42 CFR §412.208

1. (a)General rule. CMS determines the Puerto Rico adjusted DRG prospective payment rate for inpatient operating costs for each inpatient hospital discharge occurring in Federal fiscal year 1988 for a prospective payment hospital. These rates are determined as described in paragraphs (b) through (i) of this section.
2. (b)Determining target amounts. For each hospital subject to the prospective payment system for inpatient operating costs, CMS determines the Medicare target amount, as described in § 413.40(c) of this chapter, for the hospital's cost reporting period beginning in fiscal year 1987. Revisions in the target amounts made subsequent to establishment of the standardized amounts under paragraph (d) of this section do not affect the standardized amounts.
3. (c)Updating the target amounts for fiscal year 1988. CMS updates each target amount determined under paragraph (b) of this section for fiscal year 1988 by prorating the applicable percentage increase (as defined in § 412.63(f) of this chapter) for fiscal year 1988 to the midpoint of fiscal year 1988 (April 1, 1988).
4. (d)Standardizing amounts. CMS standardizes the amount updated under paragraph (c) of this section for each hospital by—
   1. (1)Adjusting for variations in case mix among hospitals;
   2. (2)Excluding an estimate of indirect medical education costs;
   3. (3)Adjusting for area variations in hospital wage levels; and
   4. (4)Excluding an estimate of the payments for hospitals that serve a disproportionate share of low-income patients.
5. (e)Computing urban and rural averages. CMS computes separate discharge-weighted averages of the standardized amounts determined under paragraph (d) of this section for urban and rural hospitals in Puerto Rico.
6. (f)Geographic classification.
   1. (1)For purposes of this paragraph (e) of this section, the following definitions apply:
      1. (i)The term urban area means a Metropolitan Statistical Area (MSA), as defined by the Executive Office of Management and Budget.
      2. (ii)The term large urban area means an MSA with a population of more than 1,000,000.
      3. (iii)The term rural area means any area outside an urban area.
   2. (2)A hospital classified as rural is deemed to be urban and receives the urban Puerto Rico payment amount if the county in which it is located meets the following criteria:
      1. (i)At least 95 percent of the perimeter of the rural county is contiguous with urban counties.
      2. (ii)The county was reclassified from an urban area to a rural area after April 20, 1983, as described in § 412.62(f)(1)(iv).
      3. (iii)At least 15 percent of employed workers in the county commute to the central county of one of the adjacent MSAs.
7. (g)Reducing for value of outlier payments. CMS reduces each of the average standardized amounts determined under paragraphs (c) through (e) of this section by a proportion equal to the proportion (estimated by CMS) of the total amount of payments based on DRG prospective payment rates that are additional payments to hospitals located in Puerto Rico for outlier cases under subpart F of this part.
8. (h)Computing Puerto Rico rates established under the prospective payment system for inpatient operating costs for urban and rural hospitals. For each discharge classified within a DRG, CMS establishes a Puerto Rico prospective payment rate, as follows:
   1. (1)For hospitals located in an urban area, the rate equals the product of—
      1. (i)The average standardized amount (computed under paragraphs (c) through (g) of this section) for hospitals located in an urban area; and
      2. (ii)The weighting factor determined under § 412.60(b) for that DRG.
   2. (2)For hospitals located in a rural area, the rate equals the product of—
      1. (i)The average standardized amount (computed under paragraphs (c) through (g) of this section) for hospitals located in a rural area; and
      2. (ii)The weighting factor determined under § 412.60(b) for that DRG.
9. (i)Adjusting for different area wage levels. CMS adjusts the proportion (as estimated by CMS from time to time) of Puerto Rico rates computed under paragraph (h) of this section that are attributable to wages and labor-related costs, for area differences in hospital wage levels, by a factor (established by CMS) reflecting the relative hospital wage level in the geographic area (that is, urban or rural area as determined under the provisions of paragraph (f) of this section) of the hospital compared to the national average hospital wage level.