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<strong>CMS</strong>-1403-FC<br />

provisions in this final notice. (For a detailed<br />

explanation of the multi-campus and New England deemed<br />

counties policies, refer to the CY 2009 PFS proposed rule<br />

(73 FR 38531 through 38532)).<br />

c. Budget Neutrality Adjustment<br />

Section 1881(b)(12)(E)(i) of the Act, as added by<br />

section 623(d) of the MMA, requires that any revisions to<br />

the ESRD composite rate payment system as a result of the<br />

MMA provision (including the geographic adjustment), be<br />

made in a budget neutral manner. <strong>This</strong> means that aggregate<br />

payments to ESRD facilities in CY 2008 should be the same<br />

as aggregate payments that would have <strong>been</strong> made if we had<br />

not made any changes to the geographic adjusters. We note<br />

that this BN adjustment only addresses the impact of<br />

changes in the geographic adjustments. A separate BN<br />

adjustment was developed for the case-mix adjustments<br />

currently in effect. As we did not propose any changes to<br />

the case-mix measures for CY 2009, the current case-mix BN<br />

adjustment will remain in effect for CY 2009. As in<br />

CY 2008, for CY 2009, we again proposed to apply a BN<br />

adjustment factor directly to the ESRD wage index values.<br />

As explained in the CY 2007 PFS final rule with comment<br />

period (71 FR 69687 through 69688), we believe this is the<br />

simplest approach because it allows us to maintain our base<br />

192

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