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Policy Updates

There are many changes happening in health care every day at the state and federal level. To help you navigate this information, we have implemented this Policy Update page as a place to post the most recent changes and proposed changes that may affect you and your facility.

For archived policy, please visit the Policy Archive.

From the NRHA

The SAMHSA-HRSA Center for Integrated Health Solutions, run by the National Council for Community Behavioral Healthcare under a cooperative agreement from the U.S. Department of Health and Human Services, is funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources Services Administration. The CIHS promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings.

CMS Announces New ACO Options and Initiatives

The Centers for Medicare & Medicaid Services (CMS) today announced new options and initiatives for providers interested in becoming Accountable Care Organizations (ACOs). First, the Center for Medicare and Medicaid Innovation (Innovation Center) will support a new ACO model that will be available to providers this summer – the Pioneer ACO Model, which is designed for advanced organizations ready to participate in shared savings. Second, the Innovation Center is seeking comment on the idea of an Advance Payment ACO Model that would provide additional up-front funding to providers to support the formation of new ACOs. And third, provider groups interested in learning more about how to coordinate patient care through ACOs can attend free new Accelerated Development Learning Sessions.  

Read more.

3 New Fact Sheets on the Medicare & Medicaid EHR Incentive Programs

CMS has issued 3 new fact sheets about the Medicare and Medicaid EHR incentive programs. These fact sheets summarize provisions in the final rule announced on July 13, 2010. Here are links to each of the July 16, 2010, fact sheets:

Additional information on the Medicare and Medicaid EHR Incentive Programs, including a link to the text of the final rule, can be found at CMS' website.

CMS to Review PECOS Enrollment Process

Medicare Working with Ordering and Referring Providers and Suppliers to Streamline Enrollment Process

The Centers for Medicare & Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chain and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need. PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.

As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010. While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS system, some providers have encountered problems. CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.

CMS issued an interim final regulation on May 5, 2010, implementing provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), and certain items and services under Medicare Part B. The new law applies to orders, referrals, and certifications made on or after July 1. The comment period for the regulation closes on July 6, after which the comments will be reviewed and considered before a final regulation is issued.

The Affordable Care Act provisions and the regulation were designed as steps to prevent fraud in Medicare by ensuring that only eligible and identifiable providers and suppliers can order and refer covered items and services to Medicare beneficiaries.

Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation. These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.

While the regulation will be effective July 6, 2010, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS. However, until the automatic rejections are operational, providers should not see any change in the processing of submitted claims: they will continue to be reviewed and paid as they have historically been reviewed and paid.

Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.

CMS will continue to send informational notices to providers reminding them of the need to submit or update their enrollment and will work with the provider community to provide guidance on enrollment and will process all applications expeditiously.

CMS to Expand Medicare Preventive Services and Improve Access to Primary Care in 2011

Proposals would implement Affordable Care Act benefits

On June 25, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would implement Affordable Care Act of 2010 key provisions that expand preventive services for Medicare beneficiaries, improve payments for primary care services, and promote access to health care services in rural areas. The proposed policies would apply to payments under the Medicare Physician Fee Schedule (MPFS) for services furnished on or after January 1, 2011.

The proposed rule would implement provisions in the Affordable Care Act that will eliminate out-of-pocket costs for beneficiaries for most preventive services, including the new annual wellness visit. This visit augments the benefits of the Initial Preventive Physical Examination (IPPE or “Welcome to Medicare Visit”) with an annual wellness visit that allows the physician and patient to develop a personalized prevention plan that includes not only the preventive services generally available to the Medicare population, but additional services that may be appropriate because of the patient’s individual risk factors.

The proposed rule would improve access to primary care services by implementing an incentive payment for primary care services furnished by primary care practitioners that can include physicians, nurse practitioners, clinical nurse specialists, and physician assistants. The proposed rule also would implement a payment incentive program for general surgeons performing major surgery in areas designated by the Secretary as Health Professional Shortage Areas (HPSAs), would allow physician assistants to order post-hospital extended care services in skilled nursing facilities, and would pay certified nurse midwives for their services under the Medicare Physician Fee Schedule (MPFS) at the same rates as physicians.

CMS will accept comments on the proposed rule until August 24, 2010, and will respond to them in a final rule to be issued on or about November 1, 2010. Except as otherwise specified, the payment policies and rates adopted in the final rule will be effective for services on or after January 1, 2011.

The Electronic Health Record (EHR) Incentive Program Website is now available on CMS.gov!

The Centers for Medicare & Medicare Services (CMS) has launched the official website for the Medicare & Medicaid EHR Incentive Programs. This website provides the most up-to-date, detailed information about the EHR incentive programs.

The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals and hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.

Bookmark CMS' EHR site and visit often to learn about who is eligible for the programs, how to register, meaningful use, upcoming EHR training and events, and much more!

PECOS Enrollment Required for Medicare Electronic Health Record (EHR) Incentive Program One More reason to Establish Your Enrollment in PECOS

Information Specific to Medicare Physicians

The Recovery Act of 2009 established CMS programs under Medicare and Medicaid to provide incentive payments for the “meaningful use” of certified EHR technology. These EHR incentive programs will provide incentive payments to eligible professionals and eligible hospitals as they demonstrate adoption, implementation, upgrading, or meaningful use of certified EHR technology.

While more detail on the EHR incentive program is forthcoming in the impending final rule, CMS is announcing that Provider Enrollment, Chain and Ownership System (PECOS) records will be used to verify Medicare enrollment prior to making Medicare EHR incentive payments. Your enrollment information must be in PECOS, so act now if you do not have an enrollment record in this system.

Enrolled in Medicare before November 2003?

If you are a physician who enrolled in Medicare before November 2003 AND have not updated your Medicare enrollment information since then, you do NOT have an enrollment record in PECOS. Act now to establish your enrollment record in PECOS. For instructions, visit CMS's website, click on “Tips to Facilitate the Medicare Enrollment Process” under “Downloads.”

If you enrolled in Medicare after November 2003, or if you enrolled before November 2003 and have updated your Medicare enrollment information since November 2003, no further action is required.

If you are unsure, here are ways to verify that you have an enrollment record in PECOS:

  • Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. Go to CMS's website, click on “Ordering Referring Report” on the left.
  • Use Internet-based PECOS to look for your PECOS enrollment record. (You will need to first set up your access to Internet-based PECOS.) If no record is displayed, you do not have an enrollment record in PECOS. Go to CMS's website, click on “Internet-based PECOS” on the left, for information on using Internet-based PECOS.
  • Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS. Go to CMS's website, click on “Medicare Fee-For-Service Contact Information” under “Downloads.”

Note: If you have submitted an enrollment application within the last 90 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this listserv message.

NOTE for physicians who reassign all their Medicare benefits to a group/clinic: If you reassign all of your Medicare benefits to a group/clinic, the group/clinic must have an enrollment record in PECOS in order for you to enroll using Internet-based PECOS. You should check with the officials of the group/clinic or with your designated Medicare enrollment contractor if you are not sure if the group/clinic has an enrollment record in PECOS. If the group/clinic does not have an enrollment record in PECOS, you will not be able to use Internet-based PECOS to submit your enrollment application to Medicare. You will need to submit a paper enrollment application (CMS-855).

The Medicare & Medicaid EHR incentive programs are designed to support providers in this period of Health IT transition and instill the use of EHRs in meaningful ways to help our nation to improve the quality, safety and efficiency of patient health care. More information on Medicare & Medicaid EHR incentive programs can be found on the CMS website.

Information Specific to Medicare Hospitals & Critical Access Hospitals

The Recovery Act of 2009 established CMS programs under Medicare and Medicaid to provide incentive payments for the “meaningful use” of certified EHR technology. These EHR incentive programs will provide incentive payments to eligible professionals and eligible hospitals as they demonstrate adoption, implementation, upgrading, or meaningful use of certified EHR technology.

While more detail on the EHR incentive program is forthcoming in the impending final rule, CMS is announcing that Provider Enrollment, Chain and Ownership System (PECOS) records will be used to verify Medicare enrollment prior to making Medicare EHR incentive payments. Your hospital’s enrollment information must be in PECOS, so act now if your hospital does not have an enrollment record in this system.

Enrolled in Medicare before November 2003?

Medicare hospitals and critical access hospitals which enrolled in Medicare before November 2003 AND have not updated Medicare enrollment information since then, do NOT have an enrollment record in PECOS. Act now to establish an enrollment record in PECOS. For instructions, go to CMS's website, click on “Tips to Facilitate the Medicare Enrollment Process” under “Downloads.”

If your hospital enrolled in Medicare after November 2003, or enrolled before November 2003 and has updated its Medicare enrollment information since November 2003, no further action is required.

If you are unsure, here are ways to verify that your hospital has an enrollment record in PECOS:

  • Use Internet-based PECOS to look for your hospital’s PECOS enrollment record. (You will need to first set up your access to Internet-based PECOS.) If no record is displayed, your hospital does not have an enrollment record in PECOS. Go to CMS's website, click on “Internet-based PECOS” on the left, for information on using Internet-based PECOS.
  • Contact your designated Medicare enrollment contractor and ask if your hospital has an enrollment record in PECOS. Go to CMS's website, click on “Medicare Fee-For-Service Contact Information” under “Downloads.”

Note: If you have submitted an enrollment application within the last 90 days, and your enrollment application has been accepted for processing by the fiscal intermediary or A/B MAC, you need not take any additional actions based on this listserv message.

The Medicare & Medicaid EHR incentive programs are designed to support providers in this period of Health IT transition and instill the use of EHRs in meaningful ways to help our nation to improve the quality, safety and efficiency of patient health care. More information on Medicare & Medicaid EHR incentive programs can be found on the CMS website.

ONC Issues Final Rule to Establish the Temporary Certification Program for EHR Technology

On June 18, 2010, the Office of the National Coordinator for Health Information Technology (ONC) issued a final rule to establish the temporary certification program for electronic health record (EHR) technology.

Telemedicine Credentialing for PPS and CAHs

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule regarding the conditions of participation for hospitals and critical access hospitals regarding the credentialing and privileging of telemedicine physicians and practitioners. We would encourage rural hospitals, telehealth providers and other rural stakeholders to review the regulation and provide comments. HRSA worked with CMS on this issue and believe it includes significant changes that address many of the concerns raised over the past year. Please note that in submitting comments to CMS it is important to note not only concerns but also support for those elements of the changes that make sense. Comments are due July 26th, 2010.

Information: Multi-payer Advanced Primary Care Practice Demonstration

On June 2, 2010, the Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) invited states to apply for participation in the Multi-payer Advanced Primary Care Practice Demonstration, an initiative in which Medicare will join Medicaid and private insurers in state-based efforts to improve the delivery of primary care and lower health care costs.

This press release is available online. Additional demonstration details, including a fact sheet and questions and answers (Qs&As), are available on the demonstrations portion of the CMS website.

Proposed Changes Affecting Hospital and Critical Access Hospital (CAH) Conditions of Participation

Below is information about a Medicare and Medicaid Programs Proposed Changes Affecting Hospital and Critical Access Hospital (CAH) Conditions of Participation regarding new credentialing and privileging processes for telemedicine services. Comment period is open until July 26th.

If you have any questions, please feel free to contact TASC at any time.

Summary

This proposed rule would revise the conditions of participation (CoPs) for both hospitals and critical access hospitals (CAHs). These revisions would allow for a new credentialing and privileging process for physicians and practitioners providing telemedicine services.

The provisions of this proposed rule would apply to all hospitals and CAHs participating in the Medicare and Medicaid programs. It has been proposed to revise both the hospital and CAH credentialing and privileging requirements to eliminate these regulatory impediments and allow for the advancement of telemedicine nationwide.

For the Governing body CoP, it is proposed that, when telemedicine services are furnished to the hospital's patients through an agreement with a Medicare- participating hospital the ‘distant-site’ hospital must specify that it has the responsibility of the governing body of the distant-site hospital providing the telemedicine services to meet the existing requirements with regard to its physicians and practitioners who are providing telemedicine services.

Dates

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 26, 2010.

Background

The current critical access hospital (CAH) CoPs require every CAH that is a member of a rural health network to have an agreement for review of physicians and practitioners seeking privileges at the CAH. The agreement must be with a hospital that is a member of the network, a Medicare Quality Improvement Organization (QIO), or another qualified entity identified in the State's rural health plan. In addition, the services provided by each doctor of medicine or osteopathy at the CAH must be evaluated by one of these same three types of outside parties. These requirements apply to all physicians and practitioners seeking privileges at the hospital or CAH, regardless of whether services will be provided in-person and on-site at the hospital or CAH, or remotely through a telecommunications system. CMS regulations currently require hospitals and CAHs receiving telemedicine services to privilege each physician or practitioner providing services to its patients as if such practitioner were on-site.

Each CAH is required to have its privileging decisions made by either its governing body or the person responsible for the CAH.

In the past, hospitals that were accredited by the Joint Commission (TJC) were deemed to have met the Medicare CoPs, including the credentialing and privileging requirements, under TJC's statutory deeming authority. Section 125 of the Medicare Improvements for Patients and Providers Act of 2008 (Pub. L. 110-275, July 15, 2008) (MIPPA), terminated the statutory recognition of TJC's hospital accreditation program, effective July 15, 2010. The law requires TJC to secure CMS approval of its standards in order to confer Medicare deemed status on hospitals after July 15, 2010. This means that we do not have the discretion under the law to accept TJC policies or standards that do not meet or exceed the Medicare CoPs. One TJC policy that has been in direct conflict with the CoPs has been TJC's practice of permitting ``privileging by proxy,'' which has allowed TJC-accredited hospitals to utilize a different methodology to privilege ``distant-site'' (as that term is defined at section 1834(m)(4)(A) of the Social Security Act (the Act)) physicians and practitioners. In short, TJC privileging by proxy standards allowed for one TJC-accredited facility to accept the privileging decisions of another TJC-accredited facility. Hospitals that have used this method to privilege distant-site medical staff technically did not meet CMS requirements that applied to other hospitals even though they were TJC-accredited. When CMS learned of specific instances of such noncompliance through on-site surveys by State Survey Agencies, the hospital was required to change its policies to come into compliance.

As of July 15, 2010, TJC will be statutorily required to enforce CMS requirements regarding privileging physicians and practitioners in the hospitals they accredit, both those providing and those receiving telemedicine services. TJC-accredited hospitals, therefore, are concerned that they may be unable to meet the long-standing CMS privileging requirements while sustaining their current telemedicine agreements. Small hospital and CAH medical staffs, in particular, are concerned about the burden of privileging hundreds of specialty physicians and practitioners that large academic medical centers make available to them.

CMS has become increasingly aware, through outreach efforts and communications with the various stakeholders in the telemedicine community of the urgent need to revise the CoPs in this area so that access to these vital services may continue in a manner that is both safe and beneficial for patients and is free of unnecessary and duplicative regulatory impediments.

Provisions of the Proposed Rule

The following provisions of this proposed rule would apply to all hospitals and CAHs participating in the Medicare and Medicaid programs. We are proposing to revise both the hospital and CAH credentialing and privileging requirements to eliminate these regulatory impediments and allow for the advancement of telemedicine nationwide while still protecting the health and safety of patients.

For the Governing body CoP, we are proposing that, when telemedicine services are furnished to the hospital's patients through an agreement with a Medicare- participating hospital (the ``distant-site'' hospital as defined at section 1834(m)(4)(A) of the Act), the agreement must specify that it is the responsibility of the governing body of the distant-site hospital providing the telemedicine services to meet the existing requirements with regard to its physicians and practitioners who are providing telemedicine services.

These existing provisions cover the distant-site hospital's governing body responsibilities for its medical staff that all Medicare-participating hospitals must meet.

The proposed requirements at Sec. 482.12(a)(8) would allow the governing body of the hospital whose patients are receiving the telemedicine services to grant privileges based on its medical staff recommendations, which would rely on information provided by the distant-site hospital, as a more efficient means of privileging the individual distant-site physicians and practitioners providing the services.

This provision would be accompanied by the proposed requirement in the ``Medical staff' CoP at Sec. 482.22(a)(3), which would provide the basis on which the hospital's governing body, through its agreement as noted above, can choose to have its medical staff rely upon information furnished by the distant-site hospital when making recommendations on privileges for the individual physicians and practitioners providing such services. This option would allow the hospital's medical staff to rely upon the credentialing and privileging decisions of the distant-site hospital in lieu of the current requirements at Sec. 482.22(a)(1) and (a)(2), which require the hospital's medical staff to conduct individual appraisals of its members and examine the credentials of each candidate in order to make a privileging recommendation to the governing body. This option would not prohibit a hospital's medical staff from continuing to perform its own periodic appraisals of telemedicine members of its staff, nor would it bar them from continuing to use the traditional credentialing and privileging process required under the current regulations. The intent of this proposed requirement is to relieve burden for smaller hospitals by providing for a less duplicative and more efficient privileging scheme with regard to physicians and practitioners providing telemedicine services.

However, in an effort to ensure accountability to the process, we are proposing within this same provision (Sec. 482.22(a)(3)) that the hospital, in order to choose this less burdensome option for privileging, must ensure that--(1) The distant-site hospital providing the telemedicine services is a Medicare-participating hospital; (2) the individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician's or practitioner's privileges; (3) the individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital, whose patients are receiving the telemedicine services, is located; and (4) with respect to a distant-site physician or practitioner granted privileges by the hospital, the hospital has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site hospital this information for use in its periodic appraisal of the individual distant-site physician or practitioner. We are also proposing, at a minimum, the information sent for use in the periodic appraisal would have to include all adverse events that may result from telemedicine services provided by the distant-site physician or practitioner to the hospital's patients and all complaints the hospital has received about the distant-site physician or practitioner.

Within the revisions to the hospital CoPs, we are also proposing that additional language be added to the current requirement at Sec. 482.22(c)(6), which requires that the hospital's medical staff bylaws include criteria for determining privileges and a procedure for applying the criteria to individuals requesting privileges. We are proposing to add language to stipulate that in cases where distant-site physicians and practitioners are requesting privileges to furnish telemedicine services through an agreement between hospitals, the criteria for determining those privileges and the procedure for applying the criteria would be subject to the proposed requirements at Sec. 482.12(a)(8) and Sec. 482.22(a)(3).

Critical Access Hospital (CAH) CoPs (Sec. 485.616 and Sec. 485.641)

The proposed revisions to the CAH CoPs are found at Sec. 485.616, ``Agreements,'' and Sec. 485.641, ``Periodic evaluation and quality assurance review.'' However, the majority of the proposed revisions, particularly those which mirror the proposed hospital revisions, are found in the ``Agreements'' CoP, specifically Sec. 485.616(c). We are proposing to add a new standard at Sec. 485.616(c) entitled, ``Agreements for credentialing and privileging of telemedicine physicians and practitioners.'' The proposed telemedicine credentialing and privileging requirements for CAHs are modeled after the hospital requirements, with almost no differences in the regulatory language. Since the only existing requirements in the CAH CoPs specific to the responsibility of the governing body to grant medical staff privileges concerns surgical privileges for practitioners, we are proposing to add language that follows the language in the hospital requirements at Sec. 482.12(a). This language delineates the responsibilities of the governing body for the medical staff privileging process.

At Sec. 485.641(b)(4)(iv), we would make a minor change to the CAH CoPs that do not have an equivalent provision in the hospital CoPs. We are proposing to add a new requirement that would allow the distant-site hospital to evaluate the quality and appropriateness of the diagnosis and treatment furnished by its own staff when providing telemedicine services to the CAH. This proposed requirement would be in addition to the three other entities already allowed to perform this function under the existing regulations.

CMS Issues final 2011 Payment Policies for Medicare Advantage Prescription Drug Plans

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CMS Issues Final Medicare Part C AND D Policy and Technical Changes Regulation (CMS-4085-F)

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New CMS Policy Proposals

The Centers for Medicare & Medicaid Services (CMS) recently proposed the fiscal year (FY) 2011 policies and payment rates for inpatient services furnished to people with Medicare by both acute care hospitals and long-term care hospitals. The proposals are intended to ensure that Medicare pays appropriately for high quality, efficient, and safe inpatient care. The proposed rule does not address inpatient hospital related provisions of the recently enacted Patient Protection and Affordable Care Act, as amended by the Health Care and Education Affordability Reconciliation Act (collectively referred to as the “Affordable Care Act”). In the near future CMS expects to provide further information on the implementation of health care reform provisions in these laws that affect FY 2010 and FY 2011 IPPS payments.

CMS similarly is proposing to update long-term care hospital (LTCH) rates by 2.4 percent for inflation and apply an adjustment of -2.5 percentage points for the estimated increase in spending in FYs 2008 and 2009 due to documentation and coding that did not reflect increases in patients’ severity of illness. Based on these two proposed provisions and other proposed changes, CMS estimates that payments to LTCHs would increase by 0.8 percent or $41 million.

The proposed rule was placed on display at the Federal Register April 19, 2010, and can be found under Special Filings. CMS will accept comments on this proposed rule until June 18, and will respond to them in a final rule to be issued by August 1, 2010.

For more information, including supporting documentation, please visit CMS' website. In addition, more information about the proposed rule, including the documentation and coding adjustment, the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) changes, and a discussion of Hospital Acquired Conditions (HACs), can be found in Fact Sheets (3) on the CMS website.

Read the CMS Press release issued on April 19, 2010.

Please also note that within the proposed rule, there are several provisions affecting critical access hospitals (CAHs), as follows:

  • Reimbursement for Services of Certified Registered Nurse Anesthetists (CRNAs)
    CMS is proposing to allow hospitals and critical access hospitals (CAHs) that are geographically urban but have applied for and been granted rural status under a provision of Medicare law to receive reimbursement for anesthesia and related care furnished by qualified CRNAs on reasonable cost basis.
  • Removal of the Annual Election Requirement on Maintaining Method II Payment
    CMS is proposing a change so that once a CAH elects the optional or “Method II” payment method for outpatient services, that election remains in place until it is terminated by the CAH.
  • Clarification of Which Provider Taxes May Be Allowable Costs
    CMS regulations currently permit certain provider taxes to be treated as allowable costs if they are related to the reasonable and necessary cost of providing patient care and they are actually incurred. CMS is proposing to clarify that FI/MACs will determine whether provider taxes are allowable on a case-by-case basis, based on reasonable cost principles and will determine if a reduction of the allowable tax expenses is proper to account for payments providers receive that are associated with the assessed tax.