Medicaid Program; Final FY 2013 and Preliminary FY 2015 Disproportionate Share Hospital Allotments, and Final FY 2013 and Preliminary FY 2015 Institutions for Mental Diseases Disproportionate Share Hospital Limits, 5448-5463 [2016-01836]

Agencies

[Federal Register Volume 81, Number 21 (Tuesday, February 2, 2016)]
[Notices]
[Pages 5448-5463]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-01836]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2398-N]
RIN 0983-ZB24


Medicaid Program; Final FY 2013 and Preliminary FY 2015 
Disproportionate Share Hospital Allotments, and Final FY 2013 and 
Preliminary FY 2015 Institutions for Mental Diseases Disproportionate 
Share Hospital Limits

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

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice announces the final federal share disproportionate 
share hospital (DSH) allotments for federal fiscal year (FY) 2013 and 
the preliminary federal share DSH allotments for FY 2015. This notice 
also announces the final FY 2013 and the preliminary FY 2015 
limitations on aggregate DSH payments that states may make to 
institutions for mental disease and other mental health facilities. In 
addition, this notice includes background information describing the 
methodology for determining the amounts of states' FY DSH allotments.

DATES: This notice is effective March 3, 2016. The final allotments and 
limitations set forth in this notice are effective for the fiscal years 
specified.

FOR FURTHER INFORMATION CONTACT: Stuart Goldstein, (410) 786-0694 and 
Richard Cuno, (410) 786-1111.

SUPPLEMENTARY INFORMATION:

I. Background

A. Fiscal Year DSH Allotments

    A state's federal fiscal year (FY) disproportionate share hospital 
(DSH) allotment represents the aggregate limit on the federal share 
amount of the state's payments to DSH hospitals in the state for the 
FY. The amount of such allotment is determined in accordance with the 
provisions of section 1923(f)(3) of the Social Security Act (the Act). 
Under such provisions, in general a state's FY DSH allotment is 
calculated by increasing the amount of its DSH allotment for the 
preceding FY by the percentage change in the Consumer Price Index for 
all Urban Consumers (CPI-U) for the previous FY.
    The Affordable Care Act amended Medicaid DSH provisions, adding 
section 1923(f)(7) of the Act which would have required reductions to 
states' FY DSH allotments beginning with FY 2014, the calculation of 
which was described in the Disproportionate Share Hospital Payment 
Reduction final rule published in the September 18, 2013 Federal 
Register (78 FR 57293). Under the DSH reduction methodology, first, 
each state's unreduced FY DSH allotment would have been calculated in 
accordance with the provisions of section 1923(f) of the Act, excluding 
section 1923(f)(7) of the Act; then, the reduction amount for each 
state would have been determined under the provisions of section 
1923(f)(7) of the Act and implementing regulations at 42 CFR 447.294; 
and, finally, the net FY DSH allotment for each state would have been 
determined by subtracting the DSH reduction amount for the state from 
its unreduced FY 2014 DSH allotment.
    The reductions under section 1923(f)(7) of the Act were most 
recently delayed and modified by the Medicare Access and CHIP 
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10), enacted on April 
16, 2015. The reductions of states' fiscal year DSH allotments under 
section 1923(f)(7) of the Act that were applicable to FY 2017 were 
repealed, and are instead scheduled to begin in FY 2018 at modified 
levels. MACRA also extended DSH allotment reductions through 2025.
    Because there is no reduction to DSH allotments for FY 2015 under 
section 1923(f)(7) of the Act, this notice contains only the state-
specific preliminary FY 2015 DSH allotments, as calculated under the 
statute without application of the reductions that would have otherwise 
been imposed. This notice also provides information on the calculation 
of such FY DSH allotments, the calculation of the states' IMD DSH 
limits, and the amounts of states' preliminary FY 2015 IMD DSH limits.

B. Determination of Fiscal Year DSH Allotments

    Generally, in accordance with the methodology specified under 
section 1923(f)(3) of the Act, a state's FY DSH allotment is calculated 
by increasing the amount of its DSH allotment for the preceding FY by 
the percentage change in the CPI-U for the previous FY. Also in 
accordance with section 1923(f)(3) of the Act, a state's DSH allotment 
for a FY is subject to the limitation that an increase to a state's DSH 
allotment for a FY cannot result in the DSH allotment exceeding the 
greater of the state's DSH allotment for the previous FY or 12 percent 
of the state's total medical assistance expenditures for the allotment 
year (this is referred to as the 12 percent limit).
    Furthermore, under section 1923(h) of the Act, federal financial 
participation

[[Page 5449]]

(FFP) for DSH payments to institutions for mental diseases (IMDs) and 
other mental health facilities is limited to state-specific aggregate 
amounts. Under this provision, the aggregate limit for DSH payments to 
IMDs and other mental health facilities is the lesser of a state's FY 
1995 total computable (state and federal share) IMD and other mental 
health facility DSH expenditures applicable to the state's FY 1995 DSH 
allotment (as reported on the Form CMS-64 as of January 1, 1997), or 
the amount equal to the product of the state's current year total 
computable DSH allotment and the applicable percentage specified in 
section 1902(h) of the Act (the applicable percentage is the IMD share 
of DSH total computable expenditures as of FY 1995).
    In general, we determine states' DSH allotments for a FY and the 
IMD DSH limits for the same FY using the most recent available 
estimates of or actual medical assistance expenditures, including DSH 
expenditures in their Medicaid programs and the most recent available 
change in the CPI-U used for the FY in accordance with the methodology 
prescribed in the statute. The indicated estimated or actual 
expenditures are obtained from states for each relevant FY from the 
most recent available quarterly Medicaid budget reports (Form CMS-37) 
or quarterly Medicaid expenditure reports (Form CMS-64), respectively, 
submitted by the states. For example, as part of the initial 
determination of a state's FY DSH allotment (referred to as the 
preliminary DSH allotments) that is determined before the beginning of 
the FY for which the DSH allotments and IMD DSH limits are being 
determined, we use estimated expenditures for the FY obtained from the 
August submission of the CMS-37 submitted by states prior to the 
beginning of the FY; such estimated expenditures are subject to update 
and revision during the FY before such actual expenditure data become 
available. We also use the most recent available estimated CPI-U 
percentage change that is available before the beginning of the FY for 
determining the states' preliminary FY DSH allotments; such estimated 
CPI-U percentage change is subject to update and revision during the FY 
before the actual CPI-U percentage change becomes available. In 
determining the final DSH allotments and IMD DSH limits for a FY we use 
the actual expenditures for the FY and actual CPI-U percentage change 
for the previous FY.

II. Provisions of the Notice

A. Calculation of the Final FY 2013 Federal Share State DSH Allotments 
and the Preliminary FY 2015 Federal Share State DSH Allotments

1. Final FY 2013 Federal Share State DSH Allotments
    Addendum 1 to this notice provides the states' final FY 2013 DSH 
allotments determined in accordance with section 1923(f)(3) of the Act. 
As described in the background section of this notice, in general, the 
DSH allotment for a FY is calculated by increasing the FY DSH allotment 
for the preceding FY by the CPI-U increase for the previous fiscal 
year. For purposes of calculating the states' final FY 2013 DSH 
allotments, the preceding final fiscal year DSH allotments (for FY 
2012) were published in the July 26, 2013 Federal Register (78 FR 
45217). For purposes of calculating the states' final FY 2013 DSH 
allotments we are using the actual Medicaid expenditures for FY 2013. 
Finally, for purposes of calculating the states' final FY 2013 DSH 
allotments, the applicable historical percentage change in the CPI-U 
for the previous FY (FY 2012) was 2.4 percent; we note that this is the 
same as the estimated 2.4 percentage change in the CPI-U for FY 2012 
that was available and used in the calculation of the preliminary FY 
2013 DSH allotments which were published in the July 26, 2013 Federal 
Register (78 FR 45217).
2. Calculation of the Preliminary FY 2015 Federal Share State DSH 
Allotments
    Addendum 2 to this notice provides the preliminary FY 2015 DSH 
allotments determined in accordance with section 1923(f)(3) of the Act. 
The preliminary FY 2015 DSH allotments contained in this notice were 
determined based on the most recent available estimates from states of 
their FY 2015 total computable Medicaid expenditures. Also, the 
preliminary FY 2015 allotments contained in this notice were determined 
by increasing the preliminary FY 2014 DSH allotments as contained in 
the notice published in the February 28, 2014 Federal Register (79 FR 
11436) by 1.6 percent, representing the most recent available estimate 
of the percentage increase in the CPI-U for FY 2014 (the previous FY to 
FY 2015).
    We will publish states' final FY 2015 DSH allotments in future 
notices based on the states' four quarterly Medicaid expenditure 
reports (Form CMS-64) for FY 2015 available following the end of FY 
2015 and the actual change in the CPI-U for FY 2014.

B. Calculation of the Final FY 2013 and Preliminary FY 2015 IMD DSH 
Limits

    Section 1923(h) of the Act specifies the methodology to be used to 
establish the limits on the amount of DSH payments that a state can 
make to IMDs and other mental health facilities. FFP is not available 
for IMD or DSH payments that exceed the IMD limits. In this notice, we 
are publishing the final FY 2013 and the preliminary FY 2015 IMD DSH 
Limits determined in accordance with the provisions discussed above.
    Addendums 3 and 4 to this notice detail each state's final FY 2013 
and preliminary FY 2015 IMD DSH Limit, respectively, determined in 
accordance with section 1923(h) of the Act.

III. Collection of Information Requirements

    This notice does not impose any new or revised information 
collection or recordkeeping requirements. The requirements and burden 
associated with form CMS-37 (OMB control number 0938-1265) and form 
CMS-64 (OMB control number 0938-1265) are unaffected by this notice. As 
it pertains to the content of this notice, CMS-37 and CMS-64 are not 
subject to formal Office of Management and Budget review under the 
authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et 
seq.).

IV. Regulatory Impact Statement

    We have examined the impact of this notice as required by Executive 
Order 12866 on Regulatory Planning and Review (September 1993), the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), 
section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform 
Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 13132 on 
Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 
804(2)).
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). This notice 
reaches the $100 million economic threshold and thus is considered a 
major rule under the Congressional Review Act.
    The final FY 2013 DSH allotments being published in this notice are 
equal

[[Page 5450]]

to the preliminary FY 2013 DSH allotments published in the July 26, 
2013 Federal Register (78 FR 45217). This is due to the actual 
percentage change in the CPI-U for FY 2012 used in the calculation of 
the final FY 2013 allotments (2.4 percent) being equal to the estimated 
percentage change in the CPI-U for FY 2012 used in the calculation of 
the preliminary FY 2013 allotments (2.4 percent). The final FY 2013 IMD 
DSH limits being published in this notice are also equal to the 
preliminary FY 2013 IMD DSH limits published in the July 26, 2013 
Federal Register (78 FR 45217). Since the final FY 2013 DSH allotments 
were equal to the preliminary FY 2013 DSH allotments, the associated FY 
2013 IMD DSH limits also remained the same.
    The preliminary FY 2015 DSH allotments being published in this 
notice are about $240 million more than the preliminary FY 2014 DSH 
allotments published in the February 28, 2014 Federal Register (79 FR 
11436). The increase in the DSH allotments is due to the application of 
the statutory formula for calculating DSH allotments under which the 
prior fiscal year allotments are increased by the percentage increase 
in the CPI-U for the prior fiscal year. The preliminary FY 2015 IMD DSH 
limits being published in this notice are about $14 million more than 
the preliminary FY 2014 IMD DSH limits published in the February 28, 
2014 Federal Register (79 FR 11436). The increase in the IMD DSH limits 
is because the DSH allotment for a FY is a factor in the determination 
of the IMD DSH limit for the FY. Since the preliminary FY 2015 DSH 
allotments are greater than the preliminary FY 2014 DSH allotments, the 
associated preliminary FY 2015 IMD DSH limits for some states also 
increased.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses, if a rule has a significant impact on a 
substantial number of small entities. For purposes of the RFA, small 
entities include small businesses, nonprofit organizations, and small 
governmental jurisdictions. Most hospitals and most other providers and 
suppliers are small entities, either by nonprofit status or by having 
revenues of less than $7.5 million to $38.5 million in any 1 year. 
Individuals and states are not included in the definition of a small 
entity. We are not preparing an analysis for the RFA because the 
Secretary has determined that this notice will not have significant 
economic impact on a substantial number of small entities. 
Specifically, any impact on providers is due to the effect of the 
various controlling statutes; providers are not impacted as a result of 
the independent regulatory action in publishing this notice. The 
purpose of the notice is to announce the latest distributions as 
required by the statute.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a Core-Based 
Statistical Area for Medicaid payment regulations and has fewer than 
100 beds. We are not preparing analysis for section 1102(b) of the Act 
because the Secretary has determined that this notice will not have a 
significant impact on the operations of a substantial number of small 
rural hospitals.
    The Medicaid statute specifies the methodology for determining the 
amounts of states' DSH allotments and IMD DSH limits; and as described 
previously, the application of the methodology specified in statute 
results in the decreases or increases in states' DSH allotments and IMD 
DSH limits for the applicable FYs. The statute applicable to these 
allotments and limits does not apply to the determination of the 
amounts of DSH payments made to specific DSH hospitals; rather, these 
allotments and limits represent an overall limit on the total of such 
DSH payments. In this regard, we do not believe that this notice will 
have a significant economic impact on a substantial number of small 
entities.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2015, that 
is approximately $144 million. This notice will have no consequential 
effect on state, local, or tribal governments, in the aggregate, or on 
the private sector.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it issues a proposed rule (and subsequent final 
rule) that imposes substantial direct requirement costs on state and 
local governments, preempts state law, or otherwise has Federalism 
implications. Since this notice does not impose any costs on state or 
local governments, the requirements of E.O. 13132 are not applicable.

A. Alternatives Considered

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

B. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in the Table 1, we have 
prepared an accounting statement showing the classification of the 
estimated expenditures associated with the provisions of this notice. 
Table 1 provides our best estimate of the change (decrease) in the 
federal share of states' Medicaid DSH payments resulting from the 
application of the provisions of the Medicaid statute relating to the 
calculation of states' FY DSH allotments and the increase in the FY DSH 
allotments from FY 2014 to FY 2015.

Table 1--Accounting Statement: Classification of Estimated Expenditures,
                       From the FY 2014 to FY 2015
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $240.
From Whom To Whom?                          Federal Government to
                                             States.
------------------------------------------------------------------------

Congressional Review Act
    This proposed regulation is subject to the Congressional Review Act 
provisions of the Small Business Regulatory Enforcement Fairness Act of 
1996 (5 U.S.C. 801 et seq.) and has been transmitted to the Congress 
and the Comptroller General for review.
    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

    Dated: December 3, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: January 20, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.

[[Page 5451]]



           Key to Addendum 1--Final DSH Allotments for FY 2013
    [The Final FY 2013 DSH Allotments for the NON-Low DSH States are
presented in the top section of this addendum, and the Final FY 2013 DSH
Allotments for the Low-DSH States are presented in the bottom section of
                             this addendum]
------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  FY 2013 FMAPs.
                           This column contains the States' FY 2013
                            Federal Medical Assistance Percentages.
Column C.................  Prior FY (2012) DSH Allotments
                           This column contains the States' prior FY
                            2012 DSH Allotments.
Column D.................  Prior FY (2012) DSH Allotments (Col C) x (100
                            percent + Percentage Increase in CPIU):
                            102.4 percent.
                           This column contains the amount in Column C
                            increased by 1 plus the percentage increase
                            in the CPI-U for the prior FY (102.4
                            percent).
Column E.................  FY 2013 TC MAP Exp. Including DSH.
                           This column contains the amount of the
                            States' FY 2013 total computable (TC)
                            medical assistance expenditures including
                            DSH expenditures.
Column F.................  FY 2013 TC DSH Expenditures.
                           This column contains the amount of the
                            States' FY 2013 total computable DSH
                            expenditures.
Column G.................  FY 2013 TC MAP Exp. Net of DSH.
                           This column contains the amount of the
                            States' FY 2013 total computable medical
                            assistance expenditures net of DSH
                            expenditures, calculated as the amount in
                            Column E minus the amount in Column F.
Column H.................  12 percent Amount.
                           This column contains the amount of the ``12
                            percent limit'' in Federal share, determined
                            in accordance with the provisions of section
                            1923(f)(3) of the Act.
Column I.................  Greater of FY 2012 Allotment or 12 percent
                            Limit.
                           This column contains the greater of the
                            State's prior FY (FY 2012) DSH allotment or
                            the amount of the 12 percent Limit,
                            determined as the maximum of the amount in
                            Column C or Column H
Column J.................  FY 2013 DSH Allotment.
                           This column contains the States' final FY
                            2013 DSH allotments, determined as the
                            minimum of the amount in Column I or Column
                            D.
                           For states with ``na'' in Columns I or D,
                            refer to the footnotes in the addendum.
------------------------------------------------------------------------


[[Page 5452]]


                                                                                              Addendum 1--Final DSH Allotments for FY 2013
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                                                                                                      Prior FY (2012)
                                                                                                       DSH allotment      FY 2013 TC MAP                        FY 2013 TC MAP    ``12% Amount'' =   Greater of Col H     FY 2013 DSH
                            State                                FY 2013 FMAPs     Prior FY (2012)    (Col C) x 100% +    Exp. including     FY 2013 TC DSH    EXP. net of DSH    Col G x .12/(1-     or Col C (12%      allotment  MIN
                                                                   (percent)        DSH allotments    Pct increase in          DSH            expenditures         Col E-F        .12/Col B)*  (in    limit, FY 2012      Col I, Col D
                                                                                                        CPIU: 102.4%                                                                    FS)             Allotment)
A                                                                              B                  C                  D                  E                  F                  G                  H                  I                  J
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ALABAMA......................................................              68.53       $315,520,769       $323,093,267     $4,999,646,843       $470,923,104     $4,528,723,739       $658,807,935       $658,807,935       $323,093,267
ARIZONA......................................................              65.68        103,890,985        106,384,369      8,437,380,837        173,082,813      8,264,298,024      1,213,410,792      1,213,410,792        106,384,369
CALIFORNIA...................................................              50.00      1,124,844,365      1,151,840,630     61,425,894,719      2,119,710,409     59,306,184,310      9,364,134,365      9,364,134,365      1,151,840,630
COLORADO.....................................................              50.00         94,912,751         97,190,657      5,048,193,724        194,191,858      4,854,001,866        766,421,347        766,421,347         97,190,657
CONNECTICUT..................................................              50.00        205,216,760        210,141,962      6,415,388,481        272,860,246      6,142,528,235        969,872,879        969,872,879        210,141,962
DISTRICT OF COLUMBIA.........................................              70.00         62,847,632         64,355,975      2,275,681,171         56,387,767      2,219,293,404        321,414,907        321,414,907         64,355,975
FLORIDA......................................................              58.08        205,216,760        210,141,962     18,411,438,180        335,009,637     18,076,428,543      2,734,059,817      2,734,059,817        210,141,962
GEORGIA......................................................              65.56        275,760,021        282,378,262      8,887,641,041        429,964,548      8,457,676,493      1,242,312,033      1,242,312,033        282,378,262
ILLINOIS.....................................................              50.00        220,608,017        225,902,609     15,493,580,784        447,072,185     15,046,508,599      2,375,764,516      2,375,764,516        225,902,609
INDIANA......................................................              67.16        219,325,413        224,589,223      7,930,553,510        337,536,579      7,593,016,931      1,109,384,374      1,109,384,374        224,589,223
KANSAS.......................................................              56.51         42,325,957         43,341,780      2,544,769,057         76,622,785      2,468,146,272        376,027,713        376,027,713         43,341,780
KENTUCKY.....................................................              70.55        148,782,151        152,352,923      5,726,056,802        216,263,666      5,509,793,136        796,685,033        796,685,033        152,352,923
LOUISIANA/1..................................................                 na                 na                 na                 na                 na                 na                 na                 na        731,960,000
MAINE........................................................              62.57        107,738,799        110,324,530      2,826,874,563         37,489,437      2,789,385,126        414,155,018        414,155,018        110,324,530
MARYLAND.....................................................              50.00         78,238,890         80,116,623      7,688,146,740        134,340,816      7,553,805,924      1,192,706,199      1,192,706,199         80,116,623
MASSACHUSETTS................................................              50.00        312,955,559        320,466,492     12,999,170,453                  0     12,999,170,453      2,052,500,598      2,052,500,598        320,466,492
MICHIGAN.....................................................              66.39        271,912,207        278,438,100     12,308,409,960        387,951,247     11,920,458,713      1,746,054,614      1,746,054,614        278,438,100
MISSISSIPPI..................................................              73.43        156,477,779        160,233,246      4,708,563,005        217,999,554      4,490,563,451        644,132,328        644,132,328        160,233,246
MISSOURI.....................................................              61.37        486,107,200        497,773,773      8,863,322,084        703,393,659      8,159,928,425      1,217,196,210      1,217,196,210        497,773,773
NEVADA.......................................................              59.74         47,456,375         48,595,328      1,797,228,664         81,373,600      1,715,855,064        257,658,605        257,658,605         48,595,328
NEW HAMPSHIRE................................................              50.00        164,274,500        168,217,088      1,188,634,372         40,923,914      1,147,710,458        181,217,441        181,217,441        168,217,088
NEW JERSEY...................................................              50.00        660,541,446        676,394,441     10,480,866,440      1,298,115,161      9,182,751,279      1,449,908,097      1,449,908,097        676,394,441
NEW YORK.....................................................              50.00      1,648,147,103      1,687,702,633     52,489,778,879      3,423,365,423     49,066,413,456      7,747,328,440      7,747,328,440      1,687,702,633
NORTH CAROLINA...............................................              65.51        302,694,721        309,959,394     11,721,921,735        617,376,633     11,104,545,102      1,631,378,246      1,631,378,246        309,959,394
OHIO.........................................................              63.58        416,846,544        426,850,861     16,628,494,101        649,120,744     15,979,373,357      2,363,633,714      2,363,633,714        426,850,861
PENNSYLVANIA.................................................              54.28        575,889,532        589,710,881     20,922,389,122        847,055,684     20,075,333,438      3,092,778,900      3,092,778,900        589,710,881
RHODE ISLAND.................................................              51.26         66,695,447         68,296,138      1,909,141,351        129,846,057      1,779,295,294        278,777,412        278,777,412         68,296,138
SOUTH CAROLINA...............................................              70.43        336,042,444        344,107,463      4,690,094,944        457,173,209      4,232,921,735        612,270,432        612,270,432        344,107,463
TENNESSEE/2..................................................                 na                 na                 na                 na                 na                 na                 na                 na         53,100,000
TEXAS........................................................              59.30        981,192,634      1,004,741,257     27,752,018,303        226,747,941     27,525,270,362      4,141,011,076      4,141,011,076      1,004,741,257
VERMONT......................................................              56.04         23,086,886         23,640,971      1,452,095,084         37,448,781      1,414,646,303        216,013,021        216,013,021         23,640,971
VIRGINIA.....................................................              50.00         89,892,713         92,050,138      7,218,485,856        186,468,433      7,032,017,423      1,110,318,540      1,110,318,540         92,050,138
WASHINGTON...................................................              50.00        189,825,503        194,381,315      7,805,501,929        366,733,930      7,438,767,999      1,174,542,316      1,174,542,316        194,381,315
WEST VIRGINIA................................................              72.04         69,260,656         70,922,912      3,007,417,198         75,434,137      2,931,983,061        422,158,680        422,158,680         70,922,912
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Total....................................................               0.00     10,004,528,519     10,244,637,203    366,054,779,932     15,047,983,957    351,006,795,975     53,874,035,598     53,874,035,598     11,029,697,203
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                             LOW DSH STATES
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ALASKA.......................................................              50.00         20,901,012         21,402,636      1,340,719,400         21,706,474      1,319,012,926     208,265,198.84        208,265,199         21,402,636
ARKANSAS.....................................................              70.17         44,262,980         45,325,292      4,156,350,929         61,000,000      4,095,350,929        592,822,640        592,822,640         45,325,292
DELAWARE.....................................................              55.67          9,289,338          9,512,282      1,557,544,100         10,874,669      1,546,669,431        236,601,110        236,601,110          9,512,282
HAWAII.......................................................              51.86         10,000,000         10,240,000      1,586,220,307         24,971,280      1,561,249,027     243,752,256.52        243,752,257         10,240,000
IDAHO........................................................              71.00         16,866,254         17,271,044      1,641,925,393         23,708,980      1,618,216,413     233,681,421.00        233,681,421         17,271,044
IOWA.........................................................              59.59         40,408,349         41,378,149      3,622,873,642         54,606,370      3,568,267,272        536,162,337        536,162,337         41,378,149
MINNESOTA....................................................              50.00         76,637,045         78,476,334      8,781,239,289         46,287,099      8,734,952,190      1,379,202,977      1,379,202,977         78,476,334
MONTANA......................................................              66.00         11,646,847         11,926,371        996,801,715         17,703,206        979,098,509        143,601,115        143,601,115         11,926,371
NEBRASKA.....................................................              55.76         29,036,347         29,733,219      1,790,372,947         45,313,162      1,745,059,785        266,831,445        266,831,445         29,733,219
NEW MEXICO...................................................              69.07         20,901,012         21,402,636      3,280,561,202         25,164,146      3,255,397,056        472,788,382        472,788,382         21,402,636
NORTH DAKOTA.................................................              52.27          9,801,133         10,036,360        775,035,726          1,265,931        773,769,795        120,521,323        120,521,323         10,036,360
OKLAHOMA.....................................................              64.00         37,157,353         38,049,129      4,481,944,280         41,759,650      4,440,184,630        655,781,115        655,781,115         38,049,129
OREGON.......................................................              62.44         46,446,693         47,561,414      5,070,815,864         76,536,235      4,994,279,629        741,894,100        741,894,100         47,561,414
SOUTH DAKOTA.................................................              56.19         11,332,733         11,604,719        758,090,042          1,441,151        756,648,891        115,454,450        115,454,450         11,604,719
UTAH.........................................................              69.61         20,129,695         20,612,808      2,087,187,059         28,794,708      2,058,392,351        298,457,958        298,457,958         20,612,808
WISCONSIN....................................................              59.74         96,998,597         99,326,563      7,034,898,860            581,325      7,034,317,535      1,056,296,932      1,056,296,932         99,326,563
WYOMING......................................................              50.00            232,233            237,807        546,576,901            463,560        546,113,341         86,228,422         86,228,422            237,807
                                                              --------------------------------------------------------------------------------------------------------------------------------------------------------------------------

[[Page 5453]]

 
    Total Low DSH States.....................................               0.00        502,047,621        514,096,764     49,509,157,656        482,177,946     49,026,979,710      7,388,343,182      7,388,343,182        514,096,763
                                                              --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
        Total................................................               0.00     10,506,576,140     10,758,733,967    415,563,937,588     15,530,161,903    400,033,775,685     61,262,378,780     61,262,378,780     11,543,793,966
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ FY 2013 DSH allotment for Louisiana determined under the provisions of section 1903(f)(3)(C) and (D) of the Act.
\2\ Tennessee's DSH allotments are determined under section 1923(f)(6)(A)(v)(II) of the Act. Under this provision, Tennessee's DSH payments for FY 2013 are limited to $53,100,000.
\3\ Beginning FY 2013, under section 1923(f)(6)(B)(II) of the Act, Hawaii's DSH allotments are determined as for low-DSH states. This means its allotments are determined as for all States, by increasing the previous fiscal year
  allotment by the CPIU for the previous fiscal year.


[[Page 5454]]


        Key to Addendum 2--Preliminary DSH Allotments for FY 2015
 [The Preliminary FY 2015 DSH Allotments for the NON-Low DSH States are
  presented in the top section of this addendum, and the Preliminary FY
 2015 DSH Allotments for the Low-DSH States are presented in the bottom
                        section of this addendum]
------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  FY 2015 FMAPs.
                           This column contains the States' FY 2015
                            Federal Medical Assistance Percentages.
Column C.................  Prior FY (2014) DSH Allotments.
                           This column contains the States' prior FY
                            2014 DSH Allotments
Column D.................  Prior FY (2014) DSH Allotments (Col C) x (100
                            percent + Percentage Increase in CPIU):
                            101.6 percent.
                           This column contains the amount in Column C
                            increased by 1 plus the estimated percentage
                            increase in the CPI-U for the prior FY
                            (101.6 percent).
Column E.................  FY 2015 TC MAP Exp. Including DSH.
                           This column contains the amount of the
                            States' projected FY 2015 total computable
                            (TC) medical assistance expenditures
                            including DSH expenditures.
Column F.................  FY 2015 TC DSH Expenditures.
                           This column contains the amount of the
                            States' projected FY 2015 total computable
                            DSH expenditures.
Column G.................  FY 2015 TC MAP Exp. Net of DSH.
                           This column contains the amount of the
                            States' projected FY 2015 total computable
                            medical assistance expenditures net of DSH
                            expenditures, calculated as the amount in
                            Column E minus the amount in Column F.
Column H.................  12 percent Amount.
                           This column contains the amount of the ``12
                            percent limit'' in Federal share, determined
                            in accordance with the provisions of section
                            1923(f)(3) of the Act.
Column I.................  Greater of FY 2014 Allotment or 12 percent
                            Limit.
                           This column contains the greater of the
                            State's prior FY (FY 2014) DSH allotment or
                            the amount of the 12 percent Limit,
                            determined as the maximum of the amount in
                            Column C or Column H.
Column J.................  FY 2015 DSH Allotment.
                           This column contains the States' preliminary
                            FY 2015 DSH allotments, determined as the
                            minimum of the amount in Column I or Column
                            D.
                           For states with ``na'' in Columns I or D,
                            refer to the footnotes in the addendum.
------------------------------------------------------------------------


[[Page 5455]]


                                                                                           Addendum 2--Preliminary DSH Allotments for FY 2015
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                      Prior FY (2014)
                                                                                                       DSH Allotment      FY 2015 TC MAP                        FY 2015 TC MAP    ``12% Amount'' =   Greater of Col H     FY 2015 DSH
                            State                                FY 2015 FMAPs     Prior FY (2014)    (Col C) x 100% +    Exp. Including     FY 2015 TC DSH    EXP. Net Of DSH    Col G x .12/(1-     or Col C (12%    Allotment Min Col
                                                                   (percent)        DSH allotments    Pct increase in        DSH \4\        Expenditures \4\       Col E-F        .12/Col B)* (in     Limit, FY 2014        I, Col D
                                                                                                        CPIU: 101.6%                                                                    FS)             allotment)
A                                                                              B                  C                  D                  E                  F                  G                  H                  I                  J
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ALABAMA......................................................              68.99       $327,939,666       $333,186,701     $5,727,646,000       $507,528,000     $5,220,118,000       $758,313,966       $758,313,966       $333,186,701
ARIZONA......................................................              68.46        107,980,135        109,707,817     11,262,757,000        167,012,000     11,095,745,000      1,614,483,959      1,614,483,959        109,707,817
CALIFORNIA...................................................              50.00      1,169,118,239      1,187,824,131     96,031,140,000        597,609,000     95,433,531,000     15,068,452,263     15,068,452,263      1,187,824,131
COLORADO.....................................................              51.01         98,648,517        100,226,893      6,927,502,000        204,899,000      6,722,603,000      1,054,867,918      1,054,867,918        100,226,893
CONNECTICUT..................................................              50.00        213,294,091        216,706,796      7,094,230,000        125,646,000      6,968,584,000      1,100,302,737      1,100,302,737        216,706,796
DISTRICT OF COLUMBIA.........................................              70.00         65,321,315         66,366,456      2,630,681,000         37,174,000      2,593,507,000        375,611,359        375,611,359         66,366,456
FLORIDA......................................................              59.72        213,294,091        216,706,796     22,430,097,000        362,102,000     22,067,995,000      3,314,083,809      3,314,083,809        216,706,796
GEORGIA......................................................              66.94        286,613,936        291,199,759      9,915,707,000        434,725,000      9,480,982,000      1,386,218,278      1,386,218,278        291,199,759
ILLINOIS.....................................................              50.76        229,291,148        232,959,806     19,753,482,000        456,614,000     19,296,868,000      3,032,535,665      3,032,535,665        232,959,806
INDIANA......................................................              66.52        227,958,061        231,605,390     10,719,730,000        474,987,000     10,244,743,000      1,499,956,649      1,499,956,649        231,605,390
KANSAS.......................................................              56.63         43,991,907         44,695,778      3,161,490,000         74,228,000      3,087,262,000        470,082,851        470,082,851         44,695,778
KENTUCKY.....................................................              69.94        154,638,217        157,112,428      8,903,447,000        241,000,000      8,662,447,000      1,254,784,004      1,254,784,004        157,112,428
LOUISIANA \1\................................................              62.05        731,960,000        743,671,360      7,995,712,000        551,048,000      7,444,664,000      1,107,551,811      1,107,551,811        743,671,360
MAINE........................................................              61.88        111,979,398        113,771,068      2,565,931,000         38,566,000      2,527,365,000        376,247,024        376,247,024        113,771,068
MARYLAND.....................................................              50.00         81,318,372         82,619,466     11,133,665,000         92,859,000     11,040,806,000      1,743,285,158      1,743,285,158         82,619,466
MASSACHUSETTS................................................              50.00        325,273,489        330,477,865     16,287,567,000                  0     16,287,567,000      2,571,721,105      2,571,721,105        330,477,865
MICHIGAN.....................................................              65.54        282,614,672        287,136,507     16,050,268,000        322,351,000     15,727,917,000      2,310,364,618      2,310,364,618        287,136,507
MISSISSIPPI..................................................              73.58        162,636,745        165,238,933      5,362,441,000        228,204,000      5,134,237,000        736,168,545        736,168,545        165,238,933
MISSOURI.....................................................              63.45        505,240,380        513,324,226      9,641,725,000        713,722,000      8,928,003,000      1,321,240,327      1,321,240,327        513,324,226
NEVADA.......................................................              64.36         49,324,258         50,113,446      2,848,030,000         78,128,000      2,769,902,000        408,565,835        408,565,835         50,113,446
NEW HAMPSHIRE................................................              50.00        170,740,344        173,472,190      1,816,048,000         76,097,000      1,739,951,000        274,729,105        274,729,105        173,472,190
NEW JERSEY...................................................              50.00        686,540,358        697,525,004     14,214,233,000      1,213,776,000     13,000,457,000      2,052,703,737      2,052,703,737        697,525,004
NEW YORK.....................................................              50.00      1,713,018,172      1,740,426,463     68,512,267,000      5,326,800,000     63,185,467,000      9,976,652,684      9,976,652,684      1,740,426,463
NORTH CAROLINA...............................................              65.88        314,608,785        319,642,526     12,482,232,000        411,389,000     12,070,843,000      1,771,107,209      1,771,107,209        319,642,526
OHIO.........................................................              62.64        433,253,624        440,185,682     21,305,059,000                  0     21,305,059,000      3,162,438,142      3,162,438,142        440,185,682
PENNSYLVANIA.................................................              51.82        598,556,544        608,133,449     24,679,963,000        787,072,000     23,892,891,000      3,731,179,141      3,731,179,141        608,133,449
RHODE ISLAND.................................................              50.00         69,320,580         70,429,709      3,117,756,000        142,487,000      2,975,269,000        469,779,316        469,779,316         70,429,709
SOUTH CAROLINA...............................................              70.64        349,269,075        354,857,380      5,636,583,000        494,437,000      5,142,146,000        743,331,228        743,331,228        354,857,380
TENNESSEE \2\................................................                 na                 na                 na                 na                 na                 na                 na                 na         53,100,000
TEXAS........................................................              58.05      1,019,812,376      1,036,129,374     35,894,535,000      2,630,047,000     33,264,488,000      5,031,931,019      5,031,931,019      1,036,129,374
VERMONT \5\..................................................              56.21         23,995,586         24,379,515      1,577,599,000         37,449,000      1,540,150,000        234,983,483        234,983,483         24,379,515
VIRGINIA.....................................................              50.00         93,430,890         94,925,784      8,689,637,000        193,862,000      8,495,775,000      1,341,438,158      1,341,438,158         94,925,784
WASHINGTON...................................................              50.03        197,297,035        200,453,788     12,536,442,000        405,243,000     12,131,199,000      1,915,089,832      1,915,089,832        200,453,788
WEST VIRGINIA................................................              71.35         71,986,756         73,138,544      3,631,855,000         71,987,000      3,559,868,000        513,556,694        513,556,694         73,138,544
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Total....................................................  .................     11,130,266,762     11,308,351,030    490,537,457,000     17,499,048,000    473,038,409,000     72,723,757,629     72,723,757,629     11,361,451,030
                                                              --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                             LOW DSH STATES
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ALASKA.......................................................              50.00         21,723,676         22,071,255      1,661,590,000         21,894,000      1,639,696,000     258,899,368.42        258,899,368         22,071,255
ARKANSAS.....................................................              70.88         46,005,171         46,741,254      6,070,657,000         65,820,000      6,004,837,000        867,437,867        867,437,867         46,741,254
DELAWARE.....................................................              53.63          9,654,966          9,809,445      1,549,168,000         24,248,000      1,524,920,000        235,738,053        235,738,053          9,809,445
HAWAII \3\...................................................              52.23         10,393,600         10,559,898      1,951,834,000                  0      1,951,834,000     304,084,384.25        304,084,384         10,559,898
IDAHO........................................................              71.75         17,530,110         17,810,592      2,009,716,000         24,470,000      1,985,246,000     286,074,779.25        286,074,779         17,810,592
IOWA.........................................................              55.54         41,998,821         42,670,802      4,714,183,000         34,688,000      4,679,495,000        716,304,508        716,304,508         42,670,802
MINNESOTA....................................................              50.00         79,653,479         80,927,935     11,849,443,000        154,792,000     11,694,651,000      1,846,523,842      1,846,523,842         80,927,935
MONTANA......................................................              65.90         12,105,267         12,298,951      1,030,146,000          1,896,000      1,028,250,000        150,860,872        150,860,872         12,298,951
NEBRASKA.....................................................              53.27         30,179,217         30,662,084      2,053,612,000         42,720,000      2,010,892,000        311,471,433        311,471,433         30,662,084
NEW MEXICO...................................................              69.65         21,723,676         22,071,255      4,758,998,000         31,196,000      4,727,802,000        685,428,779        685,428,779         22,071,255
NORTH DAKOTA.................................................              50.00         10,186,905         10,349,895      1,155,141,000          1,735,000      1,153,406,000        182,116,737        182,116,737         10,349,895
OKLAHOMA.....................................................              62.30         38,619,866         39,237,784      5,404,554,000         58,140,000      5,346,414,000        794,628,053        794,628,053         39,237,784
OREGON.......................................................              64.06         48,274,835         49,047,232      8,294,293,000         81,136,000      8,213,157,000      1,212,757,981      1,212,757,981         49,047,232
SOUTH DAKOTA.................................................              51.64         11,778,790         11,967,251        857,827,000          1,613,000        856,214,000        133,849,317        133,849,317         11,967,251
UTAH.........................................................              70.56         20,922,000         21,256,752      2,276,646,000         31,390,000      2,245,256,000        324,641,933        324,641,933         21,256,752
WISCONSIN....................................................              58.27        100,816,461        102,429,524      8,016,231,000        166,265,000      7,849,966,000      1,186,300,027      1,186,300,027        102,429,524
WYOMING......................................................              50.00            241,374            245,236        596,915,000            476,000        596,439,000         94,174,579         94,174,579            245,236
                                                              --------------------------------------------------------------------------------------------------------------------------------------------------------------------------

[[Page 5456]]

 
    Total Low DSH States.....................................  .................        521,808,214        530,157,145     64,250,954,000        742,479,000     63,508,475,000      9,591,292,512      9,591,292,512        530,157,145
                                                              --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
        Total................................................  .................     11,652,074,976     11,838,508,176    554,788,411,000     18,241,527,000    536,546,884,000     82,315,050,141     82,315,050,141     11,891,608,175
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Louisiana's FY 2015 DSH allotment is determined under the provisions of section 1923(f)(3)(C) and (D) of the Act.
\2\ Tennessee's DSH allotment for FY 2015 determined under section 1923(f)(6)(A)(vi) of the Act
\3\ Beginning FY 2013, under section 1923(f)(6)(B)(II) of the Act, Hawaii's DSH allotment for a fiscal year is determined as for low-DSH states. This means Hawaii's DSH allotment for a fiscal year is determined as for all States, by
  increasing the previous fiscal year allotment by the percentage increase in the CPIU for the previous fiscal year.
\4\ Expenditures based on the amounts reported by States on the Form CMS-37.
\5\ FMAP for Vermont for FY 2015 determined in accordance with section 1905(z)(1)(A) of the Act.


[[Page 5457]]


           Key to Addendum 3--Final IMD DSH Limits for FY 2013
    [The final FY 2013 IMD DSH Limits for the Non-Low DSH States are
  presented in the top section of this addendum and the preliminary FY
 2013 IMD DSH Limits for the Low-DSH States are presented in the bottom
                        section of the addendum]
------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  Inpatient Hospital Services FY 95 DSH Total
                            Computable
                           This column contains the States' total
                            computable FY 1995 inpatient hospital DSH
                            expenditures as reported on the Form CMS-64.
Column C.................  IMD and Mental Health Services FY 95 DSH
                            Total
                           Computable. This column contains the total
                            computable FY 1995 mental health facility
                            DSH expenditures as reported on the Form CMS-
                            64 as of January 1, 1997.
Column D.................  Total Inpatient Hospital & IMD & Mental
                            Health FY 95 DSH Total
                           Computable, Col. B + C. This column contains
                            the total computation of all inpatient
                            hospital DSH expenditures and mental health
                            facility DSH expenditures for FY 1995 as
                            reported on the Form CMS-64 as of January 1,
                            1997 (representing the sum of Column B and
                            Column C).
Column E.................  Applicable Percentage, Col. C/D.
                           This column contains the ``applicable
                            percentage'' representing the total
                            Computable FY 1995 mental health facility
                            DSH expenditures divided by total computable
                            all inpatient hospital and mental health
                            facility DSH expenditures for FY 1995 (the
                            amount in Column C divided by the amount in
                            Column D) Per section 1923(h)(2)(A)(ii)(III)
                            of the Act, for FYs after FY 2002, the
                            applicable percentage can be no greater than
                            33 percent.
Column F.................  FY 2013 Federal Share DSH Allotment
                           This column contains the states' FY 2013 DSH
                            allotments from Column J Addendum 1.
Column G.................  FY 2013 FMAP.
Column H.................  FY 2013 DSH Allotments in Total Computable,
                            Col. F/G.
                           This column contains states' FY 2013 total
                            computable DSH allotment (determined as
                            Column F/Column G).
Column I.................  Applicable Percentage Applied to FY 2013
                            Allotments in TC, Col E x Col H.
                           This column contains the applicable
                            percentage of FY 2012 total computable DSH
                            allotment (calculated as the percentage in
                            Column E multiplied by the amount in Column
                            H).
Column J.................  FY 2013 TC IMD DSH Limit. Lesser of Col.
                           I or C. This column contains the total
                            computable FY 2013 TC IMD DSH Limit equal to
                            the lesser of the amount in Column I or
                            Column C.
Column K.................  FY 2013 IMD DSH Limit in Federal Share, Col.
                            G x J.
                           This column contains the FY 2013 Federal
                            Share IMD DSH limit determined by converting
                            the total computable FY 2013 IMD DSH Limit
                            from Column J into a federal share amount by
                            multiplying it by the FY 2013 FMAP in Column
                            G.
------------------------------------------------------------------------


[[Page 5458]]


                                                                                              Addendum 3--Final IMD DSH Limits for FY 2013
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                                  Applicable
                                                                Inpatient      IMD And  mental   Total inpatient                                                                  percentage      FY 2013  TC