907 KAR 10:025. Reimbursement provisions and requirements regarding outpatient psychiatric hospital services

Link to law: http://www.lrc.ky.gov/kar/907/010/025reg.htm
Published: 2015

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CABINET FOR HEALTH AND

FAMILY SERVICES

Department for Medicaid

Services

Division of Policy and

Operations

(New Administrative

Regulation)

 

      907 KAR 10:025.

Reimbursement provisions and requirements regarding outpatient psychiatric

hospital services.

 

      RELATES TO: KRS 205.520, 42 U.S.C.

1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23)

      STATUTORY AUTHORITY: KRS 194A.030(2),

194A.050(1), 205.520(3)

      NECESSITY, FUNCTION, AND CONFORMITY: The

Cabinet for Health and Family Services, Department for Medicaid Services, has a

responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes

the cabinet, by administrative regulation, to comply with any requirement that

may be imposed or opportunity presented by federal law to qualify for federal

Medicaid funds. This administrative regulation establishes the reimbursement

provisions and requirements regarding Medicaid Program outpatient behavioral

health services provided by psychiatric hospitals to Medicaid recipients who

are not enrolled with a managed care organization.

 

      Section 1. (1) "Billing provider" means the individual who, group of

individual providers that, or organization that:

      (a) Is authorized to bill the department

or a managed care organization for a service; and

      (b) Is eligible to be reimbursed by the department

or a managed care organization for a service.

      (2) "Department" means

the Department for Medicaid Services or its designee.

      (3) "Federal

financial participation" is defined by 42 C.F.R. 400.203.

      (4) "Managed

care organization" means an entity for which the Department for Medicaid

Services has contracted to serve as a managed care organization as defined in

42 C.F.R. 438.2.

      (5) "Provider"

is defined by KRS 205.8451(7).

 

      Section 2. General Requirements. For the

department to reimburse for a service covered under this administrative

regulation, the service shall:

      (1) Meet the requirements established in

907 KAR 10:020; and

      (2) Be covered in accordance with 907 KAR

10:020.

 

      Section 3. Reimbursement. (1)(a) Except as

established in Section 4 of this administrative regulation, the department

shall reimburse a psychiatric hospital on an interim basis for outpatient behavioral

health services at a facility specific outpatient cost-to-charge ratio based on

the facility’s most recently filed cost report that has been reviewed and

approved by the department.

      (b) An outpatient behavioral health

service cost-to-charge ratio shall be expressed as a percent of the psychiatric

hospital’s outpatient behavioral health service charges.

      (2) Except as established in subsection

(4) of this section, a facility specific outpatient behavioral health service cost-to-charge

ratio paid during the course of a psychiatric hospital’s fiscal year shall be

designed to result in reimbursement, at the psychiatric hospital’s fiscal year

end, equaling ninety-five (95) percent of the psychiatric hospital’s total

outpatient behavioral health services costs, excluding diagnostic laboratory

services costs, incurred during the psychiatric hospital’s fiscal year.

      (3) Except as established in subsection

(4) of this section:

      (a) Upon reviewing a psychiatric

hospital’s as submitted cost report for the hospital’s fiscal year, the

department shall preliminarily settle reimbursement to the psychiatric hospital

equal to ninety-five (95) percent of the psychiatric hospital’s total

outpatient behavioral health services costs, excluding diagnostic laboratory

services costs, incurred in the corresponding fiscal year; and

      (b) Upon receiving and reviewing a

psychiatric hospital’s finalized outpatient behavioral health services cost

report for the hospital’s fiscal year, the department shall settle final reimbursement

to the facility equal to ninety-five (95) percent of the psychiatric hospital’s

total outpatient behavioral health services costs, excluding diagnostic

laboratory services costs, incurred in the corresponding fiscal year.

      (4)(a) The department’s total

reimbursement for psychiatric hospital outpatient behavioral health services

shall not exceed the aggregate limit established in 42 C.F.R. 447.321.

      (b) If projections indicate for a given

state fiscal year that reimbursing for a psychiatric hospital’s outpatient

behavioral health services at ninety-five (95) percent of costs would result in

the department’s total psychiatric hospital outpatient behavioral health service

reimbursement exceeding the aggregate limit established in 42 C.F.R. 447.321,

the department shall proportionately reduce the final psychiatric hospital outpatient

behavioral health service reimbursement for each psychiatric hospital to equal

a percent of costs which shall result in the total psychiatric hospital outpatient

behavioral health service reimbursement equaling the aggregate limit established

in 42 C.F.R. 447.321.

      (5) The department shall not reimburse

for a service billed by or on behalf of an entity or individual that is not a

billing provider.

 

      Section 4. Initial Interim Reimbursement and New

Hospital Reimbursement. (1)(a) Except as established in subsection (2) of this

section, until a psychiatric hospital has submitted to the department a cost

report containing twelve (12) months of outpatient behavioral health services cost

information that has been reviewed and approved by the department, the

department shall reimburse the psychiatric hospital on an interim basis for

outpatient behavioral health services using the most recently available statewide

average cost-to-charge ratio for in-state acute care hospitals.

      (b) The department shall update the

statewide average

in-state acute care hospital cost-to-charge ratio effective July 1 of each

year.

      (2)(a) After the department has

established a cost-to-charge ratio for at least two (2) psychiatric hospitals

pursuant to Section 3 of this administrative regulation, the department shall

reimburse on an interim basis a newly participating psychiatric hospital for

which a cost report containing twelve (12) months of outpatient behavioral

health services information has not been reviewed and approved by the

department, the statewide average cost-to-charge ratio of in-state psychiatric

hospitals.

      (b) The department shall update the

statewide average

in-state psychiatric hospital cost-to-charge ratio effective July 1 of each

year.

 

      Section 5. Cost Reporting Requirements. (1) A psychiatric

hospital participating in the Medicaid Program shall submit to the department a

copy of the Medicare cost report it submits to CMS, an electronic cost report

file (ECR), the Supplemental Medicaid Schedule KMAP-1, the Supplemental

Medicaid Schedule KMAP-4, and the Supplemental Medicaid Schedule KMAP-6.

      (a) A cost report shall be submitted:

      1. For the fiscal year used by the psychiatric

hospital; and

      2. Within five (5) months after the close

of the psychiatric hospital’s fiscal year.

      (b) Except as provided in subparagraphs 1,

2, or 3 of this paragraph, the department shall not grant a cost report

submittal extension.

      1. The department shall grant an

extension if an extension has been granted by Medicare. If an extension has

been granted by Medicare, when the facility submits its cost report to Medicare,

it shall simultaneously submit a copy of the cost report to the department.

      2. If a catastrophic circumstance exists,

as determined by the department (for example flood, fire, or other equivalent

occurrence), the department shall grant a thirty (30) day extension.

      3. The department shall extend the

deadline for a psychiatric hospital to submit a cost report if:

      a. The psychiatric hospital:

      (i) Requests the extension in writing;

and

      (ii) Describes the circumstances

necessitating the extension; and

      b. The department approves the extension.

      (c) A psychiatric hospital shall include

all Medicaid outpatient behavioral health services costs on the cost report

that it submits to:

      1. Medicare; and

      2. The department.

      (2)(a) If a cost report submittal date

lapses and no extension has been granted, the department shall immediately

suspend all payment to the psychiatric hospital for outpatient behavioral

health services until a complete cost report is received.

      (3) If a cost report indicates that payment

is due by a psychiatric hospital to the department, the psychiatric hospital

shall submit the amount due or submit a payment plan request with the cost report.

      (4) If a cost report indicates a payment

is due by a psychiatric hospital to the department and the psychiatric hospital

fails to remit the amount due or request a payment plan, the department shall

suspend future payment to the psychiatric hospital for outpatient behavioral

health services until the psychiatric hospital remits the payment or submits a

request for a payment plan.

      (5) An estimated payment shall not be

considered payment-in-full until a final determination of cost has been made by

the department.

      (6) A cost report submitted by a psychiatric

hospital to the department shall be subject to departmental audit and review.

      (7) Within seventy (70) days of receipt

from the Medicare intermediary, a hospital shall submit to the department a

printed copy of the final Medicare-audited cost report including adjustments.

      (8)(a) If it is determined that an

additional payment is due by a psychiatric hospital after a final determination

of cost has been made by the department, the additional payment shall be due by

a hospital to the department within sixty (60) days after notification.

      (b) If a psychiatric hospital does not

submit the additional payment within sixty (60) days, the department shall

withhold future payment to the psychiatric hospital until the department has

collected in full the amount owed by the psychiatric hospital to the department.

 

      Section 6. Outpatient Psychiatric Hospital

Laboratory Services Reimbursement.

      (1) The department shall reimburse for an

in-state or out-of-state outpatient psychiatric hospital diagnostic laboratory

service:

      (a) At the Medicare-established technical

component rate for the service in accordance with 907 KAR 1:028 if a

Medicare-established component rate exists for the service; or

      (b) By multiplying the facility’s current

outpatient cost-to-charge ratio by its billed laboratory charges if no Medicare

rate exists for the service.

      (2) Laboratory service reimbursement, in

accordance with subsection (1) of this section, shall be:

      (a) Final; and

      (b) Not settled to cost.

 

      Section 7. Out-of-State Outpatient

Psychiatric Hospital Services Reimbursement.

      (1)(a) Except as established in paragraph

(b) of this subsection, excluding laboratory services, reimbursement for

psychiatric hospital outpatient behavioral health services provided by an

out-of-state hospital shall equal ninety-five (95) percent of the statewide average

in-state psychiatric hospital cost-to-charge ratio multiplied by the applicable

covered Medicaid charges for the service.

      (b) The department shall update the

statewide average

in-state psychiatric hospital cost-to-charge ratio effective July 1 of each

year.

      (2) Out-of-state hospital reimbursement, in

accordance with subsection (1) of this section, shall be:

      (a) Final; and

      (b) Not settled to cost.

 

      Section 8. Not Applicable to Managed Care

Organizations. A managed care organization shall not be required to reimburse

in accordance with this administrative regulation for a service covered

pursuant to:

      (1) 907 KAR 10:020; and

      (2) This administrative regulation.

 

      Section 9. Federal Approval and Federal

Financial Participation. The department’s reimbursement for services pursuant

to this administrative regulation shall be contingent upon:

      (1) Receipt of federal financial

participation for the reimbursement; and

      (2) Centers for Medicare and Medicaid

Services’ approval for the reimbursement.

 

      Section 10. Appeals. A psychiatric hospital may

appeal a decision by the department regarding the application of this administrative

regulation in accordance with 907 KAR 1:671.

 

      Section 11. Incorporation by Reference.

(1) The following material is incorporated by reference:

      (a) "Supplemental Worksheet E-3,

Part III", May 2004;

      (b) "Supplemental Medicaid Schedule

KMAP-1", January 2007;

      (c) "Supplemental Medicaid Schedule

KMAP-4", January 2007;

      (d) The "Supplemental

Medicaid Schedule KMAP-5", November 2011; and

      (e) "Supplemental Medicaid Schedule

KMAP-6", January 2007.

      (2) This material may be inspected,

copied, or obtained, subject to applicable copyright law:

      (a) At the Department for Medicaid

Services, 275 East Main Street, Frankfort, Kentucky 40601, Monday through

Friday, 8 a.m. to 4:30 p.m.; or

      (b) Online at the department’s Web site

at http://www.chfs.ky.gov/dms/incorporated.htm.

 

LISA LEE, Commissioner

AUDREY TAYSE HAYNES, Secretary

      APPROVED BY AGENCY: April 10, 2015

      FILED WITH LRC: April 13, 2015 at 3 p.m.

      PUBLIC HEARING AND

PUBLIC COMMENT PERIOD: A public hearing on this

administrative regulation shall, if requested, be held on May 22, 2015 at 9:00

a.m. in the Health Services Auditorium, Suite B, Health Services

Building, First Floor, 275 East Main Street, Frankfort, Kentucky 40621. Individuals interested in attending this hearing

shall notify this agency in writing by May 15, 2015 five (5) workdays prior to

the hearing, of their intent to attend. If no notification of intent to attend

the hearing is received by that date, the hearing may be canceled. The hearing

is open to the public. Any person who attends will be given an opportunity to

comment on the proposed administrative regulation. A transcript of the public

hearing will not be made unless a written request for a transcript is made. If

you do not wish to attend the public hearing, you may submit written comments

on the proposed administrative regulation. You may submit written comments

regarding this proposed administrative regulation until close of business June

1, 2015. Send written notification of intent to attend the public hearing or

written comments on the proposed administrative regulation to:

      CONTACT

PERSON: Tricia Orme, Office of Legal Services, 275 East Main Street 5 W-B,

Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573, tricia.orme@ky.gov.

 

REGULATORY IMPACT

ANALYSIS And Tiering Statement

 

Contact person: Stuart Owen (502) 564-4321

      (1) Provide a brief summary of:

      (a) What this administrative regulation

does: This new administrative regulation establishes the reimbursement

provisions and requirements regarding Medicaid Program outpatient behavioral

health services provided by psychiatric hospitals. This administrative

regulation is being promulgated in conjunction with 907 KAR 10:020 (Coverage

provisions and requirements regarding psychiatric hospital outpatient

behavioral health services). Psychiatric hospitals are authorized to provide,

to Medicaid recipients, outpatient behavioral health services related to a

mental health disorder, substance use disorder, or co-occurring disorders. The

array of services includes a screening; an assessment; psychological testing;

crisis intervention; mobile crisis services; day treatment; peer support; parent

or family peer support; intensive outpatient program services; individual outpatient

therapy; group outpatient therapy; family outpatient therapy; collateral

outpatient therapy; service planning; a screening, brief intervention, and

referral to treatment for a substance use disorder; assertive community treatment;

comprehensive community support services; and therapeutic rehabilitation

program services. The Department for Medicaid Services (DMS) will ultimately

reimburse a psychiatric hospital ninety-five (95) percent of the hospital’s

costs for outpatient behavioral health services. To achieve this each psychiatric

hospital will annually submit a cost report identifying all of the hospital’s

outpatient behavioral health services’ costs incurred for the given fiscal

year. DMS will review and audit the report and compare the reimbursement paid

to the hospital on an interim basis (during the course of the given fiscal

year) to the psychiatric hospital’s incurred costs. If DMS’s interim

reimbursement exceeded the psychiatric hospital’s incurred costs for the fiscal

year, the psychiatric hospital will remit the amount due back to DMS. If DMS’s interim

reimbursement was less than the psychiatric hospital’s costs, DMS will send the

amount owed to the psychiatric hospital to equate to the incurred costs. DMS

will use the most recent cost report to establish an interim reimbursement

(cost-to-charge ratio) to pay the psychiatric hospital during the course of the

fiscal year. For the initial year, as no cost report yet exists, DMS will pay

on an interim basis a reimbursement equal to the statewide average

cost-to-charge ratio for acute care hospitals.

      (b) The necessity of this administrative

regulation: This administrative regulation is necessary to comply with federal

mandates. Section 1302(b)(1)(E) of the Affordable Care Act mandates that

"essential health benefits" for Medicaid programs include

"mental health and substance use disorder services, including behavioral

health treatment" for all recipients. 42 U.S.C. 1396a(a)(23), is known as

the freedom of choice of provider mandate. This federal law requires the

Medicaid Program to "provide that (A) any individual eligible for medical

assistance (including drugs) may obtain such assistance from any institution,

agency, community pharmacy or person, qualified to perform the service or

services required (including an organization which provides such services, or

arranges for their availability, on a prepayment basis), who undertakes to

provide him such services." 42 U.S.C. 1396a(a)(10)(B) requires the

Medicaid Program to ensure that services are available to Medicaid recipients

in the same amount, duration, and scope. Expanding the provider base (to

include psychiatric hospitals) will help ensure Medicaid recipient access to

services statewide and reduce or prevent the lack of availability of services

due to demand exceeding supply in any given area.

      (c) How this administrative regulation

conforms to the content of the authorizing statutes: This administrative

regulation conforms to the content of the authorizing statutes by complying

with federal mandates and enhancing and ensuring Medicaid recipients’ access to

behavioral health services.

      (d) How this administrative regulation

currently assists or will assist in the effective administration of the

statutes: This administrative regulation will assist in the effective

administration of the authorizing statutes by complying with federal mandates

and enhancing and ensuring Medicaid recipients’ access to behavioral health services.

      (2) If this is an amendment to an

existing administrative regulation, provide a brief summary of:

      (a) How the amendment will change this

existing administrative regulation: This is a new administrative regulation.

      (b) The necessity of the amendment to

this administrative regulation: This is a new administrative regulation.

      (c) How the amendment conforms to the

content of the authorizing statutes: This is a new administrative regulation.

      (d) How the amendment will assist in the

effective administration of the statutes: This is a new administrative

regulation.

      (3) List the type and number of

individuals, businesses, organizations, or state and local government affected

by this administrative regulation: Psychiatric hospitals, behavioral health

professionals authorized to provide outpatient behavioral health services in psychiatric

hospitals, and Medicaid recipients in need of outpatient behavioral health

services will be affected by the administrative regulation. Currently, there

are twelve (12) psychiatric hospitals enrolled in the Medicaid Program. The

following behavioral health professionals are authorized to provide outpatient

behavioral health services in a psychiatric hospital: licensed psychologists,

advanced practice registered nurses, licensed professional clinical counselors,

licensed clinical social workers, licensed marriage and family therapists, licensed

psychological practitioners, licensed psychological associates, certified

social workers, licensed professional counselor associates, marriage and family

therapy associates, licensed behavior analysts, licensed assistant behavior

analysts, licensed professional art therapists, licensed professional art

therapist associates, certified alcohol and drug counselors, peer support

specialists, and community support associates.

      (4) Provide an analysis of how the

entities identified in question (3) will be impacted by either the

implementation of this administrative regulation, if new, or by the change, if

it is an amendment, including:

      (a) List the actions that each of the

regulated entities identified in question (3) will have to take to comply with

this administrative regulation or amendment. Psychiatric hospitals who wish to

provide outpatient behavioral health services will need to comply with the

service requirements.

      (b) In complying with this administrative

regulation or amendment, how much will it cost each of the entities identified

in question (3). No cost is projected.

      (c) As a result of compliance, what

benefits will accrue to the entities identified in question (3). Psychiatric

hospitals will benefit by receiving Medicaid Program reimbursement for

outpatient behavioral health services. Behavioral health professionals

authorized to provide outpatient behavioral health services will benefit by

having more employment opportunities in Kentucky. Medicaid recipients in need

of outpatient behavioral health services will benefit from an expanded base of

providers from which to receive these services.

      (5) Provide an estimate of how much it will

cost to implement this administrative regulation:

      (a) Initially: DMS is unable to

accurately estimate the costs of expanding the outpatient behavioral health services

provider base due to the variables involved as DMS cannot estimate the

utilization of these services in psychiatric hospitals compared to utilization

in other authorized provider settings (independent behavioral health providers,

community mental health centers, federally-qualified health centers, rural

health clinics, and primary care centers.) However, an actuary with whom DMS

contracted has estimated an average per recipient per month increase (to DMS)

of $27.00 associated with DMS’s expansion of behavioral health services

(including substance use disorder services) as well as behavioral health

providers this year.

      (b) On a continuing basis: The response

in paragraph (a) also applies here.

      (6) What is the source of the funding to

be used for the implementation and enforcement of this administrative

regulation: The sources of revenue to be used for implementation and enforcement

of this administrative regulation are federal funds authorized under the Social

Security Act, Title XIX and matching funds of general fund appropriations.

      (7) Provide an assessment of whether an

increase in fees or funding will be necessary to implement this administrative

regulation, if new, or by the change if it is an amendment. Neither an increase

in fees nor funding is necessary to implement this administrative regulation.

      (8) State whether or not this administrative

regulation establishes any fees or directly or indirectly increases any fees:

This administrative regulation neither establishes nor increases any fees.

      (9) Tiering: Is tiering applied? Tiering

is not applied as the policies apply equally to the regulated entities.

 

FEDERAL MANDATE ANALYSIS

COMPARISON

 

      1. Federal statute or regulation

constituting the federal mandate. Section 1302(b)(1)(E) of the Affordable Care

Act, 42 U.S.C. 1396a(a)(10)(B), 42 U.S.C. 1396a(a)(23), and 42 U.S.C.

1396a(a)(30)(A).

      2. State compliance standards. KRS

205.520(3) states: "Further, it is the policy of the Commonwealth to take

advantage of all federal funds that may be available for medical assistance. To

qualify for federal funds the secretary for health and family services may by

regulation comply with any requirement that may be imposed or opportunity that

may be presented by federal law. Nothing in KRS 205.510 to 205.630 is intended

to limit the secretary's power in this respect."

      3. Minimum or uniform standards contained

in the federal mandate. Substance use disorder services are federally mandated

for Medicaid programs. Section 1302(b)(1)(E) of the Affordable Care Act

mandates that "essential health benefits" for Medicaid programs

include "mental health and substance use disorder services, including

behavioral health treatment." 42 U.S.C. 1396a(a)(23), is known as the

freedom of choice of provider mandate. This federal law requires the Medicaid

Program to "provide that (A) any individual eligible

for medical assistance (including drugs) may obtain such assistance from any

institution, agency, community pharmacy or person, qualified to perform the

service or services required (including an organization which provides such

services, or arranges for their availability, on a prepayment basis), who

undertakes to provide him such services." Medicaid recipients enrolled

with a managed care organization may be restricted to providers within the

managed care organization’s provider network. The Centers for Medicare and Medicaid

Services (CMS) – the federal agency which oversees and provides the federal

funding for Kentucky’s Medicaid Program – has expressed to the Department for

Medicaid Services (DMS) the need for DMS to expand its substance use disorder

provider base to comport with the freedom of choice of provider requirement. 42

U.S.C. 1396a(a)(10)(B) requires the Medicaid Program to ensure that services

are available to Medicaid recipients in the same amount, duration, and scope as

available to other individuals (non-Medicaid.) Expanding the provider base will

help ensure Medicaid recipient access to services statewide and reduce or

prevent the lack of availability of services due to demand exceeding supply in

any given area. Similarly, 42 U.S.C. 1396a(a)(30)(A) requires Medicaid state

plans to: "...provide such methods and procedures

relating to the utilization of, and the payment for, care and services

available under the plan (including but not limited to utilization review plans

as provided for in section 1903(i)(4)) as may be necessary to safeguard against

unnecessary utilization of such care and services and to assure that payments

are consistent with efficiency, economy, and quality of care and are sufficient

to enlist enough providers so that care and services are available under the

plan at least to the extent that such care and services are available to the

general population in the geographic area."

      4. Will this administrative regulation

impose stricter requirements, or additional or different responsibilities or

requirements, than those required by the federal mandate? The administrative

regulation does not impose stricter than federal requirements.

      5. Justification for the imposition of

the stricter standard, or additional or different responsibilities or requirements.

The administrative regulation does not impose stricter than federal

requirements.

 

FISCAL NOTE ON STATE OR

LOCAL GOVERNMENT

 

      1. What units, parts or divisions of

state or local government (including cities, counties, fire departments, or

school districts) will be impacted by this administrative regulation? The Department

for Medicaid Services will be affected by the amendment to this administrative

regulation.

      2. Identify each state or federal statute

or federal regulation that requires or authorizes the action taken by the

administrative regulation. KRS 194A.030(2), 194A.050(1), 205.520(3).

      3. Estimate the effect of this

administrative regulation on the expenditures and revenues of a state or local

government agency (including cities, counties, fire departments, or school districts)

for the first full year the administrative regulation is to be in effect.

      (a) How much revenue will this

administrative regulation generate for the state or local government (including

cities, counties, fire departments, or school districts) for the first year?

The amendment is not expected to generate revenue for state or local

government.

      (b) How much revenue will this

administrative regulation generate for the state or local government (including

cities, counties, fire departments, or school districts) for subsequent years?

The amendment is not expected to generate revenue for state or local

government.

      (c) How much will it cost to administer

this program for the first year? DMS is unable to accurately estimate the costs

of expanding the outpatient behavioral health services provider base due to the

variables involved as DMS cannot estimate the utilization of these services in psychiatric

hospitals compared to utilization in other authorized provider settings (independent

behavioral health providers, community mental health centers,

federally-qualified health centers, rural health clinics, and primary care

centers.) However, an actuary with whom DMS contracted has estimated an average

per recipient per month increase (to DMS) of $27 associated with DMS’s expansion

of behavioral health services (including substance use disorder services) as

well as behavioral health providers this year.

      (d) How much will it cost to administer

this program for subsequent years? The response to question (c) also applies

here.

      Note: If specific

dollar estimates cannot be determined, provide a brief narrative to explain the

fiscal impact of the administrative regulation.

      Revenues (+/-):

      Expenditures (+/-):

      Other Explanation: