark-equivalent health care benefit coverage. § 440.305 Scope.
(a)*General.* This subpart sets out requirements for States that elect to provide medical assistance to certain Medicaid eligible recipients within one or more groups of individuals specified by the State, through enrollment of the recipients in coverage, identified as “benchmark” or “benchmark-equivalent.”
(b)*Limitations.* A State may only apply the option in paragraph
(a)of this section for an individual whose eligibility is based on an eligibility category under section 1905(a) of the Act that would have been covered under the State's plan on or before February 8, 2006.
(c)A State may not require but may offer enrollment in benchmark or benchmark-equivalent coverage to the Medicaid eligible individuals listed in § 440.315. States allowing individuals to opt in must be in compliance with the rules specified at § 440.320. § 440.310 Applicability.
(a)*Enrollment.* The State may require “full benefit eligible” recipients not excluded in § 440.315 to enroll in benchmark or benchmark-equivalent coverage.
(b)*Full benefit eligible.* A recipient is full benefit eligible if determined by the State to be eligible to receive the standard full Medicaid benefit package under the approved Medicaid State plan if not for the application of the option available under this subpart, but does not include individuals determined eligible as medically needy individuals, or eligible because of a reduction of income based on costs incurred for medical or other remedial care under section 1902(f) of the Act or otherwise based on incurred medical costs. § 440.315 Exempt individuals. For recipients within one (or more) of the following categories, the State plan may offer, but may not require under § 440.310, the opportunity to obtain benefits through enrollment in benchmark or benchmark-equivalent coverage:
(a)The recipient is a pregnant woman who is required to be covered under the State plan under section 1902(a)(10)(A)(i) of the Act.
(b)The recipient qualifies for medical assistance under the State plan on the basis of being blind or disabled (or being treated as being blind or disabled) without regard to whether the individual is eligible for Supplemental Security Income benefits under title XVI on the basis of being blind or disabled and including an individual who is eligible for medical assistance on the basis of section 1902(e)(3) of the Act.
(c)The recipient is entitled to benefits under any part of Medicare.
(d)The recipient is terminally ill and is receiving benefits for hospice care under title XIX.
(e)The recipient is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, and is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs.
(f)The recipient is medically frail or otherwise an individual with special medical needs. For these purposes, individuals with special needs are those individuals described in § 438.50(d)(1) and § 438.50(d)(3) of this chapter.
(g)The recipient qualifies based on medical condition for medical assistance for long-term care services described in section 1917(c)(1)(C) of the Act.
(h)The recipient is an individual with respect to whom aid or assistance is made available under part B of title IV to children in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of title IV, without regard to age.
(i)The recipient qualifies for medical assistance on the basis of eligibility to receive assistance under a State plan funded under part A of title IV (as in effect on or after welfare reform effective date defined in section 1931(i) of the Act). This provision relates to those individuals who qualify for Medicaid solely on the basis of qualification under the State's TANF rules.
(j)The recipient is a woman who is receiving medical assistance by virtue of the application of sections 1902(a)(10)(ii)(XVIII) and 1902(a) of the Act.
(k)The recipient qualifies for medical assistance on the basis of section 1902(a)(10)(A)(ii)(XII) of the Act.
(l)The recipient is not a qualified alien (as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) and receives care and services necessary for the treatment of an emergency medical condition in accordance with section 1903(v) of the Act. § 440.320 State plan requirements: Optional enrollment for exempt individuals.
(a)*General rule.* A State plan that offers exempt individuals as defined in § 440.315 the option to enroll in benchmark or benchmark-equivalent coverage must identify in its State plan the exempt groups for which this coverage is available, and must comply with the following provisions:
(1)In any case in which the State offers an exempt individual the option to obtain coverage in a benchmark or benchmark-equivalent benefit package, the State must inform the individuals that the enrollment is voluntary and that the individual may opt out of the benchmark or benchmark-equivalent coverage at any time and regain immediate access to standard full Medicaid coverage under the State plan.
(2)The State must inform the exempt recipient of the benefits available under the benchmark or benchmark-equivalent benefit package and provide a comparison of how they differ from the benefits available under the standard full Medicaid program.
(3)The State must document in the exempt recipient's eligibility file that the recipient was informed in accordance with this section and voluntarily chose to enroll in the benchmark or benchmark-equivalent benefit package.
(b)[Reserved] § 440.325 State plan requirements: Coverage and benefits. Subject to requirements in § 440.345 and § 440.365, States may elect to provide any of the following of types of health benefits coverage:
(a)Benchmark coverage in accordance with § 440.330.
(b)Benchmark-equivalent coverage in accordance with § 440.335. § 440.330 Benchmark health benefits coverage. Benchmark coverage is health benefits coverage that is equal to the coverage under one or more of the following benefit plans:
(a)*Federal Employees Health Benefit Plan Equivalent Coverage (FEHBP—Equivalent Health Insurance Coverage).* A benefit plan equivalent to the standard Blue Cross/Blue Shield preferred provider option service benefit plan that is described in and offered to Federal employees under 5 U.S.C. 8903(1).
(b)*State employee coverage.* Health benefits coverage that is offered and generally available to State employees in the State.
(c)*Health Maintenance Organization
(HMO)plan.* A health insurance plan that is offered through an HMO, (as defined in section 2791(b)(3) of the Public Health Service Act) that has the largest insured commercial, non-Medicaid enrollment in the State.
(d)*Secretary approved coverage.* Any other health benefits coverage that the Secretary determines, upon application by a State, provides appropriate coverage for the population proposed to be provided such coverage. States wishing to opt for Secretarial approved coverage should submit a full description of the proposed coverage, (including a benefit-by-benefit comparison of the proposed plan to one or more of the three other benchmark plans specified above or to the State's standard full Medicaid coverage package under section 1905(a) of the Act), and of the population to which the coverage would be offered. In addition, the State should submit any other information that would be relevant to a determination that the proposed health benefits coverage would be appropriate for the proposed population. The scope of a Secretary-approved health benefits package will be limited to benefits within the scope of the categories available under a benchmark coverage package or the standard full Medicaid coverage package under section 1905(a) of the Act. § 440.335 Benchmark-equivalent health benefits coverage.
(a)*Aggregate actuarial value.* Benchmark-equivalent coverage is health benefits coverage that has an aggregate actuarial value, as determined in § 440.340 that is at least actuarially equivalent to the coverage under one of the benchmark benefit packages described in § 440.330 for the identified Medicaid population to which it will be offered.
(b)*Required coverage.* Benchmark-equivalent health benefits coverage must include coverage for the following categories of services:
(1)Inpatient and outpatient hospital services.
(2)Physicians' surgical and medical services.
(3)Laboratory and x-ray services.
(4)Well-baby and well-child care, including age-appropriate immunizations.
(5)Other appropriate preventive services, such as emergency services as designated by the Secretary.
(c)*Additional coverage.*
(1)In addition to the categories of services of this section, benchmark-equivalent coverage may include coverage for any additional services in a category included in the benchmark plan or described in section 1905(a) of the Act.
(2)If the benchmark coverage package used by the State for purposes of comparison in establishing the aggregate actuarial value of the benchmark-equivalent package includes any of the following four categories of services: Prescription drugs; mental health services; vision services; and hearing services; then the actuarial value of the coverage for each of these categories of service in the benchmark-equivalent coverage package must be at least 75 percent of the actuarial value of the coverage for that category of service in the benchmark plan used for comparison by the State.
(3)If the benchmark coverage package does not cover one of the four categories of services in paragraph (c)(2) of this section, then the benchmark-equivalent coverage package may, but is not required to, include coverage for that category of service. § 440.340 Actuarial report for benchmark-equivalent coverage.
(a)A State plan amendment that would provide for benchmark-equivalent health benefits coverage described in § 440.335, must include an actuarial report. The actuarial report must contain an actuarial opinion that the benchmark equivalent health benefits coverage meets the actuarial requirements set forth in § 440.335. The report must also specify the benchmark coverage used for comparison.
(b)The actuarial report must state that it was prepared according to the following requirements:
(1)By an individual who is a member of the American Academy of Actuaries (AAA).
(2)Using generally accepted actuarial principles and methodologies of the AAA.
(3)Using a standardized set of utilization and price factors.
(4)Using a standardized population that is representative of the population involved.
(5)Applying the same principles and factors in comparing the value of different coverage (or categories of services).
(6)Without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used.
(7)Taking into account the ability of the State to reduce benefits by taking into account the increase in actuarial value of health benefits coverage offered under the State plan that results from the limitations on cost sharing (with the exception of premiums) under that coverage.
(c)The actuary preparing the opinion must select and specify the standardized set of factors and the standardized population to be used in paragraphs (b)(3) and (b)(4) of this section.
(d)The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State's result. § 440.345 EPSDT services requirement.
(a)The State must assure access to early and periodic screening, diagnostic and treatment (EPSDT) services through benchmark or benchmark-equivalent plan benefits or as wrap-around benefits to those plans for any child under 19 years of age eligible in a category under the State plan.
(1)Sufficiency: Any wrap-around EPSDT benefits must be sufficient so that, in combination with the benchmark or benchmark-equivalent benefits plan, these individuals have access to the full EPSDT benefit.
(2)State Plan requirement: The State must include a description of how the wrap-around benefits will be provided to ensure that these recipients have access to the full EPSDT benefit.
(b)Individuals must first seek coverage of EPSDT services through the benchmark or benchmark equivalent plan before seeking coverage of such through wrap-around benefits. § 440.350 Employer-sponsored insurance health plans.
(a)A State may provide benchmark or benchmark-equivalent coverage by obtaining employer sponsored health plans (either alone or with the addition of wrap-around services covered separately under Medicaid) for individuals with access to private health insurance.
(b)The State must assure that employer sponsored plans meet the requirements of benchmark or benchmark-equivalent coverage, including the cost-effectiveness requirements at § 440.370.
(c)A State may provide benchmark or benchmark-equivalent coverage through a combination of employer sponsored health plans and additional benefit coverage provided by the State that wraps around the employer sponsored health plan which, in the aggregate, results in benchmark or benchmark-equivalent level of coverage for those recipients. § 440.355 Payment of premiums. Payment of premiums by the State, net of beneficiary contributions, to obtain benchmark or benchmark-equivalent benefit coverage on behalf of beneficiaries under this section will be treated as medical assistance under section 1905(a) of the Act. § 440.360 State plan requirement for providing additional wrap-around services. If the State opts to provide additional or wrap-around coverage to individuals enrolled in benchmark or benchmark-equivalent plans, the State plan must describe the populations covered and the payment methodology for these services. Additional or wrap-around services must be in categories that are within the scope of the benchmark coverage, or are described in section 1905(a) of the Act. § 440.365 Coverage of rural health clinic and federally qualified health center
(FQHC)services. If a State provides benchmark or benchmark-equivalent coverage to individuals, it must assure that the individual has access, through that coverage or otherwise, to rural health clinic services and FQHC services as defined in subparagraphs
(B)and
(C)of section 1905(a)(2) of the Act. Payment for these services must be made in accordance with the payment provisions of section 1902(bb) of the Act. § 440.370 Cost-effectiveness. Benchmark and benchmark-equivalent coverage and any additional benefits must be provided in accordance with Federal upper payment limits, procurement requirements and other economy and efficiency principles that would otherwise be applicable to the services or delivery system through which the coverage and benefits are obtained. § 440.375 Comparability. States have the option to amend their State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to comparability. § 440.380 Statewideness. States have the option to amend their State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to statewideness. § 440.385 Freedom of choice.
(a)States have the option to amend their State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to the requirements for free choice of provider in § 431.51 of this chapter.
(b)States may restrict recipients to obtaining services from (or through) selectively procured provider plans or practitioners that meet, accept, and comply with reimbursement, quality and utilization standards under the State Plan, to the extent that the restrictions imposed meet the following requirements:
(1)Do not discriminate among classes of providers on grounds unrelated to their demonstrated effectiveness and efficiency in providing the benchmark benefit package.
(2)Do not apply in emergency circumstances.
(3)Require that all provider plans are paid on a timely basis in the same manner as health care practitioners must be paid under § 447.45 of the chapter. § 440.390 Assurance of Transportation. A State may at its option amend its State plan to provide benchmark or benchmark-equivalent coverage to recipients without regard to the assurance of transportation to medically necessary services requirement specified in § 431.53 of this chapter. (Catalog of Federal Domestic Assistance Program No. 93.778, Medical Assistance Program) Dated: October 11, 2007. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Approved: November 1, 2007. Michael O. Leavitt, Secretary. Editorial Note: This document was received at the Office of the Federal Register on February 15, 2008. [FR Doc. E8-3206 Filed 2-21-08; 8:45 am] BILLING CODE 4120-01-P DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 447 and 457 [CMS-2244-P] RIN 0938-A047 Medicaid Program; Premiums and Cost Sharing AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. SUMMARY: This proposed rule would implement and interpret the provisions of sections 6041, 6042, and 6043 of the Deficit Reduction Act of 2005 (DRA), and section 405(a)(1) of the Tax Relief and Health Care Act of 2006 (TRHCA). These sections amend the Social Security Act (the Act) by adding a new section 1916A to provide State Medicaid agencies with increased flexibility to impose premium and cost sharing requirements on certain Medicaid recipients. This authority is in addition to the existing authority States have to impose premiums and cost sharing under section 1916 of the Act. The DRA provisions also specifically address cost sharing for non-preferred drugs and non-emergency care furnished in a hospital emergency department. DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on March 24, 2008. ADDRESSES: In commenting, please refer to file code CMS-2244-P. Because of staff and resource limitations, we cannot accept comments by facsimile
(FAX)transmission. You may submit comments in one of four ways (no duplicates, please): 1. *Electronically.* You may submit electronic comments on specific issues in this regulation to *http://www.cms.hhs.gov/eRulemaking.* Click on the link “Submit electronic comments on CMS regulations with an open comment period.” (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.) 2. *By regular mail.* You may mail written comments (one original and two copies) to the following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2244-P, P.O. Box 8016, Baltimore, MD 21244-8016. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. *By express or overnight mail.* You may send written comments (one original and two copies) to the following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-2244-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. 4. *By hand or courier.* If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number
(410)786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850. (Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. *Submission of comments on paperwork requirements.* You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the “Collection of Information Requirements” section in this document. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION CONTACT: Donna Schmidt,
(410)786-5532. SUPPLEMENTARY INFORMATION: *Submitting Comments:* We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-2244-P and the specific “issue identifier” that precedes the section on which you choose to comment. *Inspection of Public Comments:* All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: *http://www.cms.hhs.gov/eRulemaking.* Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments. Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951. I. Background A. General For more than a decade, States have been asking for the tools to modernize their Medicaid programs. With the enactment of the Deficit Reduction Act of 2005
(DRA)(Pub. L. 109-171, enacted on February 8, 2006), States now have new options to create programs that are aligned with today's Medicaid populations and the health care environment. Alternative cost sharing, benefit flexibility through benchmark plans, and the health opportunity accounts
(HOA)demonstration provide the greatest opportunities to modernize Medicaid, to make the cost of the program and health care more affordable, and to expand coverage for the uninsured. States will be able to reconnect families to the larger insurance system that serves most Americans and promote continuity of coverage. The sweeping DRA provisions on Medicaid include six chapters and 39 sections. Through a combination of new options for States and new requirements related to program integrity, the DRA will help ensure the sustainability of the Medicaid program over time. B. Statutory Authority Sections 6041, 6042, and 6043 of the DRA established a new section 1916A of the Social Security Act (the Act). Section 405(a)(1) of the Tax Relief and Health Care Act of 2006 (TRHCA) (Pub. L. 109-432, enacted on December 20, 2006) modified section 1916A of the Act. Section 1916A sets forth options for alternative premiums and cost sharing, including options for higher cost sharing for non-preferred prescription drugs and for non-emergency use of a hospital emergency room. Section 6041 of the DRA established new subsections 1916A(a) and (b), of the Act, which allow States to amend their State plans to impose alternative premiums and cost sharing on certain groups of individuals, for items and services other than drugs (which are subject to a separate provision discussed below), and to enforce payment of the premiums and cost sharing. Subsections 1916A(a) and
(b)set forth limitations on alternative premiums and cost-sharing that vary based on family income, and exclude some specific services from alternative cost sharing. Section 6041 also created a new section 1916(h) of the Act, which requires the Secretary to increase the “nominal” cost sharing amounts under section 1916 for each year (beginning with 2006) by the annual percentage increase in the medical care component of the consumer price index for all urban consumers (CPI-U) as rounded up in an appropriate manner. Section 405(a)(1) of the TRHCA modified subsections 1916A(a) and
(b)of the Act. Section 6042 of the DRA created section 1916A(c) of the Act, which provides States with additional options for establishing cost sharing requirements for drugs to encourage the use of preferred drugs. Section 405(a)(1) of the TRHCA also modified section 1916A(c) of the Act. Under section 1916A(c), States may amend their State plans to require increased cost sharing by certain groups of individuals for non-preferred drugs and to waive or reduce the otherwise applicable cost sharing for preferred drugs. States may also permit pharmacy providers to require the receipt of a cost sharing payment from an individual before filling a prescription. We believe the Congress intended to provide additional flexibilities to States in issuing the DRA. Thus, we have not defined preferred drugs or non-preferred drugs within a class of such drugs in this rule and we believe defining these terms should be at State discretion. We would anticipate that States would publish schedules of preferred drugs as part of, or as a supplement to, the required public schedule of cost sharing under 42 CFR 447.76. Section 6043 of the DRA created section 1916A(e) of the Act, which permits States to amend their State plans to allow hospitals, after an appropriate medical screening examination under section 1867 (EMTALA) of the Act, to impose higher cost sharing upon certain groups of individuals for non-emergency care or services furnished in a hospital emergency department. Section 405(a)(1) of the TRHCA modified section 1916A(e) of the Act. Under this option, if the hospital determines that an individual does not have an emergency medical condition, before providing the non-emergency services and imposing cost sharing, it must inform the individual that an available and accessible alternate non-emergency services provider can provide the services without the imposition of the same cost sharing and that the hospital can coordinate a referral to that provider. After notice is given, the hospital may require payment of the cost sharing before providing the non-emergency services to the individual. II. Provisions of the Proposed Regulations [If you choose to comment on issues in this section, please include the caption “PROVISIONS OF THE PROPOSED REGULATIONS” at the beginning of your comments.] A. Overview The Department began issuing guidance about the new flexibilities available to States within months of the enactment of the DRA. We released two letters to State Medicaid directors and health officials providing guidance on sections 6041, 6042 and 6043 of the DRA, and section 405(a)(1) of the TRHCA as it relates to sections 6041 and 6042 of the DRA respectively. States and Territories have used this guidance to design and implement the new options. These regulations formalize the guidance on alternative premiums and cost sharing. These proposed regulations would amend existing Medicaid cost sharing regulations at 42 CFR part 447 and State Children's Health Insurance Program (SCHIP) cost sharing regulations at 42 CFR part 457. We propose this approach to assist the reader in easily accessing all Medicaid and SCHIP cost sharing regulations. B. Medicaid Regulations 1. Maximum Allowable Charges (§ 447.54) We are proposing to revise § 447.54 to update the existing “nominal” Medicaid cost sharing amounts, specifically the nominal deductible amount described at § 447.54(a)(1) and the nominal copayment amounts described at § 447.54(a)(3). We are also proposing to add § 447.54(a)(4) to establish a maximum copayment amount for services provided by a managed care organization (MCO). Section 6041(b)(2) of the DRA requires the Secretary to increase the nominal cost sharing amounts under section 1916 of the Act for each year (beginning with 2006) by the annual percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) as rounded up in an appropriate manner. In accordance with the statute, we propose to increase the nominal amounts on the beginning of the Federal Fiscal Year
(FY)(October 1) in each calendar year by the percentage increase in the medical care component of the Consumer Price Index for All Urban Consumers (CPI-U) for the period of September to September ending in the preceding calendar year. We use this period to update other amounts, such as the Medicaid spousal impoverishment standards, by inflation. The first adjustment would be for FY 2007, and would be based on the CPI-U increases during the period September 2004 to September 2005. The medical care component of the CPI-U increased by 3.9 percent between September 2004 and September 2005, so we propose to update the nominal amounts by that factor and then round to the next higher 10-cent increment. We propose to round to the next higher 10-cent increment because it will simplify calculation and collection of the amounts involved. Based on this methodology, we propose a maximum deductible for $2.10 per month per family for each period of Medicaid eligibility. In addition, we propose the following copayment maximum amounts: State payment for the service Maximum copayment $10 or less $ .60 $10.01 to $25 1.10 $25.01 to $50 2.10 $50.01 or more 3.20 States should use these updated nominal amounts during FY 2007. Thereafter, these amounts will be updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding year, rounded to the next higher 10-cent increment. In addition, we have proposed to specify a maximum copayment amount for services provided by an MCO. When we published the final Medicaid managed care rules on June 14, 2002 (67 FR 40989), we also issued at § 447.60, a requirement that contracts with MCOs limit cost sharing charges an MCO may impose on Medicaid enrollees to the amounts that could be imposed if fee-for-service payment rates were applicable. Since some States do not have fee-for-service programs, we have proposed to specify maximum copayment amounts for services provided by an MCO. 2. Premiums and Cost Sharing: Basis, Purpose and Scope (§ 447.62) Section 1916A of the Act allows States to impose alternative premiums and cost sharing that are not subject to the limitations on premiums and cost sharing under section 1916 of the Act. Section 1916A of the Act does not affect the Secretary's existing waiver authority with regard to premiums and cost sharing. Section 447.62 of the regulations briefly describes this statutory provision which is the basis for § 447.64 through § 447.82. Section 447.62 also sets forth limitations on the scope of these regulations by indicating that they do not limit the Secretary's waiver authority, or affect existing waivers, concerning premiums or cost sharing. Section 405(a)(1) of the TRHCA amended section 1916A by explicitly providing certain exemptions from the provisions, and other protections, for the population with family incomes at or below 100 percent of the FPL. The statute also includes protections for individuals with family incomes between 100 and 150 percent of the FPL and individuals with family incomes above 150 percent of the FPL. 3. Premiums, Enrollment Fees, or Similar Fees: State Plan Requirements (§ 447.64) Section 1916A(a)(1) of the Act requires that the State plan specify the group or groups of individuals upon which it will impose alternate premiums. In accordance with the statute, at § 447.64(a), we propose that the State plan describe the group or groups of individuals that may be subject to such premiums, enrollment fees, or similar charges. For example, States may impose premiums upon all non-exempt childless adults (with family incomes over 150 percent of the FPL). We further propose in § 447.64(b) that the State plan must include a schedule of the premiums, enrollment fees, or similar charges and the process for informing recipients, applicants, providers, and the public of the schedule. States may vary the premiums, enrollment fees, or similar charges among the groups of individuals. Section 1916A(b)(4) of the Act requires that the State plan specify the manner and the period for which the State determines family income. In accordance with the statute, at § 447.64(c), we propose that the State plan describe the methodology used to determine family income, including the period and periodicity of those determinations. We also propose in § 447.64(d) that the State plan describe the methodology the State will use to ensure that the aggregate amount of premiums and cost sharing imposed for all individuals in the family does not exceed 5 percent of family income as applied during the monthly or quarterly period specified by the State. Section 1916A(d)(1) of the Act requires that the State specify the group or group of individuals for whom payment of premiums is a condition of eligibility. In accordance with the statute, at § 447.64(e), we propose that the State plan, list the group or groups of individuals. We further propose in § 447.64(f) that the State plan describe the premium payment terms for the group or groups. 4. General Premium Protections (§ 447.66) Under section 1916A(b)(3)(A) of the Act, the State plan may not impose premiums upon the following: • Individuals under 18 years of age who are required to be provided medical assistance under section 1902(a)(10)(A)(i) of the Act, and including individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of that title, without regard to age; • Pregnant women; • Any terminally ill individual receiving hospice care, as defined in section 1905(o) of the Act; • Any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs; • Women who are receiving Medicaid on the basis of the breast or cervical cancer eligibility group under sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act; and • Disabled children who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act. In accordance with the statute, at § 447.66(a), we propose that the State exclude these classes of individuals from the imposition of premiums. Section 1916A(b)(3)(C) of the Act clarifies that a State may exempt additional classes of individuals from premiums. At proposed § 447.66(b), we would implement this section. 5. Copayments, Coinsurance, Deductibles, or Similar Cost Sharing Charges: State Plan Requirements (§ 447.68) Section 1916A(a)(1) of the Act requires that the State plan specify the group or groups of individuals upon which it opts to impose cost sharing. In accordance with the statute, at § 447.68(a), we propose that the State plan describe the group or groups of individuals that may be subject to cost sharing. For example, States may impose cost sharing for non-exempt items and services to individuals in the section 1931 eligibility group with family incomes between 100 and 200 percent of the FPL. We further propose that the State plan must include a schedule of the copayments, coinsurance, deductibles, or similar cost sharing charges, the items or services for which the charges apply, and the process for informing recipients, applicants, providers, and the public of the schedule. States may vary cost sharing among the types of items and services. Section 1916A(b)(4) of the Act requires that the State plan specify the manner and the period for which the State determines family income. In accordance with the statute, at § 447.68(b), we propose that the State plan describe the methodology used to determine family income, including the period and periodicity of such determinations. We also propose that the State plan describe the methodology the State will use to ensure that the aggregate amount of premiums and cost sharing imposed for all individuals in the family does not exceed 5 percent of family income as applied during the monthly or quarterly period specified by the State. We further propose that the State plan describe the State's methods for tracking cost sharing charges, informing recipients and providers of their liability, and notifying recipients and providers when individual recipients have reached their aggregate limit on premiums and cost sharing. States can use the same methods that SCHIP programs use to track cost sharing. For example, States can program their automated systems to track and compute recipients' cost sharing. Finally, we propose that the State plan specify whether the State permits a provider participating under the State plan to require payment of authorized cost sharing as a condition for the provision of covered care, items, or services. 6. General Cost Sharing Protections (§ 447.70) Under section 1916A(b)(3)(B) of the Act, the State plan may not impose alternative cost sharing under 1916A(a) for the following: • Services furnished to individuals under 18 years of age who are required to be provided Medicaid under section 1902(a)(10)(A)(i) of the Act, and including services furnished to individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under part E of that title, without regard to age; • Preventive services (such as well baby and well child care and immunizations) provided to children under 18 years of age regardless of family income; • Services furnished to pregnant women, if those services relate to pregnancy or to any other medical condition that may complicate the pregnancy; • Services furnished to a terminally ill individual who is receiving hospice care (as defined in section 1905(o) of the Act); • Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs; • Emergency services as defined by the Secretary for the purposes of section 1916(a)(2)(D) of the Act; • Family planning services and supplies described in section 1905(a)(4)(C) of the Act; • Services furnished to women who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act (breast or cervical cancer provisions); and • Services furnished to disabled children who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act. In addition, section 1916A(c)(1)(B) of the Act prohibits the State plan from imposing otherwise applicable cost sharing for preferred drugs for individuals “for whom cost sharing may not otherwise be imposed under subsection
(a)due to the application of 1916A(b)(3)(B) of the Act.” Therefore, in accordance with the statute, at § 447.70(a)(1)(x), we propose that the State plan exclude these classes of individuals from the imposition of cost sharing for preferred drugs within a class. Section 1916A(b)(3)(C) of the Act clarifies that a State may exempt additional individuals or services from cost sharing. At proposed § 447.70(c), we would implement this section. Finally, section 1916A(c)(3) of the Act requires a State to charge cost sharing applicable to a preferred drug in the case of a non-preferred drug if the prescribing physician determines that the preferred drug would not be as effective for the individual or would have adverse effects for the individual or both. We would implement this section at proposed § 447.70(b). We further propose at § 447.70(b) that such overrides meet State criteria for prior authorization and be approved through the State prior authorization process. 7. Premium and Cost Sharing Exemptions and Protections for Individuals With Family Income at or Below 100 Percent of the FPL (§ 447.71) Under section 1916A(a)(2)(A) of the Act, the State plan may not impose premiums on individuals whose family income is at or below 100 percent of the FPL. In accordance with the statute, at § 447.71(a) we propose that the State plan exclude these individuals from the imposition of premiums. Under section 1916A(a)(2)(A) of the Act, the State plan may not impose cost sharing on individuals whose family income is at or below 100 percent of the FPL with the exception of cost sharing for non-preferred drugs and for non-emergency services furnished in a hospital emergency department. However, section 1916A(c)(2)(A)(i) of the Act prohibits a State from imposing, with respect to a non-preferred drug, cost sharing that exceeds the nominal amount as otherwise determined under section 1916 of the Act and described at § 447.54(a)(3) or
(4)for those individuals. In addition, section 1916A(e)(2)(B) of the Act prohibits a State from imposing, with respect to non-emergency services furnished in a hospital emergency department, cost sharing that exceeds the nominal amount as otherwise determined under section 1916 of the Act and described at § 447.54(a)(3) or (4). Furthermore, a State may only impose nominal cost sharing with respect to non-emergency services so long as no cost sharing is imposed to receive such care through an outpatient department or other alternative health care provider in the geographic area of the hospital emergency department involved. In accordance with the statute, we propose at § 447.71(b)(1) that cost sharing for non-preferred drugs for those individuals not exceed the nominal cost sharing amount. In addition, we propose at § 447.71(b)(2) that cost sharing for non-emergency services furnished in a hospital emergency department for those individuals not exceed the nominal cost sharing amount and be imposed only so long as no cost sharing is imposed on those individuals to receive such care through an outpatient department or other alternative non-emergency services provider in the geographic area of the hospital emergency department involved. Section 1916A(a)(2)(B) of the Act provides that the total aggregate amount of cost sharing imposed under sections 1916A(c), 1916A(e), and/or 1916 of the Act upon individuals whose family income is at or below 100 percent of the FPL may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis as specified by the State. In accordance with the statute, we propose at § 447.71(c) that aggregate cost sharing for individuals whose family income is at or below 100 percent of the FPL applicable to a family of the size involved not exceed the maximum permitted under § 447.78(b). At § 447.78(b), we propose that the total aggregate amount of cost sharing may not exceed 5 percent of such family's income for the monthly or quarterly period, as specified in the State plan. 8. Premium and Cost Sharing Exemptions and Protections for Individuals Whose Family Income is Above 100 Percent but Does Not Exceed 150 Percent of the FPL (§ 447.72) Under section 1916A(b)(1)(A) of the Act, the State plan may not impose premiums on individuals whose family incomes exceeds 100 percent, but does not exceed 150 percent of the FPL applicable to a family of the size involved. In accordance with the statute, at § 447.72(a), we propose that the State plan exclude these individuals from the imposition of premiums. Section 1916A(b)(1)(B)(i) of the Act provides that, in the case of individuals whose family income exceeds 100 percent, but does not exceed 150 percent of the FPL applicable to a family of the size involved, cost sharing imposed under the State plan may not exceed 10 percent of the cost of such item or service. However, section 1916A(c)(2)(A)(i) of the Act prohibits a State from imposing, with respect to a non-preferred drug, cost sharing that exceeds the nominal amount as otherwise determined under section 1916 of the Act and described at § 447.54(a)(3) for those individuals. In addition, section 1916A(e)(2)(A) of the Act prohibits a State from imposing, with respect to non-emergency services furnished in a hospital emergency department, cost sharing that exceeds twice the nominal amount as otherwise determined under section 1916 of the Act and described at § 447.54(a)(3) for those individuals. Therefore, in accordance with the statute, we propose at § 447.72(b) that cost sharing for those individuals under the State plan not exceed 10 percent of the payment the agency makes for that item or service, with the exception that it not exceed the nominal cost sharing amount for non-preferred drugs or twice the nominal cost sharing amount for non-emergency services furnished in a hospital emergency department. In the case of States that do not have fee-for-service payment rates, we propose that any copayment that the State imposes for services provided by an MCO may not exceed $5.20 for FY 2007. This proposal would provide greater flexibility to State Medicaid programs consistent with that provided to State SCHIP programs. Thereafter, any copayment that the State imposes for services provided by an MCO may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next highest 10-cent increment. Section 1916A(b)(1)(B)(ii) of the Act provides that the total aggregate amount of cost sharing imposed under section 1916 and 1916A of the Act may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis as specified by the State. In accordance with the statute, we propose at § 447.72(c) that aggregate cost sharing for individuals whose family income exceeds 100 percent, but does not exceed 150 percent of the FPL applicable to a family of the size involved, not exceed the maximum permitted under § 447.78(a). At § 447.78(a), we propose that the total aggregate amount of cost sharing may not exceed 5 percent of such family's income for the monthly or quarterly period, as specified in the State plan. 9. Premium and Cost Sharing Protections for Individuals With Family Income Above 150 Percent of the FPL (§ 447.74) Under section 1916A(b)(2) of the Act, the State plan may impose premiums upon individuals whose family income exceeds 150 percent of the FPL applicable to a family of the size involved provided that, as described at section 1916A(b)(2)(A)of the Act, the total aggregate amount of premiums and cost sharing imposed under section 1916 and 1916A of the Act not exceed 5 percent of the family income. In accordance with the statute, at § 447.74(a), we state that the State plan can impose premiums upon individuals with family income above 150 percent of the FPL subject to the aggregate limit on premiums and cost sharing. Section 1916A(b)(2)(B) of the Act provides that, in the case of individuals whose family income exceeds 150 percent of the FPL applicable to a family of the size involved, cost sharing imposed under the State plan may not exceed 20 percent of the cost of that item (including a non-preferred drug) or service. Therefore, in accordance with the statute, we propose at § 447.74(b) that cost sharing for those individuals under the State plan not exceed 20 percent of the payment the agency makes for that item or service. In the case of States that do not have fee-for-service payment rates, we propose that any copayment that the State imposes for services provided by an MCO may not exceed $5.20 for FY 2007. This proposal would provide greater flexibility to State Medicaid programs consistent with that provided to State SCHIP programs. Thereafter, any copayment that the State imposes for services provided by an MCO may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next highest 10-cent increment. Section 1916A(b)(2)(A) of the Act provides that the total aggregate amount of cost sharing imposed under section 1916 and 1916A of the Act may not exceed 5 percent of the family income of the family involved, as applied on a quarterly or monthly basis as specified by the State. In accordance with the statute, we propose at § 447.74(c) that aggregate cost sharing for individuals whose family income exceeds 150 percent of the FPL applicable to a family of the size involved, not exceed the maximum permitted under § 447.78(a). At § 447.78(a), we propose that the total aggregate amount of premiums and cost sharing may not exceed 5 percent of such family's income for the monthly or quarterly period, as specified in the State plan. 10. Public Schedule (§ 447.76) As described in this preamble, section 1916 and 1916A of the Act provides authority for States to impose premiums and cost sharing for items and services, including prescription drugs and non-emergency use of a hospital emergency department, and to require a group or groups of individuals to make payment as a condition of eligibility or of receiving that item or service. In § 447.76(a), we propose that State plans provide for schedules of premiums and cost sharing. In § 447.76(a), we propose that the public schedule contain the following information:
(1)Current premiums, enrollment fees, or similar fees;
(2)current cost sharing charges;
(3)the aggregate limits on premiums and cost sharing or only cost sharing;
(4)mechanisms for making payments for required premiums and charges;
(5)the consequences for an applicant or recipient who does not pay a premium or charge; and
(6)a list of hospitals charging alternative cost sharing for non-emergency use of the emergency department. In addition, at § 447.76(b) we propose that the State make the public schedule available to recipients, at the time of enrollment and reenrollment and when charges are revised, applicants, all participating providers, and the general public. 11. Aggregate Limits on Premiums and Cost Sharing (§ 447.78) As described above, section 1916A(b)(1)(B)(ii) of the Act provides that the total aggregate amount of cost sharing imposed under section 1916 and 1916A of the Act upon individuals with family income above 100 percent but at or below 150 percent of the FPL may not exceed 5 percent of the family income, as applied on a quarterly or monthly basis as specified by the State. Section 1916A(c)(2)(C) of the Act reiterates that this aggregate limit includes cost sharing for prescription drugs and section 1916A(e)(2)(C) of the Act reiterates that this aggregate limit includes cost sharing for non-emergency use of a hospital emergency department. Section 1916A(b)(2)(A) of the Act provides that the total aggregate amount of premiums and cost sharing imposed under section 1916 and 1916A of the Act upon individuals with family income above 150 percent of the FPL may not exceed 5 percent of the family income, as applied on a quarterly or monthly basis as specified by the State. Again, section 1916A(c)(2)(C) of the Act reiterates that this aggregate limit includes cost sharing for prescription drugs, and section 1916A(e)(2)(C) of the Act reiterates that this aggregate limit includes cost sharing for non-emergency use of a hospital emergency department. Finally, section 1916A(a)(2)(B) of the Act provides that to the extent that cost sharing under section 1916A(c) of the Act for prescription drugs, cost sharing under section 1916A(e) of the Act for non-emergency use of a hospital emergency department, and/or cost sharing under section 1916 of the Act is imposed upon individuals whose family income is at or below 100 percent of the FPL, the total aggregate amount of premiums and cost sharing imposed may not exceed 5 percent of the family income. In accordance with these provisions, at § 447.78(a), we propose that for individuals with family income above 100 percent of the FPL the aggregate amount of premiums (when applicable) and cost sharing under section 1916 and 1916A of the Act not exceed 5 percent of a family's income for the monthly or quarterly period, as specified by the State in the State plan. At § 447.78(b), we propose that for individuals whose family income is at or below 100 percent of the FPL the aggregate amount of cost sharing under sections 1916, 1916A(c), and/or 1916A(e) of the Act not exceed 5 percent of a family's income for the monthly or quarterly period, as specified by the State in the State plan. We also propose at § 447.78(c) that family income shall be determined in a manner and for that period as specified by the State in the State plan. We clarify that States may use gross income to compute family income and that they may use a different methodology for computing family income for purposes of determining the aggregate limits than for determining income eligibility. 12. Enforceability of Premiums and Cost Sharing (§ 447.80) Section 1916A(d)(1) of the Act permits a State to condition Medicaid eligibility upon the prepayment of premiums imposed under section 1916A of the Act or to terminate Medicaid eligibility for the failure to pay such a premium for 60 days or more. The statute provides States flexibility to implement these requirements for some or all groups of individuals as specified in the State plan. The statute also provides flexibility to waive payment of any premium in any case where the State determines that requiring that payment would create undue hardship. In accordance with the statute, we propose at § 447.80(a) to permit a State to condition eligibility for a group or group of individuals upon prepayment of premiums, to terminate the eligibility of an individual from a group or groups of individuals for failure to pay for 60 days or more, and to waive payment in any case where requiring the payment would create undue hardship. Section 1916A(d)(2) of the Act permits a State to allow a provider to require that an individual, as a condition of receiving an item or service, pay the cost sharing charge imposed under section 1916A of the Act. The provider is not prohibited by this authority from choosing to reduce or waive cost sharing on a case-by-case basis. However, section 1916A(a)(2)(A) specifies that section 1916A(d)(2) shall not apply in the case of an individual whose family income does not exceed 100 percent of the FPL applicable to a family of the size involved. In accordance with the statute, at § 447.80(b) we propose that a State permit a provider, including a pharmacy, to require an individual to pay cost sharing imposed under section 1916A of the Act as a condition of receiving an item or service. However, at § 447.80(b)(1) we specify that a provider, including a pharmacy or hospital, may not require an individual whose family income is at or below 100 percent of the FPL to pay the cost sharing charge as a condition of receiving the item or service. In addition, at § 447.80(b)(2) we propose that a hospital that has determined after an appropriate medical screening under section 1867 of the Act that an individual does not have an emergency medical condition must first provide the name and location of an available and accessible alternate non-emergency services provider, the fact that the alternate provider can provide the services without the imposition of that cost sharing, and a referral to coordinate scheduling of treatment before it can require payment of the cost sharing. Finally, at § 447.80(b)(3) we propose that a provider may reduce or waive cost sharing imposed under section 1916A of the Act on a case-by-case basis. 13. Restrictions on Payments to Providers (§ 447.82) Proposed § 447.82 requires States to reduce the amount of State payments to providers by the amount of recipients' cost sharing obligations under section 1916A of the Act. However, States have the ability to increase total State plan rates to providers to maintain the same level of State payment when cost sharing is introduced. C. SCHIP Regulations 1. Maximum Allowable Cost Sharing Charges on Targeted Low-Income Children in Families With Incomes From 101 to 150 Percent of the FPL (§ 457.555) We are revising § 457.555 to update the existing “nominal” SCHIP cost sharing amounts, specifically the copayment amounts described at § 457.555(a)(1) and (2), (c), and
(d)and the deductible amount described at § 447.555(a)(4). Section 6041(b)(2) of the DRA requires the Secretary to increase the nominal Medicaid cost sharing amounts under section 1916 of the Act for each year (beginning with 2006) by the annual percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) as rounded up in an appropriate manner. While section 6041(b)(2) of the DRA does not require the Secretary to increase the SCHIP nominal cost sharing amounts, we believe that our proposal is consistent with sections 2103(e)(3)(A)(ii) and 2103(e)(1)(B) of the SCHIP statute. Section 2103(e)(3)(A)(ii) of the Act specifies that a State SCHIP plan may not impose a deductible, cost sharing, or similar charge that exceeds an amount that is nominal as determined consistent with Medicaid regulations at § 447.54, with an appropriate adjustment for inflation or other reasons as the Secretary determines to be reasonable. Section 2103(e)(1)(B) of the Act prohibits a State SCHIP plan from imposing cost sharing that favors children from families with higher income over children from families with lower income. By updating the existing SCHIP nominal cost sharing amounts by the annual percentage increase in the medical care component of the CPI-U by the period of September to September ending in the preceding calendar year, we would retain nominal cost sharing amounts that reflect a SCHIP recipient's ability to pay higher cost sharing. The medical care component of the CPI-U increased by 3.9 percent between September 2004 and September 2005, so we propose to update the nominal amounts by that factor and then round to the next higher 10-cent increment. We propose to round to the next higher 10-cent increment because it will simplify calculation and collection of the amounts involved. Based on this methodology, we propose the following copayment maximum amounts: Total cost of services Maximum amount $15.00 or less $1.10 $15.01 to $40 2.10 $40.01 to $80 3.20 $80.01 or more 5.20 We also propose that the copayments for services provided by an MCO and for emergency services provided by an institution not exceed $5.20 per visit and that the copayment for non-emergency services furnished in a hospital emergency room to targeted low-income children with family income from 101 to 150 percent of the FPL not exceed $10.40. Finally, we propose that a deductible not exceed $3.20 per family per month. States should use these updated nominal amounts during FY 2007. Thereafter, we will update these amounts each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounding to the next higher 10-cent increment. III. Collection of Information Requirements Under the Paperwork Reduction Act of 1995, we are required to provide 60- day notice in the **Federal Register** and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget
(OMB)for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: • The need for the information collection and its usefulness in carrying out the proper functions of our agency. • The accuracy of our estimate of the information collection burden. • The quality, utility, and clarity of the information to be collected. • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements: Section 447.64 Premiums, Enrollment Fees, or Similar Fees: State Plan Requirements Section 447.64 requires a State imposing premiums, enrollment fees, or similar fees on individuals to describe in the State plan:
(a)The group or groups of individuals that may be subject to the premiums, enrollment fees, or similar charges.
(b)The schedule of the premiums, enrollment fees, or similar fees imposed.
(c)The methodology used to determine family income for purposes of the limitations related to family income level that are described below, including the period and periodicity of those determinations.
(d)The methodology used to ensure compliance with the requirements of § 447.78 that the aggregate amount of premiums and cost sharing imposed for all individuals in the family does not exceed 5 percent of the family income of the family involved.
(e)The process for informing the recipients, applicants, providers, and the public of the schedule of premiums, enrollment fees, or similar fees for a group or groups of individuals in accordance with § 447.76.
(f)The notice of, timeframe for, and manner of required premium payments for a group or groups of individuals and the consequences for an individual who does not pay. The burden associated with this requirement is the time and effort it would take for a State to include this detailed description in the State plan. We estimate it would take one State approximately 20 minutes to incorporate this information in their plan. We believe 56 States will be affected by this requirement for a total annual burden of 18.67 hours. Section 447.68 Copayments, Coinsurance, Deductibles, or Similar Cost Sharing Charges: State Plan Requirements Section 447.68 requires a State imposing copayments, coinsurance, deductibles, or similar cost sharing charges on individuals to describe in the State plan:
(a)The group or groups of individuals that may be subject to the cost sharing charge.
(b)The methodology used to determine family income, for purposes of the limitations on cost sharing related to family income that are described below, including the period and periodicity of those determinations.
(c)The item or service for which the charge is imposed.
(d)The methods, such as the use of integrated automated systems, for tracking cost sharing charges, informing recipients and providers of their liability, and notifying recipients and providers when individual recipients have paid the maximum cost sharing charges permitted for the period of time.
(e)The process for informing recipients, applicants, providers, and the public of the schedule of cost sharing charges for specific items and services for a group or groups of individuals in accordance with § 447.76.
(f)The methodology used to ensure that:
(1)The aggregate amount of premiums and cost sharing imposed for all individuals with family income above 100 percent of the FPL does not exceed 5 percent of the family income of the family involved.
(2)The aggregate amount of cost sharing under sections 1916, 1916A(c), and/or 1916A(e) of the Act for individuals with family income at or below 100 percent of the FPL does not exceed 5 percent of the family income of the family involved.
(g)The notice of, timeframe for, and manner of required cost sharing and the consequences for failure to pay. The burden associated with this requirement is the time and effort it would take for a State to include this detailed description in the State plan. We estimate it would take one State approximately 20 minutes to incorporate this information in their plan. We believe 56 States will be affected by this requirement for a total annual burden of 18.67 hours. Section 447.76 Public Schedule Section 447.76(a) requires States to make available to the groups in paragraph
(b)of this section a public schedule that contains the following information:
(1)Current premiums, enrollment fees, or similar fees.
(2)Current cost sharing charges.
(3)The aggregate limit on premiums and cost sharing.
(4)Mechanisms for making payments for required premiums and charges.
(5)The consequences for an applicant or recipient who does not pay a premium or charge.
(6)A list of hospitals charging alternative cost sharing for non-emergency use of the emergency department. The burden associated with this requirement is the time and effort it would take the State to prepare and make available to appropriate parties a public schedule. We estimate that it would take 20 minutes per State. We believe 56 States will be affected by this requirement for an annual burden of 18.67 hours. Section 447.80 Enforceability of Premiums and Cost Sharing Section 447.80(b)(1) states that a hospital that has determined after an appropriate medical screening pursuant to section 489.24, that an individual does not have an emergency medical condition before imposing cost sharing on an individual must provide the name and location of an available and accessible alternate non-emergency services provider as defined in section 1916A(e)(4)(B) of the Act, the fact that the alternate provider can provide the services with the imposition of a lesser cost sharing amount or no cost sharing, and a referral to coordinate scheduling of treatment by this provider before requiring payment of cost sharing. The burden associated with this requirement is the time and effort it would take for a hospital to provide the name and location of an alternate provider who can provide services of a lesser cost sharing amount or no cost sharing and a referral. We estimate the burden on a hospital to be 30 minutes. We believe the number of hospital visits will be 4 million; therefore, the total annual burden is 2 million hours. We have submitted a copy of this proposed rule to OMB for its review of the information collection requirements described above. These requirements are not effective until they have been approved by OMB. If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following: Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attn: Melissa Musotto, [CMS-2244-P], Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Katherine Astrich, CMS Desk Officer, CMS-2244-P, *katherine_astrich@omb.eop.gov* . Fax
(202)395-6974. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act
(RFA)(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis
(RIA)must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This rule reaches the economic threshold and thus is considered a major rule. The RFA requires agencies to analyze options for regulatory relief of small businesses. 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 $6.5 million to $31.5 million in any 1 year. Individuals and States are not included in the definition of a small entity. We have determined, and the Secretary certifies, that this rule would 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 a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Core-Based Statistical Area and has fewer than 100 beds. We have determined, and the Secretary certifies, that this rule would 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 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditures in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million, updated annually for inflation. That threshold level is currently approximately $127 million. We have determined that this rule would require new spending in excess of the threshold. Table 2 outlines the total increase to Medicaid enrollees cost sharing as a result of all the provisions of the DRA. This includes an estimated cost increase to Medicaid recipients of $105 million in 2007, $155 million in 2008, $255 million in 2009, $375 million in 2010, and $455 million in 2011. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have determined that this rule would not impose substantial direct requirement costs on State and local governments. B. Anticipated Effects The following chart summarizes our estimate of the anticipated effects of this rule. Table 1.—Estimated Savings of the Cost Sharing Provisions of the Deficit Reduction Act
(DRA)of 2005 [Savings in millions of dollars] 2007 2008 2009 2010 2011 Federal Share Sec. 6041 Optional alternative premiums/cost sharing 65 85 135 190 220 Sec. 6042 Cost sharing for prescription drugs 40 65 120 185 240 Sec. 6043(a) Copays for non-emergency care in ER 5 10 15 20 25 State Share Sec. 6041 Optional alternative premiums/cost sharing 50 65 105 145 165 Sec. 6042 Cost sharing for prescription drugs 30 50 90 140 180 Sec. 6043(a) Copays for non-emergency care in ER 5 5 10 15 20 Table 2.—Medicaid Enrollees Cost Sharing Impact as a Result of the Provisions of the Deficit Reduction Act
(DRA)of 2005 [Costs in millions of dollars] 2007 2008 2009 2010 2011 Medicaid Enrollee Share Total increase in Medicaid enrollee/cost sharing for all provisions 105 155 255 375 455 These estimates are based on data regarding copayments in the Medicaid program derived from a 2004 Kaiser Family Foundation survey, and data on premiums from a 2004 report by the U.S. Government Accountability Office. In addition, we have used enrollment data from the Medicaid Statistical Information System and utilization data from the 2002 Medicaid Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality. We assume that only States that currently charge copayments and/or premiums for some groups will take advantage of the option to expand the use of premiums and copayments under the DRA provisions. States now charging copayments are assumed to increase them on average to 75 percent of maximum possible levels by 2011, and states currently charging premiums are assumed to add premiums requirements for some groups not currently allowed, also reaching 75 percent of the maximum possible by 2011. In addition to direct savings from increased cost sharing, we assume there would be declines in utilization as some enrollees subject to new cost sharing requirements choose to decrease their use of services. The decline is assumed to create additional savings of 75 percent of direct savings for physician and outpatient hospital services, 100 percent for drugs, and 125 percent for dental services. These additional savings are assumed to be reduced somewhat as a result of some providers failing to collect copayments. Savings are split between Federal and State governments using an average matching rate of 57 percent. Table 2 illustrates that the estimated impact for Medicaid enrollees as a result of all of the cost-sharing provisions of the DRA are $105 million for 2007, $155 million for 2008, $255 million for 2009, $375 million for 2010, and $455 million for 2011. Although, these estimates reflect an increase of costs to beneficiaries, we do not believe this will pose a barrier to accessing health care. The law provides that States can impose alternative cost sharing. We believe through the use of alternative cost sharing, States will help recipients become more educated and efficient health care consumers. We do, however, solicit comments on these assumptions. C. Alternatives Considered This rule is necessary to implement section 1916A of the Social Security Act, which was established by the Deficit Reduction Act of 2005
(DRA)and amended by the Tax Relief and Health Care Act of 2006 (TRHCA). D. Accounting Statement and Table As required by OMB Circular A-4 (available at *http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf)* , in the table below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the decrease in Medicaid payment as a result of the changes presented in this proposed rule. All savings are classified as transfers to the Federal Government. Table.—Accounting Statement: Classification of Estimated Expenditures, from FY 2007 to FY 2011 [In millions] Category Transfers Annualized Monetized Transfers 3% Units Discount Rate $278.2 7% Units Discount Rate $270.7 From Whom To Whom? Beneficiaries to Federal Government Category Transfers Year 2007 2008 2009 2010 2011 Annualized Monetized Transfers $110 $160 $270 $395 $485 From Whom To Whom? Beneficiaries to Federal Government Category Transfers Annualized Monetized Transfers 3% Units Discount Rate $210.6 7% Units Discount Rate $205.0 From Whom To Whom? Beneficiaries to Federal Government Category Transfers Year 2007 2008 2009 2010 2011 Annualized Monetized Transfers $85 $120 $205 $300 $365 From Whom To Whom? Beneficiaries to Federal Government E. Conclusion We expect that this rule would promote the modernization of the Medicaid program. The proposed rule would provide a new option to States to create programs that are aligned with today's Medicaid populations and the health care environment. Through alternative cost sharing, States would help recipients become more educated and efficient health care consumers. Thus, this rule would help ensure the sustainability of the Medicaid program over time. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects 42 CFR Part 447 Accounting, Administrative practice and procedure, Drugs, Grant programs—Health, Health facilities, Health professions, Medicaid, Reporting and recordkeeping requirements, Rural areas. 42 CFR Part 457 Administrative practice and procedure, Grant programs—Health, Health insurance, Reporting and recordkeeping requirements. For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services propose to amend 42 CFR chapter IV as set forth below: PART 447—PAYMENTS FOR SERVICES 1. The authority citation for part 447 continues to read as follows: Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 1302). 2. Section 447.54 is amended by— a. Republishing the introductory text to paragraph (a). b. Revising paragraphs (a)(1) and (a)(3). c. Adding new paragraph (a)(4). The republication, revisions, and additions read as follows: § 447.54 Maximum allowable and nominal charges.
(a)*Non-institutional services.* Except as specified in paragraph
(b)of this section, for non-institutional services, the plan must provide that the following requirements are met:
(1)For Federal Fiscal Year 2007, any deductible it imposes does not exceed $2.10 per month per family for each period of Medicaid eligibility. For example, if Medicaid eligibility is certified for a 3-month period, the maximum deductible which may be imposed on a family for the period of eligibility is $6.30. Thereafter, any deductible should not exceed these amounts as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year, and then rounded to the next higher 10-cent increment. (3)(i) For Federal Fiscal Year 2007, any copayments it imposes under a fee-for-service delivery system do not exceed the amounts shown in the following table: State payment Maximum copayment $10 or less $.60 $10.01 to $25 1.10 $25.01 to $50 2.10 $50.01 or more 3.20
(ii)Thereafter, any copayments should not exceed these amounts as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment.
(4)For Federal Fiscal Year 2007, any copayment it imposes for services provided by an MCO may not exceed $5.20 per visit. Thereafter, any copayment should not exceed these amounts as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment. 3. Section 447.55 is amended by revising paragraph
(b)to read as follows: § 447.55 Standard copayment.
(b)This standard copayment amount for any service may be determined by applying the maximum copayment amounts specified in § 447.54(a) and
(b)to the agency's average or typical payment for that service. For example, if the agency's typical payment for prescribed drugs is $4 to $5 per prescription, the agency might set a standard copayment of $.60 per prescription. This standard copayment may be adjusted based on updated copayments as permitted under § 447.54(a)(3). 4. New §§ 447.62, 447.64, 447.66, 447.68, 447.70, 447.71, 447.72, 447.74, 447.76, 447.78, 447.80, and § 447.82, and a new undesignated center heading are added to read as follows: ALTERNATIVE PREMIUMS AND COST SHARING UNDER SECTION 1916A § 447.62 Alternative premiums and cost sharing: Basis, purpose and scope.
(a)Section 1916A of the Act sets forth options for alternative premiums and cost sharing, which are premiums and cost sharing that are not subject to the limitations under section 1916 of the Act as described in § 447.51 through § 447.56. For States that impose alternative premiums, § 447.64 through § 447.66, § 447.72, § 447.74, § 447.78, and § 447.80 prescribe State plan requirements and options for alternative premiums and the standards and conditions under which States may impose them. For States that impose alternative cost sharing, § 447.68 through § 447.72, § 447.74, § 447.78, and § 447.80 prescribe State plan requirements and options for alternative cost sharing and the standards and conditions under which States may impose alternative cost sharing. For other individuals, premiums and cost sharing must comply with the requirements described in § 447.50 through § 447.60.
(b)Neither section 1916A of the Act nor the regulations referenced in paragraph
(a)of this section affect the following:
(1)The Secretary's authority to waive limitations on premiums and cost sharing under this subpart.
(2)Existing waivers with regard to the imposition of premiums and cost sharing. § 447.64 Alternative premiums, enrollment fees, or similar fees: State plan requirements. When a State imposes alternative premiums, enrollment fees, or similar fees on individuals, the State plan must describe the following:
(a)The group or groups of individuals that may be subject to the premiums, enrollment fees, or similar charges.
(b)The schedule of the premiums, enrollment fees, or similar fees imposed.
(c)The methodology used to determine family income for purposes of the limitations related to family income level that are described below, including the period and periodicity of those determinations.
(d)The methodology used to ensure compliance with the requirements of § 447.78 that the aggregate amount of premiums and cost sharing imposed for all individuals in the family do not exceed 5 percent of the family income of the family involved.
(e)The process for informing the recipients, applicants, providers, and the public of the schedule of premiums, enrollment fees, or similar fees for a group or groups of individuals in accordance with § 447.76.
(f)The notice of, time frame for, and manner of required premium payments for a group or groups of individuals and the consequences for an individual who does not pay. § 447.66 General alternative premium protections.
(a)States may not impose alternative premiums upon the following individuals:
(1)Individuals under 18 years of age that are required to be provided medical assistance under section 1902(a)(10)(A)(i) of the Act, and including individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under Part E of that title, without regard to age.
(2)Pregnant women.
(3)Any terminally ill individual receiving hospice care, as defined in section 1905(o) of the Act.
(4)Any individual who is an inpatient in a hospital, nursing facility, intermediate care facility, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs.
(5)Women who are receiving Medicaid on the basis of the breast or cervical cancer eligibility group under sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act.
(6)Disabled children who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act.
(b)States may exempt additional classes of individuals from premiums. § 447.68 Alternative copayments, coinsurance, deductibles, or similar cost sharing charges: State plan r equirements. When a State imposes alternative copayments, coinsurance, deductibles, or similar cost sharing charges on individuals, the State plan must describe the following:
(a)The group or groups of individuals that may be subject to the cost sharing charge.
(b)The methodology used to determine family income, for purposes of the limitations on cost sharing related to family income that are described below, including the period and periodicity of those determinations.
(c)The item or service for which the charge is imposed.
(d)The methods, such as the use of integrated automated systems, for tracking cost sharing charges, informing recipients and providers of their liability, and notifying recipients and providers when individual recipients have paid the maximum cost sharing charges permitted for the period of time.
(e)The process for informing recipients, applicants, providers, and the public of the schedule of cost sharing charges for specific items and services for a group or groups of individuals in accordance with § 447.76.
(f)The methodology used to ensure that:
(1)The aggregate amount of premiums and cost sharing imposed for all individuals with family income above 100 percent of the FPL does not exceed 5 percent of the family income of the family involved.
(2)The aggregate amount of cost sharing under sections 1916, 1916A(c), and/or 1916A(e) of the Act for individuals with family income at or below 100 percent of the FPL does not exceed 5 percent of the family income of the family involved.
(g)The notice of, time frame for, and manner of required cost sharing and the consequences for failure to pay. § 447.70 General alternative cost sharing protections. (a)(1) States may not impose alternative cost sharing for the following items/services. Except as indicated, these limits do not apply to alternative cost sharing for non-preferred prescription drugs within a class of such drugs or non-emergency use of the emergency room.
(i)Services furnished to individuals under 18 years of age who are required to be provided Medicaid under section 1902(a)(10)(A)(i) of the Act, and including services furnished to individuals with respect to whom child welfare services are made available under Part B of title IV on the basis of being a child in foster care and individuals with respect to whom adoption or foster care assistance is made available under Part E of that title, without regard to age.
(ii)Preventive services (such as well baby and well child care and immunizations) provided to children under 18 years of age regardless of family income.
(iii)Services furnished to pregnant women, if those services relate to pregnancy or to any other medical condition which may complicate the pregnancy.
(iv)Services furnished to a terminally ill individual who is receiving hospice care (as defined in section 1905(o) of the Act).
(v)Services furnished to any individual who is an inpatient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or other medical institution, if the individual is required, as a condition of receiving services in that institution under the State plan, to spend for costs of medical care all but a minimal amount of the individual's income required for personal needs.
(vi)Emergency services as defined at § 447.53(b)(4), except charges for services furnished after the hospital has determined, based on the screening and any other services required under § 489.24 of this chapter, that the individual does not have an emergency medical condition consistent with the requirements of paragraph (a)(2) of this section and § 447.80(b)(1).
(vii)Family planning services and supplies described in section 1905(a)(4)(C) of the Act.
(viii)Services furnished to women who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XVIII) and 1902(aa) of the Act (breast or cervical cancer provisions).
(ix)Services furnished to disabled children who are receiving medical assistance by virtue of the application of sections 1902(a)(10)(A)(ii)(XIX) and 1902(cc) of the Act.
(x)Preferred drugs within a class for individuals for whom cost sharing may not otherwise be imposed as described in paragraphs (a)(1)(i) through (a)(1)(ix) of this section.
(2)A State may impose nominal cost sharing as defined in § 447.54 for services furnished in a hospital emergency department, other than those required under § 489.24 of this chapter, if the hospital has determined based on the screening required under § 489.24 that the individual does not have an emergency medical condition, the requirements of § 447.80(b)(1) are met, and no cost sharing is imposed to receive the care through an outpatient department or another alternative health care provider in the geographic area of the hospital emergency department involved.
(b)In the case of a drug that is a preferred drug within a class, cost sharing may not exceed the levels permitted under section 1916 of the Act. Cost sharing can be imposed that exceeds section 1916 levels only for drugs that are not preferred drugs within a class in accordance with section 1916A(c).
(c)In the case of a drug that is not a preferred drug, the cost sharing is limited to the amount imposed for a preferred drug if the following conditions are met:
(1)The prescribing physician determines that the preferred drug would be less effective or would have adverse effects for the individual or both.
(2)State criteria for prior authorization, if any, are met.
(d)States may exempt additional individuals, items, or services from cost sharing. § 447.71 Alternative premium and cost sharing exemptions and protections for individuals with family incomes at or below 100 percent of the FPL.
(a)The State may not impose premiums under the State plan on individuals whose family income is at or below 100 percent of the FPL.
(b)The State may not impose cost sharing under the State plan on individuals whose family income is at or below 100 percent of the FPL, with the following exceptions:
(1)The State may impose cost sharing for non-preferred drugs that does not exceed the nominal amount as defined in § 447.54.
(2)The State may impose cost sharing for non-emergency services furnished in a hospital emergency department that does not exceed the nominal amount as defined in § 447.54 so long as no cost sharing is imposed to receive such care through an outpatient department or other alternative non-emergency services provider in the geographic area of the hospital emergency department involved.
(c)Aggregate cost sharing of the family under sections 1916, 1916A(c), and/or 1916A(e) may not exceed the maximum permitted under § 447.78(b). § 447.72 Alternative premium and cost sharing exemptions and protections for individuals with family incomes above 100 percent but at or below 150 percent of the FPL.
(a)The State may not impose premiums under the State plan on individuals whose family income exceeds 100 percent, but does not exceed 150 percent, of the FPL.
(b)Cost sharing may not exceed 10 percent of the payment the agency makes for the item or service, with the following exceptions:
(1)Cost sharing for non-preferred drugs cannot exceed the nominal amount as defined in § 447.54.
(2)Cost sharing for non-emergency services furnished in the hospital emergency department cannot exceed twice the nominal amount as defined in § 447.54. A hospital must meet the requirements described at § 447.80 before the cost sharing can be imposed.
(3)In the case of States that do not have fee-for-service payment rates, any copayment that the State imposes for services provided by an MCO may not exceed $5.20 for Federal Fiscal Year 2007. Thereafter, any copayment may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next highest 10-cent increment.
(c)Aggregate cost sharing of the family may not exceed the maximum permitted under § 447.78(a). § 447.74 Alternative premium and cost sharing protections for individuals with family incomes above 150 percent of the FPL.
(a)States may impose premiums consistent with the aggregate limits set forth in § 447.78(a).
(b)Cost sharing may not exceed 20 percent of the payment the agency makes for the item (including a non-preferred drug) or service, with the following exception: In the case of States that do not have fee-for-service payment rates, any copayment that the State imposes for services provided by an MCO may not exceed $5.20 for Federal Fiscal Year 2007. Thereafter, any copayment may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next highest 10-cent increment.
(c)Aggregate premiums and cost sharing of the family may not exceed the maximum permitted under § 447.78(a). § 447.76 Public schedule.
(a)The State must make available to the groups in paragraph
(b)of this section a public schedule that contains the following information:
(1)Current premiums, enrollment fees, or similar fees.
(2)Current cost sharing charges.
(3)The aggregate limit on premiums and cost sharing or just cost sharing.
(4)Mechanisms for making payments for required premiums and charges.
(5)The consequences for an applicant or recipient who does not pay a premium or charge.
(6)A list of hospitals charging alternative cost sharing for non-emergency use of the emergency department.
(b)The State must make the public schedule available to the following:
(1)Recipients, at the time of their enrollment and reenrollment after a redetermination of eligibility, and when premiums, cost sharing charges, and the aggregate limits are revised.
(2)Applicants, at the time of application.
(3)All participating providers.
(4)The general public. § 447.78 Aggregate limits on alternative premiums and cost sharing.
(a)If a State imposes alternative premiums or cost sharing, the total aggregate amount of premiums and cost sharing under section 1916, 1916A(c) or 1916A(e) for individuals with family income above 100 percent of the FPL may not exceed 5 percent of the family's income for the monthly or quarterly period, as specified by the State in the State plan
(b)The total aggregate amount of cost sharing under sections 1916, 1916A(c), and/or 1916A(e) of the Act for individuals with family income at or below 100 percent of the FPL may not exceed 5 percent of the family's income for the monthly or quarterly period, as specified in the State plan.
(c)Family income shall be determined in a manner and for that period as specified by the State in the State plan.
(1)States may use gross income or any other methodology.
(2)States may use a different methodology for determining the aggregate limits than they do for determining income eligibility. § 447.80 Enforceability of alternative premiums and cost sharing.
(a)With respect to alternative premiums, a State may do the following:
(1)Require a group or groups of individuals to prepay.
(2)Terminate an individual from medical assistance on the basis of failure to pay for 60 days or more.
(3)Waive payment of a premium in any case where it determines that requiring the payment would create an undue hardship.
(b)With respect to alternative cost sharing, a State may permit a provider, including a pharmacy, to require an individual, as a condition for receiving the item or service, to pay the cost sharing charge, except as specified below.
(1)A provider, including a pharmacy and a hospital, may not require an individual whose family income is at or below 100 percent of the FPL to pay the cost sharing charge as a condition of receiving the service.
(2)A hospital that has determined after an appropriate medical screening pursuant to § 489.24, that an individual does not have an emergency medical condition, before imposing cost sharing on an individual, must provide the name and location of an available and accessible alternate non-emergency services provider as defined in section 1916A(e)(4)(B), the fact that the alternate provider can provide the services with the imposition of a lesser cost sharing amount or no cost sharing, and a referral to coordinate scheduling of treatment by this provider before requiring payment of cost sharing.
(3)The provider is not prohibited by this authority from choosing to reduce or waive cost sharing on a case-by-case basis. § 447.82 Restrictions on payments to providers. The plan must provide that the agency reduces the payment it makes to any provider by the amount of a recipient's cost sharing obligation, regardless of whether the provider successfully collects the cost sharing. PART 457—ALLOTMENTS AND GRANTS TO STATES 5. The authority citation for part 457 continues to read as follows: Authority: Section 1102 of the Social Security Act (42 U.S.C. 1302). 6. Section 457.555 is amended by— a. Republishing paragraph
(a)introductory text. b. Revising paragraphs (a)(1), (a)(2), and (a)(4). c. Revising paragraph (c). d. Revising paragraph (d). The republication and revisions read as follows: § 457.555 Maximum allowable cost sharing charges on targeted low-income children in families with income from 101 to 150 percent of the FPL.
(a)*Non-institutional services.* For targeted low-income children whose family income is from 101 to 150 percent of the FPL, the State plan must provide that for non-institutional services, including emergency services, the following requirements must be met: (1)(i) For Federal Fiscal Year 2007, any copayment or similar charge the State imposes under a fee-for-service delivery system may not exceed the following amounts: Total cost Maximum amount $15.00 or less $1.10 $15.01 to $40 2.10 $40.01 to $80 3.20 $80.01 or more 5.20
(ii)Thereafter, any copayments may not exceed these amounts as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment.
(2)For Federal Fiscal Year 2007, any copayment that the State imposes for services provided by a managed care organization may not exceed $5.20 per visit. Thereafter, any copayment may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment.
(4)For Federal Fiscal Year 2007, any deductible the State imposes may not exceed $3.20 per month, per family for each period of eligibility. Thereafter, any deductible may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment.
(c)*Institutional emergency services.* For Federal Fiscal Year 2007, any copayment that the State imposes on emergency services provided by an institution may not exceed $5.20. Thereafter, any copayment may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment.
(d)*Non-emergency use of the emergency room.* For Federal Fiscal Year 2007, for targeted low-income children whose family income is from 101 to 150 percent of the FPL, the State may charge up to twice the charge for non-institutional services, up to a maximum amount of $10.40, for services furnished in a hospital emergency room if those services are not emergency services as defined in § 457.10. Thereafter, any charge may not exceed this amount as updated each October 1 by the percentage increase in the medical care component of the CPI-U for the period of September to September ending in the preceding calendar year and then rounded to the next higher 10-cent increment. (Catalog of Federal Domestic Assistance Program No. 93.778, Medical Assistance Program) Dated: October 5, 2007. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Approved: November 1, 2007. Michael O. Leavitt, Secretary. [FR Doc. E8-3211 Filed 2-21-08; 8:45 am] BILLING CODE 4120-01-P DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency 44 CFR Part 67 [Docket No. FEMA-B-7763] Proposed Flood Elevation Determinations AGENCY: Federal Emergency Management Agency, DHS. ACTION: Proposed rule. SUMMARY: Comments are requested on the proposed Base (1 percent annual-chance) Flood Elevations
(BFEs)and proposed BFE modifications for the communities listed in the table below. The purpose of this notice is to seek general information and comment regarding the proposed regulatory flood elevations for the reach described by the downstream and upstream locations in the table below. The BFEs and modified BFEs are a part of the floodplain management measures that the community is required either to adopt or show evidence of having in effect in order to qualify or remain qualified for participation in the National Flood Insurance Program (NFIP). In addition, these elevations, once finalized, will be used by insurance agents, and others to calculate appropriate flood insurance premium rates for new buildings and the contents in those buildings. DATES: Comments are to be submitted on or before May 22, 2008. ADDRESSES: The corresponding preliminary Flood Insurance Rate Map
(FIRM)for the proposed BFEs for each community are available for inspection at the community's map repository. The respective addresses are listed in the table below. You may submit comments, identified by Docket No. FEMA-B-7763, to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472,
(202)646-3151, or (e-mail) *bill.blanton@dhs.gov* . FOR FURTHER INFORMATION CONTACT: William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472,
(202)646-3151 or.(e-mail) *bill.blanton@dhs.gov* . SUPPLEMENTARY INFORMATION: The Federal Emergency Management Agency
(FEMA)proposes to make determinations of BFEs and modified BFEs for each community listed below, in accordance with section 110 of the Flood Disaster Protection Act of 1973, 42 U.S.C. 4104, and 44 CFR 67.4(a). These proposed BFEs and modified BFEs, together with the floodplain management criteria required by 44 CFR 60.3, are the minimum that are required. They should not be construed to mean that the community must change any existing ordinances that are more stringent in their floodplain management requirements. The community may at any time enact stricter requirements of its own, or pursuant to policies established by other Federal, State, or regional entities. These proposed elevations are used to meet the floodplain management requirements of the NFIP and are also used to calculate the appropriate flood insurance premium rates for new buildings built after these elevations are made final, and for the contents in these buildings. Comments on any aspect of the Flood Insurance Study and FIRM, other than the proposed BFEs, will be considered. A letter acknowledging receipt of any comments will not be sent. *Administrative Procedure Act Statement.* This matter is not a rulemaking governed by the Administrative Procedure Act (APA), 5 U.S.C. 553. FEMA publishes flood elevation determinations for notice and comment; however, they are governed by the Flood Disaster Protection Act of 1973, 42 U.S.C. 4105, and the National Flood Insurance Act of 1968, 42 U.S.C. 4001, *et seq.* , and do not fall under the APA. *National Environmental Policy Act.* This proposed rule is categorically excluded from the requirements of 44 CFR part 10, Environmental Consideration. An environmental impact assessment has not been prepared. *Regulatory Flexibility Act.* As flood elevation determinations are not within the scope of the Regulatory Flexibility Act, 5 U.S.C. 601-612, a regulatory flexibility analysis is not required. *Executive Order 12866, Regulatory Planning and Review.* This proposed rule is not a significant regulatory action under the criteria of section 3(f) of Executive Order 12866, as amended. *Executive Order 13132, Federalism.* This proposed rule involves no policies that have federalism implications under Executive Order 13132. *Executive Order 12988, Civil Justice Reform.* This proposed rule meets the applicable standards of Executive Order 12988. List of Subjects in 44 CFR Part 67 Administrative practice and procedure, Flood insurance, Reporting and recordkeeping requirements. Accordingly, 44 CFR part 67 is proposed to be amended as follows: PART 67—[AMENDED] 1. The authority citation for part 67 continues to read as follows: Authority: 42 U.S.C. 4001, *et seq.* ; Reorganization Plan No. 3 of 1978, 3 CFR, 1978 Comp., p. 329; E.O. 12127, 44 FR 19367, 3 CFR, 1979 Comp., p. 376. § 67.4 [Amended] 2. The tables published under the authority of § 67.4 are proposed to be amended as follows: Flooding source(s) Location of referenced elevation ** * Elevation in feet
(NGVD)+ Elevation in feet
(NAVD)# Depth in feet above ground Effective Modified Communities affected Alameda County, California, and Incorporated Areas Arroyo Las Positas Approximately 1,155 feet downstream of North Livermore Avenue None +444 City of Livermore. Approximately 1,040 feet downstream of North Livermore Avenue None +445 Arroyo Las Positas (Shallow Flooding) Approximately 530 feet east of the intersection of Airway Boulevard and Terminal Court #1.5 #2 City of Livermore. Arroyo del Valle Approximately 0.7 mile downstream of Arroyo Road None +514 Unincorporated Areas of Alameda County. Approximately 1,700 feet downstream of Arroyo Road None +531 Dublin Creek Approximately 60 feet upstream of the confluence with Line J-1 None +332 City of Pleasanton. Approximately 255 feet upstream of San Ramon Road None +369 Line B At the confluence of Line B and Line D +13 +11 City of Newark. At the crossing of Line B and Mowry Avenue +13 +11 San Francisco Bay Along Oakland Inner Harbor, Alameda Harbor, Brooklyn Basin, Alaska Basin, Fartmann Basin, Tidal Canal, San Leandro Bay, and San Leandro Channel None +9 City of Alameda. San Francisco Bay Area approximately 350 feet south of Neil Armstrong Way and Edward White Way +9 +10 City of Oakland. San Francisco Bay Approximately 1,600 feet northwest of Marshlands Road and Thornton Avenue None +11 City of Fremont. Approximately 400 feet east of Quarry Road and SH 84 None +11 San Lorenzo Creek (Shallow Flooding) Shallow flooding areas between the San Francisco Bay and Center Street None #1 City of San Leandro, City of Hayward, Unincorporated Areas of Alameda County. Tassajara Creek (Zone 7) Approximately 450 feet southwest of Tassajara Road and Shadow Hill Drive None +404 Unincorporated Areas of Alameda County. Approximately 320 feet southwest of Tassajara Road and Shadow Hill Drive None +406 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES City of Alameda Maps are available for inspection at City of Alameda Public Works Department, 950 West Mall Square, Room 110, Alameda, CA. City of Fremont Maps are available for inspection at City of Fremont Development and Environmental Services Department, Engineering Division, 39550 Liberty Street, Fremont, CA. City of Hayward Maps are available for inspection at City of Hayward Engineering and Transportation Division, 777 B Street, Hayward, CA. City of Livermore Maps are available for inspection at City of Livermore Community Development Department, 1052 South Livermore Avenue, Livermore, CA. City of Newark Maps are available for inspection at City of Newark Administration Building, Building Inspection Division, 37101 Newark Boulevard, Newark, CA. City of Oakland Maps are available for inspection at City of Oakland Community and Economic Development Department, One Frank Ogawa Plaza, Oakland, CA. City of Pleasanton Maps are available for inspection at Pleasanton City Hall, 123 Main Street, Pleasanton, CA. City of San Leandro Maps are available for inspection at City of San Leandro Building Department, 835 East 14th Street, San Leandro, CA. Unincorporated Areas of Alameda County Maps are available for inspection at Alameda County Public Works Agency, 399 Elmhurst Street, Hayward, CA. Monterey County, California, and Incorporated Areas Calera Creek At the confluence with El Toro Creek +231 +236 Unincorporated Areas of Monterey County. Approximately 1.2 miles upstream of Robley Road None +469 Approximately 500 feet west of the intersection of Robley Road and Corral de Tierra None #1 Carmel River Approximately 370 feet above the mouth of the river +12 +16 Unincorporated Areas of Monterey County. Approximately 170 feet downstream of San Clemente Dam None +470 Carmel River Garland Ranch Overbank At the convergence with Carmel River main channel None +180 Unincorporated Areas of Monterey County. At the divergence from Carmel River main channel None +194 Carmel River Hacienda Overbank At the convergence with Carmel River main channel None +49 Unincorporated Areas of Monterey County. At the divergence from Carmel River main channel None +59 Carmel River North Highway 1 Overbank Approximately 600 feet downstream of State Highway 1 +28 +25 Unincorporated Areas of Monterey County, City of Carmel By The Sea. At the divergence from Carmel River main channel +40 +39 Carmel River Schulte Overbank At the convergence with Carmel River main channel None +90 Unincorporated Areas of Monterey County. At the divergence from Carmel River main channel None +102 Carmel River South Highway 1 Overbank Approximately 1,100 feet upstream of confluence with Carmel River main channel +17 +16 Unincorporated Areas of Monterey County. Approximately 500 feet downstream of divergence from Carmel River main channel +36 +38 El Toro Creek Approximately 650 feet downstream of Highway 68 +221 +222 Unincorporated Areas of Monterey County. Approximately 300 feet upstream of Highway 68 +231 +236 Harper Creek At the confluence with San Benancio Gulch None +371 Unincorporated Areas of Monterey County. Approximately 0.6 mile upstream of Rimrock Canyon Road None +605 Pacific Ocean Approximately 400 feet north of the intersection of Camino Aguajito and Del Monte Avenue None +22 Unincorporated Areas of Monterey County, City of Monterey. San Benancio Gulch At the confluence with El Toro Creek +231 +236 Unincorporated Areas of Monterey County. Approximately 0.7 mile upstream of Ridge Back Road None +839 Watson Creek At the confluence with Calera Creek +406 +408 Unincorporated Areas of Monterey County. Approximately 1.1 miles upstream of Calle Viejo None +886 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES City of Carmel By The Sea Maps are available for inspection at Carmel-by-the-Sea City Hall, East Side of Monte Verde between Ocean and 7th Avenues, Carmel-by-the-Sea, CA. City of Monterey Maps are available for inspection at City of Monterey Building and Safety Division, 580 Pacific Street, Monterey, CA. Unincorporated Areas of Monterey County Maps are available for inspection at Monterey County Water Resources Agency, 893 Blanco Circle, Salinas, CA. Tulare County, California, and Incorporated Areas Kaweah River At Mill Creek/Packwood Creek Split None +363 Unincorporated Areas of Tulare County. At downstream side of Southern Pacific Railroad None +390 Shallow Flooding (extensive area covering 19 map panels) Approximately 1,000 feet southeast of intersection of State Highway 99 and Goshen Avenue None +282 Unincorporated Areas of Tulare County, City of Farmersville, City of Visalia. Approximately 350 feet southwest of intersection of Lort Drive and Railroad #2 +391 St. Johns River Approximately 0.5 mile upstream of Avenue 328 Bridge None +317 Unincorporated Areas of Tulare County, City of Visalia. Approximately 220 feet downstream of Southern Pacific Railroad None +378 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES City of Farmersville Maps are available for inspection at Farmersville City Hall, 909 West Visalia Road, Farmersville, CA. City of Visalia Maps are available for inspection at Visalia City Hall East, 315 East Acequia, Visalia, CA. Unincorporated Areas of Tulare County Maps are available for inspection at Tulare County Resource Management Agency, 5961 South Mooney Boulevard, Visalia, CA. Avery County, North Carolina, and Incorporated Areas Linville River (upstream) Approximately 50 feet downstream of Highland Mist Road None +3695 Grandfather Village, Unincorporated Areas of Avery County. At the confluence of Big Grassy Creek None +3834 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472. ADDRESSES Grandfather Village Maps are available for inspection at Village of Grandfather Village, 2120 Highway 105, Linville, NC. Unincorporated Areas of Avery County Maps are available for inspection at Avery County Courthouse, 200 Montezuma Street, Newland, NC. Wilkes County, North Carolina, and Incorporated Areas Beaver Creek At the confluence with Yadkin River None +1079 Unincorporated Areas of Wilkes County. Approximately 750 feet upstream of Caldwell/Wilkes County boundary None +1228 Beaver Creek Tributary 1 At the confluence with Beaver Creek None +1084 Unincorporated Areas of Wilkes County. Approximately 0.7 mile upstream of the confluence with Beaver Creek None +1100 Beaver Creek Tributary 2 At the confluence with Beaver Creek None +1153 Unincorporated Areas of Wilkes County. Approximately 590 feet upstream of Livingston Road (State Road 1130) None +1169 Beaver Creek Tributary 3 At the confluence with Beaver Creek None +1159 Unincorporated Areas of Wilkes County. Approximately 0.7 mile upstream of the confluence with Beaver Creek None +1190 Big Branch At the confluence with Middle Prong Roaring River None +1300 Unincorporated Areas of Wilkes County. Approximately 1,080 feet upstream of Moxley Road (State Road 1735) None +1350 Big Bugaboo Creek At the confluence with Yadkin River None +926 Unincorporated Areas of Wilkes County. Approximately 0.9 mile upstream of the confluence of Big Bugaboo Creek Tributary 1 None +1213 Big Bugaboo Creek Tributary 1 At the confluence with Big Bugaboo Creek None +1183 Unincorporated Areas of Wilkes County. Approximately 2,000 feet upstream of the confuence with Big Bugaboo Creek None +1207 Big Sandy Creek At the confluence with East Prong Roaring River None +1226 Unincorporated Areas of Wilkes County. Approximately 1,270 feet upstream of Traphill-Brown Road (State Road 1741) None +1323 Big Warrior Creek At the confluence with Warrior Creek None +1085 Unincorporated Areas of Wilkes County. Approximately 1.8 miles upstream of the confluence of Big Warrior Creek Tributary 1 None +1275 Big Warrior Creek Tributary 1 At the confluence with Big Warrior Creek None +1128 Unincorporated Areas of Wilkes County. Approximately 0.8 mile upstream of the confluence with Big Warrior Creek None +1237 Blood Creek At the confluence with Warrior Creek None +1075 Unincorporated Areas of Wilkes County. Approximately 1,990 feet upstream of Walsh Town Road (State Road 1119) None +1081 Brier Creek At the confluence with Yadkin River None +933 Unincorporated Areas of Wilkes County. Approximately 1,370 feet upstream of Rance Staley Road (State Road 2325) None +1039 Brier Creek Tributary 1 At the confluence with Brier Creek None +933 Unincorporated Areas of Wilkes County. Approximately 1.1 miles upstream of Red White & Blue Road (State Road 2324) None +981 Brushy Creek Approximately 300 feet downstream of the Iredell/Wilkes County boundary None +905 Unincorporated Areas of Wilkes County. Approximately 100 feet upstream of the Iredell/Wilkes County boundary None +908 Cane Creek At the confluence with West Prong Roaring River None +1173 Unincorporated Areas of Wilkes County. Approximately 1.7 miles upstream of Dehart Church Road (State Road 1715) None +1325 Cub Creek At the confluence with Yadkin River +962 +963 Unincorporated Areas of Wilkes County, Town of Wilkesboro. Approximately 0.6 mile upstream of Pennell Road (State Road 2493) None +1084 Darnell Creek At the confluence with North Fork Reddies River None +1290 Unincorporated Areas of Wilkes County. Approximately 1.2 miles upstream of State Road 1567 None +1413 Double Creek At the confluence with Middle Prong Roaring River None +1293 Unincorporated Areas of Wilkes County. Approximately 100 feet upstream of confluence of Double Creek Tributary 1 None +1371 Double Creek Tributary 1 The confluence with Double Creek None +1370 Unincorporated Areas of Wilkes County. Approximately 0.5 mile upstream of confluence with Double Creek None +1396 Dugger Creek At the confluence with Elk Creek None +1278 Unincorporated Areas of Wilkes County. Approximately 1,170 feet upstream of Elk Creek Darby Road (State Road 1162) None +1323 East Prong Roaring River At the confluence with Roaring River None +1009 Unincorporated Areas of Wilkes County. Approximately 2.8 miles upstream of Longbottom Road (State Road 1737) None +1389 East Swan Creek At the confluence with Swan Creek None +911 Unincorporated Areas of Wilkes County. Approximately 0.9 mile upstream of the confluence with Swan Creek None +927 Elk Creek At the confluence with Yadkin River None +1090 Unincorporated Areas of Wilkes County. At the Watauga/Wilkes County boundary None +1349 Elk Creek Tributary 1 At the confluence with Elk Creek None +1235 Unincorporated Areas of Wilkes County. Approximately 0.8 mile upstream of Elk Creek Darby Road (State Road 1162) None +1626 Elk Creek Tributary 2 At the confluence with Elk Creek None +1237 Unincorporated Areas of Wilkes County. Approximately 1,030 feet upstream of Meadow Road None +1358 Elkin Creek Approximately 1,700 feet downstream of the Wilkes/Surry County boundary None +938 Unincorporated Areas of Wilkes County. Approximately 700 feet upstream of Union Community Road (State Road 1919) None +1293 Elkin Creek Tributary 1 At the confluence with Elkin Creek None +1185 Unincorporated Areas of Wilkes County. Approximately 0.7 mile upstream of State Road 1910 None +1213 Fishing Creek At the confluence with Yadkin River None +942 Unincorporated Areas of Wilkes County. Approximately 100 feet downstream of Speedway Road (State Road 2355) None +1063 Fishing Creek Tributary 1 At the confluence with Fishing Creek None +945 Unincorporated Areas of Wilkes County. Approximately 1.9 miles upstream of Old NC 60 Highway (State Road 2318) None +997 Fishing Creek Tributary 2 At the confluence with Fishing Creek None +1023 Unincorporated Areas of Wilkes County. Approximately 250 feet downstream of U.S. Highway 421 None +1129 Fishing Creek Tributary 2A At the confluence with Fishing Creek Tributary 2 None +1119 Unincorporated Areas of Wilkes County. Approximately 0.5 mile upstream of the confluence with Fishing Creek Tributary 2 None +1153 Fletcher Creek At the confluence with South Prong Lewis Fork None +1399 Unincorporated Areas of Wilkes County. Approximately 0.4 mile upstream of Shady Walk Lane None +1517 Gambill Creek At the confluence with West Prong Roaring River None +1343 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of the confluence with West Prong Roaring River None +1401 Gladys Fork At the confluence with Stony Fork None +1092 Unincorporated Areas of Wilkes County. Approximately 0.5 mile upstream of Mount Pleasant Road (State Road 1135) None +1141 Grassy Creek West At the confluence with Elkin Creek None +980 Unincorporated Areas of Wilkes County. At Wilkes/Surry County boundary None +987 Grassy Fork At the confluence with Elkin Creek None +1112 Unincorporated Areas of Wilkes County. Approximately 1,990 feet upstream of the confluence with Elkin Creek None +1119 Grays Creek At the confluence with the Yadkin River None +921 Unincorporated Areas of Wilkes County. Approximately 0.9 mile upstream of State Road 2321 None +929 Harris Creek At the confluence with Double Creek None +1318 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Longbottom Road (State Road 1730) None +1425 Hoopers Branch At the confluence with Reddies River None +997 Unincorporated Areas of Wilkes County, Town of North Wilkesboro. Approximately 1,580 feet upstream of Hackett Street None +1088 Huffman Branch At the confluence with North Prong Lewis Fork None +1278 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Parsonville Road (State Road 1300) None +1324 Hunting Creek Approximately 100 feet downstream of the Wilkes/Iredell County boundary None +895 Unincorporated Areas of Wilkes County. Approximately 1.4 miles upstream of Balls Mill Road (State Road 2474) None +1176 Joshua Creek At the confluence with Mulberry Creek None +1453 Unincorporated Areas of Wilkes County. Approximately 890 feet upstream of Longbottom Road (State Road 1728) None +1528 Left Prong Stony Fork At the confluence with Stony Fork None +1332 Unincorporated Areas of Wilkes County. At the Watauga/Wilkes County boundary None +1639 Lewis Fork At the confluence with Yadkin River None +1075 Unincorporated Areas of Wilkes County. At the confluence of North Prong Lewis Fork and South Prong Lewis Fork None +1077 Little Bugaboo Creek At the confluence with Big Bugaboo Creek None +1035 Unincorporated Areas of Wilkes County. Approximately 620 feet upstream of Hoots Road (State Road 2014) None +1074 Little Elkin Creek The confluence with Yadkin River None +905 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Greenhorn Road (State Road 1931) None +1177 Little Fork Creek At the confluence with North Prong Lewis Fork None +1304 Unincorporated Areas of Wilkes County. Approximately 1.4 miles upstream of Benny Parsons Road (State Road 1359) None +1664 Little Hunting Creek At the confluence with Hunting Creek None +915 Unincorporated Areas of Wilkes County. Approximately 2.0 miles upstream of Mountain View Church Road (State Road 2503) None +1281 Little Sandy Creek At the confluence with East Prong Roaring River None +1084 Unincorporated Areas of Wilkes County. Approximately 0.5 mile upstream of Longbottom Road (State Road 1737) None +1280 Little Warrior Creek At the confluence with Warrior Creek None +1075 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Thankful Church Road (State Road 1125) None +1170 Long Branch North At the Wilkes/Yadkin County boundary None +1075 Unincorporated Areas of Wilkes County. Approximately 50 feet upstream of the Wilkes/Yadkin County boundary None +1075 Middle Fork Reddies River At the confluence with Reddies River None +1202 Unincorporated Areas of Wilkes County. Approximately 0.7 mile upstream of State Road 1580 None +1326 Middle Prong Roaring River At the confluence with Roaring River None +1009 Unincorporated Areas of Wilkes County. Approximately 2.1 miles upstream of Moxley Road (State Road 1735) None +1442 Mill Creek At the confluence with Cub Creek None +964 Unincorporated Areas of Wilkes County, Town of Wilkesboro. Approximately 1,000 feet downstream of Country Club Road (State Road 2462) None +1052 Mill Creek North At the confluence with North Fork Reddies River None +1258 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Mertie Road (State Road 1570) None +2115 Moravian Creek At the confluence with Yadkin River +969 +968 Unincorporated Areas of Wilkes County, Town of Wilkesboro. At the confluence of Moravian Creek Tributary 1 None +1233 Moravian Creek Tributary 1 At the confluence with Moravian Creek None +1233 Unincorporated Areas of Wilkes County. Approximately 0.5 mile upstream of Lowe Creek Road (State Road 2488) None +1311 Mulberry Creek At the confluence with Yadkin River +955 +952 Unincorporated Areas of Wilkes County, Town of North Wilkesboro. At the confluence of Joshua Creek None +1453 Mulberry Creek Tributary 1 At the confluence with Mulberry Creek None +1294 Unincorporated Areas of Wilkes County. Approximately 0.6 mile upstream of Sparta Road/NC Highway 18 None +1405 Naked Creek At the confluence with Lewis Fork None +1075 Unincorporated Areas of Wilkes County. Approximately 110 feet downstream of Dr. Miles Road (State Road 1152) None +1172 North Fork Reddies River At the confluence with Reddies River None +1167 Unincorporated Areas of Wilkes County. Approximately 200 feet downstream of Vannoy Road (State Road 1575) None +1460 North Little Hunting Creek At the Wilkes/Yadkin County boundary None +1024 Unincorporated Areas of Wilkes County. Approximately 1,410 feet upstream of Somers Road (State Road 2400) None +1119 North Little Hunting Creek Tributary 3 At the confluence with North Little Hunting Creek None +1039 Unincorporated Areas of Wilkes County. Approximately 610 feet upstream of the U.S. Highway 421 East ramp None +1069 North Little Hunting Creek Tributary 4 At the confluence with North Little Hunting Creek None +1069 Unincorporated Areas of Wilkes County. Approximately 410 feet upstream of Somers Road (State Road 2400) None +1098 North Prong Lewis Fork At the confluence with Lewis Fork None +1077 Unincorporated Areas of Wilkes County. Approximately 2.0 miles upstream of Big Ivy Road (State Road 1360) None +1698 Osborn Creek At the confluence with Hunting Creek None +895 Unincorporated Areas of Wilkes County. Approximately 1.1 miles upstream of Hunting Creek Road (State Road 2412) None +1044 Pumpkin Creek At the confluence with Warrior Creek None +1075 Unincorporated Areas of Wilkes County. Approximately 0.4 mile upstream of Pumpkin Creek Road (State Road 1303) None +1163 Pumpkin Run At the confluence with South Prong Lewis Fork None +1298 Unincorporated Areas of Wilkes County. Approximately 1.0 mile upstream of Pumpkin Run Road (State Road 1303) None +1400 Reddies River At the confluence with Yadkin River +963 +964 Unincorporated Areas of Wilkes County, Town of North Wilkesboro. At the confluence of Middle Fork Reddies River and South Fork Reddies River None +1202 Roaring River At the confluence with Yadkin River None +936 Unincorporated Areas of Wilkes County. At the confluence of East Prong Roaring River None +1009 Rocky Creek At the Wilkes/Alexander County boundary None +1192 Unincorporated Areas of Wilkes County. Approximately 1.0 mile upstream of the confluence of Rocky Creek Tributary 1 None +1287 Rocky Creek Tributary 1 At the confluence with Rocky Creek None +1255 Unincorporated Areas of Wilkes County. Approximately 1,500 feet upstream of the confluence with Rocky Creek None +1263 Shell Creek At the confluence with Stony Fork None +1164 Unincorporated Areas of Wilkes County. Approximately 870 feet upstream of Mt. Zion Road (State Road 1155) None +1197 South Fork Reddies River At the confluence with Reddies River None +1202 Unincorporated Areas of Wilkes County. Approximately 50 feet upstream of White Oak Road (State Road 1355) None +1388 South Prong Lewis Fork At the confluence with Lewis Fork None +1077 Unincorporated Areas of Wilkes County. Approximately 1.2 miles upstream of the confluence of Fletcher Creek None +1478 South Prong Lewis Fork Tributary 1 At the confluence with South Prong Lewis Fork None +1195 Unincorporated Areas of Wilkes County. Approximately 2.4 miles upstream of the confluence with South Prong Lewis Fork None +1536 Sparks Creek At the confluence with Little Sandy Creek None +1108 Unincorporated Areas of Wilkes County. Approxmately 800 feet downstream of Cook-Lyon Road None +1200 Stony Fork At the confluence with Yadkin River None +1078 Unincorporated Areas of Wilkes County. At the Watauga/Wilkes County boundary None +1975 Swan Creek At the confluence with Yadkin River None +911 Unincorporated Areas of Wilkes County. At the confluence of East Swan Creek and West Swan Creek None +911 Tributary M-1-1 Approximately 50 feet upstream of the confluence with Tributary M-1 None +1071 Unincorporated Areas of Wilkes County, Town of North Wilkesboro. Approximately 0.5 mile upstream of Elkin Highway/NC Highway 268 None +1160 Tributary R-1 Approximately 1,360 feet upstream of Finley Street None +1090 Town of North Wilkesboro. Approximately 0.4 mile upstream of Finley Street None +1126 Tributary R-1-1 Approximately 100 feet upstream of the confluence with Tributary R-1 None +1047 Town of North Wilkesboro. Approximately 0.4 mile upstream of the confluence with Tributary R-1 None +1153 Tributary Y-1 At the confluence with Yadkin River +959 +957 Town of North Wilkesboro. Approximately 0.6 mile upstream of the confluence of Tributary Y-1-1 None +1088 Tributary Y-1-1 At the confluence with Tributary Y-1 None +959 Town of North Wilkesboro. Approximately 0.4 mile upstream of the confluence with Tributary Y-1 None +1072 Tributary Y-2 At the confluence with Yadkin River +960 +962 Town of North Wilkesboro. Approximately 0.7 mile upstream of 2nd Street/U.S. Highway 421 None +1078 Tributary Y-3 At the confluence with Yadkin River +960 +963 Town of North Wilkesboro. Approximately 100 feet downstream of D Street +991 +996 Warrior Creek At the confluence with Yadkin River None +1075 Unincorporated Areas of Wilkes County. Approximately 830 feet upstream of NC Highway 18 None +1107 West Prong Moravian Creek At the confluence with Moravian Creek None +1068 Unincorporated Areas of Wilkes County. Approximately 1.3 miles upstream of Falls Road (State Road 1108) None +1184 West Prong Moravian Creek Tributary 1 At the confluence with West Prong Moravian Creek None +1075 Unincorporated Areas of Wilkes County. Approximately 510 feet downstream of Falls Road (State Road 1108) None +1100 West Prong Roaring River At the confluence with Middle Prong Roaring River None +1091 Unincorporated Areas of Wilkes County. Approximately 2.4 miles upstream of State Road 1731 None +1561 West Swan Creek At the confluence with Swan Creek None +911 Unincorporated Areas of Wilkes County. Approximately 0.8 mile upstream of Bethel Road None +944 Whites Creek At the confluence with Yadkin River None +1075 Unincorporated Areas of Wilkes County. Approximately 1.1 miles upstream of NC Highway 268 None +1094 Yadkin River Approximately 200 feet downstream of the Yadkin/Wilkes County boundary None +903 Unincorporated Areas of Wilkes County, Town of North Wilkesboro, Town of Ronda, Town of Wilkesboro. At the Caldwell/Wilkes County boundary None +1090 Yadkin River Tributary 14 At the confluence with Yadkin River None +903 Unincorporated Areas of Wilkes County. Approximately 0.9 mile upstream of State Road 2306 None +917 Yadkin River Tributary 15 At the confluence with Yadkin River None +919 Unincorporated Areas of Wilkes County. Approximately 1.7 miles upstream of the confluence with Yadkin River None +942 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES Town of North Wilkesboro Maps are available for inspection at North Wilkesboro Town Hall, 832 Main Street, North Wilkesboro, NC. Town of Ronda Maps are available for inspection at Ronda Town Hall, 123 Chatham Street, Ronda, NC. Town of Wilkesboro Maps are available for inspection at Wilkesboro Town Hall, 203 West Main Street, Wilkesboro, NC. Unincorporated Areas of Wilkes County Maps are available for inspection at Wilkes County Office Building, 110 North Street, Wilkesboro, NC. (Catalog of Federal Domestic Assistance No. 97.022, “Flood Insurance.”) Dated: February 12, 2008. David I. Maurstad, Federal Insurance Administrator of the National Flood Insurance Program, Department of Homeland Security, Federal Emergency Management Agency. [FR Doc. E8-3362 Filed 2-21-08; 8:45 am] BILLING CODE 9110-12-P DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency 44 CFR Part 67 [Docket No. FEMA-B-7762] Proposed Flood Elevation Determinations AGENCY: Federal Emergency Management Agency, DHS. ACTION: Proposed rule. SUMMARY: Comments are requested on the proposed Base (1 percent annual-chance) Flood Elevations
(BFEs)and proposed BFE modifications for the communities listed in the table below. The purpose of this notice is to seek general information and comment regarding the proposed regulatory flood elevations for the reach described by the downstream and upstream locations in the table below. The BFEs and modified BFEs are a part of the floodplain management measures that the community is required either to adopt or show evidence of having in effect in order to qualify or remain qualified for participation in the National Flood Insurance Program (NFIP). In addition, these elevations, once finalized, will be used by insurance agents, and others to calculate appropriate flood insurance premium rates for new buildings and the contents in those buildings. DATES: Comments are to be submitted on or before May 22, 2008. ADDRESSES: The corresponding preliminary Flood Insurance Rate Map
(FIRM)for the proposed BFEs for each community are available for inspection at the community's map repository. The respective addresses are listed in the table below. You may submit comments, identified by Docket No. FEMA-B-7762, to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472,
(202)646-3151, or (e-mail) *bill.blanton@dhs.gov.* FOR FURTHER INFORMATION CONTACT: William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472,
(202)646-3151 or (e-mail) *bill.blanton@dhs.gov.* SUPPLEMENTARY INFORMATION: The Federal Emergency Management Agency
(FEMA)proposes to make determinations of BFEs and modified BFEs for each community listed below, in accordance with section 110 of the Flood Disaster Protection Act of 1973, 42 U.S.C. 4104, and 44 CFR 67.4(a). These proposed BFEs and modified BFEs, together with the floodplain management criteria required by 44 CFR 60.3, are the minimum that are required. They should not be construed to mean that the community must change any existing ordinances that are more stringent in their floodplain management requirements. The community may at any time enact stricter requirements of its own, or pursuant to policies established by other Federal, State, or regional entities. These proposed elevations are used to meet the floodplain management requirements of the NFIP and are also used to calculate the appropriate flood insurance premium rates for new buildings built after these elevations are made final, and for the contents in these buildings. Comments on any aspect of the Flood Insurance Study and FIRM, other than the proposed BFEs, will be considered. A letter acknowledging receipt of any comments will not be sent. *Administrative Procedure Act Statement.* This matter is not a rulemaking governed by the Administrative Procedure Act (APA), 5 U.S.C. 553. FEMA publishes flood elevation determinations for notice and comment; however, they are governed by the Flood Disaster Protection Act of 1973, 42 U.S.C. 4105, and the National Flood Insurance Act of 1968, 42 U.S.C. 4001 *et seq.* , and do not fall under the APA. *National Environmental Policy Act.* This proposed rule is categorically excluded from the requirements of 44 CFR part 10, Environmental Consideration. An environmental impact assessment has not been prepared. *Regulatory Flexibility Act.* As flood elevation determinations are not within the scope of the Regulatory Flexibility Act, 5 U.S.C. 601-612, a regulatory flexibility analysis is not required. *Executive Order 12866, Regulatory Planning and Review.* This proposed rule is not a significant regulatory action under the criteria of section 3(f) of Executive Order 12866, as amended. *Executive Order 13132, Federalism.* This proposed rule involves no policies that have federalism implications under Executive Order 13132. *Executive Order 12988, Civil Justice Reform.* This proposed rule meets the applicable standards of Executive Order 12988. List of Subjects in 44 CFR Part 67 Administrative practice and procedure, Flood insurance, Reporting and recordkeeping requirements. Accordingly, 44 CFR part 67 is proposed to be amended as follows: PART 67—[AMENDED] 1. The authority citation for part 67 continues to read as follows: Authority: 42 U.S.C. 4001 *et seq.* ; Reorganization Plan No. 3 of 1978, 3 CFR, 1978 Comp., p. 329; E.O. 12127, 44 FR 19367, 3 CFR, 1979 Comp., p. 376. § 67.4 [Amended] 2. The tables published under the authority of § 67.4 are proposed to be amended as follows: State City/town/county Source of flooding Location ** * Elevation in feet
(NGVD)+ Elevation in feet
(NAVD)# Depth in feet above ground Existing Modified Unincorporated Areas of Siskiyou County, California California Unincorporated Areas of Siskiyou County Panther Creek (Shallow Flooding) Shallow flooding areas between Squaw Valley Creek and McCloud River Railroad None # 1 Shallow flooding areas between Squaw Valley Creek and McLoud River Railroad None # 3 California Unincorporated Areas of Siskiyou County Squaw Valley Creek At the downstream side of Cemetery Road None * 3090 Approximately 100 feet upstream of McCloud River Railroad None * 3400 California Unincorporated Areas of Siskiyou County Squaw Valley Creek (Shallow Flooding) Shallow flooding areas between Cemetery Road and McCloud River Railroad None # 1 Shallow flooding areas between Cemetery Road and McCloud River Railroad None # 3 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES Unincorporated Areas of Siskiyou County Maps are available for inspection at the Siskiyou County Planning Department, 305 Butte Street, Yreka, CA. Unincorporated Areas of Trinity County, California California Unincorporated Areas of Trinity County Carter Gulch At the confluence with Hayfork Creek * 2319 * 2304 Approximately 960 feet upstream of Highway 3 None * 2340 California Unincorporated Areas of Trinity County Ewing Gulch At the confluence with Hayfork Creek * 2321 * 2305 Approximately 780 feet upstream of State Highway 3 None * 2343 California Unincorporated Areas of Trinity County Hayfork Creek Approximately 260 feet downstream of the confluence of Salt Creek None * 2280 Approximately 300 feet upstream of Oak Avenue None * 2322 California Unincorporated Areas of Trinity County Kellogg Gulch At the confluence with Hayfork Creek * 2317 * 2302 Approximately 980 feet upstream of State Highway 3 None 2343 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472. ADDRESSES Unincorporated Areas of Trinity County Maps are available for inspection at the Trinity County Planning Department and Planning Commission, 60 Glen Road, Weaverville, CA. Flooding source(s) Location of referenced elevation** * Elevation in feet
(NGVD)+ Elevation in feet
(NAVD)# Depth in feet above ground Effective Modified Communities affected Tehama County, California, and Incorporated Areas Grasshopper Creek Approximately 1,500 feet upstream of the confluence with Red Bank Creek None *275 Unincorporated Areas of Tehama County, City of Red Bluff. Approximately 0.4 mile upstream of South Jackson Street None *312 Highway 99W Overflow Approximately 150 feet upstream of the confluence witih Red Bank Creek None *282 Unincorporated Areas of Tehama County. Approximately 0.5 mile upstream of the confluence with Red Bank Creek None *291 Spyglass Drive Overflow At the confluence with Grasshopper Creek None *300 City of Red Bluff. At the upstream side of South Jackson Street None *308 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472. ADDRESSES City of Red Bluff Maps are available for inspection at Red Bluff City Hall, 555 Washington Street, Red Bluff, CA. Unincorporated Areas of Tehama County Maps are available for inspection at Tehama County Planning Department, 444 Oak Street, Red Bluff, CA. Tippecanoe County, Indiana, and Incorporated Areas Cole Ditch At its confluence with Burnett Creek None +627 Unincorporated Areas of Tippecanoe County. Approximately 4,000 feet upstream of County Road 150 None +669 Cole Ditch Unnamed Tributary 1 At its confluence with Cole Ditch None +647 Unincorporated Areas of Tippecanoe County, City of West Lafayette. Approximately 1,250 feet upstream of Kalberger Road None +694 Cole Ditch Unnamed Tributary 2 At its confluence with Cole Ditch None +628 Unincorporated Areas of Tippecanoe County. Approximately 1,340 feet upstream of County Road 500 None +655 Cuppy Ditch At its confluence with Cole Ditch None +649 Unincorporated Areas of Tippecanoe County. Approximately 50 feet upstream of Morehouse Road None +655 East Branch Wea Creek At its confluence with Wea Creek None +684 Unincorporated Areas of Tippecanoe County. Approximately 50 feet upstream of County Road 500 None +756 Indian Creek Approximately 2,900 feet downstream of County Road 400 None +631 Unincorporated Areas of Tippecanoe County. Approximately 1,775 feet upstream of U.S. Highway 52 None +654 Tippecanoe River At its confluence with the Wabash River None +538 Unincorporated Areas of Tippecanoe County. At the County Boundary None +544 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472. ADDRESSES City of West Lafayette Maps are available for inspection at Area Plan Commission of Tippecanoe County, 20 North Third Street, Lafayette, IN 47901. Unincorporated Areas of Tippecanoe County Maps are available for inspection at Area Plan Commission of Tippecanoe County, 20 North Third Street, Lafayette, IN 47901. Camden County, New Jersey, and Incorporated Areas Mason Run At a point located approximately 1,700 feet upstream of the confluence with North Branch Big Timber Creek +19 +20 Borough of Lindenwold, Borough of Pine Hill, Township of Gloucester. At a point located approximately 100 feet upstream of Blackwood-Clementon Road/County Route 534 None +35 North Branch Big Timber Creek At a point approximately 400 feet upstream from the confluence of Mason Run +19 +18 Borough of Clementon, Borough of Laurel Springs, Borough of Lindenwold, Borough of Stratford. At a point located approximately 2,240 feet upstream of East Atlantic Avenue/State Route 727 None +43 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472. ADDRESSES Borough of Clementon Maps are available for inspection at Clementon Borough Hall, 101 Gibbsboro Road, Clementon, NJ. Borough of Laurel Springs Maps are available for inspection at Laurel Springs Borough Hall, 135 Broadway Avenue, Laurel Springs, NJ. Borough of Lindenwold Maps are available for inspection at Lindenwold Borough Construction Office, 2001 Egg Harbor Road, Lindenwold, NJ. Borough of Pine Hill Maps are available for inspection at Pine Hill Borough Hall, 45 West 7th Avenue, Pine Hill, NJ. Borough of Stratford Maps are available for inspection at Stratford Borough Hall, 307 Union Avenue, Stratford, NJ. Township of Gloucester Maps are available for inspection at Township of Gloucester Municipal Building, 1261 Chews Landing Road, Blackwood, NJ. Monmouth County, New Jersey, and Incorporated Areas Manalapan Brook At County boundary +75 +76 Township of Manalapan, Township of Millstone. Approximately 500 feet upstream of Moonlight Court None +181 * National Geodetic Vertical Datum. + North American Vertical Datum. # Depth in feet above ground. ** BFEs to be changed include the listed downstream and upstream BFEs, and include BFEs located on the stream reach between the referenced locations above. Please refer to the revised Flood Insurance Rate Map located at the community map repository (see below) for exact locations of all BFEs to be changed. Send comments to William R. Blanton, Jr., Chief, Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472. ADDRESSES Township of Manalapan Maps are available for inspection at Manalapan Township Municipal Building, 120 Route 522, Manalapan, NJ. Township of Millstone Maps are available for inspection at Millstone Township Municipal Building, 470 Stagecoach Road, Millstone, NJ. (Catalog of Federal Domestic Assistance No. 97.022, “Flood Insurance.”) Dated: February 8, 2008. David I. Maurstad, Federal Insurance Administrator of the National Flood Insurance Program, Department of Homeland Security, Federal Emergency Management Agency. [FR Doc. E8-3366 Filed 2-21-08; 8:45 am] BILLING CODE 9110-12-P xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxx DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency 44 CFR Part 67 [Docket No. FEMA-D-7808] Proposed Flood Elevation Determinations; Correction AGENCY: Federal Emergency Management Agency, DHS. ACTION: Proposed rule; correction. SUMMARY: This document corrects the table to a proposed rule published in the **Federal Register** of July 25, 2007. This correction clarifies the table representing the flooding source(s), location of referenced elevation, the effective and modified elevation in feet and the communities affected for Henderson County, North Carolina, and Incorporated Areas; specifically, for flooding source “Boylston Creek,” than was previously published. FOR FURTHER INFORMATION CONTACT: William R. Blanton, Jr., Engineering Management Branch, Mitigation Directorate, Federal Emergency Management Agency, 500 C Street SW., Washington, DC 20472,
(202)646-2903. SUPPLEMENTARY INFORMATION: The Federal Emergency Management Agency
(FEMA)publishes proposed determinations of Base (1-percent-annual-chance) Flood Elevations
(BFEs)and modified BFEs for communities participating in the National Flood Insurance Program (NFIP), in accordance with section 110 of the Flood Disaster Protection Act of 1973, 42 U.S.C. 4104, and 44 CFR 67.4(a). These proposed BFEs and modified BFEs, together with the floodplain management criteria required by 44 CFR 60.3, are the minimum that are required. They should not be construed to mean that the community must change any existing ordinances that are more stringent in their floodplain management requirements. The community may at any time enact stricter requirements of its own, or pursuant to policies established by other Federal, State, or regional entities. These proposed BFEs are used to meet the floodplain management requirements of the NFIP and are also used to calculate the appropriate flood insurance premium rates for new buildings built after these elevations are made final, and for the contents in these buildings. Correction In proposed rule FR Doc. 07-3615, beginning on page 40791 in the issue of July 25, 2007, make the following corrections, in the table published under the authority of 44 CFR 67.4. On page 40791, in § 67.4, in the table with center heading Henderson County, North Carolina, and Incorporated Areas, the flooding source, location of referenced elevation, the effective and modified elevation in feet and the communities affected for flooding source “Boylston Creek”, needs to be corrected to read as follows: Flooding source(s) Location of referenced elevation ** * Elevation in feet
(NGVD)+ Elevation in feet
(NAVD)# Depth in feet above ground Effective Modified Communities affected * * * * * * * Henderson County, North Carolina, and Incorporated Areas * * * * * * * Boylston Creek Approximately 50 feet downstream of Banner Farm Road +2,173 +2,072 Town of Mills River. Approximately 230 feet upstream of Turkey Pen Gap Road None +2,190 * * * * * * * Dated: February 12, 2008. David I. Maurstad, Federal Insurance Administrator of the National Flood Insurance Program, Department of Homeland Security, Federal Emergency Management Agency. [FR Doc. E8-3368 Filed 2-21-08; 8:45 am] BILLING CODE 9110-12-P DEPARTMENT OF THE INTERIOR Fish and Wildlife Service 50 CFR Part 17 [FWS-R2-ES-2008-0031; 92220-1113-0000-C3] RIN 1018-AU68 Endangered and Threatened Wildlife and Plants; Establishment of a Nonessential Experimental Population of Rio Grande Silvery Minnow in the Big Bend Reach of the Rio Grande in Texas AGENCY: Fish and Wildlife Service, Interior. ACTION: Proposed rule; notice of availability of draft environmental assessment; reopening of public comment period. SUMMARY: We, the U.S. Fish and Wildlife Service (Service), announce the reopening of the public comment period on the proposed rule and draft environmental assessment regarding our proposal to establish a nonessential experimental population of Rio Grande silvery minnow ( *Hybognathus amarus* ), a Federally listed endangered fish, into its historic habitat in the Big Bend reach of the Rio Grande in Presidio, Brewster, and Terrell counties, Texas. Comments previously submitted on the proposed rule or draft EA need not be resubmitted as they have been incorporated into the public record and will be fully considered in preparation of the final rule and final environmental assessment. DATES: We will accept public comments received or postmarked on or before March 10, 2008. ADDRESSES: You may submit comments by one of the following methods: • *Federal eRulemaking Portal: http://www.regulations.gov* . Follow the instructions for submitting comments. • *U.S. mail or hand-delivery:* Public Comments Processing, Attn: RIN 1018-AU68; Division of Policy and Directives Management; U.S. Fish and Wildlife Service; 4401 N. Fairfax Drive, Suite 222; Arlington, VA 22203. We will not accept e-mail or faxes. We will post all comments on *http://www.regulations.gov* . This generally means that we will post any personal information you provide us (see the Public Comments Solicited section below for more information). FOR FURTHER INFORMATION CONTACT: Adam Zerrenner, Field Supervisor, Austin Ecological Services Field Office, 10711 Burnet Road, Suite 200, Austin, TX 78758; telephone 512/490-0057; facsimile 512/490-0974. If you use a telecommunications device for the deaf (TDD), call the Federal Information Relay Service
(FIRS)at 800-877-8339. SUPPLEMENTARY INFORMATION: Background and Additional Information We propose to reestablish the Rio Grande silvery minnow under section 10(j) of the Endangered Species Act of 1973, as amended (Act), and to classify it as a nonessential experimental population
(NEP)(72 FR 50918). On the Rio Grande, the geographic boundaries of the NEP would extend from Little Box Canyon downstream of Fort Quitman, Hudspeth County, Texas, through Big Bend National Park and the Rio Grande Wild and Scenic River, to Amistad Dam and the nearby railroad bridge (Big Bend reach of the Rio Grande). On the Pecos River, the geographic boundaries of the NEP would extend from the river's confluence with Independence Creek to its confluence with the Rio Grande. This proposed reestablishment is part of the recovery actions that the Service, Federal and State agencies, and other partners are conducting throughout the species' historic range. The proposed rule provides a plan for establishing the NEP and provides for limited allowable legal taking of Rio Grande silvery minnows within the defined NEP area. A draft environmental assessment
(EA)has been prepared on this proposed action and is available for comment (see ADDRESSES section below). For background and other information on the proposed rule and draft EA, refer to our notice published in the **Federal Register** on September 5, 2007 (72 FR 50918). Public Comments Solicited On September 5, 2007, we published a proposed rule, notice of availability of a draft environmental assessment, and notice of a public hearing regarding our proposal to establish a nonessential experimental population of the Rio Grande silvery minnow in the Big Bend reach of the Rio Grande in Texas (72 FR 50918). We accepted public comments regarding the proposed rule and draft environmental assessment for 60 days, ending November 5, 2007. During the comment period, we held a public hearing on October 10, 2007, in Alpine, Texas. In response to requests from interested parties, we are reopening the comment period for an additional 15 days (see DATES ) to offer all interested parties an opportunity to submit data and information to be considered in developing a final rule and final EA. We want the final rule to be as effective as possible and the final EA on the proposed action to evaluate all potential issues associated with this action. Therefore, we invite the public, Tribal and government agencies, the scientific community, industry, and other interested parties to submit comments or recommendations not previously submitted concerning any aspect of the proposed rule and the draft EA. Comments should be as specific as possible. To issue a final rule to implement this proposed action and to determine whether to prepare a finding of no significant impact or an environmental impact statement, we will take into consideration all comments and any additional information we receive. Such communications may lead to a final rule that differs from this proposal. You may submit your comments and materials concerning the proposed rule and draft EA by one of the methods listed in the ADDRESSES section. We will not accept comments sent by e-mail or fax or to an address not listed in the ADDRESSES section. We will not accept anonymous comments; your comments must include your first and last name, city, State, country, and postal
(zip)code. Finally, we will not consider hand-delivered comments that we do not receive, or mailed comments that are not postmarked by the date specified in the DATES section. Comments must be submitted to *http://www.regulations.gov* before midnight (Eastern Standard Time) on the date specified in the DATES section. We will post your entire comment—including your personal identifying information—on *http://www.regulations.gov* . If you provide personal identifying information in addition to the required items specified on the previous paragraph, such as your street address, phone number, or e-mail address, you may request at the top of your document we withhold this information from public review. However, we cannot guarantee that we will be able to do so. Comments and materials we receive, as well as supporting documentation we used in preparing this proposed rule, will be available for public inspection on *http://www.regulations.gov* , or by appointment, during normal business hours, at the U.S. Fish and Wildlife Service, Austin Ecological Services Field Office, 10711 Burnet Road, Suite 200, Austin, TX 78758; telephone 512/490-0057. You may obtain copies of the original proposed rule and the draft EA from the Austin Ecological Services Field Office at the address listed above or by visiting our Web site at *http://www.fws.gov/southwest/es/AustinTexas/* . Author The primary author of this notice is the staff of the U.S. Fish and Wildlife Service's Austin Ecological Services Field Office. Authority The authority for this action is the Endangered Species Act of 1973, as amended (16 U.S.C. 1531, *et seq.* ). Dated: February 14, 2008. Kenneth Stansell, Acting Director,U.S. Fish and Wildlife Service. [FR Doc. E8-3385 Filed 2-21-08; 8:45 am] BILLING CODE 4310-55-P 73 36 Friday, February 22, 2008 Notices ADVISORY COUNCIL ON HISTORIC PRESERVATION Notice of Meeting AGENCY: Advisory Council on Historic Preservation. ACTION: Notice of meeting. SUMMARY: Notice is hereby given that the Advisory Council on Historic Preservation
(ACHP)will meet on Friday, February 29, 2008. The meeting will be held in the Cash Room of the Department of the Treasury, 1500 Pennsylvania Ave., NW., Washington, DC at 9:45 a.m. The ACHP was established by the National Historic Preservation Act of 1966 (16 U.S.C. 470 *et seq.* ) to advise the President and Congress on national historic preservation policy and to comment upon Federal, federally assisted, and federally licensed undertakings having an effect upon properties listed in or eligible for inclusion in the National Register of Historic Places. The ACHP's members are the Architect of the Capitol; the Secretaries of the Interior, Agriculture, Defense, Housing and Urban Development, Commerce, Education, Veterans Affairs, and Transportation; the Administrator of the General Services Administration; the Chairman of the National Trust for Historic Preservation; the President of the National Conference of State Historic Preservation Officers; a Governor; a Mayor; a Native American; and eight non-Federal members appointed by the President. The agenda for the meeting includes the following: Call to Order—9:45 a.m. I. Chairman's Welcome II. Preservation Awards Presentation III. Native American Activities A. Native American Advisory Group B. Native American Program Report IV. National Academy of Public Administration's Review of the National Historic Preservation Program A. Response of the National Park Service B. Recommendations for ACHP Action V. Preservation Initiatives Committee A. Legislative Update B. Planning for the Future of Preserve America C. Heritage Tourism Activities VI. Federal Agency Programs Committee A. Alternate Procedures of Corps of Engineers' Appendix C B. Section 106 Users Survey C. Standard Treatments Update D. Executive Order 13287 Section 3 Reporting VII. Communications, Education, and Outreach Committee A. 2008 Preserve America Presidential Award Nominations B. Charting a Course for the Future of CEO VIII. Implementation of ACHP Recommendations from the Preserve America Summit A. Agency Progress B. Recommendations Implemented by the ACHP C. Preserve America/Save America's Treasures Authorizing Legislation IX. Chairman's Report A. ACHP Alumni Foundation B. ACHP FY 2009 Budget Request X. Executive Director's Report XI. New Business Adjourn Note: The meetings of the ACHP are open to the public. The Treasury building is part of the White House complex, so a government-issued photo ID will be required for admission into the building. If you plan to attend, you must call Kiani Morris, 202-606-8512 or e-mail at *kmorris@achp.gov* with the following information: Name, Birth Date, and Social Security Number. Entry to the building is at the Lafayette Park entrance. If you need special accommodations due to a disability, please contact the Advisory Council on Historic Preservation, 1100 Pennsylvania Avenue, NW., Room 803, Washington, DC, 202-606-8503, at least seven
(7)days prior to the meeting. For further information: Additional information concerning the meeting is available from the Executive Director, Advisory Council on Historic Preservation, 1100 Pennsylvania Avenue, NW., #803, Washington, DC 20004. Dated: February 15, 2008. John Fowler, Executive Director. [FR Doc. 08-789 Filed 2-21-08; 8:45 am]
Connectionstraces to 22
Traces to 22 documents
30 references not yet in our index
  • 22 CFR 309
  • 22 CFR 303
  • 31 USC 3701-3719
  • 31 USC 3720A
  • 31 CFR 285
  • 5 CFR 550
  • 49 CFR 32
  • 5 CFR 550.1103
  • 31 CFR 902
  • 31 CFR 903.1-903
  • 26 USC 6050P
  • 26 CFR 1.6050
  • 42 CFR 440
  • Pub. L. 109-171
  • 42 CFR 431.53
  • Pub. L. 104-193
  • 42 CFR 438.50(d)(1)
  • Pub. L. 96-354
  • Pub. L. 104-4
  • Pub. L. 109-432
  • 42 CFR 447.76
  • 42 CFR 447
  • 42 CFR 457
  • 44 CFR 67
  • 44 CFR 67.4(a)
  • 44 CFR 60.3
  • 44 CFR 10
  • 5 USC 601-612
  • 44 CFR 67.4
  • 50 CFR 17
Citation graph
cites case law
Notices
Proposed rule
Fed. Reg.Notices
U.S.C.§ 605
U.S.C.§ 5514
U.S.C.§ 2503
U.S.C.§ 2501
C.F.R.§ 901.9
C.F.R.§ 901.3
U.S.C.§ 3716
U.S.C.§ 286
Cite22 CFR 309
Cite22 CFR 303
Cite31 USC 3701-3719
Cites 52 · showing 12Cited by 0 across 0 sources
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