[Federal Register Volume 70, Number 100 (Wednesday, May 25, 2005)]
[Proposed Rules]
[Pages 30188-30327]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-10264]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Part 412



Medicare Program; Inpatient Rehabilitation Facility Prospective Payment 
System for FY 2006; Proposed Rule

  Federal Register / Vol. 70, No. 100 / Wednesday, May 25, 2005 / 
Proposed Rules  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 412

[CMS-1290-P]
RIN 0938-AN43


Medicare Program; Inpatient Rehabilitation Facility Prospective 
Payment System for FY 2006

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would update the prospective payment rates 
for inpatient rehabilitation facilities for Federal fiscal year 2006 as 
required under section 1886(j)(3)(C) of the Social Security Act (the 
Act). Section 1886(j)(5) of the Act requires the Secretary to publish 
in the Federal Register on or before August 1 before each fiscal year, 
the classification and weighting factors for the inpatient 
rehabilitation facilities case-mix groups and a description of the 
methodology and data used in computing the prospective payment rates 
for that fiscal year.
    In addition, we are proposing new policies and are proposing to 
change existing policies regarding the prospective payment system 
within the authority granted under section 1886(j) of the Act.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on July 18, 2005.

ADDRESSES: In commenting, please refer to file code CMS-1290-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of three ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to http://www.cms.hhs.gov/regulations/ecomments. (Attachments should be in Microsoft Word, WordPerfect, or 
Excel; however, we prefer Microsoft Word.)
    2. By mail. You may mail written comments (one original and two 
copies) to the following address ONLY: Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Attention: CMS-1290-
P, P.O. Box 8010, Baltimore, MD 21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses. If you 
intend to deliver your comments to the Baltimore address, please call 
telephone number (410) 786-7195 in advance to schedule your arrival 
with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 
200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Pete Diaz, (410) 786-1235. Susanne 
Seagrave, (410) 786-0044. Mollie Knight, (410) 786-7984 for information 
regarding the market basket and labor-related share. August Nemec, 
(410) 786-0612 for information regarding the tier comorbidities. Zinnia 
Ng, (410) 786-4587 for information regarding the wage index and Core-
Based Statistical Areas (CBSAs).

SUPPLEMENTARY INFORMATION:
    Submitting Comments: We welcome comments from the public on all 
issues set forth in this rule to assist us in fully considering issues 
and developing policies. You can assist us by referencing the file code 
CMS-1290-P and the specific ``issue identifier'' that precedes the 
section on which you choose to comment.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. CMS posts all electronic 
comments received before the close of the comment period on its public 
Web site as soon as possible after they have been received. Hard copy 
comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, at the headquarters of the Centers for 
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, 
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 
p.m. To schedule an appointment to view public comments, phone 1-800-
743-3951.

Table of Contents

I. Background
A. General Overview of the Current Inpatient Rehabilitation Facility 
Prospective Payment System (IRF PPS)
B. Requirements for Updating the Prospective Payment Rates for IRFs
C. Operational Overview of the Current IRF PPS
D. Quality of Care in IRFs
E. Research to Support Refinements of the Current IRF PPS
F. Proposed Refinements to the IRF PPS for Fiscal Year 2006
II. Proposed Refinements to the Patient Classification System
A. Proposed Changes to the IRF Classification System
1. Development of the IRF Classification System
2. Description and Methodology Used to Develop the IRF 
Classification System in the August 7, 2001 Final Rule
a. Rehabilitation Impairment Categories
b. Functional Status Measures and Age
c. Comorbidities
d. Development of CMG Relative Weights
e. Overview of Development of the CMG Relative Weights
B. Proposed Changes to the Existing List of Tier Comorbidities
1. Proposed Changes To Remove Codes That Are Not Positively Related 
to Treatment Costs
2. Proposed Changes to Move Dialysis to Tier One
3. Proposed Changes to Move Comorbidity Codes Based on Their 
Marginal Cost
C. Proposed Changes to the CMGs
1. Proposed Changes for Updating the CMGs
2. Proposed Use of a Weighted Motor Score Index and Correction to 
the Treatment of Unobserved Transfer to Toilet Values
3. Proposed Changes for Updating the Relative Weights
III. Proposed FY 2006 Federal Prospective Payment Rates
A. Proposed Reduction of the Standard Payment Amount to Account for 
Coding Changes
B. Proposed Adjustments to Determine the Proposed FY 2006 Standard 
Payment Conversion Factor
1. Proposed Market Basket Used for IRF Market Basket Index
a. Overview of the Proposed RPL Market Basket
b. Proposed Methodology for Operating Portion of the Proposed RPL 
Market Basket
c. Proposed Methodology for Capital Proportion of the RPL Market 
Basket
d. Labor-Related Share
2. Proposed Area Wage Adjustment
a. Proposed Revisions of the IRF PPS Geographic Classification
b. Current IRF PPS Labor Market Areas Based on MSAs

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c. Core-Based Statistical Areas (CBSAs)
d. Proposed Revisions of the IRF PPS Labor Market Areas
i. New England MSAs
ii. Metropolitan Divisions
iii. Micropolitan Areas
e. Implementation of the Proposed Changes to Revise the Labor Market 
Areas
f. Wage Index Data
3. Proposed Teaching Status Adjustment
4. Proposed Adjustment for Rural Location
5. Proposed Adjustment for Disproportionate Share of Low-Income 
Patients
6. Proposed Update to the Outlier Threshold Amount
7. Proposed Budget Neutrality Factor Methodology for Fiscal Year 
2006
8. Description of the Methodology Used to Implement the Proposed 
Changes in a Budget Neutral Manner
9. Description of the Proposed IRF Standard Payment Conversion 
Factor for Fiscal Year 2006
10. Example of the Proposed Methodology for Adjusting the Federal 
Prospective Payment Rates
IV. Provisions of the Proposed Regulations
V. Collection of Information Requirements
VI. Response to Comments
VII. Regulatory Impact Analysis

Acronyms

    Because of the many terms to which we refer by acronym in this 
propose rule, we are listing the acronyms used and their corresponding 
terms in alphabetical order below.
ADC--Average Daily Census
AHA--American Hospital Association
AMI--Acute Myocardial Infarction
BBA--Balanced Budget Act of 1997 (BBA), Pub. L. 105-33
BBRA--Medicare, Medicaid, and SCHIP [State Children's Health Insurance 
Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113
BIPA--Medicare, Medicaid, and SCHIP [State Children's Health Insurance 
Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106-
554
BLS--Bureau of Labor Statistics
CART--Classification and Regression Trees
CBSA--Core-Based Statistical Areas
CCR--Cost-to-charge ratio
CMGs--Case-Mix Groups
CMI--Case Mix Index
CMSA--Consolidated Metropolitan Statistical Area
CPI--Consumer Price Index
DSH--Disproportionate Share Hospital
ECI--Employment Cost Index
FI--Fiscal Intermediary
FIM--Functional Independence Measure
FIM-FRGs--Functional Independence Measures--Function Related Groups
FRG--Function Related Group
FTE--Full-time equivalent
FY--Federal Fiscal Year
GME--Graduate Medical Education
HCRIS--Healthcare Cost Report Information System
HIPAA--Health Insurance Portability and Accountability Act
HHA--Home Health Agency
IME--Indirect Medical Education
IFMC--Iowa Foundation for Medical Care
IPF--Inpatient Psychiatric Facility
IPPS--Inpatient Prospective Payment System
IRF--Inpatient Rehabilitation Facility
IRF-PAI--Inpatient Rehabilitation Facility--Patient Assessment 
Instrument
IRF-PPS--Inpatient Rehabilitation Facility--Prospective Payment System
IRVEN--Inpatient Rehabilitation Validation and Entry
LIP--Low-income percentage
MEDPAR--Medicare Provider Analysis and Review
MSA--Metropolitan Statistical Area
NECMA--New England County Metropolitan Area
NOS--Not Otherwise Specified
NTIS--National Technical Information Service
OMB--Office of Management and Budget
OSCAR--Online Survey, Certification, and Reporting
PAI--Patient Assessment Instrument
PLI--Professional Liability Insurance
PMSA--Primary Metropolitan Statistical Area
PPI--Producer Price Index
PPS--Prospective Payment System
RIC--Rehabilitation Impairment Category
RPL--Rehabilitation Hospital, Psychiatric Hospital, and Long-Term Care 
Hospital Market Basket
TEFRA--Tax Equity and Fiscal Responsibility Act
TEP--Technical Expert Panel

I. Background

[If you choose to comment on issues in this section, please include the 
caption ``Background'' at the beginning of your comments.]

A. General Overview of the Current Inpatient Rehabilitation Facility 
Prospective Payment System (IRF PPS)

    Section 4421 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-
33), as amended by section 125 of the Medicare, Medicaid, and SCHIP 
[State Children's Health Insurance Program] Balanced Budget Refinement 
Act of 1999 (BBRA) (Pub. L. 106-113), and by section 305 of the 
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act 
of 2000 (BIPA) (Pub. L. 106-554), provides for the implementation of a 
per discharge prospective payment system (PPS), through section 1886(j) 
of the Social Security Act (the Act), for inpatient rehabilitation 
hospitals and inpatient rehabilitation units of a hospital (hereinafter 
referred to as IRFs).
    Payments under the IRF PPS encompass inpatient operating and 
capital costs of furnishing covered rehabilitation services (that is, 
routine, ancillary, and capital costs) but not costs of approved 
educational activities, bad debts, and other services or items outside 
the scope of the IRF PPS. Although a complete discussion of the IRF PPS 
provisions appears in the August 7, 2001 final rule, we are providing 
below a general description of the IRF PPS.
    The IRF PPS, as described in the August 7, 2001 final rule, uses 
Federal prospective payment rates across 100 distinct case-mix groups 
(CMGs). Ninety-five CMGs were constructed using rehabilitation 
impairment categories, functional status (both motor and cognitive), 
and age (in some cases, cognitive status and age may not be a factor in 
defining a CMG). Five special CMGs were constructed to account for very 
short stays and for patients who expire in the IRF.
    For each of the CMGs, we developed relative weighting factors to 
account for a patient's clinical characteristics and expected resource 
needs. Thus, the weighting factors account for the relative difference 
in resource use across all CMGs. Within each CMG, the weighting factors 
were ``tiered'' based on the estimated effects that certain 
comorbidities have on resource use.
    The Federal PPS rates were established using a standardized payment 
amount (previously referred to as the budget-neutral conversion 
factor). The standardized payment amount was previously called the 
budget neutral conversion factor because it reflected a budget 
neutrality adjustment for FYs 2001 and 2002, as described in Sec.  
412.624(d)(2). However, the statute requires a budget neutrality 
adjustment only for FYs 2001 and 2002. Accordingly, for subsequent 
years we believe it is more consistent with the statute to refer to the 
standardized payment as the standardized payment conversion factor, 
rather than refer to it as a budget neutral conversion factor (see 68 
FR 45674, 45684 and 45685). Therefore, we will refer to the 
standardized payment amount in this proposed rule as the standard 
payment conversion factor.
    For each of the tiers within a CMG, the relative weighting factors 
were

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applied to the standard payment conversion factor to compute the 
unadjusted Federal prospective payment rates. Under the current system, 
adjustments that accounted for geographic variations in wages (wage 
index), the percentage of low-income patients, and location in a rural 
area were applied to the IRF's unadjusted Federal prospective payment 
rates. In addition, adjustments were made to account for the early 
transfer of a patient, interrupted stays, and high cost outliers.
    Lastly, the IRF's final prospective payment amount was determined 
under the transition methodology prescribed in section 1886(j) of the 
Act. Specifically, for cost reporting periods that began on or after 
January 1, 2002 and before October 1, 2002, section 1886(j)(1) of the 
Act and as specified in Sec.  412.626 provides that IRFs transitioning 
into the PPS would receive a ``blended payment.'' For cost reporting 
periods that began on or after January 1, 2002 and before October 1, 
2002, these blended payments consisted of 66\2/3\ percent of the 
Federal IRF PPS rate and 33\1/3\ percent of the payment that the IRF 
would have been paid had the IRF PPS not been implemented. However, 
during the transition period, an IRF with a cost reporting period 
beginning on or after January 1, 2002 and before October 1, 2002 could 
have elected to bypass this blended payment and be paid 100 percent of 
the Federal IRF PPS rate. For cost reporting periods beginning on or 
after October 1, 2002 (FY 2003), the transition methodology expired, 
and payments for all IRFs consist of 100 percent of the Federal IRF PPS 
rate.
    We established a CMS Web site that contains useful information 
regarding the IRF PPS. The Web site URL is www.cms.hhs.gov/providers/irfpps/default.asp and may be accessed to download or view 
publications, software, and other information pertinent to the IRF PPS.

B. Requirements for Updating the Prospective Payment Rates for IRFs

    On August 7, 2001, we published a final rule entitled ``Medicare 
Program; Prospective Payment System for Inpatient Rehabilitation 
Facilities'' in the Federal Register (66 FR at 41316), that established 
a PPS for IRFs as authorized under section 1886(j) of the Act and 
codified at subpart P of part 412 of the Medicare regulations. In the 
August 7, 2001 final rule, we set forth the per discharge Federal 
prospective payment rates for fiscal year (FY) 2002 that provided 
payment for inpatient operating and capital costs of furnishing covered 
rehabilitation services (that is, routine, ancillary, and capital 
costs) but not costs of approved educational activities, bad debts, and 
other services or items that are outside the scope of the IRF PPS. The 
provisions of the August 7, 2001 final rule were effective for cost 
reporting periods beginning on or after January 1, 2002. On July 1, 
2002, we published a correcting amendment to the August 7, 2001 final 
rule in the Federal Register (67 FR at 44073). Any references to the 
August 7, 2001 final rule in this proposed rule include the provisions 
effective in the correcting amendment.
    Section 1886(j)(5) of the Act and Sec.  412.628 of the regulations 
require the Secretary to publish in the Federal Register, on or before 
August 1 of the preceding FY, the classifications and weighting factors 
for the IRF CMGs and a description of the methodology and data used in 
computing the prospective payment rates for the upcoming FY. On August 
1, 2002, we published a notice in the Federal Register (67 FR at 49928) 
to update the IRF Federal prospective payment rates from FY 2002 to FY 
2003 using the methodology as described in Sec.  412.624. As stated in 
the August 1, 2002 notice, we used the same classifications and 
weighting factors for the IRF CMGs that were set forth in the August 7, 
2001 final rule to update the IRF Federal prospective payment rates 
from FY 2002 to FY 2003. We have continued to update the prospective 
payment rates each year in accordance with the methodology set forth in 
the August 7, 2001 final rule.
    In this proposed rule, we are proposing to update the IRF Federal 
prospective payment rates from FY 2005 to FY 2006, and we are proposing 
revisions to the methodology described in Sec.  412.624. The proposed 
changes to the methodology are described in more detail in this 
proposed rule. For example, we are proposing to add a new teaching 
status adjustment, and we are proposing to implement other changes to 
existing policies in a budget neutral manner, which requires applying 
additional budget neutrality factors to the standard payment amount to 
calculate the standard payment conversion factor for FY 2006. See 
section III of this proposed rule for further discussion of the 
proposed FY 2006 Federal prospective payment rates. The proposed FY 
2006 Federal prospective payment rates would be effective for 
discharges on or after October 1, 2005 and before October 1, 2006.

C. Operational Overview of the Current IRF PPS

    As described in the August 7, 2001 final rule, upon the admission 
and discharge of a Medicare Part A fee-for-service patient, the IRF is 
required to complete the appropriate sections of a patient assessment 
instrument, the Inpatient Rehabilitation Facility-Patient Assessment 
Instrument (IRF-PAI). All required data must be electronically encoded 
into the IRF-PAI software product. Generally, the software product 
includes patient grouping programming called the GROUPER software. The 
GROUPER software uses specific Patient Assessment Instrument (PAI) data 
elements to classify (or group) the patient into a distinct CMG and 
account for the existence of any relevant comorbidities.
    The GROUPER software produces a 5-digit CMG number. The first digit 
is an alpha-character that indicates the comorbidity tier. The last 4 
digits represent the distinct CMG number. (Free downloads of the 
Inpatient Rehabilitation Validation and Entry (IRVEN) software product, 
including the GROUPER software, are available at the CMS Web site at 
www.cms.hhs.gov/providers/irfpps/default.asp).
    Once the patient is discharged, the IRF completes the Medicare 
claim (UB-92 or its equivalent) using the 5-digit CMG number and sends 
it to the appropriate Medicare fiscal intermediary (FI). (Claims 
submitted to Medicare must comply with both the Administrative 
Simplification Compliance Act (ASCA), Pub. L. 107-105, and the Health 
Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 
104-191. Section 3 of ASCA requires the Medicare Program, subject to 
subsection (H), to deny payment under Part A or Part B for any expenses 
for items or services ``for which a claim is submitted other than in an 
electronic form specified by the Secretary.'' Subsection (h) provides 
that the Secretary shall waive such denial in two types of cases and 
may also waive such denial ``in such unusual cases as the Secretary 
finds appropriate.'' See also, 68 FR at 48805 (August 15, 2003). 
Section 3 of ASCA operates in the context of the Administrative 
Simplification provisions of HIPAA, which include, among others, the 
transactions and code sets standards requirements codified as 45 CFR 
part 160 and 162, subparts A and I through R (generally known as the 
Transactions Rule). The Transactions Rule requires covered entities, 
including covered providers, to conduct covered electronic transactions 
according to the applicable

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transaction standards. See the program claim memoranda issued and 
published by CMS at www.cms.hhs.gov/providers/edi/default.asp, http://www.cms.hhs.gov/provider/edi/default.asp and listed in the addenda to 
the Medicare Intermediary Manual, Part 3, section 3600. Instructions 
for the limited number of claims submitted to Medicare on paper are 
located in section 3604 of Part 3 of the Medicare Intermediary Manual.)
    The Medicare Fiscal Intermediary (FI) processes the claim through 
its software system. This software system includes pricing programming 
called the PRICER software. The PRICER software uses the CMG number, 
along with other specific claim data elements and provider-specific 
data, to adjust the IRF's prospective payment for interrupted stays, 
transfers, short stays, and deaths and then applies the applicable 
adjustments to account for the IRF's wage index, percentage of low-
income patients, rural location, and outlier payments.

D. Quality of Care in IRFs

    The IRF-PAI is the patient data collection instrument for IRFs. 
Currently, the IRF-PAI contains a blend of the functional independence 
measures items and quality and medical needs questions. The quality and 
medical needs questions (which are currently collected on a voluntary 
basis) may need to be modified to encapsulate those data necessary for 
calculation of quality indicators in the future.
    We awarded a contract to the Research Triangle Institute (RTI) with 
the primary tasks of identifying quality indicators pertinent to the 
inpatient rehabilitation setting and determining what information is 
necessary to calculate those quality indicators. These tasks included 
reviewing literature and other sources for existing rehabilitation 
quality indicators. It also involved identifying organizations involved 
in measuring or monitoring quality of care in the inpatient 
rehabilitation setting. In addition, RTI was tasked with performing 
independent testing of the quality indicators identified in their 
research.
    Once RTI has issued a final report, we will determine which 
quality-related items should be listed on the IRF-PAI. The revised IRF-
PAI will need to be approved by OMB before it is used in IRFs.
    We would like to take this opportunity to discuss our thinking 
related to broader initiatives in this area related to quality of care. 
We have supported the development of valid quality measures and have 
been engaged in a variety of quality improvement efforts focused in 
other post-acute care settings such as nursing homes. However, as 
mentioned above, any new quality-related data collected from the IRF-
PAI would have to be analyzed to determine the feasibility of 
developing a payment method that accounts for the performance of the 
IRF in providing the necessary rehabilitative care.
    Medicare beneficiaries are the primary users of IRF services. Any 
quality measures must be carefully constructed to address the unique 
characteristics of this population. Similarly, we need to consider how 
to design effective incentives; that is, superior performance measured 
against pre-established benchmarks and/or performance improvements.
    In addition, while our efforts to develop the various post-acute 
care PPSs, including the IRF PPS, have generated substantial 
improvements over the preexisting cost-based systems, each of these 
individual systems was developed independently. As a result, we have 
focused on phases of a patient's illness as defined by a specific site 
of service, rather than on the entire post-acute episode. As the 
differentiation among provider types (such as SNFs and IRFs) becomes 
less pronounced, we need to investigate a more coordinated approach to 
payment and delivery of post-acute services that focuses on the overall 
post-acute episode.
    This could entail a strategy of developing payment policy that is 
as neutral as possible regarding provider and patient decisions about 
the use of particular post-acute services. That is, Medicare should 
provide payments sufficient to ensure that beneficiaries receive high 
quality care in the most appropriate setting, so that admissions and 
any transfers between settings occur only when consistent with good 
care, rather than to generate additional revenues. In order to 
accomplish this objective, we need to collect and compare clinical data 
across different sites of service.
    In fact, in the long run, our ability to compare clinical data 
across care settings is one of the benefits that will be realized as a 
basic component of the Department's interest in the use of a 
standardized electronic health record (EHR) across all settings 
including IRFs. It is also important to recognize the complexity of the 
effort, not only in developing an integrated assessment tool that is 
designed using health information standards, but in examining the 
various provider-centric prospective payment methodologies and 
considering payment approaches that are based on patient 
characteristics and outcomes. MedPAC has recently taken a preliminary 
look at the challenges in improving the coordination of our post-acute 
care payment methods, and suggested that it may be appropriate to 
explore additional options for paying for post-acute services. We agree 
that CMS, in conjunction with MedPAC and other stakeholders, should 
consider a full range of options in analyzing our post-acute care 
payment methods, including the IRF PPS.
    We also want to encourage incremental changes that will help us 
build towards these longer term objectives. For example, medical 
records tools are now available that could allow better coordinated 
discharge planning procedures. These tools can be used to ensure 
communication of a standardized data set that then can be used to 
establish a comprehensive IRF care plan. Improved communications may 
reduce the incidence of potentially avoidable rehospitalizations and 
other negative impacts on quality of care that occur when patients are 
transferred to IRFs without a full explanation of their care needs. We 
are looking at ways that Medicare providers can use these tools to 
generate timely data across settings.
    At this time, we do not offer specific proposals related to the 
preceding discussion. Finally, some of the ideas discussed here may 
exceed our current statutory authority. However, we believe that it is 
useful to encourage discussion of a broad range of ideas for debate of 
the relative advantages and disadvantages of the various policies 
affecting this important component of the health care sector. We 
welcome comments on these and other approaches.

E. Research To Support Refinements of the Current IRF PPS

    As described in the August 7, 2001 final rule, we contracted with 
the RAND Corporation (RAND) to analyze IRF data to support our efforts 
in developing the CMG patient classification system and the IRF PPS. 
Since then, we have continued our contract with RAND to support us in 
developing potential refinements to the classification system and the 
PPS. RAND has also developed a system to monitor the effects of the IRF 
PPS on patients' access to IRF care and other post-acute care services.
    In 1995, RAND began extensive research, sponsored by us, on the 
development of a per-discharge based PPS using a patient classification 
system known as Functional Independence Measures-Function Related 
Groups (FIM-FRGs) for IRFs. The results of RAND's earliest research, 
using 1994

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data, were released in September 1997 and are contained in two reports 
available through the National Technical Information Service (NTIS). 
The reports are: Classification System for Inpatient Rehabilitation 
Patients--A Review and Proposed Revisions to the Function Independence 
Measure-Function Related Groups, NTIS order number PB98-105992INZ, and 
Prospective Payment System for Inpatient Rehabilitation, NTIS order 
number PB98-106024INZ.
    In July 1999, we contracted with RAND to update its earlier 
research. The update included an analysis of Functional Independence 
Measure (FIM) data, the Function Related Groups (FRGs), and the model 
rehabilitation PPS using 1996 and 1997 data. The purpose of updating 
the earlier research was to develop the underlying data necessary to 
support the Medicare IRF PPS based on CMGs for the November 3, 2000 
proposed rule (65 FR at 66313). RAND expanded the scope of its earlier 
research to include the examination of several payment elements, such 
as comorbidities, facility-level adjustments, and implementation 
issues, including evaluation and monitoring. Then, to develop the 
provisions of the August 7, 2001 final rule (66 FR 41316, 41323), RAND 
did similar analysis on calendar year 1998 and 1999 Medicare Provider 
Analysis and Review (MedPAR) files and patient assessment data.
    We have continued to contract with RAND to help us identify 
potential refinements to the IRF PPS. RAND conducted updated analyses 
of the patient classification system, case mix and coding changes, and 
facility-level adjustments for the IRF PPS using data from calendar 
year 2002 and FY 2003. This is the first time CMS or RAND has had data 
generated by IRFs after the implementation of the IRF PPS that are 
available for data analysis. The refinements we are proposing to make 
to the IRF PPS are based on the analyses and recommendations from RAND. 
In addition, RAND sought advice from a technical expert panel (TEP), 
which reviewed their methodology and findings.

F. Proposed Refinements to the IRF PPS for Fiscal Year 2006

    Based on analyses by RAND using calendar year 2002 and FY 2003 
data, we are proposing refinements to the IRF PPS case-mix 
classification system (the CMGs and the corresponding relative weights) 
and the case-level and facility-level adjustments. Several new 
developments warrant these proposed refinements, including--(1) the 
availability of more recent 2002 and 2003 data; (2) better coding of 
comorbidities and patient severity; (3) more complete data; (4) new 
data sources for imputing missing values; and (5) improved statistical 
approaches.
    In this proposed rule, we are proposing to make the following 
revisions:
     Reduce the standard payment amount by 1.9 percent.
    In the August 7, 2001 final rule, we used cost report data from FYs 
1998, 1997, and/or 1996 and calendar year 1999 Medicare bill data in 
calculating the initial PPS payment rates. As discussed in detail in 
section III.A of this proposed rule, analysis of calendar year 2002 
data indicates that the standard payment conversion factor is now at 
least 1.9 percent higher than it should be to reflect the actual costs 
of caring for Medicare patients in IRFs. The data demonstrate that this 
is largely because the implementation of the IRF PPS caused important 
changes in IRFs' coding practices, including increased accuracy and 
consistency in coding.
     Make revisions to the comorbidity tiers and the CMGs.
    In the August 7, 2001 final rule, we used FIM and Medicare data 
from 1998 and 1999 to construct the CMGs and to assign the comorbidity 
tiers. As discussed in detail in section II of this proposed rule, 
analysis of calendar year 2002 and FY 2003 data indicates the need to 
refine the comorbidity tiers and the CMGs to better reflect the costs 
of Medicare cases in IRFs.
     Adopt the new geographic labor market area definitions 
based on the definitions created by the Office of Management and Budget 
(OMB), known as Core-Based Statistical Areas (CBSAs), for purposes of 
computing the proposed wage index adjustment to IRF payments.
    Historically, Medicare PPSs have used market area definitions 
developed by OMB. We are proposing to adopt new market area definitions 
which are based on OMB definitions. As discussed in detail in section 
III.B.2 of this proposed rule, we believe that these designations more 
accurately reflect the local economies and wage levels of the areas in 
which hospitals are located. These are the same labor market area 
definitions implemented for acute care inpatient hospitals under the 
hospital inpatient prospective payment system (IPPS) as specified in 
Sec.  412.64(b)(1)(ii)(A) through (C), which were effective for those 
hospitals beginning October 1, 2004 as discussed in the August 11, 2004 
IPPS final rule (69 FR at 49026 through 49032).
     Implement a teaching status adjustment to payments for 
services provided in IRFs that are, or are part of, teaching hospitals.
    In previous rules, including the August 7, 2001 final rule, we 
noted that analyses of the data did not support a teaching adjustment. 
However, analysis of the more recent calendar year 2002 and fiscal year 
2003 data supports a teaching status adjustment. For the first time, as 
discussed in detail in section III.B.3 of this proposed rule, the data 
analysis has demonstrated a statistically significant relationship 
between an IRF's teaching status and the costs of caring for patients 
in that IRF. We believe this may suggest the need to account for the 
higher costs associated with major teaching programs. For reasons 
discussed in detail in section III.B.3 of this proposed rule, we are 
proposing to implement the new teaching status adjustment in a budget 
neutral manner. However, we have some concerns about proposing a 
teaching status adjustment for IRFs at this time (as discussed in 
detail in section III.B.3 of this proposed rule). Because of these 
concerns, we are specifically soliciting comments on our consideration 
of an IRF teaching status adjustment.
     Update the formulas used to compute the rural and the low-
income patient (LIP) adjustments to IRF payments.
    In the August 7, 2001 final rule, we implemented an adjustment to 
account for the higher costs in rural IRFs by multiplying their 
payments by 1.1914. As discussed in detail in section III.B.4 of this 
proposed rule, the regression analysis RAND performed on fiscal year 
2003 data suggests that this rural adjustment should be updated to 
1.241 to account for the differences in costs between rural and urban 
IRFs.
    Similarly, in the August 7, 2001 final rule, we implemented an 
adjustment to payments to reflect facilities' low-income patient 
percentage calculated as (1+ the disproportionate share hospital (DSH) 
patient percentage) raised to the power of 0.4838. As discussed in 
detail in section III.B.5 of this proposed rule, the regression 
analysis RAND performed on fiscal year 2003 data indicates that the LIP 
adjustment should now be calculated as (1 + DSH patient percentage) 
raised to the power of 0.636. For reasons discussed in detail in 
section III.B.5 of this proposed rule, we are proposing to implement 
the changes to these adjustments in a budget neutral manner.
     Update the outlier threshold amount from $11,211 (FY 2005) 
to $4,911 (FY 2006) to maintain total estimated outlier payments at 3 
percent of total estimated payments.

[[Page 30193]]

    In the August 7, 2001 final rule, we describe the process by which 
we calculate the outlier threshold, which involves simulating payments 
and then determining a threshold that would result in outlier payments 
being equal to 3 percent of total payments under the simulation. As 
discussed in detail in section III.B.6 of this proposed rule, we 
believe based on RAND's regression analysis that all of the other 
proposed updates to the IRF PPS, including the structure of the CMGs 
and the tiers, the relative weights, and the facility-level adjustments 
(such as the rural adjustment, the LIP adjustment, and the proposed 
teaching status adjustment) make it necessary to propose to adjust the 
outlier threshold amount.

II. Proposed Refinements to the Patient Classification System

[If you choose to comment on issues in this section, please include the 
caption ``Proposed Refinements to the Patient Classification System'' 
at the beginning of your comments.]

A. Proposed Changes to the IRF Classification System

1. Development of the IRF Classification System
    Section 1886(j)(2)(A)(i) of the Act, as amended by section 125 of 
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 
1999 requires the Secretary to establish ``classes of patient 
discharges of rehabilitation facilities by functional-related groups 
(each referred to as a case-mix group or CMG), based on impairment, 
age, comorbidities, and functional capability of the patients, and such 
other factors as the Secretary deems appropriate to improve the 
explanatory power of functional independence measure-function related 
groups.'' In addition, the Secretary is required to establish a method 
of classifying specific patients in IRFs within these groups as 
specified in Sec.  412.620.
    In the August 7, 2001 final rule (66 FR at 41342), we implemented a 
methodology to establish a patient classification system using CMGs. 
The CMGs are based on the FIM-FRG methodology and reflect refinements 
to that methodology.
    In general, a patient is first placed in a major group called a 
rehabilitation impairment category (RIC) based on the patient's primary 
reason for inpatient rehabilitation, (for example, a stroke). The 
patient is then placed into a CMG within the RIC, based on the 
patient's ability to perform specific activities of daily living, and 
sometimes the patient's cognitive ability and/or age. Other special 
circumstances, such as the occurrence of very short stays, or cases 
where the patient expired, are also considered in determining the 
appropriate CMG.
    We explained in the August 7, 2001 final rule that further analysis 
of FIM and Medicare data may result in refinements to CMGs. In the 
August 7, 2001 final rule, we used the most recent FIM and Medicare 
data available at that time (that is 1998 and 1999 data). Developing 
the CMGs with the 1998 and 1999 data resulted in 95 CMGs based on the 
FIM-FRG methodology. The data also supported the establishment of five 
additional special CMGs that improved the explanatory power of the FIM-
FRGs. We established one additional special CMG to account for very 
short stays and four additional special CMGs to account for cases where 
the patient expired. In addition, we established a payment of an 
additional amount for patients with at least one relevant comorbidity 
in certain CMGs.
2. Description and Methodology Used to Develop the IRF Classification 
System in the August 7, 2001 Final Rule
a. Rehabilitation Impairment Categories
    In the first step to develop the CMGs, the FIM data from 1998 and 
1999 were used to group patients into RICs. Specifically, the 
impairment code from the assessment instrument used by clients of UDSmr 
and Healthsouth indicates the primary reason for the inpatient 
rehabilitation admission. This impairment code is used to group the 
patient into a RIC. Currently, we use 21 RICs for the IRF PPS.
b. Functional Status Measures and Age
    After using the RIC to define the first division among the 
inpatient rehabilitation groups, we used functional status measures and 
age to partition the cases further. In the August 7, 2001 final rule, 
we used 1998 and 1999 Medicare bills with corresponding FIM data to 
create the CMGs and more thoroughly examine each item of the motor and 
cognitive measures. Based on the data used for the August 7, 2001 final 
rule, we found that we could improve upon the CMGs by making a slight 
modification to the motor measure. We modified the motor measure by 
removing the transfer to tub/shower item because we found that an 
increase in a patient's ability to perform functional tasks with less 
assistance for this item was associated with an increase in cost, 
whereas an increase in other functional items decreased costs. We 
describe below the statistical methodology (Classification and 
Regression Trees (CART)) that we used to incorporate a patient's 
functional status measures (modified motor score and cognitive score) 
and age into the construction of the CMGs in the August 7, 2001 final 
rule.
    We used the CART methodology to divide the rehabilitation cases 
further within each RIC. (Further information regarding the CART 
methodology can be found in the seminal literature on CART 
(Classification and Regression Trees, Leo Breiman, Jerome Friedman, 
Richard Olshen, Charles Stone, Wadsworth Inc., Belmont CA, 1984: pp. 
78-80).) We chose to use the CART method because it is useful in 
identifying statistical relationships among data and, using these 
relationships, constructing a predictive model for organizing and 
separating a large set of data into smaller, similar groups. Further, 
in constructing the CMGs, we analyzed the extent to which the 
independent variables (motor score, cognitive score, and age) helped 
predict the value of the dependent variable (the log of the cost per 
case). The CART methodology creates the CMGs that classify patients 
with clinically distinct resource needs into groups. CART is an 
iterative process that creates initial groups of patients and then 
searches for ways to divide the initial groups to decrease the clinical 
and cost variances further and to increase the explanatory power of the 
CMGs. Our current CMGs are based on historical data. In order to 
develop a separate CMG, we need to have data on a sufficient number of 
cases to develop coherent groups. Currently, we use 95 CMGs as well as 
5 special CMGs for scenarios involving short stays or the expiration of 
the patient.
c. Comorbidities
    Under the statutory authority of section 1886(j)(2)(C)(i) of the 
Act, we are proposing to make several changes to the comorbidity tiers 
associated with the CMGs for comorbidities that are not positively 
related to treatment costs, or their excessive use is questionable, or 
their condition could not be differentiated from another condition. 
Specifically, section 1886(j)(2)(C)(i) of the Act provides the 
following: The Secretary shall from time to time adjust the 
classifications and weighting factors established under this paragraph 
as appropriate to reflect changes in treatment patterns, technology, 
case mix, number of payment units for which payment is made under this 
title and other factors that may affect the relative use of resources. 
The adjustments shall be made in a manner so that changes in aggregate 
payments under the

[[Page 30194]]

classification system are a result of real changes and are not a result 
of changes in coding that are unrelated to real changes in case mix.
    A comorbidity is a specific patient condition that is secondary to 
the patient's principal diagnosis or impairment that is used to place a 
patient into a RIC. A patient could have one or more comorbidities 
present during the inpatient rehabilitation stay. Our analysis for the 
August 7, 2001 final rule found that the presence of a comorbidity 
could have a major effect on the cost of furnishing inpatient 
rehabilitation care. We also stated that the effect of comorbidities 
varied across RICs, significantly increasing the costs of patients in 
some RICs, while having no effect in others. Therefore, for the August 
7, 2001 final rule, we linked frequently occurring comorbidities to 
impairment categories in order to ensure that all of the chosen 
comorbidities were not an inherent part of the diagnosis that assigns 
the patient to the RIC.
    Furthermore, in the August 7, 2001 final rule, we indicated that 
comorbidities can affect cost per case for some of the CMGs, but not 
all. When comorbidities substantially increased the average cost of the 
CMG and were determined to be clinically relevant (not inherent in the 
diagnosis in the RIC), we developed CMG relative weights adjusted for 
comorbidities (Sec.  412.620(b)).
d. Development of CMG Relative Weights
    Section 1886(j)(2)(B) of the Act requires that an appropriate 
relative weight be assigned to each CMG. Relative weights account for 
the variance in cost per discharge and resource utilization among the 
payment groups and are a primary element of a case-mix adjusted PPS. 
The establishment of relative weights helps ensure that beneficiaries 
have access to care and receive the appropriate services that are 
commensurate to other beneficiaries that are classified in the same 
CMG. In addition, prospective payments that are based on relative 
weights encourage provider efficiency and, hence, help ensure a fair 
distribution of Medicare payments. Accordingly, as specified in Sec.  
412.620(b)(1), we calculate a relative weight for each CMG that is 
proportional to the resources needed by an average inpatient 
rehabilitation case in that CMG. For example, cases in a CMG with a 
relative weight of 2, on average, will cost twice as much as cases in a 
CMG with a relative weight of 1. We discuss the details of developing 
the relative weights below.
    As indicated in the August 7, 2001 final rule, we believe that the 
RAND analysis has shown that CMGs based on function-related groups 
(adjusted for comorbidities) are effective predictors of resource use 
as measured by proxies such as length of stay and costs. The use of 
these proxies is necessary in developing the relative weights because 
data that measure actual nursing and therapy time spent on patient 
care, and other resource use data, are not available.
e. Overview of Development of the CMG Relative Weights
    As indicated in the August 7, 2001 final rule, to calculate the 
relative weights, we estimate operating (routine and ancillary 
services) and capital costs of IRFs. For this proposed rule, we use the 
same method for calculating the cost of a case that we outlined in the 
August 7, 2001 final (66 FR at 41351 through 43153). We obtained cost-
to-charge ratios for ancillary services and per diem costs for routine 
services from the most recent available cost report data. We then 
obtain charges from Medicare bill data and derived corresponding 
functional measures from the FIM data. We omit data from rehabilitation 
facilities that are classified as all-inclusive providers from the 
calculation of the relative weights, as well as from the parameters 
that we use to define transfer cases, because these facilities are paid 
a single, negotiated rate per discharge and therefore do not maintain a 
charge structure. For ancillary services, we calculate both operating 
and capital costs by converting charges from Medicare claims into costs 
using facility-specific, cost-center specific cost-to-charge ratios 
obtained from cost reports. Our data analysis for the August 7, 2001 
final rule showed that some departmental cost-to-charge ratios were 
missing or found to be outside a range of statistically valid values. 
For anesthesiology, a value greater than 10, or less than 0.01, is 
found not to be statistically valid. For all other cost centers, values 
greater than 10 or less than 0.5 are found not to be statistically 
valid. In the August 7, 2001 final rule, we replaced individual cost-
to-charge ratios outside of these thresholds. The replacement value 
that we used for these aberrant cost-to-charge ratios was the mean 
value of the cost-to-charge ratio for the cost-center within the same 
type of hospital (either freestanding or unit). For routine services, 
per diem operating and capital costs are used to develop the relative 
weights. In addition, per diem operating and capital costs for special 
care services are used to develop the relative weights. (Special care 
services are furnished in intensive care units. We note that fewer than 
1 percent of rehabilitation days are spent in intensive care units.) 
Per diem costs are obtained from each facility's Medicare cost report 
data. We use per diem costs for routine and special care services 
because, unlike for ancillary services, we could not obtain cost-to-
charge ratios for these services from the cost report data. To estimate 
the costs for routine and special care services included in developing 
the relative weights, we sum the product of routine cost per diem and 
Medicare inpatient days and the product of the special care per diem 
and the number of Medicare special care days.
    In the August 7, 2001 final rule, we used a hospital specific 
relative value method to calculate relative weights. We used the 
following basic steps to calculate the relative weights as indicated in 
the August 7, 2001 final rule (at 66 FR 41316, 41351 through 41352).
    The first step in calculating the CMG weights is to estimate the 
effect that comorbidities have on costs. The second step required us to 
adjust the cost of each Medicare discharge (case) to reflect the 
effects found in the first step. In the third step, the adjusted costs 
from the second step were used to calculate ``relative adjusted 
weights'' in each CMG using the hospital-specific relative value 
method. The final steps are to calculate the CMG relative weights by 
modifying the ``relative adjusted weight'' with the effects of the 
existence of the comorbidity tiers (explained below) and normalizing 
the weights to 1.

B. Proposed Changes to the Existing List of Tier Comorbidities

1. Proposed Changes to Remove Codes That Are Not Positively Related to 
Treatment Costs
    While our methodology for this proposed rule for determining the 
tiers remains unchanged from the August 7, 2001 final rule, RAND's 
analysis indicates that 1.6 percent of FY 2003 cases received a tier 
payment (often in tier one) that was not justified by any higher cost 
for the case. Therefore, under statutory authority section 
1886(j)(2)(C)(i) of the Act, we are proposing several technical changes 
to the comorbidity tiers associated with the CMGs. Specifically, the 
RAND analysis found that the first 17 diagnoses shown in Table 1 below 
are no longer positively related to treatment cost after controlling 
for CMG. The

[[Page 30195]]

additional two codes were also problematic. According to RAND, code 
410.91 (AMI, NOS, Initial) was too unspecific to be differentiated from 
other related codes and code 260, Kwashiorkor, was found to be 
unrealistically represented in the data according to a RAND technical 
expert panel.
    With respect to the eighteenth code in Table One, (410.X1) Specific 
AMI, initial), we note that RAND found there is not clinical reason to 
believe that this code differs in a rehabilitation environment from all 
of the specific codes for initial AMI of the form 410.X, where X is an 
numeric digit. In other words, this code is indistinguishable from the 
seventeenth code in Table One (410.91 AMI, NOS, initial). Following 
this observation, RAND tested the other initial AMI codes as a single 
group and found that they have no positive effect on case cost. Since 
we are proposing to remove ``AMI, NOS, initial'' from the tier list 
because it is not positively related to treatment cost after 
controlling for the CMG, we believe that ``Specific AMI, initial'' 
similarly should be removed from the tier list since it is 
indistinguishable from ``AMI, NOS, initial.''
    With respect to the last code in Table One (Kwashiorkor), we are 
proposing to remove this code from the tier list as well. This 
comorbidity is positively related to cost in our data. However, RAND's 
technical expert panel (TEP) found the large number of cases coded with 
this rare disease to be unrealistic and recommended that it be removed 
from the tier list.
    Table 1 contains two malnutrition codes, and removing these two 
malnutrition codes where use is concentrated in specific hospitals is 
particularly important because these hospitals are likely receiving 
unwarrantedly high payments due to the tier one assignment of these 
cases. Thus, because we believe the excess use of these two comorbid 
conditions is inappropriate based on the findings of RAND's TEP, we are 
proposing their removal.
    The data indicate large variation in the rate of increase from the 
1999 data to the 2003 data across the conditions that make up the 
tiers. The greatest increases were for miscellaneous throat conditions 
and malnutrition, each of which were more than 10 times as frequent in 
2003 as in 1999. The growth in these two conditions was far larger than 
for any other condition. Many conditions, however, more than doubled in 
frequency, including dialysis, cachexia, obesity, and the non-renal 
complications of diabetes. The condition with the least growth, renal 
complications of diabetes, may have been affected by improved coding of 
dialysis.
    The remaining proposed changes to our initial list of diagnoses in 
Table 1 deal with tracheostomy cases. These rare cases were excluded 
from the pulmonary RIC 15 in the August 7, 2001 final rule. The new 
data indicate that they are more expensive than other cases in the same 
CMG in RIC 15, as well as in other RICs. Therefore, we believe the data 
demonstrate that tracheostomy cases should be added to the tier list 
for RIC 15. Finally, DX V55.0, ``attention to tracheostomy'' should 
initially have been part of this condition as these cases were and are 
as expensive as other tracheostomy cases. Thus, since ``attention to 
tracheostomy'' is as expensive as other tracheostomy cases, it is 
logical to group such similar cases together.
    We believe that the data provided by RAND support the removal of 
the codes in Table 1 below because they either have no impact on cost 
after controlling for their CMG or are indistinguishable from other 
codes or are unrealistically overrepresented. Therefore, we are 
proposing to remove these codes from the tier list.

                        Table 1.--Proposed List of Codes To Be Removed From the Tier List
----------------------------------------------------------------------------------------------------------------
      ICD-9-CM code            Abbreviated code title                            Condition
----------------------------------------------------------------------------------------------------------------
235.1....................  Unc behav neo oral/phar......  Miscellaneous throat conditions.
933.1....................  Foreign body in larynx.......  Miscellaneous throat conditions.
934.1....................  Foreign body bronchus........  Miscellaneous throat conditions.
530.0....................  Achalasia & cardiospasm......  Esophegeal conditions.
530.3....................  Esophageal stricture.........  Esophegeal conditions.
530.6....................  Acquired esophag diverticulum  Esophegeal conditions.
V46.1....................  Dependence on respirator.....  Ventilator status.
799.4....................  Cachexia.....................  Cachexia.
V49.75...................  Status amputation below knee.  Amputation of LE.
V49.76...................  Status amputation above knee.  Amputation of LE.
V497.7...................  Status amputation hip........  Amputation of LE.
356.4....................  Idiopathic progressive         Meningitis and encephalitis.
                            polyneuropathy.
250.90...................  Diabetes II, w unspecified     Non-renal Complications of Diabetes.
                            complications, not stated as
                            uncontrolled.
250.93...................  Diabetes I, w unspecified      Non-renal Complications of Diabetes.
                            complications, uncontrolled.
261......................  Nutritional Marasmus.........  Malnutrition.
262......................  Other severe protein calorie   Malnutrition.
                            deficiency.
410.91...................  AMI, NOS, initial............  Major comorbidities.
410.X1...................  Specific AMI, initial........  Major comorbidities.
260......................  Kwashiorkor..................  Malnutrition.
----------------------------------------------------------------------------------------------------------------

2. Proposed Changes To Move Dialysis To Tier One
    We are proposing the movement of dialysis to tier one, which is the 
tier associated with the highest payment. The data from the RAND 
analysis show that patients on dialysis cost substantially more than 
current payments for these patients and should be moved into the 
highest paid tier because this tier would more closely align payment 
with the cost of a case. Based on RAND's analysis using 2003 data, a 
patient with dialysis costs 31 percent more than a non-dialysis patient 
in the same CMG and with the same other accompanying comorbidities.
    Overall, the largest increase in the cost of a condition occurs 
among patients on dialysis, where the coefficient in the cost 
regression increases by 93 percent, from 0.1400 to 0.2697. Part of the 
explanation for the increased coefficient could be that some IRFs had 
not borne all dialysis costs for their patients in the pre-PPS period

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(because providers were previously permitted to bill for dialysis 
separately). Dialysis is currently in tier two. However, it is likely 
that, in the 1999 data, some IRFs had not borne all dialysis costs for 
their patients. Because the fraction of cases coded with dialysis 
increased by 170 percent, it is also likely that improved coding was 
part of the explanation for the increased coefficient. We believe a 170 
percent increase is such a dramatic increase that it would be highly 
unlikely that in one short time, 170 percent more patients need 
dialysis than they did before the implementation of the IRF PPS. We 
also believe that the improved coding is likely due to the fact that 
higher costs are associated with dialysis patients and therefore IRFs, 
in an effort to ensure that their payments cover these higher expenses 
will better and more carefully code comorbidities whose presence will 
result in higher PPS payments.
    Moving dialysis patients to tier one will more adequately 
compensate hospitals for the extra cost of those patients and thereby 
maintain or increase access to these services.
3. Proposed Changes To Move Comorbidity Codes Based on Their Marginal 
Cost
    Under statutory authority section 1886(j)(2)(C)(i) of the Act, we 
are proposing to move comorbidity codes based on their marginal cost. 
Another limitation with the existing tiers is that costs for several 
conditions would be more accurately predicted if their tier assignments 
were changed. After examining RAND's data, we believe that a full 4 
percent of FY 2003 cases should be moved down to tiers with lower 
payment.
    We propose that tier assignments be based on the results of 
statistical analyses RAND has performed under contract with CMS, using 
as independent variables only the proposed CMGs and conditions that we 
are proposing for tiers (for example, the CMGs and conditions that 
remain after the proposed changes have been made). We are proposing 
that the tier assignments of each of these conditions be decided based 
on the magnitude of their coefficients in RAND's statistical analysis.
    We believe the IRF PPS led to substantial changes in coding of 
comorbidities between 1999 (pre-implementation of the IRF PPS) and 2003 
(post-implementation of the IRF PPS). The percentage of cases with one 
or more comorbidities increased from 16.79 percent in the data in which 
tiers were defined (1998 through 1999) to 25.51 percent in FY 2003. 
This is an increase of 52 percent in tier incidence (52 = 100 x (25.51-
16.79)/16.79). The presence of a tier one comorbidity, the highest paid 
of the tiers, almost quadrupled during this same time period. Although, 
coding likely improved, the presence of upcoding for a higher payment 
may play a factor as well.
    The 2003 data provide a more accurate explanation of the costs that 
are associated with each of the comorbidities, largely due to having 
100 percent of the Medicare-covered IRF cases in the later data versus 
slightly more than half of the cases in 1999 data. Therefore, using the 
2003 data to propose to assign each diagnosis or condition will 
considerably improve the matching of payments to their relative costs.

C. Proposed Changes to the CMGs

    Section 1886(j)(2)(C)(i) of the Act requires the Secretary from 
time to time to adjust the classifications and weighting factors of 
patients under the IRF PPS to reflect changes in treatment patterns, 
technology, case mix, number of payment units for which payment is 
made, and other factors that may affect the relative use of resources. 
These adjustments shall be made in a manner so that changes in 
aggregate payments under the classification system are the result of 
real changes and not the result of changes in coding that are unrelated 
to real changes in case mix.
    In accordance with section 1886(j)(2)(C)(i) of the Act and as 
specified in Sec.  412.620(c) and based on the research conducted by 
RAND, we are proposing to update the CMGs used to classify IRF patients 
for purposes of establishing payment amounts. We are also proposing to 
update the relative weights associated with the payment groups based on 
FY 2003 Medicare bill and patient assessment data. We are proposing to 
replace the current unweighted motor score index used to assign 
patients to CMGs with a weighted motor score index that would improve 
our ability to accurately predict the costs of caring for IRF patients, 
as described in detail below. However, we are not proposing to change 
the methodology for computing the cognitive score index.
    As described in the August 7, 2001 final rule, we contracted with 
RAND to analyze IRF data to support our efforts in developing our 
patient classification system and the IRF PPS. We have continued our 
contract with RAND to support us in developing potential refinements to 
the classification system and the PPS. As part of this research, we 
asked RAND to examine possible refinements to the CMGs to identify 
potential improvements in the alignment between Medicare payments and 
actual IRF costs. In conducting its research, RAND used a technical 
expert panel (TEP) made up of experts from industry groups, other 
government entities, academia, and other interested parties. The 
technical expert panel reviewed RAND's methodologies and advised RAND 
on many technical issues.
    Several recent developments make significant improvements in the 
alignment between Medicare payments and actual IRF costs possible. 
First, when the IRF PPS was implemented in 2002, a new recording 
instrument was used to collect patient data, the IRF Patient Assessment 
Instrument (or the IRF PAI). The new instrument contained questions 
that improved the quality of the patient-level information available to 
researchers.
    Second, more recent data are available on a larger patient 
population. Until now, the design of the IRF PPS was based entirely on 
1999 data on Medicare rehabilitation patients from just a sample of 
hospitals. Now, we have post-PPS data from 2002 and 2003 that describe 
the entire universe of Medicare-covered rehabilitation patients.
    Finally, we believe that proposed improvements in the algorithms 
that produced the initial CMGs, as described below, should lead to new 
CMGs that better predict treatment costs in the IRF PPS.
    Using FIM (the inpatient rehabilitation facility assessment 
instrument before the PPS) and Medicare data from 1998 and 1999, RAND 
helped us develop the original structure of the IRF PPS. IRFs became 
subject to the PPS beginning with cost reporting periods on or after 
January 1, 2002. The PPS is based on assigning patients to particular 
CMGs that are designed to predict the costs of treating particular 
Medicare patients according to how well they function in four general 
categories: transfers, sphincter control, self-care (for example, 
grooming, eating), and locomotion. Patient functioning is measured 
according to 18 categories of activity: 13 motor tasks, such as 
climbing stairs, and 5 cognitive tasks, such as recall. The PPS is 
intended to align payments to IRFs as closely as possible with the 
actual costs of treating patients. If the PPS ``underpays'' for some 
kinds of care, IRFs have incentives to limit access for patients 
requiring that kind of care because payments would be less than the 
costs of providing care for a particular case so an IRF may try to

[[Page 30197]]

limit its financial ``losses''; conversely, if the PPS overpays, 
resources are wasted because IRFs' payments exceed the costs of 
providing care for a particular case.
    The fiscal year 2003 data file currently available for refining the 
CMGs is better than the 1999 data RAND originally used to construct the 
IRF PPS because it contains many more IRF cases and represents the 
universe of Medicare-covered IRF cases, rather than a sample. The best 
available data that CMS and RAND had for analysis in 1999 contained 
390,048 IRF cases, representing 64 percent of all Medicare-covered 
patients in participating IRF hospitals. The more recent data contain 
523,338 IRF cases (fiscal year 2003), representing all Medicare-covered 
patients in participating IRF hospitals. The larger file enables RAND 
to obtain greater precision in the analysis and ensures a more balanced 
and complete picture of patients under the IRF PPS.
    Also, the fiscal year 2003 data are better than the 1999 data used 
to design the IRF PPS because they include more detailed information 
about patients' level of functioning. For example, new variables are 
included in the more recent data that provide further details on 
patient functioning. Standard bowel and bladder scores on the FIM 
instrument (used to assess patients before the IRF PPS), for example, 
measured some combination of the level of assistance required and the 
frequency of accidents (that is, soiling of clothes and surroundings). 
New variables on the IRF-PAI instrument measure the level and the 
frequency separately. Since measures of the level of assistance 
required and the frequency of accidents contain slightly different 
information about the expected costliness of an IRF patient, having 
measures for these two variables separately provides additional 
information to researchers.
    Furthermore, additional optional information is recorded on the 
health status of patients in the more recent data (for example, 
shortness of breath, presence of ulcers, inability to balance).
1. Proposed Changes for Updating the CMGs
    As described in the August 7, 2001 final rule, RAND developed the 
original list of CMGs using FIM data from 1998 and 1999 to group 
patients into RICs. Table 2 below shows the final set of 95 CMGs based 
on the FIM-FRG methodology, the 5 special CMGs, and their descriptions. 
Impairment codes from the assessment instrument used by UDSmr and 
Healthsouth indicated the primary reasons for inpatient rehabilitation 
admissions. The impairment codes were used to group patients into RICs. 
Table 3 below shows each RIC and its associated impairment code.
BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C
    Given the availability of more recent, post-PPS data, we asked RAND 
to examine possible refinements to the CMGs to identify potential

[[Page 30206]]

improvements in the alignment between Medicare payments and actual IRF 
costs. In addition to analyzing fiscal year 2003 data, RAND also 
convened a TEP, made up of researchers from industry, provider 
organizations, government, and academia, to provide support and 
guidance through the process of developing possible refinements to the 
PPS. Members of the TEP reviewed drafts of RAND's reports, offered 
suggestions for additional analyses, and provided clinicians' views of 
the importance and significance of various findings.
    RAND's analysis of the FY 2003 data, along with the support and 
guidance of the TEP, strongly suggest the need to update the CMGs to 
better align payments with costs under the IRF PPS. The other option we 
considered before deciding to propose to update the CMGs with the 
fiscal year 2003 data was to maintain the same CMG structure but 
recalculate the relative weights for the current CMGs using the 2003 
data. After carefully reviewing the results of RAND's regression 
analysis, which compared the predictive ability of the CMGs under 3 
scenarios (not updating the CMGs or the relative weights, updating only 
the relative weights and not the CMGs, and updating both the relative 
weights and the CMGs), we believe (based on RAND's analysis) that 
updating both the relative weights and the CMGs will allow the 
classification system to do a much better job of reflecting changes in 
treatment patterns, technology, case mix, and other factors which may 
affect the relative use of resources.
    We believe it is appropriate to update the CMGs and the relative 
weights at this time because the 2003 data we now have represent a 
substantial improvement over the 1999 data. The more recent data 
include all Medicare-covered IRF cases rather than a subset, allowing 
us to base the proposed CMG changes on a complete picture of the types 
of patients in IRFs. In designing the IRF PPS, we used the best 
available data, but those data did not allow us to have a complete 
picture of the types of patients in IRFs. Also, the clinical coding of 
patient conditions in IRFs is vastly improved in the more recent data 
than it was in the best available data we had to design the IRF PPS. In 
addition, changes in treatment patterns, technology, case mix, and 
other factors affecting the relative use of resources in IRFs since the 
IRF PPS was implemented likely require an update to the classification 
system.
    We are currently paying IRFs based on 95 CMGs and 5 special CMGs 
developed using the CART algorithm applied to 1999 data. The CART 
algorithm that was used in designing the IRF PPS assigned patients to 
RICs according to their age and their motor and cognitive FIM scores. 
CART produced the partitions so that the reported wage-adjusted 
rehabilitation cost of the patients was relatively constant within 
partitions. Then, a subjective decision-making process was used to 
decrease the number of CMGs (to ensure that the payment system did not 
become unduly complicated), to enforce certain constraints on the CMGs 
(to ensure that, for instance, IRFs were not paid more for patients who 
had fewer comorbidities than for patients with more comorbidities), and 
to fit the comorbidity tiers. Although the use of a subjective 
decision-making process (rather than a computer algorithm) was very 
useful, there were limitations. For example, it made it difficult to 
explore the implications of variations to the CART models because a 
computer program can examine many more variations of a model in a much 
shorter time than an individual person. Furthermore, the computer is 
more efficient at accounting for all of the possible combinations and 
interactions between important variables that affect patient costs.
    In analyzing potential refinements to the IRF PPS, RAND created a 
new algorithm that would be very useful in constructing the proposed 
CMGs (the new algorithm would be based on the CART methodology 
described in detail earlier in this section of the proposed rule). RAND 
applied the new algorithm to the fiscal year 2003 IRF data. We are 
proposing to use RAND's new algorithm for refinements to the CMGs. The 
proposed algorithm would be based entirely on an iterative computerized 
process to decrease the number of CMGs, enforce constraints on the 
CMGs, and assign the comorbidity tiers. At each step in the process, 
the proposed new CART algorithm would produce all of the possible 
combinations of CMGs using all available variables. It would then 
select the variables and the CMG constructions that offer the best 
predictive ability, as measured by the greatest decrease in the mean-
squared error. We propose that the following constraints be placed on 
the algorithm, based on RAND's analysis: (1) Neighboring CMGs would 
have to differ by at least $1,500, unless eliminating the CMG would 
change the estimated costs of patients in that CMG by more than $1,000; 
(2) estimated costs for patients with lower motor or cognitive index 
scores (more functionally dependent) would always have to be higher 
than estimated costs for patients with higher motor or cognitive index 
scores (less functionally dependent). We believe that the PPS should 
not pay more for a patient who is less functionally dependent than for 
one who is more functionally dependent; and (3) each CMG must contain 
at least 50 observations (for statistical validity).
    RAND's technical expert panel, which included representatives from 
industry groups, other government entities, academia, and other 
researchers, reviewed and commented on these constraints and the rest 
of RAND's proposed methodology (developed based on RAND's analysis of 
the data) for updating the CMGs as RAND developed the improvements to 
the CART methodology.
    The following would be the most substantial differences between the 
existing CMGs and the proposed new CMGs:
     Fewer CMGs than before (87 compared with 95 in the current 
system).
     The number of CMGs under the RIC for stroke patients (RIC 
1) would decrease from 14 to 10.
     The cognitive index score would affect patient 
classification in two of the RICs (RICs 1 and 2), whereas it currently 
affects RICs 1, 2, 5, 8, 12, and 18.
     A patient's age would now affect assignment for CMGs in 
RICs 1, 4 and 8, whereas it currently affects assignment for CMGs in 
RICs 1 and 4.
    In Table 2 above, we provided the CMGs that are currently being 
used to pay IRFs. Table 4 below shows the proposed new CMGs.
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BILLING CODE 4120-01-C

    Note: CMG definitions use proposed weighted motor scores, as 
defined below.

    The primary objective in updating the CMGs is to better align IRF 
payments with the costs of caring for IRF patients, given better, more 
recent information. This requires that we improve the ability of the 
system to predict patient costs. RAND's analysis suggests that the 
proposed new CMGs clearly improve the ability of the payment system to 
predict patient costs. The proposed new CMGs would greatly improve the 
explanation of the variance in the system.
2. Proposed Use of a Weighted Motor Score Index and Correction to the 
Treatment of Unobserved Transfer to Toilet Values
    As described in detail below, we are proposing to use a weighted 
motor score index in assigning patients to CMGs, instead of the current 
motor score index that treats all components equally. We are also 
proposing to change the motor score value for the transfer to toilet 
variable to 2 rather than 1 when it is unobserved. However, we are not 
proposing changes to the cognitive score index. As described in detail 
below, we believe that a weighted motor score index, with the 
correction to the treatment of unobserved transfer to toilet values 
would improve the classification of patients into CMGs, which in turn 
would improve the accuracy of payments to IRFs.
    In order to classify a patient into a CMG, IRFs use the admission 
assessment data from the IRF-PAI to score a patient's functional 
independence measures. The functional independence measures consist of 
what are termed ``motor'' items and ``cognitive'' items. In addition to 
the functional independence measures, the patient's age may also 
influence the patient's CMG classification. The motor items are 
generally indications of the patient's physical functioning level. The 
cognitive items are generally indications of the patient's mental 
functioning level, and are related to the patient's ability to process 
and respond to empirical factual information, use judgment, and 
accurately perceive what is happening. The motor items are eating, 
grooming, bathing, dressing upper body, dressing lower body, toileting, 
bladder management, bowel management, transfer to bed/chair/wheelchair, 
transfer to toilet, walking or wheelchair use, and stair climbing. The 
cognitive items are comprehension, expression, social interaction, 
problem solving, and memory. (The CMS IRF-PAI manual includes more 
information on these items.) Each item is generally recorded on a 
patient assessment instrument and scored on a scale of 1 to 7, with a 7 
indicating complete independence in this area of functioning, and a 1 
indicating that a patient is very impaired in this area of functioning.
    As explained in the August 7, 2001 final rule (66 FR at 41349), the

[[Page 30211]]

instructions for the IRF-PAI require that providers record an 8 for an 
item to indicate that the activity did not occur (or was not observed), 
as opposed to a 1 through 7 indicating that the activity occurred and 
the estimated level of function connected with that activity.
    Please note that when the IRF-PAI form went through the approval 
process, the code 8 was removed and replaced with the code 0. 
Therefore, a 0 is now the code facilities use to record when an 
activity does not occur (or is not observed).
    In order to determine the appropriate payment for patients for whom 
an activity is coded as 0 (that is, either not performed or not 
observed), we needed to decide an appropriate way of changing the 0 to 
another code for which payment could be assigned. As discussed in the 
August 7, 2001 final rule (66 FR at 41349), we decided to assign a code 
of 1 (indicating that the patient needed ``maximal assistance'') 
whenever a code of 0 appeared for one of the items on the IRF-PAI used 
to determine payment. This was the most conservative approach we could 
have taken based on the best available data at the time because a value 
of 1 indicates that the patient needed maximal assistance performing 
the task. Thus, providers would receive the highest payment available 
for that item (although it might not be the highest payment overall, 
depending on the patient's CMG, other functional abilities, and/or 
comorbidities).
    We are proposing to change the way we treat a code of 0 on the IRF-
PAI for the transfer to toilet item. This is the only item for which we 
are proposing this change at this time because RAND's regression 
analysis demonstrated that of all the motor score values, the evidence 
supporting a change in the motor score values was the strongest with 
respect to this item. We propose to assign a code of 2, instead of a 
code of 1, to patients for whom a 0 is recorded on the IRF-PAI for the 
transfer to toilet item (as discussed below) because RAND's analysis of 
calendar year 2002 and FY 2003 data indicates that patients for whom a 
0 is recorded are more similar in terms of their characteristics and 
costliness to patients with a recorded score of 2 than to patients with 
a recorded score of 1. We are proposing to make this change in order to 
provide the most accurate payment for each patient.
    Using regression analysis on the calendar year 2002 and FY 2003 
data, which is more complete and provides more detailed information on 
patients' functional abilities than the FY 1999 data used to construct 
the IRF PPS (even though the 1999 data were the best available data at 
the time), RAND analyzed whether the assignment of 1 to items for which 
a 0 is recorded on the IRF-PAI continues to correctly assign payments 
based on patients' expected costliness. RAND examined all of the items 
in the motor score index, focusing on how often a code of 0 appears for 
the item, how similar patients with a code of 0 are to other patients 
with the same characteristics that have a score of 1 though 7, and how 
much a change in the item's score affects the prediction of a patient's 
expected costliness. Based on RAND's regression analysis, we believe it 
is appropriate to change the assignment of 0 on the transfer to toilet 
item from a 1 to a 2 for the purposes of determining IRF payments.
    Until now, the IRF PPS has used standard motor and cognitive 
scores, the sum of either 12 or 13 motor items and the sum of 5 
cognitive items, to assign patients to CMGs. This summing equally 
weights the components of the indices. These indices have been accepted 
and used for many years. Although the weighted motor score is an option 
that has been considered before, most experts believed that the data 
were not complete and accurate enough before the IRF PPS (although they 
were the most complete and accurate data available at the time). Now, 
it is believed that the data are complete and accurate enough to 
support proposing to use a weighted motor score index.
    In developing candidate indices that would weight the items in the 
score, RAND had competing goals: to develop indices that would increase 
the predictive power of the system while at the same time maintaining 
simplicity and transparency in the payment system. For example, they 
found that an ``optimal'' weighting methodology from the standpoint of 
predictive power would require computing 378 different weights (18 
different weights for the motor and cognitive indices that could all 
differ across 21 RICs). Rather than introduce this level of complexity 
to the system, RAND decided to explore simpler weighting methodologies 
that would still increase the predictive power of the system.
    RAND used regression analysis to explore the relationship of the 
FIM motor and cognitive scores to cost. The idea of these models was to 
determine the impact of each of the FIM items on cost and then weight 
each item in the index according to its relative impact on cost. Based 
on the regression analysis, RAND was able to design a weighting 
methodology for the motor score that could potentially be applied 
uniformly across all RICs.
    RAND assessed different weighting methodologies for both the motor 
score index and the cognitive score index. They discovered that 
weighting the motor score index improved the predictive ability of the 
system, whereas weighting the cognitive score index did not. 
Furthermore, the cognitive score index has never had much of an effect 
(in some RICs, it has no effect) on the assignment of patients to CMGs 
because the motor score tends to be much stronger at predicting a 
patient's expected costs in an IRF than the cognitive score.
    For these reasons, we are proposing a weighting methodology for the 
motor score index at this time. We propose to continue using the same 
methodology we have been using since the IRF PPS was first implemented 
to compute the cognitive score index (that is, summing the components 
of the index) because, among other things, a change in methodology for 
calculating this component of the system failed to improve the accuracy 
of the IRF PPS payments. Therefore, it would be futile to expend 
resources on changing this method when it would not benefit the 
program.
    Table 5 below shows the proposed optimal weights for the components 
of the motor score, averaged across all RICs and normalized to sum to 
100.0, obtained through the regression analysis. The weights relate to 
the FIM items' relative ability to predict treatment costs. Table 5 
indicates that dressing lower, toilet, bathing, and eating are the most 
effective self-care items for predicting costs; bowel and bladder 
control may not be effective at predicting costs; and that the items 
grouped in the transfer and locomotion categories might be somewhat 
more effective at predicting costs than the other categories.

   Table 5.--Proposed Optimal Weights, Averaged Across Rehabilitation
                Impairment Categories (RICs): Motor Items
------------------------------------------------------------------------
                                                                Average
           Item type             Functional independence item   optimal
                                                                 weight
------------------------------------------------------------------------
Self..........................  Dressing lower...............        1.4
Self..........................  Toilet.......................        1.2
Self..........................  Bathing......................        0.9
Self..........................  Eating.......................        0.6
Self..........................  Dressing upper...............        0.2
Self..........................  Grooming.....................        0.2
Sphincter.....................  Bladder......................        0.5
Sphincter.....................  Bowel........................        0.2
Transfer......................  Transfer to bed..............        2.2
Transfer......................  Transfer to toilet...........        1.4
Transfer......................  Transfer to tub..............        Not
                                                                included

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Locomotion....................  Walking......................        1.6
Locomotion....................  Stairs.......................        1.6
------------------------------------------------------------------------

    Based on RAND's analysis, we considered a number of different 
candidate indices before proposing a weighted index. We considered 
proposing to define some simple combinations of the four item types 
that make up the motor score index and assigning weights to the groups 
of items instead of to the individual items. For example, we considered 
proposing to sum the three transfer items together to form a group with 
a weight of two, since they contributed about twice as much in the cost 
regression as the self-care items. We also considered proposing to 
assign the self-care items a weight of one and the bladder and bowel 
items as a group a weight close to zero, since they contributed little 
to predicting cost in the regression analysis. We tried a number of 
variations and combinations of this, but RAND's TEP generally rejected 
these weighting schemes. They believed that introducing elements of 
subjectivity into the development of the weighting scheme may invite 
controversy, and that it is better to use an objective algorithm to 
derive the appropriate weights. We agree that an objective weighting 
scheme is best because it is based on regression analysis of the amount 
that various components of the motor score index contribute to 
predicting patient costs, using the best available data we have. 
Therefore, we are proposing a weighting scheme that applies the average 
optimal weights. To develop the proposed weighting scheme, RAND used 
regression analysis to estimate the relative contribution of each item 
to the prediction of costs. Based on this analysis, we are proposing to 
use the weighting scheme indicated in Table 5 above and in the 
following simple equation:

Motor score index=1.4*dressing lower + 1.2*toilet + 0.9*bathing + 
0.6*eating + 0.2*dressing upper + 0.2*grooming + 0.5*bladder + 
0.2*bowel + 2.2*transfer to bed + 1.4*transfer to toilet + 1.6*walking 
+ 1.6*stairs.

    Another reason we are proposing to use a weighted motor score index 
to assign patients to CMGs is that RAND's regression analysis showed 
that it predicts costs better than the current unweighted motor score 
index. Across all 21 RICs, the proposed weighted motor score index 
improves the explanation of variance within each RIC by 9.5 percent, on 
average.
3. Proposed Changes for Updating the Relative Weights
    Section 1886(j)(2)(B) of the Act requires that an appropriate 
relative weight be assigned to each CMG. Relative weights that account 
for the variance in cost per discharge and resource utilization among 
payment groups are a primary element of a case-mix adjusted prospective 
payment system. The accuracy of the relative weights helps to ensure 
that payments reflect as much as possible the relative costs of IRF 
patients and, therefore, that beneficiaries have access to care and 
receive the appropriate services.
    Section 1886(j)(2)(C)(i) of the Act requires the Secretary from 
time to time to adjust the classifications and weighting factors to 
reflect changes in treatment patterns, technology, case mix, number of 
payment units for which payment to IRFs is made, and other factors 
which may affect the relative use of resources. In accordance with this 
section of the Act, we are proposing to recalculate a relative weight 
for each CMG that is proportional to the resources needed by an average 
inpatient rehabilitation case in that CMG. For example, cases in a CMG 
with a relative weight of 2, on average, would cost twice as much as 
cases in a CMG with a relative weight of 1. We are not proposing any 
changes to the methodology we are using for calculating the relative 
weights, as described in the August 7, 2001 final rule (66 FR 41316, 
41351 through 41353); we are only proposing to update the relative 
weights themselves.
    As previously stated, we believe that improved coding of data, the 
availability of more complete data, proposed changes to the tier 
comorbidities and CMGs, and changes in IRF cost structures make it very 
unlikely that the relative weights assigned to the CMGs when the IRF 
PPS was first implemented still accurately represent the differences in 
costs across CMGs and across tiers. Therefore, we are proposing to 
recalculate the relative weights. However, we are not proposing any 
changes to the methodology for calculating the relative weights. 
Instead, we are proposing to update the relative weights (the relative 
weights that are multiplied by the standard payment conversion factor 
to assign relative payments for each CMG and tier) using the same 
methodology as described in the August 7, 2001 final rule (66 FR 41316, 
41351 through 41353) and as described in detail at the beginning of 
this section of this proposed rule, applied to FY 2003 Medicare billing 
data. To summarize, we are proposing to use the following basic steps 
to update the relative weights: The first step in calculating the CMG 
weights is to estimate the effects that comorbidities have on costs. 
The second step is to adjust the cost of each Medicare discharge (case) 
to reflect the effects found in the first step. In the third step, the 
adjusted costs from the second step are used to calculate ``relative 
adjusted weights'' in each CMG using the hospital-specific relative 
value method. The final steps are to calculate the CMG relative weights 
by modifying the ``relative adjusted weight'' with the effects of the 
existence of the comorbidity tiers (explained below) and normalize the 
weights to 1. Table 6 below shows the proposed relative weights, based 
on the 2003 data.

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BILLING CODE 4120-01-C

    We are proposing to make the tier and the CMG changes in such a way 
that total estimated aggregate payments to IRFs for FY 2006 are the 
same with and without the proposed changes (that is, in a budget 
neutral manner) for the following reasons. First, we believe that the 
results of RAND's analysis of 2002 and 2003 IRF cost data suggest that 
additional money does not need to be added to the IRF PPS. RAND's 
analysis found, for example, that if all IRFs had been paid based on 
100 percent of the IRF PPS payment rates throughout all of 2002 (some 
IRFs were still transitioning to PPS payments during 2002), PPS 
payments during 2002 would have been 17 percent higher than IRFs' 
costs. Furthermore, RAND did not find evidence that the overall 
costliness of patients (average case mix) in IRFs increased 
substantially in 2002 compared with 1999. As discussed in detail in 
section III.A of this proposed rule, RAND found that real case mix 
increased by at most 1.5 percent, and may have decreased by as much as 
2.4 percent. The available evidence, therefore, suggests that resources 
in the IRF PPS are likely adequate to care for the types of patients 
IRFs treat. We are open to examining other evidence regarding the 
amount of aggregate payments in the system and the types of patients 
IRFs are currently treating.
    The purpose of the CMG and tier changes is to ensure that the 
existing resources already in the IRF PPS are distributed better among 
IRFs according to the relative costliness of the types of patient they 
treat. Section 1886(j)(2)(C)(i) of the Act confers broad statutory 
authority upon the Secretary to adjust the classification and weighting 
factors in order to account for relative resource use. Consistent with 
that broad statutory authority, we are proposing to redistribute 
aggregate payments to more accurately reflect the IRF case mix.
    To ensure that total estimated aggregate payments to IRFs do not 
change, we propose to apply a factor to the standard payment amount to 
ensure that estimated aggregate payments under this subsection in the 
FY are not greater or less than those that would

[[Page 30220]]

have been made in the year without such adjustment. In section III.B.7 
and section III.B.8 of this proposed rule, we discuss the methodology 
and factor we are proposing to apply to the standard payment amount.

III. Proposed FY 2006 Federal Prospective Payment Rates

(If you choose to comment on issues in this section, please include 
the caption ``Proposed FY 2006 Federal Prospective Payment Rates'' 
at the beginning of your comments.)

A. Proposed Reduction of the Standard Payment Amount to Account for 
Coding Changes

    Section 1886(j)(2)(C)(ii) of the Act requires the Secretary to 
adjust the per payment unit payment rate for IRF services to eliminate 
the effect of coding or classification changes that do not reflect real 
changes in case mix if the Secretary determines that changes in coding 
or classification of patients have resulted or will result in changes 
in aggregate payments under the classification system. As described 
below, in accordance with this section of the Act and based on research 
conducted by RAND under contract with us, we are proposing to reduce 
the standard payment amount for patients treated in IRFs by 1.9 
percent. However, as discussed below, RAND found a range of possible 
estimates that likely accounts for the amount of case mix change that 
was due to coding. In light of the range of estimates that may be 
appropriate, we are continuing to work with RAND to further analyze the 
data and are considering adoption of an alternative percentage 
reduction. Accordingly, we solicit comments on whether the proposed 1.9 
percent is the percentage reduction that ought to be made, or if 
another percentage reduction (for example, the 3.4 percent observed 
case mix change or the 5.8 percent that RAND found in its study, 
detailed below, to be the maximum amount of change due to coding) 
should be applied.
    We are proposing to reduce the standard payment amount by 1.9 
percent because RAND's regression analysis of calendar year 2002 data 
found that payments to IRFs were about $140 million more than expected 
during 2002 because of changes in the classification of patients in 
IRFs, and that a portion of this increase in payments was due to coding 
changes that do not reflect real changes in case mix. If IRF patients 
have more costly impairments, lower functional status, or more 
comorbidities, and thus require more resources in the IRF in 2002 than 
in 1999, we would consider this a real change in case mix. Conversely, 
if IRF patients have the same impairments, functional status, and 
comorbidities in 2002 as they did in 1999 but are coded differently 
resulting in higher payment, we consider this a case mix increase due 
to coding. We believe that changes in payment amounts should accurately 
reflect changes in IRFs' patient case mix (that is, the true cost of 
treating patients), and should not be influenced by changes in coding 
practices.
    Under the IRF PPS, payments for each Medicare rehabilitation 
patient are determined using a multi-step process. First, a patient is 
assigned to a particular CMG and a tier based on four patient 
characteristics at admission: impairment, functional independence, 
comorbidities, and age. The amount of the payment for each patient is 
then calculated by taking the standard payment conversion factor 
($12,958 in FY 2005) and adjusting it by multiplying by a relative 
weight, which depends on each patient's CMG and tier assignment.
    For example, an 80-year old hip replacement patient with a motor 
score between 47 and 54 and no comorbidities would be assigned to a 
particular CMG and tier based on these characteristics. The CMG and 
tier to which he is assigned would have an associated relative weight, 
in this case 0.5511 in FY 2005 (69 FR at 45725). This relative weight 
would be multiplied by the standard payment conversion factor of 
$12,958 to equal the payment of $7,141 in FY 2005 (0.5511 x $12,958 = 
$7,141). Based on the following discussion, we are proposing lowering 
the standard payment amount by 1.9 percent to account for coding 
changes that have increased payments to IRFs. However, we solicit 
comments regarding other possible percentage reductions within the 
range RAND identified, as discussed below.
    As described in the August 7, 2001 final rule, we contracted with 
RAND to analyze IRF data to support our efforts in developing the 
classification system and the IRF PPS. We have continued our contract 
with RAND to support us in developing potential refinements to the 
classification system and the PPS for this proposed rule. As part of 
this research, we asked RAND to examine changes in case mix and coding 
since the IRF PPS. To examine these changes, RAND compared 2002 data 
from the first year of implementation of the PPS with the 1999 (pre-
PPS) data used to construct the IRF PPS.
    RAND's analysis of the 2002 data, as described in more detail 
below, demonstrates that changes in the types of patients going to IRFs 
and changes in coding both caused increases in payments to IRFs between 
1999 and 2002. The 2002 data are more complete than the 1999 data that 
were first used to design the IRF PPS because they include all 
Medicare-covered IRF cases. Although the 1999 data we used in designing 
the original standard payment rate for the IRF PPS were the best 
available data we had at the time, they were based on a sample (64 
percent) of IRF cases.
    In addition, such review was necessary because, as explained below, 
we believe that the implementation of the IRF PPS caused important 
changes in coding. The IRF PPS likely improved the accuracy and 
consistency of coding across IRFs, because of the educational programs 
that were implemented in 2001 and 2002 and because items that 
previously did not affect payments (such as comorbidities) became 
important factors for determining the PPS payments. Since these items 
now affect payments, there is greater incentive to code for them. There 
were also changes to the IRF-PAI instructions given for coding some of 
the items on the patient assessment instrument, so that the same 
patient may have been correctly coded differently in 2002 than in 1999.
    Furthermore, implementation of the IRF PPS may have caused changes 
in case mix because it increased incentives for IRFs to take patients 
with greater impairment, lower function, or comorbidities. Under the 
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L. 97-
248), IRFs were paid on the basis of Medicare reasonable costs limited 
by a facility-specific target amount per discharge. IRFs were paid on a 
per discharge basis without per discharge adjustments being made for 
the impairments, functional status, or comorbidities of patients. Thus, 
IRFs had a strong incentive to admit less costly patients to ensure 
that the costs of treating patients did not exceed their TEFRA 
payments. Under the IRF PPS, however, IRFs' PPS payments are tied 
directly to the principle diagnosis and accompanying comorbidities of 
the patient. Thus, based on the characteristics of the patients (that 
is, impairments, functional status, and comorbidities), the more costly 
the patient is expected to be, the higher the PPS payment. Therefore, 
IRFs may have greater incentives than they had under TEFRA to admit 
more costly patients.
    Thus, in light of these concerns, RAND performed an analysis using 
IRF Medicare claims data matched with FIM and IRF-PAI data and 
comparing 2002 data (post-PPS) with 1999 data (pre-

[[Page 30221]]

PPS), RAND found that the observed case mix--the expected costliness of 
patients--in IRFs increased by 3.4 percent between the two time 
periods. Thus, we paid 3.4 percent, or about $140 million, more than 
expected during 2002 because of changes in the classification of cases 
in IRFs. However, RAND found little evidence that the patients admitted 
to IRFs in 2002 had higher resource needs (that is, more impairments, 
lower functioning, or more comorbidities) than the patients admitted in 
1999. In fact, most of the changes in case mix that RAND documented 
from the acute care hospital records implied that IRF patients should 
have been less costly to treat in 2002 than in 1999. For example, RAND 
found a 16 percent decrease in the proportion of patients treated in 
IRFs following acute hospitalizations for stroke, when it compared the 
results of the 2002 data with the 1999 data. Stroke patients tend to be 
relatively more costly than other types of patients for IRFs because 
they tend to require more intensive services than other types of 
patients. A decrease in the proportion of stroke patients relative to 
other types of patients, therefore, would likely contribute to a 
decrease in the overall expected costliness of IRF patients. RAND also 
found a 22 percent increase in the proportion of cases treated in IRFs 
following a lower extremity joint replacement. Lower extremity joint 
replacement patients tend to be relatively less costly for IRFs than 
other types of patients because their care needs tend to be less 
intensive than other types of patients. For this reason, the increase 
in the proportion of these patients treated in IRFs would suggest a 
decrease in the overall expected costliness of IRF patients.
    We asked RAND to quantify the amount of the case mix change that 
was due to real case mix change (that is, the extent to which IRF 
patients had more impairments, lower functioning, or more 
comorbidities) and the amount that was due to coding. However, while 
the data permit RAND to observe the total change in expected costliness 
of patients over time with some precision, estimating the amount of 
this total change that is real and the amount that is due to coding 
generally cannot be done with the same level of precision. Therefore, 
in order to quantify the amounts that were due to real case mix change 
and the amounts that were due to coding, RAND used two approaches to 
give a range of estimates within which the correct estimates would 
logically fall--(1) one that potentially underestimates the amount of 
real case mix change and overestimates the amount of case mix change 
due to coding; and (2) one that potentially overestimates real change 
and underestimates change due to coding. These two approaches give us a 
range of estimates, which we are confident should logically border the 
actual amount of real case mix and coding change. The first approach 
uses the following assumptions:
     Changes over time in characteristics recorded during the 
acute hospitalizations preceding the inpatient rehabilitation facility 
stay were real case mix changes (as acute care hospitals had little 
incentive to change their coding of patients in response to the IRF 
PPS); and
     Changes over time in IRF coding that did not correspond 
with changes in the characteristics recorded during the acute 
hospitalizations were attributable to changes in IRF coding practices.
    To illustrate this point, suppose, for example, that the IRF 
records showed that there were a greater number of patients with a 
pulmonary condition in IRFs in 2002 than in 1999. Patients with a 
pulmonary condition tend to be relatively more costly for IRFs to treat 
than other types of patients, so an increase in the number of these 
patients would indicate an increase in the costliness of IRF patients 
(that is, an increase in IRFs' case mix). However, in 2002 IRFs had a 
much greater incentive to record if patients had a pulmonary condition 
than they did in 1999 because they got paid more for this condition in 
2002, whereas they did not in 1999. Therefore, it is reasonable to 
expect that some of the increase in the number of patients with a 
pulmonary condition was due to the fact that IRFs were recording that 
condition for patients more frequently, not that there were really more 
patients of that type (although there may also have been some more 
patients of that type). To determine the extent to which IRFs may have 
just been coding that condition more often versus the extent to which 
there actually may have been more patients with a pulmonary condition 
going to IRFs than before, RAND looked at the one source of information 
that we believe was least likely to be influenced by the incentive to 
code patients with this condition more frequently in the IRF: the acute 
care hospital record from the stay preceding the IRF stay. We believe 
that the acute care hospitals are not likely to be influenced by IRF 
PPS policies that only affect IRF payments (that is, changes in IRF 
payment policies would not likely result in monetary benefits to the 
acute care hospitals). Thus, if RAND found a substantial increase in 
the number of IRF patients with a pulmonary condition in the acute care 
hospital before going to the IRF, it would be reasonable to assume that 
more patients with a pulmonary condition were going to IRFs (a real 
increase in case mix). However, if there was little change in the 
number of IRF patients with a pulmonary condition in the acute care 
hospital before going to the IRF, then we believe it is reasonable to 
assume that a portion of the increase in patients with a pulmonary 
condition in IRFs was due to the incentives to code more of these 
patients in the IRFs.
    We believe that this first approach shows that both factors, real 
case mix change and coding change, contributed to the amount of 
observed change in 2002, the first IRF PPS rate year. However, these 
estimates (based on the best available data) do not fully address all 
of the variables that may have contributed to the change in case mix. 
For example, the model does not account for the possibility that 
patients could develop impairments, functional problems, or 
comorbidities after they leave the acute care hospital (prior to the 
IRF admission) that would make them more costly when they are in the 
IRF. We note that the introduction of a new payment system may have 
interrelated effects on providers as they adapt to new (or perceived) 
program incentives. Thus, an analysis of first year experience may not 
be fully representative of providers' behavior under a fully 
implemented system. In addition, hospital coding practices may change 
at a different rate in facilities where the IRF is a unit of an acute 
care hospital compared with freestanding IRF hospitals. Although we 
attempted to identify all of the factors that cause the variation in 
costs among the IRFs' patient population, this may not have been 
possible given that the data are from the transitional year of the new 
PPS. Finally, we want to ensure that the rate reduction will not have 
an adverse effect on beneficiaries' access to IRF care.
    For the reasons described above, we believe we should provide some 
flexibility to account for the possibility that some of the observed 
changes may be attributable to other than coding changes. Thus, in 
determining the amount of the proposed reduction in the standard 
payment amount, we examined RAND's second approach that recognizes the 
difficulty of precise measurement of real case mix and coding changes. 
Using this second approach, RAND developed an analytical procedure that 
allowed them to distinguish more fully between real case mix change and 
coding change

[[Page 30222]]

based on patient characteristics. In part, this second approach 
involves analyzing some specific examples of coding that we know have 
changed over time, such as direct indications of improvements in 
impairment coding, changes in coding instruction for bladder and bowel 
functioning, and dramatic increases in coding of certain conditions 
that affect patients' placement into tiers (resulting in higher 
payments).
    Using the two approaches, RAND found that real case mix changes in 
IRFs over this period ranged from a decrease of 2.4 percent (using the 
first approach) to an increase of 1.5 percent (using the second 
approach). This suggests that coding changes accounted for between 1.9 
percent (if real case mix increased by 1.5 percent (that is, 3.4 
percent minus 1.5 percent)) and 5.8 percent (if real case mix decreased 
by 2.4 percent (that is, 3.4 percent plus 2.4 percent)) of the increase 
in aggregate payments for 2002 compared with 1999. Thus, RAND 
recommended decreasing the standard per discharge payment amount by 
between 1.9 and 5.8 percent to adjust for the coding changes. We are 
proposing to reduce the standard payment amount by the lower of these 
two numbers, 1.9 percent, because we believe it is a reasonable 
estimate for the amount of coding change, based on RAND's analysis of 
direct indications of coding change.
    We considered proposing a reduction to the standard payment amount 
by an amount up to 5.8 percent because RAND's first approach suggested 
that coding changes could possibly have been responsible for up to 5.8 
percent of the observed increase in IRFs' case mix. Furthermore, a 
separate analysis by RAND found that if all IRFs had been paid based on 
100 percent of the IRF PPS payment rates throughout all of 2002 (some 
IRFs were still transitioning to PPS payments during 2002), PPS 
payments during 2002 would have been 17 percent higher than IRFs' 
costs. This suggests that we could potentially have proposed a 
reduction greater than 1.9 and up to 5.8 percent.
    We decided to propose a reduction of 1.9 percent, the lowest 
possible amount of change attributable to coding change. However, we 
are continuing to work with RAND to further analyze the data and are 
soliciting comments on the following factors which may have an effect 
on the amount of the reduction. First, whether changes that occurred 
within the transitional IRF PPS rate year could have impacted coding 
and patient selection and affected these analyses. Second, since we 
feel it is crucial to maintain access to IRF care, we are soliciting 
comments on the effect of the proposed range of reductions on access to 
IRF care, particularly for patients with greater resource needs. The 
analyses described here are only the first of an ongoing series of 
studies to evaluate the existence and extent of payment increases due 
to coding changes. We will continue to review the need for any further 
reduction in the standard payment amount in subsequent years as part of 
our overall monitoring and evaluation of the IRF PPS.
    Therefore, for FY 2006, we are proposing to reduce the standard 
payment amount by the lowest amount (1.9 percent) attributable to 
coding changes. We believe this approach, which is supported by RAND's 
analysis of the data, would adequately adjust for the increased 
payments to IRFs caused by purely coding changes, but would still 
provide the flexibility to account for the possibility that some of the 
observed changes in case mix may be attributed to other than coding 
changes. Furthermore, we chose the amount of the proposed reduction in 
the standard payment amount in order to recognize that IRFs' current 
cost structures may be changing as they strive to comply with other 
recent Medicare policy changes, such as the criteria for IRF 
classification commonly known as the ``75 percent rule.'' We are 
continuing to work with RAND to analyze the data and are soliciting 
comments on whether the proposed 1.9 percent is the percentage 
reduction that ought to be made, or if another percentage reduction 
(for example, the 3.4 percent observed case mix change or the 5.8 
percent that RAND found to be maximum amount of change due to coding) 
should be applied.
    To accomplish the proposed reduction of the standard payment 
conversion factor by 1.9 percent, we first propose to update the FY 
2005 standard payment conversion factor by the estimated market basket 
of 3.1 percent to get the standard payment amount for FY 2006 
($12,958*1.031 = $13,360). Next, we propose to multiply the FY 2006 
standard payment amount by 0.981, which reduces the standard payment 
amount by 1.9 percent ($13,360*0.981 = $13,106). In section III.B.7 of 
this proposed rule, we propose to further adjust the $13,106 by the 
proposed budget neutrality factors for the wage index and the other 
proposed refinements outlined in this proposed rule that would result 
in the proposed FY 2006 standard payment conversion factor. In section 
III.B.7 of this proposed rule, we provide a step-by-step calculation 
that results in the FY 2006 standard payment conversion factor.

B. Proposed Adjustments to Determine the Proposed FY 2006 Standard 
Payment Conversion Factor

1. Proposed Market Basket Used for IRF Market Basket Index
    Under the broad authority of section 1886(j)(3)(C) of the Act, the 
Secretary establishes an increase factor that reflects changes over 
time in the prices of an appropriate mix of goods and services included 
in covered IRF services, which is referred to as a market basket index. 
The market basket needs to include both operating and capital. Thus, 
although the Secretary is required to develop an increase factor under 
section 1886(j)(3)(C) of the Act, this provision gives the Secretary 
discretion in the design of such factor.
    The index currently used to update payments for rehabilitation 
facilities is the Excluded hospital including capital market basket. 
This market basket is based on 1997 Medicare cost report data and 
includes Medicare-participating rehabilitation (IRF), LTCH, psychiatric 
(IPF), cancer, and children's hospitals.
    We are unable to create a separate market basket specifically for 
rehabilitation hospitals due to the small number of facilities and the 
limited data that are provided (for instance, only about 25 percent of 
rehabilitation facility cost reports reported contract labor cost data 
for 2002). Since all IRFs are paid under the IRF PPS, nearly all LTCHs 
are paid under the LTCH PPS, and IPFs for cost reporting periods 
beginning on or after January 1, 2005 will be paid under the IPF PPS, 
we propose to update payments for rehabilitation facilities using a 
market basket reflecting the operating and capital cost structures for 
IRFs, IPFs, and LTCHs, hereafter referred to as the RPL 
(rehabilitation, psychiatric, long-term care) market basket. We propose 
to exclude children's and cancer hospitals from the RPL market basket 
because their payments are based entirely on reasonable costs subject 
to rate-of-increase limits established under the authority of section 
1886(b) of the Act, which is implemented in Sec.  413.40 of the 
regulations. They are not reimbursed under a prospective payment 
system. Also, the FY 2002 cost structures for children's and cancer 
hospitals are noticeably different than the cost structures of the 
IRFs, IPFs, and LTCHs. The services offered in IRFs, IPFs, and LTCHs 
are typically more labor-intensive than those offered in cancer and 
children's hospitals. Therefore, the compensation cost weights for 
IRFs, IPFs, and LTCHs are larger than those in cancer and children's 
hospitals. In addition, the depreciation cost weights

[[Page 30223]]

for IRFs, IPFs, and LTCHs are noticeably smaller than those for 
children's and cancer hospitals.
    In the following discussion, we provide a background on market 
baskets and describe the methodologies used to determine the operating 
and capital portions of the proposed FY 2002-based RPL market basket.
a. Overview of the Proposed RPL Market Basket
    The proposed RPL market basket is a fixed weight, Laspeyres-type 
price index that is constructed in three steps. First, a base period is 
selected (in this case, FY 2002), and total base period expenditures 
are estimated for a set of mutually exclusive and exhaustive spending 
categories based upon type of expenditure. Then the proportion of total 
operating costs that each category represents is determined. These 
proportions are called cost or expenditure weights. Second, each 
expenditure category is matched to an appropriate price or wage 
variable, referred to as a price proxy. In nearly every instance, these 
price proxies are price levels derived from publicly available 
statistical series that are published on a consistent schedule, 
preferably at least on a quarterly basis.
    Finally, the expenditure weight for each cost category is 
multiplied by the level of its respective price proxy for a given 
period. The sum of these products (that is, the expenditure weights 
multiplied by their price levels) for all cost categories yields the 
composite index level of the market basket in a given period. Repeating 
this step for other periods produces a series of market basket levels 
over time. Dividing an index level for a given period by an index level 
for an earlier period produces a rate of growth in the input price 
index over that time period.
    A market basket is described as a fixed-weight index because it 
answers the question of how much it would cost, at another time, to 
purchase the same mix of goods and services purchased to provide 
hospital services in a base period. The effects on total expenditures 
resulting from changes in the quantity or mix of goods and services 
(intensity) purchased subsequent to the base period are not measured. 
In this manner, the market basket measures only the pure price change. 
Only when the index is rebased would the quantity and intensity effects 
be captured in the cost weights. Therefore, we rebase the market basket 
periodically so the cost weights reflect changes in the mix of goods 
and services that hospitals purchase (hospital inputs) to furnish 
patient care between base periods.
    The terms rebasing and revising, while often used interchangeably, 
actually denote different activities. Rebasing means moving the base 
year for the structure of costs of an input price index (for example, 
shifting the base year cost structure from FY 1997 to FY 2002). 
Revising means changing data sources, methodology, or price proxies 
used in the input price index. We are proposing to rebase and revise 
the market basket used to update the IRF PPS.
b. Proposed Methodology for Operating Portion of the Proposed RPL 
Market Basket
    The operating portion of the proposed FY 2002-based RPL market 
basket consists of several major cost categories derived from the FY 
2002 Medicare cost reports for IRFs, IPFs, and LTCHs: Wages, drugs, 
professional liability insurance and a residual. We choose FY 2002 as 
the base year because we believe this is the most recent, relatively 
complete year of Medicare cost report data. Due to insufficient 
Medicare cost report data for IRFs, IPFs, and LTCHs, cost weights for 
benefits, contract labor, and blood and blood products were developed 
using the proposed FY 2002-based IPPS market basket (Section IV. 
Proposed Rebasing and Revision of the Hospital Market Baskets IPPS 
Hospital Proposed Rule for FY 2006), which we explain in more detail 
later in this section. For example, less than 30 percent of IRFs, IPFs, 
and LTCHs reported benefit cost data in FY 2002. We have noticed an 
increase in cost data for these expense categories over the last 4 
years. The next time we rebase the RPL market basket, there may be 
sufficient IRFs, IPFs, and LTCHs cost report data to develop the 
weights for these expenditure categories.
    Since the cost weights for the RPL market basket are based on 
facility costs, we are proposing to limit our sample to hospitals with 
a Medicare average length of stay within a comparable range of the 
total facility average length of stay. We believe this provides a more 
accurate reflection of the structure of costs for Medicare treatments. 
Our goal is to measure cost shares that are reflective of case mix and 
practice patterns associated with providing services to Medicare 
beneficiaries.
    We propose to use those cost reports for IRFs and LTCHs whose 
Medicare average length of stay is within 15 percent (that is, 15 
percent higher or lower) of the total facility average length of stay 
for the hospital. This is the same edit applied to the FY 1992 and FY 
1997 excluded hospital with capital market baskets. We propose 15 
percent because it includes those LTCHs and IRFs whose Medicare LOS is 
within approximately 5 days of the facility length of stay.
    We propose to use a less stringent measure of Medicare length of 
stay for IPFs whose average length of stay is within 30 or 50 percent 
(depending on the total facility average length of stay) of the total 
facility length of stay. This less stringent edit allows us to increase 
our sample size by over 150 reports and produce a cost weight more 
consistent with the overall facility. The edit we applied to IPFs when 
developing the FY-1997 based excluded hospital with capital market 
basket was based on the best available data at the time.
    The detailed cost categories under the residual (that is, the 
remaining portion of the market basket after excluding wages and 
salaries, drugs, and professional liability cost weights) are derived 
from the proposed FY 2002-based IPPS market basket and the 1997 
Benchmark Input-Output Tables published by the Bureau of Economic 
Analysis, U.S. Department of Commerce. The proposed FY 2002-based IPPS 
market basket is developed using FY 2002 Medicare hospital cost reports 
with the most recent and detailed cost data. The 1997 Benchmark I-O is 
the most recent, comprehensive source of cost data for all hospitals. 
Proposed cost weights for benefits, contract labor, and blood and blood 
products were derived using the proposed FY 2002-based IPPS market 
basket. For example, the ratio of the benefit cost weight to the wages 
and salaries cost weight in the proposed FY 2002-based IPPS market 
basket was applied to the RPL wages and salaries cost weight to derive 
a benefit cost weight for the RPL market basket. The remaining proposed 
operating cost categories were derived using the 1997 Benchmark Input-
Output Tables aged to 2002 using relative price changes. (The 
methodology we used to age the data involves applying the annual price 
changes from the price proxies to the appropriate cost categories. We 
repeat this practice for each year.) Therefore, using this methodology 
roughly 59 percent of the proposed RPL market basket is accounted for 
by wages, drugs and professional liability insurance data from FY 2002 
Medicare cost report data for IRFs, LTCHs, and IPFs.
    Table 7 below sets forth the complete proposed FY 2002-based RPL 
market basket including cost categories, weights, and price proxies. 
For comparison purposes, the corresponding FY 1997-based excluded 
hospital with capital market basket is listed as well.

[[Page 30224]]

    Wages and salaries are 52.895 percent of total costs for the 
proposed FY 2002-based RPL market basket compared to 47.335 percent for 
FY 1997-based excluded hospital with capital market basket. Employee 
benefits are 12.982 percent for the proposed FY 2002-based RPL market 
basket compared to 10.244 percent for FY 1997-based excluded hospital 
with capital market basket. As a result, compensation costs (wages and 
salaries plus employee benefits) for the proposed FY 2002-based RPL 
market basket are 65.877 percent of costs compared to 57.579 percent 
for the FY 1997-based excluded hospital with capital market basket. Of 
the 8 percentage point difference between the compensation shares, 
approximately 3 percentage points are due to the proposed new base year 
(FY 2002 instead of FY 1997), 3 percentage points are due to the 
revised length of stay edit and the remaining 2 percentage points are 
due to the proposed exclusion of other hospitals (that is, only 
including IRFs, IPFs, and LTCHs in the market basket).
    Following the table is a summary outlining the choice of the 
proxies used for the operating portion of the proposed market basket. 
The price proxies for the proposed capital portion are described in 
more detail in the capital methodology section. (See section III.B.1.c 
of this proposed rule.)
BILLING CODE 4120-01-P

[[Page 30225]]

[GRAPHIC] [TIFF OMITTED] TP25MY05.019


[[Page 30226]]


[GRAPHIC] [TIFF OMITTED] TP25MY05.020


[[Page 30227]]


[GRAPHIC] [TIFF OMITTED] TP25MY05.021

BILLING CODE 4120-01-C
    Below we provide the proxies that we are proposing to use for the 
FY 2002-based RPL market basket. With the exception of the Professional 
Liability proxy, all the proposed price proxies for the operating 
portion of the proposed RPL market basket are based on Bureau of Labor 
Statistics (BLS) data and are grouped into one of the following BLS 
categories:
     Producer Price Indexes--Producer Price Indexes (PPIs) 
measure price changes for goods sold in other than retail markets. PPIs 
are preferable price proxies for goods that hospitals purchase as 
inputs in producing their outputs because the PPIs would better reflect 
the prices faced by hospitals. For example, we use a special PPI for 
prescription drugs, rather than the Consumer Price Index (CPI) for 
prescription drugs because hospitals generally purchase drugs directly 
from the wholesaler. The PPIs that we use measure price change at the 
final stage of production.
     Consumer Price Indexes--Consumer Price Indexes (CPIs) 
measure change in the prices of final goods and services bought by the 
typical consumer. Because they may not represent the price faced by a 
producer,

[[Page 30228]]

we used CPIs only if an appropriate PPI was not available, or if the 
expenditures were more similar to those of retail consumers in general 
rather than purchases at the wholesale level. For example, the CPI for 
food purchased away from home is used as a proxy for contracted food 
services.
     Employment Cost Indexes--Employment Cost Indexes (ECIs) 
measure the rate of change in employee wage rates and employer costs 
for employee benefits per hour worked. These indexes are fixed-weight 
indexes and strictly measure the change in wage rates and employee 
benefits per hour. Appropriately, they are not affected by shifts in 
employment mix.
    We evaluated the price proxies using the criteria of reliability, 
timeliness, availability, and relevance. Reliability indicates that the 
index is based on valid statistical methods and has low sampling 
variability. Timeliness implies that the proxy is published regularly, 
at least once a quarter. Availability means that the proxy is publicly 
available. Finally, relevance means that the proxy is applicable and 
representative of the cost category weight to which it is applied. The 
CPIs, PPIs, and ECIs selected by us to be proposed in this regulation 
meet these criteria.
    We note that the proposed proxies are the same as those used for 
the FY 1997-based excluded hospital with capital market basket. Because 
these proxies meet our criteria of reliability, timeliness, 
availability, and relevance, we believe they continue to be the best 
measure of price changes for the cost categories. For further 
discussion on the FY 1997-based excluded hospital with capital market 
basket, see the IPPS final rule (67 FR at 50042), published in the 
Federal Register on August 1, 2002.

Wages and Salaries

    For measuring the price growth of wages in the proposed FY 2002-
based RPL market basket, we propose to use the ECI for wages and 
salaries for civilian hospital workers as the proxy for wages.

Employee Benefits

    The proposed FY 2002-based RPL market basket would use the ECI for 
employee benefits for civilian hospital workers.

Nonmedical Professional Fees

    The ECI for compensation for professional and technical workers in 
private industry would be applied to this category since it includes 
occupations such as management and consulting, legal, accounting and 
engineering services.

Fuel, Oil, and Gasoline

    The percentage change in the price of gas fuels as measured by the 
PPI (Commodity Code 0552) would be applied to this component.

Electricity

    The percentage change in the price of commercial electric power as 
measured by the PPI (Commodity Code 0542) would be applied to 
this component.

Water and Sewage

    The percentage change in the price of water and sewage maintenance 
as measured by the Consumer Price Index (CPI) for all urban consumers 
(CPI Code  CUUR0000SEHG01) would be applied to this component.

Professional Liability Insurance

    The proposed FY 2002-based RPL market basket would use the 
percentage change in the hospital professional liability insurance 
(PLI) premiums as estimated by the CMS Hospital professional liability 
index for the proxy of this category. In the FY 1997-based excluded 
hospital with capital market basket, the same price proxy was used.
    We continue to research options for improving our proxy for 
professional liability insurance. This research includes exploring 
various options for expanding our current survey, including the 
identification of another entity that would be willing to work with us 
to collect more complete and comprehensive data. We are also exploring 
other options such as third party or industry data that might assist us 
in creating a more precise measure of PLI premiums. At this time we 
have not identified a preferred option, therefore, no change is 
proposed for the proxy in this proposed rule.

Pharmaceuticals

    The percentage change in the price of prescription drugs as 
measured by the PPI (PPI Code  PPI32541DRX) would be used as a 
proxy for this category. This is a special index produced by BLS and is 
the same proxy used in the 1997-based excluded hospital with capital 
market basket.

Food, Direct Purchases

    The percentage change in the price of processed foods and feeds as 
measured by the PPI (Commodity Code 02) would be applied to 
this component.

Food, Contract Services

    The percentage change in the price of food purchased away from home 
as measured by the CPI for all urban consumers (CPI Code  
CUUR0000SEFV) would be applied to this component.

Chemicals

    The percentage change in the price of industrial chemical products 
as measured by the PPI (Commodity Code 061) would be applied 
to this component. While the chemicals hospital's purchase include 
industrial as well as other types of chemicals, the industrial 
chemicals component constitutes the largest proportion by far. Thus, we 
believe that commodity Code 061 is the appropriate proxy.

Medical Instruments

    The percentage change in the price of medical and surgical 
instruments as measured by the PPI (Commodity Code 1562) would 
be applied to this component

Photographic Supplies

    The percentage change in the price of photographic supplies as 
measured by the PPI (Commodity Code 1542) would be applied to 
this component.

Rubber and Plastics

    The percentage change in the price of rubber and plastic products 
as measured by the PPI (Commodity Code 07) would be applied to 
this component.

Paper Products

    The percentage change in the price of converted paper and 
paperboard products as measured by the PPI (Commodity Code 
0915) would be used.

Apparel

    The percentage change in the price of apparel as measured by the 
PPI (Commodity Code 381) would be applied to this component.

Machinery and Equipment

    The percentage change in the price of machinery and equipment as 
measured by the PPI (Commodity Code 11) would be applied to 
this component.

Miscellaneous Products

    The percentage change in the price of all finished goods less food 
and energy as measured by the PPI (Commodity Code SOP3500) 
would be applied to this component. Using this index would remove the 
double-counting of food and energy prices, which are captured elsewhere 
in the market basket. The weight for this cost category is higher than 
in the 1997-based index because the weight for blood and blood products 
(1.322) is added to it. In the 1997-based excluded hospital with 
capital market basket we included a separate cost

[[Page 30229]]

category for blood and blood products, using the BLS Producer Price 
Index for blood and derivatives as a price proxy. A review of recent 
trends in the PPI for blood and derivatives suggests that its movements 
may not be consistent with the trends in blood costs faced by 
hospitals. While this proxy did not match exactly with the product 
hospitals are buying, its trend over time appears to be reflective of 
the historical price changes of blood purchased by hospitals. However, 
an apparent divergence in trends in the PPI for blood and derivatives 
and trends in blood costs faced by hospitals over recent years led us 
to reevaluate whether the PPI for blood and derivatives was an 
appropriate measure of the changing price of blood. We ran test market 
baskets classifying blood in 3 separate cost categories: blood and 
blood products, contained within chemicals as was done for the 1992-
based excluded hospital with capital market basket, and within 
miscellaneous products. These categories use as proxies the following 
PPIs: the PPI for blood and blood products, the PPI for chemicals, and 
the PPI for finished goods less food and energy, respectively. Of these 
three proxies, the PPI for finished goods less food and energy moved 
most like the recent blood cost and price trends. In addition, the 
impact on the overall market basket by using different proxies for 
blood was negligible, mostly due to the relatively small weight for 
blood in the market basket.
    Therefore, we are proposing to use the PPI for finished goods less 
food and energy for the blood proxy because we believe it would best be 
able to proxy only price changes rather than nonprice factors such as 
changes in quantities or required tests associated with blood purchased 
by hospitals. We will continue to evaluate this proxy for its 
appropriateness and will explore the development of alternative price 
indexes to proxy the price changes associated with this cost.

Telephone

    The percentage change in the price of telephone services as 
measured by the CPI for all urban consumers (CPI Code  
CUUR0000SEED) would be applied to this component.

Postage

    The percentage change in the price of postage as measured by the 
CPI for all urban consumers (CPI Code  CUUR0000SEEC01) would 
be applied to this component.

Proposed Changes for All Other Services, Labor Intensive

    The percentage change in the ECI for compensation paid to service 
workers employed in private industry would be applied to this 
component.

All Other Services, Nonlabor Intensive

    The percentage change in the all-items component of the CPI for all 
urban consumers (CPI Code  CUUR0000SA0) would be applied to 
this component.
c. Proposed Methodology for Capital Portion of the RPL Market Basket
    Unlike for the operating costs of the proposed FY 2002-based RPL 
market basket, we did not have IRFs, IPFs, and LTCHs FY 2002 Medicare 
cost report data for the capital cost weights, due to a change in the 
FY 2002 cost reporting requirements. Rather, we used these hospitals' 
expenditure data for the capital cost categories of depreciation, 
interest, and other capital expenses for the most recent year available 
(FY 2001), and aged the data to a FY 2002 base year using relevant 
price proxies.
    We calculated weights for the RPL market basket capital costs using 
the same set of Medicare cost reports used to develop the operating 
share for IRFs, IPFs, and LTCHs. The resulting proposed capital weight 
for the FY 2002 base year is 10.149 percent. This is based on FY 2001 
Medicare cost report data for IRFs, IPFs, and LTCHs, aged to FY 2002 
using relevant price proxies.
    Lease expenses are not a separate cost category in the market 
basket, but are distributed among the cost categories of depreciation, 
interest, and other, reflecting the assumption that the underlying cost 
structure of leases is similar to capital costs in general. We assumed 
10 percent of lease expenses are overhead and assigned them to the 
other capital expenses cost category as overhead. We base this 
assignment of 10 percent of lease expenses to overhead on the common 
assumption that overhead is 10 percent of costs. The remaining lease 
expenses were distributed to the three cost categories based on the 
weights of depreciation, interest, and other capital expenses not 
including lease expenses.
    Depreciation contains two subcategories: building and fixed 
equipment and movable equipment. The split between building and fixed 
equipment and movable equipment was determined using the FY 2001 
Medicare cost reports for IRFs, IPFs, and LTCHs. This methodology was 
also used to compute the 1997-based index (67 FR at 50044).
    Total interest expense cost category is split between the 
government/nonprofit and for-profit hospitals. The 1997-based excluded 
hospital with capital market basket allocated 85 percent of the total 
interest cost weight to the government/nonprofit interest, proxied by 
average yield on domestic municipal bonds, and 15 percent to for-profit 
interest, proxied by average yield on Moody's Aaa bonds.
    We propose to derive the split using the relative FY 2001 Medicare 
cost report data for IPPS hospitals on interest expenses for the 
government/nonprofit and for-profit hospitals. Due to insufficient 
Medicare cost report data for IRFs, IPFs and LTCHs, we propose to use 
the same split used in the IPPS capital input price index, which is 75-
25. We believe it is important that this split reflects the latest 
relative cost structure of interest expenses for hospitals. Therefore, 
we propose to use a 75-25 split to allocate interest expenses to 
government/nonprofit and for-profit. See the Proposed IPPS Rule for FY 
2006, Section IV.D, Capital Input Price Index Section.
    Since capital is acquired and paid for over time, capital expenses 
in any given year are determined by both past and present purchases of 
physical and financial capital. The vintage-weighted capital index is 
intended to capture the long-term consumption of capital, using vintage 
weights for depreciation (physical capital) and interest (financial 
capital). These vintage weights reflect the purchase patterns of 
building and fixed equipment and movable equipment over time. 
Depreciation and interest expenses are determined by the amount of past 
and current capital purchases. Therefore, we are proposing to use the 
vintage weights to compute vintage-weighted price changes associated 
with depreciation and interest expense.
    Vintage weights are an integral part of the proposed FY 2002-based 
RPL market basket. Capital costs are inherently complicated and are 
determined by complex capital purchasing decisions, over time, based on 
such factors as interest rates and debt financing. In addition, capital 
is depreciated over time instead of being consumed in the same period 
it is purchased. The capital portion of the proposed FY 2002-based RPL 
market basket would reflect the annual price changes associated with 
capital costs, and would be a useful simplification of the actual 
capital investment process. By accounting for the vintage nature of 
capital, we are able to provide an accurate, stable annual measure of 
price changes. Annual non-vintage price changes for capital are 
unstable due to the volatility of interest rate changes and, therefore, 
do not reflect the actual annual price changes

[[Page 30230]]

for Medicare capital-related costs. The capital component of the 
proposed FY 2002-based RPL market basket would reflect the underlying 
stability of the capital acquisition process and provide hospitals with 
the ability to plan for changes in capital payments.
    To calculate the vintage weights for depreciation and interest 
expenses, we needed a time series of capital purchases for building and 
fixed equipment and movable equipment. We found no single source that 
provides the best time series of capital purchases by hospitals for all 
of the above components of capital purchases. The early Medicare Cost 
Reports did not have sufficient capital data to meet this need because 
these data were not required. While the AHA Panel Survey provided a 
consistent database back to 1963, it did not provide annual capital 
purchases. The AHA Panel Survey provided a time series of depreciation 
expenses through 1997 which could be used to infer capital purchases 
over time. From 1998 to 2001, total hospital depreciation expenses were 
calculated by multiplying the AHA Annual Survey total hospital expenses 
by the ratio of depreciation to total hospital expenses from the 
Medicare cost reports. Beginning in 2001, the AHA Annual survey began 
collecting depreciation expenses. We hope to be able to use this data 
in future rebasings.
    In order to estimate capital purchases from AHA data on 
depreciation and interest expenses, the expected life for each cost 
category (building and fixed equipment, movable equipment, and debt 
instruments) is needed. Due to insufficient Medicare cost report data 
for IRFs, IPFs and LTCHs, we propose to use FY 2001 Medicare cost 
reports for IPPS hospitals to determine the expected life of building 
and fixed equipment and movable equipment. The expected life of any 
piece of equipment can be determined by dividing the value of the asset 
(excluding fully depreciated assets) by its current year depreciation 
amount. This calculation yields the estimated useful life of an asset 
if depreciation were to continue at current year levels, assuming 
straight-line depreciation. From the FY 2001 Medicare cost reports for 
IPPS hospitals the expected life of building and fixed equipment was 
determined to be 23 years, and the expected life of movable equipment 
was determined to be 11 years.
    Although we are proposing to use this methodology for deriving the 
useful life of an asset, we plan to review it between the publication 
of the proposed and final rules. We plan to review alternate data 
sources, if available, and analyze in more detail the hospital's 
capital cost structure reported in the Medicare cost reports.
    We also propose to use the fixed and movable weights derived from 
FY 2001 Medicare cost reports for IRFs, IPFs and LTCHs to separate the 
depreciation expenses into annual amounts of building and fixed 
equipment depreciation and movable equipment depreciation. By 
multiplying the annual depreciation amounts by the expected life 
calculations from the FY 2001 Medicare cost reports, year-end asset 
costs for building and fixed equipment and movable equipment could be 
determined. We then calculated a time series back to 1963 of annual 
capital purchases by subtracting the previous year asset costs from the 
current year asset costs. From this capital purchase time series we 
were able to calculate the vintage weights for building and fixed 
equipment, movable equipment, and debt instruments. Each of these sets 
of vintage weights are explained in detail below.
    For proposed building and fixed equipment vintage weights, the real 
annual capital purchase amounts for building and fixed equipment 
derived from the AHA Panel Survey were used. The real annual purchase 
amount was used to capture the actual amount of the physical 
acquisition, net of the effect of price inflation. This real annual 
purchase amount for building and fixed equipment was produced by 
deflating the nominal annual purchase amount by the building and fixed 
equipment price proxy, the Boeckh Institutional Construction Index. 
This is the same proxy used for the FY 1997-based excluded hospital 
with capital market basket. We believe this proxy continues to meet our 
criteria of reliability, timeliness, availability, and relevance. Since 
building and fixed equipment has an expected life of 23 years, the 
vintage weights for building and fixed equipment are deemed to 
represent the average purchase pattern of building and fixed equipment 
over 23-year periods. With real building and fixed equipment purchase 
estimates available back to 1963, sixteen 23-year periods could be 
averaged to determine the average vintage weights for building and 
fixed equipment that are representative of average building and fixed 
equipment purchase patterns over time. Vintage weights for each 23-year 
period are calculated by dividing the real building and fixed capital 
purchase amount in any given year by the total amount of purchases in 
the 23-year period. This calculation is done for each year in the 23-
year period, and for each of the sixteen 23-year periods. The average 
of each year across the sixteen 23-year periods is used to determine 
the 2002 average building and fixed equipment vintage weights.
    For proposed movable equipment vintage weights, the real annual 
capital purchase amounts for movable equipment derived from the AHA 
Panel Survey were used to capture the actual amount of the physical 
acquisition, net of price inflation. This real annual purchase amount 
for movable equipment was calculated by deflating the nominal annual 
purchase amount by the movable equipment price proxy, the Producer 
Price Index for Machinery and Equipment. This is the same proxy used 
for the FY 1997-based excluded hospital with capital market basket. We 
believe this proxy, which meets our criteria, is the best measure of 
price changes for this cost category. Since movable equipment has an 
expected life of 11 years, the vintage weights for movable equipment 
are deemed to represent the average purchase pattern of movable 
equipment over 11-year periods. With real movable equipment purchase 
estimates available back to 1963, twenty-eight 11-year periods could be 
averaged to determine the average vintage weights for movable equipment 
that are representative of average movable equipment purchase patterns 
over time. Vintage weights for each 11-year period would be calculated 
by dividing the real movable capital purchase amount for any given year 
by the total amount of purchases in the 11-year period. This 
calculation is done for each year in the 11-year period, and for each 
of the twenty-eight 11-year periods. The average of each year across 
the twenty-eight 11-year periods would be used to determine the FY 2002 
average movable equipment vintage weights.
    For proposed interest vintage weights, the nominal annual capital 
purchase amounts for total equipment (building and fixed, and movable) 
derived from the AHA Panel and Annual Surveys were used. Nominal annual 
purchase amounts were used to capture the value of the debt instrument. 
Since hospital debt instruments have an expected life of 23 years, the 
vintage weights for interest are deemed to represent the average 
purchase pattern of total equipment over 23-year periods. With nominal 
total equipment purchase estimates available back to 1963, sixteen 23-
year periods could be averaged to determine the average vintage weights 
for interest that are representative of average capital purchase 
patterns over time. Vintage weights for each 23-year period would be 
calculated by dividing the nominal total capital purchase

[[Page 30231]]

amount for any given year by the total amount of purchases in the 23-
year period. This calculation would be done for each year in the 23-
year period and for each of the sixteen 23-year periods. The average of 
the sixteen 23-year periods would be used to determine the FY 2002 
average interest vintage weights. The vintage weights for the index are 
presented in Table 8 below.
    In addition to the proposed price proxies for depreciation and 
interest costs described above in the vintage weighted capital section, 
we propose to use the CPI-U for Residential Rent as a price proxy for 
other capital-related costs. The price proxies for each of the capital 
cost categories are the same as those used for the IPPS final rule (67 
FR at 50044) capital input price index.
BILLING CODE 4120-01-P

[[Page 30232]]

[GRAPHIC] [TIFF OMITTED] TP25MY05.022

BILLING CODE 4120-01-C
    The proposed FY 2006 update for IRF PPS using the proposed FY 2002-
based RPL market basket and Global Insight's 4th quarter 2004 forecast 
is be 3.1 percent. This includes increases in both the operating 
section and the capital section. Global Insight, Inc. is a nationally 
recognized economic and financial forecasting firm that contracts with 
CMS to forecast the components of the market baskets. Using the current 
FY 1997-based excluded hospital with capital market basket (66 FR at 
41427), Global Insight's fourth quarter 2004

[[Page 30233]]

forecast for FY 2006 is also 3.1 percent. Table 4 below compares the 
proposed FY 2002-based RPL market basket and the FY 1997-based excluded 
hospital with capital market basket percent changes. For both the 
historical and forecasted periods between FY 2000 and FY 2008, the 
difference between the two market baskets is minor with the exception 
of FY 2002 where the proposed FY 2002-based RPL market basket increased 
three tenths of a percentage point higher than the FY 1997-based 
excluded hospital with capital market basket. This is primarily due to 
the proposed FY 2002-based RPL market basket having a larger 
compensation (that is, the sum of wages and salaries and benefits) cost 
weight than the FY 1997-based index and the price changes associated 
with compensation costs increasing much faster than the prices of other 
market basket components. Also contributing is the ``all other nonlabor 
intensive'' cost weight, which is smaller in the proposed FY 2002-based 
RPL market basket than in the FY 1997-based index, and the slower price 
changes associated with these costs.

   TABLE 9.--Proposed FY 2002-based RPL Market Basket and FY 1997-based Excluded Hospital With Capital Market
                                     Basket Percent Changes, FY 2000-FY 2008
----------------------------------------------------------------------------------------------------------------
                                                                                                 FY 1997-based
                                                                           Proposed rebased    excluded hospital
                            Fiscal year (FY)                               FY 2002-based RPL  market basket with
                                                                             market basket          capital
----------------------------------------------------------------------------------------------------------------
Historical data:
    FY 2000.............................................................                 3.1                 3.1
    FY 2001.............................................................                 4.0                 4.0
    FY 2002.............................................................                 3.9                 3.6
    FY 2003.............................................................                 3.8                 3.7
    FY 2004.............................................................                 3.6                 3.6
    Average FYs 2000-2004...............................................                 3.7                 3.6
Forecast:
    FY 2005.............................................................                 3.7                 3.8
    FY 2006.............................................................                 3.1                 3.1
    FY 2007.............................................................                 2.9                 2.8
    FY 2008.............................................................                 2.9                 2.8
    Average FYs 2005-2008...............................................                 3.2                3.1
----------------------------------------------------------------------------------------------------------------
Source: Global Insight, Inc. 4th Qtr 2004, @USMACRO/CNTL1104 @CISSIM/TL1104.SIM

d. Labor-Related Share
    Section 1886(j)(6) of the Act specifies that the Secretary shall 
adjust the proportion (as estimated by the Secretary from time to time) 
of rehabilitation facilities' costs which are attributable to wages and 
wage-related costs, of the prospective payment rates computed under 
paragraph (3) for area differences in wage levels by a factor 
(established by the Secretary) reflecting the relative hospital wage 
level in the geographic area of the rehabilitation facility compared to 
the national average wage level for such facilities. Not later than 
October 1, 2001 (and at least every 36 months thereafter), the 
Secretary shall update the factor under the preceding sentence on the 
basis of information available to the Secretary (and updated as 
appropriate) of the wages and wage-related costs incurred in furnishing 
rehabilitation services. Any adjustments or updates made under this 
paragraph for a fiscal year shall be made in a manner that assures that 
the aggregated payments under this subsection in the fiscal year shall 
be made in a manner that assures that the aggregated payments under 
this subsection in the fiscal year are not greater or less than those 
that would have been made in the year without such adjustment.
    The labor-related share is determined by identifying the national 
average proportion of operating costs that are related to, influenced 
by, or vary with the local labor market. Using our current definition 
of labor-related, the labor-related share is the sum of the relative 
importance of wages and salaries, fringe benefits, professional fees, 
labor-intensive services, and a portion of the capital share from an 
appropriate market basket. We used the proposed FY 2002-based RPL 
market basket costs to determine the proposed labor-related share for 
the IRF PPS. The proposed labor-related share for FY 2006 would be the 
sum of the proposed FY 2006 relative importance of each labor-related 
cost category, and would reflect the different rates of price change 
for these cost categories between the base year (FY 2002) and FY 2006. 
The sum of the proposed relative importance for FY 2006 for operating 
costs (wages and salaries, employee benefits, professional fees, and 
labor-intensive services) would be 71.782 percent, as shown in the 
chart below. The portion of capital that is influenced by local labor 
markets would estimated to be 46 percent, which is the same percentage 
currently used in the IRF prospective payment system. Since the 
relative importance for capital would be 9.079 percent of the proposed 
FY 2002-based RPL market basket in FY 2006, we are proposing to take 46 
percent of 9.079 percent to determine the proposed capital labor-
related share for FY 2006. The result would be 4.176 percent, which we 
propose to add to 71.782 percent for the operating cost amount to 
determine the total proposed labor-related share for FY 2006. Thus, the 
labor-related share that we propose to use for IRF PPS in FY 2006 would 
be 75.958 percent. This proposed labor-related share is determined 
using the same methodology as employed in calculating all previous IRF 
labor-related shares (66 FR at 41357).
    Table 10 below shows the proposed FY 2006 relative importance 
labor-related share using the proposed 2002-based RPL market basket and 
the FY 1997-based excluded hospital with capital market.

[[Page 30234]]



                                  Table 10.--Proposed Total Labor-Related Share
----------------------------------------------------------------------------------------------------------------
                                                                                               FY 1997 excluded
                                                                           Proposed FY 2002-     hospital with
                                                                           based RPL market     capital market
                              Cost category                                 basket relative     basket relative
                                                                              importance          importance
                                                                           (percent) FY 2006   (percent) FY 2006
----------------------------------------------------------------------------------------------------------------
Wages and salaries......................................................              52.823              48.432
Employee benefits.......................................................              13.863              11.415
Professional fees.......................................................               2.907               4.540
All other labor intensive services......................................               2.189               4.496
                                                                         ---------------------
    Subtotal............................................................              71.782              68.883
Labor-related share of capital costs....................................               4.176               3.307
                                                                         ---------------------
    Total...............................................................              75.958              72.190
----------------------------------------------------------------------------------------------------------------

    We are currently continuing an evaluation of our labor-related 
share methodology used in the IPPS (see 67 FR at 31447 for discussion 
of our previous analysis). Our evaluation includes regression analysis 
and reviewing the makeup of cost categories based on our current labor-
related definition. A complete discussion of our research is provided 
in the FY 2006 IPPS proposed rule (See FY 2006 IPPS proposed rule, 
Section IV, B, 3). The labor-related share used in the IPPS was the 
first labor-related share used in a prospective payment system. Our 
methodology for calculating the proposed labor-related share for the 
IRF PPS is based upon the methodology used in the IPPS.
2. Proposed Area Wage Adjustment
    Section 1886(j)(6) of the Act requires the Secretary to adjust the 
proportion (as estimated by the Secretary from time to time) of 
rehabilitation facilities' costs that are attributable to wages and 
wage-related costs by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the rehabilitation facility compared to the national average wage level 
for those facilities. Not later than October 1, 2001 and at least every 
36 months thereafter, the Secretary is required to update the factor 
under the preceding sentence on the basis of information available to 
the Secretary (and updated as appropriate) of the wages and wage-
related costs incurred in furnishing rehabilitation services. Any 
adjustments or updates made under section 1886(j)(6) of the Act for a 
FY shall be made in a manner that assures the aggregated payments under 
section 1886(j)(6) of the Act are not greater or less than those that 
would have been made in the year without such adjustment.
    In our August 1, 2003 final rule, we acknowledged that on June 6, 
2003, the Office of Management and Budget (OMB) issued ``OMB Bulletin 
No.03-04,'' announcing revised definitions of Metropolitan Statistical 
Areas, and new definitions of Micropolitan Statistical Areas and 
Combined Statistical Areas. A copy of the Bulletin may be obtained at 
the following Internet address: http://www.whitehouse.gov/omb/bulletins/b03-04.html. At that time, we did not propose to apply these 
new definitions known as the Core-Based Statistical Areas (CBSAs). 
After further analysis and discussed in detail below, we are proposing 
to use revised labor market area definitions as a result of the OMB 
revised definitions to adjust the FY 2006 IRF PPS payment rate. In 
addition, the IPPS is applying these revised definitions as discussed 
in the August 11, 2004 final rule (69 FR at 49207).

a. Proposed Revisions of the IRF PPS Geographic Classification

    As discussed in the August 7, 2001 final rule, which implemented 
the IRF PPS (66 FR at 41316), in establishing an adjustment for area 
wage levels under Sec.  412.624(e)(1), the labor-related portion of an 
IRF's Federal prospective payment is adjusted by using an appropriate 
wage index. As set forth in Sec.  412.624(e)(1), an IRF's wage index is 
determined based on the location of the IRF in an urban or rural area 
as defined in Sec.  412.602 and further defined in Sec.  
412.62(f)(1)(ii) and Sec.  412.62(f)(1)(iii) as urban and rural areas, 
respectively. An urban area, under the IRF PPS, is defined in Sec.  
412.62(f)(1)(ii) as a Metropolitan Statistical Area (MSA) or New 
England County Metropolitan Area (NECMA) as defined by the Office of 
Management and Budget (OMB). Under Sec.  412.62(f)(1)(iii), a rural 
area is defined as any area outside of an urban area. In general, an 
urban area is defined as a Metropolitan Statistical Area (MSA) or New 
England County Metropolitan Area (NECMA) as defined by the Office of 
Management and Budget. Under Sec.  412.62(f)(1)(iii), a rural area is 
defined as any area outside of an urban area. The urban and rural area 
geographic classifications defined in Sec.  412.62(f)(1)(ii) and 
(f)(1)(iii), respectively, were used under the IPPS from FYs 1985 
through 2004 (as specified in Sec.  412.63(b)), and have been used 
under the IRF PPS since it was implemented for cost reporting periods 
beginning on or after January 1, 2002.
    The wage index used for the IRF PPS is calculated by using the 
acute care IPPS wage index data on the basis of the labor market area 
in which the acute care hospital is located, but without taking into 
account geographic reclassification under sections 1886(d)(8) and 
(d)(10) of the Act and without applying the ``rural floor'' under 
section 4410 of Pub. L. 105-33 (BBA). In addition, Section 4410 of Pub. 
L. 105-33 (BBA) provides that for the purposes of section 1886(d)(3)(E) 
of the Act, that the area wage index applicable to hospitals located in 
an urban area of a State may not be less than the area wage index 
applicable to hospitals located in rural areas in the State. Consistent 
with past IRF policy, we treat this provision, commonly referred to as 
the ``rural floor'', as applicable to the acute inpatient hospitals and 
not IRFs. Therefore, the hospital wage index used for IRFs is commonly 
referred to as ``pre-floor'' indicating that ``rural floor'' provision 
is not applied. As a result, the applicable IRF wage index value is 
assigned to the IRF on the basis of the labor market area in which the 
IRF is geographically located.
    Below, we will provide a description of the current labor markets 
that have been used for area wage adjustments under the IRF PPS since 
its implementation of cost reporting periods beginning on or after 
January 1, 2002. Previously, we have not described the labor market 
areas used under the IRF PPS in detail, although we have published each 
area's wage index in tables, in the IRF PPS final rules and

[[Page 30235]]

update notices, each year and noted the use of the geographic area in 
applying the wage index adjustment in IRF PPS payment examples in the 
final regulation implementing the IRF PPS (69 FR at 41367 through 
41368). The IRF industry has also understood that the same labor market 
areas in use under the IPPS (from the time the IRF PPS was implemented, 
for cost reporting periods beginning on or after January 1, 2002) would 
be used under the IRF PPS. The OMB has adopted new statistical area 
definitions (as discussed in greater detail below) and we are proposing 
to adopt new labor market area definitions based on these areas under 
the IRF PPS (as discussed in greater detail below). Therefore, we 
believe it is helpful to provide a more detailed description of the 
current IRF PPS labor market areas, in order to better understand the 
proposed change to the IRF PPS labor market areas presented below in 
this proposed rule.
    The current IRF PPS labor market areas are defined based on the 
definitions of MSAs, Primary MSAs (PMSAs), and NECMAs issued by the OMB 
(commonly referred to collectively as ``MSAs''). These MSA definitions, 
which are discussed in greater detail below, are currently used under 
the IRF PPS and other prospective payment systems, such as LTCH, IPF, 
Home Health Agency (HHA), and SNF (Skilled Nursing Facility) PPSs. In 
the IPPS final rule (67 FR at 49026 through 49034), revised labor 
market area definitions were adopted under the hospital IPPS (Sec.  
412.64(b)), which were effective October 1, 2004 for acute care 
hospitals. These new CBSAs standards were announced by the OMB late in 
2000.
b. Current IRF PPS Labor Market Areas Based on MSAs
    As mentioned earlier, since the implementation of the IRF PPS in 
the August 7, 2001 IRF PPS final rule, we have used labor market areas 
to further characterize urban and rural areas as determined under Sec.  
412.602 and further defined in Sec.  412.62(f)(1)(ii) and (f)(1)(iii). 
To this end, we have defined labor market areas under the IRF PPS based 
on the definitions of MSAs, PMSAs, and NECMAs issued by the OMB, which 
is consistent with the IPPS approach. The OMB also designates 
Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a 
population of 1 million or more, comprising two or more PMSAs 
(identified by their separate economic and social character). For 
purposes of the wage index, we use the PMSAs rather than CMSAs because 
they allow a more precise breakdown of labor costs (as further 
discussed in section III.B.2.d.ii of this proposed rule). If a 
metropolitan area is not designated as part of a PMSA, we use the 
applicable MSA.
    These different designations use counties as the building blocks 
upon which they are based. Therefore, IRFs are assigned to either an 
MSA, PMSA, or NECMA based on whether the county in which the IRF is 
located is part of that area. All of the counties in a State outside a 
designated MSA, PMSA, or NECMA are designated as rural. For the 
purposes of calculating the wage index, we combine all of the counties 
in a State outside a designated MSA, PMSA, or NECMA together to 
calculate the statewide rural wage index for each State.
c. Core-Based Statistical Areas (CBSAs)
    OMB reviews its Metropolitan Area definitions preceding each 
decennial census. As discussed in the IPPS final rule (69 FR at 49027), 
in the fall of 1998, OMB chartered the Metropolitan Area Standards 
Review Committee to examine the Metropolitan Area standards and develop 
recommendations for possible changes to those standards. Three notices 
related to the review of the standards, providing an opportunity for 
public comment on the recommendations of the Committee, were published 
in the Federal Register on the following dates: December 21, 1998 (63 
FR at 70526); October 20, 1999 (64 FR at 56628); and August 22, 2000 
(65 FR at 51060).
    In the December 27, 2000 Federal Register (65 FR at 82228 through 
82238), OMB announced its new standards. In that notice, OMB defines 
CBSA, beginning in 2003, as ``a geographic entity associated with at 
least one core of 10,000 or more population, plus adjacent territory 
that has a high degree of social and economic integration with the core 
as measured by commuting ties.'' The standards designate and define two 
categories of CBSAs: MSAs and Micropolitan Statistical Areas (65 FR at 
82235 through 82238).
    According to OMB, MSAs are based on urbanized areas of 50,000 or 
more population, and Micropolitan Statistical Areas (referred to in 
this discussion as Micropolitan Areas) are based on urban clusters of 
at least 10,000 population, but less than 50,000 population. Counties 
that do not fall within CBSAs (either MSAs or Micropolitan Areas) are 
deemed ``Outside CBSAs.'' In the past, OMB defined MSAs around areas 
with a minimum core population of 50,000, and smaller areas were 
``Outside MSAs.'' On June 6, 2003, OMB announced the new CBSAs, 
comprised of MSAs and the new Micropolitan Areas based on Census 2000 
data. (A copy of the announcement may be obtained at the following 
Internet address: http://www.whitehouse.gov/omb/bulletins/fy04/b04-03.html.)
    The new CBSA designations recognize 49 new MSAs and 565 new 
Micropolitan Areas, and revise the composition of many of the existing 
MSAs. There are 1,090 counties in MSAs under the new CBSA designations 
(previously, there were 848 counties in MSAs). Of these 1,090 counties, 
737 are in the same MSA as they were prior to the change in 
designations, 65 are in a different MSA, and 288 were not previously 
designated to any MSA. There are 674 counties in Micropolitan Areas. Of 
these, 41 were previously in an MSA, while 633 were not previously 
designated to an MSA. There are five counties that previously were 
designated to an MSA but are no longer designated to either an MSA or a 
new Micropolitan Area: Carter County, KY; St. James Parish, LA; Kane 
County, UT; Culpepper County, VA; and King George County, VA. For a 
more detailed discussion of the conceptual basis of the new CBSAs, 
refer to the IPPS final rule (67 FR at 49026 through 49034).
d. Proposed Revisions to the IRF PPS Labor Market Areas
    In its June 6, 2003 announcement, OMB cautioned that these new 
definitions ``should not be used to develop and implement Federal, 
State, and local nonstatistical programs and policies without full 
consideration of the effects of using these definitions for such 
purposes. These areas should not serve as a general-purpose geographic 
framework for nonstatistical activities, and they may or may not be 
suitable for use in program funding formulas.''
    We currently use MSAs to define labor market areas for purposes of 
the wage index. In fact, MSAs are also used to define labor market 
areas for purposes of the wage index for many of the other Medicare 
prospective payment systems (for example, LTCH, SNF, HHA, IPF, and 
Outpatient). While we recognize MSAs are not designed specifically to 
define labor market areas, we believe they represent a reasonable and 
appropriate proxy for this purpose, because they are based upon 
characteristics we believe also generally reflect the characteristics 
of unified labor market areas. For example, CBSAs reflect a core 
population plus an adjacent territory that reflects a high degree of 
social and economic integration. This integration is measured by 
commuting ties, thus demonstrating that these areas may draw workers 
from

[[Page 30236]]

the same general areas. In addition, the most recent CBSAs reflect the 
most up to date information. The OMB reviews its MA definitions 
preceding each decennial census to reflect recent population changes 
and the CBSAs are based on the Census 2000 data. Our analysis and 
discussion here are focused on issues related to adopting the new CBSA 
designations to define labor market areas for the purposes of the IRF 
PPS.
    Historically, Medicare PPSs have utilized Metropolitan Area (MA) 
definitions developed by OMB. The labor market areas currently used 
under the IRF PPS are based on the MA definitions issued by OMB. OMB 
reviews its MA definitions preceding each decennial census to reflect 
more recent population changes. Thus, the CBSAs are OMB's latest MA 
definitions based on the Census 2000 data. Because we believe that the 
OMB's latest MA designations more accurately reflect the local 
economies and wage levels of the areas in which hospitals are currently 
located, we are proposing to adopt the revised labor market area 
designations based on the OMB's CBSA designations.
    As specified in Sec.  412.624(e)(1), we explained in the August 7, 
2001 final rule that the IRF PPS wage index adjustment was intended to 
reflect the relative hospital wage levels in the geographic area of the 
hospital as compared to the national average hospital wage level. Since 
OMB's CBSA designations are based on Census 2000 data and reflect the 
most recent available geographic classifications, we are proposing to 
revise the labor market area definitions used under the IRF PPS. 
Specifically, we are proposing to revise the IRF PPS labor market 
definitions based on the OMB's new CBSA designations effective for IRF 
PPS discharges occurring on or after October 1, 2005. Accordingly, we 
are proposing to revise Sec.  412.602 to specify that for discharges 
occurring on or after October 1, 2005, the application of the wage 
index under the IRF PPS would be made on the basis of the location of 
the facility in an urban or rural area as defined in Sec.  
412.64(b)(1)(ii)(A) through (C). (As a conforming change, we are also 
proposing to revise Sec.  412.602, definitions for rural and urban 
areas effective for discharges occurring on or after October 1, 2005 
would be defined in Sec.  412.64(b)(1)(ii)(A) through (C). To further 
clarify, we will revise the regulation text to explicitly reference 
urban and rural definitions for a cost-reporting period beginning on or 
after January 1, 2002, with respect to discharges occurring during the 
period covered by such cost reports but before October 1, 2005 under 
Sec.  412.62(f)(1)(ii) and Sec.  412.62(f)(1)(iii)).
    We note that these are the same labor market area definitions 
(based on the OMB's new CBSA designations) implemented under the IPPS 
at Sec.  412.64(b), which were effective for those hospitals beginning 
October 1, 2004 as discussed in the IPPS final rule (69 FR at 49026 
through 49034). The similarity between the IPPS and the IRF PPS 
includes the adoption in the initial implementation of the IRF PPS of 
the same labor market area definitions under the IRF PPS that existed 
under the IPPS at that time, as well as the use of acute care 
hospitals' wage data in calculating the IRF PPS wage index. In 
addition, the OMB's CBSA-based designations reflect the most recent 
available geographic classifications and more accurately reflects 
current labor markets. Therefore, we believe that proposing to revise 
the IRF PPS labor market area definitions based on OMB's CBSA-based 
designations are consistent with our historical practice of modeling 
IRF PPS policy after IPPS policy.
    Below, we discuss the composition of the proposed IRF PPS labor 
market areas based on the OMB's new CBSA designations.
i. New England MSAs
    As stated above, in the August 7, 2001 final rule, we currently use 
NECMAs to define labor market areas in New England, because these are 
county-based designations rather than the 1990 MSA definitions for New 
England, which used minor civil divisions such as cities and towns. 
Under the current MSA definitions, NECMAs provided more consistency in 
labor market definitions for New England compared with the rest of the 
country, where MSAs are county-based. Under the new CBSAs, OMB has now 
defined the MSAs and Micropolitan Areas in New England on the basis of 
counties. The OMB also established New England City and Town Areas, 
which are similar to the previous New England MSAs.
    In order to create consistency among all labor market areas and to 
maintain these areas on the basis of counties, we are proposing to use 
the county-based areas for all MSAs in the nation, including those in 
New England. Census has now defined the New England area based on 
counties, creating a city- and town-based system as an alternative. We 
believe that adopting county-based labor market areas for the entire 
country except those in New England would lead to inconsistencies in 
our designations. Adopting county-based labor market areas for the 
entire country provides consistency and stability in Medicare program 
payment because all of the labor market areas throughout the country, 
including New England, would be defined using the same system (that is, 
counties) rather than different systems in different areas of the 
country, and minimizes programmatic complexity.
    In addition, we have consistently employed a county-based system 
for New England for precisely that reason: to maintain consistency with 
the labor market area definitions used throughout the country. Because 
we have never used cities and towns for defining IRF labor market 
areas, employing a county-based system in New England maintains that 
consistent practice. We note that this is consistent with the 
implementation of the CBSA-based designations under the IPPS for New 
England (see 69 FR at 49028). Accordingly, in this proposed rule, we 
are proposing to use the New England MSAs as determined under the 
proposed new CBSA-based labor market area definitions in defining the 
proposed revised IRF PPS labor market areas.
ii. Metropolitan Divisions
    Under OMB's new CBSA designations, a Metropolitan Division is a 
county or group of counties within a CBSA that contains a core 
population of at least 2.5 million, representing an employment center, 
plus adjacent counties associated with the main county or counties 
through commuting ties. A county qualifies as a main county if 65 
percent or more of its employed residents work within the county and 
the ratio of the number of jobs located in the county to the number of 
employed residents is at least 0.75. A county qualifies as a secondary 
county if 50 percent or more, but less than 65 percent, of its employed 
residents work within the county and the ratio of the number of jobs 
located in the county to the number of employed residents is at least 
0.75. After all the main and secondary counties are identified and 
grouped, each additional county that already has qualified for 
inclusion in the MSA falls within the Metropolitan Division associated 
with the main/secondary county or counties with which the county at 
issue has the highest employment interchange measure. Counties in a 
Metropolitan Division must be contiguous (65 FR at 82236).
    The construct of relatively large MSAs being comprised of 
Metropolitan Divisions is similar to the current construct of the CMSAs 
comprised of PMSAs. As noted above, in the past, OMB designated CMSAs 
as

[[Page 30237]]

Metropolitan Areas with a population of 1 million or more and comprised 
of two or more PMSAs. Under the IRF PPS, we currently use the PMSAs 
rather than CMSAs to define labor market areas because they comprise a 
smaller geographic area with potentially varying labor costs due to 
different local economies. We believe that CMSAs may be too large of an 
area with a relatively large number of hospitals, to accurately reflect 
the local labor costs of all the individual hospitals included in that 
relatively ``large'' area. A large market area designation increased 
the likelihood of including many hospitals located in areas with very 
different labor market conditions within the same market area 
designation. This variation could increase the difficulty in 
calculating a single wage index that would be relevant for all 
hospitals within the market area designation. Similarly, we believe 
that MSAs with a population of 2.5 million or greater may be too large 
of an area to accurately reflect the local labor costs of all the 
individual hospitals included in that relatively ``large'' area. 
Furthermore, as indicated above, Metropolitan Divisions represent the 
closest approximation to PMSAs, the building block of the current IRF 
PPS labor market area definitions, and therefore, would most accurately 
maintain our current structuring of the IRF PPS labor market areas. 
Therefore, as implemented under the IPPS (69 FR at 49029), we are 
proposing to use the Metropolitan Divisions where applicable (as 
describe below) under the proposed new CBSA-based labor market area 
definitions.
    In addition to being comparable to the organization of the labor 
market areas under the current MSA designations (that is, the use of 
PMSAs rather than CMSAs), we believe that proposing to use Metropolitan 
Divisions where applicable (as described below) under the IRF PPS would 
result in a more accurate adjustment for the variation in local labor 
market areas for IRFs. Specifically, if we would recognize the 
relatively ``larger'' CBSA that comprises two or more Metropolitan 
Divisions as an independent labor market area for purposes of the wage 
index, it would be too large and would include the data from too many 
hospitals to compute a wage index that would accurately reflect the 
various local labor costs of all the individual hospitals included in 
that relatively ``large'' CBSA. As mentioned earlier, a large market 
area designation increases the likelihood of including many hospitals 
located in areas with very different labor market conditions within the 
same market area designation. This variation could increase the 
difficulty in calculating a single wage index that would be relevant 
for all hospitals within the market area designation. Rather, by 
proposing to recognize Metropolitan Divisions where applicable (as 
described below) under the proposed new CBSA-based labor market area 
definitions under the IRF PPS, we believe that in addition to more 
accurately maintaining the current structuring of the IRF PPS labor 
market areas, the local labor costs would be more accurately reflected, 
thereby resulting in a wage index adjustment that better reflects the 
variation in the local labor costs of the local economies of the IRFs 
located in these relatively ``smaller'' areas.
    Below we describe where Metropolitan Divisions would be applicable 
under the proposed new CBSA-based labor market area definitions under 
the IRF PPS.
    Under the OMB's CBSA-based designations, there are 11 MSAs 
containing Metropolitan Divisions: Boston; Chicago; Dallas; Detroit; 
Los Angeles; Miami; New York; Philadelphia; San Francisco; Seattle; and 
Washington, DC. Although these MSAs were also CMSAs under the prior 
definitions, in some cases their areas have been altered. Under the 
current IRF PPS MSA designations, Boston is a single NECMA. Under the 
proposed CBSA-based labor market area designations, it would be 
comprised of four Metropolitan Divisions. Los Angeles would go from 
four PMSAs under the current IRF PPS MSA designations to two 
Metropolitan Divisions under the proposed CBSA-based labor market area 
designations. The New York CMSA would go from 15 PMSAs under the 
current IRF PPS MSA designations to only four Metropolitan Divisions 
under the proposed CBSA-based labor market area designations. The five 
PMSAs in Connecticut under the current IRF PPS MSA designations would 
become separate MSAs under the proposed CBSA-based labor market area 
designations because two MSAs became separate MSAs. The number of PMSAs 
in New Jersey, under the current IRF PPS MSA designations would go from 
five to two, with the consolidation of two New Jersey PMSAs (Bergen-
Passaic and Jersey City) into the New York-Wayne-White Plains, NY-NJ 
Division, under the proposed CBSA-based labor market area designations. 
In San Francisco, under the proposed CBSA-based labor market area 
designations there are only two Metropolitan Divisions. Currently, 
there are six PMSAs, some of which are now separate MSAs under the 
current IRF PPS labor market area designations.
    Under the current IRF PPS labor market area designations, 
Cincinnati, Cleveland, Denver, Houston, Milwaukee, Portland, 
Sacramento, and San Juan are all designated as CMSAs, but would no 
longer be designated as CMSAs under the proposed CBSA-based labor 
market area designations. As noted previously, the population threshold 
to be designated a CMSA under the current IRF PPS labor market area 
designations is 1 million. In most of these cases, counties currently 
in a PMSA would become separate, independent MSAs under the proposed 
CBSA-based labor market area designations, leaving only the MSA for the 
core area under the proposed CBSA-based labor market area designations.
iii. Micropolitan Areas
    Under the new OMB's CBSA-based designations, Micropolitan Areas are 
essentially a third area definition consisting primarily of areas that 
are currently rural, but also include some or all of areas that are 
currently designated as urban MSA. As discussed in greater detail in 
the IPPS final rule (69 FR at 49029 through 49032), how these areas are 
treated would have significant impacts on the calculation and 
application of the wage index. Specifically, whether or not 
Micropolitan Areas are included as part of the respective statewide 
rural wage indices would impact the value of the statewide rural wage 
index of any State that contains a Micropolitan Area because a 
hospital's classification as urban or rural affects which hospitals' 
wage data are included in the statewide rural wage index. As discussed 
above in section III.B.2.b of this proposed rule, we combine all of the 
counties in a State outside a designated urban area to calculate the 
statewide rural wage index for each State.
    Including Micropolitan Areas as part of the statewide rural labor 
market area would result in an increase to the statewide rural wage 
index because hospitals located in those Micropolitan Areas typically 
have higher labor costs than other rural hospitals in the State. 
Alternatively, if Micropolitan Areas were to be recognized as 
independent labor market areas, because there would be so few hospitals 
in those areas to complete a wage index, the wage indices for IRFs in 
those areas could become relatively unstable as they might change 
considerably from year to year.
    We currently use MSAs to define urban labor market areas and group 
all the hospitals in counties within each

[[Page 30238]]

State that are not assigned to an MSA into a statewide rural labor 
market area. Therefore, we used the terms ``urban'' and ``rural'' wage 
indices in the past for ease of reference. However, the introduction of 
Micropolitan Areas by the OMB potentially complicates this terminology 
because these areas include many hospitals that are currently included 
in the statewide rural labor market areas.
    We are proposing to treat Micropolitan Areas as rural labor market 
areas under the IRF PPS for the reasons outlined below. That is, 
counties that are assigned to a Micropolitan Area under the CBSA-based 
designations would be treated the same as other ``rural'' counties that 
are not assigned to either an MSA or a Micropolitan Area. Therefore, in 
determining an IRF's applicable wage index (based on IPPS hospital wage 
index data) we are proposing that an IRF in a Micropolitan Area under 
OMB's CBSA designations would be classified as ``rural'' and would be 
assigned the statewide rural wage index for the State in which it 
resides.
    In the IPPS final rule (69 FR at 49029 through 49032), we discuss 
our evaluation of the impact of treating Micropolitan areas as part of 
the statewide rural labor market area instead of treating Micropolitan 
Areas as independent labor market areas for hospitals paid under the 
IPPS. As an alternative to treating Micropolitan Areas as part of the 
statewide rural labor market area for purposes of the IRF PPS, we 
examined treating Micropolitan Areas as separate (urban) labor market 
areas, just as we did when implementing the revised labor market areas 
under the IPPS. As discussed in greater detail in that same final rule, 
the designation of Micropolitan Areas as separate urban areas for wage 
index purposes would have a dramatic impact on the calculation of the 
wage index. This is because Micropolitan areas encompass smaller 
populations than MSAs, and tend to include fewer hospitals per 
Micropolitan area. Currently, there are only 25 MSAs with one hospital 
in the MSA. However, under the new proposed CBSA-based definitions, 
there are 373 Micropolitan Areas with one hospital, and 49 MSAs with 
only one hospital.
    Since Micropolitan Areas encompass smaller populations than MSAs, 
they tend to include fewer hospitals per Micropolitan Area, recognizing 
Micropolitan Areas as independent labor market areas would generally 
increase the potential for dramatic shifts in those areas' wage indices 
from one year to the next because a single hospital (or group of 
hospitals) could have a disproportionate effect on the wage index of 
the area. The large number of labor market areas with only one hospital 
and the increased potential for dramatic shifts in the wage indexes 
from one year to the next is a problem for several reasons. First, it 
creates instability in the wage index from year to year for a large 
number of hospitals. Second, it reduces the averaging effect (this 
averaging effect allows for more data points to be used to calculate 
the representative standard of measured labor costs within a market 
area) lessening some of the incentive for hospitals to operate 
efficiently. This incentive is inherent in a system based on the 
average hourly wages for a large number of hospitals, as hospitals 
could profit more by operating below that average. In labor market 
areas with a single hospital, high wage costs are passed directly into 
the wage index with no counterbalancing averaging with lower wages paid 
at nearby competing hospitals. Third, it creates an arguably 
inequitable system when so many hospitals have wage indexes based 
solely on their own wages, while other hospitals' wage indexes are 
based on an average hourly wage across many hospitals. Therefore, in 
order to minimize the potential instability in payment levels from year 
to year, we believe it would be appropriate to treat Micropolitan Areas 
as part of the statewide rural labor market area under the IRF PPS.
    For the reasons noted above, and consistent with the treatment of 
these areas under the IPPS, we are proposing not to adopt Micropolitan 
Areas as independent labor market areas under the IRF PPS. Under the 
proposed new CBSA-based labor market area definitions, we are proposing 
that Micropolitan Areas be considered a part of the statewide rural 
labor market area. Accordingly, we are proposing that the IRF PPS 
statewide rural wage index be determined using the acute-care IPPS 
hospital wage data (the rational for using IPPS hospital wage data is 
discussed in section III.B.2.f of this proposed rule) from hospitals 
located in non-MSA areas and that the statewide rural wage index be 
assigned to IRFs located in those areas.
e. Implementation of the Proposed Changes To Revise the Labor Market 
Areas
    Under section 1886(j) of the Act, as added by section 4421 of the 
Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) and as amended by 
section 125 of the Medicare, Medicaid, and State Children's Health 
Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) 
(Pub. L. 106-113) and section 305 of the Medicare, Medicaid, and SCHIP 
Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-
554), which requires the implementation of such prospective payment 
system, the Secretary generally has broad authority in developing the 
IRF PPS, including whether and how to make adjustments to the IRF PPS.
    To facilitate an understanding of the proposed policies related to 
the proposed change to the IRF PPS labor market areas discussed above, 
in Table 3 of the Addendum of this proposed rule, we are providing a 
listing of each IRF's state and county location; existing MSA labor 
market area designation; and its proposed new CBSA designation based on 
county information from our online survey, certification, and reporting 
(OSCAR) database, and an Iowa Foundation for Medical Care (IFMC) report 
listing providers and their state and county location that submitted 
IRF-PAIs during the past 18 months (report request made in February 
2005). We encourage IRFs to review the county location and both the 
current and proposed labor market area assignments for accuracy. Any 
questions or corrections (including additions or deletions) to the 
information provided in Table 3 of the Addendum should be emailed to 
the following CMS Web address: [email protected]. A link to this 
address can be found on the following CMS Web page http://www.cms.hhs.gov/providers/irfpps/.
    When the revised labor market areas based on OMB's new CBSA-based 
designations were adopted under the IPPS beginning on October 1, 2004, 
a transition to the new designations was established due to the scope 
and substantial implications of these new boundaries and to buffer the 
subsequent substantial impacts on numerous hospitals. As discussed in 
the IPPS final rule (69 FR at 49032), during FY 2005, a blend of wage 
indices is calculated for those acute care IPPS hospitals experiencing 
a drop in their wage indices because of the adoption of the new labor 
market areas. The most substantial decrease in wage index impacts urban 
acute-care hospitals that were designated as rural under the CBSA-based 
designations.
    While we recognize that, just like IPPS hospitals, IRFs may 
experience decreases in their wage index as a result of the proposed 
labor market area changes, our data analysis showed that a majority of 
IRFs either expect no change in wage index or an increase in wage index 
based on CBSA definitions.

[[Page 30239]]

In addition, a very small number of IRFs (3 percent) would experience a 
decline of 5 percent or more in the wage index based on CBSA 
designations. A 5 percent decrease in the wage index for an IRF may 
result in a noticeable decrease in their wage index compared to what 
their wage index would have been for FY 2006 under the MSA-based 
designations. We also found that a very small number of IRFs (4 
percent) would experience a change in either rural or urban designation 
under the CBSA-based definitions. Since a majority of IRFs would not be 
significantly impacted by the proposed labor market areas, we believe 
it is not necessary to propose a transition to the proposed new CBSA-
based labor market area for the purposes of the IRF PPS wage index. The 
main purpose of a transition is to buffer hospitals that would be 
significantly impacted by a proposed policy. Since the impact of the 
proposed labor market areas upon IRFs would be minimal, the need to 
transition is absent. We recognize that there would be many 
alternatives to efficiently implement the proposed CBSA-based 
geographic designations. The statute confers broad authority to the 
Secretary under 1886(j)(6) of the Act to establish factor for area wage 
differences by a factor such that budget neutral wage index options may 
be considered. Thus, we considered three budget neutral alternatives 
that could implement the adoption of the proposed CBSA-based 
designations as discussed below. Even though a majority of IRFs would 
not be significantly impacted by the proposed labor market areas, we 
wanted to be diligent and at least examine transition policies and the 
affect on the system. We needed to conduct the analysis to determine 
how IRFs fare under such a proposed policy.
    One alternative we considered institutes a one-year transition with 
a blended wage index, equal to 50 percent of the FY 2006 MSA-based wage 
index and 50 percent of the FY 2006 CBSA-based wage index (both based 
on the FY 2001 hospital wage data), for all providers. In this 
scenario, a blended wage index of 50 percent of the FY 2006 MSA-based 
wage index and 50 percent of the FY 2006 CBSA-based wage index was used 
because in the IPPS final rule (69 FR at 49033) a blended wage index 
employed 50 percent of the FY 2001 hospital wage index data and the old 
labor market definitions, and 50 percent of the wage index employing FY 
2001 wage index data and the new labor market definitions. However, we 
found that while this would help some IRFs that are adversely affected 
by the changes to the MSAs, it would also reduce the wage index values 
(compared to fully adopting the CBSA wage index value) for IRFs that 
would be positively affected by the changes. Thus, the unadjusted 
payment rate for all providers would be slightly reduced. Therefore, a 
majority of the IRFs would not benefit if all providers are given a 
blended wage index in a budget neutral manner (such that estimated 
aggregate, overall payments to IRFs would not change under the proposed 
labor market area definitions).
    A second alternative we considered consists of a one-year 
transition with a blended wage index, equal to 50 percent of the FY 
2006 MSA wage index and 50 percent of the FY 2006 CBSA-based wage index 
(both based on the FY 2001 hospital wage data), only for providers that 
would experience a decrease due solely to the changes in the labor 
market definitions. In this second alternative, a blended wage index of 
50 percent of the FY 2006 MSA wage index and 50 percent of the FY 2006 
CBSA-based wage index was determined because in the IPPS final rule (69 
FR at 49033) a blended wage index employed 50 percent of the FY 2001 
hospital wage index data and the old labor market definitions, and 50 
percent of the wage index employing FY 2001 wage index data and the new 
labor market definitions. Therefore, providers that would experience a 
decrease in their FY 2006 wage index under the CBSA-based definitions 
compared to the wage index they would have received under the MSA-based 
definitions (in both cases using FY 2001 hospital wage data) would 
receive a blended wage index as described above.
    When we performed our analysis, we found that the unadjusted 
payment amounts decreased substantially more under this option than 
they did either by using the first option discussed above or by fully 
adopting the CBSA-based designations. As with the first alternative, 
the positive impact of blending in order decrease the impacts for a 
relatively small number of IRFs would require reduced payment rates for 
all providers, including the IRFs receiving a blended wage index.
    As discussed in the August 11, 2004 IPPS final rule (69 FR at 
49032), during FY 2005, a hold harmless policy was implemented to 
minimize the overall impact of hospitals that were in FY 2004 
designated as urban under the MSA designations, but would become rural 
under the CBSA designations. In the same final rule, hospitals were 
afforded a three-year hold harmless policy because the IPPS determined 
that acute-care hospitals that changed designations from urban to rural 
would be substantially impacted by the significant change in wage 
index. Although we considered a hold harmless policy for IRFs that 
would be substantially impacted from the change in wage index due to 
the CBSA-based designation, we found that an extremely small number of 
IRFs (4.4 percent) would change designations. In addition, currently 
urban facilities that become rural under the CBSA-based definitions 
would receive the rural facility adjustment, which we are proposing to 
increase from 19.14 percent to 24.1 percent (discussed in further 
detail in section III.B.4 of this proposed rule). Thus, the impact on 
urban facilities that become rural would be mitigated by the rural 
adjustment.
    We also found that 91 percent of rural facilities that would be 
designated as urban under the CBSA-based definitions would experience 
an increase in the wage index. Furthermore, a majority (74 percent) of 
rural facilities that become urban would experience at least a 5 
percent to 10 percent or more increase in wage index. Thus, we do not 
believe it is appropriate or necessary to adopt a hold harmless policy 
for facilities that would experience a change in designation under the 
CBSA-based definitions.
    Finally, we note that section 505 of the MMA established new 
section 1886(d)(13) of the Act. The new section 1886(d)(13) requires 
that the Secretary establish a process to make adjustments to the 
hospital wage index based on commuting patterns of hospital employees. 
We believe that this requirement for an ``out-commuting'' or ``out-
migration'' adjustment applies specifically to the IPPS. Therefore, we 
will not be proposing such an adjustment for the IRF PPS.
    We are not proposing a transition, a hold harmless policy, nor an 
``out-commuting'' adjustment under the IRF PPS from the current MSA-
based labor market areas designations to the new CBSA-based labor 
market area designations as discussed below. We are proposing to adopt 
the new CBSA-based labor market area definitions beginning with the 
2006 IRF PPS fiscal year without a transition period, without a hold 
harmless policy, and without an ``out-commuting'' adjustment. We 
believe that this proposed policy is appropriate because despite 
significant similarities between the IRF PPS and the IPPS, there are 
clear distinctions between the payment systems, particularly regarding 
wage index issues.
    The most significant distinction upon which we have based this 
proposed

[[Page 30240]]

policy determination is that where acute care hospitals have been paid 
using full wage index adjusted payments since 1983 and have used the 
previous IPPS MSA-based labor market area designations for over 10 
years, under the IRF PPS we have been using the excluded pre-
reclassification and pre-floor MSA-based wage index for cost reporting 
periods beginning on or after January 1, 2002. Since the implementation 
of the IRF PPS has only used the MSA-based labor market area 
designations since 2002 of which the first year was a transition year, 
many IRFs received a blended payment that consisted of a percentage of 
TEFRA and a percentage of the IRF PPS rate (as described below). Since 
many IRFs were initially under the transition period whereby many IRFs 
received a blend of TEFRA payments and the adjusted Federal prospective 
payment rates in accordance with section 1886(j)(1) of the Act and as 
specified in Sec.  412.626, IRFs may still be adjusting to the changes 
in wage index and thus has not established a long history of an 
expected wage index from year to year. We may reasonably expect that 
IRFs would not experience a substantial impact on their respective wage 
indices because under a relatively new IRF PPS, IRFs are adjusting to 
the change of being paid a Federal prospective payment rate. Our data 
analysis also shows that a minimal number of IRFs would experience a 
decrease of more than 5 percent in the wage index. A 5 percent decrease 
in the wage index for an IRF would possibly result in a noticeable 
decrease in their wage index compared to what their wage index would 
have been for FY 2006 under the MSA-based designations. In addition, 
under the CBSA designation, a small number of IRFs would experience a 
change from their current urban or rural designation. Therefore, the 
overall impact of IRFs under the MSA-based designations versus the 
CBSA-based designations did not result in a dramatic change overall.
    Although the wage index has been a stable feature of the acute care 
hospital IPPS since its 1983 implementation and has utilized the prior 
MSA-based labor market area designation for over 10 years, this is not 
the case for the IRF PPS which has only been implemented for cost 
reporting periods beginning on or after January 1, 2002. Therefore, if 
the proposed CBSA-based labor market area designations were adopted 
they would have a negligible impact on IRFs because the adoption of the 
CBSA-based designations are proposed in a budget neutral manner (as 
discussed in detail in section IV of this proposed rule).
    The impact of adopting the proposed CBSA-based wage index has shown 
in our impact analysis to have very little impact on the overall 
payment rates to the extent the proposed refinements to the overall 
system are also implemented (as discussed below). In addition, unlike 
other post-acute care payment systems, the IRF PPS payments apply a 
rural facility adjustment to account for higher costs in rural 
facilities (as discussed in 66 FR at 41359). We are proposing to 
increase the current rural adjustment from 19.14 percent to 24.1 
percent (as discussed in section III.4 of this proposed rule). 
Therefore, IRFs that are designated as urban under the MSA-based 
definitions, but that would be classified as rural under the proposed 
CBSA-based definitions, will receive a facility add-on of 24.1 percent.
    In sum, the IRF PPS has only been implemented for hospital cost 
reporting periods beginning on or after January 1, 2002 (which means 
that payment to IRFs have only been governed by the IRF PPS for 
slightly more than 3 years). In addition, a small number of IRFs would 
experience a change in rural or urban designations under the CBSA-based 
designations. To the extent the proposed changes in this rule are 
adopted, the change in labor market area for an urban facility to a 
rural facility is expected to be offset by the rural adjustment we are 
proposing to increase from 19.14 to 24.1 percent as discussed below. We 
also found that a majority of IRFs would experience no change in wage 
index or an increase. Thus, we are proposing to fully adopt the CBSA-
based designations without a hold harmless policy. We believe that it 
is not appropriate or necessary to propose a transition to the proposed 
new CBSA-based labor market area for the purpose of the IRF PPS wage 
index adjustment as specified under Sec.  412.624 as explained 
previously in this section. In addition, as explained above, we believe 
there are not sufficient data to support a transition from MSA-based 
designations to the proposed CBSA-based designations.
f. Wage Index Data
    In the August 7, 2001 final rule, we established an IRF wage index 
based on FY 1997 acute care hospital wage data to adjust the FY 2002 
IRF payment rates. For the FY 2003 IRF PPS payment rates, we applied 
the same wage adjustment as used for FY 2002 IRF PPS rates because we 
determined that the application of the wage index and labor-related 
share used in FY 2002 provided an appropriate adjustment to account for 
geographic variation in wage levels that was consistent with the 
statute. For the FY 2004 IRF PPS payment rates, we used the hospital 
wage index based on FY 1999 acute care hospital wage data. For the FY 
2005 IRF PPS payment rates, we used the hospital wage index based on FY 
2000 acute care hospital wage data. We are proposing to use FY 2001 
acute care hospital wage data for FY 2006 IRF PPS payment rates because 
it is the most recent final data available. We believe that a wage 
index based on acute care hospital wage data is the best proxy and most 
appropriate wage index to use in adjusting payments to IRFs, since both 
acute care hospitals and IRFs compete in the same labor markets. Since 
acute care hospitals compete in the same labor market areas as IRFs, 
the wage data of acute care hospitals should accurately capture the 
relationship of wages and wage-related costs of IRF in an area as 
comparable to the national average. In the August 1, 2001 final rule 
(66 FR at 41358) we established FY 2002 IRF PPS wage index values for 
the 2002 IRF PPS fiscal year calculated from the same data used to 
compute the FY 2001 acute care hospital inpatient wage index data 
without taking into account geographic reclassification under sections 
1886(d)(8) and (d)(10) of the Act and without applying the ``rural 
floor'' under section 4410 of Pub. L. 105-33 (BBA) (as discussed in 
section III.B.2.a of this proposed rule). Acute care hospital inpatient 
wage index data is also used to establish the wage index adjustment 
used in other PPSs (for example, LTCH, IPF, HHA, and SNF). As we 
discussed in the August 7, 2001 final rule (66 FR at 41316, 41358), 
since hospitals that are excluded from the IPPS are not required to 
provide wage-related information on the Medicare cost report and 
because we would need to establish instructions for the collection of 
this IRF data it is not appropriate at this time to propose a wage 
index specific to IRF facilities. Because we do not have an IRF 
specific wage index that we can compare to the hospital wage index, we 
are unable to determine at this time the degree to which the acute care 
hospital data fully represent IRF wages or if a geographic 
reclassification adjustment under the IRF PPS is appropriate. However, 
we believe that a wage index based on acute care hospital data is the 
best and most appropriate wage index to use in adjusting payments to 
IRFs, since both acute care hospitals and IRFs compete in the same 
labor markets. Also, we propose to continue to use the same method for 
calculating wage indices as was indicated in the August 7, 2001 final 
rule (69 FR at 41357 through 41358). In addition, 1886(d)(8) and

[[Page 30241]]

1886(d)(10) of the Act which permits reclassification is applicable 
only to inpatient acute care hospitals at this time. The wage 
adjustment established under the IRF PPS is based on an IRF's actual 
location without regard to the urban or rural designation of any 
related or affiliated provider.
    In proposing to adopt the CBSA-based designations, we recognize 
that there may be geographic areas where there are no hospitals, and 
thus no hospital wage data on which to base the calculation of the IRF 
PPS wage index. We found that this occurred in two States--
Massachusetts and Puerto Rico--where, using the CBSA-based 
designations, there were no hospitals located in rural areas. At 
present, no IRFs are affected by this lack of data, because currently 
there are no rural IRFs in these two States. If, rural IRFs open in 
these two States, we propose, for FY 2006, to use the rural FY 2001 
MSA-based hospital wage data for that State to determine the wage index 
of such IRFs. In other words, we would use the same wage data (the FY 
2001 hospital wage data) used to calculate the FY 2006 IRF wage index. 
However, rather than using CBSA-based designations, we would use MSA-
based designations to determine the rural wage index of the State. 
Using such MSA-based designations there would be rural wage indices for 
both Massachusetts and Puerto Rico. We believe this is the most 
reasonable approach, as we would be using the same hospital wage data 
used to calculate the CBSA-based wage indices.
    In the event this occurs in urban areas where IRFs are located, we 
are proposing to use the average of the urban hospital wage data 
throughout the State as a reasonable proxy for the urban areas without 
hospital wage data. Therefore, urban IRFs located in geographic areas 
without any hospital wage data would receive a wage index based on the 
average wage index for all urban areas within the State. This does not 
presently affect any urban IRFs for FY 2006 because there are no IRFs 
located in urban areas without hospital wage data. However, the policy 
would apply to future years when there may be urban IRFs located in 
geographic areas with no corresponding hospital wage data.
    We believe this policy is reasonable because it maintains a CBSA-
based wage index system, while creating an urban proxy for IRFs located 
in urban areas without corresponding hospital wage data. We note that 
we could not apply a similar averaging in rural areas, because in the 
rural areas there is no State rural hospital wage data available for 
averaging on a State-wide basis. For example, in Massachusetts and 
Puerto Rico, using a CBSA-based designation system, there are simply no 
rural hospitals in the State upon which we could base an average.
    In addition, we note that the Secretary has broad authority under 
1886(j)(6) to update the wage index on the basis of information 
available to the Secretary (and updated as appropriate) of the wages 
and wage-related costs incurred in furnishing rehabilitation services. 
Therefore, for FY 2006 we propose to use FY 2001 MSA-based hospital 
wage data for rural Massachusetts and rural Puerto Rico in the event 
there are rural IRFs in such States. In addition, for FY 2006 and 
thereafter, we propose to calculate a statewide urban average in the 
event that there exist urban IRFs in geographic areas with no 
corresponding hospital wage data. We solicit comments on these 
approaches to calculate the wage index values for areas without 
hospital wage data for this and subsequent fiscal years. We note that 
for fiscal years 2007 and thereafter, we likely will not calculate the 
MSA-based rural area indices, as the acute care hospital IPPS will no 
longer publish MSA-based wage tables. Thus, we specifically request 
comments on the approach to be used for IRFs in rural areas without 
corresponding hospital wage data for fiscal years 2007 and thereafter.
    For the reasons discussed above, we are proposing to continue the 
use of the acute care hospital inpatient wage index data generated from 
cost reporting periods beginning during FY 2001 without taking into 
account geographic reclassification as specified under sections 
1886(d)(8) and (d)(10) of the Act and without applying the ``rural 
floor'' under section 4410 of Pub. L. 105-33 (BBA) (as discussed in 
section III.B.2.a of this proposed rule). We believe that cost 
reporting period FY 2001 would be used to determine the applicable wage 
index values under the IRF PPS because these are the best available 
data. These data are the same FY 2001 acute care hospital inpatient 
wage data that were used to compute the FY 2005 wage indices. The 
proposed full wage index values that would be applicable for IRF PPS 
discharges occurring on or after October 1, 2005 are shown in Addendum 
1, Tables 2a (for urban areas) and 2b (for rural areas) in the Addendum 
of this proposed rule.
    In addition, any proposed adjustment or update to the IRF wage 
index made as specified under section 1886(j)(6) of the Act would be 
made in a budget neutral manner that assures that the estimated 
aggregated payments under this subsection in the FY year are not 
greater or less than those that would have been made in the year 
without such adjustment. Therefore, we are proposing to calculate a 
budget-neutral wage adjustment factor as established in the July 30, 
2004 notice and as specified in Sec.  412.624(e)(1). We will continue 
to use the following steps to ensure that the proposed FY 2006 IRF 
standard payment conversion factor reflects the update to the proposed 
CBSA wage indices and to the proposed labor-related share in a budget 
neutral manner:
    Step 1: Determine the total amount of the estimated FY 2005 IRF PPS 
rates using the FY 2005 standard payment conversion factor and the 
labor-related share and the wage indices from FY 2005 (as published in 
the July 30, 2004 final notice).
    Step 2: Calculate the total amount of estimated IRF PPS payments 
using the FY 2005 standard payment conversion factor and the proposed 
updated CBSA-based FY 2006 labor-related share and wage indices 
described above.
    Step 3: Divide the amount calculated in step 1 by the amount 
calculated in step 2, which equals the proposed FY 2006 budget-neutral 
wage adjustment factor of 0.9996.
    Step 4: Apply the proposed FY 2006 budget-neutral wage adjustment 
factor from step 3 to the FY 2005 IRF PPS standard payment conversion 
factor after the application of the market basket update, described 
above, to determine the proposed FY 2006 standard payment conversion 
factor.
3. Proposed Teaching Status Adjustment
    Section 1886(j)(3)(A)(v) of the Act requires the Secretary to 
adjust the prospective payment rates for the IRF PPS by such factors as 
the Secretary determines are necessary to properly reflect variations 
in necessary costs of treatment among rehabilitation facilities. Under 
this authority, in the August 7, 2001 final rule (66 FR 41316, 41359), 
we considered implementing an adjustment for IRFs that are, or are part 
of, teaching institutions. However, because the results of our 
regression analysis, using FY 1999 data, showed that the indirect 
teaching cost variable was not significant, we did not implement a 
payment adjustment for indirect teaching costs in that final rule. The 
regression analysis conducted by RAND for this proposed rule, using FY 
2003 data, shows that the indirect teaching cost variable is 
significant in explaining the higher costs of IRFs that have teaching 
programs. Therefore, we are proposing to establish a facility level 
adjustment to the Federal per discharge base rate for IRFs that are, or 
are part of,

[[Page 30242]]

teaching institutions for the reasons discussed below (the ``teaching 
status adjustment''). However, as discussed below, we have some 
concerns about proposing a teaching status adjustment. The policy 
implications of implementing a teaching status adjustment on the basis 
of the results of RAND's recent analysis oblige us to seek assurance 
that these results do not reflect an aberration based on only a single 
year's data and that the teaching status adjustment can be implemented 
in such a way that it would be equitable to all IRFs. Analysis of 
future data (FY 2004 or later) would give us such assurance because it 
would allow the effects of the other proposed changes outlined in this 
proposed rule to be realized and allow us to determine whether the 
significant coefficient on the teaching variable continues to be 
present in the future data.
    The purpose of the proposed teaching status adjustment would be to 
account for the higher indirect operating costs experienced by 
facilities that participate in graduate medical education programs.
    We are proposing to implement the proposed teaching status 
adjustment in a budget neutral manner (that is, keeping aggregate 
payments for FY 2006 with the proposed teaching adjustment the same as 
aggregate payments for FY 2006 without the proposed teaching 
adjustment) for the reasons discussed below. (As a conforming change, 
we are proposing to revise Sec.  412.624 to add a new section (e)(4) as 
the teaching status adjustment. Specifically, Sec.  412.624(e)(4) would 
be for discharges on or after October 1, 2005. We propose to adjust the 
Federal prospective payment on a facility basis by a factor as 
specified by CMS for facilities that are teaching institutions or units 
of teaching institutions. This adjustment would be made on a claim 
basis as an interim payment and the final payment in full for the claim 
would be made during the final settlement of the cost report. Thus, we 
would redesignate the current (e)(4) and (e)(5) as (e)(5) and (e)(6)).
    Medicare makes direct graduate medical education (GME) payments 
(for direct costs such as resident and teaching physician salaries, and 
other direct teaching costs) to all teaching hospitals including those 
paid under the IPPS, and those that were once paid under the TEFRA rate 
of increase limits but are now paid under other PPSs. These direct GME 
payments are made separately from payments for hospital operating costs 
and are not part of the PPSs. However, the direct GME payments may not 
address the higher indirect operating costs which may often be 
experienced by teaching hospitals. For teaching hospitals paid under 
the TEFRA rate-of-increase limits, Medicare did not make separate 
medical education payments because payments to these hospitals were 
based on the hospitals' reasonable costs. Because payments under TEFRA 
were based on hospitals' reasonable costs, the higher indirect costs 
that might be associated with teaching programs would automatically 
have been factored into the TEFRA payments.
    When the IRF PPS was implemented, we did not adjust payments to 
IRFs for indirect medical education costs because we did not find that 
adjustments for such costs were supported by the regression analyses or 
by the impact analyses. As discussed in the August 7, 2001 final rule 
(69 FR 41316, 41359), the indirect teaching variable was not 
significant for either the fully specified regression or the payment 
regression in RAND's analysis. Furthermore, the impacts among the 
various classes of facilities reflecting the fully phased-in IRF PPS 
illustrated that IRFs with the highest measure of indirect teaching 
would lose approximately 2 percent of estimated payments under the IRF 
PPS when compared with payments under TEFRA rate-of-increase limits. 
These impacts did not account for changes in behavior that facilities 
were likely to adopt in response to the inherent incentives of the IRF 
PPS, and we believed that IRFs could change their behavior to mitigate 
any potential reduction in payments.
    The earlier research conducted by RAND was based on 1999 data and 
on a sample of IRFs. RAND recently conducted research to support us in 
developing potential refinements to the IRF classification system and 
the PPS. The regression analysis conducted by RAND for this proposed 
rule, using FY 2003 data, showed that the indirect teaching cost 
variable is significant in explaining the higher costs of IRFs that 
have teaching programs.
    In conducting the analysis on the FY 2003 data, RAND used the 
resident counts that were reported on the hospital cost reports 
(worksheet S-3, line 25, column 9 for freestanding IRF hospitals and 
worksheet S-3, Part 1, line 14 (or line 14.01 for subprovider 2), 
column 9 for rehabilitation units of acute care hospitals). That is, 
for the freestanding rehabilitation hospitals, RAND used the number of 
residents and interns reported for the entire hospital. For the 
rehabilitation units of acute care hospitals, RAND used the number of 
residents and interns reported for the rehabilitation unit (reported 
separately on the cost report from the number reported for the rest of 
the hospital). RAND did not distinguish between different types of 
resident specialties, nor did they distinguish among the different 
types of services residents provide, because this information is not 
reported on the cost reports.
    RAND used regression analysis (with the logarithm of costs as the 
dependent variable) to re-examine the effect of IRFs' teaching status 
on the costs of care. With FY 2003 data that include all Medicare-
covered IRF discharges, RAND found a statistically significant 
difference in costs between IRFs with teaching programs and those 
without teaching programs in the regression analysis. The different 
results obtained using the FY 2003 data (compared with the 1999 data) 
may be due to improvements in IRF coding after implementation of the 
IRF PPS. More accurately coded data may have allowed RAND to determine 
better the differences in case mix among hospitals with and without 
teaching programs, which would then have allowed the effect of whether 
or not an IRF has a teaching program to become significant in the 
regression analysis. There are two main reasons that indirect operating 
costs may be higher in teaching hospitals: (1) Because the teaching 
activities themselves result in inefficiencies that increase costs, and 
(2) because patients needing more costly services tend to be treated 
more often in teaching hospitals than in non-teaching hospitals, that 
is, the case mix that is drawn to teaching hospitals. Quantifying more 
precisely the amount of cost increase that is due to teaching 
hospitals' case mix allows RAND to more precisely quantify the amount 
of increase due to the inefficiencies associated with a teaching 
program.
    We would propose to treat the teaching status adjustment as an 
additional payment to the Federal prospective payment rate, similar to 
the IME payments made under the IPPS (see Sec.  412.105). Any such 
teaching status adjustments for the IRF PPS facilities would be made on 
a claim basis as interim payments, but the final payment in full for 
the cost reporting period would be made through the cost report. The 
difference between those interim payments and the actual teaching 
status adjustment amount computed in the cost report would be adjusted 
through lump sum payments/recoupments when the cost report is filed and 
later settled.
    As in the IPF PPS, we would propose to calculate a teaching 
adjustment based on the IRF's ``teaching variable,'' which would be one 
plus the ratio of the number of FTE residents training in the IRF 
(subject to limitations described

[[Page 30243]]

further below) to the IRF's average daily census (ADC). In RAND's most 
recent cost regressions using data from FY 2003, the logarithm of the 
teaching variable has a coefficient value of 1.083. We would propose to 
convert this cost effect to a teaching status payment adjustment by 
treating the regression coefficient as an exponent and raising the 
teaching variable to a power equal to the coefficient value--currently 
1.083 (that is, the teaching status adjustment would be calculated by 
raising the teaching variable (1 + FTE residents/ADC) to the 1.083 
power). For a facility with a teaching variable of 0.10, and using a 
coefficient based upon the coefficient value (1.083) from the FY 2003 
data, this method would yield a 10.9 percent increase in the per 
discharge payment; for a facility with a teaching variable of 0.05, the 
payment would increase by 5.4 percent. We note that the coefficient 
value of 1.083 is based on regression analysis holding all other 
components of the payment system constant. Because we are proposing a 
number of other revisions to the payment system in this proposed rule, 
the coefficient value is subject to change for the final rule depending 
on the other revisions included in the final rule. Moreover, we are 
concerned that IRFs' responses to other proposed changes described in 
this proposed rule will influence the effects of a teaching variable on 
IRFs' costs.
    In addition, the teaching adjustment we would propose would limit 
the incentives for IRFs to add FTE residents for the purpose of 
increasing their teaching adjustment, as has been done in the payment 
systems for psychiatric facilities and acute inpatient hospitals. Thus, 
we would propose to impose a cap on the number of FTE residents that 
may be counted for purposes of calculating the teaching adjustment, 
similar to that established by sections 4621 (IME FTE cap for IPPS 
hospitals) and 4623 (direct GME FTE cap for all hospitals) of the BBA. 
We note that the FTE resident cap already applies to teaching 
hospitals, including IRFs, for purposes of direct GME payments as 
specified in Sec.  413.75 through Sec.  413.83. The proposed cap would 
limit the number of residents that teaching hospitals may count for the 
purposes of calculating the IRF PPS teaching status adjustment, not the 
number of residents teaching institutions can hire or train.
    The proposed FTE resident cap would be identical in freestanding 
teaching rehabilitation hospitals and in distinct part rehabilitation 
units with GME programs. Similar to the regulations for counting FTE 
residents under the IPPS as described in Sec.  412.105(f), we are 
proposing to calculate a number of FTE residents that trained in the 
IRF during a ``base year'' and use that FTE resident number as the cap. 
An IRF's FTE resident cap would ultimately be determined based on the 
final settlement of the IRF's most recent cost reporting period ending 
on or before November 15, 2003. We would also propose that, similar to 
new IPPS teaching hospitals, IRFs that first begin training residents 
after November 15, 2003 would initially receive an FTE cap of ``0''. 
The FTE caps for new IRFs (as well as existing IRFs) that start 
training residents in a new GME program (as defined in Sec.  413.79(l)) 
may be subsequently adjusted in accordance with the policies that are 
being applied in the IPF PPS (as described in Sec.  
412.424(d)(1)(iii)(B)(2)), which in turn are made in accordance with 
the policies described in 42 CFR 413.79(e) for IPPS hospitals. However, 
contrary to the policy for IME FTE resident caps under the IPPS, we 
would not allow IRFs to aggregate the FTE resident caps used to compute 
the IRF PPS teaching status adjustment through affiliation agreements. 
We are proposing these policies because we believe it is important to 
limit the total pool of resident FTE cap positions within the IRF 
community and avoid incentives for IRFs to add FTE residents in order 
to increase their payments. We also want to avoid the possibility of 
hospitals transferring residents between IPPS and IRF training settings 
in order to increase Medicare payments. We recognize that under the 
regulations applicable to the IPPS IME adjustment, a new teaching 
hospital that trains residents from an existing program (not a new 
program as defined in 42 CFR 413.79(l)) can receive an adjustment to 
its IME FTE cap by entering into a Medicare GME affiliation agreement 
(see Sec.  412.105(f)(1)(vi), Sec.  413.75(b), and Sec.  413.79(f)) 
with other hospitals. However, this option would not be available to 
new teaching IRFs because, as noted above, we would propose not to 
allow IRFs to aggregate the FTE resident caps used to compute the IRF 
PPS teaching adjustment through affiliation agreements.
    We would propose that residents with less than full-time status and 
residents rotating through the rehabilitation hospital or unit for less 
than a full year be counted in proportion to the time they spend in 
their assignment with the IRF (for example, a resident on a full-time, 
3-month rotation to the IRF would be counted as 0.25 FTEs for purposes 
of counting residents to calculate the ratio). No FTE resident time 
counted for purposes of the IPPS IME adjustment would be allowed to be 
counted for purposes of the teaching status adjustment for the IRF PPS.
    The denominator that we would propose to use to calculate the 
teaching status adjustment under the IPF PPS would be the IRF's average 
daily census (ADC) from the current cost reporting period because it is 
closely related to the IRF's patient load, which determines the number 
of interns and residents the IRF can train. We also believe the ADC is 
a measure that can be defined precisely and is difficult to manipulate. 
Although the IPPS IME adjustment uses the hospital's number of beds as 
the denominator, the capital PPS (as specified at Sec.  412.322) and 
the IPF PPS (as specified at Sec.  412.424) both use the ADC as the 
denominator for the indirect graduate medical education adjustments.
    If a rehabilitation hospital or unit has more FTE residents in a 
given year than in the base year (the base year being used to establish 
the cap), we would base payments in that year on the lower number (the 
cap amount). This approach would be consistent with the IME adjustment 
under the IPPS and the IPF PPS. The IRF would be free to add FTE 
residents above the cap amount, but it would not be allowed to count 
the number of FTE residents above the cap for purposes of calculating 
the teaching adjustment. This means that the cap would be an upper 
limit on the number of FTE residents that may be counted for purposes 
of calculating the teaching status adjustment. IRFs could adjust their 
number of FTE residents counted for purposes of calculating the 
teaching adjustment as long as they remained under the cap.
    On the other hand, if a rehabilitation hospital or unit were to 
have fewer FTE residents in a given year than in the base year (that 
is, fewer residents than its FTE resident cap), an adjustment in 
payments in that year would be based on the lower number (the actual 
number of FTE residents the facility hires and trains).
    We would propose to implement a teaching status adjustment in such 
a way that total estimated aggregate payments to IRFs for FY 2006 would 
be the same with and without the proposed adjustment (that is, in a 
budget neutral manner). This is because we believe that the results of 
RAND's analysis of 2002 and 2003 IRF cost data suggest that additional 
money does not need to be added to the IRF PPS. RAND's analysis found, 
for example, that if all IRFs had been paid based on 100 percent of the 
IRF PPS payment rates throughout all of 2002 (some IRFs were still 
transitioning to PPS payments during 2002), PPS

[[Page 30244]]

payments during 2002 would have been 17 percent higher than IRFs' 
costs. We are open to examining other evidence regarding the amount of 
aggregate payments in the system.
    Consideration of an adjustment to payments based on an IRF's 
teaching status is consistent with section 1886 (j)(3)(A)(v) of the 
Act, which confers broad statutory authority upon the Secretary to 
adjust the per payment unit payment rate by such factors as the 
Secretary determines are necessary to properly reflect variations in 
necessary costs of treatment among rehabilitation facilities.
    As mentioned above and discussed below, we have some concerns with 
implementing a teaching status adjustment for IRFs at this time. We are 
concerned about volatility in the data given the many changes to the 
IRF PPS that have been made in recent years and may be adopted in this 
rulemaking process. Other proposed payment policy changes have the 
potential to change the magnitude or even the effect of a teaching 
variable on costs once IRFs have fully responded to the other proposed 
policy changes in this proposed rule. We also believe it is important 
to ensure that the data accurately counts residents who provide 
services to IRF patients.
    We note that the significant coefficient we found in the analysis 
of the FY 2003 data contrasts with the statistically insignificant 
coefficient we found in the analysis of the 1999 data used to construct 
the initial IRF PPS. Although we currently believe it may be 
appropriate to propose a teaching status adjustment for IRFs based on 
analysis of the FY 2003 data, we recognize that we may need to examine 
new data (that is, FY 2004 or later) to help us to reconcile these 
contradictory findings. We also believe the analysis of this new data 
could potentially lead us to conclude that a teaching status adjustment 
is not needed.
    The results of RAND's analysis using FY 2003 data also show that 
certain refinements to the IRF case mix system (as discussed in section 
II of this proposed rule) would improve the system by more 
appropriately accounting for the variation in costs among different 
types of IRF patients. In this proposed rule, we propose numerous 
changes to the CMGs and tiers, and to the threshold amount used to 
determine whether cases qualify for outlier payments, in order to 
better align IRF payments with the costs of providing care to Medicare 
beneficiaries in IRFs. In addition, this proposed rule proposes 
substantial changes to the wage index (the adoption of CBSA market area 
definitions) and to the rural and the LIP adjustments. We believe that 
these proposed changes may have an impact on cost differences between 
teaching and non-teaching IRFs, and that we will be able to assess 
their impact on teaching and non-teaching IRFs only after the proposed 
changes have been implemented.
    Furthermore, we believe it is important to ensure that the data 
accurately count residents who participate in managing the 
rehabilitation of IRF patients. We are particularly interested in 
ensuring that the FTE resident counts used for the proposed IRF 
teaching status adjustment do not duplicate resident counts used for 
purposes of the IPPS IME adjustment, and that hospitals do not have 
incentives to shift residents from the acute care hospital to the 
hospital's rehabilitation unit for purposes of computing the proposed 
IRF teaching adjustment. We are soliciting comments on the most valid 
and reliable method of counting residents for purposes of a proposed 
teaching status adjustment. We note that any changes we may make, based 
on our further investigation of this issue or on comments we receive on 
this proposed rule, to the methodology for counting residents could 
affect the magnitude of the proposed teaching adjustment or even 
whether the data continue to indicate that the proposed teaching status 
adjustment is appropriate.
    In addition, we recognize that the proposed new teaching status 
adjustment, especially if implemented in a budget-neutral manner, is an 
important issue for all providers because it involves a redistribution 
of resources among facilities. That is, under the proposal, IRFs with 
teaching programs would receive additional payments, while IRFs without 
teaching programs would have their payments lowered to maintain total 
estimated payments for FY 2006 at the same level as without the 
proposed adjustment. For this reason, we believe caution is warranted 
in this case.
    We are specifically soliciting comments on our consideration of the 
IRF teaching status adjustment.
4. Proposed Adjustment for Rural Location
    Consistent with the broad statutory authority conferred upon the 
Secretary in section 1886(j)(3)(A)(v) of the Act, we adjust the Federal 
prospective payment amount associated with a CMG to account for an 
IRF's geographic wage variation, low-income patients and, if 
applicable, location in a rural area, as described in Sec.  412.624(e).
    Under the broad statutory authority conferred upon the Secretary in 
section 1886(j)(3)(A)(v) of the Act, we are proposing to increase the 
adjustment to the Federal prospective payment amount for IRFs located 
in rural areas from 19.14 percent to 24.1 percent. We are proposing 
this change because RAND's regression analysis, using the best 
available data we have (FY 2003), indicates that rural facilities now 
have 24.1 percent higher costs of caring for Medicare patients than 
urban facilities. We note that we propose to use the same statistical 
approach, as described in the November 3, 2000 proposed rule (65 FR 
66304, 66356 through 66357) and adopted in the August 7, 2001 final 
rule (66 FR at 41359) to estimate the proposed update to the rural 
adjustment. The statistical approach RAND used both when the PPS was 
first implemented and for the proposed update described in this 
proposed rule relies on the coefficient determined from the regression 
analysis. The 19.14 percent rural adjustment has been applied to 
payments for IRFs located in rural areas since the implementation of 
the IRF PPS. We note that the FY 2003 data are the best available data 
we have, just as the 1998 and 1999 data used in the initial development 
of the IRF PPS were the best available data at that time.
    We are proposing to implement the proposed update to the rural 
adjustment so that total estimated aggregate payments for FY 2006 are 
the same with the proposed update to the adjustment as they would have 
been without the proposed update to the adjustment (that is, in a 
budget neutral manner). We are proposing to make this proposed update 
to the rural adjustment in a budget neutral manner because we believe 
that the results of RAND's analysis of 2002 and 2003 IRF cost data (as 
discussed previously in this proposed rule) suggest that additional 
money does not need to be added to the IRF PPS. RAND's analysis found, 
for example, that if all IRFs had been paid based on 100 percent of the 
IRF PPS payment rates throughout all of 2002 (some IRFs were still 
transitioning to PPS payments during 2002), PPS payments during 2002 
would have been 17 percent higher than IRFs' costs. We are open to 
examining other evidence regarding the amount of estimated aggregate 
payments in the system.
    This is consistent with section 1886(j)(3)(A)(v) of the Act which 
confers broad statutory authority upon the Secretary to adjust the per 
payment unit payment rate by such factors as the Secretary determines 
are necessary to properly reflect variations in necessary costs of 
treatment among rehabilitation

[[Page 30245]]

facilities. To ensure that total estimated aggregate payments to IRFs 
do not change, we propose to apply a factor to the standard payment 
conversion factor to assure that the estimated aggregate payments under 
this subsection in the FY are not greater or less than those that would 
have been made in the year without the proposed update to the 
adjustment. In sections III.B.7 and III.B.8 of this proposed rule, we 
discuss the methodology and factor we are proposing to apply to the 
standard payment amount.
5. Proposed Adjustment for Disproportionate Share of Low-Income 
Patients
    Consistent with the broad statutory authority conferred upon the 
Secretary in section 1886(j)(3)(A)(v) of the Act, we adjust the Federal 
prospective payment amount associated with a CMG to account for an 
IRF's geographic wage variation, low-income patients and, if 
applicable, location in a rural area, as described in Sec.  412.624(e).
    Under the broad statutory authority conferred upon the Secretary in 
section 1886(j)(3)(A)(v) of the Act, we are proposing to update the 
low-income patient (LIP) adjustment to the Federal prospective payment 
rate to account for differences in costs among IRFs associated with 
differences in the proportion of low-income patients they treat. RAND's 
regression analysis of 2003 data indicates that the LIP formula could 
be updated to better distribute current payments among facilities 
according to the proportion of low-income patients they treat. Although 
the current formula appropriately distributed LIP-adjusted payments 
among facilities when the IRF PPS was first implemented, we believe the 
formula should be updated from time to time to reflect changes in the 
costs of caring for low-income patients.
    The proposed LIP adjustment is based on the formula used to account 
for the costs of furnishing care to low-income patients as discussed in 
the August 7, 2001 final rule (67 FR at 41360). We propose to update 
the LIP adjustment from the power of 0.4838 to the power of 0.636. 
Therefore, the proposed formula to calculate the LIP adjustment would 
be as follows: (1 + DSH patient percentage) raised to the power of 
(.636) Where DSH patient percentage =
[GRAPHIC] [TIFF OMITTED] TP25MY05.023

    We note that we propose to use the same statistical approach, as 
described in the August 7, 2001 final rule (66 FR at 41359 through 
41360), that was used to develop the original LIP adjustment. We note 
that the FY 2003 data we propose to use in calculating this adjustment 
are the best available data, just as the 1998 and 1999 data used in the 
initial development of the IRF PPS were the best available data at that 
time.
    We are proposing to implement the proposed update to the LIP 
adjustment so that total estimated aggregate payments for FY 2006 are 
the same with the proposed update to the adjustment as they would have 
been without the proposed update to the adjustment (that is, in a 
budget neutral manner). We are proposing to make this proposed update 
to the LIP adjustment in a budget neutral manner because we believe 
that the results of RAND's analysis of 2002 and 2003 IRF cost data (as 
discussed previously in this proposed rule) suggest that additional 
money does not need to be added to the IRF PPS. RAND's analysis found, 
for example, that if all IRFs had been paid based on 100 percent of the 
IRF PPS payment rates throughout all of 2002 (some IRFs were still 
transitioning to PPS payments during 2002), PPS payments during 2002 
would have been 17 percent higher than IRFs' costs. We are open to 
examining other evidence regarding the amount of estimated aggregate 
payments in the system.
    This is consistent with section 1886 (j)(3)(A)(v) of the Act which 
confers broad statutory authority upon the Secretary to adjust the per 
payment unit payment rate by such factors as the Secretary determines 
are necessary to properly reflect variations in necessary costs of 
treatment among rehabilitation facilities. To ensure that total 
estimated aggregate payments to IRFs do not change, we propose to apply 
a factor to the standard payment conversion factor to assure that the 
estimated aggregate payments under this subsection in the FY are not 
greater or less than those that would have been made in the year 
without the proposed update to the adjustment. In sections III.B.7 and 
III.B.8 of this proposed rule, we discuss the methodology and factor we 
are proposing to apply to the standard payment amount.
6. Proposed Update to the Outlier Threshold Amount
    Consistent with the broad statutory authority conferred upon the 
Secretary in sections 1886(j)(4)(A)(i) and 1886(j)(4)(A)(ii) of the 
Act, we are proposing to update the outlier threshold amount from the 
$11,211 threshold amount for FY 2005 to $4,911 in FY 2006 to maintain 
total estimated outlier payments at 3 percent of total estimated 
payments. In the August 7, 2001 final rule, we discuss our rationale 
for setting estimated outlier payments at 3 percent of total estimated 
payments (66 FR at 41362). We continue to propose to use 3 percent for 
the same reasons outlined in the August 7, 2001 final rule. We believe 
it is necessary to update the outlier threshold amount because RAND's 
analysis of the calendar year 2002 and FY 2003 data indicates that 
total estimated outlier payments will not equal 3 percent of total 
estimated payments unless we update the outlier loss threshold. We will 
continue to analyze the estimated outlier payments for subsequent years 
and adjust as appropriate in order to maintain estimated outlier 
payments at 3 percent of total estimated payments. The reasons for 
estimated outlier payments not equaling 3 percent of total estimated 
payments are discussed in more detail below.
    Section 1886(j)(4) of the Act provides the Secretary with the 
authority to make payments in addition to the basic IRF prospective 
payments for cases incurring extraordinarily high costs. In the August 
7, 2001 final rule, we codified at Sec.  412.624(e)(4) of the 
regulations (which would be redesignated as Sec.  412.624(e)(5)) the 
provision to make an adjustment for additional payments for outlier 
cases that have extraordinarily high costs relative to the costs of 
most discharges. Providing additional payments for outliers strongly 
improves the accuracy of the IRF PPS in determining resource costs at 
the patient and facility level because facilities receive additional 
compensation over and above the adjusted Federal prospective payment 
amount for uniquely high-cost cases. These additional payments reduce 
the financial losses that would otherwise be caused by treating 
patients who require more costly care and, therefore, reduce the 
incentives to underserve these patients.

[[Page 30246]]

    Under Sec.  412.624(e)(4) (which would be redesignated as Sec.  
412.624(e)(5)), we make outlier payments for any discharges if the 
estimated cost of a case exceeds the adjusted IRF PPS payment for the 
CMG plus the adjusted threshold amount (we are proposing to make this 
$4,911, which is then adjusted for each IRF by the facility's wage 
adjustment, its LIP adjustment, its rural adjustment, and its teaching 
status adjustment, if applicable). We calculate the estimated cost of a 
case by multiplying the IRF's overall cost-to-charge ratio by the 
Medicare allowable covered charge. In accordance with Sec.  
412.624(e)(4), we pay outlier cases 80 percent of the difference 
between the estimated cost of the case and the outlier threshold (the 
sum of the adjusted IRF PPS payment for the CMG and the adjusted fixed 
threshold dollar amount).
    Consistent with the broad statutory authority conferred upon the 
Secretary in sections 1886(j)(4)(A)(i) and 1886(j)(4)(A)(ii) of the 
Act, and in accordance with the methodology stated in the August 1, 
2003 final rule (68 FR at 45692 through 45693), we propose to continue 
to apply a ceiling to an IRF's cost-to-charge ratios (CCR). Also, in 
the August 1, 2003 final rule (68 FR at 45693 through 45694), we stated 
the methodology we use to adjust IRF outlier payments and the 
methodology we use to make these adjustments. We indicated that the 
methodology is codified in Sec.  412.624(e)(4) (which would be 
redesignated as Sec.  412.624(e)(5)) and Sec.  412.84(i)(3).
    On February 6, 2004, we issued manual instructions in Change 
Request 2998 stating that we would set forth the upper threshold 
(ceiling) and the national CCRs applicable to IRFs in each year's 
annual notice of prospective payment rates published in the Federal 
Register. The upper threshold CCR for IRFs that we are proposing for FY 
2006 would be 1.52 based on CBSA-based geographic designations. We are 
proposing to base this upper threshold CCR on the CBSA-based geographic 
designations because the CBSAs are the geographic designations we are 
proposing to adopt for purposes of computing the proposed wage index 
adjustment to IRF payments for FY 2006. If, instead, we were to use the 
MSA geographic designations, the upper threshold CCR amount would 
likely be different than the 1.52 we are proposing above. In addition, 
this is an estimated threshold and is subject to change in the final 
rule based on more recent data.
    In addition, we are proposing to update the national urban and 
rural CCRs for IRFs. Under Sec.  412.624(e)(4) (which would be 
redesignated as Sec.  412.624(e)(5)) and Sec.  412.84(i)(3), we are 
proposing to apply the national CCRs to the following situations:
     New IRFs that have not yet submitted their first Medicare 
cost report.
     IRFs whose operating or capital CCR is in excess of 3 
standard deviations above the corresponding national geometric mean.
     Other IRFs for whom the fiscal intermediary obtains 
accurate data with which to calculate either an operating or capital 
CCR (or both) are not available.
    The national CCR based on the facility location of either urban or 
rural would be used in each of the three situations cited above. 
Specifically, for FY 2006, we have estimated a proposed national CCR of 
0.631 for rural IRFs and 0.518 for urban IRFs. For new facilities, we 
are proposing to use these national ratios until the facility's actual 
CCR can be computed using the first tentative settled or final settled 
cost report data, which will then be used for the subsequent cost 
report period.
    In the August 7, 2001 final rule (66 FR at 41362 through 41363), we 
describe the process by which we calculate the outlier threshold. We 
continue to use this process for this proposed rule. We begin by 
simulating aggregate payments with and without an outlier policy, and 
applying an iterative process to determine a threshold that would 
result in outlier payments being equal to 3 percent of total simulated 
payments under the simulation. We note that the simulation analysis 
used to calculate the proposed $4,911 outlier threshold includes all of 
the proposed changes to the PPS discussed in this proposed rule, and is 
therefore subject to change in the final rule depending on the policies 
contained in the final rule. In addition, we will continue to analyze 
the estimated outlier payments for subsequent years and adjust as 
appropriate in order to maintain estimated outlier payments at 3 
percent of total estimated payments.
    In this proposed rule, we are proposing to update the threshold 
amount to $4,911 so that outlier payments will continue to equal 3 
percent of total estimated payments under the IRF PPS. RAND found that 
2002 outlier payments were equal to 3.1 percent of total payments in 
2002. Nevertheless, the outlier loss threshold is affected by cost-to-
charge ratios because the cost-to-charge ratios are used to compute the 
estimated cost of a case, which in turn is used to determine if a 
particular case qualifies for an outlier payment or not. For example, 
if the cost-to-charge ratio decreases, then the estimated costs of a 
case with the same reported charges would decrease. Thus, the chances 
that the case would exceed the outlier loss threshold and qualify for 
an outlier payment would decrease, decreasing the likelihood that the 
case would qualify for an outlier payment. If fewer cases were to 
qualify for outlier payments, then total estimated outlier payments 
could fall below 3 percent of total estimated payments.
    Our analyses of cost report data from FY 1999 through FY 2002 (and 
projections for FY 2004 though FY 2006) indicate that the overall cost-
to-charge ratios in IRFs have been falling since the IRF PPS was 
implemented. We are still analyzing possible reasons for this finding. 
However, because cost-to-charge ratios are used to determine whether a 
particular case qualifies for an outlier payment, this drop in the 
cost-to-charge ratios is likely responsible for much of the drop in 
total estimated outlier payments below 3 percent of total estimated 
payments. Thus, the outlier threshold would need to be lowered from 
$11,211 to $4,911 for FY 2006 in order that total estimated outlier 
payments would equal 3 percent of total estimated payments.
    In addition, we are proposing to adjust the outlier threshold for 
FY 2006 because RAND's analysis of calendar year 2002 and FY 2003 data 
indicates that many of the other proposed changes discussed in this 
proposed rule would affect what the outlier threshold would need to be 
in order for total estimated outlier payments to equal 3 percent of 
total estimated payments. The outlier loss threshold is affected by the 
definitions of all other elements of the IRF PPS, including the 
structure of the CMGs and the tiers, the relative weights, the policies 
for very short-stay cases and for cases in which the patient expires in 
the facility (that is, cases that qualify for the special CMG 
assignments), and the facility-level adjustments (such as the rural 
adjustment, the LIP adjustment, and the proposed teaching status 
adjustment). In this proposed rule, we are proposing to change many of 
these components of the IRF PPS. For the reasons discussed above, then, 
we believe it is appropriate to update the outlier loss threshold for 
FY 2006. We expect to continue to adjust the outlier threshold in the 
future when the data indicate that total estimated outlier payments 
would deviate from equaling 3 percent of total estimated payments.
7. Proposed Budget Neutrality Factor Methodology for Fiscal Year 2006
    We are proposing to make a one-time revision (for FY 2006) to the 
methodology found in Sec.  412.624(d) in

[[Page 30247]]

order to make the proposed changes to the tiers and CMGs, the rural 
adjustment, the LIP adjustment, and the proposed teaching status 
adjustment in a budget neutral manner. Accordingly, we are proposing to 
revise Sec.  412.624(d) by adding a section Sec.  412.624(d)(4) for 
fiscal year 2006. Specifically, we are proposing to revise the 
methodology found in Sec.  412.624(d) by adding a new paragraph (d)(4). 
The addition of this paragraph would provide for the application of a 
factor, as specified by the Secretary, which would be applied to the 
standard payment amount in order to make the proposed changes described 
in this preamble in a budget neutral manner for FY 2006. In addition, 
this paragraph would be used in future years if we propose refinements 
to the above-cited adjustments. According to the revised methodology, 
we propose to apply the market basket increase factor (3.1 percent) to 
the standard payment conversion factor for FY 2005 ($12,958), which 
equals $13,360. Then, we propose a one-time reduction to the standard 
payment amount of 1.9 percent to adjust for coding changes that 
increased payment to IRFs (as discussed in section III.A of this 
proposed rule), which equals $13,106. We then propose to apply the 
budget neutral wage adjustment (as discussed in section III.B.2.f of 
this proposed rule) of 0.9996 to $13,106, which would result in a 
standard payment amount of $13,101. For FY 2006 only, we propose to 
change the methodology for computing the standard payment conversion 
factor by applying budget neutrality factors for the proposed changes 
to the tiers and CMGs, the rural adjustment, the LIP adjustment, and 
the proposed teaching status adjustment. The next section contains a 
detailed explanation of these proposed budget neutrality factors, 
including the steps for computing these factors and how they affect 
total estimated aggregate payments and payments to individual IRF 
providers. The factors we are proposing to apply (as discussed in the 
next section) are 0.9994 for the proposed tier and CMG changes, 0.9865 
for the proposed teaching status adjustment, 0.9963 for the proposed 
change to the rural adjustment, and 0.9836 for the proposed change to 
the LIP adjustment. These factors are subject to change as we analyze 
more current data. We have combined these factors, by multiplying the 
four factors together, into one budget neutrality factor for all four 
of these proposed changes (0.9994 * 0.9865 * 0.9963 * 0.9836 = 0.9662). 
We apply this overall budget neutrality factor to $13,101, resulting in 
a standard payment conversion factor for FY 2006 of $12,658. Note that 
the FY 2006 standard payment conversion factor is lower than it was in 
FY 2005 because it needed to be reduced to ensure that estimated 
aggregate payments for FY 2006 would remain the same as they otherwise 
would have been without the proposed changes. If we did not proposed to 
decrease the standard payment conversion factor, each of the proposed 
changes would increase total estimated aggregate payments by increasing 
payments to rural and teaching facilities, and to facilities with a 
higher average case mix of patients and facilities that treat a higher 
proportion of low-income patients. To assess how overall payments to a 
particular type of IRF would likely be affected by the proposed budget-
neutral changes, please see Table 13 of this proposed rule.
    The FY 2006 standard payment conversion factor would be applied to 
each CMG relative weight shown in Table 6, Proposed Relative Weights 
for Case-Mix Groups, to compute the proposed unadjusted IRF prospective 
payment rates for FY 2006 shown in Table 12. To further clarify, the 
proposed one-time budget neutrality factors described above will only 
be applied for FY 2006. In addition, if no further refinements are 
proposed for subsequent fiscal years, we will use the methodology as 
described in Sec.  412.624(c)(3)(ii).
8. Description of the Methodology Used To Implement the Proposed 
Changes in a Budget Neutral Manner
    Section 1886(j)(2)(C)(i) of the Act confers broad statutory 
authority upon the Secretary to adjust the classification and weighting 
factors in order to account for relative resource use. In addition, 
section 1886(j)(2)(C)(ii) provides that insofar as the Secretary 
determines that such adjustments for a previous fiscal year (or 
estimates of such adjustments for a future fiscal year) did (or are 
likely to) result in a change in aggregated payments under the 
classification system during the fiscal year that are a result of 
changes in the coding or classification of patients that do not reflect 
real changes in case mix, the Secretary shall adjust the per payment 
unit payment rate for subsequent years to eliminate the effect of such 
coding or classification changes. Similarly, section 1886(j)(3)(A)(v) 
of the Act confers broad statutory authority upon the Secretary to 
adjust the per discharge payment rate by such factors as the Secretary 
determines are necessary to properly reflect variations in necessary 
costs of treatment among IRFs. Consistent with this broad statutory 
authority, we are proposing to better distribute aggregate payments 
among IRFs to more accurately reflect their case mix and the increased 
costs associated with IRFs that have teaching programs, are located in 
rural areas, or treat a high proportion of low-income patients.
    To ensure that total estimated aggregate payments to IRFs do not 
change with these proposed changes, we propose to apply a factor to the 
standard payment amount for each of the proposed changes to ensure that 
estimated aggregate payments in FY 2006 are not greater or less than 
those that would have been made in the year without the proposed 
changes. We propose to calculate these four factors using the following 
steps:
    Step 1: Determine the FY 2006 IRF PPS standard payment amount using 
the FY 2005 standard payment conversion factor increased by the 
estimated market basket of 3.1 percent and reduced by 1.9 percent to 
account for coding changes (as discussed in section III.A of this 
proposed rule).
    Step 2: Multiply the CBSA-based budget neutrality factor discussed 
in this preamble by the standard payment amount computed in step 1 to 
account for the wage index and labor-related share (0.9996), as 
discussed in section III.B.2.f of this proposed rule.
    Step 3: Calculate the estimated total amount of IRF PPS payments 
for FY 2006 (with no change to the tiers and CMGs, no teaching status 
adjustment, and no changes to the rural and LIP adjustments).
    Step 4: Apply the proposed new tier and CMG assignments (as 
discussed in section II) to calculate the estimated total amount of IRF 
PPS payments for FY 2006.
    Step 5: Divide the amount calculated in step 3 by the amount 
calculated in step 4 to determine the factor (currently estimated to be 
0.9994) that maintains the same total estimated aggregate payments in 
FY 2006 with and without the proposed changes to the tier and CMG 
assignments.
    Step 6: Apply the factor computed in step 5 to the standard payment 
amount from step 2, and calculate estimated total IRF PPS payment for 
FY 2006.
    Step 7: Apply the proposed change to the rural adjustment (as 
discussed in section III.B.4 of this proposed rule) to calculate the 
estimated total amount of IRF PPS payments for FY 2006.
    Step 8: Divide the amount calculated in step 6 by the amount 
calculated in step 7 to determine the factor (currently estimated to be 
0.9963) that keeps total estimated payments in FY 2006 the

[[Page 30248]]

same with and without the proposed change to the rural adjustment.
    Step 9: Apply the factor computed in step 8 to the standard payment 
amount from step 6, and calculate estimated total IRF PPS payment for 
FY 2006.
    Step 10: Apply the proposed change to the LIP adjustment (as 
discussed in section III.B.5 of this proposed rule) to calculate the 
estimated total amount of IRF PPS payments for FY 2006.
    Step 11: Divide the amount calculated in step 9 by the amount 
calculated in step 10 to determine the factor (currently estimated to 
be 0.9836) that maintains the same total estimated aggregate payments 
in FY 2006 with and without the proposed change to the LIP adjustment.
    Step 12: Apply the factor computed in step 11 to the standard 
payment amount from step 9, and calculate estimated total IRF PPS 
payment for FY 2006.
    Step 13: Apply the proposed teaching status adjustment (as 
discussed in section III.B.5 of this proposed rule) to calculate the 
estimated total amount of IRF PPS payments for FY 2006.
    Step 14: Divide the amount calculated in step 12 by the amount 
calculated in step 13 to determine the factor (currently estimated to 
be 0.9865) that maintains the same total estimated aggregate payments 
in FY 2006 with and without the proposed teaching status adjustment.
    As discussed in section III.B.9 of this proposed rule, the proposed 
FY 2006 IRF PPS standard payment conversion factor that accounts for 
the proposed new tier and CMG assignments, the proposed changes to the 
rural and the LIP adjustments, and the proposed teaching status 
adjustment applies the following factors: the market basket update, the 
reduction of 1.9 percent to account for coding changes, the budget-
neutral CBSA-based wage index and labor-related share budget neutrality 
factor of 0.9996, the proposed tier and CMG changes budget neutrality 
factor of 0.9994, the proposed rural adjustment budget neutrality 
factor of 0.9963, the proposed LIP adjustment budget neutrality factor 
of 0.9836, and the proposed teaching status adjustment budget 
neutrality factor of 0.9865.
    Each of these proposed budget neutrality factors lowers the 
proposed standard payment amount. The budget neutrality factor for the 
proposed tier and CMG changes lowers the standard payment amount from 
$13,101 to $13,093. The budget neutrality factor for the proposed 
change to the rural adjustment lowers the standard payment amount from 
$13,093 to $13,045. The budget neutrality factor for the proposed 
change to the LIP adjustment lowers the standard payment amount from 
$13,045 to $12,831. Finally, the budget neutrality factor for the 
proposed teaching status adjustment lowers the standard payment amount 
from $12,831 to $12,658. As indicated previously, the standard payment 
conversion factor would need to be lowered in order to ensure that 
total estimated payments for FY 2006 with the proposed changes equal 
total estimated payments for FY 2006 without the proposed changes. This 
is because these four proposed changes would result in an increase, on 
average, to total estimated aggregate payments to IRFs, because IRFs 
with teaching programs, IRFs located in rural areas, IRFs with higher 
case mix, and IRFs with higher proportions of low-income patients would 
receive higher payments. To maintain the same total estimated aggregate 
payments to all IRFs, then, we are proposing to redistribute payments 
among IRFs. Thus, some redistribution of payments occurs among 
facilities, while total estimated aggregate payments do not change. To 
determine how these proposed changes are estimated to affect payments 
among different types of facilities, please see Table 13 in this 
proposed rule.
9. Description of the Proposed IRF Standard Payment Conversion Factor 
for Fiscal Year 2006
    In the August 7, 2001 final rule, we established a standard payment 
amount referred to as the budget neutral conversion factor under Sec.  
412.624(c). In accordance with the methodology described in Sec.  
412.624(c)(3)(i), the budget neutral conversion factor for FY 2002, as 
published in the August 7,2001 final rule, was $11,838.00. Under Sec.  
412.624(c)(3)(i), this amount reflects, as appropriate, any adjustments 
for outlier payments, budget neutrality, and coding and classification 
changes as described in Sec.  412.624(d).
    The budget neutral conversion factor is a standardized payment 
amount and the amount reflects the budget neutrality adjustment for FY 
2002. The statute required a budget neutrality adjustment only for FYs 
2001 and 2002. Accordingly, we believed it was more consistent with the 
statute to refer to the standard payment as a standard payment 
conversion factor, rather than refer to it as a budget neutral 
conversion factor. Consequently, we changed all references to budget 
neutral conversion factor to ``standard payment conversion factor.''
    Under Sec.  412.624(c)(3)(i), the standard payment conversion 
factor for FY 2002 of $11,838.00 reflected the budget neutrality 
adjustment described in Sec.  412.624(d)(2). Under the then existing 
Sec.  412.624(c)(3)(ii), we updated the FY 2002 standard payment 
conversion factor ($11,838.00) to FY 2003 by applying an increase 
factor (the market basket) of 3.0 percent, as described in the update 
notice published in the August 1, 2002 Federal Register (67 FR at 
49931). This yielded the FY 2003 standard payment conversion factor of 
$12,193.00 that was published in the August 1, 2002 update notice (67 
FR at 49931). The FY 2003 standard payment conversion factor ($12,193) 
was used to update the FY 2004 standard payment conversion factor by 
applying an increase factor (the market basket) of 3.2 percent and 
budget neutrality factor of 0.9954, as described in the August 1, 2003 
Federal Register (68 FR at 45689). This yielded the FY 2004 standard 
payment conversion factor of $12,525 that was published in the August 
1, 2003 Federal Register (68 FR at 45689). The FY 2004 standard payment 
conversion factor ($12,525) was used to update the FY 2005 standard 
payment conversion factor by applying an increase factor (the market 
basket) of 3.1 percent and budget neutrality factor of 1.0035, as 
described in the July 30, 2004 Federal Register (69 FR at 45766). This 
yielded the FY 2005 standard payment conversion factor of $12,958 as 
published in the July 30, 2004 Federal Register (69 FR at 45766).
    We propose to use the revised methodology in accordance with Sec.  
412.624(c)(3)(ii)and as described in section III.B.7 of this proposed 
rule. To calculate the standard payment conversion factor for FY 2006, 
we are proposing to apply the market basket increase factor (3.1 
percent) to the standard payment conversion factor for FY 2005 
($12,958), which equals $13,360. Then, we propose a one-time reduction 
to the standard payment amount of 1.9 percent to adjust for coding 
changes that increased payment to IRFs, which equals $13,106. We then 
propose to apply the budget neutral wage adjustment of 0.9996 to 
$13,106, which would result in a standard payment amount of $13,101. 
Next, we propose to apply a one-time budget neutrality factor (for FY 
2006 only) for the proposed budget neutral refinements to the tiers and 
CMGs, the teaching status adjustment, the rural adjustment, and the 
adjustment for the proportion of low-income patients (of 0.9662) to 
$13,101, which would result in a standard payment conversion factor for 
FY 2006 of $12,658. The FY 2006 standard payment conversion factor 
would be applied to each CMG weight

[[Page 30249]]

shown in Table 6, Proposed Relative Weights for Case-Mix Groups, to 
compute the unadjusted IRF prospective payment rates for FY 2006 shown 
in Table 12.
10. Example of the Proposed Methodology for Adjusting the Federal 
Prospective Payment Rates
    To illustrate the methodology that we propose to use to adjust the 
Federal prospective payments (as described in section III.B.7 and 
section III.B.8 of this proposed rule), we provide an example in Table 
11 below.
    One beneficiary is in Facility A, an IRF located in rural Montana, 
and another beneficiary is in Facility B, an IRF located in the New 
York City core-based statistical area. Facility A, a non-teaching 
hospital, has a disproportionate share hospital (DSH) adjustment of 5 
percent, with a low-income patient adjustment of (1.0315), a wage index 
of (0.8701), and an applicable rural area adjustment (24.1 percent). 
Facility B, a teaching hospital, has a DSH of 15 percent, with a LIP 
adjustment of (1.0929), a wage index of (1.3311), and an applicable 
teaching status adjustment of (1.109).
    Both Medicare beneficiaries are classified to CMG 0110 (without 
comorbidities). To calculate each IRF's total proposed adjusted Federal 
prospective payment, we compute the wage-adjusted Federal prospective 
payment and multiply the result by the appropriate low-income patient 
adjustment, the rural adjustment (if applicable), and the teaching 
hospital adjustment (if applicable). Table 11 illustrates the 
components of the proposed adjusted payment calculation.
BILLING CODE 4120-01-P
[GRAPHIC] [TIFF OMITTED] TP25MY05.024

    Thus, the proposed adjusted payment for Facility A would be 
$31,671.57, and the adjusted payment for Facility B would be 
$41,637.65.

[[Page 30250]]

[GRAPHIC] [TIFF OMITTED] TP25MY05.025


[[Page 30251]]


[GRAPHIC] [TIFF OMITTED] TP25MY05.026


[[Page 30252]]


[GRAPHIC] [TIFF OMITTED] TP25MY05.027

BILLING CODE 4120-01-C

IV. Provisions of the Proposed Regulations

(If you choose to comment on issues in this section, please include 
the caption ``Provisions of the Proposed Regulations'' at the 
beginning of your comments.)

    We are proposing to make revisions to the regulation in order to 
implement the proposed prospective payment for IRFs for FY 2006 and 
subsequent fiscal years. Specifically, we are proposing to make 
conforming changes in 42 CFR part 412. These proposed revisions and 
others are discussed in detail below.

A. Section 412.602 Definitions

    In Sec.  412.602, we are proposing to revise the definitions of 
``Rural area'' and ``Urban area'' to read as follows:
    Rural area means: For cost-reporting periods beginning on or after 
January 1, 2002, with respect to discharges occurring during the period 
covered by such cost reports but before October 1, 2005, an area as 
defined in Sec.  412.62(f)(1)(iii). For discharges occurring on or 
after October 1, 2005, rural area means an area as defined in Sec.  
412.64(b)(1)(ii)(C).
    Urban area means: For cost-reporting periods beginning on or after 
January 1, 2002, with respect to discharges occurring during the period 
covered by such cost reports but before October 1, 2005, an area as 
defined in Sec.  412.62(f)(1)(ii). For discharges occurring on or after 
October 1, 2005, urban area means an area as defined in Sec.  
412.64(b)(1)(ii)(A) and Sec.  412.64(b)(1)(ii)(B).

[[Page 30253]]

B. Section 412.622 Basis of payment

    In this section, we are proposing to correct the cross references 
in paragraphs (b)(1) and (b)(2)(i). In paragraph (b)(1), we are 
proposing to remove the cross references ``Sec. Sec.  413.85 and 413.86 
of this chapter'' and add in their place ``Sec.  413.75 and Sec.  
413.85 of this chapter.'' In paragraph (b)(2)(i), we are proposing to 
remove the cross reference ``Sec.  413.80 of this chapter'' and add in 
its place ``Sec.  413.89 of this chapter.''

C. Section 412.624 Methodology for calculating the Federal prospective 
payment rates.

     In paragraph (d)(1), removing the cross reference to 
``paragraph (e)(4)'' and adding in its place ``paragraph (e)(5).''
     Adding a new paragraph (d)(4).
     Redesignating paragraphs (e)(4) and (e)(5) as paragraphs 
(e)(5) and (e)(6).
     Adding a new paragraph (e)(4).
     Revising newly redesignated paragraph (e)(5).
     Revising newly redesignated paragraph (e)(6).
     In paragraph (f)(2)(v), removing the cross references to 
``paragraphs (e)(1), (e)(2), and (e)(3) of this section'' and adding in 
their place ``paragraphs (e)(1), (e)(2), (e)(3), and (e)(4) of this 
section.''

D. Additional Changes

     Reduce the standard payment conversion factor by 1.9 
percent to account for coding changes.
     Revise the comorbidity tiers and CMGs.
     Use a weighted motor score index in assigning patients to 
CMGs.
     Update the relative weights.
     Update payments for rehabilitation facilities using a 
market basket reflecting the operating and capital cost structures for 
the RPL market basket.
     Provide the weights and proxies to use for the FY 2002-
based RPL market basket.
     Indicate the methodology for the capital portion of the 
RPL market basket.
     Adopt the new geographic labor market area definitions as 
specified in Sec.  412.64(b)(1)(ii)(A)-(C).
     Use the New England MSAs as determined under the proposed 
new CBSA-based labor market area definitions.
     Use FY 2001 acute care hospital wage data in computing the 
FY 2006 IRF PPS payment rates.
     Implement a teaching status adjustment.
     Update the formulas used to compute the rural and the LIP 
adjustments to IRF payments.
     Update the outlier threshold amount to maintain total 
outlier payments at 3 percent of total estimated payments.
     Revise the methodology for computing the standard payment 
conversion factor (for FY 2006 only) to make the proposed CMG and tier 
changes, the proposed teaching status adjustment, and the proposed 
updates to the rural and LIP adjustments in a budget neutral manner.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995.

VI. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
and, when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

VII. Regulatory Impact Analysis

[If you choose to comment on issues in this section, please include the 
caption ``Regulatory Impact Analysis'' at the beginning of your 
comments.]

A. Introduction

    The August 7, 2001 final rule established the IRF PPS for the 
payment of Medicare services for cost reporting periods beginning on or 
after January 1, 2002. We incorporated a number of elements into the 
IRF PPS, such as case-level adjustments, a wage adjustment, an 
adjustment for the percentage of low-income patients, a rural 
adjustment, and outlier payments. This proposed rule sets forth updates 
of the IRF PPS rates contained in the August 7, 2001 final rule and 
proposes policy changes with regard to the IRF PPS based on analyses 
conducted by RAND under contract with us on calendar year 2002 and FY 
2003 data (updated from the 1999 data used to design the IRF PPS).
    In constructing these impacts, we do not attempt to predict 
behavioral responses, nor do we make adjustments for future changes in 
such variables as discharges or case-mix. We note that certain events 
may combine to limit the scope or accuracy of our impact analysis, 
because such an analysis is future-oriented and, thus, susceptible to 
forecasting errors due to other changes in the forecasted impact time 
period. Some examples of such possible events are newly legislated 
general Medicare program funding changes by the Congress, or changes 
specifically related to IRFs. In addition, changes to the Medicare 
program may continue to be made as a result of the BBA, the BBRA, the 
BIPA, or new statutory provisions. Although these changes may not be 
specific to the IRF PPS, the nature of the Medicare program is such 
that the changes may interact, and the complexity of the interaction of 
these changes could make it difficult to predict accurately the full 
scope of the impact upon IRFs.
    We have examined the impacts of this proposed rule as required by 
Executive Order 12866 (September 1993, Regulatory Planning and Review) 
and the Regulatory Flexibility Act (RFA) and Impact on Small Hospitals 
(September 16, 1980, Pub. L. 96-354), section 1102(b) of the Social 
Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), 
and Executive Order 13132.
1. Executive Order 12866
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year).
    We estimate that the cost to the Medicare program for IRF services 
in FY 2006 will increase by $180 million over FY 2005 levels. The 
updates to the IRF labor-related share and wage indices are made in a 
budget neutral manner. We are proposing to make changes to the CMGs and 
the tiers, the teaching status adjustment, and the rural and LIP 
adjustments in a budget neutral manner (that is, in order that total 
estimated aggregate payments with the changes equal total estimated 
aggregate payments without the changes). This means that we are 
proposing to improve the distribution of payments among facilities 
depending on the mix of patients they treat, their teaching status, 
their geographic location (rural vs. urban), and the percentage of low-
income patients they treat, without changing total estimated aggregate

[[Page 30254]]

payments. To accomplish this redistribution of payments among 
facilities, we lower the base payment amount, which then gets adjusted 
upward for each facility according to the facility's characteristics. 
This proposed redistribution would not, however, affect aggregate 
payments to facilities. Thus, the proposed changes to the IRF labor-
related share and the wage indices, the proposed changes to the CMGs, 
the tiers, and the motor score index, the proposed teaching status 
adjustment, the proposed update to the rural adjustment, and the 
proposed update to the LIP adjustment would have no overall effect on 
estimated costs to the Medicare program. Therefore, the estimated 
increased cost to the Medicare program is due to the updated IRF market 
basket of 3.1 percent, the 1.9 percent reduction to the standard 
payment conversion factor to account for changes in coding that affect 
total aggregate payments, and the update to the outlier threshold 
amount. We have determined that this proposed rule is a major rule as 
defined in 5 U.S.C. 804(2). Based on the overall percentage change in 
payments per case estimated using our payment simulation model (a 2.9 
percent increase), we estimate that the total impact of these proposed 
changes for FY 2006 payments compared to FY 2005 payments would be 
approximately a $180 million increase. This amount does not reflect 
changes in IRF admissions or case-mix intensity, which would also 
affect overall payment changes.
2. Regulatory Flexibility Act (RFA)
    The RFA requires agencies to analyze the economic impact of our 
regulations on small entities. If we determine that the proposed 
regulation would impose a significant burden on a substantial number of 
small entities, we must examine options for reducing the burden. For 
purposes of the RFA, small entities include small businesses, nonprofit 
organizations, and government agencies. Most IRFs and most other 
providers and suppliers are considered small entities, either by 
nonprofit status or by having revenues of $6 million to $29 million in 
any 1 year. (For details, see the Small Business Administration's 
regulation that set forth size standards for health care industries at 
65 at FR 69432.) Because we lack data on individual hospital receipts, 
we cannot determine the number of small proprietary IRFs. Therefore, we 
assume that all IRFs (approximate total of 1,200 IRFs, of which 
approximately 60 percent are nonprofit facilities) are considered small 
entities for the purpose of the analysis that follows. Medicare fiscal 
intermediaries and carriers are not considered to be small entities. 
Individuals and States are not included in the definition of a small 
entity.
3. Impact on Rural Hospitals
    Section 1102(b) of the Act requires us to prepare a regulatory 
impact analysis for any proposed rule that may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. This analysis must conform to the provisions of section 603 
of the RFA. With the exception of hospitals located in certain New 
England counties, for purposes of section 1102(b) of the Act, we 
previously defined a small rural hospital as a hospital with fewer than 
100 beds that is located outside of a Metropolitan Statistical Area 
(MSA) or New England County Metropolitan Area (NECMA). However, under 
the new labor market definitions that we are proposing to adopt, we 
would no longer employ NECMAs to define urban areas in New England. 
Therefore, for purposes of this analysis, we now define a small rural 
hospital as a hospital with fewer than 100 beds that is located outside 
of a Metropolitan Statistical Area (MSA).
    As discussed in detail below, the rates and policies set forth in 
this proposed rule would not have an adverse impact on rural hospitals 
based on the data of the 169 rural units and 21 rural hospitals in our 
database of 1,188 IRFs for which data were available.
4. Unfunded Mandates Reform Act
    Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 
104-4) also requires that agencies assess anticipated costs and 
benefits before issuing any proposed rule that may result in an 
expenditure in any 1 year by State, local, or tribal governments, in 
the aggregate, or by the private sector, of at least $110 million. This 
proposed rule would not mandate any requirements for State, local, or 
tribal governments, nor would it affect private sector costs.
5. Executive Order 13132
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule that imposes 
substantial direct requirement costs on State and local governments, 
preempts State law, or otherwise has Federalism implications. We have 
reviewed this proposed rule in light of Executive Order 13132 and have 
determined that it would not have any negative impact on the rights, 
roles, or responsibilities of State, local, or tribal governments.
6. Overall Impact
    The following analysis, in conjunction with the remainder of this 
document, demonstrates that this proposed rule is consistent with the 
regulatory philosophy and principles identified in Executive Order 
12866, the RFA, and section 1102(b) of the Act. We have determined that 
the proposed rule would have a significant economic impact on a 
substantial number of small entities or a significant impact on the 
operations of a substantial number of small rural hospitals.

B. Anticipated Effects of the Proposed Rule

    We discuss below the impacts of this proposed rule on the budget 
and on IRFs.
1. Basis and Methodology of Estimates
    In this proposed rule, we are proposing policy changes and payment 
rate updates for the IRF PPS. Based on the overall percentage change in 
payments per discharge estimated using a payment simulation model 
developed by RAND under contract with CMS (a 2.9 percent increase), we 
estimate the total impact of these proposed changes for FY 2006 
payments compared to FY 2005 payments to be approximately a $180 
million increase. This amount does not reflect changes in hospital 
admissions or case-mix intensity, which would also affect overall 
payment changes.
    We have prepared separate impact analyses of each of the proposed 
changes to the IRF PPS. RAND's payment simulation model relies on the 
most recent available data (FY 2003) to enable us to estimate the 
impacts on payments per discharge of certain changes we are proposing 
in this proposed rule.
    The data used in developing the quantitative analyses of changes in 
payments per discharge presented below are taken from the FY 2003 
MedPAR file and the most current Provider-Specific File that is used 
for payment purposes. Data from the most recently available IRF cost 
reports were used to estimate costs and to categorize hospitals. Our 
analysis has several qualifications. First, we do not make adjustments 
for behavioral changes that hospitals may adopt in response to the 
proposed policy changes, and we do not adjust for future changes in 
such variables as admissions, lengths of stay, or case-mix. Second, due 
to the interdependent nature of the IRF PPS payment components, it is 
very difficult to precisely quantify the impact associated with each 
proposed change.

[[Page 30255]]

    Using cases in the FY 2003 MedPAR file, we simulated payments under 
the IRF PPS given various combinations of payment parameters.
    The proposed changes discussed separately below are the following:
     The effects of the proposed annual market basket update 
(using the proposed rehabilitation hospital, psychiatric hospital, and 
long-term care hospital (RPL) market basket) to IRF PPS payment rates 
required by sections 1886(j)(3)(A)(i) and 1886(j)(3)(C) of the Act.
     The effects of applying the proposed budget-neutral labor-
related share and wage index adjustment, as required under section 
1886(j)(6) of the Act.
     The effects of the proposed decrease to the standard 
payment conversion factor to account for the increase in estimated 
aggregate payments due to changes in coding, as required under section 
1886(j)(2)(C)(ii) of the Act.
     The effects of the proposed budget-neutral changes to the 
tier comorbidities, CMGs, motor score index, and relative weights, 
under the authority of section 1886(j)(2)(C)(i) of the Act.
     The effects of the proposed adoption of new CBSAs based on 
the new geographic area definitions announced by OMB in June 2003.
     The effects of the proposed implementation of a budget-
neutral teaching status adjustment, as permitted under section 
1886(j)(3)(A)(v) of the Act.
     The effects of the proposed budget-neutral update to the 
percentage amount by which payments are adjusted for IRFs located in 
rural areas, as permitted under section 1886(j)(3)(A)(v) of the Act.
     The effects of the proposed budget-neutral update to the 
formula used to calculate the payment adjustment for IRFs based on the 
percentage of low-income patients they treat, as permitted under 
section 1886(j)(3)(A)(v) of the Act.
     The effects of the proposed change to the outlier loss 
threshold amount to maintain total estimated outlier payments at 3 
percent of total estimated payments to IRFs in FY 2006, consistent with 
section 1886(j)(4) of the Act.
     The total change in payments based on the proposed FY 2006 
policies relative to payments based on FY 2005 policies.
    To illustrate the impacts of the proposed FY 2006 changes, our 
analysis begins with a FY 2005 baseline simulation model using: IRF 
charges inflated to FY 2005 using the market basket; the FY 2005 
PRICER; the estimated percent of outlier payments in FY 2005; the FY 
2005 CMG GROUPER (version 1.22); the MSA designations for IRFs based on 
OMB's MSA definitions prior to June 2003; the FY 2005 wage index; the 
FY 2005 labor-market share; the FY 2005 formula for the LIP adjustment; 
and the FY 2005 percentage amount of the rural adjustment.
    Each proposed policy change is then added incrementally to this 
baseline model, finally arriving at a FY 2006 model incorporating all 
of the proposed changes to the IRF PPS. This allows us to isolate the 
effects of each change. Note that, in computing estimated payments per 
discharge for each of the proposed policy changes, the outlier loss 
threshold has been adjusted so that estimated outlier payments are 3 
percent of total estimated payments.
    Our final comparison illustrates the percent change in payments per 
discharge from FY 2005 to FY 2006. One factor that affects the proposed 
changes in IRFs' payments from FY 2005 to FY 2006 is that we currently 
estimate total outlier payments during FY 2005 to be 1.2 percent of 
total estimated payments. As discussed in the August 7, 2001 final rule 
(66 FR at 41362), our policy is to set total estimated outlier payments 
at 3 percent of total estimated payments. Because estimated outlier 
payments during FY 2005 were below 3 percent of total payments, 
payments in FY 2006 would increase by an additional 1.8 percent over 
payments in FY 2005 because of the proposed change in the outlier loss 
threshold to achieve the 3 percent target.
2. Analysis of Table 13
    Table 13 displays the results of our analysis. The table 
categorizes IRFs by geographic location, including urban or rural 
location and location with respect to CMS' nine regions of the country. 
In addition, the table divides IRFs into those that are separate 
rehabilitation hospitals (otherwise called freestanding hospitals in 
this section), those that are rehabilitation units of a hospital 
(otherwise called hospital units in this section), rural or urban 
facilities by ownership (otherwise called for-profit, non-profit, and 
government), and by teaching status. The top row of the table shows the 
overall impact on the 1,188 IRFs included in the analysis.
    The next twelve rows of Table 13 contain IRFs categorized according 
to their geographic location, designation as either a freestanding 
hospital or a unit of a hospital, and by type of ownership: all urban, 
which is further divided into urban units of a hospital, urban 
freestanding hospitals, by type of ownership, and rural, which is 
further divided into rural units of a hospital, rural freestanding 
hospitals, and by type of ownership. There are 998 IRFs located in 
urban areas included in our analysis. Among these, there are 802 IRF 
units of hospitals located in urban areas and 196 freestanding IRF 
hospitals located in urban areas. There are 190 IRFs located in rural 
areas included in our analysis. Among these, there are 169 IRF units of 
hospitals located in rural areas and 21 freestanding IRF hospitals 
located in rural areas. There are 354 for-profit IRFs. Among these, 
there are 295 IRFs in urban areas and 59 IRFs in rural areas. There are 
708 non-profit IRFs. Among these, there are 603 urban IRFs and 105 
rural IRFs. There are 126 government owned IRFs. Among these, there are 
100 urban IRFs and 26 rural IRFs.
    The following three parts of Table 13 show IRFs grouped by their 
geographic location within a region, and the last part groups IRFs by 
teaching status. First, IRFs located in urban areas are categorized 
with respect to their location within a particular one of nine 
geographic regions. Second, IRFs located in rural areas are categorized 
with respect to their location within a particular one of the nine CMS 
regions. In some cases, especially for rural IRFs located in the New 
England, Mountain, and Pacific regions, the number of IRFs represented 
is small. Finally, IRFs are grouped by teaching status, including non-
teaching IRFs, IRFs with an intern and resident to ADC ratio less than 
10 percent, IRFs with an intern and resident to ADC ratio greater than 
or equal to 10 percent and less than or equal to 19 percent, and IRFs 
with an intern and resident to ADC ratio greater than 19 percent.
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3. Impact of the Proposed Market Basket Update to the IRF PPS Payment 
Rates (Using the RPL Market Basket) (Column 6, Table 13)
    In column 6 of Table 13, we present the effects of the proposed 
market basket update to the IRF PPS payment rates, as discussed in 
section III.B.1 of this proposed rule. Section 1886(j)(3)(A)(i) of the 
Act requires us annually to update the per discharge prospective 
payment rate for IRFs by an increase factor specified by the Secretary 
and based on an appropriate percentage increase in a market basket of 
goods and services comprising services for which payment is made to 
IRFs, as specified in section 1886(j)(3)(C) of the Act.
    As discussed in detail in section III.B.1 of this proposed rule, we 
are proposing to use a new market basket that reflects the operating 
and capital cost structures of inpatient rehabilitation facilities, 
inpatient psychiatric facilities, and long-term care hospitals, 
referred to as the rehabilitation hospital, psychiatric hospital, and 
long-term care hospital (RPL) market basket. The proposed FY 2006 
update for IRF PPS payments using the proposed FY 2002-based RPL market 
basket and the Global Insight's 4th quarter 2004 forecast would be 3.1 
percent.
    In the aggregate, and across all hospital groups, the proposed 
update would result in a 3.1 percent increase in overall payments to 
IRFs.
4. Impact of Updating the Budget-Neutral Labor-Related Share and MSA-
Based Wage Index Adjustment (Column 4, Table 14)
    In column 4 of Table 14, we present the effects of a budget-neutral 
update to the labor-related share and the wage index adjustment (using 
the geographic area definitions developed by OMB before June 2003), as 
discussed in section III.B.2 of this proposed rule. Since we are not 
proposing to use the MSA labor market definitions, table 14 is for 
reference purposes only.
    Section 1886(j)(6) of the Act requires us annually to adjust the 
proportion of rehabilitation facilities' costs that are attributable to 
wages and wage-related costs, of the prospective payment rates under 
the IRF PPS for area differences in wage levels by a factor reflecting 
the relative hospital wage level in the geographic area of the 
rehabilitation facility compared to the national average wage level for 
such facilities. This section of the Act also requires any such 
adjustments to be made in a budget-neutral manner.
    In accordance with section 1886(j)(6) of the Act, we are proposing 
to update the labor-related share and adopt the wage index adjustment 
based on CBSA designations in a budget neutral manner. However, if we 
do not adopt the CBSA-based designations, this would not change 
aggregated payments to IRF as indicated in the first row of column 4 in 
Table 14. If we only update the MSA-based wage index and labor-related 
share, there would be small distributional effects among different 
categories of IRFs. For example, rural IRFs would experience a 1.0 
percent decrease while urban facilities would experience a 0.1 percent 
increase in payments based on the RLP labor-related share and MSA-based 
wage index. Rural IRFs in the East South Central region would 
experience the largest decrease of 1.8 percent based on the proposed FY 
2006 labor-related share and MSA-based wage index. Urban IRFs in the 
Pacific region would experience the largest increase in payments of 0.8 
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5. Impact of the Proposed 1.9 Percent Decrease in the Standard Payment 
Amount to Account for Coding Changes (Column 11, Table 13)
    In column 11 of Table 13, we present the effects of the proposed 
decrease in the standard payment amount to account for the increase in 
aggregate payments due to changes in coding that do not reflect real 
changes in case mix, as discussed in section III.A of this proposed 
rule. Section 1886(j)(2)(C)(ii) of the Act requires us to adjust the 
per discharge PPS payment rate to eliminate the effect of coding or 
classification changes that do not reflect real changes in case mix if 
we determine that such changes result in a change in aggregate payments 
under the classification system.
    In the aggregate, and across all hospital groups, the proposed 
update would result in a 1.9 percent decrease in overall payments to 
IRFs. Thus, we estimate that the 1.9 percent reduction in the standard 
payment amount would result in a cost savings to the Medicare program 
of approximately $120 million.

[[Page 30264]]

6. Impact of the Proposed Changes to the CMG Reclassifications and 
Recalibration of Relative Weights (Column 7, Table 13)
    In column 7 of Table 13, we present the effects of the proposed 
changes to the tier comorbidities, the CMGs, the motor score index, and 
the proposed recalibration of the relative weights, as discussed in 
section II.A of this proposed rule. Section 1886(j)(2)(C)(i) of the Act 
requires us to adjust from time to time the classifications and 
weighting factors as appropriate to reflect changes in treatment 
patterns, technology, case mix, number of payment units for which 
payment under the IRF PPS is made, and any other factors which may 
affect the relative use of resources.
    As described in section II.A.3 of this proposed rule, we are 
proposing to update the tier comorbidities to remove condition codes 
from the list that we believe no longer merit additional payments, move 
dialysis patients to tier one to increase payments for these patients, 
and to align payments with the comorbidity conditions according to 
their effects on the relative costliness of patients. We are also 
proposing to update the CMGs and the relative weights for the CMGs so 
that they better reflect the relative costliness of different types of 
IRF patients. We are also proposing to replace the current motor score 
index with a weighted motor score index that better estimates the 
relative costliness of IRF patients. Finally, we are proposing to 
change the coding of patients with missing information for the transfer 
to toilet item in the motor score index from 1 to 2.
    To assess the impact of these proposed changes, we compared 
aggregate payments using the FY 2005 CMG relative weights (GROUPER 
version 1.22) to aggregate payments using the proposed FY 2006 CMG 
relative weights (GROUPER version 1.30). We note that, under the 
authority in section 1886(j)(2)(C)(i) of the Act and consistent with 
our rationale as described in section II.B.4 of this proposed rule, we 
have applied a budget neutrality factor to ensure that the overall 
payment impact of the proposed CMG changes is budget neutral (that is, 
in order that total estimated aggregate payments for FY 2006 with the 
change are equal to total estimated aggregate payment for FY 2006 
without the change). Because we found that the proposed relative 
weights we would use for calculating the FY 2006 payment rates are 
slightly higher, on average, than the relative weights we are currently 
using, and that the effect of this would be to increase aggregate 
payments, the proposed budget neutrality factor for the CMG and tier 
changes lowers the standard payment amount somewhat. Because the lower 
standard payment amount is balanced by the higher average weights, the 
effect is no change in overall payments to IRFs. However, the 
distribution of payments among facilities is affected, with some 
facilities receiving higher payments and some facilities receiving 
lower payments as a result of the tier and CMG changes, as shown in 
column 7 of Table 13.
    Although, in the aggregate, these proposed changes would not change 
overall payments to IRFs, as shown in the zero impact in the first row 
of column 7, there are distributional effects of these changes. On 
average, the impacts of these proposed changes on any particular group 
of IRFs are very small, with urban IRFs experiencing a 0.1 percent 
decrease and rural IRFs experiencing a 1.2 percent increase in 
aggregate payments. The largest impacts are a 2.7 percent increase 
among rural IRFs in the West North Central region and a 2.7 percent 
decrease among rural IRFs in the Pacific region.
7. Impact of the Proposed Changes to New Labor Market Areas (Column 4, 
Table 13)
    In accordance with the broad discretion under section 1886(j)(6) of 
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 
OMB as discussed in section III.B.2 of this proposed rule. On June 6, 
2003, OMB announced new Core-Based Statistical Areas (CBSAs), comprised 
of MSAs and the new Micropolitan Statistical Areas based on Census 2000 
data. We are proposing to adopt the new MSA definitions, consistent 
with the inpatient prospective payment system, including the 49 new 
Metropolitan areas designated under the new definitions. We are also 
proposing to adopt MSA definitions in New England in place of NECMAs. 
We are proposing not to adopt the newly defined Micropolitan 
Statistical Areas for use in the payment system, as Micropolitan 
Statistical Areas would remain part of the statewide rural areas for 
purposes of the IRF PPS payments, consistent with payments under the 
inpatient prospective payment system.
    The effects of these proposed changes to the new CBSA-based 
designations are isolated in column 4 of Table 13 by holding all other 
payment parameters constant in this simulation. That is, column 4 shows 
the percentage changes in payments when going from a model using the 
current MSA designations to a model using the proposed new CBSA 
designations (for Metropolitan areas only).
    Table 15 below compares the shifts in proposed wage index values 
for IRFs for FY 2006 relative to FY 2005. A small number of IRFs (1.6 
percent) would experience an increase of between 5 and 10 percent and 
1.5 percent of IRFs would experience an increase of more than 10 
percent. A small number of IRFs (2.5 percent) would experience 
decreases in their wage index values of at least 5 percent, but less 
than 10 percent. Furthermore, IRFs that would experience decreases in 
their wage index values of greater than 10 percent would be 0.7 
percent.
    The following table shows the projected impact for IRFs.

 Table 15.--Proposed Impact of the Proposed FY 2006 CBSA-based Area Wage
                                  Index
------------------------------------------------------------------------
                                                                 Percent
               Percent change in area wage index                 of IRFs
------------------------------------------------------------------------
Decrease Greater Than 10.0....................................       0.7
Decrease Between 5.0 and 10.0.................................       2.5
Decrease Between 2.0 and 5.0..................................       5.7
Decrease Between 0 and 2.0....................................      25.6
No Change.....................................................      37.2
Increase Between 0 and 2.0....................................      22.1
Increase Between 2.0 and 5.0..................................       3.3
Increase Between 5.0 and 10.0.................................       1.6
Increase Greater Than 10.0....................................       1.5
                                                               ---------
  Total \1\...................................................    100.0
------------------------------------------------------------------------
\1\ May not exactly equal 100 percent due to rounding.

8. Impact of the Proposed Adjustment to the Outlier Threshold Amount 
(Column 5, Table 13)
    We estimate total outlier payments in FY 2005 to be approximately 
1.2 percent of total estimated payments, so we are proposing to update 
the threshold from $11,211 in FY 2005 to $4,911 in FY 2006 in order to 
set total estimated outlier payments in FY 2006 equal to 3 percent of 
total estimated payments in FY 2006.
    The impact of this proposed change (as shown in column 5 of table 
13) is to increase total estimated payments to IRFs by about 1.8 
percent.
    The effect on payments to rural IRFs would be to increase payments 
by 3.9 percent, and the effect on payments to urban IRFs would be to 
increase payments by 1.6 percent. The largest effect would be a 9.5 
percent increase in payments to rural IRFs in the Mountain region, and 
the smallest effect would be

[[Page 30265]]

no change in payments for urban IRFs located in the East South Central 
region.
9. Impact of the Proposed Budget-Neutral Teaching Status Adjustment 
(Column 10, Table 13)
    In column 10 of Table 13, we present the effects of the proposed 
budget-neutral implementation of a teaching status adjustment to the 
Federal prospective payment rate for IRFs that have teaching programs, 
as discussed in section III.B.3 of this proposed rule. Section 
1886(j)(3)(A)(v) of the Act requires the Secretary to adjust the 
Federal prospective payment rates for IRFs under the IRF PPS for such 
factors as the Secretary determines are necessary to properly reflect 
variations in necessary costs of treatment among rehabilitation 
facilities. Under the authority of section 1886 (j)(3)(A)(v) of the 
Act, we are proposing to apply a budget neutrality factor to ensure 
that the overall payment impact of the proposed teaching status 
adjustment is budget neutral (that is, in order that total estimated 
aggregate payments for FY 2006 with the proposed adjustment would equal 
total estimated aggregate payments for FY 2006 without the proposed 
adjustment). Because IRFs with teaching programs would receive 
additional payments from the implementation of this proposed new 
teaching status adjustment, the effect of the proposed budget 
neutrality factor would be to reduce the standard payment amount, 
therefore reducing payments to IRFs without teaching programs. By 
design, however, the increased payments to teaching facilities would 
balance the decreased payments to non-teaching facilities, and total 
estimated aggregate payments to all IRFs would remain unchanged. 
Therefore, the first row of column 10 of Table 13 indicates a zero 
impact in the aggregate. However, the rest of column 10 gives the 
distributional effects among different types of providers of this 
change. Some providers' payments increase and some decrease with this 
change.
    On average, the impacts of this proposed change on any particular 
group of IRFs are very small, with urban IRFs experiencing a 0.1 
percent increase and rural IRFs experiencing a 1.1 percent decrease. 
The largest impacts are a 2.0 percent increase among urban IRFs in the 
Middle Atlantic region and 1.2 percent decreases among rural IRFs in 
the Middle Atlantic, South Atlantic, and West South Central regions.
    Overall, non-teaching hospitals would experience a 1.1 percent 
decrease. The largest impacts are a 24.3 percent increase among 
teaching facilities with intern and resident to ADC ratios greater than 
19 percent. Teaching facilities that have intern and resident to ADC 
ratios greater than or equal to 10 percent and less than or equal to 19 
percent would experience an increase of 11 percent. Teaching facilities 
with resident and intern to ADC ratios less than 10 percent would 
experience an increase of 2.6 percent.
10. Impact of the Proposed Update to the Rural Adjustment (Column 8, 
Table 13)
    In column 8 of Table 13, we present the effects of the proposed 
budget-neutral update to the percentage adjustment to the Federal 
prospective payment rates for IRFs located in rural areas, as discussed 
in section III.B.4 of this proposed rule. Section 1886(j)(3)(A)(v) of 
the Act requires the Secretary to adjust the Federal prospective 
payment rates for IRFs under the IRF PPS for such factors as the 
Secretary determines are necessary to properly reflect variations in 
necessary costs of treatment among rehabilitation facilities.
    In accordance with section 1886(j)(3)(A)(v) of the Act, we are 
proposing to change the rural adjustment percentage, based on FY 2003 
data, from 19.14 percent to 24.1 percent.
    Because we are proposing to make this proposed update to the rural 
adjustment in a budget neutral manner under the broad authority 
conferred by section 1886(j)(3)(A)(v) of the Act, payments to urban 
facilities would decrease in proportion to the total increase in 
payments to rural facilities. To accomplish this redistribution of 
resources between urban and rural facilities, we propose to apply a 
budget neutrality factor to reduce the standard payment amount. Rural 
facilities would receive an increase in payments to this amount, and 
urban facilities would not. Overall, aggregate payments to IRFs would 
not change, as indicated by the zero impact in the first row of column 
8. However, payments would be redistributed among rural and urban IRFs, 
as indicated by the rest of the column. On average, because there are a 
relatively small number of rural facilities, the impacts of this 
proposed change on urban IRFs are relatively small, with all urban IRFs 
experiencing a 0.3 percent decrease. The impact on rural IRFs is 
somewhat larger, with rural IRFs experiencing a 3.4 percent increase. 
The largest impacts are a 3.6 percent increase among rural IRFs in the 
Middle Atlantic region.
11. Impact of the Proposed Update to the LIP Adjustment (Column 9, 
Table 13)
    In column 9 of Table 13, we present the effects of the proposed 
budget-neutral update to the adjustment to the Federal prospective 
payment rates for IRFs according to the percentage of low-income 
patients they treat, as discussed in section III.B.5 of this proposed 
rule. Section 1886(j)(3)(A)(v) of the Act requires the Secretary to 
adjust the Federal prospective payment rates for IRFs under the IRF PPS 
for such factors as the Secretary determines are necessary to properly 
reflect variations in necessary costs of treatment among rehabilitation 
facilities.
    In accordance with section 1886(j)(3)(A)(v) of the Act, we are 
proposing to change the formula for the LIP adjustment, based on FY 
2003 data, to raise the amount of 1 plus the DSH patient percentage to 
the power of 0.636 instead of the power of 0.4838. Therefore, the 
formula to calculate the low-income patient or LIP adjustment would be 
as follows:
    (1 + DSH patient percentage) raised to the power of (.636) Where 
DSH patient percentage =
[GRAPHIC] [TIFF OMITTED] TP25MY05.035

    Because we are proposing to make this proposed update to the LIP 
adjustment in a budget neutral manner, payments would be redistributed 
among providers, according to their low-income percentages, but total 
estimated aggregate payments to facilities would not change. To do 
this, we propose to apply a budget neutrality factor that lowers the 
standard payment amount in proportion to the amount of payment increase 
that is attributable to the increased LIP adjustment payments. This 
would result in no change to aggregate payments, which is reflected in 
the zero impact shown in the first row of column 9 of Table 13. The 
remaining rows of the column show the

[[Page 30266]]

impacts on different categories of providers. On average, the impacts 
of this proposed change on any particular group of IRFs are small, with 
urban IRFs experiencing no change in aggregate payments and rural IRFs 
experiencing a 0.1 percent decrease in aggregate payments. The largest 
impacts are a 1.2 percent increase among IRFs with 10 percent or higher 
intern and resident to ADC ratios and 0.9 percent decrease among rural 
IRFs in the Pacific region.
12. All Proposed Changes (Column 12, Table 13)
    Column 12 of Table 13 compares our estimates of the proposed 
payments per discharge, incorporating all proposed changes reflected in 
this proposed rule for FY 2006, to our estimates of payments per 
discharge in FY 2005 (without these proposed changes). This column 
includes all of the proposed policy changes.
    Column 12 reflects all FY 2006 proposed changes relative to FY 
2005, shown in columns 4 though 11. The average increase for all IRFs 
is approximately 2.9 percent. This increase includes the effects of the 
proposed 3.1 percent market basket update. It also reflects the 1.8 
percentage point difference between the estimated outlier payments in 
FY 2005 (1.2 percent of total estimated payments) and the proposed 
estimate of the percentage of outlier payments in FY 2006 (3 percent), 
as described in the introduction to the Addendum to this proposed rule. 
As a result, payments per discharge are estimated to be 1.8 percent 
lower in FY 2005 than they would have been had the 3 percent target 
outlier payment percentage been met, resulting in a 1.8 percent greater 
increase in total FY 2006 payments than would otherwise have occurred.
    It also includes the impact of the proposed one-time 1.9 percent 
reduction in the standard payment conversion factor to account for 
changes in coding that increased payments to IRFs. Because we propose 
to make the remainder of the proposed changes outlined in this proposed 
rule in a budget-neutral manner, they do not affect total IRF payments 
in the aggregate. However, as described in more detail in each section, 
they do affect the distribution of payments among providers.
    There might also be interactive effects among the various proposed 
factors comprising the payment system that we are not able to isolate. 
For these reasons, the values in column 12 may not equal the sum of the 
proposed changes described above.
    The proposed overall change in payments per discharge for IRFs in 
FY 2006 would increase by 2.9 percent, as reflected in column 12 of 
Table 13. IRFs in urban areas would experience a 2.6 percent increase 
in payments per discharge compared with FY 2005. IRFs in rural areas, 
meanwhile, would experience a 6.8 percent increase. Rehabilitation 
units in urban areas would experience a 5 percent increase in payments 
per discharge, while freestanding rehabilitation hospitals in urban 
areas would experience a 1.1 percent decrease in payments per 
discharge. Rehabilitation units in rural areas would experience a 6.5 
percent increase in payments per discharge, while freestanding 
rehabilitation hospitals in rural areas would experience a 8.1 percent 
increase in payments per discharge.
    Overall, the largest payment increase would be 32.1 percent among 
teaching IRFs with an intern and resident to ADC ratio greater than 19 
percent and 15.8 percent among teaching IRFs with an intern and 
resident to ADC ratio greater than or equal to 10 percent and less than 
or equal to 19 percent. This is largely due to the proposed teaching 
status adjustment. Other than for teaching IRFs, the largest payment 
increase would be 12.3 percent among rural IRFs located in the Middle 
Atlantic region. This is due largely to the change in the proposed 
CBSA-based designation from urban to rural, whereby the number of cases 
in the rural Middle Atlantic Region that would receive the proposed new 
rural adjustment of 24.1 percent would increase. The only overall 
decreases in payments would occur among all urban freestanding IRFs and 
urban IRFs located in the New England, East South Central, and Mountain 
census regions. The largest of these overall payment decreases would be 
1.3 percent among all urban freestanding hospitals. This is due largely 
to the proposed change in the CBSA-based designation from rural to 
urban. For non-profit IRFs, we found that rural non-profit facilities 
would receive the largest payment increase of 8 percent. Conversely, 
for-profit urban facilities would experience a 1.1 percent overall 
decrease.
13. Accounting Statement
    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 16 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the provisions of this proposed rule. This 
table provides our best estimate of the increase in Medicare payments 
under the IRF PPS as a result of the proposed changes presented in this 
proposed rule based on the data for 1,188 IRFs in our database. All 
expenditures are classified as transfers to Medicare providers (that 
is, IRFs).

      Table 16.--Accounting Statement: Classification of Estimated
           Expenditures, From FY 2005 to FY 2006 (In millions)
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $180
From Whom To Whom?                          Federal Government To IRF
                                             Medicare Providers.
------------------------------------------------------------------------

List of Subjects in 42 CFR Part 412

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

    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services proposes to amend 42 CFR chapter IV as follows:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    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).

Subpart P--Prospective Payment for Inpatient Rehabilitation 
Hospitals and Rehabilitation Units

    2. Section 412.602 is amended by revising the definitions of 
``Rural area'' and ``Urban area'' to read as follows:


Sec.  412.602  Definitions.

* * * * *
    Rural area means: For cost-reporting periods beginning on or after 
January 1, 2002, with respect to discharges occurring during the period 
covered by such cost reports but before October 1, 2005, an area as 
defined in Sec.  412.62(f)(1)(iii). For discharges occurring on or 
after October 1, 2005, rural area means an area as defined in Sec.  
412.64(b)(1)(ii)(C).
* * * * *
    Urban area means: For cost-reporting periods beginning on or after 
January 1, 2002, with respect to discharges occurring during the period 
covered by such cost reports but before October 1, 2005, an area as 
defined in Sec.  412.62(f)(1)(ii). For discharges occurring on or after 
October 1, 2005,

[[Page 30267]]

urban area means an area as defined in Sec.  412.64(b)(1)(ii)(A) and 
Sec.  412.64(b)(1)(ii)(B).


Sec.  412.622  [Amended]

    3. Section 412.622 is amended by--
    A. In paragraph (b)(1), removing the cross references ``Sec. Sec.  
413.85 and 413.86 of this chapter'' and adding in their place ``Sec.  
413.75 and Sec.  413.85 of this chapter''.
    B. In paragraph (b)(2)(i), removing the cross reference to ``Sec.  
413.80 of this chapter'' and adding in its place ``Sec.  413.89 of this 
chapter''.
    4. Section 412.624 is amended by--
    a. In paragraph (d)(1), removing the cross reference to ``paragraph 
(e)(4)'' and adding in its place ``paragraph (e)(5)''.
    b. Adding a new paragraph (d)(4).
    c. Redesignating paragraphs (e)(4) and (e)(5) as paragraphs (e)(5) 
and (e)(6).
    d. Adding a new paragraph (e)(4).
    e. Revising newly redesignated paragraph (e)(5).
    f. Revising newly redesignated paragraph (e)(6).
    g. In paragraph (f)(2)(v), removing the cross references to 
``paragraphs (e)(1), (e)(2), and (e)(3) of this section'' and adding in 
their place ``paragraphs (e)(1), (e)(2), (e)(3), and (e)(4) of this 
section''.
    The revisions and additions read as follows:


Sec.  412.624  Methodology for calculating the Federal prospective 
payment rates.

* * * * *
    (d) * * *
    (4) Payment adjustment for Federal fiscal year 2006 and subsequent 
Federal fiscal years. CMS adjusts the standard payment conversion 
factor based on any updates to the adjustments specified in paragraph 
(e)(2), (e)(3), and (e)(4), of this section, and to any revision 
specified in Sec.  412.620(c).
    (e) * * *
    (4) Adjustments for teaching hospitals. For discharges on or after 
October 1, 2005, CMS adjusts the Federal prospective payment on a 
facility basis by a factor as specified by CMS for facilities that are 
teaching institutions or units of teaching institutions. This 
adjustment is made on a claim basis as an interim payment and the final 
payment in full for the claim is made during the final settlement of 
the cost report.
    (5) Adjustment for high-cost outliers. CMS provides for an 
additional payment to an inpatient rehabilitation facility if its 
estimated costs for a patient exceed a fixed dollar amount (adjusted 
for area wage levels and factors to account for treating low-income 
patients, for rural location, and for teaching programs) as specified 
by CMS. The additional payment equals 80 percent of the difference 
between the estimated cost of the patient and the sum of the adjusted 
Federal prospective payment computed under this section and the 
adjusted fixed dollar amount. Effective for discharges occurring on or 
after October 1, 2003, additional payments made under this section will 
be subject to the adjustments at Sec.  412.84(i), except that national 
averages will be used instead of statewide averages. Effective for 
discharges occurring on or after October 1, 2003, additional payments 
made under this section will also be subject to adjustments at Sec.  
412.84(m).
    (6) Adjustments related to the patient assessment instrument. An 
adjustment to a facility's Federal prospective payment amount for a 
given discharge will be made, as specified under Sec.  412.614(d), if 
the transmission of data from a patient assessment instrument is late.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: April 14, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
    Approved: May 4, 2005.
Michael O. Leavitt,
Secretary.
    The following addendum will not appear in the Code of Federal 
Regulations.

Addendum

    This addendum contains the tables referred to throughout the 
preamble to this proposed rule. The tables presented below are as 
follows:
    Table 1A.--FY 2006 IRF PPS MSA Labor Market Area Designations for 
Urban Areas for the purposes of comparing Wage Index values with Table 
2A.
    Table 1B.--FY 2006 IRF PPS MSA Labor Market Area Designations for 
Rural Areas for the purposes of comparing Wage Index values with Table 
2B.
    Table 2A.--Proposed Inpatient Rehabilitation Facility (IRF) wage 
index for urban areas based on proposed CBSA labor market areas for 
discharges occurring on or after October 1, 2005.
    Table 2B.--Proposed Inpatient Rehabilitation Facility (IRF) wage 
index based on proposed CBSA labor market areas for rural areas for 
discharges occurring on or after October 1, 2005.
    Table 3--Inpatient Rehabilitation Facilities with Corresponding 
State and County Location; Current Labor Market Area Designation; and 
Proposed New CBSA-based Labor Market Area Designation.

 Table 1A.--FY 2006 IRF PPS MSA Labor Market Area Designations for Urban
   Areas for the Purposes of Comparing Wage Index Values with Table 2a
------------------------------------------------------------------------
                             Urban area (Constituent Counties     Wage
            MSA                   or County Equivalents)         index
------------------------------------------------------------------------
0040......................  Abilene, TX......................     0.8009
                              Taylor, TX
0060......................  Aguadilla, PR....................     0.4294
                              Aguada, PR
                              Aguadilla, PR
                              Moca, PR
0080......................  Akron, OH........................     0.9055
                              Portage, OH
                              Summit, OH
0120......................  Albany, GA.......................     1.1266
                              Dougherty, GA
                              Lee, GA
0160......................  Albany-Schenectady-Troy, NY......     0.8570
                              Albany, NY
                              Montgomery, NY
                              Rensselaer, NY

[[Page 30268]]

 
                              Saratoga, NY
                              Schenectady, NY
                              Schoharie, NY
0200......................  Albuquerque, NM..................     1.0485
                              Bernalillo, NM
                              Sandoval, NM
                              Valencia, NM
0220......................  Alexandria, LA...................     0.8171
                              Rapides, LA
0240......................  Allentown-Bethlehem-Easton, PA...     0.9536
                              Carbon, PA
                              Lehigh, PA
                              Northampton, PA
0280......................  Altoona, PA......................     0.8462
                              Blair, PA
0320......................  Amarillo, TX.....................     0.9178
                              Potter, TX
                              Randall, TX
0380......................  Anchorage, AK....................     1.2109
                              Anchorage, AK
0440......................  Ann Arbor, MI....................     1.0816
                              Lenawee, MI
                              Livingston, MI
                              Washtenaw, MI
0450......................  Anniston,AL......................     0.7881
                              Calhoun, AL
0460......................  Appleton-Oshkosh-Neenah, WI......     0.9115
                              Calumet, WI
                              Outagamie, WI
                              Winnebago, WI
0470......................  Arecibo, PR......................     0.3757
                              Arecibo, PR
                              Camuy, PR
                              Hatillo, PR
0480......................  Asheville, NC....................     0.9501
                              Buncombe, NC
                              Madison, NC
0500......................  Athens, GA.......................     1.0202
                              Clarke, GA
                              Madison, GA
                              Oconee, GA
0520......................  Atlanta, GA......................     0.9971
                              Barrow, GA
                              Bartow, GA
                              Carroll, GA
                              Cherokee, GA
                              Clayton, GA
                              Cobb, GA
                              Coweta, GA
                              De Kalb, 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 City-Cape May, NJ.......     1.0907
                              Atlantic City, NJ
                              Cape May, NJ
0580......................  Auburn-Opelika, AL...............     0.8215
                              Lee, AL
0600......................  Augusta-Aiken, GA-SC.............     0.9208
                              Columbia, GA
                              McDuffie, GA

[[Page 30269]]

 
                              Richmond, GA
                              Aiken, SC
                              Edgefield, SC
0640......................  Austin-San Marcos, TX............     0.9595
                              Bastrop, TX
                              Caldwell, TX
                              Hays, TX
                              Travis, TX
                              Williamson, TX
0680......................  Bakersfield, CA..................     1.0036
                              Kern, CA
0720......................  Baltimore, MD....................     0.9907
                              Anne Arundel, MD
                              Baltimore, MD
                              Baltimore City, MD
                              Carroll, MD
                              Harford, MD
                              Howard, MD
                              Queen Annes, MD
0733......................  Bangor, ME.......................     0.9955
                              Penobscot, ME
0743......................  Barnstable-Yarmouth, MA..........     1.2335
                              Barnstable, MA
0760......................  Baton Rouge, LA..................     0.8354
                              Ascension, LA
                              East Baton Rouge
                              Livingston, LA
                              West Baton Rouge, LA
0840......................  Beaumont-Port Arthur, TX.........     0.8616
                              Hardin, TX
                              Jefferson, TX
                              Orange, TX
0860......................  Bellingham, WA...................     1.1642
                              Whatcom, WA
0870......................  Benton Harbor, MI................     0.8847
                              Berrien, MI
0875......................  Bergen-Passaic, NJ...............     1.1967
                              Bergen, NJ
                              Passaic, NJ
0880......................  Billings, MT.....................     0.8961
                              Yellowstone, MT
0920......................  Biloxi-Gulfport-Pascagoula, MS...     0.8649
                              Hancock, MS
                              Harrison, MS
                              Jackson, MS
0960......................  Binghamton, NY...................     0.8447
                              Broome, NY
                              Tioga, NY
1000......................  Birmingham, AL...................     0.9198
                              Blount, AL
                              Jefferson, AL
                              St. Clair, AL
                              Shelby, AL
1010......................  Bismarck, ND.....................     0.7505
                              Burleigh, ND
                              Morton, ND
1020......................  Bloomington, IN..................     0.8587
                              Monroe, IN
1040......................  Bloomington-Normal, IL...........     0.9111
                              McLean, IL
1080......................  Boise City, ID...................     0.9352
                              Ada, ID
                              Canyon, ID
1123......................  Boston-Worcester-Lawrence-Lowell-     1.1290
                             Brockton, MA-NH.
                              Bristol, MA
                              Essex, MA
                              Middlesex, MA
                              Norfolk, MA
                              Plymouth, MA
                              Suffolk, MA

[[Page 30270]]

 
                              Worcester, MA
                              Hillsborough, NH
                              Merrimack, NH
                              Rockingham, NH
                              Strafford, NH
1125......................  Boulder-Longmont, CO.............     1.0046
                              Boulder, CO
1145......................  Brazoria, TX.....................     0.8524
                              Brazoria, TX
1150......................  Bremerton, WA....................     1.0614
                              Kitsap, WA
1240......................  Brownsville-Harlingen-San Benito,     1.0125
                             TX.
                              Cameron, TX
1260......................  Bryan-College Station, TX........     0.9243
                              Brazos, TX
1280......................  Buffalo-Niagara Falls, NY........     0.9339
                              Erie, NY
                              Niagara, NY
1303......................  Burlington, VT...................     0.9322
                              Chittenden, VT
                              Franklin, VT
                              Grand Isle, VT
1310......................  Caguas, PR.......................     0.4061
                              Caguas, PR
                              Cayey, PR
                              Cidra, PR
                              Gurabo, PR
                              San Lorenzo, PR
1320......................  Canton-Massillon, OH.............     0.8895
                              Carroll, OH
                              Stark, OH
1350......................  Casper, WY.......................     0.9243
                              Natrona, WY
1360......................  Cedar Rapids, IA.................     0.8975
                              Linn, IA
1400......................  Champaign-Urbana, IL.............     0.9527
                              Champaign, IL
1440......................  Charleston-North Charleston, SC..     0.9420
                              Berkeley, SC
                              Charleston, SC
                              Dorchester, SC
1480......................  Charleston, WV...................     0.8876
                              Kanawha, WV
                              Putnam, WV
1520......................  Charlotte-Gastonia-Rock Hill, NC-     0.9711
                             SC.
                              Cabarrus, NC
                              Gaston, NC
                              Lincoln, NC
                              Mecklenburg, NC
                              Rowan, NC
                              Union, NC
                              York, SC
1540......................  Charlottesville, VA..............     1.0294
                              Albemarle, VA
                              Charlottesville City, VA
                              Fluvanna, VA
                              Greene, VA
1560......................  Chattanooga, TN-GA...............     0.9207
                              Catoosa, GA
                              Dade, GA
                              Walker, GA
                              Hamilton, TN
                              Marion, TN
1580......................  Cheyenne, WY.....................     0.8980
                              Laramie, WY
1600......................  Chicago, IL......................     1.0851
                              Cook, IL
                              De Kalb, IL
                              Du Page, IL
                              Grundy, IL

[[Page 30271]]

 
                              Kane, IL
                              Kendall, IL
                              Lake, IL
                              McHenry, IL
                              Will, IL
1620......................  Chico-Paradise, CA...............     1.0542
                              Butte, CA
1640......................  Cincinnati, OH-KY-IN.............     0.9595
                              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..     0.8022
                              Christian, KY
                              Montgomery, TN
1680......................  Cleveland-Lorain-Elyria, OH......     0.9626
                              Ashtabula, OH
                              Geauga, OH
                              Cuyahoga, OH
                              Lake, OH
                              Lorain, OH
                              Medina, OH
1720......................  Colorado Springs, CO.............     0.9792
                              El Paso, CO
1740......................  Columbia MO......................     0.8396
                              Boone, MO
1760......................  Columbia, SC.....................     0.9450
                              Lexington, SC
                              Richland, SC
1800......................  Columbus, GA-AL..................     0.8690
                              Russell, AL
                              Chattanoochee, GA
                              Harris, GA
                              Muscogee, GA
1840......................  Columbus, OH.....................     0.9753
                              Delaware, OH
                              Fairfield, OH
                              Franklin, OH
                              Licking, OH
                              Madison, OH
                              Pickaway, OH
1880......................  Corpus Christi, TX...............     0.8647
                              Nueces, TX
                              San Patricio, TX
1890......................  Corvallis, OR....................     1.0545
                              Benton, OR
1900......................  Cumberland, MD-WV................     0.8662
                              Allegany MD
                              Mineral WV
1920......................  Dallas, TX.......................     1.0054
                              Collin, TX
                              Dallas, TX
                              Denton, TX
                              Ellis, TX
                              Henderson, TX
                              Hunt, TX
                              Kaufman, TX
                              Rockwall, TX
1950......................  Danville, VA.....................     0.8643
                              Danville City, VA
                              Pittsylvania, VA
1960......................  Davenport-Moline-Rock Island, IA-     0.8773
                             IL.

[[Page 30272]]

 
                              Scott, IA
                              Henry, IL
                              Rock Island, IL
2000......................  Dayton-Springfield, OH...........     0.9231
                              Clark, OH
                              Greene, OH
                              Miami, OH
                              Montgomery, OH
2020......................  Daytona Beach, FL................     0.8900
                              Flagler, FL
                              Volusia, FL
2030......................  Decatur, AL......................     0.8894
                              Lawrence, AL
                              Morgan, AL
2040......................  Decatur, IL......................     0.8122
                              Macon, IL
2080......................  Denver, CO.......................     1.0904
                              Adams, CO
                              Arapahoe, CO
                              Broomfield, CO
                              Denver, CO
                              Douglas, CO
                              Jefferson, CO
2120......................  Des Moines, IA...................     0.9266
                              Dallas, IA
                              Polk, IA
                              Warren, IA
2160......................  Detroit, MI......................     1.0227
                              Lapeer, MI
                              Macomb, MI
                              Monroe, MI
                              Oakland, MI
                              St. Clair, MI
                              Wayne, MI
2180......................  Dothan, AL.......................     0.7596
                              Dale, AL
                              Houston, AL
2190......................  Dover, DE........................     0.9825
                              Kent, DE
2200......................  Dubuque, IA......................     0.8748
                              Dubuque, IA
2240......................  Duluth-Superior, MN-WI...........     1.0356
                              St. Louis, MN
                              Douglas, WI
2281......................  Dutchess County, NY..............     1.1657
                              Dutchess, NY
2290......................  Eau Claire, WI...................     0.9139
                              Chippewa, WI
                              Eau Claire, WI
2320......................  El Paso, TX......................     0.9181
                              El Paso, TX
2330......................  Elkhart-Goshen, IN...............     0.9278
                              Elkhart, IN
2335......................  Elmira, NY.......................     0.8445
                              Chemung, NY
2340......................  Enid, OK.........................     0.9001
                              Garfield, OK
2360......................  Erie, PA.........................     0.8699
                              Erie, PA
2400......................  Eugene-Springfield, OR...........     1.0940
                              Lane, OR
2440......................  Evansville-Henderson, IN-KY......     0.8395
                              Posey, IN
                              Vanderburgh, IN
                              Warrick, IN
                              Henderson, KY
2520......................  Fargo-Moorhead, ND-MN............     0.9114
                              Clay, MN
                              Cass, ND
2560......................  Fayetteville, NC.................     0.9363

[[Page 30273]]

 
                              Cumberland, NC
2580......................  Fayetteville-Springdale-Rogers,       0.8636
                             AR.
                              Benton, AR
                              Washington, AR
2620......................  Flagstaff, AZ-UT.................     1.0611
                              Coconino, AZ
                              Kane, UT
2640......................  Flint, MI........................     1.1178
                              Genesee, MI
2650......................  Florence, AL.....................     0.7883
                              Colbert, AL
                              Lauderdale, AL
2655......................  Florence, SC.....................     0.8960
                              Florence, SC
2670......................  Fort Collins-Loveland, CO........     1.0218
                              Larimer, CO
2680......................  Ft. Lauderdale, FL...............     1.0165
                              Broward, FL
2700......................  Fort Myers-Cape Coral, FL........     0.9371
                              Lee, FL
2710......................  Fort Pierce-Port St. Lucie, FL...     1.0046
                              Martin, FL
                              St. Lucie, FL
2720......................  Fort Smith, AR-OK................     0.8303
                              Crawford, AR
                              Sebastian, AR
                              Sequoyah, OK
2750......................  Fort Walton Beach, FL............     0.8786
                              Okaloosa, FL
2760......................  Fort Wayne, IN...................     0.9737
                              Adams, IN
                              Allen, IN
                              De Kalb, IN
                              Huntington, IN
                              Wells, IN
                              Whitley, IN
2800......................  Forth Worth-Arlington, TX........     0.9520
                              Hood, TX
                              Johnson, TX
                              Parker, TX
                              Tarrant, TX
2840......................  Fresno, CA.......................     1.0407
                              Fresno, CA
                              Madera, CA
2880......................  Gadsden, AL......................     0.8049
                              Etowah, AL
2900......................  Gainesville, FL..................     0.9459
                              Alachua, FL
2920......................  Galveston-Texas City, TX.........     0.9403
                              Galveston, TX
2960......................  Gary, IN.........................     0.9342
                              Lake, IN
                              Porter, IN
2975......................  Glens Falls, NY..................     0.8467
                              Warren, NY
                              Washington, NY
2980......................  Goldsboro, NC....................     0.8778
                              Wayne, NC
2985......................  Grand Forks, ND-MN...............     0.9091
                              Polk, MN
                              Grand Forks, ND
2995......................  Grand Junction, CO...............     0.9900
                              Mesa, CO
3000......................  Grand Rapids-Muskegon-Holland, MI     0.9519
                              Allegan, MI
                              Kent, MI
                              Muskegon, MI
                              Ottawa, MI
3040......................  Great Falls, MT..................     0.8810
                              Cascade, MT

[[Page 30274]]

 
3060......................  Greeley, CO......................     0.9444
                              Weld, CO
3080......................  Green Bay, WI....................     0.9586
                              Brown, WI
3120......................  Greensboro-Winston-Salem-High         0.9312
                             Point, NC.
                              Alamance, NC
                              Davidson, NC
                              Davie, NC
                              Forsyth, NC
                              Guilford, NC
                              Randolph, NC
                              Stokes, NC
                              Yadkin, NC
3150......................  Greenville, NC...................     0.9183
                              Pitt, NC
3160......................  Greenville-Spartanburg-Anderson,      0.9400
                             SC.
                              Anderson, SC
                              Cherokee, SC
                              Greenville, SC
                              Pickens, SC
                              Spartanburg, SC
3180......................  Hagerstown, MD...................     0.9940
                              Washington, MD
3200......................  Hamilton-Middletown, OH..........     0.9066
                              Butler, OH
3240......................  Harrisburg-Lebanon-Carlisle, PA..     0.9286
                              Cumberland, PA
                              Dauphin, PA
                              Lebanon, PA
                              Perry, PA
3283......................  Hartford, CT.....................     1.1054
                              Hartford, CT
                              Litchfield, CT
                              Middlesex, CT
                              Tolland, CT
3285......................  Hattiesburg, MS..................     0.7362
                              Forrest, MS
                              Lamar, MS
3290......................  Hickory-Morganton-Lenoir, NC.....     0.9502
                              Alexander, NC
                              Burke, NC
                              Caldwell, NC
                              Catawba, NC
3320......................  Honolulu, HI.....................     1.1013
                              Honolulu, HI
3350......................  Houma, LA........................     0.7721
                              Lafourche, LA
                              Terrebonne, LA
3360......................  Houston, TX......................     1.0117
                              Chambers, TX
                              Fort Bend, TX
                              Harris, TX
                              Liberty, TX
                              Montgomery, TX
                              Waller, TX
3400......................  Huntington-Ashland, WV-KY-OH.....     0.9564
                              Boyd, KY
                              Carter, KY
                              Greenup, KY
                              Lawrence, OH
                              Cabell, WV
                              Wayne, WV
3440......................  Huntsville, AL...................     0.8851
                              Limestone, AL
                              Madison, AL
3480......................  Indianapolis, IN.................     1.0039
                              Boone, IN
                              Hamilton, IN
                              Hancock, IN
                              Hendricks, IN

[[Page 30275]]

 
                              Johnson, IN
                              Madison, IN
                              Marion, IN
                              Morgan, IN
                              Shelby, IN
3500......................  Iowa City, IA....................     0.9654
                              Johnson, IA
3520......................  Jackson, MI......................     0.9146
                              Jackson, MI
3560......................  Jackson, MS......................     0.8406
                              Hinds, MS
                              Madison, MS
                              Rankin, MS
3580......................  Jackson, TN......................     0.8900
                              Chester, TN
                              Madison, TN
3600......................  Jacksonville, FL.................     0.9548
                              Clay, FL
                              Duval, FL
                              Nassau, FL
                              St. Johns, FL
3605......................  Jacksonville, NC.................     0.8401
                              Onslow, NC
3610......................  Jamestown, NY....................     0.7589
                              Chautaqua, NY
3620......................  Janesville-Beloit, WI............     0.9583
                              Rock, WI
3640......................  Jersey City, NJ..................     1.0923
                              Hudson, NJ
3660......................  Johnson City-Kingsport-Bristol,       0.8202
                             TN-VA.
                              Carter, TN
                              Hawkins, TN
                              Sullivan, TN
                              Unicoi, TN
                              Washington, TN
                              Bristol City, VA
                              Scott, VA
                              Washington, VA
3680......................  Johnstown, PA....................     0.7980
                              Cambria, PA
                              Somerset, PA
3700......................  Jonesboro, AR....................     0.8144
                              Craighead, AR
3710......................  Joplin, MO.......................     0.8721
                              Jasper, MO
                              Newton, MO
3720......................  Kalamazoo-Battlecreek, MI........     1.0350
                              Calhoun, MI
                              Kalamazoo, MI
                              Van Buren, MI
3740......................  Kankakee, IL.....................     1.0603
                              Kankakee, IL
3760......................  Kansas City, KS-MO...............     0.9641
                              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......................     0.9772
                              Kenosha, WI
3810......................  Killeen-Temple, TX...............     0.9242
                              Bell, TX
                              Coryell, TX
3840......................  Knoxville, TN....................     0.8508

[[Page 30276]]

 
                              Anderson, TN
                              Blount, TN
                              Knox, TN
                              Loudon, TN
                              Sevier, TN
                              Union, TN
3850......................  Kokomo, IN.......................     0.8986
                              Howard, IN
                              Tipton, IN
3870......................  La Crosse, WI-MN.................     0.9289
                              Houston, MN
                              La Crosse, WI
3880......................  Lafayette, LA....................     0.8105
                              Acadia, LA
                              Lafayette, LA
                              St. Landry, LA
                              St. Martin, LA
3920......................  Lafayette, IN....................     0.9067
                              Clinton, IN
                              Tippecanoe, IN
3960......................  Lake Charles, LA.................     0.7972
                              Calcasieu, LA
3980......................  Lakeland-Winter Haven, FL........     0.8930
                              Polk, FL
4000......................  Lancaster, PA....................     0.9883
                              Lancaster, PA
4040......................  Lansing-East Lansing, MI.........     0.9658
                              Clinton, MI
                              Eaton, MI
                              Ingham, MI
4080......................  Laredo, TX.......................     0.8747
                              Webb, TX
4100......................  Las Cruces, NM...................     0.8784
                              Dona Ana, NM
4120......................  Las Vegas, NV-AZ.................     1.1121
                              Mohave, AZ
                              Clark, NV
                              Nye, NV
4150......................  Lawrence, KS.....................     0.8644
                              Douglas, KS
4200......................  Lawton, OK.......................     0.8212
                              Comanche, OK
4243......................  Lewiston-Auburn, ME..............     0.9562
                              Androscoggin, ME
4280......................  Lexington, KY....................     0.9219
                              Bourbon, KY
                              Clark, KY
                              Fayette, KY
                              Jessamine, KY
                              Madison, KY
                              Scott, KY
                              Woodford, KY
4320......................  Lima, OH.........................     0.9258
                              Allen, OH
                              Auglaize, OH
4360......................  Lincoln, NE......................     1.0208
                              Lancaster, NE
4400......................  Little Rock-North Little, AR.....     0.8826
                              Faulkner, AR
                              Lonoke, AR
                              Pulaski, AR
                              Saline, AR
4420......................  Longview-Marshall, TX............     0.8739
                              Gregg, TX
                              Harrison, TX
                              Upshur, TX
4480......................  Los Angeles-Long Beach, CA.......     1.1732
                              Los Angeles, CA
4520......................  Louisville, KY-IN................     0.9162
                              Clark, IN

[[Page 30277]]

 
                              Floyd, IN
                              Harrison, IN
                              Scott, IN
                              Bullitt, KY
                              Jefferson, KY
                              Oldham, KY
4600......................  Lubbock, TX......................     0.8777
                              Lubbock, TX
4640......................  Lynchburg, VA....................     0.9017
                              Amherst, VA
                              Bedford City, VA
                              Bedford, VA
                              Campbell, VA
                              Lynchburg City, VA
4680......................  Macon, GA........................     0.9596
                              Bibb, GA
                              Houston, GA
                              Jones, GA
                              Peach, GA
                              Twiggs, GA
4720......................  Madison, WI......................     1.0395
                              Dane, WI
4800......................  Mansfield, OH....................     0.9105
                              Crawford, OH
                              Richland, OH
4840......................  Mayaguez, PR.....................     0.4769
                              Anasco, PR
                              Cabo Rojo, PR
                              Hormigueros, PR
                              Mayaguez, PR
                              Sabana Grande, PR
                              San German, PR
4880......................  McAllen-Edinburg-Mission, TX.....     0.8602
                              Hidalgo, TX
4890......................  Medford-Ashland, OR..............     1.0534
                              Jackson, OR
4900......................  Melbourne-Titusville-Palm Bay, FL     0.9633
                              Brevard, FL
4920......................  Memphis, TN-AR-MS................     0.9234
                              Crittenden, AR
                              De Soto, MS
                              Fayette, TN
                              Shelby, TN
                              Tipton, TN
4940......................  Merced, CA.......................     1.0575
                              Merced, CA
5000......................  Miami, FL........................     0.9870
                              Dade, FL
5015......................  Middlesex-Somerset-Hunterdon, NJ.     1.1360
                              Hunterdon, NJ
                              Middlesex, NJ
                              Somerset, NJ
5080......................  Milwaukee-Waukesha, WI...........     1.0076
                              Milwaukee, WI
                              Ozaukee, WI
                              Washington, WI
                              Waukesha, WI
5120......................  Minneapolis-St. Paul, MN-WI......     1.1066
                              Anoka, MN
                              Carver, MN
                              Chisago, MN
                              Dakota, MN
                              Hennepin, MN
                              Isanti, MN
                              Ramsey, MN
                              Scott, MN
                              Sherburne, MN
                              Washington, MN
                              Wright, MN
                              Pierce, WI

[[Page 30278]]

 
                              St. Croix, WI
5140......................  Missoula, MT.....................     0.9618
                              Missoula, MT
5160......................  Mobile, AL.......................     0.7932
                              Baldwin, AL
                              Mobile, AL
5170......................  Modesto, CA......................     1.1966
                              Stanislaus, CA
5190......................  Monmouth-Ocean, NJ...............     1.0888
                              Monmouth, NJ
                              Ocean, NJ
5200......................  Monroe, LA.......................     0.7913
                              Ouachita, LA
5240......................  Montgomery, AL...................     0.8300
                              Autauga, AL
                              Elmore, AL
                              Montgomery, AL
5280......................  Muncie, IN.......................     0.8580
                              Delaware, IN
5330......................  Myrtle Beach, SC.................     0.9022
                              Horry, SC
5345......................  Naples, FL.......................     1.0558
                              Collier, FL
5360......................  Nashville, TN....................     1.0108
                              Cheatham, TN
                              Davidson, TN
                              Dickson, TN
                              Robertson, TN
                              Rutherford, TN
                              Sumner, TN
                              Williamson, TN
                              Wilson, TN
5380......................  Nassau-Suffolk, NY...............     1.2907
                              Nassau, NY
                              Suffolk, NY
5483......................  New Haven-Bridgeport-Stamford-        1.2254
                             Waterbury-Danbury, CT.
                              Fairfield, CT
                              New Haven, CT
5523......................  New London-Norwich, CT...........     1.1596
                              New London, CT
5560......................  New Orleans, LA..................     0.9103
                              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.....................     1.3586
                              Bronx, NY
                              Kings, NY
                              New York, NY
                              Putnam, NY
                              Queens, NY
                              Richmond, NY
                              Rockland, NY
                              Westchester, NY
5640......................  Newark, NJ.......................     1.1625
                              Essex, NJ
                              Morris, NJ
                              Sussex, NJ
                              Union, NJ
                              Warren, NJ
5660......................  Newburgh, NY-PA..................     1.1170
                              Orange, NY
                              Pike, PA
5720......................  Norfolk-Virginia Beach-Newport        0.8894
                             News, VA-NC.
                              Currituck, NC
                              Chesapeake City, VA

[[Page 30279]]

 
                              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......................     1.5220
                              Alameda, CA
                              Contra Costa, CA
5790......................  Ocala, FL........................     0.9153
                              Marion, FL
5800......................  Odessa-Midland, TX...............     0.9632
                              Ector, TX
                              Midland, TX
5880......................  Oklahoma City, OK................     0.8966
                              Canadian, OK
                              Cleveland, OK
                              Logan, OK
                              McClain, OK
                              Oklahoma, OK
                              Pottawatomie, OK
5910......................  Olympia, WA......................     1.1006
                              Thurston, WA
5920......................  Omaha, NE-IA.....................     0.9754
                              Pottawattamie, IA
                              Cass, NE
                              Douglas, NE
                              Sarpy, NE
                              Washington, NE
5945......................  Orange County, CA................     1.1611
                              Orange, CA
5960......................  Orlando, FL......................     0.9742
                              Lake, FL
                              Orange, FL
                              Osceola, FL
                              Seminole, FL
5990......................  Owensboro, KY....................     0.8434
                              Daviess, KY
6015......................  Panama City, FL..................     0.8124
                              Bay, FL
6020......................  Parkersburg-Marietta, WV-OH......     0.8288
                              Washington, OH
                              Wood, WV
6080......................  Pensacola, FL....................     0.8306
                              Escambia, FL
                              Santa Rosa, FL
6120......................  Peoria-Pekin, IL.................     0.8886
                              Peoria, IL
                              Tazewell, IL
                              Woodford, IL
6160......................  Philadelphia, PA-NJ..............     1.0824
                              Burlington, NJ
                              Camden, NJ
                              Gloucester, NJ
                              Salem, NJ
                              Bucks, PA
                              Chester, PA
                              Delaware, PA
                              Montgomery, PA
                              Philadelphia, PA
6200......................  Phoenix-Mesa, AZ.................     0.9982
                              Maricopa, AZ
                              Pinal, AZ

[[Page 30280]]

 
6240......................  Pine Bluff, AR...................     0.8673
                              Jefferson, AR
6280......................  Pittsburgh, PA...................     0.8756
                              Allegheny, PA
                              Beaver, PA
                              Butler, PA
                              Fayette, PA
                              Washington, PA
                              Westmoreland, PA
6323......................  Pittsfield, MA...................     1.0439
                              Berkshire, MA
6340......................  Pocatello, ID....................     0.9601
                              Bannock, ID
6360......................  Ponce, PR........................     0.4954
                              Guayanilla, PR
                              Juana Diaz, PR
                              Penuelas, PR
                              Ponce, PR
                              Villalba, PR
                              Yauco, PR
6403......................  Portland, ME.....................     1.0112
                              Cumberland, ME
                              Sagadahoc, ME
                              York, ME
6440......................  Portland-Vancouver, OR-WA........     1.1403
                              Clackamas, OR
                              Columbia, OR
                              Multnomah, OR
                              Washington, OR
                              Yamhill, OR
                              Clark, WA
6483......................  Providence-Warwick-Pawtucket, RI.     1.1061
                              Bristol, RI
                              Kent, RI
                              Newport, RI
                              Providence, RI
                              Washington, RI
6520......................  Provo-Orem, UT...................     0.9613
                              Utah, UT
6560......................  Pueblo, CO.......................     0.8752
                              Pueblo, CO
6580......................  Punta Gorda, FL..................     0.9441
                              Charlotte, FL
6600......................  Racine, WI.......................     0.9045
                              Racine, WI
6640......................  Raleigh-Durham-Chapel Hill, NC...     1.0258
                              Chatham, NC
                              Durham, NC
                              Franklin, NC
                              Johnston, NC
                              Orange, NC
                              Wake, NC
6660......................  Rapid City, SD...................     0.8912
                              Pennington, SD
6680......................  Reading, PA......................     0.9215
                              Berks, PA
6690......................  Redding, CA......................     1.1835
                              Shasta, CA
6720......................  Reno, NV.........................     1.0456
                              Washoe, NV
6740......................  Richland-Kennewick-Pasco, WA.....     1.0520
                              Benton, WA
                              Franklin, WA
6760......................  Richmond-Petersburg, VA..........     0.9397
                              Charles City County, VA
                              Chesterfield, VA
                              Colonial Heights City, VA
                              Dinwiddie, VA
                              Goochland, VA
                              Hanover, VA

[[Page 30281]]

 
                              Henrico, VA
                              Hopewell City, VA
                              New Kent, VA
                              Petersburg City, VA
                              Powhatan, VA
                              Prince George, VA
                              Richmond City, VA
6780......................  Riverside-San Bernardino, CA.....     1.0970
                              Riverside, CA
                              San Bernardino, CA
6800......................  Roanoke, VA......................     0.8428
                              Botetourt, VA
                              Roanoke, VA
                              Roanoke City, VA
                              Salem City, VA
6820......................  Rochester, MN....................     1.1504
                              Olmsted, MN
6840......................  Rochester, NY....................     0.9196
                              Genesee, NY
                              Livingston, NY
                              Monroe, NY
                              Ontario, NY
                              Orleans, NY
                              Wayne, NY
6880......................  Rockford, IL.....................     0.9626
                              Boone, IL
                              Ogle, IL
                              Winnebago, IL
6895......................  Rocky Mount, NC..................     0.8998
                              Edgecombe, NC
                              Nash, NC
6920......................  Sacramento, CA...................     1.1848
                              El Dorado, CA
                              Placer, CA
                              Sacramento, CA
6960......................  Saginaw-Bay City-Midland, MI.....     0.9696
                              Bay, MI
                              Midland, MI
                              Saginaw, MI
6980......................  St. Cloud, MN....................     1.0215
                              Benton, MN
                              Stearns, MN
7000......................  St. Joseph, MO...................     1.0013
                              Andrews, MO
                              Buchanan, MO
7040......................  St. Louis, MO-IL.................     0.9081
                              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
                              Sullivan City, MO
7080......................  Salem, OR........................     1.0556
                              Marion, OR
                              Polk, OR
7120......................  Salinas, CA......................     1.3823
                              Monterey, CA
7160......................  Salt Lake City-Ogden, UT.........     0.9487
                              Davis, UT
                              Salt Lake, UT
                              Weber, UT
7200......................  San Angelo, TX...................     0.8167
                              Tom Green, TX

[[Page 30282]]

 
7240......................  San Antonio, TX..................     0.9023
                              Bexar, TX
                              Comal, TX
                              Guadalupe, TX
                              Wilson, TX
7320......................  San Diego, CA....................     1.1267
                              San Diego, CA
7360......................  San Francisco, CA................     1.4712
                              Marin, CA
                              San Francisco, CA
                              San Mateo, CA
7400......................  San Jose, CA.....................     1.4744
                              Santa Clara, CA
7440......................  San Juan-Bayamon, PR.............     0.4802
                              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       1.1118
                             Robles, CA.
                              San Luis Obispo, CA
7480......................  Santa Barbara-Santa Maria-Lompoc,     1.0771
                             CA.
                              Santa Barbara, CA
7485......................  Santa Cruz-Watsonville, CA.......     1.4779
                              Santa Cruz, CA
7490......................  Santa Fe, NM.....................     1.0590
                              Los Alamos, NM
                              Santa Fe, NM
7500......................  Santa Rosa, CA...................     1.2961
                              Sonoma, CA
7510......................  Sarasota-Bradenton, FL...........     0.9629
                              Manatee, FL
                              Sarasota, FL
7520......................  Savannah, GA.....................     0.9460
                              Bryan, GA
                              Chatham, GA
                              Effingham, GA
7560......................  Scranton--Wilkes-Barre--Hazleton,     0.8522
                             PA.
                              Columbia, PA
                              Lackawanna, PA
                              Luzerne, PA
                              Wyoming, PA
7600......................  Seattle-Bellevue-Everett, WA.....     1.1479
                              Island, WA
                              King, WA

[[Page 30283]]

 
                              Snohomish, WA
7610......................  Sharon, PA.......................     0.7881
                              Mercer, PA
7620......................  Sheboygan, WI....................     0.8948
                              Sheboygan, WI
7640......................  Sherman-Denison, TX..............     0.9617
                              Grayson, TX
7680......................  Shreveport-Bossier City, LA......     0.9111
                              Bossier, LA
                              Caddo, LA
                              Webster, LA
7720......................  Sioux City, IA-NE................     0.9094
                              Woodbury, IA
                              Dakota, NE
7760......................  Sioux Falls, SD..................     0.9441
                              Lincoln, SD
                              Minnehaha, SD
7800......................  South Bend, IN...................     0.9447
                              St. Joseph, IN
7840......................  Spokane, WA......................     1.0660
                              Spokane, WA
7880......................  Springfield, IL..................     0.8738
                              Menard, IL
                              Sangamon, IL
7920......................  Springfield, MO..................     0.8597
                              Christian, MO
                              Greene, MO
                              Webster, MO
8003......................  Springfield, MA..................     1.0173
                              Hampden, MA
                              Hampshire, MA
8050......................  State College, PA................     0.8461
                              Centre, PA
8080......................  Steubenville-Weirton, OH-WV......     0.8280
                              Jefferson, OH
                              Brooke, WV
                              Hancock, WV
8120......................  Stockton-Lodi, CA................     1.0564
                              San Joaquin, CA
8140......................  Sumter, SC.......................     0.8520
                              Sumter, SC
8160......................  Syracuse, NY.....................     0.9394
                              Cayuga, NY
                              Madison, NY
                              Onondaga, NY
                              Oswego, NY
8200......................  Tacoma, WA.......................     1.1078
                              Pierce, WA
8240......................  Tallahassee, FL..................     0.8655
                              Gadsden, FL
                              Leon, FL
8280......................  Tampa-St. Petersburg-Clearwater,      0.9024
                             FL.
                              Hernando, FL
                              Hillsborough, FL
                              Pasco, FL
                              Pinellas, FL
8320......................  Terre Haute, IN..................     0.8582
                              Clay, IN
                              Vermillion, IN
                              Vigo, IN
8360......................  Texarkana, AR-Texarkana, TX......     0.8413
                              Miller, AR
                              Bowie, TX
8400......................  Toledo, OH.......................     0.9524
                              Fulton, OH
                              Lucas, OH
                              Wood, OH
8440......................  Topeka, KS.......................     0.8904
                              Shawnee, KS
8480......................  Trenton, NJ......................     1.0276

[[Page 30284]]

 
                              Mercer, NJ
8520......................  Tucson, AZ.......................     0.8926
                              Pima, AZ
8560......................  Tulsa, OK........................     0.8729
                              Creek, OK
                              Osage, OK
                              Rogers, OK
                              Tulsa, OK
                              Wagoner, OK
8600......................  Tuscaloosa, AL...................     0.8440
                              Tuscaloosa, AL
8640......................  Tyler, TX........................     0.9502
                              Smith, TX
8680......................  Utica-Rome, NY...................     0.8295
                              Herkimer, NY
                              Oneida, NY
8720......................  Vallejo-Fairfield-Napa, CA.......     1.3517
                              Napa, CA
                              Solano, CA
8735......................  Ventura, CA......................     1.1105
                              Ventura, CA
8750......................  Victoria, TX.....................     0.8469
                              Victoria, TX
8760......................  Vineland-Millville-Bridgeton, NJ.     1.0573
                              Cumberland, NJ
8780......................  Visalia-Tulare-Porterville, CA...     0.9975
                              Tulare, CA
8800......................  Waco, TX.........................     0.8146
                              McLennan, TX
8840......................  Washington, DC-MD-VA-WV..........     1.0971
                              District of Columbia, DC
                              Calvert, MD
                              Charles, MD
                              Frederick, MD
                              Montgomery, MD
                              Prince Georges, MD
                              Alexandria City, VA
                              Arlington, VA
                              Clarke, VA
                              Culpepper, 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.........     0.8633
                              Black Hawk, IA
8940......................  Wausau, WI.......................     0.9570
                              Marathon, WI
8960......................  West Palm Beach-Boca Raton, FL...     1.0362
                              Palm Beach, FL
9000......................  Wheeling, OH-WV..................     0.7449
                              Belmont, OH
                              Marshall, WV
                              Ohio, WV
9040......................  Wichita, KS......................     0.9486
                              Butler, KS
                              Harvey, KS
                              Sedgwick, KS
9080......................  Wichita Falls, TX................     0.8395

[[Page 30285]]

 
                              Archer, TX
                              Wichita, TX
9140......................  Williamsport, PA.................     0.8485
                              Lycoming, PA
9160......................  Wilmington-Newark, DE-MD.........     1.1121
                              New Castle, DE
                              Cecil, MD
9200......................  Wilmington, NC...................     0.9237
                              New Hanover, NC
                              Brunswick, NC
9260......................  Yakima, WA.......................     1.0322
                              Yakima, WA
9270......................  Yolo, CA.........................     0.9378
                              Yolo, CA
9280......................  York, PA.........................     0.9150
                              York, PA
9320......................  Youngstown-Warren, OH............     0.9517
                              Columbiana, OH
                              Mahoning, OH
                              Trumbull, OH
9340......................  Yuba City, CA....................     1.0363
                              Sutter, CA
                              Yuba, CA
9360......................  Yuma, AZ.........................     0.8871
                              Yuma, AZ
------------------------------------------------------------------------


 Table 1B.--FY 2006 IRF PPS MSA Labor Market Area Designations for Rural
   Areas for the Purposes of Comparing Wage Index Values With Table 2B
------------------------------------------------------------------------
                                                                  Wage
                        Nonurban area                            Index
------------------------------------------------------------------------
Alabama......................................................     0.7637
Alaska.......................................................     1.1637
Arizona......................................................     0.9140
Arkansas.....................................................     0.7703
California...................................................     1.0297
Colorado.....................................................     0.9368
Connecticut..................................................     1.1917
Delaware.....................................................     0.9503
Florida......................................................     0.8721
Georgia......................................................     0.8247
Guam.........................................................     0.9611
Hawaii.......................................................     1.0522
Idaho........................................................     0.8826
Illinois.....................................................     0.8340
Indiana......................................................     0.8736
Iowa.........................................................     0.8550
Kansas.......................................................     0.8087
Kentucky.....................................................     0.7844
Louisiana....................................................     0.7290
Maine........................................................     0.9039
Maryland.....................................................     0.9179
Massachusetts................................................     1.0216
Michigan.....................................................     0.8740
Minnesota....................................................     0.9339
Mississippi..................................................     0.7583
Missouri.....................................................     0.7829
Montana......................................................     0.8701
Nebraska.....................................................     0.9035
Nevada.......................................................     0.9832
New Hampshire................................................     0.9940
New Jersey \1\...............................................  .........
New Mexico...................................................     0.8529
New York.....................................................     0.8403
North Carolina...............................................     0.8500
North Dakota.................................................     0.7743
Ohio.........................................................     0.8759
Oklahoma.....................................................     0.7537
Oregon.......................................................     1.0049
Pennsylvania.................................................     0.8348
Puerto Rico..................................................     0.4047
Rhode Island \1\.............................................  .........
South Carolina...............................................     0.8640
South Dakota.................................................     0.8393
Tennessee....................................................     0.7876
Texas........................................................     0.7910
Utah.........................................................     0.8843
Vermont......................................................     0.9375
Virginia.....................................................     0.8479
Virgin Islands...............................................     0.7456
Washington...................................................     1.0072
West Virginia................................................     0.8083
Wisconsin....................................................     0.9498
Wyoming......................................................    0.9182
------------------------------------------------------------------------
\1\ All counties within the State are classified urban.


   Table 2a.--Proposed Inpatient Rehabilitaion Facility Wage Index for
  Urban Areas Based on Proposed CBSA Labor Market Areas For Discharges
                  Occurring on or After October 1, 2005
------------------------------------------------------------------------
                                 Urban area  (Constituent      Full wage
         CBSA code                      counties)                 Index
------------------------------------------------------------------------
10180.....................  Abilene, TX......................     0.7850
                              Callahan County, TX
                              Jones County, TX
                              Taylor County, TX
10380.....................  Aguadilla-Isabela-San                 0.4280
                             Sebasti[aacute]n, PR.
                              Aguada Municipio, PR

[[Page 30286]]

 
                              Aguadilla Municipio, PR
                              Aasco Municipio, PR
                              Isabela Municipio, PR
                              Lares Municipio, PR
                              Moca Municipio, PR
                              Rinc[iacute]n Municipio, PR
                              San Sebasti[aacute]n Municipio,
                            PR
10420.....................  Akron, OH........................     0.9055
                              Portage County, OH
                              Summit County, OH
10500.....................  Albany, GA.......................     1.1266
                              Baker County, GA
                              Dougherty County, GA
                              Lee County, GA
                              Terrell County, GA
                              Worth County, GA
10580.....................  Albany-Schenectady-Troy, NY......     0.8650
                              Albany County, NY
                              Rensselaer County, NY
                              Saratoga County, NY
                              Schenectady County, NY
                              Schoharie County, NY
10740.....................  Albuquerque, NM..................     1.0485
                              Bernalillo County, NM
                              Sandoval County, NM
                              Torrance County, NM
                              Valencia County, NM
10780.....................  Alexandria, LA...................     0.8171
                              Grant Parish, LA
                              Rapides Parish, LA
10900.....................  Allentown-Bethlehem-Easton, PA-NJ     0.9501
                              Warren County, NJ
                              Carbon County, PA
                              Lehigh County, PA
                              Northampton County, PA
11020.....................  Altoona, PA......................     0.8462
                              Blair County, PA
11100.....................  Amarillo, TX.....................     0.9178
                              Armstrong County, TX
                              Carson County, TX
                              Potter County, TX
                              Randall County, TX
11180.....................  Ames, IA.........................     0.9479
                              Story County, IA
11260.....................  Anchorage, AK....................     1.2165
                              Anchorage Municipality, AK
                              Matanuska-Susitna Borough, AK
11300.....................  Anderson, IN.....................     0.8713
                              Madison County, IN
11340.....................  Anderson, SC.....................     0.8670
                              Anderson County, SC
11460.....................  Ann Arbor, MI....................     1.1022
                              Washtenaw County, MI
11500.....................  Anniston-Oxford, AL..............     0.7881
                              Calhoun County, AL
11540.....................  Appleton, WI.....................     0.9131
                              Calumet County, WI
                              Outagamie County, WI
11700.....................  Asheville, NC....................     0.9191
                              Buncombe County, NC
                              Haywood County, NC
                              Henderson County, NC
                              Madison County, NC
12020.....................  Athens-Clarke County, GA.........     1.0202
                              Clarke County, GA
                              Madison County, GA
                              Oconee County, GA
                              Oglethorpe County, GA
12060.....................  Atlanta-Sandy Springs-Marietta,       0.9971
                             GA.
                              Barrow County, GA

[[Page 30287]]

 
                              Bartow County, GA
                              Butts County, GA
                              Carroll County, GA
                              Cherokee County, GA
                              Clayton County, GA
                              Cobb County, GA
                              Coweta County, GA
                              Dawson County, GA
                              DeKalb County, GA
                              Douglas County, GA
                              Fayette County, GA
                              Forsyth County, GA
                              Fulton County, GA
                              Gwinnett County, GA
                              Haralson County, GA
                              Heard County, GA
                              Henry County, GA
                              Jasper County, GA
                              Lamar County, GA
                              Meriwether County, GA
                              Newton County, GA
                              Paulding County, GA
                              Pickens County, GA
                              Pike County, GA
                              Rockdale County, GA
                              Spalding County, GA
                              Walton County, GA
12100.....................  Atlantic City, NJ................     1.0931
                              Atlantic County, NJ
12220.....................  Auburn-Opelika, AL...............     0.8215
                              Lee County, AL
12260.....................  Augusta-Richmond County, GA-SC...     0.9154
                              Burke County, GA
                              Columbia County, GA
                              McDuffie County, GA
                              Richmond County, GA
                              Aiken County, SC
                              Edgefield County, SC
12420.....................  Austin-Round Rock, TX............     0.9595
                              Bastrop County, TX
                              Caldwell County, TX
                              Hays County, TX
                              Travis County, TX
                              Williamson County, TX
12540.....................  Bakersfield, CA..................     1.0036
                              Kern County, CA
12580.....................  Baltimore-Towson, MD.............     0.9907
                              Anne Arundel County, MD
                              Baltimore County, MD
                              Carroll County, MD
                              Harford County, MD
                              Howard County, MD
                              Queen Anne's County, MD
                              Baltimore City, MD
12620.....................  Bangor, ME.......................     0.9955
                              Penobscot County, ME
12700.....................  Barnstable Town, MA..............     1.2335
                              Barnstable County, MA
12940.....................  Baton Rouge, LA..................     0.8319
                              Ascension Parish, LA
                              East Baton Rouge Parish, LA
                              East Feliciana Parish, LA
                              Iberville Parish, LA
                              Livingston Parish, LA
                              Pointe Coupee Parish, LA
                              St. Helena Parish, LA
                              West Baton Rouge Parish, LA
                              West Feliciana Parish, LA
12980.....................  Battle Creek, MI.................     0.9366
                              Calhoun County, MI

[[Page 30288]]

 
13020.....................  Bay City, MI.....................     0.9574
                              Bay County, MI
13140.....................  Beaumont-Port Arthur, TX.........     0.8616
                              Hardin County, TX
                              Jefferson County, TX
                              Orange County, TX
13380.....................  Bellingham, WA...................     1.1642
                              Whatcom County, WA
13460.....................  Bend, OR.........................     1.0603
                              Deschutes County, OR
13644.....................  Bethesda-Frederick-Gaithersburg,      1.0956
                             MD.
                              Frederick County, MD
                              Montgomery County, MD
13740.....................  Billings, MT.....................     0.8961
                              Carbon County, MT
                              Yellowstone County, MT
13780.....................  Binghamton, NY...................     0.8447
                              Broome County, NY
                              Tioga County, NY
13820.....................  Birmingham-Hoover, AL............     0.9157
                              Bibb County, AL
                              Blount County, AL
                              Chilton County, AL
                              Jefferson County, AL
                              St. Clair County, AL
                              Shelby County, AL
                              Walker County, AL
13900.....................  Bismarck, ND.....................     0.7505
                              Burleigh County, ND
                              Morton County, ND
13980.....................  Blacksburg-Christiansburg-            0.7951
                             Radford, VA.
                              Giles County, VA
                              Montgomery County, VA
                              Pulaski County, VA
                              Radford City, VA
14020.....................  Bloomington, IN..................     0.8587
                              Greene County, IN
                              Monroe County, IN
                              Owen County, IN
14060.....................  Bloomington-Normal, IL...........     0.9111
                              McLean County, IL
14260.....................  Boise City-Nampa, ID.............     0.9352
                              Ada County, ID
                              Boise County, ID
                              Canyon County, ID
                              Gem County, ID
                              Owyhee County, ID
14484.....................  Boston-Quincy, MA................     1.1771
                              Norfolk County, MA
                              Plymouth County, MA
                              Suffolk County, MA
14500.....................  Boulder, CO......................     1.0046
                              Boulder County, CO
14540.....................  Bowling Green, KY................     0.8140
                              Edmonson County, KY
                              Warren County, KY
14740.....................  Bremerton-Silverdale, WA.........     1.0614
                              Kitsap County, WA
14860.....................  Bridgeport-Stamford-Norwalk, CT..     1.2835
                              Fairfield County, CT
15180.....................  Brownsville-Harlingen, TX........     1.0125
                              Cameron County, TX
15260.....................  Brunswick, GA....................     1.1933
                              Brantley County, GA
                              Glynn County, GA
                              McIntosh County, GA
15380.....................  Buffalo-Niagara Falls, NY........     0.9339
                              Erie County, NY
                              Niagara County, NY
15500.....................  Burlington, NC...................     0.8967

[[Page 30289]]

 
                              Alamance County, NC
15540.....................  Burlington-South Burlington, VT..     0.9322
                              Chittenden County, VT
                              Franklin County, VT
                              Grand Isle County, VT
15764.....................  Cambridge-Newton-Framingham, MA..     1.1189
                              Middlesex County, MA
15804.....................  Camden, NJ.......................     1.0675
                              Burlington County, NJ
                              Camden County, NJ
                              Gloucester County, NJ
15940.....................  Canton-Massillon, OH.............     0.8895
                              Carroll County, OH
                              Stark County, OH
15980.....................  Cape Coral-Fort Myers, FL........     0.9371
                              Lee County, FL
16180.....................  Carson City, NV..................     1.0352
                              Carson City, NV
16220.....................  Casper, WY.......................     0.9243
                              Natrona County, WY
16300.....................  Cedar Rapids, IA.................     0.8975
                              Benton County, IA
                              Jones County, IA
                              Linn County, IA
16580.....................  Champaign-Urbana, IL.............     0.9527
                              Champaign County, IL
                              Ford County, IL
                              Piatt County, IL
16620.....................  Charleston, WV...................     0.8876
                              Boone County, WV
                              Clay County, WV
                              Kanawha County, WV
                              Lincoln County, WV
                              Putnam County, WV
16700.....................  Charleston-North Charleston, SC..     0.9420
                              Berkeley County, SC
                              Charleston County, SC
                              Dorchester County, SC
16740.....................  Charlotte-Gastonia-Concord, NC-SC     0.9743
                              Anson County, NC
                              Cabarrus County, NC
                              Gaston County, NC
                              Mecklenburg County, NC
                              Union County, NC
                              York County, SC
16820.....................  Charlottesville, VA..............     1.0294
                              Albemarle County, VA
                              Fluvanna County, VA
                              Greene County, VA
                              Nelson County, VA
                              Charlottesville City, VA
16860.....................  Chattanooga, TN-GA...............     0.9207
                              Catoosa County, GA
                              Dade County, GA
                              Walker County, GA
                              Hamilton County, TN
                              Marion County, TN
                              Sequatchie County, TN
16940.....................  Cheyenne, WY.....................     0.8980
                              Laramie County, WY
16974.....................  Chicago-Naperville-Joliet, IL....     1.0868
                              Cook County, IL
                              DeKalb County, IL
                              DuPage County, IL
                              Grundy County, IL
                              Kane County, IL
                              Kendall County, IL
                              McHenry County, IL
                              Will County, IL
17020.....................  Chico, CA........................     1.0542

[[Page 30290]]

 
                              Butte County, CA
17140.....................  Cincinnati-Middletown, OH-KY-IN..     0.9516
                              Dearborn County, IN
                              Franklin County, IN
                              Ohio County, IN
                              Boone County, KY
                              Bracken County, KY
                              Campbell County, KY
                              Gallatin County, KY
                              Grant County, KY
                              Kenton County, KY
                              Pendleton County, KY
                              Brown County, OH
                              Butler County, OH
                              Clermont County, OH
                              Hamilton County, OH
                              Warren County, OH
17300.....................  Clarksville, TN-KY...............     0.8022
                              Christian County, KY
                              Trigg County, KY
                              Montgomery County, TN
                              Stewart County, TN
17420.....................  Cleveland, TN....................     0.7844
                              Bradley County, TN
                              Polk County, TN
17460.....................  Cleveland-Elyria-Mentor, OH......     0.9650
                              Cuyahoga County, OH
                              Geauga County, OH
                              Lake County, OH
                              Lorain County, OH
                              Medina County, OH
17660.....................  Coeur d'Alene, ID................     0.9339
                              Kootenai County, ID
17780.....................  College Station-Bryan, TX........     0.9243
                              Brazos County, TX
                              Burleson County, TX
                              Robertson County, TX
17820.....................  Colorado Springs, CO.............     0.9792
                              El Paso County, CO
                              Teller County, CO
17860.....................  Columbia, M......................     0.8396
                              Boone County, MO
                              Howard County, MO
17900.....................  Columbia, SC.....................     0.9392
                              Calhoun County, SC
                              Fairfield County, SC
                              Kershaw County, SC
                              Lexington County, SC
                              Richland County, SC
                              Saluda County, SC
17980.....................  Columbus, GA-AL..................     0.8690
                              Russell County, AL
                              Chattahoochee County, GA
                              Harris County, GA
                              Marion County, GA
                              Muscogee County, GA
18020.....................  Columbus, IN.....................     0.9388
                              Bartholomew County, IN
18140.....................  Columbus, OH.....................     0.9737
                              Delaware County, OH
                              Fairfield County, OH
                              Franklin County, OH
                              Licking County, OH
                              Madison County, OH
                              Morrow County, OH
                              Pickaway County, OH
                              Union County, OH
18580.....................  Corpus Christi, TX...............     0.8647
                              Aransas County, TX
                              Nueces County, TX

[[Page 30291]]

 
                              San Patricio County, TX
18700.....................  Corvallis, OR....................     1.0545
                              Benton County, OR
19060.....................  Cumberland, MD-WV................     0.8662
                              Allegany County, MD
                              Mineral County, WV
19124.....................  Dallas-Plano-Irving, TX..........     1.0074
                              Collin County, TX
                              Dallas County, TX
                              Delta County, TX
                              Denton County, TX
                              Ellis County, TX
                              Hunt County, TX
                              Kaufman County, TX
                              Rockwall County, TX
19140.....................  Dalton, GA.......................     0.9558
                              Murray County, GA
                              Whitfield County, GA
19180.....................  Danville, IL.....................     0.8392
                              Vermilion County, IL
19260.....................  Danville, VA.....................     0.8643
                              Pittsylvania County, VA
                              Danville City, VA
19340.....................  Davenport-Moline-Rock Island, IA-     0.8773
                             IL.
                              Henry County, IL
                              Mercer County, IL
                              Rock Island County, IL
                              Scott County, IA
19380.....................  Dayton, OH.......................     0.9303
                              Greene County, OH
                              Miami County, OH
                              Montgomery County, OH
                              Preble County, OH
19460.....................  Decatur, AL......................     0.8894
                              Lawrence County, AL
                              Morgan County, AL
19500.....................  Decatur, IL......................     0.8122
                              Macon County, IL
19660.....................  Deltona-Daytona Beach-Ormond          0.8898
                             Beach, FL.
                              Volusia County, FL
19740.....................  Denver-Aurora, CO................     1.0904
                              Adams County, CO
                              Arapahoe County, CO
                              Broomfield County, CO
                              Clear Creek County, CO
                              Denver County, CO
                              Douglas County, CO
                              Elbert County, CO
                              Gilpin County, CO
                              Jefferson County, CO
                              Park County, CO
19780.....................  Des Moines, IA...................     0.9266
                              Dallas County, IA
                              Guthrie County, IA
                              Madison County, IA
                              Polk County, IA
                              Warren County, IA
19804.....................  Detroit-Livonia-Dearborn, MI.....     1.0349
                              Wayne County, MI
20020.....................  Dothan, AL.......................     0.7537
                              Geneva County, AL
                              Henry County, AL
                              Houston County, AL
20100.....................  Dover, DE........................     0.9825
                              Kent County, DE
20220.....................  Dubuque, IA......................     0.8748
                              Dubuque County, IA
20260.....................  Duluth, MN-WI....................     1.0340
                              Carlton County, MN
                              St. Louis County, MN

[[Page 30292]]

 
                              Douglas County, WI
20500.....................  Durham, NC.......................     1.0363
                              Chatham County, NC
                              Durham County, NC
                              Orange County, NC
                              Person County, NC
20740.....................  Eau Claire, WI...................     0.9139
                              Chippewa County, WI
                              Eau Claire County, WI
20764.....................  Edison, NJ.......................     1.1136
                              Middlesex County, NJ
                              Monmouth County, NJ
                              Ocean County, NJ
                              Somerset County, NJ
20940.....................  El Centro, CA....................     0.8856
                              Imperial County, CA
21060.....................  Elizabethtown, KY................     0.8684
                              Hardin County, KY
                              Larue County, KY
21140.....................  Elkhart-Goshen, IN...............     0.9278
                              Elkhart County, IN
21300.....................  Elmira, NY.......................     0.8445
                              Chemung County, NY
21340.....................  El Paso, TX......................     0.9181
                              El Paso County, TX
21500.....................  Erie, PA.........................     0.8699
                              Erie County, PA
21604.....................  Essex County, MA.................     1.0662
                              Essex County, MA
21660.....................  Eugene-Springfield, OR...........     1.0940
                              Lane County, OR
21780.....................  Evansville, IN-KY................     0.8372
                              Gibson County, IN
                              Posey County, IN
                              Vanderburgh County, IN
                              Warrick County, IN
                              Henderson County, KY
                              Webster County, KY
21820.....................  Fairbanks, AK....................     1.1146
                              Fairbanks North Star Borough,
                            AK
21940.....................  Fajardo, PR......................     0.3939
                              Ceiba Municipio, PR
                              Fajardo Municipio, PR
                              Luquillo Municipio, PR
22020.....................  Fargo, ND-MN.....................     0.9114
                               Cass County, ND
                              Clay County, MN
22140.....................  Farmington, NM...................     0.8049
                              San Juan County, NM
22180.....................  Fayetteville, NC.................     0.9363
                              Cumberland County, NC
                              Hoke County, NC
22220.....................  Fayetteville-Springdale-Rogers,       0.8636
                             AR-MO.
                              Benton County, AR
                              Madison County, AR
                              Washington County, AR
                              McDonald County, MO
22380.....................  Flagstaff, AZ....................     1.0787
                              Coconino County, AZ
22420.....................  Flint, MI........................     1.1178
                              Genesee County, MI
22500.....................  Florence, SC.....................     0.8833
                              Darlington County, SC
                              Florence County, SC
22520.....................  Florence-Muscle Shoals, AL.......     0.7883
                              Colbert County, AL
                              Lauderdale County, AL
22540.....................  Fond du Lac, WI..................     0.9897
                              Fond du Lac County, WI
22660.....................  Fort Collins-Loveland, CO........     1.0218

[[Page 30293]]

 
                              Larimer County, CO
22744.....................  Fort Lauderdale-Pompano Beach-        1.0165
                             Deerfield Beach, FL.
                              Broward County, FL
22900.....................  Fort Smith, AR-OK................     0.8283
                              Crawford County, AR
                              Franklin County, AR
                              Sebastian County, AR
                              Le Flore County, OK
                              Sequoyah County, OK
23020.....................  Fort Walton Beach-Crestview-          0.8786
                             Destin, FL.
                              Okaloosa County, FL
23060.....................  Fort Wayne, IN...................     0.9807
                              Allen County, IN
                              Wells County, IN
                              Whitley County, IN
23104.....................  Fort Worth-Arlington, TX.........     0.9472
                              Johnson County, TX
                              Parker County, TX
                              Tarrant County, TX
                              Wise County, TX
23420.....................  Fresno, CA.......................     1.0536
                              Fresno County, CA
23460.....................  Gadsden, AL......................     0.8049
                              Etowah County, AL
23540.....................  Gainesville, FL..................     0.9459
                              Alachua County, FL
                              Gilchrist County, FL
23580.....................  Gainesville, GA..................     0.9557
                              Hall County, GA
23844.....................  Gary, IN.........................     0.9310
                              Jasper County, IN
                              Lake County, IN
                              Newton County, IN
                              Porter County, IN
24020.....................  Glens Falls, NY..................     0.8467
                              Warren County, NY
                              Washington County, NY
24140.....................  Goldsboro, NC....................     0.8778
                              Wayne County, NC
24220.....................  Grand Forks, ND-MN...............     0.9091
                              Polk County, MN
                              Grand Forks County, ND
24300.....................  Grand Junction, CO...............     0.9900
                              Mesa County, CO
24340.....................  Grand Rapids-Wyoming, MI.........     0.9420
                              Barry County, MI
                              Ionia County, MI
                              Kent County, MI
                              Newaygo County, MI
24500.....................  Great Falls, MT..................     0.8810
                              Cascade County, MT
24540.....................  Greeley, CO......................     0.9444
                              Weld County, CO
24580.....................  Green Bay, WI....................     0.9590
                              Brown County, WI
                              Kewaunee County, WI
                              Oconto County, WI
24660.....................  Greensboro-High Point, NC........     0.9190
                              Guilford County, NC
                              Randolph County, NC
                              Rockingham County, NC
24780.....................  Greenville, NC...................     0.9183
                              Greene County, NC
                              Pitt County, NC
24860.....................  Greenville, SC...................     0.9557
                              Greenville County, SC
                              Laurens County, SC
                              Pickens County, SC
25020.....................  Guayama, PR......................     0.4005
                              Arroyo Municipio, PR

[[Page 30294]]

 
                              Guayama Municipio, PR
                              Patillas Municipio, PR
25060.....................  Gulfport-Biloxi, MS..............     0.8950
                              Hancock County, MS
                              Harrison County, MS
                              Stone County, MS
25180.....................  Hagerstown-Martinsburg, MD-WV....     0.9715
                              Washington County, MD
                              Berkeley County, WV
                              Morgan County, WV
25260.....................  Hanford-Corcoran, CA.............     0.9296
                              Kings County, CA
25420.....................  Harrisburg-Carlisle, PA..........     0.9359
                              Cumberland County, PA
                              Dauphin County, PA
                              Perry County, PA
25500.....................  Harrisonburg, VA.................     0.9275
                              Rockingham County, VA
                              Harrisonburg City, VA
25540.....................  Hartford-West Hartford-East           1.1054
                             Hartford, CT.
                              Hartford County, CT
                              Litchfield County, CT
                              Middlesex County, CT
                              Tolland County, CT
25620.....................  Hattiesburg, MS..................     0.7362
                              Forrest County, MS
                              Lamar County, MS
                              Perry County, MS
25860.....................  Hickory-Lenoir-Morganton, NC.....     0.9502
                              Alexander County, NC
                              Burke County, NC
                              Caldwell County, NC
                              Catawba County, NC
25980.....................  Hinesville-Fort Stewart, GA......     0.7715
                              Liberty County, GA
                              Long County, GA
26100.....................  Holland-Grand Haven, MI..........     0.9388
                              Ottawa County, MI
26180.....................  Honolulu, HI.....................     1.1013
                              Honolulu County, HI
26300.....................  Hot Springs, AR..................     0.9249
                              Garland County, AR
26380.....................  Houma-Bayou Cane-Thibodaux, LA...     0.7721
                              Lafourche Parish, LA
                              Terrebonne Parish, LA
26420.....................  Houston-Baytown-Sugar Land, TX...     0.9973
                              Austin County, TX
                              Brazoria County, TX
                              Chambers County, TX
                              Fort Bend County, TX
                              Galveston County, TX
                              Harris County, TX
                              Liberty County, TX
                              Montgomery County, TX
                              San Jacinto County, TX
                              Waller County, TX
26580.....................  Huntington-Ashland, WV-KY-OH.....     0.9564
                              Boyd County, KY
                              Greenup County, KY
                              Lawrence County, OH
                              Cabell County, WV
                              Wayne County, WV
26620.....................  Huntsville, AL...................     0.8851
                              Limestone County, AL
                              Madison County, AL
26820.....................  Idaho Falls, ID..................     0.9059
                              Bonneville County, ID
                              Jefferson County, ID
26900.....................  Indianapolis, IN.................     1.0113
                              Boone County, IN

[[Page 30295]]

 
                              Brown County, IN
                              Hamilton County, IN
                              Hancock County, IN
                              Hendricks County, IN
                              Johnson County, IN
                              Marion County, IN
                              Morgan County, IN
                              Putnam County, IN
                              Shelby County, IN
26980.....................  Iowa City, IA....................     0.9654
                              Johnson County, IA
                              Washington County, IA
27060.....................  Ithaca, NY.......................     0.9589
                              Tompkins County, NY
27100.....................  Jackson, MI......................     0.9146
                              Jackson County, MI
27140.....................  Jackson, MS......................     0.8291
                              Copiah County, MS
                              Hinds County, MS
                              Madison County, MS
                              Rankin County, MS
                              Simpson County, MS
27180.....................  Jackson, TN......................     0.8900
                              Chester County, TN
                              Madison County, TN
27260.....................  Jacksonville, FL.................     0.9537
                              Baker County, FL
                              Clay County, FL
                              Duval County, FL
                              Nassau County, FL
                              St. Johns County, FL
27340.....................  Jacksonville, NC.................     0.8401
                              Onslow County, NC
27500.....................  Janesville, WI...................     0.9583
                              Rock County, WI
27620.....................  Jefferson City, MO...............     0.8338
                              Callaway County, MO
                              Cole County, MO
                              Moniteau County, MO
                              Osage County, MO
27740.....................  Johnson City, TN.................     0.8146
                              Carter County, TN
                              Unicoi County, TN
                              Washington County, TN
27780.....................  Johnstown, PA....................     0.8380
                              Cambria County, PA
27860.....................  Jonesboro, AR....................     0.8144
                              Craighead County, AR
                              Poinsett County, AR
27900.....................  Joplin, MO.......................     0.8721
                              Jasper County, MO
                              Newton County, MO
28020.....................  Kalamazoo-Portage, MI............     1.0676
                              Kalamazoo County, MI
                              Van Buren County, MI
28100.....................  Kankakee-Bradley, IL.............     1.0603
                              Kankakee County, IL
28140.....................  Kansas City, MO-KS...............     0.9629
                              Franklin County, KS
                              Johnson County, KS
                              Leavenworth County, KS
                              Linn County, KS
                              Miami County, KS
                              Wyandotte County, KS
                              Bates County, MO
                              Caldwell County, MO
                              Cass County, MO
                              Clay County, MO
                              Clinton County, MO
                              Jackson County, MO

[[Page 30296]]

 
                              Lafayette County, MO
                              Platte County, MO
                              Ray County, MO
28420.....................  Kennewick-Richland-Pasco, WA.....     1.0520
                              Benton County, WA
                              Franklin County, WA
28660.....................  Killeen-Temple-Fort Hood, TX.....     0.9242
                              Bell County, TX
                              Coryell County, TX
                              Lampasas County, TX
28700.....................  Kingsport-Bristol-Bristol, TN-VA.     0.8240
                              Hawkins County, TN
                              Sullivan County, TN
                              Bristol City, VA
                              Scott County, VA
                              Washington County, VA
28740.....................  Kingston, NY.....................     0.9000
                              Ulster County, NY
28940.....................  Knoxville, TN....................     0.8548
                              Anderson County, TN
                              Blount County, TN
                              Knox County, TN
                              Loudon County, TN
                              Union County, TN
29020.....................  Kokomo, IN.......................     0.8986
                              Howard County, IN
                              Tipton County, IN
29100.....................  La Crosse, WI-MN.................     0.9289
                              Houston County, MN
                              La Crosse County, WI
29140.....................  Lafayette, IN....................     0.9067
                              Benton County, IN
                              Carroll County, IN
                              Tippecanoe County, IN
29180.....................  Lafayette, LA....................     0.8306
                              Lafayette Parish, LA
                              St. Martin Parish, LA
29340.....................  Lake Charles, LA.................     0.7935
                              Calcasieu Parish, LA
                              Cameron Parish, LA
29404.....................  Lake County-Kenosha County, IL-WI     1.0342
                              Lake County, IL
                              Kenosha County, WI
29460.....................  Lakeland, FL.....................     0.8930
                              Polk County, FL
29540.....................  Lancaster, PA....................     0.9883
                              Lancaster County, PA
29620.....................  Lansing-East Lansing, MI.........     0.9658
                              Clinton County, MI
                              Eaton County, MI
                              Ingham County, MI
29700.....................  Laredo, TX.......................     0.8747
                              Webb County, TX
29740.....................  Las Cruces, NM...................     0.8784
                              Dona Ana County, NM
29820.....................  Las Vegas-Paradise, NV...........     1.1378
                              Clark County, NV
29940.....................  Lawrence, KS.....................     0.8644
                              Douglas County, KS
30020.....................  Lawton, OK.......................     0.8212
                              Comanche County, OK
30140.....................  Lebanon, PA......................     0.8570
                              Lebanon County, PA
30300.....................  Lewiston, ID-WA..................     0.9314
                              Nez Perce County, ID
                              Asotin County, WA
30340.....................  Lewiston-Auburn, ME..............     0.9562
                              Androscoggin County, ME
30460.....................  Lexington-Fayette, KY............     0.9359
                              Bourbon County, KY

[[Page 30297]]

 
                              Clark County, KY
                              Fayette County, KY
                              Jessamine County, KY
                              Scott County, KY
                              Woodford County, KY
30620.....................  Lima, OH.........................     0.9330
                              Allen County, OH
30700.....................  Lincoln, NE......................     1.0208
                              Lancaster County, NE
                              Seward County, NE
30780.....................  Little Rock-North Little Rock, AR     0.8826
                              Faulkner County, AR
                              Grant County, AR
                              Lonoke County, AR
                              Perry County, AR
                              Pulaski County, AR
                              Saline County, AR
30860.....................  Logan, UT-ID.....................     0.9094
                              Franklin County, ID
                              Cache County, UT
30980.....................  Longview, TX.....................     0.8801
                              Gregg County, TX
                              Rusk County, TX
                              Upshur County, TX
31020.....................  Longview, WA.....................     1.0224
                              Cowlitz County, WA
31084.....................  Los Angeles-Long Beach-Glendale,      1.1732
                             CA.
                              Los Angeles County, CA
31140.....................  Louisville, KY-IN................     0.9122
                              Clark County, IN
                              Floyd County, IN
                              Harrison County, IN
                              Washington County, IN
                              Bullitt County, KY
                              Henry County, KY
                              Jefferson County, KY
                              Meade County, KY
                              Nelson County, KY
                              Oldham County, KY
                              Shelby County, KY
                              Spencer County, KY
                              Trimble County, KY
31180.....................  Lubbock, TX......................     0.8777
                              Crosby County, TX
                              Lubbock County, TX
31340.....................  Lynchburg, VA....................     0.9017
                              Amherst County, VA
                              Appomattox County, VA
                              Bedford County, VA
                              Campbell County, VA
                              Bedford City, VA
                              Lynchburg City, VA
31420.....................  Macon, GA........................     0.9887
                              Bibb County, GA
                              Crawford County, GA
                              Jones County, GA
                              Monroe County, GA
                              Twiggs County, GA
31460.....................  Madera, CA.......................     0.8521
                              Madera County, CA
31540.....................  Madison, WI......................     1.0306
                              Columbia County, WI
                              Dane County, WI
                              Iowa County, WI
31700.....................  Manchester-Nashua, NH............     1.0642
                              Hillsborough County, NH
                              Merrimack County, NH
31900.....................  Mansfield, OH....................     0.9189
                              Richland County, OH
32420.....................  Mayaguez, PR.....................     0.4493

[[Page 30298]]

 
                              Hormigueros Municipio, PR
                              Mayaguez Municipio, PR
32580.....................  McAllen-Edinburg-Pharr, TX.......     0.8602
                              Hidalgo County, TX
32780.....................  Medford, OR......................     1.0534
                              Jackson County, OR
32820.....................  Memphis, TN-MS-AR................     0.9217
                              Crittenden County, AR
                              DeSoto County, MS
                              Marshall County, MS
                              Tate County, MS
                              Tunica County, MS
                              Fayette County, TN
                              Shelby County, TN
                              Tipton County, TN
32900.....................  Merced, CA.......................     1.0575
                              Merced County, CA
33124.....................  Miami-Miami Beach-Kendall, FL....     0.9870
                              Miami-Dade County, FL
33140.....................  Michigan City-La Porte, IN.......     0.9332
                              LaPorte County, IN
33260.....................  Midland, TX......................     0.9384
                              Midland County, TX
33340.....................  Milwaukee-Waukesha-West Allis, WI     1.0076
                              Milwaukee County, WI
                              Ozaukee County, WI
                              Washington County, WI
                              Waukesha County, WI
33460.....................  Minneapolis-St. Paul-Bloomington,     1.1066
                             MN-WI.
                              Anoka County, MN
                              Carver County, MN
                              Chisago County, MN
                              Dakota County, MN
                              Hennepin County, MN
                              Isanti County, MN
                              Ramsey County, MN
                              Scott County, MN
                              Sherburne County, MN
                              Washington County, MN
                              Wright County, MN
                              Pierce County, WI
                              St. Croix County, WI
33540.....................  Missoula, MT.....................     0.9618
                              Missoula County, MT
33660.....................  Mobile, AL.......................     0.7995
                              Mobile County, AL
33700.....................  Modesto, CA......................     1.1966
                              Stanislaus County, CA
33740.....................  Monroe, LA.......................     0.7903
                              Ouachita Parish, LA
                              Union Parish, LA
33780.....................  Monroe, MI.......................     0.9506
                              Monroe County, MI
33860.....................  Montgomery, AL...................     0.8300
                              Autauga County, AL
                              Elmore County, AL
                              Lowndes County, AL
                              Montgomery County, AL
34060.....................  Morgantown, WV...................     0.8730
                              Monongalia County, WV
                              Preston County, WV
34100.....................  Morristown, TN...................     0.7790
                              Grainger County, TN
                              Hamblen County, TN
                              Jefferson County, TN
34580.....................  Mount Vernon-Anacortes, WA.......     1.0576
                              Skagit County, WA
34620.....................  Muncie, IN.......................     0.8580
                              Delaware County, IN
34740.....................  Muskegon-Norton Shores, MI.......     0.9741

[[Page 30299]]

 
                              Muskegon County, MI
34820.....................  Myrtle Beach-Conway-North Myrtle      0.9022
                             Beach, SC.
                              Horry County, SC
34900.....................  Napa, CA.........................     1.2531
                              Napa County, CA
34940.....................  Naples-Marco Island, FL..........     1.0558
                              Collier County, FL
34980.....................  Nashville-Davidson--Murfreesboro,     1.0086
                             TN.
                              Cannon County, TN
                              Cheatham County, TN
                              Davidson County, TN
                              Dickson County, TN
                              Hickman County, TN
                              Macon County, TN
                              Robertson County, TN
                              Rutherford County, TN
                              Smith County, TN
                              Sumner County, TN
                              Trousdale County, TN
                              Williamson County, TN
                              Wilson County, TN
35004.....................  Nassau-Suffolk, NY...............     1.2907
                              Nassau County, NY
                              Suffolk County, NY
35084.....................  Newark-Union, NJ-PA..............     1.1687
                              Essex County, NJ
                              Hunterdon County, NJ
                              Morris County, NJ
                              Sussex County, NJ
                              Union County, NJ
                              Pike County, PA
35300.....................  New Haven-Milford, CT............     1.1807
                              New Haven County, CT
35380.....................  New Orleans-Metairie-Kenner, LA..     0.9103
                              Jefferson Parish, LA
                              Orleans Parish, LA
                              Plaquemines Parish, LA
                              St. Bernard Parish, LA
                              St. Charles Parish, LA
                              St. John the Baptist Parish, LA
                              St. Tammany Parish, LA
35644.....................  New York-Wayne-White Plains, NY-      1.3311
                             NJ.
                              Bergen County, NJ
                              Hudson County, NJ
                              Passaic County, NJ
                              Bronx County, NY
                              Kings County, NY
                              New York County, NY
                              Putnam County, NY
                              Queens County, NY
                              Richmond County, NY
                              Rockland County, NY
                              Westchester County, NY
35660.....................  Niles-Benton Harbor, MI..........     0.8847
                              Berrien County, MI
35980.....................  Norwich-New London, CT...........     1.1596
                              New London County, CT
36084.....................  Oakland-Fremont-Hayward, CA......     1.5220
                              Alameda County, CA
                              Contra Costa County, CA
36100.....................  Ocala, FL........................     0.9153
                              Marion County, FL
36140.....................  Ocean City, NJ...................     1.0810
                              Cape May County, NJ
36220.....................  Odessa, TX.......................     0.9798
                              Ector County, TX
36260.....................  Ogden-Clearfield, UT.............     0.9216
                              Davis County, UT
                              Morgan County, UT
                              Weber County, UT

[[Page 30300]]

 
36420.....................  Oklahoma City, OK................     0.8982
                              Canadian County, OK
                              Cleveland County, OK
                              Grady County, OK
                              Lincoln County, OK
                              Logan County, OK
                              McClain County, OK
                              Oklahoma County, OK
36500.....................  Olympia, WA......................     1.1006
                              Thurston County, WA
36540.....................  Omaha-Council Bluffs, NE-IA......     0.9754
                              Harrison County, IA
                              Mills County, IA
                              Pottawattamie County, IA
                              Cass County, NE
                              Douglas County, NE
                              Sarpy County, NE
                              Saunders County, NE
                              Washington County, NE
36740.....................  Orlando, FL......................     0.9742
                              Lake County, FL
                              Orange County, FL
                              Osceola County, FL
                              Seminole County, FL
36780.....................  Oshkosh-Neenah, WI...............     0.9099
                              Winnebago County, WI
36980.....................  Owensboro, KY....................     0.8434
                              Daviess County, KY
                              Hancock County, KY
                              McLean County, KY
37100.....................  Oxnard-Thousand Oaks-Ventura, CA.     1.1105
                              Ventura County, CA
37340.....................  Palm Bay-Melbourne-Titusville, FL     0.9633
                              Brevard County, FL
37460.....................  Panama City-Lynn Haven, FL.......     0.8124
                              Bay County, FL
37620.....................  Parkersburg-Marietta, WV-OH......     0.8288
                              Washington County, OH
                              Pleasants County, WV
                              Wirt County, WV
                              Wood County, WV
37700.....................  Pascagoula, MS...................     0.7974
                              George County, MS
                              Jackson County, MS
37860.....................  Pensacola-Ferry Pass-Brent, FL...     0.8306
                              Escambia County, FL
                              Santa Rosa County, FL
37900.....................  Peoria, IL.......................     0.8886
                              Marshall County, IL
                              Peoria County, IL
                              Stark County, IL
                              Tazewell County, IL
                              Woodford County, IL
37964.....................  Philadelphia, PA.................     1.0865
                              Bucks County, PA
                              Chester County, PA
                              Delaware County, PA
                              Montgomery County, PA
                              Philadelphia County, PA
38060.....................  Phoenix-Mesa-Scottsdale, AZ......     0.9982
                              Maricopa County, AZ
                              Pinal County, AZ
38220.....................  Pine Bluff, AR...................     0.8673
                              Cleveland County, AR
                              Jefferson County, AR
                              Lincoln County, AR
38300.....................  Pittsburgh, PA...................     0.8736
                              Allegheny County, PA
                              Armstrong County, PA
                              Beaver County, PA

[[Page 30301]]

 
                              Butler County, PA
                              Fayette County, PA
                              Washington County, PA
                              Westmoreland County, PA
38340.....................  Pittsfield, MA...................     1.0439
                              Berkshire County, MA
38540.....................  Pocatello, ID....................     0.9601
                              Bannock County, ID
                              Power County, ID
38660.....................  Ponce, PR........................     0.5006
                              Juana Daz Municipio, PR
                              Ponce Municipio, PR
                              Villalba Municipio, PR
38860.....................  Portland-South Portland-              1.0112
                             Biddeford, ME.
                              Cumberland County, ME
                              Sagadahoc County, ME
                              York County, ME
38900.....................  Portland-Vancouver-Beaverton, OR-     1.1403
                             WA.
                              Clackamas County, OR
                              Columbia County, OR
                              Multnomah County, OR
                              Washington County, OR
                              Yamhill County, OR
                              Clark County, WA
                              Skamania County, WA
38940.....................  Port St. Lucie-Fort Pierce, FL...     1.0046
                              Martin County, FL
                              St. Lucie County, FL
39100.....................  Poughkeepsie-Newburgh-Middletown,     1.1363
                             NY.
                              Dutchess County, NY
                              Orange County, NY
39140.....................  Prescott, AZ.....................     0.9892
                              Yavapai County, AZ
39300.....................  Providence-New Bedford-Fall           1.0929
                             River, RI-MA.
                              Bristol County, MA
                              Bristol County, RI
                              Kent County, RI
                              Newport County, RI
                              Providence County, RI
                              Washington County, RI
39340.....................  Provo-Orem, UT...................     0.9588
                              Juab County, UT
                              Utah County, UT
39380.....................  Pueblo, CO.......................     0.8752
                              Pueblo County, CO
39460.....................  Punta Gorda, FL..................     0.9441
                              Charlotte County, FL
39540.....................  Racine, WI.......................     0.9045
                              Racine County, WI
39580.....................  Raleigh-Cary, NC.................     1.0057
                              Franklin County, NC
                              Johnston County, NC
                              Wake County, NC
39660.....................  Rapid City, SD...................     0.8912
                              Meade County, SD
                              Pennington County, SD
39740.....................  Reading, PA......................     0.9215
                              Berks County, PA
39820.....................  Redding, CA......................     1.1835
                              Shasta County, CA
39900.....................  Reno-Sparks, NV..................     1.0456
                              Storey County, NV
                              Washoe County, NV
40060.....................  Richmond, VA.....................     0.9397
                              Amelia County, VA
                              Caroline County, VA
                              Charles City County, VA
                              Chesterfield County, VA
                              Cumberland County, VA
                              Dinwiddie County, VA

[[Page 30302]]

 
                              Goochland County, VA
                              Hanover County, VA
                              Henrico County, VA
                              King and Queen County, VA
                              King William County, VA
                              Louisa County, VA
                              New Kent County, VA
                              Powhatan County, VA
                              Prince George County, VA
                              Sussex County, VA
                              Colonial Heights City, VA
                              Hopewell City, VA
                              Petersburg City, VA
                              Richmond City, VA
40140.....................  Riverside-San Bernardino-Ontario,     1.0970
                             CA.
                              Riverside County, CA
                              San Bernardino County, CA
40220.....................  Roanoke, VA......................     0.8415
                              Botetourt County, VA
                              Craig County, VA
                              Franklin County, VA
                              Roanoke County, VA
                              Roanoke City, VA
                              Salem City, VA
40340.....................  Rochester, MN....................     1.1504
                              Dodge County, MN
                              Olmsted County, MN
                              Wabasha County, MN
40380.....................  Rochester, NY....................     0.9281
                              Livingston County, NY
                              Monroe County, NY
                              Ontario County, NY
                              Orleans County, NY
                              Wayne County, NY
40420.....................  Rockford, IL.....................     0.9626
                              Boone County, IL
                              Winnebago County, IL
40484.....................  Rockingham County-Strafford           1.0221
                             County, NH.
                              Rockingham County, NH
                              Strafford County, NH
40580.....................  Rocky Mount, NC..................     0.8998
                              Edgecombe County, NC
                              Nash County, NC
40660.....................  Rome, GA.........................     0.8878
                              Floyd County, GA
40900.....................  Sacramento--Arden-Arcade--            1.1700
                             Roseville, CA.
                              El Dorado County, CA
                              Placer County, CA
                              Sacramento County, CA
                              Yolo County, CA
40980.....................  Saginaw-Saginaw Township North,       0.9814
                             MI.
                              Saginaw County, MI
41060.....................  St. Cloud, MN....................     1.0215
                              Benton County, MN
                              Stearns County, MN
41100.....................  St. George, UT...................     0.9458
                              Washington County, UT
41140.....................  St. Joseph, MO-KS................     1.0013
                              Doniphan County, KS
                              Andrew County, MO
                              Buchanan County, MO
                              DeKalb County, MO
41180.....................  St. Louis, MO-IL.................     0.9076
                              Bond County, IL
                              Calhoun County, IL
                              Clinton County, IL
                              Jersey County, IL
                              Macoupin County, IL
                              Madison County, IL
                              Monroe County, IL

[[Page 30303]]

 
                              St. Clair County, IL
                              Crawford County, MO
                              Franklin County, MO
                              Jefferson County, MO
                              Lincoln County, MO
                              St. Charles County, MO
                              St. Louis County, MO
                              Warren County, MO
                              Washington County, MO
                              St. Louis City, MO
41420.....................  Salem, OR........................     1.0556
                              Marion County, OR
                              Polk County, OR
41500.....................  Salinas, CA......................     1.3823
                              Monterey County, CA
41540.....................  Salisbury, MD....................     0.9123
                              Somerset County, MD
                              Wicomico County, MD
41620.....................  Salt Lake City, UT...............     0.9561
                              Salt Lake County, UT
                              Summit County, UT
                              Tooele County, UT
41660.....................  San Angelo, TX...................     0.8167
                              Irion County, TX
                              Tom Green County, TX
41700.....................  San Antonio, TX..................     0.9003
                              Atascosa County, TX
                              Bandera County, TX
                              Bexar County, TX
                              Comal County, TX
                              Guadalupe County, TX
                              Kendall County, TX
                              Medina County, TX
                              Wilson County, TX
41740.....................  San Diego-Carlsbad-San Marcos, CA     1.1267
                              San Diego County, CA
41780.....................  Sandusky, OH.....................     0.9017
                              Erie County, OH
41884.....................  San Francisco-San Mateo-Redwood       1.4712
                             City, CA.
                              Marin County, CA
                              San Francisco County, CA
                              San Mateo County, CA
41900.....................  San German-Cabo Rojo, PR.........     0.5240
                              Cabo Rojo Municipio, PR
                              Lajas Municipio, PR
                              Sabana Grande Municipio, PR
                              San German Municipio, PR
41940.....................  San Jose-Sunnyvale-Santa Clara,       1.4722
                             CA.
                              San Benito County, CA
                              Santa Clara County, CA
41980.....................  San Juan-Caguas-Guaynabo, PR.....     0.4645
                              Aguas Buenas Municipio, PR
                              Aibonito Municipio, PR
                              Arecibo Municipio, PR
                              Barceloneta Municipio, PR
                              Barranquitas Municipio, PR
                              Bayam[oacute]n Municipio, PR
                              Caguas Municipio, PR
                              Camuy Municipio, PR
                              Can[oacute]vanas Municipio, PR
                              Carolina Municipio, PR
                              Cata[ntilde]o Municipio, PR
                              Cayey Municipio, PR
                              Ciales Municipio, PR
                              Cidra Municipio, PR
                              Comero Municipio, PR
                              Corozal Municipio, PR
                              Dorado Municipio, PR
                              Florida Municipio, PR
                              Guaynabo Municipio, PR

[[Page 30304]]

 
                              Gurabo Municipio, PR
                              Hatillo Municipio, PR
                              Humacao Municipio, PR
                              Juncos Municipio, PR
                              Las Piedras Municipio, PR
                              Lo[iacute]za Municipio, PR
                              Manat[iacute] Municipio, PR
                              Maunabo Municipio, PR
                              Morovis Municipio, PR
                              Naguabo Municipio, PR
                              Naranjito Municipio, PR
                              Orocovis Municipio, PR
                              Quebradillas Municipio, PR
                              R[iacute]o Grande Municipio, PR
                              San Juan Municipio, PR
                              San Lorenzo Municipio, PR
                              Toa Alta Municipio, PR
                              Toa Baja Municipio, PR
                              Trujillo Alto Municipio, PR
                              Vega Alta Municipio, PR
                              Vega Baja Municipio, PR
                              Yabucoa Municipio, PR
42020.....................  San Luis Obispo-Paso Robles, CA..     1.1118
                              San Luis Obispo County, CA
42044.....................  Santa Ana-Anaheim-Irvine, CA.....     1.1611
                              Orange County, CA
42060.....................  Santa Barbara-Santa Maria-Goleta,     1.0771
                             CA.
                              Santa Barbara County, CA
42100.....................  Santa Cruz-Watsonville, CA.......     1.4779
                              Santa Cruz County, CA
42140.....................  Santa Fe, NM.....................     1.0909
                              Santa Fe County, NM
42220.....................  Santa Rosa-Petaluma, CA..........     1.2961
                              Sonoma County, CA
42260.....................  Sarasota-Bradenton-Venice, FL....     0.9629
                              Manatee County, FL
                              Sarasota County, FL
42340.....................  Savannah, GA.....................     0.9460
                              Bryan County, GA
                              Chatham County, GA
                              Effingham County, GA
42540.....................  Scranton--Wilkes-Barre, PA.......     0.8543
                              Lackawanna County, PA
                              Luzerne County, PA
                              Wyoming County, PA
42644.....................  Seattle-Bellevue-Everett, WA.....     1.1492
                              King County, WA
                              Snohomish County, WA
43100.....................  Sheboygan, WI....................     0.8948
                              Sheboygan County, WI
43300.....................  Sherman-Denison, TX..............     0.9617
                              Grayson County, TX
43340.....................  Shreveport-Bossier City, LA......     0.9132
                              Bossier Parish, LA
                              Caddo Parish, LA
                              De Soto Parish, LA
43580.....................  Sioux City, IA-NE-SD.............     0.9070
                              Woodbury County, IA
                              Dakota County, NE
                              Dixon County, NE
                              Union County, SD
43620.....................  Sioux Falls, SD..................     0.9441
                              Lincoln County, SD
                              McCook County, SD
                              Minnehaha County, SD
                              Turner County, SD
43780.....................  South Bend-Mishawaka, IN-MI......     0.9447
                              St. Joseph County, IN
                              Cass County, MI
43900.....................  Spartanburg, SC..................     0.9519

[[Page 30305]]

 
                              Spartanburg County, SC
44060.....................  Spokane, WA......................     1.0660
                              Spokane County, WA
44100.....................  Springfield, IL..................     0.8738
                              Menard County, IL
                              Sangamon County, IL
44140.....................  Springfield, MA..................     1.0176
                              Franklin County, MA
                              Hampden County, MA
                              Hampshire County, MA
44180.....................  Springfield, MO..................     0.8557
                              Christian County, MO
                              Dallas County, MO
                              Greene County, MO
                              Polk County, MO
                              Webster County, MO
44220.....................  Springfield, OH..................     0.8748
                              Clark County, OH
44300.....................  State College, PA................     0.8461
                              Centre County, PA
44700.....................  Stockton, CA.....................     1.0564
                              San Joaquin County, CA
44940.....................  Sumter, SC.......................     0.8520
                              Sumter County, SC
45060.....................  Syracuse, NY.....................     0.9468
                              Madison County, NY
                              Onondaga County, NY
                              Oswego County, NY
45104.....................  Tacoma, WA.......................     1.1078
                              Pierce County, WA
45220.....................  Tallahassee, FL..................     0.8655
                              Gadsden County, FL
                              Jefferson County, FL
                              Leon County, FL
                              Wakulla County, FL
45300.....................  Tampa-St. Petersburg-Clearwater,      0.9024
                             FL.
                              Hernando County, FL
                              Hillsborough County, FL
                              Pasco County, FL
                              Pinellas County, FL
45460.....................  Terre Haute, IN..................     0.8517
                              Clay County, IN
                              Sullivan County, IN
                              Vermillion County, IN
                              Vigo County, IN
45500.....................  Texarkana, TX-Texarkana, AR......     0.8413
                              Miller County, AR
                              Bowie County, TX
45780.....................  Toledo, OH.......................     0.9524
                              Fulton County, OH
                              Lucas County, OH
                              Ottawa County, OH
                              Wood County, OH
45820.....................  Topeka, KS.......................     0.8904
                              Jackson County, KS
                              Jefferson County, KS
                              Osage County, KS
                              Shawnee County, KS
                              Wabaunsee County, KS
45940.....................  Trenton-Ewing, NJ................     1.0276
                              Mercer County, NJ
46060.....................  Tucson, AZ.......................     0.8926
                              Pima County, AZ
46140.....................  Tulsa, OK........................     0.8690
                              Creek County, OK
                              Okmulgee County, OK
                              Osage County, OK
                              Pawnee County, OK
                              Rogers County, OK
                              Tulsa County, OK

[[Page 30306]]

 
                              Wagoner County, OK
46220.....................  Tuscaloosa, AL...................     0.8336
                              Greene County, AL
                              Hale County, AL
                              Tuscaloosa County, AL
46340.....................  Tyler, TX........................     0.9502
                              Smith County, TX
46540.....................  Utica-Rome, NY...................     0.8295
                              Herkimer County, NY
                              Oneida County, NY
46660.....................  Valdosta, GA.....................     0.8341
                              Brooks County, GA
                              Echols County, GA
                              Lanier County, GA
                              Lowndes County, GA
46700.....................  Vallejo-Fairfield, CA............     1.4279
                              Solano County, CA
46940.....................  Vero Beach, FL...................     0.9477
                              Indian River County, FL
47020.....................  Victoria, TX.....................     0.8470
                              Calhoun County, TX
                              Goliad County, TX
                              Victoria County, TX
47220.....................  Vineland-Millville-Bridgeton, NJ.     1.0573
                              Cumberland County, NJ
47260.....................  Virginia Beach-Norfolk-Newport        0.8894
                             News, VA-NC.
                              Currituck County, NC
                              Gloucester County, VA
                              Isle of Wight County, VA
                              James City County, VA
                              Mathews County, VA
                              Surry County, VA
                              York County, VA
                              Chesapeake City, VA
                              Hampton City, VA
                              Newport News City, VA
                              Norfolk City, VA
                              Poquoson City, VA
                              Portsmouth City, VA
                              Suffolk City, VA
                              Virginia Beach City, VA
                              Williamsburg City, VA
47300.....................  Visalia-Porterville, CA..........     0.9975
                              Tulare County, CA
47380.....................  Waco, TX.........................     0.8146
                              McLennan County, TX
47580.....................  Warner Robins, GA................     0.8489
                              Houston County, GA
47644.....................  Warren-Farmington Hills-Troy, MI.     1.0112
                              Lapeer County, MI
                              Livingston County, MI
                              Macomb County, MI
                              Oakland County, MI
                              St. Clair County, MI
47894.....................  Washington-Arlington-Alexandria,      1.1023
                             DC-VA&-MD-WV.
                              District of Columbia, DC
                              Calvert County, MD
                              Charles County, MD
                              Prince George's County, MD
                              Arlington County, VA
                              Clarke County, VA
                              Fairfax County, VA
                              Fauquier County, VA
                              Loudoun County, VA
                              Prince William County, VA
                              Spotsylvania County, VA
                              Stafford County, VA
                              Warren County, VA
                              Alexandria City, VA
                              Fairfax City, VA

[[Page 30307]]

 
                              Falls Church City, VA
                              Fredericksburg City, VA
                              Manassas City, VA
                              Manassas Park City, VA
                              Jefferson County, WV
47940.....................  Waterloo-Cedar Falls, IA.........     0.8633
                              Black Hawk County, IA
                              Bremer County, IA
                              Grundy County, IA
48140.....................  Wausau, WI.......................     0.9570
                              Marathon County, WI
48260.....................  Weirton-Steubenville, WV-OH......     0.8280
                              Jefferson County, OH
                              Brooke County, WV
                              Hancock County, WV
48300.....................  Wenatchee, WA....................     0.9427
                              Chelan County, WA
                              Douglas County, WA
48424.....................  West Palm Beach-Boca Raton-           1.0362
                             Boynton Beach, FL.
                              Palm Beach County, FL
48540.....................  Wheeling, WV-OH..................     0.7449
                              Belmont County, OH
                              Marshall County, WV
                              Ohio County, WV
48620.....................  Wichita, KS......................     0.9457
                              Butler County, KS
                              Harvey County, KS
                              Sedgwick County, KS
                              Sumner County, KS
48660.....................  Wichita Falls, TX................     0.8332
                              Archer County, TX
                              Clay County, TX
                              Wichita County, TX
48700.....................  Williamsport, PA.................     0.8485
                              Lycoming County, PA
48864.....................  Wilmington, DE-MD-NJ.............     1.1049
                              New Castle County, DE
                              Cecil County, MD
                              Salem County, NJ
48900.....................  Wilmington, NC...................     0.9237
                              Brunswick County, NC
                              New Hanover County, NC
                              Pender County, NC
49020.....................  Winchester, VA-WV................     1.0496
                              Frederick County, VA
                              Winchester City, VA
                              Hampshire County, WV
49180.....................  Winston-Salem, NC................     0.9401
                              Davie County, NC
                              Forsyth County, NC
                              Stokes County, NC
                              Yadkin County, NC
49340.....................  Worcester, MA....................     1.0996
                              Worcester County, MA
49420.....................  Yakima, WA.......................     1.0322
                              Yakima County, WA
49500.....................  Yauco, PR........................     0.4493
                              Gu[aacute]nica Municipio, PR
                              Guayanilla Municipio, PR
                              Pe[ntilde]uelas Municipio, PR
                              Yauco Municipio, PR
49620.....................  York-Hanover, PA.................     0.9150
                              York County, PA
49660.....................  Youngstown-Warren-Boardman, OH-PA     0.9237
                              Mahoning County, OH
                              Trumbull County, OH
                              Mercer County, PA
49700.....................  Yuba City, CA....................     1.0363
                              Sutter County, CA
                              Yuba County, CA

[[Page 30308]]

 
49740.....................  Yuma, AZ.........................     0.8871
                              Yuma County, AZ
------------------------------------------------------------------------


 Table 2b.--Proposed Inpatient Rehabilitation Facility Wage Index (Based
   on Proposed CBSA Labor Market Areas) for Rural Areas for Discharges
                  Occurring on or After October 1, 2005
------------------------------------------------------------------------
                                                               Full wage
          CBSA code                     Nonurban area            index
------------------------------------------------------------------------
01...........................  Alabama.......................     0.7628
02...........................  Alaska........................     1.1746
03...........................  Arizona.......................     0.8936
04...........................  Arkansas......................     0.7406
05...........................  California....................     1.0524
06...........................  Colorado......................     0.9368
07...........................  Connecticut...................     1.1917
08...........................  Delaware......................     0.9503
10...........................  Florida.......................     0.8574
11...........................  Georgia.......................     0.7733
12...........................  Hawaii........................     1.0522
13...........................  Idaho.........................     0.8227
14...........................  Illinois......................     0.8339
15...........................  Indiana.......................     0.8653
16...........................  Iowa..........................     0.8475
17...........................  Kansas........................     0.8079
18...........................  Kentucky......................     0.7755
19...........................  Louisiana.....................     0.7345
20...........................  Maine.........................     0.9039
21...........................  Maryland......................     0.9220
22...........................  Massachusetts \2\.............     1.0216
23...........................  Michigan......................     0.8786
24...........................  Minnesota.....................     0.9330
25...........................  Mississippi...................     0.7635
26...........................  Missouri......................     0.7762
27...........................  Montana.......................     0.8701
28...........................  Nebraska......................     0.9035
29...........................  Nevada........................     0.9280
30...........................  New Hampshire.................     0.9940
31...........................  New Jersey \1\................  .........
32...........................  New Mexico....................     0.8680
33...........................  New York......................     0.8151
34...........................  North Carolina................     0.8563
35...........................  North Dakota..................     0.7743
36...........................  Ohio..........................     0.8693
37...........................  Oklahoma......................     0.7686
38...........................  Oregon........................     0.9914
39...........................  Pennsylvania..................     0.8310
40...........................  Puerto Rico \2\...............     0.4047
41...........................  Rhode Island \1\..............  .........
42...........................  South Carolina................     0.8683
43...........................  South Dakota..................     0.8398
44...........................  Tennessee.....................     0.7869
45...........................  Texas.........................     0.7966
46...........................  Utah..........................     0.8287
47...........................  Vermont.......................     0.9375
48...........................  Virgin Islands................     0.7456
49...........................  Virginia......................     0.8049
50...........................  Washington....................     1.0312
51...........................  West Virginia.................     0.7865
52...........................  Wisconsin.....................     0.9492
53...........................  Wyoming.......................     0.9182
65...........................  Guam..........................    0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified urban.
\2\ Massachusetts and Puerto Rico have areas designated as rural,
  however, no short-term, acute care hospitals are located in the
  area(s) for FY 2006 under CBSA-based designations. Therefore, we are
  proposing to use FY 2001 MSA based hospital wage data.


 Table 3.--Inpatient Rehabilitation Facilities With Corresponding State
and County Location; Current Labor Market Area Designation; and Proposed
              New CBSA-Based Labor Market Area Designation
------------------------------------------------------------------------
                                         SSA State
                                            and     FY 06 MSA    FY 06
Provider number       Provider name        county      code    CBSA code
                                            code
------------------------------------------------------------------------
26T107.........  9TH FLOOR REHAB.......      26470       3760      28140
39T231.........  DABINGTON MEMORIAL          39560       6160      37964
                  HOSPITAL.
193067.........  ACADIA REHABILITATION       19000       3880         19
                  HOSPITAL.
24T043.........  ACUTE CARE                  24230         24         24
                  REHABILITATION-ALMC.
42T070.........  ACUTE REHAB UNIT AT         42420       8140      44940
                  TUOMEY HEALTHCARE
                  SYSTEM.
14T182.........  ADVOCATE ILLINOIS           14141       1600      16974
                  MASONIC MEDICAL
                  CENTER.
14T223.........  ADVOCATE LUTHERAN           14141       1600      16974
                  GENERAL HOSPITAL.
19T202.........  AHS SUMMIT HOSPITAL         19160       0760      12940
                  LLC.
05T320.........  ALAMEDA COUNTY MEDICAL      05000       5775      36084
                  CENTER.
02T017.........  ALASKA REGIONAL             02020       0380      11260
                  HOSPITAL.
33T013.........  ALBANY MEDICAL CENTER       33000       0160      10580
                  HOSP.
14T258.........  ALEXIAN BROTHERS            14141       1600      16974
                  MEDICAL CENTER.
05T281.........  ALHAMBRA HOSPITAL           05200       4480      31084
                  MEDICAL CENTER.
52T096.........  ALL SAINTS HEALTHCARE,      52500       6600      39540
                  INC..
39T074.........  ALLEGHENY GENERAL           39010       6280      38300
                  HOSPITAL SUBURBAN
                  CAMPUS.
17T116.........  ALLEN COUNTY HOSPITAL.      17000         17         17
36T131.........  ALLIANCE COMMUNITY          36770       1320      15940
                  HOSPITAL.
393030.........  ALLIED SERVICES INST        39420       7560      42540
                  OF REHAB SERVICES.
05T305.........  ALTA BATES MEDICAL          05000       5775      36084
                  CENTER.
39T073.........  ALTOONA HOSPITAL......      39120       0280      11020
39T121.........  ALTOONA REGIONAL            39120       0280      11020
                  HEALTH SYSTEM.
35T019.........  ALTRU REHABILITATION        35170       2985      24220
                  CENTER.
05T583.........  ALVARADO HOSPITAL           05470       7320      41740
                  MEDICAL CENTER INC..
33T010.........  AMSTERDAM MEMORIAL          33380       0160         33
                  HOSPITAL.

[[Page 30309]]

 
01T036.........  ANDALUSIA REGIONAL          01190         01         01
                  HOSPITAL.
393051.........  ANGELA JANE PAVILION..      39620       6160      37964
423029.........  ANMED HEALTHSOUTH           42030       3160      11340
                  REHABILITATION
                  HOSPITAL.
04T039.........  ARKANSAS METHODIST          04270         04         04
                  HOSPITAL.
39T163.........  ARMSTRONG COUNTY            39070         39      38300
                  MEMORIAL HOSPITAL.
11T115.........  ATLANTA MEDICAL CENTER      11470       0520      12060
15T074.........  AUGUST F. HOOK REHAB        15480       3480      26900
                  CENTER.
49T018.........  AUGUSTA MEDICAL CENTER      49891         49         49
52T193.........  AURORA BAYCARE MEDICAL      52040       3080      24580
                  CENTER.
52T102.........  AURORA LAKELAND             52630         52         52
                  MEDICAL CENTER REHAB
                  UNIT.
52T035.........  AURORA SHEBOYGAN            52580       7620      43100
                  MEMORIAL MEDICAL
                  CENTER REHAB UNI.
52T064.........  AURORA SINAI MEDICAL        52390       5080      33340
                  CENTER.
43T016.........  AVERA MCKENNAN              43490       7760      43620
                  HOSPITAL.
43T012.........  AVERA SACRED HEART          43670         43         43
                  HOSPITAL.
43T014.........  AVERA ST. LUKE'S......      43060         43         43
45T280.........  BACHARACH INSTITUTE         31000       1920      19124
                  FOR REHABILITATION.
313030.........  BALL MEMORIAL HOSPITAL-     15170       0560      12100
                  REHAB.
15T089.........  BAPTIST HEALTH              04590       5280      34620
                  REHABILITATION
                  INSTITUTE.
043026.........  BAPTIST HEALTH SYSTEM.      45130       4400      30780
45T058.........  BAPTIST HOSPITAL DAVIS      10120       7240      41700
                  CTR FOR
                  REHABILITATION.
10T008.........  BAPTIST HOSPITAL            25160       5000      33124
                  DESOTO.
25T141.........  BAPTIST HOSPITAL EAST.      18550       4920      32820
18T130.........  BAPTIST HOSPITALS OF        45700       4520      31140
                  SOUTHEAST TEXAS.
45T346.........  BAPTIST MEMORIAL            25350       0840      13140
                  HOSPITAL NORTH
                  MISSISSIPPI.
25T034.........  BAPTIST MEMORIAL MED        04590         25         25
                  CENTER, NO LITTLE
                  ROCK.
04T036.........  BAPTIST REGIONAL            18990       4400      30780
                  MEDICAL CENTER.
18T080.........  BAPTIST REHAB CENTER..      44180         18         18
44T133.........  BAPTIST REHABILITATION      44780       5360      34980
                  GERMANTOWN.
44T147.........  BARBERTON CITIZENS          36780       4920      32820
                  HOSPITAL.
36T019.........  BARTLETT REGIONAL           02110       0080      10420
                  HOSPITAL.
02T008.........  BASTROP REHABILITATION      19330         02         02
                  HOSPITAL.
193058.........  BATON ROUGE GENERAL         19160         19         19
                  MEDICAL CENTER.
19T065.........  BAXTER REGIONAL             04020       0760      12940
                  MEDICAL CENTER.
04T027.........  BAY MEDICAL CENTER FOR      23080         04         04
                  REHABILITATION.
23T041.........  BAYHEALTH MEDICAL           08000       6960      13020
                  CENTER.
08T004.........  BAYLOR ALL SAINTS           45910       2190      20100
                  MEDICAL CENTER OF
                  FORT WORTH.
45T137.........  BAYLOR INSTITUTE FOR        45390       2800      23104
                  REHABILITATION AT
                  GASTON.
453036.........  BAYLOR MEDICAL CENTER.      45390       1920      19124
45T079.........  BAYLOR MEDICAL CENTER       45390       1920      19124
                  AT GARLAND.
45T097.........  BAYSHORE MEDICAL            45610       3360      26420
                  CENTER.
27T012.........  BELLEVUE HOSPITAL           33420       3040      24500
                  CENTRE.
33T204.........  BELMONT COMMUNITY           36060       5600      35644
                  HOSPITAL.
36T153.........  BELOIT MEMORIAL             52520       9000      48540
                  HOSPITAL.
52T100.........  BENEDICTINE HOSPITAL..      33740       3620      27500
33T224.........  BENEFIS HEALTHCARE....      27060         33      28740
15T088.........  BENNETT REHAB CENTER        15470       3480      11300
                  SAINT JOHN'S HEALTH
                  SYSTEM.
193070.........  BENTON REHABILITATION       19160       0760      12940
                  HOSPITAL.
36T170.........  BERGER HEALTH SYSTEM..      36660       1840      18140
22T046.........  BERKSHIRE MEDICAL           22010       6323      38340
                  CENTER.
33T169.........  BETH ISRAEL MEDICAL         33420       5600      35644
                  CENTER.
36T179.........  BETHESDA NORTH              36310       1640      17140
                  HOSPITAL.
01T104.........  BIRMINGHAM BAPT MED         01360       1000      13820
                  CNTR MONTCLAIR SNU.
10T213.........  BLAKE MEDICAL CENTER..      10400       7510      42260
14T015.........  BLESSING HOSPITAL.....      14000         14         14
23T135.........  BOGALUSA COMMUNITY          19580       2160      19804
                  REHABILITAION
                  HOSPITAL.
193052.........  BON SECOUR ST. FRANCIS      42220         19         19
                  INPATIENT REHAB
                  CENTER.
42T023.........  BONE AND JOINT              37540       3160      24860
                  HOSPITAL REHAB CENTER.
37T105.........  BOONE HOSPITAL CENTER.      26090       5880      36420
26T068.........  BORGESS-PIPP HEALTH         23380       1740      17860
                  CENTER.
23T117.........  BOSTON MED CTR CORP/        22160       3720      28020
                  UNIVE HOSP CAMPUS.
22T031.........  BOTHWELL REGIONAL           26790       1123      14484
                  HEALTH CENTER.
26T009.........  BOTSFORD GENERAL            23620         26         26
                  HOSPITAL.
23T151.........  BOULDER COMMUNITY           06060       2160      47644
                  HOSPITAL.
06T027.........  BRANDYWINE HOSPITAL...      39210       1125      14500
39T076.........  BRAZOSPORT MEMORIAL         45180       6160      37964
                  HOSPITAL.
45T072.........  BRIDGEPORT HOSPITAL...      07010       1145      26420
07T010.........  BROADWAY METHODIST          15440       3283      25540
                  REHAB.

[[Page 30310]]

 
15T132.........  BROKEN ARROW                37710       2960      23844
                  REHABILITATION.
37T176.........  BROMENN REGIONAL            14650       8560      46140
                  MEDICAL CENTER.
14T127.........  BRONSON VICKSBURG           23380       1040      14060
                  HOSPITAL.
23T190.........  BROOKS REHABILITATION       10150       3720      28020
                  HOSPITAL.
103039.........  BROOKWOOD MEDICAL           01360       3600      27260
                  CENTER.
01T139.........  BROTMAN MEDICAL CENTER      05200       1000      13820
05T144.........  BROWNSVILLE GENERAL         39330       4480      31084
                  HOSPITAL.
39T166.........  BROWNWOOD REGIONAL          45220       6280      38300
                  MEDICAL CENTER.
45T587.........  BRUNSWICK HOSPITAL....      33700         45         45
33T314.........  BRYANLGH MEDICAL            28540       5380      35004
                  CENTER WEST.
28T003.........  BRYANT T. ALDRIDGE          34630       4360      30700
                  REHABILITATION CENTER.
34T147.........  BRYN MAWR                   39210       6895      40580
                  REHABILITATION
                  HOSPITAL.
393025.........  BSA HEALTH SYSTEM.....      45860       6160      37964
45T231.........  BUFFALO MERCY               33240       0320      11100
                  REHABILITATION UNIT.
33T279.........  BURBANK REHABILITATION      22170       1280      15380
                  CENTER.
22T001.........  BURKE REHABILIATION         33800       1123      49340
                  HOSPITAL.
333028.........  CABRINI MEDICAL CENTER      33420       5600      35644
39T160.........  CALDWELL MEMORIAL           19100       6280      38300
                  HOSPITAL.
33T133.........  CAMERON REGIONAL            26240       5600      35644
                  MEDICAL CTR.
19T190.........  CANONSBURG GENERAL          39750         19         19
                  HOSPITAL.
26T057.........  CAPITAL REGION MEDICAL      26250       3760      28140
                  CENTER.
26T047.........  CARDINAL HILL               18330         26      27620
                  REHABILITATION
                  HOSPITAL.
183026.........  CARILION HEALTH SYSTEM      49801       4280      30460
49T024.........  CARLE FOUNDATION            14090       6800      40220
                  HOSPITAL.
14T091.........  CARLISLE REGIONAL           39270       1400      16580
                  MEDICAL CENTER.
39T058.........  CARLSBAD MEDICAL            32070       3240      25420
                  CENTER.
32T063.........  CAROLINAS HOSPITAL          42200         32         32
                  SYSTEM.
42T091.........  CARONDELET ST JOSEPHS       03090       2655      22500
                  HOSPITAL.
03T011.........  CARONDELET ST MARYS         03090       8520      46060
                  HOSPITAL.
03T010.........  CARSON REHABILITATION       29120       8520      46060
                  CENTER.
293029.........  CARTHAGE AREA HOSPITAL      33330         29      16180
33T263.........  CASA COLINA HOSP FOR        05200         33         33
                  REHAB MEDICINE.
053027.........  CATAWBA VALLEY MEDICAL      34170       4480      31084
                  CENTER.
34T143.........  CATHOLIC MEDICAL            30050       3290      25860
                  CENTER.
30T034.........  CATSKILL REGIONAL           33710       1123      31700
                  MEDICAL CENTER.
33T386.........  CAYUGA MEDICAL CENTER.      33730         33         33
33T307.........  CCMH INPATIENT REHAB..      39640         33      27060
39T246.........  CEDARS-SINAI MEDICAL        05200         39         39
                  CENTER.
44T161.........  CENTENNIAL MEDICAL          44180       5360      34980
                  CENTER.
05T625.........  CENTINELA HOSPITAL          05200       4480      31084
                  MEDICAL CENTER.
05T240.........  CENTRAL ARKANSAS            04720       4480      31084
                  HOSPITAL.
04T014.........  CENTRAL KANSAS MEDICAL      17040         04         04
                  CENTER.
17T033.........  CENTRAL MAINE               20000         17         17
                  REHABILITATION CENTER.
20T024.........  CENTRAL MONTGOMERY          39560       4243      30340
                  MEDICAL CENTER.
39T012.........  CENTURA HEALTH-ST.          06150       6160      37964
                  ANTHONY CENTRAL
                  HOSPITAL.
06T015.........  CGRMC ACUTE                 03100       2080      19740
                  REHABILITATION UNIT.
03T016.........  CHALMETTE MEDICAL           19430       6200      38060
                  CENTER.
45T035.........  CHAMBERSBURG HOSPITAL.      39350       3360      26420
45T237.........  CHARLESTON AREA MED         51190       7240      41700
                  CNTR.
19T185.........  CHARLOTTE INSTITUTE OF      34590       5560      35380
                  REHABILITATION.
39T151.........  CHATTANOOGA...........      44320         39         39
51T022.........  CHELSEA COMMUNITY           23800       1480      16620
                  HOSPITAL.
343026.........  CHESHIRE MEDICAL            30020       1520      16740
                  CENTER.
44T162.........  CHESTNUT HILL               39620       1560      16860
                  REHABILITATION
                  HOSPITAL.
23T259.........  CHNE REHAB............      26940       0440      11460
30T019.........  CHRISTUS JASPER             45690         30         30
                  MEMORIAL HOSPITAL.
393032.........  CHRISTUS SANTA ROSA         45130       6160      37964
                  HOSPITAL.
26T180.........  CHRISTUS SCHUMPERT          19080       7040      41180
                  HEALTH SYSTEM.
45T573.........  CHRISTUS SPOHN              45830         45         45
                  HOSPITAL SHORELINE.
19T041.........  CHRISTUS ST MICHAEL         45170       7680      43340
                  REHAB HOSPITAL.
45T046.........  CHRISTUS ST. FRANCES        19390       1880      18580
                  CABRINI HOSPITAL.
453065.........  CHRISTUS ST. JOHN.....      45610       8360      45500
19T019.........  CHRISTUS ST. JOSEPH         45610       0220      10780
                  HOSPITAL.
45T709.........  CHRISTUS ST. PATRICK        19090       3360      26420
                  HOSPITAL.
19T027.........  CHS,INC DBA ST CHARLES      38080       3960      29340
                  MEDICAL CTR.
38T047.........  CITRUS VALLEY MEDICAL       05200         38      13460
                  CENTER-VQ CAMPUS.
05T369.........  CJW INPATIENT REHAB...      49791       4480      31084

[[Page 30311]]

 
49T112.........  CL....................      45610       6760      40060
45T617.........  CLAXTON-HEPBURN             33630       3360      26420
                  MEDICAL CENTER.
33T211.........  CLINCH VALLEY MEDICAL       49920         33         33
                  CENTER.
49T060.........  CLINTON MEMORIAL            36130         49         49
                  HOSPITAL.
36T175.........  COASTAL REHABILITATION      34240         36         36
                  CTR.
36T172.........  COLISEUM                    11090       1680      17460
                  REHABILITATION CENTER.
34T131.........  COLLEGE STATION             45190         34         34
                  MEDICAL CENTER.
11T164.........  COLLETON MEDICAL            42140       4680      31420
                  CENTER.
45T299.........  COLORADO PLAINS             06430       1260      17780
                  MEDICAL CTR.
42T030.........  COLORADO RIVER MEDICAL      05460         42         42
                  CENTER.
06T044.........  COLUMBIA HOSPITAL.....      52390         06         06
05T469.........  COLUMBIA REGIONAL           26090       6780      40140
                  HOSPITAL.
52T140.........  COLUMBUS REGIONAL           15020       5080      33340
                  HOSPITAL.
26T178.........  COMANCHE COUNTY             37150       1740      17860
                  MEMORIAL HOSPITAL.
15T112.........  COMMUNITY GENERAL           33520         15      18020
                  HOSPITAL PM&R.
37T056.........  COMMUNITY HEALTH            36480       4200      30020
                  PARTNERS OF OH-WEST.
33T159.........  COMMUNITY HOSPITAL LOS      05530       8160      45060
                  GATOS.
05T188.........  COMMUNITY HOSPITAL OF       36110       7400      41940
                  SPRINGFIELD.
36T187.........  COMMUNITY HOSPITAL/         36870       2000      44220
                  WELLNESS CTRS
                  MONTPELI.
36R327.........  COMMUNITY HOSPITALS OF      36870         36         36
                  WILLIAMS COUNTY.
36T121.........  COMMUNITY HOSPTIAL....      15440         36         36
15T125.........  COMMUNITY MEDICAL           27310       2960      23844
                  CENTER.
27T023.........  COMMUNITY MEMORIAL          52660       5140      33540
                  HOSPITAL.
52T103.........  COMMUNITY                   23100       5080      33340
                  REHABILITATION CENTER.
23T078.........  COMMUNITY                   19400       0870      35660
                  REHABILITATION
                  HOSPITAL OF COUSHATTA.
193080.........  CONEY ISLAND HOSPITAL.      33331         19         19
33T196.........  CORNERSTONE                 45650       5600      35644
                  REHABILITATION
                  HOSPITAL.
453085.........  CORONA REGINAL MEDICAL      05430       4880      32580
                  CENTER.
05T329.........  CORPUS CHRISTI WARM         45830       6780      40140
                  SPGS REHAB HOSP.
453055.........  COTTAGE HOSPITAL......      23810       1880      18580
45T040.........  COVENANT HEALTH SYSTEM      45770       4600      31180
23T070.........  COVENANT HEALTHCARE...      23720       6960      40980
16T067.........  COVENANT MEDICAL            16060       8920      47940
                  CENTER.
26T040.........  COX HEALTH SYSTEMS....      26380       7920      44180
05T008.........  CPMC REGIONAL               05480       7360      41884
                  REHABILITATION CENTER.
39T110.........  CRICHTON                    39160       3680      27780
                  REHABILITATION CENTER.
04T042.........  CRITTENDEN MEMORIAL         04170       4920      32820
                  HOSPITAL.
23T254.........  CRITTENTON REHABCENTRE      23730       2160      47644
44T175.........  CROCKETT HOSPITAL           44490         44         44
                  REHAB.
26T198.........  CROSSROADS REGIONAL         26910       7040      41180
                  MEDICAL CENTER.
193088.........  CROWLEY REHAB HOSP,         19000       3880         19
                  LLC.
39T180.........  CROZER CHESTER MEDICAL      39290       6160      37964
                  CENTER.
34T008.........  CTR FOR REHAB SCOTLAND      34820         34         34
                  MEMORIAL HOSPIT.
39T233.........  CTR. FOR ACUTE              39800       9280      49620
                  REHABILITATIVE
                  MEDICINE AT HANOVER.
07T033.........  DANBURY HOSPITAL......      07000       5483      14860
05T729.........  DANIEL FREEMAN........      05200       4480      31084
49T075.........  DANVILLE REGIONAL           49241       1950      19260
                  MEDICAL CENTER.
19T003.........  DAUTERIVE HOSPITAL....      19220         19         19
15T061.........  DAVIESS COMMUNITY           15130         15         15
                  HOSPITAL.
46T041.........  DAVIS HOSPITAL AND          46050       7160      36260
                  MEDICAL CENTER.
36T038.........  DEACONESS HOSPITAL....      36310       1640      17140
37T032.........  DEACONESS HOSPITAL....      37540       5880      36420
15T019.........  DEACONESS ST. JOSEPHS.      15180         15         15
11T076.........  DEKALB MEDICAL CENTER       11370       0520      12060
                  REHABILITATION.
03T093.........  DEL E. WEBB MEMORIAL        03060       6200      38060
                  HOSPITAL.
45T646.........  DEL SOL MEDICAL CENTER      45480       2320      21340
39T081.........  DELAWARE COUNTY             39290       6160      37964
                  MEMORIAL HOSPITAL.
25T082.........  DELTA REGIONAL MEDICAL      25750         25         25
                  CENTER.
45T634.........  DENTON REGIONAL             45410       1920      19124
                  MEDICAL CENTER.
06T011.........  DENVER HEALTH MEDICAL       06150       2080      19740
                  CENTER.
49T011.........  DEPAUL CENTER FOR           49641       5720      47260
                  PHYSICAL
                  REHABILITATION.
26T176.........  DES PERES HOSPITAL....      26940       7040      41180
05T243.........  DESERT REGIONAL             05430       6780      40140
                  MEDICAL CENTER.
45T147.........  DETAR HOSPITAL........      45948       8750      47020
19T115.........  DOCTORS HOSPITAL......      11840       7680      43340
11T177.........  DOCTORS HOSPITAL OF         19480       0600      12260
                  OPELOUSAS.
19T191.........  DOCTORS HOSPITAL OF         19080       3880         19
                  SHREVEPORT.

[[Page 30312]]

 
36T151.........  DOCTORS HOSPITAL OF         36770       1320      15940
                  STARK COUNTY.
05T242.........  DOMINICAN HOSPITAL....      05540       7485      42100
39T203.........  DOYLESTOWN HOSPITAL...      39140       6160      37964
46T021.........  DRMC ACUTE                  46260         46      41100
                  REHABILITATION.
39T086.........  DUBOIS REGNL MED CNTR.      39230         39         39
34T155.........  DURHAM REGIONAL             34310       6640      20500
                  HOSPITAL.
23T230.........  E W SPARROW INPATIENT       23320       4040      29620
                  REHAB.
19T146.........  EAST JEFFERSON GENERAL      19250       5560      35380
                  HOSPITAL.
453072.........  EAST TEXAS MED CTR          45892       8640      46340
                  REHAB HOSP.
01T011.........  EASTERN HEALTH REHAB        01360       1000      13820
                  CENTER, MCE.
20T033.........  EASTERN MAINE MEDICAL       20090       0733      12620
                  CENTER.
39T162.........  EASTON HOSPITAL.......      39590       0240      10900
333029.........  EDDY COHOES                 33000       0160      10580
                  REHABILITATION CTR.
45T119.........  EDINBURG REGIONAL           45650       4880      32580
                  MEDICAL.
36T241.........  EDWIN SHAW                  36780       0080      10420
                  REHABILITATION
                  HOSPITAL.
14T208.........  EHS CHRIST HOSPITAL &       14141       1600      16974
                  MEDICAL CENTER.
03T080.........  EL DORADO HOSPITAL....      03090       8520      46060
15T018.........  ELKHART GENERAL             15190       2330      21140
                  HEALTHCARE SYSTEMS.
39T289.........  ELKINS PARK HOSPITAL..      39560       6160      37964
33T128.........  ELMHURST HOSPITAL           33590       5600      35644
                  CENTER.
11T010.........  EMORY HOSPITAL CTR FOR      11370       0520      12060
                  REHAB.
05T158.........  ENCINO-TARZANA              05200       4480      31084
                  REGIONAL MEDICAL
                  CENTER.
05T039.........  ENLOE MEDICAL CENTER..      05030       1620      17020
45T833.........  ENNIS REGIONAL MEDICAL      45470       1920      19124
                  CENTER.
39T225.........  EPHRATA COMMUNITY           39440       4000      29540
                  HOSPITAL.
33T219.........  ERIE COUNTY MEDICAL         33240       1280      15380
                  CENTER.
19T078.........  EUNICE COMMUNITY            19480       3880         19
                  MEDICAL CENTER.
39T013.........  EVANGELICAL COMMUNITY       39720         39         39
                  HOSPITAL.
14T010.........  EVANSTON NORTHWESTERN       14141       1600      16974
                  HEALTHCARE.
50T124.........  EVERGREEN HEALTHCARE..      50160       7600      42644
36T072.........  FAIRFIELD MEDICAL           36230       1840      18140
                  CENTER.
223029.........  FAIRLAWN                    22170       1123      49340
                  REHABILITATION
                  HOSPITAL.
36T077.........  FAIRVIEW HOSPITAL.....      36170       1680      17460
11T125.........  FAIRVIEW PARK HOSPITAL      11660         11         11
28T125.........  FAITH REGIONAL HEALTH       28590         28         28
                  SERVICES.
10T236.........  FAWCETT MEMORIAL            10070       6580      39460
                  HOSPITAL.
33T044.........  FAXTON-ST. LUKES            33510       8680      46540
                  HEALTHCARE.
15T064.........  FAYETTE MEMORIAL            15200         15         15
                  HOSPITAL.
36T025.........  FIRELANDS REGIONAL          36220         36      41780
                  MEDICAL CENTER.
34T115.........  FIRSTHEALTH MOORE           34620         34         34
                  REGIONAL HOSPITAL.
47T003.........  FLETCHER ALLEN HEALTH       47030       1303      15540
                  CARE.
10T068.........  FLORIDA HOSPITAL            10630       2020      19660
                  ORMOND DIVISION.
10T007.........  FLORIDA HOSPITAL            10470       5960      36740
                  REHABILITATION AND
                  SPORTS MEDICIN.
36T074.........  FLOWER REHABILITATION       36490       8400      45780
                  CENTER.
11T054.........  FLOYD MEDICAL CENTER..      11460         11      40660
39T267.........  FORBES REGIONAL             39010       6280      38300
                  HOSPITAL.
26T021.........  FOREST PARK...........      26950       7040      41180
25T078.........  FORREST GENERAL             25170       3285      25620
                  HOSPITAL REHAB UNIT.
36T132.........  FORT REHABILITATION         36080       3200      17140
                  CENTER.
10T223.........  FORT WALTON BEACH           10450       2750      23020
                  MEDICAL CENT.
453041.........  FORT WORTH                  45910       2800      23104
                  REHABILITATION
                  HOSPITAL.
26T137.........  FR....................      26480       3710      27900
52T004.........  FRANCISCAN SKEMP            52310       3870      29100
                  MEDICAL CENTER REHAB.
18T040.........  FRAZIER REHAB               18550       4520      31140
                  INSTITUTE.
17T074.........  FRED C BRAMLAGE             17300         17         17
                  INPATIENT
                  REHABILITATION UNIT.
52T177.........  FROEDTERT MEMORIAL          52390       5080      33340
                  LUTHERAN HOSPITAL.
34T116.........  FRYE REGIONAL MEDICAL       34170       3290      25860
                  CENTER.
36T194.........  GALION COMMUNITY            36160       4800         36
                  HOSPITAL.
23T244.........  GARDEN CITY HOSPITAL..      23810       2160      19804
05T432.........  GARFIELD MEDICAL            05200       4480      31084
                  CENTER.
44T035.........  GATEWAY MEDICAL CENTER      44620       1660      17300
14T125.........  GATEWAY REGIONAL            14680       7040      41180
                  MEDICAL CENTER.
183031.........  GATEWAY REHAB HOSPITAL      18550       4520      31140
183030.........  GATEWAY REHABILITATION      18070       1640      17140
                  HOSPITAL.
33T058.........  GE....................      33530       6840      40380
393047.........  GEISINGER HEALTHSOUTH       39580         39         39
                  REHABILITATION
                  HOSPITAL.
39T270.........  GEISINGER WYOMING           39480       7560      42540
                  VALLEY MEDICAL CENTER.

[[Page 30313]]

 
36T039.........  GENESIS HEALTH CARE         36610         36         36
                  SYSTEM.
16T033.........  GENESIS MEDICAL CENTER      16810       1960      19340
23T197.........  GENESYS REGIONAL            23240       2640      22420
                  MEDICAL CTR.
373026.........  GEORGE NIGH                 37550         37      46140
                  REBABILITATION CTR.
45T191.........  GEORGETOWN HEALTHCARE       45970       0640      12420
                  SYSTEM.
11T087.........  GLANCY................      11530       0520      12060
05T239.........  GLENDALE ADVENTIST          05200       4480      31084
                  MEDICAL CENTER.
05T058.........  GLENDALE MEMORIAL           05200       4480      31084
                  HOSPITAL.
33T191.........  GLENS FALLS HOSPITAL..      33750       2975      24020
19T160.........  GLENWOOD                    19360       5200      33740
                  REHABILITATION CENTER.
26T175.........  GOLDEN VALLEY MEMORIAL      26410         26         26
                  HO INPATIENT REHAB
                  FACILITY.
05T471.........  GOOD SAMARITAN              05200       4480      31084
                  HOSPITAL.
15T042.........  GOOD SAMARITAN              15410         15         15
                  HOSPITAL.
28T009.........  GOOD SAMARITAN              28090         28         28
                  HOSPITAL.
36T134.........  GOOD SAMARITAN              36310       1640      17140
                  HOSPITAL.
50T079.........  GOOD SAMARITAN              50260       8200      45104
                  HOSPITAL.
14T046.........  GOOD SAMARITAN              14490         14         14
                  REGIONAL HEALTH
                  CENTER.
03T002.........  GOOD SAMARITAN              03060       6200      38060
                  REHABILITATION
                  INSTITUTE.
39T031.........  GOOD SAMARITAN-STINE        39650         39         39
                  ACUTE REHAB.
45T037.........  GOOD SHEPHERD MEDICAL       45570       4420      30980
                  CENTER.
393035.........  GOOD SHEPHERD               39470       0240      10900
                  REHABILITATION
                  HOSPITAL.
393050.........  GOOD SHEPHERD               39590       0240      10900
                  REHABILITATION
                  HOSPITAL.
24T064.........  GRAND ITASCA CLINIC &       24300         24         24
                  HOSPITAL.
36T133.........  GRANDVIEW MEDICAL           36580       2000      19380
                  CENTER.
36T017.........  GRANT/RIVERSIDE             36250       1840      18140
                  METHODIST HOSPITALS.
23T030.........  GRATIOT COMMUNITY           23280         23         23
                  HOSPITAL.
16T057.........  GREAT RIVER MEDICAL         16280         16         16
                  CENTER.
09T008.........  GREATER SOUTHEAST           09000       8840      47894
                  COMMUNITY HOSPITAL.
363032.........  GREENBRIAR                  36510       9320      49660
                  REHABILITATION
                  HOSPITAL.
36T026.........  GREENE MEMORIAL             36290       2000      19380
                  HOSPITAL.
05T026.........  GROSSMONT HOSPITAL          05470       7320      41740
                  SHARP.
45T104.........  GUADALUPE VALLEY            45581       7240      41700
                  HOSPITAL.
45T214.........  GULF COAST MEDICAL          45954         45         45
                  CENTER.
52T087.........  GUNDERSEN LUTHERAN          52310       3870      29100
                  MEDICAL CENTER,INC..
39T185.........  GUNDERSON                   39480       7560      42540
                  REHABILITATION CENTER.
513028.........  H/S REHAB HOSPITAL OF       51050       3400      26580
                  HUNTINGTON.
23T066.........  HACKLEY HOSPITAL......      23600       3000      34740
36T137.........  HANNA HOUSE INPATIENT       36170       1680      17460
                  REHAB CENTER.
50T064.........  HARBORVIEW MEDICAL          50160       7600      42644
                  CENTER.
33T240.........  HARLEM HOSPITAL/            33420       5600      35644
                  COLUMBIA UNIVERSITY.
45T289.........  HARRIS COUNTY HOSPITAL      45610       3360      26420
                  DISTRICT.
45T135.........  HARRIS METHODIST FORT       45910       2800      23104
                  WORTH.
45T639.........  HARRIS METHODIST HEB..      45910       2800      23104
07T025.........  HARTFORD HOSPITAL.....      07010       3283      25540
03T069.........  HAVASU REGIONAL             03070       4120         03
                  MEDICAL CENTER.
17T013.........  HAYS MEDICAL CENTER...      17250         17         17
18T029.........  HAZARD ARH REGIONAL         18960         18         18
                  MEDICAL CENTER.
013028.........  HEALTH SOUTH REHAB          01500       5240      33860
                  HOSPITAL OF
                  MONTGOMERY.
23T275.........  HEALTHSOURCE SAGINAW..      23720       6960      40980
053031.........  HEALTHSOUTH                 05140       0680      12540
                  BAKERSFIELD REHAB
                  HOSPITAL.
223027.........  HEALTHSOUTH BRAINTREE       22130       1123      14484
                  REHAB HOSPITAL.
443030.........  HEALTHSOUTH CANE CREEK      44910         44         44
                  REHAB HOSPITAL.
113027.........  HEALTHSOUTH CENTRAL GA      11090       4680      31420
                  REHAB HOSPITAL.
213028.........  HEALTHSOUTH CHESAPEAKE      21220         21      41540
                  REHAB HOSPITAL.
103040.........  HEALTHSOUTH EMERALD         10020       6015      37460
                  COAST REHABILITATION
                  HOSPITAL.
393027.........  HEALTHSOUTH                 39010       6280      38300
                  HARMARVILLE
                  REHABILITATION
                  HOSPITAL.
013025.........  HEALTHSOUTH LAKESHORE       01360       1000      13820
                  REHABILITATION
                  HOSPITAL.
033025.........  HEALTHSOUTH MERIDIAN        03060       6200      38060
                  POINT REHAB HOSP.
513030.........  HEALTHSOUTH                 51300         51      34060
                  MOUNTAINVIEW REGIONAL
                  REHAB HOSPITAL.
393039.........  HEALTHSOUTH NITTANY         39200       8050      44300
                  VALLEY REHABILITATION
                  HOSPITAL.
183027.........  HEALTHSOUTH NORTHERN        18580       1640      17140
                  KENTUCKY
                  REHABILITATION.
393040.........  HEALTHSOUTH OF              39120       0280      11020
                  ALTOONA, INC.
423027.........  HEALTHSOUTH OF              42170       1440      16700
                  CHARLESTON, INC.
453047.........  HEALTHSOUTH PLANO           45310       1920      19124
                  REHABILITATION HOSP.
043032.........  HEALTHSOUTH REHAB HOSP      04710       2580      22220
                  IN PART WITH RE.
453044.........  HEALTHSOUTH REHAB HOSP      45940       0640      12420
                  OF AUSTIN.
183028.........  HEALTHSOUTH REHAB HOSP      18460         18      21060
                  OF CENTRAL KY.

[[Page 30314]]

 
063030.........  HEALTHSOUTH REHAB HOSP      06200       1720      17820
                  OF COLORADO SPGS.
423026.........  HEALTHSOUTH REHAB HOSP      42200       2655      22500
                  OF FLORENCE.
013029.........  HEALTHSOUTH REHAB HOSP      01440       3440      26620
                  OF NORTH ALA.
103042.........  HEALTHSOUTH REHAB HOSP      10260       8280      45300
                  OF SPRING HILL.
223030.........  HEALTHSOUTH REHAB HOSP      22070       8003      44140
                  OF WESTERN MA.
033029.........  HEALTHSOUTH REHAB           03090       8520      46060
                  HOSPITAL.
103031.........  HEALTHSOUTH REHAB           10570       7510      42260
                  HOSPITAL.
103038.........  HEALTHSOUTH REHAB           10120       5000      33124
                  HOSPITAL OF MIAMI.
453059.........  HEALTHSOUTH REHAB           45801       3360      26420
                  HOSPITAL OF NORTH
                  HOUSTON.
393026.........  HEALTHSOUTH REHAB           39110       6680      39740
                  HOSPITAL OF READING.
103033.........  HEALTHSOUTH REHAB           10360       8240      45220
                  HOSPITAL OF
                  TALLHASSEE.
453054.........  HEALTHSOUTH REHAB           45960       9080      48660
                  HOSPITAL OF WICHITA
                  FALLS.
453031.........  HEALTHSOUTH REHAB           45130       7240      41700
                  INSTITUTE OF SAN
                  ANTONIO.
033028.........  HEALTHSOUTH REHAB           03090       8520      46060
                  INSTITUTE OF TUCSON.
393031.........  HEALTHSOUTH REHAB OF        39270       3240      25420
                  MECHANICSBURG-ACUTE
                  REHAB.
393046.........  HEALTHSOUTH                 39320       2360      21500
                  REHABILITATION
                  HOSPITAL OF ERIE.
423028.........  HEALTHSOUTH                 42450       1520      16740
                  REHABILITATION
                  HOSPITAL.
443029.........  HEALTHSOUTH                 44780       4920      32820
                  REHABILITATION CENTER
                  OF MEMPHIS.
153027.........  HEALTHSOUTH                 15330       3850      29020
                  REHABILITATION HOSP
                  OF KOK.
393037.........  HEALTHSOUTH                 39800       9280      49620
                  REHABILITATION HOSP
                  YORK.
013030.........  HEALTHSOUTH                 01340       2180      20020
                  REHABILITATION
                  HOSPITAL.
043028.........  HEALTHSOUTH                 04650       2720      22900
                  REHABILITATION
                  HOSPITAL.
103037.........  HEALTHSOUTH                 10510       8280      45300
                  REHABILITATION
                  HOSPITAL.
153029.........  HEALTHSOUTH                 15830       8320      45460
                  REHABILITATION
                  HOSPITAL.
303027.........  HEALTHSOUTH                 30060       1123      31700
                  REHABILITATION
                  HOSPITAL.
323027.........  HEALTHSOUTH                 32000       0200      10740
                  REHABILITATION
                  HOSPITAL.
403025.........  HEALTHSOUTH                 40640       7440      41980
                  REHABILITATION
                  HOSPITAL.
443027.........  HEALTHSOUTH                 44810       3660      28700
                  REHABILITATION
                  HOSPITAL.
453029.........  HEALTHSOUTH                 45610       3360      26420
                  REHABILITATION
                  HOSPITAL.
453048.........  HEALTHSOUTH                 45700       0840      13140
                  REHABILITATION
                  HOSPITAL.
443031.........  HEALTHSOUTH                 44780       4920      32820
                  REHABILITATION
                  HOSPITAL-NORTH.
193031.........  HEALTHSOUTH                 19090       3960      29340
                  REHABILITATION
                  HOSPITAL OF
                  ALEXANDRIA.
453040.........  HEALTHSOUTH                 45910       2800      23104
                  REHABILITATION
                  HOSPITAL OF ARLINGTON.
423025.........  HEALTHSOUTH                 42390       1760      17900
                  REHABILITATION
                  HOSPITAL OF COLUMBIA.
043029.........  HEALTHSOUTH                 04150       3700      27860
                  REHABILITATION
                  HOSPITAL OF JONESBORO.
293026.........  HEALTHSOUTH                 29010       4120      29820
                  REHABILITATION
                  HOSPITAL OF LAS VEGAS.
313029.........  HEALTHSOUTH                 31310       5190      20764
                  REHABILITATION
                  HOSPITAL OF NEW
                  JERSEY.
453090.........  HEALTHSOUTH                 45451       5800      36220
                  REHABILITATION
                  HOSPITAL OF ODESSA.
393045.........  HEALTHSOUTH                 39010       6280      38300
                  REHABILITATION
                  HOSPITAL OF SEWICKLEY.
453053.........  HEALTHSOUTH                 45170       8360      45500
                  REHABILITATION
                  HOSPITAL OF TEXARKANA.
453056.........  HEALTHSOUTH                 45892       8640      46340
                  REHABILITATION
                  HOSPITAL OF TYLER.
463025.........  HEALTHSOUTH                 46170       7160      41620
                  REHABILITATION
                  HOSPITAL OF UTAH.
493028.........  HEALTHSOUTH                 49430       6760      40060
                  REHABILITATION
                  HOSPITAL OF VIRGINIA.
013032.........  HEALTHSOUTH                 01270       2880      23460
                  REHABILITATION OF
                  GADSDEN.
453057.........  HEALTHSOUTH                 45794       5800      33260
                  REHABILITATION OF
                  MIDLAND ODESSA.
293032.........  HEALTHSOUTH                 29010       4120      29820
                  REHABILITIATION
                  HOSPITAL OF HENDERSON.
103034.........  HEALTHSOUTH SEA PINES       10050       2680      22744
                  REHABILITATION
                  HOSPITAL.
193085.........  HEALTHSOUTH SPECIALTY       19350       5560      35380
                  HOSPITAL.
45T758.........  HEALTHSOUTH SPECIALTY       45390       1920      19124
                  HOSPTIAL, INC..
103028.........  HEALTHSOUTH SUNRISE         10050       2680      22744
                  REHABILITATION
                  HOSPITAL.
103032.........  HEALTHSOUTH TREASURE        10300         10      46940
                  COAST REHAB HOSPITAL.
153025.........  HEALTHSOUTH TRI-STATE       15810       2440      21780
                  REHABILITATION
                  HOSPITAL.
053034.........  HEALTHSOUTH TUSTIN          05400       5945      42044
                  REHABILITATION HOSP.
033032.........  HEALTHSOUTH VALLEY OF       03060       6200      38060
                  THE SUN.
513027.........  HEALTHSOUTH WESTERN         51530       6020      37620
                  HILLS REGIONAL REHAB
                  HOSPITAL.
193074.........  HEALTHWEST                  19250       5560      35380
                  REHABILITATION
                  HOSPITAL.
26T006.........  HEARTLAND REGIONAL          26100       7000      41140
                  MEDICAL CENTER.
333027.........  HELEN HAYES HOSPITAL..      33620       5600      35644
04T085.........  HELENA REGIONAL             04530         04         04
                  REHABILITATION CENTER.
45T229.........  HENDRICK CENTER FOR         45911       0040      10180
                  REHABILITATION.
49T118.........  HENRICO DOCTORS             49430       6760      40060
                  HOSPITAL PARHA.
23T204.........  HENRY FORD BI-COUNTY        23490       2160      47644
                  HOSPITAL.
23T146.........  HENRY FORD WYANDOTTE        23810       2160      19804
                  HOSPITAL.
05T624.........  HENRY MAYO NEWHALL          05200       4480      31084
                  MEMORIAL HOSPITAL.
34T107.........  HERITAGE HOSPITAL.....      34320       6895      40580
45T068.........  HERMANN HOSPITAL......      45610       3360      26420
23T120.........  HERRICK MEMORIAL            23450       0440         23
                  HOSPITAL.

[[Page 30315]]

 
14T011.........  HERRIN HOSPITAL.......      14990         14         14
34T004.........  HIGH POINT REGIONAL         34400       3120      24660
                  HOSPITAL.
453086.........  HIGHLANDS REGIONAL          45480       2320      21340
                  REHABILITATION HOS.
50T011.........  HIGHLINE COMMUNITY          50160       7600      42644
                  HOSPITAL.
45T101.........  HILLCREST BAPTIST           45780       8800      47380
                  MEDICAL CENTER.
37T001.........  HILLCREST KAISER            37710       8560      46140
                  REHABILITATION CENTER.
363026.........  HILLSIDE                    36790       9320      49660
                  REHABILITATION
                  HOSPITAL.
14T122.........  HINSDALE HOSPITAL--         14250       1600      16974
                  PAULSON REHAB NETWORK.
10T225.........  HOLLYWOOD MEDICAL           10050       2680      22744
                  CENTER.
10T073.........  HOLY CROSS HOSPITAL...      10050       2680      22744
14T133.........  HOLY CROSS HOSPITAL...      14141       1600      16974
52T107.........  HOLY FAMILY MEMORIAL,       52350         52         52
                  INC.
36T054.........  HOLZER MEDICAL CENTER.      36270         36         36
45T236.........  HOPKINS COUNTY              45654         45         45
                  MEMORIAL HOSPITAL.
44T046.........  HORIZON MEDICAL CENTER      44210       5360      34980
33T389.........  HOSPITAL FOR JOINT          33420       5600      35644
                  DISEASES.
07T001.........  HOSPITAL OF SAINT           07040       5483      35300
                  RAPHAEL.
39T111.........  HOSPITAL OF UNIV OF         39620       6160      37964
                  PENNSYLVANIA.
04T076.........  HOT SPRING COUNTY           04290         04         04
                  MEDICAL CENTER.
153039.........  HOWARD REGIONAL HEALTH      15330       3850      29020
                  SYSTEM-WEST CAMPUS.
52T091.........  HOWARD YOUNG MEDICAL        52420         52         52
                  CENTER.
11T200.........  HUGHSTON ORTHOPEDIC         11780       1800      17980
                  HOSPITAL.
05T438.........  HUNTINGTON MEMORIAL         05200       4480      31084
                  HOSPITAL.
23T132.........  HURLEY MEDICAL CENTER.      23240       2640      22420
17T020.........  HUTCHINSON HOSPITAL         17770         17         17
                  CORP..
133025.........  IDAHO ELKS                  13000       1080      14260
                  REHABILITATION
                  HOSPITAL.
13T018.........  IDAHO REGIONAL MEDICAL      13090         13      26820
                  CENTER.
28T081.........  IMMANUEL                    28270       5920      36540
                  REHABILITATION CENTER.
26T095.........  INDEPENDENCE REGIONAL       26470       3760      28140
                  HEALTH CENTER.
14T191.........  INGALLS MEMORIAL            14141       1600      16974
                  HOSPITAL.
23T167.........  INGHAM REGIONAL             23320       4040      29620
                  MEDICAL CENTER.
49T122.........  INOVA REHAB CENTER @        49290       8840      47894
                  INOVA MOUNT VERNON
                  HOSPITAL.
45T132.........  INPATIENT REHAB.......      45451       5800      36220
453025.........  INSTUTUTE FOR REHAB &       45610       3360      26420
                  RESEARCH,THE.
37T106.........  INTEGRIS SOUTHWEST          37540       5880      36420
                  MEDICAL CENTER.
323029.........  INTERFACE INC DBA           32220         32      22140
                  LIFECOURSE REHAB
                  SERVICES.
16T082.........  IOWA METHODIST MEDICAL      16760       2120      19780
                  CENTER.
15T024.........  J.W. SOMMER                 01160       3480      26900
                  REHABILIATION UNIT.
01T157.........  JACKSON MEMORIAL            10120       2650      22520
                  HOSPITAL.
33T014.........  JACOBI MEDICAL CENTER.      33020       5600      35644
10T022.........  JAMAICA HOSPITAL            33590       5000      33124
                  MEDICAL CENTER.
33T127.........  JAMESON HOSPITAL......      39450       5600      35644
39T016.........  JANE PHILLIPS MEMORIAL      37730         39         39
                  MEDICAL CENTER.
37T018.........  JEANES HOSPITAL.......      39620         37         37
39T080.........  JEANNETTE HOSPITAL....      39770       6160      37964
39T010.........  JEFFERSON REGIONAL          04340       6280      38300
                  MEDICAL CENTER.
04T071.........  JEFFERSON REGIONAL          39010       6240      38220
                  MEDICAL CENTER.
39T265.........  JFK JOHNSON REHAB           31270       6280      38300
                  INSTITUTE.
31T108.........  JIM THORPE REHAB UNIT.      37190       5015      20764
37T029.........  JOHN D. ARCHBOLD            11890         37         37
                  MEMORIAL HOSPITAL.
11T038.........  JOHN HEINZ INST OF          39680         11         11
                  REHAB MEDICINE.
393036.........  JOHN MUIR MEDICAL           05060       3680         39
                  CENTER.
05T180.........  JOHNSON CITY MEDICAL        44890       5775      36084
                  CTR.
44T063.........  JOHNSON REGIONAL            04350       3660      27740
                  REHABILITATION CENTER.
04T002.........  JOHNSTON R. BOWMAN          14141         04         04
                  HEALTH CTR..
14T119.........  JOINT TOWNSHIP              36050       1600      16974
                  DISTRICT MEMORIAL
                  HOSPITAL, REHABIL.
36T032.........  KADLEC MEDICAL CENTER.      50020       4320         36
33T005.........  KAISER FOUNDATION           05460       1280      15380
                  HOSPITAL-FONTANA
                  REHAB CENTER.
50T058.........  KAISER MEDICAL CENTER.      05580       6740      28420
05T140.........  KALEIDA HEALTH........      33240       6780      40140
05T073.........  KALISPELL REGIONAL          27140       8720      46700
                  MEDICAL CENTER.
27T051.........  KANSAS REHABILITATION       17880         27         27
                  HOSPITAL, INC.
173025.........  KANSAS UNIVERSITY           17986       8440      45820
                  REHAB.
17T040.........  KAPLAN REHABILITATION       19560       3760      28140
                  HOSPITAL.
193057.........  KAWEAH DELTA                05640         19         19
                  REHABILITATION
                  HOSPITAL.
05T057.........  KENMORE MERCY HOSPITAL      33240       8780      47300
33T102.........  KENT COUNTY MEMORIAL        41010       1280      15380
                  HOSPITAL.

[[Page 30316]]

 
41T009.........  KEOKUK AREA HOSPITAL..      16550       6483      39300
16T008.........  KESSLER REHAB.........      31200         16         16
313025.........  KESSLER ADVENTIST           21150       5640      35084
                  REHABILITATION
                  HOSPITAL.
213029.........  KETTERING MEDICAL           36580       8840      13644
                  CENTER.
36T079.........  KINGMAN REGIONAL            03070       2000      19380
                  MEDICAL CENTER.
03T055.........  KINGS COUNTY HOSPITAL       33331       4120         03
                  CENTER.
33T202.........  KING'S DAUGHTER             18090       5600      35644
                  MEDICAL CENTER.
18T009.........  KINGSBROOK JEWISH           33331       3400      26580
                  MEDICAL CENTER.
33T201.........  KINGWOOD MEDICAL            45610       5600      35644
                  CENTER.
45T775.........  KOOTENAI MEDICAL            13270       3360      26420
                  CENTER.
13T049.........  LA PALMA                    05400         13      17660
                  INTERCOMMUNITY
                  HOSPITAL.
05T580.........  LABETTE COUNTY MEDICAL      17490       5945      42044
                  CENTER.
17T120.........  LAC/RANCHO LOS AMIGOS       05400         17         17
                  NATIONAL MED CTR.
05T717.........  LAFAYETTE GENERAL           19270       5945      42044
                  MEDICAL CENTER.
19T002.........  LAGRANGE COMMUNITY          15430       3880      29180
                  HOSPITAL.
15T096.........  LAKE CHARLES MEMORIAL       19090         15         15
                  HOSPITAL.
19T060.........  LAKE CUMBERLAND             18972       3960      29340
                  REGIONAL HOSP.
18T132.........  LAKE HOSPITAL SYSTEM        36440         18         18
                  INC.
36T098.........  LAKE REGION HEALTHCARE      24550       1680      17460
                  CORPORATION.
24T052.........  LAKELAND HOSPITAL, ST.      23100         24         24
                  JOSEPH.
23T021.........  LAKESHORE CARRAWAY          01360       0870      35660
                  REHABILITATION
                  HOSPITAL.
01T064.........  LAKEWAY REGIONAL            44310       1000      13820
                  HOSPITAL.
44T067.........  LAKEWOOD HOSPITAL.....      36170         44      34100
36T212.........  LAKEWOOD REGIONAL           05200       1680      17460
                  MEDICAL CENTER.
05T581.........  LANCASTER COMMUNITY         05200       4480      31084
                  HOSPITAL.
05T204.........  LANCASTER GENERAL HOSP      39440       4480      31084
39T100.........  LANCASTER REGIONAL          39440       4000      29540
                  MEDICAL CENTER.
39T061.........  LANDER VALLEY MEDICAL       53060       4000      29540
                  CENTER.
53T010.........  LANE FROST HEALTH AND       37110         53         53
                  REHABILITATION CENTER.
373032.........  LANE REHABILTATION          19160         37         37
                  CENTER.
19T020.........  LAPLACE REHABILITATION      19350       0760      12940
                  HOSPITAL.
193064.........  LAPORTE HOSPITAL AND        15450       5560      35380
                  HEALTH SERVICES.
45T029.........  LAREDO MEDICAL CENTER.      45953       4080      29700
45T107.........  LAS PALMAS                  45480       2320      21340
                  REHABILITATION HOSP.
05T095.........  LAUREL GROVE HOSPITAL.      05000       5775      36084
10T246.........  LAWNWOOD REGIONAL           10550       2710      38940
                  MEDICAL CENT.
07T007.........  LAWRENCE & MEMORIAL         07050       5523      35980
                  HOSPITAL.
17T137.........  LAWRENCE MEMORIAL           17220       4150      29940
                  HOSPITAL.
46T010.........  LDS HOSPITAL..........      46170       7160      41620
32T065.........  LEA REGIONAL MEDICAL        32120         32         32
                  CENTER.
49T012.........  LEE REGIONAL MEDICAL        49520         49         49
                  CENTER.
10T084.........  LEESBURG REGIONAL           10340       5960      36740
                  MEDICAL CENTER.
193086.........  LEESVILLE                   19570         19         19
                  REHABILITATION
                  HOSPITAL LLC.
38T017.........  LEGACY GOOD SAMARITAN       38250       6440      38900
                  HOSP & MED CTR.
34T027.........  LENOIR MEMORIAL             34530         34         34
                  HOSPITAL REHAB UNIT.
05T060.........  LEON S. PETERS              05090       2840      23420
                  REHABILITATION.
36T086.........  LEVINE REHABILITATION       36110       2000      44220
                  CENTER.
49T048.........  LEWIS GALE MEDICAL          49838       6800      40220
                  CENTER.
15T006.........  LIBERTY REHABILITATION      31230         15      33140
                  INSTITUTE.
31T118.........  LIMA MEMORIAL HEALTH        36010       3640      35644
                  SYSTEM.
36T009.........  LINCOLN PARK HOSPITAL.      14141       4320      30620
14T207.........  LITTLE COMPANY OF           05200       1600      16974
                  MARY--SAN PEDRO
                  HOSPITAL REHAB.
05T078.........  LIVINGSTON REGIONAL         44660       4480      31084
                  HOSPITAL.
44T187.........  LODI MEMORIAL HOSPITAL      05490         44         44
05T336.........  LOGAN REGIONAL MEDICAL      51220       8120      44700
                  CENTER.
51T048.........  LOMA LINDA UNIVERSITY       05460         51         51
                  MEDICAL CENTER.
05T327.........  LONG BEACH MEDICAL          33400       6780      40140
                  CENTER.
33T225.........  LONG BEACH MEMORIAL         05200       5380      35004
                  MEDICAL CENTER.
05T485.........  LONG ISLAND COLLEGE         33331       4480      31084
                  HOSPITAL.
33T152.........  LONGVIEW REGIONAL           45570       5600      35644
                  PHYSICAL
                  REHABILITATION.
45T702.........  LOS ROBLES HOSPITAL &       05660       4420      30980
                  MEDICAL CENTER.
05T549.........  LOUIS A. WEISS              14141       8735      37100
                  MEMORIAL HOSPITAL.
14T082.........  LOUISIANA                   19500       1600      16974
                  REHABILIATAION
                  HOSPITAL OF MORGAN
                  CITY L.
193084.........  LOURDES...............      18720         19         19
18T102.........  LOURDES MEDICAL CENTER      50100         18         18
50R337.........  LOURDES MEDICAL CENTER      50100       6740      28420
50T023.........  LOYOLA UNIVERSITY           14141       6740      28420
                  MEDICAL CENTER.

[[Page 30317]]

 
14T276.........  LULING REHABILITATION       19440       1600      16974
                  HOSPITAL.
193060.........  LUTHERAN HOSPITAL           36170       5560      35380
                  ACUTE REHAB UNIT.
36T087.........  LUTHERAN MEDICAL            33331       1680      17460
                  CENTER.
33T306.........  MADISON COUNTY              36500       5600      35644
                  HOSPITAL INPATIENT
                  REHAB.
45T032.........  MADONNA REHABILITATION      28540       4420         45
                  HOSPITAL.
36T189.........  MAGEE REHABILITATION        39620       1840      18140
                  HOSPITAL.
283025.........  MAGNOLIA REGIONAL           25010       4360      30700
                  HEALTH CENTER.
393038.........  MAINLAND MEDICAL            45550       6160      37964
                  HOSPITAL.
25T009.........  MARIA PARHAM                34900         25         25
                  HEALTHCARE
                  ASSOCIATION, INC..
45T530.........  MARIANJOY                   14250       2920      26420
                  REHABILITATION
                  HOSPITAL.
34T132.........  MARIETTA MEMORIAL           36850         34         34
                  HOSPITAL.
143027.........  MARLETTE COMMUNITY          23750       1600      16974
                  HOSP CTR FOR REHAB.
36T147.........  MARLTON REHABILITATION      31150       6020      37620
                  HOSPITAL.
23T082.........  MARQUETTE GENERAL           23510         23         23
                  HOSPITAL.
313032.........  MARY BLACK CENTER FOR       42410       6160      15804
                  REHAB.
23T054.........  MARY FREE BED HOSPITAL      23400         23         23
                  & REHABILITATION
                  CENTER.
42T083.........  MARY GREELEY MEDICAL        16840       3160      43900
                  CENTER.
233026.........  MARYVIEW CENTER FOR         49711       3000      24340
                  PHYSICAL
                  REHABILITATION.
16T030.........  MASSILLON COMMUNITY         36770         16      11180
                  HOSPITAL.
49T017.........  MATAGORDA GENERAL           45790       5720      47260
                  HOSPITAL.
36T100.........  MAYO CLINIC HOSPITAL..      03060       1320      15940
45T465.........  MCALESTER REGIONAL          37600         45
                  HEALTH CENTER.
45.............  MCKAY-DEE HOSPITAL....      46280       6200      38060
37T034.........  MCKEE MEDICAL CENTER..      06340         37         37
46T004.........  MCKENNA REHAB               45320       7160      36260
                  INSTITUTE.
06T030.........  MCLAREN REGIONAL            23240       2670      22660
                  MEDICAL CENTER.
45T059.........  MCO REHAB HOSPITAL....      36490       7240      41700
23T141.........  MEADOWBROOK REHAB           17450       2640      22420
                  HOSPITAL.
36T048.........  MEADOWBROOK REHAB           10120       8400      45780
                  HOSPITAL OF WEST GAB.
04T088.........  MEADOWBROOK                 45610         04         04
                  REHABILITAION
                  HOSPITAL.
17T180.........  MEADVILLE MEDICAL           39260       3760      28140
                  CENTER.
103036.........  MECOSTA COUNTY GENERAL      23530       5000      33124
                  HOSPITAL.
453052.........  MED CTR OF LA AT NEW        19350       3360      26420
                  ORLEANS.
39T113.........  MEDCENTER ONE, INC....      35070         39         39
23T093.........  MEDCENTRAL HEALTH           36710         23         23
                  SYSTEM.
19T005.........  MEDICAL CENTER AT           45730       5560      35380
                  TERRELL.
35T015.........  MEDICAL CENTER OF           45910       1010      13900
                  ARLINGTON.
36T118.........  MEDICAL CENTER OF           45310       4800      31900
                  PLANO.
45T683.........  MEDICAL CENTER OF           04690       1920      19124
                  SOUTH ARKANSAS.
45T675.........  MEDICAL CITY DALLAS         45390       2800      23104
                  HOSPITAL.
45T651.........  MEDICAL CNTR OF             08010       1920      19124
                  DELAWARE.
45T647.........  MEDINA HOSPITAL.......      33550       1920      19124
08T001.........  MEMORIAL HEALTH             11220       9160      48864
                  UNIVERSITY MEDICAL
                  CENTER.
33T053.........  MEMORIAL HEALTHCARE         23770       6840      40380
                  CENTER.
11T036.........  MEMORIAL HERMAN             45840       7520      42340
                  BAPTIST HOSP ORANGE.
23T121.........  MEMORIAL HERMANN FT.        45610         23         23
                  BEND INPATIENT
                  REHABILITATION.
45T005.........  MEMORIAL HERMANN            45610       0840      13140
                  NORTHWEST HOSPITAL.
45T848.........  MEMORIAL HOSPITAL.....      10050       3360      26420
45T184.........  MEMORIAL HOSPITAL--         15700       3360      26420
                  SOUTH BEND.
10T038.........  MEMORIAL HOSPITAL AT        25230       2680      22744
                  GULFPORT.
15T058.........  MEMORIAL HOSPITAL OF        41030       7800      43780
                  RI.
25T019.........  MEMORIAL MED CENTER OF      45020       0920      25060
                  EAST TE.
41T001.........  MEMORIAL MEDICAL            14920       6483      39300
                  CENTER.
45T211.........  MEMORIAL MEDICAL            19350         45         45
                  CENTER--REHABILITATIO
                  N INSTITUTE.
14T148.........  MEMORIAL                    45794       7880      44100
                  REHABILITATION
                  HOSPITAL.
19T135.........  MENA MEDICAL CENTER...      04560       5560      35380
45T133.........  MENORAH MEDICAL CENTER      17450       5800      33260
04T015.........  MERCY FITZGERALD            39290         04         04
                  HOSPITAL.
17T182.........  MERCY FRANCISCAN            36310       3760      28140
                  HOSPITAL MT. AIRY.
39T156.........  MERCY FRANCISCAN            36310       6160      37964
                  HOSPITAL WESTERN
                  HILLS.
36T234.........  MERCY GENERAL HEALTH        23600       1640      17140
                  PARTNERS.
36T113.........  MERCY GENERAL HOSPITAL      05440       1640      17140
23T004.........  MERCY HEALTH CENTER...      17800       3000      34740
05T017.........  MERCY HEALTH CENTER,        37540       6920      40900
                  INC.
17T142.........  MERCY HEALTH SYSTEM         52520         17         17
                  CORP.
37T013.........  MERCY HEALTH SYSTEM OF      17050       5880      36420
                  KANSAS.
52T066.........  MERCY HOSPITAL........      10120       3620      27500

[[Page 30318]]

 
17T058.........  MERCY HOSPITAL........      14141         17         17
10T061.........  MERCY HOSPITAL OF           39010       5000      33124
                  PITTSBURGH.
14T158.........  MERCY HOSPITAL PORT         23730       1600      16974
                  HURON.
39T028.........  MERCY HOSPITAL              34590       6280      38300
                  REHABILITATION UNIT.
23T031.........  MERCY MEDICAL.........      01010       2160      47644
34T098.........  MERCY MEDICAL CENTER..      33400       1520      16740
013027.........  MERCY MEDICAL CENTER..      36770       5160         01
33T259.........  MERCY MEDICAL CENTER..      52690       5380      35004
36T070.........  MERCY MEDICAL CENTER-       16760       1320      15940
                  DES MOINES.
52T048.........  MERCY MEDICAL CENTER-       16300       0460      36780
                  DUBUQUE.
16T083.........  MERCY MEDICAL CENTER-       16960       2120      19780
                  SIOUX CITY.
16T069.........  MERCY MEDICAL CENTER-       16160       2200      20220
                  NORTH IOWA.
16T153.........  MERCY MEMORIAL HEALTH       37090       7720      43580
                  CENTER.
16T064.........  MERCY PROVIDENCE            39010         16         16
                  HOSPITAL.
37T047.........  MERIDIA EUCLID              36170         37         37
                  HOSPITAL.
39T136.........  MERITCARE HEALTH            35080       6280      38300
                  SYSTEM.
36T082.........  MERITER HOSPITAL INC..      52120       1680      17460
35T011.........  MERWICK REHAB HOSPITAL      31260       2520      22020
52T089.........  MESA GENERAL HOSPITAL.      03060       4720      31540
31T010.........  MESA LUTHERAN HOSPITAL      03060       8480      45940
                  REHAB.
03T017.........  MESQUITE COMMUNITY          45390       6200      38060
                  HOSPITAL.
03T018.........  METHODIST HOSPITAL....      19350       6200      38060
45T688.........  METHODIST HOSPITAL....      19350       1920      19124
19T124.........  METHODIST HOSPITAL....      24260       5560      35380
19T200.........  METHODIST HOSPITAL OF       05200       5560      35380
                  SOUTHERN CA.
24T053.........  METHODIST HOSPITAL          18500       5120      33460
                  REHABILITATION CENTER.
05T238.........  METHODIST HOSPITAL,         45610       4480      31084
                  THE.
18T056.........  METHODIST MEDICAL           45390       2440      21780
                  CENTER.
45T358.........  METHODIST MEDICAL           14800       3360      26420
                  CENTER OF ILLINOIS.
45T051.........  METHODIST NORTHLAKE...      15440       1920      19124
14T209.........  METHODIST SPECIALTY/        45130       6120      37900
                  TRANSPLANT.
15T002.........  METROHEALTH MEDICAL         36170       2960      23844
                  CENTER.
45T631.........  METROPOLITAN HOSPITAL.      33420       7240      41700
36T059.........  METROPOLITAN HOSPITAL       23400       1680      17460
                  AND METRO HEALTH
                  CORPORATION.
33T199.........  METROPOLITAN METHODIST      45130       5600      35644
                  HOSP.
23T236.........  MI LAND E. KNAPP            24260       3000      24340
                  REHABILITATION CENTER.
45T388.........  MIAMI VALLEY HOSPITAL.      36580       7240      41700
24T004.........  MICHAEL REESE HOSPITAL      14141       5120      33460
36T051.........  MID AMERICA                 17450       2000      19380
                  REHABILITATION
                  HOSPITAL.
14T075.........  MID JEFFERSON HOSPITAL      45700       1600      16974
173026.........  MIDDLETOWN REGIONAL         36080       3760      28140
                  HOSPITAL.
45T514.........  MILLER DWAN MEDICAL         24680       0840      13140
                  CENTER.
36T076.........  MILLS HEALTH CENTER...      05510       3200      17140
24T019.........  MILTON S HERSHEY            39280       2240      20260
                  MEDICAL CENTER.
05T007.........  MINDEN MEDICAL CENTER       19590       7360      41884
                  REHAB.
39T256.........  MISSION HOSPITAL......      05400       3240      25420
19T144.........  MISSION HOSPITAL......      45650       7680         19
05T567.........  MISSISSIPPI METHODIST       25240       5945      42044
                  REHABILITATION CENTER.
45T176.........  MISSISSIPPI METHODIST       25240       4880      32580
                  REHABILITATION CENTER.
253025.........  MISSOURI BAPTIST            26940       3560      27140
                  MEDICAL CENTER.
25T152.........  MISSOURI DELTA MEDICAL      26982       3560      27140
                  CENTER.
26T108.........  MOBILE INFIRMARY......      01480       7040      41180
26T113.........  MODESTO REHABILITATION      05600         26         26
                  HOSPITAL.
01T113.........  MONONGAHELA VALLEY          39750       5160      33660
                  HOSPITAL.
053036.........  MONTEFIORE MEDICAL          33020       5170      33700
                  CENTER.
39T147.........  MORGAN HOSPITAL &           15540       6280      38300
                  MEDICAL CTR.
33T059.........  MORTON PLANT NORTH BAY      10500       5600      35644
                  HOSPITAL.
15T038.........  MOSES CONE HEALTH           34400       3480      26900
                  SYSTEM.
34T091.........  MOSS REHAB............      39620       3120      24660
39T142.........  MOUNT CARMEL REGIONAL       17180       6160      37964
                  MEDICAL CENTER.
17T006.........  MOUNT SINAI MEDICAL         10120         17         17
                  CENTER.
10T034.........  MOUNTAINVIEW REGIONAL       32060       5000      33124
                  MEDICAL CENTER.
32T085.........  MT CARMEL INPATIENT         36250       4100      29740
                  REHAB UNIT.
36T035.........  MT SINAI HOSPITAL.....      33420       1840      18140
33T024.........  MUNSON MEDICAL CENTER.      23270       5600      35644
23T097.........  MUSKOGEE REGIONAL           37500         23         23
                  REHABILITATION CENTER.
37T025.........  NACOGDOCHES COUNTY          45810         37         37
                  HOSPITAL DISTRICT.

[[Page 30319]]

 
45T508.........  NAPLES COMMUNITY            10100         45         45
                  HOSPITAL, INC..
10T018.........  NASHVILLE                   44180       5345      34940
                  REHABILITATION
                  HOSPITAL.
44T026.........  NASSAU UNIVERSITY           33400       5360      34980
                  MEDICAL CENTER.
33T027.........  NATCHEZ REGIONAL            25000       5380      35004
                  MEDICAL CENTER.
25T084.........  NATIONAL PARK.........      04250         25         25
04T078.........  NATIONAL                    09000         04      26300
                  REHABILITATION
                  HOSPITAL.
093025.........  NAVARRO REGIONAL            45820       8840      47894
                  HOSPITAL.
45T447.........  NAZARETH HOSPITAL.....      39620         45         45
39T204.........  NEBRASKA METHODIST          28270       6160      37964
                  HEALTH SYSTEM.
28T040.........  NEW ENGLAND REHAB           20020       5920      36540
                  HOSPITAL OF PORTLAND.
203025.........  NEW ENGLAND                 22090       6403      38860
                  REHABILITAION
                  HOSPITAL-WOBURN.
223026.........  NEW HANOVER REGIONAL        34640       1123      15764
                  MEDICAL CENTER.
34T141.........  NEW MEXICO                  32020       9200      48900
                  REHABILITATION CENTER.
323026.........  NEW ORLEANS EAST            19350         32         32
                  REHABILITATION.
193089.........  NEW YORK METHODIST          33331       5560      35380
                  HOSPITAL.
33T236.........  NEW YORK PRESBYTERIAN       33420       5600      35644
                  HOSPITAL.
33T101.........  NEWMAN REGIONAL HEALTH      17550       5600      35644
17T001.........  NEWPORT HOSPITAL......      41020         17         17
41T006.........  NEWTON MEDICAL CENTER.      17390       6483      39300
17T103.........  NEWTON MEMORIAL             31360       9040      48620
                  HOSPITAL.
31T028.........  NEXT STEP ACUTE             39190       5640      35084
                  REHABILITATION CENTER.
39T194.........  NIX HEALTH CARE SYSTEM      45130       0240      10900
45T130.........  NOBLE HOSPITAL REHAB        22070       7240      41700
                  UNIT.
10T063.........  NORMAN REGIONAL             37130       8280      45300
                  HOSPITAL.
22T065.........  NORTH AUSTIN MEDICAL        45940       8003      44140
                  CENTER.
37T008.........  NORTH BROWARD MEDICAL       10050       5880      36420
                  CENTER.
45T809.........  NORTH CAROLINA BAPTIST      34330       0640      12420
                  HOSPITALS.
10T086.........  NORTH CENTRAL MEDICAL       45310       2680      22744
                  CENTER.
34T047.........  NORTH COLORADO MEDICAL      06610       3120      49180
                  CENTER.
45T403.........  NORTH COUNTRY REGIONAL      24030       1920      19124
                  HOSPITAL.
06T001.........  NORTH DALLAS                45620       3060      24540
                  REHABILITATION
                  HOSPITAL.
24T100.........  NORTH DALLAS                45390         24         24
                  REHABILITATION
                  HOSPITAL.
453032.........  NORTH FULTON REGIONAL       11470       1920      19124
                  HOSPITAL.
11T198.........  NORTH HILLS HOSPITAL..      45910       0520      12060
45T087.........  NORTH KANSAS CITY           26230       2800      23104
                  HOSPITAL.
26T096.........  NORTH MEMORIAL HEALTH       24260       3760      28140
                  CENTER.
24T001.........  NORTH MISS. MEDICAL         25400       5120      33460
                  CENTER.
25T004.........  NORTH MONROE MEDICAL        19360         25         25
                  CENTER.
19T197.........  NORTH OAKLAND MEDICAL       23620       5200      33740
                  CENTERS.
23T013.........  NORTH OAKS REHAB HOSP       19520       2160      47644
                  INC.
193044.........  NORTH SHORE REGIONAL        19510         19         19
                  MEDICAL CENTER.
19T204.........  NORTH SHORE UNIVERSITY      33400       5560      35380
                  HOSPITAL @ GLEN COVE.
33T181.........  NORTH SUBURBAN MEDICAL      06000       5380      35004
                  CENTER.
06T065.........  NORTHEAST GEORGIA           11550       2080      19740
                  MEDICAL CENTER.
11T029.........  NORTHEAST METHODIST         45130         11      23580
                  HOSPITAL.
45T733.........  NORTHEAST OKLAHOMA          37710       7240      41700
                  REHABILITATION
                  ASSOCIATES, LP.
373029.........  NORTHEAST REGIONAL          26000       8560      46140
                  MEDICAL CENTER.
26T022.........  NORTHEAST                   30070         26         26
                  REHABILITATION
                  HOSPITAL.
303026.........  NORTHERN CALIFORNIA         05550       1123      40484
                  REHABILITATION
                  HOSPITAL.
05T699.........  NORTHERN ILLINOIS           14640       6690      39820
                  MEDICAL CENTER.
14T116.........  NORTHERN MICHIGAN           23230       1600      16974
                  HOSPITAL.
23T105.........  NORTHERN NEVADA             29150         23         23
                  MEDICAL CENTER.
29T032.........  NORTHLAKE MEDICAL           11370       6720      39900
                  CENTER.
11T033.........  NORTHPORT MEDICAL           01620       0520      12060
                  CENTER.
01T145.........  NORTHRIDGE HOSPITAL         05200       8600      46220
                  MEDICAL CENTER.
05T116.........  NORTHWEST HEALTH            04710       4480      31084
                  SYSTEM.
04T022.........  NORTHWEST HOSPITAL....      50160       2580      22220
50T001.........  NORTHWEST MISSISSIPPI       25130       7600      42644
                  REGIONAL MED CTR.
25T042.........  NORTHWEST REGIONAL          45830         25         25
                  HOSPITAL.
45T131.........  NORWALK HOSPITAL            07000       1880      18580
                  ASSOCIATION.
07T034.........  OAK FOREST HOSPITAL...      14141       5483      14860
14T301.........  OAKLAND REGIONAL            23620       1600      16974
                  HOSPITAL.
233028.........  OAKWOOD HERITAGE            23810       2160      47644
                  HOSPITAL.
23T270.........  OCHSNER REHABILITATION      19250       2160      19804
                  CENTER.
19T036.........  OGDEN REGIONAL MEDICAL      46280       5560      35380
                  CENTER.
46T005.........  OHIO STATE UNIVERSITY       36250       7160      36260
                  HOSPITAL.
36T085.........  OHIO VALLEY GENERAL         39010       1840      18140
                  HOSPITAL ARU.

[[Page 30320]]

 
39T157.........  OM....................      18290       6280      38300
18T038.........  OPELOUSAS GENERAL           19480       5990      36980
                  HOSPITAL.
19T017.........  ORANGE REGIONAL             33540       3880         19
                  MEDICAL CENTER.
33T001.........  ORANGE REGIONAL             33540       5660      39100
                  MEDICAL CENTER.
33T126.........  OREGON REHABILITATION       38190       5660      39100
                  CENTER.
38T033.........  ORLANDO REGIONAL            10470       2400      21660
                  HEALTHCARE-CMR.
10T006.........  OSTEOPATHIC MEDICAL         45910       5960      36740
                  CENTER OF TEXAS.
45T121.........  OU MEDICAL CENTER.....      37540       2800      23104
37T093.........  OUR LADY OF LOURDES         31160       5880      36420
                  MEDICAL CENTER.
31T029.........  OUR LADY OF LOURDES         19270       6160      15804
                  REG MED CENTER.
19T102.........  OUR LADY OF THE LAKE        19160       3880      29180
                  REGIONAL MEDICAL
                  CENTER.
19T064.........  OVERLAKE HOSPITAL           50160       0760      12940
                  MEDICAL CENTER.
50T051.........  PALESTINE REGIONAL          45000       7600      42644
                  REHAB HOSPITAL.
45T113.........  PALMYRA MEDICAL CENTER      11390         45         45
11T163.........  PALOMAR MEDICAL CENTER      05470       0120      10500
05T115.........  PAMPA REGIONAL MEDICAL      45563       7320      41740
                  CENTER.
45T099.........  PARADISE VALLEY             05470         45         45
                  HOSPITAL.
05T024.........  PARIS REGIONAL MEDICAL      45750       7320      41740
                  CENTER.
45T196.........  PARK PLACE MEDICAL          45700         45         45
                  CENTER.
45T518.........  PARK PLAZA HOSPITAL...      45610       0840      13140
45T659.........  PARKLAND HEALTH AND         45390       3360      26420
                  HOSPITAL SYSTEM.
45T015.........  PARKRIDGE MEDICAL           44320       1920      19124
                  CENTER.
44T156.........  PARKVIEW HOSPITAL.....      15010       1560      16860
15T021.........  PARKVIEW MEDICAL            06500       2760      23060
                  CENTER.
06T020.........  PARKVIEW REGIONAL           45758       6560      39380
                  HOSPITAL.
45T400.........  PARKWAY REGIONAL            10120         45         45
                  MEDICAL CENTER.
10T114.........  PARMA COMMUNITY             36170       5000      33124
                  GENERAL HOSPITAL.
36T041.........  PATRICIA NEAL               44460       1680      17460
                  REHABILITATION CENTER.
44T125.........  PENINSULA HOSPITAL          33590       3840      28940
                  CENTER.
33T002.........  PENNYSLVANIA HOSPITAL,      39620       5600      35644
                  ACUTE REHABILITATION
                  UNIT.
39T226.........  PENROSE HOSPITAL/           06200       6160      37964
                  ELEANOR-CAPRON.
06T031.........  PETERSON                    51340       1720      17820
                  REHABILITATION
                  HOSPITAL AND GERIATIC
                  CEN.
513025.........  PHELPS COUNTY REGIONAL      26800       9000      48540
                  MED CENTER.
26T017.........  PHELPS MEMORIAL             33800         26         26
                  HOSPITAL.
33T261.........  PHOEBE PUTNEY.........      11390       5600      35644
11T007.........  PHOENIX BAPTIST             03060       0120      10500
                  HOSPITAL.
03T030.........  PHYSICAL                    16890       6200      38060
                  REHABILITAITON UNIT
                  AT OTTUMWA REGIONAL H.
16T089.........  PIEDMONT HOSPITAL.....      11470         16         16
11T083.........  PIKEVILLE METHODIST         18970       0520      12060
                  REHABILITATION
                  HOSPITAL.
18T044.........  PINECREST                   10490         18         18
                  REHABILITATION
                  HOSPITAL.
103030.........  PINNACLE REHAB........      37540       8960      48424
373025.........  PINNACLEHEALTH              39280       5880      36420
                  HOSPITALS.
39T067.........  PITT COUNTY MEMORIAL        34730       3240      25420
                  HOSPITAL.
34T040.........  PLAZA MEDICAL CENTER..      45910       3150      24780
45T672.........  POPLAR BLUFF REGIONAL       26110       2800      23104
                  MEDICAL CENTER.
26T119.........  PORTER ADVENTIST            06150         26         26
                  HOSPITAL.
06T064.........  PORTNEUF MEDICAL            13020       2080      19740
                  CENTER.
13T028.........  POTTSTOWN MEMORIAL          39560       6340      38540
                  MEDICAL CENTER.
39T123.........  POTTSVILLE HOSPITAL-        39650       6160      37964
                  WARNE CLINIC.
39T030.........  POUDRE VALLEY HEALTH        06340         39         39
                  CARE INC.
06T010.........  PREMIER REHABILITATION      19360       2670      22660
                  HOSPITAL.
14T007.........  PRESBYTERIAN HOSPITAL       45390       1600      16974
                  OF DALLAS.
193082.........  PRESBYTERIAN                05200       5200      33740
                  INTERCOMMUNITY
                  HOSPITAL.
45T462.........  PROVENA COVENANT            14090       1920      19124
                  MEDICAL CENTER REHAB.
05T169.........  PROVENA SAINT JOSEPH        14530       4480      31084
                  HOSPITAL.
14T113.........  PROVENA ST. JOSEPH          14989       1400      16580
                  MEDICAL CENTER.
14T217.........  PROVIDENCE ALASKA           02020       1600      16974
                  MEDICAL CENTER.
02T001.........  PROVIDENCE CENTRALIA        50200       0380      11260
                  HOSPITAL.
50T019.........  PROVIDENCE EVERETT          50300         50         50
                  MEDICAL CENTER.
50T014.........  PROVIDENCE HOLY CROSS       05200       7600      42644
                  MEDICAL CENTER.
05T278.........  PROVIDENCE HOSPITAL...      23620       4480      31084
23T019.........  PROVIDENCE MEDFORD          38140       2160      47644
                  MEDICAL CENTER.
38T075.........  PROVIDENCE PORTLAND         38250       4890      32780
                  MEDICAL CENTER.
38T061.........  PROVIDENCE SAINT            05200       6440      38900
                  JOSEPH MEDICAL CENTER.
05T235.........  PROVIDENCE ST. PETER        50330       4480      31084
                  HOSPITAL.
50T024.........  QUEEN OF ANGELS-            05200       5910      36500
                  HOLLYWOOD
                  PRESBYTERIAN MEDICAL
                  C.
05T063.........  QUEEN OF THE VALLEY         05380       4480      31084
                  HOSPITAL.

[[Page 30321]]

 
05T009.........  QUEENS HOSPITAL CENTER      33590       8720      34900
33T231.........  RANCHO REHABILITATION.      29010       5600      35644
29T007.........  RAPID CITY REGIONAL         43510       4120      29820
                  HOSPITAL.
43T077.........  REBSAMEN MEDICAL            04590       6660      39660
                  CENTER.
04T074.........  REDMOND REHABILITATION      11460       4400      30780
                  CENTER.
11T168.........  REGIONAL MEDICAL            18530         11      40660
                  CENTER.
18T093.........  REGIONAL REHAB CENTER       34850         18         18
                  AT HUGH CHATHAM.
34T097.........  REGIONAL REHAB CENTER       49661         34         34
                  OF NORTON COMMUNITY
                  HOSPITAL.
49T001.........  REGIONAL                    42280         49         49
                  REHABILITATION CENTER.
42T036.........  REGIONAL                    01500         42         42
                  REHABILITATION
                  HOSPITAL.
013033.........  REGIONS HOSPITAL REHAB      24610       5240      33860
                  INSTITUTE.
24T106.........  REHAB CARE CENTER AT        39390       5120      33460
                  INDIANA REGIONAL
                  MEDICAL CTR.
39T173.........  REHAB CENTER OF MARION      36520         39         39
36T011.........  REHAB HOSP OF R I.....      41030         36         36
413025.........  REHAB HOSP OF THE CAPE      22000       6483      39300
                  AND ISLANDS.
223032.........  REHAB HOSPITAL OF           19160       0743      12700
                  BATON ROUGE.
193028.........  REHAB INSTITUTE AT          05520       0760      12940
                  SANTA BARBARA,THE.
053028.........  REHAB INSTITUTE AT          44180       7480      42060
                  TCMC.
44T135.........  REHAB MEDICINE ST.          11260       5360      34980
                  MARY'S ATHENS.
11T006.........  REHAB UNIT OF PACIFIC       05200       0500      12020
                  ALLIANCE MEDICAL
                  CENTER.
05T018.........  REHABCARE CENTER AT         40560       4480      31084
                  HOSPITAL DR. PILA.
40T003.........  REHABILITATION CENTER       15780       6360      38660
                  AT LAFAYETTE HOME
                  HOSPITAL.
15T109.........  REHABILITATION CENTER       03020       3920      29140
                  OF NORTHERN ARIZONA.
03T023.........  REHABILITATION              15010       2620      22380
                  HOSPITAL.
153030.........  REHABILITATION              07010       2760      23060
                  HOSPITAL OF
                  CONNECTICUT,THE.
073025.........  REHABILITATION              15480       3283      25540
                  HOSPITAL OF INDIANA.
153028.........  REHABILITATION              15480       3480      26900
                  HOSPITAL OF INDIANA
                  AT ST VINCENT.
153038.........  REHABILITATION              44780       3480      26900
                  HOSPITAL OF MEMPHIS.
44T152.........  REHABILITATION              32000       4920      32820
                  HOSPITAL OF NEW
                  MEXICO.
323028.........  REHABILITATION              31190       0200      10740
                  HOSPITAL OF SOUTH
                  JERSEY.
313036.........  REHABILITATION              12020       8760      47220
                  HOSPITAL OF THE
                  PACIFIC.
123025.........  REHABILITATION              31290       3320      26180
                  HOSPITAL OF TINTON
                  FALLS.
313035.........  REHABILITATION              31300       5190      20764
                  INSTITUTE AT
                  MORRISTOWN MEMORIAL.
31T015.........  REHABILITATION              14141       5640      35084
                  INSTITUTE OF CHICAGO.
143026.........  REHABILITATION              45650       1600      16974
                  INSTITUTE OF MCALLEN.
45T811.........  REHABILITATION              23810       4880      32580
                  INSTITUTE OF MICHIGAN.
233027.........  REHABILITATION              26940       2160      19804
                  INSTITUTE OF ST
                  LOUIS, THE.
263028.........  REHABILITATION PATIENT      06200       7040      41180
                  CARE UNIT.
06T022.........  REID HOSP-ACUTE REHAB       15880       1720      17820
                  UNIT.
15T048.........  RENO REHAB ASSOCIATES,      29150         15         15
                  LIMITED PARTNERSHIP.
293027.........  RESEARCH MEDICAL            26070       6720      39900
                  CENTER.
26T027.........  RESURRECTION MEDICAL        14141         26         26
                  CENTER.
14T117.........  RHD MEMORIAL MEDICAL        45390       1600      16974
                  CENTER.
45T379.........  RICHLAND PARISH             19410       1920      19124
                  REHABILITATION
                  HOSPITA.
193075.........  RILEY MEMORIAL              25370         19         19
                  HOSPITAL.
25T081.........  RIO VISTA REHAB             45480         25         25
                  HOSPITAL.
453033.........  RIVER PARK HOSPITAL...      44880       2320      21340
44T151.........  RIVER REGION HEALTH         25740         44         44
                  SYSTEM.
25T031.........  RIVER WEST MEDICAL          19230         25         25
                  CENTER.
19T131.........  RIVERSIDE MEDICAL           14540         19      12940
                  CENTER.
14T186.........  RIVERSIDE REHAB             49622       3740      28100
                  INSTITUTE.
493027.........  RIVERVIEW HOSPITAL....      15280       5720      47260
15T059.........  RIVERVIEW MEDICAL           31290       3480      26900
                  CENTER.
31T034.........  ROCHESTER GENERAL           33370       5190      20764
                  HOSPITAL.
33T125.........  ROGER C. PEACE........      42220       6840      40380
42T078.........  ROGERS CITY                 23700       3160      24860
                  REHABILITATION
                  HOSPITAL.
233029.........  ROME MEMORIAL HOSPITAL      33510         23         23
33T215.........  ROPER REHABILITATION        42090       8680      46540
                  HOSPITAL.
42T087.........  ROWAN REGIONAL MEDICAL      34790       1440      16700
                  CENTER.
34T015.........  ROXBOROUGH............      39620       1520         34
39T304.........  RUSH OAK PARK HOSPITAL      14141       6160      37964
14T063.........  RUSH-COPLEY MEDICAL         14530       1600      16974
                  CENTER.
14T029.........  RUSK INSTITUTE........      33420       1600      16974
33T214.........  RUSK REHABILITATION         26090       5600      35644
                  CENTER LLC.
263027.........  RUTLAND REGIONAL            47100       1740      17860
                  MEDICAL CENTER.
47T005.........  SACRED HEART HOSPITAL.      52170         47         47
52T013.........  SACRED HEART REHAB          52390       2290      20740
                  INST.

[[Page 30322]]

 
523025.........  SADDLEBACK MEMORIAL         05400       5080      33340
                  MEDICAL CENTER.
05T603.........  SAGE REHAB INSTITUTE..      19160       5945      42044
193078.........  SAINT ALPHONSUS             13000       0760      12940
                  REGIONAL MEDICAL
                  CENTER.
13T007.........  SAINT ANTHONY'S HEALTH      14680       1080      14260
                  CENTER.
14T052.........  SAINT FRANCIS HOSPITAL      31230       7040      41180
313037.........  SAINT FRANCIS HOSPITAL      33230       3640      35644
33T067.........  SAINT FRANCIS HOSPITAL      44780       2281      39100
44T183.........  SAINT FRANCIS MEDICAL       14800       4920      32820
                  CENTER.
14T067.........  SAINT FRANCIS MEMORIAL      05480       6120      37900
                  HOSPITAL.
05T152.........  SAINT JOHNS MERCY           26940       7360      41884
                  MEDICAL CENTER.
26T020.........  SAINT JOSEPH HEALTH         26470       7040      41180
                  CENTER.
26T085.........  SAINT JOSEPH HOSPITAL.      14141       3760      28140
14T224.........  SAINT JOSEPH REGIONAL       15700       1600      16974
                  MEDICAL CENTER.
15T012.........  SAINT LUKE'S SOUTH          17450       7800      43780
                  HOSPITAL.
17T185.........  SAINT MARY OF NAZARETH      14141       3760      28140
                  HOSPITAL.
14T180.........  SAINT MARYS REGIONAL        29150       1600      16974
                  MEDICAL CENTER.
29T009.........  SAINT VINCENT CATHOLIC      33420       6720      39900
                  MEDICAL CENTERS OF
                  NEW YORK.
33T290.........  SAINT VINCENT HEALTH        39320       5600      35644
                  CENTER.
39T009.........  SALEM HOSPITAL              38230       2360      21500
                  REGIONAL
                  REHABILITATION CENTER.
38T051.........  SALINA REGIONAL HEALTH      17840       7080      41420
                  CENTER.
17T012.........  SALINE MEMORIAL             04620         17         17
                  HOSPITAL.
04T084.........  SALT LAKE REGIONAL          46170       4400      30780
                  MEDICAL CENTER.
46T003.........  SAM KARAS ACUTE REHAB       05370       7160      41620
                  AT NATIVIDAD MEDICAL
                  CENTER.
05T248.........  SAMARITAN MEDICAL           33330       7120      41500
                  CENTER.
33T157.........  SAN ANGELO COMMUNITY        45930         33         33
                  MEDICAL CENTER.
45T340.........  SAN ANTONIO WARM            45130       7200      41660
                  SRPINGS
                  REHABILITATION
                  HOSPITAL.
453035.........  SAN CLEMENTE HOSPITAL.      05400       7240      41700
05T585.........  SAN JACINTO METHODIST       45610       5945      42044
                  HOSPITAL.
45T424.........  SAN JOAQUIN GENERAL         05490       3360      26420
                  HOSPITAL.
05T167.........  SAN JOAQUIN VALLEY          05090       8120      44700
                  REHABILITATION HOSP.
053032.........  SAN JOSE MEDICAL            05530       2840      23420
                  CENTER.
05T215.........  SAN LUIS VALLEY             06010       7400      41940
                  REGIONAL MEDICAL
                  CENTER.
06T008.........  SANTA CLARA VALLEY          05530         06         06
                  MEDICAL CENTER.
05T038.........  SANTA ROSA MEMORIAL         05590       7400      41940
                  HOSPITAL.
05T174.........  SARASOTA MEMORIAL           10570       7500      42220
                  HOSPITAL.
10T087.........  SATILLA REGIONAL            11940       7510      42260
                  REHABILITATION
                  INSTITUTE.
11T003.........  SAVOY MEDICAL CENTER..      19190         11         11
19T025.........  SCHWAB REHABILITATION       14141         19         19
                  HOSPITAL.
143025.........  SCOTT & WHITE.........      45120       1600      16974
45T054.........  SCOTTSDALE HEALTHCARE       03060       3810      28660
                  INPATIENT REHAB.
03T038.........  SCRIPPS MEMORIAL            05470       6200      38060
                  HOSPITAL ENCINITAS.
05T503.........  SENTARA NORFOLK             49641       7320      41740
                  GENERAL HOSPITAL.
49T007.........  SEWICKLEY VALLEY            39010       5720      47260
                  HOSPITAL.
39T037.........  SHANDS REHAB HOSPITAL.      10000       6280      38300
10T113.........  SHANNON WEST TEXAS          45930       2900      23540
                  MEMORIAL HOSPITAL.
45T571.........  SHARON REGIONAL HEALTH      39530       7200      41660
                  SYSTEM.
39T211.........  SHARP MEMORIAL              05470       7610      49660
                  REHABILITATION CENTER.
05T100.........  SHELTERING ARMS             49430       7320      41740
                  REHABILITATION
                  HOSPITAL.
493025.........  SHORE REHABILITATION        31310       6760      40060
                  INSTITUTE.
313033.........  SHREVEPORT                  19080       5190      20764
                  REHABILITATION
                  HOSPITAL.
193083.........  SID PETERSON MEMORIAL       45734       7680      43340
                  HOSPITAL.
45T007.........  SIERRA VISTA REGIONAL       05500         45         45
                  MEDICAL CENTER.
05T506.........  SILVER CROSS HOSPITAL.      14989       7460      42020
14T213.........  SIMI VALLEY HOSPITAL &      05660       1600      16974
                  HEALTH CARE SVC.
05T236.........  SINAI-GRACE HOSPITAL..      23810       8735      37100
23T024.........  SINGING RIVER HOSPITAL      25290       2160      19804
25T040.........  SIOUX VALLEY HOSPITAL.      43490       0920      37700
43T027.........  SISKIN HOSPITAL FOR         44320       7760      43620
                  PHYSICAL
                  REHABILITATION.
443025.........  SISTER KENNY REHAB          24260       1560      16860
                  INSTITUTE--ABBOTT
                  NORTHWESTERN.
24T057.........  SISTER KENNY REHAB          24610       5120      33460
                  INSTITUTE--UNITED
                  HOSPITAL.
24T038.........  SKYLINE REHABILITATION      44180       5120      33460
                  CENTER.
44T006.........  SLIDELL MEMORIAL            19510       5360      34980
                  HOSPITAL.
19T040.........  SOUTH FULTON..........      11470       5560      35380
11T219.........  SOUTH GEORGIA MEDICAL       11700       0520      12060
                  CENTER.
11T122.........  SOUTH MIAMI HOSPITAL        10120         11      46660
                  PHYSICAL MEDICINE &
                  REHAB.
10T154.........  SOUTH POINTE HOSPITAL.      36170       5000      33124
36T144.........  SOUTH TEXAS REGIONAL        45060       1680      17460
                  SPECIALTY HOSPITAL.

[[Page 30323]]

 
45T165.........  SOUTHCOAST HOSPITALS        22150         45      41700
                  GROUP, INC..
22T074.........  SOUTHEAST MISSOURI          26150       1123      14484
                  HOSPITAL.
26T110.........  SOUTHEASTERN REGIONAL       34250         26         26
                  REHABILITATION CENTER.
34T028.........  SOUTHERN HILLS              51270       2560      22180
                  REGIONAL REHAB.
513026.........  SOUTHERN INDIANA            15210         51         51
                  REHABILITATION
                  HOSPITAL.
153037.........  SOUTHERN KENTUCKY           18986       4520      31140
                  REHABILITATION
                  HOSPITAL.
183029.........  SOUTHERN OHIO MEDICAL       36740         18      14540
                  CENTER.
36T008.........  SOUTHERN TENNESSEE          44250         36         36
                  MEDICAL CENTER.
44T058.........  SOUTHSIDE HOSPITAL....      33700         44         44
33T043.........  SOUTHWEST GENERAL           45130       5380      35004
                  HOSPITAL.
45T697.........  SOUTHWEST MEDICAL           19270       7240      41700
                  CENTER.
19T205.........  SOUTHWEST MISSISSIPPI       25560       3880      29180
                  REGIONAL MEDICAL
                  CENTER.
25T097.........  SOUTHWEST WASHINGTON        50050         25         25
                  MEDICAL CENTER.
50T050.........  SOUTHWESTERN MEDICAL        37540       6440      38900
                  CENTER.
37T097.........  SOUTHWESTERN                23120       5880      36420
                  REHABILITATION
                  HOSPITAL.
233025.........  SPAIN REHABILITATION        01360       3720      12980
                  CENTER.
01T033.........  SPALDING                    06150       1000      13820
                  REHABILITATION
                  HOSPITAL.
063027.........  SPRING BRANCH MEDICAL       45610       2080      19740
                  CENTER.
45T630.........  SSM DEPAUL HEALTH           26940       3360      26420
                  CENTER.
26T104.........  SSM REHABILITATION          26940       7040      41180
                  INSTITUTE.
263025.........  SSM ST. JOSEPH              26940       7040      41180
                  KIRKWOOD.
26T081.........  ST. FRANCIS MEDICAL         19360       7040      41180
                  CTR.
04T007.........  ST. AGNES MEDICAL           39620       4400      30780
                  CENTER.
19T125.........  ST. ALEXIUS MEDICAL         35070       5200      33740
                  CENTER.
39T022.........  ST. ANTHONYS MEDICAL        26940       6160      37964
                  CENTER.
35T002.........  ST. ANTHONY'S               10050       1010      13900
                  REHABILITATION
                  HOSPITAL.
26T077.........  ST. CATHERINE'S             10120       7040      41180
                  REHABILITATION
                  HOSPITAL.
103027.........  ST. DAVIDS                  45940       2680      22744
                  REHABILITATION CENTER.
103026.........  ST. EDWARD MERCY            04650       5000      33124
                  MEDICAL CENTER.
453038.........  ST. ELIZABETH HEALTH        36510       0640      12420
                  CENTER.
04T062.........  ST. FRANCIS MEDICAL         26260       2720      22900
                  CENTER.
36T064.........  ST. JOHN DETROIT            23810       9320      49660
                  RIVERVIEW HOSP.
26T183.........  ST. JOHN MACOMB             23490         26         26
                  HOSPITAL.
23T119.........  ST. JOHN MEDICAL            37710       2160      19804
                  CENTER, INC..
23T195.........  ST. JOHN NORTH SHORES       23490       2160      47644
                  HOSPITAL.
37T114.........  ST. JOHNS REGIONAL          26480       8560      46140
                  MEDICAL CENTER.
23T257.........  ST. JOHN'S REGIONAL         05660       2160      47644
                  MEDICAL CENTER.
26T001.........  ST. JOHN'S                  19250       3710      27900
                  REHABILITATION
                  HOSPITAL.
05T082.........  ST. JOSEPH HEALTH           41030       8735      37100
                  SERVICES OF RI.
193061.........  ST. JOSEPH HOSPITAL...      05110       5560      35380
41T005.........  ST. JOSEPH HOSPITAL...      30050       6483      39300
05T006.........  ST. JOSEPH HOSPITAL &       15330         05         05
                  HEALTH CENTER.
30T011.........  ST. JOSEPH REGIONAL         45190       1123      31700
                  REHAB.
15T010.........  ST. JOSEPHS HOSPITAL..      52390       3850      29020
45T011.........  ST. JOSEPH'S MERCY          04250       1260      17780
                  HEALTH CENTER.
52T136.........  ST. LAWRENCE                31260       5080      33340
                  REHABILITATION CENTER.
04T026.........  ST. LUKES EPISCOPAL         45610         04      26300
                  HOSPTIAL.
313027.........  ST. LUKES HOSPITAL OF       26470       8480      45940
                  KANSAS CITY.
45T193.........  ST. LUKES NORTHLAND         26230       3360      26420
                  HOSPITAL.
26T138.........  ST. LUKE'S                  19270       3760      28140
                  REHABILITATION
                  HOSPITAL OF LAFAYETTE.
26T062.........  ST. LUKES                   50310       3760      28140
                  REHABILITATION
                  INSTITUTE.
193087.........  ST. MARGARET MERCY          15440       3880      29180
                  HLTHCARE CTRS.
503025.........  ST. MARY MEDICAL            05200       7840      44060
                  CENTER.
15T004.........  ST. MARY MEDICAL            50350       2960      23844
                  CENTER.
05T191.........  ST. MARY-CORWIN             06500       4480      31084
                  MEDICAL CENTER.
50T002.........  ST. MARYS HOSPITAL....      24540         50         50
06T012.........  ST. MARY'S HOSPITAL         26470       6560      39380
                  BLUE SPRINGS.
24T010.........  ST. MARYS MEDICAL           15810       6820      40340
                  CENTER.
26T193.........  ST. MARYS MEDICAL           44460       3760      28140
                  CENTER.
15T100.........  ST. MARY'S MEDICAL          05480       2440      21780
                  CENTER.
44T120.........  ST. MARY'S WEST PALM        10120       3840      28940
                  BEACH.
05T457.........  ST. NICHOLAS HOSPITAL.      52580       7360      41884
10T288.........  ST. PAUL HOSPITAL.....      45390       5000      33124
52T044.........  ST. VINCENT HEALTHCARE      27550       7620      43100
45T044.........  ST. VINCENT HOSPITAL..      32240       1920      19124
27T049.........  ST. VINCENT HOSPITAL..      52040       0880      13740
32T002.........  ST. VINCENT REHAB HOSP      04590       7490      42140
                  IN PART HLTHSOUT.

[[Page 30324]]

 
52T075.........  ST. AGNES HOSPITAL....      52190       3080      24580
043031.........  ST. ALEXIUS HOSPITAL..      26940       4400      30780
52T088.........  ST. ANTHONY HOSPITAL        37540         52      22540
                  REHAB CENTER.
26T210.........  ST. ANTHONY MEDICAL         15440       7040      41180
                  CENTER.
37T037.........  ST. ANTHONY MEMORIAL        15450       5880      36420
                  HEALTH CENTERS.
15T126.........  ST. CHARLES HOSPITAL        33700       2960      23844
                  AND REHABILITATION
                  CENTER.
15T015.........  ST. CHARLES MERCY           36490         15      33140
                  HOSPITAL.
33T246.........  ST. CLAIR HOSPITAL....      39010       5380      35004
36T081.........  ST. CLAIRE MC.........      18975       8400      45780
39T228.........  ST. CLOUD HOSPITAL....      24720       6280      38300
18T018.........  ST. ELIZABETH HOSPITAL      52430         18         18
24T036.........  ST. ELIZABETH HOSPITAL      14900       6980      41060
                  REHAB.
52T009.........  ST. FRANCIS HOSPITAL        08010       0460      11540
                  REHAB.
14T187.........  ST. JAMES HOSPITAL AND      14141       7040      41180
                  HEALTH CENTERS.
08T003.........  ST. JOHN NORTHEAST          23810       9160      48864
                  COMMUNITY HOSPITAL.
14T172.........  ST. JOHNS REGIONAL          26380       1600      16974
                  HEALTH CENTER.
23T065.........  ST. JOSEPH HOSPITAL...      50360       2160      19804
26T065.........  ST. JOSEPH MEDICAL          50260       7920      44180
                  CENTER.
50T030.........  ST. JOSEPH MERCY            23800       0860      13380
                  HOSPITAL-ANN ARBOR.
50T108.........  ST. JOSEPHS HOSPITAL..      03060       8200      45104
23T156.........  ST. JOSEPH'S HOSPITAL.      33070       0440      11460
03T024.........  ST. JOSEPH'S HOSPITAL.      52700       6200      38060
33T108.........  ST. JOSEPH'S MERCY OF       23490       2335      21300
                  MACOMB.
52T037.........  ST. JOSEPH'S WAYNE          31320         52         52
                  HOSPITAL.
23T047.........  ST. JUDE MEDICAL            05400       2160      47644
                  CENTER.
31T116.........  ST. LUKE'S............      24680       0875      35644
05T168.........  ST. LUKE'S/ROOSEVELT        33420       5945      42044
                  HOSPITAL CENTER.
24T047.........  ST. LUKES ACUTE REHAB.      03060       2240      20260
33T046.........  ST. LUKES HOSPITAL....      16560       5600      35644
03T037.........  ST. LUKE'S HOSPITAL...      26940       6200      38060
16T045.........  ST. LUKE'S HOSPITAL...      36490       1360      16300
26T179.........  ST. LUKE'S REHAB UNIT       52580       7040      41180
                  AT ST. LUKE'S SOUTH
                  SHORE.
36T090.........  ST. MARY MEDICAL            39140       8400      45780
                  CENTER.
52T138.........  ST. MARY MEDICAL            15440       7620      43100
                  CENTER INC.
39T258.........  ST. MARYS HOSPITAL AND      06380       6160      37964
                  MEDICAL CENTER.
15T034.........  ST. MARY'S REGIONAL         04570       2960      23844
                  MEDICAL CENTER.
06T023.........  ST. MARY'S REGIONAL         37230       2995      24300
                  MEDICAL CENTER.
04T041.........  ST. PETERS HOSPITAL...      33000         04         04
37T026.........  ST. RITA'S MEDICAL          36010       2340         37
                  CENTER.
33T057.........  ST. ROSE DOMINICAN          29010       0160      10580
                  HOSPITAL.
36T066.........  ST. TAMMANY PARISH          19510       4320      30620
                  HOSPITAL.
29T012.........  ST. VINCENT INFIRMARY       04590       4120      29820
                  MEDICAL CENTER.
19T045.........  ST. VINCENT'S MEDICAL       07000       5560      35380
                  CENTER.
07T028.........  ST. FRANCIS HEALTH          17880       5483      14860
                  CENTER.
17T016.........  ST. JOSEPH HOSPITAL         15010       8440      45820
                  REHAB UNIT.
15T047.........  STAMFORD HOSPITAL.....      07070       2760      23060
073026.........  STANFORD HOSPITAL &         05530         07         07
                  CLINICS.
05T441.........  STANLY MEMORIAL             34830       7400      41940
                  HOSPITAL.
34T119.........  STARKE MEMORIAL             15740       1520         34
                  HOSPITAL.
15T102.........  STATEN ISLAND HOSPITAL      33610         15         15
33T160.........  STERLINGTON REHAB           19360       5600      35644
                  HOSPITAL.
193069.........  STILLWATER MEDICAL          37590       5200      33740
                  CENTER.
37T049.........  STRONG MEMORIAL             33370         37         37
                  HOSPITAL.
33T285.........  SUMMA HEALTH SYSTEM...      36780       6840      40380
29T041.........  SUMMERLIN HOSPITAL          29010       4120      29820
                  MEDICAL CENTER.
36T020.........  SUMNER REGIONAL             44820       0080      10420
                  MEDICAL CENTER.
44T003.........  SUMTER REGIONAL             11870       5360      34980
                  HOSPITAL.
11T044.........  SUN COAST HOSPITAL....      10510         11         11
10T015.........  SUN HEALTH ROBERT H         05460       8280      45300
                  BALLARD REHAB
                  HOSPITAL.
053037.........  SUNNYVIEW HOSPITAL AND      33650       6780      40140
                  REHABILITATION CENTER.
333025.........  SUNRISE HOSPITAL &          29010       0160      10580
                  MEDICAL CEN.
29T003.........  SUNY DOWNSTATE MEDICAL      33331       4120      29820
                  CENTER.
33T350.........  SUTTER AUBURN FAITH         05410       5600      35644
                  HOSPITAL.
05T498.........  SWEDISH COVENANT            14141       6920      40900
                  HOSPITAL.
14T114.........  SWEDISH GENERAL             06020       1600      16974
                  REHABILITATION.
06T034.........  SWEDISH MEDICAL CENTER      50160       2080      19740
50T025.........  TAH INPATIENT REHAB         39260       7600      42644
                  UNIT.

[[Page 30325]]

 
39T122.........  TAKOMA ADVENTIST            44290         39         39
                  HOSPITAL.
44T050.........  TAMPA GENERAL               10280         44         44
                  REHABILATION CTR.
10T128.........  TARRANT COUNTY              45910       8280      45300
                  REHABILITATION
                  HOSPITAL.
453042.........  TEMPLE UNIVERSITY           39620       2800      23104
                  HOSPITAL.
39T027.........  TERREBONNE GENERAL          19540       6160      37964
                  MEDICAL CENTER.
19T008.........  TEXOMA MEDICAL CENTER.      45564       3350      26380
28T061.........  THE ACUTE REHAB UNIT        28780         28         28
                  AT REGIONAL WEST
                  MEDICAL CENT.
20T018.........  THE AROOSTOOK MEDICAL       20010         20         20
                  CENTER.
36T163.........  THE CHRIST HOSPITAL         36310       1640      17140
                  REHAB UNIT.
09T001.........  THE GEORGE WASHINGTON       09000       8840      47894
                  UNIVERSITY ARU.
39T066.........  THE GOOD SAMARITAN          39460       3240      30140
                  HOSPITAL.
33T004.........  THE KINGSTON HOSPITAL       33740         33      28740
                  REHABILITATION CENTER.
25T099.........  THE LEFLORE                 25410         25         25
                  REHABILITATION CENTER.
33T056.........  THE PARKSIDE ACUTE          33331       5600      35644
                  REHABILITATION CENTER.
33T049.........  THE PAUL ROSENTHAL          33230       2281      39100
                  REHABILITATION CENTER
                  AT NDH.
39T044.........  THE READING HOSPITAL        39110       6680      39740
                  AND MEDICAL CENTER.
42T068.........  THE REGIONAL MEDICAL        42370         42         42
                  CENTER REHABCENTRE.
15T051.........  THE REHAB CENTER AT         15520       1020      14020
                  BLOOMINGTON HOSPITAL.
11T024.........  THE REHAB CENTER AT         11220       7520      42340
                  CANDLER.
44T059.........  THE REHAB CENTER AT         44700         44         44
                  COOKEVILLE RMC.
16T146.........  THE REHAB CENTER AT         16960       7720      43580
                  ST. LUKE'S.
11T043.........  THE REHAB CENTER AT         11220       7520      42340
                  ST. JOSEPHS.
15T008.........  THE REHABILITATION          15440       2960      23844
                  CENTER AT ST.
                  CATHERINE HOSPITA.
10T012.........  THE REHABILITATION          10350       2700      15980
                  HOSPITAL.
20T039.........  THE REHABILITATION          20050         20         20
                  INSTITUTE AT MGMC.
42T067.........  THE REHABILITATION          42060         42         42
                  UNIT AT BEAUFORT
                  MEMORIAL HOSPI.
36T211.........  THE TRINITY                 36420       8080      48260
                  REHABILITATION CENTER.
39T042.........  THE WASHINGTON              39750       6280      38300
                  HOSPITAL ACUTE
                  REHABILITATION UNIT.
52T045.........  THEDA CLARK MEDICAL         52690       0460      36780
                  CENTER.
19T004.........  THIBODAUX REGIONAL          19280       3350      26380
                  MEDICAL CENTER.
39T174.........  THOMAS JEFFERSON            39620       6160      37964
                  UNIVERSITY HOSPITAL.
343025.........  THOMS REHABILITATION        34100       0480      11700
                  HOSP.
23T015.........  THREE RIVERS                23740         23         23
                  REHABILITATION
                  PAVILION.
11T095.........  TIFT REGIONAL MEDICAL       11900         11         11
                  CENTER.
45T080.........  TITUS REGIONAL MEDICAL      45531         45         45
                  CENTER.
45T324.........  TOMBALL REGIONAL            45610       7640      43300
                  HOSPITAL.
45T670.........  TOURO REHABILITATION        19350       3360      26420
                  CENTER.
193034.........  TRI-CITY MEDICAL            05470       5560      35380
                  CENTER.
05T128.........  TRI PARISH                  19050       7320      41740
                  REHABILITATION
                  HOSPITAL LLC.
193050.........  TRINITY MEDICAL CENTER      14890         19         19
14T280.........  TRINITY REHABCARE           35500       1960      19340
                  CENTER.
35T006.........  TULANE INPATIENT REHAB      19350         35         35
                  CENTER.
19T176.........  TULSA REGIONAL MEDICAL      37710       5560      35380
                  CENTER.
37T078.........  TWELVE OAKS MEDICAL         45610       8560      46140
                  CENTER.
45T378.........  TWIN RIVERS REGIONAL        26340       3360      26420
                  MEDICAL CENTER.
26T015.........  U W HOSPITAL & CLINIC.      52120         26         26
52T098.........  UAB MEDICAL WEST            01360       4720      31540
                  REHABILITATION UNIT.
01T114.........  UC DAVIS MEDICAL            05440       1000      13820
                  CENTER.
05T599.........  UCLA MED CTR-RRU......      05200       6920      40900
05T262.........  UHS HOSPITALS.........      33030       4480      31084
33T394.........  UNC HOSPITALS.........      34670       0960      13780
34T061.........  UNION HOSPITAL........      15830       6640      20500
15T023.........  UNIONTOWN HOSPITAL....      39330       8320      45460
39T041.........  UNITED MEDICAL CENTER       53100       6280      38300
                  ARU.
53T014.........  UNITED MEDICAL              19350       1580      16940
                  REHABILITATION
                  HOSPITAL.
193079.........  UNITY HEALTH CENTER...      37620       5560      35380
37T149.........  UNITY HEALTH SYSTEM...      33370       5880         37
33T226.........  UNIV OF CA IRVINE MED       05400       6840      40380
                  CTR.
05T348.........  UNIV OF PITTSBURGH MED      39010       5945      42044
                  CTR-MUH.
39T164.........  UNIVERSITY COMMUNITY        10280       6280      38300
                  HOSPITAL.
10T173.........  UNIVERSITY HEALTH           45130       8280      45300
                  SYSTEM.
45T213.........  UNIVERSITY HOSPITAL...      33520       7240      41700
33T241.........  UNIVERSITY MEDICAL          44940       8160      45060
                  CENTER.
44T193.........  UNIVERSITY MEDICAL          45770       5360      34980
                  CENTER.
45T686.........  UNIVERSITY OF COLORADO      06150       4600      31180
                  HOSPITAL.
06T024.........  UNIVERSITY OF ILLINOIS      14141       2080      19740
                  MEDICAL CENTER AT
                  CHICAGO.
14T150.........  UNIVERSITY OF MICHIGAN      23800       1600      16974
                  HOSPITAL.

[[Page 30326]]

 
23T046.........  UNIVERSITY OF UTAH          46170       0440      11460
                  HOSPITAL.
46T009.........  UNIVERSITY OF               50160       7160      41620
                  WASHINGTON MED CTR.
50T008.........  UNIVERSITY                  25240       7600      42644
                  REHABILITATION CENTER.
25T001.........  UPMC HORIZON..........      39530       3560      27140
39T178.........  UPMC LEE REGIONAL           39160       7610      49660
                  REHAB UNIT.
39T011.........  UPMC MCKEESPORT.......      39010       3680      27780
39T002.........  UPMC NORTHWEST........      39730       6280      38300
39T091.........  UPMC PASSAVANT-             39010         39         39
                  REHABILITATION CENTER.
39T107.........  UPMC REHABILITATION         39010       6280      38300
                  HOSPITAL.
393042.........  UPMC SOUTHSIDE........      39010       6280      38300
39T131.........  UPMC ST MARGARET......      39010       6280      38300
39T102.........  UPPER VALLEY MEDICAL        36560       6280      38300
                  CENTER.
36T174.........  UTAH VALLEY REGIONAL        46240       2000      19380
                  MEDICAL CENTER-
                  REHABILITATION.
46T001.........  UVA-HEALTHSOUTH             49191       6520      39340
                  REHABILITATION
                  HOSPITAL.
493029.........  VALLEY BAPTIST HEALTH       45240       1540      16820
                  SYSTEM REHAB UNIT.
45T033.........  VALLEY HOSPITAL             29010       1240      15180
                  MEDICAL CENTER
                  REHABILITAION UNIT.
29T021.........  VALLEY MEMORIAL             05000       4120      29820
                  HOSPITAL.
05T283.........  VALLEY PRESBYTERIAN         05200       5775      36084
                  HOSPITAL.
05T126.........  VALLEY VIEW HOSPITAL..      06070       4480      31084
06T075.........  VALLEY VIEW REGIONAL        37610         06         06
                  HOSPITAL.
37T020.........  VAN MATRE HEALTHSOUTH       14991         37         37
                  REHABILITATION
                  HOSPITAL.
143028.........  VANDERBILT STALLWORTH       44180       6880      40420
                  REHAB HOSPITAL.
443028.........  VCUHS.................      49791       5360      34980
49T032.........  VERMILION                   19480       6760      40060
                  REHABILITATION
                  HOSPITAL.
193047.........  VIA CHRISTI                 17860       3880         19
                  REHABILITATION CENTER.
173028.........  VICTORIA WARM SPRINGS       45948       9040      48620
                  REHAB HOSPITAL.
453083.........  VICTORY MEMORIAL            33331       8750      47020
                  HOSPITAL.
33T242.........  VIRGINIA BAPTIST            49551       5600      35644
                  HOSPITAL.
49T021.........  VIRGINIA MASON MEDICAL      50160       4640      31340
                  CENTER.
50T005.........  VIRGINIA REGIONAL           24680       7600      42644
                  MEDICAL CENTER.
24T084.........  VISTA HEALTH ST.            14570       2240      20260
                  THERESE REHAB UNIT.
14T033.........  WACCAMAW                    42210       1600      29404
                  REHABILITATION CENTER.
42T098.........  WADSWORTH RITTMAN           36530         42         42
                  HOSPITAL.
36T195.........  WAKEMED REHAB.........      34910       1680      17460
34T069.........  WALTER O. BOSWELL           03060       6640      39580
                  MEMORIAL HOSPITAL.
03T061.........  WALTON REHABILITATION       11840       6200      38060
                  HOSPITAL.
113026.........  WARMINSTER HOSPITAL...      39140       0600      12260
39T286.........  WASHOE MEDICAL CENTER       29120       6160      37964
                  REHABILITATION
                  HOSPITAL.
29T049.........  WASHOE VILLAGE REHAB..      29150         29      16180
293030.........  WAUKESHA MEMORIAL           52660       6720      39900
                  HOSPITAL.
52T008.........  WAUSAU HOSPITAL.......      52360       5080      33340
52T030.........  WELDON CENTER FOR           22070       8940      48140
                  REHABILITATION.
22T066.........  WELLSTAR COBB HOSPITAL      11290       8003      44140
11T143.........  WELLSTAR KENNESTONE         11290       0520      12060
                  INPATIENT REHAB.
11T035.........  WENATCHEE VALLEY            50030       0520      12060
                  HOSPITAL
                  REHABILITATION CENTER.
50T148.........  WESLACO REHABILITATION      45650         50      48300
                  HOSPITAL.
453091.........  WESLEY REHABILITATION       17860       4880      32580
                  HOSPITAL.
173027.........  WESLEY WOODS GERIATRIC      11370       9040      48620
                  HOSPITAL.
11T203.........  WEST ALLIS MEMORIAL         52390       0520      12060
                  HOSPITAL.
52T139.........  WEST FLORIDA REHAB          10160       5080      33340
                  INSTITUTE.
10T231.........  WEST HOUSTON MEDICAL        45610       6080      37860
                  CENTER.
45T644.........  WEST JEFFERSON MEDICAL      19250       3360      26420
                  CENTER.
19T039.........  WEST TENNESSEE              44560       5560      35380
                  REHABILITATION CENTER.
44T002.........  WEST VIRGINIA REHAB         51190       3580      27180
                  HOSP.
513029.........  WESTCHESTER MEDICAL         33800       1480      16620
                  CENTER.
33T234.........  WESTERN PENNSYLVANIA        39010       5600      35644
                  HOSPITAL.
39T090.........  WESTERN PLAINS MEDICAL      17280       6280      38300
                  COMPLEX.
17T175.........  WESTLAKE HOSPITAL.....      14141         17         17
14T240.........  WESTMORELAND REGIONAL       39770       1600      16974
                  HOSPITAL.
39T145.........  WESTVIEW HOSPITAL.....      15480       6280      38300
15T129.........  WHITAKER                    34330       3480      26900
                  REHABILITATION CENTER.
34T014.........  WHITE COUNTY MEDICAL        04720       3120      49180
                  CENTER.
04T100.........  WHITE MEMORIAL MEDICAL      05200         04         04
                  CENTER.
05T103.........  WHITE RIVER MEDICAL         04310       4480      31084
                  CENTER.
04T119.........  WHITTIER                    22040         04         04
                  REHABILITATION
                  HOSPITAL.
223028.........  WHITTIER REHABILTATION      22170       1123      21604
                  HOSPITAL.
223033.........  WICHITA VALLEY              45960       1123      49340
                  REHABILITATION
                  HOSPITAL.

[[Page 30327]]

 
453088.........  WILLAMETTE VALLEY           38350       9080      48660
                  MEDICAL CENTER.
38T071.........  WILLIAM BEAUMONT            23620       6440      38900
                  HOSPITAL.
23T130.........  WILLIAM N. WISHARD          15480       2160      47644
                  MEMORIAL HOSPITAL.
39T045.........  WILLIAMSPORT HOSPITAL       39510       9140      48700
                  REHAB.
19T111.........  WILLIS-KNIGHTON             19080       7680      43340
                  MEDICAL CENTER.
45T469.........  WILSON N. JONES             45564       7640      43300
                  MEDICAL CENTER-MAIN
                  CAMPUS.
45T393.........  WILSON N. JONES             45564       7640      43300
                  MEDICAL CENTER-NORTH
                  CAMPUS.
49T005.........  WINCHESTER                  49962         49      49020
                  REHABILITATION CTR.
15T014.........  WINONA MEMORIAL             15480       3480      26900
                  HOSPITAL.
10T052.........  WINTER HAVEN HOSPITAL.      10520       3980      29460
33T239.........  WOMANS CHRISTIAN            33060       3610         33
                  ASSOCIATION.
33T396.........  WOODHULL MEDICAL            33331       5600      35644
                  CENTER.
45T484.........  WOODLAND HEIGHTS            45020         45         45
                  MEDICAL CENTER.
53T012.........  WYOMING MEDICAL CENTER      53120       1350      16220
50T012.........  YAKIMA REGIONAL.......      50380       9260      49420
07T022.........  YALE-NEW HAVEN              07040       5483      35300
                  HOSPITAL.
033034.........  YUMA REHABILITATION         03130       9360      49740
                  HOSPITAL.
45T766.........  ZALE LIPSHY UNIVERSITY      45390       1920      19124
                  HOSPITAL.
------------------------------------------------------------------------

[FR Doc. 05-10264 Filed 5-19-05; 4:00 pm]
BILLING CODE 4120-01-P