10A NCAC 22G .0204. DISPROPORTIONATE SHARE HOSPITALS (DSH)

(a)  Hospitals that serve a disproportionate share of low‑income patients and have Medicaid inpatient utilization rate of not less than one percent are eligible to receive rate adjustments.  The cost report data and financial information that is required in order to qualify as a disproportionate share hospital effective April 1, 1991 is based on the fiscal year ending in 1989 for each hospital, as submitted to the Division of Medical Assistance (Division) on or before April 1, 1991.  The cost report data and financial information to qualify as a disproportionate share hospital effective July 1, 1991 is based on the fiscal year ending in 1990 for each hospital, as submitted to the Division of Medical Assistance on or before September 1, 1991.  In subsequent years, qualifications effective any particular year are based on most recent available information. The patient days, costs, revenues, or charges related to nursing facility services, swing‑bed services, home health services, outpatient services, or any other service that is not a hospital inpatient service cannot be used to qualify for disproportionate share status.  A hospital is deemed to be a disproportionate share hospital if it meets the criteria of Subparagraph (a)(1) and one of the criteria included in Subparagraphs (a)(2) through (a)(6) of this Rule.

(1)           The hospital has at least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals eligible for Medicaid.  In the case of a hospital located in a rural area, as defined in Title XVIII, Section 1886(d)(2)(D) the term obstetrician includes any physician with staff privileges at the hospital to perform non-emergency obstetric services as of December 21, 1987 or at a hospital that predominantly serves individuals under 18 years of age.

(2)           The hospital's Medicaid inpatient utilization rate, defined as the percentage resulting from dividing Medicaid patient days by total patient days, is at least one standard deviation above the mean Medicaid inpatient utilization rate for all hospitals that receive Medicaid payments in the state.

(3)           The hospital's low income utilization rate exceeds 25 percent.  The low-income utilization rate is the sum of:

(A)          The ratio of the sum of Medicaid inpatient revenues plus cash subsidies received from the State and local governments, divided by the hospital's total patient revenues; and

(B)          The ratio of the hospital's gross inpatient charges for charity care less the cash subsidies for inpatient care received from the State and local governments divided by the hospital's total inpatient charges.

(4)           The sum of the hospital's Medicaid revenues, bad debts allowance net of recoveries, and charity care exceeds 20 percent of gross patient revenues.

(5)           The hospital, in ranking of hospitals in the State, from most to least in number of Medicaid patient days provided, is among the top group that accounts for 50 percent of the total Medicaid patient days provided by all hospitals in the State. 

(6)           It is a Psychiatric hospital operated by the North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, Substance Abuse Services (DMH/DD/SAS) or UNC Hospitals operated by the University of North Carolina.

(b)  The rate adjustment for a disproportionate share hospital is 2.5 percent plus one fourth of one percent for each percentage point that a hospital's Medicaid inpatient utilization rate exceeds one standard deviation of the mean Medicaid inpatient utilization rate in the State.  The rate adjustment is applied to a hospital's payment rate exclusive of any previous disproportionate share adjustments.

(c)  Effective July 1, 1994, hospitals eligible under Subparagraph (a)(6) of this Rule shall be eligible for disproportionate share payments, in addition to other payments made under the North Carolina Medicaid Hospital reimbursement methodology, from a disproportionate share pool under the circumstances specified in Subparagraphs (c)(1), (2) and (3) of this Rule.

(1)           An eligible hospital shall receive a monthly disproportionate share payment based on the monthly bed days of services to low income persons of each hospital divided by the total monthly bed days of services to low income persons of all hospitals items allocated funds.

(2)           This payment shall be in addition to the disproportionate share payments made in accordance with Subparagraphs (a)(1) through (5) of this Rule.  However, DMH/DD/SAS operated hospitals are not required to qualify under the requirements of Subparagraphs (a)(1) through (5) of this Rule.

(3)           The amount of allocated funds shall be determined by the Director of the Division of Medical Assistance, but not to exceed the quarterly grant award of funds (plus appropriate non‑federal match) earmarked for disproportionate share hospital payments less payments made under Subparagraphs (a)(1) through (5) of this Rule divided by three. 

In Subparagraph (c)(1) of this Rule, bed days of services to low income persons is defined as the number of bed days provided to individuals that have been determined by the hospital as patients that do not possess the financial resources to pay portions or all charges associated with care provided.  Low income persons include those persons that have been determined eligible for medical assistance.  The count of bed days used to determine payment is based upon the month immediately prior to the month that payments are made.  Disproportionate share payments to hospitals are limited in accordance with The Social Security Act as amended, Title XIX section 1923(g), limit on amount of payment to hospitals.

(d)  Subject to the availability of funds, hospitals licensed by the State of North Carolina shall be eligible for disproportionate share payments for such services from a disproportionate share pool under the following conditions and circumstances:

(1)           For purposes of this paragraph eligible hospitals are hospitals that for the fiscal year for which payments are being made and for the most recent fiscal year that data is available:

(A)          Qualify as disproportionate share hospitals under Subparagraphs (a)(1) through (a)(5) of this Rule;

(B)          Operate Medicare approved graduate medical education programs and reported on cost reports filed with the Division of Medical Assistance Medicaid costs attributable to such programs;

(C)          Incur unreimbursed costs (calculated without regard to payments under either this Paragraph or Paragraph (f) of this Rule) for providing inpatient and outpatient services to uninsured patients in an amount in excess of two million five hundred thousand dollars ($2,500,000.00); and

(D)          Meet the definition of qualified public hospitals set forth in Subparagraph (6) of this Paragraph;

(2)           Qualification for 12-month periods ending September 30th of each year shall be based on the most recent cost report data and uninsured patient data filed with and certified to the Division at least 60 days prior to the date of any payment under this Paragraph. 

(3)           Based on availability of funds, payments authorized by this Paragraph shall be made no more frequently than quarterly or less frequently than annually, based on available information.  If quarterly payments are made, the fourth quarter payment shall take into consideration available information for the full year.

(4)           In 12-month periods ending September 30th of each year, the percentage payment shall be ascertained and established by the Division by ascertaining funds available for payments pursuant to this Paragraph divided by the total unreimbursed costs of all hospitals that qualify for payments under this Paragraph for providing inpatient and outpatient services to uninsured patients.

(5)           The payment limits of the Social Security Act, Title XIX, Section 1923(g)(1) applied to the payments authorized by this Paragraph require on a hospital-specific basis that when this payment is added to other disproportionate share hospital payments, the total disproportionate share payments shall not exceed the percentage specified by the Social Security Act, Title XIX, Section 1923(g) of the total costs of providing inpatient and outpatient services to Medicaid and uninsured patients for the fiscal year in which such payments are made, less all payments received for services to Medicaid and uninsured patients.  The total of all disproportionate share hospital payments shall not exceed the limits on disproportionate share hospital funding as established for this State by HCFA in accordance with the provisions of the Social Security Act, Title XIX, Section 1923(f).

(6)           For purposes of this Paragraph, a qualified public hospital is a hospital that:

(A)          Qualifies for disproportionate share hospital status under Subparagraphs (a)(1) through (5) of this Rule;

(B)          Does not qualify for disproportionate share hospital status under Subparagraph (a)(6) of this Rule;

(C)          Was owned or operated by a State (or by an instrumentality or a unit of government within a State) during the period for which payments under this Paragraph are being ascertained;

(D)          Verified its status as a public hospital by certifying state, local, hospital district or authority government control on the most recent version of Form HCFA-1514 filed with the Health Care Financing Administration, U.S. Department of Health and Human Services at least 30 days prior to the date of any payment under this Subparagraph that is still valid as of the date of any such payments;

(E)           Files with the Division at least 60 days prior to the date of any payment under this Paragraph by use of a form prescribed by the Division a certification of its unreimbursed charges for inpatient and outpatient services provided to uninsured patients either during the fiscal year immediately preceding the period for which payments under this Paragraph are being ascertained or during the most recent fiscal year that data is available; and

(F)           Submits to the Division on or before 10 working days prior to the date any such payments under this Paragraph by use of a form prescribed by the Division a certification of expenditures eligible for FFP as described in 42 C.F.R. 433.51(b).

(e)  To ensure that the estimated payments pursuant to Subparagraph (d) do not exceed the upper limits to such payments established by applicable federal law and regulation described in Subparagraph (d)(5) of this Rule, such payments shall be cost settled within 12-months of receipt of the completed and audited Medicare/Medicaid cost report for the fiscal year for which such payments are made.  If any hospital received payments pursuant to Subparagraph (d) in excess of the percentage established by the Director under Subparagraph (d)(3) or (d)(4) of this Rule, ascertained without regard to other disproportionate share hospital payments that may have been received for services during the 12-month period ending September 30th for which such payments were made, such excess payments shall be refunded to the Division.  No additional payment shall be made to qualified hospitals in connection with the cost settlement.  The payments authorized by Subparagraph (d) of this Rule shall be effective in accordance with G.S. 108A-55(c).

(f)  Additional disproportionate share hospital payments for the 12-month periods ending September 30th of each year (subject to the availability of funds and to the payment limits specified in this Paragraph) shall be paid to qualified public hospitals licensed by the State of North Carolina.  For purposes of this Paragraph, a qualified public hospital is a hospital that:

(1)           Qualifies for disproportionate share hospital status under Subparagraphs (a)(1) through (5) of this Rule;

(2)           Does not qualify for disproportionate share hospital status under Subparagraph (a)(6) of this Rule;

(3)           Was owned or operated by a State (or by an instrumentality or a unit of government within a State) during the period for which payments under this Paragraph are being ascertained;

(4)           Verified its status as a public hospital by certifying state, local, hospital district or authority government control on the most recent version of Form HCFA-1514 filed with the Health Care Financing Administration, U.S. Department of Health and Human Services at least 30 days prior to the date of any payment under this Subparagraph that is still valid as of the date of any such payment;

(5)           Files with the Division at least 60 days prior to the date of any payment under this Paragraph by use of a form prescribed by the Division a certification of its unreimbursed charges for inpatient and outpatient services provided to uninsured patients either during the fiscal year immediately preceding the period for which payments under this Paragraph are being ascertained or during the most recent fiscal year that data is available.

(6)           Submits to the Division on or before 10 working days prior to the date of any such payment under this Paragraph by use of a form prescribed by the Division a certification of expenditures eligible for FFP as described in 42 C.F.R. 433.51(b).

(7)           The payments to qualified public hospitals pursuant to this Paragraph for any given period shall be based on and shall not exceed the unreimbursed charges certified to the Division by each such hospital by use of a form prescribed by the Division for inpatient and outpatient services provided to uninsured patients either for the fiscal year immediately preceding the period for which payments under this Paragraph are being ascertained or during the most recent fiscal year that data is available, to be converted by the Division to unreimbursed cost by multiplying unreimbursed charges times the cost-to-charge ratio established by the Division for each hospital for the fiscal year during which such charges were incurred.  Based on availability of funds, payments authorized by this paragraph shall be made no more frequently than quarterly or less frequently than annually, based on available information.  If quarterly payments are made, the fourth quarter payment shall take into consideration available information for the full year.

(8)           Any payments pursuant to this Paragraph shall be ascertained, paid and cost settled after any other disproportionate share hospital payments that may have been or may be paid by the Division for the same fiscal year.

(9)           The payment limits of the Social Security Act, Title XIX, Section 1923(g)(1) applied to the payments authorized by this Paragraph require on a hospital-specific basis that when such payments are added to other disproportionate share hospital payments, the total disproportionate share hospital payments shall not exceed the percentage specified by the Social Security Act, Title XIX, Section 1923(g) of the total costs of providing inpatient and outpatient services to Medicaid and uninsured patients for the fiscal year in which such payments are made, less all payments received for services to Medicaid and uninsured patients for that year.  The total of all DSH payments by the Division shall not exceed the limits on Disproportionate Share hospital funding as established for this State by HCFA in accordance with the provisions of the Social Security Act, Title XIX, Section 1923(f) for the fiscal year in which such payments are made.

(10)         To ensure that estimated payments pursuant to this Paragraph do not exceed the upper limits to such payments described in Subparagraph (f)(6) of this Rule and established by applicable federal law and regulation, such payments shall be cost settled within 12-months of receipt of the completed and audited Medicare/Medicaid cost report for the fiscal year for which such payments are made.  The federal portion of any payments in excess of either of the upper limits described in Subparagraph (f)(6) of this Rule shall be promptly repaid.  Subject to the availability of funds, and to the upper limits described in Subparagraph (d)(5) of this Rule, additional payments shall be made as part of the cost settlement process to hospitals qualified for payment under this Paragraph in an amount not to exceed the hospital-specific upper limit for each such hospital.

(11)         The payments authorized by this Paragraph shall be effective in accordance with G.S. 108A-55 (c).

(g)  Effective with dates of payment beginning October 31, 1996, hospitals that provide services to clients of state agencies are considered to be a disproportionate share hospital (DSH) when the following conditions are met:

(1)           The hospital has a Medicaid inpatient utilization rate not less than one percent and has met the requirements of Subparagraph (a)(1) of this Rule; and

(2)           The state agency has entered into a Memorandum of Understanding (MOU) with the Division of Medical Assistance (Division); and

(3)           The inpatient and outpatient services are authorized by the state agency for which the uninsured client meets the program requirements.

(A)          For purposes of this Paragraph, uninsured patients are those clients of the state agency that have no third parties responsible for any hospital services authorized by the state agency. 

(B)          DSH payments are paid for services to qualified uninsured clients on the following basis:

(i)            For inpatient services the amount of the DSH payment is determined by the state agency in accordance with the applicable Medicaid inpatient payment methodology as stated in Rule .0202 of this Section.

(ii)           For outpatient services the amount of the DSH payment is determined by the state agency in accordance with the applicable Medicaid outpatient payment methodology as stated in Session Law 2002-126, Part X, Subpart 2. Division of Medical Assistance.

(iii)          No federal funds are utilized as the non-federal share of authorized payments unless the federal funding is specifically authorized by the federal funding agency as eligible for use as the non-federal share of payments.

(C)          Based upon this Subparagraph, DSH payments as submitted by the state agency shall be paid monthly in an amount to be reviewed and approved by the Division of Medical Assistance.  The total of all payments shall not exceed the limits on disproportionate share hospital funding as set forth for the state by HCFA.

(h)  Additional disproportionate share hospital payments for the 12-month periods ending September 30th of each year (subject to the availability of funds and to the payment limits specified in this Paragraph) shall be paid to hospitals licensed by the State of North Carolina that qualify for disproportionate share hospital status under Subparagraph (a)(1) through (5) of this Rule and provide inpatient or outpatient hospital services to Medicaid Health Maintenance Organization (HMO) enrollees during the period for which payments under this Paragraph are being ascertained. 

(1)           For purposes of this Paragraph, a Medicaid HMO enrollee is a Medicaid beneficiary who receives Medicaid services through a Medicaid HMO.  A Medicaid HMO is a Medicaid managed care organization, as defined in the Social Security Act, Title XIX, Section 1903(m)(1)(A), that is licensed as an HMO and provides or arranges for services for enrollees under a contract pursuant to the Social Security Act, Title XIX, Section 1903 (m)(2)(A)(i) through (xi).

(2)           To qualify for a DSH payment under this Paragraph, a hospital shall also file with the Division at least 10 working days prior to the date of any payment under this Paragraph by use of a form prescribed by the Division a certification of its charges for inpatient and outpatient services provided to Medicaid HMO enrollees either during the fiscal year immediately preceding the period for which payments under this Paragraph are being ascertained or during the most recent fiscal year that data is available.

(3)           The payments to qualified hospitals pursuant to this Paragraph for any given period shall be based on charges certified to the Division by each hospital by use of a form prescribed by the Division for inpatient and outpatient Medicaid HMO services either for the fiscal year immediately preceding the period for which payments under this Paragraph are being ascertained or during the most recent fiscal year that data is available to be converted by the Division to cost by multiplying charges times the cost-to-charge ratio established by the Division for each hospital for the fiscal year during which such charges were incurred.  The payment shall then be determined by multiplying the cost times a percentage determined annually by the Division.  The payment percentage established by the Division shall be calculated to ensure that the Medicaid HMO DSH payment authorized by this Paragraph is equivalent as a percentage of reasonable cost to the Medicaid Supplemental payment (calculated without regard to the certified public expenditures portion of such payment) authorized by Paragraph (e) of Rule .0203 of this Section.  Based on availability of funds, payments authorized by this paragraph shall be made no more frequently than quarterly or less frequently than annually, based on available information.  If quarterly payments are made, the fourth quarter payment shall take into consideration available information for the full year.

(4)           The payment limits of the Social Security Act, Title XIX, Section 1923(g)(1) applied to the payments authorized by this Paragraph require on a hospital-specific basis that when such payments are added to other disproportionate share hospital payments, the total disproportionate share hospital payments shall not exceed the percentage specified by the Social Security Act, Title XIX, Section 1923(g) of the total costs of providing inpatient and outpatient services to Medicaid and uninsured patients for the fiscal year in which such payments are made, less all payments received for services to Medicaid and uninsured patients for that year.  The total of all DSH payments by the Division shall not exceed the limits on disproportionate share hospital funding as established for this State by HCFA in accordance with the provisions of the Social Security Act, Title XIX, Section 1923(f) for the fiscal year in which such payments are made.

(5)           To ensure that estimated payments pursuant to this Paragraph do not exceed the upper limits to such payments described in Subparagraph (h)(4) of this Rule and established by applicable federal law and regulation, such payments shall be cost settled within 12-months of receipt of the completed and audited Medicare/Medicaid cost report for the fiscal year for which such payments are made.  No additional payments shall be made in connection with the cost settlement.

(6)           The payments authorized by this Paragraph shall be effective in accordance with G.S. 108A-55(c).

(i)  Additional disproportionate share hospital payments for the 12-month periods ending September 30th of each year (subject to the availability of funds and to the payment limits specified in this Paragraph) shall be paid to large free-standing inpatient rehabilitation hospitals that are qualified public hospitals licensed by the State of North Carolina. 

(1)           For purposes of this Paragraph a large free-standing inpatient rehabilitation hospital is a hospital licensed for more than 100 rehabilitation beds. 

(2)           For purposes of this Paragraph a qualified public hospital is a hospital that:

(A)          Qualifies for disproportionate share hospital status under Subparagraph (a)(1) through (5) of this Rule;

(B)          Does not qualify for disproportionate share hospital status under Subparagraph (a)(6) of this Rule;

(C)          Was owned or operated by a State (or by an instrumentality or a unit of government within a State) during the period for which payments under this Paragraph are being ascertained; and

(D)          Verifies its status as a public hospital by certifying state, local, hospital district or authority government control on the most recent version of Form HCFA-1514 filed with the Health Care Financing Administration, U.S. Department of Health and Human Services at least 30 days prior to the date of any payment under this Paragraph that is still valid as of the date of any such payment.

(3)           Based on availability of funds, payments authorized by this Paragraph shall be made no more frequently than quarterly or less frequently than annually, based on available information.  If quarterly payments are made, the fourth quarter payment shall take into consideration available information for the full year.

(4)           Payments authorized by this Paragraph for any given period shall be based on and shall not exceed for the 12-month period ending September 30^th of the year for which payments are made the "Medicaid Deficit" for each hospital.  The Medicaid Deficit shall be calculated by ascertaining the reasonable costs of inpatient and outpatient hospital Medicaid services less Medicaid payments received or to be received for these services.  For purposes of this Subparagraph:

(A)          Reasonable costs shall be ascertained in accordance with the provisions of the Medicare Provider Reimbursement Manual as defined in Paragraph (b) of Rule .0203 of this Section; and

(B)          The phrase "Medicaid payments received or to be received for these services" shall exclude all Medicaid disproportionate share hospital payments received or to be received.

(5)           The disproportionate share hospital payments to qualified public hospitals shall be made on the basis of an estimate of costs incurred and payments received for inpatient and outpatient Medicaid services for the period for which payments are made.  The Director of the Division of Medical Assistance shall determine the amount of the estimated payments to be made by an analysis of costs incurred and payments received for Medicaid services as reported on the most recent cost reports filed before the Director's determination is made and supplemented by additional financial information available to the Director when the estimated payments are calculated if and to the extent that the Director concludes that the additional financial information is reliable and relevant.

(6)           The payment limits of the Social Security Act, Title XIX, Section 1923(g)(1) applied to the payments authorized by this Paragraph require on a hospital-specific basis that when such payments are added to other disproportionate share hospital payments, the total disproportionate share hospital payments shall not exceed the percentage specified by the Social Security Act, Title XIX, Section 1923(g) of the total costs of providing inpatient and outpatient services to Medicaid and uninsured patients for the fiscal year for which such payments are made, less all payments received for services to Medicaid and uninsured patients for that year.  The total of all DSH payments by the Division shall not exceed the limits on DSH funding as established for this State by HCFA in accordance with the provisions of the Social Security Act, Title XIX, Section 1923(f) for the fiscal year for which such payments are made.

(7)           To ensure that estimated payments pursuant to this Paragraph do not exceed the upper limits to such payments described in Subparagraph (4) of this Paragraph and established by applicable federal law and regulation, such payments shall be cost settled within 12-months of receipt of the completed and audited Medicare/Medicaid cost report for the fiscal year for which such payments are made.  No additional payments shall be made in connection with the cost settlement.

(8)           The payments authorized by this Paragraph shall be effective in accordance with G.S. 108A-55(c).

(j)  Additional disproportionate share hospital payments for the 12-month periods ending September 30th (subject to the availability of funds and to the payment limits specified in this Paragraph) shall be paid to hospitals licensed by the State of North Carolina that relates, are designated as critical access hospitals under 42 U.S.C. 1395i-4 for the period to which such payment relates; incurred for the 12-month period ending September 30th of the fiscal year to which such payments relate unreimbursed costs for providing inpatient and outpatient services to Medicaid patients, and qualify as a disproportionate share hospital under the minimum requirements specified by 42 U.S.C. 1396r-4(d).

(1)           Qualification for 12-month periods ending September 30th shall be based on the most recent cost report data filed with and certified to the Division at least 60 days prior to the date of any payment under this Paragraph.

(2)           Based on availability of funds, payments authorized by this Paragraph shall be made no more frequently than quarterly or less frequently than annually, based on available information.  If quarterly payments are made, the fourth quarter payment shall take into consideration available information for the full year.

(3)           Payments to qualified hospitals under this Paragraph for any period shall be based on and shall not exceed the "Medicaid Deficit" for each hospital.  The Medicaid Deficit shall be calculated by ascertaining the reasonable costs of inpatient and outpatient hospital Medicaid services less Medicaid payments received or to be received for these services.  For purposes of this Subparagraph:

(A)          Reasonable costs shall be ascertained in accordance with the provisions of the Medicare Provider Reimbursement Manual as defined in Paragraph (b) of Rule .0212 of this Section.

(B)          The phrase "Medicaid payments received or to be received for these services" shall exclude all Medicaid disproportionate share hospital payments received or to be received.

(C)          The disproportionate share hospital payments to qualified hospitals pursuant to this Paragraph shall be made on the basis of an estimate of costs incurred and payments received for inpatient and outpatient Medicaid services for the period for which the payment relates.  The Director of the Division of Medical Assistance shall determine the amount of the estimated payments to be made by analysis of costs incurred and payments received for Medicaid services as reported on the most recent cost reports filed before the Director's determination is made, and supplemented by additional financial information available to the Director when the estimated payments are calculated if and to the extent that the Director concludes that the additional financial information is reliable and relevant.

(D)          The payment limits of the Social Security Act, Title XIX, Section 1923(g) (1) applied to the payments authorized by this Paragraph require on a hospital-specific basis that when such payments are added to other disproportionate share hospital payments, the total disproportionate share payments shall not exceed the percentage specified by the Social Security Act, Title XIX, Section 1923(g) of the total costs of providing inpatient and outpatient services to Medicaid and uninsured patients for the fiscal year in which such payments are made, less all payments received for services to Medicaid and uninsured patients for that year.  The total of all DSH payments by the Division shall not exceed the limits on DSH hospital funding as established for this State by HCFA in accordance with the provisions of the Social Security Act, Title XIX, Section 1923 (f) for the fiscal year in which such payments are made.

(E)           To ensure that estimated payments pursuant to this Paragraph do not exceed the upper limits to such payments described in Part D of this Paragraph and established by applicable federal law and regulation, such payments shall be cost settled within 12-months of receipt of the completed and audited Medicare/Medicaid cost report for the fiscal year for which such payments are made.  No additional payments shall be made in connection with such cost settlement.

(F)           The payments authorized by this Paragraph shall be effective in accordance with G.S. 108A-55(c).

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C;

Eff. February 1, 1995;

Amended Eff. July 1, 1995;

Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. September 29, 1995, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1996;

Temporary Amendment Eff. September 16, 1998; September 30, 1997; April 15, 1997; September 25, 1996;

Temporary Amendment Expired on June 13, 1999;

Temporary Amendment Eff. September 22, 1999;

Temporary Amendment Expired on July 11, 2000;

Temporary Amendment Eff. May 15, 2002; June 1, 2001; December 10, 2001; September 21, 2000;

Amended Eff. August 1, 2004; April 1, 2003.