[Federal Register Volume 64, Number 146 (Friday, July 30, 1999)]
[Rules and Regulations]
[Pages 41490-41641]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-19334]



[[Page 41489]]

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Part II





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



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42 CFR Parts 412, 413, 483, and 485



Medicare Program; Changes to the Hospital Inpatient Prospective Payment 
Systems and Fiscal Year 2000 Rates; Final Rule

Federal Register / Vol. 64, No. 146 / Friday, July 30, 1999 / Rules 
and Regulations

[[Page 41490]]



DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 412, 413, 483, and 485

[HCFA-1053-F]
RIN 0938-AJ50


Medicare Program; Changes to the Hospital Inpatient Prospective 
Payment Systems and Fiscal Year 2000 Rates

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: We are revising the Medicare hospital inpatient prospective 
payment systems for operating costs and capital-related costs to 
implement changes arising from our continuing experience with the 
systems. In addition, in the addendum to this final rule, we describe 
changes in the amounts and factors necessary to determine rates for 
Medicare hospital inpatient services for operating costs and capital-
related costs. These changes are applicable to discharges occurring on 
or after October 1, 1999. We also set forth rate-of-increase limits as 
well as policy changes for hospitals and hospital units excluded from 
the prospective payment systems. Finally, we are revising certain 
policies governing payment to hospitals for the direct costs of 
graduate medical education.

DATES: The provisions of this final rule are effective October 1, 1999. 
This rule is a major rule as defined in Title 5, United States Code, 
section 804(2). Pursuant to 5 U.S.C. section 801(a)(1)(A), we are 
submitting a report to Congress on this rule on July 30, 1999.

FOR FURTHER INFORMATION CONTACT:
Steve Phillips, (410) 786-4531, Operating Prospective Payment, 
Diagnosis-Related Group (DRG), and Wage Index Issues.
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded 
Hospitals, and Graduate Medical Education Issues.

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I. Background

A. Summary

    Section 1886(d) of the Social Security Act (the Act) sets forth a 
system of payment for the operating costs of acute care hospital 
inpatient stays under Medicare Part A (Hospital Insurance) based on 
prospectively set rates. Section 1886(g) of the Act requires the 
Secretary to pay for the capital-related costs of hospital inpatient 
stays under a prospective payment system. Under these prospective 
payment systems, Medicare payment for hospital inpatient operating and 
capital-related costs is made at predetermined, specific rates for each 
hospital discharge. Discharges are classified according to a list of 
diagnosis-related groups (DRGs).
    Certain specialty hospitals are excluded from the prospective 
payment systems. Under section 1886(d)(1)(B) of the Act, the following 
hospitals and hospital units are excluded from the prospective payment 
systems: psychiatric hospitals or units, rehabilitation hospitals or 
units, children's hospitals, long-term care hospitals, and cancer 
hospitals. For these hospitals and units, Medicare payment for 
operating costs is based on reasonable costs subject to a hospital-
specific annual limit.
    Under section 1886(a)(4) of the Act, costs incurred directly by a 
hospital in connection with approved graduate medical education (GME) 
programs are excluded from the operating costs of inpatient hospital 
services. Hospitals with approved GME programs are paid for the direct 
costs of GME in accordance with section 1886(h) of the Act; the amount 
of payment for direct GME costs for a cost reporting period is based on 
the hospital's number of residents in that period and the hospital's 
costs per resident in a base year.
    The regulations governing the hospital inpatient prospective 
payment systems are located in 42 CFR part 412. The regulations 
governing excluded hospitals and hospital units are located in parts 
412 and 413, and the GME regulations are located in part 413.

B. Summary of the Provisions of the May 7, 1999 Proposed Rule

    On May 7, 1999, we published a proposed rule in the Federal 
Register (64 FR 24716) that set forth proposed changes to the Medicare 
hospital inpatient prospective payment systems for both operating costs 
and capital-related costs that would be effective for discharges 
occurring on or after October 1, 1999. We also proposed changes 
concerning GME costs and excluded hospitals and units, as well as 
critical access hospitals (CAHs). On June 15, 1999, we issued a 
correction notice (64 FR 31995) for the May 7, 1999 proposed rule. That 
notice corrected Table 3C of the Addendum (which lists each hospital's 
case-mix index and adjusted average hourly wage based on data on file 
at HCFA as of February 22, 1999) and made several other technical 
corrections.
    In the proposed rule, we noted that the efforts that we were 
undertaking to make the Medicare computer systems compliant on January 
1, 2000, would not delay our ability to make timely and updated 
payments to hospitals under the FY 2000 prospective payment systems 
final rule. This statement still applies and the changes and updated 
rates set forth in this final rule will be implemented on October 1, 
1999.
    The following is a summary of the contents of the proposed rule:
     In order to avoid compromising our ability to process and 
pay hospital claims during the period leading up to and immediately 
following January 1, 2000, we did not propose to implement any 
revisions to the International Classification of Diseases, Ninth 
Revision, Clinical Modification (ICD-9-CM) coding system. We did 
propose to make some limited changes to certain DRG classifications for 
FY 2000 and described other proposed decisions

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concerning DRGs. We also recalibrated the DRG relative weights based on 
the proposed DRG changes and updated Medicare claims data.
     We proposed an FY 2000 hospital wage index update, using 
FY 1996 wage data, and revisions to the wage index based on hospital 
redesignations. In addition, we proposed to begin excluding from the 
wage index Part A physician wage costs that are teaching-related, as 
well as resident and Part A certified registered nurse anesthetist 
(CRNA) costs.
     We proposed several policy changes in the regulations in 
42 CFR parts 412 and 413 and proposed to continue existing policy 
concerning classifications of sole community hospitals; the indirect 
medical education adjustment; and Medicare Geographic Classification 
Review Board (MGCRB) decisions. In addition, we updated the qualifying 
criteria for rural referral centers and proposed several changes to the 
regulations governing payments for the direct costs of GME programs.
     We discussed the special exceptions process for certain 
eligible hospitals to receive additional payments for major 
construction or renovation projects that began soon after the start of 
the capital prospective payment system and proposals that we had 
received to change the eligibility criteria for these payments.
     We discussed a number of proposals concerning Medicare 
payments to excluded hospitals and hospital units and CAHs. These 
proposed changes related to limits on and adjustments to the proposed 
target amounts for FY 2000; changes in bed size or status of excluded 
hospitals or hospital units; payment for Medicare services furnished at 
satellite hospital locations; responsibility for care of patients in 
hospitals-within-hospitals; the allowable emergency response time for 
CAHs located in frontier or other specifically defined remote areas; 
and compliance with minimum data set requirements by CAHs with swing 
bed approval.
     In the addendum to the proposed rule, we set forth 
proposed changes to the amounts and factors for determining the FY 2000 
prospective payment rates for operating costs and capital-related 
costs. We also addressed update factors for determining the rate-of-
increase limits for cost reporting periods beginning in FY 2000 for 
hospitals and hospital units excluded from the prospective payment 
system.
     In Appendix A of the proposed rule, we set forth an 
analysis of the impact that the proposed changes would have on affected 
entities.
     In Appendix B of the proposed rule, we set forth the 
technical appendix on the proposed FY 2000 capital cost model.
     In Appendix C of the proposed rule, as required by section 
1886(e)(3)(B) of the Act, we set forth our report to Congress on our 
initial estimate of a recommended update factor for FY 2000 for both 
hospitals included in and hospitals excluded from the prospective 
payment systems.
     In Appendix D of the proposed rule, as required by 
sections 1886(e)(4) and (e)(5) of the Act, we included our 
recommendation of the appropriate percentage change for FY 2000 for--

--Large urban area and other area average standardized amounts (and 
hospital-specific rates applicable to sole community hospitals and 
Medicare-dependent, small rural hospitals) for hospital inpatient 
services paid for under the prospective payment system for operating 
costs; and
--Target rate-of-increase limits to the allowable operating costs of 
hospital inpatient services furnished by hospitals and hospital units 
excluded from the prospective payment system.

     In the proposed rule, we discussed the recommendations 
concerning hospital inpatient payment policies made by the Medicare 
Payment Advisory Commission (MedPAC) and presented our responses to 
those recommendations. Under section 1805(b) of the Act, MedPAC is 
required to submit a report to Congress, not later than March 1 of each 
year, that reviews and makes recommendations on Medicare payment 
policies.

C. Public Comments Received in Response to the Proposed Rule

    We received a total of 82 timely items of correspondence containing 
multiple comments on the proposed rule. The main areas of concern 
addressed by the commenters were removal of teaching-related and CRNA 
costs from the wage index, payments for services furnished at satellite 
hospital locations, and limits on the transfer of patients in 
hospitals-within-hospitals. We also received a number of comments 
relating to the eligibility criteria for hospitals to qualify for 
capital exceptions payments.
    Summaries of the public comments received and our responses to 
those comments are set forth below under the appropriate section.

II. Changes to DRG Reclassifications and Recalibrations of Relative 
Weights

A. Background

    Under the prospective payment system, we pay for inpatient hospital 
services on the basis of a rate per discharge that varies by the DRG to 
which a beneficiary's stay is assigned. The formula used to calculate 
payment for a specific case takes an individual hospital's payment rate 
per case and multiplies it by the weight of the DRG to which the case 
is assigned. Each DRG weight represents the average resources required 
to care for cases in that particular DRG relative to the average 
resources used to treat cases in all DRGs.
    Congress recognized that it would be necessary to recalculate the 
DRG relative weights periodically to account for changes in resource 
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires 
that the Secretary adjust the DRG classifications and relative weights 
at least annually. These adjustments are made to reflect changes in 
treatment patterns, technology, and any other factors that may change 
the relative use of hospital resources.
    As discussed in more detail in section II.B.8 of this preamble, we 
are not implementing any revisions to the ICD-9-CM codes. We have 
undertaken, and continue to undertake, major efforts to ensure that all 
of the Medicare computer systems are ready to function on January 1, 
2000. If we were to implement changes to the ICD-9-CM codes on October 
1, 1999, we would endanger the functioning of the Medicare computer 
systems, and, specifically, we might compromise our ability to process 
hospital bills. We can, however, reclassify existing codes into 
different DRGs, if appropriate.
    The changes to the DRG classification system, and the recalibration 
of the DRG weights for discharges occurring on or after October 1, 
1999, are discussed below.

B. DRG Reclassification

1. General
    Cases are classified into DRGs for payment under the prospective 
payment system based on the principal diagnosis, up to eight additional 
diagnoses, and up to six procedures performed during the stay, as well 
as age, sex, and discharge status of the patient. The diagnosis and 
procedure information is reported by the hospital using ICD-9-CM codes. 
The Medicare fiscal intermediary enters the information into its claims 
processing system and subjects it to a series of automated screens 
called the

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Medicare Code Editor (MCE). These screens are designed to identify 
cases that require further review before classification into a DRG can 
be accomplished.
    After screening through the MCE and any further development of the 
claims, cases are classified by the GROUPER software program into the 
appropriate DRG. The GROUPER program was developed as a means of 
classifying each case into a DRG on the basis of the diagnosis and 
procedure codes and demographic information (that is, sex, age, and 
discharge status). It is used both to classify past cases in order to 
measure relative hospital resource consumption to establish the DRG 
weights and to classify current cases for purposes of determining 
payment. The records for all Medicare hospital inpatient discharges are 
maintained in the Medicare Provider Analysis and Review (MedPAR) file. 
The data in this file are used to evaluate possible DRG classification 
changes and to recalibrate the DRG weights.
    Currently, cases are assigned to one of 499 DRGs in 25 major 
diagnostic categories (MDCs). Most MDCs are based on a particular organ 
system of the body (for example, MDC 6, Diseases and Disorders of the 
Digestive System); however, some MDCs are not constructed on this basis 
since they involve multiple organ systems (for example, MDC 22, Burns).
    In general, cases are assigned to an MDC based on the principal 
diagnosis before assignment to a DRG. However, there are five DRGs to 
which cases are directly assigned on the basis of procedure codes. 
These are the DRGs for liver, bone marrow, and lung transplants (DRGs 
480, 481, and 495, respectively) and the two DRGs for tracheostomies 
(DRGs 482 and 483). Cases are assigned to these DRGs before 
classification to an MDC.
    Within most MDCs, cases are then divided into surgical DRGs (based 
on a surgical hierarchy that orders individual procedures or groups of 
procedures by resource intensity) and medical DRGs. Medical DRGs 
generally are differentiated on the basis of diagnosis and age. Some 
surgical and medical DRGs are further differentiated based on the 
presence or absence of complications or comorbidities (CC).
    Generally, GROUPER does not consider other procedures; that is, 
nonsurgical procedures or minor surgical procedures generally not 
performed in an operating room are not listed as operating room (OR) 
procedures in the GROUPER decision tables. However, there are a few 
non-OR procedures that do affect DRG assignment for certain principal 
diagnoses, such as extracorporeal shock wave lithotripsy for patients 
with a principal diagnosis of urinary stones.
    We proposed several changes to the DRG classification system for FY 
2000 and other decisions concerning DRGs. The proposed changes, the 
comments we received concerning them, and the final DRG changes are set 
forth below. Unless otherwise noted, our DRG analysis is based on the 
full (100 percent) FY 1998 MedPAR file, which contains data from bills 
received through March 31, 1999.
2. MDC 15 (Newborns and Other Neonates with Conditions Originating in 
the Perinatal Period)
    In the May 7, 1999 proposed rule, we noted that the following codes 
in the newborn observation series are included in the allowable 
secondary diagnoses under DRG 391 (Normal Newborn):

V29.0, Observation for suspected infectious disease
V29.1, Observation for suspected neurological condition
V29.8, Observation for other specified suspected condition
V29.9, Observation for unspecified suspected condition

There are two related codes, however, that currently are not included 
as allowable secondary diagnoses under DRG 391: V29.2 (Observation for 
suspected respiratory condition) and V29.3 (Observation for suspected 
genetic or metabolic condition). (In the proposed rule, we incorrectly 
stated that V29.3 was titled ``Observation for other genetic 
problem.'') Diagnosis codes V29.2 and V29.3 (as well as the other V29.x 
codes noted above) are used to indicate that the newborn was suspected 
of having an abnormal condition resulting from exposure from the mother 
or the birth process, but is without signs or symptoms and, after 
examination and observation, no abnormal condition is found to exist. 
Currently, when either V29.2 or V29.3 is the only secondary diagnosis 
for an otherwise healthy newborn, the case is assigned to DRG 390 
(Neonate with Other Significant Problems). Based on a belief that the 
presence of diagnosis code V29.2 or V29.3 should not exclude a newborn 
from being classified as normal, we proposed to include diagnosis codes 
V29.2 and V29.3 in the list of allowable secondary diagnoses under DRG 
391 (Normal Newborn).
    We received one comment on this proposal.
    Comment: The commenter questioned whether any of the codes in the 
V29 series should be assigned to DRG 391. The commenter believes that 
the infants assigned to diagnosis code in the V29 series do not belong 
in the same clinical group as ``normal newborn.'' The commenter 
recommended that, before moving codes V29.2 and V29.3 to DRG 391, we 
should examine data such as the average length of stay for DRGs 390 and 
391 and those cases coded with V29.x. Citing one hospital's experience, 
the commenter noted that 2.7 percent of the cases in DRG 391 were 
assigned a secondary diagnosis of V29.0 (Observation for suspected 
infectious disease). In addition, cases with secondary diagnosis codes 
V29.1, V29.8, and V29.9 represented less than 1 percent each of all 
cases in DRG 391. The commenter also reported that, for DRG 390, less 
than 1 percent of cases were assigned a secondary diagnosis code of 
V29.2 or V29.3. The commenter believes that the length of stay and 
resource consumption for these cases should be compared to other cases 
assigned to DRG 390 and DRG 391 to determine whether a separate DRG 
should be created to adequately categorize these infants.
    Response: The experience of the hospital reported by the commenter 
indicates that newborn cases with a secondary diagnosis of V29.2 or 
V29.3 represent a small percentage of newborn cases. Medicare data do 
not contain enough data on newborns to verify this.
    In the FY 1998 MedPAR file, there are only nine cases assigned to 
DRG 390 and none to DRG 391. In fact, in FY 1998, there were only 18 
cases assigned to all of MDC 15. Because of the lack of data on 
newborns in the Medicare claims file, the relative weights and lengths 
of stay for the DRGs in MDC 15 are based on non-Medicare data collected 
from 19 States. (See the September 1, 1995 final rule (60 FR 45781) for 
a detailed discussion of this policy.) Therefore, we rely closely on 
experts outside of HCFA when we make any changes in MDC 15. We had 
received information before publication of the proposed rule suggesting 
that V29.2 and V29.3 should be included with the other V29.x codes in 
DRG 391. After verifying with our medical consultants that this 
information was clinically accurate, we proposed to make this DRG 
classification change. We do note that the average lengths of stay for 
DRG 390 and 391 do not differ dramatically (3.4 and 3.1 days, 
respectively). However, the relative weight for DRG 390 is 
significantly higher than that for DRG 391 (1.5908 and 0.1516, 
respectively). Thus, we believe the amount of resource use devoted to 
newborns in DRG 390 is not

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connected to the amount of time spent in the hospital.
    The commenter did not provide any length of stay or resource use 
data nor did the commenter provide any reason that codes V29.2 or V29.3 
should be treated differently than the other codes in category V29.x. 
We believe that DRG 390, as its title indicates, should be used to 
classify newborns with significant problems. Newborns who exhibit no 
signs or symptoms and are merely evaluated or observed for a suspected 
condition that is ruled out should not be classified with newborns who 
have significant problems that require treatment.
    We note that DRG 391 includes newborns who have minor problems or 
conditions that require treatment. For example, some newborns with 
jaundice, newborns with scalp injuries or mild birth asphyxia, and 
newborns with minor skin infections are all classified to DRG 391. 
Thus, that DRG does contain newborn cases for which some medical 
treatment must be provided. We believe that including newborns observed 
for suspected respiratory, genetic, or metabolic conditions in DRG 391 
is clinically appropriate. Therefore, as proposed, we will include 
V29.2 and V29.3 as allowable secondary diagnoses under DRG 391, as are 
the rest of the codes in that category.
3. MDC 19 (Mental Diseases and Disorders)
    We proposed to revise the title of DRG 425, ``Acute Adjustment 
Reaction and Disturbances of Psychosocial Dysfunction'' under MDC 19 to 
read ``Acute Adjustment Reaction and Psychosocial Dysfunction.'' 
Correspondents had stated that the terms ``disturbances'' and 
``dysfunction'' were redundant since the terms have similar meanings.
    We received one comment in support of this revision. Therefore, we 
are adopting this proposed revision as final.
4. MDC 22 (Burns)
    In the July 31, 1998 final rule (63 FR 40957), we implemented an 
extensive redesign of the DRGs for burns to more appropriately capture 
the variation in resource use associated with different classes of burn 
patients. After these DRGs went into effect on October 1, 1998, we were 
contacted by several hospitals about our inclusion of the fifth digit 
``0'' on codes 948.10 through 948.90 to capture cases of full-thickness 
burns. These hospitals stated that codes in category 948 with a fifth 
digit of ``0'' should not be assigned to DRGs 506 through 509 as full-
thickness burns since not all of these cases will have a full-thickness 
(third degree) burn. The fifth digit ``0'' can capture cases in which 
there actually is no third degree burn. The hospitals requested that we 
consider removing from the full-thickness burn DRGs 506 through 509 all 
codes in the 948 category with a fifth digit of ``0'' as follows:

948.00  Body burn involving less than 10 percent of body surface, third 
degree less than 10 percent or unspecified
948.10 Body burn involving 10 to 19 percent of body surface, third 
degree less than 10 percent or unspecified
948.20 Body burn involving 20 to 29 percent of body surface, third 
degree less than 10 percent or unspecified
948.30 Body burn involving 30 to 39 percent of body surface, third 
degree less than 10 percent or unspecified
948.40 Body burn involving 40 to 49 percent of body surface, third 
degree less than 10 percent or unspecified
948.50 Body burn involving 50 to 59 percent of body surface, third 
degree less than 10 percent or unspecified
948.60 Body burn involving 60 to 69 percent of body surface, third 
degree less than 10 percent or unspecified
948.70 Body burn involving 70 to 79 percent of body surface, third 
degree less than 10 percent or unspecified
948.80 Body burn involving 80 to 89 percent of body surface, third 
degree less than 10 percent or unspecified
948.90 Body burn involving 90 percent or more of body surface, third 
degree less than 10 percent or unspecified.
    We agreed with the hospitals and proposed that the codes listed 
above be removed from DRGs 506 through 509 and added to DRG 510 
(Nonextensive Burns with CC or Significant Trauma) and DRG 511 
(Nonextensive Burns without CC or Significant Trauma). Hospitals have 
been instructed in Coding Clinic for ICD-9-CM, Fourth Quarter, 1994 
(pages 22 through 28) to code the site of the burn first (codes 940 
through 947), when known. Codes from category 948 may be used as a 
principal diagnosis only when the site of the burn is not specified. 
Category 948 is used as an additional code to provide information on 
the percentage of total body that is burned or to show the percentage 
of burn that was third degree. When hospitals report codes properly, 
full-thickness burns would be assigned to a code for burn of the 
specific site (940 through 947). This site code also shows the degree 
of the burn. Furthermore, for those rare cases in which the site is not 
provided, but it is known that 10 percent or more of the body has a 
third degree burn, hospitals may report this information through the 
use of category 948 with a fifth digit of ``1'' through ``9.'' All of 
these cases would continue to be classified as full-thickness burns in 
DRGs 506 through 509. Therefore, the proposed removal of codes 948.1 
through 948.9 with a fifth digit of ``0'' would not prevent cases from 
being assigned to one of the full-thickness DRGs when there is a third 
degree burn and the case is correctly coded.
    Comment: One commenter stated that while it is true that codes in 
category 948 with a fifth digit of ``0'' may be assigned when there is 
no third degree burn, fifth digit ``0'' is also used to report cases 
that have a body surface of 1 to 9 percent involved in third degree 
burns. The commenter suggested that consideration be given to these 
cases as the presence of a third degree burn represents additional risk 
to the patient.
    Response: We agree with the commenter that the presence of third 
degree burns represents additional risk to the patient and may result 
in a higher resource use. More accurately capturing this fact was one 
of the primary purposes in revising the burn DRGs in FY 1999. However, 
as the commenter noted, in category 948, the fifth digit of ``0'' 
includes cases with no third degree burns as well as third degree burns 
involving 1 to 9 percent of the body surface. It is precisely because 
many of the cases coded in 948 with a ``0'' fifth digit have no third 
degree burns that we believe it is not appropriate to include these 
codes in DRGs 506 through 509. As stated above, hospitals have been 
instructed to code the site of the burn first (codes 940 through 947), 
when known. These codes capture information on the site of the burn as 
well as whether the burn is a third degree burn. Therefore, by using 
the more precise codes in the 940 through 947 series, hospitals will be 
appropriately assigning cases with minor third degree burns to DRGs 506 
through 509.
    We are adopting as final our proposal to remove codes in the 948 
category with a fifth digit of ``0'' from the list of full-thickness 
burns.
5. Surgical Hierarchies
    Some inpatient stays entail multiple surgical procedures, each one 
of which, occurring by itself, could result in

[[Page 41494]]

assignment of the case to a different DRG within the MDC to which the 
principal diagnosis is assigned. It is, therefore, necessary to have a 
decision rule by which these cases are assigned to a single DRG. The 
surgical hierarchy, an ordering of surgical classes from most to least 
resource intensive, performs that function. Its application ensures 
that cases involving multiple surgical procedures are assigned to the 
DRG associated with the most resource-intensive surgical class.
    Because the relative resource intensity of surgical classes can 
shift as a function of DRG reclassification and recalibration, we 
reviewed the surgical hierarchy of each MDC, as we have for previous 
reclassifications, to determine if the ordering of classes coincided 
with the intensity of resource utilization, as measured by the same 
billing data used to compute the DRG relative weights.
    A surgical class can be composed of one or more DRGs. For example, 
in MDC 5, the surgical class ``heart transplant'' consists of a single 
DRG (DRG 103), and the class ``major cardiovascular procedures'' 
consists of two DRGs (DRGs 110 and 111). Consequently, in many cases, 
the surgical hierarchy has an impact on more than one DRG. The 
methodology for determining the most resource-intensive surgical class 
involves weighting each DRG for frequency to determine the average 
resources for each surgical class. For example, assume surgical class A 
includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. 
Assume also that the average charge of DRG 1 is higher than that of DRG 
3, but the average charges of DRGs 4 and 5 are higher than the average 
charge of DRG 2. To determine whether surgical class A should be higher 
or lower than surgical class B in the surgical hierarchy, we would 
weight the average charge of each DRG by frequency (that is, by the 
number of cases in the DRG) to determine average resource consumption 
for the surgical class. The surgical classes would then be ordered from 
the class with the highest average resource utilization to that with 
the lowest, with the exception of ``other OR procedures'' as discussed 
below.
    This methodology may occasionally result in a case involving 
multiple procedures being assigned to the lower-weighted DRG (in the 
highest, most resource-intensive surgical class) of the available 
alternatives. However, given that the logic underlying the surgical 
hierarchy provides that the GROUPER searches for the procedure in the 
most resource-intensive surgical class, this result is unavoidable.
    We note that, notwithstanding the foregoing discussion, there are a 
few instances when a surgical class with a lower average relative 
weight is ordered above a surgical class with a higher average relative 
weight. For example, the ``other OR procedures'' surgical class is 
uniformly ordered last in the surgical hierarchy of each MDC in which 
it occurs, regardless of the fact that the relative weight for the DRG 
or DRGs in that surgical class may be higher than that for other 
surgical classes in the MDC. The ``other OR procedures'' class is a 
group of procedures that are least likely to be related to the 
diagnoses in the MDC but are occasionally performed on patients with 
these diagnoses. Therefore, these procedures should be considered only 
if no other procedure more closely related to the diagnoses in the MDC 
has been performed.
    A second example occurs when the difference between the average 
weights for two surgical classes is very small. We have found that 
small differences generally do not warrant reordering of the hierarchy 
since, by virtue of the hierarchy change, the relative weights are 
likely to shift such that the higher-ordered surgical class has a lower 
average weight than the class ordered below it.
    Based on the preliminary recalibration of the DRGs, we proposed to 
modify the surgical hierarchy as set forth below. However, in 
developing the proposed rule, we were unable to test the effects of 
proposed revisions to the surgical hierarchy and to reflect these 
changes in the proposed relative weights due to the unavailability of 
revised GROUPER software at the time the proposed rule was prepared. 
Rather, we simulated most major classification changes to approximate 
the placement of cases under the proposed reclassification and then 
determined the average charge for each DRG. These average charges then 
serve as our best estimate of relative resource use for each surgical 
class. We tested the proposed surgical hierarchy changes after the 
revised GROUPER was received. The final changes in the DRG relative 
weights are reflected in this final rule.
    We proposed to revise the surgical hierarchy for the Pre-MDC DRGs 
and MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth and Throat) 
as follows:
     In the Pre-MDC DRGs, we proposed to reorder Lung 
Transplant (DRG 495) above Bone Marrow Transplant (DRG 481).
     In MDC 3, we proposed to reorder Tonsil and Adenoid 
Procedure Except Tonsillectomy and/or Adenoidectomy Only (DRGs 57 and 
58) above Cleft Lip and Palate Repair (DRG 52).
    We received two comments in support of the two surgical hierarchy 
proposals. In addition, based on a test of the proposed revisions using 
the most recent MedPAR file and the revised GROUPER software, we have 
found that the revisions are still supported by the data and no 
additional changes are indicated. Therefore, we are incorporating the 
proposed revisions and reorders in this final rule.
6. Refinement of Complications and Comorbidities (CC) List
    There is a standard list of diagnoses that are considered CCs. We 
developed this list using physician panels to include those diagnoses 
that, when present as a secondary condition, would be considered a 
substantial complication or comorbidity. In previous years, we have 
made changes to the standard list of CCs, either by adding new CCs or 
by deleting CCs already on the list. In the May 7, 1999 proposed rule, 
we did not propose to delete any of the diagnosis codes on the CC list.
    In the September 1, 1987 final notice concerning changes to the DRG 
classification system (52 FR 33143), we modified the GROUPER logic so 
that certain diagnoses included on the standard list of CCs would not 
be considered a valid CC in combination with a particular principal 
diagnosis. Thus, we created the CC Exclusions List. We made these 
changes to preclude coding of CCs for closely related conditions, to 
preclude duplicative coding or inconsistent coding from being treated 
as CCs, and to ensure that cases are appropriately classified between 
the complicated and uncomplicated DRGs in a pair.
    In the May 19, 1987 proposed notice concerning changes to the DRG 
classification system (52 FR 18877), we explained that the excluded 
secondary diagnoses were established using the following five 
principles:
     Chronic and acute manifestations of the same condition 
should not be considered CCs for one another (as subsequently corrected 
in the September 1, 1987 final notice (52 FR 33154)).
     Specific and nonspecific (that is, not otherwise specified 
(NOS)) diagnosis codes for a condition should not be considered CCs for 
one another.
     Conditions that may not co-exist, such as partial/total, 
unilateral/bilateral, obstructed/unobstructed, and benign/malignant, 
should not be considered CCs for one another.

[[Page 41495]]

     The same condition in anatomically proximal sites should 
not be considered CCs for one another.
     Closely related conditions should not be considered CCs 
for one another.
    The creation of the CC Exclusions List was a major project 
involving hundreds of codes. The FY 1988 revisions were intended to be 
only a first step toward refinement of the CC list in that the criteria 
used for eliminating certain diagnoses from consideration as CCs were 
intended to identify only the most obvious diagnoses that should not be 
considered complications or comorbidities of another diagnosis. For 
that reason, and in light of comments and questions on the CC list, we 
have continued to review the remaining CCs to identify additional 
exclusions and to remove diagnoses from the master list that have been 
shown not to meet the definition of a CC. (See the September 30, 1988 
final rule for the revision made for the discharges occurring in FY 
1989 (53 FR 38485); the September 1, 1989 final rule for the FY 1990 
revision (54 FR 36552); the September 4, 1990 final rule for the FY 
1991 revision (55 FR 36126); the August 30, 1991 final rule for the FY 
1992 revision (56 FR 43209); the September 1, 1992 final rule for the 
FY 1993 revision (57 FR 39753); the September 1, 1993 final rule for 
the FY 1994 revisions (58 FR 46278); the September 1, 1994 final rule 
for the FY 1995 revisions (59 FR 45334); the September 1, 1995 final 
rule for the FY 1996 revisions (60 FR 45782); the August 30, 1996 final 
rule for the FY 1997 revisions (61 FR 46171); the August 29, 1997 final 
rule for the FY 1998 revisions (62 FR 45966); and the July 31, 1998 
final rule for the FY 1999 revisions (63 FR 40954).) In the May 7, 1999 
proposed rule, we did not propose to add or delete any codes from the 
CC list.
    In addition, because we are not making changes to the ICD-9-CM 
codes for FY 2000, we are not modifying the current list for new or 
deleted codes. Therefore, there are no revisions to the CC Exclusions 
List for FY 2000.
7. Review of Procedure Codes in DRGs 468, 476, and 477
    Each year, we review cases assigned to DRG 468 (Extensive OR 
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR 
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive 
OR Procedure Unrelated to Principal Diagnosis) in order to determine 
whether it would be appropriate to change the procedures assigned among 
these DRGs.
    DRGs 468, 476, and 477 are reserved for those cases in which none 
of the OR procedures performed is related to the principal diagnosis. 
These DRGs are intended to capture atypical cases, that is, those cases 
that do not occur with sufficient frequency to represent a distinct, 
recognizable clinical group. DRG 476 is assigned to those discharges in 
which one or more of the following prostatic procedures are performed 
and are unrelated to the principal diagnosis:

60.0  Incision of prostate
60.12  Open biopsy of prostate
60.15  Biopsy of periprostatic tissue
60.18  Other diagnostic procedures on prostate and periprostatic tissue
60.21  Transurethral prostatectomy
60.29  Other transurethral prostatectomy
60.61  Local excision of lesion of prostate
60.69  Prostatectomy NEC
60.81  Incision of periprostatic tissue
60.82  Excision of periprostatic tissue
60.93  Repair of prostate
60.94  Control of (postoperative) hemorrhage of prostate
60.95  Transurethral balloon dilation of the prostatic urethra
60.99  Other operations on prostate

    All remaining OR procedures are assigned to DRGs 468 and 477, with 
DRG 477 assigned to those discharges in which the only procedures 
performed are nonextensive procedures that are unrelated to the 
principal diagnosis. The original list of the ICD-9-CM procedure codes 
for the procedures we consider nonextensive procedures, if performed 
with an unrelated principal diagnosis, was published in Table 6C in 
section IV of the Addendum to the September 30, 1988 final rule (53 FR 
38591). As part of the final rules published on September 4, 1990, 
August 30, 1991, September 1, 1992, September 1, 1993, September 1, 
1994, September 1, 1995, August 30, 1996, and August 29, 1997, we moved 
several other procedures from DRG 468 to 477, and some procedures from 
DRG 477 to 468. (See 55 FR 36135, 56 FR 43212, 57 FR 23625, 58 FR 
46279, 59 FR 45336, 60 FR 45783, 61 FR 46173, and 62 FR 45981, 
respectively.) No procedures were moved in FY 1999, as noted in the 
July 31, 1998 final rule (63 FR 40962).
 a. Adding Procedure Codes to MDCs
    We annually conduct a review of procedures producing DRG 468 or 477 
assignments on the basis of volume of cases in these DRGs with each 
procedure. Our medical consultants then identify those procedures 
occurring in conjunction with certain principal diagnoses with 
sufficient frequency to justify adding them to one of the surgical DRGs 
for the MDC in which the diagnosis falls. Based on this year's review, 
we identified several procedures that we proposed to move to surgical 
DRGs for additional MDCs so that they are not assigned to DRG 468. We 
did not identify any necessary changes in procedures under DRG 477 and, 
therefore, did not propose to move any procedures from DRG 477 to one 
of the surgical DRGs.
    First, we proposed to move three codes from DRG 468 to MDC 1 
(Diseases and Disorders of the Nervous System), all of which would be 
assigned to DRGs 7 and 8 (Peripheral and Cranial Nerve and Other 
Nervous System Procedure).\1\ Procedure code 38.7 (Interruption of the 
vena cava) is sometimes performed in conjunction with treatment for the 
principal diagnosis 434.11 (Cerebral embolism with infarction), which 
is assigned to MDC 1. Our medical advisors believe that procedure code 
38.7 is appropriately performed for some neurological conditions such 
as a cerebral embolism with infarction. Because the current DRG 
configuration does not allow this assignment, we proposed to add 
procedure code 38.7 to DRGs 7 and 8.
---------------------------------------------------------------------------

    \1\ A single title combined with two DRG numbers is used to 
signify pairs. Generally, the first DRG is for cases with CC and the 
second DRG is for cases without CC. If a third number is included, 
it represents cases with patients who are age 0-17. Occasionally, a 
pair of DRGs is split between age >17 and age 0-17.
---------------------------------------------------------------------------

    Second, we proposed that procedure codes 83.92 (Insertion or 
replacement of skeletal muscle stimulator) and 83.93 (Removal of 
skeletal muscle stimulator) both be categorized with other procedures 
on the nervous system. These procedures can be performed on patients 
with a principal diagnosis in MDC 1, such as 344.00 (Quadriplegia 
unspecified) or 344.31 (Monoplegia of lower limb, affecting dominant 
side). Therefore, these two codes would also be assigned to DRGs 7 and 
8.
    Third, procedure code 39.50 (Angioplasty or atherectomy of 
noncoronary vessel) is not currently assigned to MDC 4 (Diseases and 
Disorders of the Respiratory System). This procedure is performed for 
patients who develop pulmonary embolism. The principal diagnosis for 
pulmonary embolism is in MDC 4, and, to increase clinical coherence, we 
proposed to add procedure code 39.50 to that MDC in DRGs 76 and 77 
(Other Respiratory System OR Procedures).
    Fourth, insertion of totally implantable infusion pump (procedure 
code 86.06) is not assigned to MDC 5 (Diseases and Disorders of the 
Circulatory System) in the current DRG configuration. Infusion pumps 
should

[[Page 41496]]

be assigned to all MDCs in which subcutaneous insertion of the pump is 
appropriate. Procedure code 86.06 may be performed on patients with a 
principal diagnosis in MDC 5 such as 451.83 (Phlebitis and 
thrombophlebitis of the deep veins of other extremities). Therefore, we 
proposed to add procedure code 86.06 to DRG 120 (Other Circulatory 
System OR Procedures) in MDC 5.
    We received two comments on these MDC and DRG assignments, both of 
which concurred with our proposed changes. Therefore, we are adopting 
them as final.
b. Reassignment of Procedures Among DRGs 468, 476, and 477
    We also reviewed the list of procedures that produce assignments to 
DRGs 468, 476, and 477 to ascertain if any of those procedures should 
be moved from one of these DRGs to another based on average charges and 
length of stay. Generally, we move only those procedures for which we 
have an adequate number of discharges to analyze the data. Based on our 
review this year, we did not propose to move any procedures from DRG 
468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 
477 to DRGS 468 or 476.
8. Changes to the ICD-9-CM Coding System
    As described in section II.B.1 of this preamble, the ICD-9-CM is a 
coding system that is used for the reporting of diagnoses and 
procedures performed on a patient. In September 1985, the ICD-9-CM 
Coordination and Maintenance Committee was formed. This is a Federal 
interdepartmental committee, co-chaired by the National Center for 
Health Statistics (NCHS) and HCFA, that is charged with the mission of 
maintaining and updating the ICD-9-CM system. That mission includes 
approving coding changes, and developing errata, addenda, and other 
modifications to the ICD-9-CM to reflect newly developed procedures and 
technologies and newly identified diseases. The Committee is also 
responsible for promoting the use of Federal and non-Federal 
educational programs and other communication techniques with a view 
toward standardizing coding applications and upgrading the quality of 
the classification system.
    The NCHS has lead responsibility for the ICD-9-CM diagnosis codes 
included in the Tabular List and Alphabetic Index for Diseases, while 
HCFA has lead responsibility for the ICD-9-CM procedure codes included 
in the Tabular List and Alphabetic Index for Procedures.
    The Committee encourages participation in the above process by 
health-related organizations. In this regard, the Committee holds 
public meetings for discussion of educational issues and proposed 
coding changes. These meetings provide an opportunity for 
representatives of recognized organizations in the coding field, such 
as the American Health Information Management Association (AHIMA) 
(formerly American Medical Record Association (AMRA)), the American 
Hospital Association (AHA), and various physician specialty groups as 
well as physicians, medical record administrators, health information 
management professionals, and other members of the public, to 
contribute ideas on coding matters. After considering the opinions 
expressed at the public meetings and in writing, the Committee 
formulates recommendations, which then must be approved by the 
agencies.
    The Committee presented proposals for coding changes for FY 2000 at 
public meetings held on June 4 and November 2, 1998. Even though the 
Committee conducted public meetings and considered approval of coding 
changes for FY 2000 implementation, we are not implementing any changes 
to ICD-9-CM codes for FE 2000. We have undertaken, and continue to 
undertake, major efforts to ensure that all of the Medicare computer 
systems are ready to function on January 1, 2000. If we were to make 
system changes to capture additions, deletions, and modifications to 
ICD-9-CM codes for FY 2000, we would endanger the functioning of the 
Medicare computer systems, and, specifically, we might compromise our 
ability to process hospital bills. Therefore, the code proposals 
presented at the public meetings held on June 4 and November 2, 1998, 
that (if approved) ordinarily would have been included as new codes for 
October 1, 1999, are not included in this final rule. These code 
changes to ICD-9-CM will be considered for inclusion in the annual 
update for FY 2001. The initial meeting for consideration of coding 
changes for implementation in FY 2001 was held on May 13, 1999.
    Copies of the minutes of the 1998 meetings and the May 13, 1999 
meeting can be obtained from the HCFA Home Page at http://www.hcfa.gov/
medicare/icd9cm.htm or from http://www.hcfa.gov/events, click on 
``meetings and workshops'' link, and then click on ``reports of the 
ICD-9-CM coordination and maintenance committee'' link. Paper copies of 
these minutes are no longer available and the mailing list has been 
discontinued. We encourage commenters to address suggestions on coding 
issues involving diagnosis codes to: Donna Pickett, Co-Chairperson; 
ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 
Belcrest Road; Hyattsville, Maryland 20782. Comments may be sent by E-
mail to [email protected].
    Questions and comments concerning the procedure codes should be 
addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination 
and Maintenance Committee; HCFA, Center for Health Plans and Providers, 
Plan and Provider Purchasing Policy Group, Division of Acute Care; C4-
07-07; 7500 Security Boulevard; Baltimore, Maryland 21244-1850. 
Comments may be sent by E-mail to [email protected].
    We received one comment in support of our decision not to update 
ICD-9-CM codes given the magnitude of system changes needed during the 
period leading up to the year 2000.
9. Other Issues
a. Implantation of Muscle Stimulator
    In the July 31, 1998 final rule, we responded to a comment on the 
DRG assignment for implantation of a muscle stimulator (63 FR 40964). 
In that document, we stated that we would readdress this issue after 
reviewing the FY 1998 MedPAR file.
    There is concern in the manufacturing industry that the current DRG 
assignment for the implantation of a muscle stimulator and the 
associated tendon transfer for quadriplegics is inappropriate. When the 
procedures are performed during two separate admissions, the tendon 
transfer (procedure code 82.56 (Other hand tendon transfer or 
transplantation)) is assigned to DRGs 7 and 8, and the insertion of the 
muscle stimulator (procedure code 83.92 (Insertion or replacement of 
skeletal muscle stimulator)) is assigned to DRG 468. However, when both 
procedures are performed in the same admission, the case is assigned to 
DRGs 7 and 8.
    As discussed in section II.B.7.a of this preamble, in the May 7, 
1999 proposed rule, we proposed to assign code 83.92 to DRGs 7 and 8 in 
MDC 1. Therefore, if a case involves either procedure code 82.56 or 
83.92, or both procedure codes, the case would be assigned to DRGs 7 
and 8.
    A presentation on one type of muscle stimulator was made by a 
device manufacturer before the ICD-9-CM Coordination and Maintenance 
Committee on November 2, 1998. The manufacturer strongly suggested that 
a

[[Page 41497]]

new code assignment be made for the procedure for insertion of this 
stimulator and that it be placed in category 04.9 (Other operations on 
cranial and peripheral nerves). However, based on comments received by 
the Committee, there was an overwhelming response from the coding 
community that a new code should not be created. The commenters believe 
that these codes (82.56 and 83.92) adequately described the procedures 
since the patient receives a tendon transfer in addition to the 
skeletal muscle stimulator insertion. This is done so that the 
quadriplegic patient can achieve some hand grasping ability where there 
was none before. Some quadriplegic patients receive the tendon transfer 
on one admission and the stimulator insertion on a subsequent 
admission. Others have both procedures performed on the same admission. 
Since the tendon transfer and stimulator insertion are being performed 
on quadriplegic patients, a condition found in MDC 1, we proposed to 
add procedure codes 82.56 and 83.92 to DRGs 7 and 8. We did not receive 
any comments on this proposal. Therefore, we are adopting it as final.
b. Pancreas Transplant
    Through a Medicare Coverage Issues Manual revision (Transmittal No. 
115, April 1999), HCFA announced that, effective July 1, 1999, Medicare 
covers whole organ pancreas transplantation (procedure codes 52.80 or 
52.83) if it is performed simultaneous with or after a kidney 
transplant.
    Pancreas transplantation is generally limited to those patients 
with severe secondary complications of diabetes, including kidney 
failure. However, pancreas transplantation is sometimes performed on 
patients with labile diabetes and hypoglycemic unawareness.
    Pancreas transplantation for diabetic patients who have not 
experienced end-stage renal failure secondary to diabetes continue to 
be excluded from coverage. Medicare also excludes coverage of 
transplantation of partial pancreatic tissue or islet cells. Claims 
processing instructions to intermediaries were contained in Program 
Memorandum Transmittal No. A-99-16 (April 1999).
    We received one comment regarding the coverage and claims 
processing instructions for pancreas transplants.
    Comment: The commenter requested clarification on the date of 
coverage for services related to pancreas transplantation services 
furnished on or after July 1, 1999. Specifically, the commenter asked 
whether coverage is effective for admissions, discharges, or actual 
transplant surgery on or after that date. In addition, the commenter 
believes that if the resource use for a pancreas-kidney transplant is 
significantly greater than for a kidney transplant alone, then a new 
DRG should be created for the dual transplant. Finally, the commenter 
was unsure how hospitals should report the organ acquisition costs 
attributable to pancreas. Specifically, the commenter wanted to know if 
the costs should be included, on the hospital cost report with the 
kidney costs or whether a separate organ acquisition cost center will 
be established for pancreas acquisition costs.
    Response: As stated in Transmittal No. 115, coverage is effective 
for dates of service on or after July 1, 1999. Therefore, any pancreas 
transplant performed on or after July 1, 1999 is covered by Medicare if 
all other qualifying criteria are met.
    Under the current DRG classification, if a kidney transplant and a 
pancreas transplant are performed simultaneously on a patient with 
chronic renal failure secondary to diabetes with renal manifestations 
(diagnosis codes 250.40 through 250.43), the case is assigned to DRG 
302 (Kidney Transplant) in MDC 11 (Disease and Disorders of the Kidney 
and Urinary Tract. If a pancreas transplant is performed following a 
kidney transplant (that is, in a different hospital admission) on a 
patient with chronic renal failure secondary to diabetes with renal 
manifestations, the case is assigned to DRG 468 (Major OR Procedure 
Unrelated to Principal Diagnosis) because pancreas transplant is not 
assigned to MDC 11, the MDC to which a principal diagnosis of chronic 
renal failure secondary to diabetes is assigned.
    If a kidney and pancreas transplant are performed simultaneously or 
if a pancreas transplant is performed following a kidney transplant, on 
a patient with chronic renal failure secondary to diabetes with 
ketoacidosis (diagnosis codes 250.10 through 250.13), diabetes with 
hyperosmolarity (diagnosis codes 250.20 through 250.23), diabetes with 
other coma (diagnosis codes 250.30 through 250.33), diabetes with other 
specified manifestations (diagnosis codes 250.80 through 250.83), or 
diabetes with unspecified complication (diagnosis codes 250.90 through 
250.93), the case would be assigned to DRG 292 or 293 (Other Endocrine, 
Nutritional and Metabolic OR Procedures) in MDC 10 (Endocrine, 
Nutritional, and Metabolic Diseases and Disorders). As the commenter 
notes, it is possible that the resource use for a pancreas-kidney 
transplant or a pancreas-only transplant might be significantly 
different from a kidney-only transplant. We intend to review the 
Medicare data in our FY 1999 MedPAR file in order to analyze whether we 
should either reassign these transplants to a different DRG or create a 
new DRG. We will announce any proposals on that issue in the FY 2001 
proposed rule, which will be published in the Spring of 2000.
    A separate organ acquisition cost center has been established for 
pancreas transplantation. The Medicare cost report will include a 
separate line to account for pancreas transplantation costs. In 
addition, in this final rule, we are making a conforming change to ' 
412.2(e)(4) to include pancreas in the list of organ acquisition costs 
that are paid on a reasonable cost basis.
c. Immunotherapy
    Effective October 1, 1994, procedure code 99.28 (Injection or 
infusion of biological response modifier [BRM] as an antineoplastic 
agent) was created. This procedure is also known as BRM therapy or 
immunotherapy. At that time, we designated the code as a [email protected] code 
that does not affect DRG assignment.
    Comment: One commenter, a manufacturer of a biologic response 
modifier, requested that we create a new DRG for BRM therapy or assign 
cases in which BRM therapy is performed to an existing DRG with a high 
relative weight. The commenter suggested that DRG 403 (Lymphoma and 
Non-Acute Leukemia with CC) would be an appropriate DRG. The 
manufacturer=s particular drug is used in the treatment of metastatic 
renal cell carcinoma and metastatic melanoma.
    Response: Using the 100 percent FY 1998 MedPAR file that contains 
bills through December 31, 1998, we performed an analysis of the cases 
for which procedure code 99.28 was reported. Based on the commenter's 
request, for purposes of this analysis we examined cases only for 
hospitals that use the particular drug manufactured by the commenter. 
We identified 121 cases in 19 DRGs in 9 MDCs. No more than 31 cases 
were assigned to any one particular DRG. Of the 121 cases identified, 
31 cases were assigned to DRG 318 (Kidney and Urinary Tract Neoplasms 
with CC) and 30 of the cases were assigned to DRG 82 (Respiratory 
Neoplasms). There was a wide range of charges (between approximately 
$1,300 and $125,000 per case) associated with this therapy. The average 
length of stay was approximately 5 days. Due to the limited number of 
cases that were

[[Page 41498]]

distributed throughout 19 DRGs and the variation of charges, we 
concluded that it would be inappropriate to classify these cases into a 
single DRG. Because of the numerous principal diagnoses reported with 
BRM therapy, a single DRG for procedure code 99.28 would need to be 
placed in the pre-MDC DRG category. Similarly, it would be impossible 
to classify these cases into DRG 403 because only a few cases were 
coded with a principal diagnosis assigned to MDC 17 (Myeloproliferative 
Diseases and Disorders, and Poorly Differentiated Neoplasms), the MDC 
that includes DRG 403. Finally, the variation in charges reflected in 
the 121 cases do not persuade us that there is an analytic basis for 
combining these cases into one DRG. Using the FY 1999 MedPAR, we intend 
to do a full analysis of these cases, which we will discuss in the FY 
2001 proposed rule.
    As a final note, any DRG classification change for procedure code 
99.28 must be appropriate for all cases that receive BRM therapy, not 
just those that use the commenter's drug. Even if we might consider 
such an assignment appropriate, we have no way to distinguish between 
different drug therapies assigned to the same procedure code. The FY 
1998 MedPAR file we analyzed contained 930 cases with procedure code 
99.28. These 930 cases were assigned to 18 MDCs.
d. Heart Assist Devices
    Effective May 5, 1997, we revised Medicare coverage of heart assist 
devices to allow coverage of a ventricular assist device used for 
support of blood circulation postcardiotomy if certain conditions were 
met. In the August 29, 1997 final rule (62 FR 45973), we moved 
procedure code 37.66 (Implant of an implantable pulsatile heart assist 
device) from DRGs 110 and 111 (Major Cardiovascular Procedures) to DRG 
108 (Other Cardiothoracic Procedures) to improve payment for these 
procedures. In the July 31, 1998 final rule (63 FR 40956), in a further 
effort to improve payment for these cases, we moved procedure code 
37.66 to DRGs 104 and 105 (Cardiac Valve and Other Major Cardiothoracic 
Procedures).
    We received one comment regarding the DRG classification of 
procedure code 37.66.
    Comment: The commenter recommended that we either reclassify heart 
assist device cases to DRG 103 (Heart Transplant) or create a new DRG 
specifically for this device and technology. The commenter cited a 
discrepancy between the cost of the device implantation and payment for 
DRGs 104 and 105 as the basis for these recommendations.
    Response: We refer the reader to our response to a similar comment 
in the August 29, 1997 final rule (62 FR 45967). We note that the FY 
1998 MedPAR file has 22 cases coded with procedure code 37.66. Of these 
22 cases, 8 cases were assigned to DRG 103 (Heart Transplant) and 4 
cases to DRG 483 (Tracheostomy Except for Face, Mouth, and Neck 
Diagnoses). The remaining 10 cases would have been assigned to DRGs 104 
and 105 under the current classification.

C. Recalibration of DRG Weights

    We proposed to use the same basic methodology for the FY 2000 
recalibration as we did for FY 1999. (See the July 31, 1998 final rule 
(63 FR 40965).) That is, we recalibrated the weights based on charge 
data for Medicare discharges. However, we used the most current charge 
information available, the FY 1998 MedPAR file. (For the FY 1999 
recalibration, we used the FY 1997 MedPAR file.) The MedPAR file is 
based on fully coded diagnostic and surgical procedure data for all 
Medicare inpatient hospital bills.
    The final recalibrated DRG relative weights are constructed from FY 
1998 MedPAR data, based on bills received by HCFA through March 1999, 
from all hospitals subject to the prospective payment system and short-
term acute care hospitals in waiver States. The FY 1998 MedPAR file 
includes data for approximately 11.3 million Medicare discharges.
    The methodology used to calculate the DRG relative weights from the 
FY 1998 MedPAR file is as follows:
     All the claims were regrouped using the DRG classification 
revisions discussed above in section II.B of this preamble.
     Charges were standardized to remove the effects of 
differences in area wage levels, indirect medical education (IME) and 
disproportionate share hospital (DSH) payments, and, for hospitals in 
Alaska and Hawaii, the applicable cost-of-living adjustment.
     The average standardized charge per DRG was calculated by 
summing the standardized charges for all cases in the DRG and dividing 
that amount by the number of cases classified in the DRG.
     We then eliminated statistical outliers, using the same 
criteria as were used in computing the current weights--that is, all 
cases that are outside of 3.0 standard deviations from the mean of the 
log distribution of both the charges per case and the charges per day 
for each DRG.
     The average charge for each DRG was then recomputed 
(excluding the statistical outliers) and divided by the national 
average standardized charge per case to determine the relative weight. 
A transfer case is counted as a fraction of a case based on the ratio 
of its length of stay to the geometric mean length of stay of the cases 
assigned to the DRG. That is, a 5-day length of stay transfer case 
assigned to a DRG with a geometric mean length of stay of 10 days is 
counted as 0.5 of a total case.
     We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner 
consistent with the methodology for all other DRGs except that the 
transplant cases that were used to establish the weights were limited 
to those Medicare-approved heart, heart-lung, liver, and lung 
transplant centers that have cases in the FY 1998 MedPAR file. 
(Medicare coverage for heart, heart-lung, liver, and lung transplants 
is limited to those facilities that have received approval from HCFA as 
transplant centers.)
     Acquisition costs for kidney, heart, heart-lung, liver, 
and lung transplants continue to be paid on a reasonable cost basis. 
Unlike other excluded costs, the acquisition costs are concentrated in 
specific DRGs (DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant 
for Heart and Heart-Lung Transplants); DRG 480 (Liver Transplant); and 
DRG 495 (Lung Transplant)). Because these costs are paid separately 
from the prospective payment rate, it is necessary to make an 
adjustment to prevent the relative weights for these DRGs from 
including the effect of the acquisition costs. Therefore, we subtracted 
the acquisition charges from the total charges on each transplant bill 
that showed acquisition charges before computing the average charge for 
the DRG and before eliminating statistical outliers.
    When we recalibrated the DRG weights for previous years, we set a 
threshold of 10 cases as the minimum number of cases required to 
compute a reasonable weight. We used that same case threshold in 
recalibrating the DRG weights for FY 2000. Using the FY 1998 MedPAR 
data set, there are 40 DRGs that contain fewer than 10 cases. We 
computed the weights for the 40 low-volume DRGs by adjusting the FY 
1999 weights of these DRGs by the percentage change in the average 
weight of the cases in the other DRGs.
    The weights developed according to the methodology described above, 
using the final DRG classification changes, result in an average case 
weight that is different from the average case weight

[[Page 41499]]

before recalibration. Therefore, the new weights are normalized by an 
adjustment factor, so that the average case weight after recalibration 
is equal to the average case weight before recalibration. This 
adjustment is intended to ensure that recalibration by itself neither 
increases nor decreases total payments under the prospective payment 
system.
    Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with 
FY 1991, reclassification and recalibration changes be made in a manner 
that ensures that the aggregate payments are neither greater than nor 
less than the aggregate payments that would have been made without the 
changes. Although normalization is intended to achieve this effect, 
equating the average case weight after recalibration to the average 
case weight before recalibration does not necessarily achieve budget 
neutrality with respect to aggregate payments to hospitals because 
payment to hospitals is affected by factors other than average case 
weight. Therefore, as we have done in past years and as discussed in 
section II.A.4.b of the Addendum to this final rule, we make a budget 
neutrality adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.

D. Use of Non-MedPAR Data for Reclassification and Recalibration of the 
DRGs

1. Introduction
    As in past years, in the DRG reclassification and recalibration 
process for the FY 2000 final rule, we used the MedPAR file, which 
consists of data for approximately 11.3 million Medicare discharges. In 
the FY 1999 final rulemaking process, we used the FY 1997 MedPAR file 
to recalibrate DRGs and evaluate possible changes to DRG 
classifications; for this FY 2000 final rule, we used the FY 1998 
MedPAR file. The Conference Report that accompanied the Balanced Budget 
Act of 1997 stated that ``in order to ensure that Medicare 
beneficiaries have access to innovative new drug therapies, the 
conferees believe that HCFA should consider, to the extent feasible, 
reliable, validated data other than Medicare Provider Analysis and 
Review (MedPAR) data in annually recalibrating and reclassifying the 
DRGs'' (H.R. Conf. Rep. No. 105-217 at 734 (1997)).
    Consistent with that language, we considered non-MedPAR data in the 
rulemaking process for FY 1999 and in developing the May 7, 1999 
proposed rule for FY 2000. We received non-MedPAR data from entities on 
behalf of the manufacturer of a specific drug, platelet inhibitors. The 
manufacturer was seeking to obtain a new DRG assignment for cases 
involving platelet inhibitors. The non-MedPAR data purported to show 
cases involving platelet inhibitors. As discussed in the proposed rule, 
we concluded it was not feasible to use the non-MedPAR data submitted 
to us because, among other things, we did not have information to 
verify that the cases actually involved the drug, nor did we have 
information to verify that the cases reflected a representative sample 
(and did not simply reflect high cost cases).
    Effective October 1, 1998, we implemented a code for platelet 
inhibitors, but until we receive bills for Medicare discharges 
occurring during FY 1999, the MedPAR data do not enable us to 
distinguish between cases with platelet inhibitors and cases without 
platelet inhibitors (63 FR 40963). Representatives of the 
pharmaceutical company first presented us with non-MedPAR data during 
the rulemaking process for FY 1999. The data were compiled by a health 
information company, and purported to show, for cases from a sample of 
hospitals, the average standardized charges (as calculated by the 
health information company) for different classes of patients.
    In the FY 1999 final rule, we stated a number of reasons for 
rejecting the non-MedPAR data we had received. Basically, the data were 
unreliable and the data's use was not feasible--the data could not be 
validated or verified.
    After publication of the July 31, 1998 final rule, we met and 
corresponded on several occasions with the manufacturers, vendors, and 
legal representatives of the pharmaceutical company in an effort to 
resolve data issues. We reiterated that, among other things, we needed 
to know for each case the hospital that furnished the services. Before 
the publication of the proposed rule, we had not received information 
necessary to validate the data or the data's representativeness.
    We remain open to considering non-MedPAR data in the DRG 
reclassification and recalibration process, but, consistent with the 
Conference Report, as well as our longstanding policies, the data must 
be ``reliable'' and ``validated.'' The July 31, 1998 final rule 
reflected the major factors that we consider in evaluating whether data 
are feasible, reliable, and validated; however, because we believed it 
might be useful, we discussed these issues in much greater detail in 
the May 7, 1999 proposed rule.
2. The DRG Reclassification and Recalibration Process
    In order to understand whether it is feasible to use non-MedPAR 
data, and whether the data are reliable and validated, it is critical 
to understand the DRG recalibration and reclassification process. As 
described earlier, one of the first steps in the annual DRG 
recalibration is that the Medicare hospital inpatient claims (in the 
MedPAR file) from the preceding Federal fiscal year are classified 
using the DRG classification system (proposed or final) for the 
upcoming year. Cases are classified into DRGs based on the principal 
diagnosis, up to eight additional diagnoses, and up to six procedures 
performed during the stay, as well as age, sex, and discharge status of 
the patient. Each case is classified into one and only one DRG.
    As the term suggests, the relative weight for each DRG reflects 
relative resource use. The recalibration process requires data that 
enable us to compare resource use across DRGs. As explained earlier, as 
part of the recalibration process, we standardize the charges reflected 
on each Medicare claim to remove the effects of area wage differences, 
the IME adjustment, and the DSH adjustment; in order to standardize 
charges, we need to know which hospital furnished the service. For each 
DRG, we calculate the average of the standardized charges for the cases 
classified to the DRG. To calculate DRG relative weights, we compare 
average standardized charges across DRGs.
    In evaluating whether it is appropriate to reclassify cases from 
one DRG to another, we examine the average standardized charges for 
those cases. The recalibration process and the reclassification process 
are integrally related; to evaluate whether cases involving a certain 
procedure should be reclassified, we need to have information that (1) 
enables us to identify cases that involve the procedure and cases that 
do not involve the procedure, and (2) enables us to determine 
appropriate DRG relative weights if certain cases are reclassified.
3. Feasible, Reliable, Validated Data
    As indicated above, the Conference Report reflected the conferees' 
belief that, ``to the extent feasible,'' HCFA should consider 
``reliable, validated data'' in recalibrating and reclassifying DRGs. 
The concepts of reliability and validation are closely related. In 
order for us to use non-MedPAR data, the non-MedPAR data must be 
independently validated. When an entity submits non-MedPAR data, we

[[Page 41500]]

must be able to independently review the medical records and verify 
that a particular procedure was performed for each of the cases that 
purportedly involved the procedure. This verification requires the 
identification of a particular Medicare beneficiary and the hospital 
where the beneficiary was treated, as well as the dates involved. 
Although it is unlikely that we would review 100 percent of thousands 
of cases submitted for review, at a minimum, we must be able to 
validate data through a random sampling methodology. We must also be 
able to verify the charges that are reflected in the data.
    Independent validation is particularly critical in part because the 
non-MedPAR data might be submitted by (or on behalf of) entities that 
have a financial interest in obtaining a new DRG assignment and in 
obtaining the highest possible DRG relative weight. If we receive non-
MedPAR data that purport to reflect cases involving a certain procedure 
and a certain level of charges, we must have some way to verify the 
data.
    Even if non-MedPAR data are reliable and verifiable, that does not 
mean it is necessarily ``feasible'' to use the data for purposes of 
recalibration and reclassification. In order to be feasible for these 
purposes, the non-MedPAR data must enable us to appropriately measure 
relative resource use across DRGs. It is critical that cases are 
classified into one and only one DRG in the recalibration process, and 
that we have information that enables us to standardize charges for 
each case and determine appropriate DRG relative weights. Moreover, the 
data must reflect a complete set of cases or, at a minimum, a 
representative sample of hospitals and claims.
    If cases are classified into more than one DRG (or into the 
incorrect DRG) in the recalibration process, or if the non-MedPAR data 
reflect an unrepresentative sample of cases, the measure of relative 
resources would be distorted. For example, cases of percutaneous 
transluminal coronary angioplasty (PTCA) treated with GPIIb/IIIa 
platelet inhibitors (procedure code 99.20) are currently classified to 
DRG 112. Prior to the publication of the proposed rule, the same drug 
manufacturer discussed above provided us with information on the 
average charges for a sample of cases that purportedly involve PTCA, 
for the purpose of evaluating whether these cases should be moved to 
the higher-weighted DRG 116. However, without adequate identification 
of the cases to allow us to specifically identify all of the cases 
treated with platelet inhibitors, the relative weight for DRG 112 would 
reflect the costs of platelet inhibitor cases. This distortion would 
result in excessive payments under DRG 112, and thus undermine the 
integrity of the recalibration process.
    Therefore, in order for the use of non-MedPAR data to be feasible, 
generally we must be able to accurately and completely identify all of 
the cases to be reclassified from one DRG to another. At a minimum, we 
must have some mechanism for ensuring that DRG weights are not 
inappropriately inflated (or deflated) to the extent that a DRG weight 
reflects cases that would be reclassified to a different DRG.
    In short, then, for use of non-MedPAR data to be feasible for 
purposes of DRG recalibration and reclassification, the data must, 
among other things (1) be independently verifiable, (2) reflect a 
complete set of cases (or a representative sample of cases), and (3) 
enable us to calculate appropriate DRG relative weights and ensure that 
cases are classified to the ``correct'' DRG, and to one DRG only, in 
the recalibration process.
4. Submission of Data
    Finally, in order for use of non-MEDPAR data to be feasible, we 
must have sufficient time to evaluate and test the data. The time 
necessary to do so depends upon the nature and quality of the data 
submitted. Generally, however, a significant sample of the data should 
be submitted by August 1, approximately 8 months prior to the 
publication of the proposed rule, so that we can test the data and make 
a preliminary assessment as to the feasibility of the data's use. 
Subsequently, a complete database should be submitted no later than 
December 1 for consideration in conjunction with the next year's 
proposed rule.
5. How the Prospective Payment System Ensures Access to New 
Technologies
    As noted at the outset of this discussion, the Conference Report 
that accompanied the BBA indicated that we should consider non-MEDPAR 
data, to the extent feasible, ``in order to ensure that Medicare 
beneficiaries have access to innovative new drug therapies'' (H.R. 
Conf. Rep. No. 105-217 at 734 (1997)). There seems to be a concern 
that, if a new technology is introduced, and if the new technology is 
costly, then Medicare would not make adequate payment if the new 
technology is not immediately placed in a new DRG. This concern is 
unfounded. As explained below, the Medicare hospital inpatient 
prospective payment does ensure access to new drug therapies, and to 
new technologies in general.
    First, to the extent a case involving a new technology is extremely 
costly relative to the cases reflected in the DRG relative weight, the 
hospital might qualify for outlier payments, that is, additional 
payments over and above the standard prospective payment rate.
    Second, Medicare promotes access to new technologies by making 
payments under the prospective payment system that are designed to 
ensure that Medicare payments for a hospital's cases as a whole are 
adequate. We establish DRGs based on factors such as clinical coherence 
and resource utilization. Each diagnosis-related group encompasses a 
variety of cases, reflecting a range of services and a range of 
resources. Generally, then, each DRG reflects some higher cost cases 
and some lower cost cases.
    For some cases, the hospital's costs might be higher than the 
payment under the prospective payment system; this does not mean that 
the DRG classifications are ``inappropriate.'' For other cases, the 
hospital's costs will be lower than the payment under the prospective 
payment system. We believe that Medicare makes appropriate payments for 
a hospital's cases as a whole.
    Each year we examine the best data available to assess whether DRG 
changes are appropriate and to recalibrate DRG relative weights. As we 
have indicated on numerous occasions, it usually takes 2 years from the 
time a procedure is assigned a code to collect the appropriate MedPAR 
data and then make an assessment as to whether a DRG change is 
appropriate. This timetable applies to reclassifications that would 
lead to decreased payment as well as those that would increase payment. 
In fact, the introduction of new technologies itself might lead to 
either higher than average costs or lower costs.
    Our ability to evaluate and implement potential DRG changes depends 
on the availability of validated, representative data. We believe that 
our policies ensure access to new technologies and are critical to the 
integrity of the recalibration process. We still remain open to using 
non-MedPAR data if the data are reliable and validated and enable us to 
appropriately measure relative resource use.
    We received a number of comments regarding this issue, including 
comments from MedPAC, pharmaceutical manufacturers (including two 
manufacturers of platelet inhibitor drugs), an industry manufacturers' 
association, and several

[[Page 41501]]

cardiologists. We received only one comment from a State hospital 
association; otherwise, hospital associations were silent on this 
issue.
    Comment: MedPAC stated that HCFA's general criteria provide a valid 
basis for assessing the feasibility and appropriateness of using 
outside data to establish DRG assignments and relative weights for 
specific technologies. MedPAC believes that it would be helpful to 
entities that desire to submit useful data if HCFA would establish and 
publish explicit data standards to guide their efforts. MedPAC 
suggested the criteria might include the format and content of the 
patient care records; the minimum sample size; required documentation 
of sampling procedures; acceptable methods for ensuring that the 
sampled providers were representative of the relevant provider 
universe; and any other information that HCFA considered essential to 
establish the validity and reliability of the submitted data. MedPAC 
believes that the criteria would help to prevent misunderstandings and 
ensure HCFA's ability to assess whether the submitted data were 
adequate to serve as a basis for DRG assignment before actual MedPAR 
claims become available.
    Response: We appreciate the Commission's support of our general 
criteria. We would prefer to gain further experience working with non-
MedPAR data before we develop any specific criteria regarding sample 
sizes or methodologies. This will enable us to establish criteria that 
realistically reflect the availability of such data and the general 
suitability of the data for use in the DRG reclassification and 
recalibration process. Our intent at this time is to address some 
fundamental criteria that must be taken into consideration by outside 
parties interested in submitting non-MedPAR data.
    We note that the timetable we set forth in the proposed rule is 
intended to provide adequate opportunity to permit outside parties to 
conform their data to our needs through testing and resubmission. This 
is the primary reason we believe it is generally necessary to have a 
sample of the data 8 months prior to the publication of the proposed 
rule. We are willing to meet with outside parties interested in 
submitting non-MedPAR data for consideration, and would suggest that 
those interested in submitting such data in the future should contact 
us to discuss the specific data they wish to submit and whether the 
data may be adequate.
    Comment: One commenter, while supporting the idea that the data 
must be reliable and verifiable, indicated that HCFA should consider 
other means by which to accomplish this purpose. The commenter stated 
that many of the sources for data are restricted from releasing 
identifying elements of the data they collect. The commenter claimed, 
for example, that they could validate the method by which the data were 
assembled, thereby alleviating our concern that the cases may not 
represent Medicare beneficiaries or that the reported charges are 
inaccurate.
    Response: We are open to considering any feasible method for 
validating non-MedPAR data, and that is why at this time we are not 
specifying explicit criteria for the types of data we will or will not 
consider. Instead, we have outlined general guidelines and fundamental 
objectives that must be met. One of those fundamental objectives is 
that we must be able to validate the data and to accurately identify 
cases to be reclassified during DRG recalibration.
    In order to preserve the integrity of the DRG reclassification and 
recalibration process, we generally believe it is imperative that we 
are able to independently validate the data submitted. As noted 
previously, if we receive non-MedPAR data that purport to reflect cases 
involving a certain procedure and a certain level of charges, we must 
have some way to verify that data. In addition, it is not enough to 
simply decide that a particular diagnosis or procedure code should now 
be classified to a higher-weighted DRG. Cases in the MedPAR data used 
for recalibration with that diagnosis or procedure code should be 
reclassified accordingly. Otherwise, these cases will affect the 
calculation of the relative weights of other DRGs. Therefore, in order 
to allow us to ensure the accuracy of DRG recalibration, we must have 
some mechanism for ensuring that DRG weights are not inappropriately 
inflated.
    Comment: Some commenters stated that the criteria regarding the 
feasibility of using the data are inconsistent with the intent of the 
Conference Report language. The commenters contend that there is no 
need to identify each case involving a new technology. Rather, the 
agency can extrapolate the findings from a representative sample of 
cases and estimate which cases must be moved from one DRG to another. 
Two of the commenters stated that this approach was used in 
reclassifying lithotripsy to an appropriate DRG, and that extrapolation 
is used to some degree in setting the physician fee schedule and was 
used in the proposed outpatient prospective payment system. One 
commenter wanted us to clarify that we would accept a representative, 
statistically valid sample of both non-HCFA and HCFA data that reflect 
cases for a period of less than a full year, as well as requesting that 
we specify the sources (for example, private payers, manufacturers of 
medical technologies, or suppliers) from which we are willing to accept 
such data.
    Response: We did not rule out the use of extrapolation based on 
non-MedPAR data in the proposed rule. In fact, we stated that the data 
must reflect either a complete set of cases, or, at a minimum, a 
representative sample of hospitals and claims. However, as stated 
previously, the process of recalibrating the DRG weights requires that 
cases be moved consistent with the reclassification of diagnosis or 
procedure codes from one DRG to another. Failure to do so could lead to 
inflated or deflated relative weights, which, in turn, result in over 
or underpayments for cases in the affected DRGs.
    We are attempting to accommodate the realities faced by outside 
parties as they attempt to collect and present non-MedPAR data for 
consideration. In addition, we will continue to explore our processes 
for ways to incorporate such data while preserving the empirical and 
clinical integrity of the recalibration process.
    As noted by two commenters, in the September 3, 1986 final rule (51 
FR 31486), we did, based on analysis by the Prospective Payment 
Assessment Commission (ProPAC), assign all cases involving a principal 
diagnosis of urinary stones treated by extracorporeal shock wave 
lithotripsy (ESWL) to DRG 323 (Urinary stones, age >69 and/or CC). 
Prior to this DRG change, ESWL cases were assigned to either DRG 323 or 
DRG 324, depending on the presence of a CC or based on the patients age 
(over 69). The Commission, an independent advisory body established by 
Congress (and MedPAC's predecessor organization), obtained information 
on ESWL procedure costs and other routine and ancillary hospital 
service charges from the American Heart Association (AHA), the American 
Urological Association, and seven hospitals that furnished ESWL. In 
addition, ProPAC obtained a preliminary summary of a study conducted by 
the Institute for Health Policy Analysis at Georgetown University 
Medical Center. This study included cost data from 16 hospitals that 
furnished lithotripsy. At the time of these studies, approximately 50 
hospitals were furnishing ESWL. Because the ProPAC data were obtained 
directly from hospitals and were verified by the Commission at the

[[Page 41502]]

hospital level, we believed the data were reliable and used the data as 
a basis for reassigning ESWL cases to DRG 343 only. A full explanation 
of the study and ProPAC's analysis and recommendations can be found in 
the Technical Appendixes that accompanied ProPAC's April 1, 1986 Report 
to Congress.
    We have not precluded using either external or internal data that 
represent less than a full year's worth of cases. For example, we could 
examine a partial year's worth of cases from the current Federal fiscal 
year rather than the preceding year's complete MedPAR. Once again, 
however, a feasible approach must be developed to enable the 
appropriate classification and recalibration of the DRG weights.
    Finally, we do not believe it is necessary, or appropriate, to 
identify in advance the sources from which we are willing to accept 
data. At this time, we remain open to considering any data source that 
is reliable, verifiable, and feasible. We would note, however, that 
involving hospitals in any data collection would probably aid HCFA in 
any validation effort. Generally, if we receive non-MedPAR data, we 
will be contacting the hospitals that furnished the sources to verify 
some or all of the data.
    Comment: Two commenters stated the timeframe for submission of the 
non-MedPAR data is unreasonable. They suggested that the submission of 
data 7 months before the updated DRGs take effect (March 1) in the case 
of internal HCFA data, and 8 months (February 1) in the case of 
external data, would more appropriately ensure beneficiary access.
    Response: The length of time necessary to validate non-MedPAR data 
depends on the nature and quality of the data. In the proposed rule, we 
stated that a significant sample of the data should be submitted by 
August 1, approximately 8 months prior to the publication of the 
proposed rule, so that we can verify and test the data and make a 
preliminary assessment as to the feasibility of the data's use. 
Subsequently, a complete database should be submitted no later than 
December 1, approximately 4 months prior to the publication of the 
proposed rule.
    We do not believe that this timeframe is unreasonable. If we were 
to adopt the commenter's suggestion, we would receive non-MedPAR data 
only 2 months before the proposed rule is scheduled to be published 
(April 1). This might not allow us sufficient time to ensure that the 
data are reliable or valid prior to their use in preparing the proposed 
rule.
    We believe the timeframe we set forth is necessary to enable us to 
independently validate any non-MedPAR data submitted. In order to 
verify the data's reliability and validity, we believe we need to 
review a sufficient number of the medical records associated with the 
data. Expecting us to be able to accomplish this in a matter of weeks 
after receiving the data (which is all the time that would be available 
for data received in February due to the requirement to begin the 
process of reclassifying and recalibrating the proposed DRGs by the end 
of February in order for the proposed rule to be published by April 1) 
is unrealistic.
    Comment: Many of the commenters, including the manufacturer of the 
platelet inhibitor drug, national associations representing device and 
drug manufacturers, and individual cardiologists, argued that our 
current process has inhibited the development of new medical 
technologies, and that the criteria for the use of non-MedPAR data are 
unworkable and would further slow the development of new technologies. 
Several commenters asserted that certain new technologies (including 
platelet inhibitors) are denied to Medicare beneficiaries due to 
insufficient payment.
    Response: After 15 years of administering the prospective payment 
system, we do not have any independent evidence that Medicare 
beneficiaries are being denied access to new technologies by hospitals 
or physicians. Although we have always acknowledged that there is a 
time-lag between the time new technologies are introduced and the point 
at which we can begin to accurately identify their associated costs, we 
believe this has not hampered Medicare beneficiaries' access to these 
new technologies. The fact that under the prospective payment system a 
hospital might lose money on some cases but will gain money on other 
cases is well understood by hospitals. We received no comments from 
hospitals or beneficiary advocates complaining about access to new 
technologies in general or drug therapies in particular, and only a 
brief comment from a State hospital association that indicated that the 
use of non-MedPAR data should extend beyond drug therapies. 
Furthermore, as provided in Sec. 489.53(a)(2), HCFA may terminate its 
participation agreement with any hospital if HCFA finds that the 
hospital places restrictions on the persons it will accept for 
treatment and it fails either to exempt Medicare beneficiaries from 
those restrictions or to apply them to Medicare beneficiaries the same 
as to all people seeking care.
    Comment: Several commenters, including the manufacturer of a 
platelet inhibitor drug and individual cardiologists, specifically 
commented on our discussion in the proposed rule of the attempts by the 
manufacturer of the drug to introduce its data into the process, with 
the objective that cases in which platelet inhibitor therapy is 
administered should be reclassified from DRG 112 (Permanent 
Cardiovascular Procedures) to DRG 116 (Other Permanent Cardiac 
Pacemaker Implant or PTCA with Coronary Artery Stent Implant) for FY 
2000. The commenters stated that HCFA has been unwilling to consider 
the data. One commenter stated that HCFA refused to accept these data 
when they were offered in December 1998.
    Response: As discussed in great detail above, and also in the FY 
1999 final rule, our review of the previous data submitted by the drug 
manufacturer found the data to be insufficient. Despite our 
consultation with the manufacturer's representatives in advance of 
their submission of data during the rulemaking process for FY 1999 
(that is during the first half of calendar year 1998), in which we 
advised them that we must be able to identify individual hospitals and 
patients in order to utilize the data, this information was not 
included on over 90 percent of the cases submitted in May 1998. As 
noted in the May 7, 1999 proposed rule, we continued to meet and 
correspond with the manufacturers, contractors, and legal 
representatives of the pharmaceutical company in an effort to resolve 
data issues. At no time have we refused to consider any data offered by 
the company or its agents.
    However, our discussions with these parties led us to the 
conclusion that it might be helpful to identify general criteria for 
submission of non-MedPAR data in the proposed rule. In particular, we 
were concerned that outside parties wishing to submit non-MedPAR data 
were unfamiliar with our current process and the importance of 
accurately reclassifying and recalibrating the DRGs. The DRG relative 
weights are the principle factor in adjusting the prospective payments 
for each of approximately 11 million Medicare discharges each year. In 
addition to the potential financial implications to the Medicare Trust 
Fund and to hospitals themselves if these weights are inaccurate, 
inappropriately assigning cases to higher-weighted DRGs may create 
incentives that are not in the best interest of Medicare beneficiaries.
    We are hopeful that, by explaining the general criteria for 
submitting non-

[[Page 41503]]

MedPAR data and receiving public comments on those criteria, we can 
help to ensure that in the future those interested in submitting non-
MedPAR data will be better informed regarding how the process can work. 
In particular, we believe the timeframe we set will enable us to work 
effectively with those interested in submitting non-MedPAR data to help 
them provide data that can be used.
    Comment: A manufacturer of a platelet inhibitor drug expressed 
concern that HCFA may assign a special DRG classification for patients 
who receive coronary intervention with an angioplasty and treatment 
with platelet inhibitor therapy, but not for acute coronary syndrome 
patients who receive the same drugs without coronary intervention. 
These latter cases are assigned to DRG 124 (Circulatory Disorders 
Except Acute Myocardial Infarction, with Cardiac Catheterization and 
Complex Diagnoses) or DRG 140 (Angina Pectoris). The commenter stated 
that if we were to modify payment for one use and not the other, it 
would potentially create a financial incentive for expensive, risky, 
and invasive treatment. Making payment provisions for both indications 
at the same time, on the other hand, will give neither use an advantage 
over the other. We were asked by the commenter to evaluate platelet 
inhibitor therapy cases assigned to DRG 124 or DRG 140.
    Response: Because this is the first comment we have received 
regarding the noncoronary intervention use of the therapy, an extensive 
study of DRGs 124 and 140 before publication of this final rule was not 
feasible. We will evaluate this issue as part of our annual update for 
FY 2001, when we will have MedPAR data capturing injection or infusion 
of platelet inhibitor (ICD-9-CM procedure code 99.20). This commenter's 
concern that increasing payment for one application of platelet 
inhibitors but not for others could actually create an inappropriate 
incentive in favor of a more invasive treatment, illustrates the 
importance of proceeding cautiously in the process of DRG 
reclassification and recalibration. We have a responsibility not to 
inadvertently create financial incentives that adversely affect 
clinical decisionmaking.
    Comment: During the comment period, we received a revised set of 
data from the manufacturer seeking to have platelet inhibitor therapy 
cases receiving angioplasty reclassified from DRG 112 to DRG 116. The 
data contain 27,673 cases from 164 hospitals in which Medicare patients 
underwent an angioplasty. The commenter describes the data as Athe 
public MedPAR file with an additional field that identifies the MedPAR 
case as involving an angioplasty with or without platelet inhibitor 
therapy. Thus, HCFA can identify the patient and the hospital from 
these data such that they are reliable and verifiable. It also is a 
representative sample of claims and, therefore, it is feasible for the 
agency (HCFA) to use the data set. In light of the significant number 
of angioplasty cases contained in the data, HCFA should be able to 
utilize accepted statistical methods to extrapolate the results of 
these data and recalibrate the DRG [email protected] The manufacturer indicated 
that HCFA should reclassify angioplasty cases with platelet inhibitor 
therapy on the basis of these data.
    Included with the comment are tables summarizing the results of the 
commenter's analysis of the data, showing that angioplasty cases 
receiving platelet inhibitor therapy are more expensive than those not 
receiving platelet inhibitors. According to the commenter, the 
approximate average standardized charges for the different classes of 
patients are as follows:
     No drug, no stent: $19,877.
     No drug, with stent: $22,968.
     Drug, no stent: $26,389.
     Drug, stent: $30,139.
    Response: The submission of these data illustrates the problems of 
attempting to ensure that non-MedPAR data are reliable, validated, and 
feasible to use. Our greatest concern with respect to the data 
submitted by the commenter is that we must validate the data to assess 
whether they are reliable, and (as explained further below) this 
validation process would take significant time and resources because 
the data are not readily verifiable.
    The data file submitted by the commenter is a MedPAR file with an 
additional field. The commenter has ``marked'' certain cases in the 
MedPAR file. The file contains variables named REO-FLAG and STENT-FLAG, 
which purportedly indicate the case received the platelet inhibitor or 
a coronary stent, respectively. However, the variables were placed in 
the file by the commenter, based on information that was not made 
available to HCFA; we did not receive any information to verify that 
the cases flagged by the commenter involved platelet inhibitors. 
Although we can use the FY 1998 MedPAR data to validate whether a case 
received a coronary stent (because the FY 1998 MedPAR data include the 
corresponding procedure code (36.06)), we cannot use the FY 1998 MedPAR 
file by itself to validate whether a case involved platelet inhibitors 
because the procedure code for the use of platelet inhibitors 
(procedure code 99.20) was not effective until October 1, 1998. 
Therefore, we cannot validate the data submitted to us without further 
investigation.
    In order to do so, we believe it is necessary to review the medical 
records associated with the cases. Unless the entity submitting the 
non-MedPAR data includes medical records (or other information that 
would enable us to validate the data), the only method HCFA has to 
review medical records is through Peer Review Organization (PRO) 
review. Thus, we would need to request assistance in the PRO in each of 
the States represented in the submitted data. The PROs would then 
contact the hospitals involved to request copies of the medical 
records. Finally, based on reviewing those records, the PROs would 
notify HCFA whether the data can be validated.
    Conducting a PRO independent validation would require a minimum of 
2 to 3 months, and possibly much longer. Thus, there is not sufficient 
time available to conduct a review of the data submitted by the drug 
manufacturer. Since we cannot validate the data, it would compromise 
the integrity of the DRG recalibration process to use these data in the 
DRG reclassification and recalibration for FY 2000.
    We note that the process used by the manufacturer to collect these 
data is not specified. Based upon our prior discussions with the 
manufacturer and its contractor that prepared the data, we believe the 
164 hospitals represented in the sample have a contract for data 
analysis and review with the consultant. Although we would not rule out 
the possibility that this sample is statistically sufficient, we note 
that in general, random sampling is necessary for generalization beyond 
the sample itself.
    The analysis submitted by the commenter is similar to that 
presented in last year's final rule. As we indicated at that time, our 
general process of waiting until we have identifiable MedPAR data 
applies to changes that would enhance payment as well as those that 
would decrease payment. Absent alternative data meeting the criteria 
otherwise described in the proposed rule and in this final rule, we 
cannot reclassify the administration of platelet inhibitors with 
angioplasty (procedure code 99.20) from DRG 112 to DRG 116.
    Comment: Some commenters believed that the proposed weights for 
DRGs 112 and 116 are dramatically lower than they should be and the 
result will be a disincentive to use these technologies.

[[Page 41504]]

Another commenter stated that by not reclassifying cases receiving 
platelet inhibitors with angioplasty to DRG 116, we actually promote 
the inaccuracy of the DRG weights, by grouping these higher-cost cases 
with other lower-cost cases in DRG 112.
    Response: With regard to the comment concerning the weights of DRGs 
112 and 116, we refer the commenters to the discussion above in section 
II.C of this preamble concerning the steps we take in recalibrating the 
weights. Every year when the relative weights are recalibrated, we use 
charge information from the most recent Medicare data available. That 
is, we use the charges reported by hospitals for the cases under each 
DRG to establish the relative weights. Each DRG weight represents the 
average resources required to care for cases in that particular DRG 
relative to the average resources used to treat cases in all DRGs. We 
have not identified any problems or anomalies related to the cases in 
DRGs 112 and 116 and are confident that the relative weights are 
accurate.
    With respect to the comment about our promoting the inaccuracy of 
the DRG weights by failing to reclassify platelet inhibitor cases, the 
commenter does not appear to understand the difference between 
reclassification and recalibration. That is, the commenter argues that 
the DRG relative weights are inaccurate because high-cost cases are not 
reclassified to a higher-weighted DRG. However, our point regarding the 
accuracy of the relative weights pertains to the necessity that, in the 
process of recalibration, cases are grouped in the DRG to be used for 
payment for similar cases during the upcoming year. Thus, the relative 
weights are accurate in the sense that they are calculated by grouping 
cases according to the DRG under which they would be paid.
    Comment: One of the manufacturers of platelet inhibitor therapy 
disagreed with our statement in the proposed rule that the prospective 
payment system outlier policy would address the rationing of new 
technology to Medicare beneficiaries. The commenter argues that cases 
of platelet inhibitor therapy would not receive outlier payments 
because the cost of the drug, while it is several thousand dollars over 
the DRG payment, is not in excess of the fixed loss threshold ($14,575 
over the DRG payment in the proposed rule for FY 2000).
    Response: Section 1886(d)(5)(A) of the Act provides for payments in 
addition to the basic prospective payments for outlier cases, cases 
involving extraordinarily high costs. Our statement in the proposed 
rule was meant to apply to all new technologies, and not specifically 
to platelet inhibitor therapy. As stated previously, the prospective 
payment system reflects ``averaging principles,'' which means, among 
other things, that a hospital might lose money on some cases but will 
gain money on other cases; sometimes new technologies lead to lower 
costs and we might [email protected] hospitals for those cases. If a case does 
not qualify for an outlier payment, then presumably the case falls 
within the ``typical'' range of costs for cases in the DRG. We believe 
that, as a whole, the prospective payment system does ensure access to 
new technologies, including platelet inhibitor therapy.

III. Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New 
England County Metropolitan Areas (NECMAs) issued by the Office of 
Management and Budget (OMB). OMB also designates Consolidated MSAs 
(CMSAs). A CMSA is a metropolitan area with a population of one million 
or more, comprised of two or more PMSAs (identified by their separate 
economic and social character). For purposes of the hospital wage 
index, we use the PMSAs rather than CMSAs since they allow a more 
precise breakdown of labor costs. If a metropolitan area is not 
designated as part of a PMSA, we use the applicable MSA. Rural areas 
are areas outside a designated MSA, PMSA, or NECMA.
    We note that effective April 1, 1990, the term Metropolitan Area 
(MA) replaced the term Metropolitan Statistical Area (MSA) (which had 
been used since June 30, 1983) to describe the set of metropolitan 
areas comprised of MSAs, PMSAs, and CMSAs. The terminology was changed 
by OMB in the March 30, 1990 Federal Register to distinguish between 
the individual metropolitan areas known as MSAs and the set of all 
metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes 
of the prospective payment system, we will continue to refer to these 
areas as MSAs.
    Beginning October 1, 1993, section 1886(d)(3)(E) of the Act 
requires that we update the wage index annually. Furthermore, this 
section provides that the Secretary base the update on a survey of 
wages and wage-related costs of short-term, acute care hospitals. The 
survey should measure, to the extent feasible, the earnings and paid 
hours of employment by occupational category, and must exclude the 
wages and wage-related costs incurred in furnishing skilled nursing 
services. As discussed below in section III.F of this preamble, we also 
take into account the geographic reclassification of hospitals in 
accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when 
calculating the wage index.

B. FY 2000 Wage Index Update

    The final FY 2000 wage index values in section VI of the Addendum 
to this rule (effective for hospital discharges occurring on or after 
October 1, 1999 and before October 1, 2000) are based on the data 
collected from the Medicare cost reports submitted by hospitals for 
cost reporting periods beginning in FY 1996 (the FY 1999 wage index was 
based on FY 1995 wage data).
    The final FY 2000 wage index includes the following categories of 
data associated with costs paid under the hospital inpatient 
prospective payment system (as well as outpatient costs), which were 
also included in the FY 1999 wage index:
     Salaries and hours from short-term, acute care hospitals.
     Home office costs and hours.
     Certain contract labor costs and hours.
     Wage-related costs.
    Consistent with the wage index methodology for FY 1999, the final 
wage index for FY 2000 also continues to exclude the direct and 
overhead salaries and hours for services not paid through the inpatient 
prospective payment system, such as skilled nursing facility services, 
home health services, or other subprovider components that are not 
subject to the prospective payment system. (As discussed in section 
III.C of this preamble, we are refining the methodology for calculating 
the wage index for FY 2000.)
    We calculate a separate Puerto Rico-specific wage index and apply 
it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.) 
This wage index is based solely on Puerto Rico's data. Finally, section 
4410 of the BBA provides that, for discharges on or after October 1, 
1997, the area wage index

[[Page 41505]]

applicable to any hospital that is not located in a rural area may not 
be less than the area wage index applicable to hospitals located in 
rural areas in that State.
    Comment: In a general comment on the wage index, MedPac noted that 
new measures are needed to implement each new prospective payment 
system as well as for Medicare+Choice plans and suggested that we 
explore alternative strategies for obtaining labor prices that could be 
applied to each type of provider affected. MedPAC offers to assist us 
in examining this issue.
    Response: We agree with MedPAC that this is an area warranting 
further attention to determine whether it is appropriate to continue to 
adjust payments for these other provider types based on the relative 
average hourly wages of hospital employees, and whether the collection 
of wage data for every type of Medicare provider is feasible or 
necessary. Currently, the data used to calculate the hospital wage 
index is used broadly in payment systems for other types of Medicare 
providers. New prospective systems for skilled nursing facilities, 
hospital outpatient services, and home health agencies will continue to 
use the hospital wage index data for the foreseeable future. We have 
collected data separately for skilled nursing facilities, but, pending 
further development and auditing of these data, we continue to use the 
hospital wage data (before reclassifications by the Medicare Geographic 
Classification Review Board) for adjusting skilled nursing facility 
payments at this time.

C. FY 2000 Wage Index Methodology Changes

    In the July 31, 1998 final rule, we reiterated our position that, 
to the greatest degree possible, the hospital wage index should reflect 
the wage costs associated with the areas of the hospital included under 
the hospital inpatient prospective payment system (63 FR 40970). That 
final rule contained a detailed discussion concerning the costs related 
to teaching physicians, residents, and CRNAs, all of which are paid by 
Medicare separately from the prospective payment system. For reasons 
outlined in detail in that final rule, we decided not to remove those 
costs from the calculation of the FY 1999 wage index, but to review 
updated data and consider removing them in developing the FY 2000 wage 
index.
    In response to concerns within the hospital industry related to the 
removal of these costs from the wage index calculation, the American 
Hospital Association (AHA) convened a workgroup to develop a consensus 
recommendation. The workgroup, which consisted of representatives from 
national and State hospital associations, recommended that costs 
related to teaching physicians, residents, and CRNAs should be phased-
out of the wage index calculation over a 5-year period. Based upon our 
analysis of hospitals' FY 1996 wage data, and consistent with the AHA 
workgroup's recommendation, we proposed to phase-out these costs from 
the calculation of the wage index over a 5-year period. The proposed FY 
2000 wage index was based on a blend of 80 percent of an average hourly 
wage including these costs, and 20 percent of an average hourly wage 
excluding these costs.
    Comment: Commenters unanimously supported our proposal to remove 
teaching-related and CRNA costs from the wage index. Further, two 
commenters recommended that we emphasize that Medicare pays its share 
of teaching-related wage costs through direct graduate medical 
education (GME) payments and that these costs are being removed from 
the wage index only insofar as Medicare continues to pay the costs 
outside of the hospital prospective payment system. Additionally, 
commenters favored the proposed 5-year phase-out of these costs to 
reduce significant redistributive impacts.
    MedPAC, however, recommended that, rather than reducing the weights 
for the old calculation and increasing the weights for the new 
calculation by the proposed 20 percent each year, we should apply 
smaller weights to the new wage index calculation for the first 2 
years. Its rationale for this is its concern that inaccurate reporting 
of teaching physician data, and our methodology for removing costs for 
hospitals that fail to report these data, may inappropriately lower the 
wage index values for nonteaching hospitals in the same labor market 
areas.
    Response: We are pleased to receive strong support for our efforts 
to remove from the hospital wage index, wage costs that are associated 
with areas of the hospital not included under the hospital prospective 
payment system. Therefore, beginning with the FY 2000 wage index, and 
over a 5-year period, we are phasing-out costs related to teaching 
physicians, residents, and CRNAs. As recommended, we emphasize that our 
rationale for removing these costs from the wage index calculation is 
that Medicare pays for these costs separately, and these costs will be 
excluded from the wage index as long as they are paid separately from 
the hospital prospective payment system.
    With respect to MedPAC's recommendation that the weight given to 
the average hourly wage calculated after removing CRNAs, teaching 
physicians, and residents, should be less than 20 percent for FY 2000, 
we disagree. If we applied a percentage less than 20 percent for FY 
2000 (and FY 2001), we then would have to apply a higher percentage 
phase-out in a later fiscal year (or years) and thus increase the 
redistributive impact for that year. We believe that applying 20 
percent increments each year promotes the smoothest transition to total 
exclusion of the costs.
1. Teaching Physician Costs
    As discussed in the FY 1999 final rule and the FY 2000 proposed 
rule, before FY 1999, we included direct physician Part A costs and 
excluded contract physician Part A costs from the wage index 
calculation. Since some States prohibit hospitals from directly 
employing physicians, hospitals in these States were unable to include 
physician Part A costs because they were incurred under contract rather 
than directly. Therefore, for cost reporting periods beginning in 1995, 
we began separately collecting physician Part A costs (both direct and 
contract) so we could evaluate how to best handle these costs in the 
wage index calculation. Based on our analysis of the 1995 wage data, we 
decided to include the contract physician salaries in the wage index 
beginning with FY 1999.
    In the July 31, 1998 final rule, in response to comments regarding 
the inclusion in physician Part A costs of teaching physician costs for 
which teaching hospitals are already compensated through the Medicare 
GME payment, we stated that we would collect teaching physician data 
``as expeditiously as possible in order to analyze whether it is 
feasible to separate teaching physician costs from other physician Part 
A costs'' (63 FR 40968). Excluding teaching physician costs from the 
wage index calculation is consistent with our general policy to exclude 
from that calculation those costs that are paid separately from the 
prospective payment system.
    Because the FY 1996 cost reports did not identify teaching 
physician salaries and hours separately from physician Part A costs, we 
instructed our fiscal intermediaries to collect, through a survey, 
teaching physician costs and hours from the teaching hospitals they 
service. Specifically, we requested collection of data on the costs and 
hours related to teaching physicians that were

[[Page 41506]]

included in Line 4 (salaried), Line 10 (contracted), Line 12 (home 
office and related organizations), and Line 18 (wage-related costs) of 
the Worksheet S-3, Part II. In our instructions accompanying the 
survey, we indicated that these teaching-related costs are those 
payable under the per resident amounts (Sec. 413.86) and reported on 
Worksheet A, Line 23 of the hospital's cost report.
    Survey data were received from approximately 59 percent of teaching 
hospitals reporting physician Part A costs on their Worksheet S-3, Part 
II (500 out of 845). Our fiscal intermediaries reviewed the survey data 
for consistency with the Supplemental Worksheet A-8-2 of the hospitals' 
cost reports. Supplemental Worksheet A-8-2 is used to apply the 
reasonable compensation equivalency limits to the costs of provider-
based physicians, itemizing these costs by the corresponding line 
number on Worksheet A.
    Hospitals were given until March 5, 1999 to request changes to the 
initial survey data. Fiscal intermediaries had until April 5, 1999 to 
submit the revised data to the Health Care Provider Cost Report 
Information system (HCRIS) for inclusion in the May 1999 final wage 
data file. Due to the extraordinary effort needed to collect these data 
and the importance of accurately removing teaching physician costs, we 
allowed hospitals to request revisions to their teaching survey data up 
until June 5, 1999.
    The hospital industry workgroup also recommended that if the 
teaching data collected by the intermediaries are not accurate or 
reliable, HCFA should include only 20 percent of reported physician 
Part A costs in the calculation, based on the assumption that 80 
percent of total physician Part A costs are related to teaching 
physicians. In developing the final FY 2000 wage index (as in the 
proposed), if we had complete survey data for a hospital, that amount 
was subtracted from the amount reported on the Worksheet S-3 for 
physician Part A costs. These data had been verified by the fiscal 
intermediary before submission to us. If we did not have survey data 
for a teaching hospital as of June 5, 1999, we removed 80 percent of 
the hospital's reported total physician Part A costs and hours for the 
wage index.
    Although removing 80 percent from the amount reported on the 
Worksheet S-3 for physician Part A costs allows an estimate of teaching 
physician costs to be removed in the majority of cases in which survey 
data are not available, there are instances in which a teaching 
hospital did not report either survey data or any physician Part A 
costs on its Worksheet S-3. We identified 19 of these teaching 
hospitals in our final database (there were 72 of these hospitals 
identified in the proposed rule). For purposes of calculating the FY 
2000 wage index for these 19 hospitals, we subtracted the costs 
reported on Line 23 of the Worksheet A, Column 1 (Resident and Other 
Program Costs) from Line 1 of the Worksheet S-3. These costs (from Line 
23, Column 1 of Worksheet A) are included in Line 1 of the Worksheet S-
3, which is the sum of Column 1, Worksheet A. They also represent costs 
for which the hospital is paid through the per resident amount under 
the direct GME payment.
    We believe this approach is appropriate in situations in which 
hospitals have failed to otherwise identify their teaching physician 
costs. To determine the hours to be removed, we divided the costs 
reported on Line 23 of Worksheet A, Column 1 by the national average 
hourly wage for physician Part A costs based upon Line 4 of Worksheet 
S-3 (the national average hourly wage is $54.48). We indicate these 19 
hospitals by an asterisk in Table 3C of this final rule.
    In the proposed rule, we invited comments as to whether the 
proposed method to remove teaching-related costs based on the amount 
included in Line 23, Column 1 of Worksheet A would be an appropriate 
method for removing GME costs in the future (and perhaps other excluded 
area costs as well). We were especially concerned that the earliest 
cost report on which we would be able to make the necessary changes to 
capture the separate reporting of teaching physician Part A costs would 
be those submitted for cost reporting periods beginning during FY 1998. 
Therefore, we were considering subtracting the costs in Lines 20, 22, 
and 23 of Worksheet A from Line 1 of Worksheet S-3, Part II, in 
calculating the FY 2001 wage index. The current Worksheet S-3 is not 
designed to net out of Line 1 costs that are otherwise included in 
Column 1 of Worksheet A, but it would be possible to use data from the 
Worksheet A in a manner similar to that described above.
    Comment: Two commenters disagreed with our decision to allow 
changes to the teaching survey data but not to corresponding lines on 
Worksheet S-3 during the final wage data correction period (June 5 
deadline). They believed we should be willing to accept conforming wage 
data corrections, even during the final correction period, to achieve 
the goal of using the most accurate data available.
    Response: If hospitals had miscategorized their teaching physician 
costs on their cost report in such a way that accurately completing the 
teaching survey would result in their teaching physician survey costs 
being removed twice, we did authorize corresponding revisions to 
Worksheet S-3. For example, some hospitals included teaching physician 
costs in Line 6 of their Worksheet S-3 (which is intended for reporting 
interns and residents' costs). Therefore, reporting these costs on 
their teaching physician survey, which would be subtracted from Line 4 
for the salaries of teaching physicians directly employed by the 
hospital, would result in them being removed twice, once when the 
teaching physician data are subtracted from Line 1 of Worksheet S-3, 
and again when Line 6 of Worksheet S-3 is subtracted from Line 1.
    Comment: We received several comments regarding our proposal to use 
the teaching survey data for teaching hospitals that submitted surveys 
but to remove 80 percent of the total physician Part A costs and hours 
for nonresponsive teaching hospitals. Most commenters supported our 
reliance on the teaching survey data for the FY 2000 wage index. One 
commenter added that we should be assertive in insisting that teaching 
survey data be reported accurately by hospitals and verified by fiscal 
intermediaries, holding hospitals to a level of accountability that is 
similar to the certification of a cost report at filing. Another 
commenter urged us to incorporate the separate collection of teaching 
physician Part A data into the cost report as soon as possible to 
ensure that the data submitted by hospitals is consistent.
    Although most commenters agreed that we should reduce reported 
total physician Part A costs by 80 percent for teaching hospitals that 
do not submit the teaching survey, some took issue with this approach. 
One national and one State hospital association recommended we remove 
100 percent of reported total physician Part A costs from nonresponsive 
teaching hospitals' total costs as a penalty for not reporting their 
data. The commenters believe that, for hospitals whose proportion of 
teaching physician Part A costs relative to total physician Part A 
costs is greater than 80 percent, there is no incentive to complete the 
teaching survey. On the other hand, MedPAC recommended that, since 
HCFA's preliminary teaching survey data indicate that teaching 
physician Part A costs are 68 percent of total physician Part A costs, 
we should have adjusted the hospital's data by that amount rather than 
the higher 80

[[Page 41507]]

percent figure. MedPAC comments that, although using the 80 percent 
figure may give hospitals the incentive to submit the requested survey 
data if their ratio of teaching physician Part A costs to total 
physician Part A costs is less than 80 percent, that amount could 
inappropriately lower the wage index values for other hospitals located 
in the same MSA as the nonresponsive teaching hospital. The comments do 
acknowledge, however, the policy dilemma in terms of the incentives not 
to report that may arise by setting the percentage too low.
    Response: We appreciate the commenters' general support of using 
the survey data, as well as the efforts of hospitals and the fiscal 
intermediaries in this special data collection effort. We believe that, 
although the response rate is less than we would have preferred, the 
end result is a more accurate FY 2000 wage index.
    Although Worksheet S-3 is being revised to provide for the separate 
reporting of teaching physician Part A costs, this change will not be 
incorporated until cost reporting periods beginning during FY 1998. 
Therefore, we will have to conduct another teaching physician cost 
survey corresponding with the FY 1997 wage data. We agree with the 
commenter's suggestion that the accuracy and completeness of the survey 
data should be certified by the hospital in the same manner as the 
accuracy and completeness of the cost report data must be certified.
    In our calculation of the FY 2000 wage index, we removed 80 percent 
of physician Part A costs and hours for teaching hospitals that failed 
to report their teaching physician costs. We will consider the comment 
to remove 100 percent of these costs for nonresponsive hospitals in the 
future, however. Although the 80 percent figure was taken from the 
industry workgroup's recommendation, we believe it may be appropriate 
to consider raising this percentage to address the problem of hospitals 
failing to comply with Medicare instructions.
    We appreciate MedPAC's concern that the estimation of teaching 
physician costs for hospitals that did not report should not 
disproportionately harm other hospitals in the same labor market area. 
Similarly, however, these hospitals should not benefit from 
noncompliance. Also, as noted previously, because the teaching 
physician costs are being removed gradually, with 80 percent of the FY 
2000 wage index based on an average hourly wage that includes all of 
these costs, we do not believe it is necessary to reduce the 80 percent 
estimate to an amount based on the percentage of teaching physician 
Part A costs to all physician Part A costs for hospitals completing the 
survey to protect other hospitals in the labor market area. Any impact 
should be relatively minor for this first year.
    Comment: Two commenters believed that hospitals that contract with 
physicians for Part A services are disadvantaged because the cost 
report and teaching survey instructions seem to be designed only for 
hospitals that employ physicians.
    Response: The cost report and teaching survey do account for the 
costs of contract physicians. The first year contract physician Part A 
costs were included in the wage index was FY 1999. Beginning with the 
FY 1995 cost report, we revised Worksheet S-3 to allow a separate line 
item for reporting these costs. To improve the reporting for all 
physician-related wage costs, we made additional changes to the FY 1996 
cost report. The teaching survey was patterned after the FY 1996 
Worksheet S-3.
    The salaries on the Worksheet S-3 for employed physicians derive 
from column 1 of Worksheet A. Hospitals should report the labor costs 
associated with contract physicians in column 2 of that same worksheet. 
If hospitals report their costs properly according to the cost report 
instructions, hospitals using contract physicians will not be 
disadvantaged by the way the costs are reported. We encourage hospitals 
to be diligent in working with their intermediaries if they have 
questions about reporting costs on the cost report.
    Comment: We received four comments regarding the use of Worksheet 
A, Line 23, Column 1 as a proxy for teaching-related wage costs when a 
teaching hospital did not report either survey data or any physician 
Part A costs. One was favorable without qualifications. One commenter 
recommended that, beginning with the FY 2001 wage index, we should 
instruct hospitals to report on Worksheet S-3 the wage costs associated 
with teaching physicians directly from Worksheet A, Line 23 and the 
corresponding hours directly from hospitals' records. A national 
hospital association recommended that if we use Worksheet A, Line 23 
for teaching salaries and a national average hourly wage for physicians 
to estimate the associated hours to be removed for nonreporting 
hospitals, then we should apply this approach to all hospitals. If we 
apply this method only to hospitals that do not respond to the teaching 
survey, the commenter believed that we should penalize nonresponsive 
hospitals by increasing the hourly rate by 25 percent to ensure they 
are not advantaged by not reporting their costs.
    Several hospitals contacted us to report that, although they were 
listed as one of the 72 hospitals for whom we used Line 23 of Worksheet 
A to remove teaching physician costs, these costs were actually 
included in other lines of Worksheet S-3, such as Line 5, Physician 
Part B services, or Line 6, Interns and Residents. Therefore, since 
both of these lines are subtracted from Line 1 in our calculation, 
subtracting Line 23 from Worksheet A would remove these costs twice.
    In opposing the use of Line 23 as a proxy for teaching-related 
costs, one commenter cautioned that, particularly for hospitals in 
States that are prohibited from employing physicians, Line 23, Column 1 
may not include any teaching physician costs. MedPAC also stated 
concern with this approach, but did not cite any specific problems 
associated with it.
    Response: For FY 2000, we are removing the amount reported on 
Worksheet A, Line 23, Column 1, only in the absence of teaching survey 
or Worksheet S-3 data for a hospital but we will continue to explore 
using this approach rather than the survey for identifying GME and CRNA 
costs to be removed in the FY 2001 wage index. The approach we adopted 
has the advantage of being straightforward and easy to apply. Line 1, 
Column 1 of Worksheet S-3 is equal to Line 101 of Column 1 of the 
Worksheet A. Line 23 of Column 1, which is for the reporting of 
nonresidents' costs related to GME that are paid separately from the 
prospective payment system, is included in Line 101. Therefore, one 
could argue that the simplest way to remove GME costs from the wage 
index calculation would be to subtract the costs from Line 1 of 
Worksheet S-3 that are attributable to the GME cost centers on 
Worksheet A (Lines 22 and 23).
    In carving out an estimate of hours for the final 19 hospitals for 
which we subtracted Line 23 of Worksheet A from total salaries on 
Worksheet S-3, we removed an estimated amount of associated hours based 
on the average hourly wage of all physician Part A salaries. We did not 
increase this average hourly wage by 25 percent as a penalty for 
hospitals that did not otherwise report teaching physician costs. We do 
reserve the right to remove some or all of a hospital's wage data that 
cannot be appropriately supported by the hospital's records. We also 
reserve the right to pursue further action in the case of hospitals 
that intentionally withhold, conceal, or otherwise attempt

[[Page 41508]]

to circumvent the cost reporting requirements of their participation 
agreements.
    If we were contacted timely by a hospital that reported its costs 
from Line 23 of Worksheet A somewhere other than Line 4 of the 
Worksheet S-3, we did accommodate the hospital's request to avoid 
removing the teaching physician Part A costs twice. We note that the 
majority of these situations involved hospitals that did not follow the 
cost reporting instructions for these costs. Despite MedPAC's general 
concerns about this approach to removing costs, we did not receive any 
comments that would cause us to rule out this seemingly straightforward 
approach for removing GME and CRNA costs from the FY 2001 wage index 
for all teaching hospitals. The biggest difficulty seems to be related 
to ensuring that the cost reporting instructions are uniformly 
followed.
    Comment: Two commenters suggested using Worksheet A-8-2 of the cost 
report, ``Provider-Based Physicians Adjustments,'' to determine 
physician Part A costs, particularly for costs associated with teaching 
and contract physicians. The commenters reasoned that, because 
Worksheet A-8-2 is used to determine allowable cost and hours to be 
included in the Medicare cost report, HCFA should use Worksheet A-8-2 
to determine physician Part A labor costs for wage index purposes. Use 
of the Worksheet A-8-2 would also ensure the wage index includes only 
those physician costs paid under Part A. One of the commenters 
commended us for requesting intermediaries to compare the teaching 
survey and Worksheet A-8-2 data, but suggested that we should also 
require intermediaries to use Worksheet A-8-2 data for determining 
teaching physician wage costs when the survey data are unacceptable.
    Response: We agree that, if properly completed, Worksheet A-8-2 
should be an acceptable source for teaching physician Part A data. In 
February, we instructed intermediaries to review hospitals' teaching 
survey data for consistency with Worksheet A-8-2, and when necessary, 
revise the data accordingly. One minor problem with relying solely on 
Worksheet A-8-2 is that it may include some wage-related costs that are 
excluded from the wage index calculation; however, these should be 
insignificant. We believe that Worksheet A-8-2 is an appropriate source 
for physician Part A costs. However, we need to examine Worksheet A-8-2 
more closely before requiring that it be used to determine physician 
part A costs for future wage indexes.
    Comment: We received two comments recommending that we remove 
overhead costs associated with the teaching physician, resident, and 
CRNA direct costs that are excluded from the wage index. The commenter 
compared this action to our current policy in which we remove the 
overhead costs associated with excluded providers such as skilled 
nursing facilities or rehabilitation units from the wage data. One 
commenter offered technical assistance to HCFA in this effort.
    Response: We agree, in principle, that overhead costs associated 
with teaching-related and CRNA labor costs should be removed from the 
wage index calculation in the same way that we remove overhead costs 
associated with excluded areas of the hospital. However, we believe 
that the methodology we apply for specific patient care cost centers 
excluded from the wage data may not be appropriate for removing 
overhead related to CRNA and GME costs. Therefore, we are grateful for 
the commenter's offer of technical assistance to develop an appropriate 
methodology for allocating overhead costs related to CRNAs and GME. We 
anticipate that this issue will be discussed by HCFA's wage index 
workgroup later this year, and in next year's proposed rule for FY 
2001.
2. Resident and CRNA Part A Costs
    The wage index presently includes salaries and wage-related costs 
for residents in approved medical education programs and for CRNAs 
employed by hospitals under the rural pass-through provision 
(Sec. 412.113(c)). Because Medicare pays for these costs outside the 
prospective payment system, removing these costs from the wage index 
calculation would be consistent with our general policy to exclude 
costs that are not paid through the prospective payment system. 
However, because these costs were not separately identifiable on 
Worksheet S-3 before the FY 1995 wage data, we could not remove them.
    We began collecting the resident and CRNA wage data separately on 
the FY 1995 cost report. However, there were data reporting problems 
associated with these costs. For example, the original FY 1995 cost 
report instructions for reporting resident costs on Line 6 of Worksheet 
S-3, Part III, erroneously included teaching physician salaries and 
other teaching program costs. Also, the FY 1995 Worksheet S-3 did not 
provide for separate reporting of CRNA wage-related costs. These 
problems were corrected in the reporting instructions for the FY 1996 
cost report, and, therefore, we proposed and are now implementing the 
removal of CRNA and resident costs over a 5-year period, beginning with 
the FY 2000 wage index.
    We received no comments related to this change.
3. Transition Period
    The FY 2000 wage index is based on a blend of 80 percent of 
hospitals' average hourly wages without removing the costs and hours 
associated with teaching physician Part A, residents, and CRNAs, and 20 
percent of the average hourly wage after removing these costs and hours 
from the wage index calculation. This methodology is consistent with 
the recommendation of the industry workgroup for a 5-year phase-out of 
these costs. The transition methodology is discussed in detail in 
section III.E of this preamble.
    Comment: One hospital believed that it has been disadvantaged by 
HCFA's allowance of contract teaching physician Part A costs in the FY 
1999 wage index, and that HCFA should disallow teaching physician costs 
entirely, beginning with FY 2000. The hospital stated that it is 
experiencing difficulty meeting the criteria for geographic 
reclassification for purposes of the wage index to another MSA that 
includes a teaching hospital that reports a large amount of contract 
teaching physician Part A costs.
    Response: Our reasons for including contract physician Part A costs 
are discussed in detail in the July 31, 1998 Federal Register (63 FR 
40967). In general, it was our belief that if contract physician Part A 
costs were reliably reported by hospitals, they should be included in 
the wage data along with the Part A costs of directly employed 
physicians. In that final rule, we also discussed our position that, to 
the greatest degree possible, the hospital wage index should reflect 
the wage costs associated with the areas of the hospital included under 
the hospital inpatient prospective payment system. Therefore, based on 
data we have collected since that final rule was published, and as 
discussed above, we are removing teaching physician costs (as well as 
CRNA and resident costs) for the wage data, over a 5-year period.
    As is generally true with changes in the wage index, hospitals that 
may have once been eligible to reclassify to another MSA for purposes 
of the wage index may find that they no longer qualify after changes 
have been implemented. However, we believe that all our changes to the 
wage index are designed to more accurately reflect the wage costs 
incurred by hospitals. In the case of the teaching physician costs, we

[[Page 41509]]

believe that a 5-year phase out is appropriate to reduce significant 
redistribution impacts. With regard to the accuracy of the teaching 
hospital data, the intermediary verified the data and determined it is 
consistent with audit findings.

D. Verification of Wage Data from Medicare Cost Reports

    The data for the FY 2000 wage index were obtained from Worksheet S-
3, Parts II and III of the FY 1996 Medicare cost reports. The data file 
used to construct the final wage index includes FY 1996 data submitted 
to HCRIS as of early February 1999. As in past years, we performed an 
intensive review of the wage data, mostly through the use of edits 
designed to identify aberrant data. In the proposed rule, we discussed 
our review and methodology for resolving questionable elements in the 
hospital data (64 FR 24728). The revised data are reflected in this 
final rule. Since the proposed rule, we deleted data for four hospitals 
that reported aberrant and unverifiable wage data that would have 
significantly distorted the wage index values, and added data for seven 
hospitals that were not included in the proposed wage index but rather 
whose data have now been corrected and verified. The final FY 2000 wage 
index is calculated based on FY 1996 data for 5,038 hospitals.
    Comment: One hospital association expressed concern that a number 
of hospitals might have failed to comply with the new cost reporting 
instructions for wage-related costs, causing an overreporting of these 
costs in the FY 2000 wage index. Prior to the FY 1996 cost report, the 
lines on Worksheet S-3 for core and other wage-related costs reflected 
a hospital's total costs for those categories. However, beginning with 
the FY 1996 cost report, core and other wage-related costs must be 
reported net of costs associated with excluded areas. The commenter 
stated that wage-related costs for a significant number of hospitals 
increased at least 10 percent this year and it believed that the 
increase is due to hospitals incorrectly reporting excluded area wage-
related costs on Line 13. The commenter recommended that we develop a 
method to determine if a hospital misreports its wage-related costs, 
and that we should require correction of the data.
    Response: We believe the new cost reporting instructions for wage-
related costs, Lines 13 and 14 of Worksheet S-3, Part II, are clear 
regarding the exclusion of costs associated with excluded areas. 
Intermediaries were aware of the new cost reporting instructions and 
instructed their auditors to closely examine the costs reported in 
Lines 13 and 14 of Worksheet S-3, Part II for compliance. In addition, 
the intermediaries' FY 1996 wage data review program included an edit 
for hospitals having wage-related costs that increased 10 percent or 
more between FY 1995 and FY 1996. Furthermore, we contacted 
representatives of national hospital associations who agreed to alert 
their members of the reporting change. We are aware of numerous 
instances where intermediaries adjusted hospitals' wage-related costs 
after review. As part of the FY 1997 wage data desk review program (for 
the FY 2001 wage index), we will provide more specific instructions to 
the intermediaries to review the data reported for core and other wage-
related costs to ensure no costs associated with excluded areas are 
included.
    Comment: One commenter disagreed with the approach we used in the 
proposed rule to identify teaching hospitals to ensure that all of 
these hospitals had reported teaching physician survey data. We based 
our decision to remove either 80 percent of physician Part A costs and 
hours or the amount on Line 23, Column 1 of Worksheet A, based on 
whether the hospital had a resident-to-bed ratio greater than zero on 
the latest Provider-Specific File. The commenter suggested it would be 
more appropriate to base the identification of teaching hospitals on 
whether the hospital reported residents on its cost report for the 
period corresponding with the wage data.
    Response: We agree with this comment. It is more appropriate to 
base the identification of teaching hospitals on data from the same 
year as the wage data we use. Therefore, we revised our method to 
identify teaching hospitals based on whether they reported residents 
during their cost reporting period beginning during FY 1996.
    Comment: One State hospital association commented that the 
underrepresentation of physician Part A costs for hospitals in its 
State is due to the intermediary's exclusion of a majority of the costs 
reported by hospitals. The commenter believes there are inconsistencies 
between the two intermediaries that service hospitals in the State in 
their treatment of contract physician Part A costs. The commenter 
recommended that HCFA monitor intermediaries and enforce uniform 
application of Medicare principles and standards, particularly with 
regard to the determination of allowable physician costs on Worksheet 
A-8-2.
    Response: For wage index purposes, contract physician costs are to 
be reported according to the instructions for Worksheet S-3 Part II, 
Line 10. The physician Part A costs reported on Worksheet S-3 may 
differ slightly from those reported on worksheet A-8-2 because there 
are minor differences in the types of wage-related costs that are 
allowed for each of the worksheets. The two forms serve different 
purposes. The wage index worksheet (S-3) may include, to a reasonable 
extent, the actual costs a hospital incurs. However, Worksheet A-8-2 is 
used to determine allowable costs for Medicare cost report purposes and 
includes cost limits. The commenter did not indicate exactly what 
inconsistencies it had found. If there are inconsistencies, we would 
like to address them as soon as possible for the FY 2001 wage index.
    We note that, intermediaries have informed us that hours associated 
with contract physicians are often difficult to verify because 
hospitals have not developed reporting systems that accurately account 
for contract physician hours. Consistent with Medicare policy, 
intermediaries must exclude costs and other data that are 
insufficiently supported by a hospital's documentation.
    Comment: One commenter noted several errors in the proposed rule 
and final wage data public use file. The commenter stated that Table 3C 
of the proposed rule included some hospitals with extremely low average 
hourly wages, and that the average hourly wages reported for some 
hospitals marked with an asterisk do not seem to incorporate the 
Worksheet A, Line 23 data as described in the footnote. Additionally, 
the commenter stated that the final wage data on the Internet includes 
two different date formats for fiscal year begin and end dates, an 
eight digit format and a seven digit format. The commenter asked that 
HCFA make the appropriate corrections in the final wage index 
calculation.
    Response: We were informed shortly after publication of the 
proposed rule that there were several errors in Table 3C, including 
those noted by the commenter. As a result, we issued a revised Table 3C 
in a correction notice published in the Federal Register on June 15, 
1999 (64 FR 31995). Although the extremely low average hourly wages 
still appear in Table 3C of the correction notice just as they were 
reported by the hospitals, the aberrant data were either corrected or 
deleted in the final wage index calculation. All other errors 
identified in Table 3C were corrected through the June 15 notice. Also, 
fiscal year beginning and ending dates that appear in a 7-digit date 
format in the final wage data public use file were

[[Page 41510]]

corrected to an 8-digit date format in the final calculation.

E. Computation of the Wage Index

    The method used to compute the FY 2000 wage index is as follows:
    Step 1--As noted above, we based the FY 2000 wage index on wage 
data reported on the FY 1996 Medicare cost reports. We gathered data 
from each of the non-Federal, short-term, acute care hospitals for 
which data were reported on the Worksheet S-3, Parts II and III of the 
Medicare cost report for the hospital's cost reporting period beginning 
on or after October 1, 1995 and before October 1, 1996. In addition, we 
included data from a few hospitals that had cost reporting periods 
beginning in September 1995 and reported a cost reporting period 
exceeding 52 weeks. These data were included because no other data from 
these hospitals would be available for the cost reporting period 
described above, and because particular labor market areas might be 
affected due to the omission of these hospitals. However, we generally 
describe these wage data as FY 1996 data.
    Step 2--Salaries--The method used to compute a hospital's average 
hourly wage is a blend of 80 percent of the hospital's average hourly 
wage including all teaching physician Part A, resident, and CRNA costs, 
and 20 percent of the hospital's average hourly wage after eliminating 
all teaching physician, resident, and CRNA costs.
    In calculating a hospital's average salaries plus wage-related 
costs, including all teaching physician Part A, resident, and CRNA 
costs, we subtracted from Line 1 (total salaries) the Part B salaries 
reported on Lines 3 and 5, home office salaries reported on Line 7, and 
excluded salaries reported on Lines 8 and 8.01 (that is, direct 
salaries attributable to skilled nursing facility services, home health 
services, and other subprovider components not subject to the 
prospective payment system). We also subtracted from Line 1 the 
salaries for which no hours were reported on Lines 2, 4, and 6. To 
determine total salaries plus wage-related costs, we added to the net 
hospital salaries the costs of contract labor for direct patient care, 
certain top management, and physician Part A services (Lines 9 and 10), 
home office salaries and wage-related costs reported by the hospital on 
Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, 
16, 18, and 20). We note that contract labor and home office salaries 
for which no corresponding hours are reported were not included.
    We then calculated a hospital's salaries plus wage-related costs by 
subtracting from total salaries the salaries plus wage-related costs 
for teaching physicians (see section III.C.1 of this preamble for a 
detailed discussion of this policy), Part A CRNAs (Lines 2 and 16), and 
residents (Lines 6 and 20).
    Step 3--Hours--With the exception of wage-related costs, for which 
there are no associated hours, we computed total hours using the same 
methods as described for salaries in Step 2.
    Step 4--For each hospital reporting both total overhead salaries 
and total overhead hours greater than zero, we then allocated overhead 
costs. First, we determined the ratio of excluded area hours (sum of 
Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours 
(Line 1 minus Lines 3, 5, and 7 of Worksheet S-3, Part II). We then 
computed the amounts of overhead salaries and hours to be allocated to 
excluded areas by multiplying the above ratio by the total overhead 
salaries and hours reported on Line 13 of Worksheet S-3, Part III. 
Finally, we subtracted the computed overhead salaries and hours 
associated with excluded areas from the total salaries and hours 
derived in Steps 2 and 3.
    Step 5--For each hospital, we adjusted the total salaries plus 
wage-related costs to a common period to determine total adjusted 
salaries plus wage-related costs. To make the wage adjustment, we 
estimated the percentage change in the employment cost index (ECI) for 
compensation for each 30-day increment from October 14, 1995 through 
April 15, 1997 for private industry hospital workers from the Bureau of 
Labor Statistics' Compensation and Working Conditions. We use the ECI 
because it reflects the price increase associated with total 
compensation (salaries plus fringes) rather than just the increase in 
salaries. In addition, the ECI includes managers as well as other 
hospital workers. This methodology to compute the monthly update 
factors uses actual quarterly ECI data and ensures that the update 
factors match the actual quarterly and annual percent changes. The 
factors used to adjust the hospital's data were based on the midpoint 
of the cost reporting period, as indicated below.

                    Midpoint of Cost Reporting Period
------------------------------------------------------------------------
                                                              Adjustment
                     After                         Before       factor
------------------------------------------------------------------------
10/14/95......................................     11/15/95     1.023163
11/14/95......................................     12/15/95     1.021153
12/14/95......................................     01/15/96     1.019151
01/14/96......................................     02/15/96     1.017157
02/14/96......................................     03/15/96     1.015246
03/14/96......................................     04/15/96     1.013489
04/14/96......................................     05/15/96     1.011888
05/14/96......................................     06/15/96     1.010428
06/14/96......................................     07/15/96     1.009099
07/14/96......................................     08/15/96     1.007900
08/14/96......................................     09/15/96     1.006788
09/14/96......................................     10/15/96     1.005719
10/14/96......................................     11/15/96     1.004695
11/14/96......................................     12/15/96     1.003653
12/14/96......................................     01/15/97     1.002529
01/14/97......................................     02/15/97     1.001325
02/14/97......................................     03/15/97     1.000000
03/14/97......................................     04/15/97     0.998514
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 1996 and ending December 31, 1996 is June 30, 1996. An 
adjustment factor of 1.009099 would be applied to the wages of a 
hospital with such a cost reporting period. In addition, for the data 
for any cost reporting period that began in FY 1996 and covers a period 
of less than 360 days or more than 370 days, we annualized the data to 
reflect a 1-year cost report. Annualization is accomplished by dividing 
the costs and hours by the number of days in the cost report and then 
multiplying the results by 365.
    Step 6--Each hospital was assigned to its appropriate urban or 
rural labor market area before any reclassifications under sections 
1886(d)(8)(B) or 1886(d)(10) of the Act. Within each urban or rural 
labor market area, we added the total adjusted salaries plus wage-
related costs obtained in Step 5 for all hospitals in that area to 
determine the total adjusted salaries plus wage-related costs for the 
labor market area.
    Step 7--We divided the total adjusted salaries plus wage-related 
costs obtained under both methods in Step 6 by the sum of the 
corresponding total hours (from Step 4) for all hospitals in each labor 
market area to determine an average hourly wage for the area.
    Because the FY 2000 wage index is based on a blend of average 
hourly wages, we then added 80 percent of the average hourly wage 
calculated without removing teaching physician Part A, residents, and 
CRNA costs, and 20 percent of the average hourly wage calculated with 
these costs removed.
    Step 8--We added the total adjusted salaries plus wage-related 
costs obtained in Step 5 for all hospitals in the nation and then 
divided the sum by the national sum of total hours from Step 4 to 
arrive at a national average hourly

[[Page 41511]]

wage (using the same blending methodology described in Step 7). Using 
the data as described above, the national average hourly wage is 
$21.1800.
    Step 9--For each urban or rural labor market area, we calculated 
the hospital wage index value by dividing the area average hourly wage 
obtained in Step 7 by the national average hourly wage computed in Step 
8. We note that on July 6, 1999, OMB announced the designations of two 
new MSAs: Auburn-Opelika, Alabama, comprising Lee County, and 
Corvallis, Oregon comprising Benton County.
    Step 10--Following the process set forth above, we developed a 
separate Puerto Rico-specific wage index for purposes of adjusting the 
Puerto Rico standardized amounts. (The national Puerto Rico 
standardized amount is adjusted by a wage index calculated for all 
Puerto Rico labor market areas based on the national average hourly 
wage as described above.) We added the total adjusted salaries plus 
wage-related costs (as calculated in Step 5) for all hospitals in 
Puerto Rico and divided the sum by the total hours for Puerto Rico (as 
calculated in Step 4) to arrive at an overall average hourly wage of 
$9.86756 for Puerto Rico. For each labor market area in Puerto Rico, we 
calculated the hospital wage index value by dividing the area average 
hourly wage (as calculated in Step 7) by the overall Puerto Rico 
average hourly wage.
    Step 11--Section 4410 of the BBA provides that, for discharges on 
or after October 1, 1997, the area wage index applicable to any 
hospital that is not located in a rural area may not be less than the 
area wage index applicable to hospitals located in rural areas in that 
State. Furthermore, this wage index floor is to be implemented in such 
a manner as to ensure that aggregate prospective payment system 
payments are not greater or less than those that would have been made 
in the year if this section did not apply. For FY 2000, this change 
affects 226 hospitals in 36 MSAs. The MSAs affected by this provision 
are identified in Table 4A by a footnote.
    Comment: Two commenters suggested that, given the complexity of the 
FY 2000 wage index calculation, we should make our detailed calculation 
procedures and edits publicly available. This would enable hospitals 
and researchers to more easily replicate the wage index values. One of 
the commenters recommended that the detailed calculations and methods 
should be included in future proposed and final rules. In addition, 
they requested that we release the actual computer program used to 
calculate the wage index.
    Response: We have fully explained the steps we take to calculate 
each hospital's average hourly wage and the wage index. In addition, we 
have worked with hospitals that contacted us after attempting to 
replicate our calculations, by reviewing their results and identifying 
discrepancies. In doing so, we have been able to identify certain 
anomalies in some of the proposed wage index values, which have been 
corrected in the final wage index. Therefore, we agree that it might be 
useful to provide more information to make it easier for the public to 
replicate our calculations, and we are exploring our options. However, 
we do not generally provide our computer programs that are used to 
perform the wage index calculations, or for that matter, the programs 
we use for all other calculations we perform.
    Comment: One commenter recommended that, for leap years HCFA should 
use 366 days, rather than 365 days, when annualizing cost report data 
(see step 5 of the wage index calculation).
    Response: We agree that the commenter's recommended method of 
annualization, which recognizes an additional day for leap years, is 
theoretically more accurate than our simple, across-the-board approach. 
However, due to the intense effort required to incorporate all of the 
wage data changes processed in conjunction with hospitals' final 
opportunity to request revisions, we were unable to evaluate and 
incorporate this change into our computer program in time to be 
reflected in the final FY 2000 wage index. Therefore, we are not 
adopting this recommendation for the FY 2000 wage index calculation. We 
would note that, as described in step 5 above, we annualize any cost 
reporting period that covers a period of fewer than 360 days or more 
than 370 days. The majority of cost reporting periods are not 
annualized. In those instances where annualization is done, we would 
further point out that it does not affect the hospital's average hourly 
wage calculation, since both the costs and hours are annualized by 365. 
The impact, therefore, of this commenter's suggestion is limited to the 
calculation of the labor market area average hourly wage. Furthermore, 
if we were to account for the additional day of a leap year in our 
annualization, the impact on any particular area's average hourly wage 
could be either positive or negative.

F. Revisions to the Wage Index Based on Hospital Redesignation

    Under section 1886(d)(8)(B) of the Act, hospitals in certain rural 
counties adjacent to one or more MSAs are considered to be located in 
one of the adjacent MSAs if certain standards are met. Under section 
1886(d)(10) of the Act, the Medicare Geographic Classification Review 
Board (MGCRB) considers applications by hospitals for geographic 
reclassification for purposes of payment under the prospective payment 
system.
    The methodology for determining the wage index values for 
redesignated hospitals is applied jointly to the hospitals located in 
those rural counties that were deemed urban under section 1886(d)(8)(B) 
of the Act and those hospitals that were reclassified as a result of 
the MGCRB decisions under section 1886(d)(10) of the Act. Section 
1886(d)(8)(C) of the Act provides that the application of the wage 
index to redesignated hospitals is dependent on the hypothetical impact 
that the wage data from these hospitals would have on the wage index 
value for the area to which they have been redesignated. Therefore, as 
provided in section 1886(d)(8)(C) of the Act, the wage index values 
were determined by considering the following:
     If including the wage data for the redesignated hospitals 
would reduce the wage index value for the area to which the hospitals 
are redesignated by 1 percentage point or less, the area wage index 
value determined exclusive of the wage data for the redesignated 
hospitals applies to the redesignated hospitals.
     If including the wage data for the redesignated hospitals 
reduces the wage index value for the area to which the hospitals are 
redesignated by more than 1 percentage point, the hospitals that are 
redesignated are subject to that combined wage index value.
     If including the wage data for the redesignated hospitals 
increases the wage index value for the area to which the hospitals are 
redesignated, both the area and the redesignated hospitals receive the 
combined wage index value.
     The wage index value for a redesignated urban or rural 
hospital cannot be reduced below the wage index value for the rural 
areas of the State in which the hospital is located.
     Rural areas whose wage index values would be reduced by 
excluding the wage data for hospitals that have been redesignated to 
another area continue to have their wage index values calculated as if 
no redesignation had occurred.
     Rural areas whose wage index values increase as a result 
of excluding

[[Page 41512]]

the wage data for the hospitals that have been redesignated to another 
area have their wage index values calculated exclusive of the wage data 
of the redesignated hospitals.
     The wage index value for an urban area is calculated 
exclusive of the wage data for hospitals that have been reclassified to 
another area. However, geographic reclassification may not reduce the 
wage index value for an urban area below the statewide rural wage index 
value.
    We note that, except for those rural areas in which redesignation 
would reduce the rural wage index value, the wage index value for each 
area is computed exclusive of the wage data for hospitals that have 
been redesignated from the area for purposes of their wage index. As a 
result, several urban areas listed in Table 4A have no hospitals 
remaining in the area. This is because all the hospitals originally in 
these urban areas have been reclassified to another area by the MGCRB. 
These areas with no remaining hospitals receive the prereclassified 
wage index value. The prereclassified wage index value will apply as 
long as the area remains empty.
    The final revised wage index values for FY 2000 are shown in Tables 
4A, 4B, 4C, and 4F in the Addendum to this final rule. Hospitals that 
are redesignated should use the wage index values shown in Table 4C. 
Areas in Table 4C may have more than one wage index value because the 
wage index value for a redesignated urban or rural hospital cannot be 
reduced below the wage index value for the rural areas of the State in 
which the hospital is located. When the wage index value of the area to 
which a hospital is redesignated is lower than the wage index value for 
the rural areas of the State in which the hospital is located, the 
redesignated hospital receives the higher wage index value, that is, 
the wage index value for the rural areas of the State in which it is 
located, rather than the wage index value otherwise applicable to the 
redesignated hospitals.
    Tables 4D and 4E list the average hourly wage for each labor market 
area, before the redesignation of hospitals, based on the FY 1996 wage 
data. In addition, Table 3C in the Addendum to this final rule includes 
the adjusted average hourly wage for each hospital based on the FY 1996 
data (as calculated under Steps 4 and 5 above). The MGCRB will use the 
average hourly wage published in the final rule to evaluate a 
hospital's application for reclassification for FY 2001, unless that 
average hourly wage is later revised in accordance with the wage data 
correction policy described in Sec. 412.63(w)(2). In these cases, the 
MGCRB will use the most recent revised data used for purposes of the 
hospital wage index. We note that, in adjudicating these wage index 
reclassification requests during FY 2000, the MGCRB will use the 
average hourly wages for each hospital and labor market area that are 
reflected in the final FY 2000 wage index.
    At the time the proposed wage index was constructed, the MGCRB had 
completed its review of FY 2000 reclassification requests. Therefore, 
the proposed FY 2000 wage index values incorporated all 441 hospitals 
redesignated for purposes of the wage index (hospitals redesignated 
under section 1886(d)(8)(B) or 1886(d)(10) of the Act) for FY 2000. In 
this final rule, we have incorporated changes to the wage index that 
occurred after the proposed wage index was calculated and that resulted 
from withdrawals of requests for reclassification, wage index 
corrections, appeals, and the Administrator's review process. The 
changes may affect not only the wage index value for specific 
geographic areas, but also the wage index value redesignated hospitals 
receive, that is, whether they receive the wage index value for the 
area to which they are redesignated, or a wage index value that 
includes the data for both the hospitals already in the area and the 
redesignated hospitals. Further, the wage index value for the area from 
which the hospitals are redesignated may be affected.
    Under Sec. 412.273, hospitals that have been reclassified by the 
MGCRB are permitted to withdraw their applications within 45 days of 
the publication of the proposed rule. To be effective in FY 2000, the 
request for withdrawal of an application for reclassification had to be 
received by the MGCRB by June 21. A hospital that requests to withdraw 
its application may not later request that the MGCRB decision be 
reinstated.

G. Wage Data Corrections

    In the proposed rule, we stated that, to allow hospitals time to 
evaluate the wage data used to construct the proposed FY 2000 hospital 
wage index, we would make available in May 1999 a final public data 
file containing the FY 1996 hospital wage data.
    The final wage data file was released on May 7, 1999 (amended on 
May 14). As noted above in section III.C of this preamble, this file 
included hospitals' teaching survey data as well as cost report data. 
As with the file made available in February 1999, we made the final 
wage data file released in May 1999 available to hospital associations 
and the public (on the Internet). However, with the exception of the 
teaching survey data, this file was made available only for the limited 
purpose of identifying any potential errors made by HCFA or the 
intermediary in the entry of the final wage data that the hospital 
could not have known about before the release of the final wage data 
public use file, not for the initiation of new wage data correction 
requests.
    If, after reviewing the May 1999 final data file, a hospital 
believed that its wage data were incorrect due to a fiscal intermediary 
or HCFA error in the entry or tabulation of the final wage data, it was 
provided an opportunity to send a letter to both its fiscal 
intermediary and HCFA, outlining why the hospital believed an error 
exists and provide all supporting information, including dates. These 
requests had to be received by us and the intermediaries no later than 
June 7, 1999.
    Changes to the hospital wage data were made only in those very 
limited situations involving an error by the intermediary or HCFA that 
the hospital could not have known about before its review of the final 
wage data file. (As noted above, however, we also allowed hospitals to 
request changes to their teaching survey data. These requests had to 
comply with all of the documentation and deadline requirements 
specified in the May 7, 1999 proposed rule.) Specifically, neither the 
intermediary nor HCFA accepted the following types of requests at this 
stage of the process:
      Requests for wage data corrections that were submitted 
too late to be included in the data transmitted to HCRIS on or before 
April 5, 1999.
      Requests for correction of errors that were not, but 
could have been, identified during the hospital's review of the 
February 1999 wage data file.
      Requests to revisit factual determinations or policy 
interpretations made by the intermediary or HCFA during the wage data 
correction process.
    Verified corrections to the wage index received timely (that is, by 
June 7, 1999) are incorporated into the final wage index in this final 
rule, to be effective October 1, 1999.
    We believe the wage data correction process provides hospitals with 
sufficient opportunity to bring errors in their wage data to the 
intermediary's attention. Moreover, because hospitals had access to the 
final wage data by early May 1999, they had the opportunity to detect 
any data entry or tabulation errors made by the intermediary or HCFA 
before the development and publication of the FY 2000 wage index and 
its

[[Page 41513]]

implementation on October 1, 1999. If hospitals avail themselves of 
this opportunity, the FY 2000 wage index implemented on October 1 
should be free of these errors. Nevertheless, in the unlikely event 
that errors should occur after that date, we retain the right to make 
midyear changes to the wage index under very limited circumstances.
    Specifically, in accordance with Sec. 412.63(w)(2), we may make 
midyear corrections to the wage index only in those limited 
circumstances in which a hospital can show (1) that the intermediary or 
HCFA made an error in tabulating its data; and (2) that the hospital 
could not have known about the error, or did not have an opportunity to 
correct the error, before the beginning of FY 2000 (that is, by the 
June 7, 1999 deadline). As indicated earlier, since a hospital had the 
opportunity to verify its data, and the intermediary notified the 
hospital of any changes, we do not foresee any specific circumstances 
under which midyear corrections would be made. However, should a 
midyear correction be necessary, the wage index change for the affected 
area will be effective prospectively from the date the correction is 
made.
    In the September 1, 1994 Federal Register, we stated that we did 
not believe that a ``formal appeals process'' regarding intermediary 
decisions denying hospital requests for wage data revisions was 
necessary, given the numerous opportunities provided to hospitals to 
verify and revise their data (59 FR 45351). We continue to believe that 
the process described above provides hospitals more than adequate 
opportunity to ensure that their data are correct. Nevertheless, we 
wish to clarify that, while there is no formal appeals process that 
culminates before the publication of the final rule and that is 
described above, hospitals may later seek formal review of denials of 
requests for wage data revisions made as a result of that process.
    Once the final wage index values are calculated and published in 
the Federal Register, the last opportunity for a hospital to seek to 
have its wage data revised is under the limited circumstances described 
in Sec. 412.63(w)(2). As we noted in the September 1, 1995 Federal 
Register, however, hospitals are entitled to appeal any denial of a 
request for a wage data revision made as a result of HCFA's wage data 
correction process to the Provider Reimbursement Review Board (PRRB), 
consistent with the rules for PRRB appeals found at 42 CFR Part 405, 
Subpart R (60 FR 45795). As we also stated in the September 1, 1995 
Federal Register, and as the regulation at Sec. 412.63(w)(5) provides, 
any subsequent reversal of a denial of a wage revision request that 
results from a hospital's appeal to the PRRB or beyond will be given 
effect by paying the hospital under a revised wage index that reflects 
the revised wage data at issue. The revised wage data will not, 
however, be used for purposes of revisiting past adjudications of 
requests for geographic reclassification.
    Comment: One commenter suggested that our notices of the wage index 
review process should be more explicit regarding dates, titles, and 
addresses, and should be presented in a format similar to the request 
for hearing language contained in most Notices of Program 
Reimbursements. The commenter believes this would avoid confusion and 
misunderstandings throughout the process.
    Response: Although we believe that our notices of wage index file 
availability are already quite detailed, we agree they might be 
improved to minimize misunderstandings. For example, we intend to 
continue to work with our intermediaries to ensure that, in their 
correspondence with hospitals regarding the resolution of revision 
requests submitted by the hospitals, the intermediaries state more 
explicitly the criteria, procedures, and deadlines for requesting our 
intervention when a hospital disagrees with an intermediary's policy 
determination. We welcome any other specific recommendations.
    Comment: One commenter requested that we consider providing a mid-
year correction, as in the FY 1999 wage index, for those areas that are 
affected by a major change in the FY 2000 wage index. The commenter 
stated that further opportunity to review and adjust its wage data 
would provide a more meaningful wage index.
    Response: As we stated in the February 25, 1999 final rule 
implementing changes resulting from the limited window of opportunity 
for hospitals to request revisions to their FY 1995 data used to 
calculate the FY 1999 wage index, we believe our usual procedures 
provide ample opportunity for diligent hospitals to ensure the accuracy 
of their wage data (64 FR 93781). The limited opportunity to request 
revisions to the data used to calculate the FY 1999 wage index was 
based on a combination of circumstances unique to that year, and 
hospitals should assume in the future that all requests to change their 
wage data must conform to the well-established guidelines discussed 
above. Therefore, we do not intend to again provide such a special 
opportunity for further revision requests.

IV. Other Decisions and Changes to the Prospective Payment System 
for Inpatient Operating Costs and Graduate Medical Education Costs

A. Sole Community Hospitals (SCHs) (Sec. 412.92)

    If a hospital is classified as an SCH because, by reason of certain 
factors, it is the sole source of inpatient hospital services 
reasonably available to Medicare beneficiaries in a geographic area, 
the hospital is paid based on the highest of the following: the 
applicable adjusted Federal rate; the updated hospital-specific rate 
based on a 1982 base period; or the updated hospital-specific rate 
based on a 1987 base period. Under our existing rules, urban hospitals 
within 35 miles of another hospital cannot qualify as SCHs. Since 1983, 
we have consistently defined an ``urban'' area for purposes of 
determining if a hospital qualifies for SCH status as an MSA or NECMA 
as defined by OMB.
    In the past, we have considered and rejected two alternatives to 
the MSA definitions of an urban area for SCH purposes. These 
alternatives were the urbanized areas as defined by the Census Bureau 
and the health facility planning areas (HFPAs) as used by the Health 
Resource Services Administration. We have concluded that the MSA 
definition continues to be the most appropriate geographic delimiter 
available at this time. Therefore, in the May 7, 1999 proposed rule, we 
proposed to continue to apply the MSA definition of an urban area for 
SCH status purposes.
    We proposed to continue our current policy for several reasons. 
First, as we have previously noted, since OMB considers local commuting 
patterns in establishing urban definitions, we believe that residents 
in urban areas have access to hospital services either by living in 
close proximity to a hospital or by establishing a heavy commuting 
pattern to an area in which a hospital is located (48 FR 39780, 
September 1, 1983). We do not believe that either Census Bureau 
urbanized areas or HFPAs take commuting patterns into account in the 
way that OMB's MSAs do. We believe commuting patterns serve as an 
important indicator of whether a hospital is the sole hospital 
reasonably accessible by Medicare beneficiaries in an area.
    In addition, we note that our use of MSAs to define urban areas for 
SCH status purposes has direct statutory support. Section 1886(d)(2)(D) 
of the

[[Page 41514]]

Act specifically authorizes us to use OMB's MSA definition of urban 
areas for purposes of calculating the prospective payment system 
standardized amounts. SCH status represents an adjustment to the usual 
prospective payment that a hospital would receive, and since that 
prospective payment is based on the standardized amount, among other 
factors, we believe it would be anomalous to employ one definition of 
urban area for purposes of calculating the standardized amount and 
another for purposes of determining if the hospital qualified as an 
SCH. To do so would be to use one set of geographic delimiters in 
applying the general rule (payment under the prospective payment system 
based on the standardized amount) but a different set in determining 
exceptions to the rule (payment under the prospective payment system 
adjusted to take into account SCH status). We do not think this would 
be appropriate. For this reason, also, we propose to continue to define 
``urban'' for SCH purposes as meaning MSAs as defined by OMB, not as 
meaning either Census Bureau urbanized areas or HFPAs.
    We received one comment on our proposed retention of this 
definition.
    Comment: One commenter, which had been communicating with us before 
the issuance of the proposed rule, continued to express concern about 
our policy of defining urban areas for SCH purposes based on MSAs. The 
commenter raised several points. First, the commenter stated that our 
discussion in the proposed rule is ``misleading'' because it did not 
mention recent litigation on this issue. Second, the commenter argued 
that our proposal is flawed because it results in inequitable treatment 
of hospitals; that is, it renders a hospital's ability to qualify as an 
SCH dependent on OMB's reconfiguration of MSA boundaries, and patients' 
ability to access inpatient hospital services is not affected by those 
boundaries. Third, the commenter questioned two aspects of our 
rationale for retaining an MSA-based definition of the urban areas in 
the SCH context--that OMB considers commuting patterns when defining 
MSAs and that use of MSAs is consistent with the methodology we use for 
computing the standardized amounts. Finally, the commenter suggested 
that, if we decided to adopt our proposal to base the definition of 
urban areas for SCH purposes on MSAs, we should at least adopt an 
exception to that rule under which a hospital that is the only hospital 
in an MSA could still qualify as an SCH.
    Response: We do not agree with the commenter that we should either 
abandon our longstanding policy of defining urban areas for SCH 
purposes based on MSAs or adopt the exception to that policy that the 
commenter suggests. Although the commenter is correct in pointing out 
that there has been recent litigation involving our definition of 
``urban area'' for SCH purposes, we do not believe that our proposal 
was in any way misleading. Partly as a result of the litigation, we 
decided to reiterate and clarify our policy. Thus, we clearly stated in 
the proposed rule that we proposed to retain our longstanding 
definition in favor of other definitions based on the Census Bureau's 
urbanized areas or on HFPAs and explained the reasons for our proposal. 
We believe the proposed rule, therefore, gave interested parties more 
than adequate notice of the issue and afforded them the opportunity to 
comment.
    We continue to believe that it is appropriate to adopt an MSA-based 
definition of urban areas for SCH purposes for the reasons stated in 
the proposed rule and in our earlier discussions of the MSA-based 
definition. The commenter gave an example of a situation in which an 
urban hospital is the nearest like hospital to a rural hospital, and 
the rural hospital is likewise the nearest hospital to the urban 
hospital. The commenter stated that the rural hospital could obtain SCH 
status, but the urban hospital could not, which, the commenter 
concluded, results in inequitable treatment of similarly situated 
hospitals.
    We do not agree with this conclusion for several reasons. First, if 
the urban hospital was located more than 35 miles from the rural 
hospital, it could in fact qualify for SCH status under our rules. 
Moreover, the hospitals in this example are not similarly situated; one 
is urban and one is rural. As we have stated previously, urban areas 
generally have better roads, faster snow clearing, and more available 
hospitals, factors that affect access to inpatient hospital services. 
(See 56 FR 25483 (June 4, 1991).) Thus, even if the rural hospital in 
the commenter's example qualified as an SCH and the urban hospital did 
not, the difference in result is justified by the hospitals' different 
geographic circumstances.
    The commenter's example does nothing to demonstrate that any other 
definition of an urban area for SCH purposes is preferable to an MSA-
based definition. The somewhat unique situation the commenter 
described--an urban hospital that is closest to a rural hospital and 
vice versa--could arise no matter what definition of urban area we 
adopt.
    Similarly, while the commenter objected to hospitals' ability to 
qualify for SCH status depending on possible shifting OMB definitions 
of MSAs, the same objection could be made of any definition of urban 
area that adopts geographic delimiters promulgated by another entity--
including Census Bureau urbanized areas or HFPAs. In addition, we 
consider the fact that OMB occasionally revises the MSA boundaries to 
be a strength of that scheme. We think it is appropriate that any 
definition of urban areas for SCH purposes be reviewed periodically to 
take into account changes that have occurred in various areas' 
characteristics. Urban and rural areas do not remain static forever. 
Shifts in population and other changes can transform previously rural 
areas into urban ones, and vice versa. Because we believe the nature of 
an area as urban or rural is an important part of determining whether a 
hospital should qualify as an SCH, the mechanism for making those 
determinations should be able to account for changes in that nature.
    As noted above and in our previous discussions of this issue, we 
believe that several factors make urban hospitals more accessible to 
patients than rural ones. Contrary to the commenter's statement that 
access is not affected by MSA boundaries, we proposed to adopt MSAs as 
the definition of urban areas for SCH purposes precisely because MSAs 
provided a good gauge of the presence of factors affecting access. The 
commenter's contentions fail to convince us that we should not adopt 
this proposal.
    The commenter also argued that we have not properly considered 
reasonable alternatives to our proposed MSA-based definition of urban 
areas for SCH purposes. To the contrary, we specifically considered and 
proposed to reject two alternative definitions based on urbanized areas 
and HFPAs. The commenter offered no additional alternatives. Rather, 
the commenter questioned our reliance on OMB's use of commuting 
patterns in establishing MSAs, and stated that both urbanized areas and 
HFPAs also consider commuting patterns in the form of such factors as 
availability of roads and travel time and distance. Even if true, 
however, that means only that all three potential definitions consider 
commuting patterns in some form, and thus does not provide a basis for 
preferring a definition of urban areas other than one based on MSAs. 
The commenter pointed out that the

[[Page 41515]]

commuting patterns OMB analyzes pertain to commutes to workplaces, 
which, the commenter claimed, do not relate to access to hospital 
services. However, we have indicated that we deem commuting patterns 
important because they indicate access to areas in which hospitals are 
located. (See 48 FR 39780 (Sept. 1, 1983).) As such, they are a good 
indicator of access to hospital services.
    The commenter questioned our reliance on the fact that MSAs are 
used as the basis for determining the standardized amounts that form 
the basis of prospective payment system payments. The MSAs also supply 
the definition of urban areas used for virtually every other purpose 
under the hospital inpatient prospective payment system, including 
other special status determinations, geographic reclassification, and 
calculation of the wage index. We continue to believe that it is 
appropriate to use a definition of urban areas for SCH purposes that is 
consistent with the definition used for almost all other components of 
the prospective payment rates.
    In regard to the commenter's suggestion that, if we retain the MSA-
based definition of urban areas for SCH purposes, we adopt an exception 
to that definition under which an urban hospital that is the only 
hospital in its MSA would qualify as an SCH if it would otherwise 
qualify absent its urban location. We note that, to a large extent, we 
already apply this rule. As noted above, an urban hospital that is more 
than 35 miles from the nearest like hospital may qualify as an SCH 
notwithstanding its urban location. Thus, urban hospitals, including 
those in a sole-hospital MSA, can in fact qualify as SCHs, provided 
they are not in close proximity to another like hospital.
    We acknowledge that a small number of MSAs may contain only one 
hospital; however, we have stated that urban areas generally have more 
available hospitals (56 FR 25483 (June 4, 1991)). Again, urbanized 
areas, HFPAs, or an urban area defined under any other methodology 
might also contain only one hospital. As a result, there is nothing 
inherent in our adoption of an MSA-based definition that compels 
adoption of the exception the commenter has proposed. It continues to 
be our judgment that an urban hospital within 35 miles of another like 
hospital is not the ``sole'' source of inpatient hospital services in 
its community, given the close proximity of the other hospital and the 
other factors affecting increased access to inpatient hospital services 
that location in an urban area denotes. Thus, we have not adopted the 
commenter's proposed exception to the rule defining urban areas based 
on MSAs for SCH purposes.

B. Rural Referral Centers (Sec. 412.96)

    Under the authority of section 1886(d)(5)(C)(i) of the Act, 
Sec. 412.96 sets forth the criteria a hospital must meet in order to 
receive special treatment under the prospective payment system as a 
rural referral center. For discharges occurring before October 1, 1994, 
rural referral centers received the benefit of payment based on the 
other urban rather than the rural standardized amount. As of that date, 
the other urban and rural standardized amounts were the same. However, 
rural referral centers continue to receive special treatment under both 
the disproportionate share hospital (DSH) payment adjustment and the 
criteria for geographic reclassification.
    One of the criteria under which a rural hospital may qualify as a 
rural referral center is to have 275 or more beds available for use. A 
rural hospital that does not meet the bed size criterion can qualify as 
a rural referral center if the hospital meets two mandatory criteria 
(specifying a minimum case-mix index and a minimum number of 
discharges) and at least one of the three optional criteria (relating 
to specialty composition of medical staff, source of inpatients, or 
volume of referrals). With respect to the two mandatory criteria, a 
hospital may be classified as a rural referral center if its--
     Case-mix index is at least equal to the lower of the 
median case-mix index for urban hospitals in its census region, 
excluding hospitals with approved teaching programs, or the median 
case-mix index for all urban hospitals nationally; and
     Number of discharges is at least 5,000 discharges per year 
or, if fewer, the median number of discharges for urban hospitals in 
the census region in which the hospital is located. (The number of 
discharges criterion for an osteopathic hospital is at least 3,000 
discharges per year.)
1. Case-Mix Index
    Section 412.96(c)(1) provides that HCFA will establish updated 
national and regional case-mix index values in each year's annual 
notice of prospective payment rates for purposes of determining rural 
referral center status. The methodology we use to determine the 
national and regional case-mix index values is set forth in regulations 
at Sec. 412.96(c)(1)(ii). The proposed national case-mix index value in 
the May 7, 1999 proposed rule included all urban hospitals nationwide, 
and the proposed regional values were the median values of urban 
hospitals within each census region, excluding those with approved 
teaching programs (that is, those hospitals receiving indirect medical 
education payments as provided in Sec. 412.105).
    These values were based on discharges occurring during FY 1998 
(October 1, 1997 through September 30, 1998) and include bills posted 
to HCFA's records through December 1998. Therefore, we proposed that, 
in addition to meeting other criteria, hospitals with fewer than 275 
beds, if they are to qualify for initial rural referral center status 
for cost reporting periods beginning on or after October 1, 1999, must 
have a case-mix index value for FY 1998 that is at least--
     1.3438; or
     The median case-mix index value for urban hospitals 
(excluding hospitals with approved teaching programs as identified in 
Sec. 412.105) calculated by HCFA for the census region in which the 
hospital is located. (See the table set forth in the May 7, 1999 
proposed rule at 64 FR 24732-24733.)
    Based on the updated FY 1998 MedPAR file, which contains data from 
additional bills received through March 31, 1999, the final national 
case-mix value is 1.3438 and the median case-mix values by region are 
set forth in the following table:

------------------------------------------------------------------------
                                                               Case-mix
                           Region                            index value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................       1.2498
2. Middle Atlantic (PA, NJ, NY)............................       1.2499
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....       1.3306
4. East North Central (IL, IN, MI, OH, WI).................       1.2577
5. East South Central (AL, KY, MS, TN).....................       1.2795
6. West North Central (IA, KS, MN, MO, NE, ND, SD).........       1.1877
7. West South Central (AR, LA, OK, TX).....................       1.2994
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............       1.3438
9. Pacific (AK, CA, HI, OR, WA)............................       1.3231
------------------------------------------------------------------------

    For the benefit of hospitals seeking to qualify as referral centers 
or those wishing to know how their case-mix index value compares to the 
criteria, we are publishing each hospital's FY 1998 case-mix index 
value in Table 3C in section VI of the Addendum to this final rule. In 
keeping with our policy on discharges, these case-mix index values are 
computed based on all Medicare patient discharges subject to DRG-based 
payment.

[[Page 41516]]

2. Discharges
    Section 412.96(c)(2)(i) provides that HCFA will set forth the 
national and regional numbers of discharges in each year's annual 
notice of prospective payment rates for purposes of determining 
referral center status. As specified in section 1886(d)(5)(C)(ii) of 
the Act, the national standard is set at 5,000 discharges. In the May 
7, 1999 proposed rule, we proposed to update the regional standards. 
The proposed regional standards were based on discharges for urban 
hospitals' cost reporting periods that began during FY 1997 (that is, 
October 1, 1996 through September 30, 1997). That is the latest year 
for which we have complete discharge data available.
    Therefore, we proposed that, in addition to meeting other criteria, 
a hospital, if it is to qualify for initial rural referral center 
status for cost reporting periods beginning on or after October 1, 
1999, must have as the number of discharges for its cost reporting 
period that began during FY 1998 a figure that is at least--
     5,000; or
     The median number of discharges for urban hospitals in the 
census region in which the hospital is located, as indicated in the 
following table. (See the table set forth in the May 7, 1999 proposed 
rule at 64 FR 24733.)
    Based on the latest discharge data available for FY 1997, the final 
median number of discharges for urban hospitals by census region areas 
is as follows:

------------------------------------------------------------------------
                                                              Number of
                           Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)....................         6733
2. Middle Atlantic (PA, NJ, NY)............................         8655
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV).....         7845
4. East North Central (IL, IN, MI, OH, WI).................         7499
5. East South Central (AL, KY, MS, TN).....................         6832
6. West North Central (IA, KS, MN, MO, NE, ND, SD).........         5346
7. West South Central (AR, LA, OK, TX).....................         5380
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)...............         8026
9. Pacific (AK, CA, HI, OR, WA)............................         6151
------------------------------------------------------------------------

    We note that the number of discharges for hospitals in each census 
region is greater than the national standard of 5,000 discharges. 
Therefore, 5,000 discharges is the minimum criterion for all hospitals.
    We reiterate that an osteopathic hospital, if it is to qualify for 
rural referral center status for cost reporting periods beginning on or 
after October 1, 1999, must have at least 3,000 discharges for its cost 
reporting period that began during FY 1997.
    Comment: One commenter urged HCFA to reconsider its decision not to 
restore RRC status to those hospitals located in areas that have been 
redesignated as urban by the OMB. The commenter argued that the statute 
established only one qualification for having a hospital's RRC status 
restored; that is, a hospital must have been designated as an RRC in FY 
1991. According to the commenter, the statute provides no other 
conditions, nor does it provide HCFA with the discretion to create 
other conditions. The commenter believes that our decision not to 
restore the RRC status of hospitals located in areas redesignated as 
urban by OMB effectively requires affected hospitals to satisfy an 
additional condition that they be located in a rural area.
    Response: We responded to a comment raising the same issue in the 
May 12, 1998 final rule (63 FR 26326). We addressed our interpretation 
of section 4202(b)(1) of the BBA in the August 29, 1997 final rule with 
comment period (62 FR 45999 and 46000) as well as the May 12, 1998 
final rule, and we refer the reader to those documents.

C. Changes to the Indirect Medical Education Adjustment (Sec. 412.105)

    Section 1886(d)(5)(B) of the Act provides that prospective payment 
hospitals that have residents in an approved graduate medical education 
(GME) program receive an additional payment to reflect the higher 
indirect operating costs associated with GME. The regulations regarding 
the calculation of this additional payment, known as the indirect 
medical education (IME) adjustment, are located at Sec. 412.105.
    In the August 29, 1997 final rule (62 FR 46029), we redesignated 
the previous Sec. 412.105(g) as Sec. 412.105(f), and added a new 
paragraph (g) to implement section 1886(d)(5)(B) of the Act as revised 
by section 4621 of the BBA of 1997. However, when we redesignated 
paragraph (g) as paragraph (f), we inadvertently did not revise all of 
the relevant cross-references to reflect this redesignation. 
Specifically, at Sec. 412.105(f)(1)(iii), there are three cross-
references to paragraph (g)(1)(ii). These cross-references are 
incorrect in light of the redesignation of previous paragraph (g) as 
paragraph (f). We proposed to revise Sec. 412.105(f)(1)(iii) to correct 
these cross-references.
    We did not receive any comments on this proposal and are adopting 
it as final.

D. Medicare Geographic Classification Review Board: Conforming Changes 
Secs. 412.256 and 412.276

    In the May 12, 1998 final rule (63 FR 26321), we revised the 
regulations governing the timeframes for submittal of applications by 
hospitals to the MGCRB for geographic reclassifications and for MGCRB 
decisions to take into consideration the revised statutory publication 
schedule for the annual prospective payment policies and rates (that 
is, August 1 instead of September 1) implemented by the BBA. In making 
those changes, we inadvertently omitted conforming changes to two other 
sections of the regulations that also specify timeframes that are 
affected by the change to an August 1 publication date--Secs. 412.256 
and 412.276. We proposed to revise Sec. 412.256(c)(2) to specify that 
at the request of the hospital, the MGCRB may, for good cause, grant a 
hospital that has submitted an application by September 1 (instead of 
October 1) an extension beyond September 1 (instead of October 1) to 
complete its application. In addition, we proposed to revise 
Sec. 412.276(a) to specify that the MGCRB notifies the parties in 
writing, with a copy to HCFA, and issues a decision within 180 days 
after the ``first day of the 13-month period preceding the Federal 
fiscal year for which the hospital had filed a completed application'' 
for reclassification, to make the language consistent with the statute 
and the May 1998 changes made to the application deadline in 
Sec. 412.256(a)(2).
    We did not receive any comments on this proposal and are adopting 
it as final.
    We note that the instructions for preparing applications for FY 
2001 individual and group reclassifications, which are due to the MGCRB 
by September 1, 1999, are now available for downloading from the 
Internet at www.hcfa.gov/regs/appeals.
    Comment: One commenter requested clarification about submitting an 
application for reclassification for the standardized amount when the 
payment rates had changed during the year for which the applicable cost 
report would be used. Specifically, the commenter was concerned that 
the revised average hourly wage data, wage index, and standardized 
amounts applicable for FY 1999 beginning on or after March 1, 1999 (see 
the final rule published on February 25, 1999 (64 FR 9378)) will 
require the MGCRB to determine which

[[Page 41517]]

wage index and standardized amount value to use when evaluating 
applications seeking standardized amount geographic reclassification. 
The commenter asserted that because the MGCRB must use historical 
national adjusted operating standardized amounts and wage indices, a 
problem potentially arises when HCFA calculates more than one 
standardized amount and wage index for an area in a year, as it did in 
FY 1999. The commenter suggested the MGCRB use prorated standardized 
amount and wage index values in evaluating applications.
    Response: When the MGCRB evaluates an application for 
reclassification for the standardized amounts, it uses actual payment 
rates for actual periods. Therefore, if the payment rate changed during 
the year that applies to a hospital's application, those figures are 
incorporated into the calculation for the months during which they 
applied. The same policy holds true for wage data.

E. Payment for Direct Costs of Graduate Medical Education (Sec. 413.86)

    Under section 1886(h) of the Act, Medicare pays hospitals for the 
direct costs of graduate medical education (GME). The payments are 
based on the number of residents trained by the hospital. The BBA 
revised section 1886(h) of the Act to cap the number of residents that 
hospitals may count for direct GME. We have issued rules to implement 
the caps for GME (62 FR 46002, August 29, 1997; 63 FR 26327, May 12, 
1998; and 63 FR 40986, July 31, 1998). Since the publication of these 
rules we have received a number of questions relating to GME. In 
addition, we have received information related to other aspects of our 
GME policies. In response to these questions and information, in the 
proposed rule, we proposed to clarify certain GME policies and also 
make some technical changes to the regulations text. In addition, we 
proposed certain changes in GME policy.
1. Approved Geriatric Programs
    Under sections 1886(h)(5)(F) and (G) of the Act and Sec. 413.86(g), 
Medicare counts each resident within an initial residency period as a 
1.0 full-time equivalent (FTE) for purposes of determining GME 
payments. Each resident beyond the initial residency period is counted 
as 0.5 full-time equivalent. Section 1886(h)(5)(F) of the Act extends 
the initial residency period by up to 2 years if an individual is in a 
geriatric or preventive medicine residency or fellowship. At 
Sec. 413.86(b), we specify that an ``approved geriatric program'' is 
``a fellowship program of one or more years in length that is approved 
by the Accreditation Council for Graduate Medical Education (ACGME) 
under the ACGME's criteria for geriatric fellowship programs.'' In 
recent years, geriatric programs have been approved by other national 
organizations. Consistent with the statute, we proposed to clarify the 
definition of approved geriatric programs at Sec. 413.86(b) to include 
fellowship programs approved by the American Osteopathic Association, 
the Commission on Dental Accreditation, and the Council on Podiatric 
Medical Education. These organizations, in addition to ACGME, are 
recognized by HCFA as the accrediting bodies for determining approved 
educational activities. We also proposed to make a conforming change to 
Sec. 413.86(g)(1)(iii) to recognize approved geriatric programs 
accredited by all national approving organizations.
    We received one comment in support of our proposed revision to 
Sec. 413.86(b). We are adopting the revision as final.
2. Hospital Payment For Resident Training in Nonhospital Settings
    Under sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act, 
hospitals may count residents working in nonhospital sites for indirect 
and direct medical education respectively if the hospital incurs ``all 
or substantially all'' of these education costs. The requirements for 
counting the time residents spend training in nonhospital settings are 
addressed at Sec. 413.86(f)(4). Currently, the requirements for 
hospital payment under this provision are that the resident spend his 
or her time in patient care activities and that a written agreement 
exist between the hospital and the nonhospital site. This written 
agreement must indicate that the hospital will incur the cost of the 
residents' salaries and fringe benefits while the residents are 
training in the nonhospital site and that the hospital is providing 
reasonable compensation to the nonhospital site for supervisory 
teaching activities. In addition, the written agreement must indicate 
the compensation the hospital is providing to the nonhospital site for 
supervisory teaching activities.
    Under the statute, the time residents spend at nonhospital sites 
may be counted ``if the hospital incurs all, or substantially all, of 
the costs of the training program in that setting.'' The existing 
regulations text, however, is framed in terms of the hospital having an 
agreement that it ``will incur'' the costs in the nonhospital setting. 
We proposed to make a technical change to the regulations text by 
adding a new Sec. 413.86(f)(4)(iii), to clarify that in order to count 
residents at a nonhospital site, the hospital must actually incur all 
or substantially all of the costs for the training program, as defined 
in Sec. 413.86(b), in the nonhospital site. This definition of all or 
substantially all requires the hospital to incur the expenses of the 
residents' salaries and fringe benefits (including travel and lodging 
where applicable) and the portion of the cost of teaching physicians' 
salaries and fringe benefits attributable to direct GME.
    Comment: Many commenters supported our technical change under the 
proposed Sec. 413.86(f)(4)(iii), which provides that, in order to count 
residents training at a nonhospital site for purposes of direct and 
indirect GME payment, the hospital must actually incur all or 
substantially all of the costs for the training programs. However, we 
believe several commenters misunderstood our technical change. The 
commenters believed that the change was unnecessary because the 
existing regulations, which were issued in the July 31, 1998 final 
rule, provide adequate guidance for purposes of the hospital claiming 
direct and indirect GME for resident training in the nonhospital site.
    Response: We proposed to make the technical change in 
Sec. 413.86(f)(4)(iii) for two reasons. First, we stated in the 
preamble to the July 31, 1998 final rule that we are requiring the 
hospital to actually incur all or substantially all of the cost, but 
the regulation text only indicated that the hospital must have an 
agreement to incur the cost; that is, the regulation text did not 
include specific language requiring that the hospital actually incur 
the cost. Second, we defined the phrase ``all or substantially all'' in 
Sec. 413.86(b) but inadvertently omitted using the phrase in the policy 
specified in Sec. 413.86(f)(4).
    Comment: In regard to our proposed technical change to the 
nonhospital payment policy as specified in Sec. 413.86(f)(4)(iii), one 
commenter asked us to define the difference, if any, in our use of 
``nonprovider'' entity and ``nonhospital'' entity. In addition, the 
commenter asked whether a skilled nursing facility or a unit excluded 
from the prospective payment system is considered to be a nonhospital 
setting.
    Also, similar to the public comments addressed in the in July 31, 
1998 final rule, several commenters asked us to clarify whether 
hospitals would still be eligible to receive payments in situations 
where the teaching faculty volunteers their services and neither the 
hospital nor the nonhospital entity

[[Page 41518]]

incurs costs for supervisory teaching physicians. The commenters asked 
us to continue to support the following statement that we included in 
the July 31, 1998 final rule (63 FR 40996) allowing hospitals to remain 
eligible for payment in such situations where supervisory physicians in 
the nonhospital site are volunteering their time: ``for the purposes of 
satisfying the requirement of a written agreement, the written 
agreement between a hospital and a nonhospital site may specify that 
there is no payment to the clinic for supervisory activities because 
the clinic does not have these costs.''
    Response: For purposes of our nonhospital payment policy for GME in 
Sec. 413.86(f)(4), we use the terms ``nonhospital'' and ``nonprovider'' 
interchangeably. A free-standing SNF (that is, a SNF that is not part 
of a hospital) is a nonhospital site. An excluded unit of a hospital is 
not a nonhospital site because an excluded unit is still part of a 
hospital.
    We will continue a volunteer supervisory physician policy 
consistent with the policy stated in the July 31, 1998 final rule, as 
requested by the commenter. Hospitals may receive payment for the costs 
of training residents in the nonhospital site even though the hospital 
might not be incurring any costs for supervisory physician activities.

3. New Residency Programs

    In the regulations we published on August 29, 1997 and May 12, 
1998, we established special rules for adjusting the full-time 
equivalent (FTE) resident caps for indirect and direct GME for new 
medical residency programs. In general, the special rules allow for 
adjustments to the caps based on the number of residents participating 
in the program in its third year of existence. In Secs. 413.86(g)(6)(i) 
and 413.86(g)(6)(ii), we set forth a methodology for adjusting hospital 
FTE caps for new medical residency training programs established on or 
after January 1, 1995. In the May 7, 1999 proposed rule, we proposed 
the following clarifications, technical changes, and policy changes:
    a. In Sec. 413.86(g)(6)(i), we specify that, if a hospital had no 
residents before January 1, 1995, the adjustments for new programs are 
based on the highest number of residents in any program year during the 
third year of the newly established program. However, 
Sec. 413.86(g)(6)(ii) does not explicitly state the methodology for 
adjusting caps for hospitals that did have residents in the most recent 
cost reporting period ending before January 1, 1995. The adjustments of 
the caps for programs established on or after January 1, 1995 and on or 
before August 5, 1997, also are made based on the number of residents 
in the third year of the new program. We proposed to revise 
Sec. 413.86(g)(6)(ii) to clarify that, for a hospital that did have 
residents in the most recent cost reporting period ending on or before 
December 31, 1996, the adjustment is based on the highest number of 
residents in any program year in the third year of the new program.
    b. Sections 413.86(g)(6)(i) and 413.86(g)(6)(ii) specify that the 
adjustment to the cap is also based on the number of years in which 
residents are expected to complete each program based on the minimum 
accredited length for the type of program. We proposed to add language 
to clarify how to account for situations in which the residents spend 
an entire program year (or years) at one hospital and the remaining 
year (or years) of the program at another hospital. In this situation, 
the adjustment to the FTE cap is based on the number of years the 
residents are training at each hospital, not the minimum accredited 
length for the type of program. If we were to use the minimum 
accredited length for the program in this case, the total adjustment to 
the cap for both hospitals might exceed the total accredited slots 
available to the hospitals participating in the program. In the May 12, 
1998 final rule (63 FR 26334), we specified that the adjustment to the 
FTE cap may not exceed the number of accredited resident slots 
available.
    c. It was brought to our attention that the regulations do not 
explicitly address how to apply the cap during the first 3 years of a 
new program before the adjustments to the cap are established. In the 
May 7, 1999 proposed rule, we proposed to clarify our policy on new 
residency programs by adding language in Secs. 413.86(g)(6)(i) and 
413.86(g)(6)(ii) to specify how to determine the hospital's cap in the 
first 3 years of a new residency program, before the implementation of 
the hospital's permanent adjustment to its FTE cap effective beginning 
with the fourth year of the program. We proposed to specify that the 
cap may be adjusted during each year of the first 3 years of the 
hospital's new residency program, using the actual number of residents 
participating in the new program. The adjustment may not exceed the 
number of accredited slots available to the hospital for each program 
year.
    d. As discussed above, on August 29, 1997, we implemented the 
hospital-specific caps on the number of residents that a hospital can 
count for purposes of GME payments in a final rule with comment period 
(62 FR 46002). In both the May 12, 1998 and July 31, 1998 final rules 
(63 FR 26327 and 63 FR 40954), we responded to comments we received on 
this provision. We did not receive any comments about hospitals that 
participated in residency training in the past, had terminated their 
participation before the hospitals' cost reporting period ending in 
calendar year 1996, and have now again begun a new residency program. 
After publication of the July 31, 1998 final rule, we were contacted by 
representatives of some hospitals that had a resident cap of zero 
because they had temporarily terminated their GME programs in the past 
and had no residents training during the cost reporting period ending 
in 1996. Based on the existing regulations, these hospitals have FTE 
caps of zero. There is no provision in the existing regulations for 
making adjustments to the cap to allow these hospitals to receive 
payment for indirect and direct GME for allopathic and osteopathic 
residents.
    To address this issue, we proposed to revise Sec. 413.86(g)(6)(i) 
to allow for an adjustment to a hospital's FTE cap if the hospital had 
no allopathic and osteopathic residents in its cost reporting period 
ending during calendar year 1996. This change would allow all hospitals 
that did not participate in allopathic and osteopathic resident 
training in the cost reporting period ending in calendar year 1996 to 
receive adjustments to the indirect and direct GME FTE caps for new 
residency programs. We believe it is appropriate to revise the 
regulations to allow for payment during the first 3 years of the new 
program and for an adjustment to the FTE cap 3 years after these 
hospitals restart participation in residency training, similar to the 
existing adjustment for hospitals that never participated in residency 
training. We proposed to revise Sec. 413.86(g)(6)(i) to allow a 
hospital that has zero residents for the cost reporting period ending 
during the calendar year 1996 to receive an adjustment. This change 
would be effective for discharges occurring on or after October 1, 
1999, for purposes of the IME adjustment and for cost reporting periods 
beginning on or after October 1, 1999, for purposes of direct GME.
    In addition, we proposed to make a change in Sec. 413.86(g)(6)(ii) 
to make the language similar to that in Sec. 413.86(g)(6)(i) to specify 
that hospitals that did have residents in the cost reporting period 
ending on or before December 31, 1996, are allowed adjustments to the 
cap for new programs begun on or after January 1, 1995, and

[[Page 41519]]

on or before August 5, 1997. Existing Sec. 413.86(g)(6)(ii) refers to a 
hospital that did have residents in its most recent cost reporting 
period ending on or before January 1, 1995. The regulation states that 
these hospitals also may qualify for an adjustment to the caps, but 
only for medical residency programs created on or after January 1, 
1995, and on or before August 5, 1997. Since we proposed to revise 
Sec. 413.86(g)(6)(i) to indicate that a hospital may qualify for an 
adjustment to the cap under that paragraph if it did not have residents 
in the cost reporting period ending during calendar year 1996, we 
proposed to make a similar change in Sec. 413.86(g)(6)(ii) to indicate 
that this paragraph provides for an adjustment to the cap for hospitals 
that did have residents in its most recent reporting period ending on 
or before December 31, 1996. We proposed this revision to make the 
language of these two paragraphs consistent. Hospitals may qualify 
either under Sec. 413.86(g)(6)(i) or Sec. 413.86(g)(6)(ii). For 
hospitals that qualify under Sec. 413.86(g)(6)(i), the FTE caps are 
established 3 years after the hospital either begins or restarts 
participation in residency training for programs that began on or after 
January 1, 1995. However, for hospitals that qualify under 
Sec. 413.86(g)(6)(ii), adjustments to the cap are limited to those 
programs that began on or after January 1, 1995 and on or before August 
5, 1997.
    e. We proposed to make technical changes to Secs. 413.86(g)(6)(i) 
and 413.86(g)(6)(ii), which refer to whether a hospital had residents 
in its most recent cost reporting period on or before December 31, 
1996. Instead of simply specifying ``residents,'' we proposed to 
reference ``allopathic and osteopathic residents,'' because the FTE cap 
applies only to allopathic and osteopathy residents. There is no FTE 
cap on the number of podiatry and dentistry residents. Therefore, we 
proposed to add the words ``allopathic and osteopathic'' in 
Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) before the word 
``resident.''
    We received a number of comments on our proposals.
    Comment: One commenter supported our technical changes to the new 
residency program adjustments under proposed Secs. 413.86(g)(6)(i) and 
413.86(g)(6)(ii). The commenter agreed with our technical change of 
referencing ``allopathic and osteopathic residents'' instead of simply 
``residents.''
    The proposed rule specified that the method for calculating the 
adjustment to the cap is based on the product of the highest number of 
residents in any program year during the third year of the newly 
established program and the number of years in which residents are 
expected to complete each year program based on the minimum accredited 
length for the type of program. One commenter requested an example of a 
calculation of this adjustment.
    Response: In response to the commenter's request, we are providing 
the following example of how to calculate the new residency program 
adjustment under Sec. 413.86(g)(6)(ii). This example was included in a 
Program Memorandum (Transmittal No. A-97-13 (p. 16), September 1997) 
that transmitted billing instructions to our fiscal intermediaries.
    Example: Assume a hospital had an unweighted direct GME count of 
100 FTE residents for its cost reporting period ending June 30, 1996 
and the hospital, although it had 6 first year slots, began an internal 
medicine program on July 1, 1995 with 4 first year residents (who were 
included as part of the 100 FTE cap). On July 1, 1996, the program 
expands to 10 residents (6 first year and 4 second year residents.) On 
July 1, 1997, the program has 16 residents (6 first year residents, 6 
second year residents, and 4 third year residents). Since the minimum 
accredited length for internal medicine program listed is 3 years, the 
hospital's unweighted FTE cap can be adjusted based on 18 residents in 
the internal medicine program (6 first year residents * 3 years). In 
the hospital's cost reporting period ending June 30, 1996, the hospital 
had a total of 100 FTE residents including 4 in internal medicine. The 
hospital's cap can be adjusted up to 14 residents (18 internal medicine 
residents less 4 already included in the fiscal year ending June 30, 
1996 FTE count).
    Comment: Several commenters expressed concern about our definition 
of ``new medical residency training program'' for purposes of 
determining the FTE cap adjustment under Sec. 413.86(g). One commenter 
raised questions regarding the situation where the original sponsor of 
a residency program has been notified that it has lost its 
accreditation and a new sponsor assumes the training of all or most of 
the residents of an existing program. The commenter believed that the 
program under the new sponsor should be treated as ``new'' as well. 
Another commenter suggested we have interpreted ``new residency 
program'' to be simply a new site for a residency program that may have 
been in existence at other clinical sites in the past.
    Response: Under the existing Sec. 413.86(g)(7) (proposed to be 
redesignated as Sec. 413.86(g)(9)), we define ``new medical residency 
training program'' to be a program ``that receives initial 
accreditation by the appropriate accrediting body or begins training 
residents on or after January 1, 1995.'' The language ``begins training 
residents on or after January 1, 1995'' means that the program may have 
been accredited by the appropriate accrediting body prior to January 1, 
1995, but did not begin training in the program until on or after 
January 1, 1995. The language does not mean that it is the first time a 
particular hospital began training residents in a program on or after 
January 1, 1995, but the program was in existence at another hospital 
prior to January 1, 1995, as the commenter suggests.
    We believe there may be some confusion on the part of the 
commenters as to how to determine when a hospital may receive an 
adjustment to its FTE cap for a new residency program. The definition 
can be more easily understood if we explain the application in two 
steps. First, determine if the hospital's residency program qualifies 
to be ``new'' under Sec. 413.86(g)(9). Second, once the residency 
program is determined to meet the definition of ``new,'' apply the 
criteria under Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) to determine 
whether a hospital's new program qualifies for an adjustment to its FTE 
cap. A hospital's sponsorship of the program plays no role in 
determining whether a hospital qualifies to receive an adjustment under 
either Sec. 413.86(g)(6)(i) or Sec. 413.86(g)(6)(ii).
    If two hospitals ``merge'' separate residency programs, the single 
residency program resulting from the merger would not be considered 
``new'' for purposes of either hospital receiving an adjustment to its 
FTE cap. The programs have already been in existence and, presumably, 
the hospitals have been able to count the residents training in each 
individual program as part of the hospitals' respective FTE caps. If 
the hospital that is training the residents in the merged program would 
like to receive an adjustment to its FTE cap for the added residents it 
presumably now trains, that hospital may wish to affiliate for purposes 
of establishing an aggregate FTE cap.
    Comment: We received several comments on our clarification on how 
to account for situations when residents spend an entire program year 
(or years) at one hospital and the remaining year (or years) of the 
program at another hospital (or hospitals) during the first 3

[[Page 41520]]

years of the new residency program. We stated that, in this situation, 
the adjustment to the FTE cap is based on the number of years the 
residents are training at each hospital, not the minimum accredited 
length of the program. One commenter asked us to clarify the adjustment 
to the cap in situations where the residents rotate to multiple sites 
in a single program year during the first 3 years of a new residency 
program--that is, the residents rotate to other hospitals for partial 
years. Another commenter requested that we give examples of how to 
calculate the FTE cap adjustment in these situations.
    Response: In situations where residents spend an entire program 
year (or years) at one hospital and the remaining year (or years) of 
the program at another hospital during the first 3 years of the new 
residency program, each hospital that trains the residents receives an 
adjustment to its cap based on the product of the highest number of 
residents in any program years during the third year of the first 
program's existence and the number of years that the residents are 
training at each respective hospital. In situations where the residents 
spend partial years at different hospitals during the first 3 years of 
the new residency program, each hospital that trains the residents 
receives an adjustment to its cap based on product of the highest 
number of residents in any program year during the third year of the 
first program's existence and the minimum accredited length of the 
program.
    In response to the second commenter's request, the following are 
some examples as to how to calculate the adjustment to the FTE cap for 
a new residency program in situations where residents spend an entire 
program year (or years) at one hospital and the remaining year (or 
years) at another hospital during the first 3 years of the program. In 
addition, we are including an example where residents spend partial 
years at different hospitals during the first 3 years of the new 
residency program:

Example 1

    Assume Hospital A has 10 residents in a new internal medicine 
residency program. These 10 residents are trained at Hospital A for 2 
years of the program. In the third year of the program, 5 of the 10 
residents are rotated to Hospital B for training.
    Hospital A would receive an adjustment to its cap of 10 FTE (5 
residents * 2 years).
    Hospital B would receive an adjustment to its cap of 5 FTE (5 
residents * 1 year).

Example 2

    Assume Hospital A has the following residents training in its new 
internal medicine residency program:

Year 1-10 new program year (PGY \1\ 1) residents
Year 2--Hospital A rotates the 10 (now PGY 2) residents from Year 1 to 
Hospital B for training for 1 year and Hospital A also accepts 8 (PGY 
1) new residents.
Year 3--The 10 (now PGY 3) residents who rotated to Hospital B in Year 
2 return to Hospital A. Hospital A accepts 9 new (PGY 2) residents and 
also rotates the 8 (PGY 2) residents from Year 2 to Hospital B for 
training for 1 year. Thus, in the third year of the program, Hospital A 
has 10 (PGY 3) residents and 9 (PGY 1) residents and Hospital B has 8 
(PGY 2) residents.

    Hospital A would receive an FTE cap adjustment of 20 FTE (10 
residents * 2 years).
    Hospital B would receive an FTE cap adjustment of 8 FTE (8 
residents * 1 year).
    \1\ PGY = Program Year

Example 3

    Assume Hospital A has 10 residents in a new internal medicine 
program for one half of each of the three residency program years. 
Hospital B trains the 10 residents for the other half of each of the 
three residency years.
    Hospital A would receive an FTE cap adjustment of 15 FTEs (10 
residents * .5 FTE * 3 years).
    Hospital B would receive an FTE cap adjustment of 15 FTEs (10 
residents * .5 FTE * 3 years).
    Both Hospital A and Hospital B train a total of 5 FTE residents 
each residency program year (.5 of 10 residents each year) and this 
number is multiplied by the minimum accredited length of the residency 
program (3 years for internal medicine).
    Comment: One commenter suggested that only the hospital or 
hospitals that have received the accreditation for the new residency 
program should receive the adjustment to the FTE cap or caps.
    Response: While Medicare will provide GME payment to a hospital for 
training a resident only if that resident is participating in an 
accredited program, it is irrelevant whether the accreditation for the 
program belongs to the hospital currently training the residents or 
some other entity. Thus, we disagree with the commenter's suggestion to 
allow only hospitals that received the new residency program 
accreditation to receive a new residency program adjustment.
    Comment: Several commenters were concerned about our provision on 
the adjustment to the FTE cap during the first 3 years of a new 
residency program, as specified in proposed Sec. 413.86(g)(6)(i)(B). 
One commenter stated that it seemed inconsistent to refer to 
``adjusting the cap'' during these years when the cap is not actually 
adjusted until the third year. Another commenter suggested that, when 
looking at the number of residents training at the hospital during the 
first 3 years for purposes of deciding the cap adjustment in those 3 
years, the FTE count for cost reporting purposes should be based on the 
number of residents for which the hospital has oversight and the time 
worked in locations within or outside the hospital complex to which 
they rotate.
    Response: Section 413.86(g)(6)(i)(B) contains the provision that 
explains how a hospital is to adjust its FTE cap during the first 3 
years of establishing a new residency program--the hospital's cap may 
be adjusted during each of the first 3 years using the actual number of 
residents participating in the new program. The ``number of residents 
participating in the new program'' means the number of residents 
actually training at that hospital. It does not mean the number of 
residents within the ``oversight'' of the hospital, which could include 
the time residents spend at other types of facilities during their 
training; it only includes the time the residents spend training at the 
actual hospital site.
    When a hospital establishes a new residency program, the hospital's 
1996 FTE cap for the first 3 years is adjusted. Thus, the 1996 FTE cap 
is also receiving an adjustment during those 3 years.
    Comment: One commenter noted that while we made clarifications in 
our new residency program adjustment policy under Secs. 413.86(g)(6)(i) 
and 413.86(g)(6)(ii), we failed to make consistent changes to 
Sec. 413.86(g)(6)(iii).
    Response: We agree that we inadvertently omitted the third change. 
We are revising Sec. 413.86(g)(6)(iii) in this final rule.
    Comment: One commenter suggested that our meaning is unclear 
concerning our provision in proposed redesignated 
Sec. 413.86(g)(6)(i)(D) that allows a rural hospital that receives an 
adjustment to its FTE cap for establishing new residency programs to 
affiliate with other hospitals for the purpose of establishing an 
aggregate cap.

[[Page 41521]]

    Response: We are revising the language in this section to state 
more clearly that, in the case of hospitals in urban areas, we limit 
the use of affiliations to provide for aggregate caps only to urban 
hospitals that did not receive a new residency program adjustment for a 
program begun on or after August 6, 1997 (the date after enactment of 
the BBA). Urban hospitals that had no program or programs reported for 
their most recent cost reporting period ending on or before December 
31, 1996 and have received an FTE cap adjustment for a new program may 
not affiliate with other hospitals for purposes of establishing an 
aggregate FTE cap. However, rural hospitals that had no program or 
programs reported for the most recent cost reporting period ending on 
or before December 31, 1996 and have received an FTE cap adjustment for 
establishing a new program may affiliate with other hospitals for 
purposes of establishing an aggregate FTE cap.
    4. Adjustment to GME Caps for Certain Hospitals to Account for 
Residents in New Medical Residency Training Programs
    Section 4623 of the BBA amended section 1886(h) of the Act to 
provide for ``special rules'' in applying FTE caps for medical 
residency training programs established on or after January 1, 1995. In 
the August 29, 1997 and May 12, 1998 final rules (62 FR 46002 and 63 FR 
26327), we implemented special rules to account for residents in new 
medical residency training programs. We proposed to implement another 
special rule to permit an adjustment to the FTE cap for a hospital if 
the entire facility was under construction prior to August 5, 1997 (the 
date of enactment of the BBA) and if the hospital sponsored a new 
medical residency training program but the residents were temporarily 
trained at another hospital.
    Under current policies, if a new medical residency training program 
was established on or after January 1, 1995, a hospital may receive an 
adjustment to its FTE cap to account for residents in the new program. 
If the residents in the new program begin training in one hospital and 
are subsequently ``transferred'' to another hospital, the second 
hospital would not receive an adjustment to its FTE cap; if we made an 
adjustment for the second hospital, then two hospitals would receive an 
adjustment for the same resident.
    We believe, however, that an adjustment for the second hospital 
might be appropriate in certain limited circumstances. If the second 
hospital sponsored a new medical residency training program but the 
residents in the new program temporarily trained at the first hospital 
because the second hospital was still being built, then we believe it 
would be appropriate to permit an adjustment for the second hospital. 
Otherwise, the second hospital's FTE cap would be zero, and the 
hospital would not receive any GME or IME payments.
    We proposed to permit an adjustment under this policy only if the 
second hospital (the sponsor of the new program) began construction of 
its entire facility prior to the date of enactment of the BBA. Prior to 
August 5, 1997, a hospital would not have had knowledge of the 
provisions of the BBA and thus would not have known that a decision to 
temporarily train residents at another hospital might have resulted in 
the hospital being unable to receive GME and IME payments in the 
future. In contrast, a hospital that began construction of an entirely 
new facility after August 5, 1997, would have had notice of changes in 
the law prior to making a decision to temporarily train residents at 
another hospital.
    Thus, we proposed to add a new Sec. 413.86(g)(7) (existing 
Sec. 413.86(g)(7) would be redesignated as Sec. 413.86(g)(9)) to 
address application of the FTE caps with regard to a hospital that 
began construction of an entire facility prior to August 5, 1997, 
sponsored medical residency training programs, and temporarily trained 
those residents at another hospital(s) until the new facility was 
completed. For hospitals that meet these criteria, we proposed that the 
FTE caps will be determined in a manner similar to those hospitals that 
qualify for an adjustment to the FTE cap under Sec. 413.86(g)(6)(i). 
That is, the hospital's cap would equal the lesser of (a) the product 
of the highest number of residents in any program year during the third 
year of the first program's existence for all new residency training 
programs at either the newly constructed facility or the temporary 
training site but sponsored by the newly constructed hospital and the 
number of years in which residents are expected to complete the 
programs based on the minimum accredited length for each type of 
program; or (b) the number of accredited slots available for each year 
of the program. If the medical residency training programs sponsored by 
the newly constructed hospital have been in existence for 3 years or 
more by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap would be based on the 
number of residents training in the third year of the first of those 
programs begun at the temporary training site. If the medical residency 
training programs sponsored by the newly constructed hospital have been 
in existence for less than 3 years when the residents begin training at 
the newly constructed hospital, the hospital's cap would be based on 
the number of residents training at the newly constructed hospital in 
the third year of the first of those programs (including the years at 
the temporary training site). This provision would be effective for 
portions of cost reporting periods occurring on or after October 1, 
1999.
    Comment: With regard to our proposed change concerning our 
adjustment to the GME caps for newly constructed hospitals, one 
commenter suggested that while Secs. 413.86(g)(7)(i)(A) and (B) appear 
to be clear and straightforward, Secs. 413.86(g)(7)(ii) and (iii) are 
unclear and add confusion to the calculation of the newly constructed 
hospital's FTE cap. The commenter suggested that Secs. 413.86(g)(7)(ii) 
and (iii) be removed.
    Another commenter suggested that a newly constructed hospital under 
Sec. 413.86(g)(7) should be able to affiliate with other hospitals for 
purposes of establishing an aggregate FTE cap.
    Response: The purpose of both Secs. 413.86(g)(7)(i)(B) and 
413.86(g)(7)(ii)(B) is to clarify how to establish the newly 
constructed hospital's FTE cap in all possible situations. The 
regulation at ' 413.86(g)(7)(i)(B) addresses the calculation of the 
newly constructed hospital's FTE cap if the new program has been in 
existence for 3 or more years at the temporary training site by the 
time the residents begin training at the newly constructed hospital. 
The regulation at Sec. 413.86(g)(7)(ii)(B) addresses the calculation of 
the cap if the new program has been in existence for 3 or fewer years 
at the temporary training site by the time the residents begin training 
at the newly constructed hospital.
    We agree with the commenter's suggestion to allow a newly 
constructed hospital under Sec. 413.86(g)(7) to affiliate for purposes 
of establishing an aggregate FTE cap. We currently allow teaching 
hospitals that receive a new residency program adjustment under 
Sec. 413.86(g)(6)(ii) to affiliate with other hospitals if the teaching 
hospitals had established new programs prior to the enactment of the 
BBA. Teaching hospitals could not have known what policies would be 
enacted in the BBA. Therefore, they would not have had the opportunity 
to establish programs for purposes of affiliation in order to 
circumvent the FTE cap established by the BBA. The commenter notes that 
we used the same rationale when espousing

[[Page 41522]]

the policy on newly constructed hospitals in the proposed rule--we are 
allowing hospitals that began construction prior to August 5, 1997 to 
establish an FTE cap because the hospitals would not have had knowledge 
of the provisions of the BBA. For the same reason, we agree that the 
newly constructed hospital should be able to affiliate for purposes of 
establishing an aggregate cap because the hospital under construction 
would not have known the BBA restrictions. Therefore, we are revising 
the text of Sec. 413.86(g)(7) to include this new policy.
    In addition, consistent with this reasoning, we are allowing newly 
constructed hospitals under Sec. 413.86(g)(7) to calculate their FTE 
cap using the same methodology as articulated in Sec. 413.86(g)(6)(ii), 
the provision for teaching hospitals that establish new residency 
programs on or after January 1, 1995 and on or before August 5, 1997. 
We allow those teaching hospitals to receive a new residency program 
adjustment during that ``window'' because these hospitals could not 
have known what requirements would be enacted in the BBA if the 
teaching hospitals established new programs during that time. As stated 
above, we used the same rationale for allowing newly constructed 
hospitals to establish a cap--these hospitals could not have known 
about the BBA when the hospitals established residency programs. 
Therefore, we are adding language to Sec. 413.86(g)(7) as follows: `` * 
* * a hospital that began construction of its facility on or before 
August 5, 1997, sponsored new medical residency training programs that 
were established on or after January 1, 1995 and on or before August 5, 
1997, and either received initial accreditation by the appropriate 
accrediting body or temporarily trained those residents at another 
hospital(s) until the facility was completed, may receive an adjustment 
to its FTE cap.'' We note that we are clarifying the phrase ``prior to 
August 5, 1997'' to mean ``on or before August 5, 1997'' to make it 
consistent with this policy. We also are making conforming changes to 
Secs. 413.86(g)(7)(i)(A) and (B) and 413.86(g)(7)(ii)(B) to allow the 
cap to be adjusted for each new program established within the 
``window.'' Under the previous language, the adjustment was tied to the 
third year of the first new program. Under the new language, the 
adjustment is tied to each new program's establishment during the 
``window.'' Therefore, for example, in a situation where a newly 
constructed hospital establishes a new residency program and the first 
new program began on July 1, 1995, and a second program began on July 
1, 1997, the adjustment for the second program under the previous 
language would have been tied to the third year of the first new 
program (1997). However, under the new language, the adjustment for the 
second program is not established until the third year (1999) of the 
second program's existence.
    Comment: Another commenter suggested that we include the word 
``new'' when referring to medical residency training programs in 
Sec. 413.86(g)(7)(ii) and (iii).
    Response: We are making the revision as the commenter suggests. 
This revision will clarify that the provisions allowing an adjustment 
to the FTE cap for a facility constructed on or before August 5, 1997 
applies to new residency programs.
5. Temporary Adjustments to FTE Cap to Reflect Residents Affected by 
Hospital Closure
    In the May 12, 1998 prospective payment system final rule (63 FR 
26330), we indicated that we would allow a temporary adjustment to a 
hospital's resident cap under limited circumstances and if certain 
criteria are met when a hospital assumes the training of additional 
residents because of another hospital's closure. The temporary 
adjustment to the FTE cap is available to the hospital only for the 
period of time necessary to train those displaced residents. Once the 
residents leave the hospital or complete their programs, the hospital 
cap would be based solely on the statutory base year (with any 
applicable adjustments for new medical residency training programs or 
affiliated group arrangements).
    Under current policies, we permit a temporary adjustment to the FTE 
cap for a hospital only if it assumed additional medical residents from 
a hospital that closed in the July 1996-June 1997 residency training 
year. In the May 7, 1999 proposed rule, we proposed to allow 
adjustments to address hospital closures after this period. Thus, we 
would allow an adjustment for a hospital if it trains additional 
residents from a hospital that closes at any time, on or after July 1, 
1996. This adjustment is intended to account for residents who may have 
partially completed a medical residency training program and would be 
unable to complete their training without a residency position at 
another hospital.
    We proposed this change because hospitals have indicated a 
reluctance to accept additional residents from a closed hospital 
without a temporary adjustment to their caps. We proposed to add a new 
Sec. 413.86(g)(8) to allow a temporary adjustment to a hospital's FTE 
cap to reflect residents added because of a hospital's closure at any 
time on or after July 1, 1996. We would allow an adjustment to a 
hospital's FTE cap if the hospital meets the following criteria: (a) 
the hospital is training additional residents from a hospital that 
closed on or after July 1, 1996; and (b) the hospital that is training 
the additional residents from the closed hospital submits a request to 
its fiscal intermediary at least 60 days before the beginning of 
training of the residents for a temporary adjustment to its FTE cap. 
The hospital must also document that it is eligible for this temporary 
adjustment to its FTE cap by identifying the residents who have come 
from the closed hospital and have caused the hospital to exceed its 
cap, and specify the length of time that the adjustment is needed. 
After the displaced residents leave the hospital's training program or 
complete their residency program, the hospital's cap would be based 
solely on the statutory base year (with any applicable adjustments for 
new medical residency training programs or affiliated group 
arrangements).
    Comment: Many commenters were generally pleased with our proposed 
policy concerning the temporary adjustment to FTE caps to reflect 
residents affected by hospital closures specified under proposed 
Sec. 413.86(g)(8). However, various commenters asked us to define what 
we meant by a ``closed'' hospital.
    Response: Section 413.86(g)(8) provides that a hospital may receive 
a temporary adjustment to its FTE cap to reflect residents added 
because of another hospital's closure which occurs on or after July 1, 
1996. By hospital ``closure,'' we mean the hospital terminates its 
Medicare participation agreement with HCFA under the provisions 
specified in Sec. 489.52. To ``close,'' a hospital would have to comply 
with the requirements as specified in this section to terminate its 
agreement. We are making conforming changes in Sec. 413.86(g)(8) on the 
temporary adjustment to reference Sec. 489.52.
    Comment: Many of the commenters suggested that we include 
bankruptcy of a hospital and lost accreditation of a program, both acts 
that displace residents, as applicable to the temporary adjustment 
policy.
    Response: We do not agree with the commenters. We do not believe it 
is appropriate to expand our policy to cover any acts other than 
hospital

[[Page 41523]]

closure because, unless the hospital actually terminates its Medicare 
agreement, it will retain its statutory FTE cap. For example, in the 
case where a hospital files for bankruptcy, it continues to retain its 
FTE cap. While the bankruptcy action may displace the hospital's 
residents, the hospital continues to be subject to the statutorily 
mandated cap on FTEs. Therefore, it can still decide to train residents 
at the hospital or affiliate with other hospitals for purposes of 
establishing an aggregate cap. The hospital may, in fact, use its 
ability to affiliate in order to place its residents at a new hospital.
    Comment: One commenter explained that there were hospitals that had 
plans to close their doors earlier this year and deliberately remained 
open for various reasons until the start of the July 1, 1999 residency 
year. This commenter suggested that because hospitals are training 
these displaced residents beginning on July 1, 1999, we should change 
the effective date of the temporary adjustment provision to coincide 
with the July 1, 1999 date. Similarly, another commenter was concerned 
about affiliated groups, suggesting that because final regulations on 
affiliated groups were not published until May 12, 1998, some hospitals 
that would have liked to have participated in affiliations prior to the 
FY 1998 were not able to because there were no implementing regulations 
before the May 12, 1998 date.
    Response: The effective date of the temporary adjustment policy, 
like the effective date for all changes in this final rule, is October 
1, 1999.
    Similarly, hospitals that choose to affiliate cannot do so before 
the effective date of the May 12, 1998 regulation.
    Comment: Under the temporary adjustment provision, 
Sec. 413.86(g)(8)(ii) requires a hospital to submit a request for the 
temporary adjustment to its fiscal intermediary at least 60 days before 
the hospital begins to train the residents. One commenter suggested 
that it was not appropriate for the fiscal intermediary to be in the 
position of granting requests for adjustments. In addition, several 
commenters suggested that submitting a request at least 60 days before 
the hospital begins to train the residents is ``problematic,'' since it 
is not always easy to estimate exactly when a hospital will close and 
other hospitals can then continue training the residents.
    Response: The fiscal intermediaries have been delegated the 
authority to calculate Medicare program payments for hospitals, 
including GME payments. HCFA is not in a position to be able to respond 
to every request for a temporary FTE cap adjustment. As long as 
hospitals that request the adjustments meet each condition in our 
regulations, the hospitals will receive the adjustments.
    We agree with the commenters who suggested that requiring a 
hospital to submit a request for a temporary adjustment to an 
intermediary at least 60 days before the hospital begins to train the 
residents might be problematic for hospitals. Therefore, we are 
revising our regulations to require a hospital to submit a request for 
a temporary adjustment to an intermediary no later than 60 days after 
the hospital first begins training the displaced residents.
    Comment: One commenter requested that we clarify the provision at ' 
413.86(g)(8)(ii) that hospitals must identify residents that come from 
closed programs in order to receive a temporary adjustment to their FTE 
caps.
    Response: In order to receive a temporary adjustment to their FTE 
caps, hospitals must provide the social security numbers of the 
residents coming from the closed hospital and documentation that proves 
that the residents were training at the hospital that closed.
6. Determining the Weighted Number of FTE Residents
    Section 413.86(g)(1)(ii) states that for residency programs in 
osteopathy, dentistry, and podiatry, the minimum requirement for 
certification in a specialty or subspecialty is the minimum number of 
years of formal training necessary to satisfy the requirements of the 
appropriate approving body listed in Sec. 415.200(a). This reference is 
incorrect. The correct section in which approving bodies for residency 
programs are listed is Sec. 415.152. We proposed to make this 
correction.
    Section 413.86(g)(1)(i) specifies that the initial residency period 
is the minimum number of years of formal training necessary to satisfy 
board eligibility in the particular specialty for which the resident is 
training, as specified in the 1985-1986 Directory of Residency Training 
Programs. Section 1886(h)(5)(G)(iii) of the Act allows the Secretary to 
increase or decrease the initial residency period if the minimum number 
of years of formal training specified in a later edition of the 
directory is different from the period specified in the 1985-1986 
Directory of Residency Training Programs. We proposed to revise the 
regulations text to state that the initial residency period is 
determined using the most recently published edition of the Graduate 
Medical Education Directory, not the 1985-1986 Directory.
    Comment: At Sec. 413.86(g)(1), we proposed to update the provisions 
concerning what source to use when calculating the initial residency 
period for residencies. One commenter stated that one of the provisions 
that we updated, changing ``1985-1986 Directory of Residency Training'' 
to ``the most recently published edition of the Graduate Medical 
Education Directory,'' applies only when calculating the initial 
residency periods for allopathic residencies. The commenter suggests 
that initial residency periods for all residencies be published in the 
Federal Register. The commenter further suggested that, for determining 
the updates of initial residency periods for dental residencies, the 
most recent accreditation standards of the Commission on Dental 
Accreditation for advanced dental programs be used. Another commenter 
asked whether the most recently published edition of the Graduate 
Medical Education Directory or the initial residency periods is 
published in the Federal Register should be the guiding source when 
calculating the initial residency periods for residencies in the case 
where there is a discrepancy between the two.
    Response: Generally, proposed redesignated Sec. 413.86(g)(1)(i) 
defines the initial residency period as ``the minimum number of years 
of formal training necessary to satisfy the requirements for initial 
board eligibility in the particular specialty for which the resident is 
training, as specified in the most recently published edition of the 
Graduate Medical Education Directory.'' Proposed Sec. 413.86(g)(1)(ii) 
provided that for residency programs in osteopathy, dentistry, and 
podiatry, ``the minimum number of years of formal training necessary to 
satisfy the requirements of the appropriate approving body listed in 
Sec. 412.152 of this chapter.'' Section 412.152 lists all of the 
accreditation organizations for allopathy, osteopathy, podiatry, and 
dentistry, including the Commission on Dental Accreditation of the 
American Dental Association. In other words, while the Graduate Medical 
Education Directory only applies to allopathic residencies, as the 
first commenter suggests, the organization that the commenter 
encourages us to use as the accrediting organization for purposes of 
determining the initial residency period for dental residencies--the 
Commission on Dental Accreditation of the American Dental Association--
is already used to determine the initial residency periods for dental 
residencies.

[[Page 41524]]

    The first commenter also suggests that we publish the initial 
residency periods in the Federal Register. While we have already done 
so in the August 30, 1996 Federal Register (61 FR 46208), we plan to 
update the list of initial residency periods in upcoming regulations. 
The second commenter asked for guidance in the case where the initial 
residency periods listed in the August 30, 1996 (and in future 
regulations) differ from the information listed in the most recent 
edition of the Graduate Medical Directory. The information that we used 
to publish the initial residency periods in the August 30, 1996 Federal 
Register is based on the most recent edition of the Graduate Medical 
Directory. The Graduate Medical Directory is the most current and 
updated source of information on allopathic residencies. We agree that 
in some cases our latest listing in the Federal Register may not 
reflect the most recent update of the applicable directory. Thus, in 
the case where there is a discrepancy in the length of an initial 
residency period listed in what we publish in the Federal Register and 
what is published in the most recent edition of the Graduate Medical 
Education Directory (or other applicable publications for the other 
specialty areas), the Directory should be the guiding source.
7. Clarification of a Statement in the Preamble of the May 12, 1998 
Final Rule Relating to Affiliated Groups
    In the May 12, 1998 final rule (63 FR 26341), in the third column 
of page 26341, in the sentence prior to section ``O. Payment to Managed 
Care Plans for Graduate Medical Education,'' we stated, ``If the 
combined FTE counts for the individual hospitals that are members of 
the same affiliated group do not exceed the aggregate cap, we will pay 
each hospital based on its FTE cap as adjusted per agreements.'' The 
phrase ``do not exceed'' should have read ``exceed.'' Thus, the 
sentence should have read, ``If the combined FTE counts for individual 
hospitals that are members of the same affiliated group exceed the 
aggregate cap, we will pay each hospital based on its FTE cap as 
adjusted per agreements.'' We regret any confusion that resulted from 
this misstatement.
    Comment: Several commenters requested that we clarify that a 
nonteaching hospital that participates in an affiliated group agreement 
as specified under Sec. 413.86(g)(4) is not precluded from later 
seeking an adjustment to its FTE cap for establishing a new residency 
program.
    Response: We agree with the commenters' request. Consistent with 
our regulations at Sec. 413.86(g)(6)(i), a nonteaching hospital that 
participated (or participates) in an affiliated group for purposes of 
establishing an aggregate FTE cap does not forego its opportunities to 
later establish new residency programs and accordingly receive an 
adjustment to its individual FTE cap. The requirements under 
Sec. 413.86(g)(6)(i) specify that a hospital may receive an adjustment 
to its FTE cap for establishing a new residency program if the hospital 
had no allopathic or osteopathic residents in its most recent cost 
reporting period ending on or before December 31, 1996. In other words, 
the hospital must have a zero FTE cap based on its number of residents 
in its most recent cost reporting period ending on or before December 
31, 1996 in order to qualify to receive an adjustment under this 
provision. The fact that a nonteaching hospital has affiliated with 
other hospitals does not change the fact that in determining the 
aggregate cap for the affiliated group the nonteaching hospital still 
has an FTE cap of zero. Accordingly, consistent with our regulations, a 
nonteaching hospital that affiliates is not precluded from later 
seeking a new residency program adjustment.
    Comment: The BBA specifically required the Secretary to give 
special consideration to facilities that meet the needs of underserved 
rural areas. With this mandate in mind, several commenters requested 
that we consider recognizing new family practice programs that are 
classified as rural by the Residency Review Committee for the purpose 
of establishing a cap and receiving GME payment under Medicare.
    Response: We will consider the suggestion to apply our rules for 
rural hospitals to all hospitals with the new family practice programs 
for purposes of GME in developing future regulations.
    Comment: We received several other comments suggesting GME policy 
changes concerning rural hospitals. One commenter suggested that we 
allow rural hospitals that received a new residency program adjustment 
under Sec. 413.86(g)(6)(ii) to affiliate with other hospitals for 
purposes of establishing an aggregate FTE cap. Another commenter 
suggested that we allow rural hospitals a new residency program 
adjustment for expansions of already established residency programs at 
the rural hospitals.
    Response: Any hospital, rural or urban, that receives a new 
residency program adjustment under Sec. 413.86(g)(6)(ii) is permitted 
to affiliate for purposes of establishing an aggregate cap. As for 
allowing an FTE cap adjustment for expansions of already established 
residency programs at rural hospitals, we will take this policy 
suggestion into consideration in future regulations.
    Comment: We received many comments on various other GME issues. One 
commenter asked what level of documentation is needed to demonstrate 
for purposes of our nonhospital payment policy that a particular 
hospital and nonhospital site are a single legal entity. Another 
commenter asked for a cost report change to account for situations when 
a hospital could have one FTE cap for one-half of the year and a 
different cap for the second half of the year. One commenter suggested 
that, in a situation when two hospitals affiliate for purposes of 
establishing an aggregate cap, the hospital that is the sponsor of the 
residency program should be given the ability to better control the 
limited number of training slots as established under the aggregate 
cap. Another commenter suggested that we consider allowing a new 
residency program adjustment for family practice programs beginning on 
or after July 1, 1994. Finally, one commenter made two suggestions: (1) 
that we increase a particular hospital's FTE count because when the cap 
was set, some of the hospital's residents were rotated out to other 
hospitals to meet a Residency Review Committee (RRC) program 
requirement, and are now brought back into the hospital after the BBA 
because the hospital can now meet the RRC requirement, and (2) that we 
allow payment to a hospital that had established an ambulatory care 
rotation prior to the BBA.
    Response: We will consider all of these suggestions made by the 
commenters in future regulations.
    Comment: One commenter suggested that we discuss what happens to 
hospitals' FTE caps in situations where there is a merger of two or 
more hospitals.
    Response: We discussed the merger of hospitals and FTE caps in the 
May 12, 1998 Federal Register (63 FR 26329). Where two or more 
hospitals merge after each hospital's cost reporting period ending 
during FY 1996, the merged hospital's FTE cap will be an aggregation of 
the FTE cap for each hospital participating in the merger.

V. Changes to the Prospective Payment System for Capital-Related 
Costs: Special Exceptions Process

    Section 1886(g) of the Act requires the Secretary to pay for 
hospital capital-related costs ``in accordance with a

[[Page 41525]]

prospective payment system established by the Secretary.'' Under the 
statute, the Secretary has broad authority in establishing and 
implementing the capital prospective payment system. We initially 
implemented the capital prospective payment system in the August 30, 
1991 final rule (56 FR 43409), in which we established a 10-year 
transition period to change the payment methodology for Medicare 
inpatient capital-related costs from a reasonable cost-based 
methodology to a prospective methodology (based fully on the Federal 
rate).
    Generally, during the transition period, inpatient capital-related 
costs are paid on a per discharge basis, and the amount of payment 
depends on the relationship between the hospital-specific rate and the 
Federal rate during the hospital's base year. A hospital with a base 
year hospital-specific rate lower than the Federal rate is paid under 
the fully prospective payment methodology during the transition period. 
This method is based on a dynamic blend percentage of the hospital's 
hospital-specific rate and the applicable Federal rate for each year 
during the transition period. A hospital with a base period hospital-
specific rate greater than the Federal rate is paid under the hold 
harmless payment methodology during the transition period. A hospital 
paid under the hold harmless payment methodology receives the higher of 
(1) a blended payment of 85 percent of reasonable cost for old capital 
plus an amount for new capital based on a portion of the Federal rate 
or (2) a payment based on 100 percent of the adjusted Federal rate. The 
amount recognized as old capital is generally limited to the allowable 
Medicare capital-related costs that were in use for patient care as of 
December 31, 1990. Under limited circumstances, capital-related costs 
for assets obligated as of December 31, 1990, but put in use for 
patient care after December 31, 1990, also may be recognized as old 
capital if certain conditions are met. These costs are known as 
obligated capital costs. New capital costs are generally defined as 
allowable Medicare capital-related costs for assets put in use for 
patient care after December 31, 1990. Beginning in FY 2001, at the 
conclusion of the transition period for the capital prospective payment 
system, capital payments will be based solely on the Federal rate for 
the vast majority of hospitals.
    In the August 30, 1991 final rule, we also established a capital 
exceptions policy, which provides for exceptions payments during the 
transition period (' 412.348). Section 412.348 provides that, during 
the transition period, a hospital may receive additional payment under 
an exceptions process when its regular payments are less than a minimum 
percentage, established by class of hospital, of the hospital's 
reasonable capital-related costs. The amount of the exceptions payment 
is the difference between the hospital's minimum payment level and the 
payments the hospital would receive under the capital prospective 
payment system in the absence of an exceptions payment. The comparison 
is made on a cumulative basis for all cost reporting periods during 
which the hospital is subject to the capital prospective payment 
transition rules. The minimum payment percentages for regular capital 
exceptions payments by class of hospitals for FY 2000 are:
     For sole community hospitals, 90 percent;
     For urban hospitals with at least 100 beds that have a 
disproportionate share patient percentage of at least 20.2 percent or 
that received more than 30 percent of their net inpatient care revenues 
from State or local governments for indigent care, 80 percent;
     For all other hospitals, 70 percent of the hospital's 
reasonable inpatient capital-related costs.
    We indicated that we would carefully monitor the impact of the 
capital prospective payment system in order to determine whether some 
type of permanent exceptions process was necessary and the 
circumstances under which additional payments would be made.
    Under the special exceptions provision at Sec. 412.348(g), an 
additional payment may be made for up to 10 years beyond the end of the 
capital prospective payment system transition period for eligible 
hospitals that meet (1) a project need requirement as described at 
Sec. 412.348(g)(2), which, in the case of certain urban hospitals, 
includes an excess capacity test; and (2) a project size requirement as 
described at Sec. 412.348(g)(5). Eligible hospitals include sole 
community hospitals, urban hospitals with at least 100 beds that have a 
disproportionate share percentage of at least 20.2 percent, and 
hospitals with a combined Medicare and Medicaid inpatient utilization 
of at least 70 percent. In the September 1, 1994 final rule, we 
described the special exceptions process as `` * * * narrowly defined, 
focusing on a small group of hospitals who found themselves in a 
disadvantaged position. The target hospitals were those who had an 
immediate and imperative need to begin major renovations or 
replacements just after the beginning of the capital prospective 
payment system. These hospitals would not be eligible for protection 
under the old capital and obligated capital provisions, and would not 
have been allowed any time to accrue excess capital prospective 
payments to fund these projects'' (59 FR 45385).
    For hospitals in States with certificate of need (CON) 
requirements, the project need requirement is satisfied by obtaining a 
CON approval. For other hospitals, the project need requirement is 
satisfied by meeting an age of assets test. The project size 
requirement is satisfied if the hospital completes the qualifying 
project between the period beginning on or after its first cost 
reporting period beginning on or after October 1, 1991, and the end of 
its last cost reporting period beginning before October 1, 2001, and 
the project costs are (1) at least $200 million or (2) at least 100 
percent of the hospital's operating cost during the first 12-month cost 
reporting period beginning on or after October 1, 1991. The minimum 
payment level under special exceptions for all qualifying hospitals is 
70 percent of allowable capital-related costs. Special exception 
payments are offset against positive Medicare capital and operating 
margins.
    When we established the special exceptions process, we selected the 
hospital's cost reporting period beginning before October 1, 2001 as 
the project completion date in order to limit cost-based exceptions 
payments to a period of not more than 10 years beyond the end of the 
transition to the fully Federal capital prospective payment system. 
Because hospitals are eligible to receive special exceptions payments 
for up to 10 years from the year in which they complete their project 
(but for not more than 10 years after September 30, 2001, the end of 
the capital prospective payment transition), generally, if a project is 
completed by September 30, 2001, exceptions payments could continue up 
to September 30, 2011. In addition, we believe that for projects 
completed after the September 30, 2001 deadline, hospitals would have 
had the opportunity to reserve their prior years' capital prospective 
payment system payments for financing projects.
    In the July 31, 1998 final rule (63 FR 40999), we stated that a few 
hospitals had expressed concern with the required completion date of 
October 1, 2001, and other qualifying criteria for the special 
exceptions payment. Therefore, we solicited certain information from 
hospitals on major capital construction projects that might qualify for 
the capital special exceptions

[[Page 41526]]

payments so we could determine if any changes in the special exceptions 
criteria or process were necessary.
    In the May 7, 1999 proposed rule (64 FR 24736), we reported that 
four hospitals had responded timely to our solicitation with 
information on their major capital construction projects. The hospitals 
submitted information about their location, the cost of the project, 
the date that the CON approval was received, the start date of the 
project, and the anticipated completion date.
    The hospitals suggested changing a number of the requirements of 
the special exception provision, including (1) changing the project 
completion date requirement; (2) revising the project size requirement; 
(3) lowering the DSH qualifying percentage from 20.2 percent to 15 
percent; (4) changing the minimum payment level from 70 percent to 85 
percent; and (5) revising the qualifying criteria so that only capital 
payment margins are considered instead of both capital payment margins 
and operating margins (as is now the case). In addition, hospitals 
suggested capping special exceptions payments that result from changes 
to the special exceptions process at $40 million annually.
    When we issued the May 7, 1999 proposed rule, we had no specific 
proposal to revise the special exceptions process. However, we invited 
comments from hospitals and other interested parties on the suggestions 
and recommendations discussed above. We noted that, since the capital 
special exceptions process is budget neutral, any liberalization of the 
policy would require a commensurate reduction in the capital rate paid 
to all hospitals. That is, even after the end of the capital 
prospective payment system transition, we will continue to make an 
adjustment to the capital Federal rate in a budget neutral manner to 
pay for exceptions, as long as an exceptions policy is in force. 
Currently, the limited special exceptions policy will allow for 
exceptions payments through September 30, 2011. We also noted that, 
based on the comments we received, we may make changes to the special 
exceptions criteria in the final regulation or propose changes in the 
FY 2001 proposed rule.
    In the May 7, 1999 proposed rule, we indicated that we had little 
information about the impact of any of the suggested changes discussed 
in the proposed rule, since no hospitals are currently being paid under 
the special exceptions process. Until FY 2001, the special exceptions 
provision currently pays either the same as the regular exceptions 
process or less for high DSH and sole community hospitals. We indicated 
that we would attempt to obtain information on projects that might 
qualify for special exceptions payments through our fiscal 
intermediaries during the comment period. However, we noted that we 
were reluctant to impose a burden on the fiscal intermediaries at this 
time, since it could interfere with our major efforts to make the 
Medicare computer systems Y2K compliant prior to January 1, 2000.
    We received six comments on potential changes to the special 
exceptions process. Three were in favor of changing the process in 
various ways, and two were opposed to making any changes. In addition, 
MedPAC opposed expanding the process until we have a better estimate of 
the impact of any expansion.
    Comments: Three commenters that supported changing the special 
exception process made various suggestions as to what those changes 
should be.
    Two of the commenters believe that the way HCFA formulated the 
special exceptions process is inconsistent with Congressional intent 
because the Conference Report that accompanied the Omnibus Budget 
Reconciliation Act (OBRA) of 1993 (Public Law 103-66) indicated the 
conferees' expectation that HCFA would assess information and make 
appropriate changes to ``. . . address the problems of hospitals 
subject to lengthy CON review processes or subject to other 
circumstances which are not fully addressed in the current rules'' 
(H.R. Rep. No. 103-213, at 744 (1993)). The commenters noted that 
Congress used a separate sentence to state a belief that the Secretary 
should ``. . . evaluate whether current policies provide adequate 
protection to sole community hospitals and hospitals that serve a 
disproportionate share of low income patients.'' Thus, the commenters 
believe that Congress did not intend to limit the special exceptions 
process to any particular type of hospital and that Congress intended 
HCFA to deal separately with the problems of high DSH hospitals and to 
make the special exceptions process available to all hospitals.
    One commenter stated that eligibility for special exceptions 
payments should be based solely on when a hospital had to begin a 
capital project and the size of the project, rather than ``noncapital-
related'' tests such as the operating offset and the DSH requirement. 
The commenter argued that, if the purpose of the special exceptions 
process was to help hospitals that could not benefit from old and 
obligated capital provisions, then HCFA did not act consistently with 
that premise when it adopted criteria that limited qualifying 
hospitals. The commenter believes that HCFA may have adopted some 
criteria, such as the requirement that urban hospitals must have a DSH 
percentage of at least 20.2 and the offset of positive operating 
margins, to limit the cost of the special exceptions program. If that 
is the case, then the commenter suggested that a cap on total payments 
made under the special exceptions authority would accomplish the same 
result more fairly.
    One commenter requested that the DSH percentage requirement for 
urban hospitals (20.2 percent) be lowered. The commenter believes that 
the current requirement is not a natural result of the rationale we 
used for limiting the special exceptions process, and that, if a 
hospital builds a project during the transition, it is disadvantaged 
relative to other hospitals regardless of its DSH percentage. This 
commenter suggested that, if we do decide to retain the DSH 
requirement, the requirement be lowered to 15 percent, and that we 
adopt a sliding scale payment floor of between 15 and 20.2 DSH 
percentages in which the minimum payment level at the 15 DSH percentage 
would be 70 percent and the maximum payment level at 20.2 DSH 
percentage would be 85 percent.
    One commenter supported lowering the project size requirement from 
100 percent of the hospital's FY 1992 operating costs to 45 percent of 
those costs.
    All three commenters who advocated changes to the special 
exceptions process supported changing the offset provision so that 
eligibility for special exceptions does not take into account positive 
operating margins. They argued that the operating and capital payment 
methodologies were separately developed and that payments are 
separately calculated. If the offset against operating payments is not 
eliminated, they believe it should be modified to include outpatient 
margins as well. One of these commenters noted that a similar offset 
was not required for ``old capital.''
    Two of the commenters recommended that, if a hospital had received 
CON approval by September 1, 1995 and expended $750,000 or 10 percent 
of total project cost, then the project completion date should be 
extended to December 31, 2003. They believe that a hospital could have 
started planning a major capital project early in the transition, but, 
because of events beyond the hospital's control, the completion date 
might extend beyond the end of the transition.

[[Page 41527]]

    Two commenters suggested that we should establish a cap on special 
exceptions payments, and indicated that HCFA has the authority to set 
and implement such a cap because of the authority given the Secretary 
under section 1886(g) of the Act to implement the capital prospective 
payment system. The legislation provided for an exceptions process, as 
the Secretary determined to be appropriate. The commenter asserted that 
the ``regular'' capital exceptions process already includes a ``cap'' 
of 10 percent. The commenters recommended a cap of 1 percent of total 
capital prospective payments in a given fiscal year, and that, if 
aggregate eligibility for payments exceeds the cap, the payments would 
be reduced on a pro rata basis.
    The commenters also recommended that any exception payments a 
hospital qualifies for but does not receive because of the cap should 
be rolled over into future years so that those payments could be made 
in later years. Without a rollover provision, the commenters advocate 
setting the cap at 1.5 percent. They believe that with the expiration 
of hold harmless provisions and the exceptions floors in FY 2001, the 
suggested cap would result in lower budget neutrality adjustments than 
is currently the case.
    Using 1992 through 1996 cost report data, one of the commenters 
prepared an estimate of the number of hospitals it believes will be 
eligible for special exception payments if the criteria were changed as 
suggested by the commenter. Based on the commenter's estimate, 
aggregate eligibility for special exceptions payments would exceed the 
recommended 1 percent cap for approximately 5 years (FY 2002 through FY 
2006). The commenter also suggested that hospitals that believe they 
are eligible for special exceptions be required to submit an 
application to their fiscal intermediary in January of each year, and 
to update their application by June of each year, so that an estimate 
could be prepared of the number of hospitals that will qualify for 
special exceptions. The data could also be used to estimate the amount 
of reductions that will be required to stay within the cap. The 
commenter suggests that hospitals that did not submit the information 
could be precluded from receiving special exceptions payments in the 
following fiscal year.
    All three commenters who advocated changes to the special 
exceptions process supported raising the 70 percent minimum payment 
level to 85 percent. One commenter objected to the 70 percent minimum 
payment level, arguing that it offers little improvement over the 
Federal rate and guarantees that hospitals will take a 30-percent loss 
on their actual capital costs for each Medicare discharge. This 
commenter believes that special exceptions should be paid at the rate 
of 85 percent, which is what hospitals eligible for old capital hold 
harmless payment received.
    In addition, two of the commenters supported finalizing changes to 
the special exceptions process in the FY 2000 final rule so that 
affected hospitals can plan more effectively.
    Two national hospital associations were opposed to changing the 
special exceptions policy. They believe that the special exceptions 
process was intended to be limited in scope, and although some 
hospitals may be disadvantaged by some aspects of the fully Federal 
capital prospective payment system, they have had a number of years to 
plan for it. All other hospitals will be receiving payments based on 
the Federal rate beginning in FY 2002 and the commenters do not believe 
that the majority of hospitals should have their payments further 
reduced to expand the special exceptions process to a few hospitals. 
One of the commenters noted that Congress considered a similar proposal 
to expand the special exceptions process as part of the BBA 
deliberations and, ultimately, did not include the proposal. The 
commenter believes this failure to act was an indication of 
Congressional intent, and that HCFA has no authority to disregard it 
and adopt these changes by regulation. The other commenter stated that 
since HCFA has no reliable estimate of the number of hospitals that 
would be affected by changes to the special exceptions process, it 
would be capricious to make a change absent an impact analysis.
    Response: When we proposed the special exceptions process in 1994 
(May 27, 1994, Federal Register (59 FR 27746)), we stated ``* * * we 
are therefore proposing at Sec. 412.348 to provide special protection 
for some hospitals that are undertaking major projects to renovate or 
replace aging plant during the transition period. This special 
protection, which will provide a 70 percent minimum payment level for 
up to 10 years beyond the transition period, will be available only to 
* * * [s]ole community hospitals * * *; [u]rban hospitals with at least 
100 beds that either have a DSH percentage of 20.2 percent or receive 
at least 30 percent of their revenue from State or local funds for 
indigent care * * *; [h]ospitals with a combined inpatient Medicare and 
Medicaid utilization of at least 70 percent. * * *'' We believe this 
strict set of qualifying criteria makes it clear that we intended to 
make the special exception process limited in scope.
    Since publication of the proposed rule, we have attempted to obtain 
information on hospital projects that might qualify for special 
exceptions payments in order to assess the impact of the recommended 
changes to the existing policy. Because of the impracticality of 
obtaining data timely from every State in the country, we focused our 
efforts on certain States. Using information obtained from the 
Department of Housing and Urban Development (HUD) and the Health 
Resources and Services Administration (HRSA), we developed a list of 
States in which a large concentration of hospital construction occurred 
during the capital transition period. For several States, we contacted 
the State Department of Health's Facility and Planning Staff, who 
provided us with information on the hospital construction projects in 
their State, including the name and location of the hospital, the cost 
of the construction project, the date of CON approval (if required), 
the start date of the project, and the completion or anticipated 
completion date of the project. In conjunction with the most recent 
cost report data readily available (FY 1996), we attempted to estimate 
which of the hospital construction projects might qualify for special 
exception payments under the existing policy and how that universe of 
hospitals might change as a result of the recommended revisions to the 
special exceptions criteria.
    Because exception payments to a hospital for a given cost reporting 
period are based on a percentage of the hospital's capital costs 
incurred during the cost reporting period, we were unable to determine 
a precise estimate of the amount of payments to hospitals that might be 
eligible for special exceptions. In addition, hospitals are not 
eligible for special exception payments until the assets are put into 
use for patient care. Once eligibility for special exceptions payment 
has been demonstrated, it is some time before completed and settled 
cost reports are available to determine these payments. It is also 
difficult to predict whether particular hospitals will be able to meet 
all of the special exceptions eligibility criteria (DSH percentage, 
inpatient margins, completion date, project size, and project need 
requirements) in future years based on the earlier cost report data.
    Based on our research, we were able to identify a universe of 266 
possible hospital construction projects from two States (New York and 
Illinois) that

[[Page 41528]]

might possibly qualify for special exception payments. Our data largely 
understate the total number of eligible projects that may qualify for 
special exception payments nationally since our estimate is based on 
data from only 2 of the 50 States in the country. Our estimate includes 
all inpatient hospital construction projects in those two States, of 
which only a subset of projects will qualify for special exception 
payments. Extrapolating our estimate to the large numbers of hospital 
construction projects nationally, we believe that any changes to the 
special exceptions policy may affect a significant number of hospitals.
    Based on our belief that these changes may have an impact on a 
significant number of hospitals and our evaluation of the comments and 
after careful consideration of all the issues, we have concluded, as 
suggested by one commenter, that the more appropriate forum for 
addressing the capital special exception is the legislative process in 
Congress rather than the regulation process.
    Based on this conclusion, we are generally not addressing the 
specific changes recommended for the special exceptions process or 
eligibility criteria. However, there are some comments on the general 
policies of the special exception process that we would like to address 
individually. These include our efforts to address the OBRA 1993 
Conference Report language concerning the obligated capital provisions 
of the capital prospective payment system, the rationale for the 70 
percent minimum payment level for the special exceptions process, and 
the administrative feasibility of capping special exception payments 
and rolling over unfunded special exceptions to future years.
    First, in the Conference Report that accompanied OBRA 1993, 
Congress addressed obligated capital criteria for hospitals in States 
with a lengthy CON process. The language states, ``The conferees note 
that in the proposed rule for fiscal year 1994, changes to the hospital 
inpatient prospective payment system, that was published in the Federal 
Register on May 26, 1993, the Secretary indicated that insufficient 
information was available to complete a systematic evaluation of the 
obligated capital criteria for hospitals in states with a lengthy 
Certificate-of-Need process in time to consider appropriate changes 
during the fiscal year 1994 rulemaking process. The conferees expect 
the Secretary to complete the assessment in time for consideration in 
the fiscal year 1995 rulemaking process and that appropriate changes in 
payment policy will be made to address the problems of hospitals 
subject to a lengthy Certificate-of-Need review process or subject to 
other circumstances which are not fully addressed in the current rules. 
In addition, the conferees believe the Secretary should evaluate 
whether current policies provide adequate protection to sole community 
hospitals and hospitals that serve a disproportionate share of low 
income patients'' (H.R. Conf. Rep. No. 103-66, at 744 (1993)).
    In the May 27, 1994 proposed rule (59 FR 27744), we described our 
analysis of provisions related to obligated capital for hospitals 
subject to lengthy CON processes. We also proposed a change to the 
deadline for putting an asset into use for patient care 
(Sec. 412.302(c)(2)(i)(D)) and addressed recommendations that we had 
received from hospitals to change the capital exceptions policy, which 
would provide exceptions payments after the conclusion of the capital 
prospective payment transition period. These hospitals had asked that 
the minimum payment level for urban hospitals with at least 100 beds 
and a DSH percentage of at least 20.2 percent be guaranteed through the 
rest of the transition and extended for at least 10 years after the 
transition.
    In the September 1, 1994 final rule (59 FR 45376), we adopted the 
proposed change to the deadline for putting an asset into use in the 
obligated capital regulations (Sec. 412.348) from ``the earlier of'' 
September 30, 1996, or 4 years from the date of CON approval to ``the 
later of'' September 30, 1996, or 4 years from the date of CON 
approval. We also implemented the capital special exceptions process 
and expanded the qualifying criteria for the classes of eligible 
hospitals to include sole community hospitals; urban hospitals with at 
least 100 beds that have a DSH percentage of at least 20.2 percent or 
that receive at least 30 percent of their revenue from State or local 
funds for indigent care; and hospitals with a combined inpatient 
Medicare and Medicaid utilization of at least 70 percent.
    Because we adopted changes to both the obligated capital criteria 
and finalized the special exceptions process, we believe that we have 
appropriately addressed the issues raised in the Conference Report 
language concerning hospitals in States with a lengthy CON process as 
well as SCHs and hospitals that serve a disproportionate share of low-
income patients.
    Second, in response to the commenters' suggestion that the 70 
percent minimum payment level for special exceptions be raised to 85 
percent, we believe that this change would expand the special 
exceptions process beyond its original narrow focus. The commenters' 
comparison of the special exceptions process to hold harmless payments 
for old capital is not appropriate. Paying hospitals for 85 percent of 
the cost of old capital was reasonable to account for the change from a 
cost-based system to a prospective payment system for capital. Since 
hospitals had committed to these costs years prior to the 
implementation of the capital prospective payment system, it was 
reasonable to allow relief to hospitals for these costs. In addition, 
during the prospective payment system transition, all hospitals, based 
on their costs, were eligible for exception payments to account for 
high costs that exceed the prospective payment rate. Except for sole 
community hospitals and hospitals with a DSH percentage of at least 
20.2, hospitals received exceptions payments at the 70-percent minimum 
payment level. A 70-percent minimum payment level for special 
exceptions continues exceptions payments for qualifying hospitals with 
high costs after the transition at the same level most hospitals 
received under the regular exceptions process during the transition.
    Third, it would be extremely difficult administratively to 
implement a cap and roll-over provision such as the one advocated by 
the commenters. Hospitals are not eligible for special exception 
payments until assets are put into use for patient care. A lag time 
exists before completed and settled cost reports are available to 
determine special exception payments once eligibility has been 
demonstrated. Information taken from cost reports cannot be used to 
accurately determine whether a hospital meets all of the special 
exceptions eligibility criteria. Specifically, date of CON approval (if 
applicable) and DSH percent are not determined based on cost report 
information. Other criteria, such as project size and age of asset (if 
applicable) requirements, and their accuracy will need to be reported 
by the hospital and verified by the fiscal intermediaries.
    Even when we have a more accurate assessment of qualifying special 
exception projects, we do not believe a cap and roll-over process such 
as the commenter suggests would be administratively feasible. We intend 
to administer the existing special exception process in the post-
transition period in a manner similar to the regular exception process. 
Based on data received, we will make an estimate of special exception 
payments in the

[[Page 41529]]

coming year. If our model shows that special exception payments are 
projected to be more than 10 percent of total capital payments under 
the existing 70 percent payment level, we would reduce the minimum 
payment level to ensure that projected payments do not exceed the 10 
percent threshold. If, however, when cost reports were settled for that 
fiscal year, payments for eligible projects were determined to be more 
or less than the amount estimated, they would still be eligible for 
special exception payments, even if actual payments exceeded the amount 
we initially estimated. Each year's exception payments are determined 
separately. It would be extremely difficult to maintain an estimate of 
actual qualifying projects, given varied dates on which hospitals' 
fiscal years end, and increase or decrease the exception payment amount 
each hospital was eligible to receive. We would not know whether the 
amount budgeted for a project was more or less than the amount the 
project actually qualified for until the cost report was settled. Since 
hospitals have different cost report ending dates, it would be some 
time before all the cost reports for a given fiscal year would be 
finalized. At that time, it would be necessary for each fiscal 
intermediary to determine how much was actually paid for special 
exception, and any carryover amount for each project to a future fiscal 
year. We believe that this process would be very cumbersome, if not 
impossible, to administer.
    It is our intention in the FY 2001 proposed and final rules to 
discuss a data collection effort to assist us in modeling special 
exception payments for the FY 2002 proposed rule.
    Comment: MedPAC commented that they share HCFA's desire to keep 
special exceptions narrowly targeted. The Commission stated that many 
of the suggestions for changing the special exception process and 
criteria would unnecessarily expand payments beyond clearly 
disadvantaged hospitals whose financial health is important to 
maintaining access to care for Medicare beneficiaries. MedPAC 
recommends that, since so few hospitals responded to our request for 
information on potentially qualifying projects, we should not change 
the current special exceptions policy until we receive more information 
about the extent of financial problems hospitals are having. However, 
MedPAC does believe that we should consider increasing the special 
exceptions payment for SCHs and urban hospitals with a DSH percentage 
of at least 20.2 percent to equal the amount they receive under the 
regular exceptions policy (that is, 90 and 80 percent, respectively). 
MedPAC suggests that these increases are necessary to continue to 
provide financial protection to institutions that safeguard access to 
care for Medicare beneficiaries.
    MedPAC supports offsetting special exceptions payments against both 
capital and operating margins, because it is consistent with their 
belief that at the end of the transition the two payment systems should 
be combined.
    Response: We agree with MedPAC that, in determining eligibility for 
special exception payments, it is appropriate to examine a hospital's 
operating margins as well as its capital margins. We believe it is 
reasonable to provide an additional limit on exceptions payments for 
the period 10 to 20 years after the beginning of capital prospective 
payments. In addition, we agree that since inpatient operating and 
capital costs are so inherently intertwined in providing inpatient 
care, it is appropriate to have an operating payment offset for the 
capital special exception. It is not appropriate to consider any 
outpatient services when determining eligibility for the inpatient 
special exception payment. Any outpatient capital-related costs are 
paid to hospitals under Medicare Part B.

VI. Changes for Hospitals and Hospital Units Excluded from the 
Prospective Payment System

A. Limits on and Adjustments to the Target Amounts for Excluded 
Hospitals and Units (Secs. 413.40(b)(4), (c), (f), and (g))

1. Updated Caps
    Section 1886(b)(3) of the Act (as amended by section 4414 of the 
BBA) establishes caps on the target amounts for certain excluded 
hospitals and units for cost reporting periods beginning on or after 
October 1, 1997 through September 30, 2002. The caps on the target 
amounts apply to the following three categories of excluded hospitals: 
psychiatric hospitals and units, rehabilitation hospitals and units, 
and long-term care hospitals.
    A discussion of how the caps on the target amounts were calculated 
can be found in the August 29, 1997 final rule with comment period (62 
FR 46018); the May 12, 1998 final rule (63 FR 26344); and the July 31, 
1998 final rule (64 FR 41000). For purposes of calculating the caps on 
existing facilities, the statute requires us to calculate the 75th 
percentile of the target amounts for each class of hospital 
(psychiatric, rehabilitation, or long-term care) for cost reporting 
periods ending during FY 1996. Under section 1886(b)(3)(H)(iii) of the 
Act, the resulting amounts are updated by the market basket percentage 
increase applicable to the fiscal year.
    In the May 7, 1999 proposed rule, we proposed the following caps on 
target amounts for cost reporting periods beginning in FY 2000:
     Psychiatric hospitals and units: $11,067
     Rehabilitation hospitals and units: $20,071
     Long-term care hospitals: $39,596

These proposed caps reflected an update of 2.6 percent, the projected 
market basket increase for excluded hospitals and units.
    The final projection of the market basket percentage increase for 
excluded hospitals and units for FY 2000, based on the most recent data 
available, is 2.9 percent. Accordingly, the final caps on the target 
amounts for existing hospitals and units for cost reporting periods 
beginning during FY 2000 are as follows:

 Psychiatric hospitals and units: $11,100
 Rehabilitation hospitals and units: $20,129
 Long-term care hospitals: $39,712
2. New Excluded Hospitals and Units (Sec. 413.40(f))
a. Updated Caps for New Hospitals and Units
    Section 1886(b)(7) of the Act establishes a payment methodology for 
new psychiatric hospitals and units, rehabilitation hospitals and 
units, and long-term care hospitals. Under the statutory methodology, 
for a hospital that is within a class of hospitals specified in the 
statute and that first receives payments as a hospital or unit excluded 
from the prospective payment system on or after October 1, 1997, the 
amount of payment will be determined as follows: for the first two 12-
month cost reporting periods, the amount of payment is the lesser of 
(1) the operating costs per case, or (2) 110 percent of the national 
median of target amounts for the same class of hospitals for cost 
reporting periods ending during FY 1996, updated to the first cost 
reporting period in which the hospital receives payments and adjusted 
for differences in area wage levels.
    The amounts included in the following table reflect the updated 110 
percent of the wage neutral national median target amounts for each 
class of excluded hospitals and units for cost reporting periods 
beginning during FY 2000. These figures are based on the final FY 1999 
figures updated by the projected market basket increase of 2.9

[[Page 41530]]

percent. (The proposed amounts were based on an estimated market basket 
increase of 2.6 percent.) For a new provider, the labor-related share 
of the target amount is multiplied by the appropriate geographic area 
wage index and added to the nonlabor-related share in order to 
determine the per case limit on payment under the statutory payment 
methodology for new providers.

------------------------------------------------------------------------
                                                   Labor-     Nonlabor-
      Class of excluded hospital or unit          related      related
                                                   share        share
------------------------------------------------------------------------
Psychiatric...................................      $ 6,394      $ 2,544
Rehabilitation................................       12,574        4,999
Long-term Care................................       16,206        6,443
------------------------------------------------------------------------

    As specified at Sec. 413.40(c)(4), for purposes of determining the 
hospital's target amount for the hospital's third 12-month cost 
reporting period, the target amount for the preceding cost reporting 
period is equal to the payment amount in the second 12-month cost 
reporting period as determined in accordance with 
Sec. 413.40(f)(2)(ii)(A). The payment amount is the lesser of (1) the 
operating costs per case, or (2) 110 percent of the national median of 
target amounts for the same class of hospitals for cost reporting 
periods ending during FY 1996, updated to the first cost reporting 
period in which the hospital receives payments and adjusted for 
differences in area wage levels. It has come to our attention that 
Sec. 413.40(c)(4)(v) does not specify how to apply the update factors 
to the amount of payment for the second 12-month cost reporting period 
in order to calculate the target amount in subsequent cost reporting 
periods. Therefore, we are revising Secs. 413.40(c)(4)(v) and 
413.40(f)(2)(ii)(A) to clarify the application of the update factors 
and the base period for new psychiatric hospitals and units, 
rehabilitation hospitals and units, and long-term care hospitals.
b. Multicampus Excluded Hospitals
    Section 1886(b) of the Act, as amended by the BBA, provides for 
caps on target amounts for certain classes of excluded hospitals, and 
also provides a statutory payment methodology for new excluded 
hospitals. A question has arisen regarding the appropriate target 
amount to be used for an excluded hospital or unit that was part of a 
multicampus hospital but alters its organizational structure so that it 
is no longer part of that multicampus hospital. The question was raised 
by long-term care hospitals that are seeking alternate structures due 
to the application of the cap on hospital-specific target amounts 
specified in Sec. 413.40(c)(4)(iii).
    In these cases, to determine the appropriate target amount, we must 
determine whether the excluded hospital or unit established under the 
organizational restructure is a new provider. Under Sec. 413.40(f)(1), 
a new excluded hospital or unit is a provider of hospital inpatient 
services that (1) has operated as the type of hospital or unit for 
which HCFA granted it approval to participate in the Medicare program, 
under present or previous ownership (or both), for less than 1 full 
year; and (2) has provided the type of hospital inpatient services for 
which HCFA granted it approval to participate for less than 2 full 
years. If the new hospital is a children's hospital, a 2-year exemption 
from the application of the target amount is permitted 
(Sec. 413.40(f)(2)(i)). A new psychiatric or rehabilitation hospital or 
unit or a long-term care hospital receives, for the first two 12-month 
cost reporting periods, the lower of its new inpatient operating cost 
per case or 110 percent of a national median of target amounts for the 
class of hospital, updated and adjusted for area wages 
(Sec. 413.40(f)(2)(ii)).
    If the entity that separated itself from the multicampus hospital 
provides inpatient services of a different type than it had when it was 
part of the multicampus hospital so that it qualifies as a different 
class of excluded hospital or unit (for example, from long-term care to 
rehabilitation), we would calculate a new target amount per discharge 
for the newly created hospital or unit. However, if the entity does not 
operate as a different class of hospital or unit, it does not meet the 
criteria at Sec. 413.40(f)(1) to qualify as a new provider. Instead, if 
the entity replaces a hospital or unit that had been excluded from the 
prospective payment system (for example, the entity had previously been 
a long-term care hospital before becoming part of the multicampus 
hospital), the previously established hospital-specific target amount 
for the hospital, prior to its becoming part of the multicampus 
hospital, would again be applicable. This is consistent with our 
current policy for a hospital or unit that is excluded from the 
prospective payment system and that has periods in which the hospital 
or unit is not subject to the target amount, as specified at 
Sec. 413.40(b)(1)(i). The target amount established earlier for the 
hospital or unit is again applicable despite intervening cost reporting 
periods during which the hospital or unit was not subject to that 
target amount due to other provisions of the law or regulations that 
applied while it was part of the multicampus hospital. We proposed to 
revise Sec. 413.40(b)(1)(iii) to specify that if the entity continues 
to operate as the same class of hospital that is excluded from the 
prospective payment system, but does not replace a hospital or unit 
that existed prior to being part of a multicampus hospital (for 
example, a newly created long-term care hospital became part of a 
multicampus hospital and subsequently separates from the multicampus 
hospital to operate separately), the base period for calculating a 
hospital-specific target amount for the newly separated hospital is the 
first cost reporting period of at least 12 months effective with the 
revised Medicare certification.
    We did not receive any comments on this proposed revision. 
Therefore, we are adopting the proposed change to 
Sec. 413.40(b)(1)(iii) as final.
3. Exceptions
    The August 29, 1997 final rule with comment period (62 FR 46018) 
specified that a hospital that has a hospital-specific target amount 
that is capped at the 75th percentile of target amounts for hospitals 
in the same class (psychiatric, rehabilitation, or long-term care) 
would not be granted an adjustment payment (also referred to as an 
exception payment) based solely on a comparison of its costs or patient 
mix in its base year to its costs or patient mix in the payment year. 
Since the hospital's target amount would not be determined based on its 
own experience in a base year, any comparison of costs or patient mix 
in its base year to costs or patient mix in the payment year would be 
irrelevant.
    In addition, the July 31, 1998 final rule (63 FR 41001) revised 
Sec. 413.40(g)(1) to specify, under paragraph (g)(1)(iv), that in the 
case of a psychiatric hospital or unit, rehabilitation hospital or 
unit, or long-term care hospital, the amount of the adjustment payment 
may not exceed the applicable limit amounts for hospitals of the same 
class.
    Similarly, for hospitals and units with a FY 1998 hospital-specific 
revised target amount established under the rebasing provision at 
Sec. 413.40(b)(1)(iv), in determining whether the hospital qualifies 
for an adjustment and the amount of the adjustment, we compare the 
hospital's operating costs to the average costs and statistics for the 
cost reporting periods used to determine the FY 1998 revised target 
amount. Since the rebased FY 1998 target amount is an average of three 
cost reporting periods, as described in Sec. 413.40(b)(1)(iv), 
comparisons of costs from the cost year

[[Page 41531]]

to the FY 1998 cost period would be inaccurate. Therefore, as specified 
in the August 29, 1997 final rule with comment period (62 FR 46018), a 
determination of whether the hospital qualifies for an adjustment, and 
the amount of an adjustment, are based on a comparison of the 
hospital's operating costs and its costs used to calculate the FY 1998 
rebased target amount. For hospitals that have been rebased under the 
provisions of Sec. 413.40(b)(1)(iv) and qualify for an adjustment under 
the provisions of Sec. 413.40(g), the base year figures used for such 
items as costs, utilization, and length-of-stay should be determined 
based on the average of the costs and utilization statistics from the 
same 3 cost reporting years used in calculating the FY 1998 rebased 
target amount.
    In the proposed rule, we proposed to revise Sec. 413.40(g)(1) to 
clarify these limitations on the adjustment payments.
    We received no comments on this clarification and, therefore, are 
adopting it in this final rule.
4. Report on Adjustment Payments to the Ceiling (Sec. 413.40(g))
    Changes in the types of patients served or inpatient care services 
that distort the comparability of a cost reporting period to the base 
year are grounds for requesting an adjustment payment in accordance 
with section 1886(b)(4) of the Act. Section 4419(b) of the BBA of 1997 
requires the Secretary to publish annually in the Federal Register a 
report describing the total amount of adjustment (exception) payments 
made to excluded hospitals and units, by reason of section 1886(b)(4) 
of the Act, during the previous fiscal year. However, the data on 
adjustment payments made during the previous fiscal year are not 
available in time to publish a report describing the total amount of 
adjustment payments made to all excluded hospitals and units in the 
subsequent year's final rule published in the Federal Register.
    The process of requesting, adjudicating, and awarding an adjustment 
payment for a given cost reporting period occurs over a 2-year period 
or longer. An excluded hospital or unit must first file its cost report 
for the previous fiscal year with its intermediary within 5 months 
after the close of the previous fiscal year. The fiscal intermediary 
then reviews the cost report and issues a Notice of Program 
Reimbursement (NPR) in approximately 2 months. If the hospital's 
operating costs are in excess of the ceiling, the hospital may file a 
request for an adjustment payment within 6 months from the date of the 
NPR. The intermediary, or HCFA, depending on the type of adjustment 
requested, then reviews the request and determines if an adjustment 
payment is warranted. Therefore, it is not possible to provide data in 
a final rule on adjustments granted for cost reports ending in the 
previous Federal fiscal year, since those adjustments have not even 
been requested by that time. However, in an attempt to provide 
interested parties at least some relevant data on adjustments, we are 
publishing data on requests for adjustments that were processed by the 
fiscal intermediaries or HCFA during the previous Federal fiscal year.
    The table below includes the most recent data available from the 
fiscal intermediaries and HCFA on adjustment payments that were 
adjudicated during FY 1998. By definition these were for cost reporting 
periods ending in years prior to FY 1998. The total adjustment payments 
awarded to excluded hospitals and units during FY 1998 are $95,676,720. 
The table depicts for each class of hospital, in aggregate, the number 
of adjustment requests adjudicated, the excess operating cost over the 
ceiling, and the amount of the adjustment payment.

------------------------------------------------------------------------
                                            Excess cost     Adjustment
       Class of hospital          Number   over ceiling       Payment
------------------------------------------------------------------------
Psychiatric....................      235    $112,437,640     $55,784,497
Rehabilitation.................       93      67,353,452      26,487,095
Long-term care.................        7      10,326,069       6,085,941
Children's.....................        7       6,893,393       2,898,679
Cancer.........................        3      10,463,245       4,420,508
------------------------------------------------------------------------

5. Development of Case-Mix Adjusted Prospective Payment System for 
Rehabilitation Hospitals and Units
    Section 4421 of the BBA added a new section 1886(j) to the Act that 
mandates the phase-in of a case-mix adjusted prospective payment system 
for inpatient rehabilitation services (freestanding hospitals and 
units) for cost reporting periods beginning on or after October 1, 2000 
and before October 1, 2002. The prospective payment system will be 
fully implemented for cost reporting periods beginning on or after 
October 1, 2002.
    As provided in section 1886(j)(3)(A) of the Act, the prospective 
payment rates will be based on the inpatient operating and capital 
costs of rehabilitation facilities. Payments will be adjusted for case-
mix using patient classification groups, area wages, inflation, and 
outlier and any other factors the Secretary determines necessary. We 
will set prospective payment amounts so that total payments under the 
system during FY 2001 and FY 2002 are projected to equal 98 percent of 
the amount of payments that would have been made under the current 
payment system. Outlier payments in a fiscal year may not be projected 
or estimated to exceed 5 percent of the total payments based on the 
rates for that fiscal year.

B. Changes in Bed Size or Status of Hospital Units Excluded under the 
Prospective Payment System

    Existing regulations (Sec. 412.25(b) and (c)) specify that, for 
purposes of payment to a psychiatric or rehabilitation unit that is 
excluded from the prospective payment system, changes in the bed size 
or the status of excluded hospital units will be recognized only at the 
beginning of a cost reporting period. These regulations have been in 
effect since the inception of the hospital inpatient prospective 
payment system and were intended to simplify administration of the 
exclusion provisions of the prospective payment system by establishing 
clear rules for the timing of changes in these excluded units. The 
statutory basis and rationale for these rules are explained more fully 
in the preamble to the proposed rule (64 FR 24740).
    To provide more flexibility to hospitals while not recognizing 
changes that undermine statutory requirements and principles, we 
proposed to revise Sec. 412.25(b) and (c) to provide that, for purposes 
of exclusion from the prospective payment system, the number of beds 
and square footage of an excluded unit may be decreased, or an excluded 
unit may be closed in its entirety, at any time during a cost reporting 
period under certain conditions. The hospital would be

[[Page 41532]]

required to give the fiscal intermediary and the HCFA Regional Office a 
30-day advance written notice of the intended change and to maintain 
all information needed to accurately determine costs attributable to 
the excluded unit and proper payments. However, any unit that is closed 
during a cost reporting period could not be paid again as a unit 
excluded from the prospective payment system until the start of the 
next cost reporting period. If the number of beds or square footage of 
a unit excluded from the prospective payment system is decreased during 
a cost reporting period, that decrease would remain in effect for the 
remainder of that period.
    We noted that the number of beds and square footage of the part of 
the hospital paid under the prospective payment system may also be 
affected by a change in the size or status of a unit that is excluded 
from the prospective payment system. If the bed capacity and square 
footage were previously part of the excluded unit and are then included 
in the part of the hospital paid under the prospective payment system 
and are used to treat acute patients rather than excluded unit 
patients, the additional bed capacity and square footage would, 
starting with the effective date of the change, be counted as part of 
the hospital paid under the prospective payment system. We would count 
the bed capacity and square footage for purposes of calculating 
available bed days and the number of beds under Secs. 412.105 and 
412.106, relating to payments for the indirect costs of medical 
education and hospitals that serve a disproportionate share of low-
income patients. On the other hand, if the bed capacity and square 
footage are taken out of service or added to another hospital-based 
provider, such as a distinct-part skilled nursing facility, they would 
not be counted as part of the hospital paid under the prospective 
payment system.
    We received six comments on our proposal.
    Comment: Several commenters expressed support for the proposed 
change and indicated that it would increase hospital flexibility. No 
commenters opposed the change. However, one commenter noted that some 
California hospitals may need to temporarily vacate certain facilities 
to allow renovation and construction necessary to comply with new State 
seismic code requirements, and stated that such a relocation of a 
facility may necessitate a change in its number of beds or square 
footage. The commenter recommended that our regulations be revised to 
account for this possibility or for relocations that are necessary due 
to catastrophic occurrences such as earthquakes, floods, tornadoes, or 
other natural disasters.
    Response: We appreciate the commenters' support of our proposal and 
are adopting it as final with one change. To address the types of 
compliance or catastrophic situations described by one of the 
commenters, we are revising Sec. 412.25(b) to allow reductions in the 
number of beds in an excluded unit, or increases or decreases in the 
square footage of the excluded unit, if these changes result from 
relocation of the unit made necessary because of construction or 
renovation needed to bring a facility into compliance with changes in 
Federal, State, or local law affecting the physical facility, or 
because of catastrophic events such as fires, floods, earthquakes, or 
tornadoes. We understand that these relocations may necessitate a 
change in the square footage of a unit, although it is not clear that 
any increase in bed size would be required. We also are allowing 
corresponding exceptions to the requirements that a grandfathered 
satellite facility be operated under the same terms and conditions in 
effect on September 30, 1999 under Secs. 412.23(h)(3) and 
412.25(e)(3)).

C. Payment for Services Furnished at Satellite Hospital Locations

    Under Medicare, each hospital is treated, for purposes of 
certification, coverage, and payment, as a single institution. That is, 
each entity that is approved to participate in Medicare as a 
``hospital'' must separately comply with applicable health and safety 
requirements as a condition of participation under regulations at part 
482, with provider agreement requirements specified in regulations at 
part 489, and with requirements relating to the scope of benefits under 
Medicare Parts A and B specified in parts 409 and 410. Our policies 
that involve the movement of patients from one hospital to another, or 
from outpatient to inpatient status at the same hospital, are premised 
on the assumption that each hospital is organized and operated as a 
separate institution.
    Section 412.22(e) of the regulations permits an entity that is 
located in the same building or in separate buildings on the same 
campus as another hospital to be treated, for purposes of exclusion 
under the prospective payment systems, as a ``hospital.'' This status 
is available, however, only when the entity meets specific, stringent 
criteria designed to ensure that the hospital-within-a-hospital is 
organized as a separate entity and operates as a separate entity.
    We have received several requests for approval of ``satellite'' 
arrangements, under which an existing hospital that is excluded under 
the prospective payment system, and that is either a freestanding 
hospital or a hospital-within-a-hospital under Sec. 412.22(e), wishes 
to lease space in a building or on a campus occupied by another 
hospital, and, in some cases, to have most or all services to patients 
furnished by the other hospital under contractual agreements, including 
arrangements permitted under section 1861(w)(1) of the Act. In most 
cases, a hospital intends to have several of these satellite locations 
so that the hospital would not exist at any single location, but only 
as an aggregation of beds located at several sites. Generally, the 
excluded hospital seeks to have the satellite facility treated as if 
the satellite facility were ``part of'' the excluded hospital.
    In the preamble to the proposed rule, we explained in detail our 
reason for concern that satellite arrangements could lead to 
circumvention of several Medicare payment provisions. To prevent 
inappropriate Medicare payment for services furnished in satellite 
facilities, we proposed to revise Secs. 412.22 and 412.25 to provide 
for payment to satellite facilities of hospitals and units that are 
excluded from the prospective payment system under specific rules. With 
respect to both hospitals and units, we proposed to define a 
``satellite facility'' as a part of a hospital that provides inpatient 
services in a building also used by another hospital, or in one or more 
buildings on the same campus as buildings also used by another hospital 
but is not a ``hospital-within-a-hospital,'' since it is also part of 
another hospital. We proposed that, if the satellite facility is 
located in a hospital that is paid under the prospective payment 
system, Medicare would pay for services furnished at the satellite 
facility by using the same rates that apply to the prospective payment 
hospital within which the satellite is located. As explained in the 
proposed rule, we reasoned that, if the satellite facility is 
effectively ``part of'' the prospective payment system hospital, then 
it should be paid under the prospective payment system.
    We proposed that if the satellite facility is located in a hospital 
excluded from the prospective payment system, then Medicare would pay 
for the services furnished in the satellite facility as follows: we 
proposed to examine the discharges of the satellite facility and to 
apply the target amount for the excluded hospital in which the hospital 
is located, subject to the

[[Page 41533]]

applicable cap for the hospital of which the satellite is a part. Also, 
when the satellite facility is established, we proposed to treat it as 
a new hospital for payment purposes. That is, for the satellite's first 
two 12-month cost reporting periods, the satellite would be subject to 
the cap that applies to new hospitals of the same class as the hospital 
of which the satellite is a part. We believed that the proposed 
application of the cap for new hospitals was appropriate because we 
believe that a number of hospitals are attempting to avoid the hospital 
caps by characterizing entities as satellites rather than new 
hospitals.
    Under the proposed rule, satellite facilities excluded from the 
prospective payment system prior to the effective date of the revised 
regulations (October 1, 1999) would not be subject to those new 
regulations as long as they operate under the same terms and conditions 
in effect on September 30, 1999. We proposed to make this exception 
available only to those facilities that could document to the HCFA 
regional offices that they are operating as satellite facilities 
excluded from the prospective payment system as of that date. The 
exception would not be available to hospitals that might be excluded 
from the prospective payment system as of that date and at some later 
time enter into satellite arrangements. In addition, we proposed not to 
apply the rules for payments to satellite facilities to multicampus 
arrangements, that is, those in which a hospital has a facility at two 
or more locations but does not share a building or a campus with any 
other hospital at those locations.
    We also solicited comments on a possible further exception. In 
section 4417 of the BBA, Congress extended the long-term care hospital 
exclusion to a hospital ``that first received payment under this 
subsection [subsection 1886(d)(1)(B)(iv) of the Act] in 1986 which has 
an average inpatient length of stay (as determined by the Secretary) of 
greater than 20 days and that has 80 percent or more of its annual 
Medicare inpatient discharges with a principal diagnosis of neoplastic 
disease in the 12-month cost reporting period ending in fiscal year 
1997.'' In view of the specific provision made for a hospital meeting 
these requirements, we indicated that we were considering whether a 
satellite facility opened by such a hospital should be exempt from the 
proposed rules on satellites. We requested comment on this issue and on 
whether this exclusion could be implemented without compromising the 
effectiveness of the proposed changes.
    We noted that there may be some operational difficulties 
differentiating services, costs, and discharges of the satellite 
facilities from those of the existing hospital that is excluded from 
the prospective payment system. We indicated that, if these operational 
problems cannot be overcome, we would consider revising the regulations 
to prohibit exclusion of any hospital or hospital unit from the 
prospective payment system that is structured, entirely or in part, as 
a satellite facility in a hospital paid under the prospective payment 
system.
    We received 18 comments on this proposal.
    Comment: Several commenters objected to the proposal to pay 
satellite facilities of excluded hospitals or units under a different 
methodology than that used for the excluded hospital or unit itself. 
These commenters argued that the potential abuses described in the 
preamble to the proposed rule are likely to occur rarely, if at all, 
and that differential payment for satellite facilities would interfere 
with hospitals' flexibility to use their facilities efficiently and to 
take advantage of economies of scale. Other commenters suggested that 
the proposal, if adopted, could lead to a shortage of crucial 
rehabilitation or long-term hospital services.
    Most of the commenters suggested that the proposed changes be 
withdrawn and that no limitations be placed on the ability of excluded 
hospitals or units to establish satellite facilities and claim payment 
for their services on the same basis as services in the rest of the 
excluded hospital or unit. Other commenters suggested that we permit 
services in satellite facilities to be paid on the same basis as 
services in the remainder of the excluded hospital or unit only if 
satellite facilities were created and operated under certain rules. 
Some commenters, including a national health care association, 
suggested that our concerns could be addressed if we limit the number 
of satellite beds that an excluded hospital or unit could establish or 
require that the satellite independently meet exclusion criteria.
    Response: We have reviewed these comments and concluded that we can 
address the concerns raised in the proposed rule, especially our 
concerns with the application of the appropriate BBA cap on the 
hospital target amount, without resorting to making payments for the 
services provided in the satellite under a different methodology than 
used for the original hospital or unit.
    We have decided that, for purposes of payment, the satellite 
facility of an excluded hospital or unit may be treated as a part of 
the excluded hospital or unit and may receive payment on the same basis 
as the excluded hospital or unit, but only if the following specific 
criteria are met:
     In the case of a hospital (other than a children's 
hospital) or unit that was excluded from the prospective payment system 
before the effective date of section 4414 of the BBA (cost reporting 
periods beginning on or after October 1, 1997), the number of beds in 
the hospital or unit (including both the base hospital or unit and the 
satellite location) does not exceed the number of State-licensed and 
Medicare-certified beds in the hospital or unit on the last day of the 
hospital's or unit's last cost reporting period beginning before 
October 1, 1997. Thus, while an excluded hospital or unit can 
``transfer'' bed capacity from a base facility to a satellite, it 
cannot, through the establishment of a satellite, increase total bed 
capacity beyond the level it had in the most recent cost reporting 
period prior to the effective date of section 4414.
     The satellite facility independently complies with 
selected prospective payment system exclusion requirements applicable 
to the type of hospital unit. Specifically, a satellite of a children's 
hospital must meet the requirement with respect to treatment of 
inpatients who are predominantly individuals under age 18, as stated in 
Sec. 412.23(d)(2); a satellite of a long-term care hospital must meet 
the average length of stay requirement of Sec. 412.23(e)(1) through 
(3)(i); a satellite of a rehabilitation hospital or unit must treat an 
inpatient population meeting the requirement in Sec. 412.23(b)(2); and 
a satellite of a psychiatric unit must meet the requirement regarding 
admission of only psychiatric patients in Sec. 412.27(a).
     The satellite facility complies with certain requirements 
designed to ensure that costs are reported accurately for both the 
hospital in which the satellite is located and the hospital of which 
the satellite is a part. Specifically, a satellite of an excluded 
hospital or unit must (1) have admission and discharge records that are 
separately identified from those of the hospital in which it is located 
and are readily available; (2) have beds that are physically separate 
from (that is, not commingled with) the beds of the hospital in which 
it is located; (3) be serviced by the same fiscal intermediary as the 
hospital of which it is a part; (4) be treated as a separate cost 
center of the hospital of which it is a part, for cost reporting and 
apportionment purposes; (5) use an accounting system that properly 
allocates costs; (6) maintain

[[Page 41534]]

adequate statistical data to support the basis of allocation; and (7) 
report its costs in the cost report of the hospital of which it is a 
part, covering the same fiscal period and using the same method of 
apportionment as the hospital of which it is a part.
    If an excluded hospital or unit has a satellite location and fails 
to meet these requirements, the entire hospital or unit would lose its 
exclusion from the prospective payment system. Under Secs. 412.22(d) 
and 412.25(c), the change in status from excluded to included in the 
prospective payment system would be effective at the start of the first 
cost reporting period after the cost reporting period in which the 
hospital or unit failed to meet the requirements. Loss of exclusion 
status means that payment to the entire hospital or unit would then be 
made under the prospective payment system.
    Thus, under our policy, we permit a satellite facility to be 
excluded (and treated as part of an excluded hospital) if certain 
criteria are met, but deny excluded status to the entire hospital if 
the criteria are not met. We are adopting this policy primarily because 
of concerns about preventing inappropriate Medicare payments. As 
explained above and in the proposed rule, we believe that hospitals 
might be seeking satellite arrangements so that the services furnished 
in the satellite facility are paid on an excluded basis when they 
should be paid on a prospective payment basis. We also believe that 
hospitals are seeking satellite arrangements in order to avoid the 
effects of the payment caps that apply to new excluded hospitals under 
the BBA. Therefore, we believe it is necessary and appropriate to 
establish criteria for determining when a satellite facility may be 
treated as part of the excluded hospital and paid on an excluded basis, 
and to deny exclusion to the satellite facility if the satellite fails 
to meet those criteria.
    Another significant concern underlying our policy is 
administratively feasibility. We believe it would be administrative 
cumbersome, if not infeasible, to pay a satellite facility on a 
different basis than the rest of the excluded hospital or unit. 
Therefore, we believe that, if the satellite does not qualify for 
exclusion, then it is necessary and appropriate to deny exclusion to 
the entire hospital. If a hospital is considering whether to establish 
a satellite facility, it should keep these payment rules in mind.
    We note that these exclusion criteria would be administered in the 
same manner as the general rules for excluded hospitals and hospital 
units at Sec. 412.22 and the common requirements for excluded hospital 
units at Sec. 412.25. Specifically, the HCFA Regional Office will 
assess a hospital's or unit's compliance with the requirements before 
the start of a cost reporting period and will implement the decision at 
the start of the cost reporting period, effective for all of that 
period.
    One of the major concerns we had with payments for services at 
satellites was the ability of a hospital to circumvent the intent of 
the BBA by applying the higher cap for existing hospitals and units to 
the beds in the new satellite. By requiring that the number of beds in 
the expanded hospital or unit (including both the base hospital or unit 
and the satellite location) cannot exceed the number of State-licensed 
and Medicare-certified beds in the excluded hospital or unit at the 
time the BBA was enacted, we ensure that the excluded hospital or unit 
does not inappropriately circumvent the payment caps for new hospitals 
enacted by the BBA. For hospitals and units first excluded from the 
prospective payment system after the enactment date of the BBA, we 
would not limit the number of beds in the hospital or unit, including 
all satellites, since all beds in the hospital or unit necessarily will 
be subject to the lower cap for new excluded hospitals and units. We 
are not applying this requirement to children's hospitals since those 
hospitals are not subject to caps established by the BBA.
    Furthermore, by requiring that the satellite meet the prospective 
payment system exclusion requirements applicable to the type of 
hospital or unit, we are applying a policy to satellites that is 
similar to that currently applicable to a hospital-within-a-hospital. 
This policy, which is consistent with the suggestion of a national 
health care association, will ensure that the satellite retains the 
identity of the type of excluded hospital of which it is a part. For 
example, if we allowed the 25-day length of stay for long-term care 
hospital designation to be determined based on an examination of the 
base long-term care hospital including the satellite, the satellite 
could be excluded from the prospective payment system even if its 
patients all had short lengths of stay. By calculating the length of 
stay for patients exclusively at the satellite, we are ensuring that it 
is, in fact, a long-term care facility that warrants being excluded 
from the prospective payment system and receiving payment on a 
reasonable cost basis. Under this approach, if the satellite facility 
and the rest of the hospital or unit independently meet the applicable 
exclusion criteria, then the entire entity will be treated as one 
facility in making payments.
    We also believe it is essential to be able to identify the costs of 
satellite facilities separately from the costs of the host hospitals in 
which they are located, so that services in both facilities are paid 
for accurately and Medicare does not pay two facilities for the same 
costs. To accomplish this, we will require the satellite to meet a 
number of requirements relating to separate identification of the beds, 
patients, and costs of the satellite. We note that these requirements 
closely parallel similar requirements applicable to all excluded units 
under Sec. 412.25(a)(3) and (a)(7) through (12).
    We are revising Secs. 412.22(h) and 412.25(e) to implement this 
policy.
    Comment: Some commenters argued that paying satellite facilities of 
excluded hospitals or units under a different methodology than that 
used for the excluded hospital or unit itself would be inconsistent 
with the Medicare law, in particular, sections 1886(b)(1) and (d)(1)(A) 
and (D) of the Act.
    Response: We believe that our policies are consistent with the 
statutory scheme and the considerations underlying exclusions under the 
prospective payment system, as well as our rulemaking authority under 
section 1871 of the Act. Our policies addressing payments to satellite 
facilities are designed to prevent inappropriate payments to hospitals 
and to address potential fraud and abuse, and, at the same time, to 
permit exclusion from the prospective payment system when the 
circumstances warrant exclusion. As we discussed in the proposed rule, 
we believe that a number of excluded hospitals are seeking satellite 
arrangements so that the services furnished in the satellite facility 
are inappropriately paid on an excluded basis when they should be paid 
on a prospective payment basis; we also believe that a number of 
excluded hospitals are seeking satellite arrangements in order to avoid 
the effect of the payment caps that apply to new excluded hospitals. 
Even if hospitals are not intentionally trying to ``game'' the system, 
treating a satellite facility as ``part of'' the excluded hospital for 
payment purposes might lead to inappropriate payments in a number of 
ways.
    We believe that Congress did not contemplate satellite arrangements 
when it enacted section 1886(d) of the Act. Section 1886(d) does not 
specifically address satellite

[[Page 41535]]

arrangements; also, section 1886(d) does not mandate that certification 
status equate to payment status. The statute does, however, establish a 
scheme under which entities may be excluded from the prospective 
payment system. The purpose of exclusions is to recognize situations in 
which the principles of the prospective payment system do not apply. As 
we explained in the proposed rule, the considerations underlying 
exclusions from the prospective payment system might not apply to 
satellite facilities, which might be ``part of'' excluded hospitals 
only ``on paper.'' Thus, we believe it is necessary and appropriate to 
address Medicare payment for services furnished in satellite 
facilities.
    Comment: Several commenters approved of our proposal to grandfather 
excluded hospitals or units structured as satellite facilities on 
September 30, 1999, to the extent that they operate under the same 
terms and conditions in effect on that date.
    Response: We agree that grandfathering these facilities is 
appropriate and are adopting this part of the proposed rule without 
change. However, we wish to emphasize that this policy does not extend 
to satellites established after September 30, 1999, even if they are 
established by an excluded hospital or unit that has another satellite 
that was grandfathered.
    Comment: Two commenters expressed support for our proposal to not 
apply the new satellite rules to any hospital excluded from the 
prospective payment system by section 4417 of the BBA, as implemented 
under Sec. 412.23(e)(2) (that is, a hospital that was first excluded in 
1986, that had an average inpatient length of stay of greater than 20 
days, and that demonstrated that at least 80 percent of its annual 
Medicare inpatient discharges in the 12-month cost reporting period 
ending in FY 1997 had a principal diagnosis that reflected a finding of 
neoplastic disease).
    Response: We agree with the commenters that this is appropriate and 
are revising Sec. 412.22(h)(3) to reflect this policy.
    In addition, as discussed earlier under section VI.B of this 
preamble, we are including in Secs. 412.22(h)(4) and 412.25(e) a 
corresponding exception to the requirement that a grandfathered 
satellite facility be operated under the terms and conditions in effect 
on September 30, 1999. The corresponding change would allow for 
increases or decreases in square footage, or decreases in the number of 
beds, of the satellite facility necessitated by changes for compliance 
with Federal, State, and local law affecting the physical facility or 
because of catastrophic events such as fires, floods, earthquakes, or 
tornadoes.

D. Responsibility for Care of Patients in Hospitals-within-Hospitals

    Generally, hospitals that admit patients, including hospitals 
subject to the prospective payment system and ``hospitals-within-
hospitals'' that are excluded from the prospective payment system, 
accept overall responsibility for the patients' care and furnish all 
services they require. In accordance with section 1886(d)(5)(I) of the 
Act and implementing regulations at Sec. 412.4, for payment purposes, 
the prospective payment system distinguishes between ``discharges'' 
(situations in which a patient leaves an acute care hospital paid under 
the prospective payment system after receiving complete acute care 
treatment) and ``transfers'' (situations in which acute care treatment 
is not completed at the first hospital and the patient is transferred 
to another acute care hospital for continued, related care). The 
payment rules at Sec. 413.30, which apply to hospitals excluded from 
the prospective payment system, also are premised on the assumption 
that discharges occur only when the excluded hospital's care of the 
patient is complete.
    It has come to our attention that, given the co-location of 
prospective payment system facilities and facilities excluded from the 
prospective payment system in a hospital-within-a-hospital, and the 
absence of clinical constraints on the movement of patients, there may 
be situations in which, in these settings, patients appear to have been 
moved from one facility to another for financial rather than clinical 
reasons. The excluded hospital-within-a-hospital might have incentives 
to inappropriately discharge patients early (to the prospective payment 
system hospital within which it is located) in order to minimize its 
overall costs and, in turn, to minimize its cost per discharge. If the 
excluded hospital-within-a-hospital inappropriately discharges patients 
to the prospective payment system hospital without providing a complete 
episode of the type of care furnished by the excluded hospital, then 
Medicare would make inappropriate payments to the hospital-within-a-
hospital. This is the case because payments made to an excluded 
hospital are made on a per-stay basis, up to the hospital's per 
discharge target amount, and any artificial decrease in the hospital's 
cost per stay could lead to the hospital inappropriately circumventing, 
through decreased length of stay, its target amount cap and receiving 
inappropriate bonus and relief payments under section 4415 of the BBA.
    We believe it is important to address possible financial incentives 
for inappropriate early discharges from excluded hospitals-within-
hospitals to prospective payment system hospitals. Therefore, in the 
proposed rule, we discussed several approaches for preventing 
inappropriate Medicare payments to an excluded hospital-within-a-
hospital for inappropriate discharges to the prospective payment system 
hospital in which it is located. One approach was to provide that, if 
an excluded hospital-within-a-hospital transfers patients from its beds 
to beds of the prospective payment system hospital in which it is 
located, the hospital-within-a-hospital would not qualify for exclusion 
in the next cost reporting period. A second possible approach was to 
provide that the hospital-within-a-hospital would qualify for exclusion 
if it transfers patients to the prospective payment system hospital 
only when the services the patients require cannot be furnished by the 
hospital-within-a-hospital.
    After considering these options, we decided to propose a third 
approach. We proposed to deny exclusion to a hospital-within-a-hospital 
for a cost reporting period if, during the most recent cost reporting 
period for which information is available, the excluded hospital-
within-a-hospital transferred more than 5 percent of its inpatients to 
the prospective payment system hospital in which it is located. We 
stated that we believe that a 5-percent allowance of transfers under 
this approach would (1) avoid the need for administratively burdensome 
case review, (2) provide adequate flexibility for transfers in those 
cases in which the hospital-within-a-hospital is not equipped or 
staffed to provide the services required by the patient, and (3) limit 
the extent to which patients may be transferred inappropriately.
    We solicited comments on our proposed approach as well as 
suggestions on other ways to address the possible incentives for 
inappropriate transfers in a manner that is administratively feasible.
    We received 30 comments in response to our proposal and 
solicitation.
    Comment: Several commenters argued that the choice of a 5-percent 
limit on discharges to the host prospective payment system hospital was 
arbitrary, and that we did not cite any study or other empirical 
evidence in support of it. Other commenters stated that the proposal 
could discourage excluded

[[Page 41536]]

hospitals-within-hospitals from admitting medically complex cases, thus 
contributing to a shortage of certain types of care. Other commenters, 
including a number of physicians, respiratory therapists, and other 
clinical personnel, expressed concern that the proposed rule could 
discourage medically appropriate transfers and thus limit patients' 
ability to receive needed care. One commenter indicated that the 
proposed rule was stated only in terms of transfers from the excluded 
hospital-within-a-hospital to the host prospective payment system 
hospital, while the problems described in the preamble involve 
transfers of patients from the excluded hospital-within-a-hospital to 
the host prospective payment system hospital, followed by readmission 
of the patient to the excluded hospital-within-a-hospital. Other 
commenters suggested that while these transfers might be abusive, the 
sanction identified in the proposed rule--loss of the exclusion from 
the prospective payment system of the hospital-within-a-hospital--is 
disproportionate to the problem.
    Response: After review of all comments on this issue, we have 
decided to modify our approach. First, we agree with those commenters 
who stated that the primary focus of concern should not be discharges 
from the excluded hospital-within-a-hospital to the host prospective 
payment system hospital, but rather should include situations in which 
the discharges are then followed by readmissions to the excluded 
hospital-within-a-hospital, without any intervening movement of the 
patient from the host hospital to a skilled nursing facility, his or 
her home, or another hospital. Thus, we are revising the regulations to 
address only the latter situations.
    We also agree that there is a better way to address inappropriate 
transfers and readmissions. When the level of inappropriate transfers 
exceeds the threshold level described below, we will, instead of 
terminating a hospital's exclusion, simply not consider the earlier 
discharge in these cases to have occurred, for purposes of calculating 
the payment to the hospital or unit. That is, if a patient is 
discharged from an excluded hospital-within-a-hospital to the host 
prospective payment system hospital and is then readmitted to the 
excluded hospital-within-a-hospital directly from the host hospital, 
the readmission would mean that the earlier discharge(s) from the 
excluded hospital will not be taken into account in calculating 
payments to the hospital-within-a-hospital under the excluded hospital 
payment provisions and their implementing regulations in Sec. 413.40.
    We also considered whether this policy should be applied in all 
cases or only if a specific threshold is exceeded. We continue to 
believe that the types of cases described (discharge of the patient to 
the host prospective payment system hospital, followed by readmission 
directly to the excluded hospital-within-a-hospital) are potentially 
vulnerable to abuse and that, in principle, we should adopt a policy of 
``zero tolerance'' for these cases. At the same time, we are aware that 
this stringent approach might be difficult and controversial to 
implement and could have the unintended effect of discouraging some 
medically necessary or appropriate discharges to the host hospital. 
Therefore, we will allow a 5-percent margin to hospitals for these 
cases, in that we would not count the first discharge for purposes of 
payment as an excluded hospital only when the excluded hospital's 
number of these cases in a particular cost reporting year exceeded 5 
percent of the total number of its discharges. If a hospital exceeds 
this 5-percent threshold, we would, with respect to these cases, not 
include any previous discharges to the host prospective payment system 
hospital in calculating the excluded hospital's cost per discharge. 
That is, the entire stay would be considered one ``discharge'' for 
purposes of payments to the hospital.
    For example, assume that a patient was discharged from the excluded 
hospital-within-a-hospital to the prospective payment system hospital 
in which it is located and then was readmitted to the excluded 
hospital-within-a-hospital from the prospective payment system hospital 
(the ``host''). If the total number of discharges (to all locations) of 
the hospital-within-a-hospital in the cost reporting period is 100 and 
the number readmitted from the host after having been previously 
discharged to it is 3, the percentage would be 3 percent (3 divided by 
100), and all of the discharges, including the previous discharge to 
the host, would be taken into account. However, if the total number of 
discharges had been only 50, and of those, 3 patients had been 
readmitted from the host after a previous discharge to it, the 
percentage would be 6 percent (3 divided by 50) and the first discharge 
of the patients readmitted to the host would not be counted. Therefore, 
payment would be based on 47 discharges. In determining whether a 
patient had previously been discharged and then readmitted, we would 
consider all prior discharges, even if the discharge occurred late in 
one cost reporting period and the readmission occurred in the next cost 
reporting period.
    Thus, in the May 7, 1999 proposed rule, we proposed to deny 
exclusion to a hospital-within-a-hospital if, during the most recent 
cost reporting period for which information is available, the excluded 
hospital-within-a-hospital transferred more than 5 percent of its 
inpatients to the prospective payment system hospital in which it is 
located. After considering the public comments, in this final rule we 
are implementing a policy that differs from the proposed policy in two 
significant ways. First, rather than focusing solely on discharges to 
the host hospital, we are examining situations involving a discharge to 
the host hospital followed by a readmission to the excluded hospital. 
Second, if the 5-percent threshold is triggered, we would not deny 
exclusion to the hospital-within-a-hospital; instead, the hospital-
within-a-hospital could continue to receive payment as an excluded 
hospital-within-a-hospital, but, for purposes of determining the amount 
of payment, we would not count the first discharge for those cases 
involving a discharge followed by readmission. (If the 5-percent 
threshold is not triggered, then all discharges would be counted.)
    We continue to believe that the 5-percent threshold is appropriate 
to trigger special payment rules. We are trying to prevent 
inappropriate payments to hospitals for inappropriate transfers, and a 
5-percent threshold reflects a balance of a number of considerations. 
As indicated in the proposed rule, a 5-percent threshold would (1) 
avoid the need for administratively burdensome case review (to 
determine whether discharges or readmissions were inappropriate), (2) 
provide adequate flexibility for transfers in those cases in which the 
hospital-within-a-hospital is not equipped or staffed to provide the 
services required by the patient, and (3) address possible incentives 
for hospitals to transfer patients inappropriately.
    The rationale for this policy is largely conceptual in nature, and 
the 5-percent threshold is not based solely on any one source of 
statistics or data available to us. If we tried to set a threshold 
based solely on such statistics, it might be extremely difficult and 
time-consuming to distinguish between appropriate transfers and 
inappropriate transfers. Given the importance of preventing 
inappropriate payments, we believe it would not be prudent to delay 
implementing this policy. At this time, we believe that a 5-percent 
``allowance'' reflects an appropriate balance of the considerations 
discussed above and is

[[Page 41537]]

consistent with information available to us. However, we will continue 
to monitor this issue and review data, and we might revise the 
threshold in a future rulemaking if information indicates that a 
revision is appropriate.
    We are revising the definition of ``ceiling'' in Sec. 413.40(a)(3) 
to implement our revised policy.
    Comment: Some commenters asked whether the intent of the proposed 
rule was to exclude hospitals-within-hospitals described under 
Sec. 412.22(f) from the provision on responsibility for care of 
patients, since the proposed rule would have added a new paragraph 
(e)(6), and existing Sec. 412.22(f) states that the rules in paragraph 
(e) do not apply to hospitals described in paragraph (f).
    Response: As discussed above, we are not proceeding with the 
proposed changes at Sec. 412.22(e)(6) and are instead implementing our 
revised policy by amending the definition of ``ceiling'' in 
Sec. 413.40(a)(3). The hospitals described in Sec. 412.22(f) will be 
subject to the new policy on the same basis as other hospitals-within-
hospitals.

E. Critical Access Hospitals (CAHs)

1. Emergency Response Time Requirements for CAHs in Frontier and Remote 
Areas
    Because of the high cost of staffing rural hospital emergency rooms 
and the low volume of services in those facilities, we do not require 
CAHs to have emergency personnel on site at all times. Thus, for CAHs, 
the regulations at Sec. 485.618(d) require a doctor of medicine or a 
doctor of osteopathy, a physician assistant, or a nurse practitioner 
with training and experience in emergency care to be on call and 
immediately available by telephone or radio contact, and available on 
site within 30 minutes, on a 24-hour basis. We included this 
requirement because we recognize the need of rural residents to have 
reasonable access to emergency care in their local communities.
    Section 1820(h) of the Act, as added by section 4201 of the BBA, 
states that any medical assistance facility (MAF) in Montana shall be 
deemed to have been certified by the Secretary as a CAH if that 
facility is otherwise eligible to be designated by the State as a CAH. 
However, under the current requirements, following the initial 
transition of a MAF to CAH status, the former MAF would be subject to 
the CAH requirements during any subsequent review, one of which is the 
30-minute emergency response time for emergency services currently 
required under Sec. 485.518(d).
    Some facilities have suggested that in many ``frontier'' areas 
(that is, those having fewer than six residents per square mile), the 
requirement of a 30-minute response might be too restrictive for CAHs, 
especially those MAFs transitioning to CAH status.
    In order to recognize the special needs of sparsely populated rural 
areas in meeting beneficiaries' health needs, and at the same time to 
protect patients' health and safety, in the May 7, 1999 proposed rule, 
we proposed to revise Sec. 485.618(d) to allow a response time of up to 
60 minutes for a CAH if (1) it is located in an area of the State that 
is defined as a frontier area (that is, having fewer than six residents 
per square mile based on the latest population data published by the 
Bureau of the Census) or meets other criteria for a remote location 
adopted by the State and approved by HCFA under criteria specified in 
its rural health care plan under section 1820(b) of the Act; (2) the 
State determines that, under its rural health care plan, allowing the 
longer emergency response time is the only feasible method of providing 
emergency care to residents of the area; and (3) the State maintains 
documentation showing that a response time of up to 60 minutes at a 
particular CAH it designates is justified because other available 
alternatives would increase the time required to stabilize the patient 
in an emergency. The criteria for remote location would, like other 
parts of the rural health care plan, be subject to review and approval 
by the HCFA Regional Office, as would the State's documentation 
regarding the emergency response time.
    We noted that, under the terms of the Montana State Code applicable 
to MAFs, at times when no emergency response person is available to 
come to the facility, a MAF's director of nursing is permitted to come 
to the facility and authorize the transfer of a patient seeking 
emergency services to another facility. Under one possible reading of 
the State requirement, this activity could be seen as an alternative 
way of complying with the emergency services requirement and the MAF's 
(and CAH's) responsibilities under section 1867 of the Act (the 
Emergency Medical Treatment and Active Labor Amendments Provision) to 
provide emergency medical screening and stabilization services to 
patients who come to the hospital seeking emergency treatment. We 
requested comments on whether the Medicare regulations in 
Secs. 485.618(d) and 489.24 should be further revised to explicitly 
permit this practice to continue following the transition of a MAF to 
CAH status. We were particularly interested in obtaining comments from 
practitioners on the risks and benefits involved in adoption of this 
practice.
    We received three comments on our proposal.
    Comment: Two commenters supported our proposal to allow a 60-minute 
emergency response time for frontier areas.
    Response: We appreciate the commenters' support and are adopting 
this proposal as final without change.
    Comment: One commenter believed that the 60-minute response 
timeframe in the proposed rule is too long considering the importance 
of timely provision of emergency care even in remote areas. The 
commenter believes that if a facility wants to function as a CAH, it 
should have appropriate personnel onsite within 30 minutes to provide 
care.
    Response: As we have indicated above, we believe that we must 
recognize the special needs of sparsely populated rural areas in 
meeting beneficiaries' health needs and at the same time protect 
patients' health and safety. We believe our proposed change 
accomplishes this goal.
2. Compliance with Minimum Data Set (MDS) Requirements by CAHs with 
Swing-Bed Approval
    Existing regulations allow CAHs to obtain approval from HCFA to use 
their inpatient beds to provide posthospital SNF care (Sec. 485.645). 
To obtain this approval, however, the CAH must agree to meet specific 
requirements that also apply to SNFs, including the comprehensive 
assessment requirements at Sec. 483.20(b) of the SNF conditions of 
participation.
    Section 483.20(b)(1) specifies that a SNF must make a comprehensive 
assessment of a resident's needs, using the resident assessment 
instrument specified by the State. Section 483.20(b)(2) further 
specifies that, subject to the timeframes in Sec. 413.343(b), the 
assessments must be conducted within 14 calendar days after the patient 
is admitted; within 14 days after the facility determines, or should 
have determined, that there is a significant change in the patient's 
physical or mental condition; and at least once every 12 months. 
Section 413.343(b) specifies that in accordance with the methodology in 
Sec. 413.337(c) related to the adjustment of the Federal rates for 
case-mix (the SNF prospective payment system), patient assessments must 
be performed on the 5th, 14th, 30th, 60th, and 90th days following 
admission.

[[Page 41538]]

    It is clear that the timeframes for patient assessments required 
under Sec. 413.343(b) are linked to the prospective payment system for 
SNFs. The methodology specifically referenced in Sec. 413.337(c) refers 
to the SNF prospective payment system. Therefore, it is apparent that 
the patient assessments and concomitant timeframes for performing such 
assessments are inextricably intertwined with the case-mix adjustment 
under the SNF prospective payment system. CAHs with swing-bed approval 
are not paid for their services to SNF-level patients under that SNF 
prospective payment system but are paid under the payment method 
described in Sec. 413.114, which does not include a case-mix 
adjustment. Therefore, the timeframes for patient assessments as 
dictated by Sec. 413.343(b) are not applicable to CAHs and are not 
required to be met by CAHs. Nevertheless, to make it explicit that the 
patient assessment timeframes required under Sec. 413.343(b) do not 
apply, we proposed to revise Sec. 485.645 to state that the 
requirements in Sec. 413.343(b), and the timeframes specified in 
Sec. 483.20, do not apply to CAHs.
    Comments: We received three comments on this proposal. One 
commenter supported our proposal and stated that the clarification 
would help eliminate the confusion that has existed in the industry. 
Another commenter noted that we do not have a comparable requirement 
for screening patients in swing beds located in all other rural 
hospitals and therefore believes it is inappropriate to implement a 
standard for CAHs that exceed normal practice. Another commenter 
objected to the proposed clarification as inflexible and biased and 
urged us to defer implementing the screening policy for swing beds for 
CAHs until we have established overall policy for swing beds.
    Response: We believe that the changes we have proposed have revised 
the rules to allow for flexibility for CAHs. As stated above, CAHs with 
swing-bed approval are not paid for their services to SNF-level 
patients under the SNF prospective payment system but are paid under 
the payment method described in Sec. 413.114, which does not include a 
case-mix adjustment. However, swing beds in rural hospitals are paid 
under the SNF prospective payment system. As explained above, the 
changes proposed to the reporting requirements for CAHs are intended to 
allow the policy to be consistent with the payment policy for swing 
beds in CAHs. With the change, we are making it explicit that the 
patient assessment timeframes required under Secs. 413.343(b) and 
483.20 do not apply to CAHs.
3. Additional Comments Received on CAH Issues
    We received comments on two separate issues regarding CAHs on which 
we did not propose policy changes.
    Comment: One commenter believes that the definition of CAH is 
prohibitive in one State and recommended that we change the criteria 
for CAHs to allow a hospital that meets all the criteria except for 
being located in an urban (versus a rural) area to be considered a CAH.
    Response: We would need a change in the statute to authorize a 
change in the requirements for CAH designation, as the commenter 
recommended. Section 1820(c)(2)(B)(i) of the Act provides that a State 
may designate a facility as a CAH only if the hospital is located in a 
rural area as defined in section 1886(d)(2)(D) of the Act. Thus, we did 
not revise our regulations to address this comment.
    Comment: One commenter suggested that the reasonable cost payment 
methodology for CAHs should extend to ambulance services and requested 
that HCFA address this in the final rule.
    Response: The provision of law governing payment for outpatient CAH 
services, section 1834(g) of the Act, states that reasonable cost 
payment is to be made for outpatient CAH services. These services are 
defined, at section 1861(mm)(3) of the Act, as medical and other health 
services furnished by a CAH on an outpatient basis. Consistent with our 
policy on ambulance services, these services are treated under a 
separate benefit and are covered and paid for under separate statutory 
authority and a separate payment method. Therefore, we have no basis on 
which to authorize reasonable cost payment for ambulance services .

VII. MedPAC Recommendations

    As required by law, we reviewed the March 1, 1999 report submitted 
by MedPAC to the Congress and gave its recommendations careful 
consideration in conjunction with the proposals set forth in the May 7, 
1999 proposed rule. We also responded to the individual recommendations 
in the proposed rule. The comments we received on the treatment of the 
MedPAC recommendations are set forth below, along with our responses to 
those comments. However, if we received no comments from the public 
concerning a MedPAC recommendation or our response to that 
recommendation, we have not repeated the recommendation. 
Recommendations concerning the update factors for inpatient operating 
cost and for hospitals and hospital distinct part units excluded from 
the prospective payment system are discussed in Appendix C of this 
final rule.

A. Excluded Hospitals and Hospital Units (Recommendations 4B and 4C)

    Recommendation: The Congress should adjust the wage-related portion 
of the excluded hospital target amount caps (the 75th percentile of 
target amounts for hospitals in the same class (psychiatric hospital or 
unit, rehabilitation hospital or unit, or long-term care hospitals)) to 
account for geographic differences in labor costs. The Commission 
presumes legislation would be necessary to adjust the caps for wages.
    Response in the Proposed Rule: We previously addressed this issue 
in the May 12, 1998 final rule (63 FR 26345). In that discussion, we 
explain why we believe the statutory language, the statutory scheme, 
and the legislative history, viewed together, strongly argue against 
making a wage adjustment in applying the target amount caps under the 
current statute.
    Comment: We received two comments on our response to the MedPAC 
recommendation regarding the wage related portion of the excluded 
hospital target amount cap. Specifically, MedPAC commented that it 
would encourage HCFA to seek legislative authority to adjust the target 
amount caps for area wages. The other commenter asserted that such 
adjustments should be made since they are used for new facilities and 
because the exclusion of an adjustment is unfair to regions with higher 
labor costs.
    Response: In the May 12, 1998 final rule, we explained our decision 
not to wage adjust the caps on the target amounts. The decision was 
based on our analysis of the statutory language, the statutory scheme, 
the legislative history, and policy considerations. First, we noted 
that section 4414 of the BBA, which provides that ``* * * in the case 
of a hospital or unit that is within a class of hospital described in 
clause (iv), the Secretary shall estimate the 75th percentile of the 
target amounts for such hospitals within such class for cost reporting 
periods ending during fiscal year 1996,'' directs the Secretary to 
examine target amounts and calculate a single number for each of three 
classes of hospitals. In addition, we stated that while the statutory 
language directs the Secretary to calculate the 75th percentile of 
target amounts, it does not explicitly direct or even authorize the 
Secretary to make adjustments to that

[[Page 41539]]

number after it is calculated. We agree that the absence of an explicit 
instruction, in and of itself, does not necessarily mean that the 
Secretary cannot implement a wage adjustment. However, Congressional 
``silence'' on this issue must be construed in light of the statutory 
scheme and the legislative history, as well as policy considerations.
    With regard to the statutory scheme, we stated that in requiring 
that we calculate a separate number for each class of hospitals, the 
Congress established a scheme that directs us to recognize differences 
across types of hospitals, but does not direct us to recognize 
differences in wages. In addition to the scheme of section 4414 itself, 
we considered this section in light of other statutory provisions. We 
concluded that, because the Congress explicitly requires wage 
adjustments in some contexts, failure to require a wage adjustment in 
this context reflects a judgement by the Congress that we should not 
make one under section 4414. In terms of the legislative history, we 
noted that there is no reference in the Conference Report to a wage 
adjustment to the TEFRA caps.
    Finally, we asserted that while from a broad policy perspective a 
wage adjustment might be appropriate, policy considerations do not 
dictate a wage adjustment. A payment cap is different from a payment 
rate in that a cap only affects hospitals that are above the cap, while 
a payment rate affects all hospitals. Thus, we believe that while a 
wage adjustment might be preferable policy, the lack of a wage 
adjustment is not unreasonable. We stated that we would support a 
hospital-sponsored legislative change to permit wage adjustments and we 
will continue to do so; however, our decision, as expressed in the May 
12, 1998 final rule, remains unchanged.

B. Disproportionate Share Hospitals (DSH) (Recommendations 3C, 3D, and 
3E)

    Recommendations: The Congress should require that disproportionate 
share payments be distributed according to each hospital's share of 
low-income patient costs, defined broadly to include all care to the 
poor. The measure of low-income costs should reflect: (1) Medicare 
patients eligible for Supplemental Security Income, Medicaid patients, 
patients sponsored by other indigent care programs, and uninsured and 
underinsured patients as represented by uncompensated care (both 
charity and bad debts); and (2) services provided in both inpatient and 
outpatient settings.
    As under current policy, disproportionate share payment should be 
made in the form of an adjustment to the per-case payment rate. In this 
way, the total payment each hospital receives will reflect its volume 
of Medicare patients.
    Through a minimum threshold for low-income share, the formula for 
distributing disproportionate share payments should concentrate 
payments among hospitals with the highest shares of poor patients. A 
reasonable range for this threshold would be levels that make between 
50 percent and 60 percent of hospitals eligible for a payment. However, 
the size of the payment adjustment should increase gradually from zero 
at the threshold. The same distribution formula should apply to all 
hospitals covered by prospective payment.
    The Secretary should collect the data necessary to revise the 
disproportionate share payment system from all hospitals paid under the 
prospective payment system.
    Response in the Proposed Rule: We continue to give careful 
consideration to MedPAC's recommendations concerning the DSH adjustment 
made to operating payments under the prospective payment system.
    We are in the process of preparing a report to the Congress on the 
Medicare DSH adjustment that includes several options for amending the 
statutory disproportionate share adjustment formula. We believe that 
any adjustment to the DSH formula or data sources should be directed 
and supported by the Congress.
    The MedPAC option involves collecting data on uncompensated care, 
that is, charity and bad debts. Ideally, this would be a direct measure 
of a hospital's indigent care burden. However, there are problems 
associated with verification of such data and consistency of reporting 
nationally. We appreciate the Commission's recommendations about and 
assistance with the Medicare DSH adjustment as we formulate our 
legislative proposal and await Congressional action.
    Comment: MedPAC commented that it does not believe that the 
verification process for uncompensated care (charity and bad debt) data 
needs to be burdensome. It recommends that HCFA keep reporting 
requirements to a minimum to limit data collection problems. 
Specifically, MedPAC recommends that HCFA collect only total 
uncompensated care data rather than separate data on the two components 
of uncompensated care--bad debts and charity care. HCFA should publish 
guidelines specifying the types of unpaid charges that can be included 
so that reporting problems are minimal.
    Response: As we noted in our response to this recommendation in the 
proposed rule, we are preparing a Report to Congress on the revision of 
the DSH adjustment formula and have taken into consideration the 
inclusion of a recommendation to collect uncompensated care charge data 
by payer category (inpatient and outpatient) for our analysis. We 
believe it is important to promote the consistent reporting of data to 
the extent possible. We plan to minimize reporting problems by 
collecting only total uncompensated care data, thereby avoiding the 
problem of different definitions of bad debts, indigent care, and 
uncompensated care among States. However, we continue to anticipate 
other reporting problems such as hospital recordkeeping of these data.

VIII. Other Required Information

Requests for Data from the Public

    In order to respond promptly to public requests for data related to 
the prospective payment system, we have set up a process under which 
commenters can gain access to the raw data on an expedited basis. 
Generally, the data are available in computer tape or cartridge format; 
however, some files are available on diskette as well as on the 
Internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. In our May 7, 1999 
proposed rule, we published a list of data files that are available for 
purchase (64 FR 24746 and 24747).

List of Subjects

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

42 CFR Part 483

    Grant programs-health, Health facilities, Health professions, 
Health records, Medicaid, Medicare, Nursing homes, Nutrition, Reporting 
and recordkeeping requirements, Safety.

42 CFR Part 485

    Grant programs-health, Health facilities, Medicaid, Medicare, 
Reporting and recordkeeping requirements.


[[Page 41540]]


    42 CFR Chapter IV is amended as set forth below:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    A. Part 412 is amended as follows:
    1. The authority citation for Part 412 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. In Sec. 412.2, the introductory text of paragraph (e) is 
republished and paragraph (e)(4) is revised to read as follows:


Sec. 412.2  Basis of payment.

* * * * *
    (e) Excluded costs. The following inpatient hospital costs are 
excluded from the prospective payment amounts and are paid on a 
reasonable cost basis:
* * * * *
    (4) Heart, kidney, liver, lung, and pancreas acquisition costs 
incurred by approved transplantation centers.
* * * * *
    3. Section 412.22 is amended by adding a new paragraph (h) to read 
as follows:


Sec. 412.22  Excluded hospitals and hospital units: General rules.

* * * * *
    (h) Satellite facilities. (1) For purposes of paragraphs (h)(2) 
through (h)(4) of this section, a satellite facility is a part of a 
hospital that provides inpatient services in a building also used by 
another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital.
    (2) Except as provided in paragraph (h)(3) of this section, 
effective for cost reporting periods beginning on or after October 1, 
1999, a hospital that has a satellite facility must meet the following 
criteria in order to be excluded from the prospective payment systems 
for any period:
    (i) In the case of a hospital (other than a children's hospital) 
that was excluded from the prospective payment systems for the most 
recent cost reporting period beginning before October 1, 1997, the 
hospital's number of State-licensed and Medicare-certified beds, 
including those at the satellite facilities, does not exceed the 
hospital's number of State-licensed and Medicare-certified beds on the 
last day of the hospital's last cost reporting period beginning before 
October 1, 1997.
    (ii) The satellite facility independently complies with--
    (A) For psychiatric hospitals, the requirements under 
Sec. 412.23(a);
    (B) For rehabilitation hospitals, the requirements under 
Sec. 412.23(b)(2);
    (C) For children's hospitals, the requirements under 
Sec. 412.23(d)(2); or
    (D) For long-term care hospitals, the requirements under 
Secs. 412.23(e)(1) through (e)(3)(i).
    (iii) The satellite facility meets all of the following 
requirements:
    (A) It maintains admission and discharge records that are 
separately identified from those of the hospital in which it is located 
and are readily available.
    (B) It has beds that are physically separate from (that is, not 
commingled with) the beds of the hospital in which it is located.
    (C) It is serviced by the same fiscal intermediary as the hospital 
of which it is a part.
    (D) It is treated as a separate cost center of the hospital of 
which it is a part.
    (E) For cost reporting and apportionment purposes, it uses an 
accounting system that properly allocates costs and maintains adequate 
statistical data to support the basis of allocation.
    (F) It reports its costs on the cost report of the hospital of 
which it is a part, covering the same fiscal period and using the same 
method of apportionment as the hospital of which it is a part.
    (3) Except as provided in paragraph (h)(4) of this section, the 
provisions of paragraph (h)(2) of this section do not apply to--
    (i) Any hospital structured as a satellite facility on September 
30, 1999, and excluded from the prospective payment systems on that 
date, to the extent the hospital continues operating under the same 
terms and conditions, including the number of beds and square footage 
considered, for purposes of Medicare participation and payment, to be 
part of the hospital, in effect on September 30, 1999; or
    (ii) Any hospital excluded from the prospective payment systems 
under Sec. 412.23(e)(2).
    (4) In applying the provisions of paragraph (h)(3) of this section, 
any hospital structured as a satellite facility on September 30, 1999, 
may increase or decrease the square footage of the satellite facility 
or may decrease the number of beds in the satellite facility if these 
changes are made necessary by relocation of a facility--
    (i) To permit construction or renovation necessary for compliance 
with changes in Federal, State, or local law; or
    (ii) Because of catastrophic events such as fires, floods, 
earthquakes, or tornadoes.
    4. Section 412.25 is amended by revising paragraphs (b) and (c) and 
adding a new paragraph (e) to read as follows:


Sec. 412.25  Excluded hospital units: Common requirements.

* * * * *
    (b) Changes in the size of excluded units. For purposes of 
exclusions from the prospective payment systems under this section, 
changes in the number of beds and square footage considered to be part 
of each excluded unit are allowed as specified in paragraphs (b)(1) 
through (b)(3) of this section.
    (1) Increase in size. Except as described in paragraph (b)(3) of 
this section, the number of beds and square footage of an excluded unit 
may be increased only at the start of a cost reporting period.
    (2) Decrease in size. Except as described in paragraph (b)(3) of 
this section, the number of beds and square footage of an excluded unit 
may be decreased at any time during a cost reporting period if the 
hospital notifies its fiscal intermediary and the HCFA Regional Office 
in writing of the planned decrease at least 30 days before the date of 
the decrease, and maintains the information needed to accurately 
determine costs that are attributable to the excluded unit. Any 
decrease in the number of beds or square footage considered to be part 
of an excluded unit made during a cost reporting period must remain in 
effect for the rest of that cost reporting period.
    (3) Exception to changes in square footage and bed size. The number 
of beds in an excluded unit may be decreased, and the square footage 
considered to be part of the unit may be either increased or decreased, 
at any time, if these changes are made necessary by relocation of a 
unit--
    (i) To permit construction or renovation necessary for compliance 
with changes in Federal, State, or local law affecting the physical 
facility; or
    (ii) Because of catastrophic events such as fires, floods, 
earthquakes, or tornadoes.
    (c) Changes in the status of hospital units. For purposes of 
exclusions from the prospective payment systems under this section, the 
status of each hospital unit (excluded or not excluded) is determined 
as specified in paragraphs (c)(1) and (c)(2) of this section.
    (1) The status of a hospital unit may be changed from not excluded 
to excluded only at the start of the cost reporting period. If a unit 
is added to a

[[Page 41541]]

hospital after the start of a cost reporting period, it cannot be 
excluded from the prospective payment systems before the start of a 
hospital's next cost reporting period.
    (2) The status of a hospital unit may be changed from excluded to 
not excluded at any time during a cost reporting period, but only if 
the hospital notifies the fiscal intermediary and the HCFA Regional 
Office in writing of the change at least 30 days before the date of the 
change, and maintains the information needed to accurately determine 
costs that are or are not attributable to the excluded unit. A change 
in the status of a unit from excluded to not excluded that is made 
during a cost reporting period must remain in effect for the rest of 
that cost reporting period.
* * * * *
    (e) Satellite facilities. (1) For purposes of paragraphs (e)(2) 
through (e)(4) of this section, a satellite facility is a part of a 
hospital unit that provides inpatient services in a building also used 
by another hospital, or in one or more entire buildings located on the 
same campus as buildings used by another hospital.
    (2) Except as provided in paragraph (e)(3) of this section, 
effective for cost reporting periods beginning on or after October 1, 
1999, a hospital unit that establishes a satellite facility must meet 
the following requirements in order to be excluded from the prospective 
payment systems for any period:
    (i) In the case of a unit excluded from the prospective payment 
systems for the most recent cost reporting period beginning before 
October 1, 1997, the unit's number of State-licensed and Medicare-
certified beds, including those at the satellite facility, does not 
exceed the unit's number of State-licensed and Medicare-certified beds 
on the last day of the unit's last cost reporting period beginning 
before October 1, 1997.
    (ii) The satellite facility independently complies with--
    (A) For a rehabilitation unit, the requirements under 
Sec. 412.23(b)(2); or
    (B) For a psychiatric unit, the requirements under Sec. 412.27(a).
    (iii) The satellite facility meets all of the following 
requirements:
    (A) It maintains admission and discharge records that are 
separately identified from those of the hospital in which it is located 
and are readily available.
    (B) It has beds that are physically separate from (that is, not 
commingled with) the beds of the hospital in which it is located.
    (C) It is serviced by the same fiscal intermediary as the hospital 
unit of which it is a part.
    (D) It is treated as a separate cost center of the hospital unit of 
which it is a part.
    (E) For cost reporting and apportionment purposes, it uses an 
accounting system that properly allocates costs and maintains adequate 
statistical data to support the basis of allocation.
    (F) It reports its costs on the cost report of the hospital of 
which it is a part, covering the same fiscal period and using the same 
method of apportionment as the hospital of which it is a part.
    (3) Except as specified in paragraph (e)(4) of this section, the 
provisions of paragraph (e)(2) of this section do not apply to any unit 
structured as a satellite facility on September 30, 1999, and excluded 
from the prospective payment systems on that date, to the extent the 
unit continues operating under the same terms and conditions, including 
the number of beds and square footage considered to be part of the 
unit, in effect on September 30, 1999.
    (4) In applying the provisions of paragraph (h)(3) of this section, 
any unit structured as a satellite facility as of September 30, 1999, 
may increase or decrease the square footage of the satellite facility 
or may decrease the number of beds in the satellite facility at any 
time, if these changes are made necessary by relocation of the 
facility--
    (i) To permit construction or renovation necessary for compliance 
with changes in Federal, State, or local law affecting the physical 
facility; or
    (ii) Because of catastrophic events such as fires, floods, 
earthquakes, or tornadoes.


Sec. 412.105  [Amended]

    5. Section 412.105 is amended by revising the cross reference 
``paragraph (g)(1)(ii) of this section'' in paragraphs (f)(1)(iii) 
(three times) and (f)(2)(v) to read ``paragraph (f)(1)(ii) of this 
section''.


Sec. 412.256  [Amended]

    6. In Sec. 412.256, paragraph (c)(2), the date ``October 1'', 
appearing in two places, is revised to read ``September 1''.
    7. Section 412.276 is amended by revising paragraph (a) to read as 
follows:


Sec. 412.276  Timing of MGCRB decision and its appeal.

    (a) Timing. The MGCRB notifies the parties in writing, with a copy 
to HCFA, and issues a decision within 180 days after the first day of 
the 13-month period preceding the Federal fiscal year for which a 
hospital has filed a complete application. The hospital has 15 days 
from the date of the decision to request Administrator review.
* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED 
PAYMENT RATES FOR SKILLED NURSING FACILITIES

    B. Part 413 is amended as follows:
    1. The authority citation for Part 413 is revised to read as 
follows:

    Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and 
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42 
U.S.C. 1302, 1395f(b), 1395g, 1395l, 1395l(a), (i), and (n), 
1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww).

    2. Section 413.40 is amended by adding a sentence containing 
paragraphs (A) and (B) at the end of the definition of ``ceiling'' in 
paragraph (a)(3) and revising paragraphs (b)(1)(iii), (c)(4)(v), 
(f)(2)(ii)(A), and (g)(1) to read as follows:


Sec. 413.40  Ceiling on the rate-of-increase in hospital inpatient 
costs.

    (a) Introduction. * * *
    (3) Definitions. * * *
    Ceiling * * * For a hospital-within-a-hospital, as described in 
Sec. 412.22(e) of this chapter, the number of Medicare discharges in a 
cost reporting period does not include discharges of a patient to 
another hospital in the same building on or on the same campus, if--
    (A) The patient is subsequently readmitted to the hospital-within-
a-hospital directly from the other hospital; and
    (B) The hospital-within-a-hospital has discharged to the other 
hospital and subsequently readmitted more than 5 percent (that is, in 
excess of 5.0 percent) of the total number of inpatients discharged 
from the hospital-within-a-hospital in that cost reporting period.
* * * * *
    (b) Cost reporting periods subject to the rate-of-increase ceiling. 
(1) Base period. * * *
    (iii) When the operational structure of a hospital or unit changes 
(that is, a freestanding hospital becomes an excluded unit or an 
excluded unit becomes a freestanding hospital, or an entity of a 
multicampus hospital becomes a newly created hospital or unit or a 
hospital or unit becomes a part of a multicampus hospital), the base 
period for the hospital or unit that

[[Page 41542]]

changed its operational structure is the first cost reporting period of 
at least 12 months effective with the revised Medicare certification 
classification.
* * * * *
    (c) Cost subject to the ceiling. * * *
    (4) Target amounts. * * *
    (v) In the case of a hospital that received payments under 
paragraph (f)(2)(ii) of this section as a newly created hospital or 
unit, to determine the hospital's target amount for the hospital's 
third 12-month cost reporting period, the payment amount determined 
under paragraph (f)(2)(ii) of this section for the preceding cost 
report period is updated to the third cost reporting period.
* * * * *
    (f) Comparison to the target amount for new hospitals and units. * 
* *
    (2) Comparison. * * *
    (ii) Median target amount. (A) For cost reporting periods beginning 
on or after October 1, 1997, the amount of payment for a new 
psychiatric hospital or unit, a new rehabilitation hospital or unit, or 
a new long-term care hospital that was not paid as an excluded hospital 
prior to October 1, 1997, is the lower of the hospital's net inpatient 
operating cost per case or 110 percent of the national median of the 
target amounts for the class of excluded hospitals and units 
(psychiatric, rehabilitation, long-term care) as adjusted for 
differences in wage levels and updated to the first cost reporting 
period in which the hospital receives payment. The second cost 
reporting period is subject to the same target amount as the first cost 
reporting period.
* * * * *
    (g) Adjustment. (1) General rules. (i) HCFA adjusts the amount of 
the operating costs considered in establishing the rate-of-increase 
ceiling for one or more cost reporting periods, including both periods 
subject to the ceiling and the hospital's base period, under the 
circumstances specified in paragraphs (g)(2), (g)(3), and (g)(4) of 
this section.
    (ii) When the hospital requests an adjustment, HCFA makes an 
adjustment only to the extent that the hospital's operating costs are 
reasonable, attributable to the circumstances specified separately, 
identified by the hospital, and verified by the intermediary.
    (iii) When the hospital requests an adjustment, HCFA makes an 
adjustment only if the hospital's operating costs exceed the rate-of-
increase ceiling imposed under this section.
    (iv) In the case of a psychiatric hospital or unit, rehabilitation 
hospital or unit, or long-term care hospital, the amount of payment 
under paragraph (g)(3) of this section may not exceed the payment 
amount based on the target amount determined under paragraph 
(c)(4)(iii) of this section.
    (v) In the case of a hospital or unit that received a revised FY 
1998 target amount under the rebasing provisions of paragraph 
(b)(1)(iv) of this section, the amount of an adjustment payment for a 
cost reporting period is based on a comparison of the hospital's 
operating costs for the cost reporting period to the average costs and 
statistics for the cost reporting periods used to determine the FY 1998 
rebased target amount.
* * * * *


Sec. 413.86  [Amended]

    3. Section 413.86 is amended as follows:
    a. In paragraph (b), the definition of ``approved geriatric 
program'' is revised to read as set forth below.
    b. In paragraph (b), under paragraph (1) of the definition of 
``approved medical residency program'', the reference ``Sec. 415.200(a) 
of this chapter'' is revised to read ``Sec. 415.152 of this chapter''.
    c. In paragraph (e)(1)(ii)(C), the reference ``paragraph (j)(2) of 
this section'' is revised to read ``paragraph (k)(1) of this section''.
    d. In paragraph (e)(1)(iv), the reference, ``paragraph (j)(1) of 
this section'', is revised to read ``paragraph (k)(1) of this 
section''.
    e. A new paragraph (f)(4)(iii) is added, paragraphs (g)(1)(i), 
(ii), and (iii), (g)(6) introductory text, (g)(6)(i) and (ii), and the 
first sentence of paragraph (g)(6)(iii) are revised, paragraph (g)(7) 
is redesignated as paragraph (g)(9), and new paragraphs (g)(7) and 
(g)(8) are added to read as follows:


Sec. 413.86  Direct graduate medical education payments.

* * * * *
    (b) * * *
    Approved geriatric program means a fellowship program of one or 
more years in length that is approved by one of the national 
organizations listed in Sec. 415.152 of this chapter under that 
respective organization's criteria for geriatric fellowship programs.
* * * * *
    (f) Determining the total number of FTE residents. * * *
    (4) * * *
    (iii) The hospital must incur all or substantially all of the costs 
for the training program in the nonhospital setting in accordance with 
the definition in paragraph (b) of this section.
    (g) Determining the weighted number of FTE residents. * * *
    (1) * * *
    (i) For residency programs other than those specified in paragraphs 
(g)(1)(ii) and (g)(1)(iii) of this section, the initial residency 
period is the minimum number of years of formal training necessary to 
satisfy the requirements for initial board eligibility in the 
particular specialty for which the resident is training, as specified 
in the most recently published edition of the Graduate Medical 
Education Directory.
    (ii) For residency programs in osteopathy, dentistry, and podiatry, 
the minimum requirement for certification in a specialty or 
subspecialty is the minimum number of years of formal training 
necessary to satisfy the requirements of the appropriate approving body 
listed in Sec. 415.152 of this chapter.
    (iii) For residency programs in geriatric medicine, accredited by 
the appropriate approving body listed in 415.152 of this chapter, these 
programs are considered approved programs on the later of--
    (A) The starting date of the program within a hospital; or
    (B) The hospital's cost reporting periods beginning on or after 
July 1, 1985.
* * * * *
    (6) If a hospital establishes a new medical residency training 
program as defined in paragraph (g)(9) of this section on or after 
January 1, 1995, the hospital's FTE cap described under paragraph 
(g)(4) of this section may be adjusted as follows:
    (i) If a hospital had no allopathic or osteopathic residents in its 
most recent cost reporting period ending on or before December 31, 
1996, and it establishes a new medical residency training program on or 
after January 1, 1995, the hospital's unweighted FTE resident cap under 
paragraph (g)(4) of this section may be adjusted based on the product 
of the highest number of residents in any program year during the third 
year of the first program's existence for all new residency training 
programs and the number of years in which residents are expected to 
complete the program based on the minimum accredited length for the 
type of program. The adjustment to the cap may not exceed the number of 
accredited slots available to the hospital for the new program.
    (A) If the residents are spending an entire program year (or years) 
at one hospital and the remainder of the program at another hospital, 
the adjustment to each respective hospital's

[[Page 41543]]

cap is equal to the product of the highest number of residents in any 
program year during the third year of the first program's existence and 
the number of years the residents are training at each respective 
hospital.
    (B) Prior to the implementation of the hospital's adjustment to its 
FTE cap beginning with the fourth year of the hospital's residency 
program(s), the hospital's cap may be adjusted during each of the first 
3 years of the hospital's new residency program using the actual number 
of residents participating in the new program. The adjustment may not 
exceed the number of accredited slots available to the hospital for 
each program year.
    (C) Except for rural hospitals, the cap will not be adjusted for 
new programs established more than 3 years after the first program 
begins training residents.
    (D) An urban hospital that qualifies for an adjustment to its FTE 
cap under paragraph (g)(6)(i) of this section is not permitted to be 
part of an affiliated group for purposes of establishing an aggregate 
FTE cap.
    (E) A rural hospital that qualifies for an adjustment to its FTE 
cap under paragraph (g)(6)(i) of this section is permitted to be part 
of an affiliated group for purposes of establishing an aggregate FTE 
cap.
    (ii) If a hospital had allopathic or osteopathic residents in its 
most recent cost reporting period ending on or before December 31, 
1996, the hospital's unweighted FTE cap may be adjusted for new medical 
residency training programs established on or after January 1, 1995 and 
on or before August 5, 1997. The adjustment to the hospital's FTE 
resident limit for the new program is based on the product of the 
highest number of residents in any program year during the third year 
of the newly established program and the number of years in which 
residents are expected to complete each program based on the minimum 
accredited length for the type of program.
    (A) If the residents are spending an entire program year (or years) 
at one hospital and the remainder of the program at another hospital, 
the adjustment to each respective hospital's cap is equal to the 
product of the highest number of residents in any program year during 
the third year of the first program's existence and the number of years 
the residents are training at each respective hospital.
    (B) Prior to the implementation of the hospital's adjustment to its 
FTE cap beginning with the fourth year of the hospital's residency 
program, the hospital's cap may be adjusted during each of the first 3 
years of the hospital's new residency program, using the actual number 
of residents in the new programs. The adjustment may not exceed the 
number of accredited slots available to the hospital for each program 
year.
    (iii) If a hospital with allopathic or osteopathic residents in its 
most recent cost reporting period ending on or before December 31, 
1996, is located in a rural area (or other hospitals located in rural 
areas that added residents under paragraph (g)(6)(i) of this section), 
the hospital's unweighted FTE limit may be adjusted in the same manner 
described in paragraph (g)(6)(ii) of this section to reflect the 
increase for residents in the new medical residency training programs 
established after August 5, 1997. * * *
    (7) A hospital that began construction of its facility prior to 
August 5, 1997, and sponsored new medical residency training programs 
on or after January 1, 1995 and on or before August 5, 1997, that 
either received initial accreditation by the appropriate accrediting 
body or temporarily trained residents at another hospital(s) until the 
facility was completed, may receive an adjustment to its FTE cap.
    (i) The newly constructed hospital's FTE cap is equal to the lesser 
of:
    (A) The product of the highest number of residents in any program 
year during the third year of the newly established program and the 
number of years in which residents are expected to complete the 
programs based on the minimum accredited length for each type of 
program; or
    (B) The number of accredited slots available to the hospital for 
each year of the programs.
    (ii) If the new medical residency training programs sponsored by 
the newly constructed hospital have been in existence for 3 years or 
more by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap will be based on the 
number of residents training in the third year of the programs begun at 
the temporary training site.
    (iii) If the new medical residency training programs sponsored by 
the newly constructed hospital have been in existence for less than 3 
years by the time the residents begin training at the newly constructed 
hospital, the newly constructed hospital's cap will be based on the 
number of residents training at the newly constructed hospital in the 
third year of the programs (including the years at the temporary 
training site).
    (iv) A hospital that qualifies for an adjustment to its FTE cap 
under paragraph (g)(7) of this section may be part of an affiliated 
group for purposes of establishing an aggregate FTE cap.
    (v) The provisions of this paragraph (g)(7) are applicable during 
portions of cost reporting periods occurring on or after October 1, 
1999.
    (8) A hospital may receive a temporary adjustment to its FTE cap to 
reflect residents added because of another hospital's closure if the 
hospital meets the following criteria:
    (i) The hospital is training additional residents from a hospital 
that closed on or after July 1, 1996.
    (ii) No later than 60 days after the hospital begins to train the 
residents, the hospital submits a request to its fiscal intermediary 
for a temporary adjustment to its FTE cap, documents that the hospital 
is eligible for this temporary adjustment by identifying the residents 
who have come from the closed hospital and have caused the hospital to 
exceed its cap, and specifies the length of time the adjustment is 
needed.
    (iii) For purposes of paragraph (g)(8) of this section, ``closure'' 
means the hospital terminates its Medicare agreement under the 
provisions of Sec. 489.52 of this chapter.
* * * * *

PART 483--REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES

    C. Part 483 is amended as set forth below:
    1. The authority citation for Part 483 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. In Sec. 483.20, the introductory text of paragraph (b)(2) is 
revised to read as follows:


Sec. 483.20  Resident assessment.

* * * * *
    (b) Comprehensive assessments. * * *
    (2) When required. Subject to the timeframes prescribed in 
Sec. 413.343(b) of this chapter, a facility must conduct a 
comprehensive assessment of a resident in accordance with the 
timeframes specified in paragraphs (b)(2) (i) through (iii) of this 
section. The timeframes prescribed in Sec. 413.343(b) of this chapter 
do not apply to CAHs.
* * * * *

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

    D. Part 485 is amended as follows:
    1. The authority citation for Part 485 continues to read as 
follows:


[[Page 41544]]


    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. Section 485.618 is amended by revising paragraph (d) to read as 
follows:


Sec. 485.618  Conditions of participation: Emergency services.

* * * * *
    (d) Standard: Personnel. There must be a doctor of medicine or 
osteopathy, a physician assistant, or a nurse practitioner with 
training or experience in emergency care on call and immediately 
available by telephone or radio contact, and available on site within 
the following timeframes:
    (1) Within 30 minutes, on a 24-hour a day basis, if the CAH is 
located in an area other than an area described in paragraph (d)(2) of 
this section; or
    (2) Within 60 minutes, on a 24-hour a day basis, if all of the 
following requirements are met:
    (i) The CAH is located in an area designated as a frontier area 
(that is, an area with fewer than six residents per square mile based 
on the latest population data published by the Bureau of the Census) or 
in an area that meets criteria for a remote location adopted by the 
State in its rural health care plan, and approved by HCFA, under 
section 1820(b) of the Act.
    (ii) The State has determined under criteria in its rural health 
care plan that allowing an emergency response time longer than 30 
minutes is the only feasible method of providing emergency care to 
residents of the area served by the CAH.
    (iii) The State maintains documentation showing that the response 
time of up to 60 minutes at a particular CAH it designates is justified 
because other available alternatives would increase the time needed to 
stabilize a patient in an emergency.
* * * * *
    3. In Sec. 485.645, the introductory text of paragraph (d) is 
republished and paragraph (d)(6) is revised to read as follows:


Sec. 485.645  Special requirements for CAH providers of long-term care 
services (``swing beds'').

* * * * *
    (d) SNF services. The CAH is substantially in compliance with the 
following SNF requirements contained in subpart B of part 483 of this 
chapter:
* * * * *
    (6) Comprehensive assessment, comprehensive care plan, and 
discharge planning (Sec. 483.20 (b), (d), and (e) of this chapter, 
except that the CAH is not required to comply with the requirements for 
frequency, scope and number of assessments prescribed in 
Sec. 413.343(b)).
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance)

    Dated: July 21, 1999.
Michael M. Hash,
Deputy Administrator, Health Care Financing Administration.
    Dated: July 22, 1999.
Donna E. Shalala,
Secretary.

    Editorial Note: The following addendum and appendixes will not 
appear in the Code of Federal Regulations.

Addendum--Schedule of Standardized Amounts Effective with 
Discharges Occurring On or After October 1, 1999; Payment Amounts 
for Blood Clotting Factor Effective for Discharges Occurring On or 
After October 1, 1999; and Update Factors and Rate-of-Increase 
Percentages Effective With Cost Reporting Periods Beginning On or 
After October 1, 1999

I. Summary and Background

    In this addendum, we are setting forth the amounts and factors for 
determining prospective payment rates for Medicare inpatient operating 
costs and Medicare inpatient capital-related costs. We are also setting 
forth rate-of-increase percentages for updating the target amounts for 
hospitals and hospital units excluded from the prospective payment 
system.
    For discharges occurring on or after October 1, 1999, except for 
sole community hospitals, Medicare-dependent, small rural hospitals, 
and hospitals located in Puerto Rico, each hospital's payment per 
discharge under the prospective payment system will be based on 100 
percent of the Federal national rate.
    Sole community hospitals are paid based on whichever of the 
following rates yields the greatest aggregate payment: the Federal 
national rate, the updated hospital-specific rate based on FY 1982 cost 
per discharge, or the updated hospital-specific rate based on FY 1987 
cost per discharge. Medicare-dependent, small rural hospitals are paid 
based on the Federal national rate or, if higher, the Federal national 
rate plus 50 percent of the difference between the Federal national 
rate and the updated hospital-specific rate based on FY 1982 or FY 1987 
cost per discharge, whichever is higher. For hospitals in Puerto Rico, 
the payment per discharge is based on the sum of 50 percent of a Puerto 
Rico rate and 50 percent of a national rate.
    As discussed below in section II, we are making changes in the 
determination of the prospective payment rates for Medicare inpatient 
operating costs for FY 2000. The changes, to be applied prospectively, 
affect the calculation of the Federal rates. In section III of this 
addendum, we are updating the payments per unit for blood clotting 
factor provided to hospital inpatients who have hemophilia. We are also 
adding another product (clotting factor, porcine (HCPCS code J7191)) to 
the list of clotting factors that are paid under this benefit.
    In section IV of this addendum, we discuss our changes for 
determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2000. Section V of this addendum sets 
forth our changes for determining the rate-of-increase limits for 
hospitals excluded from the prospective payment system for FY 2000. The 
tables to which we refer in the preamble to this final rule are 
presented at the end of this addendum in section VI.

II. Changes to Prospective Payment Rates For Inpatient Operating 
Costs for FY 2000

    The basic methodology for determining prospective payment rates for 
inpatient operating costs is set forth at Sec. 412.63 for hospitals 
located outside of Puerto Rico. The basic methodology for determining 
the prospective payment rates for inpatient operating costs for 
hospitals located in Puerto Rico is set forth at Secs. 412.210 and 
412.212. Below, we discuss the factors used for determining the 
prospective payment rates. The Federal and Puerto Rico rate changes, 
once issued as final, will be effective with discharges occurring on or 
after October 1, 1999. As required by section 1886(d)(4)(C) of the Act, 
we must also adjust the DRG classifications and weighting factors for 
discharges in FY 2000.
    In summary, the standardized amounts set forth in Tables 1A and 1C 
of section VI of this addendum reflect--
     Updates of 1.1 percent for all areas (that is, the market 
basket percentage increase of 2.9 percent minus 1.8 percentage points);
     An adjustment to ensure budget neutrality as provided for 
in sections 1886 (d)(4)(C)(iii) and (d)(3)(E) of the Act by applying 
new budget neutrality adjustment factors to the large urban and other 
standardized amounts;
     An adjustment to ensure budget neutrality as provided for 
in section 1886(d)(8)(D) of the Act by removing the FY 1999 budget 
neutrality factor and applying a revised factor;

[[Page 41545]]

     An adjustment to apply the revised outlier offset by 
removing the FY 1999 outlier offsets and applying a new offset; and
     An adjustment in the Puerto Rico standardized amounts to 
reflect the application of a Puerto Rico-specific wage index.

A. Calculation of Adjusted Standardized Amounts

1. Standardization of Base-Year Costs or Target Amounts
    Section 1886(d)(2)(A) of the Act required the establishment of 
base-year cost data containing allowable operating costs per discharge 
of inpatient hospital services for each hospital. The preamble to the 
September 1, 1983 interim final rule (48 FR 39763) contains a detailed 
explanation of how base-year cost data were established in the initial 
development of standardized amounts for the prospective payment system 
and how they are used in computing the Federal rates.
    Section 1886(d)(9)(B)(i) of the Act required us to determine the 
Medicare target amounts for each hospital located in Puerto Rico for 
its cost reporting period beginning in FY 1987. The September 1, 1987 
final rule contains a detailed explanation of how the target amounts 
were determined and how they are used in computing the Puerto Rico 
rates (52 FR 33043, 33066).
    The standardized amounts are based on per discharge averages of 
adjusted hospital costs from a base period or, for Puerto Rico, 
adjusted target amounts from a base period, updated and otherwise 
adjusted in accordance with the provisions of section 1886(d) of the 
Act. Sections 1886(d)(2) (B) and (C) of the Act required us to update 
base-year per discharge costs for FY 1984 and then standardize the cost 
data in order to remove the effects of certain sources of variation in 
cost among hospitals. These effects include case mix, differences in 
area wage levels, cost-of-living adjustments for Alaska and Hawaii, 
indirect medical education costs, and payments to hospitals serving a 
disproportionate share of low-income patients.
    Under sections 1886 (d)(2)(H) and (d)(3)(E) of the Act, in making 
payments under the prospective payment system, the Secretary estimates 
from time to time the proportion of costs that are wages and wage-
related costs. Since October 1, 1997, when the market basket was last 
revised, we have considered 71.1 percent of costs to be labor-related 
for purposes of the prospective payment system. The average labor share 
in Puerto Rico is 71.3 percent. We are revising the discharge-weighted 
national standardized amount for Puerto Rico to reflect the proportion 
of discharges in large urban and other areas from the FY 1998 MedPAR 
file.
2. Computing Large Urban and Other Area Averages
    Sections 1886(d) (2)(D) and (3) of the Act require the Secretary to 
compute two average standardized amounts for discharges occurring in a 
fiscal year: one for hospitals located in large urban areas and one for 
hospitals located in other areas. In addition, under sections 
1886(d)(9) (B)(iii) and (C)(i) of the Act, the average standardized 
amount per discharge must be determined for hospitals located in urban 
and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a 
blend of 50 percent of the applicable Puerto Rico standardized amount 
and 50 percent of a national standardized payment amount.
    Section 1886(d)(2)(D) of the Act defines ``urban area'' as those 
areas within a Metropolitan Statistical Area (MSA). A ``large urban 
area'' is defined as an urban area with a population of more than 
1,000,000. In addition, section 4009(i) of Public Law 100-203 provides 
that a New England County Metropolitan Area (NECMA) with a population 
of more than 970,000 is classified as a large urban area. As required 
by section 1886(d)(2)(D) of the Act, population size is determined by 
the Secretary based on the latest population data published by the 
Bureau of the Census. Urban areas that do not meet the definition of a 
``large urban area'' are referred to as ``other urban areas.'' Areas 
that are not included in MSAs are considered ``rural areas'' under 
section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals 
located in large urban areas will be based on the large urban 
standardized amount. Payment for discharges from hospitals located in 
other urban and rural areas will be based on the other standardized 
amount.
    Based on 1997 population estimates published by the Bureau of the 
Census, 61 areas meet the criteria to be defined as large urban areas 
for FY 2000. These areas are identified by a footnote in Table 4A. We 
note that on July 6, 1999, the Office of Management and Budget 
announced the designation of the Corvallis, Oregon and the Auburn-
Opelika, Alabama MSAs. We have incorporated these changes in this final 
rule.
3. Updating the Average Standardized Amounts
    Under section 1886(d)(3)(A) of the Act, we update the area average 
standardized amounts each year. In accordance with section 
1886(d)(3)(A)(iv) of the Act, we are updating the large urban areas' 
and the other areas' average standardized amounts for FY 2000 using the 
applicable percentage increases specified in section 1886(b)(3)(B)(i) 
of the Act. Section 1886(b)(3)(B)(i)(XV) of the Act specifies that, for 
hospitals in all areas, the update factor for the standardized amounts 
for FY 2000 is equal to the market basket percentage increase minus 1.8 
percentage points.
    The percentage change in the market basket reflects the average 
change in the price of goods and services purchased by hospitals to 
furnish inpatient care. The most recent forecast of the hospital market 
basket increase for FY 2000 is 2.9 percent. Thus, for FY 2000, the 
update to the average standardized amounts equals 1.1 percent.
    As in the past, we are adjusting the FY 1999 standardized amounts 
to remove the effects of the FY 1999 geographic reclassifications and 
outlier payments before applying the FY 2000 updates. That is, we are 
increasing the standardized amounts to restore the reductions that were 
made for the effects of geographic reclassification and outliers. We 
then apply the new offsets to the standardized amounts for outliers and 
geographic reclassifications for FY 2000.
    Although the update factor for FY 2000 is set by law, we are 
required by section 1886(e)(3) of the Act to report to the Congress on 
our final recommendation of update factors for FY 2000 for both 
prospective payment hospitals and hospitals excluded from the 
prospective payment system. We have included our final recommendations 
in Appendix C to this final rule.
4. Other Adjustments to the Average Standardized Amounts
    a. Recalibration of DRG Weights and Updated Wage Index--Budget 
Neutrality Adjustment.
    Section 1886(d)(4)(C)(iii) of the Act specifies that beginning in 
FY 1991, the annual DRG reclassification and recalibration of the 
relative weights must be made in a manner that ensures that aggregate 
payments to hospitals are not affected. As discussed in section II of 
the preamble, we normalized the recalibrated DRG weights by an 
adjustment factor, so that the average case weight after recalibration 
is equal

[[Page 41546]]

to the average case weight prior to recalibration.
    Section 1886(d)(3)(E) of the Act requires us to update the hospital 
wage index on an annual basis beginning October 1, 1993. This provision 
also requires us to make any updates or adjustments to the wage index 
in a manner that ensures that aggregate payments to hospitals are not 
affected by the change in the wage index.
    To comply with the requirement of section 1886(d)(4)(C)(iii) of the 
Act that DRG reclassification and recalibration of the relative weights 
be budget neutral, and the requirement in section 1886(d)(3)(E) of the 
Act that the updated wage index be budget neutral, we used historical 
discharge data to simulate payments and compared aggregate payments 
using the FY 1999 relative weights and wage index to aggregate payments 
using the FY 2000 relative weights and wage index. The same methodology 
was used for the FY 1999 budget neutrality adjustment. (See the 
discussion in the September 1, 1992 final rule (57 FR 39832).) Based on 
this comparison, we computed a budget neutrality adjustment factor 
equal to 0.997808. We also adjust the Puerto Rico-specific standardized 
amounts for the effect of DRG reclassification and recalibration. We 
computed a budget neutrality adjustment factor for Puerto Rico-specific 
standardized amounts equal to 0.999745. These budget neutrality 
adjustment factors are applied to the standardized amounts without 
removing the effects of the FY 1999 budget neutrality adjustments. We 
do not remove the prior budget neutrality adjustment because estimated 
aggregate payments after the changes in the DRG relative weights and 
wage index should equal estimated aggregate payments prior to the 
changes. If we removed the prior year adjustment, we would not satisfy 
this condition.
    In addition, we will continue to apply these same adjustment 
factors to the hospital-specific rates that are effective for cost 
reporting periods beginning on or after October 1, 1999. (See the 
discussion in the September 4, 1990 final rule (55 FR 36073).)
    b. Reclassified Hospitals--Budget Neutrality Adjustment.
    Section 1886(d)(8)(B) of the Act provides that certain rural 
hospitals are deemed urban effective with discharges occurring on or 
after October 1, 1988. In addition, section 1886(d)(10) of the Act 
provides for the reclassification of hospitals based on determinations 
by the Medicare Geographic Classification Review Board (MGCRB). Under 
section 1886(d)(10) of the Act, a hospital may be reclassified for 
purposes of the standardized amount or the wage index, or both.
    Under section 1886(d)(8)(D) of the Act, the Secretary is required 
to adjust the standardized amounts so as to ensure that total aggregate 
payments under the prospective payment system after implementation of 
the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the 
Act are equal to the aggregate prospective payments that would have 
been made absent these provisions. To calculate this budget neutrality 
factor, we used historical discharge data to simulate payments, and 
compared total prospective payments (including IME and DSH payments) 
prior to any reclassifications to total prospective payments after 
reclassifications. In the May 7, 1999 proposed rule, we applied an 
adjustment factor of 0.994453 to ensure that the effects of 
reclassification are budget neutral. The final budget neutrality 
adjustment factor is 0.993799.
    The adjustment factor is applied to the standardized amounts after 
removing the effects of the FY 1999 budget neutrality adjustment 
factor. We note that the proposed FY 2000 adjustment reflects wage 
index and standardized amount reclassifications approved by the MGCRB 
or the Administrator as of February 26, 1999. The effects of any 
additional reclassification changes resulting from appeals and reviews 
of the MGCRB decisions for FY 2000 or from a hospital's request for the 
withdrawal of a reclassification request are reflected in the final 
budget neutrality adjustment required under section 1886(d)(8)(D) of 
the Act and published in this final rule.
    c. Outliers.
    Section 1886(d)(5)(A) of the Act provides for payments in addition 
to the basic prospective payments for ``outlier'' cases, cases 
involving extraordinarily high costs (cost outliers). Section 
1886(d)(3)(B) of the Act requires the Secretary to adjust both the 
large urban and other area national standardized amounts by the same 
factor to account for the estimated proportion of total DRG payments 
made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act 
requires the Secretary to adjust the large urban and other standardized 
amounts applicable to hospitals in Puerto Rico to account for the 
estimated proportion of total DRG payments made to outlier cases. 
Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier 
payments for any year must be projected to be not less than 5 percent 
nor more than 6 percent of total payments based on DRG prospective 
payment rates.
    i. FY 2000 outlier thresholds. For FY 1999, the fixed loss cost 
outlier threshold is equal to the prospective payment for the DRG plus 
$11,100 ($10,129 for hospitals that have not yet entered the 
prospective payment system for capital-related costs). The marginal 
cost factor for cost outliers (the percent of costs paid after costs 
for the case exceed the threshold) is 80 percent. We applied an outlier 
adjustment to the FY 1999 standardized amounts of 0.948740 for the 
large urban and other areas rates and 0.9392 for the capital Federal 
rate.
    For FY 2000, we proposed to establish a fixed loss cost outlier 
threshold equal to the prospective payment rate for the DRG plus the 
IME and DSH payments plus $14,575 ($13,309 for hospitals that have not 
yet entered the prospective payment system for capital related costs). 
In addition, we proposed to maintain the marginal cost factor for cost 
outliers at 80 percent. In setting the final FY 2000 outlier 
thresholds, we used updated data. In this final rule, we are 
establishing a fixed loss cost outlier threshold for FY 2000 equal to 
the prospective payment rate for the DRG plus the IME and DSH payments 
plus $14,050 ($12,827 for hospitals that have not yet entered the 
prospective payment system for capital related costs). In addition, we 
are maintaining the marginal cost factor for cost outliers at 80 
percent. As we have explained in the past, to calculate outlier 
thresholds we apply a cost inflation factor to update costs for the 
cases used to simulate payments. For FY 1998, we used a cost inflation 
factor of minus 2.005 percent (a cost per case decrease of 2.005 
percent). For FY 1999, we used a cost inflation factor of minus 1.724 
percent. To set the proposed FY 2000 outlier thresholds, we used a cost 
inflation factor (or cost adjustment factor) of zero percent. We are 
using a cost inflation factor of zero percent to set the final FY 2000 
outlier thresholds. This factor reflects our analysis of the best 
available cost report data as well as calculations (using the best 
available data) indicating that the percentage of actual outlier 
payments for FY 1998 is higher than we projected before the beginning 
of FY 1998, and that the percentage of actual outlier payments for FY 
1999 will likely be higher than we projected before the beginning of FY 
1999. The calculations of ``actual'' outlier payments are discussed 
further below.
    ii. Other changes concerning outliers. In accordance with section 
1886(d)(5)(A)(iv) of the Act, we calculated outlier thresholds so that 
outlier payments are projected to equal 5.1 percent of total payments 
based on DRG prospective payment rates. In

[[Page 41547]]

accordance with section 1886(d)(3(E), we reduced the FY 2000 
standardized amounts by the same percentage to account for the 
projected proportion of payments paid to outliers.
    As stated in the September 1, 1993 final rule (58 FR 46348), we 
establish outlier thresholds that are applicable to both inpatient 
operating costs and inpatient capital-related costs. When we modeled 
the combined operating and capital outlier payments, we found that 
using a common set of thresholds resulted in a higher percentage of 
outlier payments for capital-related costs than for operating costs. We 
project that the thresholds for FY 2000 will result in outlier payments 
equal to 5.1 percent of operating DRG payments and 6.0 percent of 
capital payments based on the Federal rate.
    The proposed outlier adjustment factors applied to the standardized 
amounts for FY 2000 were as follows:

------------------------------------------------------------------------
                                                   Operating    Capital
                                                 standardized   federal
                                                    amounts       rate
------------------------------------------------------------------------
National.......................................     0.948934      0.9397
Puerto Rico....................................     0.969184      0.9334
------------------------------------------------------------------------

    The final outlier adjustment factors applied to the standardized 
amounts for FY 2000 are as follows:

------------------------------------------------------------------------
                                                   Operating    Capital
                                                 standardized   federal
                                                    amounts       rate
------------------------------------------------------------------------
National.......................................     0.948859      0.9402
Puerto Rico....................................     0.968581      0.9331
------------------------------------------------------------------------

    As in the proposed rule, we apply the outlier adjustment factors 
after removing the effects of the FY 1999 outlier adjustment factors on 
the standardized amounts.
    Table 8A in section VI of this addendum contains the updated 
Statewide average operating cost-to-charge ratios for urban hospitals 
and for rural hospitals to be used in calculating cost outlier payments 
for those hospitals for which the fiscal intermediary is unable to 
compute a reasonable hospital-specific cost-to-charge ratio. Effective 
October 1, 1999, these Statewide average ratios replace the ratios 
published in the July 31, 1998 final rule (63 FR 41099). Table 8B 
contains comparable Statewide average capital cost-to-charge ratios. 
These average ratios would be used to calculate cost outlier payments 
for those hospitals for which the fiscal intermediary computes 
operating cost-to-charge ratios lower than 0.209551 OR greater than 
1.284349 and capital cost-to-charge ratios lower than 0.01290 or 
greater than 0.17205. This range represents 3.0 standard deviations 
(plus or minus) from the mean of the log distribution of cost-to-charge 
ratios for all hospitals. We note that the cost-to-charge ratios in 
Tables 8A and 8B will be used during FY 2000 when hospital-specific 
cost-to-charge ratios based on the latest settled cost report are 
either not available or outside the three standard deviations range.
    iii. FY 1998 and FY 1999 outlier payments. In the July 31, 1998 
final rule (63 FR 41009), we stated that, based on available data, we 
estimated that actual FY 1998 outlier payments would be approximately 
5.4 percent of actual total DRG payments. This was computed by 
simulating payments using actual FY 1997 bill data available at the 
time. That is, the estimate of actual outlier payments did not reflect 
FY 1998 bills but instead reflected the application of FY 1998 rates 
and policies to available FY 1997 bills. Our current estimate, using 
available FY 1998 bills, is that actual outlier payments for FY 1998 
were approximately 6.5 percent of actual total DRG payments. We note 
that the MedPAR file for FY 1998 discharges continues to be updated. 
Thus, the data indicate that, for FY 1998, the percentage of actual 
outlier payments relative to actual total payments is higher than we 
projected before FY 1998 (and thus exceeds the percentage by which we 
reduced the standardized amounts for FY 1998). In fact, the data 
indicate that the proportion of actual outlier payments for FY 1998 
exceeds 6 percent. Nevertheless, consistent with the policy and 
statutory interpretation we have maintained since the inception of the 
prospective payment system, we do not plan to recoup money and make 
retroactive adjustments to outlier payments for FY 1998.
    We currently estimate that actual outlier payments for FY 1999 will 
be approximately 6.3 percent of actual total DRG payments, higher than 
the 5.1 percent we projected in setting outlier policies for FY 1999. 
This estimate is based on simulations using the March 1999 update of 
the provider-specific file and the March 1999 update of the FY 1998 
MedPAR file (discharge data for FY 1998 bills). We used these data to 
calculate an estimate of the actual outlier percentage for FY 1999 by 
applying FY 1999 rates and policies to available FY 1998 bills.
    Comment: Several commenters indicated that the proposed 30-percent 
increase in the cost outlier threshold is too great and implementing 
that threshold will cause significant revenue losses for hospitals with 
large numbers of high-cost cases. They observed that the proposed 
increase in the fixed loss threshold may be reasonable to reach the 5.1 
percent level of outlier payments, but suggested an increase in funding 
for outlier cases from the current level of 5.1 percent to 5.5 percent, 
or even 6.0 percent, with a corresponding reduction in the fixed loss 
threshold.
    Response: Outlier payments are meant to protect hospitals against 
the financial effects of treating extraordinarily high-cost cases. 
Increasing the level of outlier payments to 5.5 percent would result in 
a corresponding offset to the standardized amounts, proportionally 
reducing payments for typical cases. We believe that it is in the best 
interest of hospitals and the program to maintain the level of outliers 
at 5.1 percent, thereby providing all hospitals with somewhat larger 
rates for typical cases.
    We also note that we estimate that actual outlier payments for FY 
1998 were equal to 6.5 percent of actual total DRG payments, and 6.3 
percent for FY 1999. We believe that outlier payments are greater than 
expected for these years in part because actual hospital costs may be 
higher than reflected in the methodology used to set outlier thresholds 
for those years. While we are attempting to improve our estimate of 
payments for FY 2000 by using a cost inflation factor of zero percent 
rather than a negative inflation factor, we believe it would be 
imprudent to raise the estimated level of outlier payments at a time 
when actual outlier payments have exceeded our estimates by more than 
one percentage point for the past 2 years.
    Comment: One commenter expressed concern that, in the proposed 
rule, we referenced our longstanding policy regarding overpayments and 
underpayments and retroactive adjustments to outlier payments. The 
commenter stated that this reference appears to be necessitated by a 
large number of hospital appeals and questioned whether we intend to 
provide a clarification instead of what appears to be a new 
interpretation.
    Response: As we stated in the proposed rule, our statement that 
``we do not plan to recoup money and make retroactive adjustments to 
outlier payments for FY 1998,'' because the actual outlier payments 
exceed 6 percent of total payments, is consistent with the policy and 
statutory interpretation we have maintained since the inception of the 
prospective payment system. We have publicly stated our policy on 
several occasions. For example, in the January 3, 1984 final rule (49 
FR 234, 265), we stated:

[[Page 41548]]

``Using data we had available, we set the outlier criteria so that an 
estimated 6 percent of total payments would be made for outliers. 
Nevertheless, there is no necessary connection between the amount of 
estimated outlier payments and the actual payments made to hospitals 
for cases that actually meet the outlier criteria. While we expect that 
under these criteria, outlier payments will approximate 6 percent of 
total payments, we will pay for any outlier that meets the criteria, 
even if aggregate outlier payments result in more than 6 percent of 
total payments.'' Also, in the September 1, 1992 final rule (57 FR 
39784), we stated that ``* * * in light of the nature of the 
prospective payment system, and our attempts to estimate outlier 
payments as accurately as possible, we believe that we have satisfied 
the statute and that no retroactive adjustment is warranted.'' In the 
same rule, we also stated that ``* * * retroactive adjustment of system 
wide elements would be contrary to the nature of the prospective 
payment system.'' Therefore, our comment in the proposed rule 
concerning the overpayment or underpayment of outliers was a 
restatement of our longstanding policy.
5. FY 2000 Standardized Amounts
    The adjusted standardized amounts are divided into labor and 
nonlabor portions. Table 1A contains the two national standardized 
amounts that are applicable to all hospitals, except for hospitals in 
Puerto Rico. Under section 1886(d)(9)(A)(ii) of the Act, the Federal 
portion of the Puerto Rico payment rate is based on the discharge-
weighted average of the national large urban standardized amount and 
the national other standardized amount (as set forth in Table 1A). The 
labor and nonlabor portions of the national average standardized 
amounts for Puerto Rico hospitals are set forth in Table 1C. This table 
also includes the Puerto Rico standardized amounts.

B. Adjustments for Area Wage Levels and Cost of Living

    Tables 1A and 1C, as set forth in this addendum, contain the labor-
related and nonlabor-related shares used to calculate the prospective 
payment rates for hospitals located in the 50 States, the District of 
Columbia, and Puerto Rico. This section addresses two types of 
adjustments to the standardized amounts that are made in determining 
the prospective payment rates as described in this addendum.
1. Adjustment for Area Wage Levels
    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act requires 
that we make an adjustment to the labor-related portion of the 
prospective payment rates to account for area differences in hospital 
wage levels. This adjustment is made by multiplying the labor-related 
portion of the adjusted standardized amounts by the appropriate wage 
index for the area in which the hospital is located. In section III of 
this preamble, we discuss the data and methodology for the FY 2000 wage 
index. The wage index is set forth in Tables 4A through 4F of this 
addendum.
2. Adjustment for Cost of Living in Alaska and Hawaii
    Section 1886(d)(5)(H) of the Act authorizes an adjustment to take 
into account the unique circumstances of hospitals in Alaska and 
Hawaii. Higher labor-related costs for these two States are taken into 
account in the adjustment for area wages described above. For FY 2000, 
we are adjusting the payments for hospitals in Alaska and Hawaii by 
multiplying the nonlabor portion of the standardized amounts by the 
appropriate adjustment factor contained in the table below.

 Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Alaska--All areas................................................  1.25
Hawaii:
    County of Honolulu...........................................  1.25
    County of Hawaii.............................................  1.15
    County of Kauai..............................................  1.225
    County of Maui...............................................  1.225
    County of Kalawao............................................  1.225
 
(The above factors are based on data obtained from the U.S. Office of
 Personnel Management.)
------------------------------------------------------------------------

C. DRG Relative Weights

    As discussed in section II of the preamble, we have developed a 
classification system for all hospital discharges, assigning them into 
DRGs, and have developed relative weights for each DRG that reflect the 
resource utilization of cases in each DRG relative to Medicare cases in 
other DRGs. Table 5 of section VI of this addendum contains the 
relative weights that we will use for discharges occurring in FY 2000. 
These factors have been recalibrated as explained in section II of the 
preamble.

D. Calculation of Prospective Payment Rates for FY 2000

General Formula for Calculation of Prospective Payment Rates for FY 
2000
    Prospective payment rate for all hospitals located outside of 
Puerto Rico except sole community hospitals and Medicare-dependent, 
small rural hospitals = Federal rate.
    Prospective payment rate for sole community hospitals = Whichever 
of the following rates yields the greatest aggregate payment: 100 
percent of the Federal rate, 100 percent of the updated FY 1982 
hospital-specific rate, or 100 percent of the updated FY 1987 hospital-
specific rate.
    Prospective payment rate for Medicare-dependent, small rural 
hospitals = 100 percent of the Federal rate, or, if the greater of the 
updated FY 1982 hospital-specific rate or the updated FY 1987 hospital-
specific rate is higher than the Federal rate, 100 percent of the 
Federal rate plus 50 percent of the difference between the applicable 
hospital-specific rate and the Federal rate.
    Prospective payment rate for Puerto Rico = 50 percent of the Puerto 
Rico rate + 50 percent of a discharge-weighted average of the national 
large urban standardized amount and the national other standardized 
amount.
1. Federal Rate
    For discharges occurring on or after October 1, 1999 and before 
October 1, 2000, except for sole community hospitals, Medicare-
dependent, small rural hospitals, and hospitals in Puerto Rico, the 
hospital's payment is based exclusively on the Federal national rate.
    The payment amount is determined as follows:
    Step 1--Select the appropriate national standardized amount 
considering the type of hospital and designation of the hospital as 
large urban or other (see Table 1A in section VI of this addendum).
    Step 2--Multiply the labor-related portion of the standardized 
amount by the applicable wage index for the geographic area in which 
the hospital is located (see Tables 4A, 4B, and 4C of section VI of 
this addendum).
    Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
    Step 4--Add the amount from Step 2 and the nonlabor-related portion 
of the standardized amount (adjusted, if appropriate, under Step 3).
    Step 5--Multiply the final amount from Step 4 by the relative 
weight

[[Page 41549]]

corresponding to the appropriate DRG (see Table 5 of section VI of this 
addendum).
2. Hospital-Specific Rate (Applicable Only to Sole Community Hospitals 
and Medicare-Dependent, Small Rural Hospitals)
    Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide that 
sole community hospitals are paid based on whichever of the following 
rates yields the greatest aggregate payment: the Federal rate, the 
updated hospital-specific rate based on FY 1982 cost per discharge, or 
the updated hospital-specific rate based on FY 1987 cost per discharge.
    Sections 1886(d)(5)(G) and (b)(3)(D) of the Act provide that 
Medicare-dependent, small rural hospitals are paid based on whichever 
of the following rates yields the greatest aggregate payment: the 
Federal rate or the Federal rate plus 50 percent of the difference 
between the Federal rate and the greater of the updated hospital-
specific rate based on FY 1982 and FY 1987 cost per discharge.
    Hospital-specific rates have been determined for each of these 
hospitals based on both the FY 1982 cost per discharge and the FY 1987 
cost per discharge. For a more detailed discussion of the calculation 
of the FY 1982 hospital-specific rate and the FY 1987 hospital-specific 
rate, we refer the reader to the September 1, 1983 interim final rule 
(48 FR 39772); the April 20, 1990 final rule with comment (55 FR 
15150); and the September 4, 1990 final rule (55 FR 35994).
    a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for FY 
2000.
    We are increasing the hospital-specific rates by 1.1 percent (the 
hospital market basket percentage increase of 2.9 percent minus 1.8 
percentage points) for sole community hospitals and Medicare-dependent, 
small rural hospitals located in all areas for FY 2000. Section 
1886(b)(3)(C)(iv) of the Act provides that the update factor applicable 
to the hospital-specific rates for sole community hospitals equals the 
update factor provided under section 1886(b)(3)(B)(iv) of the Act, 
which, for FY 2000, is the market basket rate of increase minus 1.8 
percentage points. Section 1886(b)(3)(D) of the Act provides that the 
update factor applicable to the hospital-specific rates for Medicare-
dependent, small rural hospitals equals the update factor provided 
under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2000, is the 
market basket rate of increase minus 1.8 percentage points.
    b. Calculation of Hospital-Specific Rate.
    For sole community hospitals and Medicare-dependent, small rural 
hospitals, the applicable FY 2000 hospital-specific rate is calculated 
by increasing the hospital's hospital-specific rate for the preceding 
fiscal year by the applicable update factor (1.1 percent), which is the 
same as the update for all prospective payment hospitals. In addition, 
the hospital-specific rate is adjusted by the budget neutrality 
adjustment factor (that is, 0.997808) as discussed in section II.A.4.a 
of this Addendum. The resulting rate is used in determining under which 
rate a sole community hospital or Medicare-dependent, small rural 
hospital is paid for its discharges beginning on or after October 1, 
1999, based on the formula set forth above.
3. General Formula for Calculation of Prospective Payment Rates for 
Hospitals Located in Puerto Rico Beginning On or After October 1, 1999 
and Before October 1, 2000
    a. Puerto Rico Rate. The Puerto Rico prospective payment rate is 
determined as follows:
    Step 1--Select the appropriate adjusted average standardized amount 
considering the large urban or other designation of the hospital (see 
Table 1C of section VI of the addendum).
    Step 2--Multiply the labor-related portion of the standardized 
amount by the appropriate Puerto Rico-specific wage index (see Table 4F 
of section VI of the addendum).
    Step 3--Add the amount from Step 2 and the nonlabor-related portion 
of the standardized amount.
    Step 4--Multiply the result in Step 3 by 50 percent.
    Step 5--Multiply the amount from Step 4 by the appropriate DRG 
relative weight (see Table 5 of section VI of the addendum).
    b. National Rate. The national prospective payment rate is 
determined as follows:
    Step 1--Multiply the labor-related portion of the national average 
standardized amount (see Table 1C of section VI of the addendum) by the 
appropriate national wage index (see Tables 4A and 4B of section VI of 
the addendum).
    Step 2--Add the amount from Step 1 and the nonlabor-related portion 
of the national average standardized amount.
    Step 3--Multiply the result in Step 2 by 50 percent.
    Step 4--Multiply the amount from Step 3 by the appropriate DRG 
relative weight (see Table 5 of section VI of the addendum).
    The sum of the Puerto Rico rate and the national rate computed 
above equals the prospective payment for a given discharge for a 
hospital located in Puerto Rico.
    Comment: One commenter asked if the temporary relief payment 
provision of the Balanced Budget Act of 1997 (BBA) would continue into 
FY 2000. The commenter suggested that, in light of reports that 
implementation of the hospital-related provisions of the BBA provided 
larger than expected savings, we consider extending the provision into 
next year and increasing the amount of relief.
    Response: Under section 4401(b) of the BBA, the temporary special 
payment for certain hospitals that did not receive IME or DSH payments 
and that did not qualify as Medicare-dependent, small rural hospitals 
is limited to FY 1998 and FY 1999. The statute does not provide for the 
special payment in later fiscal years. We believe that the temporary 
special payment provided under section 4401(b) of the BBA was meant to 
partially protect qualifying hospitals from the initial effects of the 
reduced updates to hospital payment rates enacted by the BBA. We 
believe that two years of relief payments is adequate to allow 
hospitals to adjust to the reduced payment updates under the BBA.

III. Changes to the Payment Rates for Blood Clotting Factor for 
Hemophilia Inpatients

    As discussed in our May 7, 1999 proposed rule (64 FR 24756), 
section 4452 of the BBA amended section 6011(d) of Public Law 101-239 
to reinstate the add-on payment for the costs of administering blood 
clotting factor to Medicare beneficiaries who have hemophilia and who 
are hospital inpatients for discharges occurring on or after October 1, 
1997. The add-on payment amount for each clotting factor, as described 
in HCFA's Common Procedure Coding System (HCPCS), is based on the 
median average wholesale price (AWP) of the several products available 
in that category of factor, discounted by 15 percent.
    Also, we are adding HCPCS code J7191 (clotting factor, porcine) to 
the list of clotting factors that will be paid under this benefit. This 
code was recently reestablished in the HCPCS coding system because it 
represents a unique product that is different from the other clotting 
factors listed.
    Based on the methodology described above, the prices per unit of 
factor for FY 2000 are as follows:

J7190 Factor VIII (antihemophilic factor, human).................   0.79

[[Page 41550]]

 
J7191 Factor VIII (antihemophilic factor, porcine)...............   1.87
J7192 Factor VIII (antihemophilic factor, recombinant)...........   1.03
J7194 Factor IX (complex)........................................   0.45
J7196 Other hemophilia clotting factors (for example, anti-         1.43
 inhibitors).....................................................
Q0160 Factor IX (antihemophilic factor, purified, nonrecombinant)   0.97
Q0161 Factor IX (antihemophilic factor, recombinant).............   1.00
 

    These prices for blood clotting factor administered to inpatients 
who have hemophilia will be effective for discharges beginning on or 
after October 1, 1999 through September 30, 2000. Payment will be made 
for the blood clotting factor only if there is an ICD-9-CM diagnosis 
code for hemophilia included on the bill.
    We received one comment on this proposed provision.
    Comment: One commenter indicated that there is a new clotting 
factor product, recombinant coagulation Factor VIIa, that is covered by 
this benefit, but was not mentioned in the proposed rule. Because this 
product is unique and packaged and dosed per microgram, and not per IU 
as the other clotting factor products listed in the HCPCS, the 
commenter requested a separate temporary code and price to be added to 
the final rule.
    Response: We agree that recombinant coagulation Factor VIIa is 
covered by this benefit. We also agree that no appropriate HCPCS code 
exists for this product. Because of constraints on Year 2000 computer 
systems changes, we are not able to establish a new HCPCS code or a 
claims process to pay for this product at this time. Therefore, any 
providers furnishing recombinant coagulation Factor VIIa to hospital 
inpatients who have hemophilia should hold their billings for Factor 
VIIa until we announce by instructions to our fiscal intermediaries 
that a new code and claims process have been established. These 
hospitals should continue to submit claims for all other covered items 
and services furnished to these Medicare beneficiaries in accordance 
with established program procedures. The price for recombinant 
coagulation Factor VIIa for FY 2000 will be $1.19 per microgram.

IV. Changes to Payment Rates for Inpatient Capital-Related Costs 
for FY 2000

    The prospective payment system for hospital inpatient capital-
related costs was implemented for cost reporting periods beginning on 
or after October 1, 1991. Effective with that cost reporting period and 
during a 10-year transition period extending through FY 2001, hospital 
inpatient capital-related costs are paid on the basis of an increasing 
proportion of the capital prospective payment system Federal rate and a 
decreasing proportion of a hospital's historical costs for capital.
    The basic methodology for determining Federal capital prospective 
rates is set forth at Secs. 412.308 through 412.352. Below we discuss 
the factors that we used to determine the Federal rate and the 
hospital-specific rates for FY 2000. The rates would be effective for 
discharges occurring on or after October 1, 1999.
    For FY 1992, we computed the standard Federal payment rate for 
capital-related costs under the prospective payment system by updating 
the FY 1989 Medicare inpatient capital cost per case by an actuarial 
estimate of the increase in Medicare inpatient capital costs per case. 
Each year after FY 1992, we update the standard Federal rate, as 
provided in Sec. 412.308(c)(1), to account for capital input price 
increases and other factors. Also, Sec. 412.308(c)(2) provides that the 
Federal rate is adjusted annually by a factor equal to the estimated 
proportion of outlier payments under the Federal rate to total capital 
payments under the Federal rate. In addition, Sec. 412.308(c)(3) 
requires that the Federal rate be reduced by an adjustment factor equal 
to the estimated proportion of payments for exceptions under 
Sec. 412.348. Furthermore, Sec. 412.308(c)(4)(ii) requires that the 
Federal rate be adjusted so that the annual DRG reclassification and 
the recalibration of DRG weights and changes in the geographic 
adjustment factor are budget neutral. For FYs 1992 through 1995, 
Sec. 412.352 required that the Federal rate also be adjusted by a 
budget neutrality factor so that aggregate payments for inpatient 
hospital capital costs were projected to equal 90 percent of the 
payments that would have been made for capital-related costs on a 
reasonable cost basis during the fiscal year. That provision expired in 
FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to 
the rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the 
0.28 percent reduction to the rate made in FY 1996 as a result of the 
revised policy of paying for transfers. In the FY 1998 final rule with 
comment period (62 FR 45966), we implemented section 4402 of the BBA, 
which requires that for discharges occurring on or after October 1, 
1997, and before October 1, 2002, the unadjusted standard Federal rate 
is reduced by 17.78 percent. A small part of that reduction will be 
restored effective October 1, 2002. As a result of the February 25, 
1999 final rule (64 FR 9378), the Federal rate changed effective March 
1, 1999, because of revisions to the GAF.
    For each hospital, the hospital-specific rate was calculated by 
dividing the hospital's Medicare inpatient capital-related costs for a 
specified base year by its Medicare discharges (adjusted for 
transfers), and dividing the result by the hospital's case-mix index 
(also adjusted for transfers). The resulting case-mix adjusted average 
cost per discharge was then updated to FY 1992 based on the national 
average increase in Medicare's inpatient capital cost per discharge and 
adjusted by the exceptions payment adjustment factor and the budget 
neutrality adjustment factor to yield the FY 1992 hospital-specific 
rate. Since FY 1992, the hospital-specific rate has been updated 
annually for inflation and for changes in the exceptions payment 
adjustment factor. For FYs 1992 through 1995, the hospital-specific 
rate was also adjusted by a budget neutrality adjustment factor. For 
discharges occurring on or after October 1, 1997, and before October 1, 
2002, the unadjusted hospital-specific rate is reduced by 17.78 
percent. A small part of this reduction will be restored effective 
October 1, 2002.
    To determine the appropriate budget neutrality adjustment factor 
and the exceptions payment adjustment factor, we developed a dynamic 
model of Medicare inpatient capital-related costs, that is, a model 
that projects changes in Medicare inpatient capital-related costs over 
time. With the expiration of the budget neutrality provision, the model 
is still used to estimate the exceptions payment adjustment and other 
factors. The model and its application are described in greater detail 
in Appendix B of this final rule.
    In accordance with section 1886(d)(9)(A) of the Act, under the 
prospective payment system for inpatient operating costs, hospitals 
located in Puerto Rico are paid for operating costs under a special 
payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a 
blended rate that consisted of 75 percent of the applicable 
standardized amount specific to Puerto Rico hospitals and 25 percent of 
the applicable national average standardized amount. However, effective 
October 1, 1998, as a result of enactment of section 4406 of the BBA, 
operating payments to hospitals in Puerto Rico are based on a blend of 
50 percent of the applicable standardized amount specific to Puerto 
Rico hospitals and 50 percent of the applicable national average 
standardized amount. In conjunction with this change to the

[[Page 41551]]

operating blend percentage, effective with discharges on or after 
October 1, 1997, we compute capital payments to hospitals in Puerto 
Rico based on a blend of 50 percent of the Puerto Rico rate and 50 
percent of the Federal rate. Section 412.374 provides for the use of 
this blended payment system for payments to Puerto Rico hospitals under 
the prospective payment system for inpatient capital-related costs. 
Accordingly, for capital-related costs we compute a separate payment 
rate specific to Puerto Rico hospitals using the same methodology used 
to compute the national Federal rate for capital.

A. Determination of Federal Inpatient Capital-Related Prospective 
Payment Rate Update

    In the July 31, 1998 final rule (63 FR 41011), we established a 
capital Federal rate of $378.05 for FY 1999. As of the March 1, 1999 
revision, the Federal rate for FY 1999 is $378.10. In the proposed 
rule, we stated that the proposed FY 2000 Federal rate was $374.31. In 
this final rule, we are establishing a FY 2000 Federal rate of $377.03.
    In the discussion that follows, we explain the factors that were 
used to determine the FY 2000 capital Federal rate. In particular, we 
explain why the FY 2000 Federal rate has decreased 0.28 percent 
compared to the FY 1999 Federal rate. Even though the FY 2000 Federal 
capital rate is less than the FY 1999 Federal rate, we estimate 
aggregate capital payments will increase by 3.64 percent during this 
same period. This increase is primarily due to the increase in the 
Federal blend percentage from 80 to 90 percent for fully prospective 
payment hospitals.
    Total payments to hospitals under the prospective payment system 
are relatively unaffected by changes in the capital prospective 
payments. Since capital payments constitute about 10 percent of 
hospital payments, a 1 percent change in the capital Federal rate 
yields only about 0.1 percent change in actual payments to hospitals. 
Aggregate payments under the capital prospective payment transition 
system are estimated to increase in FY 2000 compared to FY 1999.
1. Standard Federal Rate Update
    a. Description of the Update Framework.
    Under section 412.308(c)(1), the standard Federal rate is updated 
on the basis of an analytical framework that takes into account changes 
in a capital input price index and other factors. The update framework 
consists of a capital input price index (CIPI) and several policy 
adjustment factors. Specifically, we have adjusted the projected CIPI 
rate of increase as appropriate each year for case-mix index related 
changes, for intensity, and for errors in previous CIPI forecasts. The 
proposed rule reflected an update factor of -0.6 percent, based on the 
data available at that time. Under the update framework, the final 
update factor for FY 2000 is 0.3 percent. This update factor is based 
on a projected 0.6 percent increase in the CIPI, a 0.1 percent 
adjustment for the FY 1998 DRG reclassification and recalibration, and 
a forecast error correction of -0.4 percent. We explain the basis for 
the FY 2000 CIPI projection in section II.D of this addendum.
    Below we describe the policy adjustments that have been applied to 
the FY 2000 capital payment rates update.
    The case-mix index is the measure of the average DRG weight for 
cases paid under the prospective payment system. Because the DRG weight 
determines the prospective payment for each case, any percentage 
increase in the case-mix index corresponds to an equal percentage 
increase in hospital payments.
    The case-mix index can change for any of several reasons:
     The average resource use of Medicare patients changes 
(``real'' case-mix change).
     Changes in hospital coding of patient records result in 
higher weight DRG assignments (``coding effects'').
     The annual DRG reclassification and recalibration changes 
may not be budget neutral (``reclassification effect'').
    We define real case-mix change as actual changes in the mix (and 
resource requirements) of Medicare patients as opposed to changes in 
coding behavior that result in assignment of cases to higher-weighted 
DRGs but do not reflect higher resource requirements. In the update 
framework for the prospective payment system for operating costs, we 
adjust the update upwards to allow for real case-mix change, but remove 
the effects of coding changes on the case-mix index. We also remove the 
effect on total payments of prior changes to the DRG classifications 
and relative weights, in order to retain budget neutrality for all 
case-mix index-related changes other than patient severity. (For 
example, we adjusted for the effects of the FY 1998 DRG 
reclassification and recalibration as part of our FY 2000 update 
recommendation.) We have adopted this case-mix index adjustment in the 
capital update framework as well.
    For FY 2000, we are projecting a 0.5 percent increase in the case-
mix index. We estimate that real case-mix increase will equal 0.5 
percent in FY 2000. Therefore, the net adjustment for case-mix change 
in FY 2000 is 0.0 percentage points.
    We estimate that FY 1998 DRG reclassification and recalibration 
resulted in a -0.1 percent change in the case mix when compared with 
the case-mix index that would have resulted if we had not made the 
reclassification and recalibration changes to the DRGs. In the 
framework, we make an adjustment for DRG reclassification and 
recalibration to account for the 2-year lag on the available data used 
to estimate the effect of DRG changes. A DRG reclassification and 
recalibration adjustment of 0.1 percentage points was calculated for 
the FY 2000 update as the percent change in the case mix when compared 
with the case-mix index that would have resulted if we had not made the 
reclassification and recalibration changes to the DRGs based on FY 1998 
data. That is, in determining the effect of DRG reclassification and 
recalibration using FY 1998 data, the actual effect of DRG 
reclassification and recalibration was understated by -0.1 percent. 
Therefore, we are making a 0.1 percent adjustment for DRG 
reclassification and recalibration in the update for FY 2000.
    Comment: One commenter noted that the magnitude of the -0.7 
adjustment for FY 1998 Reclassification and Recalibration (GROUPER 
Effect) in the proposed capital (and operating) update framework 
appears to be inconsistent with past numbers published by HCFA. 
Accordingly, the commenter requested that HCFA review the data and 
computation of that adjustment in the capital update framework.
    Response: In the May 7, 1999 proposed rule (64 FR 24578), we 
estimated that FY 1998 DRG reclassification and recalibration resulted 
in a 0.7 percent change in the case-mix index when compared with the 
case-mix index that would have resulted if we had not made the 
reclassification and recalibration changes to the DRGs. Therefore, we 
proposed making a -0.7 percent adjustment for DRG reclassification and 
recalibration in the proposed capital update recommendation for FY 
2000.
    Upon review, we have discovered that incorrect data were used in 
estimating the proposed -0.7 adjustment for the effect of FY 1998 
reclassification and recalibration. We have recalculated the adjustment 
based on correct and updated data and the revised adjustment for the 
effect of FY 1998 reclassification and recalibration for the FY 2000 
capital update is +0.1.
    The capital update framework contains an adjustment for forecast

[[Page 41552]]

error. The input price index forecast is based on historical trends and 
relationships ascertainable at the time the update factor is 
established for the upcoming year. In any given year, there may be 
unanticipated price fluctuations that may result in differences between 
the actual increase in prices and the forecast used in calculating the 
update factors. In setting a prospective payment rate under the 
framework, we make an adjustment for forecast error only if our 
estimate of the change in the capital input price index for any year is 
incorrect by 0.25 percentage points or more. There is a 2-year lag 
between the forecast and the measurement of the forecast error. A 
forecast error of -0.4 percentage points was calculated for the FY 1998 
update. That is, current historical data indicate that the FY 1998 CIPI 
used in calculating the forecasted FY 1998 update factor overstated 
realized price increases by 0.4 percent. Therefore, we are making a 
-0.4 percent adjustment for forecast error in the update for FY 2000.
    Under the capital prospective payment system update framework, we 
also make an adjustment for changes in intensity. We calculate this 
adjustment using the same methodology and data as in the framework for 
the operating prospective payment system. The intensity factor for the 
operating update framework reflects how hospital services are utilized 
to produce the final product, that is, the discharge. This component 
accounts for changes in the use of quality-enhancing services, changes 
in within-DRG severity, and expected modification of practice patterns 
to remove cost-ineffective services.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI 
hospital component), and changes in real case mix. The use of total 
charges in the calculation of the intensity factor makes it a total 
intensity factor; that is, charges for capital services are already 
built into the calculation of the factor. Therefore, we have 
incorporated the intensity adjustment from the operating update 
framework into the capital update framework. Without reliable estimates 
of the proportions of the overall annual intensity increases that are 
due, respectively, to ineffective practice patterns and to the 
combination of quality-enhancing new technologies and within-DRG 
complexity, we assume, as in the revised operating update framework, 
that one-half of the annual increase is due to each of these factors. 
The capital update framework thus provides an add-on to the input price 
index rate of increase of one-half of the estimated annual increase in 
intensity to allow for within-DRG severity increases and the adoption 
of quality-enhancing technology.
    For FY 2000, we have developed a Medicare-specific intensity 
measure based on a 5-year average using FY 1994 through FY 1998 data. 
In determining case-mix constant intensity, we found that observed 
case-mix increase was 0.8 percent in FY 1994, 1.7 percent in FY 1995, 
1.6 percent in FY 1996, 0.3 percent in FY 1997, and -0.4 percent in FY 
1998. For FY 1995 and FY 1996, we estimate that real case-mix increase 
was 1.0 to 1.4 percent each year. The estimate for those years is 
supported by past studies of case-mix change by the RAND Corporation. 
The most recent study was ``Has DRG Creep Crept Up? Decomposing the 
Case Mix Index Change Between 1987 and 1988'' by G.M. Carter, J.P. 
Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991). The study 
suggested that real case-mix change was not dependent on total change, 
but was usually a fairly steady 1.0 to 1.5 percent per year. We use 1.4 
percent as the upper bound because the RAND study did not take into 
account that hospitals may have induced doctors to document medical 
records more completely in order to improve payment. Following that 
study, we consider up to 1.4 percent of observed case-mix change as 
real for FY 1994 through FY 1998. Based on this analysis, we believe 
that all of the observed case-mix increase for FY 1994, FY 1997, and FY 
1998 is real. The increases for FY 1995 and FY 1996 were in excess of 
our estimate of real case-mix increase.
    We calculate case-mix constant intensity as the change in total 
charges per admission, adjusted for price level changes (the CPI 
hospital component), and changes in real case-mix. Given estimates of 
real case mix of 0.8 percent for FY 1994, 1.0 percent for FY 1995, 1.0 
percent for FY 1996, 0.3 percent for FY 1997, and -0.4 for FY 1998, we 
estimate that case-mix constant intensity declined by an average 1.3 
percent during FYs 1994 through 1998, for a cumulative decrease of 6.3 
percent. If we assume that real case-mix increase was 0.8 percent for 
FY 1994, 1.4 percent for FY 1995, 1.4 percent for FY 1996, 0.3 percent 
for FY 1997, and -0.4 for FY 1998, we estimate that case-mix constant 
intensity declined by an average 1.5 percent during FYs 1994 through 
1998, for a cumulative decrease of 7.1 percent. Since we estimate that 
intensity has declined during that period, we are making a 0.0 percent 
intensity adjustment for FY 2000.
    In summary, the FY 2000 final capital update under our framework is 
0.3 percent. This update is based on a projected 0.6 increase in the 
CIPI, policy adjustment factors of 0.0, a 0.1 adjustment for the effect 
of FY 1998 reclassification and recalibration, and a forecast error 
correction of -0.4.
    b. Comparison of HCFA and MedPAC Update Recommendations.
    As discussed in the proposed rule, MedPAC recommended a -1.1 to 1.8 
percent update to the standard capital Federal rate and we recommended 
a -0.6 percent update. (See the May 7, 1999 proposed rule for the 
differences between the MedPAC and HCFA update frameworks (64 FR 
24758)). In this final rule, as discussed in the previous section, we 
are implementing a 0.3 percent update to the capital Federal rate.
    Comment: MedPAC noted that our update recommendation of -0.6 
percent was within the range of the -1.1 to 1.8 percent that they 
recommended. They also asserted that the distinction between inpatient 
operating and capital payment rates is arbitrary and does not foster 
efficient overall decision making about the allocation of resources. 
Accordingly, MedPAC recommended that once the transition to fully 
prospective capital payment is completed, a single prospective payment 
rate should be developed for hospital inpatient services to Medicare 
beneficiaries. MedPAC indicated that a single prospective payment rate 
for both operating and capital costs would be consistent with the way 
that hospitals purchase a majority of goods and services. MedPAC plans 
to investigate options for coordinating the capital and operating 
updates and would be pleased to work with HCFA on this effort.
    Response: We responded to a similar comment in the May 7, 1999 
proposed rule (64 FR 24759), the July 31, 1998 final rule (63 FR 
41013), and in the September 1, 1995 final rule (60 FR 45816). In those 
rules, we stated that our long-term goal was to develop a single update 
framework for operating and capital prospective payments and that we 
would begin development of a unified framework. We indicated that, in 
the meantime, we would maintain as much consistency as possible between 
the current operating and capital frameworks in order to facilitate the 
eventual development of a unified framework. In addition, we stated 
that because of the similarity of the update frameworks, the update 
frameworks could be combined without too much difficulty. We maintain 
our goal of combining the update frameworks and

[[Page 41553]]

may examine combining the payment systems after the conclusion of the 
capital prospective payment transition period. While we welcome 
MedPAC's assistance in the eventual development of a unified operating 
and capital update framework, we believe that developing a unified 
operating and capital update framework would become a higher priority 
if the actual operating update was no longer determined by Congress 
through the statute and the unified update would be appropriately 
applied directly to a combined payment rate for operating and capital 
costs.
2. Outlier Payment Adjustment Factor
    Section 412.312(c) establishes a unified outlier methodology for 
inpatient operating and inpatient capital-related costs. A single set 
of thresholds is used to identify outlier cases for both inpatient 
operating and inpatient capital-related payments. Outlier payments are 
made only on the portion of the Federal rate that is used to calculate 
the hospital's inpatient capital-related payments (for example, 90 
percent for cost reporting periods beginning in FY 2000 for hospitals 
paid under the fully prospective payment methodology). Section 
412.308(c)(2) provides that the standard Federal rate for inpatient 
capital-related costs be reduced by an adjustment factor equal to the 
estimated proportion of outlier payments under the Federal rate to 
total inpatient capital-related payments under the Federal rate. The 
outlier thresholds are set so that operating outlier payments are 
projected to be 5.1 percent of total operating DRG payments. The 
inpatient capital-related outlier reduction factor reflects the 
inpatient capital-related outlier payments that would be made if all 
hospitals were paid 100 percent of the Federal rate. For purposes of 
calculating the outlier thresholds and the outlier reduction factor, we 
model payments as if all hospitals were paid 100 percent of the Federal 
rate because, as explained above, outlier payments are made only on the 
portion of the Federal rate that is included in the hospital's 
inpatient capital-related payments.
    In the July 31, 1998 final rule, we estimated that outlier payments 
for capital in FY 1999 would equal 6.08 percent of inpatient capital-
related payments based on the Federal rate (63 FR 41013). Accordingly, 
we applied an outlier adjustment factor of 0.9392 to the Federal rate. 
For FY 2000, we estimate that outlier payments for capital will equal 
5.98 percent of inpatient capital-related payments based on the Federal 
rate. Therefore, we are establishing an outlier adjustment factor of 
0.9402 to the Federal rate. Thus, estimated capital outlier payments 
for FY 2000 represent a lower percentage of total capital standard 
payments than in FY 1999.
    The outlier reduction factors are not built permanently into the 
rates; that is, they are not applied cumulatively in determining the 
Federal rate. Therefore, the net change in the outlier adjustment to 
the Federal rate for FY 2000 is 1.0011 (0.9402/0.9392). The outlier 
adjustment increases the FY 2000 Federal rate by 0.11 percent compared 
with the FY 1999 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG 
Classifications and Weights and the Geographic Adjustment Factor
    Section 412.308(c)(4)(ii) requires that the Federal rate be 
adjusted so that aggregate payments for the fiscal year based on the 
Federal rate after any changes resulting from the annual DRG 
reclassification and recalibration and changes in the GAF are projected 
to equal aggregate payments that would have been made on the basis of 
the Federal rate without such changes. We use the actuarial model, 
described in Appendix B, to estimate the aggregate payments that would 
have been made on the basis of the Federal rate without changes in the 
DRG classifications and weights and in the GAF. We also use the model 
to estimate aggregate payments that would be made on the basis of the 
Federal rate as a result of those changes. We then use these figures to 
compute the adjustment required to maintain budget neutrality for 
changes in DRG weights and in the GAF.
    For FY 1999, we calculated a GAF/DRG budget neutrality factor of 
1.0027. In the February 25, 1999 final rule (64 FR 9381), we adopted an 
incremental GAF/DRG budget neutrality factor of 1.0028 for discharges 
on or after March 1, 1999. In the proposed rule for FY 2000, we 
proposed a GAF/DRG budget neutrality factor of 0.9986. In this final 
rule, based on calculations using updated data, we are applying a 
factor of 0.9985. The GAF/DRG budget neutrality factors are built 
permanently into the rates; that is, they are applied cumulatively in 
determining the Federal rate. This follows from the requirement that 
estimated aggregate payments each year be no more than they would have 
been in the absence of the annual DRG reclassification and 
recalibration and changes in the GAF. The incremental change in the 
adjustment from FY 1999 to FY 2000 is 0.9985. The cumulative change in 
the rate due to this adjustment is 1.0014 (the product of the 
incremental factors for FY 1993, FY 1994, FY 1995, FY 1996, FY 1997, FY 
1998, FY 1999, and FY 2000: 0.9980  x  1.0053  x  0.9998  x  0.9994  x  
0.9987  x  0.9989  x  1.0028  x  0.9985 = 1.0014).
    This factor accounts for DRG reclassifications and recalibration 
and for changes in the GAF. It also incorporates the effects on the GAF 
of FY 2000 geographic reclassification decisions made by the MGCRB 
compared to FY 1999 decisions. However, it does not account for changes 
in payments due to changes in the DSH and IME adjustment factors or in 
the large urban add-on.
4. Exceptions Payment Adjustment Factor
    Section 412.308(c)(3) requires that the standard Federal rate for 
inpatient capital-related costs be reduced by an adjustment factor 
equal to the estimated proportion of additional payments for exceptions 
under Sec. 412.348 relative to total payments under the hospital-
specific rate and Federal rate. We use an actuarial model described in 
Appendix B to determine the exceptions payment adjustment factor.
    For FY 1999, we estimated that exceptions payments would equal 2.17 
percent of aggregate payments based on the Federal rate and the 
hospital-specific rate. Therefore, we applied an exceptions reduction 
factor of 0.9783 (1--0.0217) in determining the Federal rate. In the 
May 7, 1999 proposed rule, we estimated that exceptions payments for FY 
2000 would equal 2.48 percent of aggregate payments based on the 
Federal rate and the hospital-specific rate. Therefore, we proposed an 
exceptions payment reduction factor of 0.9752 to the Federal rate for 
FY 2000. For this final rule, based on updated data, we estimate that 
exceptions payments for FY 2000 will equal 2.70 percent of aggregate 
payments based on the Federal rate and hospital-specific rate. We are, 
therefore, applying an exceptions payment reduction factor of 0.9730 
(1--0.0270) to the Federal rate for FY 2000. The final exceptions 
reduction factor for FY 2000 is 0.54 percent lower than the factor for 
FY 1999 and 0.23 percent lower than the factor in the FY 2000 proposed 
rule.
    The exceptions reduction factors are not built permanently into the 
rates; that is, the factors are not applied cumulatively in determining 
the Federal rate. Therefore, the net adjustment to the FY 2000 Federal 
rate is 0.9730/0.9783, or 0.9946.

[[Page 41554]]

5. Standard Capital Federal Rate for FY 2000
    For FY 1999 (effective March 1, 1999), the capital Federal rate was 
$378.10. As a result of changes we proposed to the factors used to 
establish the Federal rate, we proposed that the FY 2000 Federal rate 
would be $374.31. In this final rule, we are establishing a FY 2000 
Federal rate of $377.03. The Federal rate for FY 2000 was calculated as 
follows:
     The FY 2000 update factor is 1.0030; that is, the update 
is 0.30 percent.
     The FY 2000 budget neutrality adjustment factor that is 
applied to the standard Federal payment rate for changes in the DRG 
relative weights and in the GAF is 0.9985.
     The FY 2000 outlier adjustment factor is 0.9402.
     The FY 2000 exceptions payments adjustment factor is 
0.9730.
    Since the Federal rate has already been adjusted for differences in 
case mix, wages, cost of living, indirect medical education costs, and 
payments to hospitals serving a disproportionate share of low-income 
patients, we have made no additional adjustments in the standard 
Federal rate for these factors other than the budget neutrality factor 
for changes in the DRG relative weights and the GAF.
    We are providing a chart that shows how each of the factors and 
adjustments for FY 2000 affected the computation of the FY 2000 Federal 
rate in comparison to the FY 1999 Federal rate. The FY 2000 update 
factor has the effect of increasing the Federal rate by 0.30 percent 
compared to the rate in FY 1999, while the final geographic and DRG 
budget neutrality factor has the effect of decreasing the Federal rate 
by 0.15 percent. The FY 2000 outlier adjustment factor has the effect 
of increasing the Federal rate by 0.11 percent compared to FY 1999. The 
FY 2000 exceptions reduction factor has the effect of decreasing the 
Federal rate by 0.54 percent compared to the exceptions reduction for 
FY 1999. The combined effect of all the changes is to decrease the 
Federal rate by 0.28 percent compared to the Federal rate for FY 1999.

              Comparison of Factors and Adjustments: FY 1999 Federal Rate and FY 2000 Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                                                                       Percent
                                                                FY 1999      FY 2000       Change       change
----------------------------------------------------------------------------------------------------------------
Update Factor \1\...........................................       1.0010       1.0030       1.0030         0.30
GAF/DRG Adjustment Factor \1\...............................       1.0028       0.9985       0.9985        -0.15
Outlier Adjustment Factor \2\...............................       0.9392       0.9402       1.0011         0.11
Exceptions Adjustment Factor \2\............................       0.9783       0.9730       0.9946        -0.54
Federal Rate................................................      $378.10      $377.03       0.9972       -0.28
----------------------------------------------------------------------------------------------------------------
\1\ The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for
  example, the incremental change from FY 1999 to FY 2000 resulting from the application of the 0.9985 GAF/DRG
  budget neutrality factor for FY 2000 is 0.9985.
\2\ The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates;
  that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net
  change resulting from the application of the FY 2000 outlier reduction factor is 0.9402/0.9392, or 1.0011.

    As stated previously in this section, the FY 2000 Federal rate has 
decreased 0.28 percent compared to the FY 1999 Federal rate, even 
though the capital rate update factor has increased from 0.1 percent in 
FY 1999 to 0.3 percent in FY 2000. The 0.28 percent decrease in the 
Federal capital rate is a result of the combination of the FY 2000 
factors and adjustments applied to the Federal rate. Specifically, the 
exceptions reduction factor decreased 0.54 percent from 0.9783 for FY 
1999 to 0.9730 for FY 2000, which results in a larger reduction to the 
Federal capital rate for FY 2000 compared to FY 1999. Also, the GAF/DRG 
adjustment factor decreased 0.42 percent from 1.0027 for FY 1999 to 
0.9985 for FY 2000, which results in a decrease the Federal capital 
rate for FY 2000 compared to FY 1999. The outlier adjustment factor 
increased 0.11 percent from 0.9392 for FY 1999 to 0.9402 for FY 2000, 
which results in an increase to the Federal capital rate for FY 2000 
compared to FY 1999. The effect of all of these changes is a -0.28 
percent decrease in the FY 2000 Federal rate compared to FY 1999.
    Even though the FY 2000 Federal capital rate is less than the FY 
1999 Federal rate, we estimate that aggregate capital payments will 
increase 3.64 percent during this same period, primarily due to the 
increase in the Federal blend percentage (from 80 to 90 percent) for 
fully prospective payment hospitals.
    We are also providing a chart that shows how the final FY 2000 
Federal rate differs from the proposed FY 2000 Federal rate.

       Comparison of Factors and Adjustments: FY 2000 Proposed Federal Rate and FY 2000 Final Federal Rate
----------------------------------------------------------------------------------------------------------------
                                                              Proposed FY    Final FY                  Percent
                                                                  2000         2000        Change       change
----------------------------------------------------------------------------------------------------------------
Update Factor \1\...........................................       0.9940       1.0030       1.0091         0.91
GAF/DRG Adjustment Factor...................................       0.9986       0.9985       0.9999        -0.01
Outlier Adjustment Factor...................................       0.9397       0.9402       1.0005         0.05
Exceptions Adjustment Factor................................       0.9752       0.9730       0.9977        -0.23
Federal Rate................................................      $374.31      $377.03       1.0073        0.73
----------------------------------------------------------------------------------------------------------------
\1\ As noted previously in section IV.A.1.a of this addendum, upon review we discovered that incorrect data were
  used in estimating the proposed adjustment for the effect of FY 1998 reclassification and recalibration in the
  proposed rule. As a result, the revised adjustment for the effect of FY 1998 reclassification and
  recalibration for the capital update for FY 2000 is +0.1 (compared to the proposed -0.7). Accordingly, the FY
  2000 final update is 0.30 (compared to the proposed -0.06), which accounts for the 0.73 increase in the
  Federal rate from the FY 2000 proposed to FY 2000 final rule.


[[Page 41555]]

6. Special Rate for Puerto Rico Hospitals
    As explained above, hospitals in Puerto Rico are paid based on 50 
percent of the Puerto Rico rate and 50 percent of the Federal rate. The 
Puerto Rico rate is derived from the costs of Puerto Rico hospitals 
only, while the Federal rate is derived from the costs of all acute 
care hospitals participating in the prospective payment system 
(including Puerto Rico). To adjust hospitals' capital payments for 
geographic variations in capital costs, we apply a geographic 
adjustment factor (GAF) to both portions of the blended rate. The GAF 
is calculated using the operating prospective payment system wage index 
and varies depending on the MSA or rural area in which the hospital is 
located. We use the Puerto Rico wage index to determine the GAF for the 
Puerto Rico part of the capital blended rate and the national wage 
index to determine the GAF for the national part of the blended rate. 
Since we implemented a separate GAF for Puerto Rico in 1998, we also 
applied separate budget neutrality adjustments for the national GAF and 
for the Puerto Rico GAF. We applied the same budget neutrality factor 
for DRG reclassifications and recalibration nationally and for Puerto 
Rico. The Puerto Rico GAF budget neutrality factor is 0.9991, while the 
DRG adjustment is 0.9999, for a combined cumulative adjustment of 
0.9990.
    In computing the payment for a particular Puerto Rico hospital, the 
Puerto Rico portion of the rate (50 percent) is multiplied by the 
Puerto Rico-specific GAF for the MSA in which the hospital is located, 
and the national portion of the rate (50 percent) is multiplied by the 
national GAF for the MSA in which the hospital is located (which is 
computed from national data for all hospitals in the United States and 
Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to 
the Puerto Rico rate as required by the BBA. For FY 1999, before 
application of the GAF, the special rate for Puerto Rico hospitals was 
$181.10. With the changes we proposed to the factors used to determine 
the rate, the proposed FY 2000 special rate for Puerto Rico was 
$174.15. In this final rule, the FY 2000 capital rate for Puerto Rico 
is $174.81.

B. Determination of Hospital-Specific Rate Update

    Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 2000 be determined by adjusting the FY 1999 
hospital-specific rate by the following factors:
1. Hospital-Specific Rate Update Factor
    The hospital-specific rate is updated in accordance with the update 
factor for the standard Federal rate determined under 
Sec. 412.308(c)(1). For FY 2000, we are updating the hospital-specific 
rate by a factor of 1.0030.
2. Exceptions Payment Adjustment Factor
    For FYs 1992 through FY 2001, the updated hospital-specific rate is 
multiplied by an adjustment factor to account for estimated exceptions 
payments for capital-related costs under Sec. 412.348, determined as a 
proportion of the total amount of payments under the hospital-specific 
rate and the Federal rate. For FY 2000, we estimated in the proposed 
rule that exceptions payments would be 2.48 percent of aggregate 
payments based on the Federal rate and the hospital-specific rate. 
Therefore, we proposed that the updated hospital-specific rate be 
reduced by a factor of 0.9752. In this final rule, we estimate that 
exceptions payments will be 2.70 percent of aggregate payments based on 
the Federal rate and hospital-specific rate. Accordingly, for FY 2000, 
we are applying an exceptions reduction factor of 0.9730 to the 
hospital-specific rate. The exceptions reduction factors are not built 
permanently into the rates; that is, the factors are not applied 
cumulatively in determining the hospital-specific rate. The net 
adjustment to the FY 2000 hospital-specific rate is 0.9730/0.9783, or 
0.9946.
3. Net Change to Hospital-Specific Rate
    We are providing a chart to show the net change to the hospital-
specific rate. The chart shows the factors for FY 1999 and FY 2000 and 
the net adjustment for each factor. It also shows that the cumulative 
net adjustment from FY 1999 to FY 2000 is 0.9976, which represents a 
decrease of 0.24 percent to the hospital-specific rate. For each 
hospital, the FY 2000 hospital-specific rate is determined by 
multiplying the FY 1999 hospital-specific rate by the cumulative net 
adjustment of 0.9976.

                            FY 2000 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
                                                                             Final FY       Net        Percent
                                                                FY 1999        2000      adjustment     change
----------------------------------------------------------------------------------------------------------------
Update Factor...............................................       1.0010       1.0030       1.0030         0.30
Exceptions Payment Adjustment Factor........................       0.9783       0.9730       0.9946        -0.54
Cumulative Adjustments......................................       0.9793       0.9769       0.9976       -0.24
----------------------------------------------------------------------------------------------------------------
Note: The update factor for the hospital-specific rate is applied cumulatively in determining the rates. Thus,
  the incremental increase in the update factor from FY 1999 to FY 2000 is 1.0030. In contrast, the exceptions
  payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the
  exceptions reduction factor from FY 1999 to FY 2000 is 0.9730/0.9783, or 0.9946.

C. Calculation of Inpatient Capital-Related Prospective Payments for FY 
2000

    During the capital prospective payment system transition period, a 
hospital is paid for the inpatient capital-related costs under one of 
two payment methodologies--the fully prospective payment methodology or 
the hold-harmless methodology. The payment methodology applicable to a 
particular hospital is determined when a hospital comes under the 
prospective payment system for capital-related costs by comparing its 
hospital-specific rate to the Federal rate applicable to the hospital's 
first cost reporting period under the prospective payment system. The 
applicable Federal rate was determined by making adjustments as 
follows:
     For outliers by dividing the standard Federal rate by the 
outlier reduction factor for that fiscal year; and,
     For the payment adjustment factors applicable to the 
hospital (that is, the hospital's GAF, the disproportionate share 
hospital (DSH) adjustment factor, and the indirect medical education 
(IME) adjustment factor, when appropriate).
    If the hospital-specific rate is higher than the applicable Federal 
rate, the hospital is paid under the hold-harmless methodology. If the 
hospital-specific rate is lower than the applicable Federal rate, the 
hospital is paid under the fully prospective methodology.
    For purposes of calculating payments for each discharge under both 
the hold-harmless payment methodology and the fully prospective payment 
methodology,

[[Page 41556]]

the standard Federal rate is adjusted as follows: (Standard Federal 
Rate)  x  (DRG weight)  x  (GAF)  x  (Large Urban Add-on, if 
applicable)  x  (COLA adjustment for hospitals located in Alaska and 
Hawaii)  x  (1 + DSH Adjustment Factor + IME Adjustment Factor). The 
result is the adjusted Federal rate.
    Payments under the hold-harmless methodology are determined under 
one of two formulas. A hold-harmless hospital is paid the higher of the 
following:
     100 percent of the adjusted Federal rate for each 
discharge; or
     An old capital payment equal to 85 percent (100 percent 
for sole community hospitals) of the hospital's allowable Medicare 
inpatient old capital costs per discharge for the cost reporting period 
plus a new capital payment based on a percentage of the adjusted 
Federal rate for each discharge. The percentage of the adjusted Federal 
rate equals the ratio of the hospital's allowable Medicare new capital 
costs to its total Medicare inpatient capital-related costs in the cost 
reporting period.
    Once a hospital receives payment based on 100 percent of the 
adjusted Federal rate in a cost reporting period beginning on or after 
October 1, 1994 (or the first cost reporting period after obligated 
capital that is recognized as old capital under Sec. 412.302(c) is put 
in use for patient care, if later), the hospital continues to receive 
capital prospective payment system payments on that basis for the 
remainder of the transition period.
    Payment for each discharge under the fully prospective methodology 
is the sum of the following:
     The hospital-specific rate multiplied by the DRG relative 
weight for the discharge and by the applicable hospital-specific 
transition blend percentage for the cost reporting period; and
     The adjusted Federal rate multiplied by the Federal 
transition blend percentage.
    The blend percentages for cost reporting periods beginning in FY 
2000 are 90 percent of the adjusted Federal rate and 10 percent of the 
hospital-specific rate.
    Hospitals may also receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year. Section 
412.312(c) provides for a single set of thresholds to identify outlier 
cases for both inpatient operating and inpatient capital-related 
payments. Outlier payments are made only on that portion of the Federal 
rate that is used to calculate the hospital's inpatient capital-related 
payments. For fully prospective hospitals, that portion is 90 percent 
of the Federal rate for discharges occurring in cost reporting periods 
beginning during FY 2000. Thus, a fully prospective hospital will 
receive 90 percent of the capital-related outlier payment calculated 
for the case for discharges occurring in cost reporting periods 
beginning in FY 2000. For hold-harmless hospitals paid 85 percent of 
their reasonable costs for old inpatient capital, the portion of the 
Federal rate that is included in the hospital's outlier payments is 
based on the hospital's ratio of Medicare inpatient costs for new 
capital to total Medicare inpatient capital costs. For hold-harmless 
hospitals that are paid 100 percent of the Federal rate, 100 percent of 
the Federal rate is included in the hospital's outlier payments.
    The outlier thresholds for FY 2000 are in section II.A.4.c of this 
Addendum. For FY 2000, a case qualifies as a cost outlier if the cost 
for the case is greater than the prospective payment rate for the DRG 
(and any IME and DSH payments) plus $14,050.
    During the capital prospective payment system transition period, a 
hospital may also receive an additional payment under an exceptions 
process if its total inpatient capital-related payments are less than a 
minimum percentage of its allowable Medicare inpatient capital-related 
costs. The minimum payment level is established by class of hospital 
under Sec. 412.348. The minimum payment levels for portions of cost 
reporting periods occurring in FY 2000 are as follows:
     Sole community hospitals (located in either an urban or 
rural area), 90 percent.
     Urban hospitals with at least 100 beds and a 
disproportionate share patient percentage of at least 20.2 percent and 
urban hospitals with at least 100 beds that qualify for 
disproportionate share payments under Sec. 412.106(c)(2), 80 percent.
     All other hospitals, 70 percent.
    Under Sec. 412.348(d), the amount of the exceptions payment is 
determined by comparing the cumulative payments made to the hospital 
under the capital prospective payment system to the cumulative minimum 
payment levels applicable to the hospital for each cost reporting 
period subject to that system. Any amount by which the hospital's 
cumulative payments exceed its cumulative minimum payment is deducted 
from the additional payment that would otherwise be payable for a cost 
reporting period.
    New hospitals are exempted from the capital prospective payment 
system for their first 2 years of operation and are paid 85 percent of 
their reasonable costs during that period. A new hospital's old capital 
costs are its allowable costs for capital assets that were put in use 
for patient care on or before the later of December 31, 1990 or the 
last day of the hospital's base year cost reporting period, and are 
subject to the rules pertaining to old capital and obligated capital as 
of the applicable date. Effective with the third year of operation, we 
will pay the hospital under either the fully prospective methodology, 
using the appropriate transition blend in that Federal fiscal year, or 
the hold-harmless methodology. If the hold-harmless methodology is 
applicable, the hold-harmless payment for assets in use during the base 
period would extend for 8 years, even if the hold-harmless payments 
extend beyond the normal transition period.

D. Capital Input Price Index

1. Background
    Like the operating input price index, the Capital Input Price Index 
(CIPI) is a fixed-weight price index that measures the price changes 
associated with costs during a given year. The CIPI differs from the 
operating input price index in one important aspect--the CIPI reflects 
the vintage nature of capital, which is the acquisition and use of 
capital over time. Capital expenses in any given year are determined by 
the stock of capital in that year (that is, capital that remains on 
hand from all current and prior capital acquisitions). An index 
measuring capital price changes needs to reflect this vintage nature of 
capital. Therefore, the CIPI was developed to capture the vintage 
nature of capital by using a weighted-average of past capital purchase 
prices up to and including the current year.
    Using Medicare cost reports, American Hospital Association (AHA) 
data, and Securities Data Corporation data, a vintage-weighted price 
index was developed to measure price increases associated with capital 
expenses. We periodically update the base year for the operating and 
capital input prices to reflect the changing composition of inputs for 
operating and capital expenses. Currently, the CIPI is based to FY 1992 
and was last rebased in 1997. The most recent explanation of the CIPI 
was discussed in the final rule with comment period for FY 1998 
published on August 29, 1997 (62 FR 46050). The following Federal 
Register documents also describe development and revisions of the 
methodology involved with the construction of the CIPI: September 1, 
1992 (57 FR 40016), May 26, 1993 (58 FR 30448), September 1, 1993 (58 
FR 46490), May 27, 1994 (59

[[Page 41557]]

FR 27876), September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), 
and September 1, 1995 (60 FR 45815), May 31, 1996 (61 FR 27466), August 
30, 1996 (61 FR 46196), June 2, 1997 (62 FR 29953), August 29, 1997 (62 
FR 46050), May 8, 1998 (63 FR 25619), July 31, 1998 (63 FR 41017), and 
May 7, 1999 (64 FR 24763).
2. Forecast of the CIPI for Federal Fiscal Year 2000
    We are forecasting the CIPI to increase 0.6 percent for FY 2000. 
This reflects a projected 1.6 percent increase in vintage-weighted 
depreciation prices (building and fixed equipment, and movable 
equipment) and a 3.5 percent increase in other capital expense prices 
in FY 2000, partially offset by a 2.9 percent decline in vintage-
weighted interest rates in FY 2000. The weighted average of these three 
factors produces the 0.6 percent increase for the CIPI as a whole.

V. Changes to Payment Rates for Excluded Hospitals and Hospital 
Units: Rate-of-Increase Percentages

    The inpatient operating costs of hospitals and hospital units 
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of 
the Act, which is implemented in regulations at Sec. 413.40. Under 
these limits, a hospital-specific target amount (expressed in terms of 
the inpatient operating cost per discharge) is set for each hospital, 
based on the hospital's own historical cost experience trended forward 
by the applicable rate-of-increase percentages (update factors). In the 
case of a psychiatric hospital or hospital unit, rehabilitation 
hospital or hospital unit, or long-term care hospital, the target 
amount may not exceed the updated figure for the 75th percentile of 
target amounts for hospitals and units in the same class (psychiatric, 
rehabilitation, and long-term care) for cost reporting periods ending 
during FY 1996. The target amount is multiplied by the number of 
Medicare discharges in a hospital's cost reporting period, yielding the 
ceiling on aggregate Medicare inpatient operating costs for the cost 
reporting period.
    Each hospital-specific target amount is adjusted annually, at the 
beginning of each hospital's cost reporting period, by an applicable 
update factor.
    Section 1886(b)(3)(B) of the Act, which is implemented in 
regulations at Sec. 413.40(c)(3)(vii), provides that for cost reporting 
periods beginning on or after October 1, 1999 and before October 1, 
2000, the update factor depends on the hospital's or hospital unit's 
costs in relation to the ceiling. For hospitals with costs exceeding 
the ceiling by 10 percent or more, the update factor is the market 
basket increase. For hospitals with costs exceeding the ceiling by less 
than 10 percent, the update factor is the market basket minus .25 
percent for each percentage point by which costs are less than 10 
percent over the ceiling. For hospitals with costs equal to or less 
than the ceiling but greater than 66.7 percent of the ceiling, the 
update factor is the greater of 0 percent or the market basket minus 
2.5 percent. For hospitals with costs that do not exceed 66.7 percent 
of the ceiling, the update factor is 0.
    The most recent forecast of the market basket increase for FY 2000 
for hospitals and hospital units excluded from the prospective payment 
system is 2.9 percent. Therefore, the update to a hospital's target 
amount for its cost reporting period beginning in FY 2000 would be 
between 0.4 and 2.9 percent, or 0 percent.
    In addition, Sec. 413.40(c)(4)(iii) requires that for cost 
reporting periods beginning on or after October 1, 1999 and before 
October 1, 2000, the target amount for each psychiatric hospital or 
hospital unit, rehabilitation hospital or hospital unit, and long-term 
care hospital cannot exceed a cap on the target amounts for hospitals 
in the same class. In the May 7, 1999 proposed rule, based on available 
data, we estimated that, for cost reporting periods beginning in FY 
2000, the caps on target amounts would be $11,067 for psychiatric 
hospitals and hospital units, $20,071 for rehabilitation hospitals and 
hospital units, and $39,596 for long-term care hospitals. In this final 
rule, based on updated data, we are establishing the caps as follows: 
$11,100 for psychiatric hospitals and hospital units, $20,129 for 
rehabilitation hospitals and hospital units, and $36,712 for long-term 
care hospitals. Regulations at Sec. 413.40(d) specify the formulas for 
determining bonus and relief payments for excluded hospitals and 
specify established criteria for an additional bonus payment for 
continuous improvement. Regulations at Sec. 413.40(f)(2)(ii) specify 
the payment methodology for new hospitals and hospital units 
(psychiatric, rehabilitation, and long-term care) effective October 1, 
1997.

VI. Tables

    This section contains the tables referred to throughout the 
preamble to this final rule and in this Addendum. For purposes of this 
final rule, and to avoid confusion, we have retained the designations 
of Tables 1 through 5 that were first used in the September 1, 1983 
initial prospective payment final rule (48 FR 39844). Tables 1A, 1C, 
1D, 3C, 4A, 4B, 4C, 4D, 4E, 4F, 5, 7A, 7B, 8A, 8B, and 10 are presented 
below. The tables presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 3C--Hospital Case-Mix Indexes for Discharges Occurring in Federal 
Fiscal Year 1998 and Hospital Average Hourly Wage for Federal Fiscal 
Year 2000 Wage Index
Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for 
Urban Areas
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for 
Rural Areas
Table 4C--Wage Index and Capital Geographic Adjustment
Table 4D--Average Hourly Wage for Urban Areas
Table 4E--Average Hourly Wage for Rural Areas
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment 
Factor (GAF)
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting 
Factors, Geometric Mean Length of Stay, and Arithmetic Mean Length of 
Stay Points Used in the Prospective Payment System
Table 7A--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 98 MEDPAR Update 3/99 GROUPER V16.0
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay FY 98 MEDPAR Update 3/99 GROUPER V17.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban 
and Rural Hospitals (Case Weighted) July 1999
Table 8B--Statewide Average Capital Cost-to-Charge Ratios (Case 
Weighted) July 1999
Table 10--Percentage Difference in Wage Indexes for Areas That Qualify 
for a Wage Index Exception for Excluded Hospitals and Units

[[Page 41558]]



   Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
                                Nonlabor
------------------------------------------------------------------------
          Large urban areas                       Other areas
------------------------------------------------------------------------
  Labor-related     Nonlabor-related    Labor-related   Nonlabor-related
------------------------------------------------------------------------
      $2,809.18          $1,141.85          $2,764.70         $1,123.76
------------------------------------------------------------------------


               Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                         Large urban areas                  Other areas
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................       $2,785.40       $1,132.18       $2,785.40       $1,132.18
Puerto Rico.....................................        1,336.54          538.00        1,315.38          529.48
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                                 Rate
------------------------------------------------------------------------
National...................................................      $377.03
Puerto Rico................................................       174.81
------------------------------------------------------------------------


Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal
 Fiscal Year 1998, Hospital Average Hourly Wage for Federal Fiscal Year
                             2000 Wage Index
------------------------------------------------------------------------
                                                          Case     Avg.
                         Prov.                             mix     hour
                                                          index    wage
------------------------------------------------------------------------
010001................................................    1.4595   15.85
010004................................................    0.9933   15.02
010005................................................    1.1767   16.26
010006................................................    1.4579   17.31
010007................................................    1.1421   14.80
010008................................................    1.1818   17.65
010009................................................    1.0941   17.53
010010................................................    1.0799   15.91
010011................................................    1.5835   20.63
010012................................................    1.2614   19.30
010015................................................    1.0478   18.35
010016................................................    1.2492   16.13
010018................................................    0.9696   18.96
010019................................................    1.2766   15.49
010021................................................    1.2490   14.63
010022................................................    0.9597   20.51
010023................................................    1.6881   16.26
010024................................................    1.4243   16.03
010025................................................    1.3513   14.53
010027................................................    0.8132   14.93
010029................................................    1.6000   16.41
010031................................................    1.4175   18.02
010032................................................    0.8803   12.65
010033................................................    1.9945   19.68
010034................................................    1.0473   14.73
010035................................................    1.2411   17.48
010036................................................    1.0916   17.29
010038................................................    1.2337   18.33
010039................................................    1.6337   18.81
010040................................................    1.4963   19.10
010043................................................    1.0500   16.20
010044................................................    1.0246   17.02
010045................................................    1.1799   15.01
010046................................................    1.4713   17.18
010047................................................    0.9285   16.38
010049................................................    1.1887   14.48
010050................................................    1.0755   15.42
010051................................................    0.8965    9.94
010052................................................    1.0154   13.86
010053................................................    1.0508   13.18
010054................................................    1.1318   17.12
010055................................................    1.4221   18.19
010056................................................    1.3283   19.08
010058................................................    1.0358   12.78
010059................................................    1.0567   18.19
010061................................................    1.1098   15.92
010062................................................    1.0102   13.57
010064................................................    1.7584   20.90
010065................................................    1.3234   15.64
010066................................................    0.9014   12.07
010068................................................    1.3052   18.74
010069................................................    1.1329   13.57
010072................................................    1.0785   14.35
010073................................................    0.8800   12.83
010078................................................    1.2901   17.71
010079................................................    1.1867   16.87
010080................................................  ........   13.85
010081................................................    1.6351   16.98
010083................................................    1.0586   16.21
010084................................................    1.5089   18.78
010085................................................    1.3152   18.87
010086................................................    1.0122   14.93
010087................................................    1.7288   18.39
010089................................................    1.1989   16.61
010090................................................    1.6540   18.11
010091................................................    0.9933   16.36
010092................................................    1.4279   16.50
010094................................................    1.1544   18.56
010095................................................    1.0456   11.90
010097................................................    0.8654   12.90
010098................................................    0.9896   14.28
010099................................................    1.1725   15.93
010100................................................    1.2912   15.48
010101................................................    1.0199   15.42
010102................................................    0.9314   12.73
010103................................................    1.8375   19.31
010104................................................    1.6950   18.10
010108................................................    1.1528   20.79
010109................................................    1.0504   14.09
010110................................................    0.9691   15.91
010112................................................    1.1495   15.11
010113................................................    1.6159   17.24
010114................................................    1.2530   17.26
010115................................................    0.8495   13.75
010118................................................    1.2464   16.69
010119................................................    0.8457   18.17
010120................................................    0.9886   17.03
010121................................................    1.2822   15.18
010123................................................    1.1647   18.16
010124................................................    1.2264   16.27
010125................................................    1.0590   14.42
010126................................................    1.1224   17.64
010127................................................    1.3140   19.61
010128................................................    0.9265   12.57
010129................................................    1.0647   14.43
010130................................................    1.0418   16.35
010131................................................    1.3325   17.91
010134................................................    0.8150   10.78
010137................................................    1.3106   15.93
010138................................................    0.9196   12.13
010139................................................    1.6338   19.95
010143................................................    1.2282   15.71
010144................................................    1.4120   17.12
010145................................................    1.3336   20.75
010146................................................    1.1894   18.86
010148................................................    0.9791   14.64
010149................................................    1.2567   17.08
010150................................................    1.0438   16.97
010152................................................    1.2508   17.38
010155................................................    1.0794   16.70
020001................................................    1.5235   27.97
020002................................................    1.0556   26.91
020004................................................    1.1841   26.40
020005................................................    0.8955   29.01

[[Page 41559]]

 
020006................................................    1.1238   26.77
020007................................................    0.8205   24.96
020008................................................    1.0781   30.47
020009................................................    0.8199   23.18
020010................................................    0.9473   18.64
020011................................................    0.9160   29.47
020012................................................    1.2763   23.92
020013................................................    0.9595   26.82
020014................................................    1.1151   24.09
020017................................................    1.4946   24.97
020018................................................    0.8973  ......
020019................................................    0.7991  ......
020021................................................    0.8011  ......
020024................................................    1.1106   22.73
020025................................................    0.9156   27.15
020026................................................    1.2660  ......
020027................................................    0.9434  ......
030001................................................    1.2614   19.87
030002................................................    1.8069   21.63
030003................................................    2.2742   23.67
030004................................................    1.0231   17.73
030006................................................    1.5269   17.64
030007................................................    1.2538   18.56
030008................................................    2.1843  ......
030009................................................    1.2486   17.93
030010................................................    1.3867   18.80
030011................................................    1.4361   20.08
030012................................................    1.2389   19.42
030013................................................    1.2741   21.02
030014................................................    1.5098   19.47
030016................................................    1.2340   20.56
030017................................................    1.4178   20.42
030018................................................    1.8584   18.91
030019................................................    1.2403   19.92
030022................................................    1.4895   15.79
030023................................................    1.4965   22.44
030024 *..............................................    1.7469   21.67
030025................................................    0.9555   17.67
030027................................................    0.9624   17.58
030030................................................    1.6450   21.62
030033................................................    1.2353   16.84
030034................................................    0.9867   19.09
030035................................................    1.1548   19.72
030036................................................    1.2810   18.94
030037................................................    2.0844   21.44
030038................................................    1.6163   22.08
030040................................................    1.0766   17.97
030041................................................    0.8880   17.44
030043................................................    1.2200   20.77
030044................................................    0.8787   16.47
030047................................................    0.8899   19.69
030049................................................    0.8711   19.09
030054................................................    0.8646   14.49
030055................................................    1.2312   18.28
030059................................................    1.2853   21.71
030060................................................    1.1435   16.77
030061................................................    1.6875   17.35
030062................................................    1.1800   17.48
030064................................................    1.7662   18.54
030065................................................    1.8097   19.93
030067................................................    1.0273   15.62
030068................................................    1.0246   17.35
030069................................................    1.3639   19.00
030071................................................    0.9602  ......
030072................................................    0.8682  ......
030073................................................    1.0290  ......
030074................................................    0.8858  ......
030075................................................    0.7952  ......
030076................................................    0.8826  ......
030077................................................    0.8563  ......
030078................................................    1.1470  ......
030079................................................    0.9065  ......
030080................................................    1.3762   19.99
030083................................................    1.2775   23.64
030084................................................    1.1378  ......
030085................................................    1.4648   17.84
030086................................................    1.4452   18.50
030087................................................    1.6802   20.05
030088................................................    1.3656   19.58
030089................................................    1.6781   19.90
030092................................................    1.5831   21.56
030093................................................    1.4204   19.47
030094................................................    1.2697   19.48
030095................................................    1.1371   14.25
030099................................................    0.9411   18.07
030100................................................    2.0364  ......
030101................................................    1.4114  ......
030102................................................    2.5824  ......
040001................................................    1.0888   15.57
040002................................................    1.1552   14.09
040003................................................    1.1003   14.00
040004................................................    1.6291   17.29
040005................................................    1.0368   12.88
040007................................................    1.6975   19.53
040008................................................    1.0417   12.70
040010................................................    1.3432   17.62
040011................................................    0.9412   12.27
040014................................................    1.3255   15.39
040015................................................    1.2147   14.60
040016................................................    1.6858   17.54
040017................................................    1.1675   14.95
040018................................................    1.2212   17.56
040019................................................    1.0337   25.71
040020................................................    1.6146   14.81
040021................................................    1.1844   16.46
040022................................................    1.4741   16.00
040024................................................    0.9980   15.73
040025................................................    0.9100   10.95
040026................................................    1.5789   18.24
040027................................................    1.2523   14.54
040028................................................    1.0074   12.84
040029................................................    1.2995   17.78
040030................................................    0.8754   14.15
040032................................................    0.9633   13.33
040035................................................    0.9500   11.21
040036................................................    1.4559   17.91
040037................................................    1.0687   13.48
040039................................................    1.2281   13.84
040040................................................    0.9162   17.43
040041................................................    1.2619   13.36
040042................................................    1.2098   14.66
040044................................................    1.0386   11.44
040045................................................    1.0121   18.77
040047................................................    1.0270   16.39
040048................................................  ........   15.82
040050................................................    1.1544   11.79
040051................................................    1.0845   16.28
040053................................................    1.0708   15.82
040054................................................    0.9798   15.04
040055................................................    1.4290   16.10
040058................................................    1.0566   15.67
040060................................................    0.9763   11.47
040062................................................    1.6600   17.28
040064................................................    1.0495   12.40
040066................................................    1.0504   17.64
040067................................................    1.0989   13.49
040069................................................    1.0278   16.11
040070................................................    0.9313   15.48
040071................................................    1.6676   16.30
040072................................................    1.0377   15.84
040074................................................    1.2314   17.38
040075................................................    1.0145   12.75
040076................................................    1.0802   18.55
040077................................................    1.0508   12.46
040078................................................    1.5191   17.86
040080................................................    1.0065   15.74
040081................................................    0.8669   10.68
040082................................................    1.0972   16.51
040084................................................    1.1085   17.25
040085................................................    1.1526   15.78
040088................................................    1.3887   15.67
040090................................................    0.8950   17.55
040091................................................    1.1702   17.04
040093................................................    0.9194   12.90
040100................................................    1.1477   14.97
040105................................................    0.9904   14.24
040106................................................    0.9680   15.40
040107................................................    1.0685   19.62
040109................................................    1.1497   13.98
040114................................................    1.8340   18.31
040116................................................    1.1343   19.57
040118................................................    1.4205   17.43
040119................................................    1.1612   15.38
040124................................................    1.0612   17.25
040126................................................    0.9478   11.68
040132................................................  ........   13.18
040134................................................    2.7047  ......
040135................................................    2.3711  ......
050002................................................    1.4963   27.60
050006................................................    1.4139   19.53
050007................................................    1.4840   29.54
050008................................................    1.4234   25.86
050009................................................    1.6827   26.25
050013................................................    1.9903   24.85
050014................................................    1.2091   24.53
050015................................................    1.4488   25.38
050016................................................    1.1522   20.15
050017................................................    2.0965   23.66
050018................................................    1.3646   14.66
050021................................................  ........   28.50
050022................................................    1.6612   22.96
050024................................................    1.3214   20.34
050025 *..............................................    1.7668   22.00
050026................................................    1.5146   28.69
050028................................................    1.3702   16.45
050029................................................    1.4013   23.29
050030................................................    1.3135   21.01
050032................................................    1.3391   22.59
050033................................................    1.4640   24.56
050036................................................    1.7264   20.47
050038................................................    1.3454   27.83
050039................................................    1.6288   22.25

[[Page 41560]]

 
050040................................................    1.1955   30.67
050042................................................    1.2702   22.23
050043................................................    1.4927   33.23
050045................................................    1.2716   20.73
050046................................................    1.1729   31.38
050047................................................    1.5619   29.44
050051................................................    1.1199   17.84
050054................................................    1.1899   19.37
050055................................................    1.2399   29.09
050056................................................    1.3404   23.85
050057................................................    1.5981   21.76
050058................................................    1.4969   25.73
050060................................................    1.5506   20.92
050061................................................    1.4125   23.74
050063................................................    1.3477   23.07
050065................................................    1.6835   21.18
050066................................................    1.3006   21.42
050067................................................    1.2503   21.30
050068................................................    1.1029   28.48
050069................................................    1.6082   29.30
050070................................................    1.2340   32.60
050071................................................    1.3229   33.14
050072................................................    1.3883   32.97
050073................................................    1.2621   34.61
050074................................................    0.8073  ......
050075................................................    1.3460   33.52
050076................................................    2.0321   33.88
050077................................................    1.5585   23.30
050078................................................    1.2960   22.80
050079................................................    1.4849   34.43
050082................................................    1.6734   21.70
050084................................................    1.6102   23.10
050088................................................    0.9681   24.06
050089................................................    1.3381   20.02
050090................................................    1.2652   23.90
050091................................................    1.0925   22.22
050092................................................    0.8481   15.38
050093................................................    1.5646   24.08
050095................................................  ........   33.38
050096................................................    1.1459   21.67
050097................................................    1.5292   22.61
050099................................................    1.4630   24.29
050100................................................    1.6425   30.06
050101................................................    1.3595   30.01
050102................................................    1.3792   21.29
050103 *..............................................    1.5724   25.34
050104................................................    1.4491   25.44
050107................................................    1.4640   21.76
050108................................................    1.8389   25.21
050109................................................  ........   26.48
050110................................................    1.2148   20.18
050111................................................    1.2943   21.74
050112................................................    1.3851   26.29
050113................................................    1.3172   27.78
050114................................................    1.3842   25.91
050115................................................    1.4915   21.05
050116................................................    1.5226   25.59
050117................................................    1.3979   20.44
050118................................................    1.1870   24.00
050121................................................    1.2882   18.88
050122................................................    1.5694  ......
050124................................................    1.2826   23.02
050125................................................    1.3726   24.04
050126................................................    1.4571   23.84
050127................................................    1.2537   19.76
050128................................................    1.6061   24.18
050129................................................    1.7541   27.16
050131................................................    1.2640   29.06
050132................................................    1.3641   22.91
050133................................................    1.2717   24.40
050135................................................    1.4811   27.03
050136................................................    1.3553   24.43
050137................................................    1.3023   30.07
050138................................................    2.0450   37.41
050139................................................    1.2542   31.38
050140................................................    1.3201   33.66
050144................................................    1.4211   25.75
050145................................................    1.3762   33.06
050146................................................    1.5826  ......
050148................................................    1.1126   21.06
050149................................................    1.4979   23.38
050150................................................    1.2673   23.48
050152................................................    1.3291   27.75
050153................................................    1.6393   29.59
050155................................................    1.0972   22.94
050158................................................    1.3019   27.98
050159................................................    1.3226   25.21
050167................................................    1.3813   21.68
050168................................................    1.5382   25.25
050169................................................    1.4765   24.64
050170................................................    1.4490   22.20
050172................................................    1.2543   17.70
050173................................................    1.3755   23.33
050174................................................    1.7008   31.21
050175................................................    1.2707   27.79
050177................................................    1.1869   20.25
050179................................................    1.2337   19.29
050180................................................    1.5831   32.19
050183................................................    1.2743   19.98
050186................................................    1.3443   21.91
050188................................................    1.4374   27.44
050189................................................    0.9674   23.24
050191................................................    1.4686   26.73
050192................................................    1.1474   17.81
050193................................................    1.1575   23.73
050194................................................    1.2304   28.27
050195................................................    1.5638   34.78
050196................................................    1.2799   16.69
050197................................................    1.9550   31.45
050204................................................    1.5274   24.39
050205................................................    1.2839   21.15
050207................................................    1.2607   20.86
050211................................................    1.3187   31.22
050213................................................    1.5919   20.73
050214................................................    1.5454   20.87
050215................................................    1.5686   28.41
050217................................................    1.2859   19.89
050219................................................    1.1417   25.47
050222................................................    1.5169   27.07
050224................................................    1.5831   23.79
050225................................................    1.5688   20.80
050226................................................    1.3277   26.93
050228................................................    1.3226   30.38
050230................................................    1.4125   25.36
050231................................................    1.6438   25.58
050232................................................    1.5691   23.38
050233................................................  ........   31.40
050234................................................    1.1501   28.52
050235................................................    1.5560   25.86
050236................................................    1.5100   26.27
050238................................................    1.5300   24.00
050239................................................    1.5979   20.41
050240................................................    1.5284   25.25
050241................................................    1.1379   27.22
050242................................................    1.4436   30.14
050243................................................    1.5323   22.91
050245................................................    1.5075   24.40
050248................................................    1.2025   27.42
050251................................................    1.1079   18.50
050253................................................    1.4192   20.07
050254................................................    1.2000   19.69
050256................................................    1.7675   23.53
050257................................................    0.9509   19.59
050260................................................    0.9690   23.52
050261................................................    1.2104   20.45
050262................................................    1.8179   29.01
050264................................................    1.3472   29.45
050267................................................    1.6945   24.75
050270................................................    1.3631   23.73
050272................................................    1.3984   21.44
050274................................................    0.9467   21.19
050276................................................    1.1734   28.51
050277................................................    1.4821   22.31
050278................................................    1.5187   23.84
050279................................................    1.2881   21.06
050280................................................    1.6532   24.43
050281................................................    1.3916   18.59
050282................................................    1.3212   24.46
050283................................................    1.5054   27.88
050286................................................    0.9172   17.80
050289................................................    1.7326   26.72
050290................................................    1.6720   26.37
050291................................................    1.1953   26.49
050292................................................    1.1088   22.49
050293................................................    1.0656   19.18
050295................................................    1.4570   20.74
050296................................................    1.2166   25.32
050298................................................    1.3348   20.52
050299................................................    1.3248   25.77
050300................................................    1.4160   22.74
050301................................................    1.2329   26.03
050302................................................  ........   29.20
050305................................................    1.5886   32.71
050307................................................    1.2758   27.98
050308................................................    1.5082   28.40
050309................................................    1.2826   24.40
050310................................................  ........   20.62
050312................................................    1.9732   23.79
050313................................................    1.1561   23.10
050315................................................    1.3435   21.92
050317................................................  ........   19.45
050320................................................    1.2358   30.60
050324................................................    2.0041   26.27
050325................................................    1.2290   23.24
050327................................................    1.6638   22.85
050328................................................  ........   23.19
050329................................................    1.2988   21.41
050331................................................    1.3506   25.53
050333................................................    1.0612   20.15
050334................................................    1.7488   32.02
050335................................................    1.4579   20.20
050336................................................    1.3568   20.10

[[Page 41561]]

 
050342................................................    1.2515   19.35
050343................................................    0.9701   17.34
050348................................................    1.8021   20.75
050349................................................    0.8875   15.05
050350................................................    1.4042   25.07
050351................................................    1.4941   24.69
050352................................................    1.3148   23.59
050353................................................    1.6191   23.25
050355................................................    0.8391   17.16
050357................................................    1.3422   23.64
050359................................................    1.2474   20.40
050360................................................    1.4310   31.76
050366................................................    1.3326   21.34
050367................................................    1.2594   29.48
050369................................................    1.3034   24.26
050373................................................    1.3971   26.65
050376................................................    1.4232   25.30
050377................................................    1.0200   25.64
050378................................................    1.0934   22.24
050379................................................    1.0197   15.50
050380................................................    1.6047   30.58
050382................................................    1.3597   26.15
050385................................................    1.3419   25.92
050388................................................    0.8725   13.79
050390................................................    1.1965   22.57
050391................................................    1.3438   22.49
050392................................................    0.9370   21.93
050393................................................    1.4352   23.14
050394................................................    1.5741   22.24
050396................................................    1.6444   23.63
050397................................................    0.9367   20.77
050401................................................    1.1055   17.78
050404................................................    1.0664   19.28
050406................................................    1.0245   16.89
050407................................................    1.2842   30.12
050410................................................    1.0668   16.47
050411................................................    1.3582   32.24
050414................................................    1.2992   24.42
050417................................................    1.3197   21.89
050419................................................    1.3788   23.12
050420................................................    1.3062   22.68
050421................................................    1.2343  ......
050423................................................    1.0112   23.33
050424................................................    1.8400   23.78
050425................................................    1.2315   33.69
050426................................................    1.3898   23.71
050427................................................    0.9468   20.07
050430................................................    1.0003   21.34
050432................................................    1.5198   21.50
050433................................................    0.9711   16.80
050434................................................    1.0631   15.63
050435................................................    1.1647   32.99
050436................................................    1.0075   16.36
050438................................................    1.7349   24.08
050440................................................    1.2722   21.11
050441................................................    1.9397   28.71
050443................................................    0.8705   16.43
050444................................................    1.3224   24.67
050446................................................    0.8088   20.54
050447................................................    1.0850   18.42
050448................................................    1.1055   20.08
050449................................................    1.2871   22.18
050454 *..............................................    1.7729   28.69
050455................................................    1.7949   19.92
050456................................................    1.2213   17.62
050457................................................    1.9129   31.25
050459................................................    1.5220   37.09
050464................................................    1.7089   22.31
050468................................................    1.5589   23.17
050469................................................    1.1499   23.44
050470................................................    1.1391   17.03
050471................................................    1.8969   24.29
050476................................................    1.3686   23.14
050477................................................    1.4367   27.78
050478................................................    0.9911   23.05
050481................................................    1.3949   26.83
050482................................................    1.0569   16.93
050483................................................    2.2575   21.60
050485................................................    1.6066   23.19
050486................................................  ........   24.50
050488................................................    1.3257   32.86
050491................................................    1.2006   25.10
050492................................................    1.4183   21.42
050494................................................    1.2386   25.41
050496................................................    1.7595   33.02
050497................................................    0.8258  ......
050498................................................    1.2296   24.84
050502................................................    1.7271   22.63
050503................................................    1.3477   23.59
050506................................................    1.3621   21.22
050510................................................    1.2784   33.46
050512................................................    1.4429   34.31
050515................................................    1.3439   35.04
050516................................................    1.5017   25.19
050517................................................    1.2038   20.37
050522................................................    1.1593   31.73
050523................................................    1.2442   28.42
050526................................................    1.2943   26.92
050528................................................    1.1883   18.69
050531................................................    1.1101   20.73
050534................................................    1.2834   23.30
050535................................................    1.5140   24.23
050537................................................    1.3698   22.21
050539................................................    1.3269   23.25
050541................................................    1.5646   34.62
050542................................................    0.9786   17.85
050543................................................    0.8445   23.04
050545................................................    0.7658   27.57
050546................................................    0.6961   27.76
050547................................................    0.9008   27.08
050548................................................  ........   26.59
050549................................................    1.6034   27.91
050550................................................    1.3697   25.75
050551................................................    1.3532   24.05
050552................................................    1.2766   22.87
050557................................................    1.5203   22.14
050559................................................    1.2865   24.67
050561................................................    1.2133   33.93
050564................................................    1.3237   24.51
050565................................................    1.3123   22.88
050566................................................    0.9219   18.33
050567................................................    1.5570   24.23
050568................................................    1.3420   20.52
050569................................................    1.2025   24.94
050570................................................    1.6497   24.50
050571................................................    1.3946   24.37
050573................................................    1.5647   25.14
050575................................................    1.1467  ......
050577................................................    1.3600   20.52
050578................................................    1.2666   28.91
050579................................................    1.4322   30.07
050580................................................    1.2849   23.92
050581................................................    1.4507   23.57
050583................................................    1.6163   23.36
050584................................................    1.2401   23.16
050585................................................    1.2561   26.50
050586................................................    1.3532   23.84
050588................................................    1.2801   30.39
050589................................................    1.2395   24.35
050590................................................    1.3227  ......
050591................................................    1.3156   22.32
050592................................................    1.2663   26.05
050594................................................    1.6277   22.78
050597................................................    1.2260   23.18
050598................................................    1.3410   28.11
050599................................................    1.5942   26.32
050601................................................    1.6465   32.87
050603................................................    1.4208   22.75
050604................................................    1.4564   33.32
050607................................................  ........   24.10
050608................................................    1.2793   16.15
050609................................................    1.4917   31.93
050613................................................    1.1189   23.48
050615................................................    1.5453   23.70
050616................................................    1.3449   22.80
050618................................................    1.0867   21.70
050623................................................    1.5638   30.32
050624................................................    1.3297   22.34
050625................................................    1.6305   24.35
050630................................................    1.2762   24.10
050633................................................    1.2825   21.98
050635................................................  ........   37.85
050636................................................    1.4239   20.83
050638................................................    1.1491   23.63
050641................................................    1.2971   21.36
050643................................................    0.9604  ......
050644................................................    1.0737   23.12
050660................................................    1.4966  ......
050661................................................  ........   20.48
050662................................................    0.8151   28.29
050663................................................    1.1758   23.71
050667................................................    1.0967   24.11
050668................................................    1.0944   39.90
050670................................................    0.7555   21.88
050674................................................    1.2425   36.24
050675................................................    2.2195   15.84
050676................................................    1.0018   17.53
050677................................................    1.3679   33.71
050678................................................    1.2889   22.66
050680................................................    1.1178   27.32
050682................................................    0.9234   17.97
050684................................................    1.2409   21.81
050685................................................    1.1904   32.13
050686................................................    1.2866   33.25
050688................................................    1.1936   30.00
050689................................................    1.4920   34.19
050690................................................    1.4168   33.83
050693................................................    1.3155   33.30
050694................................................    1.3866   22.57
050695................................................    1.0607   23.52
050696................................................    2.1060   26.41
050697................................................    1.3204   21.47

[[Page 41562]]

 
050699................................................    0.5913   28.48
050700................................................  ........   28.45
050701................................................    1.3166   27.62
050702................................................  ........   12.25
050704................................................    1.0855   20.76
050707................................................    0.9714   27.51
050708................................................    1.4500   21.91
050709................................................    1.2519   19.42
050710................................................    1.3390   26.81
050713................................................    0.7909   15.30
050714................................................    1.3510  ......
050715................................................  ........   19.12
050717................................................    1.2647  ......
050718................................................    0.7579  ......
050719................................................    3.1984  ......
050720................................................    0.9044  ......
060001................................................    1.6835   20.59
060003................................................    1.2708   19.32
060004................................................    1.1987   21.79
060006................................................    1.2571   17.86
060007................................................    1.1650   16.38
060008................................................    1.0843   17.09
060009................................................    1.4985   21.18
060010................................................    1.6674   22.72
060011................................................    1.3925   21.97
060012................................................    1.3814   19.77
060013................................................    1.3217   19.14
060014................................................    1.8153   20.53
060015................................................    1.6320   23.57
060016................................................    1.1638   15.96
060018................................................    1.2867   21.86
060020................................................    1.6130   17.73
060022................................................    1.5677   19.65
060023................................................    1.6323   19.65
060024................................................    1.7015   22.83
060027................................................    1.6925   21.67
060028................................................    1.5331   22.25
060029................................................    0.8925   21.41
060030................................................    1.3542   20.03
060031................................................    1.5383   19.40
060032................................................    1.4782   22.37
060033................................................    1.1398   13.82
060034................................................    1.5846   21.41
060036................................................    1.1376   19.24
060037................................................    1.0079   14.05
060038................................................    0.9440   14.31
060041................................................    0.9246   14.83
060042................................................    1.0356   20.08
060043................................................    0.8801   13.05
060044................................................    1.1681   22.53
060046................................................    1.0302   20.44
060047................................................    0.9655   15.12
060049................................................    1.3171   20.64
060050................................................    1.2512   16.80
060052................................................    1.0404   12.55
060053................................................    1.0148   14.94
060054................................................    1.4104   19.39
060056................................................    0.9051   17.05
060057................................................    1.0273   23.38
060058................................................    0.9425   16.91
060060................................................    0.9200   14.89
060062................................................    0.8628   14.94
060063................................................  ........   15.09
060064................................................    1.4833   20.93
060065................................................    1.2913   24.30
060066................................................    0.9930   14.07
060068................................................  ........   19.64
060070................................................    1.1250   16.58
060071................................................    1.2078   16.95
060073................................................    0.9583   15.84
060075................................................    1.2425   22.85
060076................................................    1.4325   19.29
060085................................................    0.8869   13.48
060087................................................  ........   21.03
060088................................................    0.9983   16.67
060090................................................    0.8997   14.51
060096................................................    1.1067   23.12
060100................................................    1.5321   22.00
060103................................................    1.3211   22.34
060104................................................    1.2351   22.30
060107................................................    1.1955   13.64
060108................................................    0.4789  ......
060109................................................    1.1185  ......
070001................................................    1.7614   26.51
070002................................................    1.8336   25.46
070003................................................    1.1215   26.09
070004................................................    1.2043   23.27
070005................................................    1.4436   25.57
070006................................................    1.3881   28.71
070007................................................    1.3524   27.19
070008................................................    1.2506   26.03
070009................................................    1.2685   23.47
070010................................................    1.6992   25.94
070011................................................    1.3820   23.96
070012................................................    1.1724   25.10
070015................................................    1.3890   25.33
070016................................................    1.4259   26.30
070017................................................    1.3718   24.80
070018................................................    1.3684   28.88
070019................................................    1.1838   24.70
070020................................................    1.3222   23.72
070021................................................    1.2362   26.52
070022................................................    1.8643   25.08
070024................................................    1.3255   25.15
070025................................................    1.8686   25.41
070026................................................  ........   18.79
070027................................................    1.3113   23.64
070028................................................    1.5522   24.69
070029................................................    1.3352   22.75
070030................................................    1.2883   24.97
070031................................................    1.2420   21.66
070033................................................    1.4115   28.81
070034................................................    1.3893   29.12
070035................................................    1.4205   23.06
070036................................................    1.7251   28.95
070038................................................    0.7729  ......
070039................................................    0.9555   21.78
080001................................................    1.7133   25.28
080002................................................  ........   15.60
080003................................................    1.3835   22.40
080004................................................    1.2651   19.77
080005................................................  ........   14.43
080006................................................    1.3003   22.26
080007................................................    1.4176   20.38
090001................................................    1.6034   25.89
090002................................................    1.3475   19.70
090003................................................    1.3718   28.61
090004................................................    1.7978   24.43
090005................................................    1.3706   24.88
090006................................................    1.3152   20.08
090007................................................    1.3040   21.66
090008................................................    1.5064   21.60
090010................................................    1.0721   15.87
090011................................................    2.1194   27.37
100001................................................    1.5307   17.69
100002................................................    1.4390   21.32
100004................................................    1.0119   15.25
100006................................................    1.6160   20.63
100007................................................    1.8871   21.72
100008................................................    1.5830   20.72
100009................................................    1.4671   24.29
100010................................................    1.4977   21.91
100012................................................    1.6382   18.52
100014................................................    1.4823   19.83
100015................................................    1.4805   18.24
100017................................................    1.5923   17.77
100018................................................    1.5493   20.84
100019................................................    1.5572   19.81
100020................................................    1.3926   26.18
100022................................................    1.7978   25.89
100023................................................    1.3578   21.11
100024................................................    1.3497   20.78
100025................................................    1.7580   19.12
100026................................................    1.5873   20.76
100027................................................    1.0231   12.94
100028................................................    1.2105   19.75
100029................................................    1.3375   19.18
100030................................................    1.2542   18.82
100032................................................    1.8533   19.32
100034................................................    1.7580   18.23
100035................................................    1.5894   19.58
100038................................................    1.6636   24.78
100039................................................    1.5287   20.25
100040................................................    1.7501   18.64
100043................................................    1.3307   17.52
100044................................................    1.3922   21.14
100045................................................    1.3923   20.77
100046................................................    1.4279   21.21
100047................................................    1.8496   18.87
100048................................................    0.9391   13.50
100049................................................    1.2653   18.56
100050................................................    1.1494   16.60
100051................................................    1.2391   18.84
100052................................................    1.3875   16.19
100053................................................    1.2128   18.71
100054................................................    1.2776   18.19
100055................................................    1.3755   17.62
100056................................................    1.4973   23.65
100057................................................    1.3595   18.75
100060................................................    1.8341   22.39
100061................................................    1.4541   21.79
100062................................................    1.7297   17.96
100063................................................    1.1596   16.23
100067................................................    1.3589   17.40
100068................................................    1.3600   18.65
100069................................................    1.2996   16.14
100070................................................    1.4348   20.33
100071................................................    1.2324   16.48
100072................................................    1.2519   19.22
100073................................................    1.7170   18.16
100075................................................    1.5967   18.05
100076................................................    1.2999   16.25

[[Page 41563]]

 
100077................................................    1.3907   19.62
100078................................................    1.0296   18.28
100079................................................    1.3325  ......
100080................................................    1.6004   21.16
100081................................................    1.1059   13.96
100082................................................    1.4981   19.80
100084................................................    1.3484   20.40
100085................................................    1.4397   21.08
100086................................................    1.2337   21.16
100087................................................    1.8332   23.12
100088................................................    1.6560   20.06
100090................................................    1.3796   17.88
100092................................................    1.5762   18.19
100093................................................    1.5951   16.63
100098................................................    1.0984   19.03
100099................................................    1.2207   15.30
100102................................................    1.0153   19.33
100103................................................    0.9374   18.10
100105................................................    1.4538   21.50
100106................................................    1.0262   19.31
100107................................................    1.3128   18.01
100108................................................    0.9979   11.47
100109................................................    1.3846   22.17
100110................................................    1.3687   19.64
100112................................................    0.9703    9.77
100113................................................    1.9526   22.26
100114................................................    1.3378   23.45
100117................................................    1.1904   18.86
100118................................................    1.2978   19.76
100121................................................    1.1778   19.34
100122................................................    1.2065   18.06
100124................................................    1.2961   19.05
100125................................................    1.2709   17.33
100126................................................    1.4682   18.09
100127................................................    1.6587   19.87
100128................................................    2.2076   21.37
100129................................................    1.3074   18.57
100130................................................    1.1759   19.10
100131................................................    1.3440   22.17
100132................................................    1.2920   16.90
100134................................................    0.9738   13.47
100135................................................    1.5672   17.48
100137................................................    1.2758   19.05
100138................................................    1.0055   11.01
100139................................................    1.0894   15.64
100140................................................    1.2173   17.35
100142................................................    1.2261   18.68
100144................................................    1.1622   15.02
100145................................................  ........   19.11
100146................................................    0.9697   17.87
100147................................................    1.0080   14.68
100150................................................    1.3244   21.02
100151................................................    1.7687   19.40
100154................................................    1.5832   19.85
100156................................................    1.1101   17.13
100157................................................    1.5609   21.03
100159................................................    0.9570   16.38
100160................................................    1.2026   21.63
100161................................................    1.6995   21.50
100162................................................    1.3955   19.87
100165................................................    1.1535   18.57
100166................................................    1.4349   20.42
100167................................................    1.3548   21.81
100168................................................    1.3372   20.13
100169................................................    1.7623   20.78
100170................................................    1.4159   15.12
100172................................................    1.4335   15.18
100173................................................    1.6528   17.34
100174................................................    1.3768   20.51
100175................................................    1.1543   17.82
100176................................................    2.0764   24.70
100177................................................    1.2977   22.00
100179................................................    1.7103   20.91
100180................................................    1.4415   18.48
100181................................................    1.1065   24.57
100183................................................    1.1888   20.86
100187................................................    1.4299   20.69
100189................................................    1.3286   21.01
100191................................................    1.3182   18.47
100199................................................    1.3519   23.37
100200................................................    1.2409   22.26
100203................................................  ........   18.86
100204................................................    1.6272   20.20
100206................................................    1.3739   20.35
100207................................................  ........   15.92
100208................................................    1.3673   20.83
100209................................................    1.4791   19.73
100210................................................    1.5718   19.18
100211................................................    1.3991   25.53
100212................................................    1.6224   25.34
100213................................................    1.5100   19.12
100217................................................    1.2751   19.87
100220................................................    1.6355   19.91
100221................................................    1.8110   22.25
100222................................................    0.9440   22.19
100223................................................    1.4651   18.76
100224................................................    1.3349   24.70
100225................................................    1.3371   20.64
100226................................................    1.3508   24.86
100228................................................    1.2825   23.70
100229................................................    1.3326   18.21
100230................................................    1.3523   20.60
100231................................................    1.6815   17.40
100232................................................    1.2511   17.32
100234................................................    1.2587   21.58
100235................................................  ........   17.66
100236................................................    1.3925   21.81
100237................................................    2.1893   22.93
100238................................................    1.5454   17.63
100239................................................    1.4287   19.76
100240................................................    1.0888   17.93
100241................................................    0.8994   13.83
100242................................................    1.4298   17.12
100243................................................    1.4071   20.38
100244................................................    1.3741   17.41
100246................................................    1.3686   21.22
100248................................................    1.5873   21.54
100249................................................    1.3084   19.02
100252................................................    1.2005   17.87
100253................................................    1.4323   20.60
100254................................................    1.5401   20.91
100255................................................    1.2559   21.02
100256................................................    2.0104   23.56
100258................................................    1.6901   21.88
100259................................................    1.3409   19.86
100260................................................    1.4570   21.22
100262................................................    1.3448   19.59
100263................................................  ........   16.90
100264................................................    1.3620   17.61
100265................................................    1.2932   19.86
100266................................................    1.3567   17.73
100267................................................    1.3056   17.10
100268................................................    1.1952   23.59
100269................................................    1.4345   21.20
100270................................................    1.0181   19.86
100271................................................    1.7715   19.92
100275................................................    1.3944   21.33
100276................................................    1.2371   21.98
100277................................................    1.0333   16.14
100279................................................    1.2721   23.02
100280................................................    1.2951   16.58
100281................................................    1.2795   22.02
100282................................................    1.0837   19.77
100284................................................    1.0855  ......
110001................................................    1.2552   18.06
110002................................................    1.2532   17.37
110003................................................    1.3637   16.91
110004................................................    1.3569   18.95
110005................................................    1.1963   19.26
110006................................................    1.4201   20.13
110007................................................    1.6114   23.50
110008................................................    1.2419   18.26
110009................................................    1.1355   14.82
110010................................................    2.1768   24.55
110011................................................    1.1631   18.28
110013................................................    1.0596   16.03
110014................................................    0.9442   16.12
110015................................................    1.1403   19.48
110016................................................    1.2284   15.30
110017................................................    0.9311   10.54
110018................................................    1.1969   21.04
110020................................................    1.1913   18.53
110023................................................    1.3377   18.65
110024................................................    1.3651   19.79
110025................................................    1.3872   18.65
110026................................................    1.1354   16.14
110027................................................    1.1200   14.68
110028................................................    1.7799   19.89
110029................................................    1.3551   20.05
110030................................................    1.2989   17.68
110031................................................    1.2252   21.58
110032................................................    1.2518   16.19
110033................................................    1.4207   21.41
110034................................................    1.5887   18.19
110035................................................    1.3910   21.17
110036................................................    1.8557   24.42
110038................................................    1.4440   16.38
110039................................................    1.4173   20.77
110040................................................    1.0663   16.40
110041................................................    1.1827   16.69
110042................................................    1.1533   20.65
110043................................................    1.8094   17.22
110044................................................    1.1898   19.60
110045................................................    1.1386   19.94
110046................................................    1.2456   19.23
110048................................................    1.2372   15.65
110049................................................    1.0992   14.21
110050................................................    1.1823   18.75
110051................................................    1.0253   15.75
110052................................................  ........   15.06
110054................................................    1.3647   19.27
110056................................................    1.0854   16.50

[[Page 41564]]

 
110059................................................    1.2176   17.70
110061................................................    1.0960   13.72
110062................................................    0.9082   12.21
110063................................................    1.0542   17.97
110064................................................    1.4891   18.34
110065................................................    1.0304   13.32
110066................................................    1.4455   20.65
110069................................................    1.2576   18.35
110070................................................    1.1398   18.23
110071................................................    1.0981   14.89
110072................................................    0.9710   12.43
110073................................................    1.1423   15.14
110074................................................    1.5078   20.76
110075................................................    1.3221   17.01
110076................................................    1.4652   20.44
110078................................................    1.7591   24.71
110079................................................    1.4560   20.14
110080................................................    1.3568   23.43
110082................................................    2.0994   22.01
110083................................................    1.7625   21.36
110086................................................    1.2841   14.98
110087................................................    1.3556   20.54
110089................................................    1.2027   18.58
110091................................................    1.2778   21.38
110092................................................    1.0882   15.09
110093................................................    0.9940   14.80
110094................................................    0.9912   13.87
110095................................................    1.3528   15.95
110096................................................    1.0800   16.32
110097................................................    1.0625   15.62
110098................................................    0.9868   14.01
110100................................................    1.0558   20.38
110101................................................    1.1014   11.73
110103................................................    0.9292   11.94
110104................................................    1.0957   15.32
110105................................................    1.3084   16.52
110107................................................    1.8959   17.39
110108................................................    0.9495   15.14
110109................................................    1.1092   16.37
110111................................................    1.2038   17.32
110112................................................    0.9910   19.13
110113................................................    1.0478   15.19
110114................................................    1.0443   15.13
110115................................................    1.7515   24.83
110118................................................    1.1342   15.40
110120................................................    1.0378   15.19
110121................................................    1.2814   15.58
110122................................................    1.3852   18.85
110124................................................    1.2083   17.13
110125................................................    1.2563   17.33
110127................................................    0.8834   13.76
110128................................................    1.1927   18.97
110129................................................    1.6606   18.12
110130................................................    1.0077   13.08
110132................................................    1.1467   15.02
110134................................................    0.9641   11.56
110135................................................    1.3364   17.08
110136................................................    1.1043   16.17
110140................................................    1.0432   17.88
110141................................................    0.9978   12.51
110142................................................    0.9537   12.30
110143................................................    1.4324   21.69
110144................................................    1.0701   17.98
110146................................................    1.0869   17.61
110149................................................    1.1792   22.23
110150................................................    1.4100   18.77
110152................................................    1.0430   14.77
110153................................................    1.0935   18.69
110154................................................    0.9773   14.81
110155................................................    1.1373   17.14
110156................................................    1.0500   15.34
110161................................................    1.3183   20.87
110162................................................    0.7522  ......
110163................................................    1.4626   18.20
110164................................................    1.4197   19.49
110165................................................    1.4296   19.00
110166................................................    1.4485   19.85
110168................................................    1.6662   19.82
110169................................................    1.2028   18.72
110171................................................    1.6129   20.09
110172................................................    1.3551   25.44
110174................................................    0.9161   14.30
110176................................................    3.7291   22.40
110177................................................    1.5099   19.59
110178................................................  ........   16.85
110179................................................    1.1506   20.52
110181................................................    0.9051   13.72
110183................................................    1.3138   21.18
110184................................................    1.2424   20.95
110185................................................    1.1859   16.25
110186................................................    1.2579   17.34
110187................................................    1.2755   21.45
110188................................................    1.3546   20.05
110189................................................    1.1719   18.86
110190................................................    1.0646   19.43
110191................................................    1.3087   19.11
110192................................................    1.4455   20.77
110193................................................    1.2441   18.78
110194................................................    0.8928   15.09
110195................................................    1.0992   10.52
110198................................................    1.2874   26.19
110200................................................    1.8858   17.21
110201................................................    1.5098   19.24
110203................................................    0.9319   20.30
110204................................................    0.8239   20.57
110205................................................    1.0578   26.12
110207................................................    1.0141   12.87
110208................................................    0.9593   14.89
110209................................................    0.7100   20.46
110211................................................    0.9611   21.82
110212................................................    1.0031   12.66
110213................................................  ........   13.20
110215................................................    1.0915  ......
110216................................................    2.1653  ......
110217................................................    2.8336  ......
120001 *..............................................    1.8210   26.71
120002................................................    1.2129   24.38
120003................................................    1.1495   23.85
120004................................................    1.2588   24.05
120005................................................    1.2449   20.54
120006................................................    1.2730   23.72
120007................................................    1.7318   23.27
120009................................................    0.9876   19.02
120010 *..............................................    1.8326   25.40
120011................................................    1.3630   33.55
120012................................................    0.8391   22.52
120014................................................    1.2760   24.05
120015................................................    1.0355   29.07
120016................................................    1.0574   29.41
120018................................................    1.2117   25.61
120019................................................    1.3192   21.92
120021................................................    0.8937   19.42
120022 *..............................................    1.6843   17.93
120024................................................    1.0727   22.28
120025................................................  ........   19.02
120026................................................    1.2648   23.22
120027................................................    1.4048   24.55
120028................................................    1.2481   23.49
130001................................................    0.9681   24.95
130002................................................    1.3266   16.19
130003................................................    1.3394   19.95
130005................................................    1.4416   20.17
130006................................................    1.8354   18.87
130007................................................    1.6730   19.84
130008................................................    0.9590   12.92
130009................................................    0.9302   18.30
130010................................................    0.8926   21.43
130011................................................    1.2859   19.08
130012................................................    0.9911   22.62
130013................................................    1.3306   19.22
130014................................................    1.3247   17.98
130015................................................    0.8768   15.27
130016................................................    1.0211   17.00
130017................................................    1.1066   16.88
130018................................................    1.6255   17.97
130019................................................    1.1213   17.23
130021................................................    0.9692   12.26
130022................................................    1.2150   19.50
130024................................................    1.1595   18.38
130025................................................    1.0955   15.27
130026................................................    1.1725   20.55
130027................................................    0.9334   20.70
130028................................................    1.2849   18.21
130029................................................    1.0697   20.32
130030................................................    0.8448   18.40
130031................................................    1.0229   17.65
130034................................................    1.0325   18.82
130035................................................    1.1048   20.47
130036................................................    1.3938   13.79
130037................................................    1.3059   17.74
130043................................................    0.9589   16.07
130044................................................    0.9748   13.18
130045................................................    0.9802   16.47
130048................................................    0.9813   15.09
130049................................................    1.2324   20.39
130054................................................    0.9573   17.78
130056................................................    0.8508   15.66
130058................................................  ........   17.75
130060................................................    1.2887   20.85
130061................................................    1.2950   16.78
130062................................................    0.7200   15.11
130063................................................    1.4979  ......
140001................................................    1.2255   15.44
140002................................................    1.2571   19.26
140003................................................    1.0026   18.00
140004................................................    1.1707   17.52
140005................................................    0.9673   10.87
140007................................................    1.4692   22.40
140008................................................    1.4670   21.28
140010................................................    1.3723   25.22
140011................................................    1.2034   17.28
140012................................................    1.2770   19.44

[[Page 41565]]

 
140013................................................    1.5752   17.35
140014................................................    1.1751   20.76
140015................................................    1.2854   15.02
140016................................................    1.0294   12.54
140018................................................    1.2556   21.41
140019................................................    1.1123   15.34
140024................................................    0.9557   14.67
140025................................................    1.0826   16.95
140026................................................    1.2234   15.96
140027................................................    1.2694   17.50
140029................................................    1.3385   21.03
140030................................................    1.8214   22.44
140031................................................    1.2008   15.94
140032................................................    1.3345   17.34
140033................................................    1.2874   22.56
140034................................................    1.1851   19.15
140035................................................    1.0002   13.00
140036................................................    1.2407   17.04
140037................................................    1.0383   12.50
140038................................................    1.1029   17.61
140040................................................    1.2581   16.25
140041................................................    1.1609   17.28
140042................................................    1.0170   15.61
140043................................................    1.1892   18.95
140045................................................    1.0315   20.65
140046................................................    1.3045   16.46
140047................................................    1.0950   16.33
140048................................................    1.3056   20.58
140049................................................    1.6537   21.59
140051................................................    1.5128   20.85
140052................................................    1.3027   19.60
140053................................................    2.0158   17.82
140054................................................    1.3339   26.15
140055................................................    1.0225   14.80
140058................................................    1.2340   17.27
140059................................................    1.1394   15.39
140061................................................    1.0953   15.96
140062................................................    1.2457   27.09
140063................................................    1.4375   22.39
140064................................................    1.3249   19.25
140065................................................    1.4610   23.16
140066................................................    1.1773   16.17
140067................................................    1.8177   18.40
140068................................................    1.2883   18.87
140069................................................    1.0457   16.15
140070................................................    1.2636   19.30
140074................................................    1.0760   19.01
140075................................................    1.3671   22.51
140077................................................    1.2557   16.64
140079................................................    1.2639   21.92
140080................................................    1.5815   21.00
140081................................................    1.0826   15.51
140082................................................    1.3675   22.62
140083................................................    1.2487   18.13
140084................................................    1.2529   20.01
140086................................................    1.1147   17.37
140087................................................    1.3481   18.36
140088................................................    1.7136   24.26
140089................................................    1.2745   17.21
140090................................................    1.5324   23.59
140091................................................    1.9057   20.70
140093................................................    1.1687   19.15
140094................................................    1.3422   20.61
140095................................................    1.4016   21.54
140097................................................    0.9525   16.90
140100................................................    1.3286   19.06
140101................................................    1.2240   26.09
140102................................................    1.0445   15.08
140103................................................    1.4231   17.86
140105................................................    1.2926   20.91
140107................................................    1.0113   12.76
140108................................................    1.3335   28.60
140109................................................    1.1446   15.47
140110................................................    1.2400   18.81
140112................................................    1.1563   16.24
140113................................................    1.5588   17.92
140114................................................    1.3342   20.48
140115 *..............................................    1.3041   20.09
140116................................................    1.2341   21.83
140117................................................    1.5614   19.64
140118................................................    1.7249   23.08
140119................................................    1.7816   26.50
140120................................................    1.3740   14.84
140121................................................    1.3607    9.53
140122................................................    1.5542   23.75
140124................................................    1.1024   26.97
140125................................................    1.3478   17.10
140127................................................    1.4164   19.42
140128................................................    1.0296   17.67
140129................................................    1.1659   15.25
140130................................................    1.2488   23.77
140132................................................    1.4905   23.04
140133................................................    1.4025   19.91
140135................................................    1.2759   17.69
140137................................................    1.0383   16.51
140138................................................    1.0650   14.59
140139................................................    1.1039   16.58
140140................................................    1.1395   15.30
140141................................................    1.2644   15.18
140143................................................    1.0957   18.76
140144................................................    0.9933   19.79
140145................................................    1.1514   16.61
140146................................................    1.0740   23.74
140147................................................    1.2519   24.82
140148................................................    1.8274   19.50
140150................................................    1.6434   27.85
140151................................................    1.0618   19.30
140152................................................    1.1951   22.43
140155................................................    1.3310   17.31
140158................................................    1.3594   22.27
140160................................................    1.1737   17.88
140161................................................    1.2224   19.04
140162................................................    1.6988   18.42
140164................................................    1.4390   18.61
140165................................................    1.0866   15.42
140166................................................    1.1670   17.54
140167................................................    1.0995   16.57
140168................................................    1.1303   16.46
140170................................................    1.1327   14.14
140171................................................    0.9915   14.73
140172................................................    1.5915   20.80
140173................................................    0.8685   18.48
140174................................................    1.6130   19.92
140176................................................    1.2480   21.41
140177................................................    1.2010   18.17
140179................................................    1.3630   22.70
140180................................................    1.4469   23.25
140181................................................    1.4232   20.55
140182................................................    1.3607   20.70
140184................................................    1.2116   14.98
140185................................................    1.4938   17.36
140186................................................    1.3429   18.99
140187................................................    1.5865   17.69
140188................................................    0.9985   14.84
140189................................................    1.2534   19.08
140190................................................    1.0757   15.88
140191................................................    1.4399   24.74
140193................................................    1.0289   15.52
140197................................................    1.2537   17.98
140199................................................    1.0816   18.83
140200................................................    1.4773   21.65
140202................................................    1.3290   22.18
140203................................................    1.1563   20.78
140205................................................    0.9296   17.24
140206................................................    1.2023   20.51
140207................................................    1.2939   20.20
140208................................................    1.7156   23.94
140209................................................    1.6271   17.79
140210................................................    1.1138   12.66
140211................................................    1.2095   20.96
140213................................................    1.2790   26.20
140215................................................    0.9874   14.45
140217................................................    1.3233   23.32
140218................................................    0.9871   15.08
140220................................................    1.1223   16.73
140223................................................    1.5508   21.47
140224................................................    1.4309   22.99
140228................................................    1.6773   18.67
140230................................................    0.9381   16.60
140231................................................    1.5608   21.61
140233................................................    1.7813   18.37
140234................................................    1.2225   18.72
140236................................................    1.0843   13.13
140239................................................    1.7318   18.88
140240................................................    1.3948   24.21
140242................................................    1.6371   22.67
140245................................................    1.2029   15.56
140246................................................    1.0621   12.82
140250................................................    1.3281   23.41
140251................................................    1.3069   20.58
140252................................................    1.4989   24.49
140253................................................    1.1634   16.74
140258................................................    1.5765   21.13
140271................................................    0.9795   15.36
140275................................................    1.2739   17.96
140276................................................    2.0654   23.72
140280................................................    1.3786   18.84
140281................................................    1.6496   23.34
140285................................................    1.2739   14.71
140286................................................    1.1863   19.95
140288................................................    1.6193   21.82
140289................................................    1.3459   16.45
140290................................................    1.3383   21.24
140291................................................    1.3339   22.44
140292................................................    1.2911   22.71
140294................................................    1.1347   17.52
140297................................................  ........   21.47
140300................................................    1.4559   23.26
150001................................................    1.1041   21.70
150002................................................    1.4489   18.76
150003................................................    1.8053   19.31
150004................................................    1.5183   19.70

[[Page 41566]]

 
150005................................................    1.1499   19.00
150006................................................    1.2599   20.04
150007................................................    1.2063   19.53
150008................................................    1.4364   20.97
150009................................................    1.3649   18.22
150010................................................    1.3600   18.48
150011................................................    1.2166   19.19
150012................................................    1.6210   20.52
150013................................................    1.1027   16.00
150014................................................    1.6030   21.28
150015................................................    1.2975   22.05
150017................................................    1.9021   18.89
150018................................................    1.4575   19.56
150019................................................    1.0931   15.29
150020................................................    1.1536   14.46
150021................................................    1.6905   19.02
150022................................................    1.0882   17.92
150023................................................    1.5779   18.66
150024................................................    1.3427   17.83
150025................................................    1.4440   18.15
150026................................................    1.2077   20.51
150027................................................    1.0057   16.48
150029................................................    1.3399   21.74
150030................................................    1.2418   17.33
150031................................................    1.0791   18.01
150032................................................  ........   20.64
150033................................................    1.5759   21.69
150034................................................    1.4830   21.29
150035................................................    1.4915   19.82
150036................................................    1.0011   20.38
150037................................................    1.2875   17.79
150038................................................    1.2923   20.25
150039................................................    1.0012   17.49
150042................................................    1.2828   17.12
150043................................................    1.1061   17.98
150044................................................    1.2617   17.64
150045................................................    1.0943   17.04
150046................................................    1.3952   17.32
150047................................................    1.5995   24.88
150048................................................    1.1920   16.96
150049................................................    1.2163   16.85
150050................................................    1.1659   17.14
150051................................................    1.5091   18.20
150052................................................    1.0896   15.36
150053................................................    0.9867   18.75
150054................................................    1.1338   17.33
150056................................................    1.8954   23.30
150057................................................    2.2387   16.86
150058................................................    1.7048   20.95
150059................................................    1.3598   20.80
150060................................................    1.1844   16.01
150061................................................    1.2118   17.21
150062................................................    1.1077   18.41
150063................................................    1.0850   21.09
150064................................................    1.1848   17.03
150065................................................    1.1695   19.01
150066................................................    1.0217   14.60
150067................................................    1.1259   17.08
150069................................................    1.2229   17.39
150070................................................    0.9568   17.20
150071................................................    1.0951   14.73
150072................................................    1.1985   16.11
150073................................................    1.0647   19.03
150074................................................    1.6339   18.86
150075................................................    1.1208   14.98
150076................................................    1.1839   22.34
150077................................................    0.8124   17.58
150078................................................    1.0539   19.01
150079................................................    1.1723   15.45
150082................................................    1.5245   17.88
150084................................................    1.9902   22.92
150086................................................    1.2532   17.34
150088................................................    1.3451   19.45
150089................................................    1.4582   22.94
150090................................................    1.3308   19.06
150091................................................    1.0358   19.89
150092................................................    1.0090   15.92
150094................................................    0.9814   18.34
150095................................................    1.0848   17.12
150096................................................    1.0067   20.03
150097................................................    1.0940   18.31
150098................................................    1.1571   14.30
150099................................................  ........   18.97
150100................................................    1.6554   17.48
150101................................................    1.0910   17.56
150102................................................    1.0778   11.50
150103................................................    0.9707   17.31
150104................................................    1.1260   17.26
150105................................................    1.3381   19.17
150106................................................    1.0525   18.91
150109................................................    1.3958   18.23
150110................................................    0.9834   18.58
150111................................................    1.1588   16.17
150112................................................    1.2455   19.82
150113................................................    1.2372   19.20
150114................................................    0.9743   16.96
150115................................................    1.3404   17.06
150122................................................    1.1625   19.35
150123................................................    1.1180   15.16
150124................................................    1.0843   15.07
150125................................................    1.4619   20.32
150126................................................    1.4866   20.30
150127................................................    1.0396   22.81
150128................................................    1.2478   19.92
150129................................................    1.1853   23.47
150130................................................    1.3391   16.41
150132................................................    1.4200   19.48
150133................................................    1.1910   16.49
150134................................................    1.1949   17.06
150136................................................    0.9556   19.28
160001................................................    1.2585   19.03
160002................................................    1.0936   15.37
160003................................................    0.9994   15.77
160005................................................    1.0825   15.23
160007................................................    1.0218   15.66
160008................................................    1.1402   14.97
160009................................................    1.2212   16.09
160012................................................    1.0500   16.54
160013................................................    1.1368   17.06
160014................................................    1.0250   15.09
160016................................................    1.1678   18.37
160018................................................    0.9630   14.16
160020................................................    1.0690   14.41
160021................................................    1.1123   15.49
160023................................................    1.0852   14.20
160024................................................    1.6086   18.95
160026................................................    1.0312   18.66
160027................................................    1.0851   15.74
160028................................................    1.2328   20.54
160029................................................    1.5330   20.40
160030................................................    1.3897   17.99
160031................................................    1.1173   15.28
160032................................................    1.1540   16.18
160033................................................    1.9249   18.37
160034................................................    1.1538   14.51
160035................................................    0.8486   15.92
160036................................................    1.0544   19.20
160037................................................    1.0575   18.40
160039................................................    1.0380   17.63
160040................................................    1.2725   16.83
160041................................................    1.0640   15.47
160043................................................    0.9958   15.63
160044................................................    1.2165   16.04
160045................................................    1.8190   20.12
160046................................................    1.0270   14.77
160047................................................    1.3715   16.69
160048................................................    1.2473   13.14
160049................................................    0.9271   13.36
160050................................................    1.0702   16.42
160051................................................    0.8978   14.27
160052................................................    0.9917   17.55
160054................................................    1.0301   15.71
160055................................................    0.9883   14.06
160056................................................    1.0674   15.38
160057................................................    1.2430   17.41
160058................................................    1.8366   20.34
160060................................................    1.0432   15.95
160061................................................    1.0830   17.57
160062................................................    0.9941   14.44
160063................................................    1.1620   16.30
160064................................................    1.5338   19.91
160065................................................    1.0522   16.51
160066................................................    1.1019   16.26
160067................................................    1.4239   17.85
160068................................................    1.0224   15.85
160069................................................    1.5367   18.49
160070................................................    0.9958   15.66
160072................................................    1.0345   14.19
160073................................................    0.9972   15.05
160074................................................    1.0388   16.48
160075................................................    1.0778   17.89
160076................................................    1.0989   17.31
160077................................................    1.1087   11.40
160079................................................    1.4119   17.71
160080................................................    1.2114   17.81
160081................................................    1.1520   16.51
160082................................................    1.9236   18.76
160083................................................    1.6706   18.41
160085................................................    0.9972   18.55
160086................................................    0.9601   16.46
160088................................................    1.1561   17.53
160089................................................    1.1911   16.74
160090................................................    1.0139   16.60
160091................................................    1.0383   12.19
160092................................................    1.0120   15.80
160093................................................    1.0155   15.95
160094................................................    1.1043   16.56
160095................................................    1.0299   14.26
160097................................................    1.0774   15.21
160098................................................    0.9466   15.54
160099................................................    0.9654   13.79
160101................................................    1.0851   17.87

[[Page 41567]]

 
160102................................................    1.3432   18.36
160103................................................    0.9416   17.15
160104................................................    1.2969   19.74
160106................................................    1.1113   16.66
160107................................................    1.1505   16.56
160108................................................    1.0215   15.42
160109................................................    1.0167   16.49
160110................................................    1.5105   18.81
160111................................................    0.9969   13.17
160112................................................    1.3695   16.28
160113................................................    1.0947   14.58
160114................................................    0.9776   15.58
160115................................................    0.9770   15.76
160116................................................    1.1196   16.69
160117................................................    1.4111   17.29
160118................................................    0.9954   15.84
160120................................................    0.9721   12.56
160122................................................    1.1137   18.52
160124................................................    1.2998   17.16
160126................................................    0.9700   17.74
160129................................................    0.9742   15.89
160130................................................    1.1286   15.45
160131................................................    1.0437   14.69
160134................................................    0.9459   13.32
160135................................................    1.0163   16.33
160138................................................    1.0146   15.71
160140................................................    1.1321   18.80
160142................................................    1.0188   16.14
160143................................................    1.1242   15.92
160145................................................    1.0697   15.17
160146................................................    1.4411   16.35
160147................................................    1.2764   18.39
160151................................................    1.0545   15.74
160152................................................    0.9425   15.22
160153................................................    1.7595   19.69
170001................................................    1.2073   17.44
170004................................................    1.0739   13.06
170006................................................    1.1966   19.31
170008................................................    1.0034   13.90
170009................................................    1.1479   19.59
170010................................................    1.3585   17.90
170012................................................    1.4135   16.79
170013................................................    1.2818   17.89
170014................................................    1.0342   17.34
170015................................................    0.9809   15.89
170016................................................    1.7098   19.64
170017................................................    1.1985   17.87
170018................................................    1.1014   14.28
170019................................................    1.2400   16.66
170020................................................    1.4076   16.15
170022................................................    1.0506   17.94
170023................................................    1.4694   19.36
170024................................................    1.0663   13.06
170025................................................    1.1917   16.37
170026................................................    1.0821   13.31
170027................................................    1.3182   16.39
170030................................................    1.0600   15.24
170031................................................    0.8926   13.47
170032................................................    1.0154   14.48
170033................................................    1.4154   16.05
170034................................................    1.0335   14.63
170035................................................    0.8974   15.62
170036................................................  ........   14.17
170038................................................    0.9007   14.21
170039................................................    1.0924   14.30
170040................................................    1.5839   20.14
170041................................................    1.0515   11.47
170044................................................    0.9951   14.78
170045................................................    1.0889   12.11
170049................................................    1.3513   18.58
170051................................................    0.9883   14.16
170052................................................    1.0435   14.62
170053................................................    0.9379    9.04
170054................................................    1.0385   12.77
170055................................................    0.9812   14.99
170056................................................    0.8854   14.87
170057................................................  ........   15.09
170058................................................    1.1560   18.34
170060................................................    1.0207   17.23
170061................................................    1.1617   14.14
170063................................................    0.8974   11.33
170064................................................  ........   12.42
170066................................................    0.9451   14.48
170067................................................    0.9987   12.78
170068................................................    1.2647   15.82
170070................................................    1.0611   12.82
170072................................................    0.9119   13.34
170073................................................    1.0417   16.47
170074................................................    1.2029   14.40
170075................................................    0.9266   11.26
170076................................................    1.0180   13.58
170077................................................    0.9138   12.72
170079................................................    1.0029   14.29
170080................................................    0.9644   12.20
170081................................................    0.9118   12.51
170082................................................    0.9387   12.39
170084................................................    0.8978   12.16
170085................................................    0.8894   14.51
170086................................................    1.6767   19.85
170088................................................    0.9319   11.75
170089................................................    0.9744   18.08
170090................................................    0.9652   11.27
170092................................................  ........   12.85
170093................................................    0.8902   12.78
170094................................................    0.9571   17.71
170095................................................    1.0123   15.75
170097................................................    0.9087   15.85
170098................................................    1.1360   14.10
170099................................................    1.1529   13.55
170100................................................  ........   14.47
170101................................................    0.9694   12.88
170102................................................    0.9678   13.24
170103................................................    1.3272   16.66
170104................................................    1.4805   19.76
170105................................................    1.0590   15.93
170106................................................    0.9336   14.68
170109................................................    0.9346   16.94
170110................................................    0.9857   15.55
170112................................................    1.1452   13.39
170113................................................    1.0746   13.39
170114................................................    0.9511   14.51
170115................................................    0.9977   12.68
170116................................................    1.0599   15.76
170117................................................    0.9782   15.28
170119................................................    0.9657   13.97
170120................................................    1.2725   16.21
170122................................................    1.7569   20.13
170123................................................    1.7222   21.42
170124................................................    0.9948   10.21
170126................................................    0.9316   12.13
170128................................................    0.9613   14.99
170131................................................  ........   13.10
170133................................................    1.1278   17.11
170134................................................    0.8746   14.23
170137................................................    1.1825   17.42
170139................................................    1.0034   13.39
170142................................................    1.3143   17.32
170143................................................    1.1142   15.88
170144................................................    1.5081   16.09
170145................................................    1.1137   16.75
170146................................................    1.4464   19.97
170147................................................    1.1950   16.28
170148................................................    1.3683   17.25
170150................................................    1.1491   15.43
170151................................................    0.9386   13.37
170152................................................    1.0039   13.68
170160................................................    0.9948   13.31
170164................................................    0.9849   15.56
170166................................................    1.1213   17.57
170171................................................    1.0545   13.81
170175................................................    1.3044   17.88
170176................................................    1.6757   20.32
170182................................................    1.4288   14.20
170183................................................    1.9802   19.09
170184................................................  ........   27.01
180001................................................    1.3845   19.52
180002................................................    1.0807   18.13
180004................................................    1.1145   15.99
180005................................................    1.1967   20.63
180006................................................    0.9088   11.23
180007................................................    1.4605   17.20
180009................................................    1.3630   20.81
180010................................................    1.9352   17.55
180011................................................    1.3149   16.93
180012................................................    1.4399   18.74
180013................................................    1.4516   17.45
180014................................................    1.6962   20.80
180016................................................    1.3326   18.84
180017................................................    1.3055   15.17
180018................................................    1.2972   18.90
180019................................................    1.1916   16.76
180020................................................    1.1096   17.78
180021................................................    1.0498   15.16
180023................................................    0.9502   15.22
180024................................................    1.4071   15.33
180025................................................    1.2007   17.17
180026................................................    1.2061   14.16
180027................................................    1.2508   14.89
180028................................................    1.0896   19.35
180029................................................    1.2291   18.02
180030................................................    1.1690   17.02
180031................................................    1.1171   13.79
180032................................................    1.0592   16.09
180033................................................    1.0969   13.77
180034................................................    1.0876   17.32
180035................................................    1.6449   19.45
180036................................................    1.1569   19.19
180037................................................    1.3120   18.81
180038................................................    1.4617   17.16
180040................................................    1.9294   19.44
180041................................................    1.1888   15.17
180042................................................    1.1678   16.29

[[Page 41568]]

 
180043................................................    1.1248   16.61
180044................................................    1.1967   17.82
180045................................................    1.3993   17.73
180046................................................    1.0431   17.91
180047................................................    1.0016   15.04
180048................................................    1.2482   19.57
180049................................................    1.3489   16.08
180050................................................    1.2187   18.48
180051................................................    1.3876   15.68
180053................................................    1.0545   14.63
180054................................................    1.0894   16.39
180055................................................    1.2204   14.64
180056................................................    1.1028   16.62
180058................................................    1.0446   14.36
180059................................................    0.8725   14.26
180060................................................  ........    7.21
180063................................................    1.0690   11.91
180064................................................    1.1791   14.49
180065................................................    1.0777   20.03
180066................................................    1.0801   18.56
180067................................................    1.8973   18.53
180069................................................    1.1243   17.30
180070................................................    1.1056   13.84
180072................................................    1.1200   17.85
180075................................................  ........   15.07
180078................................................    1.0782   19.16
180079................................................    1.1816   13.41
180080................................................    1.0820   15.83
180087................................................    1.2278   14.97
180088................................................    1.6070   22.53
180092................................................    1.2232   16.31
180093................................................    1.4180   16.83
180094................................................    1.0265   12.51
180095................................................    1.1312   13.40
180099................................................    1.0423   13.70
180101................................................    1.1766   19.56
180102................................................    1.4368   17.88
180103................................................    2.3182   19.22
180104................................................    1.5485   18.87
180105................................................    0.8828   14.08
180106................................................    0.8754   13.61
180108................................................    0.8268   14.62
180115................................................    0.9601   17.11
180116................................................    1.2335   16.94
180117................................................    1.1154   18.38
180118................................................    0.9648   12.15
180120................................................    1.0190   17.81
180121................................................    1.1698   14.51
180122................................................    1.0646   16.97
180123................................................    1.3537   19.00
180124................................................    1.3291   18.41
180125................................................    1.1248   19.73
180126................................................    1.1140   12.40
180127................................................    1.2901   17.35
180128................................................    1.0665   17.05
180129................................................    0.9823   17.86
180130................................................    1.4358   19.01
180132................................................    1.2696   17.26
180133................................................    1.3414   22.23
180134................................................    1.0880   13.63
180136................................................    1.8166   17.71
180138................................................    1.2012   18.61
180139................................................    1.0562   18.77
180140................................................    0.9802   20.40
180141................................................    1.8686   20.01
180142................................................    1.7788  ......
190001................................................    0.8863   17.01
190002................................................    1.6872   18.84
190003................................................    1.3293   22.15
190004................................................    1.4227   17.54
190005................................................    1.5108   16.71
190006................................................    1.4657   17.73
190007................................................    1.0554   13.60
190008................................................    1.6184   16.89
190009................................................    1.2835   14.21
190010................................................    1.2068   17.02
190011................................................    1.1462   15.17
190013................................................    1.3006   16.57
190014................................................    1.1871   17.02
190015................................................    1.2674   18.19
190017................................................    1.3423   15.79
190018................................................    1.1075   16.98
190019................................................    1.7884   17.40
190020................................................    1.1993   17.31
190025................................................    1.3078   16.07
190026................................................    1.5549   17.22
190027................................................    1.5154   16.19
190029................................................    1.1492   17.11
190033................................................    0.9722   10.74
190034................................................    1.1721   16.51
190036................................................    1.6846   19.94
190037................................................    0.9642   12.02
190039................................................    1.4096   17.17
190040................................................    1.3336   20.32
190041................................................    1.6062   17.90
190043................................................    1.0448   12.57
190044................................................    1.1671   17.20
190045................................................    1.4154   21.69
190046................................................    1.4275   19.35
190048................................................    1.2068   16.34
190049................................................    0.9395   16.42
190050................................................    1.0788   15.38
190053................................................    1.1493   12.50
190054................................................    1.2992   16.47
190059................................................    0.8878   15.84
190060................................................    1.3886   18.37
190064................................................    1.5235   19.90
190065................................................    1.4997   19.39
190071................................................    0.8370   13.59
190077................................................    0.8845   12.83
190078................................................    1.1084   13.50
190079................................................    1.3543   17.29
190081................................................    0.8862   12.02
190083................................................    1.0663   16.14
190086................................................    1.3280   14.93
190088................................................    1.2140   19.63
190089................................................    1.1095   12.79
190090................................................    1.0412   16.56
190092................................................  ........   18.07
190095................................................    0.9939   15.73
190098................................................    1.5467   19.22
190099................................................    1.1795   18.92
190102................................................    1.6260   19.05
190103................................................    0.9068   15.57
190106................................................    1.1248   17.75
190109................................................    1.2488   14.53
190110................................................    0.9773   12.99
190111................................................    1.5936   20.04
190112................................................    1.6944   19.21
190113................................................    1.3926   18.99
190114................................................    1.0180   12.91
190115................................................    1.2776   20.49
190116................................................    1.1970   12.59
190118................................................    0.9984   12.95
190120................................................    0.9918   13.69
190122................................................    1.2902   14.83
190124................................................    1.6262   22.38
190125................................................    1.4998   18.63
190128................................................    1.1960   19.71
190130................................................    1.0021   12.43
190131................................................    1.2634   19.60
190133................................................    1.0829   13.48
190134................................................    1.0010   12.68
190135................................................    1.4336   21.35
190136................................................    0.9974   11.33
190138................................................  ........   22.71
190140................................................    0.9506   12.03
190142................................................    0.9173   14.98
190144................................................    1.1852   16.84
190145................................................    0.9756   13.99
190146................................................    1.5254   20.09
190147................................................    0.9772   14.32
190148................................................    0.9409   14.02
190149................................................    0.9956   15.19
190151................................................    1.0763   11.92
190152................................................    1.5099   20.40
190155................................................  ........   11.08
190156................................................    0.9523   12.48
190158................................................    1.2658   19.62
190160................................................    1.2656   18.47
190161................................................    1.0796   14.63
190162................................................    1.2953   19.50
190164................................................    1.1850   16.33
190167................................................    1.1283   16.29
190170................................................    0.9051   13.58
190173................................................    1.3386   19.64
190175................................................    1.4211   20.69
190176................................................    1.6017   18.82
190177................................................    1.7127   20.32
190178................................................    0.9284   10.49
190182................................................    1.3004   20.03
190183................................................    1.1900   16.11
190184................................................    0.9948   14.86
190185................................................    1.3089   19.37
190186................................................    0.9392   16.36
190189................................................  ........   26.54
190190................................................    0.9164   18.67
190191................................................    1.1467   18.14
190196................................................    0.9433   14.87
190197................................................    1.1821   17.92
190199................................................    1.1077   13.42
190200................................................    1.4896   19.41
190201................................................    1.0997   19.14
190202................................................    1.1257   17.90
190203................................................    1.4077   21.31
190204................................................    1.4949   21.21
190205................................................    1.9200   18.10
190206................................................    1.6311   20.06
190207................................................    1.2616   17.67
190208................................................    0.8087   14.61
190218................................................    1.0606   18.16
190223................................................  ........   19.26

[[Page 41569]]

 
190227................................................    1.0049   12.11
190231................................................    1.5630   16.89
190235................................................  ........   18.27
190236................................................    1.4200   22.18
190237................................................    2.6647  ......
190238................................................    1.6631  ......
190239................................................    1.1565  ......
190240................................................    0.9574  ......
200001................................................    1.3477   17.49
200002................................................    1.1150   18.77
200003................................................    1.0964   16.74
200006................................................    1.0846   19.80
200007................................................    1.0259   17.89
200008................................................    1.2221   20.50
200009................................................    1.8810   20.64
200012................................................    1.1802   17.01
200013................................................    1.1132   16.49
200015................................................  ........   20.11
200016................................................    1.0407   17.66
200017................................................  ........   19.65
200018................................................    1.2100   17.24
200019................................................    1.2510   18.64
200020................................................    1.1517   20.60
200021................................................    1.1958   19.41
200023................................................    0.8393   14.92
200024................................................    1.4795   18.65
200025................................................    1.2498   19.07
200026................................................    0.9907   17.28
200027................................................    1.2361   18.28
200028................................................    0.9208   16.93
200031................................................    1.2276   15.90
200032................................................    1.3282   17.92
200033................................................    1.7827   21.40
200034................................................    1.2767   19.24
200037................................................    1.2288   18.24
200038................................................    1.1403   19.21
200039................................................    1.2567   20.29
200040................................................    1.1161   19.30
200041................................................    1.1251   17.66
200043................................................    0.8011   16.54
200050................................................    1.2048   18.08
200051................................................    0.9887   19.59
200052................................................    0.9951   15.12
200055................................................    1.0880   17.17
200062................................................    0.9532   16.51
200063................................................    1.2440   19.67
200066................................................    1.1429   16.34
210001................................................    1.4433   18.73
210002................................................    2.0494   22.84
210003................................................    1.6842   25.37
210004................................................    1.3603   23.59
210005................................................    1.2944   19.62
210006................................................    1.1143   17.77
210007................................................    1.8010   21.54
210008................................................    1.3067   19.50
210009................................................    1.8608   21.81
210010................................................    1.1389   14.38
210011................................................    1.3616   21.24
210012................................................    1.6214   23.43
210013................................................    1.3595   18.85
210015................................................    1.3058   16.69
210016................................................    1.8547   22.15
210017................................................    1.2502   17.17
210018................................................    1.2626   21.41
210019................................................    1.6155   19.09
210022................................................    1.4895   21.82
210023................................................    1.4521   21.80
210024................................................    1.6929   19.56
210025................................................    1.3269   19.57
210026................................................    1.3215   11.64
210027................................................    1.2849   18.49
210028................................................    1.1685   18.86
210029................................................    1.2770   22.39
210030................................................    1.2555   21.02
210031................................................    1.3110   15.59
210032................................................    1.1818   18.50
210033................................................    1.2403   19.91
210034................................................    1.3179   16.12
210035................................................    1.3496   20.61
210037................................................    1.2643   18.74
210038................................................    1.4168   23.26
210039................................................    1.1908   20.73
210040................................................    1.3185   25.08
210043................................................    1.2817   18.59
210044................................................    1.3636   22.24
210045................................................    1.0866    9.69
210048................................................    1.2884   22.39
210049................................................    1.1698   17.67
210051................................................    1.4028   20.76
210054................................................    1.3672   23.51
210055................................................    1.3640   20.10
210056................................................    1.3926   20.94
210057................................................    1.3578   22.57
210058................................................    1.5015   21.50
210059................................................    1.1916   23.13
210060................................................    1.2744  ......
210061................................................    1.1312   20.02
220001................................................    1.2885   26.32
220002................................................    1.4675   22.58
220003................................................    1.1126   19.14
220004................................................  ........   20.01
220006................................................    1.3858   22.12
220008................................................    1.2978   21.89
220010................................................    1.3476   21.92
220011................................................    1.0966   28.57
220012................................................    1.3138   29.51
220015................................................    1.1694   21.78
220016................................................    1.3440   23.14
220017................................................    1.3512   25.26
220019................................................    1.1553   19.13
220020................................................    1.2443   19.99
220021................................................  ........   23.63
220023................................................    0.6351   18.76
220024................................................    1.2152   21.59
220025................................................    1.1428   19.94
220028................................................    1.4561   22.07
220029................................................    1.1597   21.87
220030................................................    1.1060   14.54
220031................................................    1.9047   28.16
220033................................................    1.2607   20.41
220035................................................    1.3065   22.00
220036................................................    1.6250   24.16
220038................................................    1.3105   22.35
220041................................................    1.1892   23.15
220042................................................    1.2714   25.28
220046................................................    1.3199   22.47
220049................................................    1.2818   23.03
220050................................................    1.1650   20.83
220051................................................    1.1795   20.48
220052................................................    1.2991   23.14
220053................................................    1.1633   21.27
220055................................................    1.2850   21.57
220057................................................    1.3594   23.00
220058................................................    1.1555   20.19
220060................................................    1.2301   26.17
220062................................................    0.5637   20.06
220063................................................    1.2667   20.95
220064................................................    1.2836   22.18
220065................................................    1.3716   20.20
220066................................................    1.3505   20.46
220067................................................    1.2871   25.74
220068................................................  ........    6.45
220070................................................    1.2178   19.77
220071................................................    1.9238   24.65
220073................................................    1.3020   25.87
220074................................................    1.3357   24.05
220075................................................    1.7963   21.54
220076................................................    1.2498   24.78
220077................................................    1.8273   24.80
220079................................................    1.1002   21.01
220080................................................    1.3051   20.50
220081................................................    0.9211   25.34
220082................................................    1.2653   20.02
220083................................................    1.1883   23.08
220084................................................    1.2499   24.66
220086................................................    1.7929   30.46
220088................................................    1.6454   23.38
220089................................................    1.2586   21.79
220090................................................    1.2248   21.64
220092................................................    1.1846   17.04
220094................................................  ........   21.99
220095................................................    1.1895   21.45
220098................................................    1.3182   20.86
220100................................................    1.3672   25.35
220101................................................    1.4445   24.33
220104................................................    1.4751   27.53
220105................................................    1.2705   21.69
220106................................................    1.2167   24.55
220107................................................  ........   20.27
220108................................................    1.1918   22.64
220110................................................    2.1062   29.19
220111................................................    1.2452   23.05
220116................................................    1.9074   24.97
220118................................................  ........   30.52
220119................................................    1.2606   22.86
220123................................................    1.0333   27.31
220126................................................    1.2501   20.96
220128................................................  ........   20.56
220133................................................    0.6976   35.27
220135................................................    1.2820   25.08
220153................................................    1.0071   23.90
220154................................................    0.9026   22.13
220162................................................    1.5209  ......
220163................................................    2.0316   27.35
220171................................................    1.6823   23.43
230001................................................    1.1547   19.20
230002................................................    1.2729   21.91
230003................................................    1.1440   19.61
230004................................................    1.6897   22.03
230005................................................    1.2524   19.40
230006................................................    1.0497   18.47
230007................................................  ........   19.43

[[Page 41570]]

 
230012................................................    0.9628   18.67
230013................................................    1.3746   20.63
230015................................................    1.1422   20.43
230017................................................    1.6115   20.40
230019................................................    1.5321   21.32
230020................................................    1.7453   21.32
230021................................................    1.5006   18.57
230022................................................    1.2699   19.76
230024................................................    1.4264   27.96
230027................................................    1.0344   18.03
230029................................................    1.5752   21.06
230030................................................    1.3412   17.70
230031................................................    1.4268   17.53
230032................................................    1.7439   20.68
230034................................................    1.2703   17.23
230035................................................    1.0782   17.56
230036................................................    1.2543   21.76
230037................................................    1.1759   19.07
230038................................................    1.7538   23.39
230040................................................    1.1335   20.39
230041................................................    1.2547   19.03
230042................................................    1.2347   19.49
230046................................................    1.9274   25.95
230047................................................    1.3582   20.64
230053................................................    1.5879   22.18
230054................................................    1.8393   19.54
230055................................................    1.1717   19.84
230056................................................    0.9022   16.41
230058................................................    1.1008   18.23
230059................................................    1.4590   19.51
230060................................................    1.3289   17.87
230062................................................    0.9642   16.30
230063................................................    1.2580   20.22
230065................................................    1.3189   21.15
230066................................................    1.3680   21.51
230069................................................    1.1982   21.79
230070................................................    1.6482   20.06
230071................................................    1.1143   22.16
230072................................................    1.2345   20.43
230075................................................    1.5088   19.43
230076................................................    1.4056   23.82
230077................................................    2.0633   20.39
230078................................................    1.1156   16.25
230080................................................    1.2475   18.91
230081................................................    1.2085   17.95
230082................................................    1.1156   17.74
230085................................................    1.2336   17.54
230086................................................    0.9507   16.98
230087................................................    1.0836   15.77
230089................................................    1.2845   21.39
230092................................................    1.3584   18.96
230093................................................    1.2332   20.19
230095................................................    1.1754   16.78
230096................................................    1.1056   22.56
230097................................................    1.6198   20.10
230099................................................    1.1227   20.25
230100................................................    1.1434   13.11
230101................................................    1.0673   18.61
230103................................................    1.0518   19.60
230104................................................    1.5580   23.47
230105................................................    1.8005   20.88
230106................................................    1.1850   18.35
230107................................................    0.9423   14.67
230108................................................    1.2110   17.42
230110................................................    1.3149   17.80
230113................................................    0.8490   11.17
230115................................................    1.0569   16.47
230116................................................    0.8683   16.36
230117................................................    1.9017   23.94
230118................................................    1.1392   21.71
230119................................................    1.3553   23.96
230120................................................    1.1300   19.64
230121................................................    1.2281   20.08
230122................................................    1.3510   18.09
230124................................................    1.1665   18.89
230125................................................  ........   15.35
230128................................................    1.4062   23.58
230130................................................    1.6919   22.52
230132................................................    1.3454   26.17
230133................................................    1.2277   17.57
230134................................................  ........   15.32
230135................................................    1.2335   22.74
230137................................................  ........   18.34
230141................................................    1.6286   23.05
230142................................................    1.2833   20.12
230143................................................    1.2819   16.45
230144................................................    1.1235   20.99
230145................................................    1.1243   16.60
230146................................................    1.2623   18.63
230147................................................    1.4122   20.51
230149................................................    1.1319   14.17
230151................................................    1.4152   20.89
230153................................................    1.0656   17.33
230154................................................    0.8898   14.58
230155................................................    1.0291   16.99
230156................................................    1.7492   23.61
230157................................................    1.1708   19.72
230159................................................    1.0227   18.84
230162................................................    0.9486   17.77
230165................................................    1.9365   23.31
230167................................................    1.7523   20.32
230169................................................    1.3609   22.86
230171................................................    1.0638   14.96
230172................................................    1.1814   20.22
230174................................................    1.3724   20.85
230175................................................    2.3801   21.81
230176................................................    1.2161   21.86
230178................................................    0.9470   16.08
230180................................................    1.1228   15.48
230184................................................    1.2506   17.29
230186................................................    1.1355  ......
230188................................................    1.1192   15.56
230189................................................    0.9459   15.91
230190................................................    0.8855   23.71
230191................................................    0.9307   17.12
230193................................................    1.3034   20.18
230195................................................    1.3593   22.37
230197................................................    1.4069   21.62
230199................................................    1.1010   18.40
230201................................................    1.2559   15.32
230204................................................    1.3711   22.95
230205................................................    0.9890   13.89
230207................................................    1.2528   20.35
230208................................................    1.2993   17.15
230211................................................    0.9109   17.51
230212................................................    1.0548   22.14
230213................................................    0.9300   15.32
230216................................................    1.5720   19.59
230217................................................    1.2676   20.95
230219................................................    0.8629   20.70
230221 *..............................................  ........   21.50
230222................................................    1.3905   20.84
230223................................................    1.2683   21.50
230227................................................    1.4220   21.38
230230................................................    1.5842   22.53
230232................................................  ........   12.64
230235................................................    1.0983   15.95
230236................................................    1.3279   23.22
230239................................................    1.1721   19.23
230241................................................    1.1923   18.85
230244................................................    1.4096   21.08
230253................................................    0.9601   21.95
230254................................................    1.2941   21.28
230257................................................    0.9124   20.47
230259................................................    1.1378   21.15
230264................................................    1.6854   15.18
230269................................................    1.3102   22.81
230270................................................    1.2083   20.08
230273................................................    1.5194   23.40
230275................................................    0.5244   17.60
230276................................................    0.5657   18.58
230277................................................    1.2485   22.50
230278................................................  ........   16.66
230279................................................    0.6550   16.04
230280................................................    1.0995   14.22
230283................................................    2.2592  ......
240001................................................    1.5332   22.85
240002................................................    1.7586   23.02
240004................................................    1.5987   23.92
240005................................................    0.8865   16.98
240006................................................    1.1679   27.11
240007................................................    1.0673   16.98
240008................................................    1.1473   21.81
240009................................................    0.9476   16.69
240010................................................    1.9899   23.63
240011................................................    1.1456   18.96
240013................................................    1.2868   18.97
240014................................................    1.0965   21.86
240016................................................    1.3894   19.86
240017................................................    1.1545   17.23
240018................................................    1.2702   19.07
240019................................................    1.1855   20.99
240020................................................    1.1176   19.57
240021................................................    0.9884   17.40
240022................................................    1.1043   19.16
240023................................................    0.9797   20.39
240025................................................    1.0961   17.25
240027................................................    1.0734   16.25
240028................................................    1.1427   19.38
240029................................................    1.1507   17.99
240030................................................    1.2812   18.44
240031................................................    0.9279   18.07
240036................................................    1.5882   20.33
240037................................................    1.0148   18.46
240038................................................    1.5017   26.35
240040................................................    1.2710   19.90
240041................................................    1.1727   19.21
240043................................................    1.2209   17.31
240044................................................    1.1345   18.92
240045................................................    1.1610   20.99
240047 *..............................................    1.5761   21.86
240048................................................  ........   23.31

[[Page 41571]]

 
240049................................................  ........   22.13
240050................................................    1.2090   24.50
240051................................................    0.9678   18.23
240052................................................    1.3021   19.22
240053................................................    1.4864   21.20
240056................................................    1.2521   22.29
240057................................................    1.8388   23.24
240058................................................    0.9316   14.91
240059................................................    1.0446   21.96
240061................................................    1.7835   25.56
240063................................................    1.4484   23.54
240064................................................    1.3231   20.76
240065................................................    1.1449   12.55
240066................................................    1.3065   22.05
240069................................................    1.1937   19.18
240071................................................    1.1063   19.19
240072................................................    1.0228   18.00
240073................................................    0.8981   15.63
240075................................................    1.2006   21.19
240076................................................    1.0723   21.07
240077................................................    0.8989   14.95
240078................................................    1.5437   22.71
240079................................................    0.9531   17.82
240080 *..............................................    1.6136   23.73
240082................................................    1.1218   18.03
240083................................................    1.2912   19.29
240084................................................    1.3307   19.61
240085................................................    1.0393   18.02
240086................................................    1.0475   15.33
240087................................................    1.1670   17.06
240088................................................    1.4004   21.02
240089................................................    0.9225   18.42
240090................................................    1.1253   18.05
240093................................................    1.2993   18.68
240094................................................    0.9638   20.57
240096................................................    0.9927   18.34
240097................................................    1.1145   23.62
240098................................................    0.9306   20.60
240099................................................    1.0713   14.38
240100................................................    1.2877   19.19
240101................................................    1.2098   17.75
240102................................................    0.9288   15.56
240103................................................    1.2084   16.88
240104................................................    1.1678   24.02
240105................................................  ........   14.79
240106................................................    1.3974   23.78
240107................................................    0.9782   19.03
240108................................................    0.9821   16.46
240109................................................    0.9815   13.15
240110................................................    0.9379   17.28
240111................................................    0.9930   17.04
240112................................................    0.9784   15.32
240114................................................    0.9362   15.49
240115................................................    1.6103   22.16
240116................................................    0.9259   15.18
240117................................................    1.1442   17.57
240119................................................    0.8629   22.50
240121................................................    0.9090   21.37
240122................................................    1.0827   18.04
240123................................................    1.0155   15.60
240124................................................    0.9602   19.05
240125................................................    0.9736   13.15
240127................................................    1.0148   14.77
240128................................................    1.1120   16.08
240129................................................    0.9953   15.42
240130................................................    0.9313   15.65
240132................................................    1.2720   24.50
240133................................................    1.2168   18.52
240135................................................    0.9183   13.60
240137................................................    1.1747   19.18
240138................................................    0.9423   13.74
240139................................................    0.9616   17.02
240141................................................    1.1570   21.99
240142................................................    1.0110   20.61
240143................................................    0.9629   14.28
240144................................................    1.0633   15.87
240145................................................    0.9100   15.00
240146 *..............................................    0.9093   16.75
240148................................................    1.0294   11.34
240150................................................    0.8795   12.83
240152................................................    1.0247   20.20
240153................................................    1.0013   15.61
240154................................................    1.0226   17.06
240155................................................    0.9164   20.42
240157................................................    1.0213   14.69
240160................................................    1.0612   16.60
240161................................................    1.0365   15.42
240162................................................    1.0748   19.04
240163................................................    0.9730   17.87
240166................................................    1.1543   16.39
240169................................................    0.9599   18.62
240170................................................    1.1064   17.65
240171................................................    1.0064   16.72
240172................................................    0.9741   16.07
240173................................................    0.9970   16.74
240179................................................    1.0360   16.65
240184................................................    0.9619   14.40
240187................................................    1.2498   17.51
240193................................................    1.0038   16.30
240196................................................    0.6772   23.27
240200................................................    0.9005   14.73
240205................................................    0.9227  ......
240206................................................    0.8330  ......
240207................................................    1.2623   23.33
240210................................................    1.2530   23.84
240211................................................    0.9634   20.55
250001................................................    1.6314   18.14
250002................................................    0.8836   15.60
250003................................................    0.9911   15.66
250004................................................    1.5373   17.12
250005................................................    0.9463   12.00
250006................................................    0.9631   15.70
250007................................................    1.2281   19.16
250008................................................    1.0321   13.32
250009................................................    1.2665   16.18
250010................................................    1.0095   13.34
250012................................................    0.9332   18.48
250015................................................    1.0380   11.07
250017................................................    1.0279   17.30
250018................................................    0.9334   13.47
250019................................................    1.4828   17.15
250020................................................    0.9516   14.06
250021................................................    0.8435    9.08
250023................................................    0.8955   13.54
250024................................................    0.8985   11.59
250025................................................    1.1484   17.89
250027................................................    0.9764   12.42
250029................................................    0.8697   14.85
250030................................................    0.9198   13.63
250031................................................    1.2472   18.77
250032................................................    1.2183   17.30
250033................................................    1.0130   15.76
250034................................................    1.5442   18.13
250035................................................    0.8342   17.41
250036................................................    0.9965   13.79
250037................................................    0.8826   10.32
250038................................................    0.9386   13.62
250039................................................    0.9969   16.51
250040................................................    1.3140   15.64
250042................................................    1.2627   16.47
250043................................................    0.9006   13.65
250044................................................    0.9882   16.75
250045................................................    1.2709   19.48
250047................................................    0.9058   12.10
250048................................................    1.5287   15.71
250049................................................    0.8842   10.76
250050................................................    1.2687   13.92
250051................................................    0.9276    9.60
250057................................................    1.1769   14.29
250058................................................    1.1854   15.42
250059................................................    1.0826   14.30
250060................................................    0.7514    7.99
250061................................................    0.8571   13.97
250063................................................    0.8309   14.97
250065................................................    0.8940   12.68
250066................................................    0.9147   14.33
250067................................................    1.1605   15.29
250068................................................    0.8225   11.43
250069................................................    1.2675   15.77
250071................................................    0.9001   11.21
250072................................................    1.4320   16.93
250077................................................    0.9344   11.41
250078................................................    1.5476   15.46
250079................................................    0.8556   19.06
250081................................................    1.2710   16.14
250082................................................    1.4184   14.02
250083................................................    0.9424    9.20
250084................................................    1.0972   19.74
250085................................................    0.9906   13.85
250088................................................    0.9812   16.75
250089................................................    1.0895   13.05
250093................................................    1.1743   15.09
250094................................................    1.3417   17.85
250095................................................    0.9930   16.36
250096................................................    1.2105   17.07
250097................................................    1.2839   18.41
250098................................................    0.9397   14.30
250099................................................    1.2925   14.41
250100................................................    1.2679   16.60
250101................................................    0.8835   16.31
250102................................................    1.5198   20.02
250104................................................    1.4479   17.54
250105................................................    0.9368   14.60
250107................................................    0.8802   13.63
250109................................................    0.8898   14.55
250112................................................    0.9928   14.20
250117................................................    1.0623   14.52
250119................................................    1.0646   12.74
250120................................................    1.0648   14.41
250122................................................    1.1767   17.71
250123................................................    1.2182   17.41
250124................................................    0.9343   12.67

[[Page 41572]]

 
250125................................................    1.2795   14.49
250126................................................    0.9354   14.71
250127................................................    0.9230  ......
250128................................................    1.0364   13.00
250131................................................    1.0826   10.28
250134................................................    0.9628   17.98
250136................................................    0.9183   18.05
250138................................................    1.2050   17.60
250141................................................    1.2056   17.12
250145................................................    0.8696   11.40
250146................................................    0.9386   13.28
250148................................................    1.2354   14.82
250149................................................    0.9692   12.98
250150................................................    1.2560  ......
260001................................................    1.6540   17.55
260002................................................    1.4391   20.59
260003................................................    1.1323   14.35
260004................................................    0.9723   13.75
260005................................................    1.6472   19.71
260006................................................    1.5189   18.94
260008................................................    1.0522   16.25
260009................................................    1.2922   17.94
260011................................................    1.5359   18.34
260012................................................    1.0022   14.46
260013................................................    1.1867   15.54
260015................................................    1.1785   21.33
260017................................................    1.1731   15.80
260018................................................    0.8870   12.23
260019................................................    1.1516   23.67
260020................................................    1.8132   21.86
260021................................................    1.4382   17.57
260022................................................    1.2554   19.35
260023................................................    1.4184   15.82
260024................................................    0.9715   13.47
260025................................................    1.3027   14.94
260027................................................    1.6141   21.01
260029................................................    1.1888   17.47
260030................................................    1.1362   11.24
260031................................................    1.5369   18.30
260032................................................    1.7266   20.81
260034................................................    1.0233   17.90
260035................................................    1.0041   12.59
260036................................................    1.0016   18.31
260039................................................    1.0672   14.20
260040................................................    1.6822   15.39
260042................................................    1.2519   17.44
260044................................................    1.0069   17.12
260047................................................    1.6386   17.28
260048................................................    1.2523   21.43
260050................................................    1.0553   18.74
260052................................................    1.3718   17.75
260053................................................    1.1217   12.01
260054................................................    1.3547   17.37
260055................................................    0.9682   13.80
260057................................................    1.0095   15.33
260059................................................    1.2434   15.79
260061................................................    1.1184   15.01
260062................................................    1.1843   20.26
260063................................................    1.0723   16.85
260064................................................    1.3324   16.50
260065................................................    1.7738   18.47
260066................................................    1.0120   14.42
260067................................................    0.8925   12.16
260068................................................    1.6794   19.83
260070................................................    1.0404   21.69
260073................................................    1.0809   13.01
260074................................................    1.2969   15.45
260077................................................    1.7295   18.26
260078................................................    1.1807   15.48
260079................................................    1.0611   14.83
260080................................................    0.9884   12.56
260081................................................    1.6614   18.96
260082................................................    1.1528   15.79
260085................................................    1.5832   19.51
260086................................................    0.9274   14.87
260091................................................    1.6930   19.61
260094................................................    1.1892   15.87
260095................................................    1.3659   19.77
260096................................................    1.5590   21.72
260097................................................    1.1452   15.79
260100................................................    1.0130   15.73
260102................................................    1.0038   16.37
260103................................................    1.3185   17.35
260104................................................    1.7110   19.12
260105................................................    1.8654   20.80
260107................................................    1.4527   18.46
260108................................................    1.8537   19.24
260109................................................    0.9906   13.44
260110................................................    1.6721   17.00
260113................................................    1.2263   14.90
260115................................................    1.2279   17.90
260116................................................    1.1041   14.57
260119................................................    1.2152   16.20
260120................................................    1.1948   17.13
260122................................................    1.0917   14.54
260123................................................    1.0487   14.00
260127................................................    1.0634   15.95
260128................................................    1.0338   11.27
260129................................................  ........   14.64
260131................................................    1.2601   19.75
260134................................................    1.1698   16.58
260137................................................    1.7102   15.22
260138................................................    1.9094   21.39
260141................................................    2.0004   17.96
260142................................................    1.1233   16.03
260143................................................    1.0016   11.94
260147................................................    0.9530   13.66
260148................................................    0.9021   10.34
260158................................................    1.0574   12.40
260159................................................    1.0116   18.22
260160................................................    1.1472   16.19
260162................................................    1.5667   20.71
260163................................................    1.2567   14.81
260164................................................    0.9190   14.31
260166................................................    1.2194   19.53
260172................................................    0.9615   12.49
260173................................................    1.0048   11.98
260175................................................    1.1265   16.29
260176................................................    1.7233   19.54
260177................................................    1.3369   20.75
260178................................................    1.4649   21.41
260179................................................    1.6106   20.74
260180................................................    1.6586   18.54
260183................................................    1.6585   20.19
260186................................................    1.5839   18.06
260188................................................    1.2743   18.58
260189................................................    0.9387   10.75
260190................................................    1.1980   18.16
260191................................................    1.2861   19.34
260193................................................    1.2221   20.51
260195................................................    1.2459   15.95
260197................................................    1.0938   16.46
260198................................................    1.2956   17.64
260200................................................    1.2113   18.88
260205................................................    1.1124  ......
260206................................................    2.6705  ......
270002................................................    1.2833   17.19
270003................................................    1.2141   22.13
270004................................................    1.6968   21.34
270006................................................    0.8808   16.19
270007................................................    1.0011   13.17
270009................................................    1.0256   17.70
270011................................................    1.0498   19.82
270012................................................    1.6001   22.88
270013................................................  ........   20.40
270014................................................    1.8500   18.56
270016................................................    0.9247   19.77
270017................................................    1.2639   19.58
270019................................................    1.0268   12.78
270021................................................    1.1669   16.65
270023................................................    1.2640   20.36
270026................................................    0.9053   15.64
270027................................................    1.0596    9.78
270028................................................    1.1731   17.21
270029................................................    0.9212   17.89
270032................................................    1.1264   17.03
270033................................................    0.8642   16.46
270035................................................    1.0021   17.65
270036................................................    0.9187   14.08
270039................................................    1.0483   15.35
270040................................................    1.1242   19.19
270041................................................    1.0440   16.78
270044................................................    1.1390   13.46
270046................................................  ........   17.10
270048................................................    1.0158   15.84
270049................................................    1.7683   21.17
270050................................................    0.9929   18.04
270051................................................    1.3159   18.95
270052................................................    1.0056   14.80
270057................................................    1.3060   20.01
270058................................................    0.9229   14.07
270059................................................    0.7506   15.60
270060................................................    0.9519   14.02
270063................................................    0.9338   14.23
270073................................................    1.0809   15.53
270074................................................    0.8781  ......
270075................................................    0.8274  ......
270079................................................    0.9373   15.03
270080................................................    1.1414   14.04
270081................................................    0.9580   15.52
270082................................................    1.1019   16.13
270083................................................    1.0075   20.82
270084................................................    0.9157   16.21
280001................................................    1.0653   17.89
280003................................................    2.1221   22.00
280005................................................    1.3612   18.75
280009................................................    1.7670   18.75
280010................................................    0.8073   16.54
280011................................................    0.8552   13.96
280012................................................  ........   16.41
280013................................................    1.7273   22.18
280014................................................    0.9006   15.24

[[Page 41573]]

 
280015................................................    1.0732   14.64
280017................................................    1.0728   14.19
280018................................................    1.0539   14.85
280020................................................    1.8150   19.40
280021................................................    1.1771   16.69
280022................................................    0.9681   15.71
280023................................................    1.3944   21.24
280024................................................    0.9612   13.91
280025................................................    0.9712   14.27
280026................................................    1.0404   16.06
280028................................................    1.0763   15.89
280029................................................    1.2096   19.05
280030................................................    1.7625   28.71
280031................................................    0.9956   13.22
280032................................................    1.3462   19.39
280033................................................    1.0807   14.93
280034................................................  ........   15.28
280035................................................    0.9131   15.33
280037................................................    1.0308   16.17
280038................................................    1.0606   16.47
280039................................................    1.0660   15.19
280040................................................    1.7369   18.97
280041................................................    0.9646   13.39
280042................................................    1.0402   15.30
280043................................................    0.9786   15.79
280045................................................    1.0415   14.27
280046................................................    1.0475   13.72
280047................................................    1.1206   18.37
280048................................................    1.1174   14.07
280049................................................    1.0856   15.63
280050................................................    0.8884   15.34
280051................................................    1.1386   15.85
280052................................................    1.0615   13.65
280054................................................    1.2474   17.58
280055................................................    0.9142   12.99
280056................................................    0.9322   14.02
280057................................................    0.9649   15.76
280058................................................    1.2501   17.88
280060................................................    1.6246   28.60
280061................................................    1.4157   17.95
280062................................................    1.1769   13.67
280064................................................    1.0166   15.51
280065................................................    1.2679   18.53
280066................................................    1.0165   11.64
280068................................................    0.9402   10.13
280070................................................    0.9894   13.74
280073................................................    0.9850   17.06
280074................................................    0.9716   15.22
280075................................................    1.1012   13.79
280076................................................    1.0276   13.92
280077................................................    1.2963   19.01
280079................................................    1.0819    9.91
280080................................................    1.0562   14.35
280081................................................    1.7212   20.92
280082................................................    1.0739   13.13
280083................................................    1.0628   17.55
280084................................................    0.9626   11.69
280085................................................    0.8210   21.58
280088................................................    1.2613   22.11
280089................................................    0.8817   17.47
280090................................................    0.8499   14.72
280091................................................    1.0928   15.22
280092................................................    0.9078   14.20
280094................................................    0.9941   15.88
280097................................................    1.0876   14.30
280098................................................    0.8785   10.17
280101................................................    1.0046   17.42
280102................................................  ........   12.94
280104................................................    0.9207   13.38
280105................................................    1.2342   18.78
280106................................................    1.0160   15.54
280107................................................    1.1351   13.46
280108................................................    1.0616   17.22
280109................................................    0.9496   11.06
280110................................................    0.9845   12.30
280111................................................    1.2649   23.08
280114................................................    0.9211   13.56
280115................................................    0.9774   16.43
280117................................................    1.0941   16.82
280118................................................    0.9071   16.92
280119................................................    0.9530  ......
280123................................................  ........   20.77
280125................................................    1.2264  ......
290001................................................    1.6989   22.42
290002................................................    0.9461   20.94
290003................................................    1.6712   25.01
290005................................................    1.3324   17.86
290006................................................    1.2261   19.88
290007................................................    1.6901   29.69
290008................................................    1.2555   20.25
290009................................................    1.6203   22.74
290010................................................    1.1253   14.48
290011................................................    1.0959   16.44
290012................................................    1.3503   21.51
290013................................................    0.9996   17.09
290014................................................    1.0332   18.38
290015................................................    0.9724   17.83
290016................................................    1.1412   12.79
290019................................................    1.3301   20.93
290020................................................    0.9828   26.15
290021................................................    1.6748   21.13
290022................................................    1.5940   24.08
290027................................................    0.8902   16.43
290029................................................    0.9227  ......
290032................................................    1.4060   22.79
290036................................................    0.5760   18.61
290038................................................    0.9361   23.14
290039................................................    1.3330   25.80
290041................................................    1.2649  ......
290043................................................    1.5247  ......
300001................................................    1.4811   21.42
300003................................................    1.9992   23.38
300005................................................    1.3421   19.99
300006................................................    1.1762   18.93
300007................................................    1.0898   19.34
300008................................................    1.2459   16.46
300009................................................    1.0636   20.01
300010................................................    1.2614   19.38
300011................................................    1.3223   21.24
300012................................................    1.3247   23.89
300013................................................    1.1162   18.97
300014................................................    1.2417   19.80
300015................................................    1.1328   19.93
300016................................................    1.2146   18.50
300017................................................    1.3266   22.34
300018................................................    1.3652   20.89
300019................................................    1.2381   20.61
300020................................................    1.3828   21.97
300021................................................    1.0721   17.35
300022................................................    1.1269   17.19
300023................................................    1.3992   20.39
300024................................................    1.2667   17.95
300028................................................    1.2841   18.05
300029................................................    1.3193   20.90
300033................................................    1.0937   19.85
300034................................................    2.1599   23.52
310001................................................    1.7867   27.60
310002................................................    1.8508   27.87
310003................................................    1.2979   27.42
310005................................................    1.2978   23.05
310006................................................    1.2138   21.56
310008................................................    1.3295   24.95
310009................................................    1.3238   23.19
310010................................................    1.2493   21.11
310011................................................    1.2567   23.40
310012................................................    1.6481   26.32
310013................................................    1.3716   22.11
310014................................................    1.6717   28.70
310015................................................    2.0397   26.76
310016................................................    1.2889   26.05
310017................................................    1.3516   26.07
310018................................................    1.0776   24.53
310019................................................    1.6759   23.09
310020................................................    1.3978   19.27
310021................................................    1.5405   22.65
310022................................................    1.3233   20.73
310024................................................    1.3299   22.78
310025................................................    1.1918   22.81
310026................................................    1.2343   23.87
310027................................................    1.3202   21.77
310028................................................    1.2507   23.52
310029................................................    1.9457   23.38
310031................................................    2.7809   25.18
310032................................................    1.3227   23.30
310034................................................    1.2856   21.69
310036................................................    1.1393   19.82
310037................................................    1.4029   27.44
310038................................................    2.0126   25.38
310039................................................    1.2557   22.03
310040................................................    1.2028   23.99
310041................................................    1.3458   23.78
310042................................................    1.2925   24.33
310043................................................    1.1863   22.09
310044................................................    1.3355   20.43
310045................................................    1.4863   28.16
310047................................................    1.3368   24.52
310048................................................    1.2892   23.33
310049................................................    1.2327   24.76
310050................................................    1.2135   22.59
310051................................................    1.3946   25.28
310052................................................    1.3043   22.58
310054................................................    1.3470   24.74
310057................................................    1.3024   20.45
310058................................................    1.1475   26.22
310060................................................    1.1966   19.11
310061................................................    1.2040   20.80
310062................................................  ........   19.27
310063*...............................................    1.3463   21.85
310064................................................    1.3574   24.21
310067................................................    1.3006   22.27
310069................................................    1.2634   24.17
310070................................................    1.4210   25.04

[[Page 41574]]

 
310072................................................    1.3713   22.22
310073................................................    1.6775   25.63
310074................................................    1.3809   24.46
310075................................................    1.4097   26.46
310076................................................    1.4991   28.90
310077................................................    1.6678   25.06
310078................................................    1.4298   23.48
310081................................................    1.3501   23.89
310083................................................    1.2768   23.68
310084................................................    1.3292   24.09
310086................................................    1.2175   21.44
310087................................................    1.3344   20.89
310088................................................    1.2069   22.34
310090................................................    1.3904   24.24
310091................................................    1.2672   22.01
310092................................................    1.3248   22.34
310093................................................    1.2003   21.23
310096................................................    1.9959   26.30
310105................................................    1.2465   24.49
310108................................................    1.4314   22.88
310110................................................    1.2678   20.14
310111................................................    1.2705   21.72
310112................................................    1.3062   22.52
310113................................................    1.2906   22.95
310115................................................    1.3002   20.07
310116................................................    1.2884   25.24
310118................................................    1.2517   24.54
310119................................................    1.7352   29.48
310120................................................    1.2046   21.69
310121................................................  ........   18.74
320001................................................    1.5262   17.85
320002................................................    1.3456   22.46
320003................................................    1.0767   15.35
320004................................................    1.2930   17.24
320005................................................    1.3126   19.87
320006................................................    1.3526   18.65
320009................................................    1.5990   17.64
320011................................................    1.1443   16.55
320012................................................    1.0529   16.00
320013................................................    1.1406   23.84
320014................................................    1.0812   15.97
320016................................................    1.1821   18.93
320017................................................    1.1290   18.15
320018................................................    1.5139   18.19
320019................................................    1.5059   19.26
320021................................................    1.8101   17.16
320022................................................    1.2310   15.84
320023................................................    1.0211   16.42
320030................................................    1.1556   16.53
320031................................................    0.9386   13.99
320032................................................    0.8993   18.75
320033................................................    1.1749   20.31
320035................................................    1.0245   25.74
320037................................................    1.1621   17.08
320038................................................    1.2322   16.29
320046................................................    1.4424   19.00
320048................................................    1.4140   19.17
320056................................................    1.1122  ......
320057................................................    0.9720  ......
320058................................................    0.8862  ......
320059................................................    1.0597  ......
320060................................................    0.9253  ......
320061................................................    1.1311  ......
320062................................................    0.8525  ......
320063................................................    1.2513   19.83
320065................................................    1.2154   16.10
320067................................................    0.8614   57.48
320068................................................    0.8969   18.18
320069................................................    0.9807   11.31
320070................................................    0.9556  ......
320074................................................    1.0870   18.65
320079................................................    1.2126   17.07
330001................................................    1.1862   25.21
330002................................................    1.4469   26.39
330003................................................    1.3432   18.05
330004................................................    1.3046   19.96
330005................................................    1.6831   24.28
330006................................................    1.3374   25.92
330007................................................    1.3674   18.80
330008................................................    1.1788   18.07
330009................................................    1.3298   30.42
330010................................................    1.2856   14.74
330011................................................    1.3008   18.04
330012................................................    1.7199   31.51
330013................................................    2.0374   19.99
330014................................................    1.3839   27.57
330016................................................    0.9911   17.41
330019................................................    1.3601   32.45
330020................................................    1.0286   14.55
330023................................................    1.3009   24.27
330024................................................    1.8309   33.62
330025................................................    1.1220   16.03
330027................................................    1.4693   32.50
330028................................................    1.4098   27.08
330029................................................    1.1581   16.56
330030................................................    1.4112   15.06
330033................................................    1.3199   16.75
330034................................................    0.5292   30.78
330036................................................    1.2759   24.32
330037................................................    1.2233   16.00
330038................................................    1.1832   16.01
330039................................................  ........   12.47
330041................................................    1.2880   30.42
330043................................................    1.3066   27.63
330044................................................    1.2646   18.70
330045................................................    1.3781   27.17
330046................................................    1.4593   31.98
330047................................................    1.1968   17.69
330048................................................    1.2630   17.62
330049................................................    1.2706   19.31
330053................................................    1.2225   15.67
330055................................................    1.5732   30.73
330056................................................    1.4694   30.22
330057................................................    1.6858   18.69
330058................................................    1.3130   16.98
330059................................................    1.6062   32.23
330061................................................    1.2760   25.07
330062................................................    1.0970   15.28
330064................................................    1.4280   32.87
330065................................................    1.2350   18.37
330066................................................    1.2659   19.94
330067................................................    1.3299   21.29
330072................................................    1.4098   29.31
330073................................................    1.1707   15.88
330074................................................    1.2820   18.16
330075................................................    1.0916   17.43
330078................................................    1.4535   17.49
330079................................................    1.2806   16.76
330080................................................    1.2173   26.88
330084................................................    1.0649   23.03
330085................................................    1.2898   18.78
330086................................................    1.2276   30.69
330088................................................    1.0486   25.62
330090................................................    1.5583   18.68
330091................................................    1.3777   18.53
330092................................................    1.0002   12.65
330094................................................    1.2368   17.72
330095................................................    1.3283   18.55
330096................................................    1.1192   16.60
330097................................................    1.2475   16.96
330100................................................    0.9953   28.11
330101................................................    1.7932   31.31
330102................................................    1.3020   17.52
330103................................................    1.2013   16.52
330104................................................    1.4136   28.77
330106................................................    1.7013   35.87
330107................................................    1.2670   28.08
330108................................................    1.2378   17.08
330111................................................    1.0739   15.20
330114................................................    0.9034   18.24
330115................................................    1.1307   16.56
330116................................................    0.8479   24.23
330118................................................    1.6335   20.76
330119................................................    1.7050   34.75
330121................................................    1.0145   15.85
330122................................................    1.0108   21.20
330125................................................    1.8904   19.75
330126................................................    1.1356   22.70
330127................................................    1.3751   29.33
330128................................................    1.3130   27.87
330132................................................    1.2002   14.70
330133................................................    1.3616   32.38
330135................................................    1.1987   18.33
330136................................................    1.3304   17.60
330140................................................    1.8211   19.50
330141................................................    1.3368   25.14
330144................................................    0.9874   15.51
330148................................................    1.0682   15.04
330151................................................    1.0931   13.97
330152................................................    1.4635   29.48
330153................................................    1.7143   17.50
330154................................................    1.7631  ......
330157................................................    1.3782   20.82
330158................................................    1.4535   26.05
330159................................................    1.2598   18.02
330160................................................    1.4258   30.57
330162................................................    1.2112   27.72
330163................................................    1.2668   20.46
330164................................................    1.3673   19.48
330166................................................    1.0666   14.18
330167................................................    1.7231   31.18
330169................................................    1.4422   33.45
330171................................................    1.3081   25.43
330175................................................    1.1866   16.69
330177................................................    0.9536   14.54
330179................................................    0.8480   12.69
330180................................................    1.2149   15.53
330181................................................    1.3246   32.47
330182................................................    2.5278   30.93
330183................................................    1.4710   20.00
330184................................................    1.3687   27.49
330185................................................    1.2683   26.95

[[Page 41575]]

 
330188................................................    1.2749   18.72
330189................................................    1.1706   17.66
330191................................................    1.3142   18.86
330193................................................    1.3094   29.80
330194................................................    1.8144   35.57
330195................................................    1.6168   31.39
330196................................................    1.2584   28.45
330197................................................    1.1217   17.00
330198................................................    1.3910   23.81
330199................................................    1.3867   27.66
330201................................................    1.6595   30.33
330202................................................    1.3321   30.79
330203 *..............................................    1.3921   19.24
330204................................................    1.3626   29.37
330205................................................    1.2157   19.46
330208................................................    1.2524   25.82
330209................................................    1.2116   24.88
330211................................................    1.1008   19.10
330212................................................    1.1242   21.18
330213................................................    1.1317   18.51
330214................................................    1.8270   32.20
330215................................................    1.2136   17.58
330218................................................    1.0783   21.71
330219................................................    1.6448   22.15
330221................................................    1.2958   32.21
330222................................................    1.2727   17.81
330223................................................    1.0436   17.28
330224................................................    1.2609   21.97
330225................................................    1.1997   25.80
330226................................................    1.2800   17.67
330229................................................    1.3032   16.25
330230................................................    1.3323   28.86
330231................................................    1.0181   29.09
330232................................................    1.2621   19.50
330233................................................    1.4710   33.30
330234................................................    2.3453   33.33
330235................................................    1.1654   19.45
330236................................................    1.3908   30.70
330238................................................    1.2201   14.80
330239................................................    1.2099   17.28
330240................................................    1.3684   30.48
330241................................................    2.0212   22.60
330242................................................    1.2840   24.74
330245................................................    1.4695   17.28
330246................................................    1.3231   26.66
330247................................................    0.8484   27.62
330249................................................    1.1958   16.48
330250................................................    1.2389   19.56
330252................................................  ........   17.04
330254................................................    1.1711   16.73
330258................................................    1.2652   30.47
330259................................................    1.4799   25.25
330261................................................    1.3017   26.17
330263................................................    1.0017   19.64
330264................................................    1.1961   23.14
330265................................................    1.3299   15.62
330267................................................    1.3394   23.56
330268................................................    0.9564   14.62
330270................................................    2.0232   28.24
330273................................................    1.2930   25.89
330275................................................    1.3094   17.42
330276................................................    1.1580   17.75
330277................................................    1.1064   17.16
330279................................................    1.2946   19.91
330285................................................    1.8724   22.47
330286................................................    1.3300   25.09
330290................................................    1.7078   32.58
330293................................................    1.1263   15.38
330304................................................    1.2300   29.37
330306................................................    1.3461   27.62
330307................................................    1.3055   20.74
330308................................................  ........   36.84
330314................................................    1.3296   24.74
330316................................................    1.2613   28.79
330327................................................    0.8785   16.97
330331................................................    1.3605   31.04
330332................................................    1.2161   27.16
330333................................................    1.2122  ......
330336................................................    1.3033   30.17
330338................................................    1.2486   23.01
330339................................................    0.9024   19.67
330340................................................    1.1804   26.92
330350................................................    1.7352   30.38
330353................................................    1.2745   33.55
330354................................................    1.5861  ......
330357................................................    1.3424   34.75
330359................................................  ........   29.29
330372................................................    1.2139   22.50
330381................................................    1.2974   29.24
330385................................................    1.1317   28.84
330386................................................    1.1738   24.67
330387................................................    0.7617  ......
330389................................................    1.7654   32.42
330390................................................    1.3622   29.79
330393................................................    1.7228   27.99
330394................................................    1.5602   18.77
330395................................................    1.3551   37.68
330396................................................    1.1225   30.72
330397................................................    1.3731   31.00
330398................................................    1.3883   30.32
330399................................................    1.2650   35.52
330400................................................    0.8755  ......
340001................................................    1.4550   19.01
340002................................................    1.8335   18.78
340003................................................    1.1380   21.97
340004................................................    1.5053   17.89
340005................................................    1.1327   14.09
340006................................................    1.0448   17.81
340007................................................    1.1625   17.17
340008................................................    1.1063   18.38
340009................................................  ........   20.50
340010................................................    1.3066   17.65
340011................................................    1.1010   14.92
340012................................................    1.1766   16.66
340013................................................    1.2440   17.43
340014................................................    1.5360   19.92
340015................................................    1.2395   19.01
340016................................................    1.1721   16.40
340017................................................    1.2566   19.22
340018................................................    1.1435   15.16
340019................................................    0.9975   13.59
340020................................................    1.2389   16.75
340021................................................    1.2577   19.67
340022................................................    1.1225   16.72
340023................................................    1.3395   17.21
340024................................................    1.1417   16.64
340025................................................    1.2484   16.82
340027................................................    1.2085   17.30
340028................................................    1.5314   17.72
340030................................................    2.0552   20.05
340031................................................    0.9565   12.39
340032................................................    1.3524   20.47
340035................................................    1.0956   18.10
340036................................................    1.1292   16.97
340037................................................    1.0029   15.53
340038................................................    1.1014   17.01
340039................................................    1.2603   20.15
340040................................................    1.7863   20.12
340041................................................    1.2563   17.76
340042................................................    1.1906   16.63
340044................................................    1.1019   16.37
340045................................................    1.0204   12.42
340047................................................    1.8911   19.60
340048................................................    0.6134  ......
340049................................................    0.7590   16.50
340050................................................    1.1658   18.56
340051................................................    1.2890   18.60
340052................................................    0.9879   21.37
340053................................................    1.6306   19.49
340054................................................    1.1743   14.47
340055................................................    1.2601   18.18
340060................................................    1.0858   17.92
340061................................................    1.7102   20.85
340063................................................    1.0122   16.92
340064................................................    1.1554   17.26
340065................................................    1.3341   18.32
340067................................................    1.0091   18.61
340068................................................    1.2353   16.70
340069................................................    1.8140   19.99
340070................................................    1.2558   18.63
340071................................................    1.1412   16.37
340072................................................    1.1342   15.60
340073................................................    1.3877   20.69
340075................................................    1.2374   18.21
340080................................................    0.9827   16.85
340084................................................    1.1280   21.78
340085................................................    1.1684   16.24
340087................................................    1.1121   16.70
340088................................................    1.2483   19.83
340089................................................    0.9798   13.86
340090................................................    1.1715   17.85
340091................................................    1.6767   19.40
340093................................................    1.0384   15.16
340094................................................    1.3871   15.96
340096................................................    1.1735   17.98
340097................................................    1.1300   21.37
340098................................................    1.5807   20.17
340099................................................    1.1289   15.09
340101................................................    1.0689   15.36
340104................................................    0.8681   15.87
340105................................................    1.3487   18.90
340106................................................    1.1391   18.08
340107................................................    1.2312   16.95
340109................................................    1.3520   17.96
340111................................................    1.1185   14.92
340112................................................    0.9997   14.60
340113................................................    1.8588   20.88
340114................................................    1.6123   20.82
340115................................................    1.5468   18.67
340116................................................    1.8562   19.48
340119................................................    1.2136   16.85
340120................................................    1.1373   14.38

[[Page 41576]]

 
340121................................................    1.0483   15.97
340123................................................    1.1257   16.22
340124................................................    1.1103   14.05
340125................................................    1.4571   19.63
340126................................................    1.3214   17.72
340127................................................    1.3040   17.38
340129................................................    1.2333   19.73
340130................................................    1.3605   19.44
340131................................................    1.5410   18.94
340132................................................    1.2906   16.94
340133................................................    1.0718   14.35
340137................................................    1.2697  ......
340138................................................    1.0653   19.28
340141................................................    1.7096   22.22
340142................................................    1.1906   16.09
340143................................................    1.4510   20.95
340144................................................    1.2510   19.19
340145................................................    1.3190   19.20
340146................................................    1.0415   13.01
340147................................................    1.2389   19.11
340148................................................    1.3628   18.42
340151................................................    1.2111   16.57
340153................................................    1.8460   20.66
340155................................................    1.3964   20.42
340156................................................    0.7271  ......
340158................................................    1.0716   17.26
340159................................................    1.1780   16.80
340160................................................    1.1654   15.53
340162................................................  ........   16.64
340164................................................    1.3637   19.68
340166................................................    1.3042   19.17
340168................................................    0.4833   14.75
340171................................................    1.1348   20.05
340173................................................    1.2020   20.21
350001................................................    0.9646   11.73
350002................................................    1.8448   17.28
350003................................................    1.2042   17.43
350004................................................    1.9290   17.90
350005................................................    1.0889   16.03
350006................................................    1.3866   16.62
350007................................................    0.9036   13.28
350008................................................    0.9709   21.70
350009................................................    1.1851   18.28
350010................................................    1.1308   15.28
350011................................................    1.9286   18.49
350012................................................    1.0793   12.73
350013................................................    1.0590   16.68
350014................................................    1.0326   15.79
350015................................................    1.7240   15.87
350016................................................  ........   11.63
350017................................................    1.3378   17.78
350018................................................    1.0325   13.64
350019................................................    1.7209   19.40
350021................................................    0.9859   12.69
350023................................................    0.9505   12.80
350024................................................    1.0053   14.37
350025................................................    0.9820   16.24
350027................................................    1.0099   17.12
350029................................................    0.8409   12.80
350030................................................    1.0653   17.35
350033................................................    0.9296   14.90
350034................................................    0.9296   18.32
350035................................................    0.8734   10.16
350038................................................    1.0783   18.74
350039................................................    1.0442   17.31
350041................................................    0.9447   14.68
350042................................................    1.0586   16.75
350043................................................    1.6076   17.16
350044................................................    0.9014   10.53
350047................................................    1.1414   17.93
350049................................................    1.2037   14.53
350050................................................    0.9242   10.57
350051................................................    0.9872   17.53
350053................................................    1.0048   13.94
350055................................................    0.9884   12.37
350056................................................    0.9227   14.74
350058................................................    0.9550   14.35
350060................................................    0.8626    9.60
350061................................................    1.0451   14.59
350063................................................    0.8913  ......
350064................................................    0.8650  ......
350068................................................    2.4777  ......
350069................................................    1.2467  ......
360001................................................    1.3010   17.39
360002................................................    1.1805   17.40
360003................................................    1.7521   22.03
360006................................................    1.9102   22.09
360007................................................    1.0878   17.10
360008................................................    1.2553   17.82
360009................................................    1.5416   17.53
360010................................................    1.2807   18.09
360011................................................    1.2954   18.95
360012................................................    1.2982   19.22
360013................................................    1.1484   20.81
360014................................................    1.1318   19.88
360016................................................    1.6655   18.77
360017................................................    1.9312   22.50
360018................................................    1.6955   21.34
360019................................................    1.2255   20.17
360020................................................    1.4599   22.95
360024................................................    1.3135   18.54
360025................................................    1.3536   19.29
360026................................................    1.3128   17.04
360027................................................    1.4745   20.36
360028................................................    1.4934   17.27
360029................................................    1.1928   18.22
360030................................................    1.3464   15.35
360031................................................    1.1973   19.90
360032................................................    1.1566   17.93
360034................................................    1.3261   15.56
360035 *..............................................    1.6492   20.33
360036................................................    1.3101   19.18
360037................................................    2.1402   22.52
360038................................................    1.6231   19.89
360039................................................    1.2936   17.40
360040................................................    1.2903   18.12
360041................................................    1.2883   18.42
360042................................................    1.1662   16.12
360044................................................    1.1577   16.79
360045................................................    1.4251   21.18
360046................................................    1.1457   19.32
360047................................................    1.1301   15.34
360048................................................    1.8831   21.17
360049................................................    1.2259   18.81
360050................................................    1.2304   12.89
360051................................................    1.6202   20.95
360052................................................    1.6991   20.02
360054................................................    1.2488   16.19
360055................................................    1.3169   23.27
360056................................................    1.3944   18.76
360057................................................    1.0590   13.81
360058................................................    1.1920   17.92
360059................................................    1.6176   21.97
360062................................................    1.4095   20.31
360063................................................    1.1426   22.79
360064................................................    1.6125   20.64
360065................................................    1.2530   19.45
360066................................................    1.6379   20.03
360067................................................    1.1487   14.57
360068................................................    1.7961   21.22
360069................................................    1.1401   17.83
360070................................................    1.7813   17.53
360071................................................    1.4168   23.80
360072................................................    1.2698   17.97
360074................................................    1.2995   18.26
360075................................................    1.3458   18.47
360076................................................    1.3578   19.59
360077................................................    1.6203   20.82
360078................................................    1.2481   20.79
360079................................................    1.8424   22.00
360080................................................    1.1428   16.64
360081................................................    1.3443   19.64
360082................................................    1.2775   22.86
360083................................................  ........   18.46
360084................................................    1.6064   20.09
360085................................................    1.8845   21.67
360086................................................    1.4307   17.04
360087................................................    1.4307   20.04
360088................................................    1.3186   22.31
360089................................................    1.1340   20.56
360090................................................    1.2673   20.40
360091................................................    1.3221   21.03
360092................................................    1.1368   15.91
360093................................................    1.1664   18.57
360094................................................    1.3406   18.31
360095................................................    1.2602   18.71
360096................................................    1.0740   17.16
360098................................................    1.4616   18.34
360099................................................    1.0145   18.55
360100................................................    1.2435   17.66
360101................................................    1.3302   22.31
360102................................................    1.2047   19.77
360103................................................  ........   22.62
360104................................................    1.1889  ......
360106................................................    1.2012   16.18
360107................................................    1.2436   18.62
360108................................................    1.0496   16.51
360109................................................    1.0898   19.52
360112................................................    1.9109   22.57
360113................................................    1.3312   22.46
360114................................................    1.0862   16.33
360115................................................    1.3561   18.19
360116................................................    1.1098   18.08
360118................................................    1.3482   18.61
360121................................................    1.2089   21.10
360123................................................    1.2389   19.13
360125................................................    1.1466   18.17
360126................................................    1.2114   20.46
360127................................................    1.1478   16.92
360128................................................    1.1562   15.58
360129................................................    0.9412   15.52
360130................................................    1.0130   15.34

[[Page 41577]]

 
360131................................................    1.3306   18.29
360132................................................    1.4151   18.27
360133................................................    1.6452   19.03
360134................................................    1.7555   20.24
360136................................................    1.0165   17.85
360137................................................    1.7409   20.26
360140................................................    0.9460   19.13
360141................................................    1.6436   22.85
360142................................................    1.0518   17.32
360143................................................    1.3319   20.44
360144................................................    1.2938   21.92
360145................................................    1.6950   19.39
360147................................................    1.2418   16.59
360148................................................    1.1492   18.89
360149................................................    1.2611   18.79
360150................................................    1.3013   20.63
360151................................................    1.3912   17.49
360152................................................    1.5355   22.00
360153................................................    1.1316   14.89
360154................................................    1.0439   13.78
360155................................................    1.3700   20.90
360156................................................    1.2856   17.92
360159................................................    1.1775   20.71
360161................................................    1.3543   19.41
360162................................................    1.0718   18.61
360163................................................    1.8529   20.38
360164................................................  ........   16.16
360165................................................    1.1711   19.48
360166................................................  ........   16.98
360170................................................    1.4463   17.18
360172................................................    1.3447   18.47
360174................................................    1.2444   19.09
360175................................................    1.1884   20.41
360176................................................    1.1409   15.47
360177................................................    1.3262   19.41
360178................................................    1.3137   17.40
360179................................................    1.4139   19.14
360180................................................    2.1661   22.09
360184................................................    0.5560   19.35
360185................................................    1.2339   18.67
360186................................................    1.0606   20.86
360187................................................    1.4030   18.02
360188................................................    0.9307   17.53
360189................................................    1.1003   17.37
360192................................................    1.3355   21.00
360193................................................  ........   17.69
360194................................................    1.1609   17.69
360195................................................    1.1446   19.02
360197................................................    1.1573   19.42
360200................................................    0.9129   17.76
360203................................................    1.1658   15.62
360204................................................    1.2012   19.35
360210................................................    1.1911   20.28
360211................................................    1.2583   19.58
360212................................................    1.3505   20.23
360213................................................    1.2574   18.33
360218................................................    1.3249   18.41
360230................................................    1.5283   21.44
360231................................................    1.1689   13.56
360234................................................    1.3667   22.43
360236................................................    1.2668   19.49
360239................................................    1.2640   19.86
360241................................................    0.4070   22.08
360242................................................    1.8361  ......
360243................................................    0.6859   13.58
360244................................................  ........   10.55
360245................................................    0.7433   15.06
360247................................................    0.4015   18.11
360248................................................  ........   21.65
370001................................................    1.7346   21.27
370002................................................    1.2288   14.08
370004................................................    1.1872   16.77
370005................................................    0.9385   17.38
370006................................................    1.1884   12.95
370007................................................    1.1457   17.15
370008................................................    1.3742   17.30
370011................................................    1.0371   14.64
370012................................................    0.8381   10.80
370013................................................    1.8493   18.04
370014................................................    1.1887   19.65
370015................................................    1.1904   17.82
370016................................................    1.3340   16.64
370017................................................    1.1216   12.98
370018................................................    1.3475   14.24
370019................................................    1.3147   16.88
370020................................................    1.2736   13.48
370021................................................    0.8600   11.26
370022................................................    1.3152   17.90
370023................................................    1.2592   16.82
370025................................................    1.3103   16.40
370026................................................    1.4917   16.90
370028................................................    1.8963   19.71
370029................................................    1.1600   13.89
370030................................................    1.1994   15.47
370032................................................    1.6025   16.64
370033................................................    1.0433   12.39
370034................................................    1.2299   14.51
370035................................................    1.7120   18.96
370036................................................    1.0585   11.46
370037................................................    1.7309   17.75
370038................................................    0.9615   12.81
370039................................................    1.1544   16.27
370040................................................    1.0110   14.26
370041................................................    0.9415   17.41
370042................................................    0.8612   14.61
370043................................................    0.9299   16.08
370045................................................    1.0224   12.44
370046................................................    0.9794   18.15
370047................................................    1.4234   15.67
370048................................................    1.2065   17.44
370049................................................    1.3139   19.84
370051................................................    0.9449   12.18
370054................................................    1.3637   16.56
370056................................................    1.5690   18.88
370057................................................    1.0262   14.66
370059................................................    1.1239   16.46
370060................................................    1.0608   15.12
370063................................................    1.1026   17.06
370064................................................    0.9372    8.75
370065................................................    0.9995   16.56
370071................................................    1.0270   14.95
370072................................................    0.8663   14.65
370076................................................    1.2551   12.86
370077................................................  ........   17.62
370078................................................    1.6865   17.24
370079................................................    0.9319   13.60
370080................................................    0.9519   14.34
370082................................................    0.8529   13.54
370083................................................    0.9651   11.49
370084................................................    1.0188   21.75
370085................................................    0.8885   11.88
370086................................................    1.1192   13.56
370089................................................    1.2148   14.50
370091................................................    1.6636   17.58
370092................................................    0.9955   14.68
370093................................................    1.7971   18.57
370094................................................    1.4454   18.38
370095................................................    0.9872   14.13
370097................................................    1.3459   23.31
370099................................................    1.1217   16.26
370100................................................    0.9773   17.10
370103................................................    0.9111   15.90
370105................................................    1.9566   17.68
370106................................................    1.5308   18.62
370108................................................    0.9670   12.24
370112................................................    1.0270   15.25
370113................................................    1.2331   16.20
370114................................................    1.6454   15.98
370121................................................    1.0409   19.55
370122................................................    1.0456   12.15
370123................................................    1.4493   16.36
370125................................................    0.8954   13.55
370126................................................    0.9646   18.24
370131................................................    0.9766   16.24
370133................................................    1.0621   10.02
370138................................................    1.0502   15.94
370139................................................    1.0969   13.30
370140................................................    1.0458   15.23
370141................................................    1.3710   12.14
370146................................................    1.0935   12.56
370148................................................    1.4517   16.41
370149................................................    1.3477   16.72
370153................................................    1.1156   15.32
370154................................................    1.0477   15.91
370156................................................    1.1036   13.64
370158................................................    1.0207   15.09
370159................................................    1.2557   17.83
370163................................................    0.9854   14.56
370165................................................    1.2557   13.22
370166................................................    1.0448   17.82
370169................................................    1.0466    9.48
370170................................................    1.0201  ......
370171................................................    1.0333  ......
370172................................................    0.8953  ......
370173................................................    1.0677  ......
370174................................................    0.7213  ......
370176................................................    1.2191   16.03
370177................................................    0.9826   11.88
370178................................................    0.9826   11.64
370179................................................    0.9491   19.27
370180................................................    0.9918  ......
370183................................................    1.0386    7.62
370186................................................    0.9783   13.35
370190................................................    1.4695   13.70
370192................................................    1.4803   16.74
370196................................................    0.8822  ......
370197................................................  ........   21.57
370198................................................    1.4366  ......
370199................................................    1.0710  ......
370200................................................    1.1757  ......
380001................................................    1.3054   22.03
380002................................................    1.2171   19.48

[[Page 41578]]

 
380003................................................    1.1769   24.74
380004................................................    1.7367   23.14
380005................................................    1.1722   23.24
380006................................................    1.2239   20.54
380007................................................    1.6506   24.29
380008................................................    1.0693   21.19
380009................................................    1.7994   25.17
380010................................................    1.0403   19.75
380011................................................    1.1050   21.14
380013................................................    1.1851   20.10
380014................................................    1.6519   23.48
380017................................................    1.9289   23.82
380018................................................    1.8307   22.08
380019................................................    1.2451   20.77
380020................................................    1.4521   21.35
380021................................................    1.2078   20.64
380022................................................    1.1103   21.61
380023................................................    1.1371   19.24
380025................................................    1.2975   24.67
380026................................................    1.1401   19.27
380027................................................    1.2810   20.16
380029................................................    1.1435   18.57
380031................................................    0.9408   22.83
380033................................................    1.7943   23.29
380035................................................    1.3526   21.65
380036................................................    1.0855   19.33
380037................................................    1.2290   21.23
380038................................................    1.2487   25.58
380039................................................    1.2583   22.12
380040................................................    1.2936   21.64
380042................................................    1.0177   19.81
380047................................................    1.6722   21.95
380048................................................    1.0388   18.38
380050................................................    1.4293   18.25
380051................................................    1.6373   21.24
380052................................................    1.2518   17.87
380055................................................  ........   21.25
380056................................................    1.1058   17.16
380060................................................    1.4643   23.29
380061................................................    1.5204   22.60
380062................................................    1.2219   18.52
380063................................................  ........   19.36
380064................................................    1.3264   19.87
380065................................................    1.3064   22.17
380066................................................    1.3262   20.42
380068................................................  ........   22.76
380069................................................    1.0690   19.58
380070................................................    1.3461   24.71
380071................................................    1.2354   20.47
380072................................................    0.9961   16.32
380075................................................    1.4230   22.17
380078................................................    1.1344   19.10
380081................................................    1.0229   20.59
380082................................................    1.2605   22.58
380083................................................    1.1703   21.81
380084................................................    1.2427   23.64
380087................................................    1.2284   14.10
380088................................................    1.0722   19.52
380089................................................    1.2782   23.74
380090................................................    1.2985   27.09
380091................................................    1.2615   22.83
390001................................................    1.5197   18.64
390002................................................    1.3161   18.08
390003................................................    1.2413   17.24
390004................................................    1.3985   18.89
390005................................................    1.0952   16.44
390006................................................    1.8485   19.60
390007................................................    1.2517   21.41
390008................................................    1.1995   16.74
390009................................................    1.7387   20.12
390010................................................    1.2493   17.23
390011................................................    1.2786   18.07
390012................................................    1.2224   20.02
390013................................................    1.2401   19.33
390015................................................    1.1327   12.94
390016................................................    1.2481   17.07
390017................................................    1.1841   16.22
390018................................................    1.2421   19.12
390019................................................    1.0759   16.40
390022................................................    1.3526   22.90
390023................................................    1.2272   19.56
390024................................................    1.1811   25.03
390025................................................    0.4279   15.71
390026................................................    1.2761   22.76
390027................................................    1.8053   27.69
390028................................................    1.8916   20.11
390029................................................    2.0498   19.69
390030................................................    1.2190   18.40
390031................................................    1.2148   19.52
390032................................................    1.2612   18.15
390035................................................    1.2648   18.51
390036................................................    1.5398   18.87
390037................................................    1.3709   22.24
390039................................................    1.1436   16.54
390040................................................    0.9484   15.12
390041................................................    1.2688   19.58
390042................................................    1.5854   21.13
390043................................................    1.1832   16.36
390044................................................    1.6421   19.54
390045................................................    1.7159   18.46
390046................................................    1.6104   20.46
390047 *..............................................    1.7392   24.58
390048................................................    1.1549   18.38
390049................................................    1.6110   21.13
390050................................................    2.1144   20.92
390051................................................    2.1338   26.05
390052................................................    1.1515   17.10
390054................................................    1.2341   17.44
390055................................................    1.8882   25.90
390056................................................    1.1205   17.17
390057................................................    1.3152   19.75
390058................................................    1.2858   19.25
390060................................................    1.2088   13.63
390061................................................    1.4942   20.48
390062................................................    1.2444   16.45
390063................................................    1.8378   19.64
390065................................................    1.2322   20.00
390066................................................    1.2608   18.71
390067................................................    1.8018   20.65
390068................................................    1.3033   17.55
390069................................................    1.2663   19.28
390070................................................    1.4159   20.19
390071................................................    1.1073   16.23
390072................................................    1.0501   15.56
390073................................................    1.6671   20.69
390074................................................    1.2469   16.60
390075................................................    1.3924   17.27
390076................................................    1.2799   21.43
390078................................................    1.1498   18.23
390079................................................    1.7562   18.20
390080................................................    1.2916   19.52
390081................................................    1.2972   23.99
390083................................................    1.2031   20.59
390084................................................    1.2677   16.35
390086................................................    1.1360   17.25
390088................................................    1.3689   23.49
390090................................................    1.8001   20.65
390091................................................    1.1280   18.37
390093................................................    1.1551   16.63
390095................................................    1.2033   13.05
390096................................................    1.4914   19.31
390097................................................    1.2750   21.41
390100................................................    1.6552   20.30
390101................................................    1.2029   17.05
390102................................................    1.3959   19.49
390103................................................    1.0911   17.71
390104................................................    1.0664   15.96
390106................................................    1.1156   16.28
390107................................................    1.3308   19.18
390108................................................    1.4026   21.29
390109................................................    1.2009   14.66
390110................................................    1.5954   21.32
390111................................................    1.9491   28.79
390112................................................    1.2904   14.04
390113................................................    1.2508   17.94
390114................................................    1.2348   22.97
390115................................................    1.3965   24.72
390116................................................    1.3025   20.60
390117................................................    1.1716   16.90
390118................................................    1.2155   16.90
390119 *..............................................    1.3896   18.59
390121................................................    1.3960   18.64
390122................................................    1.0609   17.46
390123................................................    1.2758   20.84
390125................................................    1.2088   15.94
390126................................................    1.2888   20.94
390127................................................    1.2287   21.88
390128................................................    1.2209   19.41
390130................................................    1.1335   17.33
390131................................................    1.3299   16.83
390132................................................    1.2842   20.55
390133................................................    1.7977   24.61
390135................................................    1.2393   21.25
390136................................................    1.1430   17.61
390137................................................    1.5156   16.56
390138................................................    1.3213   18.86
390139................................................    1.5077   22.94
390142................................................    1.6076   26.80
390145................................................    1.3889   20.34
390146................................................    1.2155   17.70
390147................................................    1.2656   21.11
390150................................................    1.1805   19.66
390151................................................    1.2299   20.51
390152................................................    1.1121   19.15
390153................................................    1.2219   23.12
390154................................................    1.2679   15.85
390156................................................    1.4108   21.16
390157................................................    1.3940   19.83
390158................................................  ........   21.60
390160................................................    1.2390   20.77
390161................................................    1.1929   12.37
390162................................................    1.5211   21.02

[[Page 41579]]

 
390163................................................    1.2276   15.62
390164................................................    2.1736   21.59
390166................................................    1.1138   19.96
390167................................................  ........   22.91
390168................................................    1.2592   18.99
390169................................................    1.3390   18.99
390170................................................    1.8476   22.99
390173................................................    1.2211   17.86
390174................................................    1.6855   25.24
390176................................................    1.1814   17.36
390178................................................    1.3114   17.70
390179................................................    1.3111   21.41
390180................................................    1.4575   25.12
390181................................................    1.0728   17.09
390183................................................    1.1617   19.08
390184................................................    1.1308   20.75
390185................................................    1.2169   17.65
390189................................................    1.1404   18.67
390191................................................    1.1721   16.20
390192................................................    1.1726   16.37
390193................................................    1.1915   16.47
390194................................................    1.1396   20.15
390195................................................    1.8300   23.69
390196................................................    1.5787  ......
390197................................................    1.2829   18.99
390198................................................    1.2778   15.45
390199................................................    1.2683   16.66
390200................................................    0.9687   13.59
390201................................................    1.2641   20.50
390203................................................    1.3610   21.19
390204................................................    1.2735   20.85
390206................................................    1.3965   18.57
390209................................................    1.0811   16.96
390211................................................    1.2188   17.91
390213................................................    1.1371   17.44
390215................................................    1.2554   21.43
390217................................................    1.2220   19.29
390219................................................    1.3081   21.63
390220................................................    1.1645   18.52
390222................................................    1.3169   20.91
390223................................................    1.7259   22.65
390224................................................    0.8838   15.91
390225................................................    1.1965   18.17
390226................................................    1.6019   23.16
390228................................................    1.2988   19.81
390231................................................    1.5687   24.49
390233................................................    1.3518   18.77
390235................................................    1.4228   24.60
390236................................................    1.2240   17.03
390237................................................    1.5705   21.75
390238................................................    1.2725  ......
390242................................................  ........   18.09
390244................................................    0.9246   14.41
390245................................................    1.3207   20.15
390246................................................    1.1923   17.92
390247................................................    1.0508   20.67
390249................................................    0.9293   10.73
390256................................................    1.8873   23.78
390258................................................    1.4564   21.36
390260................................................    1.0990   21.19
390262................................................    1.9277   18.67
390263................................................    1.4217   20.09
390265................................................    1.2937   19.51
390266................................................    1.2120   16.24
390267................................................    1.2587   20.51
390268................................................    1.3361   21.02
390270................................................    1.3866   17.83
390272................................................    0.4775  ......
390277................................................    0.4015   27.10
390278................................................    0.6656   19.20
390279................................................    1.0539   13.70
390283................................................    1.2887  ......
390284................................................    1.2825  ......
400001................................................    1.2244    9.86
400002................................................    1.6964    9.31
400003................................................    1.3598    9.99
400004................................................    1.1415    8.48
400005................................................    1.1222    7.85
400006................................................    1.1587   10.53
400007................................................    1.1989    7.86
400009................................................    1.0514    8.37
400010................................................    0.8930   11.66
400011................................................    1.0733    5.68
400012................................................    1.3553    7.81
400013................................................    1.2614    8.21
400014................................................    1.3933    9.54
400015................................................    1.3572   10.33
400016................................................    1.3661   12.07
400017................................................    1.1566    8.57
400018................................................    1.2826    9.45
400019................................................    1.6564   10.15
400021................................................    1.4420    9.91
400022................................................    1.3356   11.12
400024................................................    0.9529    7.56
400026................................................    0.9627    7.12
400027................................................    1.1026    8.49
400028................................................    1.2378    8.40
400031................................................    1.2515    9.78
400032................................................    1.2192    9.73
400044................................................    1.2602   11.75
400048................................................    1.0437    8.92
400061................................................    1.7071   12.28
400079................................................    1.2218    7.08
400087................................................    1.4146   10.40
400094................................................    0.9953    7.82
400098................................................    1.3997    7.21
400102................................................    1.1587    7.73
400103................................................    1.3967   10.73
400104................................................    1.2587    9.94
400105................................................    1.2156   10.17
400106................................................    1.2572    8.51
400109................................................    1.4778   10.18
400110................................................    1.1266   10.53
400111................................................    1.1973    9.56
400112................................................    1.0576   12.85
400113................................................    1.1558    9.48
400114................................................    1.0813    6.41
400115................................................    1.0388    9.13
400117................................................    1.1552   10.04
400118................................................    1.2390    8.70
400120................................................    1.2553    9.74
400121................................................    0.9964    7.11
400122................................................    1.0235    8.48
400123................................................    1.2032    9.02
400124................................................    2.8388   11.48
400125................................................    1.0258  ......
410001................................................    1.3403   22.53
410004................................................    1.2575   22.32
410005................................................    1.3736   21.24
410006................................................    1.3072   21.98
410007................................................    1.6369   20.95
410008................................................    1.2134   22.61
410009................................................    1.2947   24.08
410010................................................    1.1607   27.14
410011................................................    1.2718   24.37
410012................................................    1.9093   21.33
410013................................................    1.2981   25.01
420002................................................    1.5001   20.20
420004................................................    1.8174   19.41
420005................................................    1.1360   15.99
420006................................................    1.2057   18.24
420007................................................    1.5723   17.58
420009................................................    1.1691   17.25
420010................................................    1.1771   17.91
420011................................................    1.2447   14.99
420014................................................    1.0205   16.72
420015................................................    1.3354   17.18
420016................................................    0.9537   18.15
420018................................................    1.8084   19.73
420019................................................    1.2188   15.55
420020................................................    1.1847   17.90
420023................................................    1.4285   20.97
420026................................................    1.8906   21.90
420027................................................    1.3311   18.08
420029................................................  ........   18.35
420030................................................    1.2089   17.82
420031................................................    0.8604   13.07
420033................................................    1.1644   21.09
420036................................................    1.2900   19.74
420037................................................    1.1933   21.96
420038................................................    1.3150   16.15
420039................................................    1.0732   16.96
420042................................................  ........   14.66
420043................................................    1.1871   18.36
420048................................................    1.2367   18.03
420049................................................    1.1990   19.23
420051................................................    1.6460   18.25
420053................................................    1.1431   16.55
420054................................................    1.2387   16.55
420055................................................    1.0582   16.18
420056................................................    1.1140   15.60
420057................................................    1.1152   14.50
420059................................................    0.9721   19.13
420061................................................    1.1775   16.13
420062................................................    1.1898   18.95
420064................................................    1.1047   15.45
420065................................................    1.3888   19.06
420066................................................    0.9829   15.50
420067................................................    1.2167   18.31
420068................................................    1.3841   17.21
420069................................................    1.0603   16.32
420070................................................    1.2337   17.45
420071................................................    1.3506   18.29
420072................................................    0.9129   12.60
420073................................................    1.2811   19.20
420074................................................    1.0309   13.80
420075................................................    0.9395   16.29
420078................................................    1.8574   20.68
420079................................................    1.5169   18.77
420080................................................    1.3719   24.83
420081................................................  ........   20.42
420082................................................    1.5862   18.88

[[Page 41580]]

 
420083................................................    1.3552   23.34
420085................................................    1.4126   18.55
420086................................................    1.4345   19.31
420087................................................    1.5936   18.40
420088................................................    1.0874   17.91
420089................................................    1.2957   21.66
420091................................................    1.2752   18.57
420093................................................    1.0331   16.77
420094................................................  ........   32.68
430004................................................    0.9951   17.84
430005................................................    1.3596   15.84
430007................................................    1.0895   14.06
430008................................................    1.0961   16.76
430010................................................    1.1568   16.11
430011................................................    1.2924   16.42
430012................................................    1.3190   17.78
430013................................................    1.2075   17.24
430014................................................    1.3645   18.44
430015................................................    1.2102   16.41
430016................................................    1.8688   18.97
430018................................................    0.8830   14.91
430022................................................    0.8600   12.95
430023................................................    0.8726   11.64
430024................................................    0.9383   13.99
430026................................................  ........   10.85
430027................................................    1.7702   18.64
430028................................................    1.0723   16.72
430029................................................    0.9695   15.10
430031................................................    0.9138   12.46
430033................................................    0.9911   14.64
430034................................................    0.9542   12.85
430036................................................    0.9551   13.78
430037................................................    0.9633   15.95
430038................................................    1.0095   11.94
430040................................................    1.0562   13.37
430041................................................    0.9146   12.62
430043................................................    1.1343   13.43
430044................................................    0.9084   16.45
430047................................................    1.0290   15.62
430048................................................    1.2374   17.26
430049................................................    0.8800   14.44
430051................................................    0.9313   17.21
430054................................................    0.9661   13.50
430056................................................    0.8354   11.41
430057................................................    0.8972   15.15
430060................................................    1.0902    8.64
430062................................................  ........   10.89
430064................................................    1.0315   12.74
430065................................................  ........   12.77
430066................................................    0.9635   13.44
430073................................................    1.0645   14.98
430076................................................    0.9498   12.25
430077................................................    1.6674   17.71
430079................................................    0.9893   12.98
430081................................................    0.8927  ......
430082................................................    0.8557  ......
430083................................................    0.9273  ......
430084................................................    0.8292  ......
430085................................................    0.7951  ......
430087................................................  ........   10.45
430089................................................    0.8333   17.01
430090................................................    1.3132  ......
430091................................................    1.4508  ......
430092................................................    2.2027  ......
430093................................................    0.9944  ......
440001................................................    1.1723   15.31
440002................................................    1.6655   18.54
440003................................................    1.2107   17.47
440006................................................    1.4049   20.66
440007................................................    1.0023    7.76
440008................................................    0.9789   15.47
440009................................................    1.1546   15.46
440010................................................    0.9316   13.51
440011................................................    1.3825   17.16
440012................................................    1.7212   19.06
440014................................................    1.0054   14.61
440015................................................    1.8026   21.09
440016................................................    1.0329   14.94
440017................................................    1.7407   21.13
440018................................................    1.2959   18.21
440019................................................    1.7380   28.22
440020................................................    1.1314   15.59
440022................................................  ........   19.02
440023................................................    1.1026   14.14
440024................................................    1.2941   18.10
440025................................................    1.1546   15.28
440026................................................    0.8073   22.92
440029................................................    1.2571   18.52
440030................................................    1.2081   15.57
440031................................................    1.0313   14.30
440032................................................    1.0042   13.60
440033................................................    1.1597   14.04
440034................................................    1.5624   17.93
440035................................................    1.2300   18.16
440039................................................    1.8880   19.37
440040................................................    0.9695   17.50
440041................................................    1.0284   13.63
440046................................................    1.2340   16.88
440047................................................    0.9232   17.00
440048................................................    1.8759   18.14
440049................................................    1.6647   16.71
440050................................................    1.3886   16.76
440051................................................    0.9140   14.91
440052................................................    1.0635   16.27
440053................................................    1.3256   17.69
440054................................................    1.1374   12.31
440056................................................    1.1442   14.25
440057................................................    1.0332   12.72
440058................................................    1.2111   18.74
440059................................................    1.4218   17.53
440060................................................    1.1643   15.86
440061................................................    1.1488   16.84
440063................................................    1.6723   18.29
440064................................................    1.0849   17.62
440065................................................    1.2815   18.69
440067................................................    1.2417   22.07
440068................................................    1.2254   17.45
440070................................................    1.0048   15.04
440071................................................    1.3484   16.27
440072................................................    1.3554   16.77
440073................................................    1.2784   18.56
440078................................................    1.0266   13.09
440081................................................    1.0930   17.97
440082................................................    2.0510   23.08
440083................................................    0.9673   35.10
440084................................................    1.2069   13.37
440091................................................    1.6378   19.73
440100................................................    1.0065   13.95
440102................................................    1.1291   13.96
440103................................................    1.1144   19.21
440104................................................    1.7467   22.39
440105................................................    1.7762   16.03
440109................................................    1.0850   14.25
440110................................................    1.1007   15.92
440111................................................    1.4511   21.07
440114................................................    1.0554   13.61
440115................................................    1.0675   12.97
440120................................................    1.6383   18.30
440125................................................    1.5580   16.11
440130................................................    1.1358   16.67
440131................................................    1.1191   14.68
440132................................................    1.1320   15.91
440133................................................    1.5497   21.51
440135................................................    1.2187   20.90
440137................................................    1.0853   14.70
440141................................................    0.9707   12.48
440142................................................    1.0003   13.01
440143................................................    1.0458   17.84
440144................................................    1.2153   16.67
440145................................................    0.9558   13.66
440147................................................    1.7028   22.01
440148................................................    1.1231   17.64
440149................................................    1.0963   17.15
440150................................................    1.3332   13.08
440151................................................    1.1150   15.43
440152................................................    2.0217   17.84
440153................................................    1.1545   16.10
440156................................................    1.5019   19.61
440157................................................    1.0816   11.40
440159................................................    1.1206   17.62
440161................................................    1.8695   20.76
440162................................................  ........   14.41
440166................................................    1.6850   18.14
440168................................................    1.0595   15.95
440173................................................    1.6016   18.47
440174................................................    1.0343   17.01
440175................................................    1.0711   17.61
440176................................................    1.3789   18.75
440180................................................    1.2237   17.34
440181................................................    0.9669   11.85
440182................................................    0.9559   20.32
440183................................................    1.5916   19.44
440184................................................    1.2535   18.06
440185................................................    1.1857   18.73
440186................................................    1.0484   18.53
440187................................................    1.1034   16.25
440189................................................    1.4919   16.19
440192................................................    1.0808   19.97
440193................................................    1.2258   18.40
440194................................................    1.2517   20.33
440197................................................    1.3608   23.11
440200................................................    1.0409   16.06
440203................................................    0.9731   16.61
440206................................................    0.9468   15.55
440209................................................  ........   14.75
440210................................................    0.8584   12.33
440211................................................    0.7028  ......
440212................................................    1.3679  ......
440213................................................    2.6309  ......
440214................................................    1.3295  ......
440215................................................    3.2594  ......
450002 *..............................................    1.5331   19.92

[[Page 41581]]

 
450004................................................    1.1460   15.28
450005................................................    1.1874   15.59
450007................................................    1.2676   15.75
450008................................................    1.2574   15.75
450010................................................    1.4353   16.08
450011................................................    1.5196   18.01
450014................................................    1.1164   18.22
450015................................................    1.6333   18.44
450016................................................    1.6642   17.31
450018................................................    1.4440   20.41
450020................................................    0.9574   16.97
450021................................................    1.8603   22.69
450023................................................    1.4538   16.64
450024................................................    1.4522   16.56
450025................................................    1.7316   16.44
450028................................................    1.4999   18.43
450029................................................    1.6790   17.69
450031................................................    1.4813   20.90
450032................................................    1.3572   15.24
450033................................................    1.7147   20.86
450034................................................    1.5646   18.91
450035................................................    1.4767   16.81
450037................................................    1.5593   18.65
450039................................................    1.4220   22.08
450040................................................    1.5467   17.52
450042................................................    1.7755   17.59
450044................................................    1.6190   21.04
450046................................................    1.3229   17.09
450047................................................    1.1484   13.90
450050................................................    0.9409   13.00
450051................................................    1.5732   20.08
450052................................................    1.0005   13.53
450053................................................    1.1017   17.31
450054................................................    1.6336   21.98
450055................................................    1.1134   14.81
450056................................................    1.6266   20.00
450058................................................    1.6320   16.98
450059................................................    1.3025   14.21
450063................................................    0.9080   13.81
450064................................................    1.4194   16.42
450065................................................    1.0265   19.61
450068................................................    1.9340   22.69
450072................................................    1.1756   17.38
450073................................................    1.1201   16.62
450076................................................    1.7324  ......
450078................................................    0.8770   13.49
450079................................................    1.5304   19.49
450080................................................    1.1737   16.31
450081................................................    1.0574   16.17
450082................................................    0.9662   13.30
450083................................................    1.8059   20.18
450085................................................    1.0594   14.22
450087................................................    1.4462   21.48
450090................................................    1.1225   13.91
450092................................................    1.2258   15.73
450094................................................    1.3312   19.42
450096................................................    1.4157   16.63
450097................................................    1.3386   18.27
450098................................................    1.0981   15.48
450099................................................    1.1520   22.88
450101................................................    1.4857   16.96
450102................................................    1.7293   18.85
450104................................................    1.1823   15.98
450107................................................    1.5327   20.74
450108................................................    1.0390   16.15
450109................................................    0.9217   12.77
450110................................................  ........   21.44
450111................................................    1.2307   19.27
450112................................................    1.2575   14.76
450113................................................    1.3243   18.53
450118................................................    1.6605   15.83
450119................................................    1.4078   18.32
450121................................................    1.5371   18.23
450123................................................    1.1890   19.19
450124................................................    1.6617   21.09
450126................................................    1.3281   17.45
450128................................................    1.1958   15.89
450130................................................    1.5002   17.87
450131................................................    1.2654   17.62
450132................................................    1.6202   18.07
450133................................................    1.6004   19.92
450135................................................    1.6151   20.81
450137................................................    1.5720   23.96
450140................................................    0.9268   18.07
450143................................................    1.0303   14.46
450144................................................    1.1036   16.30
450145................................................    0.8681   14.84
450146................................................    0.9514   14.20
450147................................................    1.3107   18.07
450148................................................    1.2211   22.03
450149................................................    1.4919   24.00
450150................................................    0.9050   15.21
450151................................................    1.1068   14.84
450152................................................    1.2314   17.38
450153................................................    1.5422   19.94
450154................................................    1.1797   13.18
450155................................................    1.0303   23.77
450157................................................    1.0679   14.66
450160................................................    0.9603    8.75
450162................................................    1.2180   22.20
450163................................................    1.0045   16.98
450164................................................    1.1806   20.04
450165................................................    1.0378   15.16
450166................................................    0.9271   10.28
450169................................................  ........   15.88
450170................................................    0.9642   14.81
450176................................................    1.2922   16.30
450177................................................    1.2048   14.73
450178................................................    1.0236   16.76
450181................................................    1.0155   14.02
450184................................................    1.4598   19.97
450185................................................    1.0280   13.06
450187................................................    1.1970   17.57
450188................................................    0.9951   13.78
450191................................................    1.0175   18.80
450192................................................    1.1761   19.33
450193................................................    2.0418   22.73
450194................................................    1.3020   19.15
450196................................................    1.4363   16.49
450200................................................    1.4435   17.38
450201................................................    1.0156   17.05
450203................................................    1.1610   18.66
450209................................................    1.5661   18.66
450210................................................    1.0520   14.23
450211................................................    1.3657   17.14
450213................................................    1.7239   18.45
450214................................................    1.3278   17.25
450217................................................    0.9404   11.69
450219................................................    1.0827   15.42
450221................................................    1.1951   16.99
450222................................................    1.4958   18.45
450224................................................    1.3659   22.83
450229................................................    1.5753   16.41
450231................................................    1.6275   17.70
450234................................................    1.0446   13.30
450235................................................    1.0697   13.42
450236................................................    1.1450   15.68
450237................................................    1.5270   17.40
450239................................................    1.0085   13.64
450241................................................    0.9610   14.87
450243................................................    0.9422   12.36
450246................................................    1.0263   17.97
450249................................................    1.0666   11.63
450250................................................    0.9906   14.91
450253................................................    1.1245   15.35
450258................................................    1.0358   13.23
450259................................................  ........   17.85
450264................................................    0.8807   13.89
450269................................................    0.9970   14.93
450270................................................    1.0799   12.70
450271................................................    1.2418   15.50
450272................................................    1.2621   17.95
450276................................................    1.0970   12.71
450278................................................    0.8254   13.79
450280................................................    1.5817   19.49
450283................................................    1.0456   13.89
450286................................................  ........   12.12
450288................................................    1.1566   15.99
450289................................................    1.4628   18.35
450292................................................    1.1880   19.51
450293................................................    0.9416   14.43
450296................................................    1.3456   20.66
450299................................................    1.5391   17.97
450303................................................    0.9610   12.67
450306................................................    1.0915   13.32
450307................................................    0.8064   16.68
450309................................................    1.0981   16.21
450315................................................    0.9782   20.80
450320................................................    1.2433   19.63
450321................................................    0.9220   13.39
450322................................................    0.5973   12.46
450324................................................    1.5321   17.87
450327................................................    0.9680   16.09
450330................................................    1.1273   18.42
450334................................................    0.9752   12.27
450337................................................    0.9914   17.42
450340................................................    1.4515   15.85
450341................................................    1.0145   19.18
450346................................................    1.4978   17.10
450347................................................    1.2191   17.69
450348................................................    1.1295   12.94
450351................................................    1.2160   15.98
450352................................................    1.1896   17.85
450353................................................    1.1368   15.00
450355................................................    1.0439   14.32
450358................................................    2.0749   21.28
450362................................................    1.0930   15.35
450369................................................    1.0526   15.19
450370................................................    1.2091   15.44
450371................................................    1.2416   11.90
450372................................................    1.2361   19.86
450373................................................    1.1050   17.60

[[Page 41582]]

 
450374................................................    0.8698   12.83
450378................................................    1.2110   23.16
450379................................................    1.5565   20.28
450381................................................    0.9516   15.62
450388................................................    1.7788   17.56
450389................................................    1.2896   18.15
450393................................................    1.2509   18.74
450395................................................    1.0405   16.67
450399................................................    0.9427   16.31
450400................................................    1.3730   14.08
450403................................................    1.2446   21.37
450411................................................    0.9314   14.05
450417................................................    1.0243   13.85
450418................................................    1.3882   20.58
450419................................................    1.2157   21.82
450422................................................    1.0412   24.53
450423................................................    1.5370   19.44
450424................................................    1.2472   17.57
450429................................................    1.1166   11.38
450431................................................    1.5621   16.27
450438................................................    1.1335   16.55
450446................................................    0.7614   21.97
450447................................................    1.3915   16.61
450451................................................    1.1857   19.64
450457................................................    1.8458   19.77
450460................................................    1.0022   14.22
450462................................................    1.7379   20.13
450464................................................    0.9349   13.47
450465................................................    1.3025   15.22
450467................................................    1.0721   15.60
450469................................................    1.3893   22.10
450473................................................    1.0194   14.19
450475................................................    1.0898   16.25
450484................................................    1.4878   19.59
450488................................................    1.3277   18.68
450489................................................    0.9699   14.57
450497................................................    1.1185   11.92
450498................................................    0.9726   12.02
450508................................................    1.3869   19.87
450514................................................    1.0763   22.28
450517................................................    0.9630   12.87
450518................................................    1.5221   19.01
450523................................................    1.4824   20.26
450530................................................    1.1935   22.91
450534................................................    0.9667   24.08
450535................................................    1.2294   21.26
450537................................................    1.3395   21.74
450538................................................  ........   19.69
450539................................................    1.2636   14.25
450544................................................    1.1451   19.38
450545................................................    1.3921   16.97
450547................................................    1.0630   13.81
450551................................................    1.1015   13.91
450558................................................    1.7932   20.02
450559................................................  ........   13.46
450561................................................  ........   16.82
450563................................................    1.2612   30.37
450565................................................    1.2556   16.45
450570................................................    1.1337   17.71
450571................................................    1.4934   16.97
450573................................................    0.9884   15.67
450574................................................    0.9302   14.24
450575................................................    1.1417   19.06
450578................................................    0.9369   16.87
450580................................................    1.1529   15.36
450583................................................    1.0313   15.50
450584................................................    1.1775   13.37
450586................................................    1.0568   12.84
450587................................................    1.1748   17.11
450591................................................    1.1439   17.92
450596................................................    1.2187   14.82
450597................................................    0.9686   16.18
450603................................................    0.7880   12.77
450604................................................    1.3018   15.48
450605................................................    1.1881   20.15
450609................................................    0.8938   10.73
450610................................................    1.4658   16.75
450614................................................    0.9889   13.83
450615................................................    1.0752   14.75
450617................................................    1.3304   19.54
450620................................................    1.1230   13.71
450623................................................    1.1370   21.83
450626................................................    1.0095   19.79
450628................................................    1.0152   16.83
450630................................................    1.5196   19.19
450631................................................    1.6627   17.56
450632................................................    0.9391   12.73
450633................................................    1.5491   20.72
450634................................................    1.6032   20.29
450638................................................    1.5279   19.70
450639................................................    1.4801   20.31
450641................................................    1.0503   13.50
450643................................................    1.2187   17.43
450644................................................    1.4341   20.79
450646................................................    1.4580   19.99
450647................................................    1.8895   22.42
450648................................................    1.0047   14.75
450649................................................    1.0310   15.82
450651................................................    1.6794   20.73
450652................................................    0.9055   16.65
450653................................................    1.0887   19.28
450654................................................    0.9509   13.88
450656................................................    1.3892   18.73
450658................................................    0.9617   15.15
450659................................................    1.4870   20.56
450661................................................    1.1054   20.22
450662................................................    1.4695   18.68
450665................................................    0.8670   15.44
450666................................................    1.3171   19.35
450668................................................    1.6278   18.72
450669................................................    1.3458   22.28
450670................................................    1.3452   18.20
450672................................................    1.5856   21.21
450673................................................    1.0157   13.84
450674................................................    1.1487   20.62
450675................................................    1.3667   23.26
450677................................................    1.3315   18.79
450678................................................    1.4770   20.75
450681................................................    1.3177  ......
450683................................................    1.2748   21.17
450684................................................    1.2383   22.85
450686................................................    1.5942   15.01
450688................................................    1.3164   20.90
450690................................................    1.3880   22.41
450694................................................    1.1399   18.49
450696................................................    1.3358   17.57
450697................................................    1.3675   15.93
450698................................................    0.9133   14.40
450700................................................    0.9460   15.12
450702................................................    1.5056   21.01
450703................................................    1.1321   18.80
450704................................................    1.2429   21.62
450705................................................    0.8800   22.32
450706................................................    1.1954   21.38
450709................................................    1.1866   19.77
450711................................................    1.6330   18.24
450712................................................    0.5453   16.89
450713................................................    1.4858   23.60
450715................................................    1.4308   19.77
450716................................................    1.2691   19.99
450717................................................    1.2889   19.45
450718................................................    1.2002   19.07
450723................................................    1.4188   19.70
450724................................................    1.2574   20.07
450725................................................  ........   19.56
450727................................................    1.0500   17.75
450728................................................    0.8255   12.93
450730................................................    1.3987   20.91
450733................................................    1.4696   20.37
450735................................................    0.8297    8.00
450742................................................    1.2714   20.78
450743................................................    1.4590   15.95
450746................................................    0.9207   20.75
450747................................................    1.3342   17.38
450749................................................    1.0361   12.95
450750................................................    1.0162   14.72
450751................................................    1.2134   22.25
450754................................................    0.9408   14.89
450755................................................    1.1073   14.71
450757................................................    0.8766   13.96
450758................................................    1.9447   18.65
450760................................................    1.2078   18.07
450761................................................    0.9462   11.14
450763................................................    1.0029   17.56
450766................................................    2.0818   21.81
450769................................................    0.8516   13.62
450770................................................    0.9940   16.83
450771................................................    1.9082   21.58
450774................................................    1.6697   16.52
450775................................................    1.3660   19.97
450776................................................    1.0045   10.20
450777................................................    0.9770   19.59
450779................................................    1.2931   22.97
450780................................................    1.7380   15.28
450785................................................    0.9897   18.55
450788................................................    1.5021   20.98
450794................................................  ........   18.40
450795................................................    0.9879   14.17
450796................................................    3.3883   17.45
450797................................................    0.7701   18.59
450798................................................    0.7662    9.22
450801................................................    1.4581   16.61
450802................................................    1.4444   18.90
450803................................................    1.0992   16.20
450804................................................    1.7531   20.22
450807................................................    0.8919   13.23
450808................................................    1.9250   45.47
450809................................................    1.5460   19.03
450810................................................    0.9739  ......
450811................................................    2.3971   18.38
450812................................................  ........   20.74
450813................................................    0.9718  ......

[[Page 41583]]

 
450815................................................    2.5623  ......
450817................................................    0.6826  ......
450818................................................    1.2025  ......
450819................................................    1.5000  ......
450820................................................    1.0411  ......
450822................................................    1.2110  ......
460001................................................    1.7793   20.63
460003................................................    1.6046   20.60
460004................................................    1.7755   20.82
460005................................................    1.6581   17.58
460006................................................    1.3373   19.65
460007................................................    1.3076   20.57
460008................................................    1.3677   21.03
460009................................................    1.8478   21.11
460010................................................    2.0972   21.25
460011................................................    1.3205   16.71
460013................................................    1.4303   20.33
460014................................................    1.2254   19.55
460015................................................    1.2396   20.10
460016................................................    0.9953   18.08
460017................................................    1.3888   26.03
460018................................................    0.9230   16.86
460019................................................    1.0510   17.37
460020................................................    0.9556   17.03
460021................................................    1.3848   20.26
460022................................................    0.9569   18.21
460023................................................    1.1785   21.33
460024................................................  ........   13.03
460025................................................    0.8243   12.51
460026................................................    1.0605   17.34
460027................................................    0.9545   20.83
460029................................................    1.0958   17.25
460030................................................    1.1918   17.22
460032................................................    0.9792   19.55
460033................................................    0.9753   15.72
460035................................................    0.9477   14.28
460036................................................    1.0005   22.38
460037................................................    0.9080   18.77
460039................................................    1.0603   24.48
460041................................................    1.3072   21.69
460042................................................    1.3714   17.85
460043................................................    0.9896   23.90
460044................................................    1.1363   20.69
460046................................................  ........   17.11
460047................................................    1.6723   21.38
460049................................................    1.9825   18.82
460050................................................  ........   26.25
460051................................................    1.1552   20.98
460052................................................    1.4619  ......
470001................................................    1.3011   19.61
470003................................................    1.8338   22.59
470004................................................    1.0674   18.10
470005................................................    1.2285   21.51
470006................................................    1.2408   18.39
470008................................................    1.2590   19.41
470010................................................    1.0678   19.47
470011................................................    1.1504   21.20
470012................................................    1.2780   18.52
470015................................................    1.1985   19.26
470018................................................    1.2252   20.42
470020................................................    0.9900   18.99
470023................................................    1.3197   20.64
470024................................................    1.1528   20.41
490001................................................    1.1931   24.76
490002................................................    1.0751   12.99
490003................................................    0.6419   18.00
490004................................................    1.2740   18.77
490005................................................    1.5963   16.91
490006................................................    1.2147   15.23
490007................................................    2.0919   18.43
490009................................................    1.9489   22.95
490010................................................    1.0335   18.58
490011................................................    1.4655   18.75
490012................................................    1.1933   13.78
490013................................................    1.2476   16.93
490014................................................    1.5333   24.56
490015................................................    1.5161   19.36
490017................................................    1.3895   17.32
490018................................................    1.3002   17.94
490019................................................    1.1951   17.53
490020................................................    1.2248   17.67
490021................................................    1.3810   19.45
490022................................................    1.5532   20.72
490023................................................    1.2186   18.96
490024................................................    1.6762   16.89
490027................................................    1.1131   14.42
490030................................................    1.1907   10.50
490031................................................    1.0734   15.82
490032................................................    1.7204   21.56
490033................................................    1.1999   18.33
490037................................................    1.1999   15.97
490038................................................    1.2143   15.71
490040................................................    1.4733   22.52
490041................................................    1.2747   16.55
490042................................................    1.2324   15.27
490043................................................    1.3532   20.68
490044................................................    1.3213   17.63
490045................................................    1.2161   19.63
490046................................................    1.5370   18.61
490047................................................    1.1078   17.16
490048................................................    1.5688   17.89
490050................................................    1.4272   22.71
490052................................................    1.6372   16.94
490053................................................    1.3233   15.69
490054................................................    1.0319   15.55
490057................................................    1.5739   19.07
490059................................................    1.5941   20.37
490060................................................    1.0645   19.20
490063................................................    1.7721   28.25
490066................................................    1.3274   16.50
490067................................................    1.2535   17.19
490069................................................    1.4182   15.70
490071................................................    1.4083   19.47
490073................................................    1.5076   26.14
490074................................................  ........   19.34
490075................................................    1.3785   19.19
490077................................................    1.2263   19.79
490079................................................    1.3128   16.44
490083................................................  ........   16.64
490084................................................    1.1308   16.38
490085................................................    1.1582   16.40
490088................................................    1.1286   15.60
490089................................................    1.0694   15.86
490090................................................    1.1220   16.28
490091................................................    1.2330   19.99
490092................................................    1.2219   15.69
490093................................................    1.4339   16.48
490094................................................    1.0922   16.79
490095................................................  ........   18.25
490097................................................    1.2096   15.86
490098................................................    1.2068   14.70
490099................................................    0.9555   16.87
490100................................................  ........   17.22
490101................................................    1.2286   25.09
490104................................................    0.7018   28.49
490105................................................    0.5822   18.25
490106................................................    0.8713   16.91
490107................................................    1.3326   22.41
490108................................................    0.8935   19.75
490109................................................    0.8779   21.16
490110................................................    1.2994   15.84
490111................................................    1.2000   17.35
490112................................................    1.6550   20.52
490113................................................    1.3249   23.08
490114................................................    1.1582   16.91
490115................................................    1.1600   17.10
490116................................................    1.1704   16.44
490117................................................    1.1543   13.84
490118................................................    1.7091   20.87
490119................................................    1.3367   17.87
490120................................................    1.3095   19.98
490122................................................    1.3605   23.97
490123................................................    1.1355   16.85
490124................................................    1.0893   19.36
490126................................................    1.3233   18.23
490127................................................    1.0410   14.48
490129................................................    1.0746   27.47
490130................................................    1.3119   16.28
490132................................................    1.0183   17.02
500001................................................    1.4869   21.35
500002................................................    1.4055   21.04
500003................................................    1.4016   24.31
500005................................................    1.7533   23.48
500007................................................    1.3352   22.43
500008................................................    1.9490   24.19
500011................................................    1.3373   25.18
500012................................................    1.5530   22.28
500014................................................    1.5641   23.93
500015................................................    1.3293   23.24
500016................................................    1.4955   23.90
500019................................................    1.3833   22.37
500021................................................    1.4802   24.46
500023................................................    1.2073   27.19
500024................................................    1.6886   24.05
500025................................................    1.9090   23.96
500026................................................    1.4529   23.35
500027................................................    1.6832   25.05
500028................................................    1.0717   18.86
500029................................................    0.9086   16.81
500030................................................    1.4513   24.13
500031................................................    1.2483   23.37
500033................................................    1.3309   21.39
500036................................................    1.3911   21.90
500037................................................    1.1389   19.68
500039................................................    1.3828   23.32
500041................................................    1.3244   24.85
500042................................................    1.4121   22.13
500043................................................    1.0107   20.25
500044................................................    1.9371   23.11
500045................................................    1.0116   22.10
500048................................................    0.9601   19.30
500049................................................    1.4695   22.95

[[Page 41584]]

 
500050................................................    1.3489   20.94
500051................................................    1.6736   24.48
500052................................................    1.1621  ......
500053................................................    1.3284   22.05
500054................................................    1.8781   22.90
500055................................................    1.1284   22.88
500057................................................    1.3026   18.04
500058................................................    1.4834   23.40
500059................................................    1.0767   22.54
500060................................................    1.3712   23.54
500061................................................    1.0000   20.40
500062................................................    1.0655   19.46
500064................................................    1.6382   24.53
500065................................................    1.2532   21.42
500068................................................    1.0543   18.70
500069................................................    1.1155   20.63
500071................................................    1.2837   19.38
500072................................................    1.2021   24.46
500073................................................    0.9531   21.43
500074................................................    1.1055   18.65
500077................................................    1.3298   23.21
500079................................................    1.3220   22.98
500080................................................    0.8180   13.80
500084................................................    1.2784   22.22
500085................................................    0.9302   28.61
500086................................................    1.2601   22.31
500088................................................    1.2967   23.70
500089................................................    1.0515   17.94
500090................................................    0.8380   16.33
500092................................................    1.0165   17.29
500094................................................    0.8803   18.11
500096................................................    0.9394   20.96
500097................................................    1.0798   20.80
500098................................................    1.0464   12.99
500101................................................    1.0108   19.45
500102................................................    0.9022   20.33
500104................................................    1.2616   22.58
500106................................................    0.9351   18.71
500107................................................    1.2053   17.30
500108................................................    1.7383   27.21
500110................................................    1.2107   21.41
500118................................................    1.1490   22.92
500119................................................    1.3555   21.57
500122................................................    1.2755   21.91
500123................................................    0.9495   19.58
500124................................................    1.3681   24.15
500125................................................    1.0521   16.63
500129................................................    1.6409   23.60
500132................................................    0.9686   19.36
500134................................................    0.6491   20.96
500138................................................    3.6799  ......
500139................................................    1.4682   20.88
500141................................................    1.3726   22.94
500143................................................    0.5954   17.60
500146................................................  ........   17.85
510001................................................    1.9499   17.83
510002................................................    1.2866   17.34
510005................................................    1.0198   14.43
510006................................................    1.2719   17.88
510007................................................    1.5729   20.25
510008................................................    1.2172   17.37
510012................................................    1.0087   16.50
510013................................................    1.1012   16.62
510015................................................    0.9677   14.79
510016................................................  ........   12.03
510018................................................    1.0741   16.48
510020................................................    1.0848   12.65
510022................................................    1.8970   19.84
510023................................................    1.2380   15.94
510024................................................    1.5836   18.80
510026................................................    1.0574   13.46
510027................................................    0.9600   17.58
510028................................................    1.0520   20.73
510029................................................    1.2855   17.05
510030................................................    1.0520   18.31
510031................................................    1.4131   18.49
510033................................................    1.2904   18.81
510035................................................    1.2311   18.65
510036................................................    0.9839   13.20
510038................................................    1.0640   14.34
510039................................................    1.3990   16.06
510043................................................    0.9349   14.29
510046................................................    1.2735   17.73
510047................................................    1.2611   19.12
510048................................................    1.1332   20.37
510050................................................    1.7457   16.57
510053................................................    1.0811   15.59
510055................................................    1.2306   22.84
510058................................................    1.2795   17.98
510059................................................    2.0210   16.77
510060................................................    1.0503   15.66
510061................................................    1.0243   14.22
510062................................................    1.2784   17.63
510065................................................  ........   14.59
510066................................................  ........   12.72
510067................................................    1.2058   18.11
510068................................................    1.2058   16.29
510070................................................    1.2966   16.36
510071................................................    1.3297   16.24
510072................................................    1.0573   17.66
510077................................................    1.1370   16.41
510080................................................    1.1479   14.80
510081................................................    1.0787   13.00
510082................................................    1.1597   13.69
510084................................................    1.0361   12.48
510085................................................    1.2771   18.64
510086................................................    1.1035   13.79
510088................................................    1.0389  ......
520002................................................    1.2721   18.35
520003................................................    1.0869   16.43
520004................................................    1.1778   18.17
520006................................................    1.0164   20.44
520007................................................    1.0508   13.11
520008................................................    1.6392   22.80
520009................................................    1.6949   18.51
520010................................................    1.1559   20.34
520011................................................    1.1930   20.38
520013................................................    1.3680   21.63
520014................................................    1.1066   16.40
520015................................................    1.1978   18.32
520016................................................    0.9703   13.29
520017................................................    1.1930   19.32
520018................................................    1.1211   18.64
520019................................................    1.3095   18.31
520021................................................    1.4596   20.03
520024................................................    1.0420   14.61
520025................................................    1.0654   18.11
520026................................................    1.0296   19.81
520027................................................    1.2626   18.91
520028................................................    1.3294   19.14
520029................................................    0.8917   16.75
520030................................................    1.7395   20.00
520031................................................    1.0756   18.71
520032................................................    1.2622   17.90
520033................................................    1.2388   18.89
520034................................................    1.1058   16.69
520035................................................    1.3246   17.10
520037................................................    1.7026   20.05
520038................................................    1.3352   17.71
520039................................................    0.9990   19.60
520040................................................    1.5261   20.74
520041................................................    1.1567   15.37
520042................................................    1.1256   17.66
520044................................................    1.4143   17.79
520045................................................    1.6556   19.67
520047................................................    0.9397   17.87
520048................................................    1.4958   19.17
520049................................................    2.0506   19.57
520051................................................    1.8466   19.74
520053................................................    1.1884   16.49
520054................................................    1.0542   15.99
520057................................................    1.1944   18.32
520058................................................    1.1077   18.13
520059................................................    1.4368   19.85
520060................................................    1.4770   17.17
520062................................................    1.2487   17.80
520063................................................    1.1864   20.77
520064................................................    1.5707   21.46
520066................................................    1.4671   22.44
520068................................................    0.9618   18.08
520069................................................    1.2293   17.91
520070................................................    1.5249   17.82
520071................................................    1.2525   18.79
520074................................................    1.0559   18.69
520075................................................    1.4866   19.09
520076................................................    1.1796   16.51
520077................................................    0.9312   15.54
520078................................................    1.6373   20.56
520082................................................    1.1943   16.74
520083................................................    1.7219   22.57
520084................................................    1.0804   18.95
520087................................................    1.6992   19.39
520088................................................    1.2752   20.15
520089................................................    1.4733   20.61
520090................................................    1.2604   18.00
520091................................................    1.2778   20.07
520092................................................    1.0845   17.56
520094................................................    0.7818   19.78
520095................................................    1.2908   18.51
520096................................................    1.3848   19.30
520097................................................    1.3197   19.65
520098................................................    1.7723   20.03
520100................................................    1.2561   18.38
520101................................................    1.0650   17.85
520102................................................    1.1753   19.83
520103................................................    1.3285   21.23
520107................................................    1.2649   20.54
520109................................................    1.0080   18.63
520110................................................    1.2429   20.03
520111................................................    1.0771   17.24
520112................................................    1.1382   18.18
520113................................................    1.2755   20.59

[[Page 41585]]

 
520114................................................    1.0706   17.38
520115................................................    1.2453   17.38
520116................................................    1.2751   18.57
520117................................................    1.0083   17.42
520118................................................    0.9267   12.44
520120................................................    0.9639   15.62
520121................................................    0.9801   17.58
520122................................................    0.9988   16.76
520123................................................    0.9687   17.41
520124................................................    1.0567   16.39
520130................................................    1.0645   15.16
520131................................................    1.0215   18.80
520132................................................    1.2140   17.28
520134................................................    1.1056   17.61
520135................................................    0.9686   14.47
520136 *..............................................    1.5183   19.99
520138................................................    1.8827   20.89
520139................................................    1.2600   21.28
520140................................................    1.6650   21.42
520141................................................  ........   16.95
520142................................................    0.8577   17.70
520144................................................    1.0177   16.62
520145................................................    0.9103   17.24
520146................................................    1.0606   15.73
520148................................................    1.1737   16.93
520149................................................    0.8651   13.30
520151................................................    1.0561   18.08
520152................................................    1.1273   21.33
520153................................................    0.9014   15.45
520154................................................    1.1283   17.92
520156................................................    1.1278   19.84
520157................................................    1.1408   17.28
520159................................................    0.9357   18.74
520160................................................    1.7939   18.84
520161................................................    0.9978   18.57
520170................................................    1.1960   22.50
520171................................................    0.9558   15.73
520173................................................    1.1310   20.14
520177................................................    1.7178   21.76
520178................................................    1.0401   17.04
520187................................................    0.6853  ......
520188................................................    1.9479  ......
530002................................................    1.1799   17.59
530003................................................    0.8696   15.78
530004................................................    0.9388   16.19
530005................................................    1.1268   15.15
530006................................................    1.1073   19.34
530007................................................    1.0673   18.06
530008................................................    1.2158   22.96
530009................................................    0.9826   19.45
530010................................................    1.2456   18.93
530011................................................    1.1585   17.44
530012................................................    1.6198   19.48
530014................................................    1.4187   17.32
530015................................................    1.2855   22.65
530016................................................    1.2279   17.71
530017................................................    0.9404   13.71
530018................................................    0.9876   17.87
530019................................................    0.9171   16.76
530022................................................    1.1504   17.88
530023................................................    0.8235   20.75
530025................................................    1.3737   20.32
530026................................................    1.1260   18.92
530027................................................    0.8284   29.77
530029................................................    0.9986   17.80
530031................................................    0.8242   13.38
530032................................................    1.1799   20.21
------------------------------------------------------------------------
*Asterisk denotes teaching physician costs removed based on costs
  reporteorksheet A, Col. 1, Line 23 of FY 1996 cost report.


Table 4a.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                               Urban Areas
------------------------------------------------------------------------
                                                        Wage
         Urban area  (constituent counties)             index      GAF
------------------------------------------------------------------------
0040  Abilene, TX...................................    0.8179    0.8714
    Taylor, TX
0060  Aguadilla, PR \2\.............................    0.4249    0.5565
    Aguada, PR
    Aguadilla, PR
    Moca, PR
0080  Akron, OH.....................................    1.0163    1.0111
    Portage, OH
    Summit, OH
0120  Albany, GA....................................    1.0372    1.0253
    Dougherty, GA
    Lee, GA
0160  Albany-Schenectady-Troy, NY...................    0.8754    0.9129
    Albany, NY
    Montgomery, NY
    Rensselaer, NY
    Saratoga, NY
    Schenectady, NY
    Schoharie, NY
0200  Albuquerque, NM...............................    0.8499    0.8946
    Bernalillo, NM
    Sandoval, NM
    Valencia, NM
0220  Alexandria, LA................................    0.7910    0.8517
    Rapides, LA
0240  Allentown-Bethlehem-Easton, PA................    0.9550    o.9690
    Carbon, PA
    LeHigh, PA
    Northampton, PA
0280  Altoona, PA...................................    0.9342    0.9545
    Blair, PA
0320  Amarillo, TX..................................    0.8435    0.8900
    Potter, TX
    Randall, TX
0380  Anchorage, AK.................................    1.3009    1.1974
    Anchorage, AK
0440  Ann Arbor, MI.................................    1.1483    1.0993
    Lenawee, MI
    Livingston, MI
    Washtenaw, MI
0450  Anniston, AL..................................    0.8462    0.8919
    Calhoun, AL
0460  Appleton-Oshkosh-Neenah, WI...................    0.8913    0.9242
    Calumet, WI
    Outagamie, WI
    Winnebago,WI
0470  Arecibo, PR...................................    0.4815    0.6062
    Arecibo, PR
    Camuy, PR
    Hatillo, PR
0480  Asheville, NC.................................    0.8884    0.9222
    Buncombe, NC
    Madison, NC
0500  Athens, GA....................................    0.9800    0.9863
    Clarke, GA
    Madison, GA
    Oconee, GA
0520  Atlanta, GA...................................    1.0050    1.0034
    Barrow, GA
    Bartow, GA
    Carroll, GA
    Cherokee, GA
    Clayton, GA
    Cobb, GA
    Coweta, GA
    DeKalb, GA
    Douglas, GA
    Fayette, GA
    Forsyth, GA
    Fulton, GA
    Gwinnett, GA
    Henry, GA
    Newton, GA
    Paulding, GA
    Pickens, GA
    Rockdale, GA
    Spalding, GA
    Walton GA
0560  Atlantic-Cape May, NJ.........................    1.1050    1.0708
    Atlantic, NJ
    Cape May, NJ
0580  Auburn-Opelika, AL............................    0.7748    0.8397
    Lee, AL
0600  Augusta-Aiken, GA-SC..........................    0.9013    0.9313
    Columbia, GA
    McDuffie, GA
    Richmond, GA
    Aiken, SC
    Edgefield, SC
0640  Austin-San Marcos, TX \1\.....................    0.9081    0.9361
    Bastrop, TX
    Caldwell, TX
    Hays, TX
    Travis, TX
    Williamson, TX
0680  Bakersfield, CA \2\...........................    0.9951    0.9966
    Kern, CA
0720  Baltimore, MD \1\.............................    0.9891    0.9925
    Anne Arundel, MD
    Baltimore, MD
    Baltimore, City, MD
    Carroll, MD
    Harford, MD
    Howard, MD
    Queen Anne's, MD
0733  Bangor, ME....................................    0.9609    0.9731

[[Page 41586]]

 
    Penobscot, ME
0743  Barnstable-Yarmouth, MA.......................    1.3302    1.2158
    Barnstable, MA
0760  Baton Rouge, LA...............................    0.8707    0.9095
    Ascension, LA
    East Baton Rouge, LA
    Livingston, LA
    West Baton Rouge, LA
0840  Beaumont-Port Arthur, TX......................    0.8624    0.9036
    Hardin, TX
    Jefferson, TX
    Orange, TX
0860  Bellingham, WA................................    1.1394    1.0935
    Whatcom, WA
0870  Benton Harbor, MI \2\.........................    0.8831    0.9184
    Berrien, MI
0875  Bergen-Passaic, NJ \1\........................    1.1833    1.1222
    Bergen, NJ
    Passaic, NJ
0880  Billings, MT..................................    1.0038    1.0026
    Yellowstone, MT
0920  Biloxi-Gulfport-Pascagoula, MS................    0.7949    0.8545
    Hancock, MS
    Harrison, MS
    Jackson, MS
0960  Binghamton, NY................................    0.8750    0.9126
    Broome, NY
    Tioga, NY
1000  Birmingham, AL................................    0.8994    0.9300
    Blount, AL
    Jefferson, AL
    St. Clair, AL
    Shelby, AL
1010  Bismarck, ND..................................    0.7893    0.8504
    Burleigh, ND
    Morton, ND
1020  Bloomington, IN...............................    0.8593    0.9014
    Monroe, IN
1040  Bloomington-Normal, IL........................    0.8993    0.9299
    McLean, IL
1080  Boise City, ID................................    0.9086    0.9365
    Ada, ID
    Canyon, ID
1123  Boston-Worcester-Lawrence-Lowell-Brockton, MA-    1.1369    1.0918
 NH (MA Hospitals) \1\ \2\..........................
    Bristol, MA
    Essex, MA
    Middlesex, MA
    Norfolk, MA
    Plymouth, MA
    Suffolk, MA
    Worcester, MA
    Hillsborough, NH
    Merrimack, NH
    Rockingham, NH
    Strafford, NH
1123  Boston-Worcester-Lawrence-Lowell-Brockton, MA-    1.1358    1.0911
 NH (NH Hospitals) \1\..............................
    Bristol, MA
    Essex, MA
    Middlesex, MA
    Norfolk, MA
    Plymouth, MA
    Suffolk, MA
    Worcester, MA
    Hillsborough, NH
    Merrimack, NH
    Rockingham, NH
    Strafford, NH
1125  Boulder-Longmont, CO..........................    0.9944    0.9962
    Boulder, CO
1145  Brazoria, TX..................................    0.8516    0.8958
    Brazoria, TX
1150  Bremerton, WA.................................    1.1011    1.0682
    Kitsap, WA
1240  Brownsville-Harlingen-San Benito, TX..........    0.9212    0.9453
    Cameron, TX
1260  Bryan-College Station, TX.....................    0.8501    0.8947
    Brazos, TX
1280   \1\ Buffalo-Niagara Falls, NY................    0.9604    0.9727
    Erie, NY
    Niagara, NY
1303  Burlington, VT................................    1.0558    1.0379
    Chittenden, VT
    Franklin, VT
    Grand Isle, VT
1310  Caguas, PR....................................    0.4561    0.5842
    Caguas, PR
    Cayey, PR
    Cidra, PR
    Gurabo, PR
    San Lorenzo, PR
1320  Canton-Massillon, OH \2\......................    0.8649    0.9054
    Carrll, OH
    Stark, OH
1350  Casper, WY....................................    0.9199    0.9444
    Natrona, WY
1360  Cedar Rapids, IA..............................    0.9018    0.9317
    Linn, IA
1400  Champaign-Urbana, IL..........................    0.9163    0.9419
    Champaign, IL
1440  Charleston-North Charleston, SC...............    0.8988    0.9295
    Berkeley, SC
    Charleston, SC
    Dorchester, SC
1480  Charleston, WV................................    0.9095    0.9371
    Kanawha, WV
    Putnam, WV
1520  Charlotte-Gastonia-Rock Hill, NC-SC \1\.......    0.9433    0.9608
    Cabarrus, NC
    Gaston, NC
    Lincoln, NC
    Mecklenburg, NC
    Rowan, NC
    Stanly, NC
    Union, NC
    York, SC
1540  Charlottesville, VA...........................    1.0573    1.0389
    Albermarle, VA
    Charlottesville City, VA
    Fluvanna, VA
    Greene, VA
1560  Chattanooga, TN-GA............................    0.9731    0.9815
    Catoosa, GA
    Dade, GA
    Walker, GA
    Hamilton, TN
    Marion, TN
1580  Cheyenne, WY 2................................    0.8859    0.9204
    Laramie, WY
1600  Chicago, IL 1.................................    1.0872    1.0589
    Cook, IL
    DeKalb, IL
    DuPage, IL
    Grundy, IL
    Kane, IL
    Kendall, IL
    Lake, IL
    McHenry, IL
    Will, IL
1620  Chico-Paradise, CA............................    1.0390    1.0265
    Butte, CA
1640  Cincinnati, OH-KY-IN 1........................    0.9434    0.9609
    Dearborn, IN
    Ohio, IN
    Boone, KY
    Campbell, KY
    Gallatin, KY
    Grant, KY
    Kenton, KY
    Pendleton, KY
    Brown, OH
    Clermont, OH
    Hamilton, OH
    Warren, OH
1660  Clarksville-Hopkinsville, TN-KY...............    0.8283    0.8790
    Christian, KY
    Montgomery, TN
1680  Cleveland-Lorain-Elyria, OH 1.................    0.9688    0.9785

[[Page 41587]]

 
    Ashtabula, OH
    Cuyahoga, OH
    Geauga, OH
    Lake, OH
    Lorain, OH
    Medina, OH
1720  Colorado Springs, CO..........................    0.9218    0.9458
    El Paso, CO
1740  Columbia, MO..................................    0.8904    0.9236
    Boone, MO
1760  Columbia, SC..................................    0.9357    0.9555
    Lexington, SC
    Richland, SC
1800  Columbus, GA-AL...............................    0.8510    0.8954
    Russell, AL
    Chattahoochee, GA
    Harris, GA
    Muscogee, GA
1840  Columbus, OH..................................    0.9907    0.9936
    Delaware, OH
    Fairfield, OH
    Franklin, OH
    Licking, OH
    Madison, OH
    Pickaway, OH
1880  Corpus Christi, TX............................    0.8702    0.9092
    Nueces, TX
    San Patricio, TX
1890  Crovallis, OR.................................    1.1087    1.0732
    Benton, OR
1900  Cumberland, MD-WV (Maryland Hospitals)........    0.8801    0.9163
    Allegany, MD
    Mineral, WV
1920  Dallas, TX 1..................................    0.9589    0.9717
    Collin, TX
    Dallas, TX
    Denton, TX
    Ellis, TX
    Henderson, TX
    Hunt, TX
    Kaufman, TX
    Rockwall, TX
1950  Danville, VA..................................    0.9061    0.9347
    Danville City, VA
    Pittsylvania, VA
1960  Davenport-Moline-Rock Island, IA-IL...........    0.8706    0.9095
    Scott, IA
    Henry, IL
    Rock Island, IL
2000  Dayton-Springfield, OH........................    0.9336    0.9540
    Clark, OH
    Greene, OH
    Miami, OH
    Montgomery, OH
2020  Daytona Beach, FL 2...........................    0.8986    0.9294
    Flagler, FL
    Volusia, FL
2030  Decatur, AL...................................    0.8679    0.9075
    Lawrence, AL
    Morgan, AL
2040  Decatur, IL...................................    0.8321    0.8817
    Macon, IL
2080  Danver, CO 1..................................    1.0197    1.0134
    Adams, CO
    Arapahoe, CO
    Denver, CO
    Douglas, CO
    Jefferson, CO
2120  Des Moines, IA................................    0.8754    0.9129
    Dallas, IA
    Polk, IA
    Warren, IA
2160  Detroit, MI 1.................................    1.0421    1.0286
    Lapeer, MI
    Macomb, MI
    Monroe, MI
    Oakland, MI
    St. Clair, MI
    Wayne, MI
2180  Dothan, AL....................................    0.7836    0.8462
    Dale, AL
    Houston, AL
2190  Dover, DE.....................................    0.9335    0.9540
    Kent, DE
2200  Dubuque, IA...................................    0.8520    0.8961
    Dubuque, IA
2240  Duluth-Superior, MN-WI........................    1.0165    1.0113
    St. Louis, MN
    Douglas, WI
2281  Dutchess County, NY...........................    0.9872    0.9912
    Dutchess, NY
2290  Eau Claire, WI................................    0.8957    0.9273
    Chippewa, WI
    Eau Claire, WI
2320  El Paso, TX...................................    0.8947    0.9266
    El Paso, TX
2330  Elkhart-Goshen, IN............................    0.9379    0.9570
    Elkhart, IN
2335  Elmira, NY \2\................................    0.8636    0.9045
    Chemung, NY
2340  Enid, OK......................................    0.7953    0.8548
    Garfield, OK
2360  Erie, PA......................................    0.9023    0.9320
    Erie, PA
2400  Eugene-Springfield, OR........................    1.0765    1.0518
    Lane, OR
2440  Evansville-Henderson, IN-KY (IN Hospitals) \2\    0.8396    0.8872
    Posey, IN
    Vanderburgh, IN
    Warrick, IN
    Henderson, KY
2440  Evansville-Henderson, IN-KY (KY Hospitals)....    0.8303    0.8804
    Posey, IN
    Vanderburgh, IN
    Warrick, IN
    Henderson, KY
2520  Fargo-Moorhead, ND-MN.........................    0.8620    0.9033
    Clay, MN
    Cass, ND
2560  Fayetteville, NC..............................    0.8494    0.8942
    Cumberland, NC
2580  Fayetteville-Springdale-Rogers, AR............    0.7773    0.8415
    Benton, AR
    Washington, AR
2620  Flagstaff, AZ-UT..............................    1.0348    1.0237
    Coconino, AZ
    Kane, UT
2640  Flint, MI.....................................    1.1020    1.0688
    Genesee, MI
2650  Florence, AL..................................    0.7927    0.8529
    Colbert, AL
    Lauderdale, AL
2655  Florence, SC..................................    0.8618    0.9032
    Florence, SC
2670  Fort Collins-Loveland, CO.....................    1.0302    1.0206
    Larimer, CO
2680  Ft. Lauderdale, FL \1\........................    1.0172    1.0117
    Broward, FL
2700  Fort Myers-Cape Coral, FL \2\.................    0.8986    0.9294
    Lee, FL
2710  Fort Pierce-Port St. Lucie, FL................    1.0109    1.0075
    Martin, FL
    St. Lucie, FL
2720  Fort Smith, AR-OK.............................    0.7844    0.8468
    Crawford, AR
    Sebastian, AR
    Sequoyah, OK
2750  Fort Walton Beach, FL \2\.....................    0.8986    0.9294
    Okaloosa, FL
2760  Fort Wayne, IN................................    0.9096    0.9372
    Adams, IN
    Allen, IN
    De Kalb, IN
    Huntington, IN
    Wells, IN
    Whitley, IN
2800  Forth Worth-Arlington, TX \1\.................    0.9835    0.9887
    Hood, TX
    Johnson, TX
    Parker, TX
    Tarrant, TX
2840  Fresno, CA....................................    1.0262    1.0179
    Fresno, CA
    Madera, CA
2880  Gadsden, AL...................................    0.8754    0.9129
    Etowah, AL
2900  Gainesville, FL...............................    1.0102    1.0070
    Alachua, FL
2920  Galveston-Texas City, TX......................    0.9732    0.9816
    Galveston, TX
2960  Gary, IN......................................    0.9369    0.9563
    Lake, IN
    Porter, IN
2975  Glens Falls, NY \2\...........................    0.8636    0.9045

[[Page 41588]]

 
    Warren, NY
    Washington, NY
2980  Goldsboro, NC.................................    0.8333    0.8826
    Wayne, NC
2985  Grand Forks, ND-MN............................    0.9097    0.9372
    Polk, MN
    Grand Forks, ND
2995  Grand Junction, CO............................    0.9188    0.9437
    Mesa, CO
3000  Grand Rapids-Muskegon-Holland, MI \1\.........    1.0135    1.0092
    Allegan, MI
    Kent, MI
    Muskegon, MI
    Ottawa, MI
3040  Great Falls, MT...............................    1.0459    1.0312
    Cascade, MT
3060  Greeley, CO...................................    0.9722    0.9809
    Weld, CO
3080  Green Bay, WI.................................    0.9215    0.9456
    Brown, WI
3120  Greensboro-Winston-Salem-High Point, NC 1.....    0.9037    0.9330
    Alamance, NC
    Davidson, NC
    Davie, NC
    Forsyth, NC
    Guilford, NC
    Randolph, NC
    Stokes, NC
    Yadkin, NC
3150  Greenville, NC................................    0.9500    0.9655
    Pitt, NC
3160  Greenville-Spartanburg-Anderson, SC...........    0.9188    0.9437
    Anderson, SC
    Cherokee, SC
    Greenville, SC
    Pickens, SC
    Spartanburg, SC
3180  Hagerstown, MD................................    0.8853    0.9200
    Washington, MD
3200  Hamilton-Middletown, OH.......................    0.8989    0.9296
    Butler, OH
3240  Harrisburg-Lebanon-Carlisle, PA...............    0.9917    0.9943
    Cumberland, PA
    Dauphin, PA
    Lebanon, PA
    Perry, PA
3283  Hartford, CT \1\ \2\..........................    1.2413    1.1595
    Hartford, CT
    Litchfield, CT
    Middlesex, CT
    Tolland, CT
3285  Hattiesburg, MS \2\...........................    0.7306     0.806
    Forrest, MS
    Lamar, MS
3290  Hickory-Morganton-Lenoir, NC..................    0.9148     0.940
    Alexander, NC
    Burke, NC
    Caldwell, NC
    Catawba, NC
3320  Honolulu, HI..................................    1.1479     1.099
    Honolulu, HI
3350  Houma, LA.....................................    0.7837    0.8463
    Lafourche, LA
    Terrebonne, LA
3360  Houston, TX \1\...............................    0.9387    0.9576
    Chambers, TX
    Fort Bend, TX
    Harris, TX
    Liberty, TX
    Montgomery, TX
    Waller, TX
3400  Huntington-Ashland, WV-KY-OH..................    0.9757    0.9833
    Boyd, KY
    Carter, KY
    Greenup, KY
    Lawrence, OH
    Cabell, WV
    Wayne, WV
3440  Huntsville, AL................................    0.8822    0.9178
    Limestone, AL
    Madison, AL
3480  Indianapolis, IN \1\..........................    0.9792    0.9857
    Boone, IN
    Hamilton, IN
    Hancock, IN
    Hendricks, IN
    Johnson, IN
    Madison, IN
    Marion, IN
    Morgan, IN
    Shelby, IN
3500  Iowa City, IA.................................    0.9607    0.9729
    Johnson, IA
3520  Jackson, MI...................................    0.8840    0.9190
    Jackson, MI
3560  Jackson, MS...................................    0.8387    0.8865
    Hinds, MS
    Madison, MS
    Rankin, MS
3580  Jackson, TN...................................    0.8600    0.9019
    Madison, TN
    Chester, TN
3600  Jacksonville, FL \1\ \2\......................    0.8986    0.9294
    Clay, FL
    Duval, FL
    Nassau, FL
    St. Johns, FL
3605  Jacksonville, NC \2\..........................    0.8290    0.8795
    Onslow, NC
3610  Jamestown, NY \2\.............................    0.8636    0.9045
    Chautauqua, NY
3620  Janesville-Beloit, WI.........................    0.9656    0.9763
    Rock, WI
3640  Jersey City, NJ...............................    1.1674    1.1118
    Hudson, NJ
3660  Johson City-Kingsport-Bristol, TN-VA..........    0.8894    0.9229
    Carter, TN
    Hawkins, TN
    Sullivan, TN
    Unicoi, TN
    Washington, TN
    Bristol City, VA
    Scott, VA
    Washington, VA
3680  Johnstown, PA \2\.............................    0.8524    0.8964
    Cambria, PA
    Somerset, PA
3700  Jonesboro, AR.................................    0.7251    0.8024
    Craighead, AR
3710  Joplin, MO \2\................................    0.7723    0.8378
    Jasper, MO
    Newton, MO
3720  Kalamazoo-Battlecreek, MI.....................    0.9981    0.9987
    Calhoun, MI
    Kalamazoo, MI
    Van Buren, MI
3740  Kankakee, IL..................................    0.8598    0.9017
    Kankakee, IL
3760  Kansas City, KS-MO \1\........................    0.9322    0.9531
    Johnson, KS
    Leavenworth, KS
    Miami, KS
    Wyandotte, KS
    Cass, MO
    Clay, MO
    Clinton, MO
    Jackson, MO
    Lafayette, MO
    Platte, MO
    Ray, MO
3800  Kenosha, WI...................................    0.9033    0.9327
    Kenosha, WI
3810  Killeen-Temple, TX............................    0.9932    0.9953
    Bell, TX
    Coryell, TX
3840  Knoxville, TN.................................    0.9199    0.9444
    Anderson, TN
    Blount, TN
    Knox, TN
    Loudon, TN
    Sevier, TN
    Union, TN
3850  Kokomo, IN....................................    0.8984    0.9293
    Howard, IN
    Tipton, IN
3870  LaCrosse, WI-MN...............................    0.8933    0.9256
    Houston, MN
    La Crosse, WI
3880  Lafayette, LA.................................    0.8397    0.8872
    Acadia, LA
    Lafayette, LA
    St. Landry, LA
    St. Martin, LA
3920  Lafayette, IN.................................    0.8809    0.9168
    Clinton, IN
    Tippecanoa, IN
3960  Lake Charles, LA..............................    0.7966    0.8558

[[Page 41589]]

 
    Calcasieu, LA
3980  Lakeland-Winter Haven, FL \2\.................    0.8986    0.9294
    Polk, FL
4000  Lancaster, PA.................................    0.9255    0.9484
    Lancaster, PA
4040  Lansing-East Lansing, MI......................    0.9977    0.9984
    Clinton, MI
    Eaton, MI
    Ingham, MI
4080  Laredo, TX....................................    0.8323    0.8819
    Webb, TX
4100  Las Cruces, NM................................    0.8590    0.9012
    Dona Anam, NM
4120  Las Vegas, NV-AZ \1\..........................    1.1258    1.0845
    Mohave, AZ
    Clark, NV
    Nye, NV
4150  Lawrence, KS..................................    0.8222    0.8745
    Douglas, KS
4200  Lawton, OK....................................    0.9532    0.9677
    Comanche, OK
4243  Lewiston-Auburn, ME...........................    0.8899    0.9232
    Androscoggin, ME
4280  Lexington, KY.................................    0.8552    0.8984
    Bourbon, KY
    Clark, KY
    Fayette, KY
    Jessamine, KY
    Madison, KY
    Scott, KY
    Woodford, KY
4320  Lima, OH......................................    0.9108     0.938
    Allen, OH
    Auglaize, OH
4360  Lincoln, NE...................................    0.9670     0.977
    Lancaster, NE
4400  Little Rock-North Little Rock, AR.............    0.8614    0.9029
    Faulkner, AR
    Lonoke, AR
    Pulaski, AR
    Saline, AR
4420  Longview, Marshall, TX........................    0.8738    0.9118
    Gregg, TX
    Harrison, TX
    Upshur, TX
4480  Los Angeles-Long Beach, CA \1\................    1.2085    1.1385
    Los Angeles, CA
4520  Louisville, KY-IN.............................    0.9381    0.9572
    Clark, IN
    Floyd, IN
    Harrison, IN
    Scott, IN
    Bullitt, KY
    Jefferson, KY
    Oldham, KY
4600  Lubbock, TX...................................    0.8411    0.8883
    Lubbock, TX
4640  Lynchburg, VA.................................    0.8814    0.9172
    Amherst, VA
    Bedford, VA
    Bedford City, VA
    Campbell, VA
    Lynchburg City, VA
4680  Macon, GA.....................................    0.8530    0.8968
    Bibb, GA
    Houston, GA
    Jones, GA
    Peach, GA
    Twiggs, GA
4720  Madison, WI...................................    0.9729     0.981
    Dane, WI
4800  Mansfield, OH \2\.............................    0.8649     0.905
    Crawford, OH
    Richland, OH
4840  Mayaguez, PR..................................    0.4674    0.5940
    Anasco, PR
    Cabo Rojo, PR
    Hormigueros, PR
    Mayaguez, PR
    Sabana Grande, PR
    San German, PR
4880  McAllen-Edinburg-Mission, TX..................    0.8120    0.8671
    Hidalgo, TX
4890  Medford-Ashland, OR...........................    1.0492    1.0334
    Jackson, OR
4900  Melbourne-Titusville-Palm Bay, FL.............    0.9296    0.9512
    Brevard, FL
4920  Memphis, TN-AR-MS \1\.........................    0.8244    0.8761
    Crittenden, AR
    DeSoto, MS
    Fayette, TN
    Shelby, TN
    Tipton, TN
4940  Merced, CA....................................    1.0509    1.0346
    Merced, CA
5000  Miami, FL \1\.................................    1.0233    1.0159
    Dade, FL
5015  Middlesex-Somerset-Hunterdon, NJ \1\..........    1.0876    1.0592
    Hunterdon, NJ
    Middlesex, NJ
    Somerset, NJ
5080  Milwaukee-Waukesha, WI \1\....................    0.9845    0.9894
    Milwaukee, WI
    Ozaukee, WI
    Washington, WI
    Waukesha, WI
5120  Minneapolis-St. Paul, MN-WI \1\...............    1.0929    1.0627
    Anoka, MN
    Carver, MN
    Chisago, MN
    Dakota, MN
    Hennepin, MN
    Isanti, MN
    Ramsey, MN
    Scott, MN
    Sherburne, MN
    Washington, MN
    Wright, MN
    Pierce, WI
    St. Croix, WI
5140  Missoula, MT..................................    0.9085    0.9364
    Missoula, MT
5160  Mobile, AL....................................    0.8267    0.8778
    Baldwin, AL
    Mobile, AL
5170  Modesto, CA...................................    1.0111    1.0076
    Stanislaus, CA
5190  Monmouth-Ocean, NJ \1\........................    1.1258    1.0845
    Monmouth, NJ
    Ocean, NJ
5200  Monroe, LA....................................    0.8221    0.8745
    Quachita, LA
5240  Montgomery, AL................................    0.7724    0.8379
    Autauga, AL
    Elmore, AL
    Mongomery, AL
5280  Muncie, IN....................................    1.0834    1.0564
    Delaware, IN
5330  Myrtle Beach, SC..............................    0.8529    0.8968
    Horry, SC
5345  Naples, FL....................................    0.9839    0.9889
    Collier, FL
5360  Nashville, TN \1\.............................    0.9449    0.9619
    Cheatham, TN
    Davidson, TN
    Dickson, TN
    Robertson, TN
    Rutherford TN
    Sumner, TN
    Williamson, TN
    Wilson, TN
5380  Nassau-Suffolk, NY \1\........................    1.4074    1.2637
    Nassau, NY
    Suffolk, NY
5483  New Haven-Bridgeport-Stamford-Waterbury-          1.2417    1.1598
 Danbury, CT \1\....................................
    Fairfield, CT
    New Haven, CT
5523  New London-Norwich, CT........................    1.2428    1.1605
    New London, CT
5560  New Orleans, LA \1\...........................    0.9089    0.9367

[[Page 41590]]

 
    Jefferson, LA
    Orleans, LA
    Plaquemines, LA
    St. Bernard, LA
    St. Charles, LA
    St. James, LA
    St. John The Baptist, LA
    St. Tammany, LA
5600  New York, NY \1\..............................    1.4517    1.2908
    Bronx, NY
    Kings, NY
    New York, NY
    Putnam, NY
    Queens, NY
    Richmond, NY
    Rockland, NY
    Westchester, NY
5640  Newark, NY \1\................................    1.0772    1.0522
    Essex, NJ
    Morris, NJ
    Sussex, NJ
    Union, NJ
    Warren, NJ
5660  Newburgh, NY-PA...............................    1.0908    1.0613
    Orange, NY
    Pike, PA
5720  Norfolk-Virginia Beach-Newport News, VA-NC \1\    0.8442    0.8905
    Currituck, NC
    Chesapeake City, VA
    Gloucester, VA
    Hampton City, VA
    Isle of Wight, VA
    James City, VA
    Mathews, VA
    Newport News City, VA
    Norfolk City, VA
    Poquoson City, VA
    Portsmouth City, VA
    Suffolk City, VA
    Virginia Beach City VA
    Williamsburg City, VA
    York, VA
5775  Oakland, CA...................................    1.5095    1.3258
    Alameda, CA
    Contra Costa, CA
5790  Ocala, FL.....................................    0.9615    0.9735
    Marion, FL
5800  Odessa-Midland, TX............................    0.8873    0.9214
    Ector, TX
    Midland, TX
5880  Oklahoma City, OK \1\.........................    0.8589    0.9011
    Candian, OK
    Cleveland, OK
    Logan, OK
    McClain, OK
    Oklahoma, OK
    Pottawatomie, OK
5910  Olympia, WA...................................    1.0932    1.0629
    Thurston, WA
5920  Omaha, NE-IA..................................    1.0455    1.0309
    Pottawattamie, IA
    Cass, NE
    Douglas, NE
    Sarpy, NE
    Washington, NE
5945  Orange County, CA \1\.........................    1.1592    1.1065
    Orange, CA
5660  Orlando, FL...................................    0.9806    0.9867
    Lake, FL
    Orange, FL
    Osceola, FL
    Seminole, FL
5990  Owensboro, KY.................................    0.8104    0.8659
    Daviess, KY
6015  Panama City, FL...............................    0.9169    0.9423
6020  Parkersburg-Marietta, WV-OH (WV Hospitals)....    0.8414    0.8885
    Washington, OH
    Wood, WV
6020  Parkersburg-Marietta, WV-OH (OH Hospitals) 2..    0.8649    0.9054
    Washington, OH
    Wood, WV
6080  Pensacola, FL \2\.............................    0.8986    0.9294
    Escambia, FL
    Santa Rosa, FL
6120  Peoria-Perkin, IL.............................    0.8399    0.8874
    Peoria, IL
    Tazewell, IL
    Woodford, IL
6160  Philadelphia, PA-NJ...........................    1.1186    1.0798
    Burlington, NJ
    Camden, NJ
    Gloucester, NJ
    Salem, NJ
    Bucks, PA
    Chester, PA
    Delaware, PA
    Montgomery, PA
    Philadelphia, PA
6200  Phoenix-Messa, AZ \1\.........................    0.9464    0.9630
    Maricopa, AZ
    Pinal, AZ
6240  Pine Bluff, AR................................    0.7697    0.8359
    Jefferson, AR
6280  Pittsburgh, PA \1\............................    0.9634    0.9748
    Allegheny, PA
    Beaver, PA
    Butler, PA
    Fayette, PA
    Washington, PA
    Westmoreland, PA
6323  Pittsfield, MA \2\............................    1.1369    1.0918
    Berkshire, MA
6340  Pocatello, ID.................................    0.8973    0.9285
    Bannock, ID
6360  Ponce, PR.....................................    0.4971    0.6196
    Guayanilla, PR
    Juana Diaz, PR
    Penuelas, PR
    Ponce, PR
    Villalba, PR
    Yauco, PR
6403  Portland, ME..................................    0.9487    0.9646
    Cumberland, ME
    Sagadahoc, ME
    York, ME
6440  Portland-Vancouver, OR-WA \1\.................    1.0996    1.0672
    Clackamas, OR
    Columbia, OR
    Multnomah, OR
    Washington, OR
    Yamhill, OR
    Clark, WA
6483  Providence-Warwick-Pawtucket, RI \1\..........    1.0690    1.0468
    Bristol, RI
    Kent, RI
    Newport, RI
    Providence, RI
    Washington, RI
6520  Provo-Orem, UT................................    0.9818    0.9875
    Utah, UT
6560  Pueblo, CO....................................    0.8853    0.9200
    Pueblo, CO
6580  Punta Gorda, FL...............................    0.9508    0.9660
    Charalotte, FL
6600  Racine, WI....................................    0.9216    0.9456
    Racine, WI
6640  Raleigh-Durham-Chapel Hill, NC \1\............    0.9544    0.9685
    Chatham, NC
    Durham, NC
    Franklin, NC
    Johnston, NC
    Orange, NC
    Wake, NC
6660  Rapid City, SD................................    0.8363    0.8848
    Pennington, SD
6680  Reading, PA...................................    0.9436    0.9610
    Berks, PA
6690  Redding, CA...................................    1.1263    1.0849
    Shasta, CA
6720  Reno, NV......................................    1.0655    1.0444
    Washoe, NV
6740  Richland-Kennewick-Pasco, WA..................    1.1224    1.0823
    Benton, WA
    Franklin, WA
6760  Richmond-Petersburg, VA.......................    0.9545    0.9686

[[Page 41591]]

 
    Charles City County, VA
    Chesterfield, VA
    Colonial Heights City, VA
    Dinwiddie, VA
    Goochland, VA
    Hanover, VA
    Henrico, VA
    Hopewell City, VA
    New Kent, VA
    Petersburg City, VA
    Powhatan, VA
    Prince George, VA
    Richmond City, VA
6780  Riverside-San Bernardino, CA \1\..............    1.1061    1.0715
    Riverside, CA
    San Bernardino, CA
    6800  Roanoke, VA                                   0.8142    0.8687
    Botetourt, VA
    Roanoke, VA
    Roanoke City, VA
    Salem City, VA
6820  Rochester, MN.................................    1.1429    1.0958
    Olmsted, MN
6840  Rochester, NY \1\.............................    0.9184    0.9434
    Genesee, NY
    Livingston, NY
    Monroe, NY
    Ontario, NY
    Orleans, NY
    Wayne, NY
6880  Rockford, IL..................................    0.8783    0.9150
    Boone, IL
    Ogle, IL
    Winnebago, IL
6895  Rocky Mount, NC...............................    0.8735    0.9115
    Edgecombe, NC
    Nash, NC
6920  Sacramento, CA \1\............................    1.2284    1.1513
    El Dorado, CA
    Placer, CA
    Sacramento, CA
6960  Saginaw-Bay City-Midland, MI..................    0.9294    0.9511
    Bay, MI
    Midland, MI
    Saginaw, MI
6980  St. Cloud, MN.................................    0.9608    0.9730
    Benton, MN
    Stearns, MN
7000  St. Joseph, MO................................    0.8943    0.9264
    Andrew, MO
    Buchanan, MO
7040  St. Louis, MO-IL \1\..........................    0.9052    0.9341
    Clinton, IL
    Jersey, IL
    Madison, IL
    Monroe, IL
    St. Clair, IL
    Franklin, MO
    Jefferson, MO
    Lincoln, MO
    St. Charles, MO
    St. Louis, MO
    St. Louis City, MO
    Warren, MO
7080  Salem, OR.....................................    0.9949    0.9965
    Marion, OR
    Polk, OR
7120  Salinas, CA...................................    1.4710    1.3025
    Monterey, CA
7160  Salt Lake City-Ogden, UT \1\..................    0.9854    0.9900
    Davis, UT
    Salt Lake, UT
    Weber, UT
7200  San Angelo, TX................................    0.7845    0.8469
    Tom Green, TX
7240  San Antonio, TX \1\...........................    0.8318    0.8815
    Bexar, TX
    Comal, TX
    Guadalupe, TX
    Wilson, TX
7320  San Diego, CA \1\.............................    1.1955    1.1301
    San Diego, CA
7360  San Francisco, CA \1\.........................    1.3784    1.2458
    Marin, CA
    San Francisco, CA
    San Mateo, CA
7400  San Jose, CA \1\..............................    1.3492    1.2277
    Santa Clara, CA
7440  San Juan-Bayamon, PR \1\......................    0.4657    0.5925
    Aguas Buenas, PR
    Barceloneta, PR
    Bayamon, PR
    Canovanas, PR
    Carolina, PR
    Catano, PR
    Ceiba, PR
    Comerio, PR
    Corozal, PR
    Dorado, PR
    Fajardo, PR
    Florida, PR
    Guaynabo, PR
    Humacao, PR
    Juncos, PR
    Los Piedras, PR
    Loiza, PR
    Luguillo, PR
    Manati, PR
    Morovis, PR
    Naguabo, PR
    Naranjito, PR
    Rio Grande, PR
    San Juan, PR
    Toa Alta, PR
    Toa Baja, PR
    Trujillo Alto, PR
    Vega Alta, PR
    Vega Baja, PR
    Yabucoa, PR
7460  San Luis Obispo-Atascadero-Paso Robles, CA....    1.0470    1.0320
    San Luis Obispo, CA
7480  Santa Barbara-Santa Maria-Lompoc, CA..........    1.0819    1.0554
    Santa Barbara, CA
7485  Santa Cruz-Watsonville, CA....................    1.3927    1.2546
    Santa Cruz, CA
7490  Santa Fe, NM..................................    1.0437    1.0297
    Los Alamos, NM
    Santa Fe, NM
7500  Santa Rosa, CA................................    1.3000    1.1968
    Sonoma, CA
7510  Sarasota-Bradenton, FL........................    0.9905    0.9935
    Manatee, FL
    Sarasota, FL
7520  Savannah, GA..................................    0.9953    0.9968
    Bryan, GA
    Chatham, GA
    Effington, GA
7560  Scranton--Wilkes-Barre--Hazleton, PA \2\......    0.8524    0.8964
    Columbia, PA
    Lackawanna, PA
    Luzerne, PA
    Wyoming, PA
7600  Seattle-Bellevue-Everett, WA \1\..............    1.1289    1.0866
    Island, WA
    King, WA
    Snohomish, WA
7610  Sharon, PA \2\................................    0.8524    0.8964

[[Page 41592]]

 
    Mercer, PA
7620  Sheboygan, WI \2\.............................    0.8759    0.9133
    Sheboygan, WI
7640  Sherman-Denison, TX...........................    0.9329    0.9535
    Grayson, TX
7680  Shreveport-Bossier City, LA...................    0.9049    0.9339
    Bossier, LA
    Caddo, LA
    Webster, LA
7720  Sioux City, IA-NE.............................    0.8549    0.8982
    Woodbury, IA
    Dakota, NE
7760  Sioux Falls, SD...............................    0.8776    0.9145
    Lincoln, SD
    Minnehaha, SD
7800  South Bend, IN................................    0.9793    0.9858
    St. Joseph, IN
7840  Spokane, WA...................................    1.0799    1.0541
    Spokane, WA
7880  Springfield, IL...............................    0.8684    0.9079
    Menard, IL
    Sangamon, IL
7920  Springfield, MO...............................    0.7991    0.8576
    Christian, MO
    Greene, MO
    Webster, MO
8003  Springfield, MA \2\...........................    1.1369    1.0918
    Hampden, MA
    Hampshire, MA
8050  State College, PA.............................    0.9138    0.9401
    Centre, PA
8080  Steubenville-Weirton, OH-WV (OH Hospitals) \2\    0.8649    0.9054
    Jefferson, OH
    Brooke, WV
    Hancock, WV
8080  Steubenville-Weirton, OH-WV (OH Hospitals) \2\    0.8614    0.9029
    Jefferson, OH
    Brooke, WV
    Hancock, WV
8120  Stockton-Lodi, CA.............................    1.0518    1.0352
    San Joaquin, CA
8140  Sumter, SC \2\................................    0.8264    0.8776
    Sumter, SC
8160  Syracuse, NY..................................    0.9441    0.9614
    Cayuga, NY
    Madison, NY
    Onondaga, NY
    Oswego, NY
8200  Tacoma, WA....................................    1.1631    1.1090
    Pierce, WA
8240  Tallahassee, FL \2\...........................    0.8986    0.9294
    Gadsden, FL
    Leon, FL
8280  Tampa-St. Petersburg-Clearwater, FL \1\.......    0.9119    0.9388
    Hernando, FL
    Hillsborough, FL
    Pasco, FL
    Pinellas, FL
8320  Terre Haute, IN...............................    0.8570    0.8997
    Clay, IN
    Vermillion, IN
    Vigo, IN
8360  Texarkana, AR-Texarkana, TX...................    0.8174    0.8710
    Miller, AR
    Bowie, TX
8400  Toledo, OH....................................    0.9593    0.9719
    Fulton, OH
    Lucas, OH
    Wood, OH
8440  Topeka, KS....................................    0.9326    0.9533
    Shawnee, KS
8480  Trenton, NJ...................................    0.9955    0.9969
    Mercer, NJ
8520  Tucson, AZ....................................    0.8742    0.9120
    Pima, AZ
8560  Tulsa, OK.....................................    0.8086    0.8646
    Creek, OK
    Osage, OK
    Rogers, OK
    Tulsa, OK
    Wagoner, OK
8600  Tuscaloosa, AL................................    0.8064    0.8630
    Tuscaloosa, AL
8640  Tyler, TX.....................................    0.9369    0.9563
    Smith, TX
8680  Utica-Rome, NY \2\............................    0.8636    0.9045
    Herkimer, NY
    Oneida, NY
8720  Vallejo-Fairfield-Napa, CA....................    1.2655    1.1750
    Napa, CA
    Solano, CA
8735  Ventura, CA...................................    1.0952    1.0643
    Ventura, CA
8750  Victoria, TX..................................    0.8378    0.8859
    Victoria, TX
8760  Vineland-Millville-Bridgeton, NJ..............    1.0517    1.0351
    Cumberland, NJ
8780  Visalia-Tulare-Porterville, CA................    1.0411    1.0280
    Tulare, CA
8800  Waco, TX......................................    0.8075    0.8638
    McLennan, TX
8840  Washington, DC-MD-VA-WV \1\...................    1.1053    1.0710
    District of Columbia, DC
    Calvert, MD
    Charles, MD
    Frederick, MD
    Montgomery, MD
    Prince Georges, MD
    Alexandria City, VA
    Arlington, VA
    Clarke, VA
    Culpeper, VA
    Fairfax, VA
    Fairfax City, VA
    Falls Church City, VA
    Fauquier, VA
    Fredericksburg City, VA
    King George, VA
    Loudoun, VA
    Manassas City, VA
    Manassas Park City, VA
    Prince William, VA
    Spotsylvania, VA
    Stafford, VA
    Warren, VA
    Berkeley, WV
    Jefferson, WV
8920  Waterloo-Cedar Falls, IA......................    0.8841    0.9191
    Black Hawk, IA
8940  Wausau, WI....................................    0.9445    0.9617
    Marathon, WI
8960  West Palm Beach-Boca Raton, FL \1\,\2\........    0.9951    0.9966
    Palm Beach, FL
9000  Wheeling, WV-OH (WV Hospitals) \2\............    0.8068    0.8633
    Belmont, OH
    Marshall, WV
    Ohio, WV
9000  Wheeling, WV-OH (OH Hospitals) \2\............    0.8649    0.9054
    Belmont, OH
    Marshall, WV
    Ohio, WV
9040  Wichita, KS...................................    0.9421   0.09600
    Butler, KS
    Harvey, KS
    Sedgwick, KS
9080  Wichita Falls, TX.............................    0.7652    0.8325
    Archer, TX
    Wichita, TX
9140  Williamsport, PA \2\..........................    0.8524    0.8964
    Lycoming, PA
9160  Wilmington-Newark, DE-MD......................    1.1274    1.0856
    New Castle, DE
    Cecil, MD
9200  Wilmington, NC................................    0.9707    0.9798
    New Hanover, NC
    Brunswick, NC
9260  \2\ Yakima, WA................................    1.0446    1.0303

[[Page 41593]]

 
    Yakima, WA
9270  Yolo, CA......................................    1.0485    1.0330
    Yolo, CA
9280  York, PA......................................    0.9309    0.9521
    York, PA
9320  Youngstown-Warren, OH.........................    0.9996    0.9997
    Columbiana, OH
    Mahoning, OH
    Trumbull, OH
9340  Yuba City, CA.................................    1.0662    1.0449
    Sutter, CA
    Yuba, CA
9360  Yuma, AZ......................................    0.9924    0.9948
    Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area.
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2000.


Table 4b.--Wage Index and Capitla Geographic Adjustment Factor (GAF) for
                               Rural Areas
------------------------------------------------------------------------
                                                        Wage
                    Nonurban area                       index      GAF
------------------------------------------------------------------------
Alabama.............................................    0.7390    0.8129
Alaska..............................................    1.2057    1.1367
Arizona.............................................    0.8544    0.8978
Arkansas............................................    0.7236    0.8013
California..........................................    0.9951    0.9966
Colorado............................................    0.8813    0.9171
Connecticut.........................................    1.2413    1.1595
Delaware............................................    0.9166    0.9421
Florida.............................................    0.8986    0.9294
Georgia.............................................    0.8094    0.8652
Hawaii..............................................    1.0726    1.0492
Idaho...............................................    0.8651    0.9055
Illinois............................................    0.8047    0.8617
Indiana.............................................    0.8396    0.8872
Iowa................................................    0.7926    0.8528
Kansas..............................................    0.7460    0.8182
Kentucky............................................    0.8043    0.8615
Louisiana...........................................    0.7486    0.8201
Maine...............................................    0.8639    0.9047
Maryland............................................    0.8631    0.9041
Massachusetts.......................................    1.1369    1.0918
Michigan............................................    0.8831    0.9184
Minnesota...........................................    0.8669    0.9068
Mississippi.........................................    0.7306    0.8066
Missouri............................................    0.7723    0.8378
Montana.............................................    0.8398    0.8873
Nebraska............................................    0.8007    0.8588
Nevada..............................................    0.9097    0.9372
New Hampshire.......................................    0.9905    0.9935
New Jersey \1\......................................  ........  ........
New Mexico..........................................    0.8378    0.8859
New York............................................    0.8636    0.9045
North Carolina......................................    0.8290    0.8795
North Dakota........................................    0.7647    0.8322
Ohio................................................    0.8649    0.9054
Oklahoma............................................    0.7255    0.8027
Oregon..............................................    0.9873    0.9913
Pennsylvania........................................    0.8524    0.8964
Puerto Rico.........................................    0.4249    0.5565
Rhode Island \1\....................................  ........  ........
South Carolina......................................    0.8264    0.8776
South Dakota........................................    0.7576    0.8269
Tennessee...........................................    0.7650    0.8324
Texas...............................................    0.7471    0.8190
Utah................................................    0.8906    0.9237
Vermont.............................................    0.9427    0.9604
Virginia............................................    0.7916    0.8521
Washington..........................................    1.0446    1.0303
West Virginia.......................................    0.8068    0.8633
Wisconsin...........................................    0.8759    0.9133
Wyoming.............................................    0.8859    0.9204
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


Table 4c.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                     Hospitals That Are Reclassified
------------------------------------------------------------------------
                                                        Wage
                        Area                            index      GAF
------------------------------------------------------------------------
Abilene, TX.........................................    0.8179    0.8714
Akron, OH...........................................    0.9981    0.9987
Albany, GA..........................................    0.9544    0.9685
Alexandria, LA......................................    0.7910    0.8517
Amarillo, TX........................................    0.8435    0.8900
Anchorage, AK.......................................    1.3009    1.1974
Ann Arbor, MI.......................................    1.1343    1.0901
Atlanta, GA.........................................    1.0050    1.0034
Austin-San Marcos, TX...............................    0.9081    0.9361
Baltimore, MD.......................................    0.9891    0.9925
Baton Rouge, LA.....................................    0.8707    0.9095
Beaumont-Port Arthur, TX............................    0.8624    0.9036
Benton Harbor, MI...................................    0.8831    0.9184
Bergen-Passaic, NJ..................................    1.1833    1.1222
Billings, MT........................................    1.0038    1.0026
Biloxi-Gulfport-Pascagoula, MS......................    0.7949    0.8545
Binghamton, NY......................................    0.8750    0.9126
Birmingham, AL......................................    0.8994    0.9300
Bismarck, ND........................................    0.7893    0.8504
Boise City, ID......................................    0.9086    0.9365
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH....    1.1358    1.0911
Burlington, VT......................................    1.0122    1.0083
Caguas, PR..........................................    0.4561    0.5842
Champaign-Urbana, IL................................    0.9163    0.9419
Charleston-North Charleston, SC.....................    0.8988    0.9295
Charleston, WV......................................    0.8861    0.9205
Charlotte-Gastonia-Rock Hill, NC-SC.................    0.9433    0.9608
Chattanooga, TN-GA..................................    0.9453    0.9622
Chicago, IL.........................................    1.0872    1.0589
Cincinnati, OH-KY-IN................................    0.9434    0.9609
Clarksville-Hopkinsville, TN-KY.....................    0.8283    0.8790
Cleveland-Lorain-Elyria, OH.........................    0.9688    0.9785
Columbia, MO........................................    0.8736    0.9116
Columbia, SC........................................    0.9215    0.9456
Columbus, GA-AL.....................................    0.8318    0.8815
Columbus, OH........................................    0.9728    0.9813
Corpus Christi, TX..................................    0.8599    0.9018
Dallas, TX..........................................    0.9589    0.9717
Danville, VA........................................    0.8706    0.9095
Davenport-Moline-Rock Island, IA-IL.................    0.8606    0.9023
Dayton-Springfield, OH..............................    0.9231    0.9467
Denver, CO..........................................    1.0197    1.0134
Des Moines, IA......................................    0.8754    0.9129
Dothan, AL..........................................    0.7836    0.8462
Dover, DE...........................................    1.0511    1.0347
Duluth-Superior, MN-WI..............................    1.0165    1.0113
Elkhart-Goshen, IN..................................    0.9379    0.9570
Eugene-Springfield, OR..............................    1.0765    1.0518
Evansville-Henderson, IN-KY.........................    0.8396    0.8872
Fargo-Moorhead, ND-MN (ND and SD Hospitals).........    0.8620    0.9033
Fargo-Moorhead, ND-MN (MN Hospital).................    0.8669    0.9068
Fayetteville, NC....................................    0.8494    0.8942
Flagstaff, AZ-UT....................................    0.9860    0.9904
Flint, MI...........................................    1.0918    1.0620
Fort Collins-Loveland, CO...........................    1.0197    1.0134
Fort Pierce-Port St. Lucie, FL......................    1.0109    1.0075
Fort Smith, AR-OK...................................    0.7696    0.8358
Fort Walton Beach, FL...............................    0.8713    0.9100
Forth Worth-Arlington, TX...........................    0.9835    0.9887
Fresno, CA..........................................    1.0262    1.0179
Gadsden, AL.........................................    0.8754    0.9129
Gainesville, FL.....................................    0.9963    0.9975
Goldsboro, NC.......................................    0.8333    0.8826
Grand Forks, ND-MN..................................    0.9097    0.9372
Grand Rapids-Muskegon-Holland, MI...................    1.0017    1.0012
Great Falls, MT.....................................    1.0459    1.0312
Greeley, CO.........................................    0.9449    0.9619
Green Bay, WI.......................................    0.9215    0.9456
Greensboro-Winston-Salem-High Point, NC.............    0.9037    0.9330
Greenville, NC......................................    0.9237    0.9471
Greenville-Spartanburg-Anderson, SC.................    0.9188    0.9437
Hagerstown, MD......................................    0.8853    0.9200
Harrisburg-Lebanon-Carlisle, PA.....................    0.9793    0.9858
Hartford, CT........................................    1.1715    1.1145
Hickory-Morganton-Lenoir, NC........................    0.9148    0.9408
Honolulu, HI........................................    1.1479    1.0991
Houston, TX.........................................    0.9387    0.9576
Huntington-Ashland, WV-KY-OH........................    0.9436    0.9610
Huntsville, AL......................................    0.8608    0.9024
Indianapolis, IN....................................    0.9792    0.9857
Iowa City, IA.......................................    0.9460    0.9627
Jackson, MS.........................................    0.8268    0.8779
Jackson, TN.........................................    0.8447    0.8909
Jacksonville, FL....................................    0.8957    0.9273
Johnson City-Kingsport-Bristol, TN-VA...............    0.8894    0.9229
Jonesboro, AR.......................................    0.7251    0.8024
Joplin, MO..........................................    0.7678    0.8345

[[Page 41594]]

 
Kalamazoo-Battlecreek, MI...........................    0.9981    0.9987
Kansas City, KS-MO..................................    0.9322    0.9531
Knoxville, TN.......................................    0.9199    0.9444
Kokomo, IN..........................................    0.8984    0.9293
Lafayette, LA.......................................    0.8397    0.8872
Lansing-East Lansing, MI............................    0.9834    0.9886
Las Vegas, NV-AZ....................................    1.1258    1.0845
Lexington, KY.......................................    0.8552    0.8984
Lima, OH............................................    0.9108    0.9380
Lincoln, NE.........................................    0.9451    0.9621
Little Rock-North Little Rock, AR...................    0.8432    0.8898
Longview-Marshall, TX...............................    0.8541    0.8976
Los Angeles-Long Beach, CA..........................    1.2085    1.1385
Louisville, KY-IN...................................    0.9381    0.9572
Macon, GA...........................................    0.8530    0.8968
Madison, WI.........................................    0.9729    0.9814
Mansfield, OH.......................................    0.8649    0.9054
Memphis, TN-AR-MS...................................    0.8244    0.8761
Merced, CA..........................................    1.0509    1.0346
Milwaukee-Waukesha, WI..............................    0.9845    0.9894
Minneapolis-St. Paul, MN-WI.........................    1.0929    1.0627
Missoula, MT........................................    0.9085    0.9364
Monmouth-Ocean, NJ..................................    1.1258    1.0845
Monroe, LA..........................................    0.8062    0.8628
Montgomery, AL......................................    0.7724    0.8379
Myrtle Beach, SC....................................    0.8357    0.8843
Nashville, TN.......................................    0.9254    0.9483
New Haven-Bridgeport-Stamford-Waterbury- Danbury, CT    1.2417    1.1598
New London-Norwich, CT..............................    1.2328    1.1541
New Orleans, LA.....................................    0.9089    0.9367
New York, NY........................................    1.4399    1.2836
Newark, NJ..........................................    1.0772    1.0522
Newburgh, NY-PA.....................................    1.0837    1.0566
Norfolk-Virginia Beach-Newport News, VA-NC..........    0.8442    0.8905
Oakland, CA.........................................    1.5095    1.3258
Oklahoma City, OK...................................    0.8589    0.9011
Omaha, NE-IA........................................    1.0455    1.0309
Orange County, CA...................................    1.1592    1.1065
Orlando, FL.........................................    0.9806    0.9867
Peoria-Pekin, IL....................................    0.8399    0.8874
Philadelphia, PA-NJ.................................    1.1186    1.0798
Phoenix-Mesa, AZ....................................    0.9464    0.9630
Pittsburgh, PA......................................    0.9496    0.9652
Pocatello, ID.......................................    0.8651    0.9055
Portland, ME........................................    0.9487    0.9646
Portland-Vancouver, OR-WA...........................    1.0996    1.0672
Provo-Orem, UT......................................    0.9818    0.9875
Raleigh-Durham-Chapel Hill, NC......................    0.9544    0.9685
Roanoke, VA.........................................    0.8142    0.8687
Rockford, IL........................................    0.8783    0.9150
Sacramento, CA......................................    1.2284    1.1513
Saginaw-Bay City-Midland, MI........................    0.9294    0.9511
St. Cloud, MN.......................................    0.9608    0.9730
St. Louis, MO-IL....................................    0.9052    0.9341
Salt Lake City-Ogden, UT............................    0.9854    0.9900
San Diego, CA.......................................    1.1955    1.1301
Santa Fe, NM........................................    0.9911    0.9939
Santa Rosa, CA......................................    1.3000    1.1968
Seattle-Bellevue-Everett, WA........................    1.1289    1.0866
Sharon, PA..........................................    0.8524    0.8964
Sherman-Denison, TX.................................    0.8833    0.9185
Sioux City, IA-NE...................................    0.8549    0.8982
South Bend, IN......................................    0.9692    0.9788
Springfield, IL.....................................    0.8684    0.9079
Springfield, MO.....................................    0.7991    0.8576
Syracuse, NY........................................    0.9441    0.9614
Tallahassee, FL.....................................    0.8274    0.8783
Tampa-St. Petersburg-Clearwater, FL.................    0.9119    0.9388
Texarkana, AR-Texarkana, TX.........................    0.8174    0.8710
Toledo, OH..........................................    0.9593    0.9719
Topeka, KS..........................................    0.9326    0.9533
Tulsa, OK...........................................    0.7931    0.8532
Tuscaloosa, AL......................................    0.8064    0.8630
Tyler, TX...........................................    0.9199    0.9444
Vallejo-Fairfield-Napa, CA..........................    1.2167    1.1438
Victoria, TX........................................    0.8378    0.8859
Waco, TX............................................    0.8075    0.8638
Washington, DC-MD-VA-WV.............................    1.1053    1.0710
Waterloo-Cedar Falls, IA............................    0.8841    0.9191
Wausau, WI..........................................    0.9445    0.9617
Wichita, KS.........................................    0.9082    0.9362
Rural Colorado......................................    0.8813    0.9171
Rural Florida.......................................    0.8986    0.9294
Rural Illinois......................................    0.8047    0.8617
Rural Louisiana.....................................    0.7486    0.8201
Rural Michigan......................................    0.8831    0.9184
Rural Minnesota.....................................    0.8669    0.9068
Rural Missouri......................................    0.7723    0.8378
Rural Montana.......................................    0.8398    0.8873
Rural Oregon........................................    0.9873    0.9913
Rural Tennessee.....................................    0.7650    0.8324
Rural Texas.........................................    0.7471    0.8190
Rural Virginia (KY Hospital)........................    0.8043    0.8615
Rural Washington....................................    1.0333    1.0227
Rural Wyoming.......................................    0.8859    0.9204
------------------------------------------------------------------


             Table 4d.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
                                                                Average
                          Urban area                             hourly
                                                                  wage
------------------------------------------------------------------------
Abilene, TX..................................................    17.3227
Aguadilla, PR................................................     8.0776
Akron, OH....................................................    21.5248
Albany, GA...................................................    21.9678
Albany-Schenectady-Troy, NY..................................    18.5415
Albuquerque, NM..............................................    18.0017
Alexandria, LA...............................................    16.6660
Allentown-Bethlehem-Easton, PA...............................    21.6602
Altoona, PA..................................................    19.7859
Amarillo, TX.................................................    17.7501
Anchorage, AK................................................    27.2347
Ann Arbor, MI................................................    24.3199
Anniston, AL.................................................    17.9235
Appleton-Oshkosh-Neenah, WI..................................    18.8767
Arecibo, PR..................................................    10.1973
Asheville, NC................................................    18.8155
Athens, GA...................................................    20.5536
Atlanta, GA..................................................    21.2868
Atlantic-Cape May, NJ........................................    23.9544
Auburn-Opelika, AL...........................................    16.4103
Augusta-Aiken, GA-SC.........................................    19.0900
Austin-San Marcos, TX........................................    19.2341
Bakersfield, CA..............................................    20.3699
Baltimore, MD................................................    20.9485
Bangor, ME...................................................    20.3521
Barnstable-Yarmouth, MA......................................    28.1731
Baton Rouge, LA..............................................    18.4424
Beaumont-Port Arthur, TX.....................................    18.2648
Bellingham, WA...............................................    24.1321
Benton Harbor, MI............................................    17.9119
Bergen-Passaic, NJ...........................................    25.4749
Billings, MT.................................................    21.2596
Biloxi-Gulfport-Pascagoula, MS...............................    16.6634
Binghamton, NY...............................................    18.5327
Birmingham, AL...............................................    19.0492
Bismarck, ND.................................................    16.4329
Bloomington,IN...............................................    18.1990
Bloomington-Normal, IL.......................................    19.0474
Boise City, ID...............................................    19.1895
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.............    24.0562
Boulder-Longmont, CO.........................................    21.0610
Brazoria, TX.................................................    18.0362
Bremerton, WA................................................    23.3211
Brownsville-Harlingen-San Benito, TX.........................    19.5103
Bryan-College Station, TX....................................    18.0042
Buffalo-Niagara Falls, NY....................................    20.3404
Burlington, VT...............................................    22.3616
Caguas, PR...................................................     9.6595
Canton-Massillon, OH.........................................    18.5769
Casper, WY...................................................    19.4829
Cedar Rapids, IA.............................................    19.1010
Champaign-Urbana, IL.........................................    19.4065
Charleston-North Charleston, SC..............................    19.0373
Charleston, WV...............................................    19.2624
Charlotte-Gastonia-Rock Hill, NC-SC..........................    19.9800
Charlottesville, VA..........................................    22.3946
Chattanooga, TN-GA...........................................    20.6102
Cheyenne, WY.................................................    17.3158
Chicago, IL..................................................    23.0278
Chico-Paradise, CA...........................................    22.0066
Cincinnati, OH-KY-IN.........................................    19.9480
Clarksville-Hopkinsville, TN-KY..............................    17.1337
Cleveland-Lorain-Elyria, OH..................................    20.5190
Colorado Springs, CO.........................................    19.5228
Columbia, MO.................................................    18.8596
Columbia, SC.................................................    19.8182
Columbus, GA-AL..............................................    18.0250
Columbus, OH.................................................    20.9839
Corpus Christi, TX...........................................    18.4298
Corvallis, OR................................................    23.4819
Cumberland, MD-WV............................................    18.6405
Dallas, TX...................................................    20.3455
Danville, VA.................................................    19.1906
Davenport-Moline-Rock Island, IA-IL..........................    18.4403

[[Page 41595]]

 
Dayton-Springfield, OH.......................................    20.0366
Daytona Beach, FL............................................    19.0345
Decatur, AL..................................................    18.3823
Decatur, IL..................................................    17.6232
Denver, CO...................................................    21.5811
Des Moines, IA...............................................    18.5408
Detroit, MI..................................................    22.0711
Dothan, AL...................................................    16.5159
Dover, DE....................................................    19.7725
Dubuque, IA..................................................    18.0451
Duluth-Superior, MN-WI.......................................    21.5294
Dutchess County, NY..........................................    22.3487
Eau Claire, WI...............................................    18.9711
El Paso, TX..................................................    18.9500
Elkhart-Goshen, IN...........................................    19.8656
Elmira, NY...................................................    18.0730
Enid, OK.....................................................    16.8452
Erie, PA.....................................................    19.1114
Eugene-Springfield, OR.......................................    22.4571
Evansville, Henderson, IN-KY.................................    17.5854
Fargo-Moorhead, ND-MN........................................    18.2572
Fayetteville, NC.............................................    17.9896
Fayetteville-Springdale-Rogers, AR...........................    16.4641
Flagstaff, AZ-UT.............................................    21.9164
Flint, MI....................................................    23.3401
Florence, AL.................................................    16.7894
Florence, SC.................................................    18.2536
Fort Collins-Loveland, CO....................................    21.8189
Fort Lauderdale, FL..........................................    21.5452
Fort Myers-Cape Coral, FL....................................    18.9574
Fort Pierce-Port St. Lucie, FL...............................    21.1766
Fort Smith, AR-OK............................................    16.6129
Fort Walton Beach, FL........................................    18.4550
Fort Wayne, IN...............................................    19.2662
Fort Worth-Arlington, TX.....................................    20.8308
Fresno, CA...................................................    21.7350
Gadsden, AL..................................................    18.4020
Gainesville, FL..............................................    21.3966
Galveston-Texas City, TX.....................................    20.6131
Gary, IN.....................................................    19.8884
Glens Falls, NY..............................................    18.2277
Goldsboro, NC................................................    17.6500
Grand Forks, ND-MN...........................................    19.2683
Grand Junction, CO...........................................    19.4593
Grand Rapids-Muskegon-Holland, MI............................    21.4652
Great Falls, MT..............................................    22.1512
Greeley, CO..................................................    20.5908
Green Bay, WI................................................    19.3420
Greensboro-Winston-Salem-High Point, NC......................    19.1402
Greenville, NC...............................................    20.1214
Greenville-Spartanburg-Anderson, SC..........................    19.4594
Hagerstown, MD...............................................    18.7266
Hamilton-Middletown, OH......................................    18.9474
Harrisburg-Lebanon-Carlisle, PA..............................    21.0037
Hartford, CT.................................................    24.8124
Hattiesburg, MS..............................................    16.1679
Hickory-Morganton-Lenoir, NC.................................    19.2995
Honolulu, HI.................................................    24.3050
Houma, LA....................................................    16.5978
Houston, TX..................................................    19.8810
Huntington-Ashland, WV-KY-OH.................................    20.6646
Huntsville, AL...............................................    18.6860
Indianapolis, IN.............................................    20.7402
Iowa City, IA................................................    20.3481
Jackson, MI..................................................    18.7230
Jackson, MS..................................................    17.7627
Jackson, TN..................................................    18.2151
Jacksonville, FL.............................................    18.9712
Jacksonville, NC.............................................    16.6300
Jamestown, NY................................................    16.6418
Janesville-Beloit, WI........................................    20.4504
Jersey City, NJ..............................................    24.7265
Johnson City-Kingsport-Bristol, TN-VA........................    18.7506
Johnstown, PA................................................    18.2989
Jonesboro, AR................................................    15.3149
Joplin, MO...................................................    16.2618
Kalamazoo-Battlecreek, MI....................................    21.1395
Kankakee, IL.................................................    18.2109
Kansas City, KS-MO...........................................    19.7430
Kenosha, WI..................................................    19.1315
Killeen-Temple, TX...........................................    21.0356
Knoxville, TN................................................    19.4838
Kokomo, IN...................................................    18.8885
La Crosse, WI-MN.............................................    18.9205
Lafayette, LA................................................    17.6615
Lafayette, IN................................................    18.6572
Lake Charles, LA.............................................    16.8715
Lakeland-Winter Haven, FL....................................    18.6713
Lancaster, PA................................................    19.6017
Lansing-East Lansing, MI.....................................    21.1315
Laredo, TX...................................................    17.6272
Las Cruces, NM...............................................    18.1944
Las Vegas, NV-AZ.............................................    23.8445
Lawrence, KS.................................................    17.4151
Lawton, OK...................................................    20.1897
Lewiston-Auburn, ME..........................................    18.8489
Lexington, KY................................................    18.0690
Lima, OH.....................................................    18.8613
Lincoln, NE..................................................    20.4820
Little Rock-North Little Rock, AR............................    18.2444
Longview-Marshall, TX........................................    18.5072
Los Angeles-Long Beach, CA...................................    25.5235
Louisville, KY-IN............................................    19.8685
Lubbock, TX..................................................    17.8142
Lynchburg, VA................................................    18.6683
Macon, GA....................................................    18.0675
Madison, WI..................................................    20.6054
Mansfield, OH................................................    17.9510
Mayaguez, PR.................................................     9.9005
McAllen-Edinburg-Mission, TX.................................    17.1975
Medford-Ashland, OR..........................................    22.2214
Melbourne-Titusville-Palm Bay, FL............................    19.6889
Memphis, TN-AR-MS............................................    17.4610
Merced, CA...................................................    21.7673
Miami, FL....................................................    21.6737
Middlesex-Somerset-Hunterdon, NJ.............................    23.5556
Milwaukee-Waukesha, WI.......................................    20.8513
Minneapolis-St. Paul, MN-WI..................................    23.1482
Missoula, MT.................................................    19.2420
Mobile, AL...................................................    17.5090
Modesto, CA..................................................    21.4157
Monmouth-Ocean, NJ...........................................    23.8439
Monroe, LA...................................................    17.4115
Montgomery, AL...............................................    16.3157
Muncie, IN...................................................    22.9458
Myrtle Beach, SC.............................................    18.0643
Naples, FL...................................................    20.8392
Nashville, TN................................................    20.0138
Nassau-Suffolk, NY...........................................    29.8096
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT..........    26.1700
New London-Norwich, CT.......................................    26.3222
New Orleans, LA..............................................    19.2503
New York, NY.................................................    30.7475
Newark, NJ...................................................    24.6654
Newburgh, NY-PA..............................................    23.1041
Norfolk-Virginia Beach-Newport News, VA-NC...................    17.8754
Oakland, CA..................................................    31.8928
Ocala, FL....................................................    20.3639
Odessa-Midland, TX...........................................    18.7922
Oklahoma City, OK............................................    18.1873
Olympia, WA..................................................    23.1536
Omaha, NE-IA.................................................    22.1432
Orange County, CA............................................    24.5477
Orlando, FL..................................................    20.7465
Owensboro, KY................................................    17.1643
Panama City, FL..............................................    19.4197
Parkersburg-Marietta, WV-OH..................................    17.8217
Pensacola, FL................................................    17.8801
Peoria-Pekin, IL.............................................    17.6840
Philadelphia, PA-NJ..........................................    23.6372
Phoenix-Mesa, AZ.............................................    20.0450
Pine Bluff, AR...............................................    16.3022
Pittsburgh, PA...............................................    20.4057
Pittsfield, MA...............................................    21.7194
Pocatello, ID................................................    19.0047
Ponce, PR....................................................    10.5280
Portland, ME.................................................    20.0674
Portland-Vancouver, OR-WA....................................    23.2438
Providence-Warwick, RI.......................................    22.6420
Provo-Orem, UT...............................................    20.7946
Pueblo, CO...................................................    18.7505
Punta Gorda, FL..............................................    20.1370
Racine, WI...................................................    19.5201
Raleigh-Durham-Chapel Hill, NC...............................    20.2151
Rapid City, SD...............................................    17.7126
Reading, PA..................................................    19.9855
Redding, CA..................................................    23.8559
Reno, NV.....................................................    22.5678
Richland-Kennewick-Pasco, WA.................................    23.7721
Richmond-Petersburg, VA......................................    20.2158
Riverside-San Bernardino, CA.................................    23.7428
Roanoke, VA..................................................    17.2365
Rochester, MN................................................    24.2072
Rochester, NY................................................    19.4510
Rockford, IL.................................................    18.6017
Rocky Mount, NC..............................................    18.4997
Sacramento, CA...............................................    26.0168
Saginaw-Bay City-Midland, MI.................................    19.6689
St. Cloud, MN................................................    19.9529
St. Joseph, MO...............................................    18.9408
St. Louis, MO-IL.............................................    19.1725
Salem, OR....................................................    21.0721
Salinas, CA..................................................    31.1554
Salt Lake City-Ogden, UT.....................................    20.8711
San Angelo, TX...............................................    16.6166
San Antonio, TX..............................................    17.6168
San Diego, CA................................................    25.2676
San Francisco, CA............................................    29.6537
San Jose, CA.................................................    28.8225
San Juan-Bayamon, PR.........................................     9.8640
San Luis Obispo-Atascadero-Paso Robles, CA...................    22.1746
Santa Barbara-Santa Maria-Lompoc, CA.........................    22.9137
Santa Cruz-Watsonville, CA...................................    29.4979
Santa Fe, NM.................................................    22.1051
Santa Rosa, CA...............................................    27.5337
Sarasota-Bradenton, FL.......................................    20.9796
Savannah, GA.................................................    21.0803

[[Page 41596]]

 
Scranton-Wilkes Barre-Hazleton, PA...........................    17.7324
Seattle-Bellevue-Everett, WA.................................    23.9115
Sharon, PA...................................................    17.5441
Sheboygan, WI................................................    17.3719
Sherman-Denison, TX..........................................    19.7582
Shreveport-Bossier City, LA..................................    19.1657
Sioux City, IA-NE............................................    18.1059
Sioux Falls, SD..............................................    18.5874
South Bend, IN...............................................    20.7421
Spokane, WA..................................................    22.8719
Springfield, IL..............................................    18.3917
Springfield, MO..............................................    16.9245
Springfield, MA..............................................    22.6142
State College, PA............................................    19.3540
Steubenville-Weirton, OH-WV..................................    18.2449
Stockton-Lodi, CA............................................    22.2772
Sumter, SC...................................................    17.4486
Syracuse, NY.................................................    19.9343
Tacoma, WA...................................................    24.3099
Tallahassee, FL..............................................    17.9690
Tampa-St. Petersburg-Clearwater, FL..........................    19.1546
Terre Haute, IN..............................................    18.1515
Texarkana, AR-Texarkana, TX..................................    17.2300
Toledo, OH...................................................    20.7884
Topeka, KS...................................................    19.7520
Trenton, NJ..................................................    21.3959
Tucson, AZ...................................................    18.5157
Tulsa, OK....................................................    17.1256
Tuscaloosa, AL...............................................    17.0793
Tyler, TX....................................................    19.8429
Utica-Rome, NY...............................................    17.5752
Vallejo-Fairfield-Napa, CA...................................    28.2652
Ventura, CA..................................................    24.2606
Victoria, TX.................................................    17.7441
Vineland-Millville-Bridgeton, NJ.............................    22.2740
Visalia-Tulare-Porterville, CA...............................    22.0500
Waco, TX.....................................................    17.1037
Washington, DC-MD-VA-WV......................................    23.4111
Waterloo-Cedar Falls, IA.....................................    18.0392
Wausau, WI...................................................    20.0043
West Palm Beach-Boca Raton, FL...............................    21.2055
Wheeling, OH-WV..............................................    16.1892
Wichita, KS..................................................    19.9536
Wichita Falls, TX............................................    16.2079
Williamsport, PA.............................................    17.8945
Wilmington-Newark, DE-MD.....................................    23.8786
Wilmington, NC...............................................    20.5594
Yakima, WA...................................................    21.8833
Yolo, CA.....................................................    20.5840
York, PA.....................................................    19.7168
Youngstown-Warren, OH........................................    21.1707
Yuba City, CA................................................    22.5818
Yuma, AZ.....................................................    21.0182
------------------------------------------------------------------------


             Table 4e.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
                                                                Average
                        Nonurban area                            hourly
                                                                  wage
------------------------------------------------------------------------
Alabama......................................................    15.6529
Alaska.......................................................    25.5370
Arizona......................................................    18.0961
Arkansas.....................................................    15.3250
California...................................................    21.0766
Colorado.....................................................    18.6657
Connecticut..................................................    26.2903
Delaware.....................................................    19.4135
Florida......................................................    19.0317
Georgia......................................................    17.1426
Hawaii.......................................................    22.7187
Idaho........................................................    18.3238
Illinois.....................................................    17.0445
Indiana......................................................    17.7834
Iowa.........................................................    16.7882
Kansas.......................................................    15.8000
Kentucky.....................................................    17.0342
Louisiana....................................................    15.6336
Maine........................................................    18.2971
Maryland.....................................................    18.2815
Massachusetts................................................    24.0785
Michigan.....................................................    18.6693
Minnesota....................................................    18.3602
Mississippi..................................................    15.4749
Missouri.....................................................    16.3576
Montana......................................................    17.7804
Nebraska.....................................................    16.9591
Nevada.......................................................    19.2681
New Hampshire................................................    20.9790
New Jersey \1\...............................................
New Mexico...................................................    17.7448
New York.....................................................    18.2911
North Carolina...............................................    17.5573
North Dakota.................................................    16.1967
Ohio.........................................................    18.3192
Oklahoma.....................................................    15.3668
Oregon.......................................................    20.8991
Pennsylvania.................................................    18.0541
Puerto Rico..................................................     8.9988
Rhode Island \1\.............................................
South Carolina...............................................    17.5024
South Dakota.................................................    16.0465
Tennessee....................................................    16.2034
Texas........................................................    15.8229
Utah.........................................................    18.8636
Vermont......................................................    19.9246
Virginia.....................................................    16.7397
Washington...................................................    22.1244
West Virginia................................................    17.0883
Wisconsin....................................................    18.5514
Wyoming......................................................    18.7641
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.


                Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
                                                                                    Wage index
                      Area                          Wage index          GAF          reclass.      GAF  reclass.
                                                                                     hospitals       hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR...................................          0.9120          0.9389
Arecibo, PR.....................................          1.0334          1.0228
Caguas, PR......................................          0.9789          0.9855          0.9789          0.9855
Mayaguez, PR....................................          1.0033          1.0023
Ponce, PR.......................................          1.0669          1.0453
San Juan-Bayamon, PR............................          0.9996          0.9997
Rural Puerto Rico...............................          0.9120          0.9389
----------------------------------------------------------------------------------------------------------------


  Table 5.--List of Diagnosis Related Groups (DRGS), Relative Weighting Factors, Geometric and Arithmetic Mean
                                                 Length of Stay
----------------------------------------------------------------------------------------------------------------
                                                                             Relative    Geometric    Arithmetic
                                                                             weights      mean LOS     mean LOS
----------------------------------------------------------------------------------------------------------------
1..............       01  SURG                 CRANIOTOMY AGE >17 EXCEPT        3.0957          6.5          9.3
                                                FOR TRAUMA.
2..............       01  SURG                 CRANIOTOMY FOR TRAUMA AGE        3.1047          7.4          9.9
                                                >17.
3..............       01  SURG                 *CRANIOTOMY AGE 0-17......       1.9619         12.7         12.7
4..............       01  SURG                 SPINAL PROCEDURES.........       2.3205          4.9          7.5
5..............       01  SURG                 EXTRACRANIAL VASCULAR            1.4466          2.5          3.4
                                                PROCEDURES.
6..............       01  SURG                 CARPAL TUNNEL RELEASE.....        .8119          2.2          3.1
7..............       01  SURG                 PERIPH & CRANIAL NERVE &         2.4986          6.9         10.4
                                                OTHER NERV SYST PROC W CC.

[[Page 41597]]

 
8..............       01  SURG                 PERIPH & CRANIAL NERVE &         1.3426          2.2          3.1
                                                OTHER NERV SYST PROC W/O
                                                CC.
9..............       01  MED                  SPINAL DISORDERS &               1.1917          4.6          6.3
                                                INJURIES.
10.............       01  MED                  NERVOUS SYSTEM NEOPLASMS W       1.2036          4.9          6.6
                                                CC.
11.............       01  MED                  NERVOUS SYSTEM NEOPLASMS W/       .8283          3.0          4.1
                                                O CC.
12.............       01  MED                  DEGENERATIVE NERVOUS              .8904          4.6          6.3
                                                SYSTEM DISORDERS.
13.............       01  MED                  MULTIPLE SCLEROSIS &              .7599          4.2          5.2
                                                CEREBELLAR ATAXIA.
14.............       01  MED                  SPECIFIC CEREBROVASCULAR         1.1914          4.7          6.1
                                                DISORDERS EXCEPT TIA.
15.............       01  MED                  TRANSIENT ISCHEMIC ATTACK         .7397          3.0          3.7
                                                & PRECEREBRAL OCCLUSIONS.
16.............       01  MED                  NONSPECIFIC                      1.0985          4.6          5.9
                                                CEREBROVASCULAR DISORDERS
                                                W CC.
17.............       01  MED                  NONSPECIFIC                       .6399          2.6          3.4
                                                CEREBROVASCULAR DISORDERS
                                                W/O CC.
18.............       01  MED                  CRANIAL & PERIPHERAL NERVE        .9353          4.2          5.5
                                                DISORDERS W CC.
19.............       01  MED                  CRANIAL & PERIPHERAL NERVE        .6503          3.0          3.8
                                                DISORDERS W/O CC.
20.............       01  MED                  NERVOUS SYSTEM INFECTION         2.6125          7.7         10.2
                                                EXCEPT VIRAL MENINGITIS.
21.............       01  MED                  VIRAL MENINGITIS..........       1.5032          5.0          6.8
22.............       01  MED                  HYPERTENSIVE                      .9621          3.8          4.9
                                                ENCEPHALOPATHY.
23.............       01  MED                  NONTRAUMATIC STUPOR & COMA        .7746          3.1          4.2
24.............       01  MED                  SEIZURE & HEADACHE AGE >17        .9770          3.7          5.0
                                                W CC.
25.............       01  MED                  SEIZURE & HEADACHE AGE >17        .5911          2.6          3.4
                                                W/O CC.
26.............       01  MED                  SEIZURE & HEADACHE AGE 0-         .6337          2.8          3.6
                                                17.
27.............       01  MED                  TRAUMATIC STUPOR & COMA,         1.3581          3.3          5.3
                                                COMA >1 HR.
28.............       01  MED                  TRAUMATIC STUPOR & COMA,         1.2690          4.5          6.2
                                                COMA <1 HR AGE >17 W CC.
29.............       01  MED                  TRAUMATIC STUPOR & COMA,          .6859          2.8          3.6
                                                COMA >1 HR AGE <17 W/O CC.
30.............       01  MED                  *TRAUMATIC STUPOR & COMA,         .3318          2.0          2.0
                                                COMA >1 HR AGE 0-17.
31.............       01  MED                  CONCUSSION AGE >17 W CC...        .8497          3.2          4.3
32.............       01  MED                  CONCUSSION AGE >17 W/O CC.        .5295          2.1          2.7
33.............       01  MED                  *CONCUSSION AGE 0-17......        .2085          1.6          1.6
34.............       01  MED                  OTHER DISORDERS OF NERVOUS       1.0275          3.9          5.3
                                                SYSTEM W CC.
35.............       01  MED                  OTHER DISORDERS OF NERVOUS        .5937          2.7          3.5
                                                SYSTEM W/O CC.
36.............       02  SURG                 RETINAL PROCEDURES........        .6834          1.2          1.4
37.............       02  SURG                 ORBITAL PROCEDURES........       1.0318          2.6          3.8
38.............       02  SURG                 PRIMARY IRIS PROCEDURES...        .4875          1.9          2.6
39.............       02  SURG                 LENS PROCEDURES WITH OR           .5704          1.4          1.9
                                                WITHOUT VITRECTOMY.
40.............       02  SURG                 EXTRAOCULAR PROCEDURES            .8170          2.2          3.3
                                                EXCEPT ORBIT AGE >17.
41.............       02  SURG                 * EXTRAOCULAR PROCEDURES          .3378          1.6          1.6
                                                EXCEPT ORBIT AGE 0-17.
42.............       02  SURG                 INTRAOCULAR PROCEDURES            .6236          1.6          2.1
                                                EXCEPT RETINA, IRIS &
                                                LENS.
43.............       02  MED                  HYPHEMA...................        .4515          2.6          4.1
44.............       02  MED                  ACUTE MAJOR EYE INFECTIONS        .6496          4.1          5.0
45.............       02  MED                  NEUROLOGICAL EYE DISORDERS        .6941          2.7          3.4
46.............       02  MED                  OTHER DISORDERS OF THE EYE        .7525          3.5          4.6
                                                AGE >17 W CC.
47.............       02  MED                  OTHER DISORDERS OF THE EYE        .4784          2.5          3.2
                                                AGE >17 W/O CC.
48.............       02  MED                  * OTHER DISORDERS OF THE          .2975          2.9          2.9
                                                EYE AGE 0-17.
49.............       03  SURG                 MAJOR HEAD & NECK                1.8557          3.7          5.0
                                                PROCEDURES.
50.............       03  SURG                 SIALOADENECTOMY...........        .8401          1.6          2.0
51.............       03  SURG                 SALIVARY GLAND PROCEDURES         .8504          1.9          2.9
                                                EXCEPT SIALOADENECTOMY.
52.............       03  SURG                 CLEFT LIP & PALATE REPAIR.        .7696          1.5          1.9
53.............       03  SURG                 SINUS & MASTOID PROCEDURES       1.1784          2.3          3.6
                                                AGE >17.
54.............       03  SURG                 * SINUS & MASTOID                 .4823          3.2          3.2
                                                PROCEDURES AGE 0-17.
55.............       03  SURG                 MISCELLANEOUS EAR, NOSE,          .8686          1.9          2.9
                                                MOUTH & THROAT PROCEDURES.
56.............       03  SURG                 RHINOPLASTY...............        .8893          2.1          2.8
57.............       03  SURG                 T&A PROC, EXCEPT                 1.1589          2.8          4.5
                                                TONSILLECTOMY &/OR
                                                ADENOIDECTOMY ONLY, AGE
                                                >17.
58.............       03  SURG                 * T&A PROC, EXCEPT                .2739          1.5          1.5
                                                TONSILLECTOMY &/OR
                                                ADENOIDECTOMY ONLY, AGE 0-
                                                17.
59.............       03  SURG                 TONSILLECTOMY &/OR                .6720          1.9          2.5
                                                ADENOIDECTOMY ONLY, AGE
                                                >17.
60.............       03  SURG                 * TONSILLECTOMY &/OR              .2086          1.5          1.5
                                                ADENOIDECTOMY ONLY, AGE 0-
                                                17.
61.............       03  SURG                 MYRINGOTOMY W TUBE               1.2597          2.9          4.8
                                                INSERTION AGE >17.
62.............       03  SURG                 * MYRINGOTOMY W TUBE              .2953          1.3          1.3
                                                INSERTION AGE 0-17.
63.............       03  SURG                 OTHER EAR, NOSE, MOUTH &         1.3136          3.0          4.5
                                                THROAT O.R. PROCEDURES.
64.............       03  MED                  EAR, NOSE, MOUTH & THROAT        1.2464          4.3          6.6
                                                MALIGNANCY.
65.............       03  MED                  DYSEQUILIBRIUM............        .5261          2.3          2.9
66.............       03  MED                  EPISTAXIS.................        .5548          2.6          3.2
67.............       03  MED                  EPIGLOTTITIS..............        .8031          2.9          3.7
68.............       03  MED                  OTITIS MEDIA & URI AGE >17        .6758          3.4          4.2
                                                W CC.
69.............       03  MED                  OTITIS MEDIA & URI AGE >17        .5191          2.7          3.3
                                                W/O CC.
70.............       03  MED                  OTITIS MEDIA & URI AGE 0-         .3985          2.3          2.7
                                                17.
71.............       03  MED                  LARYNGOTRACHEITIS.........        .6136          2.7          3.4
72.............       03  MED                  NASAL TRAUMA & DEFORMITY..        .6462          2.6          3.4
73.............       03  MED                  OTHER EAR, NOSE, MOUTH &          .7667          3.3          4.3
                                                THROAT DIAGNOSES AGE >17.

[[Page 41598]]

 
74.............       03  MED                  * OTHER EAR, NOSE, MOUTH &        .3356          2.1          2.1
                                                THROAT DIAGNOSES AGE 0-17.
75.............       04  SURG                 MAJOR CHEST PROCEDURES....       3.1107          7.8          9.9
76.............       04  SURG                 OTHER RESP SYSTEM O.R.           2.7208          8.3         11.1
                                                PROCEDURES W CC.
77.............       04  SURG                 OTHER RESP SYSTEM O.R.           1.2113          3.6          5.0
                                                PROCEDURES W/O CC.
78.............       04  MED                  PULMONARY EMBOLISM........       1.3861          6.1          7.1
79.............       04  MED                  RESPIRATORY INFECTIONS &         1.6439          6.6          8.4
                                                INFLAMMATIONS AGE >17 W
                                                CC.
80.............       04  MED                  RESPIRATORY INFECTIONS &          .8980          4.5          5.6
                                                INFLAMMATIONS AGE >17 W/O
                                                CC.
81.............       04  MED                  * RESPIRATORY INFECTIONS &       1.5196          6.1          6.1
                                                INFLAMMATIONS AGE 0-17.
82.............       04  MED                  RESPIRATORY NEOPLASMS.....       1.3656          5.2          7.0
83.............       04  MED                  MAJOR CHEST TRAUMA W CC...        .9796          4.3          5.5
84.............       04  MED                  MAJOR CHEST TRAUMA W/O CC.        .5278          2.6          3.2
85.............       04  MED                  PLEURAL EFFUSION W CC.....       1.2421          5.0          6.5
86.............       04  MED                  PLEURAL EFFUSION W/O CC...        .6724          2.9          3.8
87.............       04  MED                  PULMONARY EDEMA &                1.3694          4.8          6.3
                                                RESPIRATORY FAILURE.
88.............       04  MED                  CHRONIC OBSTRUCTIVE               .9406          4.3          5.3
                                                PULMONARY DISEASE.
89.............       04  MED                  SIMPLE PNEUMONIA &               1.0855          5.1          6.1
                                                PLEURISY AGE >17 W CC.
90.............       04  MED                  SIMPLE PNEUMONIA &                .6734          3.7          4.3
                                                PLEURISY AGE >17 W/O CC.
91.............       04  MED                  SIMPLE PNEUMONIA &                .6334          3.3          4.0
                                                PLEURISY AGE 0-17.
92.............       04  MED                  INTERSTITIAL LUNG DISEASE        1.1786          5.0          6.3
                                                W CC.
93.............       04  MED                  INTERSTITIAL LUNG DISEASE         .7644          3.5          4.3
                                                W/O CC.
94.............       04  MED                  PNEUMOTHORAX W CC.........       1.1910          4.8          6.4
95.............       04  MED                  PNEUMOTHORAX W/O CC.......        .5944          2.9          3.6
96.............       04  MED                  BRONCHITIS & ASTHMA AGE           .7943          3.9          4.8
                                                >17 W CC.
97.............       04  MED                  BRONCHITIS & ASTHMA AGE           .5954          3.1          3.7
                                                >17 W/O CC.
98.............       04  MED                  BRONCHITIS & ASTHMA AGE 0-        .6859          3.3          4.5
                                                17.
99.............       04  MED                  RESPIRATORY SIGNS &               .6817          2.4          3.1
                                                SYMPTOMS W CC.
100............       04  MED                  RESPIRATORY SIGNS &               .5268          1.8          2.2
                                                SYMPTOMS W/O CC.
101............       04  MED                  OTHER RESPIRATORY SYSTEM          .8490          3.3          4.4
                                                DIAGNOSES W CC.
102............       04  MED                  OTHER RESPIRATORY SYSTEM          .5349          2.1          2.7
                                                DIAGNOSES W/O CC.
103............       05  SURG                 HEART TRANSPLANT..........      19.5100         35.7         56.5
104............       05  SURG                 CARDIAC VALVE & OTHER            7.2361          9.3         11.9
                                                MAJOR CARDIOTHORACIC PROC
                                                W CARDIAC CATH.
105............       05  SURG                 CARDIAC VALVE & OTHER            5.6607          7.6          9.4
                                                MAJOR CARDIOTHORACIC PROC
                                                W/O CARDIAC CATH.
106............       05  SURG                 CORONARY BYPASS W PTCA....       7.3334          9.1         10.9
107............       05  SURG                 CORONARY BYPASS W CARDIAC        5.4639          9.3         10.5
                                                CATH.
108............       05  SURG                 OTHER CARDIOTHORACIC             5.7715          8.3         11.0
                                                PROCEDURES.
109............       05  SURG                 CORONARY BYPASS W/O PTCA         4.0403          6.9          7.8
                                                OR CARDIAC CATH.
110............       05  SURG                 MAJOR CARDIOVASCULAR             4.1600          7.2          9.6
                                                PROCEDURES W CC.
111............       05  SURG                 MAJOR CARDIOVASCULAR             2.2267          4.9          5.7
                                                PROCEDURES W/O CC.
112............       05  SURG                 PERCUTANEOUS                     1.9222          2.7          3.8
                                                CARDIOVASCULAR PROCEDURES.
113............       05  SURG                 AMPUTATION FOR CIRC SYSTEM       2.7283          9.5         12.6
                                                DISORDERS EXCEPT UPPER
                                                LIMB & TOE.
114............       05  SURG                 UPPER LIMB & TOE                 1.5555          6.0          8.2
                                                AMPUTATION FOR CIRC
                                                SYSTEM DISORDERS.
115............       05  SURG                 PRM CARD PACEM IMPL W AMI,       3.4727          6.2          8.4
                                                HRT FAIL OR SHK, OR AICD
                                                LEAD OR GNRTR PR.
116............       05  SURG                 OTH PERM CARD PACEMAK IMPL       2.4651          2.8          3.9
                                                OR PTCA W CORONARY ARTERY
                                                STENT IMPLNT.
117............       05  SURG                 CARDIAC PACEMAKER REVISION       1.2931          2.7          4.1
                                                EXCEPT DEVICE REPLACEMENT.
118............       05  SURG                 CARDIAC PACEMAKER DEVICE         1.5480          2.0          2.9
                                                REPLACEMENT.
119............       05  SURG                 VEIN LIGATION & STRIPPING.       1.2297          3.0          4.9
120............       05  SURG                 OTHER CIRCULATORY SYSTEM         2.0136          5.0          8.2
                                                O.R. PROCEDURES.
121............       05  MED                  CIRCULATORY DISORDERS W          1.6295          5.6          6.8
                                                AMI & MAJOR COMP,
                                                DISCHARGED ALIVE.
122............       05  MED                  CIRCULATORY DISORDERS W          1.1063          3.4          4.2
                                                AMI W/O MAJOR COMP,
                                                DISCHARGED ALIVE.
123............       05  MED                  CIRCULATORY DISORDERS W          1.5108          2.7          4.4
                                                AMI, EXPIRED.
124............       05  MED                  CIRCULATORY DISORDERS            1.4020          3.4          4.5
                                                EXCEPT AMI, W CARD CATH &
                                                COMPLEX DIAG.
125............       05  MED                  CIRCULATORY DISORDERS            1.0436          2.2          2.8
                                                EXCEPT AMI, W CARD CATH W/
                                                O COMPLEX DIAG.
126............       05  MED                  ACUTE & SUBACUTE                 2.5170          9.3         12.1
                                                ENDOCARDITIS.
127............       05  MED                  HEART FAILURE & SHOCK.....       1.0144          4.2          5.4
128............       05  MED                  DEEP VEIN THROMBOPHLEBITIS        .7645          5.1          5.9
129............       05  MED                  CARDIAC ARREST,                  1.0770          1.8          2.8
                                                UNEXPLAINED.
130............       05  MED                  PERIPHERAL VASCULAR               .9469          4.7          5.9
                                                DISORDERS W CC.

[[Page 41599]]

 
131............       05  MED                  PERIPHERAL VASCULAR               .6050          3.7          4.5
                                                DISORDERS W/O CC.
132............       05  MED                  ATHEROSCLEROSIS W CC......        .6713          2.5          3.1
133............       05  MED                  ATHEROSCLEROSIS W/O CC....        .5675          1.9          2.4
134............       05  MED                  HYPERTENSION..............        .5846          2.6          3.3
135............       05  MED                  CARDIAC CONGENITAL &              .8704          3.3          4.4
                                                VALVULAR DISORDERS AGE
                                                17 W CC.
136............       05  MED                  CARDIAC CONGENITAL &              .6004          2.3          2.9
                                                VALVULAR DISORDERS AGE
                                                17 W/O CC.
137............       05  MED                  * CARDIAC CONGENITAL &            .8188          3.3          3.3
                                                VALVULAR DISORDERS AGE 0-
                                                17.
138............       05  MED                  CARDIAC ARRHYTHMIA &              .8154          3.1          4.0
                                                CONDUCTION DISORDERS W CC.
139............       05  MED                  CARDIAC ARRHYTHMIA &              .5079          2.1          2.5
                                                CONDUCTION DISORDERS W/O
                                                CC.
140............       05  MED                  ANGINA PECTORIS...........        .5829          2.3          2.8
141............       05  MED                  SYNCOPE & COLLAPSE W CC...        .7091          2.9          3.7
142............       05  MED                  SYNCOPE & COLLAPSE W/O CC.        .5419          2.2          2.7
143............       05  MED                  CHEST PAIN................        .5342          1.8          2.2
144............       05  MED                  OTHER CIRCULATORY SYSTEM         1.1526          3.8          5.4
                                                DIAGNOSES W CC.
145............       05  MED                  OTHER CIRCULATORY SYSTEM          .6497          2.2          2.8
                                                DIAGNOSES W/O CC.
146............       06  SURG                 RECTAL RESECTION W CC.....       2.7862          9.1         10.3
147............       06  SURG                 RECTAL RESECTION W/O CC...       1.6382          6.1          6.7
148............       06  SURG                 MAJOR SMALL & LARGE BOWEL        3.4289         10.1         12.1
                                                PROCEDURES W CC.
149............       06  SURG                 MAJOR SMALL & LARGE BOWEL        1.5723          6.2          6.7
                                                PROCEDURES W/O CC.
150............       06  SURG                 PERITONEAL ADHESIOLYSIS W        2.8098          9.0         11.0
                                                CC.
151............       06  SURG                 PERITONEAL ADHESIOLYSIS W/       1.3437          4.9          6.0
                                                O CC.
152............       06  SURG                 MINOR SMALL & LARGE BOWEL        1.9606          6.9          8.3
                                                PROCEDURES W CC.
153............       06  SURG                 MINOR SMALL & LARGE BOWEL        1.2170          5.0          5.6
                                                PROCEDURES W/O CC.
154............       06  SURG                 STOMACH, ESOPHAGEAL &            4.1335         10.1         13.2
                                                DUODENAL PROCEDURES AGE
                                                >17 W CC.
155............       06  SURG                 STOMACH, ESOPHAGEAL &            1.3781          3.5          4.5
                                                DUODENAL PROCEDURES AGE
                                                >17 W/O CC.
156............       06  SURG                 * STOMACH, ESOPHAGEAL &           .8432          6.0          6.0
                                                DUODENAL PROCEDURES AGE 0-
                                                17.
157............       06  SURG                 ANAL & STOMAL PROCEDURES W       1.2392          4.0          5.6
                                                CC.
158............       06  SURG                 ANAL & STOMAL PROCEDURES W/       .6561          2.1          2.6
                                                O CC.
159............       06  SURG                 HERNIA PROCEDURES EXCEPT         1.3097          3.7          5.0
                                                INGUINAL & FEMORAL AGE
                                                >17 W CC.
160............       06  SURG                 HERNIA PROCEDURES EXCEPT          .7801          2.2          2.7
                                                INGUINAL & FEMORAL AGE
                                                >17 W/O CC.
161............       06  SURG                 INGUINAL & FEMORAL HERNIA        1.0976          2.9          4.2
                                                PROCEDURES AGE >17 W CC.
162............       06  SURG                 INGUINAL & FEMORAL HERNIA         .6283          1.6          2.0
                                                PROCEDURES AGE >17 W/O CC.
163............       06  SURG                 * HERNIA PROCEDURES AGE 0-        .8720          2.1          2.1
                                                17.
164............       06  SURG                 APPENDECTOMY W COMPLICATED       2.3463          7.3          8.5
                                                PRINCIPAL DIAG W CC.
165............       06  SURG                 APPENDECTOMY W COMPLICATED       1.2655          4.4          4.9
                                                PRINCIPAL DIAG W/O CC.
166............       06  SURG                 APPENDECTOMY W/O                 1.4788          4.1          5.1
                                                COMPLICATED PRINCIPAL
                                                DIAG W CC.
167............       06  SURG                 APPENDECTOMY W/O                  .8995          2.4          2.8
                                                COMPLICATED PRINCIPAL
                                                DIAG W/O CC.
168............       03  SURG                 MOUTH PROCEDURES W CC.....       1.2039          3.3          4.6
169............       03  SURG                 MOUTH PROCEDURES W/O CC...        .7492          1.9          2.5
170............       06  SURG                 OTHER DIGESTIVE SYSTEM           2.8435          7.8         11.3
                                                O.R. PROCEDURES W CC.
171............       06  SURG                 OTHER DIGESTIVE SYSTEM           1.2556          3.6          4.8
                                                O.R. PROCEDURES W/O CC.
172............       06  MED                  DIGESTIVE MALIGNANCY W CC.       1.3144          5.1          6.9
173............       06  MED                  DIGESTIVE MALIGNANCY W/O          .7123          2.7          3.8
                                                CC.
174............       06  MED                  G.I. HEMORRHAGE W CC......        .9981          3.9          4.9
175............       06  MED                  G.I. HEMORRHAGE W/O CC....        .5456          2.5          2.9
176............       06  MED                  COMPLICATED PEPTIC ULCER..       1.0968          4.1          5.3
177............       06  MED                  UNCOMPLICATED PEPTIC ULCER        .8802          3.7          4.5
                                                W CC.
178............       06  MED                  UNCOMPLICATED PEPTIC ULCER        .6502          2.6          3.2
                                                W/O CC.
179............       06  MED                  INFLAMMATORY BOWEL DISEASE       1.0869          4.8          6.2
180............       06  MED                  G.I. OBSTRUCTION W CC.....        .9206          4.2          5.4
181............       06  MED                  G.I. OBSTRUCTION W/O CC...        .5277          2.8          3.4
182............       06  MED                  ESOPHAGITIS, GASTROENT &          .7821          3.4          4.3
                                                MISC DIGEST. DISORDERS
                                                AGE >17 W CC.
183............       06  MED                  ESOPHAGITIS, GASTROENT &          .5710          2.4          3.0
                                                MISC DIGEST. DISORDERS
                                                AGE >17 W/O CC.
184............       06  MED                  ESOPHAGITIS, GASTROENT &          .5286          2.3          3.0
                                                MISC DIGEST. DISORDERS
                                                AGE 0-17.
185............       03  MED                  DENTAL & ORAL DIS EXCEPT          .8593          3.3          4.5
                                                EXTRACTIONS &
                                                RESTORATIONS, AGE >17.
186............       03  MED                  * DENTAL & ORAL DIS EXCEPT        .3214          2.9          2.9
                                                EXTRACTIONS &
                                                RESTORATIONS, AGE 0-17.
187............       03  MED                  DENTAL EXTRACTIONS &              .7790          2.9          3.9
                                                RESTORATIONS.
188............       06  MED                  OTHER DIGESTIVE SYSTEM           1.0942          4.1          5.6
                                                DIAGNOSES AGE >17 W CC.

[[Page 41600]]

 
189............       06  MED                  OTHER DIGESTIVE SYSTEM            .5831          2.4          3.2
                                                DIAGNOSES AGE >17 W/O CC.
190............       06  MED                  OTHER DIGESTIVE SYSTEM           1.0011          3.9          5.6
                                                DIAGNOSES AGE 0-17.
191............       07  SURG                 PANCREAS, LIVER & SHUNT          4.3837         10.6         14.2
                                                PROCEDURES W CC.
192............       07  SURG                 PANCREAS, LIVER & SHUNT          1.8454          5.7          7.0
                                                PROCEDURES W/O CC.
193............       07  SURG                 BILIARY TRACT PROC EXCEPT        3.4161         10.3         12.6
                                                ONLY CHOLECYST W OR W/O
                                                C.D.E. W CC.
194............       07  SURG                 BILIARY TRACT PROC EXCEPT        1.6401          5.4          6.6
                                                ONLY CHOLECYST W OR W/O
                                                C.D.E. W/O CC.
195............       07  SURG                 CHOLECYSTECTOMY W C.D.E. W       2.9359          8.4         10.0
                                                CC.
196............       07  SURG                 CHOLECYSTECTOMY W C.D.E. W/      1.6554          4.9          5.7
                                                O CC.
197............       07  SURG                 CHOLECYSTECTOMY EXCEPT BY        2.4183          7.1          8.6
                                                LAPAROSCOPE W/O C.D.E. W
                                                CC.
198............       07  SURG                 CHOLECYSTECTOMY EXCEPT BY        1.2324          3.9          4.5
                                                LAPAROSCOPE W/O C.D.E. W/
                                                O CC.
199............       07  SURG                 HEPATOBILIARY DIAGNOSTIC         2.3317          7.1          9.6
                                                PROCEDURE FOR MALIGNANCY.
200............       07  SURG                 HEPATOBILIARY DIAGNOSTIC         3.0708          7.2         11.1
                                                PROCEDURE FOR NON-
                                                MALIGNANCY.
201............       07  SURG                 OTHER HEPATOBILIARY OR           3.5838         10.3         14.1
                                                PANCREAS O.R. PROCEDURES.
202............       07  MED                  CIRRHOSIS & ALCOHOLIC            1.3188          5.0          6.6
                                                HEPATITIS.
203............       07  MED                  MALIGNANCY OF                    1.3046          5.0          6.7
                                                HEPATOBILIARY SYSTEM OR
                                                PANCREAS.
204............       07  MED                  DISORDERS OF PANCREAS            1.2161          4.6          6.0
                                                EXCEPT MALIGNANCY.
205............       07  MED                  DISORDERS OF LIVER EXCEPT        1.1816          4.7          6.4
                                                MALIG, CIRR, ALC HEPA W
                                                CC.
206............       07  MED                  DISORDERS OF LIVER EXCEPT         .7163          3.1          4.1
                                                MALIG, CIRR, ALC HEPA W/O
                                                CC.
207............       07  MED                  DISORDERS OF THE BILIARY         1.1013          4.0          5.2
                                                TRACT W CC.
208............       07  MED                  DISORDERS OF THE BILIARY          .6455          2.3          2.9
                                                TRACT W/O CC.
209............       08  SURG                 MAJOR JOINT & LIMB               2.1175          4.6          5.2
                                                REATTACHMENT PROCEDURES
                                                OF LOWER EXTREMITY.
210............       08  SURG                 HIP & FEMUR PROCEDURES           1.8028          5.9          6.8
                                                EXCEPT MAJOR JOINT AGE
                                                >17 W CC.
211............       08  SURG                 HIP & FEMUR PROCEDURES           1.2609          4.5          4.9
                                                EXCEPT MAJOR JOINT AGE
                                                >17 W/O CC.
212............       08  SURG                 * HIP & FEMUR PROCEDURES          .8468         11.1         11.1
                                                EXCEPT MAJOR JOINT AGE 0-
                                                17.
213............       08  SURG                 AMPUTATION FOR                   1.7130          6.1          8.3
                                                MUSCULOSKELETAL SYSTEM &
                                                CONN TISSUE DISORDERS.
214............       08  SURG                 NO LONGER VALID...........        .0000           .0           .0
215............       08  SURG                 NO LONGER VALID...........        .0000           .0           .0
216............       08  SURG                 BIOPSIES OF                      2.1400          6.9          9.6
                                                MUSCULOSKELETAL SYSTEM &
                                                CONNECTIVE TISSUE.
217............       08  SURG                 WND DEBRID & SKN GRFT            2.8006          8.6         12.6
                                                EXCEPT HAND, FOR
                                                MUSCSKELET & CONN TISS
                                                DIS.
218............       08  SURG                 LOWER EXTREM & HUMER PROC        1.4900          4.2          5.3
                                                EXCEPT HIP, FOOT, FEMUR
                                                AGE >17 W CC.
219............       08  SURG                 LOWER EXTREM & HUMER PROC        1.0117          2.7          3.2
                                                EXCEPT HIP, FOOT, FEMUR
                                                AGE >17 W/O CC.
220............       08  SURG                 * LOWER EXTREM & HUMER            .5841          5.3          5.3
                                                PROC EXCEPT HIP, FOOT,
                                                FEMUR AGE 0-17.
221............       08  SURG                 NO LONGER VALID...........        .0000           .0           .0
222............       08  SURG                 NO LONGER VALID...........        .0000           .0           .0
223............       08  SURG                 MAJOR SHOULDER/ELBOW PROC,        .9378          2.0          2.6
                                                OR OTHER UPPER EXTREMITY
                                                PROC W CC.
224............       08  SURG                 SHOULDER, ELBOW OR FOREARM        .8042          1.7          2.0
                                                PROC, EXC MAJOR JOINT
                                                PROC, W/O CC.
225............       08  SURG                 FOOT PROCEDURES...........       1.0518          3.2          4.5
226............       08  SURG                 SOFT TISSUE PROCEDURES W         1.4383          4.1          6.0
                                                CC.
227............       08  SURG                 SOFT TISSUE PROCEDURES W/O        .8181          2.1          2.8
                                                CC.
228............       08  SURG                 MAJOR THUMB OR JOINT PROC,       1.0516          2.4          3.6
                                                OR OTH HAND OR WRIST PROC
                                                W CC.
229............       08  SURG                 HAND OR WRIST PROC, EXCEPT        .7348          1.9          2.4
                                                MAJOR JOINT PROC, W/O CC.
230............       08  SURG                 LOCAL EXCISION & REMOVAL         1.1722          3.2          4.8
                                                OF INT FIX DEVICES OF HIP
                                                & FEMUR.
231............       08  SURG                 LOCAL EXCISION & REMOVAL         1.3623          3.1          4.6
                                                OF INT FIX DEVICES EXCEPT
                                                HIP & FEMUR.
232............       08  SURG                 ARTHROSCOPY...............       1.1567          2.4          4.1
233............       08  SURG                 OTHER MUSCULOSKELET SYS &        2.0424          5.3          7.5
                                                CONN TISS O.R. PROC W CC.
234............       08  SURG                 OTHER MUSCULOSKELET SYS &        1.2450          2.7          3.5
                                                CONN TISS O.R. PROC W/O
                                                CC.
235............       08  MED                  FRACTURES OF FEMUR........        .7479          3.8          5.1
236............       08  MED                  FRACTURES OF HIP & PELVIS.        .7157          3.9          5.0
237............       08  MED                  SPRAINS, STRAINS, &               .5451          2.9          3.6
                                                DISLOCATIONS OF HIP,
                                                PELVIS & THIGH.

[[Page 41601]]

 
238............       08  MED                  OSTEOMYELITIS.............       1.2831          6.4          8.4
239............       08  MED                  PATHOLOGICAL FRACTURES &          .9660          4.9          6.3
                                                MUSCULOSKELETAL & CONN
                                                TISS MALIGNANCY.
240............       08  MED                  CONNECTIVE TISSUE                1.2328          5.0          6.7
                                                DISORDERS W CC.
241............       08  MED                  CONNECTIVE TISSUE                 .6089          3.2          4.0
                                                DISORDERS W/O CC.
242............       08  MED                  SEPTIC ARTHRITIS..........       1.0168          5.1          6.7
243............       08  MED                  MEDICAL BACK PROBLEMS.....        .7164          3.7          4.7
244............       08  MED                  BONE DISEASES & SPECIFIC          .7024          3.8          4.8
                                                ARTHROPATHIES W CC.
245............       08  MED                  BONE DISEASES & SPECIFIC          .4801          2.8          3.6
                                                ARTHROPATHIES W/O CC.
246............       08  MED                  NON-SPECIFIC ARTHROPATHIES        .5545          3.0          3.7
247............       08  MED                  SIGNS & SYMPTOMS OF               .5563          2.6          3.4
                                                MUSCULOSKELETAL SYSTEM &
                                                CONN TISSUE.
248............       08  MED                  TENDONITIS, MYOSITIS &            .7554          3.6          4.6
                                                BURSITIS.
249............       08  MED                  AFTERCARE, MUSCULOSKELETAL        .6504          2.5          3.5
                                                SYSTEM & CONNECTIVE
                                                TISSUE.
250............       08  MED                  FX, SPRN, STRN & DISL OF          .6700          3.2          4.1
                                                FOREARM, HAND, FOOT AGE
                                                >17 W CC.
251............       08  MED                  FX, SPRN, STRN & DISL OF          .4608          2.3          2.9
                                                FOREARM, HAND, FOOT AGE
                                                >17 W/O CC.
252............       08  MED                  * FX, SPRN, STRN & DISL OF        .2537          1.8          1.8
                                                FOREARM, HAND, FOOT AGE 0-
                                                17.
253............       08  MED                  FX, SPRN, STRN & DISL OF          .7261          3.7          4.8
                                                UPARM, LOWLEG EX FOOT AGE
                                                >17 W CC.
254............       08  MED                  FX, SPRN, STRN & DISL OF          .4339          2.6          3.2
                                                UPARM, LOWLEG EX FOOT AGE
                                                >17 W/O CC.
255............       08  MED                  * FX, SPRN, STRN & DISL OF        .2954          2.9          2.9
                                                UPARM, LOWLEG EX FOOT AGE
                                                0-17.
256............       08  MED                  OTHER MUSCULOSKELETAL             .7687          3.8          5.1
                                                SYSTEM & CONNECTIVE
                                                TISSUE DIAGNOSES.
257............       09  SURG                 TOTAL MASTECTOMY FOR              .9134          2.3          2.9
                                                MALIGNANCY W CC.
258............       09  SURG                 TOTAL MASTECTOMY FOR              .7227          1.8          2.1
                                                MALIGNANCY W/O CC.
259............       09  SURG                 SUBTOTAL MASTECTOMY FOR           .8673          1.9          2.8
                                                MALIGNANCY W CC.
260............       09  SURG                 SUBTOTAL MASTECTOMY FOR           .6444          1.3          1.5
                                                MALIGNANCY W/O CC.
261............       09  SURG                 BREAST PROC FOR NON-              .9188          1.7          2.2
                                                MALIGNANCY EXCEPT BIOPSY
                                                & LOCAL EXCISION.
262............       09  SURG                 BREAST BIOPSY & LOCAL             .8392          2.7          3.9
                                                EXCISION FOR NON-
                                                MALIGNANCY.
263............       09  SURG                 SKIN GRAFT &/OR DEBRID FOR       2.0609          8.7         11.8
                                                SKN ULCER OR CELLULITIS W
                                                CC.
264............       09  SURG                 SKIN GRAFT &/OR DEBRID FOR       1.1216          5.3          7.1
                                                SKN ULCER OR CELLULITIS W/
                                                O CC.
265............       09  SURG                 SKIN GRAFT &/OR DEBRID           1.5650          4.4          7.0
                                                EXCEPT FOR SKIN ULCER OR
                                                CELLULITIS W CC.
266............       09  SURG                 SKIN GRAFT &/OR DEBRID            .8495          2.4          3.3
                                                EXCEPT FOR SKIN ULCER OR
                                                CELLULITIS W/O CC.
267............       09  SURG                 PERIANAL & PILONIDAL              .9815          2.9          4.1
                                                PROCEDURES.
268............       09  SURG                 SKIN, SUBCUTANEOUS TISSUE        1.1979          2.4          3.8
                                                & BREAST PLASTIC
                                                PROCEDURES.
269............       09  SURG                 OTHER SKIN, SUBCUT TISS &        1.6147          5.6          7.9
                                                BREAST PROC W CC.
270............       09  SURG                 OTHER SKIN, SUBCUT TISS &         .7447          2.2          3.1
                                                BREAST PROC W/O CC.
271............       09  MED                  SKIN ULCERS...............        .9905          5.6          7.1
272............       09  MED                  MAJOR SKIN DISORDERS W CC.       1.0003          4.8          6.3
273............       09  MED                  MAJOR SKIN DISORDERS W/O          .6275          3.3          4.4
                                                CC.
274............       09  MED                  MALIGNANT BREAST DISORDERS       1.1335          4.7          6.6
                                                W CC.
275............       09  MED                  MALIGNANT BREAST DISORDERS        .6322          2.6          3.9
                                                W/O CC.
276............       09  MED                  NON-MALIGANT BREAST               .6529          3.5          4.4
                                                DISORDERS.
277............       09  MED                  CELLULITIS AGE >17 W CC...        .8312          4.7          5.8
278............       09  MED                  CELLULITIS AGE >17 W/O CC.        .5621          3.7          4.4
279............       09  MED                  CELLULITIS AGE 0-17.......        .6641          4.1          5.1
280............       09  MED                  TRAUMA TO THE SKIN, SUBCUT        .6736          3.3          4.2
                                                TISS & BREAST AGE >17 W
                                                CC.
281............       09  MED                  TRAUMA TO THE SKIN, SUBCUT        .4596          2.4          3.1
                                                TISS & BREAST AGE >17 W/O
                                                CC.
282............       09  MED                  * TRAUMA TO THE SKIN,             .2569          2.2          2.2
                                                SUBCUT TISS & BREAST AGE
                                                0-17.
283............       09  MED                  MINOR SKIN DISORDERS W CC.        .7129          3.6          4.7
284............       09  MED                  MINOR SKIN DISORDERS W/O          .4373          2.5          3.2
                                                CC.
285............       10  SURG                 AMPUTAT OF LOWER LIMB FOR        2.0217          7.7         10.6
                                                ENDOCRINE, NUTRIT, &
                                                METABOL DISORDERS.
286............       10  SURG                 ADRENAL & PITUITARY              2.2287          5.2          6.6
                                                PROCEDURES.
287............       10  SURG                 SKIN GRAFTS & WOUND DEBRID       1.8045          7.4         10.4
                                                FOR ENDOC, NUTRIT & METAB
                                                DISORDERS.
288............       10  SURG                 O.R. PROCEDURES FOR              2.0665          4.6          5.7
                                                OBESITY.
289............       10  SURG                 PARATHYROID PROCEDURES....        .9756          2.1          3.0

[[Page 41602]]

 
290............       10  SURG                 THYROID PROCEDURES........        .9174          1.9          2.4
291............       10  SURG                 THYROGLOSSAL PROCEDURES...        .6732          1.6          2.0
292............       10  SURG                 OTHER ENDOCRINE, NUTRIT &        2.4719          7.1         10.4
                                                METAB O.R. PROC W CC.
293............       10  SURG                 OTHER ENDOCRINE, NUTRIT &        1.1942          3.5          5.0
                                                METAB O.R. PROC W/O CC.
294............       10  MED                  DIABETES AGE >35..........        .7518          3.7          4.7
295............       10  MED                  DIABETES AGE 0-35.........        .7464          3.0          3.9
296............       10  MED                  NUTRITIONAL & MISC                .8556          4.0          5.3
                                                METABOLIC DISORDERS AGE
                                                >17 W CC.
297............       10  MED                  NUTRITIONAL & MISC                .5204          2.8          3.5
                                                METABOLIC DISORDERS AGE
                                                >17 W/O CC.
298............       10  MED                  NUTRITIONAL & MISC                .4954          2.4          3.5
                                                METABOLIC DISORDERS AGE 0-
                                                17.
299............       10  MED                  INBORN ERRORS OF                  .9475          3.8          5.4
                                                METABOLISM.
300............       10  MED                  ENDOCRINE DISORDERS W CC..       1.0779          4.8          6.2
301............       10  MED                  ENDOCRINE DISORDERS W/O CC        .5889          2.8          3.6
302............       11  SURG                 KIDNEY TRANSPLANT.........       3.5669          8.2          9.7
303............       11  SURG                 KIDNEY, URETER & MAJOR           2.5401          7.2          8.8
                                                BLADDER PROCEDURES FOR
                                                NEOPLASM.
304............       11  SURG                 KIDNEY, URETER & MAJOR           2.3458          6.5          8.9
                                                BLADDER PROC FOR NON-
                                                NEOPL W CC.
305............       11  SURG                 KIDNEY, URETER & MAJOR           1.1857          3.2          3.9
                                                BLADDER PROC FOR NON-
                                                NEOPL W/O CC.
306............       11  SURG                 PROSTATECTOMY W CC........       1.2448          3.7          5.4
307............       11  SURG                 PROSTATECTOMY W/O CC......        .6588          2.0          2.4
308............       11  SURG                 MINOR BLADDER PROCEDURES W       1.5907          4.1          6.1
                                                CC.
309............       11  SURG                 MINOR BLADDER PROCEDURES W/       .9442          2.0          2.5
                                                O CC.
310............       11  SURG                 TRANSURETHRAL PROCEDURES W       1.0869          3.0          4.3
                                                CC.
311............       11  SURG                 TRANSURETHRAL PROCEDURES W/       .6126          1.6          1.9
                                                O CC.
312............       11  SURG                 URETHRAL PROCEDURES, AGE         1.0270          3.1          4.6
                                                >17 W CC.
313............       11  SURG                 URETHRAL PROCEDURES, AGE          .6640          1.8          2.4
                                                >17 W/O CC.
314............       11  SURG                 * URETHRAL PROCEDURES, AGE        .4950          2.3          2.3
                                                0-17.
315............       11  SURG                 OTHER KIDNEY & URINARY           2.0660          4.5          7.8
                                                TRACT O.R. PROCEDURES.
316............       11  MED                  RENAL FAILURE.............       1.3380          4.9          6.7
317............       11  MED                  ADMIT FOR RENAL DIALYSIS..        .6965          2.1          3.2
318............       11  MED                  KIDNEY & URINARY TRACT           1.1413          4.4          6.0
                                                NEOPLASMS W CC.
319............       11  MED                  KIDNEY & URINARY TRACT            .6187          2.1          2.9
                                                NEOPLASMS W/O CC.
320............       11  MED                  KIDNEY & URINARY TRACT            .8647          4.4          5.4
                                                INFECTIONS AGE >17 W CC.
321............       11  MED                  KIDNEY & URINARY TRACT            .5785          3.3          3.9
                                                INFECTIONS AGE >17 W/O CC.
322............       11  MED                  KIDNEY & URINARY TRACT            .5606          3.0          3.7
                                                INFECTIONS AGE 0-17.
323............       11  MED                  URINARY STONES W CC, &/OR         .7816          2.4          3.2
                                                ESW LITHOTRIPSY.
324............       11  MED                  URINARY STONES W/O CC.....        .4475          1.6          1.9
325............       11  MED                  KIDNEY & URINARY TRACT            .6287          3.0          3.9
                                                SIGNS & SYMPTOMS AGE >17
                                                W CC.
326............       11  MED                  KIDNEY & URINARY TRACT            .4203          2.2          2.7
                                                SIGNS & SYMPTOMS AGE >17
                                                W/O CC.
327............       11  MED                  * KIDNEY & URINARY TRACT          .3541          3.1          3.1
                                                SIGNS & SYMPTOMS AGE 0-17.
328............       11  MED                  URETHRAL STRICTURE AGE >17        .7024          2.7          3.7
                                                W CC.
329............       11  MED                  URETHRAL STRICTURE AGE >17        .5172          1.7          2.4
                                                W/O CC.
330............       11  MED                  * URETHRAL STRICTURE AGE 0-       .3189          1.6          1.6
                                                17.
331............       11  MED                  OTHER KIDNEY & URINARY           1.0157          4.1          5.5
                                                TRACT DIAGNOSES AGE >17 W
                                                CC.
332............       11  MED                  OTHER KIDNEY & URINARY            .6104          2.6          3.4
                                                TRACT DIAGNOSES AGE >17 W/
                                                O CC.
333............       11  MED                  OTHER KIDNEY & URINARY            .7642          3.3          4.4
                                                TRACT DIAGNOSES AGE 0-17.
334............       12  SURG                 MAJOR MALE PELVIC                1.5864          4.3          5.0
                                                PROCEDURES W CC.
335............       12  SURG                 MAJOR MALE PELVIC                1.1911          3.3          3.5
                                                PROCEDURES W/O CC.
336............       12  SURG                 TRANSURETHRAL                     .8965          2.8          3.6
                                                PROSTATECTOMY W CC.
337............       12  SURG                 TRANSURETHRAL                     .6229          2.0          2.2
                                                PROSTATECTOMY W/O CC.
338............       12  SURG                 TESTES PROCEDURES, FOR           1.1552          3.3          5.1
                                                MALIGNANCY.
339............       12  SURG                 TESTES PROCEDURES, NON-          1.0600          2.9          4.5
                                                MALIGNANCY AGE >17.
340............       12  SURG                 * TESTES PROCEDURES, NON-         .2834          2.4          2.4
                                                MALIGNANCY AGE 0-17.
341............       12  SURG                 PENIS PROCEDURES..........       1.1141          2.1          3.2
342............       12  SURG                 CIRCUMCISION AGE >17......        .8601          2.6          3.5
343............       12  SURG                 * CIRCUMCISION AGE 0-17...        .1540          1.7          1.7
344............       12  SURG                 OTHER MALE REPRODUCTIVE          1.1025          1.6          2.4
                                                SYSTEM O.R. PROCEDURES
                                                FOR MALIGNANCY.
345............       12  SURG                 OTHER MALE REPRODUCTIVE           .8816          2.5          3.7
                                                SYSTEM O.R. PROC EXCEPT
                                                FOR MALIGNANCY.
346............       12  MED                  MALIGNANCY, MALE                  .9645          4.2          5.7
                                                REPRODUCTIVE SYSTEM, W CC.
347............       12  MED                  MALIGNANCY, MALE                  .5828          2.3          3.1
                                                REPRODUCTIVE SYSTEM, W/O
                                                CC.
348............       12  MED                  BENIGN PROSTATIC                  .6983          3.2          4.2
                                                HYPERTROPHY W CC.
349............       12  MED                  BENIGN PROSTATIC                  .4345          2.0          2.5
                                                HYPERTROPHY W/O CC.
350............       12  MED                  INFLAMMATION OF THE MALE          .6957          3.6          4.4
                                                REPRODUCTIVE SYSTEM.

[[Page 41603]]

 
351............       12  MED                  * STERILIZATION, MALE.....        .2363          1.3          1.3
352............       12  MED                  OTHER MALE REPRODUCTIVE           .6769          2.7          3.9
                                                SYSTEM DIAGNOSES.
353............       13  SURG                 PELVIC EVISCERATION,             1.9721          5.4          7.1
                                                RADICAL HYSTERECTOMY &
                                                RADICAL VULVECTOMY.
354............       13  SURG                 UTERINE,ADNEXA PROC FOR          1.5134          4.8          5.8
                                                NON-OVARIAN/ADNEXAL MALIG
                                                W CC.
355............       13  SURG                 UTERINE,ADNEXA PROC FOR           .9477          3.2          3.4
                                                NON-OVARIAN/ADNEXAL MALIG
                                                W/O CC.
356............       13  SURG                 FEMALE REPRODUCTIVE SYSTEM        .7916          2.2          2.6
                                                RECONSTRUCTIVE PROCEDURES.
357............       13  SURG                 UTERINE & ADNEXA PROC FOR        2.3699          7.0          8.7
                                                OVARIAN OR ADNEXAL
                                                MALIGNANCY.
358............       13  SURG                 UTERINE & ADNEXA PROC FOR        1.2357          3.7          4.4
                                                NON-MALIGNANCY W CC.
359...