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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
recognize that different types of entities are in many cases affected by mutually exclusive sections of the final rule, and therefore, for the purposes of our estimate we assume that each reviewer reads approximately 50 percent of the rule.
Using the wage information from the Bureau of Labor Statistics BLS for medical and health service managers Code 119111; we estimate that the cost of reviewing this rule is $114.24 per hour, including overhead and fringe benefits https www.bls.gov/oes/
current/oes_nat.htm. This final rule
consists of approximately 72,000 words.
Assuming an average reading speed of 250 words per minute, it would take approximately 2.4 hours for the staff to review half of it. For each hospice that reviews the rule, the estimated cost is $274.18 2.4 hour $114.24. Therefore, we estimate that the total cost of reviewing this regulation is $14,531.54
$274.18 53 reviewers.
D. Accounting Statement and Table As required by OMB Circular A4
available at https
www.whitehouse.gov/sites/

whitehouse.gov/files/omb/circulars/A4/
a-4.pdf, in Table 26, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule. Table 26 provides our best estimate of the possible changes in Medicare payments under the hospice benefit as a result of the policies in this rule. This estimate is based on the data for 4,995 hospices in our impact analysis file, which was constructed using FY 2020 claims available in May 2021. All expenditures are classified as transfers to hospices.

TABLE 26: Accounting Statement:
Classification of Estimated Transfers and Costs, From FY 2021 to FY 2022
Cateory Annualized Monetized Transfers From Whom to Whom?

Transfers $ 480 million
Federal Government to Medicare Hospices
The net increase of $480 million in transfer payments is a result of the 2.0 percent hospice payment update compared to payments in FY 2021.

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. The great majority of hospitals and most other health care providers and suppliers are small entities by meeting the Small Business Administration SBA definition of a small business in the service sector, having revenues of less than $8.0
million to $41.5 million in any 1 year, or being nonprofit organizations. For purposes of the RFA, we consider all hospices as small entities as that term is used in the RFA. The Department of Health and Human Services practice in interpreting the RFA is to consider effects economically significant only if greater than 5 percent of providers reach a threshold of 3 to 5 percent or more of total revenue or total costs. The effect of the FY 2022 hospice payment update percentage results in an overall increase in estimated hospice payments of 2.0 percent, or $480 million. The distributional effects of the final FY
2022 hospice wage index do not result in a greater than 5 percent of hospices experiencing decreases in payments of 3
percent or more of total revenue.
Therefore, the Secretary has certified that this rule will not create a significant economic impact on a substantial number of small entities.

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In addition, section 1102b 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 1102b of the Act, we define a small rural hospital as a hospital that is located outside of a MSA and has fewer than 100 beds.
This rule will only affect hospices.
Therefore, the Secretary has certified that this rule will not have a significant impact on the operations of a substantial number of small rural hospitals see Table 25.
F. Unfunded Mandates Reform Act UMRA
Section 202 of the Unfunded Mandates Reform Act of 1995 UMRA
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 2021, that threshold is approximately $158
million. This rule is not anticipated to have an effect on state, local, or tribal governments, in the aggregate, or on the private sector of $158 million or more in any 1 year.

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G. Federalism 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 reviewed this rule under these criteria of Executive Order 13132, and have determined that it will not impose substantial direct costs on state or local governments.
H. Conclusion We estimate that aggregate payments to hospices in FY 2022 will increase by $480 million as a result of the market basket update, compared to payments in FY 2021. We estimate that in FY 2022, hospices in urban areas will experience, on average, 2.0 percent increase in estimated payments compared to FY
2021. While hospices in rural areas will experience, on average, 2.2 percent increase in estimated payments compared to FY 2021. Hospices providing services in the Outlying and South Atlantic regions would experience the largest estimated increases in payments of 2.9 percent and 2.5 percent, respectively. Hospices serving patients in areas in the New England and Middle Atlantic regions would experience, on average, the
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E. Regulatory Flexibility Act RFA