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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations to align with the policy changes that the IPPS finalized in the FY 2021 IPPS final rule 85 FR 58865 through 58870. We believe that the IPF IME policy relating to hospital closure and displaced students is susceptible to the same vulnerabilities as IPPS GME policy.
Hence, if an IPF with a large number of residents training in its residency program announces that it is closing, these residents will become displaced and will need to find alternative positions at other IPF hospitals or risk being unable to become Board-certified.
Although we proposed to adopt a policy under the IPF PPS that is consistent with an applicable policy under the IPPS, the actual caps under the two payment systems may not be commingled. In other words, the resident cap applicable under the IPPS
is separate from the resident cap applicable under the IPF PPS; moreover, a provider cannot add its IPF resident cap to its IPPS resident cap in order to increase the number of residents it receives payment for under either payment system.
As stated in the November 2004 IPF
PPS final rule 69 FR 66922, we implemented regulations at 412.424d1iii to establish a facilitylevel adjustment for IPFs that are, or are part of, teaching hospitals. The facilitylevel adjustment we are providing for teaching hospitals under IPF PPS
parallels the IME payments paid under the IPPS. Both payments are add on adjustments to the amount per case and both are based in part on the number of full-time equivalent FTE residents training at the facility.
The regulation at 42 CFR
412.424d1iiiF permits an IPF to temporarily adjust its FTE cap to reflect residents added because of another hospital or programs closure. We first implemented regulations regarding residents displaced by teaching hospital and program closures in the May 6, 2011 IPF PPS final rule 76 FR 26431.
In that final rule, we adopted the IPPS
definition of closure of a hospital at 42 CFR 413.79h1i to apply to IPF
closures as well, and to mean that the IPF terminates its Medicare provider agreement as specified in 42 CFR
489.52. In the proposed rule, we proposed to codify this definition, as well as, the definition of an IPF program closure, at 412.402.
Although not explicitly stated in regulatory text, our current policy is that a displaced resident is one that is physically present at the hospital training on the day prior to or the day of hospital or program closure. This longstanding policy derived from the fact that in the regulations text, there are
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requirements that the receiving hospital identifies the residents who have come from the closed IPF
412.424d1iiiF1ii or identifies the residents who have come from another IPFs closed program 412.424d1iiiF2i, and that the IPF that closed its program identifies the residents who were in training at the time of the programs closure 412.424d1iiiF2ii. We considered the residents who were physically present at the IPF to be those residents who were training at the time of the programs closure, thereby granting them the status of displaced residents. Although we did not want to limit the displaced residents to only those physically present at the time of closure, it becomes much more administratively challenging for the following groups of residents at closing IPFs/programs to continue their training: 1 Residents who leave the program after the closure is publicly announced to continue training at another IPF, but before the actual closure; 2 residents assigned to and training at planned rotations at other IPFs who will be unable to return to their rotations at the closing IPF or program; and 3 individuals such as medical students or would-be fellows who matched into resident programs at the closing IPF or program but have not yet started training at the closing IPF or program. Other groups of residents who, under current policy, are already considered displaced residents include1 residents who are physically training in the IPF on the day prior to or day of program or IPF
closure; and 2 residents who would have been at the closing IPF or IPF
program on the day prior to or of closure but were on approved leave at that time, and are unable to return to their training at the closing IPF or IPF program.
We proposed to amend the IPF policy with regard to closing teaching IPFs and closing residency programs to address the needs of residents attempting to find alternative IPFs in which to complete their training. Additionally, this proposal addresses the incentives of originating and receiving IPFs with regard to ensuring we appropriately account for their indirect teaching costs by way of an appropriate IPF teaching adjustment based on each programs resident FTEs. We proposed to change two aspects of the current IPF policy, which are discussed in the following section.
First, rather than link the status of displaced residents, for the purpose of the receiving IPFs request to increase their FTE cap, to the residents presence at the closing IPF or program on the day
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prior to or the day of program or IPF
closure, we proposed that the ideal day will be the day that the closure was publicly announced, for example, via a press release or a formal notice to the Accreditation Council on Graduate Medical Education ACGME. This will provide greater flexibility for the residents to transfer while the IPF
operations or residency programs were winding down, rather than waiting until the last day of IPF or program operation.
This will address the needs of the first group of residents as previously described: Residents who leave the IPF
program after the closure was publicly announced to continue training at another IPF, but before the day of actual closure.
Second, by removing the link between the status of displaced residents and their presence at the closing IPF or program on the day prior to or the day of program or IPF closure, we proposed to also allow the second and third group of residents who are not physically at the closing IPF/closing program, but had intended to train at or return to training at, in the case of residents on rotation to be considered displaced residents.
Thus, we proposed to revise our teaching policy with regard to which residents can be considered displaced for the purpose of the receiving IPFs request to increase their FTE cap in the situation where an IPF announces publicly that it is closing or that it is closing an IPF residency programs.
Specifically, we are adopting the definitions of closure of a hospital, closure of a hospital residency training program, and displaced resident as defined at 42 CFR 413.79h but with respect to IPFs and for the purposes of accounting for indirect teaching costs.
In addition, we proposed to change another detail of the IPF teaching policy specific to the requirements for the receiving IPF. To apply for the temporary increase in the FTE resident cap, the receiving IPF will have to submit a letter to its Medicare Administrative Contractor MAC
within 60 days of beginning the training of the displaced residents. As established under existing regulation at 412.424d1iiiF1ii and 412.424d1iiiF2i, this letter must identify the residents who have come from the closed IPF or program that have caused the receiving IPF to exceed its cap, and the receiving IPF
must specify the length of time the adjustment is needed. Moreover, we want to propose clarifications on how the information will be delivered in this letter. Consistent with IPPS teaching policy, we proposed that the letter from the receiving IPF will have to include:

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