[Federal Register Volume 70, Number 156 (Monday, August 15, 2005)]
[Rules and Regulations]
[Pages 47880-48006]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-15419]



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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; Final Rule

  Federal Register / Vol. 70, No. 156 / Monday, August 15, 2005 / Rules 
and Regulations  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 412

[CMS-1290-F]
RIN 0938-AN43


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

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

ACTION: Final rule.

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SUMMARY: This final rule will 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 
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 implementing new policies and are changing 
existing policies regarding the prospective payment system within the 
authority granted under section 1886(j) of the Act.

DATES: These regulations are effective October 1, 2005. The updated IRF 
prospective payment rates are applicable for discharges on or after 
October 1, 2005 and on or before September 30, 2006 (FY 2006).

FOR FURTHER INFORMATION CONTACT: Pete Diaz, (410) 786-1235. Susanne 
Seagrave, (410) 786-0044. Mollie Knight, (410) 786-7948 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:

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. Summary of the FY 2006 Proposed Update to the IRF PPS
II. Provisions of the Proposed Regulations
III. Analysis of and Responses to Public Comments
IV. Research to Support Refinements of the Current IRF PPS
V. Refinements to the Patient Classification System
    A. 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. Changes to the Existing List of Tier Comorbidities
    1. Changes to Remove Codes That Are Not Positively Related to 
Treatment Costs
    2. Changes to Move Dialysis to Tier One
    3. Changes to Move Comorbidity Codes Based on Their Marginal 
Cost
    C. Changes to the CMGs
    1. Changes for Updating the CMGs
    2. Use of a Weighted Motor Score Index and Correction to the 
Treatment of Unobserved Transfer to Toilet Values
    3. Changes for Updating the Relative Weights
VI. FY 2006 Federal Prospective Payment Rates
    A. Reduction of the Standard Payment Amount to Account for 
Coding Changes
    B. Adjustments to Determine the FY 2006 Standard Payment 
Conversion Factor
    1. Market Basket Used for IRF Market Basket Index
    a. Overview of the RPL Market Basket
    b. Methodology for Operating Portion of the RPL Market Basket
    c. Methodology for Capital Proportion of the RPL Market Basket
    d. Labor-Related Share
    2. Area Wage Adjustment
    a. Revisions of the IRF PPS Geographic Classification
    b. Current IRF PPS Labor Market Areas Based on MSAs
    c. Core-Based Statistical Areas (CBSAs)
    d. Revisions of the IRF PPS Labor Market Areas
    i. New England MSAs
    ii. Metropolitan Divisions
    iii. Micropolitan Areas
    e. Implementation of the CBSA-Based Labor Market Areas
    f. Wage Index Data
    3. Teaching Status Adjustment
    4. Adjustment for Rural Location
    5. Adjustment for Disproportionate Share of Low-Income Patients
    6. Update to the Outlier Threshold Amount
    7. Budget Neutrality Factor Methodology for Fiscal Year 2006
    8. Description of the Methodology Used to Implement the Changes 
in a Budget Neutral Manner
    9. Description of the IRF Standard Payment Conversion Factor for 
Fiscal Year 2006
    10. Example of the Methodology for Adjusting the Federal 
Prospective Payment Rates
VII. Quality of Care in IRFs
VIII. Miscellaneous Comments Within the Scope of the Proposed Rule
IX. Miscellaneous Comments Outside the Scope of the Proposed Rule
X. Provisions of the Final Regulations
XI. Collection of Information Requirements
XII. Regulatory Impact Analysis

Acronyms

    Because of the many terms to which we refer by acronym in this 
final 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 (FIMTM is a 
registered trademark of UDSMR)
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

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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

    We received approximately 55 timely items of correspondence on the 
Inpatient Rehabilitation Facility Prospective Payment System for FY 
2006 proposed rule (70 FR 30188). Summaries of the public comments and 
our responses to those comments are set forth below under the 
appropriate section heading of this final rule.

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) of our regulations. 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 final rule as the 
standard payment conversion factor.
    For each of the tiers within a CMG, the relative weighting factors 
were 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 provide 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 http://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 final 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 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

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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.
    We published a proposed rule in the Federal Register (70 FR 30189) 
to update the IRF Federal prospective payment rates from FY 2005 to FY 
2006, and we proposed revisions to the methodology described in Sec.  
412.624.

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 
http://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 an alphanumeric CMG code 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 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 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 code, 
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. Summary of the FY 2006 Proposed Update to the IRF PPS

    In the FY 2006 proposed rule (70 FR 30188), we proposed a number of 
refinements to the IRF PPS case-mix classification system (the CMGs and 
the corresponding relative weights) and the case-level and facility-
level adjustments. The refinements that we proposed were based on 
analyses by RAND using calendar year 2002 and FY 2003 data.
    Several new developments warranted proposing these 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.
    Our proposals included the following key changes:
    The FY 2006 IRF PPS proposed rule (70 FR 30188, 30234 through 
30241) included a proposal to adopt OMB's Core Based Statistical Area 
(CBSA) market area definitions in a budget neutral manner. This 
geographic adjustment is made using a 1-year lag of the pre-
reclassification hospital wage index (FY 2001 hospital wage data).
    The FY 2006 proposed rule (70 FR 30188, 30222) also included a 
proposal to implement a payment adjustment to account for changes in 
coding. We proposed to reduce the standard payment amount by 1.9 
percent to account for changes in coding following implementation of 
the IRF PPS. The analysis conducted by CMS's contractor found that the 
real change in the case-mix was between negative 2.4 percent and 
positive 1.5 percent, with the rest of the change (between 1.9 percent 
and 5.8 percent) attributable to coding changes. CMS proposed to reduce 
the standard payment amount by the lowest of these estimates.
    In addition, in the FY 2006 proposed rule (70 FR 30188), we 
proposed modifications to the case mix groups, tier comorbidities, and 
relative weights. The proposed rule included a number of adjustments to 
the IRF classification system that are designed to improve the system's 
ability to predict IRF costs. The new data indicate that moving or 
eliminating some comorbidity codes from the tiers, redefining the case 
mix groups, and other minor changes to the system could improve the 
ability of the classification system to ensure that Medicare payments 
to IRFs continue to be aligned with the costs of care.
    In addition, the FY 2006 IRF PPS proposed rule (70 FR 30188, 30241) 
contained a proposal to implement a new teaching status adjustment for 
IRFs, similar to the one recently adopted for inpatient psychiatric 
facilities. We proposed to implement the teaching status adjustment in 
a budget neutral manner.
    The FY 2006 IRF PPS proposed rule (70 FR 30188, 30222) also 
contained a proposal to revise the market basket. We proposed to use a 
new market basket reflecting the operating and capital cost structures 
for rehabilitation, psychiatric, and long term care hospitals to update 
IRF payment rates. The proposed new market basket excludes cancer 
hospitals and children's hospitals. For the FY 2006 proposed rule (70 
FR 30188), we proposed a market basket increase for FY 2006 of 3.1 
percent.
    In the FY 2006 proposed rule (70 FR 30188, 30244 through 30246), we 
also proposed to update the rural adjustment (from 19.1 percent to 24.1 
percent), the low-income patient adjustment (from an exponent of 0.484 
to an exponent of 0.636), and the outlier threshold amount (from 
$11,211 to $4,911). We proposed to implement the changes to the rural 
and low-income percentage updates in a budget neutral manner.

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    Lastly, in the FY 2006 proposed rule (70 FR 30188), we estimated 
that the proposed changes would increase costs to the Medicare program 
for IRF services in FY 2006 by $180 million over FY 2005 levels. The 
estimated increased cost to the Medicare program was due to the 
estimated IRF market basket of 3.1 percent, the 1.9 percent reduction 
to the standard payment amount to account for changes in coding that 
affect total estimated aggregate payments, and the update to the 
outlier threshold amount. We proposed to make the changes to the IRF 
labor-related share and the wage indices, the case mix groups, tier 
comorbidities, and relative weights, the new IME adjustment, the 
updated rural adjustment, and the updated LIP adjustment in a budget 
neutral manner. Thus, these proposed changes would have no overall 
effect on estimated costs to the Medicare program.

II. Provisions of the Proposed Regulations

    In the FY 2006 proposed update to the IRF PPS (70 FR 30188), 
hereinafter referred to as the FY 2006 proposed rule, we proposed to 
make revisions to the regulations to implement the proposed PPS for 
IRFs for FY 2006 and subsequent fiscal years. Specifically, we proposed 
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 proposed 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).

B. Section 412.622 Basis of Payment

    In this section, we proposed to correct the cross references in 
paragraphs (b)(1) and (b)(2)(i). In paragraph (b)(1), we proposed to 
remove the cross references ``Sec.  413.85 and Sec.  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 proposed 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 this section, we proposed to make the following revisions:
     In paragraph (d)(1), remove the cross reference to 
``paragraph (e)(4)'' and add in its place ``paragraph (e)(5).''
     Add a new paragraph (d)(4).
     Redesignate paragraphs (e)(4) and (e)(5) as paragraphs 
(e)(5) and (e)(6).
     Add a new paragraph (e)(4).
     Revise newly redesignated paragraph (e)(5).
     Revise newly redesignated paragraph (e)(6).
     Add a new paragraph (e)(7).
     In paragraph (f)(2)(v), remove the cross references to 
``paragraphs (e)(1), (e)(2), and (e)(3) of this section'' and add in 
their place ``paragraphs (e)(2), (e)(3), (e)(4), and (e)(7) of this 
section.''

D. Additional Changes

    We also proposed the following changes:
     Reduce the standard payment amount 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.
     Implement a budget neutral 3 year hold harmless policy for 
FY 2005 rural IRFs redesignated as urban in FY 2006.
     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 
estimated 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 CMG and tier changes, 
the teaching status adjustment, and the updates to the rural and LIP 
adjustments in a budget neutral manner.

III. Analysis of and Responses to Public Comments

    As stated above, we received approximately 55 timely items of 
correspondence containing multiple comments on the FY 2006 proposed 
rule (70 FR 30188) from providers, health industry organizations, the 
Medicare Payment Advisory Commission, and others. In general, 
commenters expressed some concerns about our proposals in light of 
other changes occurring in the IRF PPS at this time and suggested that 
we wait to implement the proposals until other recent IRF policy 
changes are fully implemented. However, many commenters supported the 
proposed changes to the facility-level adjustments. Summaries of the 
public comments received on the proposed provisions and our responses 
to those comments are provided in the appropriate sections of the 
preamble of this final rule.

IV. Research To Support Refinements of the Current IRF PPS

    As described in the August 7, 2001 final rule, we contracted with 
the RAND Corporation 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.

1. History of RAND's Research on the IRF PPS

    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 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

[[Page 47884]]

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. The refinements we proposed to 
make to the IRF PPS, and which we are finalizing in this final rule, 
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.

2. Data Files Used for Analysis of the Current 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.
    Public comments and our responses on RAND's research to support the 
proposed refinements are summarized below:
    Comment: Several commenters expressed concerns about basing the 
refinements that we proposed in the FY 2006 proposed rule (70 FR 30188) 
on analyses of calendar year 2002 and FY 2003 data, which do not 
reflect IRF case mix changes currently taking place in response to our 
recent enforcement of the classification criterion, commonly known as 
the ``75 percent rule.'' These commenters suggested that we wait for 
analysis of future data (CY 2005 or beyond) to become available before 
implementing refinements to the IRF PPS.
    Response: As discussed in the August 7, 2001 final rule (66 FR 
41316), we used RAND's analysis of calendar year 1998 and 1999 Medicare 
Provider Analysis and Review (MedPAR) files and patient assessment data 
to develop the initial classification system and prospective payment 
amounts for the IRF PPS. These data were from a period of time before 
the IRF PPS when IRFs' reimbursement was based on costs, subject to 
certain limits, rather than on prospective payment amounts. 
Furthermore, we used the best available 1998 and 1999 data from a time 
period that also preceded enforcement of the 75 percent rule 
requirements. Today, we have 2002 and 2003 data that represents all 
Medicare-covered IRF cases in a post-PPS environment and, therefore, 
portrays a recent and complete picture of IRFs' patient populations. In 
addition, the IRF payment system has undergone a major transformation 
since the 1998 and 1999 data in the form of a change from a cost-based 
payment system to a PPS that became effective with the cost reporting 
periods beginning on or after January 1, 2002. Because of this 
transformation, we believe the data we have on which to base 
refinements to the IRF PPS will help ensure that IRF PPS payments 
accurately reflect the costs of care in an IRF.
    This is because these data allow RAND to obtain precision in their 
analyses, and ensures that the data are not over- or under-representing 
particular types of facilities or patients. We believe it is 
appropriate and necessary to implement refinements to the IRF PPS at 
this time, based on the best available data we have from calendar year 
2002 and FY 2003. Since analysis of this data indicates that we have an 
opportunity at this time, through the proposed refinements, to improve 
the alignment between IRF payments and the cost of care, we believe it 
is important to proceed with the refinements discussed in this final 
rule.
    However, we agree with the commenters that we should continue to 
collect the best available data we can to monitor the IRF PPS and 
ensure that IRF payments are appropriately aligned with costs of care 
and that Medicare patients continue to have appropriate access to IRF 
services. We will, whenever necessary, use the best data available in 
the future to propose appropriate refinements that will further improve 
the alignment between IRF payments and the costs of care. Thus, to the 
extent changes in case mix occur due to enforcement of the 75 percent 
rule, these changes should appear in later data that we will use to 
propose refinements in the future.
    Comment: Several commenters noted that 98 IRF providers in RAND's 
analysis data affiliated with HealthSouth decided to omit home office 
cost data from the 2002 and 2003 cost reports that were filed with us. 
The commenters questioned whether this omission might have affected the 
results of RAND's analysis and, therefore, our proposed policies.
    Response: After publication of the FY 2006 proposed rule (70 FR 
30188), we learned that 98 providers in our data file that were 
affiliated with HealthSouth omitted home office cost data from the 2002 
and 2003 cost reports that were filed with us and that RAND used in the 
analysis of the FY 2006 proposed rule (70 FR 30188). These data were a 
voluntary omission on the part of these providers, but nevertheless 
affect some of the distributional policies (that is, the proposed 
teaching status adjustment, the proposed changes to the rural and LIP 
adjustments, and the proposed change to the outlier threshold) 
contained in the proposed rule. However, because RAND used the 
hospital-specific relative value method (that is, the methodology that 
effectively controls for inter-hospital variation while estimating the 
relative costs of different types of patients within each hospital) for 
all of the proposed changes to the classification system described in 
section V of this final rule (that is, the proposed changes to the tier 
comorbidities, the proposed changes to the CMG definitions, the 
proposed weighted motor score methodology, the proposed change to the 
coding of the transfer-to-toilet item, and the proposed update of the 
relative weights), these proposed changes would not have been affected 
by the omission of the home office cost data. In other words, RAND 
examined the relative costs of patients within each IRF, so the fact 
that the omission of HealthSouth's home office costs caused total costs 
to be understated in the cost report data would not have mattered for 
the proposed classification system changes described in section V of 
this final rule.
    In addition, the omission of the home office cost data would have 
no effect on the proposed 1.9 percent reduction to the standard payment 
amount (discussed in section VI.A of this final rule) because cost 
report data were not

[[Page 47885]]

used in the analysis that supports this proposed reduction.
    Although the omission of the home office cost data, in theory, 
could have had some effect on the estimates of the proposed FY 2002-
based RPL market basket (discussed in section VI.B.1 of this final 
rule), our Office of the Actuary conducted some preliminary analyses of 
the effects on the market basket calculation and, based on these 
analyses, determined that these effects would likely be small. Home 
office costs represent only one of many cost categories (including, but 
not limited to, salaries, benefits, professional liability insurance, 
and pharmacueticals) that are used to develop the cost category 
weights. We believe the absence of HealthSouth home office costs in 
this market basket has a minor impact on the distribution of these 
weights and, by extension, the final market basket update itself. Thus, 
we did not believe it was necessary to recalculate the market basket.
    Finally, since the facility-level adjustments we proposed in the FY 
2006 proposed rule (70 FR 30188) were calculated using regression 
analysis based on the relative total costs associated with care in 
different types of IRFs (that is, urban/rural, teaching/non-teaching, 
low DSH percentage/high DSH percentage), the omission of HealthSouth's 
home office costs had some effect on the results of these analyses. The 
largest example is for the cost differential between urban and rural 
facilities in our analysis. Since the providers that omitted the home 
office cost data were largely urban facilities, their lower reported 
total cost data caused the differential between urban and rural 
facilities to be larger in the initial analyses. The same was true, to 
a lesser extent, with the teaching status adjustment and the LIP 
adjustment.
    Furthermore, the omission of the home office cost data caused 
overall reported costs to be lower in these facilities and, therefore, 
affected the cost-to-charge ratios computed for these facilities for 
FYs 2002 and 2003. We used these cost-to-charge ratios to determine the 
proposed update to the outlier threshold amount. Therefore, analysis of 
the data indicates that the outlier threshold amount we proposed in the 
FY 2006 proposed rule (70 FR 30188) was affected by the omission of the 
home office cost data.
    Given that the facility-level adjustments, such as the rural, LIP, 
and teaching status adjustments, and the outlier threshold amount for 
all IRFs were likely affected by the decision of this one large for-
profit chain provider to omit home office cost data from the FY 2002 
and FY 2003 cost reports, we believe it is appropriate for us to 
recalculate the values for these adjustments and for the outlier 
threshold using data that accounts for the omitted home office costs. 
Thus, we obtained the FY 2004 HealthSouth home office cost statement 
and, from this cost report statement, compiled the home office cost 
data for each of the individual HealthSouth IRF providers listed. Of 
the 98 providers that omitted home office cost data for FYs 2002 and 
2003, 92 of the providers have had home office cost data reported on 
the FY 2004 home office cost statement; and six providers did not have 
any home office cost information for FY 2004.
    We considered several options with respect to incorporating the 
missing HealthSouth home office costs into the data RAND used to 
conduct the analyses for this final rule. First, we considered the 
option of removing all of the HealthSouth cost report data from the 
analysis and re-computing the facility-level adjustments (that is, the 
rural adjustment, the LIP adjustment, and the teaching status 
adjustment) and the outlier threshold without the HealthSouth cost 
report data. Dropping all of the cost report data for 98 of the 1,188 
facilities in RAND's analysis file, especially when they are large 
urban facilities, would seem to skew the data even further because we 
would be leaving out a substantial amount of cost report data connected 
with one specific type of IRF provider (i.e., urban IRFs). Leaving out 
the data for these facilities would make other types of IRFs that are 
left in the data appear to have more of an effect on the regression 
analysis than they actually do. Since we were hoping to reduce the bias 
in the data, rather than increase the bias, we generally rejected this 
option.
    The second option we considered was to update the analysis using FY 
2004 data for all providers and re-compute the facility-level 
adjustments and the outlier threshold using the FY 2004 cost report 
data. Unfortunately, the FY 2004 data have only recently been submitted 
by all IRF providers, and it would have been impossible for RAND and 
CMS to have completed all the necessary re-analysis of all of the 
proposed policies with the FY 2004 cost report data for all IRF 
providers in time for the proposed policies to be implemented in FY 
2006.
    The third option we considered was to use the FY 2004 home office 
cost data that we were able to obtain from the HealthSouth home office 
cost statement for 92 of the 98 HealthSouth IRF providers, standardize 
all of the other cost report data from FY 2003 for the 98 HealthSouth 
providers and the other non-HealthSouth providers using the most recent 
market basket for FY 2004, and fill in the FY 2004 home office cost 
data for the 92 HealthSouth providers for which we had data. This 
option enabled us to meet the October 1 implementation date of our 
updates as well as to make those updates and payment adjustments as 
accurate as possible. Next, we considered two options for treating the 
six HealthSouth facilities for which we did not have FY 2004 home 
office cost data: We considered leaving those six IRFs' cost data as 
is, without adding any home office cost data since we had none from FY 
2004 to add. The other option we considered for treating these six 
facilities was to take the average home office costs as a percentage of 
total costs for the 92 facilities (which came to approximately 13 
percent) and use this as an estimate of home office costs for the 6 
facilities. We chose the second of the two options, which meant that we 
inflated total costs for those six facilities by the average of about 
13 percent, because it seemed inappropriate to ignore the fact that 
cost data was missing for these six facilities and 13 percent appeared 
to be a reasonable estimate of home office costs generally for IRFs 
(from the general analysis we were able to perform).
    Because we believe the data file that results from the third option 
is more complete than the data RAND previously used to compute the 
proposed facility-level adjustments and the proposed outlier threshold 
amount for the FY 2006 proposed rule (70 FR 30188), we used the data 
from the third option described above to re-compute the values for the 
teaching status adjustment (described in more detail in section VI.B.3 
of this final rule), the rural adjustment (described in more detail in 
section VI.B.4 of this final rule), the LIP adjustment (described in 
more detail in section VI.B.5 of this final rule), and the outlier 
threshold amount (described in more detail in section VI.B.6 of this 
final rule). Because the values of these adjustments have changed, we 
also re-computed the budget neutrality factors and, thus, the standard 
payment conversion factor.
    Comment: Several commenters requested that we make IRF claims data, 
IRF-PAI data, patient-specific CMG data, and cost report files 
available to the public so that the public would have the opportunity 
to recreate the analyses used in developing the proposed refinements 
for the FY 2006 proposed rule (70 FR 30188).
    Response: The data files mentioned by the commenters are generally 
available (and were generally available

[[Page 47886]]

during the comment period for the FY 2006 proposed rule (70 FR 30188)) 
to the public through CMS's standard data distribution systems. More 
information on CMS's data distribution policies is available on CMS's 
website at http://www.cms.hhs.gov/researchers/statsdata.asp.
    Comment: A few commenters requested that we make available RAND's 
research using FY 2003 data. They noted that 3 of the 4 reports 
published on RAND's website for public access are based on analysis of 
calendar year 2002 data. One of RAND's publicly available reports is 
based on analysis of FY 2003 data.
    Response: We asked RAND to use the best available, most current 
data possible for the analyses contained in the FY 2006 proposed rule 
(70 FR 30188) and this final rule. This was generally FY 2003 data.
    The updated analysis is generally not contained in RAND's reports, 
and RAND has indicated to CMS that they have no plans to publish the 
updated analyses (using the FY 2003 data) after publication of the 
final rule. However, RAND informed us that, in all of the FY 2003 
analyses for the FY 2006 proposed rule (70 FR 30188) and for this final 
rule, they used the identical methodologies presented in the reports 
available on RAND's website and reviewed by RAND's technical expert 
panel. The only change was that RAND used updated data from FY 2003 
(and FY 2004 HealthSouth home office cost data, as discussed above). 
Thus, interested parties should examine the reports available on RAND's 
website for the detailed methodology used to develop the proposed and 
final revisions. In addition, interested parties may contact RAND 
directly for more information regarding the analysis of FY 2003 data.
    Comment: One commenter asked whether a large number of short period 
cost reports for periods ending in 2001 might have affected RAND's 
research findings and, if so, how RAND handled this issue in the data.
    Response: We were unable to find any reasons for the unusually 
large number of short period cost reports the commenter is indicating 
for cost report periods ending in 2001. However, since some of RAND's 
analysis for this final rule was based on calendar year 2002 data, and 
the majority of RAND's analysis for this final rule was based on FY 
2003 data, we do not believe that a spike in the number of short period 
cost reports in 2001 would have had an effect on RAND's analyses.

V. Refinements to the Patient Classification System

A. 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

[[Page 47887]]

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. Therefore, we are removing these codes from 
the tiers that increase payment.

c. Comorbidities

    Under the statutory authority of section 1886(j)(2)(C)(i) of the 
Act, we proposed 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 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 final rule as we 
indicated in the FY 2006 proposed rule (70 FR 30188), 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 less 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.

[[Page 47888]]

For the FY 2006 proposed rule (70 FR 30188) and this final rule, 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.
    Our methodology for determining the IRF classification system 
remains unchanged from the August 7, 2001 final rule.

B. Changes to the Existing List of Tier Comorbidities

1. Changes To Remove Codes That Are Not Positively Related to Treatment 
Costs
    While our methodology for this final rule for determining the tiers 
remains unchanged from the August 7, 2001 final rule, as we indicated 
in the FY 2006 proposed rule (70 FR 30188), 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, as we proposed in the FY 2006 proposed rule (70 FR 30188) we are 
implementing 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 additional two 
codes were also problematic. According to RAND, code 410.91 (AMI, NOS, 
Initial) was not specific enough to be differentiated from other 
related codes and code 260, Kwashiorkor, was found to be 
unrealistically represented in the data according to the 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 no 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.X1, 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. Thus, 
as we indicated in the FY 2006 proposed rule (70 FR 30188), we proposed 
to remove ``AMI, NOS, initial'' from the tier list because it is not 
positively related to treatment cost after controlling for the CMG. In 
addition, for similar reasons, we proposed in the FY 2006 proposed rule 
(70 FR 30188) to remove ``Specific AMI, initial from the tier list 
since it is indistinguishable from ``AMI, NOS, initial.''
    As we proposed in the FY 2006 proposed rule (70 FR 30188), with 
respect to the last code in Table One (Kwashiorkor), we are removing 
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 as we proposed in the 
FY 2006 proposed rule (70 FR 30188), we are removing these two 
malnutrition codes. As we stated in the FY 2006 Proposed Rule (70 FR 
30188), removal of these 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, they will be removed.
    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.
    As we proposed in the FY 2006 proposed rule (70 FR 30188), we are 
finalizing changes to our initial list of diagnoses that 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 in order 
to receive a higher payment. Finally, the new data indicate that DX 
V55.0, ``attention to tracheostomy'' should be 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. 
Therefore, we are finalizing our proposal to remove the RIC 15 
exclusion for code V55.0 (attention to tracheostomy) so that code V55.0 
can receive appropriate payment for the additional costs it incurs.
    As we stated in the FY 2006 proposed rule (70 FR 30188), 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 finalizing our 
proposed policy to remove these codes from the tier list.

        Table 1.--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.....  Esophageal conditions.
530.6.............  Acquired esophag           Esophageal conditions.
                     diverticulum.

[[Page 47889]]

 
V46.1 *...........  Dependence on respirator.  Ventilator status.
799.4.............  Cachexia.................  Cachexia.
V49.75............  Status amputation below    Amputation of LE.
                     knee.
V49.76............  Status amputation above    Amputation of LE.
                     knee.
V49.77............  Status amputation hip....  Amputation of LE.
356.4.............  Idiopathic progressive     Meningitis and
                     polyneuropathy.            encephalitis.
250.90............  Diabetes II, w             Non-renal complications
                     unspecified                of diabetes.
                     complications, not
                     stated as uncontrolled.
250.93............  Diabetes I, w unspecified  Non-renal complications
                     complications,             of diabetes.
                     uncontrolled.
261...............  Nutritional Marasmus.....  Malnutrition.
262...............  Other severe protein       Malnutrition.
                     calorie deficiency.
410.91............  AMI, NOS, initial........  Major comorbidities.
410.X1............  Specific AMI, initial....  Major comorbidities.
260...............  Kwashiorkor..............  Malnutrition.
------------------------------------------------------------------------
* V46.11 and V46.12 were not in existence when the data used in the
  analysis was collected. Since these codes are subcategories of code
  V46.1 (the code we proposed to remove from the tiers that make
  additional payment), they will be removed from the comorbidity tiers
  as well.

    We received numerous comments on the proposed changes to the 
existing list of tier comorbidities which are summarized below:
    Comment: One commenter remarked that kwashiorkor should be omitted 
from the list of comorbidities to be deleted from the list of 
comorbidities that increase the payment rate of the CMG because some of 
the software packages used by the industry allow this code to be used 
for the coding of the inpatient's comorbidities.
    Response: We disagree with the commenter. Kwashiorkor is a severe 
malnutrition of infants and young children, primarily in tropical and 
subtropical regions, caused by deficiency in the quality and quantity 
of protein in the diet. It is characterized by anemia, edema, potbelly, 
loss of pigment in the skin, hair loss or change in hair color, 
hypoalbuminemia, and bulky stools containing undigested food. In 
addition, an inpatient with this condition most likely would not be 
able to receive the three hours of intensive rehabilitation that is a 
qualifying guideline to be an inpatient within an IRF. While protein 
deficiencies may be noted in patients within an IRF, by definition, the 
incidence of Kwashiorkor could not be as high as reported. Also, as 
previously stated, RAND's TEP reported that the data indicate large 
variation in the rate of increase across conditions. However, coding of 
malnutrition increased by more than 10 times, and RAND found the large 
number of cases coded with this rare disease to be unrealistic and 
recommended that it be removed from the tier list. Consequently, 
kwashiorkor will be eliminated from the list of comorbidities that 
increase the payment rate of the CMG.
    Comment: One commenter wrote that code V46.1 is listed in the 
proposed list of codes to be removed from the tier list. Since this 
code contains two other codes, the commenter wanted to know if it is 
our intention to remove both codes in this category, namely V46.11 
(Dependence on respirator, status) and V46.12 (Encounter for respirator 
dependence during power failure) or just one of these codes.
    Response: First, we want to explain how codes V46.11 and V46.12 
became codes that are used to increase the CMG payment rate. In the 
August 7, 2001 final rule (66 FR 41316), we published Appendix C that 
listed the ICD-9-CM comorbid condition codes which are used to increase 
the CMG payment rate. The ICD-9-CM codes of the comorbid conditions are 
recorded by the IRF's staff on the IRF-PAI, and that data as well as 
some other data recorded on the IRF-PAI is used to classify an 
inpatient into a CMG payment rate. One of the codes we published as 
part of Appendix C was V46.1. Each year the codes used in the ICD-9-CM 
coding system undergo a review resulting in updates to some of the 
existing codes. In accordance with a review that updated the ICD-9-CM 
coding system V46.11 and V46.12 were added to the ICD-9-CM coding 
system as subcategories of V46.1. We believe that the comorbid 
condition represented by the code V46.11 or V46.12 is a derivative of 
the comorbid condition represented by the code V46.1. Therefore, in 
2005 we updated the CMG grouper software which resulted in the CMG 
payment being increased by the same amount if the IRF-PAI data of an 
inpatient included codes V46.1, or V46.11, or V46.12.
    The analysis that our data contractor performed, using certain data 
after the IRF PPS was implemented, shows that the comorbid condition 
represented by code V46.1 does not have an effect upon treatment cost 
after controlling for the CMG. Therefore, code V46.1 and its derivative 
codes that comprise it (V46.11 and V46.12) will be removed from the 
list of codes that are used by the IRF PPS to increase the CMG payment 
rate.
    Comment: Several commenters urged us to consider not removing codes 
V49.75, V49.76, and V49.77 from the list of comorbidity codes that 
increase the CMG payment because of concerns with the complexity of a 
patient with an amputation.
    Response: After controlling for the CMG, RAND found that these 
codes do not impact cost. Further, IRFs do not incur additional costs 
to treat these comorbidities after controlling for the CMG. This means 
that the CMG to which the inpatient is assigned, already accounts for 
the costs associated with the treatment of inpatients with an 
amputation and no additional payment is needed beyond the CMG amount to 
adequately reimburse for such a case. Therefore we are removing these 
codes from the list of comorbidities that increase the CMG payment.
    Comment: Several commenters mentioned a concern with the code 
V497.7 in the table of codes to be removed. They believed it to be a 
typographical error where the actual code to be removed is V49.77.
    Response: We agree with the commenters and have made the correction 
to the typographical error. The corrected code to be removed is V49.77.
    Comment: Several commenters noted that there is a discrepancy with 
code 428.3 (vocal cord paralysis, not otherwise specified) in CMS' list 
of

[[Page 47890]]

codes being reassigned based on their marginal cost in the Comorbidity 
Tier Reassignment Changes File found at http://www.cms.hhs.gov/providers/irfpps/fy06nprm.asp. They stated that it should actually be 
code 478.30 (vocal cord paralysis, not otherwise specified).
    Response: We agree with the commenters and shall make the 
appropriate corrections to the typographical error within the file.
    Comment: Several commenters noted an error with the description of 
meningitis and encephalitis for code 356.4 in the Comorbidity Tier 
Reassignment Changes File found at http://www.cms.hhs.gov/providers/irfpps/fy06nprm.asp.
    Response: We agree with the commenters and the description will be 
amended to read idiopathic progressive polyneuropathy for code 356.4.
    Comment: Commenters expressed concern for the removal of codes 
530.0 (achalasia and cardiospasm), 530.3 (stricture and stenosis of 
esophagus) and 530.6 (diverticulum of esophagus) that are used to 
record esophageal conditions because of costs associated with these 
conditions and requested that they not be removed from the tier list 
which increases payment for these comorbidities.
    Response: After controlling for the CMG, RAND found that these 
comorbidities do not positively impact costs, meaning that the CMG 
encompasses sufficient payment to compensate for these comorbidities. 
Therefore, we are removing codes 530.0, 530.3 and 530.6 from the list 
of comorbidities that increase CMG payment.
    Comment: Several commenters agreed with CMS' proposed policy to 
remove malnutrition codes 261 (nutritional marasmus) and 262 (other 
severe protein-calorie malnutrition), while others opposed the proposed 
policy to remove these codes. In addition, several commenters suggested 
that CMS examine the impact of malnutrition on increasing the length of 
stay within an IRF.
    Response: We acknowledge both opinions as expressed by the 
different commenters. The RAND TEP, and our Medical Officers, believes 
these codes are drastically overstated and inpatients with these levels 
of malnutrition would not be candidates for three hours of intensive 
therapy. In addition, after controlling for the CMG, both of these 
codes do not positively affect payment. Therefore we believe it is 
appropriate to remove malnutrition codes 261 and 262 from the list of 
comorbidity codes that are used to increase the CMG payment rate. 
Additionally, we will continue to examine the impact of comorbidities, 
including malnutrition, upon IRF Medicare-covered inpatients.
    Comment: One commenter suggested adding codes 250.91 and 250.92 to 
the list of comorbidities to be removed from the list of codes used to 
increase payment because they believe those codes to be similar in 
description to codes 250.90 and 250.93.
    Response: Only the first 17 codes within Table 1 were found to have 
no positive effect on cost after controlling for the CMG. The data 
analysis performed by RAND does not indicate that at this time 250.91 
and 250.93 should be removed from the list of codes used to increase 
the CMG payment rate because they continue to positively affect costs. 
Therefore we believe it is inappropriate to remove them from the list 
of comorbidities that impact cost. Consequently, we are not removing 
any other codes from the list of codes used to increase the CMG payment 
rate.
    Comment: One commenter recommended that several codes be added to 
our comorbidity tier system based upon suggestions from the RAND TEP, 
namely codes 428.0 (congestive heart failure), V43.3 (heart valve 
replacement), 250.1 (insulin dependent diabetes without mention of 
complications, not stated as controlled) and 438.2X (hemi-paresis due 
to an old stroke).
    Response: After examining the RAND recommendations, our Medical 
Officers felt that codes V43.3 and 438.2X were too vague and non-
descript to capture the necessary information needed for these codes to 
be added to the list of codes used to increase the CMG payment rate. 
However, in response to the comments our Medical Officers re-evaluated 
the effect on cost by the comorbid condition represented by code 250.1 
(insulin dependent diabetes without mention of complications, not 
stated as controlled). They determined that code 250.1 should be added 
to the list of codes used to increase the CMG payment rate. They also 
determined that the code should be a tier 3 code because the other 250 
series of codes related to diabetes are in tier 3. Therefore, this code 
will be added as a tier 3 code to the list of codes used to increase 
the CMG payment rate. There will be no excluded RICs with code 250.1. 
After examining the comments, our Medical Officers continue to believe 
that 428.9 (heart failure, unspecified), was too non-descript and 
should not be added to the list of codes that can increase payment. 
However, our Medical Officers agree with the commenter regarding other 
numerous congestive heart failure codes including Code 428.1--Left 
Heart Failure, Code 428.20--Systolic Heart Failure Unspecified, Code 
428.21--Systolic Heart Failure Acute, Code 428.22--Systolic Heart 
Failure Chronic, Code 428.23--Systolic Hear Failure Acute on Chronic, 
Code 428.30--Diastolic Heart Failure Unspecified, Code 428.31--
Diastolic Heart Failure Acute, Code 428.32--Diastolic Heart Failure 
Chronic, Code 428.33--Diastolic Heart Failure Acute on Chronic, Code 
428.40--Combined Systolic and Diastolic Heart Failure Unspecified, Code 
428.41--Combined Systolic and Diastolic Heart Failure Acute, Code 
428.42--Combined Systolic and Diastolic Heart Failure Chronic, and Code 
428.43--Combined Systolic and Diastolic Heart Failure Acute on Chronic, 
largely due to the increased costs associated with these codes. 
Therefore, these 428 cardiac codes will be added to the list of codes 
used to increase the CMG payment rate as tier 3 codes because of their 
similarity to certain cardiac codes with respect to resource 
utilization. However, these codes will not be used to increase the CMG 
payment rate if the CMG code is one of the CMG codes derived from RIC 
14 (the cardiac RIC) because these cardiac codes costs have been 
accounted for in the CMGs associated with RIC 14.
    Comment: A commenter believes that the CMG payment rate should 
include an adjustment for mental health problems, such as a depression. 
The commenter believes that a patient's mental health status has an 
effect on the patient treatment costs an IRF incurs.
    Response: The significance and appropriateness of a patient's state 
of mental health in response to an impairment that requires a patient 
to undergo intensive inpatient rehabilitation is a subject that we 
believe requires further study. Additional study will help to determine 
the effect of the patient's state of mental health on treatment costs. 
An ICD-9-CM code may be used to show that a patient is exhibiting signs 
that a rehabilitation clinician believes indicate a mental disorder. 
However, quantifying by use of ICD-9-CM codes the association between a 
patient's state of mental health and how it affects a patient's 
response to rehabilitation treatment is at best limited. For example, 
we believe that in response to a stroke or hip fracture, or some other 
impairment, a situational depression may be a rational response. 
However, that does not mean that the IRF will incur additional costs 
that were not already taken into account when the CMG payment rates 
were developed. In addition, mental disorders vary greatly

[[Page 47891]]

in severity as does how a patient's functioning is affected by a mental 
disorder.
    There would have to be multiple factors taken into consideration 
before any type of mental disorder could be added to the list of 
comorbidities that would increase payment of the CMG. The data for a 
complete psychiatric evaluation must be made available to correctly 
code for these comorbidities. In addition, this is a budget neutral 
system, and no additional funding will be added to the system. Under 
our final rule, funds will not be added but simply be redistributed 
among the comorbidities among the tiers that increase payment. This is 
because the changes associated with the comorbidity tiers and CMGs are 
done in a budget neutral manner. On the assumption that there is an 
even distribution of these psychiatric patients among IRFs, and these 
patients may receive the redistributed payment, the addition of these 
codes may not contribute to an increased payment for inpatients with 
these comorbid conditions and may affectively lower payments for CMG's 
with other comorbid conditions because the same amount of funding is 
distributed across more comorbid conditions. Also, few IRFs have 
psychiatric personnel and rehabilitation doctors rarely have the time 
required to observe the patient to make a complete psychiatric 
evaluation and thus some codes may be assigned (or not assigned) in 
error. In addition, RAND's TEP believed that it would be inappropriate 
to use ICD-9-CM diagnoses to identify patients with affective 
disorders. Therefore, in this final rule, we are not adding codes for 
depression and mental disorders to the list of codes used to increase 
payment.
    Comment: We received comments to both challenge and support the 
removal of certain comorbidity codes from the tier list including code 
799.4 Cachexia, and code 933.1 (foreign body in larynx). Commenters 
stated that these conditions required more resources, and thus 
increased treatment costs. The other commenter stated that the CMG 
already covered these costs.
    Response: The data analysis did not show that the comorbid 
conditions indicated by these codes increased the costs of treating an 
inpatient with these comobidities after controlling for the CMG because 
their CMG payment rate covers costs associated with their corresponding 
treatment. The more recent RAND analysis found that after controlling 
for the CMG, these comobidities do not impact cost. Therefore, we are 
removing them from the comorbidity tiers that would increase payment.
    Comment: One commenter made a general statement stating that the 
list of comorbidities that comprise the tiers do not reflect the 
challenges that contribute to higher costs in the rehabilitation 
setting.
    Response: We disagree with the commenter because the RAND 
regression analyses show that the comorbid conditions that comprise the 
tiers positively impact cost and provide additional payments for 
services not included in the payment associated with the CMG.
    Final Decision: In this final rule, we are adopting the proposal to 
remove the comorbidity tier codes set forth in Table 1 of the FY 2006 
proposed rule (70 FR 30188). We are also removing codes V46.11 and 
V46.12 because they are subcategories of code V46.1, which has been 
found to have no impact on cost after controlling for the CMG. We are 
adding several codes that the RAND analyses found to positively impact 
costs. We chose to add codes 250.1 (insulin dependent diabetes without 
mention of complications, not stated as controlled), as well as 
numerous congestive heart failure codes including Code 428.1--Left 
Heart Failure, Code 428.20--Systolic Heart Failure Unspecified, Code 
428.21--Systolic Heart Failure Acute, Code 428.22--Systolic Heart 
Failure Chronic, Code 428.23--Systolic Heart Failure Acute on Chronic, 
Code 428.30--Diastolic Heart Failure Unspecified, Code 428.31--
Diastolic Heart Failure Acute, Code 428.32--Diastolic Heart Failure 
Chronic, Code 428.33--Diastolic Heart Failure Acute on Chronic, Code 
428.40--Combined Systolic and Diastolic Heart Failure Unspecified, Code 
428.41--Combined Systolic and Diastolic Heart Failure Acute, Code 
428.42--Combined Systolic and Diastolic Heart Failure Chronic, and Code 
428.43--Combined Systolic and Diastolic Heart Failure Acute on Chronic, 
which our Medical Officers believe were specific enough to be used in 
our list of codes that are used to increase the CMG payment amount.
2. Changes To Move Dialysis to Tier One
    As we proposed in the FY 2006 proposed rule (70 FR 30188), we are 
finalizing the movement of dialysis from comorbidity tier two to 
comorbidity tier one, which is the tier associated with the highest 
payment. The data from the RAND analysis show that patients on dialysis 
cost more than the tier payment to which dialysis is currently 
assigned, 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, 
which was the previous data analysis time period(because providers were 
previously permitted to bill for dialysis separately). 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 the time periods used for the data analysis, 170 
percent more patients needed dialysis when compared to the time period 
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 better and more 
carefully coded comorbidities whose presence resulted in higher PPS 
payments.
    Therefore we are moving dialysis patients to comorbidity tier one 
will more adequately compensate IRFs for the extra cost of those 
patients and thereby maintain or increase access to these services.
    Comment: A number of commenters supported our decision to move 
dialysis patients to tier one due to the increase cost of dialysis 
patients.
    Response: We agree with these commenters. The data analyses 
performed by RAND found evidence that suggested that a dialysis patient 
cost 31 percent more than a non-dialysis patient in the same CMG. 
Therefore, as proposed in the FY 2006 proposed rule (70 FR 30188), we 
are moving dialysis to tier 1 because the additional payment associated 
with tier 1 more closely approximate the additional costs associated 
with the treatment of an inpatient with this condition.
    Final Decision: As proposed in the FY 2006 proposed rule (70 FR 
30188), we are adopting the decision to move dialysis patients to 
comorbidity tier one.

[[Page 47892]]

3. Changes To Move Comorbidity Codes Based on Their Marginal Cost
    Under section 1886(j)(2)(C)(i) of the Act, as was proposed in the 
FY 2006 proposed rule (70 FR 30188), we are refining how we pay for a 
comorbidity based on marginal cost. A commonly understood definition of 
marginal cost is the increase or decrease in costs as a result of one 
higher or lower unit of a good or service. In this situation, we are 
reassigning comorbidities to tiers based on their marginal costs, and 
by this we mean the increase or decrease in costs as a result of one 
higher or lower comorbidity tier. Payment for several comorbidities 
would be more accurate if their tier assignments were changed, and 
after examining RAND's data, we believe that of the FY 2003 cases, a 
full 4 percent of cases should be associated with comorbidity tiers 
that have a lower payment than the comorbidity tiers to which they were 
assigned. Therefore, comorbidities would be more accurate if their tier 
assignments were more appropriately based on their marginal costs.
    As we proposed in the FY 2006 proposed rule (70 FR 30188), 
comorbidity tier assignments in this final rule are based on the 
results of statistical analyses RAND has performed under contract with 
CMS, using as independent variables only the CMGs and conditions for 
tiers. As we proposed in the FY 2006 proposed rule (70 FR 30188), tier 
assignments of each of these conditions for the final rule are 
determined 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 according to the 
data used to define the comorbidity tiers (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 recording of a tier one 
comorbidity, the highest paid of the tiers, almost quadrupled during 
this same time period. Although, improved coding likely increased the 
recording of comorbidities, those coding the comorbidities may have 
been motivated by the objective to use coding changes as a means to 
increase the CMG payment.
    The 2003 data provides an excellent comprehensive picture of the 
costs that are associated with each of the comorbidities. We believe 
this because CMS has data for 100 percent of the Medicare-covered IRF 
cases. Therefore, as we indicated in the FY 2006 proposed rule, we 
believe that using the 2003 data to assign the comorbidities to a 
payment tier ensures heightened accuracy with respect to the matching 
of payments to relative costs of a case.
    We received several comments on the proposed changes to the 
existing list identifying which tier is associated with a particular 
comorbidity. The public comments are summarized below.
    Comment: One commenter suggested that we postpone reassigning 
comorbidity tiers based on their marginal costs, and again instead 
perform the data analysis used to reassign the comorbidity codes based 
on marginal costs using more current data.
    Response: This final rule reflects the most recent analysis of 
data. In the future, we will continue to perform data analyses and, as 
necessary, adjust the payment rates to achieve the most accurate 
payment. In this final rule, we are adopting the policy we proposed in 
the FY 2006 proposed rule (70 FR 30188), and reassigning comorbidities 
to tiers based on their marginal cost because we believe that this 
reassignment is based on the best comprehensive post-PPS implementation 
data that are available at this time.
    Comment: One commenter recommended that we not reassign any 
comorbidity codes based on their marginal costs under the premise that 
there is no concrete evidence of upcoding.
    Response: Taking into consideration that we believe that there has 
been improved coding due to prospective payment based system, the 
recommendations of RAND's technical expert panel, and the guidance of 
our Medical Officers, we believe that the comorbidity codes should be 
assigned based on their marginal costs in order to increase the 
association between costs and payment.
    Final Decision: In summary, we are adopting all of the proposals 
set forth in the FY 2006 proposed rule (70 FR 30188), with regard to 
the removal of the list of codes from comorbidity tiers that increase 
payment, the movement of dialysis patients to tier one, the code V55.0 
will no longer be excluded from RIC 15, and comorbidity codes will now 
be reassigned based on their marginal costs.

C. 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 the FY 2006 proposed rule (70 FR 30188, 30196), 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 proposed to 
update the CMGs used to classify IRF patients for purposes of 
establishing payment amounts. We also proposed to update the relative 
weights associated with the payment groups based on FY 2003 Medicare 
bill and patient assessment data. We proposed replacing 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 proposed not 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 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 assessment 
instrument was used to collect patient data, the IRF Patient Assessment 
Instrument (IRF-PAI). The new instrument contained items 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

[[Page 47893]]

rehabilitation patients from just a sample of hospitals (the best 
available data at the time). Now, we have post-PPS data from 2002 and 
2003 that describe the entire universe of Medicare-covered 
rehabilitation patients.
    Finally, we believe that 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 the inpatient rehabilitation facility assessment instrument 
before the PPS, which is commonly referred to as the FIM, 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 starting 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 putting on clothing, and 5 cognitive tasks, 
such as memory. 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 for a 
particular case would be less than the costs of providing care, so an 
IRF may try to 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 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 IRFs. The more recent data contain 523,338 IRF cases 
(fiscal year 2003), representing all Medicare-covered patients in 
participating IRFs. The larger file enables RAND to obtain greater 
precision in the analysis and portrays a more recent and complete 
picture of patients under the IRF PPS.
    Also, the fiscal year 2003 data 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. Changes for Updating the CMGs
    In the FY 2006 proposed rule (70 FR 30188), we proposed to revise 
the definitions of the CMGs based on regression analysis by RAND of the 
FY 2003 data. As described in the August 7, 2001 final rule, RAND 
developed the original list of CMGs using FIM data from 1998 and 1999 
(see the FY 2006 proposed rule (70 FR 30188, 30198 through 30202) for a 
table of the original CMG listing).
    Given the availability of more recent, post-PPS data, 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 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.
    As we explained in the FY 2006 proposed rule (70 FR 30188), RAND's 
analysis of the FY 2003 data, along with the support and guidance of 
the TEP, strongly suggested the need to update the CMGs to better align 
payments with costs under the IRF PPS. The other option we considered 
before proposing 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), as we stated in 
the FY 2006 proposed rule (70 FR 30188), we believed and continue to 
believe (based on RAND's analysis) that updating both the relative 
weights and the CMGs will allow the classification system to do a 
better job of reflecting changes in treatment patterns, technology, 
case mix, and other factors which may affect the relative use of 
resources.
    We continue to believe it is appropriate to update both the CMGs 
and the relative weights at this time because the 2003 data we now have 
represent a more recent and broader set of data elements. The more 
recent data include all Medicare-covered IRF cases rather than a 
subset, allowing us to base the 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 may not have contained a complete 
picture of the types of patients in IRFs. Also, the improved clinical 
coding of patient conditions in IRFs is better reflected 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.
    Prior to the finalization of the proposed changes contained in this 
final rule, we paid 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

[[Page 47894]]

the implications of variations to the CART models because an individual 
person is not able to examine as many variations of a model in as short 
a period of time as a computer program. 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 CMGs (the 
new algorithm would be based on the CART methodology described in 
detail in section V.A.2.b of this final rule). RAND applied the new 
algorithm to the fiscal year 2003 IRF data. In the FY 2006 proposed 
rule (70 FR 30188), we proposed to use RAND's new algorithm for 
refinements to the CMGs. The algorithm is 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 new CART algorithm produces all of the possible 
combinations of CMGs using all available variables. It then selects the 
variables and the CMG constructions that offer the best predictive 
ability, as measured by the greatest decrease in the mean-squared 
error. We proposed to place the following constraints 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 are the most substantial differences between the CMGs 
used prior to October 1, 2005 and the proposed new CMGs for FY 2006:
     Fewer CMGs than before (87 now compared with 95 in the 
prior system). The 5 special CMGs for very short stay cases and cases 
in which the patient expires would remain unchanged.
     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 previously 
affected 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 previously affected assignment for CMGs in 
RICs 1 and 4.
    The primary objective in updating the CMGs is to better align IRF 
payments with the costs of caring for IRF patients, given 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 variance in the system.
    Public comments and our responses on the proposed changes for 
updating the CMGs are summarized below.
    Comment: Several commenters raised concerns that the FY 2003 data 
used to update the CMGs did not reflect the full enforcement of the 75 
percent rule and that CMS should, therefore, wait until the data 
reflect full enforcement before making any changes to the CMGs.
    Response: We agree that additional changes to the CMGs may 
potentially be necessary in the future if enforcement of the 75 percent 
rule results in substantial changes to IRFs' patient populations. 
However, we believe it is now appropriate to begin refining the system 
because several recent developments make significant improvements in 
the alignment between Medicare payments and actual IRF costs possible. 
First, when the IRF PPS was implemented for cost reporting periods 
beginning on or after January 1, 2002, a new recording instrument 
called the IRF-PAI was used to collect patient data. The new instrument 
contained questions that improved the quality of the patient-level 
information available to researchers. The 2003 data used in the 
proposed refinements reflects this data.
    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. Even though this was the best available data at the time, we 
now 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 above, lead to new CMGs 
that better predict treatment costs in the IRF PPS.
    We further note that making refinements to the IRF patient 
classification system now, based on post-PPS data, does not preclude us 
from making future refinements to the system if IRFs' case mix and care 
practices change over time. We will continue to monitor the IRF PPS, 
and make refinements as needed, to ensure that IRF payments are aligned 
as closely as possible with the costs of providing care.
    Comment: One commenter believed that the proposed changes to the 
CMGs would make IRF quality measurement more difficult over time 
because the proposed changes to the CMG definitions would mean that a 
case classified into a particular CMG (such as CMG 0107) before October 
1, 2005 (when the proposed changes would be implemented) would not 
necessarily be classified into CMG 0107 after October 1, 2005. Thus, 
people attempting to create a one-for-one crosswalk between the CMGs 
before October 1, 2005 and the proposed CMGs after October 1, 2005 
would be unable to do so. The commenter noted that many quality 
measurement tools currently being used by IRFs require such a one-for-
one crosswalk.
    Response: We recognize the importance of monitoring IRF quality of 
care over time. However, we do not believe that the proposed changes to 
the CMGs inhibit the ability to monitor quality in IRFs over time. 
Quality of care is not measured by a payment rate, but by data 
reflecting various indicators of the treatment patients receive. In the 
FY 2006 proposed rule (70 FR 30188), we did not propose changes to the 
patient assessment form itself or changes to the coding of the 
underlying data that is used to classify patients into CMGs. Therefore, 
comparisons of the underlying patient classification data could still 
be used to monitor quality in these facilities over time.
    Comment: One commenter expressed concerns that the cognitive scores 
are not used as often in the definitions of the proposed revisions to 
the CMGs as they were in the original CMGs defined in the August 7, 
2001 final rule. This commenter stated that the cognitive scores are 
important predictors of how costly patients are likely to be in the IRF 
setting. The commenter also stated that,

[[Page 47895]]

if cognitive scores are not used as often as motor scores for assigning 
patients to CMGs, the reason may be that measures of patients' 
cognitive abilities may not currently be as well developed as measures 
of patients' motor abilities. Therefore, this commenter recommended 
that we develop more sensitive measures that have better predictive 
qualities.
    Response: As we noted previously, the cognitive score used to 
classify IRF patients into CMGs is made up of cognitive items from the 
IRF-PAI. These 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. Patients' 
cognitive functioning clearly affects their expected costliness in an 
IRF. However, RAND's regression analysis, in which they explored the 
relationship of the FIM motor and cognitive scores to cost, showed that 
patients' cognitive scores generally did not predict patients' expected 
costliness above and beyond what patients' motor scores already were 
able to predict. Thus, we see no reason to use cognitive scores in CMG 
definitions for which they do not add predictive ability. When the 
cognitive scores add information that increases the predictive ability 
of the classification system, we make use of this information in the 
CMG assignment.
    We agree with one of the commenter's points that the cognitive 
score may not predict costs as well as the motor score because the 
cognitive items may not be as sensitive to patients' cognitive status 
as the motor items are to patients' physical functioning. We further 
agree with the commenter that more work could be done to better 
identify measures of cognitive functioning. Along these lines, CMS has 
awarded a contract to the Research Triangle Institute (RTI) to perform 
research and data analysis to support possible changes to the IRF-PAI 
instrument that would better capture physical and cognitive functioning 
information on IRF patients. CMS remains open to examining well-
constructed peer-reviewed studies by other types of providers, 
researchers, and other interested parties in order to improve upon the 
cognitive assessment functioning measures for the Medicare population. 
Until then, we will use the best cognitive functioning information 
available for IRF patients to classify patients into the most 
appropriate CMGs so IRF payments align as closely as possible with the 
costs of care in IRFs.
    Final Decision: After carefully considering all the comments we 
received on the proposed changes to the CMG definitions, we are 
finalizing our decision to adopt the CMG definitions presented below in 
Table 2. Based on RAND's regression analysis of FY 2003 data, the best 
data available for analysis, we believe these changes will increase the 
accuracy of IRF PPS payments.

                            Table 2.--Case Mix Groups (CMGs), With the Associated Rehabilitation Impairment Categories (RICs)
                                                 [Beginning with discharges on or after October 1, 2005]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                    RIC                      CMG No.                                            CMG description
--------------------------------------------------------------------------------------------------------------------------------------------------------
01 Stroke (Stroke)........................       0101  Motor >51.05.
                                                 0102  Motor >44.45 & Motor <51.05 & Cognitive >18.5.
                                                 0103  Motor >44.45 & Motor <51.05 & Cognitive <18.5.
01 Stroke (Stroke)........................       0104  Motor >38.85 & Motor <44.45.
                                                 0105  Motor >34.25 & Motor <38.85.
                                                 0106  Motor >30.05 & Motor <34.25.
                                                 0107  Motor >26.15 & Motor <30.05.
                                                 0108  Motor <26.15 & Age >84.5.
                                                 0109  Motor >22.35 & Motor <26.15 & Age <84.5.
                                                 0110  Motor <22.35 & Age <84.5.
02 Traumatic brain injury (TBI)...........       0201  Motor >53.35 & Cognitive >23.5.
                                                 0202  Motor >44.25 & Motor <53.35 & Cognitive >23.5.
                                                 0203  Motor >44.25 & Cognitive <23.5.
                                                 0204  Motor >40.65 & Motor <44.25.
                                                 0205  Motor >28.75 & Motor <40.65.
                                                 0206  Motor >22.05 & Motor <28.75.
                                                 0207  Motor <22.05.
03 Nontraumatic brain injury (NTBI).......       0301  Motor >41.05.
                                                 0302  Motor >35.05 & Motor <41.05.
                                                 0303  Motor >26.15 & Motor <35.05.
                                                 0304  Motor <26.15.
04 Traumatic spinal cord injury (TSCI)....       0401  Motor >48.45.
                                                 0402  Motor >30.35 & Motor <48.45.
                                                 0403  Motor >16.05 & Motor <30.35.
                                                 0404  Motor <16.05 & Age >63.5.
                                                 0405  Motor <16.05 & Age <63.5.
05 Nontraumatic spinal cord injury (NTSCI)       0501  Motor >51.35.
05 Nontraumatic spinal cord injury (NTSCI)       0502  Motor >40.15 & Motor <51.35.
                                                 0503  Motor >31.25 & Motor <40.15.
                                                 0504  Motor >29.25 & Motor <31.25.
                                                 0505  Motor >23.75 & Motor <29.25.
                                                 0506  Motor <23.75.
06 Neurological (Neuro)...................       0601  Motor >47.75.
                                                 0602  Motor >37.35 & Motor <47.75.
                                                 0603  Motor >25.85 & Motor <37.35.
                                                 0604  Motor <25.85.
07 Fracture of LE (FracLE)................       0701  Motor >42.15.
                                                 0702  Motor >34.15 & Motor <42.15.
                                                 0703  Motor >28.15 & Motor <34.15.
                                                 0704  Motor <28.15.
08 Replacement of LE joint (RepLE)........       0801  Motor >49.55.

[[Page 47896]]

 
                                                 0802  Motor >37.05 & Motor <49.55.
                                                 0803  Motor >28.65 & Motor <37.05 & Age >83.5.
                                                 0804  Motor >28.65 & Motor <37.05 & Age <83.5.
                                                 0805  Motor >22.05 & Motor <28.65.
                                                 0806  Motor <22.05.
09 Other orthopedic(Ortho)................       0901  Motor >44.75.
                                                 0902  Motor >34.35 & Motor <44.75.
                                                 0903  Motor >24.15 & Motor <34.35.
                                                 0904  Motor <24.15.
10 Amputation, lower extremity (AMPLE)....       1001  Motor >47.65.
                                                 1002  Motor >36.25 & Motor <47.65.
                                                 1003  Motor <36.25.
11 Amputation, other (AMP-NLE)............       1101  Motor >36.35.
11 Amputation, other (AMP-NLE)............       1102  Motor <36.35.
12 Osteoarthritis (OsteoA)................       1201  Motor >37.65.
                                                 1202  Motor >30.75 & Motor <37.65.
                                                 1203  Motor <30.75.
13 Rheumatoid, other arthritis (RheumA)...       1301  Motor >36.35.
                                                 1302  Motor >26.15 & Motor <36.35.
                                                 1303  Motor <26.15.
14 Cardiac (Cardiac)......................       1401  Motor >48.85.
                                                 1402  Motor >38.55 & Motor <48.85.
                                                 1403  Motor >31.15 & Motor <38.55.
                                                 1404  Motor <31.15.
15 Pulmonary (Pulmonary)..................       1501  Motor >49.25.
                                                 1502  Motor >39.05 & Motor <49.25.
                                                 1503  Motor >29.15 & Motor <39.05.
                                                 1504  Motor <29.15.
16 Pain Syndrome (Pain)...................       1601  Motor >37.15.
                                                 1602  Motor >26.75 & Motor <37.15.
                                                 1603  Motor <26.75.
17 Major multiple trauma, no brain injury        1701  Motor >39.25.
 or spinal cord injury (MMT-NBSCI).
                                                 1702  Motor >31.05 & Motor <39.25.
                                                 1703  Motor >25.55 & Motor <31.05.
                                                 1704  Motor <25.55.
18 Major multiple trauma, with brain or          1801  Motor >40.85.
 spinal cord injury (MMT-BSCI).
                                                 1802  Motor >23.05 & Motor <40.85.
                                                 1803  Motor <23.05.
19 Guillian Barre (GB)....................       1901  Motor >35.95.
19 Guillian Barre (GB.....................       1902  Motor >18.05 & Motor <35.95
                                                 1903  Motor <18.05.
20 Miscellaneous (Misc)...................       2001  Motor >49.15.
                                                 2002  Motor >38.75 & Motor <49.15.
                                                 2003  Motor >27.85 & Motor <38.75.
                                                 2004  Motor <27.85.
21 Burns (Burns)..........................       2101  Motor >0.
Special CMGs..............................       5001  Short-stay cases, length of stay is 3 days or fewer.
                                                 5101  Expired, orthopedic, length of stay is 13 days or fewer.
                                                 5102  Expired, orthopedic, length of stay is 14 days or more.
                                                 5103  Expired, not orthopedic, length of stay is 15 days or fewer.
                                                 5104  Expired, not orthopedic, length of stay is 16 days or more.
--------------------------------------------------------------------------------------------------------------------------------------------------------
 Note: CMG definitions use weighted motor scores, as defined below.

2. Use of a Weighted Motor Score Index and Change to the Treatment of 
Unobserved Transfer to Toilet Values
    In the FY 2006 proposed rule (70 FR 30188, 30210), we proposed to 
use a weighted motor score index in assigning patients to CMGs, instead 
of the motor score index previously used that treated all components 
equally. We also proposed to change how the IRF PPS GROUPER software 
would assign a value for the transfer-to-toilet item when it is coded 
by the provider with a 0. We proposed that the software would assign 
this item a value of 2 instead of a 1 when the activity is coded by the 
provider with a 0. However, we proposed not to change the cognitive 
score index. As described in detail below, we continue to believe that 
a weighted motor score index, with the change to the scoring of the 
transfer to toilet item when the provider records a 0 value for the 
activity on the IRF-PAI, will improve the classification of patients 
into CMGs, which in turn will improve the accuracy of payments to IRFs.
    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

[[Page 47897]]

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, transfer to tub or shower, 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 the IRF-PAI and scored on a scale of 0 to 7, with 
a 7 indicating complete independence in this area of functioning, a 1 
indicating that a patient is very impaired in this area of functioning, 
and a 0 indicating that the activity did not occur.
    As explained in the August 7, 2001 final rule (66 FR 41349), the 
instructions for the IRF-PAI required that providers record an 8 for an 
item to indicate that the activity did not occur, as opposed to a 1 
through 7 indicating that the activity occurred and the estimated level 
of function connected with that activity. However, when the IRF-PAI 
form was finalized, the code 8 had been removed and was replaced with 
the code 0. Therefore, facilities now record a 0 when an activity does 
not occur.
    To determine the appropriate payment for patients for whom an 
activity is coded as 0 (that is, the activity did not occur), 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), for purposes of classifying patients into 
CMGs, we decided to assign a code of 1 (indicating that the patient 
needed ``total 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 
total assistance performing the task. The result of recoding a 0 as a 1 
and using that value to classify a patient into a CMG is that the 
provider might receive a higher payment for that item (although it 
might not be the highest payment overall, depending on the patient's 
other functional abilities and/or comorbidities).
    In the FY 2006 proposed rule (70 FR 30188), we proposed 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 that we proposed to 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 proposed 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 
proposed to make this change 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 believed 
and continue to 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 using a weighted motor score index.
    In developing candidate indices that would weight the items in the 
score, RAND had the following competing goals: developing 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, RAND 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 proposed a weighting methodology for the 
motor score index. We proposed 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

[[Page 47898]]

method when it would not benefit the program.
    Table 3 below shows the optimal weights from the regression 
analysis 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 3 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.
    We are making no changes to Table 3, which was Table 5 in the FY 
2006 proposed rule (70 FR 30188, 30211).

   Table 3.-Optimal Weights, Averaged Across Rehabilitation Impairment
                            Categories (RICs)
                              [Motor Items]
------------------------------------------------------------------------
                                                                Average
              Item type               Functional independence   optimal
                                                item             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........      (\1\)
Locomotion..........................  Walking................        1.6
Locomotion..........................  Stairs.................       1.6
------------------------------------------------------------------------
\1\ Not included.

    Based on RAND's analysis, we considered a number of different 
candidate indices before we proposed using a weighted index. We 
considered defining 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 
summing 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 assigning 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 proposed to use a weighting scheme that applies the 
average optimal weights. To develop the weighting scheme, RAND used 
regression analysis to estimate the relative contribution of each item 
to the prediction of costs. Based on this analysis, we proposed the 
weighting scheme indicated in Table 3 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 proposed 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.
    Public comments and our responses on the proposal to use a weighted 
motor score index and to change the treatment of unobserved transfer to 
toilet values are summarized below.
    Comment: One commenter suggested that the optimal weights for the 
bladder and bowel items may be too low because incontinence is the most 
cited reason patients receive inpatient post-acute care.
    Response: We believe that the weights for the bladder and bowel 
items are appropriate since they were determined based on regression 
analysis of the effects of these items on the prediction of IRF costs. 
The purpose of the optimal weights for the proposed weighted motor 
score index is not to indicate the reasons patients receive inpatient 
post-acute care but rather to estimate the influence of various motor 
score items on the expected costs of treating patients in the IRF 
setting. While we do not disagree that incontinence may be a 
significant reason that many patients receive post-acute care in an 
inpatient setting, the optimal weights described above were obtained 
from RAND's regression analysis of the functional items on patient 
costs using FY 2003 data.
    Comment: Several commenters were concerned that the proposed 
weighted motor score is complex, creates added costs for providers, 
will require retraining of staff, is not sensitive to differences among 
RICs, and that RAND's technical expert panel did not support the 
weighting methodology.
    Response: We proposed a weighted motor score index because RAND's 
analysis indicates that a weighted motor score index will improve the 
classification of patients into CMGs, which in turn will improve the 
accuracy of payments to IRFs.
    As we stated earlier, 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

[[Page 47899]]

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). Although this would have made the 
score more sensitive to differences among RICs, as the commenter 
requested, it would have made the score substantially more complex and 
less transparent. Thus, we proposed a weighting methodology that 
balances these two competing goals.
    With regard to the commenter's statement regarding the lack of 
support for the weighting methodology, RAND's technical expert panel 
generally endorsed the particular weighting methodology we proposed to 
implement. Furthermore, in the technical expert panel's discussions, 
participants told RAND that the weighting methodology would not be 
difficult for providers to implement. They stated that providers 
typically have software that computes the motor score, and that 
software would only require slight modifications to accommodate the new 
weighting methodology. Staff members in IRFs that complete the patient 
assessments would continue to input the same information they currently 
do into the software and therefore, in general, staff should not need 
to be retrained. We are not proposing any changes to how providers code 
items on the IRF-PAI, only how the information is used to classify 
patients into CMGs for determining the payment rate. We wish to point 
out that the weighted motor score for classifying patients into CMGs 
will be computed automatically by the GROUPER software, not by a 
clinician. CMS will issue the new GROUPER software at no cost to 
providers, and the new GROUPER software can be used in the same manner 
as the old GROUPER software. Thus, the proposed change to the weighted 
motor score index would not be expected to add to providers' costs. 
However, CMS will assist providers in any training efforts that may be 
required to implement the proposed new weighting methodology.
    Comment: Two commenters raised concerns regarding the proposed 
change in assignment of the transfer-to-toilet item. They indicated 
that this change could artificially elevate the motor score, reduce 
payments, and have a negative impact on severely ill patients, 
specifically spinal cord injury patients.
    Response: We proposed to assign the transfer-to-toilet item on the 
IRF-PAI a value of 2, instead of 1, when the provider has recorded a 
value of 0 (meaning the activity did not occur) because RAND's 
regression 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 proposed to make 
this change in order to provide the most accurate payment for each 
patient.
    We do not believe this proposed change will have a significant 
effect on payment or on access to care for patients for the following 
reasons: (1) The transfer-to-toilet item is only 1 of 12 items that 
make up the motor score index, (2) we are only proposing to change the 
score on this item by 1 point (which results in a 1.4 increase to the 
weighted motor score index), and (3) this change will only affect those 
patients for whom a 0 is recorded for this item (only about 2.8 percent 
of all IRF cases RAND examined).
    Furthermore, the payment for a particular patient with a 0 value 
for this item would only change if the proposed 1.4 point increase in 
the motor score index changes the patient's CMG classification. For 
this to happen, the patient's motor score would have to be within 1.4 
points of a CMG boundary. In particular, as the commenter noted the 
example of spinal cord injury patients, we will use RIC 04 (traumatic 
spinal cord injury) as an example. The difference in motor scores 
values that would qualify a patient for CMG 0402 versus CMG 0401 is 
18.1 points, and the difference in motor scores values that would 
qualify a patient for CMG 0403 versus CMG 0402 is 14.3 points. Because 
these ranges are relatively large, we believe patients will rarely 
change CMGs as a result of a 1.4 point increase in the motor score 
index.
    We proposed this change in coding of the transfer-to-toilet item 
because, based on RAND's analysis, we believe this proposed change will 
improve the accuracy of payments in the IRF PPS. As always, we are 
concerned that all patients have appropriate access to IRF services. 
Accordingly, we will monitor the impact of this proposed change and the 
other proposed changes to the IRF classification system finalized in 
this final rule to ensure that patients continue to have adequate 
access to IRF care.
    Comment: One commenter was concerned that the weighted motor score 
might disproportionately affect IRF payments for certain types of 
patients with certain conditions, such as cognitively impaired patients 
with significant lower body impairments or with significant 
dysfunctions in upper body and bladder/bowel problems.
    Response: We do not believe the weighted motor score methodology 
will have a disproportionate affect on any particular groups of 
patients. RAND's data analysis and RAND's technical expert panel did 
not raise any concerns regarding any particular groups of patients that 
would be unduly affected by these changes. We believe that the types of 
patients the commenter mentioned were included in the data RAND used to 
determine the optimal weights for the weighted motor score and to 
calibrate the appropriate payments. The purpose of the proposed 
weighted motor score, as with all of the proposed changes discussed in 
this final rule, is to align payments more appropriately with the costs 
of caring for all types of patients in IRFs. CMS will continue to 
closely monitor the data to ensure that no groups of patients are 
disproportionately affected by the change to a weighted motor score 
index.
    Comment: One commenter indicated that CMS, in proposing to 
implement the weighted motor score, did not seek enough review from 
experts who developed and researched the FIM items.
    Response: As discussed in this final rule under section IV, we 
contracted with RAND to examine potential refinements to the IRF PPS. 
RAND sought advice from a technical expert panel, which reviewed their 
methodology and findings regarding the proposed weighted motor score 
methodology and generally endorsed the methodology we proposed in the 
FY 2006 proposed rule (70 FR 30188). RAND's technical expert panel 
included representatives from industry groups, other government 
entities, academia, and other researchers, including members with 
expertise in the FIM items. Thus, we believe RAND sought sufficient 
review from experts in the field in developing the proposed weighted 
motor score methodology.
    Comment: One commenter requested that CMS remove the transfer to 
tub item from the IRF-PAI, to reduce the length of the form, because 
the transfer-to-tub item is not used in classifying patients into CMGs 
for payment purposes.
    Response: We did not propose any changes to the IRF-PAI. However, 
we will take this comment into consideration in future reviews of the 
IRF-PAI. We would need to more fully consider the benefits and costs of 
removing this item from the IRF-PAI form to determine if this change is 
appropriate.

[[Page 47900]]

    Final Decision: After carefully considering all of the comments we 
received on the proposed weighted motor score methodology, we are 
finalizing our decision to adopt the methodology as described above. 
Specifically, the weighted motor score index will be computed using the 
following 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.
    In addition, we are finalizing our decision to reassign a value of 
2 instead of 1 when providers code a 0 for the transfer-to-toilet item 
on a patient's IRF-PAI. Based on RAND's regression analysis of FY 2003 
data, the best data available for analysis, we believe these changes 
will increase the accuracy of IRF PPS payments.
3. Changes to the Relative Weights
    In the FY 2006 proposed rule (70 FR 30188), we proposed to update 
the relative weights assigned to each CMG. 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 proposed 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 did not propose to 
change the methodology for calculating the relative weights, as 
described in the August 7, 2001 final rule (66 FR 41316, 41351 through 
41353) and consequently, we only proposed to update the relative 
weights themselves.
    As previously stated, we believe that improved coding of data, the 
availability of more complete data, and changes to the tier 
comorbidities and CMGs helped us decide to propose to update the 
relative weights assigned to the CMGs so that they could continue to 
accurately represent the differences in costs across CMGs and across 
tiers. Therefore, we proposed to recalculate the relative weights. 
However, we proposed no change to the methodology for calculating the 
relative weights. Instead, we proposed 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 noted previously in 
section V.C.3 of this final rule, using FY 2003 Medicare billing data. 
To summarize, we proposed 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.
    We proposed to make the tier and the CMG changes in such a way that 
total estimated aggregate payments to IRFs for FY 2006 would be the 
same with or without the 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 VI.A of this final 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 IRF PPS payments, in aggregate, are likely adequate to 
pay for the types of patients IRFs treat.
    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 to account for relative resource use. Consistent with that 
broad statutory authority, we proposed to update the relative weights 
to more accurately reflect the IRF case mix.
    To ensure that total estimated aggregate payments to IRFs do not 
change, we proposed to apply a factor to the standard payment amount to 
ensure that estimated aggregate payments due to the proposed changes to 
the tier comorbidities, the CMGs, the weighted motor score, and the 
relative weights for FY 2006 are not greater or less than those that 
would have been made in FY 2006 without the proposed changes. In 
section VI.B.7 and section VI.B.8 of this final rule, we discuss the 
methodology and factor we proposed to apply to the standard payment 
amount.
    Public comments and our responses on the proposed changes for 
updating the relative weights are summarized below.
    Comment: Several commenters noted that, in many of the CMGs, the 
average length of stay has decreased. One commenter suggested that 
there might have been inconsistencies between the relative weights and 
the average length of stay values reported in the proposed Table 6 in 
the FY 2006 proposed rule (70 FR 30188, 30213 through 30219).
    Response: RAND's analysis found that the average length of stay in 
IRFs has decreased substantially in recent years. This decrease is 
reflected in the average length of stay values for most of the CMGs in 
the proposed Table 6 in the FY 2006 proposed rule (70 FR 30188, 30213 
through 30219). However, with the exception of determining IRF payments 
in certain transfer cases, the average length of stay does not affect 
IRF payments. CMS does not require IRFs to treat these average length 
of stay values as goals or targets for particular cases. IRFs are 
generally free to treat particular patients for as few or as many days 
as they deem medically appropriate. We encourage IRFs to admit patients 
for the length of time that results in the best quality of care for the 
patient. The

[[Page 47901]]

length of stay portion of the proposed Table 6 in the FY 2006 proposed 
rule (70 FR 30188, 30213 through 30219) is provided for informational 
purposes only.
    The relative weights for each of the CMGs and tiers represent the 
relative costliness of patients in those CMGs and tiers compared with 
patients in other CMGs and tiers. The average length of stay for each 
CMG and tier represents the average number of days patients in that CMG 
and tier were treated in IRFs, based on the FY 2003 data. IRF PPS 
payments are determined on a per-discharge basis, meaning that 
providers are paid a pre-determined payment amount according to that 
patient's CMG and tier classification, regardless of the number of days 
the patient is treated in the IRF. The only exceptions to this general 
policy are for very short-stay cases and for certain transfer cases. 
Because payments are made on a per-discharge basis, there is not 
necessarily any correlation between the number of days a patient is 
treated in the IRF and the payment amount for that patient. If, for 
example, the relative weight for a particular CMG in tier 1 is higher 
than the relative weight for that same CMG in the no-comorbidity tier, 
this means that cases in that CMG in tier 1 are expected to be more 
costly for the IRF to treat than cases in that CMG in the no-
comorbidity tier. The average length of stay for patients in that CMG 
in tier 1, however, could be lower than the average length of stay of 
patients in that CMG in the no-comorbidity tier because the treatment 
for patients in that CMG in tier 1 could be much more intensive for a 
shorter period of time than the treatment for patients in the no-
comorbidity tier, who could require less-intensive treatment over a 
longer period of time. Thus, the relative weights may not bear a 
relationship to the length of stay, and the two need not be consistent 
with each other.
    Comment: Several commenters expressed concerns about decreases in 
the relative weights for certain CMGs, particularly for the stroke and 
traumatic brain injury CMGs. These commenters stated that, if the 
relative weights and, consequently, the payment rates for certain CMGs 
were to decrease, it could potentially lead to reduced access to IRF 
care for patients in the affected CMGs.
    Response: The commenters were not clear as to which CMG weights 
they were using as a comparison with the proposed FY 2006 relative 
weights in Table 6 of the FY 2006 proposed rule (70 FR 30188, 30213 
through 30219). We believe that the commenter was comparing the 
proposed FY 2006 relative weights published in the FY 2006 proposed 
rule (70 FR 30188, 30213 through 30219) to the FY 2005 relative weights 
published in the July 30, 2004 notice updating the payment rates (69 FR 
45721). Because we proposed revised definitions of the CMGs, as 
described in section V.C.1 of this final rule, the proposed new 
relative weights for the proposed new CMGs cannot be compared with the 
FY 2005 relative weights based on the FY 2005 CMG definitions. The 
types of patients included in each CMG, as defined in Table 4 and Table 
6 of the FY 2006 proposed rule (70 FR 30188, 30207 through 30210, 30213 
through 30219) are likely not the same patients included in the CMGs 
under the FY 2005 CMG definitions.
    Furthermore, as previously stated, the improved coding of data, the 
availability of more complete data, proposed changes to the tier 
comorbidities and CMGs, and changes in IRF cost structures contributed 
to our decision to propose to update the relative weights assigned to 
the CMGs so that the weights continue to represent the differences in 
costs across CMGs and across tiers. For these reasons, we have proposed 
to recalculate the relative weights to ensure that IRF payments remain 
aligned as closely as possible with the costs of care. We will continue 
to monitor beneficiaries' access to IRF care to ensure that the changes 
to the IRF classification system noted in this final rule do not impede 
access to IRF care for Medicare beneficiaries in general or for 
beneficiaries with any particular conditions. In particular, we believe 
it is important to ensure that stroke patients have appropriate access 
to rehabilitation services, as this population benefits considerably 
from receiving prompt rehabilitation care.
    Nevertheless, we asked RAND to review the average relative weights 
for the stroke and traumatic brain injury RICs both under the FY 2005 
CMG definitions and under the proposed new CMG definitions. The average 
relative weights were essentially identical within these two RICs, 
meaning that providers would use essentially the same relative weight 
to calculate payments for an ``average'' stroke patient and an 
``average'' traumatic brain injury patient in FY 2006 as they used to 
calculate payments for the ``average'' stroke patient and the 
``average'' traumatic brain injury patient in FY 2005. We believe, 
based on RAND's regression analysis of FY 2003 data, that the proposed 
changes to the classification system will improve the alignment of IRF 
payments with the costs of care and, thereby, improve access to care 
for IRF patients.
    Comment: One commenter stated that if the proposed recalculation of 
the relative weights were to result in lower payments for some patients 
and, therefore, were to lead to payments that did not adequately cover 
treatment costs for those patients, then patients' access to IRF care 
might suffer. A couple of commenters requested that CMS phase in the 
proposed changes to the classification system.
    Response: We considered proposing a phase in of the proposed 
changes to the classification system, but we believe a phase in of the 
changes would have introduced undue complication to the classification 
system because it would have required individual providers, fiscal 
intermediaries, and CMS to compute two different sets of CMGs to 
determine payments.
    The intent of the proposed changes to the IRF classification 
system, including the proposed recalculation of the relative weights, 
was to ensure that IRF payments are aligned as closely as possible with 
the costs of care. We believe these proposed revisions will help us to 
ensure that IRF payments and costs continue to be aligned as 
appropriately as possible. We will continue to monitor beneficiaries' 
access to IRF care to ensure that the payment system continues to 
provide such access to IRF care.
    To assist providers in adopting the changes to the classification 
system we are finalizing in this final rule, we will make the new 
GROUPER and PRICER software available for download on the CMS Web site 
as soon as possible and before implementation of the final changes. 
Furthermore, our analysis of the impacts, detailed in section XII of 
this final rule, indicate that aggregate effects on provider payments 
of the proposed changes are expected to be small.
    Comment: One commenter noted that the proposed relative weights for 
the burn CMG (CMG 2101) for tier 1 and tier 2 are the same. The 
commenter asked whether this could be an error.
    Response: This was not an error. The FY 2003 data do not contain 
enough patients in CMG 2101 in tiers 1 and 2 to estimate precise 
relative weights for each tier. Accordingly, RAND combined patients in 
these two tiers to estimate the proposed and final relative weights for 
both tiers.
    Comment: Several commenters requested that CMS make available to 
the public the patient-level data on CMG assignments, the IRF-PAI data, 
the MedPAR files, and the cost report data RAND used for their analysis 
to enable the public to replicate RAND's analysis.

[[Page 47902]]

    Response: The data files the commenters requested are generally 
available (and were generally available during the comment period for 
the FY 2006 proposed rule) through CMS's standard data distribution 
systems. Please refer to CMS's Web site at http://www.cms.hhs.gov/researchers/statsdata.asp for more information about obtaining data 
from CMS.
    Comment: One commenter asked if CMS could provide the standard 
deviation information for the average length of stay information listed 
for each CMG and tier.
    Response: We will consider posting this type of information on our 
Web site.
    Comment: One commenter noted the operational challenges, such as 
the large number of revisions that need to be made to the GROUPER 
software, of implementing the changes to the IRF classification system 
that CMS has proposed and further requested that CMS make available the 
new CMG GROUPER to the public.
    Response: We agree with the commenter that the operational issues 
of implementing the proposed changes to the classification system may 
be challenging, but we will provide the necessary assistance to ensure 
a smooth transition to the new tiers and CMGs, the new weighted motor 
score methodology, and the new relative weights. As is our practice, we 
will make the new GROUPER and PRICER software available for download on 
the CMS Web site as soon as possible and prior to implementation of the 
finalized changes. In addition, we will evaluate whether provider, 
fiscal intermediary, or regional office training may be required to 
promote understanding of any final changes and assist in the 
implementation of such changes. Our foremost goal will be to ensure a 
smooth implementation of changes because we believe that any final 
changes to the classification system will improve the accuracy of 
payments in the IRF PPS.
    Comment: Several commenters requested that CMS evaluate the effects 
of the proposed changes to the IRF classification system after the 
changes are implemented and propose additional refinements to the 
classification system in future years, if necessary.
    Response: We agree with the commenter that it will be important to 
evaluate the effects of any changes to the classification system to 
ensure that IRF payments continue to be aligned as closely as possible 
with the costs of care. CMS intends to monitor the data carefully to 
ensure that patients who require inpatient rehabilitation services have 
adequate access to these services. We will propose refinements if, in 
the future, we later identify the need to make modifications to the 
classification system to ensure that IRF payments remain aligned with 
the costs of care.
    Final Decision: After carefully considering all the comments we 
received on the proposed re-calculation of the relative weights, we are 
finalizing our proposal to adopt the relative weights presented in 
Table 4, without change. However, we note that, after reviewing the 
average length of stay values in response to the comments we received, 
we have made a slight revision to the methodology for computing the 
average length of stay values reported in Table 4 to be consistent with 
the way we presented average length of stay values in the August 7, 
2001 final rule (66 FR 41316).

                              Table 4.--Relative Weights for Case-Mix Groups (CMGs)
----------------------------------------------------------------------------------------------------------------
                         CMG description           Relative weights                 Average length of stay
                         (M = motor, C = -----------------------------------------------------------------------
          CMG            cognitive, A =
                              age)         Tier 1   Tier 2   Tier 3    None    Tier 1   Tier 2   Tier 3    None
----------------------------------------------------------------------------------------------------------------
0101..................  Stroke M > 51.05   0.7691   0.7299   0.6484   0.6350        8       11        9        9
0102..................  Stroke M > 44.45   0.9471   0.8989   0.7985   0.7820       11       15       11       10
                         and M < 51.05
                         and C > 18.5.
0103..................  Stroke M > 44.45   1.1162   1.0594   0.9411   0.9217       14       13       12       12
                         and M < 51.05
                         and C < 18.5.
0104..................  Stroke M > 38.85   1.1859   1.1255   0.9999   0.9792       13       14       13       13
                         and M < 44.45.
0105..................  Stroke M > 34.25   1.4233   1.3509   1.2001   1.1753       16       17       15       15
                         and M < 38.85.
0106..................  Stroke M > 30.05   1.6567   1.5724   1.3969   1.3680       18       20       18       18
                         and M < 34.25.
0107..................  Stroke M > 26.15   1.9121   1.8148   1.6122   1.5790       21       23       20       21
                         and M < 30.05.
0108..................  Stroke M < 26.15   2.2106   2.0981   1.8639   1.8254       27       29       24       24
                         and A > 84.5.
0109..................  Stroke M > 22.35   2.1976   2.0858   1.8529   1.8147       23       26       24       23
                         and M < 26.15
                         and A < 84.5.
0110..................  Stroke M < 22.35   2.6262   2.4926   2.2143   2.1686       30       33       28       28
                         and A < 84.5.
0201..................  Traumatic brain    0.8140   0.6826   0.6021   0.5648       10        9        9        8
                         injury M >
                         53.35 and C >
                         23.5.
0202..................  Traumatic brain    1.0437   0.8753   0.7720   0.7241       12       10       11        9
                         injury M >
                         44.25 and M <
                         53.35 and C >
                         23.5.
0203..................  Traumatic brain    1.2487   1.0472   0.9236   0.8664       15       15       12       12
                         injury M >
                         44.25 and C <
                         23.5.
0204..................  Traumatic brain    1.3356   1.1201   0.9879   0.9267       15       16       13       13
                         injury M >
                         40.65 and M <
                         44.25.
0205..................  Traumatic brain    1.6381   1.3738   1.2116   1.1365       17       18       16       15
                         injury M >
                         28.75 and M <
                         40.65.
0206..................  Traumatic brain    2.1379   1.7930   1.5814   1.4833       23       22       21       20
                         injury M >
                         22.05 and M <
                         28.75.
0207..................  Traumatic brain    2.7657   2.3194   2.0457   1.9188       35       29       26       25
                         injury M <
                         22.05.
0301..................  Non-traumatic      1.1293   0.9536   0.8440   0.7764       12       12       11       10
                         brain injury M
                         > 41.05.
0302..................  Non-traumatic      1.4729   1.2438   1.1008   1.0126       14       16       14       13
                         brain injury M
                         > 35.05 and M <
                         41.05.
0303..................  Non-traumatic      1.7575   1.4841   1.3136   1.2083       20       19       17       16
                         brain injury M
                         > 26.15 and M <
                         35.05.
0304..................  Non-traumatic      2.4221   2.0453   1.8103   1.6651       31       25       23       21
                         brain injury M
                         < 26.15.
0401..................  Traumatic spinal   0.9891   0.8517   0.7656   0.6837       12       12       10       10
                         cord injury M >
                         48.45.
0402..................  Traumatic spinal   1.3640   1.1746   1.0558   0.9428       19       16       14       12
                         cord injury M >
                         30.35 and M <
                         48.45.
0403..................  Traumatic spinal   2.3743   2.0446   1.8379   1.6412       22       24       23       22
                         cord injury M >
                         16.05 and M <
                         30.35.
0404..................  Traumatic spinal   4.2567   3.6656   3.2950   2.9424       51       46       39       37
                         cord injury M <
                         16.05 and A >
                         63.5.
0405..................  Traumatic spinal   3.2477   2.7967   2.5139   2.2449       32       38       33       28
                         cord injury M <
                         16.05 and A <
                         63.5.
0501..................  Non-traumatic      0.7705   0.6449   0.5641   0.5059        9        8        8        7
                         spinal cord
                         injury M >
                         51.35.

[[Page 47903]]

 
0502..................  Non-traumatic      1.0316   0.8634   0.7553   0.6774       13       12       10        9
                         spinal cord
                         injury M >
                         40.15 and M <
                         51.35.
0503..................  Non-traumatic      1.3676   1.1446   1.0013   0.8979       15       15       13       12
                         spinal cord
                         injury M >
                         31.25 and M <
                         40.15.
0504..................  Non-traumatic      1.7120   1.4328   1.2534   1.1240       20       19       16       15
                         spinal cord
                         injury M >
                         29.25 and M <
                         31.25.
0505..................  Non-traumatic      2.0289   1.6981   1.4855   1.3321       23       22       19       18
                         spinal cord
                         injury M >
                         23.75 and M <
                         29.25.
0506..................  Non-traumatic      2.7607   2.3106   2.0212   1.8126       29       28       25       23
                         spinal cord
                         injury M <
                         23.75.
0601..................  Neurological M >   0.8965   0.7331   0.6966   0.6493       11       10        9        9
                         47.75.
0602..................  Neurological M >   1.1925   0.9752   0.9267   0.8636       13       13       12       12
                         37.35 and M <
                         47.75.
0603..................  Neurological M >   1.5266   1.2484   1.1863   1.1056       16       17       15       15
                         25.85 and M <
                         37.35.
0604..................  Neurological M <   1.9539   1.5979   1.5183   1.4151       22       20       20       19
                         25.85.
0701..................  Fracture of        0.9055   0.7736   0.7265   0.6585       12       11       10        9
                         lower extremity
                         M > 42.15.
0702..................  Fracture of        1.1757   1.0044   0.9432   0.8549       13       14       13       12
                         lower extremity
                         M > 34.15 and M
                         < 42.15.
0703..................  Fracture of        1.4636   1.2504   1.1742   1.0643       16       17       15       14
                         lower extremity
                         M > 28.15 and M
                         < 34.15.
0704..................  Fracture of        1.7962   1.5345   1.4410   1.3062       20       20       19       18
                         lower extremity
                         M < 28.15.
0801..................  Replacement of     0.6561   0.5511   0.5109   0.4596        7        7        7        6
                         lower extremity
                         joint M > 49.55.
0802..................  Replacement of     0.8570   0.7198   0.6673   0.6004       10       10        9        8
                         lower extremity
                         joint M > 37.05
                         and M < 49.55.
0803..................  Replacement of     1.2707   1.0672   0.9894   0.8901       15       15       13       12
                         lower extremity
                         joint M > 28.65
                         and M < 37.05
                         and A > 83.5.
0804..................  Replacement of     1.1069   0.9296   0.8618   0.7754       13       12       11       10
                         lower extremity
                         joint M > 28.65
                         and M < 37.05
                         and A < 83.5.
0805..................  Replacement of     1.3937   1.1705   1.0852   0.9763       17       16       14       13
                         lower extremity
                         joint M > 22.05
                         and M < 28.65.
0806..................  Replacement of     1.6726   1.4047   1.3023   1.1716       18       19       17       15
                         lower extremity
                         joint M < 22.05.
0901..................  Other orthopedic   0.8412   0.7658   0.6805   0.6090       10       11       10        9
                         M > 44.75.
0902..................  Other orthopedic   1.1054   1.0063   0.8942   0.8002       13       13       12       11
                         M > 34.35 and M
                         < 44.75.
0903..................  Other orthopedic   1.4583   1.3276   1.1797   1.0557       18       19       16       15
                         M > 24.15 and M
                         < 34.35.
0904..................  Other orthopedic   1.8281   1.6643   1.4788   1.3234       25       23       20       19
                         M < 24.15.
1001..................  Amputation,        0.9638   0.8888   0.7931   0.7312       11       11       11       10
                         lower extremity
                         M > 47.65.
1002..................  Amputation,        1.2709   1.1719   1.0457   0.9641       14       15       14       13
                         lower extremity
                         M > 36.25 and M
                         < 47.65.
1003..................  Amputation,        1.7876   1.6483   1.4709   1.3561       19       22       19       18
                         lower extremity
                         M < 36.25.
1101..................  Amputation, non-   1.2544   1.0496   0.9189   0.8462       14       15       12       11
                         lower extremity
                         M > 36.35.
1102..................  Amputation, non-   1.8780   1.5713   1.3756   1.2668       19       19       18       17
                         lower extremity
                         M < 36.35.
1201..................  Osteoarthritis M   1.0184   0.8794   0.8106   0.7317       11       12       11       10
                         > 37.65.
1202..................  Osteoarthritis M   1.3181   1.1383   1.0492   0.9470       15       16       14       13
                         > 30.75 and M <
                         37.65.
1203..................  Osteoarthritis M   1.6238   1.4022   1.2925   1.1666       21       19       17       16
                         < 30.75.
1301..................  Rheumatoid,        1.0338   0.9617   0.8325   0.7358       12       13       11       10
                         other arthritis
                         M > 36.35.
1302..................  Rheumatoid,        1.4324   1.3325   1.1534   1.0195       15       18       15       14
                         other arthritis
                         M > 26.15 and M
                         < 36.35.
1303..................  Rheumatoid,        1.8308   1.7032   1.4743   1.3032       22       21       20       18
                         other arthritis
                         M < 26.15.
1401..................  Cardiac M >        0.8172   0.7352   0.6396   0.5806       10        9        9        8
                         48.85.
1402..................  Cardiac M >        1.1034   0.9926   0.8636   0.7839       12       13       12       11
                         38.55 and M <
                         48.85.
1403..................  Cardiac M >        1.3735   1.2356   1.0750   0.9759       16       16       14       13
                         31.15 and M <
                         38.55.
1404..................  Cardiac M <        1.7419   1.5671   1.3633   1.2376       21       20       18       16
                         31.15.
1501..................  Pulmonary M >      0.9222   0.8995   0.7687   0.7397       11       12       10       10
                         49.25.
1502..................  Pulmonary M >      1.1659   1.1371   0.9718   0.9352       12       15       12       12
                         39.05 and M <
                         49.25.
1503..................  Pulmonary M >      1.4269   1.3917   1.1894   1.1445       12       17       15       15
                         29.15 and M <
                         39.05.
1504..................  Pulmonary M <      1.8812   1.8348   1.5681   1.5089       21       22       20       18
                         29.15.
1601..................  Pain syndrome M    1.0065   0.8544   0.7731   0.6904       12       11       10        9
                         > 37.15.
1602..................  Pain syndrome M    1.3810   1.1724   1.0607   0.9473       15       17       14       13
                         > 26.75 and M <
                         37.15.
1603..................  Pain syndrome M    1.6988   1.4421   1.3048   1.1653       19       19       17       16
                         < 26.75.
1701..................  Major multiple     1.0102   0.9634   0.8323   0.7321       12       12       11       10
                         trauma without
                         brain or spinal
                         cord injury M >
                         39.25.
1702..................  Major multiple     1.3305   1.2688   1.0962   0.9643       14       16       15       13
                         trauma without
                         brain or spinal
                         cord injury M >
                         31.05 and M <
                         39.25.
1703..................  Major multiple     1.5832   1.5098   1.3043   1.1474       17       20       17       16
                         trauma without
                         brain or spinal
                         cord injury M >
                         25.55 and M <
                         31.05.
1704..................  Major multiple     1.9808   1.8889   1.6319   1.4355       26       26       21       20
                         trauma without
                         brain or spinal
                         cord injury M <
                         25.55.
1801..................  Major multiple     1.2118   0.9832   0.8245   0.7282       15       13       12       10
                         trauma with
                         brain or spinal
                         cord injury M >
                         40.85.
1802..................  Major multiple     1.9385   1.5728   1.3190   1.1649       20       21       18       16
                         trauma with
                         brain or spinal
                         cord injury M >
                         23.05 and M <
                         40.85.

[[Page 47904]]

 
1803..................  Major multiple     3.4784   2.8222   2.3668   2.0903       43       33       30       27
                         trauma with
                         brain or spinal
                         cord injury M <
                         23.05.
1901..................  Guillian Barre M   1.2362   1.0981   1.0677   0.9349       14       13       14       12
                         > 35.95.
1902..................  Guillian Barre M   2.3162   2.0574   2.0004   1.7515       27       25       24       23
                         > 18.05 and M <
                         35.95.
1903..................  Guillian Barre M   3.3439   2.9703   2.8881   2.5287       37       39       31       33
                         < 18.05.
2001..................  Miscellaneous M    0.8743   0.7387   0.6623   0.6047       10       10        9        8
                         > 49.15.
2002..................  Miscellaneous M    1.1448   0.9672   0.8671   0.7917       12       13       11       11
                         > 38.75 and M <
                         49.15.
2003..................  Miscellaneous M    1.4789   1.2495   1.1202   1.0227       16       16       15       14
                         > 27.85 and M <
                         38.75.
2004..................  Miscellaneous M    1.9756   1.6692   1.4964   1.3663       25       22       20       18
                         < 27.85.
2101..................  Burns M > 0.....   2.1858   2.1858   1.5910   1.4762       29       24       19       17
5001..................  Short-stay        .......  .......  .......   0.2201  .......  .......  .......        2
                         cases, length
                         of stay is 3
                         days or fewer.
5101..................  Expired,          .......  .......  .......   0.6351  .......  .......  .......        8
                         orthopedic,
                         length of stay
                         is 13 days or
                         fewer.
5102..................  Expired,          .......  .......  .......   1.6002  .......  .......  .......       22
                         orthopedic,
                         length of stay
                         is 14 days or
                         more.
5103..................  Expired, not      .......  .......  .......   0.7204  .......  .......  .......        8
                         orthopedic,
                         length of stay
                         is 15 days or
                         fewer.
5104..................  Expired, not      .......  .......  .......   1.8771  .......  .......  .......       24
                         orthopedic,
                         length of stay
                         is 16 days or
                         more.
----------------------------------------------------------------------------------------------------------------

    Based on RAND's regression analysis of FY 2003 data, the best data 
available for analysis, we believe these changes will increase the 
accuracy of IRF PPS payments.

VI. FY 2006 Federal Prospective Payment Rates

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

    In the FY 2006 proposed rule (70 FR 30188), we proposed to reduce 
the standard payment amount by 1.9 percent 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 proposed to reduce the 
standard payment amount for patients treated in IRFs by 1.9 percent.
    We proposed 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 as many as 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). However, based on the following discussion, we are lowering 
the standard payment amount by 1.9 percent to account for coding 
changes, as opposed to real case mix changes, that have increased 
payments to IRFs.
    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 the FY 2006 proposed rule (70 FR 
30188) and this final 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,

[[Page 47905]]

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. In 
addition, the IRF PPS changed the instructions for coding some of the 
FIM items on the IRF-PAI, so that the same patient may have been 
correctly coded differently in 2002 than in 1999.
    Although we believe implementation of the IRF PPS resulted in 
changes to how the patient assessment data have been coded, 
implementation of the IRF PPS may have also 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. Comparing 
2002 data (post-PPS) with 1999 data (pre-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 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.

[[Page 47906]]

    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. 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 believed and continue to 
believe that 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 
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 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 
proposed 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. That is, RAND analyzed specific 
examples of coding that we know have changed over time, such as direct 
indications of improvements in impairment coding, changes in coding 
instructions for bladder and bowel functioning, and dramatic increases 
in coding of certain conditions that affect patients' placement into 
tiers (resulting in higher payments) in deriving the 1.9 percent 
estimate.
    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 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. 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 proposed 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, will adequately adjust for the increased payments 
to IRFs caused by purely coding changes, but will 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 to propose a 1.9 percent reduction in the 
standard payment amount 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.''
    Public comments and our responses on the proposed reduction of the 
standard payment amount to account for coding changes are summarized 
below.
    Comment: Several commenters objected to CMS implementing an across 
the board reduction to payment rates to account for coding changes 
until the full impact of CMS's recent decision to enforce the 75 
percent rule is known. These commenters generally also noted that 
RAND's analysis was based on 2002 data, which was the year facilities 
were transitioning to the IRF PPS.
    Response: We believe a 1.9 percent reduction to the standard 
payment amount to account for coding changes is appropriate at this 
time for the following reasons. First, CMS is required by statute 
(section 1886(j)(2)(C)(ii) of the Act) to adjust payment rates for IRF 
services if we find evidence that changes in coding (that do not 
reflect real changes in case mix) have resulted or will result in 
changes in aggregate payments under the IRF classification system. As 
discussed in the proposed rule and above, CMS contracted with RAND to 
examine changes in case mix and coding since the IRF PPS, using the 
most current available data. Using regression analysis of calendar year 
2002 data, RAND 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. 
Specifically, RAND found that IRF payments were at least 1.9 percent 
higher because of changes in coding, based on direct indications of 
coding changes. Thus, we believe we have a responsibility to conform to 
the requirements of the statute and accordingly adjust payment rates 
for IRFs.
    Second, analyses by RAND and by CMS's Office of the Actuary have 
both shown high Medicare margins among IRFs since implementation of the 
IRF PPS. RAND's analysis 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. An analysis by CMS's

[[Page 47907]]

Office of the Actuary supports these results. Given the evidence of 
high Medicare margins among IRFs, we believe that a 1.9 percent 
decrease in rates to account for coding changes will not affect 
beneficiary access to IRF services because IRFs will continue to be 
paid adequately to reflect the cost of resources needed to treat 
Medicare beneficiaries.
    Furthermore, we continue to find evidence that enforcement of the 
75 percent rule between July 2004 and July 2005 at the 50 percent 
compliance threshold did not have as large an impact on patients' 
access to IRF care as some industry analysts contend. At this time, CMS 
is finding no significant problems regarding access to care in IRFs; to 
the contrary, the trend is toward increasing utilization in all 
settings. For example, when we compared calendar years 2003 to 2004, we 
found that the number of IRF cases increased about 1.2 percent. We do 
not believe that beneficiary access to rehabilitation care will be 
unduly affected when IRFs have to meet a compliance threshold of 60 
percent for cost reporting periods starting between July 1, 2005 and 
June 30, 2006. Based on the current available evidence, we do not 
believe that simultaneously reducing the standard payment amount by 1.9 
percent to adjust for coding changes and phasing in enforcement of the 
75 percent rule will have an undue effect on beneficiary access to IRF 
services. However, we will closely monitor the available data to ensure 
that beneficiaries' access to rehabilitation care is maintained.
    Finally, we believe that the fact that 2002 was the year IRFs were 
transitioning to the IRF PPS further supports the finding that at least 
1.9 percent of the payments in that year were due to coding changes and 
not to real changes in case mix. IRFs had not fully transitioned to the 
full Federal payment rates in 2002. Therefore, they were likely only 
beginning to adjust to the new incentives of the IRF PPS and had only 
begun changing their coding practices. Had the full Federal payment 
rates for 2002 been fully implemented in 2002, then providers might 
have changed their coding practices even more than they did in 2002.
    Accordingly, RAND was likely only observing the initial provider 
responses to the new IRF PPS. Because RAND's estimate of the 1.9 
percent is based on direct indication of coding changes that occurred 
in 2002, we believe that the 1.9 percent proposed reduction to the 
standard payment amount is appropriate at this time. In the future, we 
will examine later years of data in which providers were fully subject 
to the IRF PPS and make any necessary adjustments to the standard 
payment amount as we are required to do by statute to eliminate the 
effect on payments of coding or classification changes that do not 
reflect real changes in case mix.
    Comment: A few commenters questioned RAND's assumption that 
characteristics of the patients recorded during the acute 
hospitalizations preceding the IRF stays are relevant for the condition 
of those same patients in the IRF stays.
    Response: RAND's methodology in which they assumed that patient 
characteristics recorded during the acute hospitalizations preceding 
the IRF stays were relevant for the case mix of patients in the IRF 
stays produced a much higher estimate of the amount of coding change 
than we proposed to adopt in the FY 2006 proposed rule (70 FR 30188, 
30221 though 30222). This methodology suggested a 5.8 percent reduction 
to the standard payment amount to account for coding change, as 
discussed above. As explained in the FY 2006 proposed rule (70 FR 
30188, 30222), we used the estimate of the amount of coding change from 
RAND's second approach, which involved analyzing specific examples of 
coding that we know have changed over time, such as direct indications 
of improvements in impairment coding, changes in coding instructions 
for bladder and bowel functioning, and dramatic increases in coding of 
certain conditions that affect patients' placement into tiers 
(resulting in higher payments). This second approach produced the 1.9 
percent estimate we proposed to use to adjust the standard payment 
amount.
    Comment: One commenter requested that CMS conduct educational 
efforts for providers that instruct providers on how to code patients 
appropriately, rather than reducing the standard payment amount by 1.9 
percent.
    Response: As we discussed earlier in detail in this final rule 
under section VI.A, we proposed to reduce the standard payment amount 
by 1.9 percent to account for the effects of coding changes that 
occurred between 1999 and 2002 that resulted in higher than expected 
payments to IRFs, beginning in 2002. Section 1886(j)(2)(C)(ii) of the 
Act requires the Secretary to make such an adjustment to eliminate the 
effects 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. 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 was due to coding changes that do not reflect real 
changes in case mix. Any provider education and training that CMS would 
conduct now would not revise RAND's finding that, based upon calendar 
year 2002 data, coding changes occurred that did not reflect real 
changes in case mix.
    However, we agree with the commenter that provider education and 
training is important so that providers correctly code patients in 
IRFs. For this reason, CMS conducted extensive provider training in 
2002 when the IRF PPS was first implemented, and we will continue to 
educate providers as to how to code the IRF-PAI items through our IRF-
PAI coding help desk. We are open to considering other methods of 
provider education to encourage accurate provider coding. The primary 
resource providers should refer to is the IRF-PAI manual when they have 
questions regarding the correct way to code patients in IRFs. This 
manual is available on CMS's Web site at http://www.cms.hhs.gov/providers/IRFPPS/IRFPAI-MANUAL040104.asp and is updated regularly. The 
1.9 percent reduction adjustment to the standard payment amount is not 
intended to penalize providers for coding changes, but to reflect the 
statutory mandate to adjust IRF PPS payments when 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.
    Comment: One commenter questioned whether, in doing the analysis 
described above, RAND accounted for the 1.16 percent behavioral offset 
adjustment that CMS applied to the initial IRF PPS payment rates in the 
August 7, 2001 final rule (66 FR 41316).
    Response: As explained in detail in RAND's report entitled 
``Preliminary Analyses of Changes in Coding and Case Mix Under the 
Inpatient Rehabilitation Facility Prospective Payment System'' 
(available on RAND's Web site at http://www.rand.org/publications/TR/TR213/), RAND accounted for the 1.16 percent behavioral offset 
adjustment when they estimated the amount of observed case mix change 
that was due to real case mix change and the amount that was due to 
coding change. The range of estimates for the amount of case mix and 
coding change that RAND developed and that is reported above in this 
final rule contains an adjustment to

[[Page 47908]]

account for this behavioral offset. If RAND had not taken account of 
the behavioral offset, their estimates of the amount of observed case 
mix change that was due to coding change would have been larger than 
noted in both the FY 2006 proposed rule (70 FR 30188) and in this final 
rule.
    Comment: One commenter suggested that the proposed 1.9 percent 
reduction of the standard payment amount could be implemented without 
undue hardship for facilities.
    Response: We agree with the commenter. RAND estimates 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 IRF payments are 
likely more than adequate to support this type of adjustment for coding 
changes.
    Final Decision: After carefully considering all the comments we 
received on the proposed 1.9 percent reduction to the standard payment 
amount to adjust for coding changes between 1999 and 2002 that did not 
reflect real changes in case mix and resulted in increases in aggregate 
payments under the IRF classification system, we are finalizing our 
proposal to adopt the adjustment described above. In accordance with 
section 1886(j)(2)(C)(ii) of the Act, and based on RAND's analysis of 
2002 data compared with 1999 data, we believe this change is necessary 
to allow payment amounts to accurately reflect changes in IRFs' patient 
case mix (that is, the true cost of treating patients), and to ensure 
that they are not influenced by changes in coding practices.
    We are finalizing our methodology for reducing the standard payment 
amount by 1.9 percent. First, we update the FY 2005 standard payment 
conversion factor by the estimated FY 2006 market basket of 3.6 percent 
(estimated for this final rule) to get the standard payment amount for 
FY 2006 ($12,958*1.036 = $13,425). Next, we multiply the FY 2006 
standard payment amount by 0.981, which reduces the standard payment 
amount by 1.9 percent ($13,425*0.981 = $13,169). In section VI.B.7 of 
this final rule, we will further adjust the $13,169 by the budget 
neutrality factors for the wage index and the other final changes 
outlined in this final rule that will result in the FY 2006 standard 
payment conversion factor. In section VI.B.7 of this final rule, we 
provide a step-by-step calculation that results in the FY 2006 standard 
payment conversion factor.

B. Adjustments To Determine the FY 2006 Standard Payment Conversion 
Factor

1. 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, 
in the FY 2006 proposed rule (70 FR 30188), we proposed and are 
finalizing 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. As 
proposed and for this final rule, we are excluding 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 then 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 
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 we proposed and are finalizing 
for purposes of determining the operating and capital portions of the 
FY 2002-based RPL market basket.
a. Overview of the RPL Market Basket
    The 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

[[Page 47909]]

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, 
we are 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 rebasing and revising the market 
basket used to update the IRF PPS.
b. Methodology for Operating Portion of the RPL Market Basket
    As proposed, the operating portion of the FY 2002-based RPL market 
basket, which is being adopted in this final rule, 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 FY 2002-based IPPS 
market basket (Section IV. Rebasing and Revision of the Hospital Market 
Baskets IPPS Hospital 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 propose to 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, as proposed and for this final rule, we are limiting 
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.
    As proposed, for this final rule, we are using 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 are using 15 percent because it includes those LTCHs and 
IRFs whose Medicare LOS is within approximately 5 days of the facility 
length of stay.
    As proposed, for this final rule, we 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 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 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. Consistent 
with the proposed rule, cost weights for benefits, contract labor, and 
blood and blood products for this final rule were derived using the FY 
2002-based IPPS market basket. For example, the ratio of the benefit 
cost weight to the wages and salaries cost weight in the 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. As 
proposed and for this final rule, the remaining 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, this methodology results in roughly 59 percent 
of the 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 5 below sets forth the complete 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.
    As proposed and for this final rule, wages and salaries are 52.895 
percent of total costs for the 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 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 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 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 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 that we proposed and we are finalizing for the operating 
portion of the RPL market basket. The price proxies for the capital 
portion are described in more detail in the capital methodology 
section. (See section III.B.1.c of this rule.)

[[Page 47910]]



   Table 5.--FY 2002-Based RPL Market Basket Cost Categories, Weights and Proxies With FY 1997-Based Excluded
                             Hospital With Capital Market Basket Used for Comparison
----------------------------------------------------------------------------------------------------------------
                                             FY 1997-based
                                               excluded        FY 2002-based
            Expense categories               hospital with      RPL market      FY 2002 RPL market basket price
                                            capital market        basket                    proxies
                                                basket
----------------------------------------------------------------------------------------------------------------
Total....................................           100.000           100.000
                                          ====================================
Compensation.............................            57.579            65.877
    Wages and Salaries *.................            47.335            52.895  ECI--Wages and Salaries, Civilian
                                                                                Hospital Workers.
    Employee Benefits *..................            10.244            12.982  ECI--Benefits, Civilian Hospital
                                                                                Workers.
Professional fees Non-Medical *..........             4.423             2.892  ECI--Compensation for
                                                                                Professional, Specialty &
                                                                                Technical Workers.
Utilities................................             1.180             0.656
    Electricity..........................             0.726             0.351  PPI--Commercial Electric Power.
    Fuel Oil, Coal, etc..................             0.248             0.108  PPI Refined Petroleum Products.
    Water and Sewage.....................             0.206             0.197  CPI-U--Water & Sewage
                                                                                Maintenance.
Professional Liability Insurance.........             0.733             1.161  CMS--Professional Liability
                                                                                Premium Index.
All Other Products and Services..........            27.117            19.265
All Other Prod. Products.................            17.914            13.323
    Pharmaceuticals......................             6.318             5.103  PPI Prescription Drugs.
    Food: Direct Purchase................             1.122             0.873  PPI Processed Foods & Feeds.
    Food: Contract Service...............             1.043             0.620  CPI-U Food Away From Home.
    Chemicals............................             2.133             1.100  PPI Industrial Chemicals.
    Blood and Blood Products **..........             0.748  ................
    Medical Instruments..................             1.795             1.014  PPI Medical Instruments &
                                                                                Equipment.
    Photographic Supplies................             0.167             0.096  PPI Photographic Supplies.
    Rubber and Plastics..................             1.366             1.052  PPI Rubber & Plastic Products.
    Paper Products.......................             1.110             1.000  PPI Converted Paper & Paperboard
                                                                                Products.
    Apparel..............................             0.478             0.207  PPI Apparel.
    Machinery and Equipment..............             0.852             0.297  PPI Machinery & Equipment.
    Miscellaneous Products...............             0.783             1.963  PPI Finished Goods less Food and
                                                                                Energy.
All Other Services.......................             9.203             5.942
    Telephone............................             0.348             0.240  CPI-U--Telephone Services.
    Postage..............................             0.702             0.682  CPI-U--Postage.
    All Other: Labor Intensive*..........             4.453             2.219  ECI--Compensation for Private
                                                                                Service Occupations.
    All Other: Non-Labor Intensive.......             3.700             2.800  CPI-U All Items.
Capital-Related Costs....................             8.968            10.149
    Depreciation.........................             5.586             6.186
    Fixed Assets.........................             3.503             4.250  Boeckh Institutional
                                                                                Construction: 23 year useful
                                                                                life.
    Movable Equipment....................             2.083             1.937  WPI--Machinery & Equipment: 11
                                                                                year useful life.
    Interest Costs.......................             2.682             2.775
    Non-profit...........................             2.280             2.081  Average yield on domestic
                                                                                municipal bonds (Bond Buyer 20
                                                                                bonds)--vintage weighted (23
                                                                                years).
    For-profit...........................             0.402             0.694  Average yield on Moody's Aaa
                                                                                bonds--vintage weighted (23
                                                                                years).
    Other Capital-Related Costs..........             0.699             1.187  CPI-U--Residential Rent.
----------------------------------------------------------------------------------------------------------------
* Labor-related.
** Blood and blood related products is included in miscellaneous products.
Note: Due to rounding, weights may not sum to total.

    Below we provide the proxies that we are using for the FY 2002-
based RPL market basket in this final rule. We made no changes to the 
proposed price proxies in this final rule. With the exception of the 
Professional Liability proxy, all the price proxies for the operating 
portion of the 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, 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

[[Page 47911]]

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 used in this regulation meet 
these criteria.
    We note that the 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 in the FY 2002-based RPL market 
basket, we use the ECI for wages and salaries for civilian hospital 
workers as the proxy for wages for measuring the price growth of wages 
in the FY 2002-based RPL market basket.

Employee Benefits

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

Nonmedical Professional Fees

    The ECI for compensation for professional and technical workers in 
private industry is 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) is applied to this component.

Electricity

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

Water and Sewerage

    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) is applied to this component.

Professional Liability Insurance

    The FY 2002-based RPL market basket uses 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 
implemented in the proxy in this final rule.

Pharmaceuticals

    The percentage change in the price of prescription drugs as 
measured by the PPI (PPI Code PPI32541DRX) is 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) is 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) is applied to this component.

Chemicals

    The percentage change in the price of industrial chemical products 
as measured by the PPI (Commodity Code 061) is 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) is 
applied to this component.

Photographic Supplies

    The percentage change in the price of photographic supplies as 
measured by the PPI (Commodity Code 1542) is 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) is 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) is used.

Apparel

    The percentage change in the price of apparel as measured by the 
PPI (Commodity Code 381) is 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) is 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) is 
applied to this component. Using this index removes 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 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

[[Page 47912]]

of the changing price of blood. As discussed in the FY 2006 proposed 
rule (70 FR 30188), 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, as proposed, for this final rule, we are using 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) is 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) is 
applied to this component.

All Other Services, Labor Intensive

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

c. Methodology for Capital Portion of the RPL Market Basket

    Unlike for the operating costs of the 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, as was proposed, for this 
final rule we are using 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 aging the 
data to a FY 2002 base year using relevant price proxies.
    As proposed, for this final rule 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. As 
proposed, for this final rule the resulting 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. As proposed, for this final rule 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).
    As proposed, for this final rule 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.
    As proposed, for this final rule we derived 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, as proposed and for this final rule, we used 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, as proposed in 
the FY 2006 proposed rule (70 FR 30188) we are using a 75-25 split to 
allocate interest expenses to government/nonprofit and for-profit. See 
the IPPS Rule for FY 2006, Section IV.D, Capital Input Price Index 
Section (70 FR 23406).
    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, as proposed, for this final 
rule we are using the vintage weights to compute vintage-weighted price 
changes associated with depreciation and interest expense.
    Vintage weights are an integral part of the 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 FY 2002-based RPL market 
basket reflects the annual price changes associated with capital costs, 
and is 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 for Medicare capital-related costs. The 
capital component of the FY 2002-based RPL market basket reflects 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 need 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

[[Page 47913]]

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 any 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, as proposed, for this final rule, we are 
using FY 2001 Medicare cost reports for IPPS hospitals to determine the 
expected life of building and fixed equipment and movable equipment. We 
believe this data source reflects the latest relative cost structure of 
depreciation expenses for hospitals. 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.
    Between the publication of the June 24, 2005 proposed rule and this 
final rule, we conducted a further review of the methodology used to 
derive the useful life of an asset. Based on this brief analysis into 
the capital cost structures of hospitals, we are not changing the 
expected life of fixed and moveable assets for the final rule.
    As proposed, for this final rule, we are using 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.
    As proposed, for this final rule, for 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 are 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.
    As proposed, for this final rule, for 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 are 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 
are 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 is used to determine the FY 
2002 average movable equipment vintage weights.
    As proposed, for this final rule, for 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 are 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 are calculated by dividing the nominal total capital purchase 
amount for 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 the 
sixteen 23-year periods is used to determine the FY 2002 average 
interest vintage weights. The vintage weights for the index are 
presented in Table 6 below.

[[Page 47914]]

    In addition to the price proxies for depreciation and interest 
costs described above in the vintage weighted capital section, as 
proposed, for this final rule, we used 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.

                                          Table 6.--CMS FY 2002-Based RPL Market Basket Capital Vintage Weights
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Fixed assets (23 year        Movable assets (11 year      Interest: capital-related
                             Year                                         weights)                      weights)                  (23 year weights)
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.............................................................                         0.021                         0.065                         0.010
2.............................................................                         0.022                         0.071                         0.012
3.............................................................                         0.025                         0.077                         0.014
4.............................................................                         0.027                         0.082                         0.016
5.............................................................                         0.029                         0.086                         0.019
6.............................................................                         0.031                         0.091                         0.023
7.............................................................                         0.033                         0.095                         0.026
8.............................................................                         0.035                         0.100                         0.029
9.............................................................                         0.038                         0.106                         0.033
10............................................................                         0.040                         0.112                         0.036
11............................................................                         0.042                         0.117                         0.039
12............................................................                         0.045  ............................                         0.043
13............................................................                         0.047  ............................                         0.048
14............................................................                         0.049  ............................                         0.053
15............................................................                         0.051  ............................                         0.056
16............................................................                         0.053  ............................                         0.059
17............................................................                         0.056  ............................                         0.062
18............................................................                         0.057  ............................                         0.064
19............................................................                         0.058  ............................                         0.066
20............................................................                         0.060  ............................                         0.070
21............................................................                         0.060  ............................                         0.071
22............................................................                         0.061  ............................                         0.074
23............................................................                         0.061  ............................                         0.076
                                                               -------------------------------
    Total.....................................................                        1.0000                        1.0000                        1.0000
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The final FY 2006 update for IRF PPS using the FY 2002-based RPL 
market basket is 3.6 percent. This is based on Global Insight's 2nd 
quarter 2005 forecast, incorporating two more quarters of historical 
data than published in the FY 2006 IRF proposed rule. 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 second 
quarter 2005 forecast for FY 2006 is also 3.6 percent. Table 7 below 
compares the 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 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 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 FY 2002-based RPL market basket than in 
the FY 1997-based index, and the slower price changes associated with 
these costs.

Table 7.--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 excluded
                  Fiscal year (FY)                      Rebased FY 2002-based RPL    hospital 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                           3.7
    Average FYs 2000-2004...........................                           3.7                           3.6
Forecast:                                             ............................  ............................
    FY 2005.........................................                           3.8                           3.9
    FY 2006.........................................                           3.6                           3.6
    FY 2007.........................................                           3.2                           3.1
    FY 2008.........................................                           3.1                           2.9

[[Page 47915]]

 
    Average FYs 2005-2008...........................                           3.4                          3.4
----------------------------------------------------------------------------------------------------------------
 Source: Global Insight, Inc. 2nd Qtr 2005, @USMACRO/CNTL0605 @CISSIM/TL0505.SIM.

    Comment: One commenter recommended that the current update be 
increased to reflect the differences between the updates given in FY 
2004 and FY 2005 and the final market basket increases. Another 
commenter recommended that CMS adopt a forecast error adjustment.
    Response: There is currently no mechanism for adjusting for 
forecast error in the IRF PPS. Also, the FY 2005 updates is not based 
on historical data. The forecast error for FY 2005 will not be 
available until we publish the 2005q4 forecast (with historical data 
through 2005q3) version of the market basket. We have been actively 
working with our contractor to minimize forecast error. The specific 
details of our analysis are provided in the response to following 
comment.
    Comment: Several commenters requested that CMS review and revise 
the methodology used to forecast the FY 2006 market basket. They are 
concerned that the proposed FY 2006 update of 3.1 percent is a dramatic 
underestimation. One commenter requested that CMS make the calculation 
of the projected FY 2006 available to the public.
    Response: Before we published the FY 2006 proposed rule, we had 
been actively working with our forecasting firm, Global Insight, Inc. 
(GII), to improve the forecasting accuracy of the market baskets. GII 
is a nationally recognized economic and financial forecasting firm that 
contracts with CMS to forecast the components of the market baskets. 
Among other services GII provides to CMS, GII calculates projected 
inflation factors for price proxies using models that take into account 
sectoral, national, and global economic trends.
    Over the last several years, dramatic fluctuations in the price of 
certain costs have made it difficult to forecast price proxy inflation. 
The driving force behind a significant portion of this uncertainty has 
been the instability of energy costs. With our input and consultation, 
however, GII recently re-evaluated and modified their forecasting 
models to help improve their forecasting accuracy. Using these improved 
forecasting models, GII calculated updated inflation factors for the 
major cost categories in Table 8.

 Table 8.--Comparison of the 4 Quarter Moving Average Percent Changes for Several Cost Category Weights Between
                                      the FY 2006 Proposed and Final Rules
----------------------------------------------------------------------------------------------------------------
                                                                                GII 2004q4
                                                           FY 2002-based      forecast of FY       GII 2005q2
                    Expense category                        cost weights      2006 (Proposed     forecast of FY
                                                                                  Rule)        2006 (Final Rule)
----------------------------------------------------------------------------------------------------------------
Total--RPL02...........................................             100.00                3.1                3.6
Compensation...........................................             65.877                3.5                3.9
Utilities..............................................              0.656                0.8                3.6
Professional Fees......................................              2.892                3.6                3.8
Professional Liability Insurance.......................              1.161                8.4                5.2
All Other..............................................             19.265                2.5                3.2
All Other Products.....................................             13.323                2.6                3.5
All Other Services.....................................              5.942                2.4                2.6
Capital................................................             10.149                0.9                1.1
----------------------------------------------------------------------------------------------------------------

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. As proposed, for this final rule, we are 
using the FY 2002-based RPL market basket costs to determine the labor-
related share for the IRF PPS. The labor-related share for FY 2006 is 
the sum of the FY 2006 relative importance of each labor-related cost 
category, and reflects the different rates of price change for these 
cost categories between the base year (FY 2002) and FY 2006. For this 
final rule, we are revising the labor-related share to reflect Global 
Insight's second quarter 2005 forecast, incorporating two more quarters 
of

[[Page 47916]]

historical data than published in the FY 2006 IRF proposed rule. Thus, 
for this final rule, the sum of the relative importance for FY 2006 for 
operating costs (wages and salaries, employee benefits, professional 
fees, and labor-intensive services) is 71.708 percent, as shown in the 
chart below. The portion of capital that is influenced by local labor 
markets is estimated to be 46 percent, which is the same percentage 
currently used in the IRF prospective payment system. Since the 
relative importance for capital is 9.037 percent of the FY 2002-based 
RPL market basket in FY 2006, we took 46 percent of 9.037 percent to 
determine the capital labor-related share for FY 2006. The result is 
4.157 percent, which we add to 71.708 percent for the operating cost 
amount to determine the total labor-related share for FY 2006. Thus, 
the labor-related share that we are using for IRF PPS in FY 2006 is 
75.865 percent. This labor-related share is determined using the same 
methodology as employed in calculating all previous IRF labor-related 
shares (66 FR at 41357).
    Table 9 below shows the final FY 2006 relative importance labor-
related share using the 2002-based RPL market basket and the labor-
related share using the FY 1997-based excluded hospital with capital 
market.

                                       Table 9.--Total Labor-Related Share
----------------------------------------------------------------------------------------------------------------
                                                                                             FY 1997 excluded
                                                                   FY 2002-based RPL      hospital with capital
                         Cost category                           market basket relative   market basket relative
                                                                importance (percent) FY  importance (percent) FY
                                                                          2006                     2006
----------------------------------------------------------------------------------------------------------------
Wages and salaries............................................                   52.592                   48.185
Employee benefits.............................................                   14.028                   11.542
Professional fees.............................................                    2.921                    4.558
All other labor intensive services............................                    2.167                    4.450
    Subtotal..................................................                   71.708                   68.735
                                                               ==========================
Labor-related share of capital costs..........................                    4.157                    3.289
                                                               --------------------------
    Total.....................................................                   75.865                   72.024
----------------------------------------------------------------------------------------------------------------

    Public comments that we received are summarized below.
    Comment: Several commenters objected to our proposal to change the 
labor-related share to 75.958 percent. One commenter suggested CMS 
maintain the FY 2005 labor-related share of 72.359 percent until CMS 
can develop an IRF-specific wage index. Another commenter stated there 
is no precedent to change the labor-related share. Another commenter 
requested that if CMS implemented a change in the LRS, they request a 
transition where the transitional labor-related share would be composed 
of 80 percent of the current labor-related share and 20 percent of the 
proposed labor-related share.
    Response: Identical to previous updates, the labor-related share is 
calculated as the sum of the relative importance of those costs that 
are related to, influenced by, or vary with the local labor market. 
Specifically, the FY 2006 labor related share is equal to the relative 
importance of wages and salaries, fringe benefits, professional fees, 
labor-intensive services, and a portion of the capital share from the 
RPL market basket.
    We calculate the labor-related relative importance for FY 2006 in 
four steps. First, we compute the FY 2006 price index level for the 
total market basket and each cost category of the market basket. 
Second, we calculate a ratio for each cost category by dividing the FY 
2006 price index level for that cost category by the total market 
basket price index level. Third, we determine the FY 2006 relative 
importance for each cost category by multiplying this ratio by the base 
year (FY 2002) weight. Finally, we sum the FY 2006 relative importance 
for each of the labor-related cost categories (wages and salaries, 
employee benefits, nonmedical professional fees, labor-intensive 
services, and capital-related expenses) to produce the FY 2006 labor-
related relative importance.
    The price proxies that move the different cost categories in the 
market basket do not necessarily change at the same rate, and the 
relative importance captures these changes. Accordingly, the relative 
importance figure more closely reflects the cost share weights for FY 
2006 when compared to the base year weights from the RPL market basket. 
Thus, the LRS has been and should be revised with each fiscal year 
update.
    CMS disagrees with the commenter's suggestion to transition from 
the FY 2005 to the FY 2006 labor-related share. We note the FY 2006 
labor-related share is based on the same methodology used to calculate 
the FY 2005 labor-related share (that is, it is composed of the costs 
that are related to, influenced by, or vary with the local labor 
market). Furthermore, the FY 2006 labor-related share is based on the 
2002-based RPL market basket, which we believe adequately reflects the 
current cost structures of Medicare-participating IRFs. Therefore, we 
do not believe a transition is necessary.
    Comment: Several commenters suggested that we include professional 
liability insurance (PLI) in the labor-related share since these costs 
are included in the wage index. The commenters also claim that 
professional liability insurance costs are wage-related.
    Response: The wage index includes, as a fringe benefit cost, PLI 
for those policies that list actual names or specific titles of covered 
employees (59 FR 45358). The benefit cost weight in the market basket, 
included in the labor-related share, is also based on the same wage 
index benefit data. Therefore, the labor-related share includes these 
PLI costs. General PLI coverage maintained by hospitals is not 
recognized as a wage-related cost for purposes of the wage index or 
labor-related share.
    Although general PLI costs do vary by geographic region, this 
variance is primarily influenced by state legislation and risk level, 
not by local wage rates. In fact, areas with high wage indices may have 
low relative PLI costs. For example, the malpractice geographic price 
indices, used in the Medicare physician payment system, for San 
Francisco, Los Angeles, and Boston regions are below 1, while their 
hospital wage indices for comparable areas are much greater than 1.
    Comment: Several commenters recommended CMS delay the 
implementation of the RPL market

[[Page 47917]]

basket until CMS has reviewed the accuracy of the cost report data. 
Specifically, they requested CMS investigate HealthSouth's claim to 
have omitted home office and some depreciation costs from their 2002 
and 2003 Medicare cost reports.
    Response: The FY 2006 market basket update is based on the RPL 
market basket using FY 2002 Medicare cost report data. CMS has 
determined that, in the absence of FY 2002 HealthSouth home office cost 
report data, we will not incorporate preliminary FY 2004 HealthSouth 
home office costs into the 2002-based RPL market basket. (Due to a 
change in Medicare cost report requirements beginning with FY 2002, we 
used FY 2001 capital costs aged to FY 2002 in the 2002-based RPL market 
basket. Therefore, HealthSouth's depreciation costs were included in 
the RPL market basket and reflected in the FY 2006 market basket 
update.)
    Home office costs represent only one of many cost categories 
(including but not limited to salaries, benefits, professional 
liability insurance, and pharmaceuticals) that are used to develop the 
cost category weights. We believe the absence of HealthSouth home 
office costs in this market basket has a minor impact on the 
distribution of these weights and, by extension, the final market 
basket update itself. When CMS receives full FY 2004 Medicare cost 
report data from HealthSouth, we plan to re-evaluate this decision.
    Final Decision: We are finalizing our decision to update payments 
for rehabilitation facilities using the RPL market basket reflecting 
the operating and capital cost structures for IRFs, IPFs, and LTCHs.
2. 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 
will have been made in the year without such adjustment.
    In our August 1, 2003 final rule (68 FR 45674), 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 in section VI.B.2.d, we proposed to 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). We will adopt the CBSA-based geographic classifications 
as proposed in the FY 2006 IRF PPS proposed rule (70 FR 30188) and 
described below in section VI.B.2.d and section VI.B.2.e.

a. Revisions to 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 commonly referred to as ``pre-reclassification''. 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 the ``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.
    In the FY 2006 IRF PPS proposed rule (70 FR 30188, 30235), we 
described the 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. However, we published each area's wage index in the IRF PPS 
final rules and update notices, each year and noted the use of the 
geographic area in applying the wage index adjustment in the IRF PPS 
payment examples in the final regulation implementing the IRF PPS (69 
FR 41316, 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) are used under the IRF PPS. The OMB adopted new 
statistical area definitions (70 FR 30188, 30235-30238) and we proposed 
to adopt the new labor market area definitions based on these areas 
under the IRF PPS. Therefore, we are providing a more detailed 
description of the current IRF PPS labor market areas in this final 
rule, in order for the public to better understand the change to the 
IRF PPS labor market areas.

[[Page 47918]]

    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 
are used before October 1, 2005, 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 are 
effective October 1, 2004 for acute care hospitals. These new CBSA 
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 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) 
for discharges before October 1, 2005. We 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 described in 
section VI.B.2.d.ii of this final 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. 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 non-statistical 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 non-statistical 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 the same general areas. In addition, the most recent CBSAs reflect 
the most up-to-date information. The OMB reviews its Metropolitan Area 
(MA) definitions preceding each decennial census to reflect recent 
population changes and the CBSAs are based on the Census 2000 data. 
Thus, we proposed to adopt the new CBSA designations to define labor 
market areas for the purposes of the IRF PPS.
    Historically, Medicare PPSs have utilized 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 
proposed to adopt the

[[Page 47919]]

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 will adopt the 
labor market area definitions used under the IRF PPS as proposed in the 
FY 2006 IRF PPS proposed rule (70 FR 30188). Specifically, we will 
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 will 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 will 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 proposed in the FY 
2006 IRF PPS proposed rule (70 FR 30188).
    As a conforming change, we will revise Sec.  412.602, definitions 
for rural and urban areas effective for discharges occurring on or 
after October 1, 2005 will be defined in Sec.  412.64(b)(1)(ii)(A) 
through (C) as proposed in the FY 2006 IRF PPS proposed rule (70 FR 
30188) and adopted in this final rule. In addition (as proposed in the 
FY 2006 IRF PPS proposed rule at 70 FR 30188), 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-based designations) implemented under the 
IPPS at Sec.  412.64(b), which are 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' pre-reclassification and pre-floor 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 
revising 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.
    In sections VI.B.2.d.i. through VI.B.2.d.iii of this final rule and 
as described in the FY 2006 IRF PPS proposed rule (70 FR 30188), we 
describe the composition of the 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.
    To create consistency among all labor market areas and to maintain 
these areas on the basis of counties, we proposed to and are adopting 
in this final rule 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 will lead to 
inconsistencies in our designations. Adopting county-based labor market 
areas for the entire country provides consistency and stability in the 
Medicare payment program because all the labor market areas throughout 
the country, including New England, will be defined using the same 
system (that is, counties) rather than different systems in different 
areas of the country, and minimizes programmatic complexity.
    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, as specified in the FY 2006 
proposed rule (70 FR 30188), we are using the New England MSAs as 
determined under the new CBSA-based labor market area definitions in 
defining the revised IRF PPS labor market areas in this final rule.
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 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

[[Page 47920]]

market area designation. This variation could increase the difficulty 
in calculating a single wage index that will 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, will most accurately 
maintain our current structuring of the IRF PPS labor market areas. As 
implemented under the IPPS (69 FR at 49029), we proposed and for this 
final rule, we are using the Metropolitan Divisions where applicable 
(as describe below) under the 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 using Metropolitan Divisions 
where applicable (as described below) under the IRF PPS will result in 
a more accurate adjustment for the variation in local labor market 
areas for IRFs. Specifically, if we were to 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 will 
be too large and will include the data from too many hospitals to 
compute a wage index that will 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 will be relevant for all hospitals 
within the market area designation. Rather, by recognizing Metropolitan 
Divisions where applicable (as described below) under the 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 will 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. In 
section VI.B.2.d.ii.of this final rule, we describe where Metropolitan 
Divisions will be applicable under the new CBSA-based labor market area 
definitions under the IRF PPS final rule.
    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 
CBSA-based labor market area designations, it is comprised of four 
Metropolitan Divisions. Los Angeles will go from four PMSAs under the 
current IRF PPS MSA designations to two Metropolitan Divisions under 
the CBSA-based labor market area designations. The New York CMSA will 
go from 15 PMSAs under the current IRF PPS MSA designations to four 
Metropolitan Divisions under the CBSA-based labor market area 
designations. The five PMSAs in Connecticut under the current IRF PPS 
MSA designations will become separate MSAs under the 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 will 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 CBSA-based labor market 
area designations. In San Francisco, under the 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 will no 
longer be designated as CMSAs under the 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 will become separate, independent MSAs under the CBSA-based 
labor market area designations, leaving only the MSA for the core area 
under the CBSA-based labor market area designations.
    We note that subsequent to the publication of the FY 2006 IRF PPS 
proposed rule (70 FR 30188), titles to certain CBSAs were changed based 
on OMB Bulletin No. 05-02 (November 2004). The title changes listed 
below are nomenclatures that do not result in substantive changes to 
the CBSA-based designations. Thus, these changes are listed below and 
will be incorporated into the FY 2007 CBSA-based urban wage index 
tables.

 CBSA 36740: Orlando-Kissimmee, FL
 CBSA 37620: Parkersburg-Marietta-Vienna, WV-OH
 CBSA 42060: Santa Barbara-Santa Monica, CA
 CBSA 13644: Bethesda-Gaithersburg-Frederick, MD
 CBSA 32580: McAllen-Edinburg-Mission, TX
 CBSA 26420: Huston-Sugar Land-Baytown, TX
 CBSA 35644: New York-White Plains-Wayne, NY-NJ
ii. Micropolitan Areas Under the New OMB 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 will 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 will 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 VI.B.2.b of this final 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 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.
    Since the implementation of the IRF PPS, we used MSAs to define 
urban labor market areas and group all the

[[Page 47921]]

hospitals in counties within each 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 proposed 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) 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, in the 
FY 2006 proposed rule (70 FR 30188), 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 will 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 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 will 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 will 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 proposed and are adopting Micropolitan 
Areas as independent labor market areas under the IRF PPS. Under the 
new CBSA-based labor market area definitions, Micropolitan Areas are 
considered a part of the statewide rural labor market area. 
Accordingly, we will determine an IRF PPS statewide rural wage index 
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 final 
rule) from hospitals located in non-MSA areas assign the statewide 
rural wage index to IRFs located in those areas.

e. Implementation of the CBSA-Based 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.
    In the FY 2006 IRF PPS proposed rule (70 FR 30188), Table 3 listed 
IRFs that submitted an IRF-PAI in the past 18-months. The data in Table 
3 was obtained from a report we requested in February 2005 from the 
Iowa Foundation for Medical Care (IFMC). IFMC is the CMS contractor 
where the IRF-PAI database is located. Table 3 listed each IRF's 
provider number; provider name; and State and county location; existing 
MSA-based labor market area designation; and its CBSA-based 
designation. The purpose of Table 3 was to only facilitate an 
understanding of the policies related to the proposed change to the IRF 
PPS labor market areas discussed above by illustrating an IRF's change 
from the MSA-based designation to the proposed CBSA-based designation. 
Thus, FIs will not be instructed to use Table 3 in the FY 2006 IRF PPS 
proposed rule (70 FR 30188) to alter the information regarding an IRF's 
State and county location or to make changes to the provider specific 
file based on Table 3 of the FY 2006 IRF PPS proposed rule.
    Table 1 of the addendum of this final rule is a crosswalk file of 
all counties/areas in the United States, Guam, Puerto Rico, and the 
Virgin Islands with the corresponding State and county code, county and 
State name, FY 2006 MSA number, FY 2006 MSA-based urban or rural 
designation, FY 2006 MSA-based wage index, FY 2006 CBSA-based wage 
index, FY 2006 CBSA number, FY 2006 CBSA-based urban or rural 
designation, and FY 2006 blended one-year transition wage index as 
discussed below in Section VI.B.2.e. Table 1 of the addendum to this 
final rule will be used by FIs to determine the FY 2006 one-year 
transition wage index for IRFs located in areas as documented in the 
FI's provider specific file.
    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 CBSA-based designations in 
order 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

[[Page 47922]]

wage indices is calculated for those acute care IPPS hospitals 
experiencing a drop in their wage index 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.
    In the FY 2006 IRF PPS proposed rule (70 FR 30188), we recognize 
that, just like IPPS hospitals, IRFs may experience decreases in their 
wage index as a result of the labor market area changes. Our data 
analysis for the FY 2006 IRF PPS proposed rule (70 FR 30188) indicated 
that a majority of IRFs either expect no change in wage index or an 
increase in wage index based on CBSA definitions. Based on this 
analysis for the FY 2006 IRF PPS proposed rule (70 FR 30188), we found 
a very small number of IRFs (3 percent) will 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 labor market areas, we did not propose a 
transition to the new CBSA-based labor market area, nor did we propose 
to adopt a hold harmless policy, nor an ``out-commuting'' policy for 
the purposes of the IRF PPS wage index.
    Public comments and our responses on the proposed changes for 
implementing the area wage adjustments are summarized below:
    Comment: A large number of commenters urged CMS to develop a 
transition policy or implement a similar transition policy as was 
implemented under the IPPS to minimize the fiscal impact of the change 
in wage index. Many advocated for 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. We also received a few 
comments recommending a multi-year transition and possibly a permanent 
blended wage index. Overall, commenters expressed concerns for IRFs 
that would experience a significant decrease in the wage index. In 
general, commenters request that we mitigate the impact of the change 
from the MSA-based designation to the CBSA-based designations over time 
with a transition policy.
    Response: We recognize that some IRFs will experience decreases in 
their applicable wage index as a result of the conversion from the MSA-
based designations to the CBSA-based designations. After further 
analysis of various transition options suggested by commenters as well 
as our further data analysis to support the policies in this final 
rule, we considered various transition options to determine a 
transition policy that would mitigate the impact on IRFs that would 
experience a decrease in the wage index, and buffer the overall impact 
on the unadjusted payment rate. Based on the commenters' 
recommendations, we carefully reviewed various budget neutral 
transition policies such as a blended wage index as well as a floor and 
ceiling approach as discussed in detail below.
    We reviewed a floor and ceiling transition policy option. Although 
this option seemed to minimize the impact on IRFs, we found that this 
approach would provide relief to IRFs that experience a decrease in the 
wage index, but with respect to IRFs that would get a significant 
increase in the wage index, it would also limit the amount they could 
expect their wage index to increase. The difficulty of developing a 
floor and ceiling transition policy is determining an appropriate floor 
and a ceiling that would best mitigate IRFs that experience a decrease 
in the wage index while lessening the overall impact on the unadjusted 
base payment kept us from choosing this option.
    Although a few commenters recommended a permanent blended wage 
index (comprised of the MSA-based wage index and the CBSA-based wage 
index), we do not believe this is appropriate. Beginning in FY 2006, 
acute care hospital will receive 100 percent of the IPPS wage index 
based on the new CBSA wage index. From FY 2006 and forward, CMS will no 
longer maintain the geographic classifications based on MSAs. 
Therefore, MSA-based wage indexes will not be able to reflect the same 
amount of accuracy as they currently represent by having the 
geographical classification updated annually. By developing a permanent 
blended wage index, CMS would only be geographically updating the CBSA-
based areas and not the MSA-based areas. Consequently, we believe that 
implementation of a permanent blended wage index would result in a wage 
index that is not as accurate as a wage index based on the CBSA 
methodology, as thoroughly discussed in section VI.B.2.d.
    Several commenters suggested that IRFs be afforded the same 
transition as adopted by IPPS (69 FR 48916, 49032-49034). Therefore, 
another budget neutral one-year transition policy we considered would 
blend the wage index for IRFs that would experience a reduction in the 
wage index. The blended wage index would consist of 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), only for 
IRFs that experience a decrease due solely to the changes in the labor 
market definitions. Although some commenters recommended this 
transition policy, we believe that this would not allow all IRFs the 
ability to transition from the MSA-based wage index to the CBSA-based 
wage index because this transition policy only focuses on the blending 
the wage index for IRFs that experience a decrease in the wage index. 
In addition, we found that this would change the budget neutrality 
factor applied to the base rates from 0.9996 if there was no transition 
to 0.9977 under this transition policy. Therefore, the budget 
neutrality factor under the transition policy for only those IRFs that 
experience a decrease in the wage index would reduce the unadjusted 
base rate by approximately more than 20 dollars. The overall impact 
based on the reduction of the unadjusted base rate would result in all 
IRFs experiencing a reduction in payments. Under this approach, we 
found that IRFs would experience a significant reduction in the 
unadjusted payment amount, which would not mitigate the change in 
estimated payments for IRFs.
    The last one-year budget neutral blended transition policy we 
analyzed would allow all IRFs to transition from an MSA-based wage 
index to a CBSA-based wage index. This transition policy would be 
comprised of 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 IRFs. As discussed in the FY 2006 IRF PPS 
proposed rule (70 FR 30188), the one-year blended wage index for all 
IRFs would result in a slight decrease of budget neutrality factor 
applied to the base rates from 0.9996 if there was no transition to 
0.9995 under this transition policy. As a result, the budget neutrality 
factor applied to the unadjusted payment amount would reduce the 
unadjusted payment amount by approximately 1 dollar as compared to 
fully adopting the CBSA-based designations. This slight decrease to the 
unadjusted payment amount will lessen the overall payment reduction 
impact

[[Page 47923]]

on all providers--regardless of urban or rural designations.
    Although a blended wage index for all IRFs would also help IRFs 
that are adversely affected by the changes from MSAs to CBSAs, it would 
reduce the expected higher CBSA wage index values for IRFs that are 
positively affected by the changes (compared to fully adopting the 
CBSA-based wage index). To clarify, a blended wage index for IRFs that 
experience any increase due to the change from an MSA-based wage index 
to a CBSA-based wage index would be lessened. Thus, this would allow 
all IRFs one year to financially prepare for a change in wage index due 
to the change from FY 2005 MSA-based to FY 2006 CBSA-based 
designations--regardless of an increase or decrease in wage index.
    In addition, although the blended wage index would limit the wage 
index increase for IRFs that experience an increase due to the change 
from an MSA-based wage index to a CBSA-based wage index during FY 2006, 
these IRFs will continue to see an increase in their wage index. 
However, the dampening effect of the blended wage index for IRFs that 
experience an increase in their wage index does not significantly 
impact these IRFs based solely on the wage index. The increase in the 
wage index these IRFs would experience would still take effect because 
the blended wage index would be an average of the MSA-based wage index 
and a CBSA-based wage index and the CBSA-based wage index would be 
greater than the MSA-based wage index. Therefore, IRFs in this scenario 
would not be significantly impacted by a blended wage index. In other 
words, IRFs that have higher CBSA wage index values and are subject to 
the blend will continue to have a benefit of having their payment 
derived, in part, from the higher CBSA wage index. We believe this 
option helps create an equitable situation for all IRFs.
    Many commenters urged and supported a transition to adopting the 
CBSA-based designations. Thus, this blended wage index (50 percent of 
the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-
based wage index and both based on the FY 2001 hospital wage data) 
would provide IRFs a one-year transition from the MSA-based 
designations to the CBSA-based designations. In addition, the one year 
transition of a blended wage for all IRFs would result in 93 percent of 
all IRFs experiencing a wage index change between a decrease by up to 2 
percent or an increase by up to 2 percent. In any given year, even 
under the MSA-based wage index, many IRFs experience a 2 percent change 
in wage index and this 2 percent change would most likely be a wage 
index change that would not significantly impact IRF payments based 
solely on the wage index. Thus, from year to year, almost all IRFs are 
expected to experience a minimal change in wage index values. In 
comparison, if we fully adopted the CBSA-based wage index without a 
transition as proposed, 85 percent of the IRFs would experience a 
change between a decrease by up to 2 percent or an increase by up to 2 
percent. By providing a one year transition for all IRFs to receive a 
blended wage index (50 percent of the FY 2006 MSA-based wage index and 
50 percent of the FY 2006 CBSA-based wage index and both based on the 
FY 2001 hospital wage data), a larger majority of IRFs will experience 
a minimal change in wage index from FY 2005 to FY 2006.
    We decided not to provide for a longer transition, as recommended 
by a few commenters, because we have already, in effect, provided one 
year at a higher wage index level for all IRFs by retaining the 
previous labor market definitions for two years after the new labor 
market definitions became available. For example, we did not implement 
the new labor market area definitions as quickly as was done for 
facilities paid under the IPPS. Furthermore, since most IRFs benefit 
from a one year blended wage index, there will be minimal affect on 
IRFs. Thus, a one year transition is sufficient to minimize the impact 
of adopting the CBSA-based designations because we believe that the 
transition period allows IRFs sufficient time to adjust their necessary 
business practices. In addition to the one year blended wage index, we 
are implementing a longer, 3-year hold harmless transition (as 
discussed in this section below of this final rule (section VI.B.2.e)) 
for a group of IRFs that during FY 2005 are as designated as rural, and 
for FY 2006 will be designated as urban under the new CBSA-based 
geographic designation method. We are implementing a longer hold 
harmless transition for these IRFs because, as a group they experience 
a reduction in payments due to the labor market revisions and the loss 
of the rural adjustment.
    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. 
After consideration of the recommendations presented by the commenters 
and based on our further analysis, we will implement a budget neutral 
one-year transition policy such that a blended wage index (50 percent 
of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-
based wage index that are both based on the FY 2001 hospital wage data) 
will apply to all IRFs. This transition policy will be effective for 
discharges occurring on or after October 1, 2005 and on or before 
September 30, 2006. This transition will mitigate the large negative 
impacts for IRFs that experience a decrease in the wage index and allow 
all IRFs to transition from the MSA-based wage index to the CBSA-based 
wage index for one-year. Therefore, for FY 2007 and subsequent years, 
we will adopt the full CBSA-based wage index for all IRFs.
    Comment: Several commenters requested CMS to consider a multi-year 
hold harmless policy as was implemented by IPPS.
    Response: 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 will 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 
will be substantially impacted by the significant change in wage index. 
Although we considered a hold harmless policy in our FY 2006 proposed 
rule, we did not propose a hold harmless policy because we believed 
that rural IRFs (under the MSA-based designations) that change to an 
urban designation (based on the CBSA-based geographic classification) 
would experience a significant increase to the wage index under the 
CBSA-based designations that would mitigate a significant decrease in 
payments. However, many commenters urged CMS to reconsider a hold 
harmless policy because the commenters demonstrated that some rural 
facilities would experience undue hardship with the loss of the rural 
adjustment under Sec.  412.624(e)(3).
    In our analysis (discussed in the FY 2006 IRF PPS proposed rule (70 
FR 30188)), we found that 91 percent of rural facilities that would be 
designated as urban under the CBSA-based definitions will experience an 
increase in the wage index. A majority (74 percent) of rural facilities 
that become urban will experience at least a 5 percent to 10 percent or 
more increase in wage index. Although these rural IRFs experience wage 
index increases, several commenters emphasized that a

[[Page 47924]]

majority of rural providers that change designations may experience a 
wage index increase of at least 5 percent or more, the loss of the 
rural adjustment would be such a large negative impact on the rural 
IRFs that it may potentially cause undue hardship for these rural 
facilities.
    In response to the commenters concerns, we considered different 
hold harmless policies such as a multi-year hold harmless policy as 
well as a phase-out of the rural adjustment for rural IRFs under the 
MSA-based designations that received a rural adjustment of 19.14 
percent in FY 2005. A commenter recommended a phase-out of the FY 2005 
rural adjustment of 19.14 percent because this option allows IRFs that 
change designations, from rural to urban, time to adjust to the loss of 
the 19.14 percent rural adjustment which would result in loss of 
payments. Other commenters concurred that the loss of the FY 2005 rural 
adjustment far exceeds the urban CBSA-based increase in wage index. 
Thus, commenters believed that this would have significant payment 
implications, particularly large negative impacts for rural IRFs that 
change designations because they will experience significant payment 
losses.
    After further consideration of hold harmless policies as 
recommended by commenters, we have decided to implement a hold harmless 
policy to mitigate significant payment implications, particularly large 
negative impacts. We will implement a 3 year budget neutral hold 
harmless policy for those IRFs that meet the definition in Sec.  
412.602 as rural in FY 2005 and will become urban under the FY 2006 
CBSA-based designations. We will afford existing IRFs designated in FY 
2005 as rural IRFs (pursuant to Sec.  412.602) and redesignated as an 
urban facility in FY 2006 (pursuant to Sec.  412.602) in FY 2006, whose 
payment is lower because of such redesignation, a 3 year time span to 
adjust to the loss of the FY 2005 rural adjustment of 19.14 percent 
because the loss of the 19.14 percent rural adjustment would result in 
a significant loss of payments. This adjustment will be in addition to 
the one-year blended wage index (comprised of FY 2006 MSA-based wage 
index and FY 2006 CBSA-based wage index both based on FY 2001 hospital 
data) for all IRFs.
    Although our intent under our hold harmless policy is to mitigate 
the negative payment effect upon a rural facility that is redesignated 
as an urban facility (effective FY 2006), the hold harmless policy 
should not result in an IRF that comes under the hold harmless policy 
to realize greater payments than the IRF would have if instead the IRF 
would have been paid under its rural designation in FY 2006 including 
the FY 2005 rural adjustment of 19.14 percent. Therefore, we will make 
the appropriate payment modification to the additional adjustment made 
under our hold harmless policy so that an existing FY 2005 rural IRF 
that is redesignated from rural to urban in FY 2006 will in FY 2006 or 
FY 2007 not realize payments that are greater than what the payments 
would have been if the facility would have instead been paid under its 
rural designation in FY 2006 including the FY 2005 rural adjustment of 
19.14 percent. In other words, if an existing FY 2005 IRF is 
redesignated from rural to urban in FY 2006, and it will realize an 
increase in payments during the one year transition due to the hold 
harmless policy, it will not receive the full two-thirds of the 19.14 
percent rural adjustment. However, if this same IRF realizes a decrease 
in payment in FY 2007 solely because of such redesignation in FY 2006, 
it will receive one-third of the 19.14 percent rural adjustment in such 
case.
    As stated above, the hold harmless policy is specifically for FY 
2005 rural IRFs that become urban in FY 2006 and that experience a loss 
in payment because of this redesignation. Thus, we are not implementing 
a hold harmless policy for urban facilities (under the MSA-based 
designation) that become rural (under the CBSA-based designation) 
because these IRFs will receive the updated FY 2006 rural adjustment of 
21.3 percent that they did not receive in FY 2005 as an urban facility. 
The gain of this payment adjustment should more than mitigate the loss 
of the wage index decreases associated with the rural designations. For 
FY 2005, rural facilities that remain rural under the FY 2006 CBSA-
based designation, we are not extending the hold harmless policy for 
these IRFs because these rural IRFs will receive the updated FY 2006 
rural adjustment of 21.3 percent, which is higher than the FY 2005 
rural adjustment of 19.14 percent. We are also not extending the hold 
harmless policy for facilities that remain in their urban geographic 
designations from the MSA-based designation to the CBSA-based 
designation because we have mitigated the impact of the change in wage 
index value by implementing a one year transition wage index (comprised 
of 50 percent FY 2006 MSA-based wage index and 50 percent of the FY 
2006 CBSA-based wage index) for all IRFs as discussed in detail above. 
As was previously stated, the purpose of the hold harmless policy is to 
mitigate the significant payment implications for existing rural IRFs 
that may need time to adjust to the loss of their FY 2005 rural payment 
adjustment that experience a reduction in payments solely because of 
such redesignation. Our decision to implement the hold harmless policy 
only for existing FY 2005 rural IRFs that will be adversely impacted, 
is supported by comments received primarily requesting implementation 
of a method that mitigates the adverse payment impacts because of the 
loss of the rural adjustment.
    Due to our review and analysis, we determined that a 3 year budget 
neutral hold harmless policy would best accomplish the goals of 
mitigating the loss of the rural adjustment for existing FY 2005 rural 
IRFs. The incremental steps needed to reduce the impact of the loss of 
the FY 2005 rural adjustment of 19.14 percent will be phased out for 
years FY 2006, FY 2007, and FY 2008.
    Thus, the budget neutral 3 year hold harmless policy will apply to 
the existing FY 2005 rural IRFs (under the MSA-based designation) that 
will change designations and experience a reduction in payments due to 
the loss of the FY 2005 rural adjustment of 19.14 percent and meets the 
intent of this policy. The hold harmless policy will allow existing FY 
2005 rural IRFs adversely affected by the change in designation to 
receive two-thirds of the FY 2005 rural adjustment of 19.14 percent 
(specifically 12.76 percent hold harmless adjustment) for FY 2006 as 
well as the blended wage index (comprised of 50 percent of the FY 2006 
MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage 
index both based on FY 2001 hospital data). For FY 2007, existing FY 
2005 rural IRFs that are a part of the FY 2006 hold harmless policy 
will receive the full FY 2007 CBSA wage index and one-third of the FY 
2005 rural adjustment of 19.14 percent (specifically, a 6.38 percent 
hold harmless adjustment). For FY 2008, existing FY 2005 rural IRFs 
that are a part of the FY 2006 hold harmless policy will receive the 
full FY 2008 CBSA-based wage index without a rural adjustment as long 
as the IRF is designated as urban under the FY 2008 CBSA-based 
designation (illustrated in Table 10 below).

[[Page 47925]]



     Table 10.--IRF 3-Year Hold Harmless Policy for IRFs Designated as Rural Under the MSA-Based Designation
----------------------------------------------------------------------------------------------------------------
                                                       FY 2006               FY 2007               FY 2008
----------------------------------------------------------------------------------------------------------------
                                                   50% of MSA Wage
                  Wage Index                      Index and 50% of      Full FY 2007 CBSA     Full FY 2008 CBSA
                                                   CBSA Wage Index         Wage Index            Wage Index
----------------------------------------------------------------------------------------------------------------
Rural Adjustment (Phase out)*.................                 12.76                  6.38                  N/A
----------------------------------------------------------------------------------------------------------------
*Based on the FY 2005 Rural Adjustment of 19.14 percent.

    As is shown by the table, making incremental reductions to the 
19.14 percent rural adjustment that certain rural IRFs received during 
FY 2005 results in these IRFs still being paid a portion of that rural 
adjustment in FY 2006 and FY 2007.
    We believe that an incremental reduction of the FY 2005 rural 
adjustment of 19.14 percent is appropriate because of our analysis to 
implement a one third compared to a two thirds hold harmless adjustment 
of the 19.14 percent rural adjustment in FY 2006. We analyzed the 34 
IRFs (in our analysis file) that would be impacted by the hold harmless 
policy to determine the effect on their IRF PPS payments if we did not 
implement a hold harmless policy. We also reviewed the payment impacts 
on these IRFs if the hold harmless policy implemented one third of the 
FY 2005 rural adjustment of 19.14 percent versus two thirds of the FY 
2005 rural adjustment of 19.14 percent in FY 2006 (as described in the 
section XII).
    We found that if we did not adopt a hold harmless policy, the 34 
rural IRFs that change designations from a rural facility (under the 
MSA-based designations) to an urban facility (under the CBSA-based 
designations) would experience a significant reduction in per case 
payment. We also considered a one year hold harmless policy that would 
allow the 34 IRFs in our analysis to receive a blended wage index as 
well as only a one third of the FY 2005 rural adjustment of 19.14 
percent. Based on our analysis, a one year hold harmless policy would 
slightly mitigate the payment reductions for rural IRFs in our analysis 
file.
    Our analysis of whether a multi-year hold harmless policy would 
provide a sufficient buffer to the loss of payments, found that a 3 
year hold harmless policy of two thirds of the 19.14 percent rural 
adjustment in the FY 2006 and one third in FY 2007 would be the most 
appropriate. Based on a 3 year hold harmless policy, we found these 
IRFs would be mitigated from significant payment reductions. We 
determined that a 3 year hold harmless policy that provides two thirds 
of the 19.14 percent adjustment in FY 2006 and one third in FY 2007 
would appropriately mitigate the adverse payment impacts for existing 
FY 2005 rural IRFs that are designated as urban IRFs in FY 2006.
    To determine whether an existing FY 2005 rural IRF would meet part 
of the criteria for the hold harmless policy, we have developed Table 2 
in the addendum. Table 2 of this addendum is a crosswalk file of 
counties/areas in the United States and Puerto Rico that would change 
from a rural MSA-based designation to an urban area under the CBSA-
based designation. These areas are listed in Table 2 of the addendum to 
identify areas affected by the budget neutral 3 year hold harmless 
policy as described in this section. Table 2 of the addendum provides 
the State and county code, State and county name, MSA number, MSA rural 
designations, FY 2006 MSA-based wage index, FY 2006 CBSA-based wage 
index, CBSA number, CBSA urban designations, and the applicable FY 2006 
transition wage index as described in section VI.2.B.e. The FIs will 
also be instructed to use Table 2 of the addendum to identify IRFs in 
these areas that will be impacted by the budget neutral 3 year hold 
harmless policy (as discussed in detail in this section) based on the 
FI's existing data in the provider specific file.
    As a conforming change to Sec. 412.624(e), we are finalizing the 
hold harmless policy by adding new paragraph (e)(7). Paragraph (e)(7) 
of Sec. 412.624(e) will read as follows: Adjustments for certain 
facilities geographically redesignated in FY 2006.
    (i) General. For a facility defined as an urban facility under 
Sec. 412.602 in FY 2006 that was previously defined as a rural facility 
in FY 2005 as the term rural was defined in FY 2005 under Sec. 412.602 
and whose payment, after applying the adjustment under this paragraph, 
will be lower only because of being defined as an urban facility in FY 
2006 and it no longer qualified for the rural adjustment under 
Sec. 412.624(e)(3) in FY 2006, CMS will adjust the facility's payment 
using the following method:
    (A) For discharges occurring on or after October 1, 2005, and on or 
before September 30, 2006, the facility's payment will be increased by 
an adjustment of two thirds of its prior FY 2005 19.14 percent rural 
adjustment.
    (B) For discharges occurring on or after October 1, 2006, and on or 
before September 30, 2007, the facility's payment will be increased by 
an adjustment of one third of its FY 2005 19.14 percent rural 
adjustment.
    (ii) Exception. For discharges occurring on or after October 1, 
2005 and on or before September 30, 2007, facilities whose payments, 
after applying the adjustment under this paragraph (e)(7)(i) of this 
section, will be higher because of being defined as an urban facility 
in FY 2006 and no longer being qualified for the rural adjustment under 
412.624(e)(3) in FY 2006, CMS will adjust the facility's payment by a 
portion of the applicable additional adjustment described in paragraph 
(e)(7)(i)(A) and (e)(7)(i)(B) of this section as determined by us.
    In addition, we did not receive comments regarding section 505 of 
the MMA that established a new section 1886(d)(13) of the Act. As 
discussed in the FY 2006 IRF PPS proposed rule (70 FR 30188), 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 are not implementing such an adjustment for the IRF 
PPS in this final rule.
    Comment: A number of commenters advised us that Table 3 of the FY 
2006 IRF PPS proposed rule contained a formatting problem that resulted 
in provider numbers, provider names, state and county location, MSA-
based designation, and CBSA-based designations to be misaligned.
    Response: Once this error was brought to our attention, we 
immediately published a public use file on our webpage to show the 
provider level

[[Page 47926]]

table as developed in Microsoft Excel. The web address for the FY 2006 
IRF PPS proposed rule's public use files may be found at http://www.cms.hhs.gov/providers/irfpps/fy06nprm.asp. Table 3, as published 
in the FY 2006 IRF PPS proposed rule (70 FR 30188), was produced for 
informational purposes only. Therefore, the information an IRF's FI has 
on file for each IRF will not be altered based on Table 3. We will not 
be reproducing a provider level table that crosswalks the MSA-based and 
CBSA-based designations for this final rule as it was only published in 
the proposed rule to help facilitate the public's understanding of the 
proposed policy.
    For the purposes of determining a wage index for FY 2006 IRF PPS 
rate year, we will publish a crosswalk table (Table 1 of this addendum) 
listing the State and county code, State and county name, the MSA-based 
designations, CBSA-based designations and the blended wage index 
(comprised of 50 percent of the FY 2006 MSA-based wage index and 50 
percent of the FY 2006 CBSA-base wage index both based on the FY 2001 
hospital wage data) for discharges occurring on or after October 1, 
2005 and on or before September 30, 2006. In the FY 2006 IRF PPS 
proposed rule (70 FR 30188), we published a FY 2006 CBSA urban and 
rural wage index table to illustrate the proposed policy to fully adopt 
the FY 2006 CBSA wage index. Since we are no longer fully adopting the 
FY 2006 CBSA wage index, we will publish a table for FIs to determine 
an IRFs blended wage index values for FY 2006 (specifically a blend of 
50 percent FY 2006 MSA-based wage index and 50 percent of the FY 2006 
CBSA-based wage index). Thus, Table 1 of this addendum will be used by 
FIs to determine the FY 2006 one-year blended transitional wage index 
(comprised of FY 2006 MSA-based and FY 2006 CBSA-based wage index) as 
finalized in this rule.
    Final Decision: In summary (as discussed in detail above in the 
comments and responses, and based on further analysis of various policy 
options to implement the CBSA-based designations), we will implement a 
budget neutral one-year transition policy that blends the FY 2006 MSA-
based wage index and FY 2006 CBSA-based wage index (both based on FY 
2001 hospital wage data) for discharges occurring on or after October 
1, 2005 and on or before September 30, 2006 for all IRFs. In addition 
to the blended wage index for FY 2006, we will implement a budget 
neutral 3 year hold harmless policy for existing FY 2005 rural IRFs 
that will lose the FY 2005 rural adjustment of 19.14 percent, 
experience a loss in payments due to the change from an MSA-based rural 
designation to a CBSA-based urban designation, and meets the intent of 
the hold harmless policy (as discussed in detail above).

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. As was proposed in the FY 2006 IRF 
PPS proposed rule (70 FR 30188) and for this final rule, we will use FY 
2001 acute care hospital wage data for FY 2006 IRF PPS payment rates 
because it is the most recent final data available. As was proposed in 
the FY 2006 IRF PPS proposed rule (70 FR 30188), and for this final 
rule, we will adopt the methodology discussed in the proposed rule (70 
FR at 30188, 30241) to calculate a wage index in the event that there 
is no hospital data for an area (urban or rural) under the CBSA-based 
designations (70 FR 30188, 30241).
    A summary of public comments and our responses on the wage index 
data are discussed below:
    Comment: Many commenters argue that a majority of IRFs are hospital 
units and should be treated the same as hospitals whereby IRFs should 
be allowed to be reclassified to the same geographic area as the 
hospital. One commenter urged CMS to develop instructions and begin 
collecting IRF-specific wage index data in order to allow IRFs to 
establish a geographic reclassification criteria for IRFs. Commenters 
also urged CMS to use FY 2002 hospital wage data for the FY 2006 IRF 
PPS rate year because it is more current than the finalized data 
available. One commenter request that CMS develop a ``rural floor'' 
like that of IPPS.
    Response: 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 VI.B.2.a 
of this final 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 implement 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, if any, to which the acute care hospital data 
fully represent IRF wages or if a geographic reclassification 
adjustment under the IRF PPS is appropriate.
    Although commenters request CMS to develop a ``rural floor'' like 
the IPPS, we believe the ``rural floor'' is applicable only to the 
acute care hospital payment system. Furthermore, as stated in section 
VI.B.2, section 4410 of the Balanced Budget Act of 1997 (Pub. L. 105-
33) applies specifically to acute care hospitals and not excluded 
hospitals and excluded units. Thus, we believe that the acute care 
hospital ``pre-reclassification and pre-floor'' wage data is the best 
proxy and most appropriate wage index. In addition and as discussed 
above in section VI.B.2.e we will implement a blended wage index to 
mitigate the impacts an IRF may experience as a result of the change 
from MSA-based designations to CBSA-based designations. Furthermore, 
under the IRF PPS, IRFs are paid a rural adjustment under Sec.  
412.624(e)(3) as discussed in detail in section VI.B.4 to account for 
higher costs among rural facilities versus urban facilities.
    Although commenters request instructions to be developed in order 
to collect IRF specific wage data, we did not propose to develop 
instructions at this time. At this time, we are unable to develop a 
separate wage index for rehabilitation facilities. Further, in order to 
accumulate the data needed, we would need to make modifications to the 
cost report. In the future, we will continue to research wage data 
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

[[Page 47927]]

data fully represents IRF wages. However, we continue to believe it is 
an appropriate proxy because the hospital wage data is currently the 
most appropriate data for adjusting payments made to IRFs.
    Several comments request the ability to allow IRFs to reclassify 
like that of acute care hospitals. To emphasize and as discussed in 
section VI.B.2, we believe that actual location of an IRF as opposed to 
the location of affiliated providers is most appropriate for 
determining the wage adjustment because the data support the premise 
that the prevailing wages in the area in which a facility is located 
influences the cost of a case. As demonstrated by the update rural 
adjustment and research conducted by RAND. The research and findings 
that update the rural adjustment is discussed in detail in section 
VI.B.4. We continue to review the facility adjustment to account for 
higher costs in different types of IRFs by updating our facility 
adjustments.
    Final Decision: 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 would accurately capture the relationship of wages and 
wage-related costs of IRF in an area as comparable to the national 
average.
    Therefore, as we proposed in the FY 2006 proposed rule (70 FR 
30188) and for this final rule, we continue to 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 will 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 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. Therefore, we 
continue to believe reclassification of IRFs is inappropriate at this 
time.
    In adopting 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 for FY 2006, this occurred in two States--
Massachusetts and Puerto Rico--where, using the CBSA-based 
designations, there were no hospitals located in rural areas. If rural 
IRFs open in Massachusetts or Puerto Rico for FY 2006, we proposed and 
for this final rule, we are using the rural FY 2001 MSA-based hospital 
wage data for Massachusetts and Puerto Rico to determine the wage index 
of such IRFs. In other words, we proposed and as finalized in this 
final rule, we will use the same wage data (the FY 2001 hospital wage 
data) used to calculate the FY 2006 IRF wage index. However, as we 
proposed in the FY 2006 proposed rule (70 FR 30188), for this final 
rule, rather than using CBSA-based designations, we will use MSA-based 
designations to determine the rural wage index of any States where 
there is no wage data available under the CBSA-based designations. By 
using such MSA-based designations there will be rural wage indices for 
both Massachusetts and Puerto Rico. We believe this is the most 
reasonable approach, as we are 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, as 
we proposed in the FY 2006 proposed rule (70 FR 30188), for this final 
rule, we will 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 will 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 
will 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, as we proposed in the FY 2006 proposed rule (70 
FR 30188), for this final rule, we will 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. To clarify for rural areas without 
hospital wage data, we will use the most recent final years wage index 
available. In addition, for FY 2006 and thereafter, we are finalizing 
our proposed policy to calculate a statewide urban average in the event 
that there exist urban IRFs in geographic areas with no corresponding 
hospital wage data. Although we solicited comments on these approaches 
to calculate the wage index values for areas without hospital wage data 
for this and subsequent fiscal years, we did not receive any comments 
regarding our proposed methodology as discussed in our FY 2006 IRF PPS 
proposed rule. As a result, for any urban areas where there is no urban 
hospital wage data, we will calculate an average of the urban hospital 
wage data throughout the State as a reasonable proxy.
    For the reasons discussed above, as we proposed in the FY 2006 
proposed rule (70 FR 30188), for this final rule, we will 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 VI.B.2.a of this final rule). We believe that data from FY 2001 
cost reporting periods to determine the applicable wage index values 
under the IRF PPS in this final rule are appropriate because these are 
the most recent final available data. These data are the same FY 2001 
acute care hospital inpatient wage data that were used to compute the 
IPPS FY 2005 wage indices. The final IRF wage indices are computed as 
follows:
     Compute an average hourly wage for each urban and rural 
area.
     Compute a national average hourly wage.
     Divide the average hourly wage for each urban and rural 
area by the national average hourly wage--the result is a wage index 
for each urban and rural area.

The one-year blended wage index values that are applicable for IRF PPS 
discharges occurring on or after October

[[Page 47928]]

1, 2005 and on or before September 30, 2006 are shown in Table 1 of the 
addendum of this final rule.
    In addition, for this final rule as we proposed in the FY 2006 
proposed rule (70 FR 30188), any adjustment or update to the IRF wage 
index made as specified under section 1886(j)(6) of the Act will 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 will have been made in the year without 
such adjustment. Therefore, as we proposed in the FY 2006 proposed rule 
(70 FR 30188), for this final rule, we will calculate a budget-neutral 
wage adjustment factor as specified in Sec.  412.624(e)(1). We will 
continue to use the following steps to ensure that the FY 2006 IRF 
standard payment conversion factor reflects the one-year blended FY 
2006 MSA and CBSA wage indices (both based on FY 2001 hospital wage 
data) and to the 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 updated 
CBSA-based FY 2006 labor-related share and FY 2006 blended wage indices 
described above.
    Step 3 Divide the amount calculated in step 1 by the amount 
calculated in step 2, which equals the FY 2006 budget-neutral wage 
adjustment factor of 0.9995 (as discussed in section VI.B.7 and 
VI.B.8).
    Step 4 Apply the 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 FY 2006 standard payment conversion factor.
3. Teaching Status Adjustment
    In the FY 2006 proposed rule (70 FR 30188), we proposed to 
implement a teaching status adjustment for IRFs that are, or are part 
of, teaching institutions. 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 the FY 2006 
proposed rule (70 FR 30188), 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 proposed to 
establish a facility level adjustment to the Federal per discharge base 
rate for IRFs that are, or are part of, teaching institutions for the 
reasons discussed below (the ``teaching status adjustment'').
    The purpose of the proposed teaching status adjustment is to 
account for the higher indirect operating costs experienced by 
facilities that participate in graduate medical education programs.
    We proposed to implement the proposed teaching status adjustment in 
a budget neutral manner (that is, keeping estimated aggregate payments 
for FY 2006 with the proposed teaching adjustment the same as estimated 
aggregate payments for FY 2006 without the proposed teaching 
adjustment) for the reasons discussed below. (As a conforming change, 
we proposed to revise Sec.  412.624 by adding 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 proposed to adjust 
the Federal prospective payment on a facility basis by a factor that we 
specified for facilities that are teaching institutions or units of 
teaching institutions. We proposed that this adjustment 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 proposed to 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 final 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, Part 1, 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

[[Page 47929]]

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 proposed 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). In addition, 
we proposed that the 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 proposed 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 further below) to the IRF's average daily census 
(ADC). In RAND's cost regressions for the FY 2006 proposed rule (70 FR 
30188), using data from FY 2003, the logarithm of the teaching variable 
had a coefficient value of 1.083. We proposed 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, then estimated at 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 was based on regression analysis holding all other components of 
the payment system constant. In the FY 2006 proposed rule (70 FR 30188) 
we noted that, because we were proposing a number of other revisions to 
the payment system, the coefficient value was subject to change for the 
final rule depending on the other revisions included in the final rule. 
Moreover, we noted that we had concerns that IRFs' responses to other 
proposed changes described in the FY 2006 proposed rule (70 FR 30188) 
would influence the effects of a teaching variable on IRFs' costs.
    In addition, we proposed that the teaching adjustment 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 proposed 
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 noted 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 proposed 
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 also proposed 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 proposed 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. In proposing not to allow affiliation agreements, we 
also wanted 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 proposed not to allow IRFs to aggregate the FTE 
resident caps used to compute the IRF PPS teaching adjustment through 
affiliation agreements.
    We also proposed that residents with less than full-time status and 
residents rotating through the rehabilitation hospital or unit for less 
than a full year

[[Page 47930]]

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.
    We proposed that the denominator used to calculate the teaching 
status adjustment under the IRF 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 proposed to 
implement the 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 payments during 2002 
would have been 17 percent higher than IRFs' costs. We noted that we 
were open to examining other evidence regarding the amount of aggregate 
payments in the system.
    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.
    In the FY 2006 proposed rule, we discussed some concerns we had 
with implementing a teaching status adjustment at this time, including 
concerns about the volatility of the data, concerns about the effect 
that other proposed changes could have on the magnitude of the teaching 
status adjustment, and concerns about the best way to count residents 
who provide services to IRF patients. These concerns are described in 
more detail in the FY 2006 proposed rule (70 FR 30188). As a result of 
these concerns, we specifically solicited comments on our consideration 
of a teaching status adjustment.
    Public comments and our responses on the proposed teaching status 
adjustment are summarized below.
    Comment: Several commenters questioned CMS's rationale for not 
allowing affiliation agreements, if CMS is only concerned about not 
increasing the pool of residents in IRFs. One commenter suggested that 
allowing affiliation agreements among IRFs would not necessarily 
increase the total pool of residents in IRFs.
    Response: In the FY 2006 proposed rule (70 FR 30188), we stated 
that we are not allowing IRFs to enter into affiliation agreements with 
IPPS hospitals for the purposes of aggregating the FTE resident caps 
because we want to avoid the possibility that hospitals will transfer 
residents between IPPS and IRF training settings in order to increase 
Medicare payments. In deciding on our proposal not to allow affiliation 
agreements under the IRF PPS, we considered several factors. First, in 
general, we considered that IPPS hospitals provide training to 
residents in a wide range of specialties. Because of the wide variety 
of training provided, IPPS hospitals often need to send residents to 
train at other hospitals, since the case mix of one hospital might not 
be sufficiently broad to provide residents with an acceptable range of 
training opportunities in a particular specialty. The broad nature of 
the training offered at IPPS hospitals, and hence, the need to cross-
train residents, is a primary reason for permitting IPPS hospitals 
under the Balanced Budget Act of 1997 to enter into GME affiliation 
agreements with other IPPS hospitals. However, because IRFs are a 
highly specialized type of provider, we do not believe that a 
significant amount of cross-training is required among IRFs. Although 
we imagine that there could be instances in which residents training in 
one IRF could receive a different type of training experience in 
another IRF, we believe these situations are likely to be limited and 
do not warrant having an affiliation agreement policy to allow IRFs to 
aggregate their FTE resident caps for the teaching status adjustment. 
Furthermore, we note that even without a specific affiliations policy, 
IRFs are not precluded from cross-training residents amongst themselves 
or with IPPS hospitals. If cross-training is necessary, it can be done 
in such a way that the overall number of FTE residents training in each 
facility remains unchanged. Accordingly, we are finalizing our proposed 
policy to not create a specific GME affiliation provision for the IRF 
teaching status adjustment. In the future, if we find there is in fact 
a need to allow affiliation agreements among IRFs, we may consider 
revising this policy in a future rulemaking process.
    Comment: Several commenters noted possible inaccuracies in the 
teaching status information for a few of the facilities in the rate 
setting file we posted on the CMS website in conjunction with the FY 
2006 proposed rule (70 FR 30188).
    Response: To clarify, the rate setting file posted on the CMS 
website will not be used to determine payments for providers. The 
fiscal intermediaries use their own data files to determine whether the 
IRFs under their responsibility qualify for teaching status adjustment 
payments and the amounts of any such payments. Therefore, if providers 
have concerns about their particular teaching status data, they should 
contact their fiscal intermediaries to ensure that the fiscal 
intermediaries have the correct information.
    With regard to the information in the rate setting file posted on 
the CMS website, this information was used to compute the value of the 
coefficient used as the exponent in the formula for

[[Page 47931]]

the proposed teaching status adjustment. Consequently, we asked RAND to 
investigate the accuracy of the information. RAND has made the 
appropriate corrections to the information and, using the revised 
information, has recomputed the coefficient used as the exponent. Based 
on this and the incorporation of the HealthSouth home office cost data 
from FY 2004 (as described in detail in section IV of this final rule), 
we have revised the exponent from 1.083, which is what we had proposed 
in the FY 2006 proposed rule (70 FR 30188), to 0.9012 for this final 
rule.
    Comment: Several commenters objected to our proposal to implement 
the proposed teaching adjustment based on analysis of one year of data. 
However, several other commenters suggested that such concerns were 
unfounded and did not warrant overriding RAND's statistically valid 
findings.
    Response: Since publication of the FY 2006 proposed rule (70 FR 
30188), RAND has further analyzed FY 2002 and FY 2003 data, and has 
found that the teaching status variable is significantly related to 
costs in both sets of data. Furthermore, we believe that IRFs with 
teaching programs may have been underrepresented in the 1998 and 1999 
data used to construct the IRF PPS, and that this may have contributed 
to the lack of a statistically significant finding using the pre-PPS 
data. In addition, the statistically significant difference in costs 
between teaching and non-teaching facilities has been validated in 
other inpatient settings, including IPPS hospitals and IPFs. Therefore, 
we are reassured that this result does not represent an aberration 
based on only a single year's data, but instead represents a result of 
using more recent, more complete data. However, we will continue to 
evaluate the need for this adjustment in the future. If we later find 
that the other refinements described in this final rule constitute 
enough of an improvement to the system by more appropriately accounting 
for the variation in costs among different types of IRF patients that 
the teaching status adjustment becomes unnecessary, we will consider 
eliminating the adjustment in the future. However, we believe there is 
enough evidence at this time that IRFs with teaching programs have 
higher costs to implement the adjustment.
    Comment: One commenter requested that CMS change the data that will 
be used to establish the FTE resident cap for IRFs from our proposal to 
use IRFs' most recent cost reporting periods ending on or before 
November 15, 2003, to use IRFs' most recent cost reporting periods 
ending on or before November 15, 2004 to ensure that the FTE resident 
caps will be based on the most accurate historical resident count data 
possible.
    Response: We agree with this commenter and are revising our 
methodology for setting the FTE resident cap accordingly. Since we 
published the FY 2006 proposed rule (70 FR 30188), the FTE resident cap 
used for the teaching status adjustment for IPFs has been set similarly 
based on cost reporting periods ending on or before November 15, 2004. 
We believe this change is appropriate and maintains consistency within 
the Medicare program.
    Comment: One commenter requested that CMS have a process in place 
for re-examining the teaching status data, especially the data used to 
set the FTE resident cap, so that facilities would have the opportunity 
to rectify any problems with the data that might affect payments.
    Response: We agree with this commenter. We recognize that there may 
be problems with some of the resident count data on the historical cost 
reports, since this data has not previously been used for payment 
adjustments in the IRF PPS. For this reason, we proposed in the FY 2006 
proposed rule (70 FR 30188) that 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 
and, based on this and the previous comment (refer to the response 
above), we are changing this to the final settlement of the IRF's most 
recent cost reporting period ending on or before November 15, 2004. We 
believe this will allow facilities the opportunity to ensure the 
accuracy of the FTE resident count data before the final settlement of 
the cost report data. In case this does not occur, we will authorize 
the fiscal intermediaries to resolve any disputes that may occur 
regarding the data used to set an IRF's FTE resident cap and correct 
any inaccuracies.
    With regard to the FTE resident count data or the average daily 
census data used to compute an IRF's teaching status adjustment, we 
specifically note in this final rule that any teaching status 
adjustments for the IRF PPS facilities will be made on a claim basis as 
interim payments, but the final payments in full for the cost reporting 
periods will be made through the final settlement of the cost report. 
The difference between the interim payments and the actual teaching 
status adjustment amounts computed in the cost reports will be adjusted 
through lump sum payments/recoupments when the cost report is filed and 
later settled. We believe this process gives providers and fiscal 
intermediaries ample opportunity to ensure that the data used to 
compute the teaching status adjustment payments is as complete and 
accurate as possible. As the proposed teaching status adjustment is 
implemented, we will monitor the situation and issue further guidance 
to the fiscal intermediaries as necessary to ensure fair and accurate 
payments for this adjustment.
    Comment: The majority of commenters expressed support for CMS 
eventually implementing an IRF teaching status adjustment, especially 
since teaching IRFs were likely underrepresented in the 1998 and 1999 
data used in the August 7, 2001 final rule to design the IRF PPS. 
However, while supporting the adjustment, several commenters suggested 
that CMS wait to implement a teaching status adjustment for at least a 
year, until data from FY 2004 (or later) can be analyzed.
    Response: CMS considered carefully the suggestion to wait an 
additional year or more before implementing the proposed teaching 
status adjustment. However, RAND's regression analyses of calendar year 
2002 and FY 2003 data both support the need for a teaching status 
adjustment for IRFs because they both indicate that IRFs with teaching 
programs have significantly higher costs than IRFs without teaching 
programs. Given RAND's findings, we believe it is important to adjust 
IRF payments accordingly in order to better align IRF payments with the 
costs of care. In addition, we believe it is important to maintain 
consistency with other parts of the Medicare program, such as the IPF 
PPS that recently instituted a teaching status adjustment for IPFs 
based on regression analysis that shows that IPFs with teaching 
programs have significantly higher costs than IPFs without teaching 
programs.
    Comment: Several commenters strongly disagreed with the proposed 
implementation of a teaching status adjustment for IRFs. Among the 
reasons cited were that it was based on analysis of a single year of 
data, that it would support inefficiencies in teaching hospitals (when 
the purpose of a PPS is to encourage providers to operate efficiently), 
that the data do not adequately support the need for a teaching status 
adjustment, that it would reduce payments to non-teaching hospitals, 
and that teaching hospitals would likely continue to operate even if 
they do not receive the adjustment.
    Response: We carefully considered these comments. However, we 
continue

[[Page 47932]]

to believe that an IRF teaching status adjustment is warranted at this 
time because RAND's regression analysis, based on calendar year 2002 
and FY 2003 data shows that IRFs with teaching programs have 
significantly higher costs than non-teaching IRFs. Although we do not 
believe it is appropriate to encourage or perpetuate inefficiencies, we 
believe that IRFs with teaching programs provide a valuable service to 
beneficiaries and to the Medicare program. To the extent that the 
residency training services, therefore, lead to higher indirect costs 
of providing care, we believe it is important to recognize these 
differences and encourage access to care in these facilities. While, as 
one commenter notes, teaching IRFs more than likely would continue to 
operate even without the IRF teaching status adjustment, the intent of 
the adjustment is to better align payments in these facilities with the 
costs of care.
    Furthermore, we believe that IRFs with teaching programs may have 
been underrepresented in the 1998 and 1999 data used to construct the 
IRF PPS, and that this may have contributed to the lack of a 
statistically significant finding using the pre-PPS data. In addition, 
the statistically significant difference in costs between teaching and 
non-teaching facilities has been validated in other inpatient settings, 
including IPPS hospitals and IPFs.
    We proposed, and are finalizing in this final rule, to implement 
the IRF teaching status adjustment in a budget neutral manner in order 
to ensure that estimated aggregate payments to IRFs for FY 2006 will be 
the same with or without the teaching status adjustment. Given that the 
impact on IRFs without teaching programs of this provision is not large 
(see Table 13 of this final rule), we do not believe that implementing 
the teaching status adjustment in a budget neutral manner will unduly 
affect non-teaching IRFs. However, the teaching status adjustment will 
help to better align payments with the costs of care in teaching IRFs.
    Furthermore, we believe that a teaching status adjustment for IRFs 
is consistent with the teaching status adjustment recently implemented 
in the IPF PPS.
    Comment: One commenter suggested that CMS track the percentage of 
time residents spend in the rehabilitation unit of the hospital to 
compute the teaching adjustment, instead of using the resident and 
intern to ADC ratio we proposed in the proposed rule.
    Response: This information is not currently captured in the cost 
report data, which would make this suggestion substantially more 
difficult to implement than the teaching status variable we proposed in 
the FY 2006 proposed rule (70 FR 30188). We also believe that 
collecting this type of information would impose additional costs on 
acute care hospitals that have IRF units, because they would be 
required to record the amount of time residents spend on rehabilitation 
units. We also believe that it would be difficult if not impossible to 
audit this type of information.
    Comment: One commenter suggested that CMS focus the teaching 
adjustment on rehabilitation education programs, to the exclusion of 
other resident training programs.
    Response: Information on resident specialties is not currently 
reported in the cost report data. We believe that collecting and 
reporting this new type of data would impose undue additional costs on 
IRFs and on hospitals that have IRF units. Furthermore, we believe that 
this policy would contradict the way that residency programs 
traditionally operate because they require residents from different 
specialties to rotate in different areas of the hospital to gain 
experience in various areas of medicine.
    Comment: One commenter recommended that an exception process be 
allowed to enable IRF teaching programs to apply for an increase in 
their cap should a compelling reason arise, such as an expansion of the 
teaching hospital or unit or the addition of a new program.
    Response: Similar to the GME resident cap policy for IPPS 
hospitals, we will not allow exceptions to the FTE resident caps for 
IRFs due to expansions of existing facilities or additions of new 
teaching programs. As we indicated previously, we believe it is 
important to limit the total pool of FTE resident cap positions within 
the IRF community.
    Final Decision: After carefully considering all of the comments we 
received on the proposed IRF teaching status adjustment, we are 
finalizing our decision to adopt the proposed policy in this final 
rule, with the following revisions.
    In RAND's most recent cost regressions using data from FY 2003, 
including the HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule), the logarithm of 
the teaching variable has a coefficient value of 0.9012 (as opposed to 
the coefficient value of 1.083 we proposed in the FY 2006 proposed rule 
(70 FR 30188)). In the final policy, we are converting 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 of 0.9012 (that is, the teaching status 
adjustment would be calculated by raising the teaching variable (1 + 
FTE residents/ADC) to the 0.9012 power).
    Secondly, based on a commenter's suggestion, we are changing the 
base period for determining an IRF's FTE resident cap from the final 
settlement of the IRF's most recent cost reporting period ending on or 
before November 15, 2003, which was what we had proposed in the FY 2006 
proposed rule (70 FR 30188), to the final settlement of the IRF's most 
recent cost reporting period ending on or before November 15, 2004. 
Thus, the policy in the IRF PPS would be consistent with the FTE 
resident cap policy in the IPF PPS.
4. Adjustment for Rural Location
    In the FY 2006 proposed rule (70 FR 30188), we proposed to update 
the adjustment to the Federal prospective payment amount for IRFs 
located in rural areas from 19.14 percent to 24.1 percent, based on 
analysis of FY 2003 data. 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, teaching status and 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 proposed 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 proposed this 
change because RAND's regression analysis, using the best available 
data we had (FY 2003), indicated that rural facilities had 24.1 percent 
higher costs of caring for Medicare patients than urban facilities. We 
noted that we proposed 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 when the PPS was first implemented, for 
the FY 2006 proposed rule (70 FR 30188), and for this final 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 noted that 
the FY 2003 data are the best available data we have, just as the 1998

[[Page 47933]]

and 1999 data used in the initial development of the IRF PPS were the 
best available data at that time.
    We proposed 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 proposed to make this update to the rural 
adjustment in a budget neutral manner because we believed and continue 
to believe that the results of RAND's analysis of 2002 and 2003 IRF 
cost data (as discussed previously in section IV of this final 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.
    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 proposed to 
apply a factor to the standard payment amount to ensure 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 VI.B.7 and 
VI.B.8 of this final rule, we discuss the methodology and factor we 
proposed to apply to the standard payment amount.
    Public comments and our responses on the proposed update to the 
rural adjustment are summarized below.
    Comment: Overall, commenters generally supported this proposal. 
Some said that CMS should delay implementing the proposal until the 
full effects of the 75 percent rule can be analyzed.
    Response: For the reasons discussed in section IV of this final 
rule, we do not believe we should wait until the full effects of the 75 
percent rule can be analyzed before implementing any of the proposed 
changes in this final rule. Making the changes now does not preclude us 
from making additional revisions in the future if we find any potential 
effects of the 75 percent rule on IRFs' case mix or cost structures 
that would warrant such refinements.
    Comment: One commenter expressed concerns that the proposed 
increases to the facility-level adjustments would encourage 
inefficiencies in the provision of care.
    Response: While we agree with the commenter that one of the 
purposes of a PPS is to encourage the efficient provision of services, 
we also believe it is important to recognize that certain providers, 
such as those operating in rural areas, may incur higher costs than 
other providers, for reasons largely beyond their control. To encourage 
the efficient provision of care in rural areas, so that Medicare 
beneficiaries have adequate access to IRF services in these areas, we 
believe it is important to recognize the differential in costs between 
urban and rural providers.
    Final Decision: After carefully considering all of the comments we 
received on this proposed change to the rural adjustment, we are 
finalizing our decision to adopt the update to the rural adjustment in 
this final rule, with the following change.
    In RAND's most recent cost regressions using data from FY 2003, 
including the HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule), rural facilities 
were found to have 21.3 percent higher costs of caring for Medicare 
patients than urban facilities (rather than the 24.1 percent we 
proposed in the FY 2006 proposed rule (70 FR 30188)). Thus, we are 
implementing a rural adjustment of 21.3 percent.
5. Adjustment for Disproportionate Share of Low-Income Patients
    In the FY 2006 proposed rule (70 FR 30188), we proposed to update 
the low-income patient (LIP) adjustment to the Federal prospective 
payment rate, based on analysis of FY 2003 data. 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, teaching status and 
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 proposed 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 formula used prior to October 1, 2005 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 proposed to update 
the LIP adjustment from the power of 0.4838 to the power of 0.636. 
Therefore, the formula we proposed to use to calculate the LIP 
adjustment was as follows:
(1 + DSH patient percentage) raised to the power of (0.636)
[GRAPHIC] [TIFF OMITTED] TR15AU05.000

    We note that we proposed 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 proposed 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 proposed to implement this update to the LIP adjustment so that 
total estimated aggregate payments for FY 2006 would be the same with 
the proposed update to the adjustment as they would have been without 
the update to the adjustment (that is, in a budget neutral manner). We 
proposed to make this proposed update to the LIP adjustment in a budget 
neutral manner because we believed and continue to believe that the 
results of RAND's analysis of 2002 and 2003 IRF cost data (as discussed 
previously in this final rule) suggest that additional money does not 
need to be added to the IRF PPS.

[[Page 47934]]

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.
    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 proposed to 
apply a factor to the standard payment amount to ensure 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 VI.B.7 and 
VI.B.8 of this final rule, we discuss the methodology and factor we 
proposed to apply to the standard payment amount.
    Public comments and our responses on the proposed update to the LIP 
adjustment are summarized below.
    Comment: Overall, commenters generally supported this proposal. 
Some said that CMS should delay implementing the proposal until the 
full effects of the 75 percent rule can be analyzed.
    Response: For the reasons discussed in section IV of this final 
rule, we do not believe we should wait until the full effects of the 75 
percent rule can be analyzed before implementing any of the proposed 
changes in this final rule. Making the changes now does not preclude us 
from making additional revisions in the future if we find any potential 
effects of the 75 percent rule on IRFs' case mix or cost structures 
that would warrant such refinements.
    Comment: One commenter expressed concerns that the proposed 
increases to the facility-level adjustments would encourage 
inefficiencies in the provision of care.
    Response: While we agree with the commenter that one of the 
purposes of a PPS is to encourage the efficient provision of services, 
we also believe it is important to recognize that certain providers, 
such as those providers that treat a higher proportion of low-income 
patients, may incur higher costs than other providers, for reasons 
largely beyond their control. To encourage the efficient provision of 
care among providers that treat a large number of low-income patients, 
so that low-income Medicare beneficiaries have adequate access to IRF 
services, we believe it is important to recognize the higher costs 
these providers incur.
    Final Decision: After carefully considering all of the comments we 
received on this proposed change to the LIP adjustment, we are 
finalizing our decision to adopt the proposed policy in this final 
rule, with the following change.
    Based on RAND's most recent cost regressions using data from FY 
2003, including the HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule), we are updating 
the LIP adjustment to the power of 0.6229 (rather than the value of 
0.636 we proposed in the FY 2006 proposed rule (70 FR 30188)). 
Therefore, the formula for calculating the LIP adjustment will be as 
follows: (1 + DSH patient percentage) raised to the power of (0.6229) 
where the DSH patient percentage =
[GRAPHIC] [TIFF OMITTED] TR15AU05.001

6. Update to the Outlier Threshold Amount
    In the FY 2006 proposed rule (70 FR 30188), we proposed to update 
the outlier threshold amount, based on analysis of FY 2003 data. 
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 proposed 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 discussed our rationale 
for setting estimated outlier payments at 3 percent of total estimated 
payments (66 FR at 41362). In the FY 2006 proposed rule (70 FR 30188), 
we proposed to continue using 3 percent for the same reasons outlined 
in the August 7, 2001 final rule. We believed and continue to believe 
that 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 in FY 2006 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 we proposed to redesignate as Sec.  412.624(e)(5) in 
the FY 2006 proposed rule (70 FR 30188)) 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.
    Under Sec.  412.624(e)(4) (which we proposed to redesignate as 
Sec.  412.624(e)(5) in the FY 2006 proposed rule (70 FR 30188)), we 
would 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. In the FY 2006 proposed rule (70 FR 30188), 
we proposed to make this $4,911, which would then be adjusted for each 
IRF by the facility's wage adjustment, its LIP adjustment, its rural 
adjustment, and its teaching status adjustment, if applicable. In the 
FY 2006 proposed rule (70 FR 30188), we stated that we would 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) (which we proposed in the FY 2006 proposed 
rule (70 FR 30188) to

[[Page 47935]]

redesignate as Sec.  412.624(e)(5)), we also stated that we would 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 proposed in the FY 
2006 proposed rule (70 FR 30188) 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 we proposed in the FY 2006 proposed rule (70 FR 
30188) to redesignate 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 proposed in the FY 
2006 proposed rule (70 FR 30188) for FY 2006 would be 1.52 based on 
CBSA-based geographic designations. We proposed to base this upper 
threshold CCR on the CBSA-based geographic designations because the 
CBSAs are the geographic designations we proposed in the FY 2006 
proposed rule (70 FR 30188) to adopt for purposes of computing the 
proposed wage index adjustment to IRF payments for FY 2006.
    In addition, in the FY 2006 proposed rule (70 FR 30188), we 
proposed to update the national urban and rural CCRs for IRFs. Under 
Sec.  412.624(e)(4) (which we proposed in the FY 2006 proposed rule (70 
FR 30188) to redesignate as Sec.  412.624(e)(5)) and Sec.  
412.84(i)(3), we proposed 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 accurate data with which to calculate 
either an operating or capital CCR (or both) are not available.
    In the FY 2006 proposed rule (70 FR 30188), we proposed to use the 
national CCR based on the facility location of either urban or rural in 
each of the three situations cited above. Specifically, for FY 2006, we 
estimated a proposed national CCR of 0.631 for rural IRFs and 0.518 for 
urban IRFs. For new facilities, we proposed to use these national 
ratios until the facility's actual CCR could be computed using the 
first tentative settled or final settled cost report data, which would 
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. In 
the FY 2006 proposed rule (70 FR 30188), we proposed to use this same 
process for the FY 2006 IRF PPS. We proposed to simulate aggregate 
payments with and without an outlier policy, and then apply an 
iterative process to determine a threshold that would result in the 
simulated outlier payments being equal to 3 percent of total simulated 
payments under the simulation. In the FY 2006 proposed rule (70 FR 
30188), we noted that the simulation analysis used to calculate the 
proposed outlier threshold amount included all of the other proposed 
changes to the PPS discussed in the FY 2006 proposed rule (70 FR 
30188). As stated in the FY 2006 proposed rule (70 FR 30188), we 
proposed to 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 the FY 2006 proposed rule (70 FR 30188), we proposed to update 
the threshold amount so that estimated outlier payments would 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.
    As we discussed in the FY 2006 proposed rule (70 FR 30188), our 
analyses of cost report data from FY 1999 through FY 2002 (and 
projections for FY 2004 through 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, as we discussed in the FY 2006 proposed rule (70 FR 
30188), the outlier threshold would need to be lowered for FY 2006 in 
order that total estimated outlier payments would equal 3 percent of 
total estimated payments.
    In addition, we proposed in the FY 2006 proposed rule (70 FR 30188) 
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 the FY 2006 proposed rule (70 FR 30188) 
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 the FY 
2006 proposed rule (70 FR 30188), we proposed to change many of these 
components of the IRF PPS. For the reasons discussed above and in the 
FY 2006 proposed rule (70 FR 30188), then, we believed and continue to 
believe that it is appropriate to update the outlier loss threshold for 
FY 2006. We also stated in the FY 2006 proposed rule (70 FR 30188) that 
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.
    Public comments and our responses on the proposed update to the 
outlier threshold amount are summarized below.

[[Page 47936]]

    Comment: One commenter suggested that CMS notify fiscal 
intermediaries that, as a result of the lowering of the outlier 
threshold amount, more cases would likely qualify for outlier payments. 
Such notification would enable the fiscal intermediaries to adjust 
their systems accordingly.
    Response: We agree with the commenter's suggestion and will notify 
the fiscal intermediaries about the change to the outlier threshold 
amount and the implications of this for the number of cases that 
qualify for outlier payments.
    Comment: Several commenters requested that CMS incorporate any 
unused outlier payments from years in which aggregate outlier payments 
are below the 3 percent target back into the base payments.
    Response: We have responded to similar comments a number of times 
in the context of other prospective payment systems, including in rules 
at 70 FR 24168, 24196-24197, 57 FR 39784, 58 FR 46347, 59 FR 45408, 60 
FR 45856, 61 FR 27496, and 56 FR 43227, 61 FR 46229-46230. As we have 
explained before and as explained below, we do not make adjustments to 
PPS payment rates to account for differences between projected and 
actual outlier payments in a previous year. We believe our outlier 
policies are consistent with the statute and the goals of the 
prospective payment system and are equitable.
    In accordance with section 1886(j)(4) of the Act, we implemented 
the IRF PPS outlier policy at 42 CFR 412.624(d)(1). These regulations 
provide that CMS determines a reduction factor equal to the estimated 
proportion of additional outlier payments described in paragraph (e)(4) 
of this section (which is redesignated as (e)(5) in this final rule). 
We set outlier criteria before the beginning of each fiscal year so 
that outlier payments are projected to equal 3 percent of estimated 
total IRF PPS payments. In doing so, we use the best available data at 
the time to make our estimates. We do not believe that Congress 
intended that the standardized amounts for a given fiscal year should 
be adjusted (upward or downward) to reflect any difference between 
projected and actual outlier payments for a past year. Payments for a 
given discharge in a given fiscal year are generally intended to 
reflect or address the average costs of that discharge in that year; 
that goal would be undermined if we adjusted PPS payments to account 
for ``underpayments'' or ``overpayments'' in other years.
    Outlier payments are ``funded'' through a prospective adjustment to 
the base rates. We do not set money aside into a discrete ``pool'' 
dedicated solely for outlier payments. Outlier payments are based on 
estimates. If outlier payments for a given year turn out to be greater 
than projected, we do not recoup money from hospitals; if outlier 
payments for a given year are lower than projected, we do not make an 
adjustment to account for the difference. If estimates turn out to be 
inaccurate, we believe the more appropriate action is to continue to 
examine the outlier policy and to try to refine the methodology for 
setting outlier thresholds. Thus, consistent with this approach, for 
this final rule we are finalizing our decision to update the outlier 
threshold amount to $5,132 for FY 2006 to make estimated outlier 
payments equal to 3 percent of total estimated IRF PPS payments in FY 
2006.
    Comment: One commenter indicated a concern about the methodology 
used by CMS to estimate cost and charge growth for the purposes of 
calculating the outlier threshold amount. This commenter recommended an 
alternative methodology for the IPPS and encouraged CMS to apply that 
same methodology to the IRF PPS to ensure that the full 3 percent of 
outlier funds is used.
    Response: We have reviewed the comments submitted for consideration 
in the IPPS, and we appreciate the alternative methodologies suggested 
by the commenters and have considered them carefully. The cost-to-
charge ratio applied to charges provides Medicare the most accurate 
measure of a provider's per-case cost for the purpose of paying for 
high-cost outlier cases at the point that we process the initial claim. 
The cost-to-charge ratio is based on the providers' own cost and charge 
information as reported by the providers. For the purposes of this 
final rule, we have used the same methodology for projecting cost and 
charge growth that is used in the IPPS and in other Medicare payment 
systems, and we believe this methodology is appropriate for IRFs for 
the same reasons it is appropriate for IPPS hospitals. This methodology 
ensures that we pay the appropriate amounts over and above the standard 
PPS payment amount for unusually high-cost cases.
    Comment: Overall, commenters generally supported the proposal to 
decrease the outlier threshold. Some said that CMS should delay 
implementing the proposal until the full effects of the 75 percent rule 
can be analyzed.
    Response: For the reasons discussed in section IV of this final 
rule, we do not believe we should wait until the full effects of the 75 
percent rule can be analyzed before implementing any of the proposed 
changes in this final rule. Making the changes now does not preclude us 
from making additional revisions in the future if we find any potential 
effects of the 75 percent rule on IRFs' case mix or cost structures 
that would warrant such refinements.
    Final Decision: After carefully considering all of the comments we 
received on this proposed change to the outlier threshold amount, we 
are finalizing our decision to adopt the proposed policy in this final 
rule (including the redesignation of Sec.  412.624(e)(4) as Sec.  
412.624(e)(5)), with the following change.
    Using data from FY 2003, and including the HealthSouth home office 
cost data from FY 2004 (as described in detail in section IV of this 
final rule), RAND has calculated the outlier threshold amount of $5,132 
(instead of the $4,911 outlier threshold amount we proposed in the FY 
2006 proposed rule (70 FR 30188)) that would maintain estimated outlier 
payments at 3 percent of total estimated IRF payments for FY 2006. 
Therefore, we are finalizing our decision to set the FY 2006 outlier 
loss threshold at $5,132.
    In addition, we are finalizing our decision to adopt the proposed 
upper threshold CCR for IRFs for FY 2006 of 1.52 based on CBSA-based 
geographic designations. We are basing this upper threshold CCR on the 
CBSA-based geographic designations because the CBSAs are the geographic 
designations we are adopting (with a one-year transition policy as 
described in section VI.B.2.e of this final rule) for the purposes of 
computing the wage index adjustment to IRF payments for FY 2006.
    We are also finalizing our decision to update the national urban 
and rural CCRs for IRFs. Under Sec.  412.624(e)(4) (which we are 
redesignating as Sec.  412.624(e)(5) in this final rule), we will 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 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 will be used in each of the three situations cited above. 
Specifically, for FY 2006, we are adopting a national CCR of 0.631 for

[[Page 47937]]

rural IRFs and 0.518 for urban IRFs. For new facilities, we will 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.
7. Budget Neutrality Factor Methodology for Fiscal Year 2006
    In the FY 2006 proposed rule (70 FR 30188), we proposed to make a 
revision (for FY 2006) to the methodology found in Sec.  412.624(d) in 
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 proposed to 
revise Sec.  412.624(d) by adding a section Sec.  412.624(d)(4) for 
fiscal year 2006 and, as applicable, for fiscal years thereafter to the 
extent the adjustments are updated in the future. Specifically, we 
proposed 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 the preamble of the FY 2006 proposed rule 
(70 FR 30188) 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.
    Final Decision: We did not specifically receive any comments on the 
proposed budget neutrality factor methodology for FY 2006. Therefore, 
we are finalizing our decision to adopt this budget neutrality factor 
methodology for FY 2006, with the change that we are incorporating 
HealthSouth home office cost data from FY 2004 (as described in detail 
in section IV of this final rule) into the data we used previously to 
compute the budget neutrality factors. Based on RAND's analysis of FY 
2003 data, including the HealthSouth home office cost data from FY 2004 
(as described in detail in section IV of this final rule) and using the 
methodology described in section VI.B.8 of this final rule, we will 
apply the market basket increase factor (estimated for this final rule 
to be 3.6 percent) to the standard payment conversion factor for FY 
2005 ($12,958), which equals $13,425. Then, we will apply 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 
VI.A of this final rule), which equals $13,169. We will then apply the 
budget neutral wage adjustment (as discussed in section VI.B.2.f of 
this final rule) of 0.9995 to $13,169, which will result in a standard 
payment amount of $13,163. For FY 2006 and any applicable FYs 
thereafter, to the extent any of the adjustments are updated, we will 
apply budget neutrality factors to the standard payment amount using 
Sec.  412.624(c)(3)(ii), which incorporates by reference Sec.  
412.624(d)(4), for the applicable changes to the tiers and CMGs, the 
rural adjustment, the LIP adjustment, and the teaching status 
adjustment we are finalizing in this final rule. We note that even if 
we do not update any of the adjustments (and therefore utilize Sec.  
412.624(d)(4)), we will use Sec.  412.624(c)(3) to update the payment 
rates for FY 2006 and thereafter. The next section contains a detailed 
explanation of these budget neutrality factors we are finalizing in 
this final rule, including the steps for computing these factors and 
how they will affect total estimated aggregate payments and estimated 
payments to individual IRF providers. The factors we will apply (as 
discussed in the next section) are 0.9995 for the tier and CMG changes, 
0.9889 for the teaching status adjustment, 0.9961 for the change to the 
rural adjustment, and 0.9851 for the change to the LIP adjustment. We 
have combined these factors, by multiplying the four factors together, 
into one budget neutrality factor for all four of these changes (0.9995 
* 0.9889 * 0.9961 * 0.9851 = 0.9699). We will apply this overall budget 
neutrality factor to $13,163, resulting in a standard payment 
conversion factor for FY 2006 of $12,767. Note that the FY 2006 
standard payment conversion factor will be lower than it was in FY 2005 
because it needs to be reduced to ensure that estimated aggregate 
payments for FY 2006 will remain the same as they otherwise would have 
been without the proposed changes. If we do not decrease the standard 
payment conversion factor, each of the changes we are finalizing in 
this final rule 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 
estimated payments to a particular type of IRF will likely be affected 
by any of the changes we are finalizing in this final rule, please see 
Table 13 of this final rule.
    The FY 2006 standard payment conversion factor would be applied to 
each CMG relative weight shown in Table 4, Relative Weights for Case-
Mix Groups, to compute the unadjusted IRF prospective payment rates for 
FY 2006 shown in Table 12. To further clarify, the budget neutrality 
factors described above will only be applied for FY 2006 and in 
applicable years thereafter to the extent the adjustments are updated. 
Therefore, for fiscal years 2006 and thereafter, we will generally use 
the methodology as described in Sec.  412.624(c)(3)(ii).
8. Description of the Methodology Used To Implement the 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 proposed in the FY 2006 proposed rule (70 FR 30188) 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.
    Furthermore, to ensure that total estimated aggregate payments to 
IRFs would not change with these proposed changes, we also proposed in 
the FY 2006 proposed rule (70 FR 30188) to apply a factor to the 
standard payment amount for each of the proposed changes to ensure that 
estimated aggregate payments in FY 2006 would not be greater or less 
than those that would have been made in the year without the proposed 
changes.
    Final Decision: We did not specifically receive any comments on the 
description of the methodology used to implement the changes in a 
budget neutral manner. Therefore, we are finalizing our decision to 
adopt this

[[Page 47938]]

budget neutrality factor methodology for FY 2006, with the change that 
we are incorporating HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule) into the data we 
used previously to compute the budget neutrality factors. Based on 
RAND's analysis of FY 2003 data, including the HealthSouth home office 
cost data from FY 2004 (as described in detail in section IV of this 
final rule) and using the methodology described below, we will apply 
the budget neutrality factors to the standard payment amount for each 
of the changes described below to ensure that estimated aggregate 
payments in FY 2006 will be the same with or without the changes. We 
are finalizing our decision in this final rule 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 3.6 percent (estimated for this final rule) 
and reduced by 1.9 percent to account for coding changes (as discussed 
in section VI.A of this final 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 (0.9995), as 
discussed in section VI.B.2.f of this final 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 new tier and CMG assignments (as discussed in 
section V of this final rule) 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 (0.9995) that maintains 
the same total estimated aggregate payments in FY 2006 with and without 
the 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 change to the rural adjustment (as discussed in 
section VI.B.4 of this final 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 (0.9961) that keeps total 
estimated payments in FY 2006 the same with and without the 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 change to the LIP adjustment (as discussed in 
section VI.B.5 of this final 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 (0.9851) that maintains 
the same total estimated aggregate payments in FY 2006 with and without 
the 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 
payments for FY 2006.
    Step 13 Apply the teaching status adjustment (as discussed in 
section VI.B.3 of this final 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 (0.9889) that maintains 
the same total estimated aggregate payments in FY 2006 with and without 
the teaching status adjustment.
    As discussed in section VI.B.9 of this final rule, the FY 2006 IRF 
PPS standard payment conversion factor that accounts for the new tier 
and CMG assignments, the changes to the rural and the LIP adjustments, 
and the 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 0.9995, the tier and CMG 
changes budget neutrality factor of 0.9995, the rural adjustment budget 
neutrality factor of 0.9961, the LIP adjustment budget neutrality 
factor of 0.9851, and the teaching status adjustment budget neutrality 
factor of 0.9889.
    Each of these budget neutrality factors lowers the standard payment 
amount. The budget neutrality factor for the tier and CMG changes 
lowers the standard payment amount from $13,163 to $13,156. The budget 
neutrality factor for the change to the rural adjustment lowers the 
standard payment amount from $13,156 to $13,105. The budget neutrality 
factor for the change to the LIP adjustment lowers the standard payment 
amount from $13,105 to $12,910. Finally, the budget neutrality factor 
for the teaching status adjustment lowers the standard payment amount 
from $12,910 to $12,767. As indicated previously, the standard payment 
conversion factor will be lowered in order to ensure that total 
estimated payments for FY 2006 with the changes equal total estimated 
payments for FY 2006 without the changes. This is because these four 
changes would otherwise 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 redistributing payments among IRFs. 
Thus, some redistribution of payments occurs among facilities, while 
total estimated aggregate payments do not change. To determine how the 
changes we are finalizing in this final rule are estimated to affect 
payments among different types of facilities, please see Table 13 in 
this final rule.
9. Description of the 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 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) to FY 2003 by applying an increase factor 
(the market basket) of

[[Page 47939]]

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).
    In the FY 2006 proposed rule (70 FR 30188), we proposed to use the 
revised methodology in accordance with Sec.  412.624(c)(3)(ii) and as 
described in section VI.B.7 of the FY 2006 proposed rule (70 FR 30188) 
to propose an update to the standard payment conversion factor for FY 
2006.
    Final Decision: We did not specifically receive any comments on the 
proposed standard payment conversion factor for FY 2006. Therefore, we 
are finalizing our decision to adopt the proposed methodology for 
computing the standard payment conversion factor, with the change that 
we are incorporating HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule) into the FY 2003 
data we used previously to compute the final standard payment 
conversion factor for FY 2006. Based on RAND's analysis of FY 2003 
data, including the HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule) and using the 
methodology we are finalizing in section VI.B.7 and section VI.B.8 of 
this final rule, we will calculate the standard payment conversion 
factor for FY 2006 by applying the market basket increase factor 
(estimated for this final rule to be 3.6 percent) to the standard 
payment conversion factor for FY 2005 ($12,958), which equals $13,425. 
Then, we will apply 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 $13,169. We will then apply the budget neutral wage 
adjustment of 0.9995 to $13,169, which will result in a standard 
payment amount of $13,163. Next, we will apply a budget neutrality 
factor for FY 2006 for the 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 0.9699) to 
$13,163, which will result in a standard payment conversion factor for 
FY 2006 of $12,767. The FY 2006 standard payment conversion factor will 
be applied to each CMG weight shown in Table 4 of this final rule, 
Relative Weights for Case-Mix Groups, to compute the unadjusted IRF 
prospective payment rates for FY 2006 shown in Table 12 of this final 
rule.
10. Example of the Methodology for Adjusting the Federal Prospective 
Payment Rates
    To illustrate the methodology that we will use to adjust the 
Federal prospective payments (as described in section VI.B.7 and 
section VI.B.8 of this final rule), we provide an example in Table 11 
below. Note that the methodology we are finalizing in this final rule 
has changed somewhat from the methodology we proposed in the FY 2006 
proposed rule (70 FR 30188) because, upon further analysis, CMS 
discovered that the example used to illustrate the proposed adjustments 
to the Federal prospective payments in the FY 2006 proposed rule (70 FR 
30188) did not calculate payments as accurately as the one we are 
finalizing in this final rule. Therefore, we have made a slight 
adjustment to the methodology we are finalizing in this final rule to 
ensure that payments are calculated as accurately as possible. 
Accordingly, we will multiply the teaching status adjustment, if 
applicable, by the wage adjusted Federal payment amount, rather than by 
the rural and LIP adjusted Federal payment amount as we proposed in the 
FY 2006 proposed rule (70 FR 30188), and add the resulting amount to 
the FY 2006 adjusted Federal prospective payment to compute the total 
FY 2006 adjusted Federal prospective payment (as illustrated in the 
following example).
    We summarize 3 examples for computing total FY 2006 adjusted 
Federal prospective payment rates in Table 11 below. These examples are 
based on 3 beneficiaries classified into CMG 0110 (without 
comorbidities) receiving care in 3 different hypothetical IRFs. IRFs A, 
B, and C have the following characteristics:
     Facility A is a non-teaching IRF located in rural Duke 
County, Massachusetts with a disproportionate share hospital (DSH) 
adjustment of 5 percent (1.031) and the FY 2006 blended wage index of 
1.0216;
     Facility B is a teaching IRF located in urban Queens 
County, New York with a disproportionate share hospital (DSH) 
adjustment of 10 percent (1.0612) and a FY 2006 blended wage index of 
1.3449. The teaching status adjustment of 1.0910 will also be applied; 
and,
     Facility C is a non-teaching IRF located in Kings County, 
California with a disproportionate share hospital (DSH) adjustment of 
20 percent (1.1203) and a FY 2006 blended wage index of 0.9797. The 
Kings County, California IRF was designated as a rural facility in FY 
2005 (based on the MSA designation), but is classified as urban in FY 
2006 (based on the CBSA designation). Therefore, this IRF will receive 
a hold harmless adjustment of 12.76 percent. The hold harmless 
adjustment applies to IRFs that are defined as rural under Sec.  
412.602 during FY 2005 and are classified as urban under Sec.  412.602 
in FY 2006 (as discussed in detail in section VI.B.2.e).
    To calculate each IRF's total adjusted Federal prospective payment, 
we compute the wage-adjusted Federal prospective payment and multiply 
the result by the appropriate low-income patient adjustment, and the 
rural adjustment (if applicable). In order to calculate the teaching 
hospital adjustment (if applicable), we multiply the teaching 
adjustment by the Wage Adjusted Federal payment. Then, we apply the 
amount to the Adjusted Rural and LIP Federal Prospective Payment Rate. 
Table 11 illustrates the components of the adjusted payment 
calculation.

                      Table 11.--Example of Computing an IRF's Federal Prospective Payment
----------------------------------------------------------------------------------------------------------------
                                                         Facility A  Dukes      Facility B     Facility C  Kings
                                                             County, MA     Queens County, NY      County, CA
----------------------------------------------------------------------------------------------------------------
Federal Prospective Payment............................         $27,686.52         $27,686.52         $27,686.52

[[Page 47940]]

 
Labor Share............................................          x 0.75865          x 0.75865          x 0.75865
Labor Portion of Federal Payment.......................       = $21,004.38       = $21,004.38       = $21,004.38
FY 2006 Transition Wage Index (shown in Table 1 in the            x 1.0216           x 1.3449           x 0.9797
 addendum).............................................
Wage-Adjusted Amount...................................       = $21,458.07       = $28,248.79       = $20,577.99
                                                        ====================
Nonlabor Amount........................................          $6,682.14          $6,682.14          $6,682.14
Wage-Adjusted Federal Payment..........................         $28,140.21         $34,930.93         $27,260.13
Rural Adjustment.......................................           x 1.2130           x 1.0000           x 1.1276
    Subtotal...........................................       = $34,134.08       = $34,930.93       = $30,738.52
LIP Adjustment.........................................             1.0310             1.0612             1.1203
                                                        ====================
FY 2006 Adjusted Rural and LIP Federal Prospective              $35,192.24         $37,068.70         $34,436.37
 Payment Rate..........................................
Wage-Adjusted Federal Payment..........................         $28,140.21         $34,930.93         $27,260.13
Teaching status adjustment.............................           x 1.0000           x 1.0900           x 1.0000
                                                              = $28,140.21       = $38,074.71       = $27,260.13
Teaching Status addition to FY 2006 Adjusted Rural and               $0.00          $3,143.78              $0.00
 LIP Federal Prospective Payment Rate..................
                                                        --------------------
    Total FY 2006 Adjusted Federal Prospective Payment.         $35,192.24         $40,212.49         $34,436.37
----------------------------------------------------------------------------------------------------------------

    Thus, the adjusted payment for Facility A will be $35,192.24, the 
adjusted payment for Facility B will be $40,212.49, and the adjusted 
payment for Facility C will be $34,436.37.

                         Table 12.--FY 2006 Payment Rate Table Based on All Refinements
----------------------------------------------------------------------------------------------------------------
                                                   Payment Rate    Payment Rate    Payment Rate    Payment Rate
                       CMG                            Tier 1          Tier 2          Tier 3      No Comorbidity
----------------------------------------------------------------------------------------------------------------
0101............................................       $9,819.10       $9,318.63       $8,278.12       $8,107.05
0102............................................       12,091.63       11,476.26       10,194.45        9,983.79
0103............................................       14,250.53       13,525.36       12,015.02       11,767.34
0104............................................       15,140.39       14,369.26       12,765.72       12,501.45
0105............................................       18,171.27       17,246.94       15,321.68       15,005.06
0106............................................       21,151.09       20,074.83       17,834.22       17,465.26
0107............................................       24,411.78       23,169.55       20,582.96       20,159.09
0108............................................       28,222.73       26,786.44       23,796.41       23,304.88
0109............................................       28,056.76       26,629.41       23,655.97       23,168.27
0110............................................       33,528.70       31,823.02       28,269.97       27,686.52
0201............................................       10,392.34        8,714.75        7,687.01        7,210.80
0202............................................       13,324.92       11,174.96        9,856.12        9,244.58
0203............................................       15,942.15       13,369.60       11,791.60       11,061.33
0204............................................       17,051.61       14,300.32       12,612.52       11,831.18
0205............................................       20,913.62       17,539.30       15,468.50       14,509.70
0206............................................       27,294.57       22,891.23       20,189.73       18,937.29
0207............................................       35,309.69       29,611.78       26,117.45       24,497.32
0301............................................       14,417.77       12,174.61       10,775.35        9,912.30
0302............................................       18,804.51       15,879.59       14,053.91       12,927.86
0303............................................       22,438.00       18,947.50       16,770.73       15,426.37
0304............................................       30,922.95       26,112.35       23,112.10       21,258.33
0401............................................       12,627.84       10,873.65        9,774.42        8,728.80
0402............................................       17,414.19       14,996.12       13,479.40       12,036.73
0403............................................       30,312.69       26,103.41       23,464.47       20,953.20
0404............................................       54,345.29       46,798.72       42,067.27       37,565.62
0405............................................       41,463.39       35,705.47       32,094.96       28,660.64
0501............................................        9,836.97        8,233.44        7,201.86        6,458.83
0502............................................       13,170.44       11,023.03        9,642.92        8,648.37
0503............................................       17,460.15       14,613.11       12,783.60       11,463.49
0504............................................       21,857.10       18,292.56       16,002.16       14,350.11
0505............................................       25,902.97       21,679.64       18,965.38       17,006.92
0506............................................       35,245.86       29,499.43       25,804.66       23,141.46
0601............................................       11,445.62        9,359.49        8,893.49        8,289.61
0602............................................       15,224.65       12,450.38       11,831.18       11,025.58
0603............................................       19,490.10       15,938.32       15,145.49       14,115.20
0604............................................       24,945.44       20,400.39       19,384.14       18,066.58
0701............................................       11,560.52        9,876.55        9,275.23        8,407.07
0702............................................       15,010.16       12,823.17       12,041.83       10,914.51
0703............................................       18,685.78       15,963.86       14,991.01       13,587.92

[[Page 47941]]

 
0704............................................       22,932.09       19,590.96       18,397.25       16,676.26
0801............................................        8,376.43        7,035.89        6,522.66        5,867.71
0802............................................       10,941.32        9,189.69        8,519.42        7,665.31
0803............................................       16,223.03       13,624.94       12,631.67       11,363.91
0804............................................       14,131.79       11,868.20       11,002.60        9,899.53
0805............................................       17,793.37       14,943.77       13,854.75       12,464.42
0806............................................       21,354.08       17,933.80       16,626.46       14,957.82
0901............................................       10,739.60        9,776.97        8,687.94        7,775.10
0902............................................       14,112.64       12,847.43       11,416.25       10,216.15
0903............................................       18,618.12       16,949.47       15,061.23       13,478.12
0904............................................       23,339.35       21,248.12       18,879.84       16,895.85
1001............................................       12,304.83       11,347.31       10,125.51        9,335.23
1002............................................       16,225.58       14,961.65       13,350.45       12,308.66
1003............................................       22,822.29       21,043.85       18,778.98       17,313.33
1101............................................       16,014.92       13,400.24       11,731.60       10,803.44
1102............................................       23,976.43       20,060.79       17,562.29       16,173.24
1201............................................       13,001.91       11,227.30       10,348.93        9,341.61
1202............................................       16,828.18       14,532.68       13,395.14       12,090.35
1203............................................       20,731.05       17,901.89       16,501.35       14,893.98
1301............................................       13,198.52       12,278.02       10,628.53        9,393.96
1302............................................       18,287.45       17,012.03       14,725.46       13,015.96
1303............................................       23,373.82       21,744.75       18,822.39       16,637.95
1401............................................       10,433.19        9,386.30        8,165.77        7,412.52
1402............................................       14,087.11       12,672.52       11,025.58       10,008.05
1403............................................       17,535.47       15,774.91       13,724.53       12,459.32
1404............................................       22,238.84       20,007.17       17,405.25       15,800.44
1501............................................       11,773.73       11,483.92        9,813.99        9,443.75
1502............................................       14,885.05       14,517.36       12,406.97       11,939.70
1503............................................       18,217.23       17,767.83       15,185.07       14,611.83
1504............................................       24,017.28       23,424.89       20,019.93       19,264.13
1601............................................       12,849.99       10,908.12        9,870.17        8,814.34
1602............................................       17,631.23       14,968.03       13,541.96       12,094.18
1603............................................       21,688.58       18,411.29       16,658.38       14,877.39
1701............................................       12,897.22       12,299.73       10,625.97        9,346.72
1702............................................       16,986.49       16,198.77       13,995.19       12,311.22
1703............................................       20,212.71       19,275.62       16,652.00       14,648.86
1704............................................       25,288.87       24,115.59       20,834.47       18,327.03
1801............................................       15,471.05       12,552.51       10,526.39        9,296.93
1802............................................       24,748.83       20,079.94       16,839.67       14,872.28
1803............................................       44,408.73       36,031.03       30,216.94       26,686.86
1901............................................       15,782.57       14,019.44       13,631.33       11,935.87
1902............................................       29,570.93       26,266.83       25,539.11       22,361.40
1903............................................       42,691.57       37,921.82       36,872.37       32,283.91
2001............................................       11,162.19        9,430.98        8,455.58        7,720.20
2002............................................       14,615.66       12,348.24       11,070.27       10,107.63
2003............................................       18,881.12       15,952.37       14,301.59       13,056.81
2004............................................       25,222.49       21,310.68       19,104.54       17,443.55
2101............................................       27,906.11       27,906.11       20,312.30       18,846.65
5001............................................            0.00            0.00            0.00         2810.02
5101............................................            0.00            0.00            0.00       18,108.32
5102............................................            0.00            0.00            0.00       20,429.75
5103............................................            0.00            0.00            0.00        9,197.35
5104............................................            0.00            0.00            0.00       23,964.94
----------------------------------------------------------------------------------------------------------------

VII. 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, taking into account and 
responding to public comments in the Federal Register as part of the 
Paperwork Reduction Act process, we will publish our rationale for 
revising the IRF-PAI. Then in accordance with the Paperwork

[[Page 47942]]

Reduction Act, we will publish our proposed revisions to the IRF-PAI 
and solicit public comments. The revised IRF-PAI will need to be 
approved by OMB before it is used in IRFs.
    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, 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 re-hospitalizations 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.
    It is important to note that some of the ideas discussed above 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. Thus, we 
solicited comments on these and other approaches.
    Comment: Most commenters were supportive of the concept of 
providing incentives for high quality and improved patient outcomes 
within the structure of Medicare's payment systems. Commenters were 
also generally supportive of advancing approaches that resulted in more 
consistent payments for similar services across the various post acute 
care settings and a more seamless system of care, though several noted 
important distinctions between the type of care provided in IRF 
compared to other settings. For example, one commenter objected to the 
implication that the differentiation among provider types (such as SNFs 
and IRFs) could become less pronounced. This commenter stated that 
there is a big difference in care and rehabilitation between these two 
types of facilities and suggested that we ask patients about this 
difference. Many Commenters noted that, in advancing these policy 
goals, CMS should facilitate stakeholder input to ensure that the 
knowledge and experience of providers, beneficiaries, and others with 
critical knowledge is factored into the development process.
    Response: CMS appreciates the thoughtful comments provided on these 
important issues. By advancing a more seamless system of payments and 
benefits in post acute care, Medicare can ensure that patients receive 
high quality care in the most appropriate setting, and that decisions 
about where patients receive care are guided by decisions of patients 
and their families working with physicians, rather than in response to 
financial incentives or barriers created by administrative guidelines. 
In addition, pay for performance has the potential to promote real 
improvements in quality and outcomes as demonstrated by the work CMS 
has advanced already; for example, the Premier Hospital Demonstration.
    We agree with commenters that CMS should involve stakeholders and 
work collaboratively with providers, patients and practitioners in the 
field to advance these objectives. In developing additional IRF-PAI 
quality items and related quality measures through our research with 
RTI, as described in section VII above, RTI has already begun to do 
that by convening meetings of a Technical Expert Panel to consider the 
critical methodological and clinical issues. The research we are 
conducting through the RTI contract will provide data that will promote 
and advance efforts to develop and consider pay for performance 
approaches in IRFs, as well as approaches to measuring and rewarding 
quality improvement more broadly in post acute care. We also agree 
that, in developing a more integrated strategy for payment and care 
delivery within Medicare's post acute benefits, it will be important to 
consider not only how various provider types are similar but also how 
they are different.

VIII. Miscellaneous Public Comments Within the Scope of the Proposed 
Rule

    Comment: We received a comment regarding a change made to Sec.  
412.25(a) when the inpatient psychiatric facility (IPF) PPS was 
published on November 15, 2004 (69 FR 66922). The commenter requested 
that we add the reference to a rehabilitation unit that was removed by 
the IPF PPS final rule.
    Response: We agree with making the change requested by the 
commenter.

[[Page 47943]]

Section 412.1 specifies the scope of part 412. In order to expand the 
existing scope of part 412 the IPF PPS final rule revised Sec.  412.1 
by redesignating paragraphs (a)(2) and (a)(3) as paragraphs (a)(3) and 
(a)(4) and adding a new paragraph (a)(2). The added paragraph (a)(2) 
specified that in accordance with section 124 of Pub. L. 106-113 we 
were establishing a per diem prospective payment system for the 
inpatient operating and capital costs of hospital inpatient services 
furnished to Medicare beneficiaries by a psychiatric facility that 
meets the conditions of subpart N of part 412. Redesignated as 
paragraph (a)(3) is the paragraph that specifies the statutory basis 
for the establishment of the IRF PPS.
    In order to conform Sec.  412.25(a) to the revision we made as 
stipulated above to Sec.  412.1 the IPF PPS final rule revised Sec.  
412.25(a), which specifies the basis for exclusion from being paid 
under the IPPS. Prior to publishing the IPF PPS final rule, Sec.  
412.25(a) read as follows:
    (a) Basis for exclusion. In order to be excluded from the 
prospective payment systems specified in Sec.  412.1(a)(1), a 
psychiatric or rehabilitation unit must meet the following 
requirements.
    When the IPF PPS final rule revised Sec.  412.25(a) the intended 
purpose of the revision was to include a reference to new paragraph 
(a)(2) that, as stipulated above, we had added to Sec.  412.1. However, 
when we revised Sec.  412.25(a), we inadvertently removed the words 
``or rehabilitation'' from the existing Sec.  412.25(a). Therefore, in 
order to correct the inadvertent removal of the words ``or 
rehabilitation'' from Sec.  412.25(a), we are making a technical 
correction so that Sec.  412.25(a) will read as follows:
    (a) Basis for exclusion. In order to be excluded from the 
prospective payment systems as specified in Sec.  412.1(a)(1) and be 
paid under the inpatient psychiatric facility prospective payment 
system as specified in Sec.  412.1(a)(2) or the inpatient 
rehabilitation facility prospective payment system as specified in 
Sec.  412.1(a)(3), a psychiatric or rehabilitation unit must meet the 
following requirements.

IX. Miscellaneous Public Comments Outside the Scope of the Proposed 
Rule

    Comment: We received a number of comments expressing concerns about 
various aspects of CMS's enforcement of the 75 percent rule. Several 
commenters stated that enforcement of the 75 percent rule would lead 
many IRFs to close, would arbitrarily exclude patients in certain RICs 
from receiving treatment in IRFs, and would create access to care 
problems for patients.
    Response: These comments are not specifically related to the 
proposed changes to the IRF PPS that were discussed in the FY 2006 
proposed rule (70 FR 30188). We responded to similar comments in the 
May 7, 2004 final rule (69 FR 25752) that established the changes to 
the criteria for being classified as an IRF. Because the responses to 
these comments in the May 7, 2004 final rule are very lengthy, we refer 
the reader to that final rule for the detailed responses to these and 
other comments regarding the 75 percent rule.
    Comment: One commenter asked that we provide the algorithm (that 
is, the computer software) that the fiscal intermediaries use in their 
presumptive determinations of IRF compliance with the 75 percent rule.
    Response: We will take this into consideration, and may make the 
computer software available to all interested parties at a future date.
    Comment: One commenter suggested that CMS consider implementing a 
cost-of-living adjustment for IRFs located in Alaska, to offset higher 
non-labor costs in Alaska.
    Response: In the August 7, 2001 final rule (66 FR 41316, 41361), we 
referred to Section 1886(j)(4)(B), which authorizes, but does not 
require, the Secretary to take into account the unique circumstances of 
IRFs located in Alaska and Hawaii. In the data used to prepare the 
August 7, 2001 final rule, there was only one IRF in Hawaii and one in 
Alaska. In the August 7, 2001 final rule, we explained that, due to the 
small number of IRFs in Alaska and Hawaii in the data, analyses were 
inconclusive regarding whether a cost-of-living adjustment would 
improve payment equity for these facilities. Therefore, we did not 
implement an adjustment for facilities located in Alaska and Hawaii in 
the August 7, 2001 final rule.
    In the FY 2003 data used for the FY 2006 proposed rule (70 FR 
30188) and for this final rule, there were 3 IRFs in Alaska and 1 IRF 
in Hawaii. We continue to believe that this may be too small a number 
of facilities for us to determine, based on analysis of the data, 
whether a cost-of-living adjustment would improve payment equity for 
these facilities. However, we will consider conducting such an analysis 
in the future.
    Comment: Some commenters suggested changes to the items on the IRF-
PAI, such as deleting the transfer to tub item and revising the 
instructions for the items that describe preventable conditions that 
occur on admission to the IRF and preventable conditions that occur 
while the patient is in an IRF.
    Response: We have contracted with the Research Triangle Institute 
(RTI) to analyze and recommend changes to the IRF-PAI that would 
improve our ability to assess quality of care in IRFs. Any changes to 
the IRF-PAI that CMS might decide to propose in the future, based on 
RTI's recommendations, would require clearance by the Office of 
Management and Budget. However, we will take the commenters suggestions 
into consideration.
    Comment: Several commenters suggested that CMS allow general 
hospitals to increase physiatrist training if they also decrease 
training in one or more specialties reimbursed under the inpatient PPS.
    Response: This comment does not relate to the IRF PPS and is 
outside the scope of this rule. We will forward it to the component of 
the Agency that works on the IPPS for their consideration.

IX. Provisions of the Final Regulations

    The provisions of this final rule restate the provisions of the FY 
2006 proposed rule (70 FR 30188), except as noted elsewhere in the 
preamble. Following is a highlight of the changes we made from the 
proposed rule:
     We are adding 2 codes that were not on the proposed list 
of ICD-9-CM codes to be removed from the comorbidity tiers (V46.11 and 
V46.12). We are adding these codes to the list to be removed because 
these codes are derived from code V46.1, which was determined by RAND 
to have no positive impact on payment when controlling for the CMG.
     We are adding the following codes to the list of 
comorbidities we proposed in the proposed rule: 250.1 (insulin 
dependent diabetes without mention of complications, not stated as 
controlled), code 428.1-Left Heart Failure, code 428.20-Systolic Heart 
Failure Unspecified, code 428.21-Systolic Heart Failure Acute, code 
428.22-Systolic Heart Failure Chronic, code 428.23-Systolic Hear 
Failure Acute on Chronic, code 428.30-Diastolic Heart Failure 
Unspecified, code 428.31-Diastolic Heart Failure Acute, code 428.32-
Diastolic Heart Failure Chronic, code 428.33-Diastolic Heart Failure 
Acute on Chronic, code 428.40-Combined Systolic and Diastolic Heart 
Failure Unspecified, code 428.41-Combined Systolic and Diastolic Heart 
Failure Acute, code 428.42-Combined Systolic and Diastolic Heart 
Failure Chronic, and code 428.43-Combined Systolic and Diastolic Heart 
Failure Acute on Chronic. For this final rule, we decided to add these 
codes to the list of

[[Page 47944]]

comorbidities we proposed in the proposed rule because of the increased 
costs associated with these codes. After receiving the comments to add 
additional codes to the list of comorbidity codes used to increase the 
CMG payment rate, our Medical Officers, similar to RAND's TEP, believe 
that several of the codes suggested should be added to these tiers that 
increase payment for the CMG.
     We are updating the market basket estimate, based on the 
FY 2002-based RPL market basket and the Global Insight's 2nd quarter 
2005 forecast, to 3.6 percent (from 3.1 percent in the proposed rule).
     We are changing our proposed policy to adopt the CBSA-
based wage index without a transition to implementing the CBSA-based 
wage index with a budget neutral one-year blended wage index. Thus, the 
FY 2006 wage index is comprised of 50 percent of the FY 2006 MSA-based 
wage index and 50 percent of the FY 2006 CBSA-based wage index (both 
based on FY 2001 hospital wage data) for all IRFs.
     We are changing our proposed policy to not adopt a hold 
harmless policy to adopting a budget neutral 3 year hold harmless 
policy for FY 2005 rural IRFs that will be classified as urban under 
the FY 2006 CBSA-based designations. The 3 year hold harmless policy 
will only apply to existing rural FY 2005 IRFs that will experience a 
decrease in payments due solely to the loss of the FY 2005 rural 
adjustment of 19.14 percent because of the adoption of the CBSA-based 
designations.
     We are changing the exponent for the teaching status 
adjustment formula to 0.9012 (from 1.083 in the proposed rule), based 
on RAND's most recent cost regressions using data from FY 2003, 
including the HealthSouth home office cost data from FY 2004 (as 
described in detail in section IV of this final rule).
     We are changing the rural adjustment to 21.3 percent (from 
24.1 percent in the proposed rule), based on RAND's most recent cost 
regressions using data from FY 2003, including the HealthSouth home 
office cost data from FY 2004 (as described in detail in section IV of 
this final rule).
     We are changing the exponent for the LIP adjustment 
formula to 0.6229 (from 0.636 in the proposed rule), based on RAND's 
most recent cost regressions using data from FY 2003, including the 
HealthSouth home office cost data from FY 2004 (as described in detail 
in section IV of this final rule).
     We are changing the outlier threshold amount to $5,132 
(from $4,911 in the proposed rule), based on RAND's most recent cost 
regressions using data from FY 2003, including the HealthSouth home 
office cost data from FY 2004 (as described in detail in section IV of 
this final rule).
     We are changing the base period for determining an IRF's 
FTE resident cap from the final settlement of the IRF's most recent 
cost reporting period ending on or before November 15, 2003, which was 
what we had proposed in the FY 2006 proposed rule, to the final 
settlement of the IRF's most recent cost reporting period ending on or 
before November 15, 2004.
     We are changing the budget neutrality factors applied to 
the standard payment amount in the methodology used to implement the 
changes in a budget neutral manner (section VI.B.8 of this final rule) 
to 0.9995 for the changes to the tier comorbidities and the CMGs, 
0.9961 for the change to the rural adjustment, 0.9851 for the change to 
the LIP adjustment, and 0.9889 for the implementation of the new 
teaching status adjustment. These changes are necessary to ensure that 
the tier and CMG changes, the rural adjustment change, the LIP 
adjustment change, and the implementation of the new teaching status 
adjustment will be done in a budget neutral manner for FY 2006 (that 
is, such that estimated aggregate IRF payments for FY 2006 with the 
changes will equal estimated aggregate IRF payment in FY 2006 without 
the changes).
     We are changing the budget neutrality factor for the wage 
index changes for FY 2006 to 0.9995, to ensure that the wage index 
changes described in section VI.B.2 of this final rule will be made in 
a budget neutral manner.
     We are changing the standard payment conversion factor for 
FY 2006 to $12,767 (from $12,658 in the proposed rule), based on RAND's 
most recent cost regressions using data from FY 2003, including the 
HealthSouth home office cost data from FY 2004 (as described in detail 
in section IV of this final rule).

X. 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.

XI. Regulatory Impact Analysis

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 an outlier payment policy. This final rule updates the 
FY 2005 IRF PPS payment rates specified in the July 30, 2004 notice (69 
FR 45721) and implements policy changes with regard to the IRF PPS 
based on analyses conducted by RAND under contract with us on CY 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 final 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 19, 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

[[Page 47945]]

(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 $210 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 making 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 improving 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 payments. To redistribute payments 
among facilities, we lowered the base payment amount, which then gets 
adjusted upward for each facility according to the facility's 
characteristics. This redistribution will not, however, affect 
estimated aggregate payments to facilities. Thus, the changes to the 
IRF labor-related share and the wage indices, the changes to the CMGs, 
the tiers, and the motor score index, the teaching status adjustment, 
the update to the rural adjustment, and the update to the LIP 
adjustment have no overall effect on estimated costs to the Medicare 
program. Therefore, the estimated increased cost to the Medicare 
program is due to the combined effect of the updated IRF market basket 
of 3.6 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 final 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 3.4 percent 
increase), we estimate that the total impact of these changes for 
estimated FY 2006 payments compared to estimated FY 2005 payments will 
be approximately a $210 million increase. This amount does not reflect 
changes in IRF admissions or case-mix intensity, which also may affect 
the overall estimated change in payments from FY 2005 to FY 2006.
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 regulation will 
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 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 final 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 adopting, we will 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 final rule will 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 final rule that may result in expenditures 
in any 1 year by State, local, or tribal governments, in the aggregate, 
or by the private sector, of at least $110 million. This final rule 
will not mandate any requirements for State, local, or tribal 
governments, nor will it affect private sector costs.
5. Executive Order 13132
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a final rule that imposes 
substantial direct requirement costs on State and local governments, 
preempts State law, or otherwise has Federalism implications. We have 
reviewed this final rule in light of Executive Order 13132 and have 
determined that it will 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 final 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 final rule has 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 Final Rule

    We discuss below the impacts of this final rule on the budget and 
on IRFs.
1. Basis and Methodology of Estimates
    In this final rule, we are implementing 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 3.4 percent increase), we 
estimate the total impact of these changes for estimated FY 2006 
payments compared to estimated FY 2005 payments to be approximately a 
$210 million increase. This amount does not reflect changes in hospital 
admissions or case-mix intensity, which also may affect the overall 
change in payments from FY 2005 to FY 2006.
    We have prepared separate impact analyses of each of the 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 implementing in this 
final rule.
    The data used in developing the quantitative analyses of estimated 
changes in payments per discharge

[[Page 47946]]

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. The data also include the FY 2004 
home office costs for HealthSouth facilities, as described in section 
IV of the preamble to this final rule.
    Our analysis has several qualifications. First, we do not make 
adjustments for behavioral changes that hospitals may adopt in response 
to the 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 change.
    Using cases in the FY 2003 MedPAR file, we simulated payments under 
the IRF PPS given various combinations of payment parameters.
    The changes discussed separately below are the following:
     The effects of the annual market basket update (using the 
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 budget-neutral labor-related 
share and wage index adjustment, as required under section 1886(j)(6) 
of the Act.
     The effects of the decrease to the standard payment amount 
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 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 one year budget-neutral transition 
policy for adopting the new CBSA-based geographic area definitions 
announced by OMB in June 2003.
     The effects of the 3 year budget-neutral hold-harmless 
policy for IRFs that are rural under Sec.  412.602 during FY 2005, but 
are urban under Sec.  412.602 during FY 2006 and lose the rural 
adjustment resulting in a loss of estimated IRF PPS payments and meets 
the intent of the hold harmless policy.
     The effects of the implementation of a budget-neutral 
teaching status adjustment, as permitted under section 1886(j)(3)(A)(v) 
of the Act.
     The effects of the 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 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 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 estimated payments based on the FY 
2006 policies relative to estimated payments based on FY 2005 policies.
    To illustrate the impacts of the FY 2006 estimated changes, our 
analysis begins with a FY 2005 baseline simulation model using: IRF 
charges from FY 2003 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 policy change is then added incrementally to this baseline 
model, finally arriving at an FY 2006 model incorporating all of the 
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 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 estimated 
payments per discharge from FY 2005 to FY 2006. One factor that affects 
the changes in IRFs' estimated 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, estimated outlier payments in FY 2006 are projected to 
increase by an additional 1.8 percent over estimated payments in FY 
2005 because of the 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

[[Page 47947]]

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.

                                            Table 13.--Projected Impact of FY 2006 Refinements to the IRF PPS
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                         New CMG,
                                                       FY06 Wage                           new                             Teach.
                                 Number of  Number of  Index and   Outlier     Market     tiers,     Rural     New LIP     Status      1.9%      Total
  Facility classification  (1)   IRFs  (2)    cases      Labor-      (5)       Basket   and motor   adjust.    adjust.    adjust.    reduct.    change %
                                               (3)       share                  (6)       score       (8)        (9)        (10)       (11)       (12)
                                                          (4)                              (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total..........................      1,188    461,738       0.0%       1.8%       3.6%       0.0%       0.0%       0.0%       0.0%      -1.9%        3.4
Urban unit.....................        802    261,229        0.1        2.3        3.6        0.9       -0.2        0.1        0.5       -1.9        5.3
Rural unit.....................        169     34,664       -1.3        3.1        3.6        1.7        1.3       -0.1       -0.9       -1.9        5.5
Urban hospital.................        196    158,968        0.2        0.5        3.6       -1.7        0.0       -0.1       -0.5       -1.9        0.0
Rural hospital.................         21      6,877       -1.6        7.0        3.6       -0.7        1.3        0.0       -1.0       -1.9        6.5
Urban For-Profit...............        295    154,526        0.4        0.7        3.6       -1.8        0.0        0.0       -0.8       -1.9        0.0
Rural For-Profit...............         59     11,952       -1.9        3.8        3.6        0.2        1.3        0.2       -1.0       -1.9        4.2
Urban Non-Profit...............        603    237,384        0.0        2.1        3.6        1.0       -0.2        0.0        0.5       -1.9        5.0
Rural Non-Profit...............        105     23,793       -1.0        4.1        3.6        1.7        1.3       -0.3       -0.8       -1.9        6.7
Urban Government...............        100     28,287       -0.2        2.5        3.6        0.5        0.0        0.5        1.7       -1.9        6.7
Rural Government...............         26      5,796       -1.5        2.6        3.6        1.4        1.3        0.3       -1.0       -1.9        4.8
Urban..........................        998    420,197        0.1        1.6        3.6       -0.1       -0.1        0.0        0.1       -1.9        3.2
Rural..........................        190     41,541       -1.4        3.8        3.6        1.2        1.3       -0.1       -0.9       -1.9        5.7
Urban by region:
    New England................         35     20,612       -0.3        1.7        3.6       -0.7       -0.3       -0.3       -0.6       -1.9        1.1
    Middle Atlantic............        156     76,962       -0.4        2.0        3.6        1.1       -0.2        0.0        1.6       -1.9        5.8
    South Atlantic.............        124     73,677        0.4        0.6        3.6       -0.5        0.1        0.0       -0.3       -1.9        1.9
    East North Central.........        189     69,315        0.1        2.3        3.6        1.2       -0.2       -0.2        0.1       -1.9        4.9
    East South Central.........         54     30,473        0.2        0.0        3.6       -1.4        0.4        0.1       -0.5       -1.9        0.6
    West North Central.........         71     22,217       -0.1        2.1        3.6        0.6       -0.2       -0.1        0.1       -1.9        4.2
    West South Central.........        184     76,088        0.5        1.8        3.6       -0.7       -0.3       -0.1       -0.5       -1.9        2.3
    Mountain...................         69     24,287       -0.2        1.2        3.6       -2.2       -0.1       -0.1       -0.5       -1.9       -0.2
    Pacific....................        116     26,566        0.8        2.2        3.6       -0.8       -0.3        1.1        0.0       -1.9        4.7
Rural by region:
    New England................          4        924        0.4        2.1        3.6        1.7        1.2       -0.4       -0.9       -1.9        5.9
    Middle Atlantic............         19      5,377       -1.1        8.2        3.6        1.5        1.4       -0.4       -1.0       -1.9       10.3
    South Atlantic.............         22      5,440       -1.0        2.5        3.6        1.2        1.3        0.1       -1.0       -1.9        4.8
    East North Central.........         28      5,618       -1.0        3.0        3.6        1.9        1.2       -0.4       -0.9       -1.9        5.5
    East South Central.........         20      5,362       -1.9        2.2        3.6        1.1        1.3        0.3       -0.7       -1.9        3.9
    West North Central.........         30      5,351       -1.3        2.3        3.6        2.7        1.2       -0.2       -0.6       -1.9        5.8
    West South Central.........         54     12,016       -1.7        4.3        3.6        0.3        1.3        0.1       -1.0       -1.9        4.9
    Mountain...................          9        902       -3.2        9.4        3.6        2.6        1.2       -0.4       -0.9       -1.9       10.2
    Pacific....................          4        551        0.9        2.8        3.6       -2.7        1.1       -0.8       -0.8       -1.9        2.0
Teaching status:
    Non-teaching...............      1,053    400,072        0.0        1.6        3.6       -0.1        0.0       -0.1       -0.9       -1.9        2.2
    Resident to ADC less than           71     39,888        0.3        2.5        3.6        0.3       -0.3        0.2        2.2       -1.9        7.0
     10%.......................
    Resident to ADC 10%-19%....         42     17,793       -0.9        2.8        3.6        0.4       -0.3        1.1        9.1       -1.9       14.3
    Resident to ADC greater             22      3,985       -0.1        4.1        3.6        0.0       -0.3        1.1       19.5       -1.9       27.4
     than 19%..................
--------------------------------------------------------------------------------------------------------------------------------------------------------

3. Impact of the Market Basket Update to the IRF PPS Payment Rates 
(Using the RPL Market Basket) (Column 6)
    In column 6 of Table 13, we present the estimated effects of the 
market basket update to the IRF PPS payment rates, as discussed in 
section VI.B.1 of this final 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 VI.B.1 of this final rule, we are 
using 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 RPL market basket. The FY 2006 update for IRF PPS payments using 
the FY 2002-based RPL market basket and the Global Insight's 2nd 
quarter 2005 forecast will be 3.6 percent.
    In the aggregate, and across all hospital groups, the update will 
result in a 3.6 percent increase in overall estimated payments to IRFs.
4. Impact of the 1.9 Percent Decrease in the Standard Payment Amount To 
Account for Coding Changes (Column 11)
    In column 11 of Table 13, we present the estimated effects of the 
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 VI.A of this final 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 update will 
result in a 1.9 percent decrease in overall estimated payments to IRFs. 
Thus, we estimate that the 1.9 percent reduction in the standard 
payment amount will result in a cost savings to the Medicare program of 
approximately $120 million.
5. Impact of the Changes to the CMGs and Tiers and Recalibration of 
Relative Weights (Column 7)
    In column 7 of Table 13, we present the estimated effects of the 
changes to the tier comorbidities, the CMGs, the motor score index, and 
the recalibration of the relative weights, as discussed in section V of 
this final rule. Section 1886(j)(2)(C)(i) of the Act requires us to

[[Page 47948]]

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 V.A.3 of this final rule, we are updating 
the tier comorbidities to remove certain comorbid condition codes from 
the list of comorbid conditions used to increase payment that we 
believe no longer merit additional payments, moving dialysis patients 
to tier one to increase payments for these patients, and aligning 
payments with the comorbidity conditions according to their effects on 
the relative costliness of patients. We are also updating 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 
replacing the previous, unweighted motor score index with a weighted 
motor score index that better estimates the relative costliness of IRF 
patients. Finally, we are changing the GROUPER software so that, in 
cases where the provider has coded a 0 for the transfer to toilet item 
on the IRF-PAI, the GROUPER will change this raw score of 0 to a 2 
instead of a 1.
    To assess the impact of these changes, we compared estimated 
aggregate payments using the FY 2005 CMG relative weights (GROUPER 
version 1.22) to estimated aggregate payments using the 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 VI.B.8 of this final rule, we 
have applied a budget neutrality factor to ensure that the overall 
estimated payment impact of the tier and 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 relative weights we 
will use for calculating the FY 2006 payment rates are slightly higher, 
on average, than the relative weights we used in FY 2005, and that the 
effect of this would have been to increase estimated aggregate payments 
in FY 2006, the 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 estimated payments to IRFs. However, the 
distribution of estimated payments among facilities is affected, with 
some facilities receiving higher estimated payments and some facilities 
receiving lower estimated payments as a result of the tier and CMG 
changes, as shown in column 7 of Table 13.
    Although, in the aggregate, these changes will not change overall 
estimated 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 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 estimated 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.
6. Impact of the Adoption (With a Blended One-Year Transition) of the 
New CBSA Labor Market Areas and the Changes to the Labor Share (Column 
4)
    In accordance with the broad discretion under section 1886(j)(6) of 
the Act, we previously defined 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 VI.B.2 of this final 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 adopting the new CBSA definitions with a one-year blended 
transition as described in section VI.B.2 of this final rule, 
consistent with the inpatient prospective payment system, including the 
49 new Metropolitan areas designated under the new definitions. We are 
also adopting CBSA definitions in New England in place of NECMAs. We 
are not adopting the newly defined Micropolitan Statistical Areas for 
use in the payment system, as Micropolitan Statistical Areas will 
remain part of the statewide rural areas for purposes of the IRF PPS 
payments, consistent with payments under the inpatient prospective 
payment system.
    The estimated effects of these changes to the new CBSA-based 
designations with a one year blended transition, combined with the new 
labor share, 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 estimated payments when going from a model 
using the FY 2005 MSA designations to a model using the FY 2006 CBSA 
designations blended with the FY 2006 MSA designations and using the 
new labor share. As described in section VI.B.2 of this final rule, we 
are implementing a blended wage index for FY 2006 equal to 50 percent 
of the FY 2006 CBSA wage index value and 50 percent of the FY 2006 MSA 
wage index value for all IRFs for one year. The estimated effects of 
this policy are shown in column 4 of table 13.
    Table 14 below compares the shifts in wage index values for IRFs 
for FY 2006 relative to FY 2005. A small number of IRFs (0.9 percent) 
will experience an increase of between 5 and 10 percent and 0.6 percent 
of IRFs will experience an increase of more than 10 percent. A small 
number of IRFs (0.6 percent) will experience decreases in their wage 
index values of at least 5 percent, but less than 10 percent. 
Furthermore, IRFs that will experience decreases in their wage index 
values of greater than 10 percent will be 0.1 percent.
    The following table shows the projected impact for IRFs.

     Table 14.--Impact of the FY 2006 Blended Transition Wage Index
------------------------------------------------------------------------
                                                                Percent
              Percent change in area wage index                 of IRFs
------------------------------------------------------------------------
Decrease Greater Than 10.0...................................        0.1
Decrease Between 5.0 and 10.0................................        0.6
Decrease Between 2.0 and 5.0.................................        2.7
Decrease Between 0 and 2.0...................................       31.0
No Change....................................................       37.2
Increase Between 0 and 2.0...................................       24.5
Increase Between 2.0 and 5.0.................................        2.4
Increase Between 5.0 and 10.0................................        0.9
Increase Greater Than 10.0...................................        0.6
    Total \1\................................................     100.0
------------------------------------------------------------------------
\1\ May not exactly equal 100 percent due to rounding.

    In addition, our analysis file consisted of 34 rural IRFs that 
change designations from a rural facility (under the MSA-based 
designations) to an urban facility (under the CBSA-based designations) 
and would experience estimated payment reductions due to the loss of 
the 19.14 percent rural adjustment. Based on our analysis, these IRFs 
would experience a reduction in estimated payments of between 
approximately $207 to up to approximately $3,070 (average amount of 
approximately $1,472) without a hold harmless policy.
    Based on our estimates, the hold harmless policy would mitigate the 
estimated payment reductions of those rural IRFs in our analysis file. 
Although, we found that 5 IRFs would experience estimated payment 
increases under the hold harmless policy of between

[[Page 47949]]

approximately $9 to approximately $380, these IRFs will not receive 
additional payments under the hold harmless policy. The remaining 29 
rural IRFs under our hold harmless policy can expect estimated payment 
reductions of between approximately $32 to approximately $1,167 
(average amount of approximately $426) in FY 2006 compared to our 
estimates above.
7. Impact of the Change to the Outlier Threshold Amount (Column 5)
    We estimate total outlier payments in FY 2005 to be approximately 
1.2 percent of total estimated payments, so we are updating the 
threshold from $11,211 in FY 2005 to $5,132 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 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 will be to increase estimated 
payments by 3.8 percent, and the effect on payments to urban IRFs will 
be to increase estimated payments by 1.6 percent. The largest effect 
will be a 9.4 percent increase in estimated payments to rural IRFs in 
the Mountain region, and the smallest effect will be no change in 
estimated payments for urban IRFs located in the East South Central 
region.
8. Impact of the Budget-Neutral Teaching Status Adjustment (Column 10)
    In column 10 of Table 13, we present the estimated effects of the 
budget-neutral implementation of a teaching status adjustment to the 
Federal prospective payment rate for IRFs that have teaching programs, 
as discussed in section VI.B.3 of this final 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 applying a budget neutrality factor to ensure that the overall 
estimated payment impact of the teaching status adjustment is budget 
neutral (that is, in order that total estimated aggregate payments for 
FY 2006 with the adjustment will equal total estimated aggregate 
payments for FY 2006 without the adjustment). Because IRFs with 
teaching programs will receive additional payments from the 
implementation of this new teaching status adjustment, the effect of 
the budget neutrality factor will be to reduce the standard payment 
amount, therefore reducing estimated payments to IRFs without teaching 
programs. By design, however, the estimated increases in payments to 
teaching facilities will balance the estimated decreases in payments to 
non-teaching facilities, and total estimated aggregate payments to all 
IRFs will remain unchanged. Therefore, the first row of column 10 of 
Table 13 contains our projection of a zero impact in the aggregate. 
However, the rest of column 10 gives the estimated distributional 
effects among different types of providers of this change. Some 
providers' estimated payments increase and some decrease with this 
change.
    On average, the estimated impacts of this change on any particular 
group of IRFs are very small, with urban IRFs experiencing a 0.1 
percent estimated increase and rural IRFs experiencing a 0.9 percent 
estimated decrease.
    The largest decrease in estimated payments is a 1.0 percent 
decrease among freestanding rural IRFs, rural for-profit facilities, 
rural government-owned facilities, and rural facilities in the Middle 
Atlantic, South Atlantic, and West South Central regions.
    Overall, non-teaching hospitals will experience a 0.9 percent 
estimated decrease. The largest impacts are a 19.5 percent estimated 
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 will experience an estimated increase of 
9.1 percent. Teaching facilities with resident and intern to ADC ratios 
less than 10 percent will experience an estimated increase of 2.2 
percent.
9. Impact of the Update to the Rural Adjustment (Column 8)
    In column 8 of Table 13, we present the estimated effects of the 
budget-neutral update to the percentage adjustment to the Federal 
prospective payment rates for IRFs located in rural areas, as discussed 
in section VI.B.4 of this final 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 
changing the rural adjustment percentage, based on FY 2003 data with an 
adjustment to account for the absence of HealthSouth home office costs 
in that year (see the discussion in section IV of the preamble to this 
final rule), from 19.14 percent to 21.3 percent.
    Because we are making this 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, estimated payments to urban facilities 
will decrease in proportion to the total increase in estimated payments 
to rural facilities. To accomplish this estimated redistribution of 
resources between urban and rural facilities, we applied a budget 
neutrality factor to reduce the standard payment amount. Rural 
facilities will receive an increase to the standard payment amount, and 
urban facilities will not. Overall, estimated aggregate payments to 
IRFs will not change, as indicated by the zero impact we project in the 
first row of column 8. However, estimated payments will 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 estimated impacts of this change on urban IRFs 
are relatively small, with all urban IRFs experiencing a 0.1 percent 
estimated decrease. The estimated impact on rural IRFs is somewhat 
larger, with rural IRFs experiencing a 1.3 percent estimated increase. 
The largest estimated impacts are a 1.4 percent estimated increase 
among rural IRFs in the Middle Atlantic region and a 0.3 percent 
estimated decrease among urban facilities in the New England, West 
South Central, and Pacific regions, and among all categories of 
teaching facilities.
10. Impact of the Update to the LIP Adjustment (Column 9)
    In column 9 of Table 13, we present the estimated effects of the 
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 VI.B.5 of this final 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 
changing the formula for the LIP adjustment, based on FY 2003 data with 
an adjustment to account for the absence of HealthSouth home office 
costs in that year (see the discussion in

[[Page 47950]]

section IV of the preamble to this final rule), to raise the amount of 
1 plus the DSH patient percentage to the power of 0.6229 instead of the 
power of 0.4838. Therefore, the formula to calculate the low-income 
patient or LIP adjustment will be as follows:

(1 + DSH patient percentage) raised to the power of (.6229)
Where DSH patient percentage =
[GRAPHIC] [TIFF OMITTED] TR15AU05.002

    Because we are making this update to the LIP adjustment in a budget 
neutral manner, estimated payments will be redistributed among 
providers, according to their low-income percentages, but total 
estimated aggregate payments to facilities will not change. To do this, 
we applied a budget neutrality factor that lowered the standard payment 
amount in proportion to the amount of estimated payment increase that 
is attributable to the increased LIP adjustment payments. This will 
result in no change to estimated aggregate payments, which is reflected 
in the projected zero impact shown in the first row of column 9 of 
Table 13. The remaining rows of the column show the estimated impacts 
on different categories of providers. On average, the estimated impacts 
of this change on any particular group of IRFs are small, with urban 
IRFs experiencing no change in estimated aggregate payments and rural 
IRFs experiencing a 0.1 percent decrease in estimated aggregate 
payments. The largest estimated impacts are a 1.1 percent estimated 
increase among IRFs with 10 percent or higher intern and resident to 
ADC ratios and a 0.8 percent estimated decrease among rural IRFs in the 
Pacific region.
11. All Changes (Column 12)
    Column 12 of Table 13 compares our estimates of the payments per 
discharge, incorporating all changes reflected in this final rule for 
FY 2006, to our estimates of payments per discharge in FY 2005 (without 
these changes). This column includes all of the policy changes.
    Column 12 reflects all estimated FY 2006 changes relative to FY 
2005, shown in columns 4 though 11. The average estimated increase for 
all IRFs is approximately 3.4 percent. This estimated increase includes 
the effects of the 3.6 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 
estimate of the percentage of outlier payments in FY 2006 (3 percent), 
as described in section VI.B.6 of this final 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 estimated FY 2006 payments than would otherwise have occurred.
    It also includes the estimated impact of the 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 are 
making the remainder of the changes outlined in this final rule in a 
budget-neutral manner, they do not affect total estimated IRF payments 
in the aggregate. However, as described in more detail in each section, 
they do affect the estimated distribution of payments among providers.
    There might also be interactive effects among the various factors 
comprising the payment system that we are not able to isolate. For 
these reasons, the estimated values in column 12 may not equal the sum 
of the estimated changes described above.
12. Accounting Statement
    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 15 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the provisions of this final rule. This 
table provides our best estimate of the increase in Medicare payments 
under the IRF PPS as a result of the changes presented in this final 
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 15.--Accounting Statement: Classification of Estimated
                  Expenditures, From FY 2005 to FY 2006
                              [In millions]
------------------------------------------------------------------------
           Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers  $210.
From Whom to Whom?............  Federal Government to IRF Medicare
                                 Providers.
------------------------------------------------------------------------

13. Alternatives Considered
    Because we have determined that this final rule will have a 
significant economic impact on IRFs, we will discuss the alternative 
changes to the IRF PPS that we considered. We reviewed the options 
considered in the proposed rule and took into consideration comments 
received during the public comment period as discussed in the preamble 
of this final rule.
    The other option we considered before deciding 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 and a 
careful review of the comments we received on the FY 2006 proposed rule 
(70 FR 30188)) that updating both the relative weights and the CMGs 
will allow the classification system to do a better job of reflecting 
changes in treatment patterns, technology, case mix, and other factors 
which may affect the relative use of resources. For these reasons, we 
believe these changes will

[[Page 47951]]

improve the accuracy of payments in the IRF PPS.
    We considered alternative options before deciding to implement an 
objective weighted motor score methodology for classifying patients 
into CMGs. The first of these options was to keep the non-weighted 
motor score methodology used previously. However, we considered 
weighted motor score methodologies because RAND's regression analysis 
indicated that the weighted methodologies would substantially improve 
the predictive ability of the system. We had not previously proposed 
weighted motor score methodologies for the IRF PPS because most experts 
previously 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). However, the technical expert panel that 
reviewed RAND's analyses and advised RAND regarding the methodology 
generally indicated that the data are now sufficient to support a 
weight motor score.
    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 proposed a weighting methodology for the motor score index, 
but proposed to use the same cognitive score index used previously for 
the IRF classification system. We believe that it would be futile to 
expend resources on changing the cognitive score methodology at this 
time when it would not benefit the Medicare program.
    We considered various weighted motor score methodologies, including 
one which 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.
    We also considered defining some simple combinations of the items 
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 
summing 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 assigning 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. For 
this reason, we decided to adopt the weighting scheme that applies the 
average optimal weights.
    We considered a reduction to the standard payment amount by an 
amount up to 5.8 percent because one of RAND's methodologies for 
determining the amount of real change in case mix and the amount of 
coding change that occurred between 1999 and 2002 suggested that coding 
change 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 implemented a reduction greater 
than 1.9 and up to 5.8 percent.
    We decided to implement a 1.9 percent reduction to the standard 
payment amount, the lowest possible amount of change attributable to 
coding change for the following reasons. First, the analyses described 
in this final rule 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. Second, we believe 
this approach, which is supported by RAND's analysis of the data, will 
adequately adjust for the increased payments to IRFs caused purely by 
coding changes, but will 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 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 
criterion for IRF classification commonly known as the ``75 percent 
rule.'' We considered the public comments we received on this issue and 
believe that 1.9 percent is the appropriate reduction to the standard 
payment amount at this time.
    We considered no transition to implement the CBSA-based geographic 
classifications. However, based on further analysis (and in response to 
comments), we considered various transition options. One option we 
considered was a 1-year budget neutral transition with a blended wage 
index (comprised of the FY 2006 MSA-based wage index and FY 2006 CBSA-
based wage index) for IRFs that would experience a decrease in the wage 
index. We also considered floor and ceiling options as requested by 
commenters. However, the options did not reflect the policy goals to 
mitigate the overall impact of IRFs transitioning from the MSA-based 
wage index to the CBSA-based wage index while lessening the overall 
impact on the unadjusted base payment that would be equitable to all 
IRFs.
    We also considered not adopting a hold harmless policy. However, 
based on additional review we determined that it was appropriate to 
implement a budget neutral 3 year hold harmless policy that would 
better reflect policy and maintain fiscal integrity of existing FY 2005 
rural IRFs that will be redesignated as urban facilities under the 
CBSA-based designation.
    We considered not proposing to add a teaching status adjustment to 
the IRF PPS because we had some concerns about proposing a teaching 
status adjustment for IRFs. The policy implications of implementing a 
teaching status adjustment on the basis of the results of RAND's recent 
analysis caused us to seek assurance that these results did not reflect 
an aberration based on only a single year's data and that the teaching 
status adjustment could be implemented in such a way that it would be 
equitable to all IRFs.
    However, the regression analysis conducted by RAND for CY 2002 and 
FY 2003 showed a statistically significant difference in costs between 
IRFs with teaching programs and those without teaching programs. After

[[Page 47952]]

reviewing RAND's analysis and the comments we received on the teaching 
status adjustment we proposed in the FY 2006 proposed rule (70 FR 
30188), which were generally favorable, we determined that a teaching 
status adjustment for IRFs is appropriate at this time. We will 
continue to analyze the need for this adjustment in future data.
    We believe that the analysis conducted by RAND using calendar year 
2002 and FY 2003 data (the best available data we have and the first 
available data since implementation of the IRF PPS) left us little 
option other than to update the rural and LIP adjustments and the 
outlier loss threshold amount. The regression analysis indicated that 
facility-level adjustments (the rural and the LIP adjustments) should 
be updated to better reflect the costs of care among different types of 
IRF facilities. Similarly the regression analysis indicated that the 
outlier threshold amount needed to be updated so that estimated outlier 
payments for FY 2006 would equal 3 percent of total estimated IRF 
payments for FY 2006.
14. Conclusion
    Overall, estimated payments per discharge for IRFs in FY 2006 are 
projected to increase by 3.4 percent, as reflected in column 12 of 
Table 13. IRFs in urban areas will experience a 3.2 percent increase in 
estimated payments per discharge compared with FY 2005. IRFs in rural 
areas, meanwhile, will experience a 5.7 percent estimated increase. 
Rehabilitation units in urban areas will experience a 5.3 percent 
increase in estimated payments per discharge, while freestanding 
rehabilitation hospitals in urban areas will experience no change in 
estimated payments per discharge. Rehabilitation units in rural areas 
will experience a 5.5 percent increase in estimated payments per 
discharge, while freestanding rehabilitation hospitals in rural areas 
will experience a 6.5 percent increase in estimated payments per 
discharge.
    Overall, the largest estimated payment increase will be 27.4 
percent among teaching IRFs with an intern and resident to ADC ratio 
greater than 19 percent and 14.3 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 
teaching status adjustment. Other than for teaching IRFs, the largest 
estimated payment increase will be 10.3 percent among rural IRFs 
located in the Middle Atlantic region. This is due largely to the 
change in the CBSA-based designation from urban to rural, whereby the 
number of cases in the rural Middle Atlantic Region that will receive 
the new rural adjustment of 21.3 percent is projected to increase. The 
only overall decrease in estimated payments will occur among urban IRFs 
located in the Mountain census region, a decrease in estimated payments 
of 0.2 percent. This is due largely to the change in the CBSA-based 
designation from rural to urban. For non-profit IRFs, we found that 
rural non-profit facilities will receive the largest estimated payment 
increase of 6.7 percent. Conversely, for-profit urban facilities are 
projected to experience no change in payments for FY 2006.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects in 42 CFR Part 412

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

0
For the reasons set forth in the preamble, CMS amends 42 CFR chapter IV 
part 412 as set forth below:

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

0
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).


0
2. Section 412.25 is amended by revising paragraph (a), introductory 
text, to read as follows:


Sec.  412.25  Excluded hospital units: Common requirements.

    (a) Basis for exclusion. In order to be excluded from the 
prospective payment systems as specified in Sec.  412.1(a)(1) and be 
paid under the inpatient psychiatric facility prospective payment 
system as specified in Sec.  412.1(a)(2) or the inpatient 
rehabilitation facility prospective payment system as specified in 
Sec.  412.1(a)(3), a psychiatric or rehabilitation unit must meet the 
following requirements.
* * * * *

0
3. 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, 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]

0
4. Section 412.622 is amended by--
0
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''.
0
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''.

0
5. Section 412.624 is amended by--
0
A. In paragraph (d)(1), removing the cross reference to ``paragraph 
(e)(4)'' and adding in its place ``paragraph (e)(5)''.
0
B. Adding a new paragraph (d)(4).
0
C. Revising paragraphs (e)(4) and (e)(5).
0
D. Adding new paragraphs (e)(6) and (e)(7).
0
E. 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)(2), (e)(3), (e)(4), and (e)(7) 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 applicable 
Federal fiscal years. CMS adjusts the standard payment conversion 
factor based on any updates to the adjustments specified in paragraph 
(e)(2), (e)(3), (e)(4) and (e)(7), of this section, and to any revision 
specified in Sec.  412.620(c) by a factor as specified by the 
Secretary.
    (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

[[Page 47953]]

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.
    (7) Adjustments for certain facilities geographically redesignated 
in FY 2006.
    (i) General. For a facility defined as an urban facility under 
Sec.  412.602 in FY 2006 that was previously defined as a rural 
facility in FY 2005 as the term rural was defined in FY 2005 under 
Sec.  412.602 and whose payment, after applying the adjustment under 
this paragraph, will be lower only because of being defined as an urban 
facility in FY 2006 and it no longer qualified for the rural adjustment 
under Sec.  412.624(e)(3) in FY 2006, CMS will adjust the facility's 
payment using the following method:
    (A) For discharges occurring on or after October 1, 2005, and on or 
before September 30, 2006, the facility's payment will be increased by 
an adjustment of two thirds of its prior FY 2005 19.14 percent rural 
adjustment.
    (B) For discharges occurring on or after October 1, 2006, and on or 
before September 30, 2007, the facility's payment will be increased by 
an adjustment of one third of its FY 2005 19.14 percent rural 
adjustment.
    (ii) Exception. For discharges occurring on or after October 1, 
2005 and on or before September 30, 2007, facilities whose payments, 
after applying the adjustment under this paragraph (e)(7)(i) of this 
section, will be higher because of being defined as an urban facility 
in FY 2006 and no longer being qualified for the rural adjustment under 
Sec.  412.624(e)(3) in FY 2006, CMS will adjust the facility's payment 
by a portion of the applicable additional adjustment described in 
paragraph (e)(7)(i)(A) and (e)(7)(i)(B) of this section as determined 
by us.
* * * * *

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: July 26, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
    Approved: July 27, 2005.
Michael O. Leavitt,
Secretary.

    The following addendum will not appear in the Code of Federal 
Regulations.

[[Page 47954]]



                              Table 1.--FY 2006 IRF PPS Transition Wage Index Table
           [For discharges occurring on or after October 1, 2005 and on or before September 30, 2006]
----------------------------------------------------------------------------------------------------------------
                                                                         2006                 CBSA    Transition
  SSA state/         County name        MSA No.  MSA urban/  2006 MSA-   CBSA-   CBSA No.    urban/   wage index
  county code                                       rural    based WI  based WI              rural         *
----------------------------------------------------------------------------------------------------------------
01000.........  Autauga County,            5240  Urban         0.8300    0.8300     33860  Urban         0.8300
                 Alabama.
01010.........  Baldwin County,            5160  Urban         0.7932    0.7628     99901  Rural         0.7780
                 Alabama.
01020.........  Barbour County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01030.........  Bibb County, Alabama.        01  Rural         0.7637    0.9157     13820  Urban         0.8397
01040.........  Blount County,             1000  Urban         0.9198    0.9157     13820  Urban         0.9178
                 Alabama.
01050.........  Bullock County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01060.........  Butler County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01070.........  Calhoun County,            0450  Urban         0.7881    0.7881     11500  Urban         0.7881
                 Alabama.
01080.........  Chambers County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01090.........  Cherokee County,             01  Rural         0.7637     .7628     99901  Rural         0.7633
                 Alabama.
01100.........  Chilton County,              01  Rural         0.7637    0.9157     13820  Urban         0.8397
                 Alabama.
01110.........  Choctaw County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01120.........  Clarke County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01130.........  Clay County, Alabama.        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01140.........  Cleburne County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01150.........  Coffee County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01160.........  Colbert County,            2650  Urban         0.7883    0.7883     22520  Urban         0.7883
                 Alabama.
01170.........  Conecuh County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01180.........  Coosa County, Alabama        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01190.........  Covington County,            01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01200.........  Crenshaw County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01210.........  Cullman County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01220.........  Dale County, Alabama.      2180  Urban         0.7596    0.7628     99901  Rural         0.7612
01230.........  Dallas County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01240.........  De Kalb County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01250.........  Elmore County,             5240  Urban         0.8300    0.8300     33860  Urban         0.8300
                 Alabama.
01260.........  Escambia County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01270.........  Etowah County,             2880  Urban         0.8049    0.8049     23460  Urban         0.8049
                 Alabama.
01280.........  Fayette County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01290.........  Franklin County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01300.........  Geneva County,               01  Rural         0.7637    0.7537     20020  Urban         0.7587
                 Alabama.
01310.........  Greene County,               01  Rural         0.7637    0.8336     46220  Urban         0.7987
                 Alabama.
01320.........  Hale County, Alabama.        01  Rural         0.7637    0.8336     46220  Urban         0.7987
01330.........  Henry County, Alabama        01  Rural         0.7637    0.7537     20020  Urban         0.7587
01340.........  Houston County,            2180  Urban         0.7596    0.7537     20020  Urban         0.7567
                 Alabama.
01350.........  Jackson County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01360.........  Jefferson County,          1000  Urban         0.9198    0.9157     13820  Urban         0.9178
                 Alabama.
01370.........  Lamar County, Alabama        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01380.........  Lauderdale County,         2650  Urban         0.7883    0.7883     22520  Urban         0.7883
                 Alabama.
01390.........  Lawrence County,          21030  Urban         0.8894    0.8894     19460  Urban         0.8894
                 Alabama.
01400.........  Lee County, Alabama..      0580  Urban         0.8215    0.8215     12220  Urban         0.8215
01410.........  Limestone County,          3440  Urban         0.8851    0.8851     26620  Urban         0.8851
                 Alabama.
01420.........  Lowndes County,              01  Rural         0.7637    0.8300     33860  Urban         0.7969
                 Alabama.
01430.........  Macon County, Alabama        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01440.........  Madison County,            3440  Urban         0.8851    0.8851     26620  Urban         0.8851
                 Alabama.
01450.........  Marengo County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01460.........  Marion County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01470.........  Marshall County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01480.........  Mobile County,             5160  Urban         0.7932    0.7995     33660  Urban         0.7964
                 Alabama.
01490.........  Monroe County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01500.........  Montgomery County,         5240  Urban         0.8300    0.8300     33860  Urban         0.8300
                 Alabama.
01510.........  Morgan County,             2030  Urban         0.8894    0.8894     19460  Urban         0.8894
                 Alabama.
01520.........  Perry County, Alabama        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01530.........  Pickens County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01540.........  Pike County, Alabama.        01  Rural         0.7637    0.7628     99901  Rural         0.7633
01550.........  Randolph County,             01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01560.........  Russell County,            1800  Urban         0.8690    0.8690     17980  Urban         0.8690
                 Alabama.
01570.........  St Clair County,           1000  Urban         0.9198    0.9157     13820  Urban         0.9178
                 Alabama.
01580.........  Shelby County,             1000  Urban         0.9198    0.9157     13820  Urban         0.9178
                 Alabama.
01590.........  Sumter County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01600.........  Talladega County,            01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01610.........  Tallapoosa County,           01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01620.........  Tuscaloosa County,         8600  Urban         0.8440    0.8336     46220  Urban         0.8388
                 Alabama.
01630.........  Walker County,               01  Rural         0.7637    0.9157     13820  Urban         0.8397
                 Alabama.
01640.........  Washington County,           01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01650.........  Wilcox County,               01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
01660.........  Winston County,              01  Rural         0.7637    0.7628     99901  Rural         0.7633
                 Alabama.
02013.........  Aleutians County             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 East, Alaska.

[[Page 47955]]

 
02016.........  Aleutians County             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 West, Alaska.
02020.........  Anchorage County,          0380  Urban         1.2109    1.2165     11260  Urban         1.2137
                 Alaska.
02030.........  Angoon County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02040.........  Barrow-North Slope           02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02050.........  Bethel County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02060.........  Bristol Bay Borough          02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02068.........  Denali County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02070.........  Bristol Bay County,          02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02080.........  Cordova-Mc Carthy            02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02090.........  Fairbanks County,            02  Rural         1.1637    1.1146     21820  Urban         1.1392
                 Alaska.
02100.........  Haines County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02110.........  Juneau County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02120.........  Kenai-Cook Inlet             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02122.........  Kenai Peninsula              02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Borough, Alaska.
02130.........  Ketchikan County,            02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02140.........  Kobuk County, Alaska.        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02150.........  Kodiak County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02160.........  Kuskokwin County,            02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02164.........  Lake and Peninsula           02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Borough, Alaska.
02170.........  Matanuska County,            02  Rural         1.1637    1.2165     11260  Urban         1.1901
                 Alaska.
02180.........  Nome County, Alaska..        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02185.........  North Slope Borough,         02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02188.........  Northwest Arctic             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Borough, Alaska.
02190.........  Outer Ketchikan              02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02200.........  Prince Of Wales              02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02201.........  Prince of Wales-Outer        02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Ketchikan Census
                 Area, Alaska.
02210.........  Seward County, Alaska        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02220.........  Sitka County, Alaska.        02  Rural         1.1637    1.1746     99902  Rural         1.1692
02230.........  Skagway-Yakutat              02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02231.........  Skagway-Yakutat-             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Angoon Census Area,
                 Alaska.
02232.........  Skagway-Hoonah-Angoon        02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Census Area, Alaska.
02240.........  Southeast Fairbanks          02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02250.........  Upper Yukon County,          02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02260.........  Valdz-Chitna-Whitier         02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02261.........  Valdex-Cordove Census        02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Area, Alaska.
02270.........  Wade Hampton County,         02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02280.........  Wrangell-Petersburg          02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 County, Alaska.
02282.........  Yakutat Borough,             02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
02290.........  Yukon-Koyukuk County,        02  Rural         1.1637    1.1746     99902  Rural         1.1692
                 Alaska.
03000.........  Apache County,               03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03010.........  Cochise County,              03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03020.........  Coconino County,           2620  Urban         1.0611    1.0787     22380  Urban         1.0699
                 Arizona.
03030.........  Gila County, Arizona.        03  Rural         0.9140    0.8936     99903  Rural         0.9038
03040.........  Graham County,               03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03050.........  Greenlee County,             03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03055.........  La Paz County,               03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03060.........  Maricopa County,           6200  Urban         0.9982    0.9982     38060  Urban         0.9982
                 Arizona.
03070.........  Mohave County,             4120  Urban         1.1121    0.8936     99903  Rural         1.0029
                 Arizona.
03080.........  Navajo County,               03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03090.........  Pima County, Arizona.      8520  Urban         0.8926    0.8926     46060  Urban         0.8926
03100.........  Pinal County, Arizona      6200  Urban         0.9982    0.9982     38060  Urban         0.9982
03110.........  Santa Cruz County,           03  Rural         0.9140    0.8936     99903  Rural         0.9038
                 Arizona.
03120.........  Yavapai County,              03  Rural         0.9140    0.9892     39140  Urban         0.9516
                 Arizona.
03130.........  Yuma County, Arizona.      9360  Urban         0.8871    0.8871     49740  Urban         0.8871
04000.........  Arkansas County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04010.........  Ashley County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04020.........  Baxter County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04030.........  Benton County,             2580  Urban         0.8636    0.8636     22220  Urban         0.8636
                 Arkansas.
04040.........  Boone County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04050.........  Bradley County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04060.........  Calhoun County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04070.........  Carroll County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04080.........  Chicot County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04090.........  Clark County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04100.........  Clay County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04110.........  Cleburne County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04120.........  Cleveland County,            04  Rural         0.7703    0.8673     38220  Urban         0.8188
                 Arkansas.
04130.........  Columbia County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.

[[Page 47956]]

 
04140.........  Conway County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04150.........  Craighead County,          3700  Urban         0.8144    0.8144     27860  Urban         0.8144
                 Arkansas.
04160.........  Crawford County,           2720  Urban         0.8303    0.8283     22900  Urban         0.8293
                 Arkansas.
04170.........  Crittenden County,         4920  Urban         0.9234    0.9217     32820  Urban         0.9226
                 Arkansas.
04180.........  Cross County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04190.........  Dallas County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04200.........  Desha County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04210.........  Drew County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04220.........  Faulkner County,           4400  Urban         0.8826    0.8826     30780  Urban         0.8826
                 Arkansas.
04230.........  Franklin County,             04  Rural         0.7703    0.8283     22900  Urban         0.7993
                 Arkansas.
04240.........  Fulton County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04250.........  Garland County,              04  Rural         0.7703    0.9249     26300  Urban         0.8476
                 Arkansas.
04260.........  Grant County,                04  Rural         0.7703    0.8826     30780  Urban         0.8265
                 Arkansas.
04270.........  Greene County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04280.........  Hempstead County,            04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04290.........  Hot Spring County,           04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04300.........  Howard County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04310.........  Independence County,         04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04320.........  Izard County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04330.........  Jackson County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04340.........  Jefferson County,          6240  Urban         0.8673    0.8673     38220  Urban         0.8673
                 Arkansas.
04350.........  Johnson County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04360.........  Lafayette County,            04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04370.........  Lawrence County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04380.........  Lee County, Arkansas.        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04390.........  Lincoln County,              04  Rural         0.7703    0.8673     38220  Urban         0.8188
                 Arkansas.
04400.........  Little River County,         04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04410.........  Logan County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04420.........  Lonoke County,             4400  Urban         0.8826    0.8826     30780  Urban         0.8826
                 Arkansas.
04430.........  Madison County,              04  Rural         0.7703    0.8636     22220  Urban         0.8170
                 Arkansas.
04440.........  Marion County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04450.........  Miller County,             8360  Urban         0.8413    0.8413     45500  Urban         0.8413
                 Arkansas.
04460.........  Mississippi County,          04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04470.........  Monroe County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04480.........  Montgomery County,           04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04490.........  Nevada County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04500.........  Newton County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04510.........  Ouachita County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04520.........  Perry County,                04  Rural         0.7703    0.8826     30780  Urban         0.8265
                 Arkansas.
04530.........  Phillips County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04540.........  Pike County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04550.........  Poinsett County,             04  Rural         0.7703    0.8144     27860  Urban         0.7924
                 Arkansas.
04560.........  Polk County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04570.........  Pope County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
04580.........  Prairie County,              04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04590.........  Pulaski County,            4400  Urban         0.8826    0.8826     30780  Urban         0.8826
                 Arkansas.
04600.........  Randolph County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04610.........  St Francis County,           04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04620.........  Saline County,             4400  Urban         0.8826    0.8826     30780  Urban         0.8826
                 Arkansas.
04630.........  Scott County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04640.........  Searcy County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04650.........  Sebastian County,          2720  Urban         0.8303    0.8283     22900  Urban         0.8293
                 Arkansas.
04660.........  Sevier County,               04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04670.........  Sharp County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04680.........  Stone County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04690.........  Union County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04700.........  Van Buren County,            04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04710.........  Washington County,         2580  Urban         0.8636    0.8636     22220  Urban         0.8636
                 Arkansas.
04720.........  White County,                04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04730.........  Woodruff County,             04  Rural         0.7703    0.7406     99904  Rural         0.7555
                 Arkansas.
04740.........  Yell County, Arkansas        04  Rural         0.7703    0.7406     99904  Rural         0.7555
05000.........  Alameda County,            5775  Urban         1.5220    1.5220     36084  Urban         1.5220
                 California.
05010.........  Alpine County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05020.........  Amador County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05030.........  Butte County,              1620  Urban         1.0542    1.0542     17020  Urban         1.0542
                 California.
05040.........  Calaveras County,            05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05050.........  Colusa County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05060.........  Contra Costa County,       5775  Urban         1.5220    1.5220     36084  Urban         1.5220
                 California.

[[Page 47957]]

 
05070.........  Del Norte County,            05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05080.........  Eldorado County,           6920  Urban         1.1848    1.1700     40900  Urban         1.1774
                 California.
05090.........  Fresno County,             2840  Urban         1.0407    1.0536     23420  Urban         1.0472
                 California.
05100.........  Glenn County,                05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05110.........  Humboldt County,             05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05120.........  Imperial County,             05  Rural         1.0297    0.8856     20940  Urban         0.9577
                 California.
05130.........  Inyo County,                 05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05140.........  Kern County,               0680  Urban         1.0036    1.0036     12540  Urban         1.0036
                 California.
05150.........  Kings County,                05  Rural         1.0297    0.9296     25260  Urban         0.9797
                 California.
05160.........  Lake County,                 05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05170.........  Lassen County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05200.........  Los Angeles County,        4480  Urban         1.1732    1.1732     31084  Urban         1.1732
                 California.
05210.........  Los Angeles County,        4480  Urban         1.1732    1.1732     31084  Urban         1.1732
                 California.
05300.........  Madera County,             2840  Urban         1.0407    0.8521     31460  Urban         0.9464
                 California.
05310.........  Marin County,              7360  Urban         1.4712    1.4712     41884  Urban         1.4712
                 California.
05320.........  Mariposa County,             05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05330.........  Mendocino County,            05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05340.........  Merced County,             4940  Urban         1.0575    1.0575     32900  Urban         1.0575
                 California.
05350.........  Modoc County,                05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05360.........  Mono County,                 05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05370.........  Monterey County,           7120  Urban         1.3823    1.3823     41500  Urban         1.3823
                 California.
05380.........  Napa County,               8720  Urban         1.3517    1.2531     34900  Urban         1.3024
                 California.
05390.........  Nevada County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05400.........  Orange County,             5945  Urban         1.1611    1.1611     42044  Urban         1.1611
                 California.
05410.........  Placer County,             6920  Urban         1.1848    1.1700     40900  Urban         1.1774
                 California.
05420.........  Plumas County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05430.........  Riverside County,          6780  Urban         1.0970    1.0970     40140  Urban         1.0970
                 California.
05440.........  Sacramento County,         6920  Urban         1.1848    1.1700     40900  Urban         1.1774
                 California.
05450.........  San Benito County,           05  Rural         1.0297    1.4722     41940  Urban         1.2510
                 California.
05460.........  San Bernardino             6780  Urban         1.0970    1.0970     40140  Urban         1.0970
                 County, California.
05470.........  San Diego County,          7320  Urban         1.1267    1.1267     41740  Urban         1.1267
                 California.
05480.........  San Francisco County,      7360  Urban         1.4712    1.4712     41884  Urban         1.4712
                 California.
05490.........  San Joaquin County,        8120  Urban         1.0564    1.0564     44700  Urban         1.0564
                 California.
05500.........  San Luis Obispo            7460  Urban         1.1118    1.1118     42020  Urban         1.1118
                 County, California.
05510.........  San Mateo County,          7360  Urban         1.4712    1.4712     41884  Urban         1.4712
                 California.
05520.........  Santa Barbara County,      7480  Urban         1.0771    1.0771     42060  Urban         1.0771
                 California.
05530.........  Santa Clara County,        7400  Urban         1.4744    1.4722     41940  Urban         1.4733
                 California.
05540.........  Santa Cruz County,         7485  Urban         1.4779    1.4779     42100  Urban         1.4779
                 California.
05550.........  Shasta County,             6690  Urban         1.1835    1.1835     39820  Urban         1.1835
                 California.
05560.........  Sierra County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05570.........  Siskiyou County,             05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05580.........  Solano County,             8720  Urban         1.3517    1.4279     46700  Urban         1.3898
                 California.
05590.........  Sonoma County,             7500  Urban         1.2961    1.2961     42220  Urban         1.2961
                 California.
05600.........  Stanislaus County,         5170  Urban         1.1966    1.1966     33700  Urban         1.1966
                 California.
05610.........  Sutter County,             9340  Urban         1.0363    1.0363     49700  Urban         1.0363
                 California.
05620.........  Tehama County,               05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05630.........  Trinity County,              05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05640.........  Tulare County,             8780  Urban         0.9975    0.9975     47300  Urban         0.9975
                 California.
05650.........  Tuolumne County,             05  Rural         1.0297    1.0524     99905  Rural         1.0411
                 California.
05660.........  Ventura County,            8735  Urban         1.1105    1.1105     37100  Urban         1.1105
                 California.
05670.........  Yolo County,               9270  Urban         0.9378    1.1700     40900  Urban         1.0539
                 California.
05680.........  Yuba County,               9340  Urban         1.0363    1.0363     49700  Urban         1.0363
                 California.
06000.........  Adams County,              2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.
06010.........  Alamosa County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06020.........  Arapahoe County,           2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.
06030.........  Archuleta County,            06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06040.........  Baca County, Colorado        06  Rural         0.9368    0.9368     99906  Rural         0.9368
06050.........  Bent County, Colorado        06  Rural         0.9368    0.9368     99906  Rural         0.9368
06060.........  Boulder County,            1125  Urban         1.0046    1.0046     14500  Urban         1.0046
                 Colorado.
06070.........  Chaffee County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06080.........  Cheyenne County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06090.........  Clear Creek County,          06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06100.........  Conejos County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06110.........  Costilla County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06120.........  Crowley County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06130.........  Custer County,               06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06140.........  Delta County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06150.........  Denver County,             2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.

[[Page 47958]]

 
06160.........  Dolores County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06170.........  Douglas County,            2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.
06180.........  Eagle County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06190.........  Elbert County,               06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06200.........  El Paso County,            1720  Urban         0.9792    0.9792     17820  Urban         0.9792
                 Colorado.
06210.........  Fremont County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06220.........  Garfield County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06230.........  Gilpin County,               06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06240.........  Grand County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06250.........  Gunnison County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06260.........  Hinsdale County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06270.........  Huerfano County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06280.........  Jackson County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06290.........  Jefferson County,          2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.
06300.........  Kiowa County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06310.........  Kit Carson County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06320.........  Lake County, Colorado        06  Rural         0.9368    0.9368     99906  Rural         0.9368
06330.........  La Plata County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06340.........  Larimer County,            2670  Urban         1.0218    1.0218     22660  Urban         1.0218
                 Colorado.
06350.........  Las Animas County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06360.........  Lincoln County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06370.........  Logan County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06380.........  Mesa County, Colorado      2995  Urban         0.9900    0.9900     24300  Urban         0.9900
06390.........  Mineral County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06400.........  Moffat County,               06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06410.........  Montezuma County,            06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06420.........  Montrose County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06430.........  Morgan County,               06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06440.........  Otero County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06450.........  Ouray County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06460.........  Park County, Colorado        06  Rural         0.9368    1.0904     19740  Urban         1.0136
06470.........  Phillips County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06480.........  Pitkin County,               06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06490.........  Prowers County,              06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06500.........  Pueblo County,             6560  Urban         0.8752    0.8752     39380  Urban         0.8752
                 Colorado.
06510.........  Rio Blanco County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06520.........  Rio Grande County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06530.........  Routt County,                06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06540.........  Saguache County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06550.........  San Juan County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06560.........  San Miguel County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06570.........  Sedgwick County,             06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06580.........  Summit County,               06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06590.........  Teller County,               06  Rural         0.9368    0.9792     17820  Urban         0.9580
                 Colorado.
06600.........  Washington County,           06  Rural         0.9368    0.9368     99906  Rural         0.9368
                 Colorado.
06610.........  Weld County, Colorado      3060  Urban         0.9444    0.9444     24540  Urban         0.9444
06620.........  Yuma County, Colorado        06  Rural         0.9368    0.9368     99906  Rural         0.9368
06630.........  Broomfield County,         2080  Urban         1.0904    1.0904     19740  Urban         1.0904
                 Colorado.
07000.........  Fairfield County,          5483  Urban         1.2254    1.2835     14860  Urban         1.2545
                 Connecticut.
07010.........  Hartford County,           3283  Urban         1.1054    1.1054     25540  Urban         1.1054
                 Connecticut.
07020.........  Litchfield County,         3283  Urban         1.1054    1.1054     25540  Urban         1.1054
                 Connecticut.
07030.........  Middlesex County,          3283  Urban         1.1054    1.1054     25540  Urban         1.1054
                 Connecticut.
07040.........  New Haven County,          5483  Urban         1.2254    1.1807     35300  Urban         1.2031
                 Connecticut.
07050.........  New London County,         5523  Urban         1.1596    1.1596     35980  Urban         1.1596
                 Connecticut.
07060.........  Tolland County,            3283  Urban         1.1054    1.1054     25540  Urban         1.1054
                 Connecticut.
07070.........  Windham County,              07  Rural         1.1917    1.1917     99907  Rural         1.1917
                 Connecticut.
08000.........  Kent County, Delaware      2190  Urban         0.9825    0.9825     20100  Urban         0.9825
08010.........  New Castle County,         9160  Urban         1.1121    1.1049     48864  Urban         1.1085
                 Delaware.
08020.........  Sussex County,               08  Rural         0.9503    0.9503     99908  Rural         0.9503
                 Delaware.
09000.........  Washington Dc County,      8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Dist Of Col.
10000.........  Alachua County,            2900  Urban         0.9459    0.9459     23540  Urban         0.9459
                 Florida.
01010.........  Baker County, Florida        10  Rural         0.8721    0.9537     27260  Urban         0.9129
10020.........  Bay County, Florida..      6015  Urban         0.8124    0.8124     37460  Urban         0.8124
10030.........  Bradford County,             10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10040.........  Brevard County,            4900  Urban         0.9633    0.9633     37340  Urban         0.9633
                 Florida.
10050.........  Broward County,            2680  Urban         1.0165    1.0165     22744  Urban         1.0165
                 Florida.
10060.........  Calhoun County,              10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10070.........  Charlotte County,          6580  Urban         0.9441    0.9441     39460  Urban         0.9441
                 Florida.

[[Page 47959]]

 
10080.........  Citrus County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10090.........  Clay County, Florida.      3600  Urban         0.9548    0.9537     27260  Urban         0.9543
10100.........  Collier County,            5345  Urban         1.0558    1.0558     34940  Urban         1.0558
                 Florida.
10110.........  Columbia County,             10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10120.........  Dade County, Florida.      5000  Urban         0.9870    0.9870     33124  Urban         0.9870
10130.........  De Soto County,              10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10140.........  Dixie County, Florida        10  Rural         0.8721    0.8574     99910  Rural         0.8648
10150.........  Duval County, Florida      3600  Urban         0.9548    0.9537     27260  Urban         0.9543
10160.........  Escambia County,           6080  Urban         0.8306    0.8306     37860  Urban         0.8306
                 Florida.
10170.........  Flagler County,            2020  Urban         0.8900    0.8574     99910  Rural         0.8737
                 Florida.
10180.........  Franklin County,             10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10190.........  Gadsden County,            8240  Urban         0.8655    0.8655     45220  Urban         0.8655
                 Florida.
10200.........  Gilchrist County,            10  Rural         0.8721    0.9459     23540  Urban         0.9090
                 Florida.
10210.........  Glades County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10220.........  Gulf County, Florida.        10  Rural         0.8721    0.8574     99910  Rural         0.8648
10230.........  Hamilton County,             10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10240.........  Hardee County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10250.........  Hendry County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10260.........  Hernando County,           8280  Urban         0.9024    0.9024     45300  Urban         0.9024
                 Florida.
10270.........  Highlands County,            10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10280.........  Hillsborough County,       8280  Urban         0.9024    0.9024     45300  Urban         0.9024
                 Florida.
10290.........  Holmes County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10300.........  Indian River County,         10  Rural         0.8721    0.9477     46940  Urban         0.9099
                 Florida.
10310.........  Jackson County,              10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10320.........  Jefferson County,            10  Rural         0.8721    0.8655     45220  Urban         0.8688
                 Florida.
10330.........  Lafayette County,            10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10340.........  Lake County, Florida.      5960  Urban         0.9742    0.9742     36740  Urban         0.9742
10350.........  Lee County, Florida..      2700  Urban         0.9371    0.9371     15980  Urban         0.9371
10360.........  Leon County, Florida.      8240  Urban         0.8655    0.8655     45220  Urban         0.8655
10370.........  Levy County, Florida.        10  Rural         0.8721    0.8574     99910  Rural         0.8648
10380.........  Liberty County,              10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10390.........  Madison County,              10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10400.........  Manatee County,            7510  Urban         0.9629    0.9629     42260  Urban         0.9629
                 Florida.
10410.........  Marion County,             5790  Urban         0.9153    0.9153     36100  Urban         0.9153
                 Florida.
10420.........  Martin County,             2710  Urban         1.0046    1.0046     38940  Urban         1.0046
                 Florida.
10430.........  Monroe County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10440.........  Nassau County,             3600  Urban         0.9548    0.9537     27260  Urban         0.9543
                 Florida.
10450.........  Okaloosa County,           2750  Urban         0.8786    0.8786     23020  Urban         0.8786
                 Florida.
10460.........  Okeechobee County,           10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10470.........  Orange County,             5960  Urban         0.9742    0.9742     36740  Urban         0.9742
                 Florida.
10480.........  Osceola County,            5960  Urban         0.9742    0.9742     36740  Urban         0.9742
                 Florida.
10490.........  Palm Beach County,         8960  Urban         1.0362    1.0362     48424  Urban         1.0362
                 Florida.
10500.........  Pasco County, Florida      8280  Urban         0.9024    0.9024     45300  Urban         0.9024
10510.........  Pinellas County,           8280  Urban         0.9024    0.9024     45300  Urban         0.9024
                 Florida.
10520.........  Polk County, Florida.      3980  Urban         0.8930    0.8930     29460  Urban         0.8930
10530.........  Putnam County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10540.........  Johns County, Florida      3600  Urban         0.9548    0.9537     27260  Urban         0.9543
10550.........  St Lucie County,           2710  Urban         1.0046    1.0046     38940  Urban         1.0046
                 Florida.
10560.........  Santa Rosa County,         6080  Urban         0.8306    0.8306     37860  Urban         0.8306
                 Florida.
10570.........  Sarasota County,           7510  Urban         0.9629    0.9629     42260  Urban         0.9629
                 Florida.
10580.........  Seminole County,           5960  Urban         0.9742    0.9742     36740  Urban         0.9742
                 Florida.
10590.........  Sumter County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10600.........  Suwannee County,             10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10610.........  Taylor County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10620.........  Union County, Florida        10  Rural         0.8721    0.8574     99910  Rural         0.8648
10630.........  Volusia County,            2020  Urban         0.8900    0.8898     19660  Urban         0.8899
                 Florida.
10640.........  Wakulla County,              10  Rural         0.8721    0.8655     45220  Urban         0.8688
                 Florida.
10650.........  Walton County,               10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
10660.........  Washington County,           10  Rural         0.8721    0.8574     99910  Rural         0.8648
                 Florida.
11000.........  Appling County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11010.........  Atkinson County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11011.........  Bacon County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11020.........  Baker County, Georgia        11  Rural         0.8247    1.1266     10500  Urban         0.9757
11030.........  Baldwin County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11040.........  Banks County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11050.........  Barrow County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11060.........  Bartow County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11070.........  Ben Hill County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.

[[Page 47960]]

 
11080.........  Berrien County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11090.........  Bibb County, Georgia.      4680  Urban         0.9596    0.9887     31420  Urban         0.9742
11100.........  Bleckley County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11110.........  Brantley County,             11  Rural         0.8247    1.1933      5260  Urban         1.0090
                 Georgia.
11120.........  Brooks County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11130.........  Bryan County, Georgia      7520  Urban         0.9460    0.9460     42340  Urban         0.9460
11140.........  Bulloch County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11150.........  Burke County, Georgia        11  Rural         0.8247    0.9154     12260  Urban         0.8701
11160.........  Butts County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11161.........  Calhoun County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11170.........  Camden County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11180.........  Candler County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11190.........  Carroll County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11200.........  Catoosa County,            1560  Urban         0.9207    0.9207     16860  Urban         0.9207
                 Georgia.
11210.........  Charlton County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11220.........  Chatham County,            7520  Urban         0.9460    0.9460     42340  Urban         0.9460
                 Georgia.
11230.........  Chattahoochee County,      1800  Urban         0.8690    0.8690     17980  Urban         0.8690
                 Georgia.
11240.........  Chattooga County,            11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11250.........  Cherokee County,           0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11260.........  Clarke County,             0500  Urban         1.0202    1.0202     12020  Urban         1.0202
                 Georgia.
11270.........  Clay County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11280.........  Clayton County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11281.........  Clinch County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11290.........  Cobb County, Georgia.      0520  Urban         0.9971    0.9971     12060  Urban         0.9971
11291.........  Coffee County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11300.........  Colquitt County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11310.........  Columbia County,           0600  Urban         0.9208    0.9154     12260  Urban         0.9181
                 Georgia.
11311.........  Cook County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11320.........  Coweta County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11330.........  Crawford County,             11  Rural         0.8247    0.9887     31420  Urban         0.9067
                 Georgia.
11340.........  Crisp County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11341.........  Dade County, Georgia.      1560  Urban         0.9207    0.9207     16860  Urban         0.9207
11350.........  Dawson County,               11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11360.........  Decatur County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11370.........  De Kalb County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11380.........  Dodge County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11381.........  Dooly County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11390.........  Dougherty County,          0120  Urban         1.1266    1.1266     10500  Urban         1.1266
                 Georgia.
11400.........  Douglas County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11410.........  Early County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11420.........  Echols County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11421.........  Effingham County,          7520  Urban         0.9460    0.9460     42340  Urban         0.9460
                 Georgia.
11430.........  Elbert County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11440.........  Emanuel County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11441.........  Evans County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11450.........  Fannin County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11451.........  Fayette County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11460.........  Floyd County, Georgia        11  Rural         0.8247    0.8878     40660  Urban         0.8563
11461.........  Forsyth County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11462.........  Franklin County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11470.........  Fulton County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11471.........  Gilmer County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11480.........  Glascock County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11490.........  Glynn County, Georgia        11  Rural         0.8247    1.1933     15260  Urban         1.0090
11500.........  Gordon County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11510.........  Grady County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11520.........  Greene County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11530.........  Gwinnett County,           0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11540.........  Habersham County,            11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11550.........  Hall County, Georgia.        11  Rural         0.8247    0.9557     23580  Urban         0.8902
11560.........  Hancock County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11570.........  Haralson County,             11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11580.........  Harris County,             1800  Urban         0.8690    0.8690     17980  Urban         0.8690
                 Georgia.
11581.........  Hart County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11590.........  Heard County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11591.........  Henry County, Georgia      0520  Urban         0.9971    0.9971     12060  Urban         0.9971
11600.........  Houston County,            4680  Urban         0.9596    0.8489     47580  Urban         0.9043
                 Georgia.
11601.........  Irwin County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990

[[Page 47961]]

 
11610.........  Jackson County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11611.........  Jasper County,               11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11612.........  Jeff Davis County,           11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11620.........  Jefferson County,            11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11630.........  Jenkins County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11640.........  Johnson County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11650.........  Jones County, Georgia      4680  Urban         0.9596    0.9887     31420  Urban         0.9742
11651.........  Lamar County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11652.........  Lanier County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11660.........  Laurens County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11670.........  Lee County, Georgia..      0120  Urban         1.1266    1.1266     10500  Urban         1.1266
11680.........  Liberty County,              11  Rural         0.8247    0.7715     25980  Urban         0.7981
                 Georgia.
11690.........  Lincoln County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11691.........  Long County, Georgia.        11  Rural         0.8247    0.7715     25980  Urban         0.7981
11700.........  Lowndes County,              11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11701.........  Lumpkin County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11702.........  Mc Duffie County,          0600  Urban         0.9208    0.9154     12260  Urban         0.9181
                 Georgia.
11703.........  Mc Intosh County,            11  Rural         0.8247    1.1933      5260  Urban         1.0090
                 Georgia.
11710.........  Macon County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11720.........  Madison County,            0500  Urban         1.0202    1.0202     12020  Urban         1.0202
                 Georgia.
11730.........  Marion County,               11  Rural         0.8247    0.8690     17980  Urban         0.8469
                 Georgia.
11740.........  Meriwether County,           11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11741.........  Miller County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11750.........  Mitchell County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11760.........  Monroe County,               11  Rural         0.8247    0.9887     31420  Urban         0.9067
                 Georgia.
11770.........  Montgomery County,           11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11771.........  Morgan County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11772.........  Murray County,               11  Rural         0.8247    0.9558     19140  Urban         0.8903
                 Georgia.
11780.........  Muscogee County,           1800  Urban         0.8690    0.8690     17980  Urban         0.8690
                 Georgia.
11790.........  Newton County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11800.........  Oconee County,             0500  Urban         1.0202    1.0202     12020  Urban         1.0202
                 Georgia.
11801.........  Oglethorpe County,           11  Rural         0.8247    1.0202     12020  Urban         0.9225
                 Georgia.
11810.........  Paulding County,           0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11811.........  Peach County, Georgia      4680  Urban         0.9596    0.7733     99911  Rural         0.8665
11812.........  Pickens County,            0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11820.........  Pierce County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11821.........  Pike County, Georgia.        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11830.........  Polk County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11831.........  Pulaski County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11832.........  Putnam County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11833.........  Quitman County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11834.........  Rabun County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11835.........  Randolph County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11840.........  Richmond County,           0600  Urban         0.9208    0.9154     12260  Urban         0.9181
                 Georgia.
11841.........  Rockdale County,           0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11842.........  Schley County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11850.........  Screven County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11851.........  Seminole County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11860.........  Spalding County,           0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11861.........  Stephens County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11862.........  Stewart County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11870.........  Sumter County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11880.........  Talbot County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11881.........  Taliaferro County,           11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11882.........  Tattnall County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11883.........  Taylor County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11884.........  Telfair County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11885.........  Terrell County,              11  Rural         0.8247    1.1266     10500  Urban         0.9757
                 Georgia.
11890.........  Thomas County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11900.........  Tift County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11901.........  Toombs County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11902.........  Towns County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11903.........  Treutlen County,             11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11910.........  Troup County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11911.........  Turner County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11912.........  Twiggs County,             4680  Urban         0.9596    0.9887     31420  Urban         0.9742
                 Georgia.
11913.........  Union County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11920.........  Upson County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990

[[Page 47962]]

 
11921.........  Walker County,             1560  Urban         0.9207    0.9207     16860  Urban         0.9207
                 Georgia.
11930.........  Walton County,             0520  Urban         0.9971    0.9971     12060  Urban         0.9971
                 Georgia.
11940.........  Ware County, Georgia.        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11941.........  Warren County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11950.........  Washington County,           11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11960.........  Wayne County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11961.........  Webster County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11962.........  Wheeler County,              11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11963.........  White County, Georgia        11  Rural         0.8247    0.7733     99911  Rural         0.7990
11970.........  Whitfield County,            11  Rural         0.8247    0.9558     19140  Urban         0.8903
                 Georgia.
11971.........  Wilcox County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11972.........  Wilkes County,               11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11973.........  Wilkinson County,            11  Rural         0.8247    0.7733     99911  Rural         0.7990
                 Georgia.
11980.........  Worth County, Georgia        11  Rural         0.8247    1.1266     10500  Urban         0.9757
12005.........  Kalawao County,              12  Rural         1.0522    1.0522     99912  Rural         1.0522
                 Hawaii.
12010.........  Hawaii County, Hawaii        12  Rural         1.0522    1.0522     99912  Rural         1.0522
12020.........  Honolulu County,           3320  Urban         1.1013    1.1013     26180  Urban         1.1013
                 Hawaii.
12040.........  Kauai County, Hawaii.        12  Rural         1.0522    1.0522     99912  Rural         1.0522
12050.........  Maui County, Hawaii..        12  Rural         1.0522    1.0522     99912  Rural         1.0522
13000.........  Ada County, Idaho....      1080  Urban         0.9352    0.9352     14260  Urban         0.9352
13010.........  Adams County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13020.........  Bannock County, Idaho      6340  Urban         0.9601    0.9601     38540  Urban         0.9601
13030.........  Bear Lake County,            13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13040.........  Benewah County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13050.........  Bingham County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13060.........  Blaine County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13070.........  Boise County, Idaho..        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13080.........  Bonner County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13090.........  Bonneville County,           13  Rural         0.8826    0.9059     26820  Urban         0.8943
                 Idaho.
13100.........  Boundary County,             13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13110.........  Butte County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13120.........  Camas County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13130.........  Canyon County, Idaho.      1080  Urban         0.9352    0.9352     14260  Urban         0.9352
13140.........  Caribou County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13150.........  Cassia County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13160.........  Clark County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13170.........  Clearwater County,           13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13180.........  Custer County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13190.........  Elmore County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13200.........  Franklin County,             13  Rural         0.8826    0.9094     30860  Urban         0.8960
                 Idaho.
13210.........  Fremont County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13220.........  Gem County, Idaho....        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13230.........  Gooding County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13240.........  Idaho County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13250.........  Jefferson County,            13  Rural         0.8826    0.9059     26820  Urban         0.8943
                 Idaho.
13260.........  Jerome County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13270.........  Kootenai County,             13  Rural         0.8826    0.9339     17660  Urban         0.9083
                 Idaho.
13280.........  Latah County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13290.........  Lemhi County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13300.........  Lewis County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13310.........  Lincoln County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13320.........  Madison County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13330.........  Minidoka County,             13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13340.........  Nez Perce County,            13  Rural         0.8826    0.9314     30300  Urban         0.9070
                 Idaho.
13350.........  Oneida County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13360.........  Owyhee County, Idaho.        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13370.........  Payette County, Idaho        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13380.........  Power County, Idaho..        13  Rural         0.8826    0.9601     38540  Urban         0.9214
13390.........  Shoshone County,             13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13400.........  Teton County, Idaho..        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13410.........  Twin Falls County,           13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
13420.........  Valley County, Idaho.        13  Rural         0.8826    0.8227     99913  Rural         0.8527
13430.........  Washington County,           13  Rural         0.8826    0.8227     99913  Rural         0.8527
                 Idaho.
14000.........  Adams County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14010.........  Alexander County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14020.........  Bond County, Illinois        14  Rural         0.8340    0.9076     41180  Urban         0.8708
14030.........  Boone County,              6880  Urban         0.9626    0.9626     40420  Urban         0.9626
                 Illinois.
14040.........  Brown County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.

[[Page 47963]]

 
14050.........  Bureau County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14060.........  Calhoun County,              14  Rural         0.8340    0.9076     41180  Urban         0.8708
                 Illinois.
14070.........  Carroll County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14080.........  Cass County, Illinois        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14090.........  Champaign County,          1400  Urban         0.9527    0.9527     16580  Urban         0.9527
                 Illinois.
14100.........  Christian County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14110.........  Clark County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14120.........  Clay County, Illinois        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14130.........  Clinton County,            7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Illinois.
14140.........  Coles County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14141.........  Cook County, Illinois      1600  Urban         1.0851    1.0868     16974  Urban         1.0860
14150.........  Crawford County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14160.........  Cumberland County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14170.........  De Kalb County,            1600  Urban         1.0851    1.0868     16974  Urban         1.0860
                 Illinois.
14180.........  De Witt County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14190.........  Douglas County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14250.........  Du Page County,            1600  Urban         1.0851    1.0868     16974  Urban         1.0860
                 Illinois.
14310.........  Edgar County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14320.........  Edwards County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14330.........  Effingham County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14340.........  Fayette County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14350.........  Ford County, Illinois        14  Rural         0.8340    0.9527     16580  Urban         0.8934
14360.........  Franklin County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14370.........  Fulton County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14380.........  Gallatin County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14390.........  Greene County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14400.........  Grundy County,             1600  Urban         1.0851    1.0868     16974  Urban         1.0860
                 Illinois.
14410.........  Hamilton County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14420.........  Hancock County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14421.........  Hardin County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14440.........  Henderson County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14450.........  Henry County,              1960  Urban         0.8773    0.8773     19340  Urban         0.8773
                 Illinois.
14460.........  Iroquois County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14470.........  Jackson County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14480.........  Jasper County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14490.........  Jefferson County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14500.........  Jersey County,             7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Illinois.
14510.........  Jo Daviess County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14520.........  Johnson County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14530.........  Kane County, Illinois      1600  Urban         1.0851    1.0868     16974  Urban         1.0860
14540.........  Kankakee County,           3740  Urban         1.0603    1.0603     28100  Urban         1.0603
                 Illinois.
14550.........  Kendall County,            1600  Urban         1.0851    1.0868     16974  Urban         1.0860
                 Illinois.
14560.........  Knox County, Illinois        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14570.........  Lake County, Illinois      1600  Urban         1.0851    1.0342     29404  Urban         1.0597
14580.........  La Salle County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14590.........  Lawrence County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14600.........  Lee County, Illinois.        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14610.........  Livingston County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14620.........  Logan County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14630.........  Mc Donough County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14640.........  Mc Henry County,           1600  Urban         1.0851    1.0868     16974  Urban         1.0860
                 Illinois.
14650.........  Mclean County,             1040  Urban         0.9111    0.9111     14060  Urban         0.9111
                 Illinois.
14660.........  Macon County,              2040  Urban         0.8122    0.8122     19500  Urban         0.8122
                 Illinois.
14670.........  Macoupin County,             14  Rural         0.8340    0.9076     41180  Urban         0.8708
                 Illinois.
14680.........  Madison County,            7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Illinois.
14690.........  Marion County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14700.........  Marshall County,             14  Rural         0.8340    0.8886     37900  Urban         0.8613
                 Illinois.
14710.........  Mason County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14720.........  Massac County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14730.........  Menard County,             7880  Urban         0.8738    0.8738     44100  Urban         0.8738
                 Illinois.
14740.........  Mercer County,               14  Rural         0.8340    0.8773     19340  Urban         0.8557
                 Illinois.
14750.........  Monroe County,             7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Illinois.
14760.........  Montgomery County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14770.........  Morgan County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14780.........  Moultrie County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14790.........  Ogle County, Illinois      6880  Urban         0.9626    0.8339     99914  Rural         0.8983
14800.........  Peoria County,             6120  Urban         0.8886    0.8886     37900  Urban         0.8886
                 Illinois.
14810.........  Perry County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.

[[Page 47964]]

 
14820.........  Piatt County,                14  Rural         0.8340    0.9527     16580  Urban         0.8934
                 Illinois.
14830.........  Pike County, Illinois        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14831.........  Pope County, Illinois        14  Rural         0.8340    0.8339     99914  Rural         0.8340
14850.........  Pulaski County,              14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14860.........  Putnam County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14870.........  Randolph County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14880.........  Richland County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14890.........  Rock Island County,        1960  Urban         0.8773    0.8773     19340  Urban         0.8773
                 Illinois.
14900.........  St Clair County,           7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Illinois.
14910.........  Saline County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14920.........  Sangamon County,           7880  Urban         0.8738    0.8738     44100  Urban         0.8738
                 Illinois.
14921.........  Schuyler County,             14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14940.........  Scott County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14950.........  Shelby County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14960.........  Stark County,                14  Rural         0.8340    0.8886     37900  Urban         0.8613
                 Illinois.
14970.........  Stephenson County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14980.........  Tazewell County,           6120  Urban         0.8886    0.8886     37900  Urban         0.8886
                 Illinois.
14981.........  Union County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14982.........  Vermilion County,            14  Rural         0.8340    0.8392     19180  Urban         0.8366
                 Illinois.
14983.........  Wabash County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14984.........  Warren County,               14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14985.........  Washington County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14986.........  Wayne County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14987.........  White County,                14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14988.........  Whiteside County,            14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14989.........  Will County, Illinois      1600  Urban         1.0851    1.0868     16974  Urban         1.0860
14990.........  Williamson County,           14  Rural         0.8340    0.8339     99914  Rural         0.8340
                 Illinois.
14991.........  Winnebago County,          6880  Urban         0.9626    0.9626     40420  Urban         0.9626
                 Illinois.
14992.........  Woodford County,           6120  Urban         0.8886    0.8886     37900  Urban         0.8886
                 Illinois.
15000.........  Adams County, Indiana      2760  Urban         0.9737    0.8653     99915  Rural         0.9195
15010.........  Allen County, Indiana      2760  Urban         0.9737    0.9807     23060  Urban         0.9772
15020.........  Bartholomew County,          15  Rural         0.8736    0.9388     18020  Urban         0.9062
                 Indiana.
15030.........  Benton County,               15  Rural         0.8736    0.9067     29140  Urban         0.8902
                 Indiana.
15040.........  Blackford County,            15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15050.........  Boone County, Indiana      3480  Urban         1.0039    1.0113     26900  Urban         1.0076
15060.........  Brown County, Indiana        15  Rural         0.8736    1.0113     26900  Urban         0.9425
15070.........  Carroll County,              15  Rural         0.8736    0.9067     29140  Urban         0.8902
                 Indiana.
15080.........  Cass County, Indiana.        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15090.........  Clark County, Indiana      4520  Urban         0.9162    0.9122     31140  Urban         0.9142
15100.........  Clay County, Indiana.      8320  Urban         0.8582    0.8517     45460  Urban         0.8550
15110.........  Clinton County,            3920  Urban         0.9067    0.8653     99915  Rural         0.8860
                 Indiana.
15120.........  Crawford County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15130.........  Daviess County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15140.........  Dearborn County,          11640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Indiana.
15150.........  Decatur County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15160.........  De Kalb County,            2760  Urban         0.9737    0.8653     99915  Rural         0.9195
                 Indiana.
15170.........  Delaware County,           5280  Urban         0.8580    0.8580     34620  Urban         0.8580
                 Indiana.
15180.........  Dubois County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15190.........  Elkhart County,            2330  Urban         0.9278    0.9278     21140  Urban         0.9278
                 Indiana.
15200.........  Fayette County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15210.........  Floyd County, Indiana      4520  Urban         0.9162    0.9122     31140  Urban         0.9142
15220.........  Fountain County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15230.........  Franklin County,             15  Rural         0.8736    0.9516     17140  Urban         0.9126
                 Indiana.
15240.........  Fulton County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15250.........  Gibson County,               15  Rural         0.8736    0.8372     21780  Urban         0.8554
                 Indiana.
15260.........  Grant County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15270.........  Greene County,               15  Rural         0.8736    0.8587     14020  Urban         0.8662
                 Indiana.
15280.........  Hamilton County,           3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15290.........  Hancock County,            3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15300.........  Harrison County,           4520  Urban         0.9162    0.9122     31140  Urban         0.9142
                 Indiana.
15310.........  Hendricks County,          3480  Urban         1.0039    1.0113   0126900  Urban         1.0076
                 Indiana.
15320.........  Henry County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15330.........  Howard County,             3850  Urban         0.8986    0.8986     29020  Urban         0.8986
                 Indiana.
15340.........  Huntington County,         2760  Urban         0.9737    0.8653     99915  Rural         0.9195
                 Indiana.
15350.........  Jackson County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15360.........  Jasper County,               15  Rural         0.8736    0.9310     23844  Urban         0.9023
                 Indiana.
15370.........  Jay County, Indiana..        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15380.........  Jefferson County,            15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.

[[Page 47965]]

 
15390.........  Jennings County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15400.........  Johnson County,            3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15410.........  Knox County, Indiana.        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15420.........  Kosciusko County,            15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15430.........  Lagrange County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15440.........  Lake County, Indiana.      2960  Urban         0.9342    0.9310     23844  Urban         0.9326
15450.........  La Porte County,             15  Rural         0.8736    0.9332     33140  Urban         0.9034
                 Indiana.
15460.........  Lawrence County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15470.........  Madison County,            3480  Urban         1.0039    0.8713     11300  Urban         0.9376
                 Indiana.
15480.........  Marion County,             3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15490.........  Marshall County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15500.........  Martin County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15510.........  Miami County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15520.........  Monroe County,             1020  Urban         0.8587    0.8587     14020  Urban         0.8587
                 Indiana.
15530.........  Montgomery County,           15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15540.........  Morgan County,             3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15550.........  Newton County,               15  Rural         0.8736    0.9310     23844  Urban         0.9023
                 Indiana.
15560.........  Noble County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15570.........  Ohio County, Indiana.      1640  Urban         0.9595    0.9516     17140  Urban         0.9556
15580.........  Orange County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15590.........  Owen County, Indiana.        15  Rural         0.8736    0.8587     14020  Urban         0.8662
15600.........  Parke County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15610.........  Perry County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15620.........  Pike County, Indiana.        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15630.........  Porter County,             2960  Urban         0.9342    0.9310     23844  Urban         0.9326
                 Indiana.
15640.........  Posey County, Indiana      2440  Urban         0.8395    0.8372     21780  Urban         0.8384
15650.........  Pulaski County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15660.........  Putnam County,               15  Rural         0.8736    1.0113     26900  Urban         0.9425
                 Indiana.
15670.........  Randolph County,             15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15680.........  Ripley County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15690.........  Rush County, Indiana.        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15700.........  St Joseph County,          7800  Urban         0.9447    0.9447     43780  Urban         0.9447
                 Indiana.
15710.........  Scott County, Indiana      4520  Urban         0.9162    0.8653     99915  Rural         0.8908
15720.........  Shelby County,             3480  Urban         1.0039    1.0113     26900  Urban         1.0076
                 Indiana.
15730.........  Spencer County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15740.........  Starke County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15750.........  Steuben County,              15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15760.........  Sullivan County,             15  Rural         0.8736    0.8517     45460  Urban         0.8627
                 Indiana.
15770.........  Switzerland County,          15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15780.........  Tippecanoe County,         3920  Urban         0.9067    0.9067     29140  Urban         0.9067
                 Indiana.
15790.........  Tipton County,             3850  Urban         0.8986    0.8986     29020  Urban         0.8986
                 Indiana.
15800.........  Union County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15810.........  Vanderburgh County,        2440  Urban         0.8395    0.8372     21780  Urban         0.8384
                 Indiana.
15820.........  Vermillion County,         8320  Urban         0.8582    0.8517     45460  Urban         0.8550
                 Indiana.
15830.........  Vigo County, Indiana.      8320  Urban         0.8582    0.8517     45460  Urban         0.8550
15840.........  Wabash County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15850.........  Warren County,               15  Rural         0.8736    0.8653     99915  Rural         0.8695
                 Indiana.
15860.........  Warrick County,            2440  Urban         0.8395    0.8372     21780  Urban         0.8384
                 Indiana.
15870.........  Washington County,           15  Rural         0.8736    0.9122     31140  Urban         0.8929
                 Indiana.
15880.........  Wayne County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15890.........  Wells County, Indiana      2760  Urban         0.9737    0.9807     23060  Urban         0.9772
15900.........  White County, Indiana        15  Rural         0.8736    0.8653     99915  Rural         0.8695
15910.........  Whitley County,            2760  Urban         0.9737    0.9807     23060  Urban         0.9772
                 Indiana.
16000.........  Adair County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16010.........  Adams County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16020.........  Allamakee County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16030.........  Appanoose County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16040.........  Audubon County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16050.........  Benton County, Iowa..        16  Rural         0.8550    0.8975     16300  Urban         0.8763
16060.........  Black Hawk County,         8920  Urban         0.8633    0.8633     47940  Urban         0.8633
                 Iowa.
16070.........  Boone County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16080.........  Bremer County, Iowa..        16  Rural         0.8550    0.8633     47940  Urban         0.8592
16090.........  Buchanan County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16100.........  Buena Vista County,          16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16110.........  Butler County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16120.........  Calhoun County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16130.........  Carroll County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16140.........  Cass County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513

[[Page 47966]]

 
16150.........  Cedar County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16160.........  Cerro Gordo County,          16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16170.........  Cherokee County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16180.........  Chickasaw County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16190.........  Clarke County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16200.........  Clay County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16210.........  Clayton County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16220.........  Clinton County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16230.........  Crawford County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16240.........  Dallas County, Iowa..      2120  Urban         0.9266    0.9266     19780  Urban         0.9266
16250.........  Davis County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16260.........  Decatur County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16270.........  Delaware County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16280.........  Des Moines County,           16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16290.........  Dickinson County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16300.........  Dubuque County, Iowa.      2200  Urban         0.8748    0.8748     20220  Urban         0.8748
16310.........  Emmet County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16320.........  Fayette County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16330.........  Floyd County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16340.........  Franklin County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16350.........  Fremont County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16360.........  Greene County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16370.........  Grundy County, Iowa..        16  Rural         0.8550    0.8633     47940  Urban         0.8592
16380.........  Guthrie County, Iowa.        16  Rural         0.8550    0.9266     19780  Urban         0.8908
16390.........  Hamilton County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16400.........  Hancock County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16410.........  Hardin County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16420.........  Harrison County, Iowa        16  Rural         0.8550    0.9754     36540  Urban         0.9152
16430.........  Henry County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16440.........  Howard County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16450.........  Humboldt County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16460.........  Ida County, Iowa.....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16470.........  Iowa County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16480.........  Jackson County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16490.........  Jasper County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16500.........  Jefferson County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16510.........  Johnson County, Iowa.      3500  Urban         0.9654    0.9654     26980  Urban         0.9654
16520.........  Jones County, Iowa...        16  Rural         0.8550    0.8975     16300  Urban         0.8763
16530.........  Keokuk County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16540.........  Kossuth County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16550.........  Lee County, Iowa.....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16560.........  Linn County, Iowa....      1360  Urban         0.8975    0.8975     16300  Urban         0.8975
16570.........  Louisa County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16580.........  Lucas County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16590.........  Lyon County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16600.........  Madison County, Iowa.        16  Rural         0.8550    0.9266     19780  Urban         0.8908
16610.........  Mahaska County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16620.........  Marion County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16630.........  Marshall County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16640.........  Mills County, Iowa...        16  Rural         0.8550    0.9754     36540  Urban         0.9152
16650.........  Mitchell County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16660.........  Monona County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16670.........  Monroe County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16680.........  Montgomery County,           16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16690.........  Muscatine County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16700.........  OBrien County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16710.........  Osceola County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16720.........  Page County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16730.........  Palo Alto County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16740.........  Plymouth County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16750.........  Pocahontas County,           16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16760.........  Polk County, Iowa....      2120  Urban         0.9266    0.9266     19780  Urban         0.9266
16770.........  Pottawattamie County,      5920  Urban         0.9754    0.9754     36540  Urban         0.9754
                 Iowa.
16780.........  Poweshiek County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16790.........  Ringgold County, Iowa        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16800.........  Sac County, Iowa.....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16810.........  Scott County, Iowa...      1960  Urban         0.8773    0.8773     19340  Urban         0.8773
16820.........  Shelby County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513

[[Page 47967]]

 
16830.........  Sioux County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16840.........  Story County, Iowa...        16  Rural         0.8550    0.9479     11180  Urban         0.9015
16850.........  Tama County, Iowa....        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16860.........  Taylor County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16870.........  Union County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16880.........  Van Buren County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16890.........  Wapello County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16900.........  Warren County, Iowa..      2120  Urban         0.9266    0.9266     19780  Urban         0.9266
16910.........  Washington County,           16  Rural         0.8550    0.9654     26980  Urban         0.9102
                 Iowa.
16920.........  Wayne County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16930.........  Webster County, Iowa.        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16940.........  Winnebago County,            16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16950.........  Winneshiek County,           16  Rural         0.8550    0.8475     99916  Rural         0.8513
                 Iowa.
16960.........  Woodbury County, Iowa      7720  Urban         0.9094    0.9070     43580  Urban         0.9082
16970.........  Worth County, Iowa...        16  Rural         0.8550    0.8475     99916  Rural         0.8513
16980.........  Wright County, Iowa..        16  Rural         0.8550    0.8475     99916  Rural         0.8513
17000.........  Allen County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17010.........  Anderson County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17020.........  Atchison County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17030.........  Barber County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17040.........  Barton County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17050.........  Bourbon County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17060.........  Brown County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17070.........  Butler County, Kansas      9040  Urban         0.9486    0.9457     48620  Urban         0.9472
17080.........  Chase County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17090.........  Chautauqua County,           17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17100.........  Cherokee County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17110.........  Cheyenne County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17120.........  Clark County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17130.........  Clay County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17140.........  Cloud County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17150.........  Coffey County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17160.........  Comanche County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17170.........  Cowley County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17180.........  Crawford County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17190.........  Decatur County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17200.........  Dickinson County,            17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17210.........  Doniphan County,             17  Rural         0.8087    1.0013     41140  Urban         0.9050
                 Kansas.
17220.........  Douglas County,            4150  Urban         0.8644    0.8644     29940  Urban         0.8644
                 Kansas.
17230.........  Edwards County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17240.........  Elk County, Kansas...        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17250.........  Ellis County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17260.........  Ellsworth County,            17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17270.........  Finney County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17280.........  Ford County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17290.........  Franklin County,             17  Rural         0.8087    0.9629     28140  Urban         0.8858
                 Kansas.
17300.........  Geary County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17310.........  Gove County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17320.........  Graham County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17330.........  Grant County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17340.........  Gray County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17350.........  Greeley County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17360.........  Greenwood County,            17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17370.........  Hamilton County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17380.........  Harper County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17390.........  Harvey County, Kansas      9040  Urban         0.9486    0.9457     48620  Urban         0.9472
17391.........  Haskell County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17410.........  Hodgeman County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17420.........  Jackson County,              17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
17430.........  Jefferson County,            17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
17440.........  Jewell County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17450.........  Johnson County,            3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Kansas.
17451.........  Kearny County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17470.........  Kingman County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17480.........  Kiowa County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17490.........  Labette County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17500.........  Lane County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17510.........  Leavenworth County,        3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Kansas.

[[Page 47968]]

 
17520.........  Lincoln County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17530.........  Linn County, Kansas..        17  Rural         0.8087    0.9629     28140  Urban         0.8858
17540.........  Logan County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17550.........  Lyon County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17560.........  Mc Pherson County,           17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17570.........  Marion County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17580.........  Marshall County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17590.........  Meade County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17600.........  Miami County, Kansas.      3760  Urban         0.9641    0.9629     28140  Urban         0.9635
17610.........  Mitchell County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17620.........  Montgomery County,           17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17630.........  Morris County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17640.........  Morton County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17650.........  Nemaha County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17660.........  Neosho County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17670.........  Ness County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17680.........  Norton County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17690.........  Osage County, Kansas.        17  Rural         0.8087    0.8904     45820  Urban         0.8496
17700.........  Osborne County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17710.........  Ottawa County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17720.........  Pawnee County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17730.........  Phillips County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17740.........  Pottawatomie County,         17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17750.........  Pratt County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17760.........  Rawlins County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17770.........  Reno County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17780.........  Republic County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17790.........  Rice County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17800.........  Riley County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17810.........  Rooks County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17820.........  Rush County, Kansas..        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17830.........  Russell County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17840.........  Saline County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17841.........  Scott County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17860.........  Sedgwick County,           9040  Urban         0.9486    0.9457     48620  Urban         0.9472
                 Kansas.
17870.........  Seward County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17880.........  Shawnee County,            8440  Urban         0.8904    0.8904     45820  Urban         0.8904
                 Kansas.
17890.........  Sheridan County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17900.........  Sherman County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17910.........  Smith County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17920.........  Stafford County,             17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17921.........  Stanton County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17940.........  Stevens County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17950.........  Sumner County, Kansas        17  Rural         0.8087    0.9457     48620  Urban         0.8772
17960.........  Thomas County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17970.........  Trego County, Kansas.        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17980.........  Wabaunsee County,            17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
17981.........  Wallace County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17982.........  Washington County,           17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17983.........  Wichita County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17984.........  Wilson County, Kansas        17  Rural         0.8087    0.8079     99917  Rural         0.8083
17985.........  Woodson County,              17  Rural         0.8087    0.8079     99917  Rural         0.8083
                 Kansas.
17986.........  Wyandotte County,          3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Kansas.
18000.........  Adair County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18010.........  Allen County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18020.........  Anderson County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18030.........  Ballard County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18040.........  Barren County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18050.........  Bath County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18060.........  Bell County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18070.........  Boone County,              1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18080.........  Bourbon County,            4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
18090.........  Boyd County, Kentucky     13400  Urban         0.9564    0.9564     26580  Urban         0.9564
18100.........  Boyle County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18110.........  Bracken County,              18  Rural         0.7844    0.9516     17140  Urban         0.8680
                 Kentucky.
18120.........  Breathitt County,            18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18130.........  Breckinridge County,         18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18140.........  Bullitt County,            4520  Urban         0.9162    0.9122     31140  Urban         0.9142
                 Kentucky.

[[Page 47969]]

 
18150.........  Butler County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18160.........  Caldwell County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18170.........  Calloway County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18180.........  Campbell County,           1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18190.........  Carlisle County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18191.........  Carroll County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18210.........  Carter County,             3400  Urban         0.9564    0.7755     99918  Rural         0.8660
                 Kentucky.
18220.........  Casey County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18230.........  Christian County,          1660  Urban         0.8022    0.8022     17300  Urban         0.8022
                 Kentucky.
18240.........  Clark County,              4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
18250.........  Clay County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18260.........  Clinton County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18270.........  Crittenden County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18271.........  Cumberland County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18290.........  Daviess County,            5990  Urban         0.8434    0.8434     36980  Urban         0.8434
                 Kentucky.
18291.........  Edmonson County,             18  Rural         0.7844    0.8140     14540  Urban         0.7992
                 Kentucky.
18310.........  Elliott County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18320.........  Estill County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18330.........  Fayette County,            4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
18340.........  Fleming County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18350.........  Floyd County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18360.........  Franklin County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18361.........  Fulton County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18362.........  Gallatin County,           1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18390.........  Garrard County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18400.........  Grant County,              1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18410.........  Graves County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18420.........  Grayson County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18421.........  Green County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18440.........  Greenup County,            3400  Urban         0.9564    0.9564     26580  Urban         0.9564
                 Kentucky.
18450.........  Hancock County,              18  Rural         0.7844    0.8434     36980  Urban         0.8139
                 Kentucky.
18460.........  Hardin County,               18  Rural         0.7844    0.8684     21060  Urban         0.8264
                 Kentucky.
18470.........  Harlan County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18480.........  Harrison County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18490.........  Hart County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18500.........  Henderson County,          2440  Urban         0.8395    0.8372     21780  Urban         0.8384
                 Kentucky.
18510.........  Henry County,                18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18511.........  Hickman County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18530.........  Hopkins County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18540.........  Jackson County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18550.........  Jefferson County,          4520  Urban         0.9162    0.9122     31140  Urban         0.9142
                 Kentucky.
18560.........  Jessamine County,          4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
18570.........  Johnson County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18580.........  Kenton County,             1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18590.........  Knott County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18600.........  Knox County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18610.........  Larue County,                18  Rural         0.7844    0.8684     21060  Urban         0.8264
                 Kentucky.
18620.........  Laurel County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18630.........  Lawrence County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18640.........  Lee County, Kentucky.        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18650.........  Leslie County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18660.........  Letcher County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18670.........  Lewis County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18680.........  Lincoln County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18690.........  Livingston County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18700.........  Logan County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18710.........  Lyon County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18720.........  Mc Cracken County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18730.........  Mc Creary County,            18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18740.........  Mc Lean County,              18  Rural         0.7844    0.8434     36980  Urban         0.8139
                 Kentucky.
18750.........  Madison County,            4280  Urban         0.9219    0.7755     99918  Rural         0.8487
                 Kentucky.
18760.........  Magoffin County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18770.........  Marion County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18780.........  Marshall County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18790.........  Martin County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18800.........  Mason County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18801.........  Meade County,                18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18802.........  Menifee County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.

[[Page 47970]]

 
18830.........  Mercer County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18831.........  Metcalfe County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18850.........  Monroe County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18860.........  Montgomery County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18861.........  Morgan County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18880.........  Muhlenberg County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18890.........  Nelson County,               18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18900.........  Nicholas County,             18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18910.........  Ohio County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18920.........  Oldham County,             4520  Urban         0.9162    0.9122     31140  Urban         0.9142
                 Kentucky.
18930.........  Owen County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18931.........  Owsley County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18932.........  Pendleton County,          1640  Urban         0.9595    0.9516     17140  Urban         0.9556
                 Kentucky.
18960.........  Perry County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18970.........  Pike County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18971.........  Powell County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18972.........  Pulaski County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18973.........  Robertson County,            18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18974.........  Rockcastle County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18975.........  Rowan County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18976.........  Russell County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18977.........  Scott County,              4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
18978.........  Shelby County,               18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18979.........  Simpson County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18980.........  Spencer County,              18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18981.........  Taylor County,               18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18982.........  Todd County, Kentucky        18  Rural         0.7844    0.7755     99918  Rural         0.7800
18983.........  Trigg County,                18  Rural         0.7844    0.8022     17300  Urban         0.7933
                 Kentucky.
18984.........  Trimble County,              18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18985.........  Union County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18986.........  Warren County,               18  Rural         0.7844    0.8140     14540  Urban         0.7992
                 Kentucky.
18987.........  Washington County,           18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18988.........  Wayne County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18989.........  Webster County,              18  Rural         0.7844    0.8372     21780  Urban         0.8108
                 Kentucky.
18990.........  Whitley County,              18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18991.........  Wolfe County,                18  Rural         0.7844    0.7755     99918  Rural         0.7800
                 Kentucky.
18992.........  Woodford County,           4280  Urban         0.9219    0.9359     30460  Urban         0.9289
                 Kentucky.
19000.........  Acadia County,             3880  Urban         0.8105    0.7345     99919  Rural         0.7725
                 Louisiana.
19010.........  Allen County,                19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19020.........  Ascension County,          0760  Urban         0.8354    0.8319     12940  Urban         0.8337
                 Louisiana.
19030.........  Assumption County,           19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19040.........  Avoyelles County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19050.........  Beauregard County,           19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19060.........  Bienville County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19070.........  Bossier County,            7680  Urban         0.9111    0.9132     43340  Urban         0.9122
                 Louisiana.
19080.........  Caddo County,              7680  Urban         0.9111    0.9132     43340  Urban         0.9122
                 Louisiana.
19090.........  Calcasieu County,          3960  Urban         0.7972    0.7935     29340  Urban         0.7954
                 Louisiana.
19100.........  Caldwell County,             19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19110.........  Cameron County,              19  Rural         0.7290    0.7935     29340  Urban         0.7613
                 Louisiana.
19120.........  Catahoula County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19130.........  Claiborne County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19140.........  Concordia County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19150.........  De Soto County,              19  Rural         0.7290    0.9132     43340  Urban         0.8211
                 Louisiana.
19160.........  East Baton Rouge           0760  Urban         0.8354    0.8319     12940  Urban         0.8337
                 County, Louisiana.
19170.........  East Carroll County,         19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19180.........  East Feliciana               19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 County, Louisiana.
19190.........  Evangeline County,           19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19200.........  Franklin County,             19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19210.........  Grant County,                19  Rural         0.7290    0.8171     10780  Urban         0.7731
                 Louisiana.
19220.........  Iberia County,               19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19230.........  Iberville County,            19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19240.........  Jackson County,              19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19250.........  Jefferson County,          5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19260.........  Jefferson Davis              19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 County, Louisiana.
19270.........  Lafayette County,          3880  Urban         0.8105    0.8306     29180  Urban         0.8206
                 Louisiana.
19280.........  Lafourche County,          3350  Urban         0.7721    0.7721     26380  Urban         0.7721
                 Louisiana.
19290.........  La Salle County,             19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19300.........  Lincoln County,              19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.

[[Page 47971]]

 
19310.........  Livingston County,         0760  Urban         0.8354    0.8319     12940  Urban         0.8337
                 Louisiana.
19320.........  Madison County,              19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19330.........  Morehouse County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19340.........  Natchitoches County,         19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19350.........  Orleans County,            5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19360.........  Ouachita County,           5200  Urban         0.7913    0.7903     33740  Urban         0.7908
                 Louisiana.
19370.........  Plaquemines County,        5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19380.........  Pointe Coupee County,        19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19390.........  Rapides County,            0220  Urban         0.8171    0.8171     10780  Urban         0.8171
                 Louisiana.
19400.........  Red River County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19410.........  Richland County,             19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19420.........  Sabine County,               19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19430.........  St Bernard County,         5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19440.........  St Charles County,         5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19450.........  St Helena County,            19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19460.........  St James County,           5560  Urban         0.9103    0.7345     99919  Rural         0.8224
                 Louisiana.
19470.........  St John Baptist            5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 County, Louisiana.
19480.........  St Landry County,          3880  Urban         0.8105    0.7345     99919  Rural         0.7725
                 Louisiana.
19490.........  St Martin County,          3880  Urban         0.8105    0.8306     29180  Urban         0.8206
                 Louisiana.
19500.........  St Mary County,              19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19510.........  St Tammany County,         5560  Urban         0.9103    0.9103     35380  Urban         0.9103
                 Louisiana.
19520.........  Tangipahoa County,           19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19530.........  Tensas County,               19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19540.........  Terrebonne County,         3350  Urban         0.7721    0.7721     26380  Urban         0.7721
                 Louisiana.
19550.........  Union County,                19  Rural         0.7290    0.7903     33740  Urban         0.7597
                 Louisiana.
19560.........  Vermilion County,            19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19570.........  Vernon County,               19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19580.........  Washington County,           19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19590.........  Webster County,            7680  Urban         0.9111    0.7345     99919  Rural         0.8228
                 Louisiana.
19600.........  West Baton Rouge           0760  Urban         0.8354    0.8319     12940  Urban         0.8337
                 County, Louisiana.
19610.........  West Carroll County,         19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
19620.........  West Feliciana               19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 County, Louisiana.
19630.........  Winn County,                 19  Rural         0.7290    0.7345     99919  Rural         0.7318
                 Louisiana.
20000.........  Androscoggin County,       4243  Urban         0.9562    0.9562     30340  Urban         0.9562
                 Maine.
20010.........  Aroostook County,            20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20020.........  Cumberland County,         6403  Urban         1.0112    1.0112     38860  Urban         1.0112
                 Maine.
20030.........  Franklin County,             20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20040.........  Hancock County, Maine        20  Rural         0.9039    0.9039     99920  Rural         0.9039
20050.........  Kennebec County,             20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20060.........  Knox County, Maine...        20  Rural         0.9039    0.9039     99920  Rural         0.9039
20070.........  Lincoln County, Maine        20  Rural         0.9039    0.9039     99920  Rural         0.9039
20080.........  Oxford County, Maine.        20  Rural         0.9039    0.9039     99920  Rural         0.9039
20090.........  Penobscot County,          0733  Urban         0.9955    0.9955     12620  Urban         0.9955
                 Maine.
20100.........  Piscataquis County,          20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20110.........  Sagadahoc County,          6403  Urban         1.0112    1.0112     38860  Urban         1.0112
                 Maine.
20120.........  Somerset County,             20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20130.........  Waldo County, Maine..        20  Rural         0.9039    0.9039     99920  Rural         0.9039
20140.........  Washington County,           20  Rural         0.9039    0.9039     99920  Rural         0.9039
                 Maine.
20150.........  York County, Maine...      6403  Urban         1.0112    1.0112     38860  Urban         1.0112
21000.........  Allegany County,           1900  Urban         0.8662    0.8662     19060  Urban         0.8662
                 Maryland.
21010.........  Anne Arundel County,       0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21020.........  Baltimore County,          0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21030.........  Baltimore City             0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 County, Maryland.
21040.........  Calvert County,            8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Maryland.
21050.........  Caroline County,             21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.
21060.........  Carroll County,            0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21070.........  Cecil County,              9160  Urban         1.1121    1.1049     48864  Urban         1.1085
                 Maryland.
21080.........  Charles County,            8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Maryland.
21090.........  Dorchester County,           21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.
21100.........  Frederick County,          8840  Urban         1.0971    1.0956     13644  Urban         1.0964
                 Maryland.
21110.........  Garrett County,              21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.
21120.........  Harford County,            0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21130.........  Howard County,             0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21140.........  Kent County, Maryland        21  Rural         0.9179    0.9220     99921  Rural         0.9200
21150.........  Montgomery County,         8840  Urban         1.0971    1.0956     13644  Urban         1.0964
                 Maryland.
21160.........  Prince Georges             8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Maryland.
21170.........  Queen Annes County,        0720  Urban         0.9907    0.9907     12580  Urban         0.9907
                 Maryland.
21180.........  St Marys County,             21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.

[[Page 47972]]

 
21190.........  Somerset County,             21  Rural         0.9179    0.9123     41540  Urban         0.9151
                 Maryland.
21200.........  Talbot County,               21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.
21210.........  Washington County,         3180  Urban         0.9940    0.9715     25180  Urban         0.9828
                 Maryland.
21220.........  Wicomico County,             21  Rural         0.9179    0.9123     41540  Urban         0.9151
                 Maryland.
21230.........  Worcester County,            21  Rural         0.9179    0.9220     99921  Rural         0.9200
                 Maryland.
22000.........  Barnstable County,         0743  Urban         1.2335    1.2335     12700  Urban         1.2335
                 Massachusetts.
22010.........  Berkshire County,          6323  Urban         1.0439    1.0439     38340  Urban         1.0439
                 Massachusetts.
22020.........  Bristol County,            1123  Urban         1.1290    1.0929     39300  Urban         1.1110
                 Massachusetts.
22030.........  Dukes County,                22  Rural         1.0216    1.0216     99922  Rural         1.0216
                 Massachusetts.
22040.........  Essex County,              1123  Urban         1.1290    1.0662     21604  Urban         1.0976
                 Massachusetts.
22060.........  Franklin County,             22  Rural         1.0216    1.0176     44140  Urban         1.0196
                 Massachusetts.
22070.........  Hampden County,            8003  Urban         1.0173    1.0176     44140  Urban         1.0175
                 Massachusetts.
22080.........  Hampshire County,          8003  Urban         1.0173    1.0176     44140  Urban         1.0175
                 Massachusetts.
22090.........  Middlesex County,          1123  Urban         1.1290    1.1189     15764  Urban         1.1240
                 Massachusetts.
22120.........  Nantucket County,            22  Rural         1.0216    1.0216     99922  Rural         1.0216
                 Massachusetts.
22130.........  Norfolk County,            1123  Urban         1.1290    1.1771     14484  Urban         1.1531
                 Massachusetts.
22150.........  Plymouth County,           1123  Urban         1.1290    1.1771     14484  Urban         1.1531
                 Massachusetts.
22160.........  Suffolk County,            1123  Urban         1.1290    1.1771     14484  Urban         1.1531
                 Massachusetts.
22170.........  Worcester County,          1123  Urban         1.1290    1.0996     49340  Urban         1.1143
                 Massachusetts.
23000.........  Alcona County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23010.........  Alger County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23020.........  Allegan County,            3000  Urban         0.9519    0.8786     99923  Rural         0.9153
                 Michigan.
23030.........  Alpena County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23040.........  Antrim County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23050.........  Arenac County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23060.........  Baraga County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23070.........  Barry County,                23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
23080.........  Bay County, Michigan.      6960  Urban         0.9696    0.9574     13020  Urban         0.9635
23090.........  Benzie County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23100.........  Berrien County,            0870  Urban         0.8847    0.8847     35660  Urban         0.8847
                 Michigan.
23110.........  Branch County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23120.........  Calhoun County,            3720  Urban         1.0350    0.9366     12980  Urban         0.9858
                 Michigan.
23130.........  Cass County, Michigan        23  Rural         0.8740    0.9447     43780  Urban         0.9094
23140.........  Charlevoix County,           23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23150.........  Cheboygan County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23160.........  Chippewa County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23170.........  Clare County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23180.........  Clinton County,            4040  Urban         0.9658    0.9658     29620  Urban         0.9658
                 Michigan.
23190.........  Crawford County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23200.........  Delta County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23210.........  Dickinson County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23220.........  Eaton County,              4040  Urban         0.9658    0.9658     29620  Urban         0.9658
                 Michigan.
23230.........  Emmet County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23240.........  Genesee County,            2640  Urban         1.1178    1.1178     22420  Urban         1.1178
                 Michigan.
23250.........  Gladwin County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23260.........  Gogebic County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23270.........  Grand Traverse               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 County, Michigan.
23280.........  Gratiot County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23290.........  Hillsdale County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23300.........  Houghton County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23310.........  Huron County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23320.........  Ingham County,             4040  Urban         0.9658    0.9658     29620  Urban         0.9658
                 Michigan.
23330.........  Ionia County,                23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
23340.........  Iosco County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23350.........  Iron County, Michigan        23  Rural         0.8740    0.8786     99923  Rural         0.8763
23360.........  Isabella County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23370.........  Jackson County,            3520  Urban         0.9146    0.9146     27100  Urban         0.9146
                 Michigan.
23380.........  Kalamazoo County,          3720  Urban         1.0350    1.0676      2820  Urban         1.0513
                 Michigan.
23390.........  Kalkaska County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23400.........  Kent County, Michigan      3000  Urban         0.9519    0.9420     24340  Urban         0.9470
23410.........  Keweenaw County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23420.........  Lake County, Michigan        23  Rural         0.8740    0.8786     99923  Rural         0.8763
23430.........  Lapeer County,             2160  Urban         1.0227    1.0112     47644  Urban         1.0170
                 Michigan.
23440.........  Leelanau County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23450.........  Lenawee County,            0440  Urban         1.0816    0.8786     99923  Rural         0.9801
                 Michigan.
23460.........  Livingston County,         0440  Urban         1.0816    1.0112     47644  Urban         1.0464
                 Michigan.
23470.........  Luce County, Michigan        23  Rural         0.8740    0.8786     99923  Rural         0.8763
23480.........  Mackinac County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.

[[Page 47973]]

 
23490.........  Macomb County,             2160  Urban         1.0227    1.0112     47644  Urban         1.0170
                 Michigan.
23500.........  Manistee County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23510.........  Marquette County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23520.........  Mason County,                23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23530.........  Mecosta County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23540.........  Menominee County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23550.........  Midland County,            6960  Urban         0.9696    0.8786     99923  Rural         0.9241
                 Michigan.
23560.........  Missaukee County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23570.........  Monroe County,             2160  Urban         1.0227    0.9506     33780  Urban         0.9867
                 Michigan.
23580.........  Montcalm County,             23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23590.........  Montmorency County,          23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23600.........  Muskegon County,           3000  Urban         0.9519    0.9741     34740  Urban         0.9630
                 Michigan.
23610.........  Newaygo County,              23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
23620.........  Oakland County,            2160  Urban         1.0227    1.0112     47644  Urban         1.0170
                 Michigan.
23630.........  Oceana County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23640.........  Ogemaw County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23650.........  Ontonagon County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23660.........  Osceola County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23670.........  Oscoda County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23680.........  Otsego County,               23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23690.........  Ottawa County,             3000  Urban         0.9519    0.9388     26100  Urban         0.9454
                 Michigan.
23700.........  Presque Isle County,         23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23710.........  Roscommon County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23720.........  Saginaw County,            6960  Urban         0.9696    0.9814     40980  Urban         0.9755
                 Michigan.
23730.........  St Clair County,           2160  Urban         1.0227    1.0112     47644  Urban         1.0170
                 Michigan.
23740.........  St Joseph County,            23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23750.........  Sanilac County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23760.........  Schoolcraft County,          23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23770.........  Shiawassee County,           23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23780.........  Tuscola County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
23790.........  Van Buren County,          3720  Urban         1.0350    1.0676     28020  Urban         1.0513
                 Michigan.
23800.........  Washtenaw County,          0440  Urban         1.0816    1.1022     11460  Urban         1.0919
                 Michigan.
23810.........  Wayne County,              2160  Urban         1.0227    1.0349     19804  Urban         1.0288
                 Michigan.
23830.........  Wexford County,              23  Rural         0.8740    0.8786     99923  Rural         0.8763
                 Michigan.
24000.........  Aitkin County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24010.........  Anoka County,              5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24020.........  Becker County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24030.........  Beltrami County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24040.........  Benton County,             6980  Urban         1.0215    1.0215     41060  Urban         1.0215
                 Minnesota.
24050.........  Big Stone County,            24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24060.........  Blue Earth County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24070.........  Brown County,                24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24080.........  Carlton County,              24  Rural         0.9339    1.0340     20260  Urban         0.9840
                 Minnesota.
24090.........  Carver County,             5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24100.........  Cass County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24110.........  Chippewa County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24120.........  Chisago County,            5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24130.........  Clay County,               2520  Urban         0.9114    0.9114     22020  Urban         0.9114
                 Minnesota.
24140.........  Clearwater County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24150.........  Cook County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24160.........  Cottonwood County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24170.........  Crow Wing County,            24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24180.........  Dakota County,             5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24190.........  Dodge County,                24  Rural         0.9339    1.1504     40340  Urban         1.0422
                 Minnesota.
24200.........  Douglas County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24210.........  Faribault County,            24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24220.........  Fillmore County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24230.........  Freeborn County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24240.........  Goodhue County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24250.........  Grant County,                24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24260.........  Hennepin County,           5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24270.........  Houston County,            3870  Urban         0.9289    0.9289     29100  Urban         0.9289
                 Minnesota.
24280.........  Hubbard County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24290.........  Isanti County,             5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24300.........  Itasca County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24310.........  Jackson County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24320.........  Kanabec County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24330.........  Kandiyohi County,            24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.

[[Page 47974]]

 
24340.........  Kittson County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24350.........  Koochiching County,          24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24360.........  Lac Qui Parle County,        24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24370.........  Lake County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24380.........  Lake Of Woods County,        24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24390.........  Le Sueur County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24400.........  Lincoln County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24410.........  Lyon County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24420.........  Mc Leod County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24430.........  Mahnomen County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24440.........  Marshall County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24450.........  Martin County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24460.........  Meeker County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24470.........  Mille Lacs County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24480.........  Morrison County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24490.........  Mower County,                24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24500.........  Murray County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24510.........  Nicollet County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24520.........  Nobles County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24530.........  Norman County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24540.........  Olmsted County,            6820  Urban         1.1504    1.1504     40340  Urban         1.1504
                 Minnesota.
24550.........  Otter Tail County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24560.........  Pennington County,           24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24570.........  Pine County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24580.........  Pipestone County,            24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24590.........  Polk County,               2985  Urban         0.9091    0.9091     24220  Urban         0.9091
                 Minnesota.
24600.........  Pope County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24610.........  Ramsey County,             5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24620.........  Red Lake County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24630.........  Redwood County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24640.........  Renville County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24650.........  Rice County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24660.........  Rock County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24670.........  Roseau County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24680.........  St Louis County,           2240  Urban         1.0356    1.0340     20260  Urban         1.0348
                 Minnesota.
24690.........  Scott County,              5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24700.........  Sherburne County,          5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24710.........  Sibley County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24720.........  Stearns County,            6980  Urban         1.0215    1.0215     41060  Urban         1.0215
                 Minnesota.
24730.........  Steele County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24740.........  Stevens County,              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24750.........  Swift County,                24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24760.........  Todd County,                 24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24770.........  Traverse County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24780.........  Wabasha County,              24  Rural         0.9339    1.1504     40340  Urban         1.0422
                 Minnesota.
24790.........  Wadena County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24800.........  Waseca County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24810.........  Washington County,         5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24820.........  Watonwan County,             24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24830.........  Wilkin County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24840.........  Winona County,               24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 Minnesota.
24850.........  Wright County,             5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Minnesota.
24860.........  Yellow Medicine              24  Rural         0.9339    0.9330     99924  Rural         0.9335
                 County, Minnesota.
25000.........  Adams County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25010.........  Alcorn County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25020.........  Amite County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25030.........  Attala County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25040.........  Benton County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25050.........  Bolivar County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25060.........  Calhoun County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25070.........  Carroll County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25080.........  Chickasaw County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25090.........  Choctaw County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25100.........  Claiborne County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25110.........  Clarke County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25120.........  Clay County,                 25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25130.........  Coahoma County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25140.........  Copiah County,               25  Rural         0.7583    0.8291     27140  Urban         0.7937
                 Mississippi.

[[Page 47975]]

 
25150.........  Covington County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25160.........  Desoto County,             4920  Urban         0.9234    0.9217     32820  Urban         0.9226
                 Mississippi.
25170.........  Forrest County,            3285  Urban         0.7362    0.7362     25620  Urban         0.7362
                 Mississippi.
25180.........  Franklin County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25190.........  George County,               25  Rural         0.7583    0.7974     37700  Urban         0.7779
                 Mississippi.
25200.........  Greene County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25210.........  Grenada County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25220.........  Hancock County,            0920  Urban         0.8649    0.8950     25060  Urban         0.8800
                 Mississippi.
25230.........  Harrison County,           0920  Urban         0.8649    0.8950     25060  Urban         0.8800
                 Mississippi.
25240.........  Hinds County,              3560  Urban         0.8406    0.8291     27140  Urban         0.8349
                 Mississippi.
25250.........  Holmes County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25260.........  Humphreys County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25270.........  Issaquena County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25280.........  Itawamba County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25290.........  Jackson County,            0920  Urban         0.8649    0.7974     37700  Urban         0.8312
                 Mississippi.
25300.........  Jasper County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25310.........  Jefferson County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25320.........  Jefferson Davis              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 County, Mississippi.
25330.........  Jones County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25340.........  Kemper County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25350.........  Lafayette County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25360.........  Lamar County,              3285  Urban         0.7362    0.7362     25620  Urban         0.7362
                 Mississippi.
25370.........  Lauderdale County,           25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25380.........  Lawrence County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25390.........  Leake County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25400.........  Lee County,                  25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25410.........  Leflore County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25420.........  Lincoln County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25430.........  Lowndes County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25440.........  Madison County,            3560  Urban         0.8406    0.8291     27140  Urban         0.8349
                 Mississippi.
25450.........  Marion County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25460.........  Marshall County,             25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
25470.........  Monroe County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25480.........  Montgomery County,           25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25490.........  Neshoba County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25500.........  Newton County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25510.........  Noxubee County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25520.........  Oktibbeha County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25530.........  Panola County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25540.........  Pearl River County,          25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25550.........  Perry County,                25  Rural         0.7583    0.7362     25620  Urban         0.7473
                 Mississippi.
25560.........  Pike County,                 25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25570.........  Pontotoc County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25580.........  Prentiss County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25590.........  Quitman County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25600.........  Rankin County,             3560  Urban         0.8406    0.8291     27140  Urban         0.8349
                 Mississippi.
25610.........  Scott County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25620.........  Sharkey County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25630.........  Simpson County,              25  Rural         0.7583    0.8291     27140  Urban         0.7937
                 Mississippi.
25640.........  Smith County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25650.........  Stone County,                25  Rural         0.7583    0.8950     25060  Urban         0.8267
                 Mississippi.
25660.........  Sunflower County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25670.........  Tallahatchie County,         25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25680.........  Tate County,                 25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
25690.........  Tippah County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25700.........  Tishomingo County,           25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25710.........  Tunica County,               25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
25720.........  Union County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25730.........  Walthall County,             25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25740.........  Warren County,               25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25750.........  Washington County,           25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25760.........  Wayne County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25770.........  Webster County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25780.........  Wilkinson County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25790.........  Winston County,              25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25800.........  Yalobusha County,            25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
25810.........  Yazoo County,                25  Rural         0.7583    0.7635     99925  Rural         0.7609
                 Mississippi.
26000.........  Adair County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.

[[Page 47976]]

 
26010.........  Andrew County,             7000  Urban         1.0013    1.0013     41140  Urban         1.0013
                 Missouri.
26020.........  Atchison County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26030.........  Audrain County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26040.........  Barry County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26050.........  Barton County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26060.........  Bates County,                26  Rural         0.7829    0.9629     28140  Urban         0.8729
                 Missouri.
26070.........  Benton County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26080.........  Bollinger County,            26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26090.........  Boone County,              1740  Urban         0.8396    0.8396     17860  Urban         0.8396
                 Missouri.
26100.........  Buchanan County,           7000  Urban         1.0013    1.0013     41140  Urban         1.0013
                 Missouri.
26110.........  Butler County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26120.........  Caldwell County,             26  Rural         0.7829    0.9629     28140  Urban         0.8729
                 Missouri.
26130.........  Callaway County,             26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26140.........  Camden County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26150.........  Cape Girardeau               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 County, Missouri.
26160.........  Carroll County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26170.........  Carter County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26180.........  Cass County, Missouri      3760  Urban         0.9641    0.9629     28140  Urban         0.9635
26190.........  Cedar County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26200.........  Chariton County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26210.........  Christian County,          7920  Urban         0.8597    0.8557     44180  Urban         0.8577
                 Missouri.
26220.........  Clark County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26230.........  Clay County, Missouri      3760  Urban         0.9641    0.9629     28140  Urban         0.9635
26240.........  Clinton County,            3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Missouri.
26250.........  Cole County, Missouri        26  Rural         0.7829    0.8338     27620  Urban         0.8084
26260.........  Cooper County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26270.........  Crawford County,             26  Rural         0.7829    0.9076     41180  Urban         0.8453
                 Missouri.
26280.........  Dade County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26290.........  Dallas County,               26  Rural         0.7829    0.8557     44180  Urban         0.8193
                 Missouri.
26300.........  Daviess County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26310.........  De Kalb County,              26  Rural         0.7829    1.0013     41140  Urban         0.8921
                 Missouri.
26320.........  Dent County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26330.........  Douglas County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26340.........  Dunklin County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26350.........  Franklin County,           7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26360.........  Gasconade County,            26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26370.........  Gentry County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26380.........  Greene County,             7920  Urban         0.8597    0.8557     44180  Urban         0.8577
                 Missouri.
26390.........  Grundy County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26400.........  Harrison County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26410.........  Henry County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26411.........  Hickory County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26412.........  Holt County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26440.........  Howard County,               26  Rural         0.7829    0.8396     17860  Urban         0.8113
                 Missouri.
26450.........  Howell County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26460.........  Iron County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26470.........  Jackson County,            3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Missouri.
26480.........  Jasper County,             3710  Urban         0.8721    0.8721     27900  Urban         0.8721
                 Missouri.
26490.........  Jefferson County,          7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26500.........  Johnson County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26510.........  Knox County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26520.........  Laclede County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26530.........  Lafayette County,          3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Missouri.
26540.........  Lawrence County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26541.........  Lewis County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26560.........  Lincoln County,            7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26570.........  Linn County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26580.........  Livingston County,           26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26590.........  Mc Donald County,            26  Rural         0.7829    0.8636     22220  Urban         0.8233
                 Missouri.
26600.........  Macon County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26601.........  Madison County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26620.........  Maries County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26630.........  Marion County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26631.........  Mercer County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26650.........  Miller County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26660.........  Mississippi County,          26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26670.........  Moniteau County,             26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26680.........  Monroe County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.

[[Page 47977]]

 
26690.........  Montgomery County,           26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26700.........  Morgan County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26710.........  New Madrid County,           26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26720.........  Newton County,             3710  Urban         0.8721    0.8721     27900  Urban         0.8721
                 Missouri.
26730.........  Nodaway County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26740.........  Oregon County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26750.........  Osage County,                26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26751.........  Ozark County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26770.........  Pemiscot County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26780.........  Perry County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26790.........  Pettis County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26800.........  Phelps County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26810.........  Pike County, Missouri        26  Rural         0.7829    0.7762     99926  Rural         0.7796
26820.........  Platte County,             3760  Urban         0.9641    0.9629     28140  Urban         0.9635
                 Missouri.
26821.........  Polk County, Missouri        26  Rural         0.7829    0.8557     44180  Urban         0.8193
26840.........  Pulaski County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26850.........  Putnam County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26860.........  Ralls County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26870.........  Randolph County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26880.........  Ray County, Missouri.      3760  Urban         0.9641    0.9629     28140  Urban         0.9635
26881.........  Reynolds County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26900.........  Ripley County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26910.........  St Charles County,         7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26911.........  St Clair County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26930.........  St Francois County,          26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26940.........  St Louis County,           7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26950.........  St Louis City County,      7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26960.........  Ste Genevieve County,        26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26970.........  Saline County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26980.........  Schuyler County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26981.........  Scotland County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26982.........  Scott County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26983.........  Shannon County,              26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26984.........  Shelby County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26985.........  Stoddard County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26986.........  Stone County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26987.........  Sullivan County,             26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26988.........  Taney County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26989.........  Texas County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26990.........  Vernon County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26991.........  Warren County,             7040  Urban         0.9081    0.9076     41180  Urban         0.9079
                 Missouri.
26992.........  Washington County,           26  Rural         0.7829    0.9076     41180  Urban         0.8453
                 Missouri.
26993.........  Wayne County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26994.........  Webster County,            7920  Urban         0.8597    0.8557     44180  Urban         0.8577
                 Missouri.
26995.........  Worth County,                26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
26996.........  Wright County,               26  Rural         0.7829    0.7762     99926  Rural         0.7796
                 Missouri.
27000.........  Beaverhead County,           27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27010.........  Big Horn County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27020.........  Blaine County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27030.........  Broadwater County,           27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27040.........  Carbon County,               27  Rural         0.8701    0.8961     13740  Urban         0.8831
                 Montana.
27050.........  Carter County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27060.........  Cascade County,            3040  Urban         0.8810    0.8810     24500  Urban         0.8810
                 Montana.
27070.........  Chouteau County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27080.........  Custer County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27090.........  Daniels County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27100.........  Dawson County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27110.........  Deer Lodge County,           27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27113.........  Yellowstone National         27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Park, Montana.
27120.........  Fallon County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27130.........  Fergus County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27140.........  Flathead County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27150.........  Gallatin County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27160.........  Garfield County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27170.........  Glacier County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27180.........  Golden Valley County,        27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27190.........  Granite County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27200.........  Hill County, Montana.        27  Rural         0.8701    0.8701     99927  Rural         0.8701

[[Page 47978]]

 
27210.........  Jefferson County,            27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27220.........  Judith Basin County,         27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27230.........  Lake County, Montana.        27  Rural         0.8701    0.8701     99927  Rural         0.8701
27240.........  Lewis And Clark              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 County, Montana.
27250.........  Liberty County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27260.........  Lincoln County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27270.........  Mc Cone County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27280.........  Madison County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27290.........  Meagher County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27300.........  Mineral County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27310.........  Missoula County,           5140  Urban         0.9618    0.9618     33540  Urban         0.9618
                 Montana.
27320.........  Musselshell County,          27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27330.........  Park County, Montana.        27  Rural         0.8701    0.8701     99927  Rural         0.8701
27340.........  Petroleum County,            27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27350.........  Phillips County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27360.........  Pondera County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27370.........  Powder River County,         27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27380.........  Powell County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27390.........  Prairie County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27400.........  Ravalli County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27410.........  Richland County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27420.........  Roosevelt County,            27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27430.........  Rosebud County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27440.........  Sanders County,              27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27450.........  Sheridan County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27460.........  Silver Bow County,           27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27470.........  Stillwater County,           27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27480.........  Sweet Grass County,          27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27490.........  Teton County, Montana        27  Rural         0.8701    0.8701     99927  Rural         0.8701
27500.........  Toole County, Montana        27  Rural         0.8701    0.8701     99927  Rural         0.8701
27510.........  Treasure County,             27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27520.........  Valley County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27530.........  Wheatland County,            27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27540.........  Wibaux County,               27  Rural         0.8701    0.8701     99927  Rural         0.8701
                 Montana.
27550.........  Yellowstone County,        0880  Urban         0.8961    0.8961     13740  Urban         0.8961
                 Montana.
28000.........  Adams County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28010.........  Antelope County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28020.........  Arthur County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28030.........  Banner County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28040.........  Blaine County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28050.........  Boone County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28060.........  Box Butte County,            28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28070.........  Boyd County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28080.........  Brown County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28090.........  Buffalo County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28100.........  Burt County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28110.........  Butler County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28120.........  Cass County, Nebraska      5920  Urban         0.9754    0.9754     36540  Urban         0.9754
28130.........  Cedar County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28140.........  Chase County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28150.........  Cherry County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28160.........  Cheyenne County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28170.........  Clay County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28180.........  Colfax County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28190.........  Cuming County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28200.........  Custer County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28210.........  Dakota County,             7720  Urban         0.9094    0.9070     43580  Urban         0.9082
                 Nebraska.
28220.........  Dawes County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28230.........  Dawson County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28240.........  Deuel County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28250.........  Dixon County,                28  Rural         0.9035    0.9070     43580  Urban         0.9053
                 Nebraska.
28260.........  Dodge County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28270.........  Douglas County,            5920  Urban         0.9754    0.9754     36540  Urban         0.9754
                 Nebraska.
28280.........  Dundy County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28290.........  Fillmore County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28300.........  Franklin County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28310.........  Frontier County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28320.........  Furnas County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.

[[Page 47979]]

 
28330.........  Gage County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28340.........  Garden County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28350.........  Garfield County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28360.........  Gosper County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28370.........  Grant County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28380.........  Greeley County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28390.........  Hall County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28400.........  Hamilton County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28410.........  Harlan County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28420.........  Hayes County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28430.........  Hitchcock County,            28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28440.........  Holt County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28450.........  Hooker County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28460.........  Howard County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28470.........  Jefferson County,            28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28480.........  Johnson County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28490.........  Kearney County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28500.........  Keith County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28510.........  Keya Paha County,            28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28520.........  Kimball County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28530.........  Knox County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28540.........  Lancaster County,          4360  Urban         1.0208    1.0208     30700  Urban         1.0208
                 Nebraska.
28550.........  Lincoln County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28560.........  Logan County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28570.........  Loup County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28580.........  Mc Pherson County,           28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28590.........  Madison County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28600.........  Merrick County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28610.........  Morrill County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28620.........  Nance County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28630.........  Nemaha County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28640.........  Nuckolls County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28650.........  Otoe County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28660.........  Pawnee County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28670.........  Perkins County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28680.........  Phelps County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28690.........  Pierce County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28700.........  Platte County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28710.........  Polk County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28720.........  Redwillow County,            28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28730.........  Richardson County,           28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28740.........  Rock County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
28750.........  Saline County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28760.........  Sarpy County,              5920  Urban         0.9754    0.9754     36540  Urban         0.9754
                 Nebraska.
28770.........  Saunders County,             28  Rural         0.9035    0.9754     36540  Urban         0.9395
                 Nebraska.
28780.........  Scotts Bluff County,         28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28790.........  Seward County,               28  Rural         0.9035    1.0208     30700  Urban         0.9622
                 Nebraska.
28800.........  Sheridan County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28810.........  Sherman County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28820.........  Sioux County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28830.........  Stanton County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28840.........  Thayer County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28850.........  Thomas County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28860.........  Thurston County,             28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28870.........  Valley County,               28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28880.........  Washington County,         5920  Urban         0.9754    0.9754     36540  Urban         0.9754
                 Nebraska.
28890.........  Wayne County,                28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28900.........  Webster County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28910.........  Wheeler County,              28  Rural         0.9035    0.9035     99928  Rural         0.9035
                 Nebraska.
28920.........  York County, Nebraska        28  Rural         0.9035    0.9035     99928  Rural         0.9035
29000.........  Churchill County,            29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29010.........  Clark County, Nevada.      4120  Urban         1.1121    1.1378     29820  Urban         1.1250
29020.........  Douglas County,              29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29030.........  Elko County, Nevada..        29  Rural         0.9832    0.9280     99929  Rural         0.9556
29040.........  Esmeralda County,            29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29050.........  Eureka County, Nevada        29  Rural         0.9832    0.9280     99929  Rural         0.9556
29060.........  Humboldt County,             29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29070.........  Lander County, Nevada        29  Rural         0.9832    0.9280     99929  Rural         0.9556

[[Page 47980]]

 
29080.........  Lincoln County,              29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29090.........  Lyon County, Nevada..        29  Rural         0.9832    0.9280     99929  Rural         0.9556
29100.........  Mineral County,              29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29110.........  Nye County, Nevada...      4120  Urban         1.1121    0.9280     99929  Rural         1.0201
29120.........  Carson City County,          29  Rural         0.9832    1.0352     16180  Urban         1.0092
                 Nevada.
29130.........  Pershing County,             29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
29140.........  Storey County, Nevada        29  Rural         0.9832    1.0456     39900  Urban         1.0144
29150.........  Washoe County, Nevada      6720  Urban         1.0456    1.0456     39900  Urban         1.0456
29160.........  White Pine County,           29  Rural         0.9832    0.9280     99929  Rural         0.9556
                 Nevada.
30000.........  Belknap County, New          30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
30010.........  Carroll County, New          30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
30020.........  Cheshire County, New         30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
30030.........  Coos County, New             30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
30040.........  Grafton County, New          30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
30050.........  Hillsboro County, New      1123  Urban         1.1290    1.0642     31700  Urban         1.0966
                 Hampshire.
30060.........  Merrimack County, New      1123  Urban         1.1290    1.0642     31700  Urban         1.0966
                 Hampshire.
30070.........  Rockingham County,         1123  Urban         1.1290    1.0221     40484  Urban         1.0756
                 New Hampshire.
30080.........  Strafford County, New      1123  Urban         1.1290    1.0221     40484  Urban         1.0756
                 Hampshire.
30090.........  Sullivan County, New         30  Rural         0.9940    0.9940     99930  Rural         0.9940
                 Hampshire.
31000.........  Atlantic County, New       0560  Urban         1.0907    1.0931     12100  Urban         1.0919
                 Jersey.
31100.........  Bergen County, New         0875  Urban         1.1967    1.3311     35644  Urban         1.2639
                 Jersey.
31150.........  Burlington County,         6160  Urban         1.0824    1.0675     15804  Urban         1.0750
                 New Jersey.
31160.........  Camden County, New         6160  Urban         1.0824    1.0675     15804  Urban         1.0750
                 Jersey.
31180.........  Cape May County, New       0560  Urban         1.0907    1.0810     36140  Urban         1.0859
                 Jersey.
31190.........  Cumberland County,         8760  Urban         1.0573    1.0573     47220  Urban         1.0573
                 New Jersey.
31200.........  Essex County, New          5640  Urban         1.1625    1.1687     35084  Urban         1.1656
                 Jersey.
31220.........  Gloucester County,         6160  Urban         1.0824    1.0675     15804  Urban         1.0750
                 New Jersey.
31230.........  Hudson County, New         3640  Urban         1.0923    1.3311     35644  Urban         1.2117
                 Jersey.
31250.........  Hunterdon County, New      5015  Urban         1.1360    1.1687     35084  Urban         1.1524
                 Jersey.
31260.........  Mercer County, New         8480  Urban         1.0276    1.0276     45940  Urban         1.0276
                 Jersey.
31270.........  Middlesex County, New      5015  Urban         1.1360    1.1136     20764  Urban         1.1248
                 Jersey.
31290.........  Monmouth County, New       5190  Urban         1.0888    1.1136     20764  Urban         1.1012
                 Jersey.
31300.........  Morris County, New         5640  Urban         1.1625    1.1687     35084  Urban         1.1656
                 Jersey.
31310.........  Ocean County, New          5190  Urban         1.0888    1.1136     20764  Urban         1.1012
                 Jersey.
31320.........  Passaic County, New        0875  Urban         1.1967    1.3311     35644  Urban         1.2639
                 Jersey.
31340.........  Salem County, New          6160  Urban         1.0824    1.1049     48864  Urban         1.0937
                 Jersey.
31350.........  Somerset County, New       5015  Urban         1.1360    1.1136     20764  Urban         1.1248
                 Jersey.
31360.........  Sussex County, New         5640  Urban         1.1625    1.1687     35084  Urban         1.1656
                 Jersey.
31370.........  Union County, New          5640  Urban         1.1625    1.1687     35084  Urban         1.1656
                 Jersey.
31390.........  Warren County, New         5640  Urban         1.1625    0.9501     10900  Urban         1.0563
                 Jersey.
32000.........  Bernalillo County,         0200  Urban         1.0485    1.0485     10740  Urban         1.0485
                 New Mexico.
32010.........  Catron County, New           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32020.........  Chaves County, New           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32025.........  Cibola County, New           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32030.........  Colfax County, New           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32040.........  Curry County, New            32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32050.........  De Baca County, New          32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32060.........  Dona Ana County, New       4100  Urban         0.8784    0.8784     29740  Urban         0.8784
                 Mexico.
32070.........  Eddy County, New             32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32080.........  Grant County, New            32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32090.........  Guadalupe County, New        32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32100.........  Harding County, New          32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32110.........  Hidalgo County, New          32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32120.........  Lea County, New              32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32130.........  Lincoln County, New          32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32131.........  Los Alamos County,         7490  Urban         1.0590    0.8680     99932  Rural         0.9635
                 New Mexico.
32140.........  Luna County, New             32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32150.........  Mc Kinley County, New        32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32160.........  Mora County, New             32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32170.........  Otero County, New            32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32180.........  Quay County, New             32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32190.........  Rio Arriba County,           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 New Mexico.
32200.........  Roosevelt County, New        32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32210.........  Sandoval County, New       0200  Urban         1.0485    1.0485     10740  Urban         1.0485
                 Mexico.
32220.........  San Juan County, New         32  Rural         0.8529    0.8049     22140  Urban         0.8289
                 Mexico.
32230.........  San Miguel County,           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 New Mexico.
32240.........  Santa Fe County, New       7490  Urban         1.0590    1.0909     42140  Urban         1.0750
                 Mexico.
32250.........  Sierra County, New           32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.

[[Page 47981]]

 
32260.........  Socorro County, New          32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32270.........  Taos County, New             32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32280.........  Torrance County, New         32  Rural         0.8529    1.0485     10740  Urban         0.9507
                 Mexico.
32290.........  Union County, New            32  Rural         0.8529    0.8680     99932  Rural         0.8605
                 Mexico.
32300.........  Valencia County, New       0200  Urban         1.0485    1.0485     10740  Urban         1.0485
                 Mexico.
33000.........  Albany County, New         0160  Urban         0.8570    0.8650     10580  Urban         0.8610
                 York.
33010.........  Allegany County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33020.........  Bronx County, New          5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33030.........  Broome County, New         0960  Urban         0.8447    0.8447     13780  Urban         0.8447
                 York.
33040.........  Cattaraugus County,          33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 New York.
33050.........  Cayuga County, New         8160  Urban         0.9394    0.8151     99933  Rural         0.8773
                 York.
33060.........  Chautauqua County,         3610  Urban         0.7589    0.8151     99933  Rural         0.7870
                 New York.
33070.........  Chemung County, New        2335  Urban         0.8445    0.8445     21300  Urban         0.8445
                 York.
33080.........  Chenango County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33090.........  Clinton County, New          33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33200.........  Columbia County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33210.........  Cortland County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33220.........  Delaware County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33230.........  Dutchess County, New       2281  Urban         1.1657    1.1363     39100  Urban         1.1510
                 York.
33240.........  Erie County, New York      1280  Urban         0.9339    0.9339     15380  Urban         0.9339
33260.........  Essex County, New            33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33270.........  Franklin County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33280.........  Fulton County, New           33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33290.........  Genesee County, New        6840  Urban         0.9196    0.8151     99933  Rural         0.8674
                 York.
33300.........  Greene County, New           33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33310.........  Hamilton County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33320.........  Herkimer County, New       8680  Urban         0.8295    0.8295     46540  Urban         0.8295
                 York.
33330.........  Jefferson County, New        33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33331.........  Kings County, New          5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33340.........  Lewis County, New            33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33350.........  Livingston County,         6840  Urban         0.9196    0.9281     40380  Urban         0.9239
                 New York.
33360.........  Madison County, New        8160  Urban         0.9394    0.9468     45060  Urban         0.9431
                 York.
33370.........  Monroe County, New         6840  Urban         0.9196    0.9281     40380  Urban         0.9239
                 York.
33380.........  Montgomery County,         0160  Urban         0.8570    0.8151     99933  Rural         0.8361
                 New York.
33400.........  Nassau County, New         5380  Urban         1.2907    1.2907     35004  Urban         1.2907
                 York.
33420.........  New York County, New       5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33500.........  Niagara County, New        1280  Urban         0.9339    0.9339     15380  Urban         0.9339
                 York.
33510.........  Oneida County, New         8680  Urban         0.8295    0.8295     46540  Urban         0.8295
                 York.
33520.........  Onondaga County, New       8160  Urban         0.9394    0.9468     45060  Urban         0.9431
                 York.
33530.........  Ontario County, New        6840  Urban         0.9196    0.9281     40380  Urban         0.9239
                 York.
33540.........  Orange County, New         5660  Urban         1.1170    1.1363     39100  Urban         1.1267
                 York.
33550.........  Orleans County, New        6840  Urban         0.9196    0.9281     40380  Urban         0.9239
                 York.
33560.........  Oswego County, New         8160  Urban         0.9394    0.9468     45060  Urban         0.9431
                 York.
33570.........  Otsego County, New           33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33580.........  Putnam County, New         5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33590.........  Queens County, New         5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33600.........  Rensselaer County,         0160  Urban         0.8570    0.8650     10580  Urban         0.8610
                 New York.
33610.........  Richmond County, New       5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33620.........  Rockland County, New       5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 York.
33630.........  St Lawrence County,          33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 New York.
33640.........  Saratoga County, New       0160  Urban         0.8570    0.8650     10580  Urban         0.8610
                 York.
33650.........  Schenectady County,        0160  Urban         0.8570    0.8650     10580  Urban         0.8610
                 New York.
33660.........  Schoharie County, New      0160  Urban         0.8570    0.8650     10580  Urban         0.8610
                 York.
33670.........  Schuyler County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33680.........  Seneca County, New           33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33690.........  Steuben County, New          33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33700.........  Suffolk County, New        5380  Urban         1.2907    1.2907     35004  Urban         1.2907
                 York.
33710.........  Sullivan County, New         33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33720.........  Tioga County, New          0960  Urban         0.8447    0.8447     13780  Urban         0.8447
                 York.
33730.........  Tompkins County, New         33  Rural         0.8403    0.9589     27060  Urban         0.8996
                 York.
33740.........  Ulster County, New           33  Rural         0.8403    0.9000     28740  Urban         0.8702
                 York.
33750.........  Warren County, New         2975  Urban         0.8467    0.8467     24020  Urban         0.8467
                 York.
33760.........  Washington County,         2975  Urban         0.8467    0.8467     24020  Urban         0.8467
                 New York.
33770.........  Wayne County, New          6840  Urban         0.9196    0.9281     40380  Urban         0.9239
                 York.
33800.........  Westchester County,        5600  Urban         1.3586    1.3311     35644  Urban         1.3449
                 New York.
33900.........  Wyoming County, New          33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
33910.........  Yates County, New            33  Rural         0.8403    0.8151     99933  Rural         0.8277
                 York.
34000.........  Alamance County, N         3120  Urban         0.9312    0.8967     15500  Urban         0.9140
                 Carolina.

[[Page 47982]]

 
34010.........  Alexander County, N        3290  Urban         0.9502    0.9502     25860  Urban         0.9502
                 Carolina.
34020.........  Alleghany County, N          34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34030.........  Anson County, N              34  Rural         0.8500    0.9743     16740  Urban         0.9122
                 Carolina.
34040.........  Ashe County, N               34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34050.........  Avery County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34060.........  Beaufort County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34070.........  Bertie County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34080.........  Bladen County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34090.........  Brunswick County, N        9200  Urban         0.9237    0.9237     48900  Urban         0.9237
                 Carolina.
34100.........  Buncombe County, N         0480  Urban         0.9501    0.9191     11700  Urban         0.9346
                 Carolina.
34110.........  Burke County, N            3290  Urban         0.9502    0.9502     25860  Urban         0.9502
                 Carolina.
34120.........  Cabarrus County, N         1520  Urban         0.9711    0.9743     16740  Urban         0.9727
                 Carolina.
34130.........  Caldwell County, N         3290  Urban         0.9502    0.9502     25860  Urban         0.9502
                 Carolina.
34140.........  Camden County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34150.........  Carteret County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34160.........  Caswell County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34170.........  Catawba County, N          3290  Urban         0.9502    0.9502     25860  Urban         0.9502
                 Carolina.
34180.........  Chatham County, N          6640  Urban         1.0258    1.0363     20500  Urban         1.0311
                 Carolina.
34190.........  Cherokee County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34200.........  Chowan County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34210.........  Clay County, N               34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34220.........  Cleveland County, N          34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34230.........  Columbus County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34240.........  Craven County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34250.........  Cumberland County, N       2560  Urban         0.9363    0.9363     22180  Urban         0.9363
                 Carolina.
34251.........  Currituck County, N        5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Carolina.
34270.........  Dare County, N               34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34280.........  Davidson County, N         3120  Urban         0.9312    0.8563     99934  Rural         0.8938
                 Carolina.
34290.........  Davie County, N            3120  Urban         0.9312    0.9401     49180  Urban         0.9357
                 Carolina.
34300.........  Duplin County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34310.........  Durham County, N           6640  Urban         1.0258    1.0363     20500  Urban         1.0311
                 Carolina.
34320.........  Edgecombe County, N        6895  Urban         0.8998    0.8998     40580  Urban         0.8998
                 Carolina.
34330.........  Forsyth County, N          3120  Urban         0.9312    0.9401     49180  Urban         0.9357
                 Carolina.
34340.........  Franklin County, N         6640  Urban         1.0258    1.0057     39580  Urban         1.0158
                 Carolina.
34350.........  Gaston County, N           1520  Urban         0.9711    0.9743     16740  Urban         0.9727
                 Carolina.
34360.........  Gates County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34370.........  Graham County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34380.........  Granville County, N          34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34390.........  Greene County, N             34  Rural         0.8500    0.9183     24780  Urban         0.8842
                 Carolina.
34400.........  Guilford County, N        13120  Urban         0.9312    0.9190     24660  Urban         0.9251
                 Carolina.
34410.........  Halifax County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34420.........  Harnett County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34430.........  Haywood County, N            34  Rural         0.8500    0.9191     11700  Urban         0.8846
                 Carolina.
34440.........  Henderson County, N          34  Rural         0.8500    0.9191     11700  Urban         0.8846
                 Carolina.
34450.........  Hertford County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34460.........  Hoke County, N               34  Rural         0.8500    0.9363     22180  Urban         0.8932
                 Carolina.
34470.........  Hyde County, N               34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34480.........  Iredell County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34490.........  Jackson County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34500.........  Johnston County, N         6640  Urban         1.0258    1.0057     39580  Urban         1.0158
                 Carolina.
34510.........  Jones County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34520.........  Lee County, N                34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34530.........  Lenoir County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34540.........  Lincoln County, N          1520  Urban         0.9711    0.8563     99934  Rural         0.9137
                 Carolina.
34550.........  Mc Dowell County, N          34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34560.........  Macon County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34570.........  Madison County, N          0480  Urban         0.9501    0.9191     11700  Urban         0.9346
                 Carolina.
34580.........  Martin County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34590.........  Mecklenburg County, N      1520  Urban         0.9711    0.9743     16740  Urban         0.9727
                 Carolina.
34600.........  Mitchell County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34610.........  Montgomery County, N         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34620.........  Moore County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34630.........  Nash County, N             6895  Urban         0.8998    0.8998     40580  Urban         0.8998
                 Carolina.
34640.........  New Hanover County, N      9200  Urban         0.9237    0.9237     48900  Urban         0.9237
                 Carolina.
34650.........  Northampton County, N        34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34660.........  Onslow County, N           3605  Urban         0.8401    0.8401     27340  Urban         0.8401
                 Carolina.
34670.........  Orange County, N           6640  Urban         1.0258    1.0363     20500  Urban         1.0311
                 Carolina.
34680.........  Pamlico County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.

[[Page 47983]]

 
34690.........  Pasquotank County, N         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34700.........  Pender County, N             34  Rural         0.8500    0.9237     48900  Urban         0.8869
                 Carolina.
34710.........  Perquimans County, N         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34720.........  Person County, N             34  Rural         0.8500    1.0363     20500  Urban         0.9432
                 Carolina.
34730.........  Pitt County, N             3150  Urban         0.9183    0.9183     24780  Urban         0.9183
                 Carolina.
34740.........  Polk County, N               34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34750.........  Randolph County, N         3120  Urban         0.9312    0.9190     24660  Urban         0.9251
                 Carolina.
34760.........  Richmond County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34770.........  Robeson County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34780.........  Rockingham County, N         34  Rural         0.8500    0.9190     24660  Urban         0.8845
                 Carolina.
34790.........  Rowan County, N            1520  Urban         0.9711    0.8563     99934  Rural         0.9137
                 Carolina.
34800.........  Rutherford County, N         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34810.........  Sampson County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34820.........  Scotland County, N           34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34830.........  Stanly County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34840.........  Stokes County, N           3120  Urban         0.9312    0.9401     49180  Urban         0.9357
                 Carolina.
34850.........  Surry County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34860.........  Swain County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34870.........  Transylvania County,         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 N Carolina.
34880.........  Tyrrell County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34890.........  Union County, N            1520  Urban         0.9711    0.9743     16740  Urban         0.9727
                 Carolina.
34900.........  Vance County, N              34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34910.........  Wake County, N             6640  Urban         1.0258    1.0057     39580  Urban         1.0158
                 Carolina.
34920.........  Warren County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34930.........  Washington County, N         34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34940.........  Watauga County, N            34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34950.........  Wayne County, N            2980  Urban         0.8778    0.8778     24140  Urban         0.8778
                 Carolina.
34960.........  Wilkes County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34970.........  Wilson County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
34980.........  Yadkin County, N           3120  Urban         0.9312    0.9401     49180  Urban         0.9357
                 Carolina.
34981.........  Yancey County, N             34  Rural         0.8500    0.8563     99934  Rural         0.8532
                 Carolina.
35000.........  Adams County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35010.........  Barnes County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35020.........  Benson County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35030.........  Billings County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35040.........  Bottineau County, N          35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35050.........  Bowman County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35060.........  Burke County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35070.........  Burleigh County, N         1010  Urban         0.7505    0.7505     13900  Urban         0.7505
                 Dakota.
35080.........  Cass County, N Dakota      2520  Urban         0.9114    0.9114     22020  Urban         0.9114
35090.........  Cavalier County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35100.........  Dickey County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35110.........  Divide County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35120.........  Dunn County, N Dakota        35  Rural         0.7743    0.7743     99935  Rural         0.7743
35130.........  Eddy County, N Dakota        35  Rural         0.7743    0.7743     99935  Rural         0.7743
35140.........  Emmons County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35150.........  Foster County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35160.........  Golden Valley County,        35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 N Dakota.
35170.........  Grand Forks County, N      2985  Urban         0.9091    0.9091     24220  Urban         0.9091
                 Dakota.
35180.........  Grant County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35190.........  Griggs County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35200.........  Hettinger County, N          35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35210.........  Kidder County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35220.........  La Moure County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35230.........  Logan County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35240.........  Mc Henry County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35250.........  Mc Intosh County, N          35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35260.........  Mc Kenzie County, N          35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35270.........  Mc Lean County, N            35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35280.........  Mercer County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35290.........  Morton County, N           1010  Urban         0.7505    0.7505     13900  Urban         0.7505
                 Dakota.
35300.........  Mountrail County, N          35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35310.........  Nelson County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35320.........  Oliver County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35330.........  Pembina County, N            35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35340.........  Pierce County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35350.........  Ramsey County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35360.........  Ransom County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.

[[Page 47984]]

 
35370.........  Renville County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35380.........  Richland County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35390.........  Rolette County, N            35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35400.........  Sargent County, N            35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35410.........  Sheridan County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35420.........  Sioux County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35430.........  Slope County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35440.........  Stark County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35450.........  Steele County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35460.........  Stutsman County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35470.........  Towner County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35480.........  Traill County, N             35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35490.........  Walsh County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35500.........  Ward County, N Dakota        35  Rural         0.7743    0.7743     99935  Rural         0.7743
35510.........  Wells County, N              35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
35520.........  Williams County, N           35  Rural         0.7743    0.7743     99935  Rural         0.7743
                 Dakota.
36000.........  Adams County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36010.........  Allen County, Ohio...      4320  Urban         0.9258    0.9330     30620  Urban         0.9294
36020.........  Ashland County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36030.........  Ashtabula County,          1680  Urban         0.9626    0.8693     99936  Rural         0.9160
                 Ohio.
36040.........  Athens County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36050.........  Auglaize County, Ohio      4320  Urban         0.9258    0.8693     99936  Rural         0.8976
36060.........  Belmont County, Ohio.      9000  Urban         0.7449    0.7449     48540  Urban         0.7449
36070.........  Brown County, Ohio...      1640  Urban         0.9595    0.9516     17140  Urban         0.9556
36080.........  Butler County, Ohio..      3200  Urban         0.9066    0.9516     17140  Urban         0.9291
36090.........  Carroll County, Ohio.      1320  Urban         0.8895    0.8895     15940  Urban         0.8895
36100.........  Champaign County,            36  Rural         0.8759    0.8693     99936  Rural         0.8726
                 Ohio.
36110.........  Clark County, Ohio...      2000  Urban         0.9231    0.8748     44220  Urban         0.8990
36120.........  Clermont County, Ohio      1640  Urban         0.9595    0.9516     17140  Urban         0.9556
36130.........  Clinton County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36140.........  Columbiana County,         9320  Urban         0.9517    0.8693     99936  Rural         0.9105
                 Ohio.
36150.........  Coshocton County,            36  Rural         0.8759    0.8693     99936  Rural         0.8726
                 Ohio.
36160.........  Crawford County, Ohio      4800  Urban         0.9105    0.8693     99936  Rural         0.8899
36170.........  Cuyahoga County, Ohio      1680  Urban         0.9626    0.9650     17460  Urban         0.9638
36190.........  Darke County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36200.........  Defiance County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36210.........  Delaware County, Ohio      1840  Urban         0.9753    0.9737     18140  Urban         0.9745
36220.........  Erie County, Ohio....        36  Rural         0.8759    0.9017     41780  Urban         0.8888
36230.........  Fairfield County,          1840  Urban         0.9753    0.9737     18140  Urban         0.9745
                 Ohio.
36240.........  Fayette County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36250.........  Franklin County, Ohio      1840  Urban         0.9753    0.9737     18140  Urban         0.9745
36260.........  Fulton County, Ohio..      8400  Urban         0.9524    0.9524     45780  Urban         0.9524
36270.........  Gallia County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36280.........  Geauga County, Ohio..      1680  Urban         0.9626    0.9650     17460  Urban         0.9638
36290.........  Greene County, Ohio..      2000  Urban         0.9231    0.9303     19380  Urban         0.9267
36300.........  Guernsey County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36310.........  Hamilton County, Ohio      1640  Urban         0.9595    0.9516     17140  Urban         0.9556
36330.........  Hancock County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36340.........  Hardin County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36350.........  Harrison County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36360.........  Henry County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36370.........  Highland County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36380.........  Hocking County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36390.........  Holmes County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36400.........  Huron County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36410.........  Jackson County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36420.........  Jefferson County,          8080  Urban         0.8280    0.8280     48260  Urban         0.8280
                 Ohio.
36430.........  Knox County, Ohio....        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36440.........  Lake County, Ohio....      1680  Urban         0.9626    0.9650     17460  Urban         0.9638
36450.........  Lawrence County, Ohio      3400  Urban         0.9564    0.9564     26580  Urban         0.9564
36460.........  Licking County, Ohio.      1840  Urban         0.9753    0.9737     18140  Urban         0.9745
36470.........  Logan County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36480.........  Lorain County, Ohio..      1680  Urban         0.9626    0.9650     17460  Urban         0.9638
36490.........  Lucas County, Ohio...      8400  Urban         0.9524    0.9524     45780  Urban         0.9524
36500.........  Madison County, Ohio.      1840  Urban         0.9753    0.9737     18140  Urban         0.9745
36510.........  Mahoning County, Ohio      9320  Urban         0.9517    0.9237     49660  Urban         0.9377
36520.........  Marion County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36530.........  Medina County, Ohio..      1680  Urban         0.9626    0.9650     17460  Urban         0.9638

[[Page 47985]]

 
36540.........  Meigs County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36550.........  Mercer County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36560.........  Miami County, Ohio...      2000  Urban         0.9231    0.9303     19380  Urban         0.9267
36570.........  Monroe County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36580.........  Montgomery County,         2000  Urban         0.9231    0.9303     19380  Urban         0.9267
                 Ohio.
36590.........  Morgan County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36600.........  Morrow County, Ohio..        36  Rural         0.8759    0.9737     18140  Urban         0.9248
36610.........  Muskingum County,            36  Rural         0.8759    0.8693     99936  Rural         0.8726
                 Ohio.
36620.........  Noble County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36630.........  Ottawa County, Ohio..        36  Rural         0.8759    0.9524     45780  Urban         0.9142
36640.........  Paulding County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36650.........  Perry County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36660.........  Pickaway County, Ohio      1840  Urban         0.9753    0.9737     18140  Urban         0.9745
36670.........  Pike County, Ohio....        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36680.........  Portage County, Ohio.      0080  Urban         0.9055    0.9055     10420  Urban         0.9055
36690.........  Preble County, Ohio..        36  Rural         0.8759    0.9303     19380  Urban         0.9031
36700.........  Putnam County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36710.........  Richland County, Ohio      4800  Urban         0.9105    0.9189     31900  Urban         0.9147
36720.........  Ross County, Ohio....        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36730.........  Sandusky County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36740.........  Scioto County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36750.........  Seneca County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36760.........  Shelby County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36770.........  Stark County, Ohio...      1320  Urban         0.8895    0.8895     15940  Urban         0.8895
36780.........  Summit County, Ohio..      0080  Urban         0.9055    0.9055     10420  Urban         0.9055
36790.........  Trumbull County, Ohio      9320  Urban         0.9517    0.9237     49660  Urban         0.9377
36800.........  Tuscarawas County,           36  Rural         0.8759    0.8693     99936  Rural         0.8726
                 Ohio.
36810.........  Union County, Ohio...        36  Rural         0.8759    0.9737     18140  Urban         0.9248
36820.........  Van Wert County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36830.........  Vinton County, Ohio..        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36840.........  Warren County, Ohio..      1640  Urban         0.9595    0.9516     17140  Urban         0.9556
36850.........  Washington County,         6020  Urban         0.8288    0.8288     37620  Urban         0.8288
                 Ohio.
36860.........  Wayne County, Ohio...        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36870.........  Williams County, Ohio        36  Rural         0.8759    0.8693     99936  Rural         0.8726
36880.........  Wood County, Ohio....      8400  Urban         0.9524    0.9524     45780  Urban         0.9524
36890.........  Wyandot County, Ohio.        36  Rural         0.8759    0.8693     99936  Rural         0.8726
37000.........  Adair County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37101.........  Alfalfa County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37020.........  Atoka County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37030.........  Beaver County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37040.........  Beckham County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37050.........  Blaine County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37060.........  Bryan County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37070.........  Caddo County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37080.........  Canadian County,           5880  Urban         0.8966    0.8982     36420  Urban         0.8974
                 Oklahoma.
37090.........  Carter County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37100.........  Cherokee County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37110.........  Choctaw County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37120.........  Cimarron County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37130.........  Cleveland County,          5880  Urban         0.8966    0.8982     36420  Urban         0.8974
                 Oklahoma.
37140.........  Coal County, Oklahoma        37  Rural         0.7537    0.7686     99937  Rural         0.7612
37150.........  Comanche County,           4200  Urban         0.8212    0.8212     30020  Urban         0.8212
                 Oklahoma.
37160.........  Cotton County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37170.........  Craig County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37180.........  Creek County,              8560  Urban         0.8729    0.8690     46140  Urban         0.8710
                 Oklahoma.
37190.........  Custer County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37200.........  Delaware County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37210.........  Dewey County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37220.........  Ellis County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37230.........  Garfield County,           2340  Urban         0.9001    0.7686     99937  Rural         0.8344
                 Oklahoma.
37240.........  Garvin County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37250.........  Grady County,                37  Rural         0.7537    0.8982     36420  Urban         0.8260
                 Oklahoma.
37260.........  Grant County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37270.........  Greer County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37280.........  Harmon County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37290.........  Harper County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37300.........  Haskell County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37310.........  Hughes County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.

[[Page 47986]]

 
37320.........  Jackson County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37330.........  Jefferson County,            37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37340.........  Johnston County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37350.........  Kay County, Oklahoma.        37  Rural         0.7537    0.7686     99937  Rural         0.7612
37360.........  Kingfisher County,           37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37370.........  Kiowa County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37380.........  Latimer County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37390.........  Le Flore County,             37  Rural         0.7537    0.8283     22900  Urban         0.7910
                 Oklahoma.
37400.........  Lincoln County,              37  Rural         0.7537    0.8982     36420  Urban         0.8260
                 Oklahoma.
37410.........  Logan County,              5880  Urban         0.8966    0.8982     36420  Urban         0.8974
                 Oklahoma.
37420.........  Love County, Oklahoma        37  Rural         0.7537    0.7686     99937  Rural         0.7612
37430.........  Mc Clain County,           5880  Urban         0.8966    0.8982     36420  Urban         0.8974
                 Oklahoma.
37440.........  Mc Curtain County,           37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37450.........  Mc Intosh County,            37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37460.........  Major County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37470.........  Marshall County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37480.........  Mayes County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37490.........  Murray County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37500.........  Muskogee County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37510.........  Noble County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37520.........  Nowata County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37530.........  Okfuskee County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37540.........  Oklahoma County,           5880  Urban         0.8966    0.8982     36420  Urban         0.8974
                 Oklahoma.
37550.........  Okmulgee County,             37  Rural         0.7537    0.8690     46140  Urban         0.8114
                 Oklahoma.
37560.........  Osage County,              8560  Urban         0.8729    0.8690     46140  Urban         0.8710
                 Oklahoma.
37570.........  Ottawa County,               37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37580.........  Pawnee County,               37  Rural         0.7537    0.8690     46140  Urban         0.8114
                 Oklahoma.
37590.........  Payne County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37600.........  Pittsburg County,            37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37610.........  Pontotoc County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37620.........  Pottawatomie County,       5880  Urban         0.8966    0.7686     99937  Rural         0.8326
                 Oklahoma.
37630.........  Pushmataha County,           37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37640.........  Roger Mills County,          37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37650.........  Rogers County,             8560  Urban         0.8729    0.8690     46140  Urban         0.8710
                 Oklahoma.
37660.........  Seminole County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37670.........  Sequoyah County,           2720  Urban         0.8303    0.8283     22900  Urban         0.8293
                 Oklahoma.
37680.........  Stephens County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37690.........  Texas County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37700.........  Tillman County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37710.........  Tulsa County,              8560  Urban         0.8729    0.8690     46140  Urban         0.8710
                 Oklahoma.
37720.........  Wagoner County,            8560  Urban         0.8729    0.8690     46140  Urban         0.8710
                 Oklahoma.
37730.........  Washington County,           37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37740.........  Washita County,              37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37750.........  Woods County,                37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
37760.........  Woodward County,             37  Rural         0.7537    0.7686     99937  Rural         0.7612
                 Oklahoma.
38000.........  Baker County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38010.........  Benton County, Oregon      1890  Urban         1.0545    1.0545     18700  Urban         1.0545
38020.........  Clackamas County,          6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Oregon.
38030.........  Clatsop County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38040.........  Columbia County,           6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Oregon.
38050.........  Coos County, Oregon..        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38060.........  Crook County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38070.........  Curry County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38080.........  Deschutes County,            38  Rural         1.0049    1.0603     13460  Urban         1.0326
                 Oregon.
38090.........  Douglas County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38100.........  Gilliam County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38110.........  Grant County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38120.........  Harney County, Oregon        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38130.........  Hood River County,           38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38140.........  Jackson County,            4890  Urban         1.0534    1.0534     32780  Urban         1.0534
                 Oregon.
38150.........  Jefferson County,            38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38160.........  Josephine County,            38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38170.........  Klamath County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38180.........  Lake County, Oregon..        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38190.........  Lane County, Oregon..      2400  Urban         1.0940    1.0940     21660  Urban         1.0940
38200.........  Lincoln County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38210.........  Linn County, Oregon..        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38220.........  Malheur County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.

[[Page 47987]]

 
38230.........  Marion County, Oregon      7080  Urban         1.0556    1.0556     41420  Urban         1.0556
38240.........  Morrow County, Oregon        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38250.........  Multnomah County,          6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Oregon.
38260.........  Polk County, Oregon..      7080  Urban         1.0556    1.0556     41420  Urban         1.0556
38270.........  Sherman County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38280.........  Tillamook County,            38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38290.........  Umatilla County,             38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38300.........  Union County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38310.........  Wallowa County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38320.........  Wasco County, Oregon.        38  Rural         1.0049    0.9914     99938  Rural         0.9982
38330.........  Washington County,         6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Oregon.
38340.........  Wheeler County,              38  Rural         1.0049    0.9914     99938  Rural         0.9982
                 Oregon.
38350.........  Yamhill County,            6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Oregon.
39000.........  Adams County,                39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39010.........  Allegheny County,          6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39070.........  Armstrong County,            39  Rural         0.8348    0.8736     38300  Urban         0.8542
                 Pennsylvania.
39080.........  Beaver County,             6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39100.........  Bedford County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39110.........  Berks County,              6680  Urban         0.9215    0.9215     39740  Urban         0.9215
                 Pennsylvania.
39120.........  Blair County,              0280  Urban         0.8462    0.8462     11020  Urban         0.8462
                 Pennsylvania.
39130.........  Bradford County,             39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39140.........  Bucks County,              6160  Urban         1.0824    1.0865     37964  Urban         1.0845
                 Pennsylvania.
39150.........  Butler County,             6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39160.........  Cambria County,            3680  Urban         0.7980    0.8380     27780  Urban         0.8180
                 Pennsylvania.
39180.........  Cameron County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39190.........  Carbon County,             0240  Urban         0.9536    0.9501     10900  Urban         0.9519
                 Pennsylvania.
39200.........  Centre County,             8050  Urban         0.8461    0.8461     44300  Urban         0.8461
                 Pennsylvania.
39210.........  Chester County,            6160  Urban         1.0824    1.0865     37964  Urban         1.0845
                 Pennsylvania.
39220.........  Clarion County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39230.........  Clearfield County,           39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39240.........  Clinton County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39250.........  Columbia County,           7560  Urban         0.8522    0.8310     99939  Rural         0.8416
                 Pennsylvania.
39260.........  Crawford County,             39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39270.........  Cumberland County,         3240  Urban         0.9286    0.9359     25420  Urban         0.9323
                 Pennsylvania.
39280.........  Dauphin County,            3240  Urban         0.9286    0.9359     25420  Urban         0.9323
                 Pennsylvania.
39290.........  Delaware County,           6160  Urban         1.0824    1.0865     37964  Urban         1.0845
                 Pennsylvania.
39310.........  Elk County,                  39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39320.........  Erie County,               2360  Urban         0.8699    0.8699     21500  Urban         0.8699
                 Pennsylvania.
39330.........  Fayette County,            6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39340.........  Forest County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39350.........  Franklin County,             39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39360.........  Fulton County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39370.........  Greene County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39380.........  Huntingdon County,           39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39390.........  Indiana County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39400.........  Jefferson County,            39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39410.........  Juniata County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39420.........  Lackawanna County,         7560  Urban         0.8522    0.8543     42540  Urban         0.8533
                 Pennsylvania.
39440.........  Lancaster County,          4000  Urban         0.9883    0.9883     29540  Urban         0.9883
                 Pennsylvania.
39450.........  Lawrence County,             39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39460.........  Lebanon County,            3240  Urban         0.9286    0.8570     30140  Urban         0.8928
                 Pennsylvania.
39470.........  Lehigh County,             0240  Urban         0.9536    0.9501     10900  Urban         0.9519
                 Pennsylvania.
39480.........  Luzerne County,            7560  Urban         0.8522    0.8543     42540  Urban         0.8533
                 Pennsylvania.
39510.........  Lycoming County,           9140  Urban         0.8485    0.8485     48700  Urban         0.8485
                 Pennsylvania.
39520.........  Mc Kean County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39530.........  Mercer County,             7610  Urban         0.7881    0.9237     49660  Urban         0.8559
                 Pennsylvania.
39540.........  Mifflin County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39550.........  Monroe County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39560.........  Montgomery County,         6160  Urban         1.0824    1.0865     37964  Urban         1.0845
                 Pennsylvania.
39580.........  Montour County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39590.........  Northampton County,        0240  Urban         0.9536    0.9501     10900  Urban         0.9519
                 Pennsylvania.
39600.........  Northumberland               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 County, Pennsylvania.
39610.........  Perry County,              3240  Urban         0.9286    0.9359     25420  Urban         0.9323
                 Pennsylvania.
39620.........  Philadelphia County,       6160  Urban         1.0824    1.0865     37964  Urban         1.0845
                 Pennsylvania.
39630.........  Pike County,               5660  Urban         1.1170    1.1687     35084  Urban         1.1429
                 Pennsylvania.
39640.........  Potter County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39650.........  Schuylkill County,           39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39670.........  Snyder County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.

[[Page 47988]]

 
39680.........  Somerset County,           3680  Urban         0.7980    0.8310     99939  Rural         0.8145
                 Pennsylvania.
39690.........  Sullivan County,             39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39700.........  Susquehanna County,          39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39710.........  Tioga County,                39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39720.........  Union County,                39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39730.........  Venango County,              39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39740.........  Warren County,               39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39750.........  Washington County,         6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39760.........  Wayne County,                39  Rural         0.8348    0.8310     99939  Rural         0.8329
                 Pennsylvania.
39770.........  Westmoreland County,       6280  Urban         0.8756    0.8736     38300  Urban         0.8746
                 Pennsylvania.
39790.........  Wyoming County,            7560  Urban         0.8522    0.8543     42540  Urban         0.8533
                 Pennsylvania.
39800.........  York County,               9280  Urban         0.9150    0.9150     49620  Urban         0.9150
                 Pennsylvania.
40010.........  Adjuntas County,             40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40020.........  Aguada County, Puerto      0060  Urban         0.4294    0.4280     10380  Urban         0.4287
                 Rico.
40030.........  Aguadilla County,          0060  Urban         0.4294    0.4280     10380  Urban         0.4287
                 Puerto Rico.
40040.........  Aguas Buenas County,       7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40050.........  Aibonito County,             40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40060.........  Anasco County, Puerto      4840  Urban         0.4769    0.4280     10380  Urban         0.4525
                 Rico.
40070.........  Arecibo County,            0470  Urban         0.3757    0.4645     41980  Urban         0.4201
                 Puerto Rico.
40080.........  Arroyo County, Puerto        40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Rico.
40090.........  Barceloneta County,        7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40100.........  Barranquitas County,         40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40110.........  Bayamon County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40120.........  Cabo Rojo County,          4840  Urban         0.4769    0.5240     41900  Urban         0.5005
                 Puerto Rico.
40130.........  Caguas County, Puerto      1310  Urban         0.4061    0.4645     41980  Urban         0.4353
                 Rico.
40140.........  Camuy County, Puerto       0470  Urban         0.3757    0.4645     41980  Urban         0.4201
                 Rico.
40145.........  Canovanas County,          7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40150.........  Carolina County,           7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40160.........  Catano County, Puerto      7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Rico.
40170.........  Cayey County, Puerto       1310  Urban         0.4061    0.4645     41980  Urban         0.4353
                 Rico.
40180.........  Ceiba County, Puerto       7440  Urban         0.4802    0.3939     21940  Urban         0.4371
                 Rico.
40190.........  Ciales County, Puerto        40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Rico.
40200.........  Cidra County, Puerto       1310  Urban         0.4061    0.4645     41980  Urban         0.4353
                 Rico.
40210.........  Coamo County, Puerto         40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Rico.
40220.........  Comerio County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40230.........  Corozal County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40240.........  Culebra County,              40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40250.........  Dorado County, Puerto      7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Rico.
40260.........  Fajardo County,            7440  Urban         0.4802    0.3939     21940  Urban         0.4371
                 Puerto Rico.
40265.........  Florida County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40270.........  Guanica County,              40  Rural         0.4047    0.4493     49500  Urban         0.4270
                 Puerto Rico.
40280.........  Guayama County,              40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Puerto Rico.
40290.........  Guayanilla County,         6360  Urban         0.4954    0.4493     49500  Urban         0.4724
                 Puerto Rico.
40300.........  Guaynabo County,           7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40310.........  Gurabo County, Puerto      1310  Urban         0.4061    0.4645     41980  Urban         0.4353
                 Rico.
40320.........  Hatillo County,            0470  Urban         0.3757    0.4645     41980  Urban         0.4201
                 Puerto Rico.
40330.........  Hormigueros County,        4840  Urban         0.4769    0.4493     32420  Urban         0.4631
                 Puerto Rico.
40340.........  Humacao County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40350.........  Isabela County,              40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Puerto Rico.
40360.........  Jayuya County, Puerto        40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Rico.
40370.........  Juana Diaz County,         6360  Urban         0.4954    0.5006     38660  Urban         0.4980
                 Puerto Rico.
40380.........  Juncos County, Puerto      7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Rico.
40390.........  Lajas County, Puerto         40  Rural         0.4047    0.5240     41900  Urban         0.4644
                 Rico.
40400.........  Lares County, Puerto         40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Rico.
40410.........  Las Marias County,           40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40420.........  Las Piedras County,        7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40430.........  Loiza County, Puerto       7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Rico.
40440.........  Luquillo County,           7440  Urban         0.4802    0.3939     21940  Urban         0.4371
                 Puerto Rico.
40450.........  Manati County, Puerto      7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Rico.
40460.........  Maricao County,              40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40470.........  Maunabo County,              40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40480.........  Mayaguez County,           4840  Urban         0.4769    0.4493     32420  Urban         0.4631
                 Puerto Rico.
40490.........  Moca County, Puerto        0060  Urban         0.4294    0.4280     10380  Urban         0.4287
                 Rico.
40500.........  Morovis County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40510.........  Naguabo County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40520.........  Naranjito County,          7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40530.........  Orocovis County,             40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40540.........  Patillas County,             40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Puerto Rico.

[[Page 47989]]

 
40550.........  Penuelas County,           6360  Urban         0.4954    0.4493     49500  Urban         0.4724
                 Puerto Rico.
40560.........  Ponce County, Puerto       6360  Urban         0.4954    0.5006     38660  Urban         0.4980
                 Rico.
40570.........  Quebradillas County,         40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40580.........  Rincon County, Puerto        40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Rico.
40590.........  Rio Grande County,         7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40610.........  Sabana Grande County,      4840  Urban         0.4769    0.5240     41900  Urban         0.5005
                 Puerto Rico.
40620.........  Salinas County,              40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40630.........  San German County,         4840  Urban         0.4769    0.5240     41900  Urban         0.5005
                 Puerto Rico.
40640.........  San Juan County,           7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40650.........  San Lorenzo County,         310  Urban         0.4061    0.4645     41980  Urban         0.4353
                 Puerto Rico.
40660.........  San Sebastian County,        40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Puerto Rico.
40670.........  Santa Isabel County,         40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40680.........  Toa Alta County,           7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40690.........  Toa Baja County,           7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40700.........  Trujillo Alto County,      7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40710.........  Utuado County, Puerto        40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Rico.
40720.........  Vega Alta County,          7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40730.........  Vega Baja County,          7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40740.........  Vieques County,              40  Rural         0.4047    0.4047     99940  Rural         0.4047
                 Puerto Rico.
40750.........  Villalba County,           6360  Urban         0.4954    0.5006     38660  Urban         0.4980
                 Puerto Rico.
40760.........  Yabucoa County,            7440  Urban         0.4802    0.4645     41980  Urban         0.4724
                 Puerto Rico.
40770.........  Yauco County, Puerto       6360  Urban         0.4954    0.4493     49500  Urban         0.4724
                 Rico.
41000.........  Bristol County, Rhode      6483  Urban         1.1061    1.0929     39300  Urban         1.0995
                 Island.
41010.........  Kent County, Rhode         6483  Urban         1.1061    1.0929     39300  Urban         1.0995
                 Island.
41020.........  Newport County, Rhode      6483  Urban         1.1061    1.0929     39300  Urban         1.0995
                 Island.
41030.........  Providence County,         6483  Urban         1.1061    1.0929     39300  Urban         1.0995
                 Rhode Island.
41050.........  Washington County,         6483  Urban         1.1061    1.0929     39300  Urban         1.0995
                 Rhode Island.
42000.........  Abbeville County, S          42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42010.........  Aiken County, S            0600  Urban         0.9208    0.9154     12260  Urban         0.9181
                 Carolina.
42020.........  Allendale County, S          42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42030.........  Anderson County, S         3160  Urban         0.9400    0.8670     11340  Urban         0.9035
                 Carolina.
42040.........  Bamberg County, S            42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42050.........  Barnwell County, S           42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42060.........  Beaufort County, S           42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42070.........  Berkeley County, S         1440  Urban         0.9420    0.9420     16700  Urban         0.9420
                 Carolina.
42080.........  Calhoun County, S            42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42090.........  Charleston County, S       1440  Urban         0.9420    0.9420     16700  Urban         0.9420
                 Carolina.
42100.........  Cherokee County, S         3160  Urban         0.9400    0.8683     99942  Rural         0.9042
                 Carolina.
42110.........  Chester County, S            42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42120.........  Chesterfield County,         42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 S Carolina.
42130.........  Clarendon County, S          42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42140.........  Colleton County, S           42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42150.........  Darlington County, S         42  Rural         0.8640    0.8833     22500  Urban         0.8737
                 Carolina.
42160.........  Dillon County, S             42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42170.........  Dorchester County, S       1440  Urban         0.9420    0.9420     16700  Urban         0.9420
                 Carolina.
42180.........  Edgefield County, S        0600  Urban         0.9208    0.9154     12260  Urban         0.9181
                 Carolina.
42190.........  Fairfield County, S          42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42200.........  Florence County, S         2655  Urban         0.8960    0.8833     22500  Urban         0.8897
                 Carolina.
42210.........  Georgetown County, S         42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42220.........  Greenville County, S       3160  Urban         0.9400    0.9557     24860  Urban         0.9479
                 Carolina.
42230.........  Greenwood County, S          42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42240.........  Hampton County, S            42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42250.........  Horry County, S            5330  Urban         0.9022    0.9022     34820  Urban         0.9022
                 Carolina.
42260.........  Jasper County, S             42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42270.........  Kershaw County, S            42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42280.........  Lancaster County, S          42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42290.........  Laurens County, S            42  Rural         0.8640    0.9557     24860  Urban         0.9099
                 Carolina.
42300.........  Lee County, S                42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42310.........  Lexington County, S        1760  Urban         0.9450    0.9392     17900  Urban         0.9421
                 Carolina.
42320.........  Mc Cormick County, S         42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42330.........  Marion County, S             42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42340.........  Marlboro County, S           42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42350.........  Newberry County, S           42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42360.........  Oconee County, S             42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42370.........  Orangeburg County, S         42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42380.........  Pickens County, S          3160  Urban         0.9400    0.9557     24860  Urban         0.9479
                 Carolina.
42390.........  Richland County, S         1760  Urban         0.9450    0.9392     17900  Urban         0.9421
                 Carolina.
42400.........  Saluda County, S             42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.

[[Page 47990]]

 
42410.........  Spartanburg County, S      3160  Urban         0.9400    0.9519     43900  Urban         0.9460
                 Carolina.
42420.........  Sumter County, S           8140  Urban         0.8520    0.8520     44940  Urban         0.8520
                 Carolina.
42430.........  Union County, S              42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 Carolina.
42440.........  Williamsburg County,         42  Rural         0.8640    0.8683     99942  Rural         0.8662
                 S Carolina.
42450.........  York County, S             1520  Urban         0.9711    0.9743     16740  Urban         0.9727
                 Carolina.
43010.........  Aurora County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43020.........  Beadle County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43030.........  Bennett County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43040.........  Bon Homme County, S          43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43050.........  Brookings County, S          43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43060.........  Brown County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43070.........  Brule County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43080.........  Buffalo County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43090.........  Butte County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43100.........  Campbell County, S           43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43110.........  Charles Mix County, S        43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43120.........  Clark County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43130.........  Clay County, S Dakota        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43140.........  Codington County, S          43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43150.........  Corson County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43160.........  Custer County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43170.........  Davison County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43180.........  Day County, S Dakota.        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43190.........  Deuel County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43200.........  Dewey County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43210.........  Douglas County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43220.........  Edmunds County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43230.........  Fall River County, S         43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43240.........  Faulk County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43250.........  Grant County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43260.........  Gregory County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43270.........  Haakon County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43280.........  Hamlin County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43290.........  Hand County, S Dakota        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43300.........  Hanson County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43310.........  Harding County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43320.........  Hughes County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43330.........  Hutchinson County, S         43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43340.........  Hyde County, S Dakota        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43350.........  Jackson County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43360.........  Jerauld County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43370.........  Jones County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43380.........  Kingsbury County, S          43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43390.........  Lake County, S Dakota        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43400.........  Lawrence County, S           43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43410.........  Lincoln County, S          7760  Urban         0.9441    0.9441     43620  Urban         0.9441
                 Dakota.
43420.........  Lyman County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43430.........  Mc Cook County, S            43  Rural         0.8393    0.9441     43620  Urban         0.8917
                 Dakota.
43440.........  Mc Pherson County, S         43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43450.........  Marshall County, S           43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43460.........  Meade County, S              43  Rural         0.8393    0.8912     39660  Urban         0.8653
                 Dakota.
43470.........  Mellette County, S           43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43480.........  Miner County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43490.........  Minnehaha County, S        7760  Urban         0.9441    0.9441     43620  Urban         0.9441
                 Dakota.
43500.........  Moody County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43510.........  Pennington County, S       6660  Urban         0.8912    0.8912     39660  Urban         0.8912
                 Dakota.
43520.........  Perkins County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43530.........  Potter County, S             43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43540.........  Roberts County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43550.........  Sanborn County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43560.........  Shannon County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43570.........  Spink County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43580.........  Stanley County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43590.........  Sully County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43600.........  Todd County, S Dakota        43  Rural         0.8393    0.8398     99943  Rural         0.8396
43610.........  Tripp County, S              43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43620.........  Turner County, S             43  Rural         0.8393    0.9441     43620  Urban         0.8917
                 Dakota.
43630.........  Union County, S              43  Rural         0.8393    0.9070     43580  Urban         0.8732
                 Dakota.

[[Page 47991]]

 
43640.........  Walworth County, S           43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43650.........  Washabaugh County, S         43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43670.........  Yankton County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
43680.........  Ziebach County, S            43  Rural         0.8393    0.8398     99943  Rural         0.8396
                 Dakota.
44000.........  Anderson County,           3840  Urban         0.8508    0.8548     28940  Urban         0.8528
                 Tennessee.
44010.........  Bedford County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44020.........  Benton County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44030.........  Bledsoe County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44040.........  Blount County,             3840  Urban         0.8508    0.8548     28940  Urban         0.8528
                 Tennessee.
44050.........  Bradley County,              44  Rural         0.7876    0.7844     17420  Urban         0.7860
                 Tennessee.
44060.........  Campbell County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44070.........  Cannon County,               44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44080.........  Carroll County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44090.........  Carter County,             3660  Urban         0.8202    0.8146     27740  Urban         0.8174
                 Tennessee.
44100.........  Cheatham County,           5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44110.........  Chester County,            3580  Urban         0.8900    0.8900     27180  Urban         0.8900
                 Tennessee.
44120.........  Claiborne County,            44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44130.........  Clay County,                 44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44140.........  Cocke County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44150.........  Coffee County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44160.........  Crockett County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44170.........  Cumberland County,           44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44180.........  Davidson County,           5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44190.........  Decatur County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44200.........  De Kalb County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44210.........  Dickson County,            5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44220.........  Dyer County,                 44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44230.........  Fayette County,            4920  Urban         0.9234    0.9217     32820  Urban         0.9226
                 Tennessee.
44240.........  Fentress County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44250.........  Franklin County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44260.........  Gibson County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44270.........  Giles County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44280.........  Grainger County,             44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44290.........  Greene County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44300.........  Grundy County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44310.........  Hamblen County,              44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44320.........  Hamilton County,           1560  Urban         0.9207    0.9207     16860  Urban         0.9207
                 Tennessee.
44330.........  Hancock County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44340.........  Hardeman County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44350.........  Hardin County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44360.........  Hawkins County,            3660  Urban         0.8202    0.8240     28700  Urban         0.8221
                 Tennessee.
44370.........  Haywood County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44380.........  Henderson County,            44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44390.........  Henry County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44400.........  Hickman County,              44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44410.........  Houston County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44420.........  Humphreys County,            44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44430.........  Jackson County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44440.........  Jefferson County,            44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44450.........  Johnson County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44460.........  Knox County,               3840  Urban         0.8508    0.8548     28940  Urban         0.8528
                 Tennessee.
44470.........  Lake County,                 44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44480.........  Lauderdale County,           44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44490.........  Lawrence County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44500.........  Lewis County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44510.........  Lincoln County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44520.........  Loudon County,             3840  Urban         0.8508    0.8548     28940  Urban         0.8528
                 Tennessee.
44530.........  Mc Minn County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44540.........  Mc Nairy County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44550.........  Macon County,                44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44560.........  Madison County,            3580  Urban         0.8900    0.8900     27180  Urban         0.8900
                 Tennessee.
44570.........  Marion County,             1560  Urban         0.9207    0.9207     16860  Urban         0.9207
                 Tennessee.
44580.........  Marshall County,             44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44590.........  Maury County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44600.........  Meigs County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44610.........  Monroe County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44620.........  Montgomery County,         1660  Urban         0.8022    0.8022     17300  Urban         0.8022
                 Tennessee.
44630.........  Moore County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.

[[Page 47992]]

 
44640.........  Morgan County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44650.........  Obion County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44660.........  Overton County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44670.........  Perry County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44680.........  Pickett County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44690.........  Polk County,                 44  Rural         0.7876    0.7844     17420  Urban         0.7860
                 Tennessee.
44700.........  Putnam County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44710.........  Rhea County,                 44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44720.........  Roane County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44730.........  Robertson County,          5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44740.........  Rutherford County,         5360  Urban         1.0108    1.0086      4980  Urban         1.0097
                 Tennessee.
44750.........  Scott County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44760.........  Sequatchie County,           44  Rural         0.7876    0.9207     16860  Urban         0.8542
                 Tennessee.
44770.........  Sevier County,             3840  Urban         0.8508    0.7869     99944  Rural         0.8189
                 Tennessee.
44780.........  Shelby County,             4920  Urban         0.9234    0.9217     32820  Urban         0.9226
                 Tennessee.
44790.........  Smith County,                44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44800.........  Stewart County,              44  Rural         0.7876    0.8022     17300  Urban         0.7949
                 Tennessee.
44810.........  Sullivan County,           3660  Urban         0.8202    0.8240     28700  Urban         0.8221
                 Tennessee.
44820.........  Sumner County,             5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44830.........  Tipton County,             4920  Urban         0.9234    0.9217     32820  Urban         0.9226
                 Tennessee.
44840.........  Trousdale County,            44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44850.........  Unicoi County,             3660  Urban         0.8202    0.8146     27740  Urban         0.8174
                 Tennessee.
44860.........  Union County,              3840  Urban         0.8508    0.8548     28940  Urban         0.8528
                 Tennessee.
44870.........  Van Buren County,            44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44880.........  Warren County,               44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44890.........  Washington County,         3660  Urban         0.8202    0.8146     27740  Urban         0.8174
                 Tennessee.
44900.........  Wayne County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44910.........  Weakley County,              44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44920.........  White County,                44  Rural         0.7876    0.7869     99944  Rural         0.7873
                 Tennessee.
44930.........  Williamson County,         5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
44940.........  Wilson County,             5360  Urban         1.0108    1.0086     34980  Urban         1.0097
                 Tennessee.
45000.........  Anderson County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45010.........  Andrews County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45020.........  Angelina County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45030.........  Aransas County, Texas        45  Rural         0.7910    0.8647     18580  Urban         0.8279
45040.........  Archer County, Texas.      9080  Urban         0.8395    0.8332     48660  Urban         0.8364
45050.........  Armstrong County,            45  Rural         0.7910    0.9178     11100  Urban         0.8544
                 Texas.
45060.........  Atascosa County,             45  Rural         0.7910    0.9003     41700  Urban         0.8457
                 Texas.
45070.........  Austin County, Texas.        45  Rural         0.7910    0.9973     26420  Urban         0.8942
45080.........  Bailey County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45090.........  Bandera County, Texas        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45100.........  Bastrop County, Texas      0640  Urban         0.9595    0.9595     12420  Urban         0.9595
45110.........  Baylor County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45113.........  Bee County, Texas....        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45120.........  Bell County, Texas...      3810  Urban         0.9242    0.9242     28660  Urban         0.9242
45130.........  Bexar County, Texas..      7240  Urban         0.9023    0.9003     41700  Urban         0.9013
45140.........  Blanco County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45150.........  Borden County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45160.........  Bosque County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45170.........  Bowie County, Texas..      8360  Urban         0.8413    0.8413     45500  Urban         0.8413
45180.........  Brazoria County,           1145  Urban         0.8524    0.9973     26420  Urban         0.9249
                 Texas.
45190.........  Brazos County, Texas.      1260  Urban         0.9243    0.9243     17780  Urban         0.9243
45200.........  Brewster County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45201.........  Briscoe County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45210.........  Brooks County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45220.........  Brown County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45221.........  Burleson County,             45  Rural         0.7910    0.9243      7780  Urban         0.8577
                 Texas.
45222.........  Burnet County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45223.........  Caldwell County,           0640  Urban         0.9595    0.9595     12420  Urban         0.9595
                 Texas.
45224.........  Calhoun County, Texas        45  Rural         0.7910    0.8470     47020  Urban         0.8190
45230.........  Callahan County,             45  Rural         0.7910    0.7850     10180  Urban         0.7880
                 Texas.
45240.........  Cameron County, Texas      1240  Urban         1.0125    1.0125     15180  Urban         1.0125
45250.........  Camp County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45251.........  Carson County, Texas.        45  Rural         0.7910    0.9178     11100  Urban         0.8544
45260.........  Cass County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45270.........  Castro County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45280.........  Chambers County,           3360  Urban         1.0117    0.9973     26420  Urban         1.0045
                 Texas.
45281.........  Cherokee County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.

[[Page 47993]]

 
45290.........  Childress County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45291.........  Clay County, Texas...        45  Rural         0.7910    0.8332     48660  Urban         0.8121
45292.........  Cochran County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45300.........  Coke County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45301.........  Coleman County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45310.........  Collin County, Texas.      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45311.........  Collingsworth County,        45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45312.........  Colorado County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45320.........  Comal County, Texas..      7240  Urban         0.9023    0.9003     41700  Urban         0.9013
45321.........  Comanche County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45330.........  Concho County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45340.........  Cooke County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45341.........  Coryell County, Texas      3810  Urban         0.9242    0.9242     28660  Urban         0.9242
45350.........  Cottle County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45360.........  Crane County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45361.........  Crockett County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45362.........  Crosby County, Texas.        45  Rural         0.7910    0.8777     31180  Urban         0.8344
45370.........  Culberson County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45380.........  Dallam County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45390.........  Dallas County, Texas.      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45391.........  Dawson County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45392.........  Deaf Smith County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45400.........  Delta County, Texas..        45  Rural         0.7910    1.0074     19124  Urban         0.8992
45410.........  Denton County, Texas.      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45420.........  De Witt County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45421.........  Dickens County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45430.........  Dimmit County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45431.........  Donley County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45440.........  Duval County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45450.........  Eastland County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45451.........  Ector County, Texas..      5800  Urban         0.9632    0.9798     36220  Urban         0.9715
45460.........  Edwards County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45470.........  Ellis County, Texas..      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45480.........  El Paso County, Texas      2320  Urban         0.9181    0.9181     21340  Urban         0.9181
45490.........  Erath County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45500.........  Falls County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45510.........  Fannin County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45511.........  Fayette County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45520.........  Fisher County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45521.........  Floyd County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45522.........  Foard County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45530.........  Fort Bend County,          3360  Urban         1.0117    0.9973     26420  Urban         1.0045
                 Texas.
45531.........  Franklin County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45540.........  Freestone County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45541.........  Frio County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45542.........  Gaines County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45550.........  Galveston County,          2920  Urban         0.9403    0.9973     26420  Urban         0.9688
                 Texas.
45551.........  Garza County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45552.........  Gillespie County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45560.........  Glasscock County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45561.........  Goliad County, Texas.        45  Rural         0.7910    0.8470     47020  Urban         0.8190
45562.........  Gonzales County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45563.........  Gray County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45564.........  Grayson County, Texas      7640  Urban         0.9617    0.9617     43300  Urban         0.9617
45570.........  Gregg County, Texas..      4420  Urban         0.8739    0.8801     30980  Urban         0.8770
45580.........  Grimes County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45581.........  Guadaloupe County,         7240  Urban         0.9023    0.9003     41700  Urban         0.9013
                 Texas.
45582.........  Hale County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45583.........  Hall County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45590.........  Hamilton County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45591.........  Hansford County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45592.........  Hardeman County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45600.........  Hardin County, Texas.      0840  Urban         0.8616    0.8616     13140  Urban         0.8616
45610.........  Harris County, Texas.      3360  Urban         1.0117    0.9973     26420  Urban         1.0045
45620.........  Harrison County,           4420  Urban         0.8739    0.7966     99945  Rural         0.8353
                 Texas.
45621.........  Hartley County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45630.........  Haskell County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45631.........  Hays County, Texas...      0640  Urban         0.9595    0.9595     12420  Urban         0.9595

[[Page 47994]]

 
45632.........  Hemphill County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45640.........  Henderson County,          1920  Urban         1.0054    0.7966     99945  Rural         0.9010
                 Texas.
45650.........  Hidalgo County, Texas      4880  Urban         0.8602    0.8602     32580  Urban         0.8602
45651.........  Hill County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45652.........  Hockley County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45653.........  Hood County, Texas...      2800  Urban         0.9520    0.7966     99945  Rural         0.8743
45654.........  Hopkins County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45660.........  Houston County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45661.........  Howard County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45662.........  Hudspeth County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45670.........  Hunt County, Texas...      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45671.........  Hutchinson County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45672.........  Irion County, Texas..        45  Rural         0.7910    0.8167     41660  Urban         0.8039
45680.........  Jack County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45681.........  Jackson County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45690.........  Jasper County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45691.........  Jeff Davis County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45700.........  Jefferson County,          0840  Urban         0.8616    0.8616     13140  Urban         0.8616
                 Texas.
45710.........  Jim Hogg County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45711.........  Jim Wells County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45720.........  Johnson County, Texas      2800  Urban         0.9520    0.9472     23104  Urban         0.9496
45721.........  Jones County, Texas..        45  Rural         0.7910    0.7850     10180  Urban         0.7880
45722.........  Karnes County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45730.........  Kaufman County, Texas      1920  Urban         1.0054    1.0074     19124  Urban         1.0064
45731.........  Kendall County, Texas        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45732.........  Kenedy County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45733.........  Kent County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45734.........  Kerr County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45740.........  Kimble County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45741.........  King County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45742.........  Kinney County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45743.........  Kleberg County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45744.........  Knox County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45750.........  Lamar County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45751.........  Lamb County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45752.........  Lampasas County,             45  Rural         0.7910    0.9242     28660  Urban         0.8576
                 Texas.
45753.........  La Salle County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45754.........  Lavaca County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45755.........  Lee County, Texas....        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45756.........  Leon County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45757.........  Liberty County, Texas      3360  Urban         1.0117    0.9973     26420  Urban         1.0045
45758.........  Limestone County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45759.........  Lipscomb County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45760.........  Live Oak County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45761.........  Llano County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45762.........  Loving County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45770.........  Lubbock County, Texas      4600  Urban         0.8777    0.8777     31180  Urban         0.8777
45771.........  Lynn County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45772.........  Mc Culloch County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45780.........  Mc Lennan County,          8800  Urban         0.8146    0.8146     47380  Urban         0.8146
                 Texas.
45781.........  Mc Mullen County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45782.........  Madison County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45783.........  Marion County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45784.........  Martin County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45785.........  Mason County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45790.........  Matagorda County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45791.........  Maverick County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45792.........  Medina County, Texas.        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45793.........  Menard County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45794.........  Midland County, Texas      5800  Urban         0.9632    0.9384     33260  Urban         0.9508
45795.........  Milam County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45796.........  Mills County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45797.........  Mitchell County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45800.........  Montague County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45801.........  Montgomery County,         3360  Urban         1.0117    0.9973     26420  Urban         1.0045
                 Texas.
45802.........  Moore County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45803.........  Morris County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45804.........  Motley County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938

[[Page 47995]]

 
45810.........  Nacogdoches County,          45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45820.........  Navarro County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45821.........  Newton County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45822.........  Nolan County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45830.........  Nueces County, Texas.      1880  Urban         0.8647    0.8647     18580  Urban         0.8647
45831.........  Ochiltree County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45832.........  Oldham County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45840.........  Orange County, Texas.      0840  Urban         0.8616    0.8616     13140  Urban         0.8616
45841.........  Palo Pinto County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45842.........  Panola County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45843.........  Parker County, Texas.      2800  Urban         0.9520    0.9472     23104  Urban         0.9496
45844.........  Parmer County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45845.........  Pecos County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45850.........  Polk County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45860.........  Potter County, Texas.      0320  Urban         0.9178    0.9178     11100  Urban         0.9178
45861.........  Presidio County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45870.........  Rains County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45871.........  Randall County, Texas      0320  Urban         0.9178    0.9178     11100  Urban         0.9178
45872.........  Reagan County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45873.........  Real County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45874.........  Red River County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45875.........  Reeves County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45876.........  Refugio County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45877.........  Roberts County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45878.........  Robertson County,            45  Rural         0.7910    0.9243     17780  Urban         0.8577
                 Texas.
45879.........  Rockwall County,           1920  Urban         1.0054    1.0074     19124  Urban         1.0064
                 Texas.
45880.........  Runnels County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45881.........  Rusk County, Texas...        45  Rural         0.7910    0.8801     30980  Urban         0.8356
45882.........  Sabine County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45883.........  San Augustine County,        45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45884.........  San Jacinto County,          45  Rural         0.7910    0.9973     26420  Urban         0.8942
                 Texas.
45885.........  San Patricio County,       1880  Urban         0.8647    0.8647     18580  Urban         0.8647
                 Texas.
45886.........  San Saba County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45887.........  Schleicher County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45888.........  Scurry County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45889.........  Shackelford County,          45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45890.........  Shelby County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45891.........  Sherman County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45892.........  Smith County, Texas..      8640  Urban         0.9502    0.9502     46340  Urban         0.9502
45893.........  Somervell County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45900.........  Starr County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45901.........  Stephens County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45902.........  Sterling County,             45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45903.........  Stonewall County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45904.........  Sutton County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45905.........  Swisher County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45910.........  Tarrant County, Texas      2800  Urban         0.9520    0.9472     23104  Urban         0.9496
45911.........  Taylor County, Texas.      0040  Urban         0.8009    0.7850     10180  Urban         0.7930
45912.........  Terrell County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45913.........  Terry County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45920.........  Throckmorton County,         45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45921.........  Titus County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45930.........  Tom Green County,          7200  Urban         0.8167    0.8167     41660  Urban         0.8167
                 Texas.
45940.........  Travis County, Texas.      0640  Urban         0.9595    0.9595     12420  Urban         0.9595
45941.........  Trinity County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45942.........  Tyler County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45943.........  Upshur County, Texas.      4420  Urban         0.8739    0.8801     30980  Urban         0.8770
45944.........  Upton County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45945.........  Uvalde County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45946.........  Val Verde County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45947.........  Van Zandt County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45948.........  Victoria County,           8750  Urban         0.8469    0.8470     47020  Urban         0.8470
                 Texas.
45949.........  Walker County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45950.........  Waller County, Texas.      3360  Urban         1.0117    0.9973     26420  Urban         1.0045
45951.........  Ward County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45952.........  Washington County,           45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45953.........  Webb County, Texas...      4080  Urban         0.8747    0.8747     29700  Urban         0.8747
45954.........  Wharton County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938

[[Page 47996]]

 
45955.........  Wheeler County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45960.........  Wichita County, Texas      9080  Urban         0.8395    0.8332     48660  Urban         0.8364
45961.........  Wilbarger County,            45  Rural         0.7910    0.7966     99945  Rural         0.7938
                 Texas.
45962.........  Willacy County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45970.........  Williamson County,         0640  Urban         0.9595    0.9595     12420  Urban         0.9595
                 Texas.
45971.........  Wilson County, Texas.      7240  Urban         0.9023    0.9003     41700  Urban         0.9013
45972.........  Winkler County, Texas        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45973.........  Wise County, Texas...        45  Rural         0.7910    0.9472     23104  Urban         0.8691
45974.........  Wood County, Texas...        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45980.........  Yoakum County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45981.........  Young County, Texas..        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45982.........  Zapata County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
45983.........  Zavala County, Texas.        45  Rural         0.7910    0.7966     99945  Rural         0.7938
46000.........  Beaver County, Utah..        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46010.........  Box Elder County,            46  Rural         0.8843    0.8287     99946  Rural         0.8565
                 Utah.
46020.........  Cache County, Utah...        46  Rural         0.8843    0.9094     30860  Urban         0.8969
46030.........  Carbon County, Utah..        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46040.........  Daggett County, Utah.        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46050.........  Davis County, Utah...      7160  Urban         0.9487    0.9216     36260  Urban         0.9352
46060.........  Duchesne County, Utah        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46070.........  Emery County, Utah...        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46080.........  Garfield County, Utah        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46090.........  Grand County, Utah...        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46100.........  Iron County, Utah....        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46110.........  Juab County, Utah....        46  Rural         0.8843    0.9588     39340  Urban         0.9216
46120.........  Kane County, Utah....      2620  Urban         1.0611    0.8287     99946  Rural         0.9449
46130.........  Millard County, Utah.        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46140.........  Morgan County, Utah..        46  Rural         0.8843    0.9216     36260  Urban         0.9030
46150.........  Piute County, Utah...        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46160.........  Rich County, Utah....        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46170.........  Salt Lake County,          7160  Urban         0.9487    0.9561     41620  Urban         0.9524
                 Utah.
46180.........  San Juan County, Utah        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46190.........  Sanpete County, Utah.        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46200.........  Sevier County, Utah..        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46210.........  Summit County, Utah..        46  Rural         0.8843    0.9561     41620  Urban         0.9202
46220.........  Tooele County, Utah..        46  Rural         0.8843    0.9561     41620  Urban         0.9202
46230.........  Uintah County, Utah..        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46240.........  Utah County, Utah....      6520  Urban         0.9613    0.9588     39340  Urban         0.9601
46250.........  Wasatch County, Utah.        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46260.........  Washington County,           46  Rural         0.8843    0.9458     41100  Urban         0.9151
                 Utah.
46270.........  Wayne County, Utah...        46  Rural         0.8843    0.8287     99946  Rural         0.8565
46280.........  Weber County, Utah...      7160  Urban         0.9487    0.9216     36260  Urban         0.9352
47000.........  Addison County,              47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47010.........  Bennington County,           47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47020.........  Caledonia County,            47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47030.........  Chittenden County,         1303  Urban         0.9322    0.9322     15540  Urban         0.9322
                 Vermont.
47040.........  Essex County, Vermont        47  Rural         0.9375    0.9375     99947  Rural         0.9375
47050.........  Franklin County,           1303  Urban         0.9322    0.9322     15540  Urban         0.9322
                 Vermont.
47060.........  Grand Isle County,         1303  Urban         0.9322    0.9322     15540  Urban         0.9322
                 Vermont.
47070.........  Lamoille County,             47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47080.........  Orange County,               47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47090.........  Orleans County,              47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47100.........  Rutland County,              47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47110.........  Washington County,           47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47120.........  Windham County,              47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
47130.........  Windsor County,              47  Rural         0.9375    0.9375     99947  Rural         0.9375
                 Vermont.
48010.........  St Croix County,             48  Rural         0.7456    0.7456     99948  Rural         0.7456
                 Virgin Islands.
48020.........  St Thomas-John               48  Rural         0.7456    0.7456     99948  Rural         0.7456
                 County, Virgin
                 Islands.
49000.........  Accomack County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49010.........  Albemarle County,          1540  Urban         1.0294    1.0294     16820  Urban         1.0294
                 Virginia.
49011.........  Alexandria City            8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Virginia.
49020.........  Alleghany County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49030.........  Amelia County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49040.........  Amherst County,            4640  Urban         0.9017    0.9017     31340  Urban         0.9017
                 Virginia.
49050.........  Appomattox County,           49  Rural         0.8479    0.9017     31340  Urban         0.8748
                 Virginia.
49060.........  Arlington County,          8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49070.........  Augusta County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49080.........  Bath County, Virginia        49  Rural         0.8479    0.8049     99949  Rural         0.8264

[[Page 47997]]

 
49088.........  Bedford City County,       4640  Urban         0.9017    0.9017     31340  Urban         0.9017
                 Virginia.
49090.........  Bedford County,            4640  Urban         0.9017    0.9017     31340  Urban         0.9017
                 Virginia.
49100.........  Bland County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49110.........  Botetourt County,          6800  Urban         0.8428    0.8415     40220  Urban         0.8422
                 Virginia.
49111.........  Bristol City County,       3660  Urban         0.8202    0.8240     28700  Urban         0.8221
                 Virginia.
49120.........  Brunswick County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49130.........  Buchanan County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49140.........  Buckingham County,           49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49141.........  Buena Vista City             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49150.........  Campbell County,           4640  Urban         0.9017    0.9017     31340  Urban         0.9017
                 Virginia.
49160.........  Caroline County,             49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49170.........  Carroll County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49180.........  Charles City County,       6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49190.........  Charlotte County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49191.........  Charlottesville City       1540  Urban         1.0294    1.0294     16820  Urban         1.0294
                 County, Virginia.
49194.........  Chesapeake County,         5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49200.........  Chesterfield County,       6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49210.........  Clarke County,             8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49211.........  Clifton Forge City           49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49212.........  Colonial Heights           6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 County, Virginia.
49213.........  Covington City               49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49220.........  Craig County,                49  Rural         0.8479    0.8415     40220  Urban         0.8447
                 Virginia.
49230.........  Culpeper County,           8840  Urban         1.0971    0.8049     99949  Rural         0.9510
                 Virginia.
49240.........  Cumberland County,           49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49241.........  Danville City County,      1950  Urban         0.8643    0.8643     19260  Urban         0.8643
                 Virginia.
49250.........  Dickenson County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49260.........  Dinniddie County,          6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49270.........  Emporia County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49280.........  Essex County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49288.........  Fairfax City County,       8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49290.........  Fairfax County,            8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49291.........  Falls Church City          8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Virginia.
49300.........  Fauquier County,           8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49310.........  Floyd County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49320.........  Fluvanna County,           1540  Urban         1.0294    1.0294     16820  Urban         1.0294
                 Virginia.
49328.........  Franklin City County,        49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49330.........  Franklin County,             49  Rural         0.8479    0.8415     40220  Urban         0.8447
                 Virginia.
49340.........  Frederick County,            49  Rural         0.8479    1.0496     49020  Urban         0.9488
                 Virginia.
49342.........  Fredericksburg City        8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Virginia.
49343.........  Galax City County,           49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49350.........  Giles County,                49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49360.........  Gloucester County,         5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49370.........  Goochland County,          6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49380.........  Grayson County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49390.........  Greene County,             1540  Urban         1.0294    1.0294     16820  Urban         1.0294
                 Virginia.
49400.........  Greensville County,          49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49410.........  Halifax County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49411.........  Hampton City County,       5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49420.........  Hanover County,            6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49421.........  Harrisonburg City            49  Rural         0.8479    0.9275     25500  Urban         0.8877
                 County, Virginia.
49430.........  Henrico County,            6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49440.........  Henry County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49450.........  Highland County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49451.........  Hopewell City County,      6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49460.........  Isle Of Wight County,      5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49470.........  James City Co County,      5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49480.........  King And Queen               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 County, Virginia.
49490.........  King George County,        8840  Urban         1.0971    0.8049     99949  Rural         0.9510
                 Virginia.
49500.........  King William County,         49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49510.........  Lancaster County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49520.........  Lee County, Virginia.        49  Rural         0.8479    0.8049     99949  Rural         0.8264
49522.........  Lexington County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49530.........  Loudoun County,            8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49540.........  Louisa County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49550.........  Lunenburg County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49551.........  Lynchburg City             4640  Urban         0.9017    0.9017     31340  Urban         0.9017
                 County, Virginia.
49560.........  Madison County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49561.........  Martinsville City            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.

[[Page 47998]]

 
49563.........  Manassas City County,      8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49565.........  Manassas Park City         8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Virginia.
49570.........  Mathews County,            5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49580.........  Mecklenburg County,          49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49590.........  Middlesex County,            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49600.........  Montgomery County,           49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49610.........  Nansemond, Virginia..        49  Rural         0.8479    0.8049     99949  Rural         0.8264
49620.........  Nelson County,               49  Rural         0.8479    1.0294     16820  Urban         0.9387
                 Virginia.
49621.........  New Kent County,           6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49622.........  Newport News City          5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 County, Virginia.
49641.........  Norfolk City County,       5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49650.........  Northampton County,          49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49660.........  Northumberland               49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49661.........  Norton City County,          49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49670.........  Nottoway County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49680.........  Orange County,               49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49690.........  Page County, Virginia        49  Rural         0.8479    0.8049     99949  Rural         0.8264
49700.........  Patrick County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49701.........  Petersburg City            6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 County, Virginia.
49710.........  Pittsylvania County,       1950  Urban         0.8643    0.8643     19260  Urban         0.8643
                 Virginia.
49711.........  Portsmouth City            5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 County, Virginia.
49712.........  Poquoson City County,      5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49720.........  Powhatan County,           6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49730.........  Prince Edward County,        49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49740.........  Prince George County,      6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49750.........  Prince William             8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 County, Virginia.
49770.........  Pulaski County,              49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49771.........  Radford City County,         49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49780.........  Rappahannock County,         49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49790.........  Richmond County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49791.........  Richmond City County,      6760  Urban         0.9397    0.9397     40060  Urban         0.9397
                 Virginia.
49800.........  Roanoke County,            6800  Urban         0.8428    0.8415     40220  Urban         0.8422
                 Virginia.
49801.........  Roanoke City County,       6800  Urban         0.8428    0.8415     40220  Urban         0.8422
                 Virginia.
49810.........  Rockbridge County,           49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49820.........  Rockingham County,           49  Rural         0.8479    0.9275     25500  Urban         0.8877
                 Virginia.
49830.........  Russell County,              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49838.........  Salem County,              6800  Urban         0.8428    0.8415     40220  Urban         0.8422
                 Virginia.
49840.........  Scott County,              3660  Urban         0.8202    0.8240     28700  Urban         0.8221
                 Virginia.
49850.........  Shenandoah County,           49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49860.........  Smyth County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49867.........  South Boston City            49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49870.........  Southampton County,          49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49880.........  Spotsylvania County,       8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49890.........  Stafford County,           8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49891.........  Staunton City County,        49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49892.........  Suffolk City County,       5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 Virginia.
49900.........  Surry County,                49  Rural         0.8479    0.8894     47260  Urban         0.8687
                 Virginia.
49910.........  Sussex County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49920.........  Tazewell County,             49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49921.........  Virginia Beach City        5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 County, Virginia.
49930.........  Warren County,             8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
49950.........  Washington County,         3660  Urban         0.8202    0.8240     28700  Urban         0.8221
                 Virginia.
49951.........  Waynesboro City              49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 County, Virginia.
49960.........  Westmoreland County,         49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49961.........  Williamsburg City          5720  Urban         0.8894    0.8894     47260  Urban         0.8894
                 County, Virginia.
49962.........  Winchester City              49  Rural         0.8479    1.0496     49020  Urban         0.9488
                 County, Virginia.
49970.........  Wise County, Virginia        49  Rural         0.8479    0.8049     99949  Rural         0.8264
49980.........  Wythe County,                49  Rural         0.8479    0.8049     99949  Rural         0.8264
                 Virginia.
49981.........  York County, Virginia      5720  Urban         0.8894    0.8894     47260  Urban         0.8894
50000.........  Adams County,                50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50010.........  Asotin County,               50  Rural         1.0072    0.9314     30300  Urban         0.9693
                 Washington.
50020.........  Benton County,             6740  Urban         1.0520    1.0520     28420  Urban         1.0520
                 Washington.
50030.........  Chelan County,               50  Rural         1.0072    0.9427     48300  Urban         0.9750
                 Washington.
50040.........  Clallam County,              50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50050.........  Clark County,              6440  Urban         1.1403    1.1403     38900  Urban         1.1403
                 Washington.
50060.........  Columbia County,             50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50070.........  Cowlitz County,              50  Rural         1.0072    1.0224     31020  Urban         1.0148
                 Washington.
50080.........  Douglas County,              50  Rural         1.0072    0.9427     48300  Urban         0.9750
                 Washington.

[[Page 47999]]

 
50090.........  Ferry County,                50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50100.........  Franklin County,           6740  Urban         1.0520    1.0520     28420  Urban         1.0520
                 Washington.
50110.........  Garfield County,             50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50120.........  Grant County,                50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50130.........  Grays Harbor County,         50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50140.........  Island County,             7600  Urban         1.1479    1.0312     99950  Rural         1.0896
                 Washington.
50150.........  Jefferson County,            50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50160.........  King County,               7600  Urban         1.1479    1.1492     42644  Urban         1.1486
                 Washington.
50170.........  Kitsap County,             1150  Urban         1.0614    1.0614     14740  Urban         1.0614
                 Washington.
50180.........  Kittitas County,             50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50190.........  Klickitat County,            50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50200.........  Lewis County,                50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50210.........  Lincoln County,              50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50220.........  Mason County,                50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50230.........  Okanogan County,             50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50240.........  Pacific County,              50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50250.........  Pend Oreille County,         50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50260.........  Pierce County,             8200  Urban         1.1078    1.1078     45104  Urban         1.1078
                 Washington.
50270.........  San Juan County,             50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50280.........  Skagit County,               50  Rural         1.0072    1.0576     34580  Urban         1.0324
                 Washington.
50290.........  Skamania County,             50  Rural         1.0072    1.1403     38900  Urban         1.0738
                 Washington.
50300.........  Snohomish County,          7600  Urban         1.1479    1.1492     42644  Urban         1.1486
                 Washington.
50310.........  Spokane County,            7840  Urban         1.0660    1.0660     44060  Urban         1.0660
                 Washington.
50320.........  Stevens County,              50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50330.........  Thurston County,           5910  Urban         1.1006    1.1006     36500  Urban         1.1006
                 Washington.
50340.........  Wahkiakum County,            50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50350.........  Walla Walla County,          50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50360.........  Whatcom County,            0860  Urban         1.1642    1.1642     13380  Urban         1.1642
                 Washington.
50370.........  Whitman County,              50  Rural         1.0072    1.0312     99950  Rural         1.0192
                 Washington.
50380.........  Yakima County,             9260  Urban         1.0322    1.0322     49420  Urban         1.0322
                 Washington.
51000.........  Barbour County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51010.........  Berkeley County, W         8840  Urban         1.0971    0.9715     25180  Urban         1.0343
                 Virginia.
51020.........  Boone County, W              51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51030.........  Braxton County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51040.........  Brooke County, W           8080  Urban         0.8280    0.8280     48260  Urban         0.8280
                 Virginia.
51050.........  Cabell County, W           3400  Urban         0.9564    0.9564     26580  Urban         0.9564
                 Virginia.
51060.........  Calhoun County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51070.........  Clay County, W               51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51080.........  Doddridge County, W          51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51090.........  Fayette County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51100.........  Gilmer County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51110.........  Grant County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51120.........  Greenbrier County, W         51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51130.........  Hampshire County, W          51  Rural         0.8083    1.0496     49020  Urban         0.9290
                 Virginia.
51140.........  Hancock County, W          8080  Urban         0.8280    0.8280     48260  Urban         0.8280
                 Virginia.
51150.........  Hardy County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51160.........  Harrison County, W           51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51170.........  Jackson County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51180.........  Jefferson County, W        8840  Urban         1.0971    1.1023     47894  Urban         1.0997
                 Virginia.
51190.........  Kanawha County, W          1480  Urban         0.8876    0.8876     16620  Urban         0.8876
                 Virginia.
51200.........  Lewis County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51210.........  Lincoln County, W            51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51220.........  Logan County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51230.........  Mc Dowell County, W          51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51240.........  Marion County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51250.........  Marshall County, W         9000  Urban         0.7449    0.7449     48540  Urban         0.7449
                 Virginia.
51260.........  Mason County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51270.........  Mercer County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51280.........  Mineral County, W          1900  Urban         0.8662    0.8662     19060  Urban         0.8662
                 Virginia.
51290.........  Mingo County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51300.........  Monongalia County, W         51  Rural         0.8083    0.8730     34060  Urban         0.8407
                 Virginia.
51310.........  Monroe County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51320.........  Morgan County, W             51  Rural         0.8083    0.9715     25180  Urban         0.8899
                 Virginia.
51330.........  Nicholas County, W           51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51340.........  Ohio County, W             9000  Urban         0.7449    0.7449     48540  Urban         0.7449
                 Virginia.
51350.........  Pendleton County, W          51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51360.........  Pleasants County, W          51  Rural         0.8083    0.8288     37620  Urban         0.8186
                 Virginia.
51370.........  Pocahontas County, W         51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.

[[Page 48000]]

 
51380.........  Preston County, W            51  Rural         0.8083    0.8730     34060  Urban         0.8407
                 Virginia.
51390.........  Putnam County, W           1480  Urban         0.8876    0.8876     16620  Urban         0.8876
                 Virginia.
51400.........  Raleigh County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51410.........  Randolph County, W           51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51420.........  Ritchie County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51430.........  Roane County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51440.........  Summers County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51450.........  Taylor County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51460.........  Tucker County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51470.........  Tyler County, W              51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51480.........  Upshur County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51490.........  Wayne County, W            3400  Urban         0.9564    0.9564     26580  Urban         0.9564
                 Virginia.
51500.........  Webster County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51510.........  Wetzel County, W             51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
51520.........  Wirt County, W               51  Rural         0.8083    0.8288     37620  Urban         0.8186
                 Virginia.
51530.........  Wood County, W             6020  Urban         0.8288    0.8288     37620  Urban         0.8288
                 Virginia.
51540.........  Wyoming County, W            51  Rural         0.8083    0.7865     99951  Rural         0.7974
                 Virginia.
52000.........  Adams County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52010.........  Ashland County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52020.........  Barron County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52030.........  Bayfield County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52040.........  Brown County,              3080  Urban         0.9586    0.9590     24580  Urban         0.9588
                 Wisconsin.
52050.........  Buffalo County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52060.........  Burnett County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52070.........  Calumet County,            0460  Urban         0.9115    0.9131     11540  Urban         0.9123
                 Wisconsin.
52080.........  Chippewa County,           2290  Urban         0.9139    0.9139     20740  Urban         0.9139
                 Wisconsin.
52090.........  Clark County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52100.........  Columbia County,             52  Rural         0.9498    1.0306     31540  Urban         0.9902
                 Wisconsin.
52110.........  Crawford County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52120.........  Dane County,               4720  Urban         1.0395    1.0306     31540  Urban         1.0351
                 Wisconsin.
52130.........  Dodge County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52140.........  Door County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52150.........  Douglas County,            2240  Urban         1.0356    1.0340     20260  Urban         1.0348
                 Wisconsin.
52160.........  Dunn County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52170.........  Eau Claire County,         2290  Urban         0.9139    0.9139     20740  Urban         0.9139
                 Wisconsin.
52180.........  Florence County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52190.........  Fond Du Lac County,          52  Rural         0.9498    0.9897     22540  Urban         0.9698
                 Wisconsin.
52200.........  Forest County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52210.........  Grant County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52220.........  Green County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52230.........  Green Lake County,           52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52240.........  Iowa County,                 52  Rural         0.9498    1.0306     31540  Urban         0.9902
                 Wisconsin.
52250.........  Iron County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52260.........  Jackson County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52270.........  Jefferson County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52280.........  Juneau County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52290.........  Kenosha County,            3800  Urban         0.9772    1.0342     29404  Urban         1.0057
                 Wisconsin.
52300.........  Kewaunee County,             52  Rural         0.9498    0.9590     24580  Urban         0.9544
                 Wisconsin.
52310.........  La Crosse County,          3870  Urban         0.9289    0.9289     29100  Urban         0.9289
                 Wisconsin.
52320.........  Lafayette County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52330.........  Langlade County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52340.........  Lincoln County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52350.........  Manitowoc County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52360.........  Marathon County,           8940  Urban         0.9570    0.9570     48140  Urban         0.9570
                 Wisconsin.
52370.........  Marinette County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52380.........  Marquette County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52381.........  Menominee County,            52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52390.........  Milwaukee County,          5080  Urban         1.0076    1.0076     33340  Urban         1.0076
                 Wisconsin.
52400.........  Monroe County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52410.........  Oconto County,               52  Rural         0.9498    0.9590     24580  Urban         0.9544
                 Wisconsin.
52420.........  Oneida County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52430.........  Outagamie County,          0460  Urban         0.9115    0.9131     11540  Urban         0.9123
                 Wisconsin.
52440.........  Ozaukee County,            5080  Urban         1.0076    1.0076     33340  Urban         1.0076
                 Wisconsin.
52450.........  Pepin County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52460.........  Pierce County,             5120  Urban         1.1066    1.1066    133460  Urban         1.1066
                 Wisconsin.
52470.........  Polk County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52480.........  Portage County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52490.........  Price County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.

[[Page 48001]]

 
52500.........  Racine County,             6600  Urban         0.9045    0.9045     39540  Urban         0.9045
                 Wisconsin.
52510.........  Richland County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52520.........  Rock County,               3620  Urban         0.9583    0.9583     27500  Urban         0.9583
                 Wisconsin.
52530.........  Rusk County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52540.........  St Croix County,           5120  Urban         1.1066    1.1066     33460  Urban         1.1066
                 Wisconsin.
52550.........  Sauk County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52560.........  Sawyer County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52570.........  Shawano County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52580.........  Sheboygan County,          7620  Urban         0.8948    0.8948     43100  Urban         0.8948
                 Wisconsin.
52590.........  Taylor County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52600.........  Trempealeau County,          52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52610.........  Vernon County,               52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52620.........  Vilas County,                52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52630.........  Walworth County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52640.........  Washburn County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52650.........  Washington County,         5080  Urban         1.0076    1.0076     33340  Urban         1.0076
                 Wisconsin.
52660.........  Waukesha County,           5080  Urban         1.0076    1.0076     33340  Urban         1.0076
                 Wisconsin.
52670.........  Waupaca County,              52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52680.........  Waushara County,             52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
52690.........  Winnebago County,          0460  Urban         0.9115    0.9099     36780  Urban         0.9107
                 Wisconsin.
52700.........  Wood County,                 52  Rural         0.9498    0.9492     99952  Rural         0.9495
                 Wisconsin.
53000.........  Albany County,               53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53010.........  Big Horn County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53020.........  Campbell County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53030.........  Carbon County,               53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53040.........  Converse County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53050.........  Crook County, Wyoming        53  Rural         0.9182    0.9182     99953  Rural         0.9182
53060.........  Fremont County,              53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53070.........  Goshen County,               53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53080.........  Hot Springs County,          53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53090.........  Johnson County,              53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53100.........  Laramie County,            1580  Urban         0.8980    0.8980     16940  Urban         0.8980
                 Wyoming.
53110.........  Lincoln County,              53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53120.........  Natrona County,            1350  Urban         0.9243    0.9243     16220  Urban         0.9243
                 Wyoming.
53130.........  Niobrara County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53140.........  Park County, Wyoming.        53  Rural         0.9182    0.9182     99953  Rural         0.9182
53150.........  Platte County,               53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53160.........  Sheridan County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53170.........  Sublette County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53180.........  Sweetwater County,           53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53190.........  Teton County, Wyoming        53  Rural         0.9182    0.9182     99953  Rural         0.9182
53200.........  Uinta County, Wyoming        53  Rural         0.9182    0.9182     99953  Rural         0.9182
53210.........  Washakie County,             53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
53220.........  Weston County,               53  Rural         0.9182    0.9182     99953  Rural         0.9182
                 Wyoming.
65010.........  Agana County, Guam...        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65020.........  Agana Heights County,        65  Rural         0.9611    0.9611     99965  Rural         0.9611
                 Guam.
65030.........  Agat County, Guam....        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65040.........  Asan County, Guam....        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65050.........  Barrigada County,            65  Rural         0.9611    0.9611     99965  Rural         0.9611
                 Guam.
65060.........  Chalan Pago County,          65  Rural         0.9611    0.9611     99965  Rural         0.9611
                 Guam.
65070.........  Dededo County, Guam..        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65080.........  Inarajan County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65090.........  Maite County, Guam...        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65100.........  Mangilao County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65110.........  Merizo County, Guam..        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65120.........  Mongmong County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65130.........  Ordot County, Guam...        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65140.........  Piti County, Guam....        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65150.........  Santa Rita County,           65  Rural         0.9611    0.9611     99965  Rural         0.9611
                 Guam.
65160.........  Sinajana County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65170.........  Talofofo County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65180.........  Tamuning County, Guam        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65190.........  Toto County, Guam....        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65200.........  Umatac County, Guam..        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65210.........  Yigo County, Guam....        65  Rural         0.9611    0.9611     99965  Rural         0.9611
65220.........  Yona County, Guam....        65  Rural         0.9611    0.9611     99965  Rural        0.9611
----------------------------------------------------------------------------------------------------------------
* Transition Wage Index is comprised of 50 percent of FY 2006 MSA-based wage index and 50 percent of FY 2006
  CBSA based wage index (both based on FY 2001 hospital wage data).


[[Page 48002]]


                                  Table 2.--FY 2006 IRF PPS Hold Harmless Areas
                                    [For Federal Fiscal Years 2006 and 2007]
----------------------------------------------------------------------------------------------------------------
                                                                         2006                 CBSA    Transition
  SSA state/         County name        MSA No.  MSA urban/  2006 MSA-   CBSA-   CBSA No.    urban/   wage index
  county code                                       rural    based WI  based WI              rural         *
----------------------------------------------------------------------------------------------------------------
01030.........  Bibb County, Alabama.        01  Rural         0.7637    0.9157     13820  Urban         0.8397
01100.........  Chilton County,              01  Rural         0.7637    0.9157     13820  Urban         0.8397
                 Alabama.
01300.........  Geneva County,               01  Rural         0.7637    0.7537     20020  Urban         0.7587
                 Alabama.
01310.........  Greene County,               01  Rural         0.7637    0.8336     46220  Urban         0.7987
                 Alabama.
01320.........  Hale County, Alabama.        01  Rural         0.7637    0.8336     46220  Urban         0.7987
01330.........  Henry County, Alabama        01  Rural         0.7637    0.7537     20020  Urban         0.7587
01420.........  Lowndes County,              01  Rural         0.7637    0.8300     33860  Urban         0.7969
                 Alabama.
01630.........  Walker County,               01  Rural         0.7637    0.9157     13820  Urban         0.8397
                 Alabama.
02090.........  Fairbanks County,            02  Rural         1.1637    1.1146     21820  Urban         1.1392
                 Alaska.
02170.........  Matanuska County,            02  Rural         1.1637    1.2165     11260  Urban         1.1901
                 Alaska.
03120.........  Yavapai County,              03  Rural         0.9140    0.9892     39140  Urban         0.9516
                 Arizona.
04120.........  Cleveland County,            04  Rural         0.7703    0.8673     38220  Urban         0.8188
                 Arkansas.
04230.........  Franklin County,             04  Rural         0.7703    0.8283     22900  Urban         0.7993
                 Arkansas.
04250.........  Garland County,              04  Rural         0.7703    0.9249     26300  Urban         0.8476
                 Arkansas.
04260.........  Grant County,                04  Rural         0.7703    0.8826     30780  Urban         0.8265
                 Arkansas.
04390.........  Lincoln County,              04  Rural         0.7703    0.8673     38220  Urban         0.8188
                 Arkansas.
04430.........  Madison County,              04  Rural         0.7703    0.8636     22220  Urban         0.8170
                 Arkansas.
04520.........  Perry County,                04  Rural         0.7703    0.8826     30780  Urban         0.8265
                 Arkansas.
04550.........  Poinsett County,             04  Rural         0.7703    0.8144     27860  Urban         0.7924
                 Arkansas.
05120.........  Imperial County,             05  Rural         1.0297    0.8856     20940  Urban         0.9577
                 California.
05150.........  Kings County,                05  Rural         1.0297    0.9296     25260  Urban         0.9797
                 California.
05450.........  San Benito County,           05  Rural         1.0297    1.4722     41940  Urban         1.2510
                 California.
06090.........  Clear Creek County,          06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06190.........  Elbert County,               06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06230.........  Gilpin County,               06  Rural         0.9368    1.0904     19740  Urban         1.0136
                 Colorado.
06460.........  Park County, Colorado        06  Rural         0.9368    1.0904     19740  Urban         1.0136
06590.........  Teller County,               06  Rural         0.9368    0.9792     17820  Urban         0.9580
                 Colorado.
10010.........  Baker County, Florida        10  Rural         0.8721    0.9537     27260  Urban         0.9129
10200.........  Gilchrist County,            10  Rural         0.8721    0.9459     23540  Urban         0.9090
                 Florida.
10300.........  Indian River County,         10  Rural         0.8721    0.9477     46940  Urban         0.9099
                 Florida.
10320.........  Jefferson County,            10  Rural         0.8721    0.8655     45220  Urban         0.8688
                 Florida.
10640.........  Wakulla County,              10  Rural         0.8721    0.8655     45220  Urban         0.8688
                 Florida.
11020.........  Baker County, Georgia        11  Rural         0.8247    1.1266     10500  Urban         0.9757
11110.........  Brantley County,             11  Rural         0.8247    1.1933     15260  Urban         1.0090
                 Georgia.
11120.........  Brooks County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11150.........  Burke County, Georgia        11  Rural         0.8247    0.9154     12260  Urban         0.8701
11160.........  Butts County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11330.........  Crawford County,             11  Rural         0.8247    0.9887     31420  Urban         0.9067
                 Georgia.
11350.........  Dawson County,               11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11420.........  Echols County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11460.........  Floyd County, Georgia        11  Rural         0.8247    0.8878     40660  Urban         0.8563
11490.........  Glynn County, Georgia        11  Rural         0.8247    1.1933     15260  Urban         1.0090
11550.........  Hall County, Georgia.        11  Rural         0.8247    0.9557     23580  Urban         0.8902
11570.........  Haralson County,             11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11590.........  Heard County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11611.........  Jasper County,               11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11651.........  Lamar County, Georgia        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11652.........  Lanier County,               11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11680.........  Liberty County,              11  Rural         0.8247    0.7715     25980  Urban         0.7981
                 Georgia.
11691.........  Long County, Georgia.        11  Rural         0.8247    0.7715     25980  Urban         0.7981
11700.........  Lowndes County,              11  Rural         0.8247    0.8341     46660  Urban         0.8294
                 Georgia.
11703.........  Mc Intosh County,            11  Rural         0.8247    1.1933     15260  Urban         1.0090
                 Georgia.
11730.........  Marion County,               11  Rural         0.8247    0.8690     17980  Urban         0.8469
                 Georgia.
11740.........  Meriwether County,           11  Rural         0.8247    0.9971     12060  Urban         0.9109
                 Georgia.
11760.........  Monroe County,               11  Rural         0.8247    0.9887     31420  Urban         0.9067
                 Georgia.
11772.........  Murray County,               11  Rural         0.8247    0.9558     19140  Urban         0.8903
                 Georgia.
11801.........  Oglethorpe County,           11  Rural         0.8247    1.0202     12020  Urban         0.9225
                 Georgia.
11821.........  Pike County, Georgia.        11  Rural         0.8247    0.9971     12060  Urban         0.9109
11885.........  Terrell County,              11  Rural         0.8247    1.1266     10500  Urban         0.9757
                 Georgia.
11970.........  Whitfield County,            11  Rural         0.8247    0.9558     19140  Urban         0.8903
                 Georgia.
11980.........  Worth County, Georgia        11  Rural         0.8247    1.1266     10500  Urban         0.9757
13070.........  Boise County, Idaho..        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13090.........  Bonneville County,           13  Rural         0.8826    0.9059     26820  Urban         0.8943
                 Idaho.
13200.........  Franklin County,             13  Rural         0.8826    0.9094     30860  Urban         0.8960
                 Idaho.
13220.........  Gem County, Idaho....        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13250.........  Jefferson County,            13  Rural         0.8826    0.9059     26820  Urban         0.8943
                 Idaho.
13270.........  Kootenai County,             13  Rural         0.8826    0.9339     17660  Urban         0.9083
                 Idaho.
13340.........  Nez Perce County,            13  Rural         0.8826    0.9314     30300  Urban         0.9070
                 Idaho.

[[Page 48003]]

 
13360.........  Owyhee County, Idaho.        13  Rural         0.8826    0.9352     14260  Urban         0.9089
13380.........  Power County, Idaho..        13  Rural         0.8826    0.9601     38540  Urban         0.9214
14020.........  Bond County, Illinois        14  Rural         0.8340    0.9076     41180  Urban         0.8708
14060.........  Calhoun County,              14  Rural         0.8340    0.9076     41180  Urban         0.8708
                 Illinois.
14350.........  Ford County, Illinois        14  Rural         0.8340    0.9527     16580  Urban         0.8934
14670.........  Macoupin County,             14  Rural         0.8340    0.9076     41180  Urban         0.8708
                 Illinois.
14700.........  Marshall County,             14  Rural         0.8340    0.8886     37900  Urban         0.8613
                 Illinois.
14740.........  Mercer County,               14  Rural         0.8340    0.8773     19340  Urban         0.8557
                 Illinois.
14820.........  Piatt County,                14  Rural         0.8340    0.9527     16580  Urban         0.8934
                 Illinois.
14960.........  Stark County,                14  Rural         0.8340    0.8886     37900  Urban         0.8613
                 Illinois.
14982.........  Vermilion County,            14  Rural         0.8340    0.8392     19180  Urban         0.8366
                 Illinois.
15020.........  Bartholomew County,          15  Rural         0.8736    0.9388     18020  Urban         0.9062
                 Indiana.
15030.........  Benton County,               15  Rural         0.8736    0.9067     29140  Urban         0.8902
                 Indiana.
15060.........  Brown County, Indiana        15  Rural         0.8736    1.0113     26900  Urban         0.9425
15070.........  Carroll County,              15  Rural         0.8736    0.9067     29140  Urban         0.8902
                 Indiana.
15230.........  Franklin County,             15  Rural         0.8736    0.9516     17140  Urban         0.9126
                 Indiana.
15250.........  Gibson County,               15  Rural         0.8736    0.8372     21780  Urban         0.8554
                 Indiana.
15270.........  Greene County,               15  Rural         0.8736    0.8587     14020  Urban         0.8662
                 Indiana.
15360.........  Jasper County,               15  Rural         0.8736    0.9310     23844  Urban         0.9023
                 Indiana.
15450.........  La Porte County,             15  Rural         0.8736    0.9332     33140  Urban         0.9034
                 Indiana.
15550.........  Newton County,               15  Rural         0.8736    0.9310     23844  Urban         0.9023
                 Indiana.
15590.........  Owen County, Indiana.        15  Rural         0.8736    0.8587     14020  Urban         0.8662
15660.........  Putnam County,               15  Rural         0.8736    1.0113     26900  Urban         0.9425
                 Indiana.
15760.........  Sullivan County,             15  Rural         0.8736    0.8517     45460  Urban         0.8627
                 Indiana.
15870.........  Washington County,           15  Rural         0.8736    0.9122     31140  Urban         0.8929
                 Indiana.
16050.........  Benton County, Iowa..        16  Rural         0.8550    0.8975     16300  Urban         0.8763
16080.........  Bremer County, Iowa..        16  Rural         0.8550    0.8633     47940  Urban         0.8592
16370.........  Grundy County, Iowa..        16  Rural         0.8550    0.8633     47940  Urban         0.8592
16380.........  Guthrie County, Iowa.        16  Rural         0.8550    0.9266     19780  Urban         0.8908
16420.........  Harrison County, Iowa        16  Rural         0.8550    0.9754     36540  Urban         0.9152
16520.........  Jones County, Iowa...        16  Rural         0.8550    0.8975     16300  Urban         0.8763
16600.........  Madison County, Iowa.        16  Rural         0.8550    0.9266     19780  Urban         0.8908
16640.........  Mills County, Iowa...        16  Rural         0.8550    0.9754     36540  Urban         0.9152
16840.........  Story County, Iowa...        16  Rural         0.8550    0.9479     11180  Urban         0.9015
16910.........  Washington County,           16  Rural         0.8550    0.9654     26980  Urban         0.9102
                 Iowa.
17210.........  Doniphan County,             17  Rural         0.8087    1.0013     41140  Urban         0.9050
                 Kansas.
17290.........  Franklin County,             17  Rural         0.8087    0.9629     28140  Urban         0.8858
                 Kansas.
17420.........  Jackson County,              17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
17430.........  Jefferson County,            17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
17530.........  Linn County, Kansas..        17  Rural         0.8087    0.9629     28140  Urban         0.8858
17690.........  Osage County, Kansas.        17  Rural         0.8087    0.8904     45820  Urban         0.8496
17950.........  Sumner County, Kansas        17  Rural         0.8087    0.9457     48620  Urban         0.8772
17980.........  Wabaunsee County,            17  Rural         0.8087    0.8904     45820  Urban         0.8496
                 Kansas.
18110.........  Bracken County,              18  Rural         0.7844    0.9516     17140  Urban         0.8680
                 Kentucky.
18291.........  Edmonson County,             18  Rural         0.7844    0.8140     14540  Urban         0.7992
                 Kentucky.
18450.........  Hancock County,              18  Rural         0.7844    0.8434     36980  Urban         0.8139
                 Kentucky.
18460.........  Hardin County,               18  Rural         0.7844    0.8684     21060  Urban         0.8264
                 Kentucky.
18510.........  Henry County,                18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18610.........  Larue County,                18  Rural         0.7844    0.8684     21060  Urban         0.8264
                 Kentucky.
18740.........  Mc Lean County,              18  Rural         0.7844    0.8434     36980  Urban         0.8139
                 Kentucky.
18801.........  Meade County,                18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18890.........  Nelson County,               18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18978.........  Shelby County,               18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18980.........  Spencer County,              18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18983.........  Trigg County,                18  Rural         0.7844    0.8022     17300  Urban         0.7933
                 Kentucky.
18984.........  Trimble County,              18  Rural         0.7844    0.9122     31140  Urban         0.8483
                 Kentucky.
18986.........  Warren County,               18  Rural         0.7844    0.8140     14540  Urban         0.7992
                 Kentucky.
18989.........  Webster County,              18  Rural         0.7844    0.8372     21780  Urban         0.8108
                 Kentucky.
19110.........  Cameron County,              19  Rural         0.7290    0.7935     29340  Urban         0.7613
                 Louisiana.
19150.........  De Soto County,              19  Rural         0.7290    0.9132     43340  Urban         0.8211
                 Louisiana.
19180.........  East Feliciana               19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 County, Louisiana.
19210.........  Grant County,                19  Rural         0.7290    0.8171     10780  Urban         0.7731
                 Louisiana.
19230.........  Iberville County,            19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19380.........  Pointe Coupee County,        19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19450.........  St Helena County,            19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 Louisiana.
19550.........  Union County,                19  Rural         0.7290    0.7903     33740  Urban         0.7597
                 Louisiana.
19620.........  West Feliciana               19  Rural         0.7290    0.8319     12940  Urban         0.7805
                 County, Louisiana.
21190.........  Somerset County,             21  Rural         0.9179    0.9123     41540  Urban         0.9151
                 Maryland.

[[Page 48004]]

 
21220.........  Wicomico County,             21  Rural         0.9179    0.9123     41540  Urban         0.9151
                 Maryland.
22060.........  Franklin County,             22  Rural         1.0216    1.0176     44140  Urban         1.0196
                 Massachusetts.
23070.........  Barry County,                23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
23130.........  Cass County, Michigan        23  Rural         0.8740    0.9447     43780  Urban         0.9094
23330.........  Ionia County,                23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
23610.........  Newaygo County,              23  Rural         0.8740    0.9420     24340  Urban         0.9080
                 Michigan.
24080.........  Carlton County,              24  Rural         0.9339    1.0340     20260  Urban         0.9840
                 Minnesota.
24190.........  Dodge County,                24  Rural         0.9339    1.1504     40340  Urban         1.0422
                 Minnesota.
24780.........  Wabasha County,              24  Rural         0.9339    1.1504     40340  Urban         1.0422
                 Minnesota.
25140.........  Copiah County,               25  Rural         0.7583    0.8291     27140  Urban         0.7937
                 Mississippi.
25190.........  George County,               25  Rural         0.7583    0.7974     37700  Urban         0.7779
                 Mississippi.
25460.........  Marshall County,             25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
25550.........  Perry County,                25  Rural         0.7583    0.7362     25620  Urban         0.7473
                 Mississippi.
25630.........  Simpson County,              25  Rural         0.7583    0.8291     27140  Urban         0.7937
                 Mississippi.
25650.........  Stone County,                25  Rural         0.7583    0.8950     25060  Urban         0.8267
                 Mississippi.
25680.........  Tate County,                 25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
25710.........  Tunica County,               25  Rural         0.7583    0.9217     32820  Urban         0.8400
                 Mississippi.
26060.........  Bates County,                26  Rural         0.7829    0.9629     28140  Urban         0.8729
                 Missouri.
26120.........  Caldwell County,             26  Rural         0.7829    0.9629     28140  Urban         0.8729
                 Missouri.
26130.........  Callaway County,             26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26250.........  Cole County, Missouri        26  Rural         0.7829    0.8338     27620  Urban         0.8084
26270.........  Crawford County,             26  Rural         0.7829    0.9076     41180  Urban         0.8453
                 Missouri.
26290.........  Dallas County,               26  Rural         0.7829    0.8557     44180  Urban         0.8193
                 Missouri.
26310.........  De Kalb County,              26  Rural         0.7829    1.0013     41140  Urban         0.8921
                 Missouri.
26440.........  Howard County,               26  Rural         0.7829    0.8396     17860  Urban         0.8113
                 Missouri.
26590.........  Mc Donald County,            26  Rural         0.7829    0.8636     22220  Urban         0.8233
                 Missouri.
26670.........  Moniteau County,             26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26750.........  Osage County,                26  Rural         0.7829    0.8338     27620  Urban         0.8084
                 Missouri.
26821.........  Polk County, Missouri        26  Rural         0.7829    0.8557     44180  Urban         0.8193
26992.........  Washington County,           26  Rural         0.7829    0.9076     41180  Urban         0.8453
                 Missouri.
27040.........  Carbon County,               27  Rural         0.8701    0.8961     13740  Urban         0.8831
                 Montana.
28250.........  Dixon County,                28  Rural         0.9035    0.9070     43580  Urban         0.9053
                 Nebraska.
28770.........  Saunders County,             28  Rural         0.9035    0.9754     36540  Urban         0.9395
                 Nebraska.
28790.........  Seward County,               28  Rural         0.9035    1.0208     30700  Urban         0.9622
                 Nebraska.
29120.........  Carson City County,          29  Rural         0.9832    1.0352     16180  Urban         1.0092
                 Nevada.
29140.........  Storey County, Nevada        29  Rural         0.9832    1.0456     39900  Urban         1.0144
32220.........  San Juan County, New         32  Rural         0.8529    0.8049     22140  Urban         0.8289
                 Mexico.
32280.........  Torrance County, New         32  Rural         0.8529    1.0485     10740  Urban         0.9507
                 Mexico.
33730.........  Tompkins County, New         33  Rural         0.8403    0.9589     27060  Urban         0.8996
                 York.
33740.........  Ulster County, New           33  Rural         0.8403    0.9000     28740  Urban         0.8702
                 York.
34030.........  Anson County, N              34  Rural         0.8500    0.9743     16740  Urban         0.9122
                 Carolina.
34390.........  Greene County, N             34  Rural         0.8500    0.9183     24780  Urban         0.8842
                 Carolina.
34430.........  Haywood County, N            34  Rural         0.8500    0.9191     11700  Urban         0.8846
                 Carolina.
34440.........  Henderson County, N          34  Rural         0.8500    0.9191     11700  Urban         0.8846
                 Carolina.
34460.........  Hoke County, N               34  Rural         0.8500    0.9363     22180  Urban         0.8932
                 Carolina.
34700.........  Pender County, N             34  Rural         0.8500    0.9237     48900  Urban         0.8869
                 Carolina.
34720.........  Person County, N             34  Rural         0.8500    1.0363     20500  Urban         0.9432
                 Carolina.
34780.........  Rockingham County, N         34  Rural         0.8500    0.9190     24660  Urban         0.8845
                 Carolina.
36220.........  Erie County, Ohio....        36  Rural         0.8759    0.9017     41780  Urban         0.8888
36600.........  Morrow County, Ohio..        36  Rural         0.8759    0.9737     18140  Urban         0.9248
36630.........  Ottawa County, Ohio..        36  Rural         0.8759    0.9524     45780  Urban         0.9142
36690.........  Preble County, Ohio..        36  Rural         0.8759    0.9303     19380  Urban         0.9031
36810.........  Union County, Ohio...        36  Rural         0.8759    0.9737     18140  Urban         0.9248
37250.........  Grady County,                37  Rural         0.7537    0.8982     36420  Urban         0.8260
                 Oklahoma.
37390.........  Le Flore County,             37  Rural         0.7537    0.8283     22900  Urban         0.7910
                 Oklahoma.
37400.........  Lincoln County,              37  Rural         0.7537    0.8982     36420  Urban         0.8260
                 Oklahoma.
37550.........  Okmulgee County,             37  Rural         0.7537    0.8690     46140  Urban         0.8114
                 Oklahoma.
37580.........  Pawnee County,               37  Rural         0.7537    0.8690     46140  Urban         0.8114
                 Oklahoma.
38080.........  Deschutes County,            38  Rural         1.0049    1.0603     13460  Urban         1.0326
                 Oregon.
39070.........  Armstrong County,            39  Rural         0.8348    0.8736     38300  Urban         0.8542
                 Pennsylvania.
40050.........  Aibonito County,             40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40080.........  Arroyo County, Puerto        40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Rico.
40100.........  Barranquitas County,         40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40190.........  Ciales County, Puerto        40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Rico.
40270.........  Guanica County,              40  Rural         0.4047    0.4493     49500  Urban         0.4270
                 Puerto Rico.
40280.........  Guayama County,              40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Puerto Rico.
40350.........  Isabela County,              40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Puerto Rico.
40390.........  Lajas County, Puerto         40  Rural         0.4047    0.5240     41900  Urban         0.4644
                 Rico.

[[Page 48005]]

 
40400.........  Lares County, Puerto         40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Rico.
40470.........  Maunabo County,              40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40530.........  Orocovis County,             40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40540.........  Patillas County,             40  Rural         0.4047    0.4005     25020  Urban         0.4026
                 Puerto Rico.
40570.........  Quebradillas County,         40  Rural         0.4047    0.4645     41980  Urban         0.4346
                 Puerto Rico.
40580.........  Rincon County, Puerto        40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Rico.
40660.........  San Sebastian County,        40  Rural         0.4047    0.4280     10380  Urban         0.4164
                 Puerto Rico.
42080.........  Calhoun County, S            42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42150.........  Darlington County, S         42  Rural         0.8640    0.8833     22500  Urban         0.8737
                 Carolina.
42190.........  Fairfield County, S          42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42270.........  Kershaw County, S            42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
42290.........  Laurens County, S            42  Rural         0.8640    0.9557     24860  Urban         0.9099
                 Carolina.
42400.........  Saluda County, S             42  Rural         0.8640    0.9392     17900  Urban         0.9016
                 Carolina.
43430.........  Mc Cook County, S            43  Rural         0.8393    0.9441     43620  Urban         0.8917
                 Dakota.
43460.........  Meade County, S              43  Rural         0.8393    0.8912     39660  Urban         0.8653
                 Dakota.
43620.........  Turner County, S             43  Rural         0.8393    0.9441     43620  Urban         0.8917
                 Dakota.
43630.........  Union County, S              43  Rural         0.8393    0.9070     43580  Urban         0.8732
                 Dakota.
44050.........  Bradley County,              44  Rural         0.7876    0.7844     17420  Urban         0.7860
                 Tennessee.
44070.........  Cannon County,               44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44280.........  Grainger County,             44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44310.........  Hamblen County,              44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44400.........  Hickman County,              44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44440.........  Jefferson County,            44  Rural         0.7876    0.7790     34100  Urban         0.7833
                 Tennessee.
44550.........  Macon County,                44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44690.........  Polk County,                 44  Rural         0.7876    0.7844     17420  Urban         0.7860
                 Tennessee.
44760.........  Sequatchie County,           44  Rural         0.7876    0.9207     16860  Urban         0.8542
                 Tennessee.
44790.........  Smith County,                44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
44800.........  Stewart County,              44  Rural         0.7876    0.8022     17300  Urban         0.7949
                 Tennessee.
44840.........  Trousdale County,            44  Rural         0.7876    1.0086     34980  Urban         0.8981
                 Tennessee.
45030.........  Aransas County, Texas        45  Rural         0.7910    0.8647     18580  Urban         0.8279
45050.........  Armstrong County,            45  Rural         0.7910    0.9178     11100  Urban         0.8544
                 Texas.
45060.........  Atascosa County,             45  Rural         0.7910    0.9003     41700  Urban         0.8457
                 Texas.
45070.........  Austin County, Texas.        45  Rural         0.7910    0.9973     26420  Urban         0.8942
45090.........  Bandera County, Texas        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45221.........  Burleson County,             45  Rural         0.7910    0.9243     17780  Urban         0.8577
                 Texas.
45224.........  Calhoun County, Texas        45  Rural         0.7910    0.8470     47020  Urban         0.8190
45230.........  Callahan County,             45  Rural         0.7910    0.7850     10180  Urban         0.7880
                 Texas.
45251.........  Carson County, Texas.        45  Rural         0.7910    0.9178     11100  Urban         0.8544
45291.........  Clay County, Texas...        45  Rural         0.7910    0.8332     48660  Urban         0.8121
45362.........  Crosby County, Texas.        45  Rural         0.7910    0.8777     31180  Urban         0.8344
45400.........  Delta County, Texas..        45  Rural         0.7910    1.0074     19124  Urban         0.8992
45561.........  Goliad County, Texas.        45  Rural         0.7910    0.8470     47020  Urban         0.8190
45672.........  Irion County, Texas..        45  Rural         0.7910    0.8167     41660  Urban         0.8039
45721.........  Jones County, Texas..        45  Rural         0.7910    0.7850     10180  Urban         0.7880
45731.........  Kendall County, Texas        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45752.........  Lampasas County,             45  Rural         0.7910    0.9242     28660  Urban         0.8576
                 Texas.
45792.........  Medina County, Texas.        45  Rural         0.7910    0.9003     41700  Urban         0.8457
45878.........  Robertson County,            45  Rural         0.7910    0.9243     17780  Urban         0.8577
                 Texas.
45881.........  Rusk County, Texas...        45  Rural         0.7910    0.8801     30980  Urban         0.8356
45884.........  San Jacinto County,          45  Rural         0.7910    0.9973     26420  Urban         0.8942
                 Texas.
45973.........  Wise County, Texas...        45  Rural         0.7910    0.9472     23104  Urban         0.8691
46020.........  Cache County, Utah...        46  Rural         0.8843    0.9094     30860  Urban         0.8969
46110.........  Juab County, Utah....        46  Rural         0.8843    0.9588     39340  Urban         0.9216
46140.........  Morgan County, Utah..        46  Rural         0.8843    0.9216     36260  Urban         0.9030
46210.........  Summit County, Utah..        46  Rural         0.8843    0.9561     41620  Urban         0.9202
46220.........  Tooele County, Utah..        46  Rural         0.8843    0.9561     41620  Urban         0.9202
46260.........  Washington County,           46  Rural         0.8843    0.9458     41100  Urban         0.9151
                 Utah.
49030.........  Amelia County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49050.........  Appomattox County,           49  Rural         0.8479    0.9017     31340  Urban         0.8748
                 Virginia.
49160.........  Caroline County,             49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49220.........  Craig County,                49  Rural         0.8479    0.8415     40220  Urban         0.8447
                 Virginia.
49240.........  Cumberland County,           49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49330.........  Franklin County,             49  Rural         0.8479    0.8415     40220  Urban         0.8447
                 Virginia.
49340.........  Frederick County,            49  Rural         0.8479    1.0496     49020  Urban         0.9488
                 Virginia.
49350.........  Giles County,                49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49421.........  Harrisonburg City            49  Rural         0.8479    0.9275     25500  Urban         0.8877
                 County, Virginia.
49480.........  King And Queen               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 County, Virginia.
49500.........  King William County,         49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.

[[Page 48006]]

 
49540.........  Louisa County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49600.........  Montgomery County,           49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49620.........  Nelson County,               49  Rural         0.8479    1.0294     16820  Urban         0.9387
                 Virginia.
49770.........  Pulaski County,              49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49771.........  Radford City County,         49  Rural         0.8479    0.7951     13980  Urban         0.8215
                 Virginia.
49820.........  Rockingham County,           49  Rural         0.8479    0.9275     25500  Urban         0.8877
                 Virginia.
49900.........  Surry County,                49  Rural         0.8479    0.8894     47260  Urban         0.8687
                 Virginia.
49910.........  Sussex County,               49  Rural         0.8479    0.9397     40060  Urban         0.8938
                 Virginia.
49962.........  Winchester City              49  Rural         0.8479    1.0496     49020  Urban         0.9488
                 County, Virginia.
50010.........  Asotin County,               50  Rural         1.0072    0.9314     30300  Urban         0.9693
                 Washington.
50030.........  Chelan County,               50  Rural         1.0072    0.9427     48300  Urban         0.9750
                 Washington.
50070.........  Cowlitz County,              50  Rural         1.0072    1.0224     31020  Urban         1.0148
                 Washington.
50080.........  Douglas County,              50  Rural         1.0072    0.9427     48300  Urban         0.9750
                 Washington.
50280.........  Skagit County,               50  Rural         1.0072    1.0576     34580  Urban         1.0324
                 Washington.
50290.........  Skamania County,             50  Rural         1.0072    1.1403     38900  Urban         1.0738
                 Washington.
51020.........  Boone County, W              51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51070.........  Clay County, W               51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51130.........  Hampshire County, W          51  Rural         0.8083    1.0496     49020  Urban         0.9290
                 Virginia.
51210.........  Lincoln County, W            51  Rural         0.8083    0.8876     16620  Urban         0.8480
                 Virginia.
51300.........  Monongalia County, W         51  Rural         0.8083    0.8730     34060  Urban         0.8407
                 Virginia.
51320.........  Morgan County, W             51  Rural         0.8083    0.9715     25180  Urban         0.8899
                 Virginia.
51360.........  Pleasants County, W          51  Rural         0.8083    0.8288     37620  Urban         0.8186
                 Virginia.
51380.........  Preston County, W            51  Rural         0.8083    0.8730     34060  Urban         0.8407
                 Virginia.
51520.........  Wirt County, W               51  Rural         0.8083    0.8288     37620  Urban         0.8186
                 Virginia.
52100.........  Columbia County,             52  Rural         0.9498    1.0306     31540  Urban         0.9902
                 Wisconsin.
52190.........  Fond Du Lac County,          52  Rural         0.9498    0.9897     22540  Urban         0.9698
                 Wisconsin.
52240.........  Iowa County,                 52  Rural         0.9498    1.0306     31540  Urban         0.9902
                 Wisconsin.
52300.........  Kewaunee County,             52  Rural         0.9498    0.9590     24580  Urban         0.9544
                 Wisconsin.
52410.........  Oconto County,               52  Rural         0.9498    0.9590     24580  Urban        0.9544
                 Wisconsin.
----------------------------------------------------------------------------------------------------------------
* Transition Wage Index is comprised of 50 percent of FY 2006 MSA-based wage index and 50 percent of FY 2006
  CBSA based wage index (both based on FY 2001 hospital wage data).

[FR Doc. 05-15419 Filed 8-1-05; 4:16 pm]
BILLING CODE 4120-03-U