[Federal Register Volume 71, Number 217 (Thursday, November 9, 2006)]
[Rules and Regulations]
[Pages 65884-66006]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 06-9068]



[[Page 65883]]

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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 Parts 414 and 484



Medicare Program; Home Health Prospective Payment System Rate Update 
for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to 
Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical 
Equipment; Final Rule

  Federal Register / Vol. 71, No. 217 / Thursday, November 9, 2006 / 
Rules and Regulations  

[[Page 65884]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 414 and 484

[CMS-1304-F]
RIN 0938-AN76


Medicare Program; Home Health Prospective Payment System Rate 
Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes 
to Medicare Payment for Oxygen Equipment and Capped Rental Durable 
Medical Equipment; Final Rule

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

ACTION: Final rule.

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SUMMARY: This final rule sets forth an update to the 60-day national 
episode rates and the national per-visit amounts under the Medicare 
prospective payment system for home health services. In addition, this 
final rule sets forth policy changes related to Medicare payment for 
certain durable medical equipment for the purpose of implementing 
sections 1834(a)(5) and 1834(a)(7) of the Social Security Act, as 
amended by section 5101 of the Deficit Reduction Act of 2005. This 
final rule also responds to public comments on the August 3, 2006, 
proposed rule that pertain to a number of issues including the 
requirement that home health payments are based on the reporting of 
specific quality data by home health agencies.

DATES: Effective Date: These regulations are effective on January 1, 
2007.

FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131, or 
Sharon Ventura, (410) 786-1985 (for issues related to the home health 
prospective payment system). Doug Brown, (410) 786-0028 (for issues 
related to reporting home health quality data). Alexis Meholic, (410) 
786-2300 (for issues related to payments for oxygen equipment and 
capped rental durable medical equipment).

SUPPLEMENTARY INFORMATION: 

I. Background

A. Statutory Background

    The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on 
August 5, 1997, significantly changed the way Medicare pays for 
Medicare home health services. Until the implementation of a home 
health prospective payment system (HH PPS) on October 1, 2000, home 
health agencies (HHAs) received payment under a cost-based 
reimbursement system. Section 4603 of the BBA governed the development 
of the HH PPS.
    Section 4603(a) of the BBA provides the authority for the 
development of a PPS for all Medicare-covered home health services 
provided under a plan of care that were paid on a reasonable cost basis 
by adding section 1895, entitled ``Prospective Payment For Home Health 
Services,'' to the Social Security Act (the Act).
    Section 1895(b)(1) of the Act requires the Secretary to establish a 
PPS for all costs of home health services paid under Medicare.
    Section 1895(b)(3)(A) of the Act requires that (1) the computation 
of a standard prospective payment amount include all costs of home 
health services covered and paid for on a reasonable cost basis and be 
initially based on the most recent audited cost report data available 
to the Secretary, and (2) the prospective payment amounts be 
standardized to eliminate the effects of case-mix and wage levels among 
HHAs.
    Section 1895(b)(3)(B) of the Act addresses the annual update to the 
standard prospective payment amounts by the home health applicable 
increase percentage as specified in the statute.
    Section 1895(b)(4) of the Act governs the payment computation. 
Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the 
standard prospective payment amount to be adjusted for case-mix and 
geographic differences in wage levels. Section 1895(b)(4)(B) of the Act 
requires the establishment of an appropriate case-mix adjustment factor 
that explains a significant amount of the variation in cost among 
different units of services. Similarly, section 1895(b)(4)(C) of the 
Act requires the establishment of wage-adjustment factors that reflect 
the relative level of wages and wage-related costs applicable to the 
furnishing of home health services in a geographic area compared to the 
national average applicable level. These wage-adjustment factors may be 
the factors used by the Secretary for the different area wage levels 
for purposes of section 1886(d)(3)(E) of the Act.
    Section 1895(b)(5) of the Act gives the Secretary the option to 
grant additions or adjustments to the payment amount otherwise made in 
the case of outliers because of unusual variations in the type or 
amount of medically necessary care. Total outlier payments in a given 
fiscal year cannot exceed 5 percent of total payments projected or 
estimated.
    On February 8, 2006, the Congress enacted the Deficit Reduction Act 
(DRA) of 2005 (Pub. L. 109-171). This legislation made additional 
changes to the HH PPS.
    Section 5201 of the DRA changed the CY 2006 update from the 
applicable home health market basket percentage increase minus 0.8 
percentage points to a 0 percent update.
    Section 5201 of the DRA amended section 421(a) of the MMA. The 
amended section 421(a) of the MMA requires, for home health services 
furnished in a rural area (as defined in section 1886(d)(2)(D) of the 
Act) with respect to episodes and visits beginning on or after January 
1, 2006 and before January 1, 2007, that the Secretary increase by 5 
percent the payment amount otherwise made under section 1895 of the 
Act. The statute waives budget neutrality for purposes of this increase 
as it specifically requires that the Secretary not reduce the standard 
prospective payment amount (or amounts) under section 1895 of the Act 
applicable to home health services furnished during a period to offset 
the increase in payments resulting in the application of this section 
of the statute.
    The 0 percent update to the payment rates and the rural add-on 
provisions of the DRA were implemented through Pub. 100-20, One Time 
Notification, Transmittal 211 issued February 10, 2006.
    In addition, section 5201(c) of the DRA amends the statute to add 
section 1895(b)(3)(B)(v) to the Act, requiring HHAs to submit data for 
purposes of measuring health care quality. This requirement is 
applicable for 2007 and each subsequent year. For 2007 and each 
subsequent year, in the case of a HHA that does not submit quality 
data, the home health market basket percentage increase would be 
reduced by 2 percentage points.

B. Updates

1. 2000 Final Rule
    On July 3, 2000, we published a final rule (65 FR 41128) in the 
Federal Register to implement the HH PPS legislation. That final rule 
established requirements for a new PPS for HHAs as required by section 
4603 of the BBA, and as subsequently amended by section 5101 of the 
Omnibus Consolidated and Emergency Supplemental Appropriations Act 
(OCESAA) for Fiscal Year 1999 (Pub. L. 105-277), enacted on October 21, 
1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, and 
SCHIP Balanced Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113), 
enacted on November 29, 1999. The requirements include the 
implementation of a PPS for home

[[Page 65885]]

health services, consolidated billing requirements, and a number of 
other related changes. The PPS described in that rule replaced the 
retrospective reasonable-cost-based system that was used by Medicare 
for the payment of home health services under Part A and Part B.
2. 2005 Final Rule
    On November 9, 2005, we published a final rule (70 FR 68132), which 
set forth an update to the 60-day national episode rates and the 
national per-visit amounts under the Medicare prospective payment 
system for home health services for CY 2006. As part of that final 
rule, we adopted revised area labor market Metropolitan Statistical 
Area designations for CY 2006. In implementing the new area labor 
market designations, we allowed for a 1-year transition period. This 
transition consists of a blend of 50 percent of the new area labor 
market designations' wage index and 50 percent of the previous area 
labor market designations' wage index. In addition, we revised the 
fixed dollar loss ratio, which is used in the calculation of outlier 
payments.

C. System for Payment of Home Health Services

    Generally, Medicare makes payment under the HH PPS on the basis of 
a national standardized 60-day episode payment, adjusted for case mix 
and wage index. For episodes with four or fewer visits, Medicare pays 
on the basis of a national per-visit amount by discipline, referred to 
as a low utilization payment adjustment (LUPA). Medicare also adjusts 
the 60-day episode payment for certain intervening events that give 
rise to a partial episode payment adjustment (PEP adjustment) or a 
significant change in condition adjustment (SCIC). For certain cases 
that exceed a specific cost threshold, an outlier adjustment may also 
be available. For a complete and full description of the HH PPS as 
required by the BBA and as amended by OCESAA and BBRA, see the July 3, 
2000 HH PPS final rule (65 FR 41128).

D. Changes in Payment for Oxygen and Oxygen Equipment and Other Durable 
Medical Equipment (Capped Rental Items)

    The Medicare payment rules for durable medical equipment (DME) are 
set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D 
of our regulations. General payment rules for DME are set forth in 
section 1834(a)(1) of the Act and Sec.  414.210 of our regulations, and 
Sec.  414.210 also contains paragraphs relating to maintenance and 
servicing of items and replacement of items. Specific rules for oxygen 
and oxygen equipment are set forth in section 1834(a)(5) of the Act and 
Sec.  414.226 of our regulations, and specific rules for capped rental 
items are set forth in section 1834(a)(7) of the Act and Sec.  414.229 
of our regulations. Rules for determining a period of continuous use 
for the rental of DME are set forth in Sec.  414.230 of our 
regulations. The Medicare payment basis for DME is equal to 80 percent 
of either the lower of the actual charge or the fee schedule amount for 
the item. The beneficiary coinsurance is equal to 20 percent of either 
the lower of the actual charge or the fee schedule amount for the item.
    In accordance with the rules set forth in section 1834(a)(5) of the 
Act and Sec.  414.226 of our regulations, since 1989, suppliers have 
been paid monthly for furnishing oxygen and oxygen equipment to 
Medicare beneficiaries. Suppliers have also been paid an add-on fee for 
furnishing portable oxygen equipment to patients when medically 
necessary. Before the enactment of the DRA, these monthly payments 
continued for the duration of use of the equipment, provided that 
Medicare Part B coverage and eligibility criteria were met. Medicare 
covers three types of oxygen delivery systems: (1) Stationary or 
portable oxygen concentrators, which concentrate oxygen in room air; 
(2) stationary or portable liquid oxygen systems, which use oxygen 
stored as a very cold liquid in cylinders and tanks; and (3) stationary 
or portable gaseous oxygen systems, which administer compressed oxygen 
directly from cylinders. Both liquid and gaseous oxygen systems require 
delivery of oxygen contents.
    Medicare payment for furnishing oxygen and oxygen equipment is made 
on a monthly basis and the fee schedule amounts vary by State. Payment 
for oxygen contents for both stationary and portable equipment is 
included in the fee schedule allowances for stationary equipment. 
Medicare fee schedules for home oxygen equipment are modality neutral; 
meaning that in a given State, there is one fee schedule amount that 
applies to all stationary systems and one fee schedule amount that 
applies to all portable systems.
    Effective January 1, 2006, section 5101(b) of the DRA amended the 
Act at section 1834(a)(5) of the Act, limiting to 36 months the total 
number of continuous months for which Medicare will pay for oxygen 
equipment on a rental basis. At the end of the 36-month period, this 
section mandates that the supplier transfer title to the stationary and 
portable oxygen equipment to the beneficiary. Section 5101(b) of the 
DRA does not, however, limit the number of months for which Medicare 
will pay for oxygen contents for beneficiary-owned stationary or 
portable gaseous or liquid systems, and payment will continue to be 
made as long as the oxygen remains medically necessary. Section 5101(b) 
of the DRA also provides that payment for reasonable and necessary 
maintenance and servicing of beneficiary-owned oxygen equipment will be 
made for parts and labor not covered by a supplier's or manufacturer's 
warranty. In the case of beneficiaries using oxygen equipment on 
December 31, 2005, the 36-month rental period prescribed by the DRA 
begins on January 1, 2006.
    In accordance with the rules set forth in section 1834(a)(7) of the 
Act and Sec.  414.229 of our regulations, before the enactment of the 
DRA, suppliers of capped rental items (that is, other DME not described 
in paragraphs (2) through (6) of section 1834(a) of the Act) were paid 
on a rental or purchase option basis. Payment for most items in the 
capped rental category was made on a monthly rental basis, with rental 
payments being capped at 15 months or 13 months, depending on whether 
the beneficiary chose to continue renting the item or to take over 
ownership of the item through the ``purchase option.'' For all capped 
rental items, the supplier was required to inform the beneficiary of 
his or her purchase option, during the 10th rental month, to enter into 
a purchase agreement under which the supplier would transfer title to 
the item to the beneficiary on the first day after the 13th continuous 
month during which payment was made for the rental of the item. 
Therefore, if the beneficiary chose the purchase option, rental 
payments to the supplier would continue through the 13th month of 
continuous use of the equipment, after which time title to the 
equipment would transfer from the supplier to the beneficiary. Medicare 
would also make payment for any reasonable and necessary repair or 
maintenance and servicing of the equipment following the transfer of 
title. If the beneficiary did not choose the purchase option, rental 
payments would continue through the 15th month of continuous use. In 
these cases, suppliers would maintain title to the equipment but would 
have to continue furnishing the item to the beneficiary as long as 
medical necessity continued. Beginning 6 months after the 15th month of 
continuous use in which payment was made, Medicare would also make 
semi-annual maintenance and servicing payments to suppliers. These 
payments were approximately equal to 10 percent

[[Page 65886]]

of the purchase price for the equipment as determined by the statute. 
Total Medicare payments made through the 13th and 15th months of rental 
equal 105 and 120 percent, respectively, of the purchase price for the 
equipment.
    In the case of power-driven wheelchairs, since 1989 payment has 
also been made on a lump-sum purchase basis at the time that the item 
is initially furnished to the beneficiary if the beneficiary chooses to 
obtain the item in this manner. Most beneficiaries choose to obtain 
power-driven wheelchairs via this lump-sum purchase option.
    Effective for items for which the first rental month occurs on or 
after January 1, 2006, section 5101(a) of the DRA of 2005 amended 
section 1834(a)(7) of the Act, limiting to 13 months the total number 
of continuous months for which Medicare will pay for DME in this 
category. After a 13-month period of continuous use during which rental 
payments are made, the statute requires that the supplier transfer 
title to the equipment to the beneficiary. Beneficiaries may still 
elect to obtain power-driven wheelchairs on a lump-sum purchase 
agreement basis. In all cases, payment for reasonable and necessary 
maintenance and servicing of beneficiary-owned equipment will be made 
for parts and labor not covered by the supplier's or manufacturer's 
warranty.

E. Requirements for Issuance of Regulations

    Section 902 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) amended section 1871(a) of the Act and 
requires the Secretary, in consultation with the Director of the Office 
of Management and Budget, to establish and publish timelines for the 
publication of Medicare final regulations based on the previous 
publication of a Medicare proposed or interim final regulation. Section 
902 of the MMA also states that the timelines for these regulations may 
vary but shall not exceed 3 years after publication of the preceding 
proposed or interim final regulation except under exceptional 
circumstances.
    This final rule finalizes provisions set forth in the August 3, 
2006 proposed rule. In addition, this final rule has been published 
within the 3-year time limit imposed by section 902 of the MMA. 
Therefore, we believe that the final rule is in accordance with the 
Congress' intent to ensure timely publication of final regulations.

II. Provisions of the Proposed Regulations

    We published a proposed rule in the Federal Register on August 3, 
2006 (71 FR 44081) that set forth a proposed update to the 60-day 
national episode rates and the national per-visit amounts under the 
Medicare prospective payment system for home health services. In 
addition, that proposed rule set forth proposed policy changes related 
to Medicare payment for certain durable medical equipment for the 
purpose of implementing sections 1834(a)(5) and 1834(a)(7) of the 
Social Security Act, as amended by section 5101 of the Deficit 
Reduction Act of 2005. That proposed rule also invited comments on a 
number of issues including payments based on reporting quality data, 
the adoption of health information technology, as well as how to 
improve data transparency for consumers.

A. National Standardized 60-Day Episode Rate

    The Medicare HH PPS has been effective since October 1, 2000. As 
set forth in the final rule published July 3, 2000 in the Federal 
Register (65 FR 41128), the unit of payment under the Medicare HH PPS 
is a national standardized 60-day episode rate. As set forth in Sec.  
484.220, we adjust the national standardized 60-day episode rate by a 
case mix grouping and a wage index value based on the site of service 
for the beneficiary. The proposed CY 2007 HH PPS rates used the same 
case-mix methodology and application of the wage index adjustment to 
the labor portion of the HH PPS rates as set forth in the July 3, 2000 
final rule. In the October 22, 2004 final rule, we rebased and revised 
the home health market basket, resulting in a labor-related share of 
76.775 percent and a non-labor portion of 23.225 percent (69 FR 62126). 
We multiply the national 60-day episode rate by the patient's 
applicable case-mix weight. We divide the case-mix adjusted amount into 
a labor and non-labor portion. We multiply the labor portion by the 
applicable wage index based on the site of service of the beneficiary.
    As required by section 1895(b)(3)(B) of the Act, we have updated 
the HH PPS rates annually in a separate Federal Register document. 
Section 484.225 sets forth the specific annual percentage update. To 
reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201 
of the DRA, we proposed to revise Sec.  484.225, paragraph (g) as 
follows:

    (g) For 2007 and subsequent calendar years, the unadjusted 
national rate is equal to the rate for the previous calendar year 
increased by the applicable home health market basket index amount 
unless the HHA has not submitted quality data in which case the 
unadjusted national rate is equal to the rate for the previous 
calendar year increased by the applicable home health market basket 
index amount minus 2 percentage points.

    For CY 2007, we proposed to use again the design and case-mix 
methodology described in section III.G of the HH PPS July 3, 2000 final 
rule (65 FR 41192 through 41203). For CY 2007, we will base the wage 
index adjustment to the labor portion of the PPS rates on the most 
recent pre-floor and pre-reclassified hospital wage index as discussed 
in section II.F of the August 3, 2006 proposed rule (not including any 
reclassifications under section 1886(d)(8)(B) of the Act).
    As discussed in the July 3, 2000 HH PPS final rule, for episodes 
with four or fewer visits, Medicare pays the national per-visit amount 
by discipline, referred to as a LUPA. We update the national per-visit 
amounts by discipline annually by the applicable home health market 
basket percentage. We adjust the national per-visit amount by the 
appropriate wage index based on the site of service for the beneficiary 
as set forth in Sec.  484.230. We will adjust the labor portion of the 
updated national per-visit amounts by discipline used to calculate the 
LUPA by the most recent pre-floor and pre-reclassified hospital wage 
index, as discussed in section II.F of the August 3, 2006 proposed 
rule.
    Medicare pays the 60-day case-mix and wage-adjusted episode payment 
on a split percentage payment approach. The split percentage payment 
approach includes an initial percentage payment and a final percentage 
payment as set forth in Sec.  484.205(b)(1) and Sec.  484.205(b)(2). We 
may base the initial percentage payment on the submission of a request 
for anticipated payment (RAP) and the final percentage payment on the 
submission of the claim for the episode, as discussed in Sec.  409.43. 
The claim for the episode that the HHA submits for the final percentage 
payment determines the total payment amount for the episode and whether 
we make an applicable adjustment to the 60-day case-mix and wage-
adjusted episode payment. The end date of the 60-day episode as 
reported on the claim determines which calendar year rates Medicare 
would use to pay the claim.
    We may also adjust the 60-day case-mix and wage-adjusted episode 
payment based on the information submitted on the claim to reflect the 
following:

[[Page 65887]]

     A low utilization payment provided on a per-visit basis as 
set forth in Sec.  484.205(c) and Sec.  484.230.
     A partial episode payment adjustment as set forth in Sec.  
484.205(d) and Sec.  484.235.
     A significant change in condition adjustment as set forth 
in Sec.  484.205(e) and Sec.  484.237.
     An outlier payment as set forth in Sec.  484.205(f) and 
Sec.  484.240.

B. CY 2007 Update to the Home Health Market Basket Index

    Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the 
DRA, requires for CY 2007 that the standard prospective payment amounts 
be increased by a factor equal to the applicable home health market 
basket update. The proposed rule contained a home health market basket 
update of 3.1 percent. Since publication of the proposed rule, we have 
estimated a new home health market basket update of 3.3 percent for CY 
2007.
CY 2007 Adjustments
    In calculating the annual update for the CY 2007 60-day episode 
rates, we first look at the CY 2006 rates as a starting point. The CY 
2006 national 60-day episode rate, as modified by section 5201(a)(4) of 
the DRA (and implemented through Pub. 100-20, One Time Notification, 
Transmittal 211 issued February 10, 2006) is $2,264.28.
    In order to calculate the CY 2007 national 60-day episode rate, we 
multiply the CY 2006 national 60-day episode rate ($2,264.28) by the 
estimated home health market basket update of 3.3 percent for CY 2007. 
The estimated home health market basket percentage increase reflects 
changes over time in the prices of an appropriate mix of goods and 
services included in covered home health services. The estimated home 
health market basket percentage increase is generally used to update 
the HH PPS rates on an annual basis.
    We increase the CY 2006 60-day episode payment rate by the 
estimated home health market basket update (3.3 percent) ($2,264.28 x 
1.033) to yield the updated CY 2007 national 60-day episode rate 
($2,339.00) (see Table 1 below). The CY 2007 HH PPS rates apply to 
episodes ending on or after January 1, 2007, and before January 1, 
2008.

Table 1.--National 60-Day Episode Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007,
                                           Before Case-Mix Adjustment
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                                         Multiply by the Estimated Home
  Total CY 2006 Prospective Payment     Health Market Basket Update (3.3       CY 2007 Updated National 60-Day
      Amount Per 60-day Episode                    Percent)\1\                          Episode Rate
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                    $2,264.28                               x 1.033                             $2,339.00
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\1\ The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
  3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.

National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed Costs 
Used in Outlier Calculations
    As discussed previously in the August 3, 2006 proposed rule, the 
policies governing the LUPAs and outlier calculations set forth in the 
July 3, 2000 HH PPS final rule will continue during CY 2007. In 
calculating the annual update for the CY 2007 national per-visit 
amounts we use to pay LUPAs and to compute the imputed costs in outlier 
calculations, we look again at the CY 2006 rates as a starting point. 
We then multiply those amounts by the estimated home health market 
basket update for CY 2007 (3.3 percent) to yield the updated per-visit 
amounts for each home health discipline for CY 2007 (episodes ending on 
or after January 1, 2007, and before January 1, 2008) (see Table 2 
below).

  Table 2.--National Per-Visit Amounts for LUPAs and Outlier Calculations Updated by the Estimated Home Health
                                        Market Basket Update for CY 2007
----------------------------------------------------------------------------------------------------------------
                                                                             Multiply by the
                                                         Final CY 2006 per-   estimated home   CY 2007 per-visit
              Home health discipline type                visit amounts per    health market      payment amount
                                                           60-day episode      basket (3.3       per discipline
                                                             for LUPAs         percent) \1\        for LUPAs
----------------------------------------------------------------------------------------------------------------
Home Health Aide.......................................             $44.76            x 1.033             $46.24
Medical Social Services................................             158.45            x 1.033             163.68
Occupational Therapy...................................             108.81            x 1.033             112.40
Physical Therapy.......................................             108.08            x 1.033             111.65
Skilled Nursing........................................              98.85            x 1.033             102.11
Speech-Language Pathology..............................             117.44            x 1.033             121.32
----------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
  3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.

C. Rural Add-On

    As stated above, section 5201(b) of the DRA requires, for home 
health services furnished in a rural area (as defined in section 
1886(d)(2)(D) of the Act) with respect to episodes and visits beginning 
on or after January 1, 2006 and before January 1, 2007, that the 
Secretary increase by 5 percent the payment amount otherwise made under 
section 1895 of the Act. The statute waives budget neutrality related 
to this provision as it specifically states that the Secretary shall 
not reduce the standard prospective payment amount (or amounts) under 
section 1895 of the Act applicable to home health services furnished 
during a period to offset the increase in payments resulting in the 
application of this section of the statute.
    While the rural add-on primarily affects those episodes paid based 
on CY 2006 rates, it also affects a number of CY 2007 episodes. For 
example, an episode that begins on December 20, 2006 and ends on 
February 17, 2007 for services furnished in a rural area, will be paid 
based on CY 2007 rates because the episode ends on or after January 1, 
2007 and before January 1, 2008; and the

[[Page 65888]]

episode will also receive the rural add-on because the episode begins 
on or after January 1, 2006 and before January 1, 2007.
    The applicable case-mix and wage index adjustment is subsequently 
applied to the 60-day episode amount for the provision of home health 
services where the site of service for the beneficiary is a non-
Metropolitan Statistical Area (MSA). Similarly, the applicable wage 
index adjustment is subsequently applied to the LUPA per-visit amounts 
adjusted for the provision of home health services where the site of 
service for the beneficiary is a non-MSA area. We implemented this 
provision for CY 2006 on February 13, 2006 through Pub. 100-20, One 
Time Notification, Transmittal 211 issued February 10, 2006. The 5 
percent rural add-on is noted in tables 3 and 4 below.

     Table 3.--Payment Amounts for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the
      Estimated Home Health Market Basket Update for CY 2007 with Rural Add-on, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
                                                                              CY 2007 Payment amount per 60-day
                                                                              episode beginning in CY 2006 and
  CY 2007 Total prospective payment          5 Percent rural add-on         before January 1, 2007 and ending in
      amount per 60-day episode                                                 CY 2007 for a beneficiary who
                                                                                  resides in a non-MSA area
----------------------------------------------------------------------------------------------------------------
                       $2,339                                x 1.05                             $2,455.95
----------------------------------------------------------------------------------------------------------------


  Table 4.--Per-Visit Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated
                         Home Health Market Basket Update for CY 2007 with Rural Add-on
----------------------------------------------------------------------------------------------------------------
                                                                                               CY 2007 per-visit
                                                                                                 payment amount
                                                                                                 per discipline
                                                                                                   for 60-day
                                                                                                    episodes
                                                         CY 2007 Per-visit  Multiply by the 5   beginning on or
              Home health discipline type                     amounts       percent rural add-  after January 1,
                                                                                    on           in CY 2006 and
                                                                                               ending in CY 2007
                                                                                               for a beneficiary
                                                                                                who resides in a
                                                                                                  non-MSA area
----------------------------------------------------------------------------------------------------------------
Home Health Aide.......................................             $46.24             x 1.05             $48.55
Medical Social Services................................             163.68             x 1.05             171.86
Occupational Therapy...................................             112.40             x 1.05             118.02
Physical Therapy.......................................             111.65             x 1.05             117.23
Skilled Nursing........................................             102.11             x 1.05             107.22
Speech-Language Pathology..............................             121.32             x 1.05             127.39
----------------------------------------------------------------------------------------------------------------

D. Home Health Care Quality Improvement

    Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to 
the Act, requiring that ``each home health agency shall submit to the 
Secretary such data that the Secretary determines are appropriate for 
the measurement of health care quality. Such data shall be submitted in 
a form and manner, and at a time, specified by the Secretary for 
purposes of this clause.'' In addition, section 1895(b)(3)(B)(v)(I) of 
the Act, as also added by section 5201(c)(2) of the DRA, dictates that 
``for 2007 and each subsequent year, in the case of a home health 
agency that does not submit data to the Secretary in accordance with 
subclause (II) with respect to such a year, the home health market 
basket percentage increase applicable under such clause for such year 
shall be reduced by 2 percentage points.''
    The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required 
the use of a standardized assessment instrument for quality oversight 
of HHAs. A standardized assessment instrument provides an HHA with a 
uniform mechanism to assess the needs of their patients and provide CMS 
with a uniform mechanism to assess the HHA's ability to adequately 
address those needs. To fulfill the OBRA 87 mandate, CMS required that, 
as part of their comprehensive assessment process, HHAs collect and 
report Outcome and Assessment Information Set (OASIS) data and later 
mandated the submission of this data as a Medicare Condition of 
Participation for home health agencies at 42 CFR 484.20 and 484.55.
    The OASIS data provide consumers and HHAs with ten publicly-
reported home health quality measures which have been endorsed by the 
National Quality Forum (NQF). Reporting this quality data has also 
required the development of several supporting mechanisms such as the 
HAVEN software used to encode and transmit data using a CMS standard 
electronic record layout, edit specifications, and data dictionary. Use 
of the HAVEN software, which includes the OASIS, has become a standard 
practice within HHA operations. These early investments in data 
infrastructure and supporting software that CMS and HHAs have made over 
the past several years in order to create this quality reporting 
structure, have made quality reporting and measurement an important 
component of the HHA industry. The 10 measures are:

(1) Improvement in ambulation/locomotion
(2) Improvement in bathing
(3) Improvement in transferring
(4) Improvement in management of oral medications
(5) Improvement in pain interfering with activity
(6) Acute care hospitalization
(7) Emergent care
(8) Improvement in dyspnea
(9) Improvement in urinary incontinence
(10) Discharge to community

    We proposed to use OASIS data and the 10 quality measures based on 
those data as the appropriate measure of home health quality for CY 
2007. Continuing to use the OASIS instrument minimizes

[[Page 65889]]

the burden to providers and ensures that costs associated with the 
development and testing of a new reporting mechanism are not incurred. 
We believe that the noted 10 quality measures are the most appropriate 
measure of home health quality. Accordingly, for CY 2007, we proposed 
to require that the OASIS data, specifically the 10 quality measures, 
be submitted by HHAs, to meet the requirement that each HHA submit data 
appropriate for the measurement of health care quality, as determined 
by the Secretary.
    Additionally, section 1895(b)(3)(B)(v)(II) of the Act provides the 
Secretary with the discretion to require the submission of the required 
data in a form, manner, and time specified by him. For CY 2007, we 
proposed to consider OASIS data submitted by HHAs to CMS for episodes 
beginning on or after July 1, 2005 and before July 1, 2006 as meeting 
the reporting requirement. This proposed reporting time period would 
allow a full 12 months of data and provides CMS the time necessary to 
analyze and make any necessary payment adjustments to the CY 2007 
payment rates for HHAs that fail to meet the reporting requirement. 
HHAs that met the reporting requirement would be eligible for the full 
home health market basket percentage increase. Using historical data to 
determine a prospective update is also used for hospital pay for 
reporting.
    As discussed in the August 3, 2006 proposed rule, during the next 
few years, we noted that we would be pursuing the development of 
patient level process measures for home health agencies. We also 
proposed to continue to refine the current OASIS tool in response to 
recommendations from a Technical Expert Panel conducted to review the 
data elements that make up the OASIS tool. These process measures would 
refer to specific care practices that are, or are not, followed by the 
home health agency for each patient. An example of this type of measure 
may be: the percentage of patients at risk of falls for whom prevention 
of falls was addressed in the care plan. We expect to introduce these 
additional measures over CY 2008 and CY 2009 so as to complement the 
existing OASIS outcome measures. During the years leading to CY 2010 
payments, we will test and refine these measures to determine if they 
can more accurately reflect the level of quality care being provided at 
HHAs without being overly burdensome with the data collection 
instrument. Some process measures are in the very early stages of 
development. To the extent that evidence-based data are available on 
which to determine the appropriate measure specifications, and adequate 
risk-adjustments are made, we anticipate collecting and reporting these 
measures as part of each agency's home health quality plan. We believe 
that future modifications to the current OASIS tool including reducing 
the number of questions on the tool, refining possible responses, as 
well as adding new process measures will be made. In all cases, we 
anticipate that any future quality measures should be evidence-based, 
clearly linked to improved outcomes, and able to be reliably captured 
with the least burden to the provider. We are also beginning work in 
order to measure patient experience of care (in the form of a patient 
satisfaction survey) in the home health setting.
    We recognize, however, that the conditions of participation (42 CFR 
part 484) that require OASIS submission also provide for exclusions 
from this requirement. Generally, agencies are not subject to the OASIS 
submission requirement, and thus do not receive Medicare payments, for 
patients that are not Medicare beneficiaries or for patients that are 
not receiving Medicare-covered home health services. Under the 
conditions of participation, agencies are excluded from the OASIS 
reporting requirement on individual patients if:
     Those patients are receiving only non-skilled services,
     Neither Medicare nor Medicaid is paying for home health 
care (patients receiving care under a Medicare or Medicaid Managed Care 
Plan are not excluded from the OASIS reporting requirement),
     Those patients are receiving pre- or post-partum services,
     Those patients are under 18 years of age.
    We believe that the rationale behind our proposal to exclude these 
agencies from submitting OASIS data on patients excluded from OASIS 
submission as a condition of participation is equally applicable to 
HHAs for purposes of meeting the DRA quality data reporting 
requirement. If an agency is not submitting OASIS for patients excluded 
from OASIS submission as a condition of participation, we believe that 
the submission of OASIS data for quality measures for Medicare payment 
purposes is also not necessary. Accordingly, we proposed that HHAs 
would not need to submit quality measures for DRA reporting purposes 
for those patients who are excluded from OASIS submission as a 
condition of participation.
    Additionally, we proposed that agencies that are newly certified 
(on or after May 31, 2006 for payments to be made in CY 2007) would be 
excluded from the DRA reporting requirement as data submission and 
analysis would not be possible for an agency certified this late in the 
reporting time period. In future years, agencies that certify on or 
after May 31 of the preceding year involved would be excluded from any 
payment penalty under the DRA for the following calendar year. For 
example, for purposes of determining compliance with the quality data 
reporting requirement for CY 2007, if HHA ``X'' were to enroll in the 
Medicare Program on or before May 30, 2006, CMS would expect HHA ``X'' 
to submit the required quality data (unless covered by another 
exclusion protocol) on or before June 30, 2006 (the end of the 
reporting period for payments effectuated in CY 2007). However, if HHA 
``Y'' was to enroll in the Medicare Program on or after May 31, 2006, 
CMS would automatically exclude HHA ``Y'' from the DRA quality data 
reporting requirements and the agency would be entitled to the full 
market basket increase for CY 2007. We note that these proposed 
exclusions would only affect reporting requirements under the DRA and 
would not otherwise affect the agency's OASIS reporting 
responsibilities under the conditions of participation.
    We proposed to require that all HHAs, unless covered by these 
specific exclusions, meet the reporting requirement, or be subject to a 
2 percent reduction in the home health market basket percentage 
increase in accordance with section 1895(b)(3)(B)(v)(I) of the Act. The 
2 percent reduction would apply to all episodes ending on or before 
December 31, 2007. We provide the reduced payment rates in tables 5, 6, 
7, and 8 below.

[[Page 65890]]



 Table 5.--For HHAs That Do Not Submit the Required Quality Data-- National 60-Day Episode Amount Updated by the
  Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
                                         Multiply by the estimated home        CY 2007 updated national 60-day
  Total CY 2006 prospective payment     health market basket update (3.3      episode rate for HHAs that do not
      amount per 60-day episode           Percent \1\ minus 2 percent)          submit required quality data
----------------------------------------------------------------------------------------------------------------
                    $2,264.28                               x 1.013                            $2,293.72
----------------------------------------------------------------------------------------------------------------
\1\The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
  3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.


    Table 6--For HHAs That Do Not Submit the Required Quality Data--National Per-Visit Amounts Updated by the
                Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points
----------------------------------------------------------------------------------------------------------------
                                                                                               CY 2007 per-visit
                                                                             Multiply by the     payment amount
                                                         Final CY 2006 per-   estimated home     per discipline
              Home health discipline type                visit amounts per    health market     for HHAs that do
                                                           60-day episode     basket update        not submit
                                                                             (3.3 percent \1\   required quality
                                                                             minus 2 percent)         data
----------------------------------------------------------------------------------------------------------------
Home Health Aide.......................................             $44.76            x 1.013             $45.34
Medical Social Services................................             158.45            x 1.013             160.51
Occupational Therapy...................................             108.81            x 1.013             110.22
Physical Therapy.......................................             108.08            x 1.013             109.49
Skilled Nursing........................................              98.85            x 1.013             100.14
Speech-Language Pathology..............................             117.44            x 1.013            118.97
----------------------------------------------------------------------------------------------------------------
\1\The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc,
  3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.


 Table 7.--For HHAs That Do Not Submit the Required Quality Data-- Payment Amount for 60-Day Episodes Beginning
    in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2
                        Percentage Points, with Rural Add-on, Before Case-Mix Adjustment
----------------------------------------------------------------------------------------------------------------
                                                                              CY 2007 Payment amount per 60-day
                                                                              episode beginning in CY 2006 and
   CY 2007 Updated national 60-day                                           ending in CY 2007 for a beneficiary
  episode rate for HHAs that do not          5 Percent rural add-on           who resides in a non-MSA area for
    submit required quality data                                              HHAs that do not submit required
                                                                                        quality data
----------------------------------------------------------------------------------------------------------------
                    $2,293.72                                x 1.05                             $2,408.41
----------------------------------------------------------------------------------------------------------------


     Table 8--For HHAs That Do Not Submit the Required Quality Data-- Per-Visit Payment Amounts for Episodes
Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus
                                     2 Percentage Points, with Rural Add-on
----------------------------------------------------------------------------------------------------------------
                                                                                               CY 2007 Per-visit
                                                                                                payment amounts
                                                                                                  for episodes
                                                                                                beginning in CY
                                                         CY 2007 Per-visit                      2006 and ending
                                                          amounts for HHAs   5 Percent rural    in CY 2007 for a
              Home health discipline type                   that do not           add-on        beneficiary who
                                                          submit required                      resides in a non-
                                                            quality data                       MSA area for HHAs
                                                                                                  that do not
                                                                                                submit required
                                                                                                  quality data
----------------------------------------------------------------------------------------------------------------
Home Health Aide.......................................             $45.34             x 1.05             $47.61
Medical Social Services................................             160.51             x 1.05             168.54
Occupational Therapy...................................             110.22             x 1.05             115.73
Physical Therapy.......................................             109.49             x 1.05             114.96
Skilled Nursing........................................             100.14             x 1.05             105.55
Speech-Language Pathology..............................             118.97             x 1.05             124.92
----------------------------------------------------------------------------------------------------------------

    Section 1895(b)(3)(B)(v)(III) of the Act further requires that the 
``Secretary shall establish procedures for making data submitted under 
subclause (II) available to the public.'' Additionally, the statute 
requires that ``such procedures shall ensure that a home health agency 
has the opportunity to review the data that is to be made public with 
respect to the agency prior to such data being made public.'' To meet 
the requirement for making such data public, we proposed

[[Page 65891]]

to continue to use the CMS Home Health Compare Web site whereby HHAs 
are listed geographically. Currently the 10 proposed quality measures 
are posted on the CMS Home Health Compare Web site. Consumers can 
search for all Medicare-approved home health providers that serve their 
city or zip code and then find the agencies offering the types of 
services they need as well as the required quality measures. See http://www.medicare.gov/HHCompare. HHAs would continue to have access 
(through the Home Health Compare contractor) to its own quality data 
(updated periodically) and we would establish a process by which 
agencies would receive a report before reporting the data publicly.
    Currently, the CMS Home Health Compare Web site does not publicly 
report data when agencies have fewer than 20 episodes of care within a 
reporting period. In light of the DRA requirements, we recognize the 
need to provide the required data to the public and would make these 
statistics available through expansion of the CMS Home Health Compare 
Web site.
    In the July 27, 2005 Medicare Payment Advisory Commission (MedPAC) 
testimony before the U.S. Senate Committee on Finance, MedPAC expressed 
support for the concept of differential payments for Medicare 
providers, which could create incentives to improve quality. To support 
this initiative, MedPAC stated that ``outcome measures from CMS' 
Outcome-based Quality Indicators'' (currently collected through the 
OASIS instrument) ``could form the starter set.'' MedPAC further states 
``* * * the Agency for Healthcare Research and Quality concur(s) that a 
set of these measures is reliable and adequately risk adjusted.''
    The MedPAC testimony recognizes that while the goal of care for 
many home health patients is improving health and functioning, for some 
patients the goal of the HHA is to simply stabilize their conditions 
and prevent further decline. Additionally, the MedPAC testimony 
reflects that measures of structure and process could also be 
considered.
    Various home health outcome measures are now in common use and have 
been studied for some time. A number of these measures have been 
endorsed by the National Quality Forum (NQF) and are evidence-based, 
well accepted, and not unduly burdensome. When determining outcome 
measures that will be most appropriate, it is important to measure 
aspects of care that providers can control and are adequately risk-
adjusted. Home-based care presents particular difficulties for provider 
control because patient conditions are compounded by a variety of home 
environment and support system issues.
    We are currently pursuing the development of patient-level process 
measures for HHAs, as well as refining the current OASIS tool in 
response to recommendations from a Technical Expert Panel conducted to 
review the data elements that make up the OASIS tool. These additional 
measures would complement the existing OASIS outcome measures and would 
assist us in identifying processes of care that lead to improvements 
for certain populations of patients. These process measures are 
currently in the very early stages of development. As we stated 
previously, to the extent that evidence-based data are available on 
which to determine the appropriate measure specifications, and adequate 
risk-adjustments are made, we anticipate collecting and reporting these 
measures as part of our home health quality plan. Possible 
modifications to the current OASIS tool include reducing the number of 
questions on the tool, refining possible responses, as well as adding 
new process measures.
    We solicited comments on how to make the outcome measures more 
useful. We also solicited comments on measures of home health care 
processes for which there is evidence of improved care to 
beneficiaries. In all cases, we noted that measures should be evidence-
based, clearly linked to improved outcomes, and able to be reliably 
captured with the least burden to the provider. We also considered 
measures of patient experience of care in the home health setting, as 
well as efficiency measures, and solicited comment on the use of these 
measures and their importance in the home health setting. In the 
proposed rule, we noted that we would address any changes to the HH PPS 
quality data submission requirement in future rulemaking.
    We also stated our intent to provide guidance on the 
specifications, definitions, and reporting requirements of any 
additional measures through the standard protocol for measure 
development.
    We proposed to revise the regulations at Sec.  484.225 to reflect 
these proposed payment requirements which would require submission of 
quality data. For CY 2007, we will finalize the requirement to use the 
10 OASIS measures as meeting the DRA quality data reporting requirement 
as discussed in section II.D. of the August 3, 2006 proposed rule and 
the regulations at Sec.  484.225.

E. Outliers and Fixed Dollar Loss Ratio

    Outlier payments are payments made in addition to regular 60-day 
case-mix and wage-adjusted episode payments for episodes that incur 
unusually large costs due to patient home health care needs. Outlier 
payments are made for episodes for which the estimated cost exceeds a 
threshold amount. The episode's estimated cost is the sum of the 
national wage-adjusted per-visit payment amounts for all visits 
delivered during the episode. The outlier threshold for each case-mix 
group, PEP adjustment, or total SCIC adjustment is defined as the 60-
day episode payment amount, PEP adjustment, or total SCIC adjustment 
for that group plus a fixed dollar loss amount. Both components of the 
outlier threshold are wage-adjusted.
    The wage-adjusted fixed dollar loss (FDL) amount represents the 
amount of loss that an agency must bear before an episode becomes 
eligible for outlier payments. The FDL is computed by multiplying the 
wage-adjusted 60-day episode payment amount by the FDL ratio, which is 
a proportion expressed in terms of the national standardized episode 
payment amount. The outlier payment is defined to be a proportion of 
the wage-adjusted estimated costs beyond the wage-adjusted threshold. 
The proportion of additional costs paid as outlier payments is referred 
to as the loss-sharing ratio.
    Section 1895(b)(5) of the Act requires that estimated total outlier 
payments are no more than 5 percent of total estimated HH PPS payments. 
In response to the concerns about potential financial losses that might 
result from unusually expensive cases expressed in comments to the 
October 28, 1999 proposed rule (64 FR 58133), the July 2000 final rule 
set the target for estimated outlier payments at the 5 percent level. 
The FDL ratio and the loss-sharing ratio were then selected so that 
estimated total outlier payments would meet the 5 percent target.
    For a given level of outlier payments, there is a trade-off between 
the values selected for the FDL ratio and the loss-sharing ratio. A 
high FDL ratio reduces the number of episodes that can receive outlier 
payments, but makes it possible to select a higher loss-sharing ratio 
and, therefore, increase outlier payments for outlier episodes. 
Alternatively, a lower FDL ratio means that more episodes can qualify 
for outlier payments, but outlier payments per episode must be lower. 
As a result of public comments on the October 28, 1999 proposed rule, 
in our July 2000 final rule, we made the decision to attempt to do the 
former.

[[Page 65892]]

    In the July 2000 final rule, we chose a value of 0.80 for the loss-
sharing ratio, which preserves incentives for agencies to attempt to 
provide care efficiently for outlier cases. A loss-sharing ratio of 
0.80 was also consistent with the loss-sharing ratios used in other 
Medicare PPS outlier policies. Furthermore, we estimated the value of 
the FDL ratio that would yield estimated total outlier payments that 
were 5 percent of total home health PPS payments. The resulting value 
for the FDL ratio for the July 2000 final rule was 1.13.
    Our CY 2005 update to the HH PPS rates (69 FR 62124) changed the 
FDL ratio from the original 1.13 to 0.70 to allow more home health 
episodes to qualify for outlier payments and to better meet the 5 
percent target of outlier payments to total HH PPS payments. We stated 
in that CY 2005 update that we planned to continue to monitor the 
outlier expenditures on a yearly basis and to make adjustments as 
necessary (69 FR 62129). To do so, we planned on using the best 
Medicare data available at the time of publication. For the CY 2005 
update, we used CY 2003 home health claims data.
    Our CY 2006 update to the HH PPS rates (70 FR 68132) changed the 
FDL ratio from 0.70 to 0.65 to allow even more home health episodes to 
qualify for outlier payments and to better meet the 5 percent target of 
outlier payments to total HH PPS payments. For the CY 2006 update, we 
used CY 2004 home health claims data.
    At the time of publication of the August 3, 2006 proposed rule, we 
did not have more recent data, but we noted that we may update the FDL 
ratio for CY 2007 depending on the availability of more recent data. We 
further noted that if we updated the FDL ratio for the CY 2007 update, 
we would use the same methodology performed in updating the current FDL 
ratio described in the October 22, 2004 final rule. Subsequent to the 
publication of the August 3, 2006 proposed rule, we have now obtained 
more recent data, that is, CY 2005 home health claims data.
    Accordingly for this final rule, we have used the same methodology 
and performed an analysis on the CY 2005 HH PPS analytic data to update 
the FDL ratio for CY 2007. The results of this analysis indicate that 
an FDL ratio of 0.67 is consistent with the existing loss-sharing ratio 
of 0.80 and a projected target percentage of estimated outlier payments 
of 5 percent. Therefore, we are updating the FDL ratio from the current 
0.65 to 0.67 for CY 2007.
    Expressed in terms of a fixed dollar loss amount, an FDL ratio of 
0.67 indicates that providers would absorb approximately $1,567 of 
their costs (before wage adjustment), in addition to their loss-sharing 
portion of the estimated cost in excess of the outlier threshold. This 
fixed dollar loss amount of approximately $1,567 is computed by 
multiplying the standard 60-day episode payment amount (2,339.00) by 
the FDL ratio (0.67). In contrast, using the current FDL ratio (0.65), 
the fixed dollar loss amount would be approximately $1,520 ($2,339.00 x 
0.65)

F. Hospital Wage Index--Revised OMB Definitions for Geographical 
Statistical Areas

    Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the 
Secretary to establish area wage adjustment factors that reflect the 
relative level of wages and wage-related costs applicable to the 
furnishing of home health services and to provide appropriate 
adjustments to the episode payment amounts under the HH PPS to account 
for area wage differences. We apply the appropriate wage index value to 
the labor portion (76.775 percent; see 60 FR 62126) of the HH PPS rates 
based on the geographic area in which the beneficiary received home 
health services as discussed in section II.A of the August 3, 2006 
proposed rule. Generally, we determine each HHA's labor market area 
based on definitions of Metropolitan Statistical Areas (MSAs) issued by 
the Office of Management and Budget (OMB).
    We acknowledged in our October 22, 2004 final rule that on June 6, 
2003, the OMB issued an OMB Bulletin (No. 03-04) announcing revised 
definitions for MSAs, new definitions for Micropolitan Statistical 
Areas and Combined Statistical Areas, and guidance on using the 
statistical definitions. 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 Core-Based Statistical Areas (CBSAs). In the 
November 9, 2005 final rule, we adopted the OMB-revised definitions and 
implemented a one-year transition policy consisting of a 50/50 blend of 
the MSA-based and the new CBSA-based wage indexes.
    As discussed previously and set forth in the July 3, 2000 final 
rule, the statute provides that the wage adjustment factors may be the 
factors used by the Secretary for purposes of section 1886(d)(3)(E) of 
the Act for hospital wage adjustment factors. Again, as discussed in 
the July 3, 2000 final rule, we proposed to use the pre-floor and pre-
reclassified hospital wage index data to adjust the labor portion of 
the HH PPS rates based on the geographic area in which the beneficiary 
receives the home health services. We believe the use of the pre-floor 
and pre-reclassified hospital wage index data results in the 
appropriate adjustment to the labor portion of the costs as required by 
statute. For the CY 2007 update to the home health payment rates, we 
proposed to continue using the most recent pre-floor and pre-
reclassified hospital wage index available at the time of publication. 
See Addenda A and B of this final rule, respectively, for the rural and 
urban hospital wage indexes using the CBSA designations. For the HH PPS 
rates addressed in the August 3, 2006 proposed rule, we used 
preliminary 2007 pre-floor and pre-reclassified hospital wage index 
data. We incorporated updated hospital wage index data for the 2007 
pre-floor and pre-reclassified hospital wage index to be used in this 
final rule (not including any reclassifications under section 
1886(d)(8)(B) of the Act).
    As implemented under the HH PPS in the July 3, 2000 HH PPS final 
rule, each HHA's labor market is determined based on definitions of 
MSAs issued by OMB. In general, an urban area is defined as an MSA or 
New England County Metropolitan Area (NECMA) as defined by OMB. 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 are 
defined in Sec.  412.62(f)(1)(ii) and Sec.  412.62(f)(1)(iii), 
respectively, and have been used under the HH PPS since it was 
implemented.
    Under the HH PPS, the wage index value is based upon the site of 
service for the beneficiary (defined by section 1861(m) of the Act as 
the beneficiary's place of residence). As has been our longstanding 
practice, any area not included in an MSA (urban area) is considered to 
be nonurban (Sec.  412.64(b)(1)(ii)(C)) and receives the statewide 
rural wage index value (see, for example, 65 FR 41173).
    For CY 2007, we proposed using 100 percent of the CBSA-based wage 
area designations for purposes of determining the HH PPS wage index 
adjustment.
    In adopting the CBSA designations, we identified some geographic 
areas where there were no hospitals, and thus no hospital wage data on 
which to base the calculation of the CY 2007 home health wage index. 
For CY 2006, we adopted a policy in the HH PPS final rule (70 FR 68132) 
of using the CY 2005 pre-floor, pre-reclassified hospital wage index 
value for rural areas when no rural hospital wage data are available. 
We also adopted a policy that for urban labor markets without an urban 
hospital

[[Page 65893]]

from which a hospital wage index can be derived, all of the CBSAs 
within the State would be used to calculate a statewide urban average 
wage index to use as a reasonable proxy for these areas. We have not 
received any concerns from the industry regarding our policy to 
calculate an urban wage index, using an average of all of the urban 
CBSAs wage index values within the State, for urban labor markets 
without an urban hospital from which a hospital wage index can be 
derived. Consequently, in the August 3, 2006 proposed rule, we proposed 
to continue to apply the average wage index from all urban areas in the 
state to any urban areas lacking hospital wage data in that state. 
Currently, the only CBSA that would be affected by this is CBSA 25980 
Hinesville, Georgia.
    In the August 3, 2006 proposed rule, we again proposed to apply the 
CY 2005 pre-floor/pre-reclassified hospital wage index to rural areas 
where no hospital wage data is available. Currently, the only rural 
areas that would be affected by this are Massachusetts and Puerto Rico. 
Since publication of the CY 2006 HH PPS final rule, representatives of 
the home health industry have expressed concerns with this policy, 
specifically as it applies to Massachusetts. In response to these 
concerns and in recognition that, in the future, there may be 
additional rural areas impacted by a lack of hospital wage data from 
which to derive a wage index, we considered alternative methodologies 
for imputing a rural wage index for areas where no hospital wage data 
are available.
    We specifically considered imputing a rural wage index by computing 
a simple average of all of the statewide (rural) wage indexes at the 
Census Division level. Census Divisions are defined by the U.S. Census 
Bureau and may be found at www.census.gov/geo/www/us_regdiv.pdf. 
Massachusetts is located in Census Division I, along with Connecticut, 
Maine, New Hampshire, Vermont and Rhode Island. The Census Bureau 
states, ``Puerto Rico and the Island Areas are not part of any census 
region or census division.'' Therefore, we could not compute a rural 
wage index for Puerto Rico using this alternative methodology.
    In the August 3, 2006 proposed rule, we solicited comments on the 
current methodology and alternative methodologies for determining a 
wage index for areas without the necessary hospital wage data. Since 
publication of the August 3, 2006 proposed rule, we have received 
numerous comments regarding our policy for determining a wage index for 
rural areas without the necessary hospital wage data. In direct 
response to these comments, we have decided to revise the methodology 
for imputing a rural wage index. We discuss the change to the 
methodology for imputing a rural wage index in section III of this 
final rule.

G. Payment for Oxygen, Oxygen Equipment and Capped Rental DME Items

    As discussed in the August 3, 2006 proposed rule, we would amend 
our regulations at Sec.  414.226 by revising the payment rules for 
oxygen and oxygen equipment in paragraph (a), adding a new paragraph 
(f) that provides that the beneficiary assumes ownership of oxygen 
equipment on the first day that begins after the 36th continuous month 
in which rental payments are made, and adding a new paragraph (g) that 
contains new supplier requirements that we believe are necessary in 
light of the amendments made to section 1834(a)(5) of the Act by 
section 5101(b) of the DRA. As discussed in the August 3, 2006 proposed 
rule, we would amend our regulations at Sec.  414.226 by adding a new 
paragraph (c) that establishes new classes and national payment amounts 
for oxygen and oxygen equipment based on our authority in section 
1834(a)(9)(D) of the Act. We also proposed to revise paragraph (b) of 
this section to incorporate the special payment rules for oxygen 
equipment mandated by section 1834(a)(21) of the Act. The provisions of 
section 1834(a)(21), which we believe are self-implementing, resulted 
in adjustments to Medicare payment amounts for oxygen contents and 
stationary oxygen equipment as well as portable oxygen equipment in 
2005, which were implemented through program instructions. We are now 
seeking to codify these changes to make our regulations consistent with 
the payment methodology for these items in 2005 and 2006, and because 
the payment reductions mandated by section 1834(a)(21) are incorporated 
into our proposal, as more fully discussed in section I of the August 
3, 2006 proposed rule, to create new payment classes for oxygen and 
oxygen equipment. The August 3, 2006 proposed rule indicated that we 
would redesignate old paragraph (c) of this section as paragraph (d) 
and would amend this paragraph to indicate under what situations 
payments would be made for the items and services described in new 
paragraph (c). Finally, the August 3, 2006 proposed rule indicated that 
we would redesignate old paragraph (d) of this section as paragraph (e) 
and would make technical changes to this paragraph so that the cross-
references are accurate in light of the other changes we proposed to 
make to Sec.  414.226.
    The August 3, 2006 proposed rule would also amend our regulations 
at Sec.  414.229 by revising the payment rules for capped rental 
durable medical equipment (DME) items (also called capped rental items) 
in paragraph (a), revising paragraph (f) to provide for new payment 
rules for capped rental items furnished beginning on or after January 
1, 2006, revising paragraph (g) to provide for supplier requirements 
that we believe are necessary in light of the amendments made to 
section 1834(a)(7)(A) of the Act by section 5101(a) of the DRA, and 
adding a new paragraph (h) to address the lump-sum purchase option for 
power-driven wheelchairs furnished on or after January 1, 2006. The 
language in current paragraphs (f) and (g) of this section is obsolete, 
and therefore, we proposed to delete this language.
    The August 3, 2006 proposed rule indicated that we would amend our 
regulations at Sec.  414.210 by revising the maintenance and servicing 
rules in paragraph (e) and the replacement of equipment rules in 
paragraph (f) to further implement the new supplier requirements that 
we proposed below.
    Finally, we proposed to revise Sec.  414.230(b) to incorporate 
section 5101(b)(2)(B) of the DRA, which provides that for all 
beneficiaries receiving oxygen equipment paid for under section 1834(a) 
on December 31, 2005, the period of continuous use begins on January 1, 
2006. We also proposed to revise Sec.  414.230(f), which governs when a 
new period of continuous use begins if a beneficiary receives new 
equipment, to account for the fact that oxygen equipment is paid on a 
modality neutral basis.
    Section 5101(a) of the DRA changes the Medicare payment methodology 
for capped rental equipment to beneficiary ownership after 13 months of 
continuous use, for those beneficiaries who need the equipment for more 
than 13 months. This section also makes the transfer of title for the 
capped rental items a requirement rather than a beneficiary option 
after 13 months of continuous use. The changes made by this section of 
the DRA apply to capped rental items, including rented power-driven 
wheelchairs, for which the first rental month occurs on or after 
January 1, 2006. We proposed to update Sec.  414.229 of our regulations 
to reflect these new statutory requirements. However, for capped rental 
items and rented power-driven wheelchairs for which the first rental 
month occurred before January 1, 2006, the existing rules in Sec.  
414.229 would continue to apply. In

[[Page 65894]]

addition, as was the case before enactment of the DRA, beneficiaries 
may elect to obtain power-driven wheelchairs furnished on or after 
January 1, 2006, on a lump-sum purchase basis.
    Section 5101(b) of the DRA changes the Medicare payment methodology 
for oxygen equipment from continuous rental to beneficiary ownership 
after 36 months of continuous use, for those beneficiaries who 
medically need the oxygen equipment for more than 36 months. For 
beneficiaries who were receiving oxygen equipment on December 31, 2005 
for which payment was made under section 1834(a) of the Act, the 36-
month rental period began on January 1, 2006. For beneficiaries who 
begin to rent oxygen equipment on or after January 1, 2006, the 36-
month rental period commences at the time they begin to rent the 
equipment. We proposed to update Sec.  414.226 of our regulations to 
incorporate these new requirements.
    In light of the changes made by sections 5101(a) and (b) of the 
DRA, we believe it was necessary to propose additional supplier 
requirements in order to maintain beneficiary protections and access to 
oxygen, oxygen equipment, and capped rental DME items under section 
1834(a) of the Act. For both capped rental DME items and oxygen 
equipment, the DRA amendments make the transfer of title from the 
supplier to the beneficiary a requirement rather than an option after 
the statutorily-prescribed rental period ends for each category of 
items. Therefore, suppliers and beneficiaries should be aware that 
title to these items will automatically transfer to the beneficiary if 
the medical need for the equipment continues for a period of continuous 
use that is longer than 36 months for oxygen equipment and 13 months 
for capped rental items. We are concerned that there may be incentives 
for suppliers to avoid having to transfer title to equipment to 
beneficiaries as required by the DRA. For example, we are aware of 
cases where a supplier has informed beneficiaries that it would decline 
to accept assignment for capped rental items and would charge 
beneficiaries who elected the purchase option the full retail price for 
the item during the 13th rental month (which was right before the 
supplier would be required to transfer title under the purchase 
option). In these cases, the beneficiary would become financially 
liable for the total retail price for the equipment in the 13th month 
if they elected the purchase option. In our August 3, 2006 proposed 
rule, we made several proposals relating to the furnishing of oxygen 
equipment and capped rental items which we believe protect 
beneficiaries from these types of abusive practices and which we 
believe are reasonable for a supplier to comply with. Our authority to 
promulgate these requirements stems from our authority to administer 
the payment rules at section 1834(a)(5) of the Act for oxygen equipment 
and section 1834(a)(7) of the Act for capped rental items, as well as 
the general authority provided in section 1871 of the Act for 
prescribing regulations necessary for administering the Medicare 
program. Other than the length of the rental periods, which the DRA 
made effective beginning on January 1, 2006 for all oxygen equipment 
and for capped rental items for which the first rental period began on 
or after that date, we proposed that the requirements presented in this 
section of the regulations would be effective on January 1, 2007, and 
would apply to suppliers that furnish oxygen equipment or capped rental 
items on a rental basis.
    We believe that a supplier of an item that is subject to these new 
payment rules that furnishes the item in the first month for which a 
rental payment is made has an obligation to continue furnishing the 
item to the beneficiary for the entire period of medical need in which 
payments are made, up to and including the time when title to the 
equipment transfers to the beneficiary. We believe it is reasonable for 
the beneficiary to have an expectation that he or she will not be 
forced to change equipment or suppliers during the period of medical 
need unless he or she wants to. Therefore, we proposed that unless an 
exception applies, the supplier that furnishes oxygen equipment or a 
capped rental item for the first month of the statutorily prescribed 
rental period must continue to furnish the oxygen equipment or the 
capped rental item for as long as the equipment remains medically 
necessary, up to and including the last month for which a rental 
payment is made by Medicare. We believe that this proposal was 
necessary to ensure beneficiary access to equipment during a period of 
medical need, which we believe could be jeopardized if suppliers have 
the option to take back the rented equipment just before the rental 
period expires in order to retain title to that equipment. We proposed 
that this requirement would be subject to the following exceptions: (1) 
Cases where the item becomes subject to a competitive acquisition 
program implemented in accordance with section 1847(a) of the Act; (2) 
cases where a beneficiary relocates on either a temporary or permanent 
basis to an area that is outside the normal service area of the initial 
supplier; (3) cases where the beneficiary chooses to obtain equipment 
from a different supplier; and (4) other cases where CMS or the carrier 
determine that an exception is warranted. We have proposed rules in 
connection with the first exception in our Notice of Proposed 
Rulemaking for Competitive Acquisition for Certain Durable Medical 
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other 
Issues. These proposed rules are addressed beginning on page 25662 of 
the May 1, 2006 proposed rule (71 FR 25654). If the second exception 
applies, we proposed that the supplier or beneficiary would need to 
arrange for another supplier in the new area to furnish the item on 
either a temporary or permanent basis. This proposed exception is 
consistent with what currently happens when beneficiaries move outside 
a supplier's service area on either a temporary or permanent basis. The 
third exception is intended to protect a beneficiary's right to obtain 
the equipment from the supplier of his or her choice. Finally, we 
proposed to allow other exceptions to this proposed requirement on a 
case-by-case basis at the discretion of CMS or the Medicare contractor. 
CMS will be monitoring the case-by-case determinations made by the 
Medicare contractor.
    We are concerned that there might be potential incentives for a 
supplier to replace more valuable or newer equipment used by the 
beneficiary with less valuable or older equipment from its inventory at 
some point before the 36th rental month for oxygen equipment or 13th 
rental month for capped rental DME expires in order to avoid losing 
title to the more valuable equipment. In order to avoid such potential 
situations, we proposed that the supplier may not provide different 
equipment from that which was initially furnished to the beneficiary at 
any time during the 36-month period for oxygen equipment or 13th rental 
month for capped rental DME unless one of the following exceptions 
applies: (1) The equipment is lost, stolen, or irreparably damaged; (2) 
the equipment is being repaired while loaner equipment is in use; (3) 
there is a change in the beneficiary's medical condition such that the 
equipment initially furnished is no longer appropriate or medically 
necessary; or (4) the carrier determines that a change in equipment is 
warranted. However, we proposed that a change from one oxygen equipment 
modality to another

[[Page 65895]]

without physician documentation that such a change is medically 
necessary for the individual would not be considered a change in 
equipment that is warranted under the fourth exception stated above 
since there is no medical basis for the change. In those cases where 
the equipment is replaced, we proposed that the replacement item must 
be equipment that is, at minimum, in the same condition as the 
equipment being replaced. That proposal was intended to safeguard 
beneficiary access to quality oxygen equipment and capped rental items 
throughout the duration of the rental period.
    Under Medicare, suppliers who furnish items of DME can accept 
assignment on all claims for Medicare services or on a claim-by-claim 
basis. Assignment is an agreement between the supplier and the 
beneficiary under which the supplier agrees to request direct payment 
from Medicare for the item, to accept 80 percent of the Medicare 
allowed payment amount for the item from the carrier, and to charge the 
beneficiary not more than the remaining 20 percent of the Medicare 
approved payment amount, plus any unmet deductible. If a supplier 
elects not to accept assignment, Medicare pays the beneficiary 80 
percent of the Medicare allowed payment amount, after subtracting any 
unmet deductible, and there is no limit under Title XVIII of the Act on 
the amount the supplier can charge the beneficiary for rental of the 
DME item. The beneficiary, in these situations, is financially 
responsible for the difference between 80 percent of the Medicare 
allowed payment amount and the amount the supplier charges for the 
rental of the DME item.
    Section 1842(h) allows suppliers to sign a participation agreement 
where the supplier agrees voluntarily, before a calendar year, to 
accept assignment for all Medicare items and services furnished to a 
beneficiary for the following calendar year. Current supplier 
participation agreements are renewable annually. However, the 
agreements do not apply for a full period of medical need for specific 
beneficiaries in cases where such need extends for more than a calendar 
year. Nor do current participation agreements apply to periods of 
medical need where such a period overlaps calendar years. In the latter 
case, while a supplier may renew its participation agreement annually, 
a beneficiary would not know before choosing a supplier whether the 
supplier would be willing to accept assignment of all claims during the 
13-month or 36-month rental period.
    In order for the beneficiary to make an informed choice, we 
proposed that before furnishing the oxygen equipment or a capped rental 
item, the supplier must disclose to the beneficiary its intentions 
regarding whether it will accept assignment of all monthly rental 
claims for the equipment during the period of medical necessity, up to 
and including the 36th month of continuous use for oxygen equipment or 
the 13th rental month of continuous use for capped rental DME in which 
rental payments could potentially be made. We believe that it is 
reasonable for the supplier to disclose to each beneficiary its 
intentions regarding assignment of claims for all months during a 
rental period as this decision has a direct financial effect on the 
beneficiary. A supplier's intentions could be expressed in the form of 
a written agreement between the supplier and a beneficiary. This 
proposal would require suppliers to give beneficiaries advance notice 
of the possible extent of their financial liability during the period 
of medical need in which monthly rental payments are made for the 
equipment, so that they can use this information to help select a 
supplier. Additionally, to promote informed beneficiary choices, we 
plan to post information on a CMS and/or CMS contractor Web site(s) 
indicating supplier specific information on oxygen equipment and capped 
rental items such as (1) the percentage of beneficiaries for whom each 
supplier accepted assignment during a prior period of time (for 
example, a quarter), and/or (2) the percentage of cases in which the 
supplier accepted assignment during the beneficiary's entire rental 
period. We believe that those proposals create reasonable rules for 
suppliers that furnish oxygen equipment and capped rental items and 
ensure that beneficiaries have information necessary to make informed 
choices that could have significant financial consequences for them.

H. Payment for Oxygen Contents for Beneficiary-Owned Oxygen Equipment

    Section 1834(a)(5) of the Act, as amended by section 5101(b)(1) of 
the DRA, requires that Medicare continue to make monthly payments for 
the delivery and refilling of oxygen contents for the period of medical 
need after beneficiaries own their own gaseous or liquid oxygen 
stationary or portable equipment. Before the enactment of the DRA, 
Medicare made monthly payments for the delivery and refilling of oxygen 
contents for beneficiaries who own their own stationary and/or portable 
equipment (equipment they obtained on a purchase basis before June 1, 
1989, out-of-pocket, or before they enrolled in Medicare Part B). In 
accordance with the DRA, we proposed that after the supplier transfers 
title to the stationary and/or portable oxygen equipment to the 
beneficiary, Medicare would continue to make separate monthly payments 
for gaseous or liquid oxygen contents until medical necessity ends. We 
also proposed that if the beneficiary-owned equipment is replaced, and 
Medicare pays for the replacement in accordance with proposed revised 
Sec.  414.210(f) (see section K of this final rule for a more complete 
discussion of our proposed oxygen equipment replacement policies), a 
new 36-month rental period start and the payment for oxygen contents 
would be included in the monthly rental payments. We proposed that all 
oxygen content payment amounts would be based on new rates developed in 
accordance with our proposal to establish new payment classes, as 
discussed in section I below.
    In transferring title to gaseous or liquid oxygen equipment used 
during the 36-month rental period, we proposed that suppliers must 
transfer title for all equipment that will meet the beneficiary's 
continued medical need, including those oxygen cylinders or vessels 
that are refilled at the supplier's place of business. Customary 
practice by suppliers for refilling oxygen contents is to deliver to 
the beneficiary cylinders filled with contents and take back the empty 
cylinders to the supplier's place of business to refill the oxygen 
contents. Under our proposal, title would transfer for both sets of 
cylinders, meaning the ones that are being used by the beneficiary for 
the month and the ones that the supplier refills in its business 
location and delivers for use during the next subsequent month. This 
policy would apply to both gaseous and liquid oxygen stationary 
equipment and portable systems. Similarly, in those cases where the 
beneficiary uses an oxygen equipment system which includes a compressor 
which fills portable gaseous cylinders in the beneficiary's home, we 
proposed that suppliers must transfer title for this equipment to the 
beneficiary.
    Concerns have been raised regarding beneficiary access to, and 
safety issues associated with, the delivery of oxygen contents for 
beneficiary-owned stationary and portable gaseous or liquid equipment. 
We believe that these concerns are based on the misconception that 
beneficiaries become responsible for filling their own cylinders. To 
the contrary, there are numerous State and Federal regulations 
governing the safe handling, filling, and transport of oxygen and those 
regulations are unaffected by the DRA oxygen provisions. We expect that

[[Page 65896]]

suppliers will continue to furnish replacement contents for 
beneficiary-owned gaseous and liquid systems in the same way that they 
have furnished replacement contents for beneficiary-owned equipment in 
the past. For example, suppliers that deliver a 1 month supply of 
gaseous cylinders to a beneficiary's home at the same time that they 
are picking up empty cylinders that the beneficiary used during the 
previous month could continue this practice under section 5101(b) of 
the DRA.

I. Classes of Oxygen and Oxygen Equipment

    Based on information from paid Medicare claims with dates of 
service in calendar year 2004, distribution of usage among the four 
general categories of oxygen systems was: (a) 69 percent of 
beneficiaries used both a stationary concentrator (which does not 
require delivery of oxygen contents) and a portable system that 
requires delivery of gaseous or liquid oxygen, (b) 5 percent of 
beneficiaries used a stationary system that requires delivery of 
gaseous or liquid oxygen and a portable system that requires delivery 
of gaseous or liquid oxygen, (c) 24 percent of beneficiaries used a 
stationary concentrator system only, and (d) 2 percent of beneficiaries 
used only a stationary system that requires delivery of liquid or 
gaseous oxygen. The prevalent use of stationary concentrator systems is 
due, in part, to the fact that this system is the most cost-effective 
and dependable of the stationary oxygen modalities. The main reason 
that the concentrator system is the most cost-effective system is that 
the oxygen is concentrated from room air, and therefore, the high cost 
of delivering contents to the beneficiary's residence is removed when 
this system is used. Medicare's current payment structure results in 
two separate payments for beneficiaries using both stationary and 
portable systems, both of which are modality neutral, meaning that the 
payment amount does not differ depending on the type of oxygen delivery 
system (gaseous, liquid, or concentrator) that is furnished. One 
payment, hereinto referred to as the ``stationary payment,'' includes 
payment for the rental of stationary equipment, delivery of stationary 
oxygen contents (for gaseous or liquid systems), and delivery of 
portable oxygen contents (for gaseous or liquid systems). A separate 
add-on payment, hereinto referred to as the ``portable add-on,'' is 
also made in cases where the beneficiary is renting portable oxygen 
equipment. As a result of this payment methodology which has been in 
place since 1989, suppliers have a financial incentive to furnish low 
cost concentrator systems as opposed to more expensive gaseous or 
liquid systems because the monthly payment is the same regardless of 
which system is used. Finally, in implementing section 1834(a)(5) and 
(9) of the Act, monthly payment amounts were established through 
regulations at Sec.  414.226 for (1) stationary and portable oxygen 
contents (for beneficiaries who use stationary and, if applicable, 
portable equipment), and (2) portable oxygen contents only (for 
beneficiaries who only use portable oxygen equipment). The current 
average statewide monthly payment amounts are:

------------------------------------------------------------------------
 
------------------------------------------------------------------------
          Equipment & Contents          Oxygen Contents Only
------------------------------------------------------------------------
Stationary Pmt..................   $199  Stationary & Portable...   $156
Portable Add-on.................     32  Portable Only...........     21
------------------------------------------------------------------------

    Based on our data, 36 percent of Medicare beneficiaries continue 
using oxygen equipment for more than 3 years, that is, beyond the 36th 
month after which title for the equipment would transfer to the 
beneficiary in accordance with the DRA.
    We have heard concerns about the appropriateness of the current 
payment structure for oxygen and oxygen equipment in light of changes 
in the technologies for oxygen delivery systems that have occurred 
since 1989, and these concerns have been amplified in light of the 
recent changes made by the DRA. The specific concerns pertain to 
beneficiary access to (1) portable oxygen contents after title to the 
equipment transfers to the beneficiary, (2) devices that allow a 
beneficiary to fill portable tanks at home (otherwise referred to in 
the oxygen equipment industry as transfilling systems), and (3) 
portable oxygen concentrators. As we implement the DRA provisions for 
oxygen equipment and promulgate additional supplier requirements, we 
want to ensure that the Medicare payment methodology results in 
payments for oxygen and oxygen equipment that are accurate, do not 
impede beneficiary access to innovations in technology, and do not 
create inappropriate incentives for suppliers.
    Some believe that Medicare's stationary payment for equipment and 
contents (average of $199) is ``too high'' and that Medicare's payment 
for portable oxygen contents only for beneficiary-owned portable 
equipment (average of $21) is ``too low''. While some contend that the 
overall payment (stationary payment plus portable add-on) for oxygen 
and oxygen equipment is adequate as long as the beneficiary continues 
to rent the equipment, they are concerned about the adequacy of 
Medicare's $21 monthly payment for furnishing oxygen contents for 
beneficiary-owned portable equipment. Some believe that Medicare's 
current average monthly payment of $156 for oxygen contents, which 
includes payment for both stationary and portable systems, is high 
enough to create an incentive for suppliers to furnish stationary 
oxygen systems that require the ongoing delivery of oxygen contents, 
rather than stationary concentrator systems that do not require 
delivery of oxygen contents.
    Some technologies provide an attachment to a stationary oxygen 
concentrator that allows beneficiaries to fill their own portable tanks 
at home. Delivery of portable oxygen contents to the beneficiary's home 
is, therefore, not necessary since this equipment refills the 
beneficiary's rented or owned portable oxygen tanks. This transfilling 
technology eliminates the need for frequent and costly trips by a 
supplier to a beneficiary's home to refill portable oxygen tanks and 
would save the Medicare program and beneficiaries who use portable 
equipment the expense of paying for delivery of portable oxygen 
contents. We note that we are not aware that a similar ``transfilling'' 
technology has been developed that would be capable of filling 
stationary tanks in the beneficiary's home. Therefore, there remains a 
need for ongoing delivery of gaseous or liquid oxygen contents for 
stationary equipment. In accordance with the DRA, after 36 months of 
continuous use, title for the transfilling equipment and accompanying 
portable oxygen tanks would transfer to the beneficiary who would then 
own a portable equipment system that self-generates oxygen in their 
home. However, some are concerned that current Medicare payment rules 
that

[[Page 65897]]

allow payment for oxygen contents for stationary equipment creates an 
incentive for suppliers to furnish stationary oxygen equipment that 
require liquid or gaseous oxygen deliveries, rather than concentrators 
and transfilling equipment that self-generate oxygen in the 
beneficiary's home. In addition, portable oxygen concentrators are now 
available that meet both the beneficiary's stationary and portable 
oxygen needs. Some have raised concern about whether the combination of 
the Medicare stationary payment and portable add-on payment 
(approximately $231 per month), which is what is currently paid for 
portable oxygen concentrators, is sufficient to facilitate use of this 
new technology which, like a transfilling system, eliminates the need 
for delivery of oxygen contents, but is more expensive than a 
``standard'' or ``non-portable'' concentrator.
    In light of these concerns, we proposed regulatory changes to 
address the Medicare payment rates for oxygen and oxygen equipment. We 
proposed to address these issues by using our authority under section 
1834(a)(9)(D) of the Act to establish separate classes and monthly 
payment rates for items of oxygen and oxygen equipment. Specifically, 
there are two changes we proposed for oxygen and oxygen equipment:
    1. We proposed to establish a new class and monthly payment amount 
for oxygen generating portable oxygen equipment (for example, portable 
concentrators and transfilling systems).
    2. We proposed to establish separate classes and monthly payment 
amounts for gaseous and liquid oxygen contents that must be delivered 
for beneficiary-owned stationary and portable oxygen equipment.
    The first change involves creating a new separate class for 
portable oxygen systems that generate their own oxygen and therefore 
eliminate the need for delivery of oxygen contents (for example, 
portable concentrator systems or transfilling systems). A higher 
monthly payment amount would be allowed, as described below, for these 
systems to account for the increased, up-front costs to the supplier of 
furnishing these more expensive concentrator or transfilling systems, 
which would be partially offset by the reduced payments that the 
supplier would receive from the Medicare program and beneficiaries due 
to the fact that these systems do not require the delivery of oxygen 
contents.
    The second change involves creating two separate classes 
(stationary contents only and portable contents only) and monthly 
payment rates for furnishing oxygen contents for beneficiary-owned 
stationary and portable systems. Currently, the combined average 
monthly payment amount of $156 for furnishing oxygen contents for 
beneficiary-owned stationary and portable systems includes payment for 
both stationary contents and portable contents. The current fee 
schedule amounts for oxygen contents are based on calendar year data 
from 1986 for the combined average Medicare monthly payment for both 
stationary and portable contents divided by number of rental months for 
stationary liquid and gaseous oxygen equipment. As a result, the 
current combined stationary/portable contents payment results in 
Medicare payments for portable contents even in those cases where the 
beneficiary does not use portable oxygen equipment. Under our proposal 
to create one payment class for oxygen contents used for stationary 
equipment, and a separate class for oxygen contents used for portable 
equipment, new national monthly payment amounts for stationary contents 
delivery and portable contents delivery would be established by 
splitting the combined payment of $156 into two new payments as 
explained below. This change would increase the monthly payment for 
furnishing portable oxygen contents and would address the concerns that 
the monthly payment rate of $21 is too low for the delivery and filling 
of portable tanks after the beneficiary assumes ownership of the 
equipment in accordance with the DRA.
    In order to achieve budget neutrality for the new classes of oxygen 
and increase payment amounts for furnishing portable contents, we would 
need to reduce other Medicare oxygen payment rates. Budget neutrality 
would require that Medicare's total spending for all modalities of 
stationary and portable systems, including contents, be the same under 
the proposed change as they would be without the change.
    We proposed to achieve budget neutrality by reducing the current 
monthly payment amounts (the stationary payment) for stationary oxygen 
equipment and oxygen contents (for stationary or portable equipment) 
made during the rental period. This reduction in payment is necessary 
to offset increased payments for the changes identified above and to 
meet the requirement in section 1834(a)(9)(D)(ii) that the classes and 
payments be established in a budget neutral fashion. In most cases, 
suppliers furnish Medicare beneficiaries with stationary oxygen 
concentrators. These devices can be purchased for $1,000 or less and 
the current, average Medicare payment of $199 pays suppliers $1,990 
over 10 months. We believe that these facts indicate that making a 
reduction (from $199 on average to $177) in Medicare payment for this 
relatively inexpensive oxygen equipment in order to pay oxygen 
suppliers adequately for furnishing portable oxygen contents and more 
expensive portable oxygen equipment technologies is warranted. With 
this approach, the proposed new classes, as well as proposed new 
national monthly payment rates, would be as follows:
    1. Stationary Payment: $177.
    2. Portable Add-On: $32.
    3. Oxygen Generating Portable Equipment Add-On (portable 
concentrators or transfilling systems): $64.
    4. Stationary Contents Delivery: $101.
    5. Portable Contents Delivery: $55.
    We provide a detailed discussion of the payment rate calculations/
adjustments in the paragraphs that follow. Under the proposed new 
oxygen and oxygen equipment class structure described above, in those 
cases where the beneficiary needs both stationary and portable oxygen, 
monthly payments of $241 or $209 (proposed revised stationary payment 
of $177 plus one of two proposed portable equipment payments, $32 or 
$64) would be made during rental months 1 through 36. The stationary 
payment (which includes payment for stationary equipment, as well as 
oxygen contents for stationary and portable systems) of $177 would be 
made during rental months 1 through 36 for beneficiaries who only need 
stationary oxygen and oxygen equipment. Monthly payments of $101 for 
stationary oxygen contents and/or $55 for portable oxygen contents 
would be made in cases where beneficiaries own their stationary and/or 
portable oxygen equipment. As explained in more detail in the 
paragraphs that follow, the $101 payment is for stationary oxygen 
contents only and is derived from the current payment of $156, which is 
made for both stationary and portable oxygen contents. The $55 payment 
for portable oxygen contents only is also derived from the current 
payment of $156 that is made for both stationary and portable oxygen 
contents and would replace the current statewide portable oxygen 
contents fees (average of $21), which was based on a relatively small 
number of claims and allowed services compared to the number of claims 
and allowed services that were used in computing the statewide fees 
(average of $156) for a combination of stationary and portable oxygen 
contents.

[[Page 65898]]

    As noted above, the proposed national payment rates for delivery of 
oxygen contents for beneficiary-owned gaseous/liquid equipment were 
derived from the current average payment for a combined oxygen contents 
delivery of $156. We proposed to establish $101, or 65 percent of $156, 
as the monthly payment rate for delivery of larger, heavier, 
beneficiary-owned stationary gaseous oxygen cylinders or liquid oxygen 
vessels and $55, or 35 percent of $156, as the monthly payment rate for 
delivery of smaller, lighter, beneficiary-owned portable gaseous oxygen 
cylinders or liquid oxygen vessels. The 65/35 split is based on our 
understanding that there are higher costs associated with delivering 
stationary tanks (cylinders of gaseous oxygen and vessels of liquid 
oxygen) which are approximately twice as large as the portable tanks. 
Such costs include supplier overhead costs, including the costs to 
purchase, maintain, and dispatch trucks, obtain insurance, and purchase 
fuel. The 65/35 split is intended to account for the difference in 
costs associated with the size of the tanks. Larger tanks take up more 
space on the trucks, take longer to fill, are harder to move, and 
result in increased fuel costs.
    We estimate that the increase from $21 to $55 in the monthly 
payment rate for delivery of oxygen contents for beneficiary-owned 
portable equipment will result in increased expenditures of 
approximately $22 million over a 24 month period, or $11 million 
annually. This figure is based on current data on utilization of 
portable oxygen by Medicare beneficiaries.
    The add-on payment amount of $64 for the oxygen generating portable 
equipment class was calculated based on data indicating long term 
savings generated from use of equipment that eliminated the need for 
payment of $55 per month for portable oxygen contents. The first step 
in calculating the proposed $64 payment for oxygen generating portable 
equipment involves the computation of a national, enhanced, modality 
neutral monthly payment amount of $241 for new technology systems 
(stationary concentrators and transfilling systems, as well as portable 
concentrators), which was derived from the sum of the current average 
stationary payment ($199), the current average portable add-on payment 
($32), and an additional $10 to pay suppliers for furnishing more 
expensive equipment that eliminates the need for delivery of portable 
oxygen contents. Specifically, we calculated the modality neutral 
increased payment (that is, $10 above the current combination of the 
stationary payment and portable add-on payment) by estimating potential 
savings that the Medicare program would realize as a result of not 
having to pay for delivery of oxygen contents for beneficiary-owned 
portable oxygen systems in the fourth and fifth years of use. We 
calculated the increased payment to be equal to potential savings from 
not delivering oxygen contents. In calculating this increased payment, 
we were only factoring in savings from the fourth and fifth years of 
use since we assume that most beneficiaries will elect to obtain 
replacement equipment after the 5-year reasonable useful lifetime for 
their equipment has expired. Since our data indicate that 35.8 percent 
of beneficiaries will use oxygen equipment for more than 3 years, and 
that approximately 74 percent of these beneficiaries use portable 
equipment, the $10 amount is calculated based on the following formula, 
and is rounded to the nearest dollar:
[GRAPHIC] [TIFF OMITTED] TR09NO06.000

    We estimate that the additional $10 payment per month for oxygen 
generating portable equipment (transfilling units and portable 
concentrators) will result in increased expenditures of approximately 
$15 million over a 36 month period, or $5 million annually. This figure 
is based on current data on utilization of stationary and portable 
oxygen by Medicare beneficiaries over 36 months.
    The second step in calculating the proposed $64 add-on payment for 
the proposed new class of oxygen generating portable equipment involves 
subtracting the proposed new stationary payment. Therefore, the 
national monthly payment of $241 computed in the first step above would 
be reduced by $177, the proposed new adjusted stationary payment 
amount, to arrive at the proposed add-on payment of $64 for just the 
oxygen generating portable equipment. In addition, to offset the 
increased annual payments of approximately $16 million that will result 
from increased payments for portable oxygen contents ($11 million) and 
newer technology oxygen generating portable equipment ($5 million), we 
proposed to decrease the current stationary payment by $22 ($199-$177). 
We estimated that this offset would result in annual Medicare savings 
of approximately $16 million, and would therefore offset the increased 
payments for new technology oxygen generating portable equipment and 
delivery of oxygen contents for other beneficiary-owned portable 
equipment. We proposed that these fees be established on a nationwide 
basis due to the fact that the variation in the current statewide fee 
schedule amounts for oxygen and oxygen equipment, as well as the 
portable equipment add-on payment, are currently only 3 percent and 5 
percent, respectively.
    We proposed that the $64 add-on payment would be made for oxygen 
generating portable equipment only if the equipment eliminates the need 
for delivery or portable oxygen contents. However, if transfilling 
equipment is used in connection with a stationary oxygen concentrator 
(whether as an integrated system component or as a separate part) to 
both deliver stationary oxygen and fill portable oxygen tanks, Medicare 
would make both a $177 stationary payment for the stationary oxygen 
concentrator and stationary oxygen contents, and a separate $64 oxygen 
generating portable equipment payment for the portable oxygen 
transfilling equipment.
    There are also portable oxygen transfilling products that are not 
part of or used in conjunction with a stationary oxygen concentrator. 
These products are only used to fill portable oxygen tanks in the 
beneficiary's home. If the beneficiary is using one of these products, 
Medicare would make a $64 oxygen generating portable equipment payment. 
If the patient is also renting any type of stationary oxygen equipment 
(gaseous, liquid, or concentrator), Medicare would make a separate, 
additional $177 stationary equipment payment for that equipment.
    If a portable oxygen concentrator is furnished, Medicare would make 
the $64 oxygen generating portable equipment add-on payment if the 
portable oxygen concentrator is used as both the beneficiary's 
stationary oxygen equipment and portable oxygen equipment. In this 
case, the portable oxygen concentrator equipment would fall under both 
the stationary oxygen equipment class and the oxygen generating 
portable equipment class. Therefore, the $177 stationary payment would 
also be made in this situation, since the equipment being furnished 
meets the beneficiary's needs for both stationary and portable oxygen 
equipment. In this case, it would be necessary for the supplier to use 
two HCPCS codes to bill for this device since it is being used as both 
the stationary and portable oxygen equipment for the beneficiary. If 
the beneficiary owns any type of stationary equipment (concentrator, 
liquid, or gaseous), and is also furnished with a portable oxygen 
concentrator, only the

[[Page 65899]]

oxygen generating payment of $64 would be made (that is, the supplier 
would not also receive the $177 payment) and the portable oxygen 
concentrator equipment would fall under the oxygen generating portable 
equipment class because it is only being used to meet the beneficiary's 
need for portable oxygen equipment. Finally, if, the beneficiary is 
renting any type of stationary equipment (concentrator, liquid, or 
gaseous), and is also furnished with a portable oxygen concentrator, 
the oxygen generating add-on payment of $64 would be paid for the 
portable oxygen concentrator and the stationary payment of $177 would 
be paid separately for the stationary oxygen equipment and contents.
    In summary, we proposed new payment classes for oxygen contents for 
beneficiary-owned stationary equipment, oxygen contents for 
beneficiary-owned portable equipment, and oxygen generating portable 
equipment. Payments for oxygen contents for beneficiary-owned portable 
equipment and oxygen generating portable equipment would exceed what is 
currently paid for these items to ensure access to portable oxygen 
regardless of the type of equipment used. These increased payments 
would be offset by a reduction in the stationary payment. The six broad 
categories of oxygen equipment used by beneficiaries are as follows:
    A. Concentrator and liquid or gaseous portable equipment.
    B. Concentrator and/or oxygen generating portable equipment.
    C. Liquid or gaseous stationary equipment and liquid or gaseous 
portable equipment.
    D. Liquid or gaseous stationary equipment and oxygen generating 
portable equipment.
    E. Concentrator only.
    F. Liquid or gaseous stationary equipment only.
    Based on our proposed new payment classes, Medicare payment under 
these six categories would be as follows:

----------------------------------------------------------------------------------------------------------------
                                                                              Contents for beneficiary-owned
            Category                  Equipment rental  and contents                     equipment
----------------------------------------------------------------------------------------------------------------
A...............................  $209 ($177 + $32)                       $55
B...............................  $241 ($177 + $64)                       $0
C...............................  $209 ($177 + $32)                       $156 ($101 + $55)
D...............................  $241 ($177 + $64)                       $101
E...............................  $177                                    $0
F...............................  $177                                    $101
----------------------------------------------------------------------------------------------------------------

    We proposed to revise our regulations in order to implement these 
new payment classes and payment amounts, effective for claims with 
dates of service on or after January 1, 2007.

J. Payment for Maintenance and Servicing of Oxygen and Oxygen Equipment 
and Capped Rental Items

    Immediately following passage of the DRA, concerns were raised 
regarding the ability of a beneficiary to obtain maintenance and 
servicing of his or her DME once he or she has taken title to it. We 
believe that these concerns are largely based on misconceptions that 
the beneficiary will ``be on his or her own'' in terms of maintenance 
and servicing of equipment and submission of claims for payment for 
these services. We believe that these concerns are unfounded because 
Medicare payment has traditionally been made for reasonable and 
necessary repair and maintenance of beneficiary-owned DME. In addition, 
section 1834(a)(5)(F)(ii)(II)(bb) of the Act, as amended by section 
5101(b)(1)(B) of the DRA, and Section 1834(a)(7)(A)(iv) of the Act, as 
amended by Section 5101(A)(1) of the DRA, require that Medicare 
continue to pay for reasonable and necessary maintenance and servicing 
for parts and labor not covered under a manufacturer's or supplier's 
warranty in amounts determined to be appropriate by the Secretary.
    Medicare has also traditionally paid for loaner equipment used 
while the beneficiary's equipment is being repaired, or in some cases, 
when the beneficiary does not have access to the equipment (for 
example, in cases when a natural disaster such as a hurricane forces 
the beneficiary to be evacuated from his or her home). We proposed to 
continue Medicare payment for such loaner equipment.
    We are not aware of instances where beneficiaries have encountered 
problems in finding suppliers to provide maintenance and servicing of 
beneficiary-owned DME. Section 414.210(e) of our regulations currently 
provides that reasonable and necessary charges for maintenance and 
servicing of DME are those charges made for parts and labor not 
otherwise covered under a manufacturer's or supplier's warranty. This 
definition has been applied in paying claims for maintenance and 
servicing of beneficiary-owned DME for several years, and the wording 
of this regulatory definition is parallel to that used in amended 
sections 1834(a)(7)(A)(iv) and (a)(5)(F)(ii)(II)(bb) of the Act in 
describing the ``maintenance and servicing'' payments that are 
permitted for capped rental DME and oxygen equipment after title has 
transferred to the beneficiary. We proposed to continue use of this 
existing regulatory definition to define ``maintenance and servicing'' 
in section 5101 of the DRA. We, however, also proposed to apply our 
existing policy of not covering certain routine maintenance or periodic 
servicing of purchased equipment, such as testing, cleaning, 
regulating, changing filters, and general inspection of beneficiary-
owned DME that can be done by the beneficiary or caregiver, to 
beneficiary-owned oxygen equipment and to continue that policy for 
beneficiary-owned capped rental equipment. As specified in current 
program instructions at section 110.2.B of chapter 15 of the Medicare 
Benefit Policy Manual (Pub 100-02), ``the owner [of the equipment] is 
expected to perform such routine maintenance rather than a retailer or 
some other person who charges the beneficiary.'' We expect that the 
supplier, when transferring title to the equipment to the beneficiary, 
would also provide to the beneficiary any operating manuals published 
by the manufacturer which describe the servicing an owner may perform 
to properly maintain the equipment. We also believe that these owner 
manuals are commonly available at the various manufacturer Web sites. 
In addition, the Durable Medical Equipment, Prosthetics, Orthotics and 
Supplies (DMEPOS) supplier standards at Sec.  424.57(c)(12) require 
suppliers to provide the beneficiary with necessary information and 
instructions on how to use DME items safely and effectively. We believe 
that after receiving this information, and after becoming familiar with 
the equipment during the 13 or 36 month rental period, the beneficiary 
and/or caregiver should be very knowledgeable regarding the routine

[[Page 65900]]

maintenance required for the item. All non-routine maintenance of 
beneficiary-owned oxygen equipment and capped rental items which would 
need to be performed by authorized technicians would be covered as 
reasonable and necessary maintenance and servicing. Examples of the 
types of maintenance that would be covered are currently listed in 
program instructions at section 110.2.B of chapter 15 of the Medicare 
Benefit Policy Manual (Pub 100-02) and include ``breaking down sealed 
components and performing tests which require specialized testing 
equipment not available to the beneficiary.''
    We proposed that maintenance and servicing of beneficiary-owned 
oxygen equipment and capped rental items would be reasonable and 
necessary if it is non-routine maintenance and servicing necessary to 
make the equipment serviceable. Payment is currently made under the 
Medicare program for parts and labor associated with repairing 
beneficiary-owned DME. Medicare allowed payment amounts for replacement 
parts are currently paid based on the carrier's individual 
consideration of the item. With regard to replacement parts for 
beneficiary-owned oxygen equipment or capped rental equipment, we 
proposed that the carrier pay for the parts in a lump sum amount based 
on its consideration of the cost of the item, as is consistent with 
what our carriers currently do when evaluating maintenance and 
servicing claims for other beneficiary-owned DME. Currently, payment 
for labor is based on 15-minute increments in amounts that are 
established by the carriers and updated on an annual basis by the same 
factor specified in section 1834(a)(14) of the Act, which is used to 
update fee schedule amounts for DME. We proposed that the carriers use 
the same fee for labor that is currently used in paying for labor 
associated with repairing, maintaining, and servicing other 
beneficiary-owned DME, as we are not aware of any past problems 
associated with access to these services paid at these rates. We 
believe that the current methods and fees used by carriers in paying 
for maintenance and servicing of beneficiary-owned DME are reasonable 
given that we are not aware of any past problems associated with access 
to these services paid at these rates. In most cases, neither the 
Medicare program nor the beneficiary actually pays the full amount for 
repairing or maintaining an item since manufacturer warranties that 
cover all or part of these costs are widespread. For example, some 
manufacturers of commonly used oxygen concentrators offer full 
warranties that cover all parts and labor for 5 years. Rules in Sec.  
414.210(f) regarding replacement of DME that has been in continuous use 
for the equipment's reasonable useful lifetime provide that the 
beneficiary can elect to obtain replacement equipment after the 
reasonable useful lifetime for the equipment has expired. Therefore, we 
believe that the beneficiary should incur little, if any, expense for 
repair or maintenance of necessary equipment in cases where 
manufacturer warranties exist that cover parts and labor necessary to 
repair a new item during a 5-year period.

K. Payment for Replacement of Beneficiary-Owned Oxygen Equipment, 
Capped Rental Items, and Associated Supplies and Accessories

    Medicare has traditionally paid for replacement beneficiary-owned 
DME after the expiration of the equipment's useful lifetime (see Sec.  
414.210(f) and Sec.  414.229(g) of our regulations), and for 
replacement supplies and accessories used in conjunction with 
beneficiary-owned DME when these supplies and accessories are necessary 
for the effective use of the DME (see Sec.  110.3 of Chapter 15 of the 
Medicare Benefit Policy Manual (pub. 100-02)). Examples of supplies 
include drugs and administration sets used with infusion pumps. 
Examples of accessories include masks and tubing used with respiratory 
equipment. We proposed to apply these policies to beneficiary-owned 
oxygen equipment, as well as the supplies and accessories used in 
conjunction with this equipment, and to continue to apply these 
policies to beneficiary-owned capped rental items, as well as the 
supplies and accessories used in conjunction with these items.
    Specifically, we proposed to update Sec.  414.210(f) and Sec.  
414.229(g) of our regulations to reflect that payment may be made for 
the replacement of beneficiary-owned oxygen equipment and capped rental 
DME in cases where the item is lost, stolen, or irreparably damaged, or 
in cases where the item has been in continuous use for its reasonable 
useful lifetime. We proposed that payment for the replacement be made 
on a rental basis in accordance with the payment rules in Sec.  414.226 
for oxygen equipment and Sec.  414.229 for capped rental items. We also 
proposed to revise Sec.  414.229 to reflect that these proposed changes 
to the replacement policy for beneficiary-owned capped rental items 
only apply to those items for which the first rental month occurs on or 
after January 1, 2007 since the DRA does not apply to capped rental 
items for which the first rental month occurs before January 1, 2006. 
The current rules will remain in place for capped rental items to which 
the DRA does not apply.
    We are aware that some manufacturer warranties may cover 
replacement of oxygen or capped rental equipment within a certain time 
period after the item is furnished. As was our policy before the 
enactment of DRA (see Sec.  110.2.C of Chapter 15 of the Medicare 
Benefit Policy Manual (pub. 100-02)), we proposed that Medicare not pay 
for the replacement of beneficiary-owned oxygen equipment or capped 
rental items covered by a manufacturer's or supplier's warranty. In 
cases where equipment replacement is not covered by a manufacturer's or 
supplier's warranty, we proposed that the supplier must still replace 
beneficiary-owned oxygen equipment or beneficiary-owned capped rental 
items at no cost to the beneficiary or to the Medicare program if: (1) 
The total accumulated costs, as illustrated in the example below, to 
repair the item after transfer of title to the beneficiary exceed 60 
percent of the replacement cost; and (2) the item has been in 
continuous use for less than its reasonable useful lifetime, as 
established in accordance with the procedures set forth in proposed 
revised Sec.  414.210(f). For example, a capped rental item that can be 
replaced for $1,000 (total of fee schedule payments after 13 rental 
months) and for which title has transferred to the beneficiary in 
accordance with section 1834(a)(7)(A)(ii) of the Act can be used to 
illustrate what we mean when we use the term ``accumulated costs'' 
above. In this example, if Medicare has paid a total of $500 for 3 
repairs necessary to make the item functional, and a fourth repair 
costing $200 is needed in order to make the item functional, the 
accumulated costs for repair in this case will equal $700, which 
exceeds $600 or 60 percent of the $1,000 cost to replace the item. In 
this case, the supplier would be required to furnish a replacement 
item. The greater than 60 percent of cost threshold for replacement is 
consistent with the threshold repair costs that can result in the 
replacement of prosthetics (artificial limbs) in accordance with 
section 1834(h)(1)(G) of the Act. We believe this threshold should 
apply to oxygen equipment and capped rental items as well, because 
artificial limbs, like these items, are built to withstand repeated 
use.
    We proposed that the supplier be responsible for the cost of the 
replacement equipment because we believe that the item in this case did 
not last for the entire reasonable useful

[[Page 65901]]

lifetime. After the beneficiary acquires title to the item, the 
supplier that transferred title would be responsible for furnishing the 
replacement item. We proposed this provision to safeguard the 
beneficiary from receiving, and the Medicare program from paying for, 
substandard equipment, and to avoid creating an incentive for suppliers 
to increase the number of claims submitted for repairs in an effort to 
recover revenue lost as a result of DRA section 5101. We believe that 
this requirement is not unreasonable since suppliers should be 
furnishing items in good working order and are otherwise bound by 
regulations at Sec.  424.57(c)(15) to accept returns from beneficiaries 
of substandard items. Exceptions to this rule may be granted by CMS or 
the carrier as appropriate (for example, the supplier would not be 
responsible for replacing an item in need of repair due to beneficiary 
neglect or abuse).

L. Periods of Continuous Use

    Rules that apply in determining a period of continuous use for 
rental of DME are found at Sec.  414.230 of our regulations. We 
proposed that these rules would continue to apply in implementing 
section 5101 of the DRA, with one exception. The rules in Sec.  
414.230(f) provide that a new period of continuous use begins for new 
or additional equipment prescribed by a physician and found to be 
medically necessary, even if the new or additional equipment is similar 
to the old equipment.
    Medicare payments for stationary and portable oxygen and oxygen 
equipment are currently modality neutral, which means that the same 
payment amounts apply to the different types of oxygen equipment 
furnished to Medicare beneficiaries. Since there is no distinction made 
between oxygen equipment modalities for payment purposes under the 
Medicare program, we do not believe that it is necessary or appropriate 
to begin a new period of continuous use when the beneficiary changes 
from one oxygen equipment modality to another. We proposed to revise 
Sec.  414.230(f) of our regulations to designate the existing language 
in this section as paragraph (f)(1) and to add a new paragraph (f)(2) 
to reflect this exception, effective for oxygen equipment furnished on 
or after January 1, 2007. We also proposed to revise Sec.  414.230(b) 
to incorporate section 5101(b)(2)(B) of the DRA, which provides that 
for all beneficiaries receiving oxygen equipment paid for under section 
1834(a) on December 31, 2005, the period of continuous use begins on 
January 1, 2006.

M. Other Issues: Health Care Information Transparency, Health 
Information Technology, and Medicare Payment Structures

    Both Medicare's payment structures and the actual delivery of post 
acute care have evolved significantly over the past decade. Before the 
BBA, HHAs and other post-acute settings such as inpatient 
rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) 
were paid on the basis of cost. Since that time, we have implemented 
various legislative mandates that established prospective payment 
systems in these settings. The PPS methodologies used in these settings 
rely on patient-level clinical information to provide pricing, support 
the provision of high quality services, and encourage the efficient 
delivery of care. CMS is exploring refinements to the existing 
provider-oriented ``silos'' to create a more seamless system for 
payment and delivery of post-acute care (PAC) under Medicare. This new 
model could feature more consistent payments for the same type of care 
across different sites of service, value based purchasing incentives, 
and the collection of uniform clinical assessment information to 
support quality and discharge planning functions.
    CMS is considering a demonstration to determine whether incentive 
payments to HHAs impact improvements in the quality of care of Medicare 
beneficiaries.
    Section 5008 of the Deficit Reduction Act of 2005 (DRA) provides 
for a demonstration on uniform assessment and data collection across 
different sites of service. This 3-year demonstration project is to be 
established by January 1, 2008. We are in the early stages of 
developing a standard, comprehensive assessment instrument to be 
completed at hospital discharge and ultimately integrated with PAC 
assessments. The demonstration will enable us to test the usefulness of 
this instrument, and analyze cost and outcomes across different PAC 
sites. The lessons learned from this demonstration will inform efforts 
to improve the post-acute payment systems.
    We have evaluated the existing assessment instruments that managed 
care and other insurers use. These instruments will form the basis of 
our efforts to create a discharge assessment tool that can serve to 
facilitate post-hospital placement decisions; enhance the safety and 
quality of care during patient transfers through transmission of core 
information to a receiving provider; and provide baseline information 
for longitudinal follow-up of health and function.
    In the April 25, 2006 Inpatient Prospective Payment System proposed 
rule (71 FR 23996), we discussed in detail the Health Care Information 
Transparency Initiative and our efforts to promote effective use of 
Health Information Technology (HIT) as a means to help improve health 
care quality and improve efficiency. Specifically, with regard to the 
transparency initiative, we discussed several potential options for 
making pricing and quality information available to the public (71 FR 
24120 through 24121). We solicited comments on ways the Department can 
encourage transparency in health care quality and pricing whether 
through its leadership on voluntary initiatives or through regulatory 
requirements. We also sought comments on the Department's statutory 
authority to impose such requirements. In addition, we discussed the 
potential for HIT to facilitate improvements in the quality and 
efficiency of health care services (71 FR 24100 through 24101). We 
solicited comments on our statutory authority to encourage the adoption 
and use of HIT. The 2007 Budget states that ``the Administration 
supports the adoption of Health Information Technology (HIT) as a 
normal cost of doing business to ensure patients receive high quality 
care.'' We also sought comments on the appropriate role of HIT in 
potential value-based purchasing programs, beyond the intrinsic 
incentives of a PPS to provide efficient care, encourage the avoidance 
of unnecessary costs, and increase quality of care. In addition, we 
sought comments on promotion of the use of effective HIT and how CMS 
can encourage its use in HHAs.
    We intend to consider both the health care information transparency 
initiative and the use of HIT as we refine and update all Medicare 
payment systems. Therefore, we sought comments on these initiatives as 
applied to the HH PPS in the August 3, 2006 proposed rule, including 
the Department's statutory authority to impose any such requirements. 
We stated that we may address these initiatives in the final HH PPS 
rule. For example, a HIT proposal could include adding a requirement 
that HHAs use HIT that is compliant with and certified by the 
Certification Commission for Health Information Technology (CCHIT) in 
the areas in which the technology is available. As noted previously, 
the CMS Home Health Compare Web site contains home health quality 
information. We note that we are in the process of seeking input on 
these initiatives in various proposed Medicare

[[Page 65902]]

payment rules being issued this year. In particular, we intend to 
consider both the health care information initiative and the use of HIT 
as we refine and update all Medicare payment systems.

III. Analysis of and Responses to Public Comments

    We received approximately 106 comments on the August 3, 2006 
proposed rule.

General

    Comment: Several commenters raised concerns about combining several 
unrelated matters into a single public notice. The commenters believed 
the style to be confusing and counter to CMS' initiatives for better 
public communication.
    Response: We recognize the commenters concern and note that we make 
every attempt to provide sufficient information in the Federal Register 
document to clearly and specifically state the contents of the Federal 
Register document. We note that we targeted a similarly situated 
audience in that suppliers of oxygen equipment, DME suppliers, and HHAs 
all provide services in the post-acute care setting.
    Comment: Several commenters requested that telehealth services be 
directly funded. These commenters believe that utilization of 
telehealth services would save Medicare money by reducing 
hospitalization and decreasing the use of multiple medical services.
    Response: Telehealth services are not a recognized visit or service 
under the HH PPS. Specifically, in section 1895(e)(1)(B) of the Act, 
telecommunications services are not considered a home health visit for 
the purposes of eligibility or payment under this title.
    Comment: A commenter stated that CMS should indefinitely retain the 
5 percent rural add-on. Other commenters recognized that it would take 
congressional action to extend the 5 percent rural add-on for rural 
providers. Nonetheless, these commenters supported an extension of the 
rural add-on period. In addition, commenters recommended that CMS 
examine the differences between the cost of providing home health 
services in a rural setting and those costs of providing home health 
services in an urban area.
    Response: The rural add-on was a temporary add-on established by 
the DRA. Specifically, section 5201 of the DRA required, for home 
health services furnished in a rural area with respect to episodes and 
visits beginning on or after January 1, 2006 and before January 1, 
2007, that we increase by 5 percent the payment amount that otherwise 
would be made for the services. The statute does not provide for a 
continuation of the rural add-on. We will continue to monitor the HH 
PPS to help ensure that home health providers continue to receive 
appropriate reimbursement for the services they provide.

Market Basket

    Comment: Several commenters believe that the proposed market basket 
update falls short of increased costs in the delivery of home health 
services. Specifically, they state that labor costs have risen 
significantly with the continuing shortage of nursing and therapy 
staff, transportation costs skyrocketed in 2005-2006 at a rate far 
greater than the estimated 2.2 percent that was set out in the 2006 
rate setting rule, technology costs, and costs associated with 
regulatory compliance have grown. Some of these commenters believe the 
problem with the estimated market basket increase appears to stem from 
two weaknesses in the calculation formula: The use of FY 2000 cost 
reports and the accuracy of the projection. These commenters believe 
the FY 2000 cost reports are inaccurate because they only contained a 
portion of the operational changes that have occurred since the onset 
of the prospective payment system.
    Response: The home health market basket is a fixed-weight 
Laspeyres-type price index, which measures the average change in the 
price of goods and services purchased by HHAs in providing an efficient 
level of home health care services. Furthermore, the projected 
estimated HH market basket has been fairly consistent with the actual 
market basket determination. Since the inception of the PPS in FY 2001 
including years through CY 2005, the forecasted average annual increase 
of the home health market basket has been 3.3 percent while the actual 
average annual increase of the home health market basket has been 3.2 
percent.
    With respect to the use of the FY 2000 cost reports, they represent 
the most recent and complete cost reports available at the time of the 
most recent rebasing of the home health market basket presented in the 
CY 2005 proposed rule. Our recent analysis of Medicare cost report data 
for 2001 through 2003 shows very similar cost weights, including those 
associated with compensation, to the FY 2000 based market basket. 
Therefore, we believe the use of the FY 2000 cost reports continue to 
accurately reflect a proxy of home health weights.
    We further note that for the final rule, we are using the 2006 3rd 
quarter forecast with historical data through 2006, 2nd quarter, which 
results in a forecast for the home health market basket for CY 2007 of 
3.3 percent. This projection includes a higher forecast for the CPI for 
private transportation (2.2 percent) and higher forecast for the price 
of compensation (3.5 percent) compared to the forecast in the proposed 
rule of 0.3 percent and 3.4 percent, respectively.
    Comment: One commenter suggested that CMS move away from using the 
CPI for private transportation to proxy price changes associated with 
transportation costs and substitute it with a more accurate reflection 
of home health care transportation experience.
    Response: We believe the CPI for private transportation is an 
accurate proxy for the price changes associated with home health care 
agencies' transportation costs. This CPI measures the price changes of 
new and used motor vehicles, motor fuels, motor vehicle parts and 
equipment, maintenance and repair, and insurance costs. We believe that 
home health agencies incur all of these transportation costs.
    Comment: One commenter suggested that the market basket weights 
assigned to each input should be re-examined every 2 years using cost 
report data that are less than 2 years old. The commenter also suggests 
that the validity of the weights should be periodically tested using 
audited cost report data.
    Response: We rebase the home health market basket on a periodic 
basis. When we rebase a market basket, we examine the costs for each 
year since the most recent rebasing. In general, cost weights remain 
stable from year to year and become less so over a longer time period, 
such as 5 or more years. Additionally, we always use the most recent 
and complete cost report data at the time of rebasing. For the CY 2005 
proposed rule, the most recent and complete cost report data available 
was for the year 2000. We are also confident in the validity of the 
Medicare cost report data received by the industry. Thus, we believe a 
formal audit is not required. However, as part of the standard rebasing 
methodology in calculating the cost report weights, we trim the data to 
remove the impact of outliers.
    Comment: One commenter recommended that the shortfalls in annual 
cost increase projections be added to succeeding year inflation 
updates. The commenter stated, for example, the under-projection in

[[Page 65903]]

transportation cost increases in 2006 should be reflected in 2007 and 
2008.
    Response: We believe that the accuracy of the market basket updates 
has been reasonable, as evidenced by the last several years which 
contained average forecasted updates of 3.3 percent while actual 
average annual increase of the home health market basket has been 3.2 
percent.
    Comment: One commenter suggested that projections should be 
thoroughly evaluated and validated. The commenter is aware that CMS 
uses a proprietary system, Global Insights, Inc. (GII), in determining 
its projections and believes this system should be examined by a CMS 
Technical Expert Panel in the immediate future.
    Response: GII is an independent firm that forecasts price proxies 
and other economic indicators. We believe that the projections we use 
are unbiased and consistent across all GII customers, both private and 
government. Moreover, we continue to work closely with GII to 
continually monitor the reasonableness of its projections.
    Comment: Other commenters expressed support for a market basket 
update of 3.1 percent and a 15 percent adjustment to the standardized 
rates for dually eligible beneficiaries.
    Response: We appreciate the support for the proposed market basket 
increase. Section 1895(b)(3)(B) of the Act requires the unadjusted 
national rate for CY 2007 to be increased by the applicable home health 
market basket index amount. The home health market basket for CY 2007 
is forecasted to be 3.3 percent. We do not, however, have the statutory 
authority to establish a 15 percent adjustment to the standardized 
rates for dually eligible beneficiaries.
    Comment: One commenter stated that home care providers should 
receive their full Medicare market basket update for 2007 and each 
subsequent year.
    Response: HHAs will receive payments based on a full market basket 
update for services provided to Medicare beneficiaries for CY 2007 and 
subsequent years as provided at section 1895(b)(3)(B)(v) of the Act, 
subject to submitting the required quality measures and other possible 
legislative mandates.

Quality/Pay for Reporting

    Comment: A commenter recommended that CMS make the penalty for not 
submitting the required quality data budget neutral and thus increase 
the national standardized episode amount. This would provide a small 
reward for the majority of agencies that already comply with the data 
submission requirement.
    Response: Section 1895(b)(3)(B)(V)(I) of the Act, added by section 
5201(c)(2) of the DRA, stipulates that the market basket percentage 
increase be reduced by 2 percentage points for HHAs who fail to submit 
required data. The statute does not provide that the reduction in the 
market basket percentage increase be budget neutral.
    Comment: Several commenters supported CMS' proposed and continued 
use of the OASIS instrument and reporting infrastructure in response to 
the DRA requirements.
    Response: We appreciate the commenters' support for this decision. 
One of our goals is to allow HHAs to fulfill the DRA's quality data 
reporting requirements in the most efficient and least burdensome way 
possible.
    Comment: Several commenters believe that CMS needs to continue to 
refine and enhance the OASIS assessment instrument and associated 
quality measures.
    Response: As we stated previously, we intend to refine the current 
OASIS instrument and associated quality measures. We will also continue 
improving the assessment instrument's accuracy in reflecting both the 
health status and improvements in condition of our beneficiaries.
    Comment: Several commenters confused the various HH Conditions of 
Participation requirements, that is, the completion, completeness, and 
accuracy of the OASIS assessment, with the reporting requirements 
established by the DRA.
    Response: The proposed rule dealt solely with the requirements of 
section 5201(c)(2) of the DRA to specify the health quality data needed 
for quality measurements under the HH PPS. To meet the requirements 
established in the DRA, we proposed to rely on the data submitted by 
home health providers through the OASIS instrument. The regulations 
surrounding completion, completeness, timeliness or other rules 
associated with the OASIS were not affected by the HH PPS proposed 
rule.
    Comment: A few commenters were concerned that the reporting 
timeframe established in the proposed rule is over before publication 
of the final rule. The commenters noted that prior notification of 
payment penalties associated with the DRA quality measures requirement 
could not be known before the reporting period commenced.
    Response: We acknowledge the commenters' concern, but we believe 
our proposed approach adequately addresses these issues. Section 
5201(c)(2) of the DRA amends the Act to such that ``each home health 
agency shall submit to the Secretary such data that the Secretary 
determines are appropriate for the measurement of health care quality. 
Such data shall be submitted in a form and manner, and at a time, 
specified by the Secretary.'' In considering how to best implement this 
provision while still obtaining the needed quality measures, our 
approach was to use processes and mechanisms that were already in place 
and functioning, as the most efficient and appropriate way to meet the 
statutory requirements. Using historical data to determine the 
prospective update is similar to the methodology used for hospital pay 
for reporting. In this manner, by utilizing an existing system, we were 
able to provide the least burdensome measures on the providers, and 
would penalize only those providers who were not otherwise meeting the 
OASIS submission requirement under the home health Conditions of 
Participation.
    Comment: One commenter supported CMS' initiative to refine the home 
health quality measures and to complement those measures with health 
information technology. This commenter stated that the proper use of 
new quality measures in certain areas coupled with the appropriate use 
of health information technology will help to promote quality care, 
efficiency, save Federal dollars, and satisfy the needs of our 
beneficiaries.
    Response: We appreciate the commenter's support and will continue 
to pursue using health information technology to further the goals of 
providing appropriate payments for quality services under the HH PPS.

Outlier Payments and Fixed Dollar Loss Ratio

    Comment: A commenter expressed concerns with CMS' proposal to 
update the fixed dollar loss ratio in the final rule if current data 
become available. The commenter believes that CMS has an obligation to 
modify PPS outlier criteria each year until the 5 percent set aside is 
realized. Commenters urged CMS to ensure that data is available before 
the final rule is published. The commenter recommended that CMS provide 
an opportunity for review and comment before implementation of any 
change that reduces the likely number of episodes qualifying for 
outlier payments. Another commenter urged CMS to retain or increase the 
current outlier payment structure.
    Response: Section 1895(b)(5) of the Act states that the ``Secretary 
may provide for an addition or adjustment to the payment amount 
otherwise made in the case of outliers * * * [t]he total

[[Page 65904]]

amount * * * may not exceed 5 percent of the total payments projected 
or estimated to be made based on the'' HH PPS. The statute makes clear 
that to the extent the Secretary chooses to provide for an outlier 
adjustment in HH PPS, such adjustment may not be more than 5 percent of 
the projected or estimated HH PPS payments. The statute does not 
provide for an outlier adjustment of 5 percent.
    At the time of publication of the August 3, 2006 proposed rule, we 
did not have more recent data, but noted that we may update the FDL 
ratio for CY 2007 depending on the availability of more recent data. We 
stated that depending on the availability of more recent data at the 
time of publication of the HH PPS final rule for CY 2007, we may, if 
necessary, implement an update to the FDL ratio for the CY 2007 update 
to the HH PPS rates. Subsequent to the publication of the August 3, 
2006 proposed rule, we have now obtained more recent data, that is, CY 
2005 home health claims data. Accordingly, for this final rule, we have 
used the same methodology and performed analysis using the CY 2005 data 
to update the FDL ratio for CY 2007. For CY 2007, we are not only 
retaining the current outlier payment structure but also increasing the 
FDL ratio to allow more episodes to qualify for outlier payments. This 
new FDL ratio is 0.67.

Home Health Wage Index

    Comment: Several commenters expressed serious concerns about the 
use of the pre-floor, pre-reclassified hospital wage index for 
adjusting for geographic variation in wages. These commenters believe 
that CMS has the regulatory authority to take immediate steps to 
implement a wage index that secures a reasonable level of parity with 
hospitals in the geographic areas served by HHAs. Specific 
recommendations include applying the State-specific rural floor to all 
urban areas and implementing a reclassification value proxy for HHAs 
operating in areas where hospitals have been reclassified. Commenters 
also made recommendations that CMS consider a wholesale revision and 
reform of the home health wage index.
    Response: These commenters are referring to the rural floor and 
geographic reclassification applicable to hospital payments. The rural 
floor provision is provided at section 4410 of Public Law 105-33 and is 
specific to hospitals. The reclassification provision provided at 
section 1886(d)(10) of the Act is also specific to hospitals. Because 
these floors and reclassifications apply only to hospitals, and not to 
HHAs, we believe the use of the most recent available pre-floor and 
pre-reclassified hospital wage index data results in the appropriate 
adjustment to the labor portion of home health costs as required at 
1895(b)(4)(C). As to the revision and reform of the home health wage 
index, we further note that CMS has, along with the industry, explored 
the feasibility of developing a home health specific wage index. 
Because of the volatility of the home health wage data and the 
significant amount of resources that would be required to improve the 
quality of those data, we do not expect to propose a home health 
specific wage index until we can demonstrate that a home health 
specific wage index would be more reflective of the wages and salaries 
paid in a specific area, that it would significantly improve our 
ability to determine payment for HHAs, and that we can justify the 
resources required to collect the data, as well as the increased burden 
on providers.
    Comment: One commenter was concerned about the wage index for CBSA 
12940 ``East Baton Rouge, Ascension, Livingston, West Baton Rouge, 
Louisiana.'' The commenter stated that the proposed ``wage index 
reflects a decrease from .8593 in CY 2006 to .8099 in CY 2007, a 
decrease of nearly 6%.'' The commenter believes this must be the result 
of an error and that this wage index should be reviewed for accuracy.
    Response: First, the wage index that is applied to payments for 
services furnished to home health patients in CY 2006 in CBSA 12940 is 
not 0.8593. In CY 2006, we apply a transition wage index of either 
0.7967 or 0.8618 (depending on the State and county code where the 
beneficiary resides) to payments for home health services provided in 
CBSA 12940. This is clearly noted in Addendum A of the CY 2006 HH PPS 
final rule (70 FR 68161). The wage index value of 0.8593 would have 
been applied to payments for home health services rendered in CBSA 
12940 had we not implemented a transition policy for CY 2006. As noted 
in the CY 2006 final rule (70 FR 68138), we implemented a transition 
policy based on the concern about the potential negative financial 
impact of moving to a CBSA-based wage index. The final wage index value 
for CBSA 12940 will be 0.8084 for CY 2007.
    Second, the change in the wage index value for CBSA 12940 is also 
due in part to the inclusion of wage data from the following counties: 
East and West Feliciana Counties, Iberville County, Pointe Coupee 
County, and St. Helena County. These five counties were previously 
classified as rural. However, under the CBSA designations, which we 
implemented beginning in CY 2006, they are now part of CBSA 12940.
    We further note that we employ processes to review the accuracy of 
the wage index. The home health wage index is derived from the pre-
floor, pre-reclassified hospital wage index which is calculated based 
on cost report data from hospitals paid under the hospital inpatient 
prospective payment system (IPPS). All IPPS hospitals must complete the 
wage index survey (Worksheet S-3, Parts II and III) as part of their 
Medicare cost reports. Cost reports will be rejected if Worksheet S-3 
is not completed. Additionally, intermediaries perform desk reviews on 
all hospitals' Worksheet S-3 wage data, and we run edits on the wage 
data to further ensure the accuracy and validity of the wage data. In 
addition, HHAs have the opportunity to submit comments on the hospital 
wage index data during the annual IPPS rulemaking period. Therefore, we 
believe our review processes result in an accurate reflection of the 
applicable wages for the areas given.
    Comment: A commenter expressed concern because implementation of a 
CBSA-based wage index places Lake County, Illinois in the same CBSA as 
Racine, Wisconsin rather than in the CBSA-based wage index that 
includes Chicago. The commenter states that Lake County, Illinois draws 
from the same employment pool as does the Chicago metro area. The 
commenter further states that this situation requires dual licensure in 
order for HHAs in Illinois to hire nurses from Wisconsin.
    Response: Lake County, Illinois is not included in the same CBSA 
with Racine, Wisconsin. Racine County is in CBSA 39540 and has a CY 
2007 wage index of 0.9356. Lake County, Illinois is included with 
Kenosha County, Wisconsin in CBSA 29404. Lake County and Kenosha County 
are adjacent counties in the States of Illinois and Wisconsin, 
respectively. The CY 2007 wage index for CBSA 29404 is 1.0570. OMB 
considers Lake County and Kenosha County to be part of the same 
Metropolitan Division. OMB defines a ``metropolitan division'' as ``a 
county or group of counties within a core-based statistical area that 
contains a core with a population of at least 2.5 million. A 
metropolitan division consists of one or more main counties that 
represent an employment center or centers, plus adjacent counties 
associated with the main county or counties through commuting ties.'' 
This information is available at the following Web address: http://www.whitehouse.gov/omb/bulletins/b03-04.html. We believe that

[[Page 65905]]

the OMB geographic designations generally reflect the general labor 
market.
    State participation in the Nurse Licensure Compact alleviates the 
need for nurses to be licensed in multiple states. The state of 
Wisconsin participates in the Nurse Licensure Compact but Illinois does 
not. Illinois' participation in the Nurse Licensure Compact would 
alleviate the need for nurses to be licensed in both states.
    Comment: Other commenters had issues with the decreases in wage 
index that they will experience in the move to a full CBSA-based wage 
index in CY 2007.
    Response: We appreciate the detailed concerns sent by the 
commenters regarding the impact of the wage index update for their 
specific areas. We note that there will always be some areas that 
experience an increase in wage index values while others experience a 
decrease in wage index values. Variability in wage index values occurs 
each year as wage index values fluctuate from year to year based on the 
changes to the hospital wage data. As a result, wage index values 
within the system increase or decrease. We are aware of the changes to 
wage index values may be due in part to the adoption of the revised OMB 
designations, and in light of these concerns, we provided a one-year 
transition period for CY 2006. As to the appropriateness of what CBSA a 
particular area has been designated into, CBSA designations are 
determined by the Office of Management and Budget (OMB). We continue to 
believe that OMB's CBSA designations reflect the most recent available 
geographic classifications and are a reasonable and appropriate way to 
define geographic areas for purposes of determining wage index values.
    Comment: One commenter recommended that CMS apply a transition 
policy that would phase in large and unexpected wage index reductions 
over a two-year period, similar to the transition CMS applied for the 
IPPS conversion to CBSAs.
    Response: As noted previously, we implemented a one-year transition 
policy as a means to gradually introduce the changes and impact of a 
CBSA-based wage index to the HH PPS. We believe that the transitional 
one-year period was appropriate and do not agree that a longer 
transition period is necessary or appropriate. We again note that 
fluctuations in each wage index would be expected even if we did not 
adopt the revised OMB designations.
    Comment: Commenters raised concerns with CMS' proposal to continue 
to use the CY 2005 rural wage index for areas where there is no rural 
hospital data to compute a wage index.
    Commenters also raised concerns with the alternative methodology 
that we discussed, that is, basing the imputed rural wage index on data 
from the state's Census Division. Commenters believe that this type of 
situation highlights the need to move away from using pre-floor, pre-
reclassified hospital wage data for the home health wage index. 
Commenters recommended a number of alternative methodologies for 
imputing a wage index value for areas where there are no rural hospital 
data to compute a wage index value. The commenters all believe that an 
imputed proxy should be reflective of the most local data available. 
Almost all of these comments specifically refer to the wage index for 
rural Massachusetts.
    Response: As noted above, several commenters recommended 
alternative methodologies for imputing a rural wage index. One 
recommended alternative was to use CAH data to impute a wage index for 
rural Massachusetts. However, CAHs are not required to submit the cost 
reporting worksheets that we use to compute the hospital wage index. 
Requiring CAHs to do so would impose an additional data collection 
burden on them. Additionally, those data would then need to be 
collected and audited. Therefore, we believe this option would be 
unduly burdensome and inefficient.
    Another alternative that was recommended was to use the rural wage 
index from the single state closest to the Massachusetts rural area. 
Rhode Island is the closest State to the Massachusetts rural area, but 
Rhode Island has no rural areas. The commenter acknowledged this and 
proposed using the wage index for Connecticut. We do not believe that 
using the rural wage index from the closest State is appropriate 
because this methodology is not easy to apply to other states where 
this situation could arise.
    Another alternative that was recommended was to use the same 
methodology that we use to calculate an ``imputed rural floor'' for PPS 
hospitals with no rural areas (69 FR 49111). This methodology compares 
the three States that lack rural hospital wage data (Rhode Island, New 
Jersey, and Massachusetts) to those three States as a class. As the 
commenter recognized, this approach does not match the criterion for 
using rural data. The commenter also recognized that since it uses data 
from hospitals in New Jersey, it does not meet the criterion of using 
the most local data available. We agree with the commenter that this is 
not the optimum alternative for imputing a rural wage index for the HH 
PPS.
    A fourth alternative that was recommended was to use the average 
wage index from contiguous CBSAs as an acceptable proxy for a rural 
wage index.
    A fifth alternative that was suggested was to use BLS wage data to 
derive a ratio of rural wages to wages in an urban MSA within the 
State. That ratio could then be multiplied by the wage index from the 
urban MSA to derive an estimated wage index for the rural area. We do 
not believe that using the BLS data to impute a rural wage index is the 
best alternative as it does not meet our criterion of using pre-floor, 
pre-reclassified hospital data. Also, using the BLS wage data would 
require a determination as to which health sector occupations to 
consider. This alternative methodology would also not weight the 
occupations appropriately. In contrast, the pre-floor, pre-reclassified 
hospital wage data encompasses wages and hours, that is, actual 
utilization per occupation.
    Using OMB's geographic classification system, the entire rural 
Massachusetts area, consists of Dukes and Nantucket Counties. Both of 
these counties are islands. This creates a unique set of circumstances 
to consider.
    As we stated in the August 3, 2006 proposed rule, we also believe 
that an imputed proxy should (1) use pre-floor, pre-reclassified 
hospital data, (2) use rural wage data, (3) be easy to evaluate, and 
(4) be easily updatable from year-to-year. After a thorough review of 
the comments received and a further review of the needs and concerns 
inherent in this situation, we agree with the commenters that an 
additional criterion should be added, that is, that the most ``local'' 
data available should be used to impute a rural wage index. We have re-
evaluated our proposed method of imputing a rural wage index, (that is, 
using the CY 2005 wage index) and have decided that a more appropriate 
proxy is needed. Although our proposed methodology uses local, rural 
pre-floor, pre-reclassified hospital wage data, this method is not 
updateable from year-to-year. In addition, we now believe that the 
alternative methodology noted in the August 3, 2006 proposed rule (that 
is, using an average of the wage indexes in the Census Division) is not 
optimal because although it uses pre-floor, pre-reclassified hospital 
wage data from rural areas, it does not use the most local data 
available.
    We believe that the alternative methodology of using the wage index 
from contiguous CBSAs best meets our criteria for imputing a rural wage 
index and represents an appropriate wage index proxy for rural areas 
without

[[Page 65906]]

hospital wage data. While it does not use rural data, it does use pre-
floor, pre-reclassified hospital wage data, it is easy to evaluate, it 
is updateable from year to year, and it uses the most local data 
available. Therefore, we are revising our methodology for imputing a 
wage index for rural areas without hospital wage data. We will use the 
average wage index from all CBSAs that are contiguous to that rural 
area if the rural area does not have rural hospital wage data.
    In determining an imputed rural wage index, we interpret 
``contiguous'' as sharing a border. In the case of Massachusetts, the 
entire rural area consists of Dukes and Nantucket Counties. We 
determined that the borders of Dukes and Nantucket Counties are 
``contiguous'' with Barnstable and Bristol Counties. The wage indexes 
for Barnstable (1.2539) and Bristol (1.0783) are averaged resulting in 
an imputed rural wage index of 1.1661 for rural Massachusetts for CY 
2007. While we believe that this policy could be readily applied to 
other rural areas that lack hospital wage data (possibly due to 
hospitals converting to a different provider type (such as a CAH) that 
does not submit the appropriate wage data), should a similar situation 
arise in the future, we may re-examine this policy.
    However, we do not believe that this final policy is appropriate 
for Puerto Rico. As noted in the August 3, 2006 proposed rule, there 
are sufficient economic differences between the hospitals in the United 
States and those in Puerto Rico, including the fact that hospitals in 
Puerto Rico are paid on blended Federal/Commonwealth-specific rates 
that a separate distinct policy for Puerto Rico is necessary. 
Consequently, any alternative methodology for imputing a wage index for 
rural Puerto Rico would need to take into account those differences. 
Our policy of imputing a rural wage index based on the wage index(es) 
of CBSAs contiguous to that rural area does not recognize the unique 
circumstances of Puerto Rico. We received neither comments on our 
proposed approach to impute a wage index for rural areas in Puerto Rico 
nor any alternative suggestions. While we have not yet identified an 
alternative methodology for imputing a wage index for rural Puerto 
Rico, we will continue to evaluate the feasibility of using existing 
hospital wage data and, possibly, wage data from other sources.
    Accordingly, we will continue to use the most recent wage index 
previously available for Puerto Rico, that is, the wage index from 
2004, which is 0.4047.

Health Care Information Transparency and Health Information Technology

    Comment: One commenter addressed our discussion of health care 
information transparency and health information technology. The 
commenter disagreed with our implication that public comment was 
previously solicited from the home health community via the 2006 IPPS 
proposed rule published on August 25, 2006. However, the commenter is 
pleased that CMS has initiated a public dialogue in this area. The 
commenter suggests that CMS conduct a technology inventory in home 
health services to determine utilization and perceived roadblocks to 
expanded utilization. The commenter also believes that any such mandate 
must be accompanied by adjustments in payments. Additional commenters 
raised concerns about the potential impact of health information 
technology. Commenters do not believe that CMS has sufficiently 
supported the significant investments agencies have had to make in the 
past several years to establish and maintain HIT capabilities. 
Commenter concerns focused on the potential financial impact on 
providers who have invested significantly in HIT. Commenters believe 
that HIT requires a shared investment between providers and purchasers 
of care, to include CMS.
    Response: As explained in the proposed rule, we intend to consider 
both the health care information transparency initiative and the use of 
HIT as we refine and update all Medicare payment systems. As previously 
stated, the 2007 Budget states that ``the Administration supports the 
adoption of health information technology (HIT) as a normal cost of 
doing business to ensure patients receive high quality care.'' We are 
not including specific recommendations in this final rule. However, we 
appreciate the input and recommendations provided in the use of HIT and 
welcome further comments on this important topic from HHAs.
    Comment: One commenter stated that the public does not understand 
how Medicare's HH PPS works. The commenter believes that a prospective 
system is a ``soft'' reimbursement methodology, as payment rates have 
little relationship to home health pricing noting that in some 
instances the HH PPS payment far exceeds charges and in other instances 
the payment falls short of charges.
    Response: We are actively pursuing the goal of price and quality 
transparency generally in the health care system. We have already 
released payment information on inpatient services and ambulatory 
surgical centers and are considering how to do so in other care 
settings. We agree that any pricing information released publicly 
should be clearly understood by the public, both consumers and 
patients. We recognize that Medicare payment for home health services 
captures a wide variety of costs and that payment rates may not always 
exactly match the costs for specific patients. However, as a 
prospective payment system, HH PPS payments estimate the average cost 
of providing services and are designed to recognize the higher costs 
associated with care for more severely ill patients. As such, the 
information could be of great interest to individual patients and the 
general public when they consider treatment options. It may also be 
important for patients and their families to understand what services 
the payment covers, to assist in planning for their health care needs.
    The price of home health care is also an important component of 
price information in broader episodes of care. For example, a patient 
hospitalized with congestive heart failure may have a variety of post-
acute care options, including being discharged home without home health 
services. The ability to identify the cost of different services, 
including home health, in a total episode of care allows patients, 
providers, and the Medicare program to be better educated about the 
value of different mixes of services. This type of analysis, including 
knowing the price of home health services, could provide valuable data 
such as re-admission information and indicating the value of specific 
care sites to patients.
    We are not including specific recommendations in this final rule. 
However, we will continue to identify price and quality information 
that could be publicly released to help inform patient and consumer 
health care decisions and encourage higher value health care. We 
welcome further comments on this important topic from HHAs.

Consolidated Billing and Supply Issues

    Comment: One commenter requested that CMS exclude HCPCS Code A7043 
(vacuum drainage bottle and tubing for use with implanted catheter) 
from the HH PPS. The commenter believes that the regulations authorize 
CMS to exclude prosthetic devices and items related to prosthetic 
devices that are covered under Part B from the HH PPS. The commenter 
stated that the Pleurx pleural catheter and vacuum drainage bottle meet 
the definition of a prosthetic device because they replace the 
malfunctioning pleura by artificially

[[Page 65907]]

draining the pleura. Additionally, the commenter believes that the HH 
PPS rates do not adequately compensate HHAs when they care for 
beneficiaries requiring the Pleurx pleural catheter and vacuum drainage 
bottle.
    Response: We addressed consolidated billing requirements in the 
Final Rule for the HH PPS published on July 3, 2000 (65 FR 41139). 
Medical supplies are a covered home health service and are bundled into 
the payment rate under the HH PPS. Section 1861(m)(5) specifically 
includes catheters and catheter supplies as a covered home health 
service. Therefore, vacuum drainage bottles and tubing for use with an 
implanted catheter are bundled medical supplies while the patient is 
under a home health episode of care.
    Moreover, as we have consistently noted in responding to comments, 
the statute does not provide for an exception or carve-out of medical 
supplies from the PPS rate for patients under a plan of care under the 
HH PPS. The costs of all such supplies are included in the HH PPS rate 
(see 65 FR 41139).
    We disagree with the commenter that the HH PPS rates do not 
adequately compensate HHAs when they care for beneficiaries requiring 
vacuum drainage bottles and tubing for use with the implanted catheter 
because this medical supply was included within the original list of 
199 non-routine medical codes subject to home health consolidated 
billing effective October 1, 2000. While the HCPCS code for vacuum 
drainage bottles has changed, the cost of vacuum drainage bottles was 
included in the original case-mix weights used to determine the HH PPS 
rates (65 FR 41138).
    Comment: Several commenters raised concerns about being unable to 
obtain the same brand of single-use urinary catheter from their HHA 
that they received directly from a DMEPOS supplier prior to receiving 
home health. These commenters believed that excluding HCPCS code A4353, 
which includes single-use catheters, would allow them to receive their 
catheters directly from the DMEPOS supplier. A number of commenters 
also request that HHAs be allowed to omit a patient's chronic urinary 
condition from the patient's specific home health plan of care which 
they say will allow the patient to continue to obtain the same name 
brand of single-use catheter they were using prior to receiving home 
health.
    Response: As noted above, medical supplies are bundled into the HH 
PPS payment rate and cannot be excluded from that rate. As to this 
specific item under HCPCS code A4353, that item is considered to be a 
medical supply and accordingly bundled into the HH PPS payment rate.
    We remind the commenters that if they believe that a product is not 
adequately described in the existing HCPCS Level II code set, they may 
submit an application to CMS to revise the code set, using the format 
and guidance provided on CMS' HCPCS Web site at www.cms.hhs.gov/medhcpcsgeninfo.
    We note that under consolidated billing, the billing for those 
medical supplies is the responsibility of the HHA. If the patient's 
physician determines that a particular feature of a given supply is 
medically necessary for the patient, the physician may specify the 
designated feature in the physician's order for the supply and in the 
plan of care. If the HHA determines that there exists an appropriate 
substitute for the supply ordered by the physician, it may provide that 
patient with the appropriate substitute supply. If the home health 
patient does not agree with the HHA that the substitute supply is 
appropriate, the patient should contact us through the Medicare Hotline 
at 1-800-MEDICARE (1-800-633-4227). This toll-free helpline is 
available 24 hours a day, 7 days a week to answer questions. 
Beneficiaries can speak to a customer service representative in English 
or Spanish. TTY users should call 1-877-486-2048.
    We disagree with the request that a HHA omit a medical condition 
from a plan of care in order to allow the patient to obtain desired 
medical supplies outside of the plan of care. The regulations at 42 CFR 
484.18 require that the plan of care covers all pertinent diagnoses, 
including types of services and equipment required. In addition to 
calling 1-800-MEDICARE, if the home health patient believes that she is 
not receiving the necessary Medicare covered supplies, she may call the 
Regional Home Health Intermediary (RHHI) or CMS regional office. Under 
the Contacts section of our Web site at http://www.cms.hhs.gov/center/hha.asp we provide information on how to contact the RHHIs and CMS 
regional offices.

HH PPS Refinements

    Comment: One commenter urged CMS to undertake a review of the HH 
PPS and make appropriate adjustments to the case-mix weights before 
2008. Another commenter requested that there be a review of LUPA rates, 
and to subsequently increase the LUPA rates to ensure that they cover 
the costs of providing care to those patients. One commenter 
recommended that an ``add-on'' to the HH PPS payment be made for dually 
eligible beneficiaries in order to recognize the added costs incurred 
by such patients. The same commenter also believes that the costs 
associated with wound care are not adequately paid for in the current 
case-mix system.
    Response: Our ongoing research agenda on the HH PPS refinements 
encompasses review of case-mix adjustment and other payment adjustment 
provisions under the HH PPS. Our continuing work also includes review 
of overall system performance to the extent data permit analysis of 
this topic. We intend to address certain aspects of the HH PPS, which 
could include LUPA rates, when we initiate a refinement regulation. We 
also note it is common with new payment systems for providers to go 
through a period of adaptation. The adaptation process influences the 
data we use to study refinements, and those data lag by up to a year 
from the time a service is rendered to when the claim is submitted and 
processed into a standard analytical file. Our study results will be 
more effective and provide a better basis for policy proposals when the 
data used in the studies reflect the ``end point'' of the adaptation 
period. Assuming that the necessary data files will become complete, we 
believe that the end point of the adaptation period will allow us to 
pursue a refinement rule in the near future.
    Comment: A commenter recommended that CMS establish a home health 
technical advisory group to regularly review and update the multitude 
of component parts of the HH PPS reimbursement methodology.
    Response: We appreciate the comment; however, we do not believe 
such a group is necessary at this time. We have always received input 
from the industry on various aspects of our Medicare payment systems, 
and we anticipate this practice will continue into the future. 
Additionally, for the past few years, we have conducted ``open-door'' 
forums to provide the public with an opportunity to provide input and 
comment on the HH PPS and related issues. Finally, as part of ongoing 
refinement research, a technical expert panel (TEP) addressed the 
various aspects of the HH PPS for possible refinements to the system. 
We strongly believe that specific refinements to the HH PPS, if 
appropriate, should be addressed in a single refinement regulation. In 
doing so, the causes and effects that any particular refinement would 
have on the rest of the system could be taken into effect, eliminating 
the risk of

[[Page 65908]]

implementing any one refinement in a vacuum and resulting in a complete 
and responsible refinement to the system.

Classes of Oxygen and Oxygen Equipment

Statutory Authority
    Comment: One commenter asserted that the statute does not give 
authority for CMS to create new classes for these items and that 
payments must be made at the rate set by statute.
    Response: We disagree. Section 1834(a)(9)(D) of the Act provides 
authority to create separate classes and payment amounts for any item 
of oxygen and oxygen equipment as long as they are budget neutral, that 
is, the separate classes and payment amounts do not result in 
expenditures for any year to be more or less than expenditures that 
would otherwise have been made if the classes had not been established.
New Oxygen Generating Portable Equipment Technology
    Comment: One commenter commended CMS for recognizing the many 
benefits that oxygen generating portable equipment (OGPE) can provide. 
Some commenters urged that the proposed payment rate for OGPE be 
increased to provide adequate compensation for suppliers and to 
encourage suppliers to invest in the new technologies. Two commenters 
asked CMS to reconsider the proposed payment rates for OGPE to 
accurately reflect the cost of the equipment; which is claimed to range 
from $2,500 to $3,500. Some commenters recommended that CMS should not 
implement the proposed payment rates changes at this time and that 
setting new payment rates should be delayed until sufficient data is 
gathered to identify the costs of oxygen services.
    Response: We appreciate the support for our proposal to create a 
new payment category for OGPE. We do not agree with the commenters who 
suggested delaying the new categories because we are concerned that 
maintaining the current system could create incentives for suppliers to 
utilize older technology rather than newer technology that may be more 
appropriate for certain beneficiaries. We believe that it is 
appropriate and necessary to implement a new payment class for OGPE in 
order to ensure access to these items; therefore, we will finalize a 
new payment category for OGPE.
    In the proposed rule, we explained that there are currently two 
different types of OGPE: transfilling units that work independently or 
in conjunction with standard, stationary oxygen concentrators to fill 
portable oxygen canisters in the home; or portable oxygen concentrators 
that meet both the patient's stationary and portable oxygen needs. In 
both cases, the supplier can bill for both the monthly payment for 
oxygen and oxygen equipment (currently averaging $199.84) and the 
portable equipment add-on (currently averaging $31.79). In establishing 
the new payment rate for OGPE, we proposed to consider the savings that 
would be generated from use of these new technologies. The savings 
would come from not having to make payments for portable oxygen 
contents for beneficiary owned portable systems that generate their own 
oxygen. The new, enhanced monthly payment for OGPE would be paid in 
conjunction with the monthly payment for stationary equipment. The 
combined monthly payments for stationary oxygen equipment and OGPE 
would provide extra payments to suppliers of the newer technology 
portable oxygen equipment, with the extra payments being directly 
linked to the savings generated for the program by eliminating the need 
to make future payments for portable oxygen contents.
    The proposed add-on for OGPE of $64 was derived using a multiple 
step process described in section I of the provisions of the proposed 
regulation. As explained above, this process would involve determining 
savings generated from not having to pay proposed monthly payments of 
$55 for portable oxygen contents during the beneficiary ownership 
period and applying the savings evenly over the 36-month OGPE rental 
period. A total payment of $241 was proposed for stationary equipment 
($177) plus the OGPE add-on payment ($64). The final process for 
calculating the OGPE add-on payment, like the proposed process, 
involved determining savings generated from not having to pay final 
monthly payments of $77.45 for portable oxygen contents during the 
beneficiary ownership period and applying the savings evenly over the 
36-month OGPE rental period. To determine these savings we multiplied 
$77.45 by 24 months (number of months in the equipment ownership 
period) to get $1,858.80. We divided $1,858.80 by the 36 months of the 
rental period to get the OGPE add-on of $51.63 per month. However, as 
explained above in the discussion of the final methodology necessary to 
assure annual budget neutrality of the new classes of oxygen and oxygen 
equipment, distribution of use of items in the various classes over 
five years is factored into the calculation used to determine the 
budget neutrality adjustment factor. Therefore, the final payment rates 
for the new classes are based on current utilization and an assumption 
of the number of beneficiaries that will be using OGPE in the future. 
The total payment for stationary equipment and OGPE for 2007 is $250.03 
($198.40 for stationary + $51.63 for OGPE). The total payment for 
stationary equipment and OGPE is estimated to be $250.03 in 2008, 
$244.84 in 2009, and $241.02 in 2010; this compares to the total 
payment in the proposed rule of $241.
    We also note that in response to comments on the budget neutrality 
of our proposal, the final national limited monthly payment rates for 
each oxygen class were computed using weighted average fee schedule 
amounts instead of straight average fee schedule amounts. As a result, 
we have used slightly different numbers in our responses to comments 
than we used in the proposed rule. Our revised budget neutrality 
analysis is discussed in full below.
    Comment: One commenter stated that CMS needs to provide assurance 
that payment rates will not decrease, except in the case of competitive 
bidding, and that each year the rates will be increased by the 
percentage change in the Consumer Price Index for Urban Consumers (CPI-
U), the covered item update factor that is generally established as the 
annual update for DME, unless otherwise indicated.
    Response: We cannot provide assurance that oxygen payment rates 
will never be decreased in the future or that rates will always be 
increased by the CPI-U update. CMS is required to implement provisions 
of law passed by Congress, including the covered item updates to the 
fee schedule amounts for oxygen and oxygen equipment. Further, in order 
to maintain annual budget neutrality for the oxygen payment classes as 
required by Section 1834(a)(9)(D)(ii) of the Act, CMS may need to 
adjust the payment amounts as appropriate.
Definition of Modality
    Comment: Many commenters asked us to clarify the definition of 
``modality.'' The commenters stated that the definition should be based 
on clinical characteristics of the beneficiary rather than physical 
characteristics of the device such that: a stationary oxygen class of 
patients who are moribund, bed bound with limited need to leave the 
home; a portable oxygen class of patients who require oxygen at night 
only and have limited mobility; and an ambulatory oxygen class of 
patients

[[Page 65909]]

whose oxygen needs include support for frequent ambulation. The 
commenters state that the HCPCS code should be modified to ensure that 
each respective clinical class can be identified.
    Response: Medicare currently pays for two classes of oxygen 
equipment, stationary and portable. For the stationary class, there are 
three modalities that Medicare pays the same ``modality neutral'' 
payment rate for: concentrators, liquid cylinders and gaseous tanks. 
For the portable class, Medicare makes a modality neutral payment for 
all types of portable equipment. For the final rule, we are adding a 
new payment class for OGPE and new separate payment classes for 
delivery of stationary and portable oxygen contents. As has always been 
the case, a physician may order a specific oxygen equipment modality 
based on the clinical needs of the patient, and the supplier is bound 
by that order. However, there is currently no Medicare national 
coverage determination (NCD) that establishes medical necessity 
criteria for different oxygen modalities. Therefore, at this time, we 
do not believe it is necessary or appropriate to separate oxygen and 
oxygen equipment into different classes based on the clinical 
characteristics of different beneficiary populations.
    Comment: A few commenters asked us to clarify the medical policy 
that defines the criteria allowing patients to switch from one modality 
of oxygen equipment to another modality. The commenters also asked CMS 
to create a payment policy to pay suppliers for this type of equipment 
change. Some commenters recommended that CMS instruct its DME program 
safeguard contractor (PSC) to incorporate specific medical necessity 
coverage requirements in a local coverage determination (LCD) that 
specifies under what circumstances or diagnoses a beneficiary could 
change from one modality of equipment to another, how suppliers will be 
paid for furnishing a new equipment modality to a beneficiary, and 
specific documentation requirements for both the supplier and physician 
for a change in modality.
    Response: A physician prescription for home oxygen is required for 
coverage for home oxygen equipment. Generally, the physician prescribes 
the units of oxygen the patient needs and the beneficiary works with 
the supplier in deciding the modality of the oxygen equipment. In the 
final rule, we are allowing beneficiaries the option to change 
modalities during their rental period (this policy modification is 
discussed below); however, as we proposed in section L of the proposed 
rule, a new 36-month rental period would not begin in order to comply 
with the modality neutral payment rules for oxygen and oxygen equipment 
that we developed in accordance with sections 1834(a)(5) and (9) of the 
Act. Even if Medicare coverage rules and medical necessity criteria for 
different modalities of oxygen equipment were established in an NCD or 
LCD, there would be no effect on Medicare payments for specific types 
of items furnished under each payment class. It is important to note, 
however, that Medicare coverage and medical necessity for oxygen and 
oxygen equipment is outside the scope of this rulemaking effort.
Stationary and Portable Oxygen Contents
    Comment: One commenter asked for justification of the 65 percent 
and 35 percent apportionment of the payment for oxygen contents. We 
also received comments recommending the same payment rate for all types 
of oxygen contents because oxygen contents are the same regardless of 
the weight of the container. One commenter recommended we keep the 
reduction of approximately $22 to stationary equipment (from $199 to 
$177) and reallocate the excess savings to (a) portable gaseous oxygen 
contents and/or equipment, increasing the rates to $75 to $80 and 
applying the increased rate to portable gaseous oxygen equipment 
furnished during the equipment rental period and portable gaseous 
oxygen contents furnished after the equipment rental period and (b) 
portable liquid oxygen contents and/or equipment, increasing the rates 
to $90 to $95 and applying the increased rate to portable liquid oxygen 
equipment furnished during the equipment rental period and portable 
liquid oxygen contents furnished after the equipment rental period.
    Response: In the proposed rule, we proposed to apportion the 
current oxygen contents rate of $156 per month by 65 percent and 35 
percent based on the weight of the containers and other factors that 
might make delivery of stationary oxygen contents more expensive than 
delivery of portable oxygen contents. Stationary oxygen containers are 
larger and heavier than the portable oxygen containers; therefore, we 
proposed to apportion a greater amount of the payment to delivery of 
stationary oxygen contents. We received comments indicating that the 
average monthly costs of furnishing both types of oxygen contents are 
the same despite the fact that stationary oxygen contents are bulkier 
than portable oxygen contents. This is because stationary oxygen 
contents are delivered and refilled at a lower frequency than portable 
oxygen contents. Therefore, we are modifying the proposed payment rates 
for the two types of oxygen contents based on an even (that is, 50-50 
percent) split in the current $154.90 weighted average payment amount 
for both stationary and portable oxygen contents. As a result, we will 
be paying the same monthly rate of $77.45 for delivery of each of 
stationary oxygen contents and portable oxygen contents. We will 
therefore continue to pay $154.90 in cases where both stationary and 
portable oxygen contents are medically necessary and are delivered. A 
payment of $77.45 per month rather than $55 per month for delivery of 
portable oxygen contents will further ensure that beneficiaries will 
receive necessary contents for their portable oxygen systems and is 
consistent with a suggestion from one commenter that payment for 
delivery of portable gaseous oxygen contents should be from $75 to $80. 
Most patients currently use gaseous portable oxygen systems as opposed 
to liquid portable gaseous systems or portable concentrators. A very 
small number of beneficiaries use stationary liquid or gaseous systems, 
and, in most cases, the supplier that delivers stationary oxygen 
contents for beneficiaries who use both stationary and portable liquid 
or gaseous systems would also be the supplier of the portable oxygen 
contents as well. Therefore, we believe that reducing the proposed 
payment for stationary oxygen contents from $101 to $77.45 is 
appropriate in light of the increased payment for portable oxygen 
contents.
    Comment: One commenter suggested that CMS establish a delivery fee 
for each time a supplier delivers oxygen.
    Response: The longstanding Medicare policy for payment for delivery 
of DME and other supplier expenses is that payment for these costs are 
included in the single payment made for furnishing the equipment. This 
policy is based on section 1834(a)(5) of the Act, which provides that a 
monthly payment amount recognized under section 1834(a)(9) be paid for 
oxygen and oxygen equipment, and section 1834(a)(9), which mandates 
that monthly payment (or fee schedule) amounts be calculated based on 
payments made in 1986 under the reasonable charge payment methodology. 
The reasonable charges that were used to calculate the fee schedule 
payment amounts included delivery costs and all other costs for 
furnishing the equipment. Therefore,

[[Page 65910]]

the cost associated with the delivery of oxygen contents is included in 
the fee schedule payment amounts for stationary and portable oxygen 
contents. Furthermore, section 1834(a)(9)(D)(i) of the Act requires 
that monthly payment rates are to be established for each class of 
oxygen and oxygen equipment. Since total Medicare expenditures under 
the new classes and payment amounts will be the same as they would have 
been under the old classes and fee schedule amounts, we believe that 
the new payment rates incorporate the delivery costs that made up part 
of the old fee schedule amounts.
    Comment: One commenter was concerned that the payment rate for 
delivery of oxygen contents for beneficiary-owned portable oxygen 
equipment would not be enough to cover the number of tanks or cylinders 
needed for each beneficiary. The commenter indicated that under the 
previous payment methodology where monthly payments for oxygen and 
oxygen equipment were made as long as medical necessity continued, 
suppliers were able to offset costs associated with delivering portable 
oxygen contents with the payment made for the stationary oxygen and 
oxygen equipment. The commenter expressed concern that the proposed $55 
monthly payment for delivery of portable oxygen contents will not cover 
the costs of delivering more than 11 portable tanks per month. In 
addition, the commenter stated that this figure does not include the 
cost of delivery. Another commenter noted that the current fee schedule 
amount of approximately $21 per month would not cover the costs of one 
delivery per month of portable oxygen contents, and that this will 
force suppliers to adopt a policy whereby the beneficiary must pick up 
tanks from the supplier's store.
    Response: We agree with the commenters that the payment rate for 
portable oxygen contents of $21 is insufficient as a monthly payment 
for the delivery of portable oxygen contents, and therefore; we are 
finalizing our proposal to increase it in this final rule. We are 
dividing $154.90, the current weighted average payment amount for both 
stationary and portable oxygen contents evenly so that the payment rate 
for portable oxygen contents will be increased from the current 
weighted average payment amount of $20.77 to $77.45 per month. The 
revised payment rate for stationary oxygen contents will also be $77.45 
per month. These monthly payment rates include delivery of tanks and 
cylinders, a service that the supplier is required to perform in order 
to be in compliance with standards set forth at Sec.  424.57(c)(12). 
Based on comments received on this issue, we believe that the finalized 
payment rate of $77.45 will adequately pay suppliers for delivery of 
stationary or portable oxygen contents. We are therefore confident that 
the payment rate adequately covers the supplier's costs of delivering 
oxygen contents.
    Comment: One commenter asked for clarification on payment if there 
is a change in equipment due to medical necessity. For example, the 
commenter asked whether a new 36-month rental period starts when there 
is an increase in the patient's oxygen volume that would require 
delivery of more portable oxygen tanks.
    Response: As we discuss more fully below, suppliers can furnish 
another capped rental item or type of oxygen equipment with a physician 
prescription or if the beneficiary would like newer technology or an 
upgraded item. However, unless the change in equipment is based on 
medical necessity, a new rental period will not start. In addition, 
because there is no distinction made between oxygen equipment 
modalities for payment purposes under the Medicare program, we would 
not consider a change from one modality to another to be a change in 
the type of equipment furnished to a beneficiary. Accordingly, a new 
period of continuous use would not start in those circumstances.
Budget Neutrality
    Comment: Several commenters claimed that the proposed rates were 
not budget neutral. They claimed that the calculation of decreased 
expenditures that would result from a $22 reduction in payment for 
stationary equipment is underestimated and that such payment reduction 
translates to savings ranging from $239 million to $260 million. One 
commenter stated that the proposed rule was not budget neutral for each 
year as required by statute. Another commenter pointed out that the 
2004 data did not have specific utilization rates for portable 
concentrators or transfilling systems since separate HCPCS codes did 
not exist for these services at that time.
    Response: We have revised the offset/budget neutrality calculations 
that we proposed based on comments received and have modified the 
payment rates for the classes of oxygen accordingly.
    First, in response to the commenter that expressed concern with our 
use of 2004 data, we have updated our analysis by using the latest 
available data from the SADMERC on the number of beneficiaries for 
which claims were received from July 1, 2006 through September 30, 
2006, for HCPCS codes E0424, E0431, E0434, E0439, E1390, E1391, and 
E1392 to determine the distribution of beneficiaries among the 
categories of stationary and portable oxygen equipment. This data is 
used to count the number of beneficiaries using items in each equipment 
class. The number and percent distribution of beneficiaries using the 
different categories of equipment are shown in table 10. These latest 
data show 0.3 percent of beneficiaries using portable concentrators. 
While using these later claims gives us data on users of portable 
concentrators, we do not have data on beneficiaries using transfilling 
systems since the code for such equipment began on October 1, 2006. 
Thus, for purposes of calculating rates, we had to make an assumption 
about the percent of beneficiaries who will use OGPE equipment (which 
include both portable concentrators and transfilling systems) after the 
new classes and payment rates go into effect. From comments received, 
we assumed a shift of 5 percent of beneficiaries towards OGPE for our 
budget neutrality calculations. We will revisit this assumption on an 
annual basis and make adjustments through program instructions to rates 
applicable to years after 2007 if actual utilization of oxygen 
equipment by beneficiaries is different from our assumptions.

                  Table 10.--Categories of Oxygen Users
------------------------------------------------------------------------
                                                            Percent of
          Equipment/Modality                Number of          users
                                          beneficiaries      (percent)
------------------------------------------------------------------------
Stationary Equipment Only.............           327,863            31.3
Liquid/Gas Stationary AND Portable                57,950             5.5
 Equipment............................
Concentrator AND Portable Equipment...           657,948            62.8

[[Page 65911]]

 
Stationary AND Oxygen Generating                   3,248             0.3
 Portable Equipment...................
                                       ---------------------------------
    Total Number of Beneficiaries.....         1,047,009           100.0
------------------------------------------------------------------------

    As in the proposed rule, we used a five year period for determining 
the rate changes because the reasonable useful lifetime policy for DME 
equipment allows beneficiaries to elect to obtain a new item after five 
years of use. Therefore, we assumed that Medicare would make three 
years of rental payments and two years of payment for oxygen contents.
    To calculate budget neutral rates, as in the proposed rule, we 
compared estimates of Medicare spending for oxygen equipment and 
contents based on current classes of items and payment rates with 
estimates of the spending that Medicare would make based on the new 
classes and payment rates outlined in this final rule. In order to 
further address the concerns of commenters that the payment rates for 
the new classes be budget neutral, we compared the payment rates for 
the new classes to the current, weighted average monthly payment 
amounts for oxygen and oxygen equipment (for example, $199.84 for 
stationary equipment), as opposed to comparing them to the straight 
average monthly payment amounts rounded to the nearest dollar (for 
example, $199 for stationary equipment). Based on the concerns 
expressed by commenters regarding the importance of assuring the budget 
neutrality of the new classes of oxygen and oxygen equipment, we are 
using the average of the current monthly payments per State weighted by 
actual utilization by State to establish a more precise average 
Medicare payment for each class of oxygen and oxygen equipment. To 
estimate total expenditures for oxygen and oxygen equipment for a given 
year, we multiplied the monthly payment rate for each category of 
equipment by the total number of users of each such category, then by 
the percent of users at the midpoint of each of three equipment rental 
years, then by 12 for the number of months in a year. Then, we 
multiplied the monthly payment rate for each category of oxygen 
contents by the total number of users of each such category, then by 
the percent of users at the midpoint of each of two beneficiary 
ownership years, then by 12 for the number of months in a year. We 
added the estimated spending for equipment and contents to obtain the 
five year total of payments for equipment and contents. We used data 
from the September 2006 OIG report, entitled ``Medicare Home Oxygen 
Equipment: Cost and Servicing'' (OEI-09-04-00420), on the distribution 
of the number of beneficiaries using stationary concentrators by the 
number of months rented that showed the following percentages of oxygen 
users at the midpoint of each year: 61 percent for the first year, 36 
percent for the second year, 26 percent for the third year, 19 percent 
for the fourth year, and 14 percent for the fifth year. We then used 
this same methodology to estimate Medicare spending incorporating the 
payment rate changes in this final rule. Since spending is greater 
under the payment rate changes in this final rule, we applied a budget 
neutrality adjustment to the monthly payment amount for stationary 
equipment in order to achieve the same expenditures that would be spent 
under payment rates without the changes in the final rule.
    In response to comments received about our proposed methodology not 
being budget neutral annually, we calculated budget-neutral rates for a 
five-year period from 2006 to 2010, applying the methodology described 
above. The complete, detailed budget neutrality analysis, data, and 
payment rate calculations are available at the following internet 
website: http://www.cms.hhs.gov/DMEPOSFeeSched/. This results in 
smaller budget-neutrality adjustments in the early years and larger 
ones in the later years because the increased expenditures in the first 
three years results primarily from the OGPE add-on payment. The full 
effect of the higher payments for portable oxygen contents will not be 
realized until 2010, which will be the second year of the equipment 
ownership for beneficiaries who have been renting oxygen equipment on a 
continuous basis since 2006.
    Table 11 shows the 2007 budget neutral monthly payment rates and 
our estimates of the budget neutral monthly payment rates for 2008 
through 2010 for the five classes of oxygen and oxygen equipment, in 
addition to the combined rates for stationary and portable oxygen 
contents. The rates for stationary equipment decrease by year to offset 
the new OGPE class and the increase in the portable contents rate. 
Table 12 shows the 2007 monthly payment rates and our estimates of the 
monthly payment rates for 2008 through 2010 for four of the most common 
combinations of oxygen equipment.

Table 11.--Current Weighted Average Monthly Payment Amounts Compared to Proposed and Final Monthly Payment Rates
                                   for Classes of Oxygen and Oxygen Equipment
----------------------------------------------------------------------------------------------------------------
              Oxygen class                  Current    Proposed   Final 2007     2008*       2009*       2010*
----------------------------------------------------------------------------------------------------------------
                                   During Equipment Rental Period (36 Months)
----------------------------------------------------------------------------------------------------------------
Stationary Equipment (offset needed)....     $199.84     $177.00     $198.40     $198.40     $193.21     $189.39
                                                        (-22.84)     (-1.44)     (-1.44)     (-6.63)    (-10.45)
Portable Add-on.........................       31.79       32.00       31.79       31.79       31.79       31.79
OGPE Add-on.............................         N/A       64.00       51.63       51.63       51.63       51.63
----------------------------------------------------------------------------------------------------------------


[[Page 65912]]


 
              Oxygen class                  Current    Proposed   Final 2007     2008        2009        2010
----------------------------------------------------------------------------------------------------------------
                                   Contents Payments After Equipment Ownership
----------------------------------------------------------------------------------------------------------------
Stationary & Portable Contents..........      154.90      156.00      154.90      154.90      154.90      154.90
Portable Contents Only..................       20.77       55.00       77.45       77.45       77.45       77.45
Stationary Contents Only................         N/A     $101.00      $77.45      $77.45      $77.45     $77.45
----------------------------------------------------------------------------------------------------------------
*Rates for 2008 and beyond are budget-neutral based on assumed OGPE utilization of 5 percent. Actual OGPE
  utilization will be reviewed on an annual basis and rates will be adjusted, if necessary, through program
  instructions to ensure annual budget neutrality.


                                            Table 12.--Payments for Various Combinations of Oxygen Equipment
                                                      [Estimated for calendar years 2008 thru 2010]
--------------------------------------------------------------------------------------------------------------------------------------------------------
         Categories of equipment                            During rental period                                  Contents after ownership
--------------------------------------------------------------------------------------------------------------------------------------------------------
Concentrator only:
    2007/2008............................  $198.40                                                 $0
    2009.................................  193.21                                                   0
    2010.................................  189.39                                                  0
Concentrator + gaseous portable:
    2007/2008............................  230.19 (198.40 + 31.79)                                 77.45
    2009.................................  225.00 (193.21 + 31.79)                                 77.45
    2010.................................  221.18 (189.39 + 31.79)                                 77.45
Concentrator + OGPE:
    2007/2008............................  250.03 (198.40 + 51.63)                                 0
    2009.................................  244.84 (193.21 + 51.63)                                 0
    2010.................................  241.02 (189.39 + 51.63)                                 0
Liquid stationary & portable:
    2007/2008............................  230.19 (198.40 + 31.79)                                 154.90 (77.45 x 2)
    2009.................................  225.00 (193.21 + 31.79)                                 154.90 (77.45 x 2)
    2010.................................  221.18 (189.39 + 31.79)                                 154.90 (77.45 x 2)
--------------------------------------------------------------------------------------------------------------------------------------------------------

    These estimates assume that 5 percent of oxygen users will use OGPE 
equipment in all years. However, we will monitor actual use and, as 
part of our annual budget-neutrality determination, we will revise 
rates through program instructions under the methodology specified in 
this final rule if actual OGPE usage is different from our assumption. 
We also plan to revise the payment rates in the future based on updated 
data on the distribution of beneficiaries using oxygen equipment and 
the number of months they use the equipment. These rates apply to all 
beneficiaries who use oxygen equipment on or after January 1, 2007, 
including both new and existing users.
    Comment: Some expressed concern that the proposed payment amounts 
for portable oxygen equipment and portable oxygen contents are not 
sufficient to offset the cost of providing these systems. The 
commenters recommend reallocating the savings that comes from the 
proposed reduction of the stationary class to upwardly adjust the 
monthly payment for portable equipment and contents. Some commenters 
strongly urged CMS to offset any future cuts in home oxygen 
concentrator payments with appropriate increases in other classes of 
oxygen specifically portable and ambulatory classes.
    Response: We have changed the payment amounts based on comments 
received and have increased portable contents payment amount from 
approximately $20.77 to $77.45 per month and have increased the add-on 
rate for OGPE from approximately $31.79 (the current portable add-on 
rate during the rental period) to $51.63 per month. We have also 
recalculated the offsets for budget neutrality and in order to maintain 
budget neutrality, and will not be reducing stationary payments from 
approximately $199.84 to $177 as proposed. The stationary equipment 
payment will be $198.40 in 2007, and is projected to be $198.40 in 
2008, $193.21 in 2009, and $189.39 in 2010, based on current 
calculations discussed above. The fees for 2008 and later would be 
adjusted on an annual basis, if necessary, to ensure the annual budget 
neutrality of the change in payment classes and rates. We will annually 
reevaluate the actual distribution of oxygen equipment and make any 
adjustment in the payment amounts through program instructions that are 
necessary to maintain annual budget neutrality as required by section 
1834(a)(9)(D)(ii) of the Act.
Data
    Comment: A few commenters were concerned about the lack of data 
provided that established the budget neutrality proposal and asked CMS 
to release the data and assumptions. A few commenters stated that the 
proposed rule did not conform to the requirements of the Data Quality 
Act (DQA) that require Agencies to provide information on sources of 
the disseminated information as well as supporting data and models in a 
scientific, financial, or statistical context so the public may 
question the objectivity of the data and source.
    Response: The DQA requires agencies to, among other things, issue 
guidelines to ensure and maximize the quality, objectivity, utility, 
and integrity of information disseminated by the agency. While the DQA 
applies to a wide variety of information dissemination activities and 
all types of media, it has not been established that the DQA applies to 
rulemaking. Nevertheless, we are providing extensive details in this 
final rule about the data and methodology used to calculate budget 
neutrality. Consistent with our guidelines for information quality 
assurance, the information upon which we relied is from a reliable 
source that uses accepted methods for data collection and analysis, and 
we reviewed the quality of the information before using it. Where CMS 
is responsible for disseminating influential information (that is, 
information that will have a substantial impact on important public 
policies or important private sector decisions), we ensure that there 
is a high degree of transparency about the data and methods to 
facilitate its reproducibility by qualified third parties. To the 
extent

[[Page 65913]]

the data upon which we rely is not confidential, our guidelines call 
for identification and documentation of data sets in producing 
estimates and projections, and for clear descriptions of the methods 
used.
Transition
    Comment: Some commenters asked CMS to allow for a grace period 
during which suppliers could transfer patients, with their consent, to 
other modalities. Many commenters urged CMS to allow for a 
grandfathering process so that those who began renting oxygen on 
January 1, 2006 would be under former payment rates and policies. These 
commenters argued that the final rule should only apply prospectively.
    Response: The final rule, including the new oxygen payment classes 
and rates, will be effective on January 1, 2007. However, as explained 
above and illustrated in table 11, the new payment rates will be 
annually adjusted if necessary to ensure budget neutrality. We disagree 
with the comment that we allow for a grandfathering provision whereby 
beneficiaries who began renting equipment on January 1, 2006 be allowed 
to continue under the former payment rates and policies. Such an 
approach would deny such beneficiaries the opportunity to obtain access 
to the new technology equipment. We will periodically reevaluate actual 
distribution and make any adjustment in payment amounts through program 
instructions that are necessary to maintain annual budget neutrality as 
required by statute. Adjustments in payment amounts will be determined 
based on the model we are using to ensure annual budget neutrality as 
explained above. As we discuss below, we will allow for changes in 
modalities during the rental period if the beneficiary requests an 
upgrade or if the physician provides a new order for the equipment 
modality.
    Comment: One commenter strongly urged CMS to adopt a blended rate 
during a three-year transition policy. Traditionally CMS has 
established blended rates by taking 75 percent of the original rate and 
25 percent of the new rate during the first year; 50 percent and 50 
percent in the second year; and 25 percent and 75 percent in the third 
year.
    Response: As explained above, we have revised the calculation of 
the budget-neutral oxygen equipment payment amounts in response to 
comments. Our revised approach calculates the budget-neutral rates that 
will apply for the first five years based on our estimates of the 
number of beneficiaries that will use specific types of equipment 
during each of these years. We have also determined that we may need to 
adjust the rates on an annual basis after the fifth year to ensure that 
budget neutrality is maintained. Based on our calculations, we do not 
believe that the blended percentages recommended by the commenter would 
result in budget neutral payment amounts.
Deficit Reduction Act Requirements
Rental Cap
    Comment: Numerous commenters were concerned that the 36-month 
rental period for oxygen equipment will not help beneficiaries and will 
create undue hardship for them because they will lose services that 
they have valued for years. Moreover, they stated that current Medicare 
benefit guidelines, as well as guidelines issued by all major national 
insurance companies, State Medicaid programs and all home care industry 
accreditation organizations, have always classified oxygen equipment as 
``high maintenance equipment needing frequent maintenance service which 
is not recommended or advisable for patients to own.'' Other commenters 
predicted that hospital admissions will likely be increased as a result 
of the cap. These commenters argued that capping home oxygen services 
would direct patients toward the most expensive part of our health care 
system, which is hospitalization. Another commenter felt it was 
inappropriate to transfer title to this equipment to a patient because 
medical oxygen is a prescribed drug. The commenter believes that 
allowing beneficiaries to assume ownership is akin to giving them the 
source of a controlled substance.
    Response: The Congress mandated in section 1834(a)(5)(F)(ii)(I) of 
the Act (added by section 5101(b)(1) of the DRA) that on the first day 
that begins after the 36th continuous month during which payment is 
made for rented oxygen equipment, title to the oxygen equipment must 
transfer to the beneficiary. Section 1834(a)(5)(F)(ii)(II) provides 
that the Secretary must make reasonable and necessary maintenance and 
servicing payments for the equipment after the beneficiary assumes 
ownership of it and we are planning to do so, as detailed in the 
provisions of this final rule and in response to comments received 
regarding maintenance and servicing of beneficiary-owned equipment. 
Suppliers will be paid on a monthly basis for the delivery of oxygen 
contents in tanks and cylinders in accordance with the requirements of 
section 1834(a)(5)(F)(ii)(II) of the Act. As part of this ongoing 
service, we expect suppliers to deliver tanks and cylinders in proper 
working condition. As a result, we believe that beneficiary-owned 
equipment will be properly maintained and that beneficiaries will not 
suffer undue hardship as a result of the title transfer provisions. We 
also do not see how the title transfer provisions will affect how much 
oxygen beneficiaries use, since oxygen must be prescribed by a 
physician and delivered by a supplier in accordance with that 
prescription.
    Comment: Several commenters remarked that, as beneficiaries, they 
cannot afford to take care of their oxygen equipment once title to the 
equipment has transferred to them and request that we reconsider the 
rule. One commenter noted that his/her portable equipment must be 
replaced at least a couple of times a year due to malfunctions.
    Response: Although section 1834(a)(5)(F) of the Act requires 
beneficiary ownership of oxygen equipment after 36 continuous rental 
payments are made, this subparagraph also mandates that payment be made 
for reasonable and necessary maintenance and servicing of the 
beneficiary-owned equipment. The provisions of this final rule describe 
the changes we are making in the regulations to ensure that the 
beneficiary will continue to have access to equipment that will 
function for the entire reasonable useful lifetime established for the 
equipment. In accordance with existing regulations, if the equipment 
has been in continuous use for the equipment's useful lifetime, the 
beneficiary may elect to obtain new equipment. However, we note that a 
beneficiary would not be required to obtain new oxygen equipment as 
long as the equipment continued to function properly. In addition, as 
we discuss below, we are finalizing a provision under which a supplier 
may be required to replace the item at no charge to the beneficiary if 
the equipment does not function for the entire useful lifetime. In 
addition to meeting the annual Part B deductible, for assigned claims, 
the beneficiary is only responsible for paying 20 percent of the 
allowed charge for reasonable and necessary maintenance and servicing 
of beneficiary-owned equipment. We believe that these policies will 
help limit beneficiary costs once title to oxygen equipment has 
transferred.
    Comment: One commenter expressed concern about the 13-month rental 
period for capped rental DME and recommended that CMS reconsider the 
assignment of certain products to the capped rental category, 
particularly

[[Page 65914]]

those that sell for under $250.00 or rent for under $25.00 per month. 
The commenter argued that the expense of submitting and processing 
claims for 13 months exceeds any savings from short-term rentals.
    Response: The statute only allows for purchase of DME that is: 
inexpensive or routinely purchased (section 1834(a)(2)(A) of the Act); 
a power-driven wheelchair (section 1834(a)(7)(A)(iii) of the Act); or 
customized (section 1834(a)(4) of the Act). In accordance with the 
statute, inexpensive DME includes equipment having a purchase price of 
$150 or less and routinely purchased DME is equipment that is acquired 
at least 75 percent of the time by purchase. In accordance with section 
1834(a)(7) of the Act, capped rental DME is DME not described in any of 
the other payment categories in paragraphs (2) through (6) of section 
1834(a) of the Act. We do not have authority to redefine these 
categories because they are statutorily based.
Transfer of Title
    Comment: A commenter noted that the loss of title to the oxygen 
equipment will serve as a disincentive for suppliers to invest in 
advancing oxygen equipment technology. As a result, manufacturers will 
shift their research and development efforts away from the development 
of smaller, longer-lasting portable systems and instead, focus on the 
development of cheaper devices.
    Response: We are obligated to implement section 
1834(a)(5)(F)(ii)(I) of the Act, which requires that on the first day 
that begins after the 36th continuous month in which rental payments 
are made for oxygen equipment, the supplier transfer title to the 
equipment to the beneficiary. However, we disagree with the commenter 
that this rule will act to stymie advancements in oxygen equipment 
technology and are finalizing policies in this rule that we believe 
will properly incentivize suppliers to invest in new oxygen technology. 
In the case of portable oxygen equipment, the purpose of establishing 
an additional payment class for OGPE is to increase payments for the 
newer, more efficient, but more expensive OGPE technologies. In 
addition, as discussed below, we are clarifying in this final rule that 
beneficiaries may select newer technology items or upgraded items 
during the equipment rental period by agreeing to sign an Advanced 
Beneficiary Notification (ABN).
    Comment: Several commenters were concerned about the development of 
a secondary market for oxygen equipment resulting from individuals 
interested in selling their used equipment. They stated that the sale 
of these medical devices would not be monitored to ensure the condition 
of the device being sold, patient safety or clinical effectiveness. 
Several commenters requested that we work with the FDA to develop 
standardized guidelines that apply specifically to the public's resale 
of used medical devices.
    Response: We are aware that there may be safety issues associated 
with the resale of used oxygen equipment, and our regulations would not 
supersede any other Federal or State laws that govern these 
transactions. However, section 1834(a)(5)(F)(ii)(I) specifically 
mandates beneficiary ownership of both stationary and portable oxygen 
equipment after 36 months of continuous use. It has long been common 
practice for suppliers to pick up beneficiary-owned DME after medical 
necessity ends, in cases where the beneficiary or relatives of the 
beneficiary make such a request. In order to minimize the possibility 
that beneficiaries will incorrectly dispose of oxygen equipment that is 
no longer medically necessary, we will encourage suppliers to advise 
beneficiaries that they can pick-up and store the beneficiary's oxygen 
equipment if the beneficiary no longer needs it. Suppliers would be 
paid for picking up and storing oxygen tanks and cylinders that are no 
longer medically necessary (see below for a full discussion of this 
modification to our maintenance and servicing proposal). We will also 
note in the final regulations that in cases where suppliers have picked 
up beneficiary-owned oxygen equipment under these circumstances and the 
beneficiary's medical necessity for the equipment subsequently resumes, 
the supplier must return to the beneficiary similar equipment of equal 
or greater value to the beneficiary-owned equipment that was picked up, 
unless the beneficiary elects to obtain new equipment because the 
reasonable useful lifetime for the previous equipment has expired, or 
unless a different oxygen modality is prescribed and the beneficiary 
signs an advanced beneficiary notice (ABN) (see below for a full 
discussion of this policy modification).
    Comment: Several commenters urged that CMS and the Food and Drug 
Administration (FDA) discuss the ability of suppliers of oxygen 
contents for beneficiary-owned equipment to comply with 21 CFR 210 and 
211. Further, the commenters stated that CMS must outline the process 
for reimbursing suppliers for any in-home services they would need to 
perform in the event of an FDA recall after the beneficiary takes title 
to the device. Another commenter noted that once the beneficiary takes 
ownership, many devices will no longer be trackable for recall 
purposes. Several commenters recommended that CMS develop safety 
standards that can be applied to beneficiary owned equipment. Standards 
would help ensure that beneficiaries/caregivers comply with Department 
of Transportation (DOT), FDA and the Compressed Gas Association oxygen 
guidelines as well as ensure that they do not inappropriately handle or 
dispose of cylinders. One commenter observed that the proposed rule 
provided no clarification on how many cylinders Medicare expects to be 
transferred in ownership to the patient. There are several factors that 
can influence the number of cylinders a patient receives, such as 
oxygen liter flow, activity level of the patient, and distance from the 
patient's residence to the supplier's warehouse. Given these variables, 
the commenter noted that a patient could receive from 2-6 cylinders at 
the time of set-up. Additionally, beneficiaries may receive more 
cylinders temporarily to accommodate travels outside of the supplier's 
service area. One commenter questioned how CMS will address instances 
where beneficiaries require more or less portable cylinders post title 
transfer. Another commenter requested that Medicare not require 
suppliers to transfer title to oxygen tanks to beneficiaries since it 
would be burdensome and unmanageable for suppliers to keep track of 
virtually identical tanks. Under the current regulatory framework for 
oxygen as a medical gas, one commenter noted that suppliers are not 
permitted to label oxygen containers with the beneficiary's name which 
makes it difficult to develop tracking systems to ensure that each 
patient's cylinders can be identified. One commenter estimated that 
beneficiaries use anywhere from 2 to 10 or more tanks of oxygen per 
week. Another commenter recommended that we not require transfer of 
title for both sets of cylinder vessels, but rather only those that are 
in use in the home and not the ones that the supplier refills in its 
business location. One commenter recommended that we retain the 
current, efficient approach where the supplier owns all the cylinders 
because this allows the supplier to use different cylinders with the 
same patient. Several commenters noted that our proposal to transfer 
title to both the oxygen cylinder that is being filled and the one in 
the beneficiary's home is unworkable given

[[Page 65915]]

its impact on supplier's operations and the regulatory framework for 
oxygen as a medical gas. The FDA guidance defines the custody, control 
and management of filling liquid container to be in compliance when the 
filling company owns the liquid containers. When the patient owns the 
liquid containers after 36 months, the company would no longer be able 
to fill the container without extensive testing prior to filling 
because the containers would be considered by FDA to be out of the 
filler's control. In addition, the filling company would no longer be 
assured that the container was maintained in accordance with the 
manufacturer's specification. The DOT requires that the filling company 
have access to service and maintenance records in order to determine 
which inspections and tests to perform and at what frequency. If this 
information is not available to the filler, then the FDA mandates 
additional testing which requires more sophisticated testing equipment 
than the typical supplier of home medical oxygen has available. 
Similarly, in accordance with DOT regulations, a cylinder filled with a 
hazardous material may not be offered for transportation unless it was 
filled by the owner of the cylinder or with the owner's consent. This 
requires that the manufacturer of the medical oxygen, that is, the 
company that fills the oxygen container under FDA regulations, to have 
the equipment owner's permission prior to refilling the container. 
After the patient owns the oxygen equipment, compliance with this 
regulation will be very difficult for the supplier, especially if the 
transfilling is done by a third-party. The new supplier has no 
knowledge of how the compressed gas cylinders have been stored and 
maintained and how or when federally-mandated hydrostatic testing has 
been performed. The commenter predicted that it is likely that the new 
supplier will decline to service the cylinders for fear of employee 
injury and subsequent liability. Several commenters urged us to confer 
with the FDA about the application of FDA regulations to patient owned 
cylinders.
    Response: We are aware that oxygen tanks and cylinders must be 
handled in accordance with Federal statutes and regulations and expect 
that suppliers' equipment will meet the requirements set forth in these 
statutes and regulations before they transfer title to the equipment to 
the beneficiaries. Once title transfers, the supplier will still be 
required to deliver refilled oxygen contents in tanks and cylinders. We 
are also aware that beneficiaries might not know about other Federal 
laws that govern the disposal and resale of oxygen equipment. Although 
CMS doesn't administer or enforce these laws, we believe it is 
appropriate to take steps to ensure that beneficiaries are made aware 
of them. Therefore, we are adding a provision to the final rule that 
would require suppliers to educate beneficiaries at the time of title 
transfer about safety issues associated with disposing of oxygen 
equipment that is no longer medically necessary, and to advise 
beneficiaries that they must comply with any applicable Federal, State, 
and local laws that govern the disposal or resale of oxygen equipment. 
In addition, as we stated above, we would encourage suppliers to advise 
beneficiaries that they can pick-up and store the tanks once they are 
no longer medically necessary, and Medicare would pay for this service 
(discussed below). Further, suppliers could offer to buy the tanks back 
from the beneficiary.
    In the proposed rule, we proposed that the title to two sets of 
cylinders or tanks would be transferred to the beneficiary after 36 
months of continuous rental. That is, title would transfer for one set 
of cylinders or tanks that the beneficiary would use at home, and title 
would transfer for a second set that would be refilled at the 
supplier's location. The number of tanks or cylinders is dependent on 
how many tanks or cylinders a beneficiary uses and how many tank or 
cylinder deliveries a supplier makes during a given month. After 
considering the comments, we have concluded that it is unrealistic and 
inappropriate to require suppliers to comply with a policy where 
beneficiaries own specific tanks that must be refilled by suppliers for 
specific beneficiaries. Therefore, we are changing this policy in this 
final rule. Even though the beneficiary owns the equipment, the 
supplier may switch out the tanks or cylinders with their tank and 
cylinder supply, similar to how propane tanks are refilled in the 
market today. Just as owners of propane tanks receive different tanks 
each time they need replacement contents, we are clarifying in this 
final rule that this propane tank model will be the practice under 
Medicare with delivery and refilling of oxygen contents for 
beneficiary-owned oxygen tanks and cylinders. Because this policy 
modification will enable suppliers to continue swapping tanks and 
cylinders for beneficiaries, as they currently do, we believe that 
suppliers should also be able to handle recall situations as they 
currently do. In the case of other beneficiary-owned oxygen equipment 
such as concentrators, we expect suppliers to handle recalls in the 
same way manner that they currently handle recalls of other 
beneficiary-owned DME, such as power-driven wheelchairs. The decision 
regarding whether such services would be considered reasonable and 
necessary maintenance and servicing would be made by the Medicare 
contractor. For example, if suppliers currently bill and are paid by 
Medicare contractors for labor and parts when performing in-home 
services needed in the event of an FDA recall after the beneficiary 
takes title to a DME device such as a power wheelchair, then they 
should continue this practice. If the supplier has never furnished DME 
paid on a purchase basis by Medicare or capped rental items, they 
should consult with the Medicare contractor to determine if these 
services would be considered reasonable and necessary maintenance and 
servicing.
    Comment: One commenter stated that the OIG study on oxygen entitled 
``Medicare Home Oxygen Equipment: Cost and Servicing,'' is flawed and 
presents an inaccurate representation of Medicare ``equipment and 
servicing.''
    Response: The commenter provides no factual information to support 
their claim that the findings of this study are flawed. Although none 
of the policies of this final rule are based solely on the findings in 
this report, we do believe that the information in the report is 
credible and provides useful information regarding the maintenance and 
servicing of and costs of oxygen concentrators as reported by 
suppliers. Since we did not author the OIG study on oxygen, any 
concerns or comments about the contents of this report should be 
addressed to the Department of Health and Human Services, Office of the 
Inspector General.
    Comment: A commenter requested access to the Medicare Common 
Working File (CWF), the system that houses beneficiary specific 
information regarding Medicare eligibility and past claims history, in 
order to obtain beneficiary specific information such as whether the 
beneficiary has received the ``same or similar'' equipment from another 
supplier in the past. The commenter stated that suppliers must also be 
able to access historical usage data so that they may understand 
whether they will be paid for the equipment and services they are being 
asked to provide within 2 to 4 hours of the typical referral. Another 
commenter suggested that if access to information in the CWF was not 
possible, CMS must establish criteria for using ABNs to notify the 
beneficiaries of their financial

[[Page 65916]]

responsibility if there is ``same or similar'' medical equipment.
    Response: The request for access to the CWF is outside the scope of 
this rulemaking process. We note that general criteria for use of the 
ABN can be found in Chapter 30 of the Medicare Claims Processing 
Manual, located at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
    Comment: Several commenters questioned whether Medicare would 
require suppliers to transfer title to capped rental items and oxygen 
equipment to beneficiaries who have not paid their coinsurance or 
deductibles under Part B. One commenter recommended that we provide an 
exception to the title transfer requirement if a beneficiary has failed 
to pay his or her coinsurance for a significant period (such as more 
than 6 months) across the course of the 36-month rental period. The 
commenter also suggested that we could take responsibility, once the 
title transfers, for attempting to collect the amount of missed 
coinsurance payments from the beneficiary or pay the supplier's bad 
debt for unpaid deductibles and coinsurance. Several commenters urged 
that we clarify this provision in the final rule and recommended that 
title to the equipment should not transfer to the patient until payment 
is made in full for all services rendered through the 36th month. 
(Medicare typically pays the 36th month's rate approximately 30 days 
later).
    Response: Section 5101 of the DRA is clear that the title to 
equipment transfers from the supplier to the beneficiary on the first 
day that begins after the 13th continuous month in which payment is 
made for capped rental items and on the first day that begins after the 
36th continuous month in which payment is made for oxygen equipment. 
The statute mandates that ownership transfer after the 13th and 36th 
continuous month for capped rental items and oxygen equipment, and does 
not make transfer of ownership contingent on payment of beneficiary 
coinsurance. We believe that suppliers have a sufficient period of time 
to collect any outstanding beneficiary coinsurance during the rental 
period before title is required to be transferred. In addition, our 
rules would not preclude a supplier from seeking unpaid coinsurance or 
deductible amounts from a beneficiary after title has transferred. CMS 
or the carrier will have the discretion to review cases that allow 
suppliers to stop furnishing an item to a beneficiary, if warranted.
    Comment: Some commenters are concerned that the proposed rule does 
not provide sufficient clarity and specificity for stakeholders and 
Medicare beneficiaries alike to fully recognize the impact the final 
rule will have on beneficiaries when it becomes effective. The 
commenters predicted that the complexity of oxygen equipment, as well 
as the fact that each different type of equipment carries with it 
different safety and routine maintenance requirements, will be 
overwhelming for the average Medicare beneficiary.
    Response: We recognize that equipment maintenance may be 
overwhelming for some beneficiaries and, as we explain in more detail 
below, we are revising the final rule to allow for payment every six 
months for general maintenance and servicing of certain beneficiary-
owned oxygen equipment. These payments would be made in addition to 
payment for any reasonable and necessary replacement parts and repairs 
that are non-routine and not covered by the manufacturer's warranty. We 
intend to monitor the implementation of these provisions to ensure 
beneficiary safety.
Back Up Equipment
    Comment: Some suppliers furnish backup oxygen equipment for use by 
beneficiaries in the event of power failures or malfunction of primary 
oxygen equipment. Several commenters requested that the final rule 
state that since Medicare has not made any rental payments for backup 
oxygen equipment, title to this equipment should not transfer to the 
beneficiary. The commenters believe that title to backup equipment does 
not transfer under the coverage rules established under Medicare 
contractor local coverage determinations (LCDs) for oxygen equipment.
    Response: We agree with the commenters that the title for backup 
oxygen equipment would not transfer to the beneficiary after 36 months 
because Medicare does not make rental payments for this equipment. In 
addition, the LCDs referred to by the commenters correctly reflect 
Medicare's policy that equipment is not medically necessary if it is 
identical or similar to equipment already in use by the beneficiary and 
is used to meet the same set of medical needs. That is, backup 
equipment is a second piece of equipment used for precautionary reasons 
to deal with an emergency in case the primary piece of equipment 
malfunctions rather than to meet a different set of medical needs. 
Therefore, the beneficiary-ownership provision would not apply to 
backup oxygen equipment.
Payment for Oxygen, Oxygen Equipment and Capped Rental DME
    Comment: Several commenters requested that a new rental period 
begin whenever a change in supplier takes place, regardless of the 
reason. One commenter indicated that now that payments for oxygen 
equipment will be limited to 36 months of continuous use, the 
administrative burden on suppliers, such as ascertaining how many 
Medicare rental payments have already been made for specific items used 
by specific beneficiaries, will increase. The new suppliers will need 
additional resources to complete a thorough screening of all new 
patients to determine the amount of Medicare payments that may be made 
for specific items.
    Response: Longstanding policy found in Sec.  414.230(g) regarding a 
change in suppliers during a period of continuous use of rented DME 
indicates that a change in supplier will not result in a new rental 
episode. In accordance with the amendments made by section 5101 of the 
DRA to section 1834(a)(7)(A) of the Act, and section 1834(a)(5) of the 
Act, payment may not extend over a period of continuous use of longer 
than 13 or 36 months, respectively, for capped rental items and oxygen 
equipment. For the reasons indicated below, we are applying the policy 
in Sec.  414.230(g) to all beneficiary-owned capped rental items and 
oxygen equipment.
    Comment: One commenter requested that we acknowledge those 
situations in which the title is not held by a supplier that rents 
oxygen equipment or cylinders to beneficiaries. The commenter indicated 
that it is common practice for a supplier to rent equipment from a 
manufacturer and never hold title to the equipment, but stated that the 
36-month rental cap for oxygen equipment fails to address this common 
problem.
    Response: We understand that in some instances, suppliers furnish 
oxygen equipment to beneficiaries that they themselves have rented from 
manufacturers or leasing companies. However, under section 
1834(a)(5)(F)(ii)(I) of the Act (added by section 5101(b)(1)(B) of the 
DRA), suppliers are required to transfer title of oxygen equipment to 
beneficiaries on the first day that begins after the 36th month during 
which payment is made for the equipment. In addition, under section 
1834(a)(7)(A)(ii) of the Act (added by section 5101(a)(1) of the DRA), 
suppliers are required to transfer title of capped rental equipment to 
beneficiaries on the first day that begins

[[Page 65917]]

after the 13th month during which payment is made for the equipment. 
Therefore, regardless of what arrangements a supplier might make with a 
manufacturer or leasing company, the supplier must be in a position to 
transfer title to the equipment in accordance with these statutory 
provisions.
Payment for Maintenance and Servicing
    Comment: One commenter requested that during the period of 
continuous use, suppliers be permitted to continue the current practice 
of replacing equipment in need of service or repair with equipment of 
the same type that is in good working order. The commenter further 
requested that the rule build in the added costs of administration and 
delivery if the original piece of equipment must be delivered to the 
patient.
    Response: We recognize that under current practice, suppliers 
sometimes choose to replace oxygen or capped rental equipment, rather 
than repair it, during the rental period, and as we discuss below, we 
have decided to allow this practice to continue. However, as discussed 
in detail in the proposed rule, we continue to be concerned that 
beneficiaries be protected from situations where equipment may be 
replaced with equipment of lesser value prior to the transfer of title 
to the equipment. Therefore, we would require that the replacement 
equipment must be in the same or better condition as the equipment 
being replaced. Delivery of the equipment is included in the monthly 
rental payment amount.
    Comment: Several commenters stated that the proposed rule does not 
address the service components that are currently provided to 
beneficiaries which may require trained and qualified personnel to 
administer. These services include: Verifying oxygen purity, oxygen 
dose verification, verification of alarm system functions, cleaning and 
replacement of filters, disposable oxygen accessories, 24-hour, 7-day 
per week on-call and emergency support, patient training, and clinical 
professional support. The proposed rule also does not address that some 
manufacturers require equipment maintenance, which requires disassembly 
of the device, to be performed every 5,000 hours and this must be 
performed at the supplier's facility. This additional equipment 
maintenance requires suppliers to incur the additional costs of picking 
up the equipment and providing loaner equipment. One commenter stated 
that regular maintenance takes place in the patient's home, on average, 
every 90 days. Another commenter provided a statistic from the June 
2006 Morrison Informatics Inc. study, which demonstrated that non-
equipment costs comprise 72 percent of suppliers' total costs. 
Commenters also noted that the new quality standards confirm that the 
non-equipment professional and administrative services cost categories 
reported in the Morrison study are legitimate costs that should be 
recognized in the Medicare payment for home oxygen. Further, the rule 
does not address reimbursement for licensed respiratory therapists who 
conduct in-home clinical patient assessments according to written or 
verbal physician orders for beneficiaries who own oxygen equipment. The 
commenters urged CMS to allow patients to continue receiving these 
assessments, but note that this activity will only be sustainable if 
CMS establishes a new HCPCS code and appropriate reimbursement rate. 
The commenter noted that suppliers cannot provide these assessments 
without fair reimbursement rates because it could constitute an illegal 
inducement and raise other fraud and abuse concerns. Commenters stated 
that we need to establish regular and ongoing payment after ownership 
transfers to support beneficiary access to necessary clinical, support, 
and other services.
    Response: Section 1834(a)(5)(F)(ii)(II) of the Act requires CMS to 
pay separately for any reasonable and necessary maintenance and 
servicing after the beneficiary assumes ownership of oxygen equipment, 
and section 1834(a)(7)(A)(iv) of the Act requires the same in the case 
of capped rental DME items. We proposed to use the standard in Sec.  
414.210(e) of our regulations to define the ``maintenance and 
servicing'' for which Medicare would make payment under section 5101 of 
the DRA. We also proposed to apply our existing policy of not covering 
certain routine or periodic servicing of purchased equipment, such as 
testing, cleaning, regulating, changing filters, and general 
inspection, that could be done by the beneficiary or caregiver, and 
referred to chapter 15, section 110.2B of the Medicare Benefit Policy 
Manual for further guidance on what types of routine maintenance would 
not be covered. After considering comments that raise concerns 
regarding a beneficiary's ability to properly maintain his or her 
oxygen equipment, as well as safety issues that could arise if the 
equipment is not properly maintained, we have decided to revise our 
policy in the final rule under which, beginning 6 months after title to 
oxygen equipment transfers to the beneficiary, the supplier may bill 
for general maintenance and servicing of certain beneficiary-owned 
oxygen equipment once every 6 months. We believe that allowing payment 
every 6 months is reasonable based on findings by the Department of 
Health and Human Services, Office of the Inspector General, in a 
September 2006 report entitled ``Medicare Home Oxygen Equipment: Cost 
and Servicing,'' that the current frequency of suppliers in checking 
concentrators (every four months, on average) exceeds the guidelines of 
the two major manufacturers that accounted for two-thirds of the 
concentrators rented by beneficiaries sampled for purposes of the 
report. In addition, according to guidelines from two major 
concentrator manufacturers, comprehensive preventative maintenance need 
only performed annually or after several thousand hours of use. Under 
this policy, suppliers could bill for general maintenance and servicing 
of all oxygen equipment except liquid or gaseous equipment (stationary 
and portable) because these types of systems consist primarily of tanks 
or cylinders, as well as replacement supplies and accessories (for 
example, masks and tubing) which we proposed to pay for separately, and 
we would expect that as a part of the tank and cylinder filling 
process, suppliers would check to ensure that the tanks and cylinders 
were functioning properly. However, we will make payment for the pick-
up and storage or disposal of tanks and cylinders that are no longer 
medically needed by the beneficiary. We are also specifying that the 
general maintenance and servicing payments for oxygen equipment other 
than liquid and gaseous equipment would not begin until at least 6 
months after the date that title to the equipment transfers because 
suppliers should only be transferring title to equipment that is in 
good working order and that has been routinely maintained. Payment for 
general maintenance and servicing would be limited to 30 minutes of 
labor, which we believe will adequately compensate suppliers based on 
findings by the OIG in the same September 2006 report that many routine 
maintenance activities performed by suppliers on concentrators could be 
performed in less than 5 minutes. Finally, as we explained above, these 
payments for general maintenance and servicing would be made in 
addition to payment for reasonable and necessary repairs of 
beneficiary-owned oxygen equipment. Suppliers would be able to bill for 
such

[[Page 65918]]

non-routine maintenance, to the extent that the parts and labor are not 
covered by the manufacturer's warranty, beginning immediately after the 
beneficiary assumes ownership of the equipment, and as we proposed, 
payment would be made for the parts in a lump sum amount based on the 
carrier's consideration of the cost for the item because this is 
consistent with how we currently pay for replacement parts for other 
beneficiary-owned DME. We would also make an additional labor payment 
if such non-routine maintenance is performed at the same time as 
general maintenance, as long as the non-routine repair takes longer 
than 30 minutes. In addition, we are finalizing our proposal to pay on 
a purchase basis for all supplies and accessories (e.g., tubing, masks, 
cannulas, etc.) necessary for the effective use of beneficiary-owned 
oxygen equipment.
    In addition, to further limit the possibility raised by commenters 
that beneficiaries will incorrectly dispose of tanks and cylinders, we 
are modifying our proposal to allow suppliers to submit a bill for 
picking up beneficiary-owned oxygen tanks and cylinders that are no 
longer medically necessary should a beneficiary request such a pick-up. 
The supplier could submit this bill any time after the beneficiary has 
acquired ownership to the tanks or cylinders. This pick-up allowance 
would not apply to other types of oxygen equipment, such as 
concentrators, because beneficiary storage of such equipment does not 
raise safety concerns.
    In-home clinical patient assessments by licensed respiratory 
therapists fall outside the scope of the Medicare Part B benefit for 
DME.
    Comment: Several commenters requested that Medicare develop 
standard protocols for routine maintenance of oxygen equipment and 
reimburse suppliers for providing this service. Several commenters 
requested that the non-routine maintenance include: inspection of 
internal components for dust, debris, wear; internal filter changes; 
oxygen purity testing that requires an oxygen analyzer device; coil 
cleaning and any maintenance that requires breaking internal seals. 
Several commenters requested that ``routine maintenance'' and ``non-
routine maintenance'' be clearly defined in the final rule, 
specifically for oxygen and capped rental DME. Several commenters 
proposed that routine maintenance be defined as follows: wiping down 
outside surfaces of oxygen devices, changing the external cabinet 
filter, changing oxygen tubing and cleaning and replacing oxygen 
humidifier bottles.
    Response: As we explained above, we are modifying our maintenance 
and servicing proposal for oxygen equipment to allow for general 
maintenance and servicing of oxygen equipment other than liquid or 
gaseous oxygen equipment. Medicare will pay for up to 30 minutes of 
labor spent performing general, routine maintenance during each of 
these maintenance calls. Medicare will also pay separately for any 
replacement parts that are necessary to properly service the equipment 
during these calls, and for labor associated with any non-routine 
maintenance required as part of the visit if it takes longer than the 
30 minutes we are already paying for under the general maintenance and 
servicing policy. However, to the extent that a supplier services 
beneficiary-owned oxygen equipment more often than every six months, or 
services beneficiary-owned capped rental items at any time, Medicare 
will only make payments for non-routine maintenance and servicing. In 
the proposed rule, we stated that examples of the types of maintenance 
and servicing that would be covered as non-routine maintenance of 
oxygen equipment and capped rental DME can be found in section 110.2.B 
of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). This 
policy has been in the manual for many years and we have never 
experienced any major problems associated with interpretation of these 
guidelines on what constitutes reasonable and necessary maintenance and 
servicing. We also believe that the examples provided in the manual 
represent good, general guidance that will enable beneficiaries and 
suppliers to discern what types of maintenance and servicing would be 
covered. We therefore do not believe that it is necessary to provide a 
listing of every service that constitutes routine and non-routine 
maintenance.
    Comment: Several commenters recommended that we develop a 
methodology to provide for emergency services for beneficiary-owned 
equipment. Commenters also requested that this emergency mechanism, 
including after-hours care, in-home assessments, patient education and 
adherence monitoring, take into account the value of the therapists' 
time, mileage reimbursement expense and related costs. One commenter 
noted that patients rely on the 24-hour, 7-day-a-week on-call service 
to answer major and minor questions related to their equipment. A large 
percentage of these calls result in an in-home visit after hours and on 
the weekend.
    Response: Payment will be made for any reasonable and necessary 
maintenance and servicing of beneficiary-owned DME, including emergency 
situations. In addition, consistent with current Medicare policies, 
payment for rental of loaner equipment would be made while repairs of 
beneficiary-owned equipment are provided. In-home clinical patient 
assessments by licensed respiratory therapists fall outside the scope 
of the Medicare Part B benefit for DME.
    Comment: One commenter predicts that a number of beneficiaries may 
hire a third party to perform routine maintenance tasks that the 
beneficiary would otherwise be responsible for performing once he or 
she takes title to oxygen equipment to ensure that there is no chance 
for error. As a result, these beneficiaries may likely pay more for 
home oxygen therapy than they are paying under the current provisions.
    Response: As we discussed above, we are allowing payment for 
general maintenance and servicing of beneficiary-owned oxygen equipment 
other than liquid or gaseous oxygen equipment. In addition, a liquid or 
gaseous system consists of only tanks or cylinders, which we would 
expect a supplier to maintain as part of the filling process, and 
supplies, which we will pay for separately. As a result, we expect that 
a beneficiary's maintenance costs will not be significantly higher 
under this rule than it was under the previous rules.
    Comment: One commenter recommended that we conduct a study in a 
clearly-defined marketplace to ascertain the level of hospitalizations, 
emergency room visits, physician office visits, or other Part A/B 
expenses incurred by beneficiaries as a result of their being unable to 
access a qualified supplier after they assume ownership of the medical 
equipment under the new rules.
    Response: We disagree that such a study is necessary. As described 
in detail above, we have provided for appropriate payments for 
maintenance, servicing, and repairs of beneficiary-owned equipment. 
Therefore, we believe that beneficiaries will have sufficient access to 
qualified suppliers after assuming ownership of equipment.
    Comment: A few commenters noted that the proposed rule does not 
provide any guidelines or timetable as to how often Medicare will pay 
to replace the disposable supplies associated with home oxygen therapy, 
such as cannulas, oxygen tubing, humidification bottles, adaptors, and 
filters. These components

[[Page 65919]]

require frequent replacement and are currently included in the monthly 
Medicare rental fee. As the proposed rule is currently drafted, 
suppliers would be required to provide replacements of necessary 
supplies for free and commenters believe that this will lead to a 
reduction in the number of suppliers that furnish oxygen.
    Response: Medicare has traditionally paid for supplies and 
accessories that are necessary to use in conjunction with the 
beneficiary-owned DME item. This policy can be found in section 110.3 
of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). We 
proposed to apply this policy to supplies and accessories used in 
conjunction with beneficiary-owned oxygen equipment and capped rental 
items and did not receive comments opposing this proposal. Therefore, 
we are finalizing our proposal to pay separately for these supplies and 
accessories as often as is reasonable and necessary.
    Comment: Several commenters are concerned that serious health 
problems could affect a Medicare beneficiary's ability to understand 
and take responsibility for routine maintenance and servicing of his or 
her oxygen equipment. Commenters noted that some beneficiaries are 
physically and mentally unable to perform the necessary routine 
maintenance on equipment, and it is simply unsafe to impose the 
responsibility for maintaining this equipment on beneficiaries. Another 
commenter noted that even the OIG's September 2006 Oxygen Report, 
entitled ``Medicare Home Oxygen Equipment: Cost and Servicing'' (OEI-
09-04-00420), reinforced the point that a certain percentage of 
patients will not be able to perform routine maintenance by stating 
that ``50 percent of the service visits conducted through the surveyed 
patients included what has been describes routine maintenance.'' Other 
commenters noted that transferring the burden of maintenance and repair 
of sophisticated oxygen technologies to the beneficiary and, therefore, 
the total management of their home oxygen therapy regimen, presents 
serious risk to patient safety and care. Commenters also indicated that 
oxygen and oxygen equipment are more technically complex than other 
types of DME and can cause serious injury if improperly maintained and 
serviced.
    Response: Although we believe that the one commenter misquoted the 
OIG report and took their data out of context, we agree with the 
commenters' general concerns regarding the ability of beneficiaries to 
properly maintain their oxygen equipment once they acquire title to it 
and are revising the rule to permit payments for general maintenance 
and servicing of certain beneficiary-owned equipment as explained 
above.
    Comment: Several commenters suggested that we establish HCPCS codes 
to adequately describe the parts and repair services that will be 
covered and reimbursed for beneficiary-owned oxygen equipment. Another 
commenter requested that we implement a national policy and fee 
schedule for repair parts and labor that is eligible for either a 
Consumer Price Index (CPI) or Medicare Economic Index (MEI) adjustment 
annually. The fee schedule should reflect the fully-loaded costs of 
providing repair, not just repair parts and labor. A standardized 
approach will address those instances where a supplier goes out of 
business and is unable to assist in maintaining equipment. Another 
commenter indicated that services that are currently included as part 
of the monthly bundled rate for oxygen and equipment would no longer be 
provided after the 36th month unless a HCPCS code and allowable is 
developed.
    Response: We have generally given the carrier discretion to 
determine rates for labor and parts with respect to the non-routine 
repair of beneficiary-owned equipment based on reasonable charges and 
believe that this methodology results in adequate reimbursement to 
suppliers. However, should these commenters wish to make specific 
requests or recommendations for addition of specific codes for 
replacement parts, we would encourage them to participate in the HCPCS 
editorial process, which is described online at: http://www.cms.hhs.gov/MedHCPCSGenInfo/.
    Comment: Several commenters request that we provide guidance on the 
type of documentation that CMS expects suppliers to obtain to support 
repair claims. They stated that DME MACs and CMS must have clear 
policies outlining when Medicare will pay for repairs and the 
documentation it will require to support those claims.
    Response: In accordance with the rules at Sec.  414.210(e), 
Medicare carriers have long had discretion to require any documentation 
from suppliers that is necessary to enable them to make determinations 
regarding whether maintenance and servicing of beneficiary-owned DME is 
reasonable and necessary. The carriers provide guidance to suppliers 
regarding the specific documentation that is needed for these purposes.
    Comment: Several commenters requested that ``labor'' be redefined 
to start when the technician leaves the facility and ends when he or 
she returns to the shop. The labor time charge should not be just for 
technician time in the home or shop. The commenters noted that the 
current parts and labor fees do not take into consideration any travel 
time or time to evaluate the equipment.
    Response: Medicare payment for labor is based on 15-minute 
increments for time when the technician is working on the equipment. 
Separate payment is not allowed for delivery and service charges for 
DME such as travel time to and from the beneficiary's home. Such 
payment is included in the payment for the item or service. This policy 
has been in place for many years and we have not encountered serious 
problems with access to repair of beneficiary-owned DME. However, this 
policy does allow for additional payment for extraordinary expenses in 
rare or unusual circumstances as specified in current program 
instructions. This policy can be found in section 60 of Chapter 20 of 
the Medicare Claims Processing Manual (Pub. 100-04). This payment 
determination for travel is at the discretion of the carrier.
Payment for Replacement of Equipment
    Comment: Many commenters expressed concern about our equipment 
replacement proposal. Numerous commenters believed that this provision 
places an unreasonable economic burden on suppliers. Commenters 
indicated that we should specify that, once ownership shifts to the 
patient, it becomes the patient's responsibility to maintain and repair 
the equipment. Some commenters believe that, given the 5-year useful 
life of the equipment, the circumstances that would require equipment 
to be replaced may be so far removed from the date that title 
transferred that there would be no plausible connection between the 
supplier's actions and a conclusion that the supplier delivered 
substandard equipment. Commenters noted that the proposed rule does not 
allow for the supplier to receive a new continuous rental period for 
replacement equipment which is not yet patient-owned, so it is 
inequitable to require a supplier to replace free of charge the 
patient-owned equipment that prematurely fails because the patient did 
not maintain it in accordance with the manufacturer's guidelines. This 
situation should be remedied by providing for a new continuous rental 
should the beneficiary's action during the ownership useful lifetime 
period result

[[Page 65920]]

in the premature failure of the equipment. Commenters also complained 
that routine maintenance often must be performed by the user and that 
the supplier has no means to ensure when or if this was done or done 
correctly. Several commenters indicated that manufacturer warranties 
for oxygen equipment are void if the title is transferred. Therefore, 
requiring that the supplier that furnished the oxygen equipment replace 
at no cost items that, under Medicare rules, did not last for the 
entire reasonable useful lifetime would subject suppliers to undue 
financial burden.
    Response: We expect that equipment furnished by the supplier will 
function for the entire period established under Medicare regulations 
and program instructions as the equipment's reasonable useful lifetime. 
If this is not the case, then the supplier has not furnished a quality 
item of durable medical equipment for which they have been paid. If 
suppliers have information or data that proves that specific types of 
DME do not routinely last for 5 years, they can furnish this 
information to CMS for consideration in possibly establishing a new 
reasonable useful lifetime for equipment.
    Comment: A commenter stated that suppliers are financially unable 
to furnish additional equipment in the event it needs to be replaced 
after the title is transferred. Another commenter noted that once the 
title is transferred, patients may find it difficult to locate an 
oxygen supplier that is willing or able to provide them with a loaner 
unit on short notice.
    Response: We expect that oxygen equipment and capped rental items 
furnished by the supplier will function for the entire period 
established under Medicare regulations and program instructions as the 
reasonable useful lifetime. As long as suppliers are furnishing items 
that meet this standard, they should not generally need to replace 
beneficiary-owned items and should not suffer the kind of financial 
hardship envisioned by the commenter. In addition, we believe that the 
modifications to our maintenance and servicing policy will limit the 
possibility that oxygen equipment will not be properly maintained after 
the beneficiary acquires title to it. Accordingly, we are finalizing 
our proposal to require that suppliers replace malfunctioning oxygen 
equipment that does not last for its reasonable useful lifetime, 
however, as explained more fully below, we are modifying it to allow 
carriers greater discretion in determining when a supplier must replace 
the item at no charge to the beneficiary or the Medicare program. We 
are also finalizing the same proposal with respect to capped rental 
DME. The replacement item must be equipment of equal or greater value 
to the equipment being replaced. We have never encountered major 
problems associated with beneficiaries obtaining servicing of 
equipment. Due to the current abundance of oxygen suppliers, we believe 
that this will also be the case with regard to servicing of 
beneficiary-owned oxygen equipment.
    Comment: A commenter noted that our current definition of ``useful 
life'' exceeds the warranty that manufacturers typically provide on 
most of the current oxygen technologies, and expressed concern that 
forcing a supplier to be financially responsible for a device beyond 
the manufacturer's warranty period would impose a significant financial 
burden on suppliers. The commenter stated that Medicare should modify 
its definition of ``useful life'' and develop technology or equipment-
specific definitions. Another commenter noted that it is unclear in the 
rule if we are basing ``lifetime'' on manufacturer warranty or some 
other basis. The commenter stated that basing our definition of 
``lifetime'' on the manufacturer warranty could be problematic since an 
equipment's ``lifetime'' varies widely by manufacturer and type of 
equipment.
    Response: Under Sec.  414.220(f) of our regulations, the reasonable 
useful lifetime of durable medical equipment is either the period 
established through program instructions or, in the absence of program 
instructions, the period determined by our carriers (at least five 
years). These periods are not based on manufacturer warranties. If 
suppliers have information or data that proves that specific types of 
durable medical equipment do not routinely last for five years, they 
can furnish this information to CMS for consideration in possibly 
establishing a new reasonable useful lifetime for equipment. In 
addition, consistent with how we currently measure the reasonable 
useful lifetime for capped rental items, we would measure the 
reasonable useful lifetime for oxygen equipment beginning on the date 
that the equipment is furnished to the beneficiary.
    Comment: Several commenters requested that we not adopt the 
proposal that a supplier be required to replace equipment once 
accumulated repair costs exceed 60 percent of the cost to replace the 
equipment. Although the commenters acknowledged that the 60 percent 
threshold was based on a similar replacement provision for artificial 
limbs, the commenters do not believe that the proposal is appropriate 
since unlike oxygen, artificial limbs do not require regular 
maintenance or additional supplies that must be regularly replaced in 
order to function properly. The commenters also noted that the proposed 
rule does not define ``replacement cost'' and how such cost would be 
calculated in determining the 60 percent threshold. According to the 
commenters, the proposal is not clear regarding whether the 
``replacement cost'' is the original cost to Medicare of the equipment 
being replaced, the Medicare fee schedule amount, or the fair market 
value of the item. Several commenters requested that we eliminate the 
60 percent analysis and reimburse at the cost of each incident of 
repair rather than the accumulation of repairs. Several commenters 
noted that given the 5-year useful lifetime of the equipment, the 
circumstances that would require equipment to be replaced may be so far 
removed from the date that title transferred that there would be no 
plausible connection between the supplier's actions and a conclusion 
that the supplier delivered substandard equipment. Several commenters 
requested that responsibility for the equipment shift to the patient 
once the title transfers because the supplier will not have any record 
of routine maintenance in years four and five, placing the supplier in 
the position of having to replace equipment that may not have been 
properly maintained. One commenter suggested that we could establish a 
supplier responsibility period of 30 days following transfer of title 
that would require replacement if the repair costs were 60 percent of 
the replacement cost. Some commenters indicated that we appear to be 
trying to balance appropriate coverage for needed non-warranty repairs 
with beneficiary protection from receiving poor quality equipment via 
the proposed rule that covers repairs until they accumulate to 60 
percent of the replacement cost. Some commenters indicated that some 
equipment, such as semi-electric hospital beds and power wheelchairs, 
have component parts that can be quite expensive to repair/replace and 
that these costs could easily exceed the 60 percent trigger but still 
be in the equipment's useful lifetime. Repairs of such equipment are 
often a function of active use, not poor quality of defective 
equipment.
    One commenter remarked that there are areas of the proposed rule 
that present legal concerns because Medicare does not have statutory 
authority to implement these requirements. The

[[Page 65921]]

commenter is unaware of any statutory requirement for the repair or 
replacement of patient-owned equipment or for the use of a 60 percent 
threshold. Moreover, CMS has not conducted any independent laboratory 
studies or manufacturer surveys of DME or oxygen equipment to determine 
if the 5-year ``average useful life'' is accurate or current before 
making it subject to such a provision.
    Response: We agree with the commenters that the proposed 60 percent 
threshold may not be pertinent in all cases and have revised the final 
rule to reflect a more general policy. Equipment furnished must 
function for the entire period established under Medicare regulations 
and program instructions as the reasonable useful lifetime. We are 
modifying our proposal to permit our contractors to use the 60 percent 
repair threshold at their discretion when making case-by-case 
determinations on whether a supplier must replace equipment that does 
not function during the reasonable useful lifetime. However, we 
continue to believe that the 60 percent threshold is a useful factor 
for our carriers to consider because it is probative of whether the 
beneficiary has been furnished with, and the Medicare program has paid 
for, a substandard item.
    The replacement item must be equipment of equal or greater value to 
the equipment being replaced. Under Sec.  414.210(f) of our 
regulations, the reasonable useful lifetime for DME is five years, 
unless we determine otherwise. For a capped rental DME item, Sec.  
414.229(b) of our regulations specifies that the monthly fee schedule 
amount for rental of the item equals ten percent of the purchase price 
for the item; therefore, the replacement cost of the item is equal to 
the rental fee schedule amount multiplied by ten. For oxygen equipment, 
there is no established purchase price for Medicare purposes, so the 
replacement cost of an item will be established by the carrier on an 
individual, case-by-case basis using information such as invoices to 
determine the replacement cost of the item. With respect to 
beneficiary-owned oxygen equipment, ``repair'' costs will not include 
the costs of labor associated with general maintenance and servicing of 
the equipment.
    Comment: One commenter requested that we provide information about 
how equipment failures due to beneficiary neglect or abuse will be 
determined. Another commenter questioned who is responsible for 
providing the replacement equipment in the event that there is more 
than one supplier involved, for example, if the beneficiary moves.
    Response: We are finalizing a policy that would allow CMS or the 
carrier to make determinations if replacement equipment is warranted. 
We will be monitoring the number of replacement equipment provided to a 
beneficiary. In the case that a beneficiary is abusing or neglecting 
the equipment, CMS or the carrier may determine that the supplier is 
not responsible for furnishing replacement equipment.
    Comment: One commenter suggested that in lieu of prohibiting the 
replacement of equipment during the period of continuous use, CMS can 
require that the beneficiary receive title to equipment that is of 
comparable quality to the equipment delivered at the beginning of the 
period of continuous use.
    Response: As we explained above, we have decided to modify our 
proposal and allow suppliers to furnish different equipment during the 
rental period as long as the equipment is of equal or greater value as 
the equipment being replaced.
    Comment: Several commenters questioned that under the proposed 
regulations, a new period of continuous use would begin only when 
beneficiary-owned equipment is lost, stolen or irreparably damaged. The 
commenter requested that a new period of continuous use begin when a 
supplier furnishes replacement equipment during the period of 
continuous use. Otherwise, suppliers replacing lost equipment will be 
forced to transfer title to two devices, but receive payment only for 
one. Alternatively, commenters suggested allowing the carriers to make 
the determination whether to initiate a new period of continuous use on 
a case-by-case basis. Two commenters stated that while they agree with 
the proposed provision that a new period of continuous use would begin 
when beneficiary-owned equipment is lost, stolen, or irreparably 
damaged, they questioned our decision to apply this exception only to 
beneficiary-owned equipment. The commenters noted that when equipment 
is lost, stolen, or irreparably damaged during the period of continuous 
use and a supplier furnishes replacement equipment, a new period of 
continuous use should begin; otherwise, the regulation would impose a 
patently unfair result when rented equipment is lost or damaged through 
no fault of the supplier. The commenters suggested if this is the case, 
CMS should allow carriers to make the determination whether to initiate 
a new period of continuous use on a case-by-case basis to ensure a more 
balanced application of the requirement to transfer equipment ownership 
to beneficiaries.
    Response: Current rules regarding replacement of capped rental 
items located at Sec.  414.229(g) allow for replacement of rented items 
if the carrier determines that the item is lost or irreparably damaged. 
In the proposed rule, we inadvertently deleted this text when we 
proposed to revise Sec.  414.229(g), although we never intended to 
change this longstanding policy, which reflects our belief that 
suppliers should be compensated for furnishing a new rental item if the 
item is needed as a result of circumstances beyond the supplier's 
control. Therefore, as part of this final rule, we will reincorporate 
this policy in our regulations but will move it to Sec.  414.210(f), 
the general section on replacement of equipment, so that the policy 
applies to all rented items. To be consistent with what we proposed in 
the context of beneficiary-owned items, we will also specify that this 
policy would also apply if an item is stolen.
    However, we continue to believe that a new period of continuous use 
should not automatically begin whenever the beneficiary changes 
equipment (that is, from equipment falling under one HCPCS code to 
different but similar equipment described by another HCPCS code). This 
is consistent with longstanding policy relating to payment for DME. 
This policy can be found in section 30.5.4 of Chapter 20 of the 
Medicare Claims Processing Manual (Pub. 100-04). In no case can a new 
rental period begin for a change in equipment from one product within a 
HCPCS code to another product within the same HCPCS code or from one 
oxygen modality within a payment class to another oxygen modality 
within a payment class. Items falling within the same HCPCS code and 
paid based on the same payment rules and fee schedule amounts are 
considered the same item or service for Medicare purposes. Likewise, 
oxygen modalities falling under the same payment class and paid based 
on the same payment rules and fee schedule amounts are considered the 
same item or service for Medicare purposes. Oxygen modality changes are 
generally done for the convenience of the beneficiary, and not because 
they are medically necessary. The Medicare NCD and contractor LCDs 
establish medical necessity criteria for oxygen and oxygen equipment, 
but do not establish separate medical necessity criteria for different 
types or modalities of stationary or portable oxygen equipment. We also 
note that beneficiaries who wish to exchange

[[Page 65922]]

equipment or oxygen modalities during the rental period for reasons 
other than medical necessity can be required to sign an ABN.
Periods of Continuous Use
    Comment: Several commenters requested that we clarify how a ``break 
in service'' applies to short-term or intermittent usage of home oxygen 
therapy. They stated that patients that fall within the Group II oxygen 
coverage guidelines may not be sufficiently hypoxemic to require 
ongoing oxygen therapy and their short-term use should not be included 
in the 36-month continuous rental period. They also stated that other 
``breaks in service'' that should not count towards the period include 
skilled nursing facility stays or acute care admissions any longer than 
a month. The commenters noted that current rules at Sec.  414.230(c) 
state that an interruption in the use of the equipment of not longer 
than 60 consecutive days plus the days remaining in the rental month in 
which use ceases is temporary, regardless of the reason for the 
interruption. Current Medicare program instructions indicate that a new 
rental period begins in cases where the interruption is greater than 60 
days plus the days remaining in the rental month in which use ceases if 
it is supported by new medical necessity documentation. The commenters 
believe that there is no basis for CMS to apply different break-in-
service rules to oxygen.
    One commenter stated that beneficiary enrollment/disenrollment in 
Medicare managed care plans further complicates our proposals on 
switching equipment and consistent assignment during the rental period. 
The commenter indicated that a single beneficiary may be in traditional 
Medicare, enroll in one HMO, disenroll and go back on transitional 
Medicare, then enroll in a different HMO all in one rental period. The 
commenter questioned how these scenarios can possibly be addressed in a 
reasonable manner under the proposed rule.
    Response: The rules for defining a period of continuous use for 
which we make payments for DME were first adopted in an October 9, 1991 
interim final rule with comment (56 FR 50821). In that rule, we stated 
that we believed certain language in the House Committee Report 
accompanying section 4062(b)(1) of the Omnibus Reconciliation Act of 
1987 (Pub. L. 100-203) (which authorized the implementation of the DME 
fee schedules) indicated that Congress did not intend for a period of 
continuous use to automatically terminate each time there was a break 
in service. Therefore, we stated that an interruption in the rental 
period of not longer than 60 days plus the days remaining in the rental 
month in which the use ceases would be considered a temporary 
suspension of the period of continuous use pending resumption of 
medical need. This precedent, which we finalized in a December 3, 1992 
final rule (57 FR 57109), has now become longstanding Medicare policy, 
has worked well throughout the years and has addressed all of the 
situations highlighted by the commenters (e.g., short term use of DME, 
breaks-in-service, etc.). Therefore, we believe that these rules should 
continue to apply. In accordance with Sec.  414.230(c) and current 
program instructions found in section 30.5.4 of Chapter 20 of the 
Medicare Claims Processing Manual (Pub. 100-04), if the interruption is 
less than 60 consecutive days plus the days remaining in the rental 
month in which use ceases, contractors will not begin a new rental 
period. Also, when an interruption continues beyond the end of the 
rental month in which the use ceases, contractors will not make payment 
for additional rental until use of the item resumes. Contractors will 
establish a new date of service when use resumes. Unpaid months of 
interruption do not count toward the 15-month limit. These policies 
will apply to beneficiary-owned oxygen equipment and capped rental DME. 
In addition, because Medicare makes payment for a rental item on the 
date of delivery of the item, and payment for each subsequent rental 
month on the same day, or ``anniversary date'' for that month, if the 
break in service is short, the supplier would still be paid for that 
rental month.
    Comment: Several commenters were concerned about the impact and 
interaction of the proposed DRA policy and payment changes and the 
competitive bidding provisions. One commenter noted that certain DRA 
provisions and planned competitive bidding provisions overlap and 
conflict. The commenters requested that we clarify the conflicts in 
both final rules. The commenter stated that, for example, a rule 
conflict exists when a contract supplier is forced to accept an oxygen 
patient with only 6 months rental left in the 36-month rental period. 
To address this conflict, the commenter suggested that we allow the 36-
month period to start over again whenever a patient switches suppliers 
if less than 36 months of continuous use have transpired.
    Response: We will address issues that pertain to the Medicare 
DMEPOS Competitive Bidding Program in the final rule for that program.
    Comment: Several commenters requested that we clarify which 
supplier's equipment transfers to the beneficiary if the beneficiary 
has two residences in different areas and uses a local supplier in each 
area. They stated that ``snow birds'' may face hurdles in maintaining 
access to equipment unless a new period of continuous use begins when 
they change suppliers. The commenters suggested that extended travel 
outside of the supplier's service area should not be counted toward the 
period of continuous use to the extent the supplier is not paid for 
furnishing the oxygen equipment during that period. Another commenter 
noted that the proposed rule does not address how suppliers that 
coordinate services for patients who travel after they have purchased 
the equipment will be reimbursed. Another commenter indicated that the 
proposed rule was unclear on the methodology for those who have two 
homes during different times of the year. The supplier in the new area 
will not have the full 36 months to collect reimbursement.
    Response: We expect that travel arrangements for beneficiaries with 
oxygen equipment would be handled by suppliers in the same manner that 
such instances are currently arranged for beneficiaries with capped 
rental items. Capped rental items have been paid under these 
circumstances and addressed through program instructions since 1989. 
The capped rental policies that apply when a beneficiary changes 
suppliers are listed in section 30.5.4 of chapter 20 of the Medicare 
Claims Processing Manual (Pub. 100-04) and indicate that if a 
beneficiary changes suppliers during or after the rental period, this 
does not result in new rental episode. The equipment furnished to the 
beneficiary at the time that transfer of title is required by the 
statute and this final rule is the equipment for which the beneficiary 
would receive title to.
Beneficiary Safeguards
    Comment: One commenter stated that we should add an additional 
safeguard to protect beneficiaries if their initial supplier decides to 
discontinue service once title of the oxygen equipment transfers to the 
beneficiary. The commenter recommended that we add a new paragraph in 
Sec.  414.226(g) requiring the supplier that furnishes the oxygen 
equipment throughout the rental period to notify the beneficiary no 
later than 3 months before the end of the rental period that the 
supplier will no longer continue to provide services once the transfer 
of title takes place. The commenter believes this will give the

[[Page 65923]]

beneficiary adequate notice and time to find another comparable 
supplier and will not leave a gap in their service once ownership takes 
place. The commenter noted that current DME Quality Standards establish 
certain ``consumer services,'' but they do not address this issue.
    Response: We agree with this comment but believe that 2 months is a 
more reasonable period of time in terms of how much advance notice 
should be given to beneficiaries in these situations. We have revised 
Sec.  414.226(g) to require the supplier to notify the beneficiary no 
later than 2 months before the end of the rental period if the supplier 
will no longer continue to maintain and service the equipment, and/or 
deliver oxygen contents, once the transfer of title takes place. 
Likewise, in order to be consistent with our policies, we are revising 
Sec.  414.229(g) to require the supplier of a capped rental item to 
disclose no later than two months before title transfers whether it 
will continue to maintain and service the item. Because we recognize 
that there may be isolated cases where a supplier cannot satisfy this 
requirement (such as if the supplier goes out of business), we (or our 
carriers) will also allow for exceptions on a case-by-case basis.
    Comment: One commenter stated that we should require suppliers to 
re-train beneficiaries (and/or their caregivers) on the services they 
will need to perform on oxygen equipment at the time the suppliers 
transfer ownership and to verify in writing that the beneficiary/
caregiver has actually performed the tasks for which they will be 
responsible to ensure that they are capable of doing so. The commenter 
recommended that we add an additional safeguard in Sec.  414.226(g) 
that would require the supplier at the time of transfer to re-train the 
beneficiary and/or caregiver with respect to information regarding 
preparation of formulas, features, routine use, troubleshooting, 
cleaning, maintenance, safety conditions, and infection control. The 
commenter stated that although these requirements are currently 
contained in the DME Quality Standards, their supplier is only required 
to verify that the beneficiary received the instructions and 
information at the time of setup, not that he or she understood them or 
could perform them. The commenter believes that re-training and 
verification in writing by the supplier that the beneficiary and/or 
caregiver can actually carry out the tasks could prevent serious 
injuries and life-threatening situations in the future.
    Response: We do not believe that it is necessary to revise Sec.  
414.226(g) as recommended. The DRA requires CMS to pay separately for 
any reasonable and necessary maintenance and servicing of capped rental 
or oxygen equipment after title transfers to the beneficiary. We 
proposed to continue our longstanding policy of paying for reasonable 
and necessary repairs and non-routine maintenance and servicing that a 
beneficiary cannot perform. In response to comments, we have also 
decided to add an exception in the final rule under which, beginning 6 
months after title to oxygen equipment transfers to the beneficiary, 
the supplier may bill for general maintenance and servicing of certain 
beneficiary-owned oxygen equipment once every 6 months. As for routine 
maintenance that may be necessary beyond what Medicare will pay for, we 
also note, as we did in the proposed rule, that by the time title 
transfers for oxygen equipment and capped rental items, beneficiaries 
and/or their caregivers should be very familiar with their equipment 
and the routine maintenance that is required to maintain it. In 
addition, we note that we would expect that at the time of title 
transfer, suppliers would provide beneficiaries with operating manuals 
describing their equipment and the servicing that must be done to 
maintain it. Beneficiaries could also access many of these manuals on 
manufacturer Web sites.
    Comment: One commenter was concerned that if the beneficiary 
safeguards are imposed at the same time as reduced reimbursement, the 
viability of many oxygen suppliers will be threatened, thus affecting 
patient access to oxygen equipment and contents.
    Response: We appreciate the comment. However, we believe that the 
provisions discussed in the proposed rule and in this final rule with 
respect to oxygen equipment, oxygen contents, and capped rental DME 
items are necessary to ensure that our beneficiaries receive the 
appropriate equipment and service both during the rental period and 
after they assume title to the item. In addition, the beneficiary 
safeguards that we are implementing with this final rule reflect what 
we believe to be fair business practices, are consistent with our 
DMEPOS Quality Standards, and should not impose undue burdens on the 
suppliers. We have clarified our proposals in a number of places after 
considering all of the comments received in order to reduce the burden 
on suppliers.
    Comment: One commenter recommended that in conjunction with this 
rule, we should impose safeguards (for instance, limits on the number 
of times a beneficiary can switch suppliers) that prevent beneficiaries 
from gaming the system.
    Response: We do not agree that having no limits on the number of 
times that a beneficiary can switch suppliers will encourage gaming 
because under this rule, changing suppliers does not result in a new 
period of continuous use. Although we cannot envision every conceivable 
gaming scenario, we believe that we have fully considered the needs of 
beneficiaries in adopting this rule and that the protections we are 
implementing will strongly discourage gaming by unscrupulous suppliers.
    Comment: One commenter agreed with our proposed beneficiary 
safeguards since suppliers should be furnishing items in good working 
order and are otherwise bound by regulations at Sec.  424.57(c)(15) to 
accept returns from beneficiaries of substandard items.
    Response: We appreciate the support of our proposed beneficiary 
safeguards. We believe that these changes in concert with the 
implementation of the DMEPOS quality standards will ensure that 
beneficiaries receive quality equipment and appropriate services 
throughout the rental period and after title transfer.
    Comment: We received numerous comments regarding our continuity of 
equipment proposal. Commenters stated that our attempt to ensure that 
suppliers do not substitute substandard equipment to patients just 
before the required transfer of title is too restrictive. Several 
commenters recommended that suppliers be allowed to exchange and/or 
change a beneficiary's equipment during the period of medical need, 
provided this exchange/change is documented. However, commenters were 
concerned that the proposed rule does not define a change in medical 
condition or provide enough detail to understand how and when patients 
will be entitled to switch oxygen modalities, or how it will be 
documented so that suppliers will be paid appropriately and promptly. 
Commenters also asked for additional clarity regarding our 
interpretation of ``modality'' and asked for specific circumstances 
when patients may be changed from one type of equipment to another. 
Commenters recommended that we allow suppliers to judiciously exchange 
or change a patient's equipment during the period of medical need 
provided that this exchange or change is sufficiently documented and 
that the supplier certifies that the new equipment is not a lesser-
quality device. Commenters also recommended that we instruct our DME

[[Page 65924]]

Program Safeguard Contractor (PSC) medical directors to incorporate 
specific medical necessity coverage and documentation requirements in 
the revised Oxygen and Oxygen Equipment LCD before the proposed January 
1, 2007 implementation date of this regulation. Specifically, the 
revised LCD should address: (a) Under what circumstances or diagnoses 
it is medically necessary to change from one oxygen modality or 
equipment type to another; (b) how suppliers will be reimbursed for 
changing equipment; and (c) specific documentation requirements for 
both the supplier and the physician to ensure that the contractors can 
make appropriate coverage determination.
    Commenters also raised concerns about the potential impact the 
continuity of equipment proposals could have on beneficiary access to 
new oxygen technology. They stated that there are fairly common 
circumstances where a supplier must exchange equipment in order to best 
serve the beneficiary. For example, if suppliers cannot exchange 
equipment, they may have to perform a complex repair in the patient's 
home. Suppliers should not be placed in a situation where they have to 
choose between not being able to provide service to the beneficiary at 
the time of need versus providing a higher level of equipment and 
taking a financial loss over the remaining rental period if they are 
unable to switch to the prescribed level of equipment. Commenters 
recommended that the proposed rule be modified to clarify that it is 
acceptable for a supplier to exchange equipment if (a) the exchange is 
for same or similar equipment; or (b) the exchange is to equipment that 
better matches a physician's order.
    Commenters also stated that it is unreasonable to mandate a 
supplier to continue to service a beneficiary if the beneficiary is 
non-compliant with the supplier's instruction on the safe and 
appropriate use of the medical equipment. They recommended that the 
oxygen supplier be responsible for transferring title for the total 
number of liquid oxygen vessels or oxygen cylinders that would be 
present in the patient's home at one time.
    Response: We appreciate the concerns presented by the commenters. 
Medicare pays for two classes of equipment, stationary and portable. 
For the stationary class, there are three modalities that Medicare pays 
the same ``modality neutral'' payment rate for: concentrator, liquid 
cylinders, and gaseous tanks. For the portable class, Medicare makes a 
modality neutral payment for all types of portable equipment. As we 
explained above, we are finalizing our proposal to add a new payment 
class for oxygen-generating portable equipment and separate classes for 
delivery of stationary and portable oxygen contents. As has always been 
the case, a physician may order a specific oxygen equipment modality 
based on the clinical needs of the patient; and the supplier is bound 
by that order. In addition, there is currently no Medicare national 
coverage determination (NCD) that establishes medical necessity 
criteria for different oxygen modalities. The carrier would still 
maintain the ability to determine that a change in equipment is 
warranted for reasons other than those described above. Instructions 
for the DME PSC contractors are not part of rulemaking, and will be 
handled under local carrier coverage policies.
    After considering all of the comments, we are finalizing a policy 
that would allow for four general exceptions to the rule that a 
supplier may not exchange equipment during the rental period. We 
believe that these exceptions are flexible enough to allow 
beneficiaries and suppliers to exchange equipment where appropriate, 
but limited enough to protect beneficiaries from a situation where 
their equipment could be replaced with less valuable equipment just 
prior to the date when they acquire ownership of it. In all cases, the 
replacement item must be equipment of equal or greater value to the 
equipment being replaced.
    (1) The supplier replaces an item with the same, or equivalent, 
make and model of equipment because the item initially furnished was 
lost, stolen, irreparably damaged, is being repaired, or no longer 
functions.
    (2) The physician orders different equipment for the beneficiary. 
If the need for different equipment is based on medical necessity, then 
the order must indicate why the equipment initially furnished is no 
longer medically necessary, and the supplier must retain this order in 
the beneficiary's medical record.
    (3) The beneficiary chooses to obtain a newer technology item or 
upgraded item and signs an ABN.
    (4) CMS or its carriers determine that a change in equipment is 
warranted.
    Comment: We received numerous comments regarding our proposal to 
require that a supplier that furnishes rented oxygen equipment or 
capped rental items to the beneficiary must continue to furnish that 
item throughout the whole rental period except in certain situations. 
These comments focused on varying scenarios where patients move or 
choose to switch suppliers due to dissatisfaction with their service. 
Commenters were concerned that patients in these situations will 
experience an access-to-care issue as few suppliers will accept such a 
patient if he/she has only a few months left on the rental schedule but 
would be expected to provide oxygen equipment, including the back-up 
and other un-reimbursed equipment. This will create inequities as a 
supplier might be required to provide a brand new piece of equipment to 
a beneficiary for 10 months of the 36 months, as an example, and this 
de facto diminished reimbursement could deter suppliers from offering 
services to Medicare beneficiaries and diminish beneficiary access to 
oxygen supplies. Commenters recommended that we specify that a new 36-
month period begins in conjunction with this provision.
    Response: In an October 9, 1991 interim final rule with comment 
period (56 FR 50821), we first adopted our policy that precludes a new 
period of continuous use from beginning when a beneficiary changes 
suppliers. In adopting that policy, we looked to the House Committee 
Report that accompanied the enactment of the Omnibus Budget 
Reconciliation Act of 1987 (Pub. L. 100-203), which authorized 
implementation of the fee schedules for DME. The House report stated 
that a change in suppliers during an otherwise uninterrupted period 
should be considered continuous. Therefore, we adopted Sec.  
414.230(g), which provides that if the beneficiary changes suppliers 
during or after the equipment rental period, that change would not 
result in a new rental period. Since we first adopted this policy, we 
believe that suppliers have been able to adequately accommodate 
beneficiaries who change suppliers, and we see no reason to change this 
policy now.
    After reviewing the comments on this issue, we have maintained our 
proposal requiring a supplier who furnishes rented oxygen equipment/
capped rental for the first month for which payment is made to continue 
to furnish that item throughout the 36/13-month period of continuous 
use for as long as it is medically necessary, except in the following 
cases:
     The item becomes subject to a competitive acquisition 
program;
     A beneficiary relocates on either a temporary or permanent 
basis to an area that is outside the normal service area of the initial 
supplier;
     The beneficiary chooses to obtain equipment from a 
different supplier; or
     Other cases in which CMS or the carrier determine that an 
exception is warranted.


[[Page 65925]]


We continue to believe that these policies are necessary to ensure that 
beneficiaries have adequate access to oxygen equipment and capped 
rental items because they protect beneficiaries from a situation in 
which an unscrupulous supplier could try to take back the equipment 
just before the rental period expires in order to retain title to it. 
We note, however, that our rules would not require a supplier to accept 
a beneficiary as a customer simply because a beneficiary chooses to 
change suppliers. In addition, we note that we are considering certain 
policies that would address how contract suppliers are reimbursed if 
they must begin furnishing items to beneficiaries midway through the 
rental period under a competitive bidding program, and we expect to 
fully address this issue in the final rule that implements the Medicare 
DMEPOS Competitive Bidding Program.

    Comment: One commenter noted that our literal interpretation of the 
DRA would require suppliers to track equipment by serial number in 
order to make sure the beneficiary receives title to the equipment that 
the supplier furnished originally. The commenter stated that this will 
be very difficult for suppliers to accomplish and suggested that during 
the period of continuous use, suppliers be permitted to continue the 
current practice of simply replacing equipment in need of service or 
repair with equipment of the same type that is in good working order. 
This practice will allow suppliers to streamline their operations and 
serve beneficiaries more efficiently equipment that must be repaired or 
serviced at the supplier's facility. The commenter further stated that 
we can address this issue simply by requiring that the beneficiary 
receive title to equipment that is of comparable quality to the 
equipment delivered at the beginning of the period of continuous use. 
Another commenter stated that we should not impede service delivery by 
restricting replacement of equipment during the capped rental period. 
The commenter indicated the equipment requirement would limit the 
ability of the new patient to try new or different equipment/enhanced 
technology.
    Response: Suppliers have access to and frequently use current 
inventory tracking technology that allows them to easily track specific 
items they take from their inventory and furnish to a patient in their 
home. This is a normal part of the supplier's business. As explained 
above, suppliers of oxygen tanks and cylinders do not need to track 
specific tanks and cylinders belonging to beneficiaries. In addition, 
as explained above, this final rule allows the suppler to replace 
equipment during the rental period in certain situations.
    Comment: One commenter remarked that the proposed rule states that 
the current supplier or beneficiary is responsible for finding a new 
supplier if a beneficiary needs to relocate from one service area to 
another service area during the rental period. The commenter indicated 
that this should be limited to the beneficiary since it is the choice 
of the beneficiary to relocate and not that of the supplier.
    Response: While the proposal states that the supplier or 
beneficiary would need to arrange for another supplier in the new area 
to furnish the item, it does not mandate that the supplier, rather than 
the beneficiary, must make these arrangements. In cases where the 
supplier elects not to provide this service to the beneficiary, the 
beneficiary or caregiver for the beneficiary would need to make these 
arrangements. This proposal is consistent with current practice and is 
being adopted as part of this final rule.
Assignment
    Comment: We received numerous comments on the Medicare assignment 
proposal. Some commenters requested clarification of our notice 
requirements about Medicare assignment to ensure it is consistent with 
the general rule that participating suppliers agree to accept 
assignment on an annual basis and can modify their status as a 
participating supplier as well. They also requested clarification that 
suppliers disclose to beneficiaries their intent to accept assignment 
on all claims for the duration of the rental period, and stated that 
the supplier should be able to clarify under what circumstances 
assignment would no longer be appropriate, such as if the beneficiary 
is no longer eligible for coverage. Some commenters noted that we do 
not have the authority to change Medicare assignment terms and should 
not require suppliers to disclose their intentions regarding assignment 
for the entire duration of the rental periods. Commenters indicated 
that current Medicare supplier standards require a supplier to inform 
patients of whether or not it will accept assignment for one month at a 
time (per claim) and that it is unreasonable for us to expect a 
supplier to commit to accepting assignment for the entire rental period 
when policies, payment levels or other things could change by the end 
of the first year. Some commenters requested that we not adopt our 
proposal to post assignment statistics for each supplier on our 
website, but that if we proceed with publication, we should coordinate 
this effort with suppliers to ensure correct information is distributed 
to the public. Some commenters observed that we do not indicate how 
often we will make web postings and how we will verify the accuracy of 
postings. This could result in an inaccurate picture of a supplier's 
assignment history since suppliers could choose not to accept 
assignment for a variety of reasons, which a basic percentage will not 
demonstrate. If we intend to post assignment information, commenters 
believe that we should give suppliers 30 days notice, as well as an 
opportunity to review information prior to posting and to correct 
erroneous information or identify the risks posed by erroneous 
information. Commenters indicated that we cannot require suppliers to 
enter into private contracts for the duration of the period of 
continuous use. Finally, commenters stated that we must clarify in the 
final regulation whether a supplier may accept assignment for a portion 
of the rental period, since allowing this type of assignment 
arrangement would still further the stated intent to create a 
reasonable rule for suppliers and ensure that beneficiaries have the 
information necessary to make informed choices.
    Response: Under Medicare, DME suppliers can accept assignment on a 
claim-by-claim basis. If a supplier accepts assignment, the supplier 
agrees to request direct payment from Medicare for the item, to accept 
80 percent of the Medicare allowed payment amount for the item from the 
carrier, and to charge the beneficiary not more than the remaining 20 
percent of the Medicare approved payment amount, plus any unmet 
deductible. If a supplier elects not to accept assignment, Medicare 
pays the beneficiary 80 percent of the Medicare allowed payment amount, 
after subtracting any unmet deductible, and there is no limit under 
Title XVIII of the Act on the amount the supplier can charge the 
beneficiary for rental of the DME item. The beneficiary, in these 
situations, is financially responsible for the difference between 80 
percent of the Medicare allowed payment amount and the amount the 
supplier charges for the rental of the DME item.
    Suppliers can also sign a participation agreement where they agree 
voluntarily, before a calendar year, to accept assignment for all 
Medicare items and services furnished to a beneficiary for the 
following calendar year. Current supplier participation agreements are 
renewable annually.
    In the proposed rule, we did not propose to change the current 
voluntary

[[Page 65926]]

participation agreement. Nor did we propose to change acceptance of 
assignment on a claim-by-claim basis for suppliers who do not sign 
participation agreements. However, we did point out that the calendar 
year participation agreements do not coincide with a beneficiary's full 
period of medical need in cases where such need extends for more than a 
calendar year or where such a period overlaps calendar years. While a 
supplier may renew its participation agreement annually, a beneficiary 
would not know, before choosing a supplier, the intentions of the 
supplier regarding acceptance of assignment of all claims during the 
13-month or 36-month rental period.
    We proposed to require suppliers to give beneficiaries advance 
notice of the possible extent of their financial liability during the 
period of medical need in which monthly rental payments are made for 
the equipment so that they can use this information to make an informed 
choice of supplier. We proposed that before furnishing the oxygen 
equipment or a capped rental item, the supplier must disclose to the 
beneficiary its intentions regarding whether it will accept assignment 
of all monthly rental claims for the equipment during the period of 
medical need, up to and including the 36th month of continuous use for 
oxygen equipment or the 13th rental month of continuous use for capped 
rental DME in which rental payments could potentially be made. We 
indicated that we believe it is reasonable for the supplier to disclose 
to each beneficiary its intentions regarding acceptance of assignment 
as this decision has a direct financial effect on the beneficiary.
    While we proposed to require an up-front declaration on assignment 
intentions, a supplier would not be bound by such declaration unless 
the supplier chooses to do so. For example, a supplier who routinely 
signs participation agreements and intends to accept assignment for all 
months during a beneficiary's period of medical need may choose to let 
such information be known to the beneficiary. Such supplier might want 
to use such information as a marketing advantage. A supplier's 
declaration could indicate that the supplier intends to accept 
assignment for a portion of the period of medical need. A beneficiary 
could use such information from such supplier and compare it with the 
declaration from another supplier who intends to accept assignment for 
the entire period of medical need and make a selection between such two 
suppliers.
    While we proposed that a supplier's intentions could be expressed 
in the form of a written agreement between the supplier and a 
beneficiary, we did not propose to require a binding written agreement. 
A supplier could select the form of the declaration. If a supplier 
chose to offer a written agreement, the nature of such agreement would 
be between the supplier and the beneficiary. We believe that the 
required declaration is consistent with and complements the voluntary 
participation agreement because they represent different things; the 
former is a beneficiary-specific declaration of intentions applicable 
to the beneficiary's period of medical need but is not binding, while 
the latter is a voluntary agreement that applies to claims for all 
beneficiaries served for a calendar year and is binding.
    Assignment applies with respect to covered-Medicare services. Thus, 
a supplier's declaration of assignment acceptance would only apply to 
covered-Medicare services.
    In the proposed rule, we indicated that in order to promote 
informed beneficiary choices, we plan to post information on a CMS and/
or CMS contractor Web site(s) indicating supplier specific information 
on oxygen equipment and capped rental items such as (1) the percentage 
of beneficiaries for whom each supplier accepted assignment during a 
prior period of time (for example, a quarter), and/or (2) the 
percentage of cases in which the supplier accepted assignment during 
the beneficiary's entire rental period. We do not agree with the 
commenters who asked that we not post information about assignment 
statistics for each supplier. We believe that such information is 
necessary to promote informed beneficiary choices of suppliers. It 
would not be possible to promote more informed beneficiary choices 
among suppliers if we did not publish such information. Publication of 
such information is consistent with the Agency's goal of promoting 
transparency. We expect that the supplier-specific assignment 
information that we post would be derived from Medicare paid claims 
data. We plan to give suppliers the opportunity to review information 
prior to posting the first time we post information. After a period of 
time, we believe that the assignment information for a supplier is 
likely to be relatively stable. Thus, rather than delaying the posting 
of information on an ongoing basis by providing an opportunity to 
review information prior to each posting, we would post the information 
and allow a supplier to contact us or the carrier if a supplier 
believes that erroneous information was posted. We have not decided how 
often we would post assignment statistics.
    Comment: One commenter asked for clarification on whether or not 
in-home clinical assessments will be part of patient care after they 
have received home oxygen therapy for 36 months. The commenter strongly 
encouraged us to allow patients to continue to receive these 
assessments according to physician orders. The commenter noted that 
this activity is sustainable only if we establish a new code and an 
appropriate reimbursement rate.
    Response: In-home clinical assessments are the responsibility of 
the physician, not the supplier and are therefore outside the scope of 
the DME benefit. It is the obligation of the physician to ensure that 
beneficiaries continue to be evaluated, as medically necessary.

IV. Provisions of the Final Regulations

    In this final rule, we generally adopt the provisions of the August 
3, 2006 proposed rule. We have, however, changed the methodology we 
will use to impute a wage index for rural areas. We will calculate a 
rural wage index by averaging the wage indexes from all CBSAs that we 
believe are contiguous to that rural area if that rural area lacks 
rural hospital wage data. In addition, we are revising the fixed-dollar 
loss ratio used in the calculation of the outlier payment to reflect 
the most recent available data.
    We are finalizing a policy regarding change of equipment during a 
rental period to allow for changes under four general scenarios: (1) 
The supplier replaces an item with the same, or equivalent, make and 
model of equipment because the item initially furnished was lost, 
stolen, irreparably damaged, is being repaired, or no longer functions; 
(2) the physician orders different equipment for the beneficiary. If 
the need for different equipment is based on medical necessity, then 
the order must indicate why the equipment initially furnished is no 
longer medically necessary and the supplier must retain this order in 
the beneficiary medical record; (3) the beneficiary chooses to obtain a 
newer technology item or upgraded item and signs an advanced 
beneficiary notice (ABN); or (4) CMS or the carrier determines that a 
change in equipment is warranted. The Medicare contractor can also 
determine that a change in equipment is warranted for additional 
reasons.
    We reincorporated a policy that we inadvertently deleted from 
section 414.229(g) of our current regulations in the proposed rule with 
regard to replacement of equipment to allow for

[[Page 65927]]

replacement of rented capped rental items in cases where the item is 
lost or irreparably damaged. We stated that we would be continuing that 
policy, applying it to all rented items, and also applying it to cases 
where an item has been stolen. We also stated that we would move that 
policy from Sec.  414.229(g) to Sec.  414.210(f) since it would now 
apply to all rented items.
    We have revised the policy that requires suppliers to replace 
beneficiary-owned equipment that they furnished that fails to function 
for the full period established as the reasonable useful lifetime for 
the equipment. The need for the replacement of the equipment will not 
automatically be mandated merely because the repair costs are greater 
than 60 percent of the cost to replace the item. Rather, the 
determination regarding the need for replacement will be made by the 
Medicare contractor on an individual case-by-case basis.
    We added a provision to require suppliers to provide information to 
beneficiaries at the time of title transfer for oxygen equipment on how 
to safely dispose of oxygen equipment that is no longer medically 
necessary and advise that beneficiaries must comply with all Federal, 
State, and local laws that apply to the disposal, transport, and resale 
of oxygen equipment.
    We have revised the policy for maintenance and servicing of 
beneficiary-owned oxygen equipment so that beginning 6 months after 
title to oxygen equipment transfers to the beneficiary, the supplier 
may bill for general maintenance and servicing of beneficiary-owned 
oxygen equipment once every 6 months. Payment for each of these general 
maintenance calls would be limited to 30 minutes of labor, plus the 
reasonable cost for any replacement parts. Under this policy, suppliers 
could bill for general maintenance and servicing of all oxygen 
equipment except liquid or gaseous oxygen equipment (stationary and 
portable). We are also specifying that these general maintenance and 
servicing payments would not begin until at least 6 months after the 
date that title to the equipment transfers. Finally, we will make these 
payments for general maintenance and servicing in addition to payment 
for any non-routine repairs needed for beneficiary-owned oxygen 
equipment. Suppliers would be able to bill for such non-routine 
maintenance beginning immediately after the beneficiary assumes 
ownership of the equipment.
    We have revised the provisions regarding transfer of title for 
oxygen tanks to clarify that, although Medicare payments for oxygen 
equipment are limited to 36 months and the statute requires transfer of 
ownership after 36 months, the arrangement between the supplier and 
beneficiary allows the supplier to replace the beneficiary-owned tanks 
with new or different tanks of equal or greater value when the supplier 
picks up empty tanks to be refilled with oxygen contents and delivers 
refilled tanks back to the beneficiary. We have also revised the 
provisions to allow for a servicing payment when suppliers pick up 
tanks that are no longer medically necessary. We have also made several 
clarifying changes to the regulation text.
    We have also added a provision that would require a supplier to 
disclose at least 2 months before the date that the beneficiary will 
assume ownership of oxygen equipment or a capped rental item whether 
the supplier can maintain and service the item after the title 
transfers and, in the case of oxygen equipment, whether the supplier 
can deliver oxygen contents. We or our carriers would have discretion 
to make exceptions to this requirement on a case-by-case basis.

V. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 30-day notice in the Federal Register and solicit public 
comment when a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    We are soliciting public comment on each of these issues for the 
following sections of this document that contain information collection 
requirements:

Section 414.2267 Oxygen and Oxygen Equipment

    This section requires the supplier to disclose to the beneficiary, 
prior to the furnishing of oxygen equipment, whether or not it will 
accept assignment of all monthly rental claims for the duration of the 
rental period.
    The burden associated with this requirement is the time and effort 
put forth by the supplier to educate the beneficiary and to disclose 
information regarding its intent to accept assignment. While this 
information collection is subject to the PRA, we believe this 
requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, 
the burden associated with this requirement is exempt from the PRA.
    This section requires a supplier to retain the physician's order 
submitted for a different type of equipment in the patient's medical 
record and to disclose to the beneficiary its intentions regarding 
whether it will accept assignment of all monthly rental claims for the 
duration of the rental period.
    The burden associated with this requirement is the time and effort 
put forth by the supplier to retain and disclose the required 
information. While this information collection is subject to the PRA, 
we believe this requirement meets the requirements of 5 CFR 
1320.3(b)(2), and as such, the burden associated with this requirement 
is exempt from the PRA.

Section 414.229 Other Durable Medical Equipment--Capped Rental Items

    This section requires a supplier to retain the physician's order 
submitted for a different type of equipment in the patient's medical 
record and to disclose to the beneficiary its intentions regarding 
whether it will accept assignment of all monthly rental claims for the 
duration of the rental period.
    The burden associated with this requirement is the time and effort 
put forth by the supplier to retain and disclose the required 
information. While this information collection is subject to the PRA, 
we believe this requirement meets the requirements of 5 CFR 
1320.3(b)(2), and as such, the burden associated with this requirement 
is exempt from the PRA.
    If you comment on these information collection and recordkeeping 
requirements, please mail copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic 
Operations and Regulatory Affairs, Division of Regulations Development, 
Attn: Melissa Musotto, [CMS-1304-F], Room C4-26-05, 7500 Security 
Boulevard, Baltimore, MD 21244-1850; and
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC

[[Page 65928]]

20503, Attn: Carolyn Lovett, CMS Desk Officer, CMS-1304-F, [email protected]. Fax (202) 395-6974.

VI. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (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.
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year). 
This final rule will be a major rule, as defined in Title 5, United 
States Code, section 804(2), because we estimate the impact to the 
Medicare program, and the annual effects to the overall economy, will 
be more than $100 million. The update set forth in this final rule will 
apply to Medicare payments under the HH PPS in CY 2007. Accordingly, 
the following analysis describes the impact in CY 2007 only. We 
estimate that there will be an additional $440 million in CY 2007 
expenditures attributable to the CY 2007 estimated home health market 
basket update of 3.3 percent. We estimate that the effect of the wage 
index update will bring CY 2007 expenditures to $410 million.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and small government 
agencies. Most hospitals and most other providers and suppliers are 
small entities, either by nonprofit status or by having revenues of $6 
million to $29 million in any 1 year. For purposes of the RFA, 
approximately 75 percent of HHAs are considered small businesses 
according to the Small Business Administration's size standards with 
total revenues of $11.5 million or less in any 1 year. Individuals and 
States are not included in the definition of a small entity. As stated 
above, this final rule will provide an update to all HHAs for CY 2007 
as required by statute. This final rule will have a significant 
positive effect upon small entities that are HHAs.
    Based on our analysis of 2003 claims data, we also estimate that 
approximately 90 percent of registered DME suppliers are considered 
small businesses according to the Small Business Administration's size 
standards. The size standard for NAICS code, 532291, Home Health 
Equipment Rental is $6 million. (see http://www.sba.gov/size/sizetable2002.html, read May 9, 2005.) This final rule will reduce 
payments for oxygen equipment and capped rental items and, therefore, 
will have a significant negative effect upon small entities that are 
DME suppliers overall. However, as explained in detail below, we 
believe that Medicare payments will still be adequate for the items 
affected by this rule and that suppliers whose primary line of business 
involves furnishing these items will remain profitable.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule 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 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a Metropolitan 
Statistical Area and has fewer than 100 beds. We have determined that 
this final rule will not have a significant economic impact on the 
operations of a substantial number of small rural hospitals.
    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 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 $120 million. We believe this final rule will 
not mandate expenditures in that amount.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
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 rule under the threshold criteria 
of Executive Order 13132, Federalism. We have determined that this 
final rule will not have substantial direct effects on the rights, 
roles, and responsibilities of States.

B. Anticipated Effects

1. Home Health PPS
    This final rule will update the HH PPS rates contained in Pub. 100-
20, One Time Notification, Transmittal 211, published February 10, 
2006. We updated the rates in the CY 2006 final rule (70 FR 68132, 
November 9, 2005) through Transmittal 211 to take account of the DRA 
changes, specifically the 0 percent update and the rural add-on. The 
impact analysis of this final rule presents the projected effects of 
the change from the CY 2006 transition wage index (50/50 blend of MSA-
based and CBSA-based designations) to the CY 2007 CBSA-based 
designations in determining the wage index used to calculate the HH PPS 
rates for CY 2007. We estimate the effects by estimating payments while 
holding all other payment variables constant. We use the best data 
available, but we do not attempt to predict behavioral responses to 
these changes, and we do not make adjustments for future changes in 
such variables as days or case-mix.
    This analysis incorporates the latest estimates of growth in 
service use and payments under the Medicare home health benefit, based 
on the latest available Medicare claims from 2004. 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 made by 
the Congress, or changes specifically related to HHAs. In addition, 
changes to the Medicare program may continue to be made as a result of 
the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000, the MMA, the DRA, or new 
statutory provisions. Although these changes may not be specific to the 
HH 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 HHAs.
    Our discussion for this final rule will focus on the impact of 
changes in the wage index, most notably the adoption of the full CBSA 
designations. The impacts of the updated wage data are shown in Table 
13 below. The breakdown of the various impacts displayed in the table 
follows.
    The rows display the estimated effect of the changes on different 
categories. The first row of figures represents the

[[Page 65929]]

estimated effects on all facilities. The next 2 rows show the effect on 
urban and rural facilities. This is followed, in the next 4 rows, by 
impacts on urban and rural facilities based on whether they are a 
hospital-based or freestanding facility. The next 20 rows show the 
effect on urban and rural facilities based on the census region in 
which they are located.
    The first column shows the breakdown of all HHAs by urban or rural 
status, hospital-based or freestanding status, and census division.
    The second column in the table shows the number of facilities in 
the impact database. A facility is considered urban if it is located in 
a CBSA and, conversely, rural if it is not located in a CBSA.
    The third column of the table shows the effect of the annual update 
to the wage index. This represents the effect of using the most recent 
wage data available to determine the estimated home health market 
basket update. The total impact of this change is -0.2 percent; 
however, there are distributional effects of the change.
    The fourth column of the table shows the effect of all the changes 
on the CY 2007 payments. The estimated market basket update of 3.3 
percentage points is constant for all providers and is included in this 
column. Although the market basket increase for CY 2007 is 3.3 percent, 
fluctuations in the wage index impact the projected payments as well. 
The total impact of the wage index update is -0.2 percent. Therefore, 
including effects of the wage index, we project that total aggregate 
payments will increase by 3.1 percent, assuming that facilities do not 
change their care delivery and billing practices in response.
    As can be seen from this table, the combined effects of all of the 
changes, including the updated wage index and the market basket 
increase of 3.3 percent, will vary by specific types of providers and 
by location. For example, HHAs in the rural Pacific show the largest 
estimated increase in payment at 11.0 percent, while HHAs in the rural 
Mountain census division show the smallest increase in payments at 0.5 
percent. Rural HHAs do somewhat better than urban HHAs, seeing an 
estimated increase in payments of 3.6 percent and 3.1 percent 
respectively. Amongst the different type of facility categories, 
freestanding rural HHAs do best, with an estimated increase in payments 
of 3.8 percent. Hospital-based urban HHAs are next with an estimated 
increase in payments of 3.4 percent, followed by hospital-based rural 
and freestanding urban HHAs following with estimated increases of 3.2 
percent and 3.0 percent respectively.

                           Table 13.--Projected Impact of CY 2007 Update to the HH PPS
----------------------------------------------------------------------------------------------------------------
                                                                                   Updated  wage  Total CY  2007
                                                                     Number of         data           change
                                                                    facilities       (percent)       (percent)
----------------------------------------------------------------------------------------------------------------
Total...........................................................           7,370            -0.2             3.1
Urban...........................................................           5,273            -0.2             3.1
Rural...........................................................           2,097             0.3             3.6
Hospital based urban............................................           1,988             0.1             3.4
Freestanding urban..............................................           3,285            -0.3             3.0
Hospital based rural............................................           1,201            -0.1             3.2
Freestanding rural..............................................             896             0.5             3.8
----------------------------------------------------------------------------------------------------------------
                                                 Urban by Region
----------------------------------------------------------------------------------------------------------------
New England.....................................................             254            -1.2             2.1
Middle Atlantic.................................................             423            -0.2             3.1
South Atlantic..................................................             913            -0.4             2.8
East North Central..............................................             886             0.4             3.7
East South Central..............................................             222            -0.6             2.7
West North Central..............................................             304             0.1             3.4
West South Central..............................................           1,300            -0.8             2.5
Mountain........................................................             281             1.6             4.9
Pacific.........................................................             649             0.4             3.7
Outlying........................................................              41            -4.2             1.0
----------------------------------------------------------------------------------------------------------------
                                                 Rural by Region
----------------------------------------------------------------------------------------------------------------
New England.....................................................              43            -1.1             2.2
Middle Atlantic.................................................              82             0.1             3.4
South Atlantic..................................................             239            -0.7             2.6
East North Central..............................................             284             1.6             5.0
East South Central..............................................             215             0.1             3.4
West North Central..............................................             488             0.2             3.5
West South Central..............................................             475            -0.4             2.8
Mountain........................................................             173            -2.7             0.5
Pacific.........................................................              88             7.5            11.0
Outlying........................................................              10             8.9            12.5
----------------------------------------------------------------------------------------------------------------

    The impact of the wage index for CY 2007 is shown in Addendum C to 
this document. Addendum C to this document shows a side-by-side 
comparison, by State and county code, of the CY 2006 transition wage 
index, which was a 50/50 blend of MSA-based and CBSA-based pre-floor, 
pre-reclassified hospital wage indexes, and pre-floor, pre-reclassified 
hospital wage index for the CY 2007 HH PPS update. In the last column 
of Addendum C to this document, we show the percentage change in the 
wage index from CY 2006 to the wage index for CY 2007. We estimate that 
there will be an additional $410 million in CY 2007 expenditures 
attributable to the CY 2007 estimated

[[Page 65930]]

market basket increase of 3.3 percent and the wage index update of -0.2 
percent. Thus, the anticipated expenditures outlined in this final rule 
will exceed the $100 million annual threshold for a major rule as 
defined in 5 U.S.C. section 804(2).
    This final rule will have a positive effect on providers of 
Medicare home health services by increasing their Medicare payment 
rates. We anticipate that very few HHAs will not submit the quality 
data required by section 1895(b)(3)(B)(v)(II) of the Act necessary to 
receive the full market basket percentage increase. Submission of OASIS 
data is a Medicare condition of participation for HHAs. Therefore, we 
expect that very few HHAs would be subject to the 2 percent reduction 
in payments in CY 2007. As indicated in the rule, most HHAs that do not 
report OASIS provide pediatric, non-Medicare, or personal care only. 
However, CMS is aware of instances of non-compliance among a very small 
portion of HHAs with regard to OASIS submission.
    For the purposes of the CY 2007 impact analysis, we anticipate that 
less than 1 percent of HHAs, involving less than 1 percent of total 
Medicare HH payments, would fail to submit quality data and hence will 
be subject to the 2 percent reduction. This is not enough to impact the 
estimated $410 million in additional expenditures. Finally, we do not 
believe there is a differential impact due to the aggregate nature of 
the update. We do not anticipate specific effects on other providers.
2. Oxygen and Oxygen Equipment Provisions
    As mandated by the DRA of 2005, this final rule limits to 36 months 
the total number of continuous months for which Medicare will pay for 
oxygen equipment, after which the title to the oxygen equipment will be 
transferred from the supplier to the beneficiary. Since Medicare 
currently pays for oxygen equipment on a monthly basis for as long as 
it is medically necessary, this change will result in savings to 
Medicare. In addition, the DRA mandates that Medicare continue to make 
monthly payments for furnishing contents for beneficiary-owned oxygen 
equipment, as well as payments for reasonable and necessary maintenance 
and servicing of beneficiary-owned oxygen equipment.
    Approximately one million beneficiaries now receive oxygen therapy. 
Although monthly rental payments already have been reduced by 30 
percent by section 4552 of the Balanced Budget Act of 1997 and 
approximately 10 percent by section 302(c)(2) of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003, Medicare 
allowed charges rose to $2.72 billion by 2005, a 68 percent increase 
since 1998 that reflects the growing use. Before the amendments to 
section 1834(a)(5) of the Act made by the DRA, Medicare continued to 
make rental payments for as long as medical necessity continued, even 
when the total payments greatly exceeded the cost of purchasing the 
equipment and the supplier retained title to the equipment. We believe 
the DRA amendments to the Act will result in a loss of revenue to 
suppliers that will no longer receive payments for oxygen equipment 
after the 36th month of continuous use.
    Based on data for items furnished in calendar year 2005, oxygen 
concentrators accounted for approximately 94 percent of Medicare 
utilization for stationary oxygen systems, in terms of both allowed 
charges and allowed services. Since oxygen concentrators can typically 
be purchased for $1,000 or less, we believe that 36 months of payment 
at approximately $200 per month will ensure the supplier is reimbursed 
for its cost for furnishing the equipment. The $200 allowed payment 
amount may be re-adjusted in the future to assure that payments are 
adequate, but not excessive. This could be accomplished though the 
competitive acquisition programs mandated by section 1847 of the Act or 
in accordance with our authority for adjusting fee schedule amounts at 
section 1842(b)(8) and (9) of the Act. Based on data gathered by the 
OIG in the course of developing their September 2006 report (OEI-09-04-
00420), approximately 22 percent of Medicare beneficiaries rented 
oxygen equipment for 36 months or longer and approximately 16 percent 
of Medicare beneficiaries rented oxygen equipment for 48 months or 
longer. In section IV, ``Provisions of the Final Regulation'' section 
of this preamble, we are allowing beneficiaries to obtain replacement 
oxygen equipment in cases where their equipment has been in continuous 
use for the reasonable useful lifetime of the equipment. Unless CMS or 
its carriers establish a specific reasonable useful lifetime for oxygen 
equipment, the default lifetime for DME of 5 years will apply. The main 
effect of this rule on suppliers is that they will not be able to 
receive payment for the equipment beyond 36 months for approximately 22 
percent of Medicare patients. They will also not be able to receive 
payment for furnishing the same item to subsequent patients in these 
cases since they lose title to the equipment. In the case of oxygen 
concentrator systems and portable oxygen transfilling systems, delivery 
of oxygen contents is not necessary, and therefore, payment will not be 
made for the furnishing of contents for these types of beneficiary 
owned equipment. Under the old payment rules, payment for oxygen 
concentrators used for stationary equipment purposes would have 
continued at approximately $200 per month for the entire period of 
medical need. Section 5101(b) of the DRA mandates that payment for 
oxygen equipment end and that title to the equipment transfer after 36 
months of continuous use.
    In the case of liquid and gaseous oxygen systems, suppliers will 
continue to be paid for furnishing oxygen contents for beneficiary-
owned systems. The current statewide monthly payment amounts for oxygen 
and oxygen equipment that would be paid during the 36-month period of 
continuous use for beneficiaries who only use stationary equipment 
range from $194.48 to $200.41, with the weighted average statewide fee 
being $199.84. The current statewide monthly payment amount for 
furnishing oxygen contents for beneficiary owned equipment range from 
$137.54 to $198.12, with the weighted average statewide fee being 
$154.90. The average decrease in Medicare fee schedule amounts that may 
result from the DRA changes for liquid and gaseous systems after the 
36-month period (that is, shift from monthly payments for equipment and 
contents to monthly payments for contents only), is expected to be 
$44.94 ($199.84-$154.90). Therefore, this is the level of monthly 
reimbursement that would be lost after the 36-month period for 
suppliers that furnish oxygen and oxygen equipment to beneficiaries in 
these situations and who continue to furnish contents to these 
beneficiaries. Based on current fee schedule amounts for all oxygen and 
oxygen equipment, this equates to an average reduction in payment (from 
$199.84 to $154.90) of approximately 22 percent.
    At the current monthly statewide fee schedule rates, which range 
from $194.48 to $200.41, suppliers of oxygen equipment are expected to 
be paid from $7,001.28 to $7,214.76 over 36 months. By comparison, a 
medical center operated by the Department of Veterans Affairs (VA) in 
Tampa, Florida, is the largest VA center in terms of number of veterans 
on oxygen therapy and services approximately 1,000 patients on oxygen 
by contracting with a locally based manufacturer to purchase the oxygen 
concentrators for $895 each. The medical center contracts with a local

[[Page 65931]]

supplier for $90 to deliver and set up the concentrator to the 
patient's home. This local supplier also provides service and 
maintenance of the equipment at any time throughout the year for $48 
per service episode. If the equipment needs to be replaced, the local 
supplier will furnish another concentrator for a $90 fee. The VA total 
payments over 5 years for an oxygen concentrator used by a veteran in 
this center plus payment for 10 episodes of maintenance and servicing, 
assuming servicing every 6 months, will be $1,435, compared to total 
Medicare allowed charges of $7,164, on average, for a Medicare 
beneficiary. Based on this comparison, the Medicare payment amounts and 
methodology appear to be more than adequate.
    We do not anticipate that transfer of ownership for oxygen 
equipment to the beneficiary after 36 months of continuous use will be 
a significant financial burden to suppliers because the effect is 
limited to a maximum of 36 percent of a supplier's Medicare business 
and because suppliers of oxygen equipment primarily furnish lower cost 
oxygen concentrators. We also do not anticipate a significant change in 
the rate of assignment of claims for oxygen equipment based on our 
belief that suppliers will be adequately reimbursed for furnishing the 
oxygen equipment.
    In accordance with the statute and this final rule, suppliers will 
also receive payments for reasonable and necessary maintenance and 
servicing of beneficiary-owned oxygen equipment, including a general 
maintenance and servicing payment for certain oxygen equipment every 6 
months, beginning 6 months after the date that the beneficiary assumes 
ownership of the equipment.
    Finally, the new oxygen and oxygen equipment classes and national 
payment amounts that are established as part of this final rule, will 
likely result in a shift in utilization between the various oxygen 
equipment modalities, which could impact supplier revenues and sales 
volume for certain oxygen equipment manufacturers. However, since the 
payment amounts will be budget-neutral in accordance with section 
1834(a)(9)(D)(ii) of the Act, there will not be a significant impact on 
overall Medicare payments to suppliers.
3. Capped Rental DME
    This final rule, which limits to 13 months the total number of 
continuous months for which Medicare would pay for capped rental DME, 
after which the ownership of the capped rental item would be 
transferred from the supplier to the beneficiary, will result in 
significant savings for the Medicare program. Savings will be realized 
through: (1) The gradual elimination of rental payments for the 14th 
and 15th months of continuous use; and (2) changing the semi-annual 
payment for maintenance and servicing to payment only when reasonable 
and necessary maintenance and servicing is needed. We anticipate that 
suppliers may lose money due to the loss of 1 to 2 months rental in 
cases where beneficiaries need the item for more than 13 months and 
would not have otherwise selected the purchase option currently 
described in Sec.  414.229(d). The average of the 2006 fee schedule 
amounts for all capped rental items for months 14 and 15 is 
approximately $152. We do not believe suppliers will suffer financially 
as a result of this provision based on data which show that in 2004, 97 
percent of suppliers accepted assignment for beneficiaries who chose 
the purchase option (Sec.  414.229(d)) in the 10th month of a capped 
rental period. This is an indication that suppliers were willing to 
accept the Medicare payment as payment in full for the capped rental 
item, even though they had been informed that the beneficiary will take 
over ownership of the item after the 13th month of continuous use. 
Therefore, we do not anticipate that transfer of ownership for capped 
rental equipment to the beneficiary after 13 months of continuous use 
will be a significant financial burden to suppliers.
    For items for which the first rental payment falls on or after 
January 1, 2006, Medicare will only pay for maintenance and servicing 
as necessary. In a June 2002 report (OEI-03-00-00410), the Office of 
Inspector General (OIG) indicated that only 9 percent of the capped 
rental equipment with a June 2000 service date actually received any 
servicing between June and December 2000. Out of the $7.3 million 
Medicare paid for maintenance services from June 2000, OIG estimated 
that $6.5 million was paid for equipment that received no actual 
servicing. The OIG recommended to CMS in 2002 that we eliminate the 
semi-annual maintenance payment currently allowed for capped rental 
equipment and pay only for repairs when needed.
    The combination of these two factors provides strong evidence that 
the Medicare rules for paying for maintenance and servicing of capped 
rental equipment furnished before January 1, 2006, were not cost-
effective.

Impact on Beneficiaries

    The DRA provisions and this final rule will result in savings for 
Medicare beneficiaries using oxygen equipment and capped rental items. 
For capped rental items, Medicare payments will be made for 13 
continuous months and for oxygen equipment, payments will be made for 
36 continuous months. After the rental period for each category of 
equipment expires, ownership of the equipment will transfer from the 
suppliers to the beneficiaries. Beneficiaries will continue to be 
financially responsible for a 20 percent coinsurance payment during the 
13- or 36-month rental periods for capped rental items and oxygen 
equipment, respectively. However, even though beneficiaries will still 
be required to make a 20 percent coinsurance payment in connection with 
each maintenance and servicing call, beneficiaries will no longer have 
to make a monthly 20 percent coinsurance payment for oxygen equipment 
after they own it, or a 20 percent coinsurance payment every 6 months 
for maintenance and servicing of beneficiary-owned capped rental items, 
even if maintenance and servicing is not needed. This will result in 
significant savings to beneficiaries.
    For example, before the DRA, Medicare and the beneficiary made 
continuous payments for the rental of oxygen equipment that totaled 
about $200 per month. Of this amount, the beneficiary paid coinsurance 
of $40 which will equal $480 for a single year's rental, $1,440 over 36 
months, and $2,400 over 5 years. After the DRA, beneficiaries will only 
pay a coinsurance amount for up to 36 months for the rental of oxygen 
equipment, after which time they will own the equipment. Thus, the DRA 
oxygen provisions result in savings of approximately $480 if 
beneficiaries use the equipment for 4 years, and $960 if they use the 
equipment for 5 years. As a result of the provision of this final rule 
that allows for a general maintenance and servicing call every 6 
months, beneficiaries could pay approximately $6 in coinsurance 
payments for assigned claims, and more for unassigned claims for 
supplier labor associated with these services. However, the beneficiary 
can elect not to have these services performed if they feel that their 
equipment is not in need of servicing.
    For capped rental items, beneficiaries will save coinsurance by not 
being responsible for any equipment payment after the 13th rental month 
or the automatic semi-annual maintenance and servicing payment that was 
approximately equal to 10 percent of the

[[Page 65932]]

purchase price for the equipment. Before the DRA, Medicare and the 
beneficiary would pay up to 15 months for capped rental items, and 
Medicare and the beneficiary would also pay for maintenance and 
servicing every 6 months. Thus, beneficiaries will save coinsurance 
payments related to both the equipment itself and the maintenance and 
servicing of that equipment.
    This final rule will assure beneficiaries that unless certain 
prescribed exceptions apply, suppliers that furnish the equipment for 
the first month will continue to furnish the equipment for the entire 
36-month period of continuous use for oxygen equipment or the 13-month 
period of continuous use for capped rental.
    Beneficiaries will also be assured that their oxygen and capped 
rental equipment would not be impermissibly swapped by the supplier at 
any time during the rental period. Under the final rule, we require 
that a supplier may not provide different rented equipment to the 
beneficiary at any time during the 36 rental months for oxygen 
equipment or the 13 rental months for capped rental DME unless one of 
the following three exceptions apply: (1) The supplier replaces an item 
with the same, or equivalent, make and model of equipment because the 
item initially furnished was lost, stolen, irreparably damaged, is 
being repaired, or no longer functions; (2) The physician orders a 
different equipment for the beneficiary. If the need for different 
equipment is based on medical necessity, the order must indicate why 
the equipment initially furnished is no longer appropriate or medically 
necessary, and the supplier must retain this order in the beneficiary's 
medical record; (3) The beneficiary chooses to obtain a newer 
technology item or upgraded item and signs an ABN; or (4) CMS or the 
carrier determines that a change in equipment is warranted.
    We are requiring that suppliers inform beneficiaries whether they 
intend to accept or not accept assignment on all monthly rental claims 
during the 13-month rental period for capped rental items or the 36-
month rental period for oxygen equipment in an upfront manner.
    This final rule will also assure beneficiaries that following the 
transfer of title, the supplier must replace an item at no cost to the 
beneficiary in cases where the carrier determines that the item 
furnished by the supplier will not last for the entire reasonable 
useful lifetime established for the equipment. In making this 
determination, the carrier may consider whether the accumulated costs 
of repair exceed 60 percent of the cost to replace the item.

C. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 14 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 HH PPS as a result of the changes presented in this final 
rule based on the data for 7,370 HHAs in our database. All expenditures 
are classified as transfers to Medicare providers (that is, HHAs).

      Table 14.--Accounting Statement: Classification of Estimated
                  Expenditures, From CY 2006 to CY 2007
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $410
From Whom to Whom?........................  Federal Government to HHAs.
------------------------------------------------------------------------

    In Table 15 below, we have prepared an accounting statement showing 
the classification of the expenditures associated with the DME 
provisions of this final rule. This table provides our best estimate of 
the decrease in Medicare payments under the DME benefit as a result of 
the changes presented in this final rule based on the 2004 allowed 
charge data for oxygen and capped rental DME in our database. All 
expenditures are classified as transfers to the Medicare program and 
its beneficiaries.

      Table 15.--Accounting Statement: Classification of Estimated
                              Expenditures
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Monetized Transfers in FY 2007............  $80
Monetized Transfers in FY 2008............  $130
Monetized Transfers in FY 2009............  $170
Monetized Transfers in FY 2010............  $220
Monetized Transfers in FY 2011............  $280
From Whom to Whom?........................  Suppliers to Federal
                                             Government and
                                             beneficiaries.
------------------------------------------------------------------------

    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 414

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 484

    Health facilities, Health professions, Medicare, Reporting and 
recordkeeping requirements.

0
For the reasons set forth in the preamble, the Centers for Medicare & 
Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

Subpart D--Payment for Durable Medical Equipment and Prosthetic and 
Orthotic Devices

0
1. The authority citation for part 414 continues to read as follows:

    Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social 
Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)).


0
2. Amend Sec.  414.210 as follows:
0
A. Revise paragraph (e).
0
B. Revise the introductory text to paragraph (f).
0
C. Revise paragraph (f)(2).
0
D. Add new paragraphs (f)(3) and (f)(4).
    The revisions read as follows:


Sec.  414.210  General payment rules.

* * * * *
    (e) Maintenance and servicing--(1) General rule. Except as provided 
in paragraph (e)(2) of this section, the carrier pays the reasonable 
and necessary charges for maintenance and servicing of beneficiary-
owned equipment. Reasonable and necessary charges are those made for 
parts and labor not otherwise covered under a manufacturer's or 
supplier's warranty. Payment is made for replacement parts in a lump 
sum based on the carrier's consideration of the item. The carrier 
establishes a reasonable fee for labor associated with repairing, 
maintaining, and servicing the item. Payment is not made for 
maintenance and servicing of a rented item other than the maintenance 
and servicing fee for other durable medical equipment as described in 
Sec.  414.229(e).
    (2) Additional maintenance and servicing payment for certain

[[Page 65933]]

beneficiary-owned oxygen equipment. In addition to the maintenance and 
servicing payments described in paragraph (e)(1) of this section, the 
carrier makes a maintenance and servicing payment for oxygen equipment 
other than liquid and gaseous equipment (stationary and portable) as 
follows:
    (i) For the first 6-month period following the date on which title 
to the equipment transfers to the beneficiary in accordance with Sec.  
414.226(f), no payments are to be made.
    (ii) During each succeeding 6-month period, payment may be made for 
30 minutes of labor for general maintenance and servicing of the 
equipment.
    (3) Additional payment for picking up oxygen tanks and cylinders. 
The carrier pays the reasonable and necessary charges for a supplier to 
pick up and store or dispose of beneficiary-owned oxygen tanks and 
cylinders that are no longer medically necessary.
    (4) Exception to Maintenance and Servicing Payments. For items 
purchased on or after June 1, 1989, no payment is made under the 
provisions of paragraph (e)(1) of this section for the maintenance and 
servicing of:
    (i) Items requiring frequent and substantial servicing, as defined 
in Sec.  414.222(a);
    (ii) Capped rental items, as defined in Sec.  414.229(a), that are 
not beneficiary-owned in accordance with Sec.  414.229(d), Sec.  
414.229(f)(2), or Sec.  414.229(h); and
    (iii) Oxygen equipment, as described in Sec.  414.226, that is not 
beneficiary-owned in accordance with Sec.  414.226(f).
    (5) Supplier replacement of beneficiary-owned equipment based on 
accumulated repair costs. A supplier that transfers title to oxygen 
equipment or a capped rental item to a beneficiary in accordance with 
Sec.  414.226(f) or Sec.  414.229(f)(2) is responsible for furnishing 
replacement equipment at no cost to the beneficiary or to the Medicare 
program if the carrier determines that the item furnished by the 
supplier will not last for the entire reasonable useful lifetime 
established for the equipment in accordance with Sec.  414.210(f)(1). 
In making this determination, the carrier may consider whether the 
accumulated costs of repair exceed 60 percent of the cost to replace 
the item.
    (f) Payment for replacement of equipment. If an item of DME or a 
prosthetic or orthotic device paid for under this subpart has been in 
continuous use by the patient for the equipment's reasonable useful 
lifetime or if the carrier determines that the item is lost, stolen, or 
irreparably damaged, the patient may elect to obtain a new piece of 
equipment.
* * * * *
    (2) If the beneficiary elects to obtain replacement oxygen 
equipment, payment is made in accordance with Sec.  414.226(a).
    (3) If the beneficiary elects to obtain a replacement capped rental 
item, payment is made in accordance with Sec.  414.229(a)(2) or (a)(3).
    (4) For all other beneficiary-owned items, if the beneficiary 
elects to obtain replacement equipment, payment is made on a purchase 
basis.

0
3. Amend Sec.  414.226 by--
0
A. Revising paragraph (a) and the heading of paragraph (b).
0
B. Revising paragraph (b)(3).
0
C. Adding paragraphs (b)(4) and (b)(5).
0
D. Redesignating paragraph (d) as paragraph (e).
0
E. Redesignating paragraph (c) as paragraph (d).
0
F. Revising newly redesignated paragraph (d).
0
G. Adding a new paragraph (c).
0
H. Revising newly redesignated paragraph (e)(1) introductory text.
0
I. Revising newly redesignated paragraph (e)(1)(i).
0
J. Revising newly redesignated paragraph (e)(2)(i).
0
K. Revising newly redesignated paragraph (e)(2)(ii).
0
L. Adding new paragraphs (f) and (g).
    The revisions and additions read as follows:


Sec.  414.226  Oxygen and oxygen equipment.

    (a) Payment rules--(1) Oxygen equipment. Payment for rental of 
oxygen equipment is made based on a monthly fee schedule amount during 
the period of medical need, but for no longer than a period of 
continuous use of 36 months. A period of continuous use is determined 
under the provisions in Sec.  414.230.
    (2) Oxygen contents. Payment for purchase of oxygen contents is 
made based on a monthly fee schedule amount until medical necessity 
ends.
    (b) Monthly fee schedule amount for items furnished prior to 2007.
* * * * *
    (3) For 1991 through 2006, the fee schedule amounts for items 
described in paragraphs (b)(1)(iii) and (iv) of this section are 
determined using the methodology contained in Sec.  414.220(d), (e), 
and (f).
    (4) For 1991 through 2006, the fee schedule amounts for items 
described in paragraphs (b)(1)(i) and (ii) of this section are 
determined using the methodology contained in Sec.  414.220(d), (e), 
and (f).
    (5) For 2005 and 2006, the fee schedule amounts determined under 
paragraph (b)(4) of this section are reduced using the methodology 
described in section 1834(a)(21)(A) of the Act.
    (c) Monthly fee schedule amount for items furnished for years after 
2006. (1) For 2007, national limited monthly payment rates are 
calculated and paid as the monthly fee schedule amounts for the 
following classes of items:
    (i) Stationary oxygen equipment (including stationary 
concentrators) and oxygen contents (stationary and portable).
    (ii) Portable equipment only (gaseous or liquid tanks).
    (iii) Oxygen generating portable equipment only.
    (iv) Stationary oxygen contents only.
    (v) Portable oxygen contents only.
    (2) The national limited monthly payment rate for items described 
in paragraph (c)(1)(i) of this section is equal to the weighted average 
fee schedule amount established under paragraph (b)(5) of this section 
reduced by $1.44.
    (3) The national limited monthly payment rate for items described 
in paragraph (c)(1)(ii) of this section is equal to the weighted 
average of the fee schedule amounts established under paragraph (b)(5) 
of this section.
    (4) The national limited monthly payment rate for items described 
in paragraph (c)(1)(iii) of this section is equal to the national 
limited monthly payment rate established under paragraph (c)(5) of this 
section, multiplied by 24, and divided by 36.
    (5) The national limited monthly payment rate for items described 
in paragraphs (c)(1)(iv) and (c)(1)(v) of this section is equal to 50 
percent of the weighted average fee schedule amounts established under 
paragraph (b)(3) of this section for items described in paragraph 
(b)(1)(iii) of this section.
    (6) Beginning in 2008, CMS makes an annual adjustment to the 
national limited monthly payment rates for each class of items 
described in paragraph (c)(1) of this section to ensure that such 
payment rates do not result in expenditures for any year that are more 
or less than the expenditures that would have been made if such classes 
had not been established.
    (d) Application of monthly fee schedule amounts. (1) The fee 
schedule amount for items described in paragraph (c)(1)(i) of this 
section is paid when the beneficiary rents stationary oxygen equipment.
    (2) Subject to the limitation set forth in paragraph (e)(2) of this 
section, the fee schedule amount for items described

[[Page 65934]]

in paragraphs (c)(1)(ii) and (c)(1)(iii) of this section is paid when 
the beneficiary rents portable oxygen equipment.
    (3) The fee schedule amount for items described in paragraph 
(c)(1)(iv) of this section is paid when the beneficiary owns stationary 
oxygen equipment that requires delivery of gaseous or liquid oxygen 
contents.
    (4) The fee schedule amount for items described in paragraph 
(c)(1)(v) of this section is paid when the beneficiary owns portable 
oxygen equipment described in paragraph (c)(1)(ii) of this section, or 
rents portable oxygen equipment described in paragraph (c)(1)(ii) of 
this section and does not rent stationary oxygen equipment.
    (e) Volume adjustments. (1) The fee schedule amount for an item 
described in paragraph (c)(1)(i) of this section is adjusted as 
follows:
    (i) If the attending physician prescribes an oxygen flow rate 
exceeding four liters per minute, the fee schedule amount is increased 
by 50 percent, subject to the limit in paragraph (e)(2) of this 
section.
* * * * *
    (2) * * *
    (i) The sum of the monthly fee schedule amount for the items 
described in paragraphs (c)(1)(i) and (c)(1)(ii) or (c)(1)(iii) of this 
section; or
    (ii) The adjusted fee schedule amount described in paragraph 
(e)(1)(i) of this section.
* * * * *
    (f) Ownership of equipment. On the first day that begins after the 
36th continuous month in which payment is made for oxygen equipment 
under paragraph (a)(1) of this section, the supplier must transfer 
title to the oxygen equipment to the beneficiary. At the time of title 
transfer, the supplier must provide information to the beneficiary on 
how to safely dispose of oxygen equipment that is no longer medically 
necessary and advise that the beneficiary must comply with all Federal, 
State, and local laws that apply to the disposal, transport, and resale 
of oxygen equipment.
    (g) Additional supplier requirements for rentals that begin on or 
after January 1, 2007. (1) The supplier that furnishes oxygen equipment 
for the first month during which payment is made under this section 
must continue to furnish the equipment until medical necessity ends, or 
the 36-month period of continuous use ends, whichever is earlier, 
unless--
    (i) The item becomes subject to a competitive acquisition program 
implemented in accordance with section 1847(a) of the Act;
    (ii) The beneficiary relocates to an area that is outside the 
normal service area of the supplier that initially furnished the 
equipment;
    (iii) The beneficiary elects to obtain oxygen equipment from a 
different supplier prior to the expiration of the 36-month rental 
period; or
    (iv) CMS or the carrier determines that an exception should apply 
in an individual case based on the circumstances.
    (2) Oxygen equipment furnished under this section may not be 
replaced by the supplier prior to the expiration of the 36-month rental 
period unless:
    (i) The supplier replaces an item with the same, or equivalent, 
make and model of equipment because the item initially furnished was 
lost, stolen, irreparably damaged, is being repaired, or no longer 
functions;
    (ii) A physician orders different equipment for the beneficiary. If 
the order is based on medical necessity, then the order must indicate 
why the equipment initially furnished is no longer medically necessary 
and the supplier must retain this order in the beneficiary's medical 
record;
    (iii) The beneficiary chooses to obtain a newer technology item or 
upgraded item and signs an advanced beneficiary notice (ABN); or
    (iv) CMS or the carrier determines that a change in equipment is 
warranted.
    (3) Before furnishing oxygen equipment, the supplier must disclose 
to the beneficiary its intentions regarding whether it will accept 
assignment of all monthly rental claims for the duration of the rental 
period. A supplier's intentions could be expressed in the form of a 
written agreement between the supplier and the beneficiary.
    (4) No later than two months before the date on which the supplier 
must transfer title to oxygen equipment to the beneficiary, the 
supplier must disclose to the beneficiary--
    (i) Whether it can maintain and service the equipment after the 
beneficiary acquires title to it; and
    (ii) Whether it can continue to deliver oxygen contents to the 
beneficiary after the beneficiary acquires title to the equipment.

0
4. Amend Sec.  414.229 by--
0
A. Revising paragraphs (a), (f) and (g).
0
B. Adding paragraph (h).
    The revisions and additions read as follows:


Sec.  414.229  Other durable medical equipment-capped rental items.

    (a) General payment rule. Payment is made for other durable medical 
equipment that is not subject to the payment provisions set forth in 
Sec.  414.220 through Sec.  414.228 as follows:
    (1) For items furnished prior to January 1, 2006, payment is made 
on a rental or purchase option basis in accordance with the rules set 
forth in paragraphs (b) through (e) of this section.
    (2) For items other than power-driven wheelchairs furnished on or 
after January 1, 2006, payment is made in accordance with the rules set 
forth in paragraph (f) of this section.
    (3) For power-driven wheelchairs furnished on or after January 1, 
2006, payment is made in accordance with the rules set forth in 
paragraphs (f) or (h) of this section.
* * * * *
    (f) Rules for capped rental items furnished beginning on or after 
January 1, 2006. (1) For items furnished on or after January 1, 2006, 
payment is made based on a monthly rental fee schedule amount during 
the period of medical need, but for no longer than a period of 
continuous use of 13 months. A period of continuous use is determined 
under the provisions in Sec.  414.230.
    (2) The supplier must transfer title to the item to the beneficiary 
on the first day that begins after the 13th continuous month in which 
payments are made under paragraph (f)(1) of this section.
    (3) Payment for maintenance and servicing of beneficiary-owned 
equipment is made in accordance with Sec.  414.210(e).
    (g) Additional supplier requirements for capped rental items that 
are furnished beginning on or after January 1, 2007. (1) The supplier 
that furnishes an item for the first month during which payment is made 
using the methodology described in paragraph (f)(1) of this section 
must continue to furnish the equipment until medical necessity ends, or 
the 13-month period of continuous use ends, whichever is earlier, 
unless--
    (i) The item becomes subject to a competitive acquisition program 
implemented in accordance with section 1847(a) of the Act;
    (ii) The beneficiary relocates to an area that is outside the 
normal service area of the supplier that initially furnished the 
equipment;
    (iii) The beneficiary elects to obtain the equipment from a 
different supplier prior to the expiration of the 13-month rental 
period; or
    (iv) CMS or the carrier determines that an exception should apply 
in an individual case based on the circumstances.
    (2) A capped rental item furnished under this section may not be 
replaced by the supplier prior to the expiration of the 13-month rental 
period unless:

[[Page 65935]]

    (i) The supplier replaces an item with the same, or equivalent, 
make and model of equipment because the item initially furnished was 
lost, stolen, irreparably damaged, is being repaired, or no longer 
functions;
    (ii) A physician orders different equipment for the beneficiary. If 
the need for different equipment is based on medical necessity, then 
the order must indicate why the equipment initially furnished is no 
longer medically necessary and the supplier must retain this order in 
the beneficiary's medical record;
    (iii) The beneficiary chooses to obtain a newer technology item or 
upgraded item and signs an advanced beneficiary notice (ABN); or
    (iv) CMS or the carrier determines that a change in equipment is 
warranted.
    (3) Before furnishing a capped rental item, the supplier must 
disclose to the beneficiary its intentions regarding whether it will 
accept assignment of all monthly rental claims for the duration of the 
rental period. A supplier's intentions could be expressed in the form 
of a written agreement between the supplier and the beneficiary.
    (4) No later than two months before the date on which the supplier 
must transfer title to a capped rental item to the beneficiary, the 
supplier must disclose to the beneficiary whether it can maintain and 
service the item after the beneficiary acquires title to it. CMS or its 
carriers may make exceptions to this requirement on a case-by-case 
basis.
    (h) Purchase of power-driven wheelchairs furnished on or after 
January 1, 2006. Suppliers must offer beneficiaries the option to 
purchase power-driven wheelchairs at the time the equipment is 
initially furnished. Payment is made on a lump-sum purchase basis if 
the beneficiary chooses this option.

0
5. Amend Sec.  414.230 by--
0
A. Revising paragraph (b).
0
B. Revising paragraph (f).
    The revisions read as follows:


Sec.  414.230  Determining a period of continuous use.

* * * * *
    (b) Continuous use. (1) A period of continuous use begins with the 
first month of medical need and lasts until a beneficiary's medical 
need for a particular item of durable medical equipment ends.
    (2) In the case of a beneficiary receiving oxygen equipment on 
December 31, 2005, the period of continuous use for the equipment 
begins on January 1, 2006.
* * * * *
    (f) New equipment. (1) If a beneficiary changes equipment or 
requires additional equipment based on a physician's prescription, and 
the new or additional equipment is found to be necessary, a new period 
of continuous use begins for the new or additional equipment. A new 
period of continuous use does not begin for base equipment that is 
modified by an addition.
    (2) A new period of continuous use does not begin when a 
beneficiary changes from one stationary oxygen equipment modality to 
another or from one portable oxygen equipment modality to another.
* * * * *

PART 484--HOME HEALTH SERVICES

0
6. The authority citation for part 484 continues to read as follows:

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


0
7. Amend Sec.  484.225 as follows:
0
A. Revise paragraph (f).
0
B. Redesignate paragraph (g) as paragraph (h).
0
C. Add new paragraph (g).
0
D. Revise newly redesignated paragraph (h).
0
E. Add new paragraph (i).
    The revisions and additions read as follows:


Sec.  484.225  Annual update of the unadjusted national prospective 60-
day episode payment rate.

* * * * *
    (f) For calendar year 2005, the unadjusted national prospective 60-
day episode payment rate is equal to the rate from the previous 
calendar year, increased by the applicable home health market basket 
minus 0.8 percentage points.
    (g) For calendar year 2006, the unadjusted national prospective 60-
day episode payment rate is equal to the rate from calendar year 2005.
    (h) For 2007 and subsequent calendar years, in the case of a home 
health agency that submits home health quality data, as specified by 
the Secretary, the unadjusted national prospective 60-day episode rate 
is equal to the rate for the previous calendar year increased by the 
applicable home health market basket index amount.
    (i) For 2007 and subsequent calendar years, in the case of a home 
health agency that does not submit home health quality data, as 
specified by the Secretary, the unadjusted national prospective 60-day 
episode rate is equal to the rate for the previous calendar year 
increased by the applicable home health market basket index amount 
minus 2 percentage points. Any reduction of the percentage change will 
apply only to the calendar year involved and will not be taken into 
account in computing the prospective payment amount for a subsequent 
calendar year.

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

    Dated: October 20, 2006.
Leslie V. Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: October 31, 2006.
Michael O. Leavitt,
Secretary.

    Note: The following addenda will not be published in the Code of 
Federal Regulations.


[[Page 65936]]



Addendum A.--CY 2007 Wage Index for Rural Areas by CBSA; Applicable Pre-
             Floor and Pre-Reclassified Hospital Wage Index
------------------------------------------------------------------------
                                                                  Wage
          CBSA code                     Nonurban area             index
------------------------------------------------------------------------
01..........................  Alabama.........................    0.7591
02..........................  Alaska..........................    1.0661
03..........................  Arizona.........................    0.8908
04..........................  Arkansas........................    0.7307
05..........................  California......................    1.1454
06..........................  Colorado........................    0.9325
07..........................  Connecticut.....................    1.1709
08..........................  Delaware........................    0.9705
10..........................  Florida.........................    0.8594
11..........................  Georgia.........................    0.7593
12..........................  Hawaii..........................    1.0448
13..........................  Idaho...........................    0.8120
14..........................  Illinois........................    0.8320
15..........................  Indiana.........................    0.8538
16..........................  Iowa............................    0.8681
17..........................  Kansas..........................    0.7998
18..........................  Kentucky........................    0.7768
19..........................  Louisiana.......................    0.7438
20..........................  Maine...........................    0.8443
21..........................  Maryland........................    0.8926
22..........................  Massachusetts \1\...............    1.1661
23..........................  Michigan........................    0.9062
24..........................  Minnesota.......................    0.9153
25..........................  Mississippi.....................    0.7738
26..........................  Missouri........................    0.7927
27..........................  Montana.........................    0.8590
28..........................  Nebraska........................    0.8677
29..........................  Nevada..........................    0.8944
30..........................  New Hampshire...................    1.0853
31..........................  New Jersey \2\..................  ........
32..........................  New Mexico......................    0.8332
33..........................  New York........................    0.8232
34..........................  North Carolina..................    0.8588
35..........................  North Dakota....................    0.7215
36..........................  Ohio............................    0.8658
37..........................  Oklahoma........................    0.7629
38..........................  Oregon..........................    0.9753
39..........................  Pennsylvania....................    0.8320
40..........................  Puerto Rico \3\.................    0.4047
41..........................  Rhode Island \2\................  ........
42..........................  South Carolina..................    0.8566
43..........................  South Dakota....................    0.8480
44..........................  Tennessee.......................    0.7827
45..........................  Texas...........................    0.7965
46..........................  Utah............................    0.8140
47..........................  Vermont.........................    0.9744
48..........................  Virgin Islands..................    0.8467
49..........................  Virginia........................    0.7940
50..........................  Washington......................    1.0263
51..........................  West Virginia...................    0.7607
52..........................  Wisconsin.......................    0.9553
53..........................  Wyoming.........................    0.9295
65..........................  Guam............................   0.9611
------------------------------------------------------------------------
\1\ There are no short-term, acute care hospitals located in rural areas
  in Massachusetts from which to calculate a wage index for CY07.
  Therefore, the rural wage index for Massachusetts will be imputed
  using the methodology discussed in Section III of this rule.
\2\ All counties within the State are classified as urban.
\3\ There are no short-term, acute care hospitals located in rural areas
  in Puerto Rico from which to calculate a wage index for CY07.
  Therefore, we will continue to use the wage index from CY05 which was
  the last year in which we had ``rural'' hospital data.


Addendum B.--CY 2007 Wage Index for Urban Areas by CBSA; Applicable Pre-
             Floor and Pre-Reclassified Hospital Wage Index
------------------------------------------------------------------------
                                  Urban area (constituent         Wage
          CBSA code                      counties)               index
------------------------------------------------------------------------
10180.......................  Abilene, TX....................     0.8000
                                Callahan County, TX
                                Jones County, TX
                                Taylor County, TX
10380.......................  Aguadilla-Isabela-San               0.3915
                               Sebastian, PR.
                                Aguada Municipio, PR
                                Aguadilla Municipio, PR
                                Anasco Municipio, PR
                                Isabela Municipio, PR
                                Lares Municipio, PR
                                Moca Municipio, PR
                                Rincon Municipio, PR
                                San Sebastian Municipio, PR
10420.......................  Akron, OH......................     0.8654
                                Portage County, OH
                                Summit County, OH
10500.......................  Albany, GA.....................     0.8991
                                Baker County, GA
                                Dougherty County, GA
                                Lee County, GA
                                Terrell County, GA
                                Worth County, GA
10580.......................  Albany-Schenectady-Troy, NY....     0.8720
                                Albany County, NY
                                Rensselaer County, NY
                                Saratoga County, NY
                                Schenectady County, NY
                                Schoharie County, NY
10740.......................  Albuquerque, NM................     0.9458
                                Bernalillo County, NM
                                Sandoval County, NM
                                Torrance County, NM
                                Valencia County, NM
10780.......................  Alexandria, LA.................     0.8006
                                Grant Parish, LA
                                Rapides Parish, LA
10900.......................  Allentown-Bethlehem-Easton, PA-     0.9947
                               NJ.

[[Page 65937]]

 
                                Warren County, NJ
                                Carbon County, PA
                                Lehigh County, PA
                                Northampton County, PA
11020.......................  Altoona, PA....................     0.8812
                                Blair County, PA
11100.......................  Amarillo, TX...................     0.9169
                                Armstrong County, TX
                                Carson County, TX
                                Potter County, TX
                                Randall County, TX
11180.......................  Ames, IA.......................     0.9760
                                Story County, IA
111260......................  Anchorage, AK..................     1.2023
                                Anchorage Municipality, AK
                                Matanuska-Susitna Borough, AK
11300.......................  Anderson, IN...................     0.8681
                                Madison County, IN
11340.......................  Anderson, SC...................     0.9017
                                Anderson County, SC
11460.......................  Ann Arbor, MI..................     1.0826
                                Washtenaw County, MI
11500.......................  Anniston-Oxford, AL............     0.7770
                                Calhoun County, AL
11540.......................  Appleton, WI...................     0.9455
                                Calumet County, WI
                                Outagamie County, WI
11700.......................  Asheville, NC..................     0.9216
                                Buncombe County, NC
                                Haywood County, NC
                                Henderson County, NC
                                Madison County, NC
2020........................  Athens-Clarke County, GA.......     0.9856
                                Clarke County, GA
                                Madison County, GA
                                Oconee County, GA
                                Oglethorpe County, GA
12060.......................  Atlanta-Sandy Springs-Marietta,     0.9762
                               GA.
                                Barrow County, GA
                                Bartow County, GA
                                Butts County, GA
                                Carroll County, GA
                                Cherokee County, GA
                                Clayton County, GA
                                Cobb County, GA
                                Coweta County, GA
                                Dawson County, GA
                                DeKalb County, GA
                                Douglas County, GA
                                Fayette County, GA
                                Forsyth County, GA
                                Fulton County, GA
                                Gwinnett County, GA
                                Haralson County, GA
                                Heard County, GA
                                Henry County, GA
                                Jasper County, GA
                                Lamar County, GA
                                Meriwether County, GA
                                Newton County, GA
                                Paulding County, GA
                                Pickens County, GA
                                Pike County, GA
                                Rockdale County, GA
                                Spalding County, GA
                                Walton County, GA
12100.......................  Atlantic City, NJ..............     1.1831
                                Atlantic County, NJ
2220........................  Auburn-Opelika, AL.............     0.8096
                                Lee County, AL

[[Page 65938]]

 
12260.......................  Augusta-Richmond County, GA-SC.     0.9667
                                Burke County, GA
                                Columbia County, GA
                                McDuffie County, GA
                                Richmond County, GA
                                Aiken County, SC
                                Edgefield County, SC
12420.......................  Austin-Round Rock, TX..........     0.9344
                                Bastrop County, TX
                                Caldwell County, TX
                                Hays County, TX
                                Travis County, TX
                                Williamson County, TX
12540.......................  Bakersfield, CA................     1.0725
                                Kern County, CA
12580.......................  Baltimore-Towson, MD...........     1.0088
                                Anne Arundel County, MD
                                Baltimore County, MD
                                Carroll County, MD
                                Harford County, MD
                                Howard County, MD
                                Queen Anne's County, MD
                                Baltimore City, MD
12620.......................  Bangor, ME.....................     0.9711
                                Penobscot County, ME
12700.......................  Barnstable Town, MA............     1.2539
                                Barnstable County, MA
12940.......................  Baton Rouge, LA................     0.8084
                                Ascension Parish, LA
                                East Baton Rouge Parish, LA
                                East Feliciana Parish, LA
                                Iberville Parish, LA
                                Livingston Parish, LA
                                Pointe Coupee Parish, LA
                                St. Helena Parish, LA
                                West Baton Rouge Parish, LA
                                West Feliciana Parish, LA
12980.......................  Battle Creek, MI...............     0.9762
                                Calhoun County, MI
13020.......................  Bay City, MI...................     0.9251
                                Bay County, MI
13140.......................  Beaumont-Port Arthur, TX.......     0.8595
                                Hardin County, TX
                                Jefferson County, TX
                                Orange County, TX
13380.......................  Bellingham, WA.................     1.1104
                                Whatcom County, WA
13460.......................  Bend, OR.......................     1.0743
                                Deschutes County, OR
13644.......................  Bethesda-Frederick-                 1.0903
                               Gaithersburg, MD.
                                Frederick County, MD
                                Montgomery County, MD
13740.......................  Billings, MT...................     0.8712
                                Carbon County, MT
                                Yellowstone County, MT
13780.......................  Binghamton, NY.................     0.8786
                                Broome County, NY
                                Tioga County, NY
13820.......................  Birmingham-Hoover, AL..........     0.8894
                                Bibb County, AL
                                Blount County, AL
                                Chilton County, AL
                                Jefferson County, AL
                                St. Clair County, AL
                                Shelby County, AL
                                Walker County, AL
13900.......................  Bismarck, ND...................     0.7240
                                Burleigh County, ND
                                Morton County, ND
13980.......................  Blacksburg-Christiansburg-          0.8213
                               Radford, VA.

[[Page 65939]]

 
                                Giles County, VA
                                Montgomery County, VA
                                Pulaski County, VA
                                Radford City, VA
14020.......................  Bloomington, IN................     0.8533
                                Greene County, IN
                                Monroe County, IN
                                Owen County, IN
14060.......................  Bloomington-Normal, IL.........     0.8944
                                McLean County, IL
14260.......................  Boise City-Nampa, ID...........     0.9401
                                Ada County, ID
                                Boise County, ID
                                Canyon County, ID
                                Gem County, ID
                                Owyhee County, ID
14484.......................  Boston-Quincy, MA..............     1.1679
                                Norfolk County, MA
                                Plymouth County, MA
                                Suffolk County, MA
14500.......................  Boulder, CO....................     1.0350
                                Boulder County, CO
14540.......................  Bowling Green, KY..............     0.8148
                                Edmonson County, KY
                                Warren County, KY
14740.......................  Bremerton-Silverdale, WA.......     1.0913
                                Kitsap County, WA
14860.......................  Bridgeport-Stamford-Norwalk, CT     1.2659
                                Fairfield County, CT
15180.......................  Brownsville-Harlingen, TX......     0.9430
                                Cameron County, TX
15260.......................  Brunswick, GA..................     1.0164
                                Brantley County, GA
                                Glynn County, GA
                                McIntosh County, GA
15380.......................  Buffalo-Niagara Falls, NY......     0.9424
                                Erie County, NY
                                Niagara County, NY
15500.......................  Burlington, NC.................     0.8674
                                Alamance County, NC
15540.......................  Burlington-South Burlington, VT     0.9474
                                Chittenden County, VT
                                Franklin County, VT
                                Grand Isle County, VT
15764.......................  Cambridge-Newton-Framingham, MA     1.0970
                                Middlesex County, MA
5804........................  Camden, NJ.....................     1.0392
                                Burlington County, NJ
                                Camden County, NJ
                                Gloucester County, NJ
15940.......................  Canton-Massillon, OH...........     0.9031
                                Carroll County, OH
                                Stark County, OH
15980.......................  Cape Coral-Fort Myers, FL......     0.9342
                                Lee County, FL
16180.......................  Carson City, NV................     1.0025
                                Carson City, NV
16220.......................  Casper, WY.....................     0.9145
                                Natrona County, WY
16300.......................  Cedar Rapids, IA...............     0.8888
                                Benton County, IA
                                Jones County, IA
                                Linn County, IA
16580.......................  Champaign-Urbana, IL...........     0.9644
                                Champaign County, IL
                                Ford County, IL
                                Piatt County, IL
16620.......................  Charleston, WV.................     0.8542
                                Boone County, WV
                                Clay County, WV

[[Page 65940]]

 
                                Kanawha County, WV
                                Lincoln County, WV
                                Putnam County, WV
16700.......................  Charleston-North Charleston, SC     0.9145
                                Berkeley County, SC
                                Charleston County, SC
                                Dorchester County, SC
16740.......................  Charlotte-Gastonia-Concord, NC-     0.9554
                               SC.
                                Anson County, NC
                                Cabarrus County, NC
                                Gaston County, NC
                                Mecklenburg County, NC
                                Union County, NC
                                York County, SC
16820.......................  Charlottesville, VA............     1.0125
                                Albemarle County, VA
                                Fluvanna County, VA
                                Greene County, VA
                                Nelson County, VA
                                Charlottesville City, VA
16860.......................  Chattanooga, TN-GA.............     0.8948
                                Catoosa County, GA
                                Dade County, GA
                                Walker County, GA
                                Hamilton County, TN
                                Marion County, TN
                                Sequatchie County, TN
16940.......................  Cheyenne, WY...................     0.9060
                                Laramie County, WY
16974.......................  Chicago-Naperville-Joliet, IL..     1.0751
                                Cook County, IL
                                DeKalb County, IL
                                DuPage County, IL
                                Grundy County, IL
                                Kane County, IL
                                Kendall County, IL
                                McHenry County, IL
                                Will County, IL
17020.......................  Chico, CA......................     1.1053
                                Butte County, CA
17140.......................  Cincinnati-Middletown, OH-KY-IN     0.9601
                                Dearborn County, IN
                                Franklin County, IN
                                Ohio County, IN
                                Boone County, KY
                                Bracken County, KY
                                Campbell County, KY
                                Gallatin County, KY
                                Grant County, KY
                                Kenton County, KY
                                Pendleton County, KY
                                Brown County, OH
                                Butler County, OH
                                Clermont County, OH
                                Hamilton County, OH
                                Warren County, OH
17300.......................  Clarksville, TN-KY.............     0.8436
                                Christian County, KY
                                Trigg County, KY
                                Montgomery County, TN
                                Stewart County, TN
17420.......................  Cleveland, TN..................     0.8109
                                Bradley County, TN
                                Polk County, TN
17460.......................  Cleveland-Elyria-Mentor, OH....     0.9400
                                Cuyahoga County, OH
                                Geauga County, OH
                                Lake County, OH
                                Lorain County, OH
                                Medina County, OH

[[Page 65941]]

 
17660.......................  Coeur d'Alene, ID..............     0.9344
                                Kootenai County, ID
17780.......................  College Station-Bryan, TX......     0.9045
                                Brazos County, TX
                                Burleson County, TX
                                Robertson County, TX
17820.......................  Colorado Springs, CO...........     0.9701
                                El Paso County, CO
                                Teller County, CO
17860.......................  Columbia, MO...................     0.8542
                                Boone County, MO
                                Howard County, MO
17900.......................  Columbia, SC...................     0.8933
                                Calhoun County, SC
                                Fairfield County, SC
                                Kershaw County, SC
                                Lexington County, SC
                                Richland County, SC
                                Saluda County, SC
17980.......................  Columbus, GA-AL................     0.8239
                                Russell County, AL
                                Chattahoochee County, GA
                                Harris County, GA
                                Marion County, GA
                                Muscogee County, GA
18020.......................  Columbus, IN...................     0.9318
                                Bartholomew County, IN
18140.......................  Columbus, OH...................     1.0107
                                Delaware County, OH
                                Fairfield County, OH
                                Franklin County, OH
                                Licking County, OH
                                Madison County, OH
                                Morrow County, OH
                                Pickaway County, OH
                                Union County, OH
18580.......................  Corpus Christi, TX.............     0.8564
                                Aransas County, TX
                                Nueces County, TX
                                San Patricio County, TX
18700.......................  Corvallis, OR..................     1.1546
                                Benton County, OR
19060.......................  Cumberland, MD-WV..............     0.8446
                                Allegany County, MD
                                Mineral County, WV
19124.......................  Dallas-PlanoIrving, TX.........     1.0075
                                Collin County, TX
                                Dallas County, TX
                                Delta County, TX
                                Denton County, TX
                                Ellis County, TX
                                Hunt County, TX
                                Kaufman County, TX
                                Rockwall County, TX
19140.......................  Dalton, GA.....................     0.9093
                                Murray County, GA
                                Whitfield County, GA
19180.......................  Danville, IL...................     0.9266
                                Vermilion County, IL
19260.......................  Danville, VA...................     0.8451
                                Pittsylvania County, VA
                                Danville City, VA
19340.......................  Davenport-Moline-Rock Island,       0.8846
                               IA-IL.
                                Henry County, IL
                                Mercer County, IL
                                Rock Island County, IL
                                Scott County, IA
19380.......................  Dayton, OH.....................     0.9037
                                Greene County, OH
                                Miami County, OH

[[Page 65942]]

 
                                Montgomery County, OH
                                Preble County, OH
19460.......................  Decatur, AL....................     0.8159
                                Lawrence County, AL
                                Morgan County, AL
19500.......................  Decatur, IL....................     0.8172
                                Macon County, IL
19660.......................  Deltona-Daytona Beach-Ormond        0.9263
                               Beach, FL.
                                Volusia County, FL
19740.......................  Denver-Aurora, CO..............     1.0930
                                Adams County, CO
                                Arapahoe County, CO
                                Broomfield County, CO
                                Clear Creek County, CO
                                Denver County, CO
                                Douglas County, CO
                                Elbert County, CO
                                Gilpin County, CO
                                Jefferson County, CO
                                Park County, CO
19780.......................  Des Moines, IA.................     0.9214
                                Dallas County, IA
                                Guthrie County, IA
                                Madison County, IA
                                Polk County, IA
                                Warren County, IA
19804.......................  Detroit-Livonia-Dearborn, MI...     1.0281
                                Wayne County, MI
20020.......................  Dothan, AL.....................     0.7381
                                Geneva County, AL
                                Henry County, AL
                                Houston County, AL
20100.......................  Dover, DE......................     0.9847
                                Kent County, DE
20220.......................  Dubuque, IA....................     0.9133
                                Dubuque County, IA
20260.......................  Duluth, MN-WI..................     1.0042
                                Carlton County, MN
                                St. Louis County, MN
                                Douglas County, WI
20500.......................  Durham, NC.....................     0.9826
                                Chatham County, NC
                                Durham County, NC
                                Orange County, NC
                                Person County, NC
20740.......................  Eau Claire, WI.................     0.9630
                                Chippewa County, WI
                                Eau Claire County, WI
20764.......................  Edison, NJ.....................     1.1190
                                Middlesex County, NJ
                                Monmouth County, NJ
                                Ocean County, NJ
                                Somerset County, NJ
20940.......................  El Centro, CA..................     0.9076
                                Imperial County, CA
21060.......................  Elizabethtown, KY..............     0.8697
                                Hardin County, KY
                                Larue County, KY
21140.......................  Elkhart-Goshen, IN.............     0.9426
                                Elkhart County, IN
21300.......................  Elmira, NY.....................     0.8240
                                Chemung County, NY
21340.......................  El Paso, TX....................     0.9053
                                El Paso County, TX
21500.......................  Erie, PA.......................     0.8827
                                Erie County, PA
21604.......................  Essex County, MA...............     1.0418
                                Essex County, MA
21660.......................  Eugene-Springfield, OR.........     1.0876
                                Lane County, OR

[[Page 65943]]

 
21780.......................  Evansville, IN-KY..............     0.9071
                                Gibson County, IN
                                Posey County, IN
                                Vanderburgh County, IN
                                Warrick County, IN
                                Henderson County, KY
                                Webster County, KY
21820.......................  Fairbanks, AK..................     1.1059
                                Fairbanks North Star Borough,
                              AK
21940.......................  Fajardo, PR....................     0.4036
                                Ceiba Municipio, PR
                                Fajardo Municipio, PR
                                Luquillo Municipio, PR
22020.......................  Fargo, ND-MN...................     0.8250
                                Cass County, ND
                                Clay County, MN
22140.......................  Farmington, NM.................     0.8589
                                San Juan County, NM
22180.......................  Fayetteville, NC...............     0.8945
                                Cumberland County, NC
                                Hoke County, NC
22220.......................  Fayetteville-Springdale-Rogers,     0.8865
                               AR-MO.
                                Benton County, AR
                                Madison County, AR
                                Washington County, AR
                                McDonald County, MO
22380.......................  Flagstaff, AZ..................     1.1601
                                Coconino County, AZ
22420.......................  Flint, MI......................     1.0969
                                Genesee County, MI
22500.......................  Florence, SC...................     0.8388
                                Darlington County, SC
                                Florence County, SC
22520.......................  Florence-Muscle Shoals, AL.....     0.7843
                                Colbert County, AL
                                Lauderdale County, AL
22540.......................  Fond du Lac, WI................     1.0063
                                Fond du Lac County, WI
22660.......................  Fort Collins-Loveland, CO......     0.9544
                                Larimer County, CO
22744.......................  Fort Lauderdale-Pompano Beach-      1.0133
                               Deerfield Beach, FL.
                                Broward County, FL
22900.......................  Fort Smith, AR-OK..............     0.7731
                                Crawford County, AR
                                Franklin County, AR
                                Sebastian County, AR
                                Le Flore County, OK
                                Sequoyah County, OK
23020.......................  Fort Walton Beach-Crestview-        0.8643
                               Destin, FL.
                                Okaloosa County, FL
23060.......................  Fort Wayne, IN.................     0.9517
                                Allen County, IN
                                Wells County, IN
                                Whitley County, IN
23104.......................  Fort Worth-Arlington, TX.......     0.9569
                                Johnson County, TX
                                Parker County, TX
                                Tarrant County, TX
                                Wise County, TX
23420.......................  Fresno, CA.....................     1.0943
                                Fresno County, CA
23460.......................  Gadsden, AL....................     0.8066
                                Etowah County, AL
23540.......................  Gainesville, FL................     0.9277
                                Alachua County, FL
                                Gilchrist County, FL
23580.......................  Gainesville, GA................     0.8958
                                Hall County, GA
23844.......................  Gary, IN.......................     0.9334
                                Jasper County, IN

[[Page 65944]]

 
                                Lake County, IN
                                Newton County, IN
                                Porter County, IN
24020.......................  Glens Falls, NY................     0.8324
                                Warren County, NY
                                Washington County, NY
24140.......................  Goldsboro, NC..................     0.9171
                                Wayne County, NC
24220.......................  Grand Forks, ND-MN.............     0.7949
                                Polk County, MN
                                Grand Forks County, ND
24300.......................  Grand Junction, CO.............     0.9668
                                Mesa County, CO
24340.......................  Grand Rapids-Wyoming, MI.......     0.9455
                                Barry County, MI
                                Ionia County, MI
                                Kent County, MI
                                Newaygo County, MI
24500.......................  Great Falls, MT................     0.8598
                                Cascade County, MT
24540.......................  Greeley, CO....................     0.9602
                                Weld County, CO
24580.......................  Green Bay, WI..................     0.9787
                                Brown County, WI
                                Kewaunee County, WI
                                Oconto County, WI
24660.......................  Greensboro-High Point, NC......     0.8866
                                Guilford County, NC
                                Randolph County, NC
                                Rockingham County, NC
24780.......................  Greenville, NC.................     0.9432
                                Greene County, NC
                                Pitt County, NC
24860.......................  Greenville, SC.................     0.9804
                                Greenville County, SC
                                Laurens County, SC
                                Pickens County, SC
25020.......................  Guayama, PR....................     0.3235
                                Arroyo Municipio, PR
                                Guayama Municipio, PR
                                Patillas Municipio, PR
25060.......................  Gulfport-Biloxi, MS............     0.8915
                                Hancock County, MS
                                Harrison County, MS
                                Stone County, MS
25180.......................  Hagerstown-Martinsburg, MD-WV..     0.9038
                                Washington County, MD
                                Berkeley County, WV
                                Morgan County, WV
25260.......................  Hanford-Corcoran, CA...........     1.0282
                                Kings County, CA
25420.......................  Harrisburg-Carlisle, PA........     0.9402
                                Cumberland County, PA
                                Dauphin County, PA
                                Perry County, PA
25500.......................  Harrisonburg, VA...............     0.9073
                                Rockingham County, VA
                                Harrisonburg City, VA
25540.......................  Hartford-West Hartford-East         1.0894
                               Hartford, CT.
                                Hartford County, CT
                                Litchfield County, CT
                                Middlesex County, CT
                                Tolland County, CT
25620.......................  Hattiesburg, MS................     0.7430
                                Forrest County, MS
                                Lamar County, MS
                                Perry County, MS
25860.......................  Hickory-Lenoir-Morganton, NC...     0.9010
                                Alexander County, NC
                                Burke County, NC

[[Page 65945]]

 
                                Caldwell County, NC
                                Catawba County, NC
25980\1\....................  Hinesville-Fort Stewart, GA....     0.9178
                                Liberty County, GA
                                Long County, GA
26100.......................  Holland-Grand Haven, MI........     0.9163
                                Ottawa County, MI
26180.......................  Honolulu, HI...................     1.1096
                                Honolulu County, HI
26300.......................  Hot Springs, AR................     0.8782
                                Garland County, AR
26380.......................  Houma-Bayou Cane-Thibodaux, LA.     0.8082
                                Lafourche Parish, LA
                                Terrebonne Parish, LA
26420.......................  Houston-Baytown-Sugar Land, TX.     1.0008
                                Austin County, TX
                                Brazoria County, TX
                                Chambers County, TX
                                Fort Bend County, TX
                                Galveston County, TX
                                Harris County, TX
                                Liberty County, TX
                                Montgomery County, TX
                                San Jacinto County, TX
                                Waller County, TX
26580.......................  Huntington-Ashland, WVKYOH.....     0.8997
                                Boyd County, KY
                                Greenup County, KY
                                Lawrence County, OH
                                Cabell County, WV
                                Wayne County, WV
26620.......................  Huntsville, AL.................     0.9007
                                Limestone County, AL
                                Madison County, AL
26820.......................  Idaho Falls, ID................     0.9088
                                Bonneville County, ID
                                Jefferson County, ID
26900.......................  Indianapolis, IN...............     0.9895
                                Boone County, IN
                                Brown County, IN
                                Hamilton County, IN
                                Hancock County, IN
                                Hendricks County, IN
                                Johnson County, IN
                                Marion County, IN
                                Morgan County, IN
                                Putnam County, IN
                                Shelby County, IN
26980.......................  Iowa City, IA..................     0.9714
                                Johnson County, IA
                                Washington County, IA
27060.......................  Ithaca, NY.....................     0.9928
                                Tompkins County, NY
27100.......................  Jackson, MI....................     0.9560
                                Jackson County, MI
27140.......................  Jackson, MS....................     0.8271
                                Copiah County, MS
                                Hinds County, MS
                                Madison County, MS
                                Rankin County, MS
                                Simpson County, MS
27180.......................  Jackson, TN....................     0.8853
                                Chester County, TN
                                Madison County, TN
27260.......................  Jacksonville, FL...............     0.9165
                                Baker County, FL
                                Clay County, FL
                                Duval County, FL
                                Nassau County, FL
                                St. Johns County, FL

[[Page 65946]]

 
27340.......................  Jacksonville, NC...............     0.8231
                                Onslow County, NC
27500.......................  Janesville, WI.................     0.9655
                                Rock County, WI
27620.......................  Jefferson City, MO.............     0.8332
                                Callaway County, MO
                                Cole County, MO
                                Moniteau County, MO
                                Osage County, MO
>27740......................  Johnson City, TN...............     0.8043
                                Carter County, TN
                                Unicoi County, TN
                                Washington County, TN
27780.......................  Johnstown, PA..................     0.8620
                                Cambria County, PA
27860.......................  Jonesboro, AR..................     0.7662
                                Craighead County, AR
                                Poinsett County, AR
27900.......................  Joplin, MO.....................     0.8605
                                Jasper County, MO
                                Newton County, MO
28020.......................  Kalamazoo-Portage, MI..........     1.0704
                                Kalamazoo County, MI
                                Van Buren County, MI
28100.......................  Kankakee-Bradley, IL...........     1.0083
                                Kankakee County, IL
28140.......................  Kansas City, MOKS..............     0.9495
                                Franklin County, KS
                                Johnson County, KS
                                Leavenworth County, KS
                                Linn County, KS
                                Miami County, KS
                                Wyandotte County, KS
                                Bates County, MO
                                Caldwell County, MO
                                Cass County, MO
                                Clay County, MO
                                Clinton County, MO
                                Jackson County, MO
                                Lafayette County, MO
                                Platte County, MO
                                Ray County, MO
28420.......................  Kennewick-Richland-Pasco, WA...     1.0343
                                Benton County, WA
                                Franklin County, WA
28660.......................  Killeen-TempleFort Hood, TX....     0.8901
                                Bell County, TX
                                Coryell County, TX
                                Lampasas County, TX
28700.......................  Kingsport-Bristol-Bristol, TNVA     0.7985
                                Hawkins County, TN
                                Sullivan County, TN
                                Bristol City, VA
                                Scott County, VA
                                Washington County, VA
28740.......................  Kingston, NY...................     0.9367
                                Ulster County, NY
28940.......................  Knoxville, TN..................     0.8249
                                Anderson County, TN
                                Blount County, TN
                                Knox County, TN
                                Loudon County, TN
                                Union County, TN
29020.......................  Kokomo, IN.....................     0.9669
                                Howard County, IN
                                Tipton County, IN
29100.......................  La Crosse, WIMN................     0.9426
                                Houston County, MN
                                La Crosse County, WI
29140.......................  Lafayette, IN..................     0.8931

[[Page 65947]]

 
                                Benton County, IN
                                Carroll County, IN
                                Tippecanoe County, IN
29180.......................  Lafayette, LA..................     0.8289
                                Lafayette Parish, LA
                                St. Martin Parish, LA
29340.......................  Lake Charles, LA...............     0.7914
                                Calcasieu Parish, LA
                                Cameron Parish, LA
29404.......................  Lake County-Kenosha County, IL-     1.0570
                               WI.
                                Lake County, IL
                                Kenosha County, WI
29460.......................  Lakeland, FL...................     0.8879
                                Polk County, FL
29540.......................  Lancaster, PA..................     0.9589
                                Lancaster County, PA
29620.......................  Lansing-East Lansing, MI.......     1.0088
                                Clinton County, MI
                                Eaton County, MI
                                Ingham County, MI
29700.......................  Laredo, TX.....................     0.7811
                                Webb County, TX
29740.......................  Las Cruces, NM.................     0.9273
                                Dona Ana County, NM
29820.......................  Las Vegas-Paradise, NV.........     1.1430
                                Clark County, NV
29940.......................  Lawrence, KS...................     0.8365
                                Douglas County, KS
30020.......................  Lawton, OK.....................     0.8065
                                Comanche County, OK
30140.......................  Lebanon, PA....................     0.8679
                                Lebanon County, PA
30300.......................  Lewiston, ID-WA................     0.9853
                                Nez Perce County, ID
                                Asotin County, WA
30340.......................  LewistonAuburn, ME.............     0.9126
                                Androscoggin County, ME
30460.......................  Lexington-Fayette, KY..........     0.9181
                                Bourbon County, KY
                                Clark County, KY
                                Fayette County, KY
                                Jessamine County, KY
                                Scott County, KY
                                Woodford County, KY
30620.......................  Lima, OH.......................     0.9042
                                Allen County, OH
30700.......................  Lincoln, NE....................     1.0092
                                Lancaster County, NE
                                Seward County, NE
30780.......................  Little Rock-North Little Rock,      0.8890
                               AR.
                                Faulkner County, AR
                                Grant County, AR
                                Lonoke County, AR
                                Perry County, AR
                                Pulaski County, AR
                                Saline County, AR
30860.......................  Logan, UT-ID...................     0.9022
                                Franklin County, ID
                                Cache County, UT
30980.......................  Longview, TX...................     0.8788
                                Gregg County, TX
                                Rusk County, TX
                                Upshur County, TX
31020.......................  Longview, WA...................     1.0011
                                Cowlitz County, WA
31084.......................  Los Angeles-Long Beach-             1.1760
                               Glendale, CA.
                                Los Angeles County, CA
31140.......................  Louisville, KY-IN..............     0.9118
                                Clark County, IN
                                Floyd County, IN

[[Page 65948]]

 
                                Harrison County, IN
                                Washington County, IN
                                Bullitt County, KY
                                Henry County, KY
                                Jefferson County, KY
                                Meade County, KY
                                Nelson County, KY
                                Oldham County, KY
                                Shelby County, KY
                                Spencer County, KY
                                Trimble County, KY
31180.......................  Lubbock, TX....................     0.8613
                                Crosby County, TX
                                Lubbock County, TX
31340.......................  Lynchburg, VA..................     0.8694
                                Amherst County, VA
                                Appomattox County, VA
                                Bedford County, VA
                                Campbell County, VA
                                Bedford City, VA
                                Lynchburg City, VA
31420.......................  Macon, GA......................     0.9519
                                Bibb County, GA
                                Crawford County, GA
                                Jones County, GA
                                Monroe County, GA
                                Twiggs County, GA
31460.......................  Madera, CA.....................     0.8154
                                Madera County, CA
31540.......................  Madison, WI....................     1.0840
                                Columbia County, WI
                                Dane County, WI
                                Iowa County, WI
31700.......................  Manchester-Nashua, NH..........     1.0243
                                Hillsborough County, NH
                                Merrimack County, NH
31900.......................  Mansfield, OH..................     0.9271
                                Richland County, OH
32420.......................  Mayaguez, PR...................     0.3848
                                Hormigueros Municipio, PR
                                Mayaguez Municipio, PR
32580.......................  McAllen-Edinburg-Pharr, TX.....     0.8773
                                Hidalgo County, TX
32780.......................  Medford, OR....................     1.0818
                                Jackson County, OR
32820.......................  Memphis, TN-MS-AR..............     0.9373
                                Crittenden County, AR
                                DeSoto County, MS
                                Marshall County, MS
                                Tate County, MS
                                Tunica County, MS
                                Fayette County, TN
                                Shelby County, TN
                                Tipton County, TN
32900.......................  Merced, CA.....................     1.1471
                                Merced County, CA
33124.......................  Miami-Miami Beach-Kendall, FL..     0.9812
                                Miami-Dade County, FL
33140.......................  Michigan City-La Porte, IN.....     0.9118
                                LaPorte County, IN
33260.......................  Midland, TX....................     0.9786
                                Midland County, TX
33340.......................  Milwaukee-Waukesha-West Allis,      1.0218
                               WI.
                                Milwaukee County, WI
                                Ozaukee County, WI
                                Washington County, WI
                                Waukesha County, WI
33460.......................  Minneapolis-St. Paul-               1.0946
                               Bloomington, MN-WI.
                                Anoka County, MN
                                Carver County, MN

[[Page 65949]]

 
                                Chisago County, MN
                                Dakota County, MN
                                Hennepin County, MN
                                Isanti County, MN
                                Ramsey County, MN
                                Scott County, MN
                                Sherburne County, MN
                                Washington County, MN
                                Wright County, MN
                                Pierce County, WI
                                St. Croix County, WI
33540.......................  Missoula, MT...................     0.8928
                                Missoula County, MT
33660.......................  Mobile, AL.....................     0.7913
                                Mobile County, AL
33700.......................  Modesto, CA....................     1.1729
                                Stanislaus County, CA
33740.......................  Monroe, LA.....................     0.7997
                                Ouachita Parish, LA
                                Union Parish, LA
33780.......................  Monroe, MI.....................     0.9707
                                Monroe County, MI
33860.......................  Montgomery, AL.................     0.8009
                                Autauga County, AL
                                Elmore County, AL
                                Lowndes County, AL
                                Montgomery County, AL
34060.......................  Morgantown, WV.................     0.8423
                                Monongalia County, WV
                                Preston County, WV
34100.......................  Morristown, TN.................     0.7933
                                Grainger County, TN
                                Hamblen County, TN
                                Jefferson County, TN
34580.......................  Mount Vernon-Anacortes, WA.....     1.0517
                                Skagit County, WA
34620.......................  Muncie, IN.....................     0.8562
                                Delaware County, IN
34740.......................  Muskegon-Norton Shores, MI.....     0.9941
                                Muskegon County, MI
34820.......................  Myrtle Beach-Conway-North           0.8810
                               Myrtle Beach, SC.
                                Horry County, SC
34900.......................  Napa, CA.......................     1.3374
                                Napa County, CA
34940.......................  Naples-Marco Island, FL........     0.9941
                                Collier County, FL
34980.......................  Nashville-Davidson-                 0.9847
                               Murfreesboro, TN.
                                Cannon County, TN
                                Cheatham County, TN
                                Davidson County, TN
                                Dickson County, TN
                                Hickman County, TN
                                Macon County, TN
                                Robertson County, TN
                                Rutherford County, TN
                                Smith County, TN
                                Sumner County, TN
                                Trousdale County, TN
                                Williamson County, TN
                                Wilson County, TN
35004.......................  Nassau-Suffolk, NY.............     1.2662
                                Nassau County, NY
                                Suffolk County, NY
35084.......................  Newark-Union, NJ-PA............     1.1892
                                Essex County, NJ
                                Hunterdon County, NJ
                                Morris County, NJ
                                Sussex County, NJ
                                Union County, NJ
                                Pike County, PA

[[Page 65950]]

 
35300.......................  New Haven-Milford, CT..........     1.1953
                                New Haven County, CT
35380.......................  New Orleans-Metairie-Kenner, LA     0.8831
                                Jefferson Parish, LA
                                Orleans Parish, LA
                                Plaquemines Parish, LA
                                St. Bernard Parish, LA
                                St. Charles Parish, LA
                                St. John the Baptist Parish,
                              LA
                                St. Tammany Parish, LA
35644.......................  New York-Wayne-White Plains, NY-    1.3177
                               NJ.
                                Bergen County, NJ
                                Hudson County, NJ
                                Passaic County, NJ
                                Bronx County, NY
                                Kings County, NY
                                New York County, NY
                                Putnam County, NY
                                Queens County, NY
                                Richmond County, NY
                                Rockland County, NY
                                Westchester County, NY
35660.......................  Niles-Benton Harbor, MI........     0.8915
                                Berrien County, MI
35980.......................  Norwich-New London, CT.........     1.1932
                                New London County, CT
36084.......................  Oakland-Fremont-Hayward, CA....     1.5819
                                Alameda County, CA
                                Contra Costa County, CA
36100.......................  Ocala, FL......................     0.8867
                                Marion County, FL
36140.......................  Ocean City, NJ.................     1.0472
                                Cape May County, NJ
36220.......................  Odessa, TX.....................     1.0073
                                Ector County, TX
36260.......................  Ogden-Clearfield, UT...........     0.8995
                                Davis County, UT
                                Morgan County, UT
                                Weber County, UT
36420.......................  Oklahoma City, OK..............     0.8843
                                Canadian County, OK
                                Cleveland County, OK
                                Grady County, OK
                                Lincoln County, OK
                                Logan County, OK
                                McClain County, OK
                                Oklahoma County, OK
36500.......................  Olympia, WA....................     1.1081
                                Thurston County, WA
36540.......................  Omaha-Council Bluffs, NE-IA....     0.9450
                                Harrison County, IA
                                Mills County, IA
                                Pottawattamie County, IA
                                Cass County, NE
                                Douglas County, NE
                                Sarpy County, NE
                                Saunders County, NE
                                Washington County, NE
36740.......................  Orlando, FL....................     0.9452
                                Lake County, FL
                                Orange County, FL
                                Osceola County, FL
                                Seminole County, FL
36780.......................  Oshkosh-Neenah, WI.............     0.9315
                                Winnebago County, WI
36980.......................  Owensboro, KY..................     0.8748
                                Daviess County, KY
                                Hancock County, KY
                                McLean County, KY
37100.......................  Oxnard-Thousand Oaks-Ventura,       1.1546
                               CA.

[[Page 65951]]

 
                                Ventura County, CA
37340.......................  Palm Bay-Melbourne-Titusville,      0.9443
                               FL.
                                Brevard County, FL
37460.......................  Panama City-Lynn Haven, FL.....     0.8027
                                Bay County, FL
37620.......................  Parkersburg-Marietta, WV-OH....     0.7977
                                Washington County, OH
                                Pleasants County, WV
                                Wirt County, WV
                                Wood County, WV
37700.......................  Pascagoula, MS.................     0.8215
                                George County, MS
                                Jackson County, MS
37860.......................  Pensacola-Ferry Pass-Brent, FL.     0.8000
                                Escambia County, FL
                                Santa Rosa County, FL
37900.......................  Peoria, IL.....................     0.8982
                                Marshall County, IL
                                Peoria County, IL
                                Stark County, IL
                                Tazewell County, IL
                                Woodford County, IL
37964.......................  Philadelphia, PA...............     1.0996
                                Bucks County, PA
                                Chester County, PA
                                Delaware County, PA
                                Montgomery County, PA
                                Philadelphia County, PA
38060.......................  Phoenix-Mesa-Scottsdale, AZ....     1.0287
                                Maricopa County, AZ
                                Pinal County, AZ
38220.......................  Pine Bluff, AR.................     0.8383
                                Cleveland County, AR
                                Jefferson County, AR
                                Lincoln County, AR
38300.......................  Pittsburgh, PA.................     0.8674
                                Allegheny County, PA
                                Armstrong County, PA
                                Beaver County, PA
                                Butler County, PA
                                Fayette County, PA
                                Washington County, PA
                                Westmoreland County, PA
38340.......................  Pittsfield, MA.................     1.0266
                                Berkshire County, MA
38540.......................  Pocatello, ID..................     0.9400
                                Bannock County, ID
                                Power County, ID
38660.......................  Ponce, PR......................     0.4842
                                Juana Diaz Municipio, PR
                                Ponce Municipio, PR
                                Villalba Municipio, PR
38860.......................  Portland-South Portland-            0.9908
                               Biddeford, ME.
                                Cumberland County, ME
                                Sagadahoc County, ME
                                York County, ME
38900.......................  Portland-Vancouver-Beaverton,       1.1416
                               OR-WA.
                                Clackamas County, OR
                                Columbia County, OR
                                Multnomah County, OR
                                Washington County, OR
                                Yamhill County, OR
                                Clark County, WA
                                Skamania County, WA
38940.......................  Port St. Lucie-Fort Pierce, FL.     0.9833
                                Martin County, FL
                                St. Lucie County, FL
39100.......................  Poughkeepsie-Newburgh-              1.0911
                               Middletown, NY.
                                Dutchess County, NY
                                Orange County, NY

[[Page 65952]]

 
39140.......................  Prescott, AZ...................     0.9836
                                Yavapai County, AZ
39300.......................  Providence-New Bedford-Fall         1.0783
                               River, RI-MA.
                                Bristol County, MA
                                Bristol County, RI
                                Kent County, RI
                                Newport County, RI
                                Providence County, RI
                                Washington County, RI
39340.......................  Provo-Orem, UT.................     0.9537
                                Juab County, UT
                                Utah County, UT
39380.......................  Pueblo, CO.....................     0.8753
                                Pueblo County, CO
39460.......................  Punta Gorda, FL................     0.9405
                                Charlotte County, FL
39540.......................  Racine, WI.....................     0.9356
                                Racine County, WI
39580.......................  Raleig-hCary, NC...............     0.9864
                                Franklin County, NC
                                Johnston County, NC
                                Wake County, NC
39660.......................  Rapid City, SD.................     0.8833
                                Meade County, SD
                                Pennington County, SD
39740.......................  Reading, PA....................     0.9622
                                Berks County, PA
39820.......................  Redding, CA....................     1.3198
                                Shasta County, CA
39900.......................  Reno-Sparks, NV................     1.1963
                                Storey County, NV
                                Washoe County, NV
40060.......................  Richmond, VA...................     0.9177
                                Amelia County, VA
                                Caroline County, VA
                                Charles City County, VA
                                Chesterfield County, VA
                                Cumberland County, VA
                                Dinwiddie County, VA
                                Goochland County, VA
                                Hanover County, VA
                                Henrico County, VA
                                King and Queen County, VA
                                King William County, VA
                                Louisa County, VA
                                New Kent County, VA
                                Powhatan County, VA
                                Prince George County, VA
                                Sussex County, VA
                                Colonial Heights City, VA
                                Hopewell City, VA
                                Petersburg City, VA
                                Richmond City, VA
40140.......................  Riverside-San Bernardino-           1.0904
                               Ontario, CA.
                                Riverside County, CA
                                San Bernardino County, CA
40220.......................  Roanoke, VA....................     0.8647
                                Botetourt County, VA
                                Craig County, VA
                                Franklin County, VA
                                Roanoke County, VA
                                Roanoke City, VA
                                Salem City, VA
40340.......................  Rochester, MN..................     1.1408
                                Dodge County, MN
                                Olmsted County, MN
                                Wabasha County, MN
40380.......................  Rochester, NY..................     0.8994
                                Livingston County, NY
                                Monroe County, NY

[[Page 65953]]

 
                                Ontario County, NY
                                Orleans County, NY
                                Wayne County, NY
40420.......................  Rockford, IL...................     0.9989
                                Boone County, IL
                                Winnebago County, IL
40484.......................  Rockingham County-Strafford         1.0159
                               County, NH.
                                Rockingham County, NH
                                Strafford County, NH
40580.......................  Rocky Mount, NC................     0.8854
                                Edgecombe County, NC
                                Nash County, NC
40660.......................  Rome, GA.......................     0.9193
                                Floyd County, GA
40900.......................  Sacramento--Arden-Arcade--          1.3372
                               Roseville, CA.
                                El Dorado County, CA
                                Placer County, CA
                                Sacramento County, CA
                                Yolo County, CA
40980.......................  Saginaw-Saginaw Township North,     0.8874
                               MI.
                                Saginaw County, MI
41060.......................  St. Cloud, MN..................     1.0362
                                Benton County, MN
                                Stearns County, MN
41100.......................  St. George, UT.................     0.9265
                                Washington County, UT
41140.......................  St. Joseph, MO-KS..............     1.0118
                                Doniphan County, KS
                                Andrew County, MO
                                Buchanan County, MO
                                DeKalb County, MO
41180.......................  St. Louis, MO-IL...............     0.9005
                                Bond County, IL
                                Calhoun County, IL
                                Clinton County, IL
                                Jersey County, IL
                                Macoupin County, IL
                                Madison County, IL
                                Monroe County, IL
                                St. Clair County, IL
                                Crawford County, MO
                                Franklin County, MO
                                Jefferson County, MO
                                Lincoln County, MO
                                St. Charles County, MO
                                St. Louis County, MO
                                Warren County, MO
                                Washington County, MO
                                St. Louis City, MO
41420.......................  Salem, OR......................     1.0438
                                Marion County, OR
                                Polk County, OR
41500.......................  Salinas, CA....................     1.4337
                                Monterey County, CA
41540.......................  Salisbury, MD..................     0.8953
                                Somerset County, MD
                                Wicomico County, MD
41620.......................  Salt Lake City, UT.............     0.9402
                                Salt Lake County, UT
                                Summit County, UT
                                Tooele County, UT
41660.......................  San Angelo, TX.................     0.8362
                                Irion County, TX
                                Tom Green County, TX
41700.......................  San Antonio, TX................     0.8844
                                Atascosa County, TX
                                Bandera County, TX
                                Bexar County, TX
                                Comal County, TX
                                Guadalupe County, TX

[[Page 65954]]

 
                                Kendall County, TX
                                Medina County, TX
                                Wilson County, TX
41740.......................  San Diego-Carlsbad-San Marcos,      1.1354
                               CA.
                                San Diego County, CA
41780.......................  Sandusky, OH...................     0.9302
                                Erie County, OH
41884.......................  San Francisco-San Mateo-Redwood     1.5165
                               City, CA.
                                Marin County, CA
                                San Francisco County, CA
                                San Mateo County, CA
41900.......................  San German-Cabo Rojo, PR.......     0.4885
                                Cabo Rojo Municipio, PR
                                Lajas Municipio, PR
                                Sabana Grande Municipio, PR
                                San German Municipio, PR
41940.......................  San Jose-Sunnyvale-Santa Clara,     1.5543
                               CA.
                                San Benito County, CA
                                Santa Clara County, CA
41980.......................  San Juan-Caguas-Guaynabo, PR...     0.4452
                                Aguas Buenas Municipio, PR
                                Aibonito Municipio, PR
                                Arecibo Municipio, PR
                                Barceloneta Municipio, PR
                                Barranquitas Municipio, PR
                                Bayamon Municipio, PR
                                Caguas Municipio, PR
                                Camuy Municipio, PR
                                Canovanas Municipio, PR
                                Carolina Municipio, PR
                                Catano Municipio, PR
                                Cayey Municipio, PR
                                Ciales Municipio, PR
                                Cidra Municipio, PR
                                Comerio Municipio, PR
                                Corozal Municipio, PR
                                Dorado Municipio, PR
                                Florida Municipio, PR
                                Guaynabo Municipio, PR
                                Gurabo Municipio, PR
                                Hatillo Municipio, PR
                                Humacao Municipio, PR
                                Juncos Municipio, PR
                                Las Piedras Municipio, PR
                                Loiza Municipio, PR
                                Manati Municipio, PR
                                Maunabo Municipio, PR
                                Morovis Municipio, PR
                                Naguabo Municipio, PR
                                Naranjito Municipio, PR
                                Orocovis Municipio, PR
                                Quebradillas Municipio, PR
                                Rio Grande Municipio, PR
                                San Juan Municipio, PR
                                San Lorenzo Municipio, PR
                                Toa Alta Municipio, PR
                                Toa Baja Municipio, PR
                                Trujillo Alto Municipio, PR
                                Vega Alta Municipio, PR
                                Vega Baja Municipio, PR
                                Yabucoa Municipio, PR
42020.......................  San Luis Obispo-Paso Robles, CA     1.1598
                                San Luis Obispo County, CA
42044.......................  Santa Ana-Anaheim-Irvine, CA...     1.1473
                                Orange County, CA
42060.......................  Santa Barbara-Santa Maria-          1.1091
                               Goleta, CA.
                                Santa Barbara County, CA
42100.......................  Santa Cruz-Watsonville, CA.....     1.5457
                                Santa Cruz County, CA
42140.......................  Santa Fe, NM...................     1.0824

[[Page 65955]]

 
                                Santa Fe County, NM
42220.......................  Santa Rosa-Petaluma, CA........     1.4464
                                Sonoma County, CA
42260.......................  Sarasota-Bradenton-Venice, FL..     0.9868
                                Manatee County, FL
                                Sarasota County, FL
42340.......................  Savannah, GA...................     0.9351
                                Bryan County, GA
                                Chatham County, GA
                                Effingham County, GA
42540.......................  Scranton-Wilkes-Barre, PA......     0.8347
                                Lackawanna County, PA
                                Luzerne County, PA
                                Wyoming County, PA
42644.......................  Seattle-Bellevue-Everett, WA...     1.1434
                                King County, WA
                                Snohomish County, WA
42680.......................  Sebastian-Vero Beach, FL.......     0.9573
43100.......................  Sheboygan, WI..................     0.9026
                                Sheboygan County, WI
43300.......................  Sherman-Denison, TX............     0.8502
                                Grayson County, TX
43340.......................  Shreveport-Bossier City, LA....     0.8865
                                Bossier Parish, LA
                                Caddo Parish, LA
                                De Soto Parish, LA
43580.......................  Sioux City, IA-NE-SD...........     0.9200
                                Woodbury County, IA
                                Dakota County, NE
                                Dixon County, NE
                                Union County, SD
43620.......................  Sioux Falls, SD................     0.9559
                                Lincoln County, SD
                                McCook County, SD
                                Minnehaha County, SD
                                Turner County, SD
43780.......................  South Bend-Mishawaka, IN-MI....     0.9842
                                St. Joseph County, IN
                                Cass County, MI
43900.......................  Spartanburg, SC................     0.9174
                                Spartanburg County, SC
44060.......................  Spokane, WA....................     1.0447
                                Spokane County, WA
44100.......................  Springfield, IL................     0.8890
                                Menard County, IL
                                Sangamon County, IL
44140.......................  Springfield, MA................     1.0079
                                Franklin County, MA
                                Hampden County, MA
                                Hampshire County, MA
44180.......................  Springfield, MO................     0.8469
                                Christian County, MO
                                Dallas County, MO
                                Greene County, MO
                                Polk County, MO
                                Webster County, MO
44220.......................  Springfield, OH................     0.8593
                                Clark County, OH
44300.......................  State College, PA..............     0.8784
                                Centre County, PA
44700.......................  Stockton, CA...................     1.1442
                                San Joaquin County, CA
44940.......................  Sumter, SC.....................     0.8083
                                Sumter County, SC
45060.......................  Syracuse, NY...................     0.9691
                                Madison County, NY
                                Onondaga County, NY
                                Oswego County, NY
45104.......................  Tacoma, WA.....................     1.0789
                                Pierce County, WA

[[Page 65956]]

 
45220.......................  Tallahassee, FL................     0.8942
                                Gadsden County, FL
                                Jefferson County, FL
                                Leon County, FL
                                Wakulla County, FL
45300.......................  Tampa-St. Petersburg-               0.9144
                               Clearwater, FL.
                                Hernando County, FL
                                Hillsborough County, FL
                                Pasco County, FL
                                Pinellas County, FL
45460.......................  Terre Haute, IN................     0.8765
                                Clay County, IN
                                Sullivan County, IN
                                Vermillion County, IN
                                Vigo County, IN
45500.......................  Texarkana, TX-Texarkana, AR....     0.8104
                                Miller County, AR
                                Bowie County, TX
45780.......................  Toledo, OH.....................     0.9586
                                Fulton County, OH
                                Lucas County, OH
                                Ottawa County, OH
                                Wood County, OH
45820.......................  Topeka, KS.....................     0.8730
                                Jackson County, KS
                                Jefferson County, KS
                                Osage County, KS
                                Shawnee County, KS
                                Wabaunsee County, KS
45940.......................  Trenton-Ewing, NJ..............     1.0835
                                Mercer County, NJ
46060.......................  Tucson, AZ.....................     0.9202
                                Pima County, AZ
46140.......................  Tulsa, OK......................     0.8103
                                Creek County, OK
                                Okmulgee County, OK
                                Osage County, OK
                                Pawnee County, OK
                                Rogers County, OK
                                Tulsa County, OK
                                Wagoner County, OK
46220.......................  Tuscaloosa, AL.................     0.8542
                                Greene County, AL
                                Hale County, AL
                                Tuscaloosa County, AL
46340.......................  Tyler, TX......................     0.8811
                                Smith County, TX
46540.......................  Utica-Rome, NY.................     0.8396
                                Herkimer County, NY
                                Oneida County, NY
46660.......................  Valdosta, GA...................     0.8369
                                Brooks County, GA
                                Echols County, GA
                                Lanier County, GA
                                Lowndes County, GA
46700.......................  Vallejo-Fairfield, CA..........     1.5137
                                Solano County, CA
47020.......................  Victoria, TX...................     0.8560
                                Calhoun County, TX
                                Goliad County, TX
                                Victoria County, TX
47220.......................  Vineland-Millville-Bridgeton,       0.9832
                               NJ.
                                Cumberland County, NJ
47260.......................  Virginia Beach-Norfolk-Newport      0.8790
                               News, VA-NC.
                                Currituck County, NC
                                Gloucester County, VA
                                Isle of Wight County, VA
                                James City County, VA
                                Mathews County, VA
                                Surry County, VA

[[Page 65957]]

 
                                York County, VA
                                Chesapeake City, VA
                                Hampton City, VA
                                Newport News City, VA
                                Norfolk City, VA
                                Poquoson City, VA
                                Portsmouth City, VA
                                Suffolk City, VA
                                Virginia Beach City, VA
                                Williamsburg City, VA
47300.......................  Visalia-Porterville, CA........     0.9968
                                Tulare County, CA
47380.......................  Waco, TX.......................     0.8633
                                McLennan County, TX
47580.......................  Warner Robins, GA..............     0.8380
                                Houston County, GA
47644.......................  Warren-Farmington Hills-Troy,       1.0054
                               MI.
                                Lapeer County, MI
                                Livingston County, MI
                                Macomb County, MI
                                Oakland County, MI
                                St. Clair County, MI
47894.......................  Washington-Arlington-               1.1054
                               Alexandria, DC-VA-MD-WV.
                                District of Columbia, DC
                                Calvert County, MD
                                Charles County, MD
                                Prince George's County, MD
                                Arlington County, VA
                                Clarke County, VA
                                Fairfax County, VA
                                Fauquier County, VA
                                Loudoun County, VA
                                Prince William County, VA
                                Spotsylvania County, VA
                                Stafford County, VA
                                Warren County, VA
                                Alexandria City, VA
                                Fairfax City, VA
                                Falls Church City, VA
                                Fredericksburg City, VA
                                Manassas City, VA
                                Manassas Park City, VA
                                Jefferson County, WV
47940.......................  Waterloo-Cedar Falls, IA.......     0.8408
                                Black Hawk County, IA
                                Bremer County, IA
                                Grundy County, IA
48140.......................  Wausau, WI.....................     0.9722
                                Marathon County, WI
48260.......................  Weirton-Steubenville, WV-OH....     0.8063
                                Jefferson County, OH
                                Brooke County, WV
                                Hancock County, WV
48300.......................  Wenatchee, WA..................     1.0346
                                Chelan County, WA
                                Douglas County, WA
48424.......................  West Palm Beach-Boca Raton-         0.9649
                               Boynton Beach, FL.
                                Palm Beach County, FL
48540.......................  Wheeling, WV-OH................     0.7010
                                Belmont County, OH
                                Marshall County, WV
                                Ohio County, WV
48620.......................  Wichita, KS....................     0.9063
                                Butler County, KS
                                Harvey County, KS
                                Sedgwick County, KS
                                Sumner County, KS
48660.......................  Wichita Falls, TX..............     0.8311
                                Archer County, TX
                                Clay County, TX

[[Page 65958]]

 
                                Wichita County, TX
48700.......................  Williamsport, PA...............     0.8139
                                Lycoming County, PA
48864.......................  Wilmington, DE-MD-NJ...........     1.0684
                                New Castle County, DE
                                Cecil County, MD
                                Salem County, NJ
48900.......................  Wilmington, NC.................     0.9835
                                Brunswick County, NC
                                New Hanover County, NC
                                Pender County, NC
49020.......................  Winchester, VA-WV..............     1.0091
                                Frederick County, VA
                                Winchester City, VA
                                Hampshire County, WV
49180.......................  Winston-Salem, NC..............     0.9276
                                Davie County, NC
                                Forsyth County, NC
                                Stokes County, NC
                                Yadkin County, NC
49340.......................  Worcester, MA..................     1.0722
                                Worcester County, MA
49420.......................  Yakima, WA.....................     0.9847
                                Yakima County, WA
49500.......................  Yauco, PR......................     0.3854
                                Guanica Municipio, PR
                                Guayanilla Municipio, PR
                                Penuelas Municipio, PR
                                Yauco Municipio, PR
49620.......................  York-Hanover, PA...............     0.9397
                                York County, PA
49660.......................  Youngstown-Warren-Boardman, OH-     0.8802
                               PA.
                                Mahoning County, OH
                                Trumbull County, OH
                                Mercer County, PA
49700.......................  Yuba City, CA..................     1.0730
                                Sutter County, CA
                                Yuba County, CA
49740.......................  Yuma, AZ.......................     0.9109
                                Yuma County, AZ
------------------------------------------------------------------------
\1\ At this time, there are no hospitals in these urban areas on which
  to base a wage index. Therefore, the urban wage index value is based
  on the average wage index of all urban areas within the State.


 Addendum C.--Comparison of HH PPS Transition Wage Index for CY 2006 and Pre-Floor and Pre-Reclassified Hospital
                                             Wage Index For CY 2007
----------------------------------------------------------------------------------------------------------------
                                                                          CY 2006 HH
                                                                             PPS      CY2007 CBSA-    Percent
      SSA state/county code              County name          CBSA No.    transition   based wage  change CY2006-
                                                                          wage index     index         CY2007
----------------------------------------------------------------------------------------------------------------
01000...........................  Autauga County, Alabama.        33860       0.8618       0.8009         -7.07
01010...........................  Baldwin County, Alabama.        99901       0.7654       0.7591         -0.82
01020...........................  Barbour County, Alabama.        99901       0.7439       0.7591          2.04
01030...........................  Bibb County, Alabama....        13820       0.8196       0.8894          8.52
01040...........................  Blount County, Alabama..        13820       0.8980       0.8894         -0.96
01050...........................  Bullock County, Alabama.        99901       0.7439       0.7591          2.04
01060...........................  Butler County, Alabama..        99901       0.7439       0.7591          2.04
01070...........................  Calhoun County, Alabama.        11500       0.7682       0.7770          1.15
01080...........................  Chambers County, Alabama        99901       0.7439       0.7591          2.04
01090...........................  Cherokee County, Alabama        99901       0.7439       0.7591          2.04
01100...........................  Chilton County, Alabama.        13820       0.8196       0.8894          8.52
01110...........................  Choctaw County, Alabama.        99901       0.7439       0.7591          2.04
01120...........................  Clarke County, Alabama..        99901       0.7439       0.7591          2.04
01130...........................  Clay County, Alabama....        99901       0.7439       0.7591          2.04
01140...........................  Cleburne County, Alabama        99901       0.7439       0.7591          2.04
01150...........................  Coffee County, Alabama..        99901       0.7439       0.7591          2.04
01160...........................  Colbert County, Alabama.        22520       0.8272       0.7843         -5.19
01170...........................  Conecuh County, Alabama.        99901       0.7439       0.7591          2.04

[[Page 65959]]

 
01180...........................  Coosa County, Alabama...        99901       0.7439       0.7591          2.04
01190...........................  Covington County,               99901       0.7439       0.7591          2.04
                                   Alabama.
01200...........................  Crenshaw County, Alabama        99901       0.7439       0.7591          2.04
01210...........................  Cullman County, Alabama.        99901       0.7439       0.7591          2.04
01220...........................  Dale County, Alabama....        99901       0.7574       0.7591          0.22
01230...........................  Dallas County, Alabama..        99901       0.7439       0.7591          2.04
01240...........................  De Kalb County, Alabama.        99901       0.7439       0.7591          2.04
01250...........................  Elmore County, Alabama..        33860       0.8618       0.8009         -7.07
01260...........................  Escambia County, Alabama        99901       0.7439       0.7591          2.04
01270...........................  Etowah County, Alabama..        23460       0.7938       0.8066          1.61
01280...........................  Fayette County, Alabama.        99901       0.7439       0.7591          2.04
01290...........................  Franklin County, Alabama        99901       0.7439       0.7591          2.04
01300...........................  Geneva County, Alabama..        20020       0.7577       0.7381         -2.59
01310...........................  Greene County, Alabama..        46220       0.8039       0.8542          6.26
01320...........................  Hale County, Alabama....        46220       0.8039       0.8542          6.26
01330...........................  Henry County, Alabama...        20020       0.7577       0.7381         -2.59
01340...........................  Houston County, Alabama.        20020       0.7711       0.7381         -4.28
01350...........................  Jackson County, Alabama.        99901       0.7439       0.7591          2.04
01360...........................  Jefferson County,               13820       0.8980       0.8894         -0.96
                                   Alabama.
01370...........................  Lamar County, Alabama...        99901       0.7439       0.7591          2.04
01380...........................  Lauderdale County,              22520       0.8272       0.7843         -5.19
                                   Alabama.
01390...........................  Lawrence County, Alabama        19460       0.8469       0.8159         -3.66
01400...........................  Lee County, Alabama.....        12220       0.8100       0.8096         -0.05
01410...........................  Limestone County,               26620       0.9146       0.9007         -1.52
                                   Alabama.
01420...........................  Lowndes County, Alabama.        33860       0.8025       0.8009         -0.20
01430...........................  Macon County, Alabama...        99901       0.7439       0.7591          2.04
01440...........................  Madison County, Alabama.        26620       0.9146       0.9007         -1.52
01450...........................  Marengo County, Alabama.        99901       0.7439       0.7591          2.04
01460...........................  Marion County, Alabama..        99901       0.7439       0.7591          2.04
01470...........................  Marshall County, Alabama        99901       0.7439       0.7591          2.04
01480...........................  Mobile County, Alabama..        33660       0.7876       0.7913          0.47
01490...........................  Monroe County, Alabama..        99901       0.7439       0.7591          2.04
01500...........................  Montgomery County,              33860       0.8618       0.8009         -7.07
                                   Alabama.
01510...........................  Morgan County, Alabama..        19460       0.8469       0.8159         -3.66
01520...........................  Perry County, Alabama...        99901       0.7439       0.7591          2.04
01530...........................  Pickens County, Alabama.        99901       0.7439       0.7591          2.04
01540...........................  Pike County, Alabama....        99901       0.7439       0.7591          2.04
01550...........................  Randolph County, Alabama        99901       0.7439       0.7591          2.04
01560...........................  Russell County, Alabama.        17980       0.8560       0.8239         -3.75
01570...........................  St Clair County, Alabama        13820       0.8980       0.8894         -0.96
01580...........................  Shelby County, Alabama..        13820       0.8980       0.8894         -0.96
01590...........................  Sumter County, Alabama..        99901       0.7439       0.7591          2.04
01600...........................  Talladega County,               99901       0.7439       0.7591          2.04
                                   Alabama.
01610...........................  Tallapoosa County,              99901       0.7439       0.7591          2.04
                                   Alabama.
01620...........................  Tuscaloosa County,              46220       0.8705       0.8542         -1.87
                                   Alabama.
01630...........................  Walker County, Alabama..        13820       0.8196       0.8894          8.52
01640...........................  Washington County,              99901       0.7439       0.7591          2.04
                                   Alabama.
01650...........................  Wilcox County, Alabama..        99901       0.7439       0.7591          2.04
01660...........................  Winston County, Alabama.        99901       0.7439       0.7591          2.04
02013...........................  Aleutians County East,          99902       1.1933       1.0661        -10.66
                                   Alaska.
02016...........................  Aleutians County West,          99902       1.1933       1.0661        -10.66
                                   Alaska.
02020...........................  Anchorage County, Alaska        11260       1.1840       1.2023          1.55
02030...........................  Angoon County, Alaska...        99902       1.1933       1.0661        -10.66
02040...........................  Barrow-North Slope              99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02050...........................  Bethel County, Alaska...        99902       1.1933       1.0661        -10.66
02060...........................  Bristol Bay Borough             99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02068...........................  Denali County, Alaska...        99902       1.1933       1.0661        -10.66
02070...........................  Bristol Bay County,             99902       1.1933       1.0661        -10.66
                                   Alaska.
02080...........................  Cordova-Mc Carthy               99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02090...........................  Fairbanks County, Alaska        21820       1.1648       1.1059         -5.06
02100...........................  Haines County, Alaska...        99902       1.1933       1.0661        -10.66
02110...........................  Juneau County, Alaska...        99902       1.1933       1.0661        -10.66
02120...........................  Kenai-Cook Inlet County,        99902       1.1933       1.0661        -10.66
                                   Alaska.
02122...........................  Kenai Peninsula Borough,        99902       1.1933       1.0661        -10.66
                                   Alaska.
02130...........................  Ketchikan County, Alaska        99902       1.1933       1.0661        -10.66
02140...........................  Kobuk County, Alaska....        99902       1.1933       1.0661        -10.66
02150...........................  Kodiak County, Alaska...        99902       1.1933       1.0661        -10.66
02160...........................  Kuskokwin County, Alaska        99902       1.1933       1.0661        -10.66

[[Page 65960]]

 
02164...........................  Lake and Peninsula              99902       1.1933       1.0661        -10.66
                                   Borough, Alaska.
02170...........................  Matanuska County, Alaska        11260       1.1892       1.2023          1.10
02180...........................  Nome County, Alaska.....        99902       1.1933       1.0661        -10.66
02185...........................  North Slope Borough,            99902       1.1933       1.0661        -10.66
                                   Alaska.
02188...........................  Northwest Arctic                99902       1.1933       1.0661        -10.66
                                   Borough, Alaska.
02190...........................  Outer Ketchikan County,         99902       1.1933       1.0661        -10.66
                                   Alaska.
02200...........................  Prince Of Wales County,         99902       1.1933       1.0661        -10.66
                                   Alaska.
02201...........................  Prince of Wales-Outer           99902       1.1933       1.0661        -10.66
                                   Ketchikan Census
                                   Area,AK.
02210...........................  Seward County, Alaska...        99902       1.1933       1.0661        -10.66
02220...........................  Sitka County, Alaska....        99902       1.1933       1.0661        -10.66
02230...........................  Skagway-Yakutat County,         99902       1.1933       1.0661        -10.66
                                   Alaska.
02231...........................  Skagway-Yakutat-Angoon          99902       1.1933       1.0661        -10.66
                                   Census Area, Alaska.
02232...........................  Skagway-Hoonah-Angoon           99902       1.1933       1.0661        -10.66
                                   Census Area, Alaska.
02240...........................  Southeast Fairbanks             99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02250...........................  Upper Yukon County,             99902       1.1933       1.0661        -10.66
                                   Alaska.
02260...........................  Valdz-Chitna-Whitier            99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02261...........................  Valdex-Cordove Census           99902       1.1933       1.0661        -10.66
                                   Area, Alaska.
02270...........................  Wade Hampton County,            99902       1.1933       1.0661        -10.66
                                   Alaska.
02280...........................  Wrangell-Petersburg             99902       1.1933       1.0661        -10.66
                                   County, Alaska.
02282...........................  Yakutat Borough, Alaska.        99902       1.1933       1.0661        -10.66
02290...........................  Yukon-Koyukuk County,           99902       1.1933       1.0661        -10.66
                                   Alaska.
03000...........................  Apache County, Arizona..        99903       0.8907       0.8908          0.01
03010...........................  Cochise County, Arizona.        99903       0.8907       0.8908          0.01
03020...........................  Coconino County, Arizona        22380       1.1969       1.1601         -3.07
03030...........................  Gila County, Arizona....        99903       0.8907       0.8908          0.01
03040...........................  Graham County, Arizona..        99903       0.8907       0.8908          0.01
03050...........................  Greenlee County, Arizona        99903       0.8907       0.8908          0.01
03055...........................  La Paz County, Arizona..        99903       0.8907       0.8908          0.01
03060...........................  Maricopa County, Arizona        38060       1.0127       1.0287          1.58
03070...........................  Mohave County, Arizona..        99903       0.9962       0.8908        -10.58
03080...........................  Navajo County, Arizona..        99903       0.8907       0.8908          0.01
03090...........................  Pima County, Arizona....        46060       0.9007       0.9202          2.16
03100...........................  Pinal County, Arizona...        38060       1.0127       1.0287          1.58
03110...........................  Santa Cruz County,              99903       0.8907       0.8908          0.01
                                   Arizona.
03120...........................  Yavapai County, Arizona.        39140       0.9457       0.9836          4.01
03130...........................  Yuma County, Arizona....        49740       0.9126       0.9109         -0.19
04000...........................  Arkansas County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04010...........................  Ashley County, Arkansas.        99904       0.7605       0.7307         -3.92
04020...........................  Baxter County, Arkansas.        99904       0.7605       0.7307         -3.92
04030...........................  Benton County, Arkansas.        22220       0.8661       0.8865          2.36
04040...........................  Boone County, Arkansas..        99904       0.7605       0.7307         -3.92
04050...........................  Bradley County, Arkansas        99904       0.7605       0.7307         -3.92
04060...........................  Calhoun County, Arkansas        99904       0.7605       0.7307         -3.92
04070...........................  Carroll County, Arkansas        99904       0.7605       0.7307         -3.92
04080...........................  Chicot County, Arkansas.        99904       0.7605       0.7307         -3.92
04090...........................  Clark County, Arkansas..        99904       0.7605       0.7307         -3.92
04100...........................  Clay County, Arkansas...        99904       0.7605       0.7307         -3.92
04110...........................  Cleburne County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04120...........................  Cleveland County,               38220       0.8212       0.8383          2.08
                                   Arkansas.
04130...........................  Columbia County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04140...........................  Conway County, Arkansas.        99904       0.7605       0.7307         -3.92
04150...........................  Craighead County,               27860       0.7911       0.7662         -3.15
                                   Arkansas.
04160...........................  Crawford County,                22900       0.8238       0.7731         -6.15
                                   Arkansas.
04170...........................  Crittenden County,              32820       0.9407       0.9373         -0.36
                                   Arkansas.
04180...........................  Cross County, Arkansas..        99904       0.7605       0.7307         -3.92
04190...........................  Dallas County, Arkansas.        99904       0.7605       0.7307         -3.92
04200...........................  Desha County, Arkansas..        99904       0.7605       0.7307         -3.92
04210...........................  Drew County, Arkansas...        99904       0.7605       0.7307         -3.92
04220...........................  Faulkner County,                30780       0.8747       0.8890          1.63
                                   Arkansas.
04230...........................  Franklin County,                22900       0.7987       0.7731         -3.21
                                   Arkansas.
04240...........................  Fulton County, Arkansas.        99904       0.7605       0.7307         -3.92
04250...........................  Garland County, Arkansas        26300       0.8375       0.8782          4.86
04260...........................  Grant County, Arkansas..        30780       0.8246       0.8890          7.81
04270...........................  Greene County, Arkansas.        99904       0.7605       0.7307         -3.92
04280...........................  Hempstead County,               99904       0.7605       0.7307         -3.92
                                   Arkansas.
04290...........................  Hot Spring County,              99904       0.7605       0.7307         -3.92
                                   Arkansas.
04300...........................  Howard County, Arkansas.        99904       0.7605       0.7307         -3.92
04310...........................  Independence County,            99904       0.7605       0.7307         -3.92
                                   Arkansas.

[[Page 65961]]

 
04320...........................  Izard County, Arkansas..        99904       0.7605       0.7307         -3.92
04330...........................  Jackson County, Arkansas        99904       0.7605       0.7307         -3.92
04340...........................  Jefferson County,               38220       0.8680       0.8383         -3.42
                                   Arkansas.
04350...........................  Johnson County, Arkansas        99904       0.7605       0.7307         -3.92
04360...........................  Lafayette County,               99904       0.7605       0.7307         -3.92
                                   Arkansas.
04370...........................  Lawrence County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04380...........................  Lee County, Arkansas....        99904       0.7605       0.7307         -3.92
04390...........................  Lincoln County, Arkansas        38220       0.8212       0.8383          2.08
04400...........................  Little River County,            99904       0.7605       0.7307         -3.92
                                   Arkansas.
04410...........................  Logan County, Arkansas..        99904       0.7605       0.7307         -3.92
04420...........................  Lonoke County, Arkansas.        30780       0.8747       0.8890          1.63
04430...........................  Madison County, Arkansas        22220       0.8203       0.8865          8.07
04440...........................  Marion County, Arkansas.        99904       0.7605       0.7307         -3.92
04450...........................  Miller County, Arkansas.        45500       0.8283       0.8104         -2.16
04460...........................  Mississippi County,             99904       0.7605       0.7307         -3.92
                                   Arkansas.
04470...........................  Monroe County, Arkansas.        99904       0.7605       0.7307         -3.92
04480...........................  Montgomery County,              99904       0.7605       0.7307         -3.92
                                   Arkansas.
04490...........................  Nevada County, Arkansas.        99904       0.7605       0.7307         -3.92
04500...........................  Newton County, Arkansas.        99904       0.7605       0.7307         -3.92
04510...........................  Ouachita County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04520...........................  Perry County, Arkansas..        30780       0.8246       0.8890          7.81
04530...........................  Phillips County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04540...........................  Pike County, Arkansas...        99904       0.7605       0.7307         -3.92
04550...........................  Poinsett County,                27860       0.7828       0.7662         -2.12
                                   Arkansas.
04560...........................  Polk County, Arkansas...        99904       0.7605       0.7307         -3.92
04570...........................  Pope County, Arkansas...        99904       0.7605       0.7307         -3.92
04580...........................  Prairie County, Arkansas        99904       0.7605       0.7307         -3.92
04590...........................  Pulaski County, Arkansas        30780       0.8747       0.8890          1.63
04600...........................  Randolph County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04610...........................  St Francis County,              99904       0.7605       0.7307         -3.92
                                   Arkansas.
04620...........................  Saline County, Arkansas.        30780       0.8747       0.8890          1.63
04630...........................  Scott County, Arkansas..        99904       0.7605       0.7307         -3.92
04640...........................  Searcy County, Arkansas.        99904       0.7605       0.7307         -3.92
04650...........................  Sebastian County,               22900       0.8238       0.7731         -6.15
                                   Arkansas.
04660...........................  Sevier County, Arkansas.        99904       0.7605       0.7307         -3.92
04670...........................  Sharp County, Arkansas..        99904       0.7605       0.7307         -3.92
04680...........................  Stone County, Arkansas..        99904       0.7605       0.7307         -3.92
04690...........................  Union County, Arkansas..        99904       0.7605       0.7307         -3.92
04700...........................  Van Buren County,               99904       0.7605       0.7307         -3.92
                                   Arkansas.
04710...........................  Washington County,              22220       0.8661       0.8865          2.36
                                   Arkansas.
04720...........................  White County, Arkansas..        99904       0.7605       0.7307         -3.92
04730...........................  Woodruff County,                99904       0.7605       0.7307         -3.92
                                   Arkansas.
04740...........................  Yell County, Arkansas...        99904       0.7605       0.7307         -3.92
05000...........................  Alameda County,                 36084       1.5346       1.5819          3.08
                                   California.
05010...........................  Alpine County,                  99905       1.0915       1.1454          4.94
                                   California.
05020...........................  Amador County,                  99905       1.0915       1.1454          4.94
                                   California.
05030...........................  Butte County, California        17020       1.0511       1.1053          5.16
05040...........................  Calaveras County,               99905       1.0915       1.1454          4.94
                                   California.
05050...........................  Colusa County,                  99905       1.0915       1.1454          4.94
                                   California.
05060...........................  Contra Costa County,            36084       1.5346       1.5819          3.08
                                   California.
05070...........................  Del Norte County,               99905       1.0915       1.1454          4.94
                                   California.
05080...........................  Eldorado County,                40900       1.3056       1.3372          2.42
                                   California.
05090...........................  Fresno County,                  23420       1.0483       1.0943          4.39
                                   California.
05100...........................  Glenn County, California        99905       1.0915       1.1454          4.94
05110...........................  Humboldt County,                99905       1.0915       1.1454          4.94
                                   California.
05120...........................  Imperial County,                20940       0.9841       0.9076         -7.77
                                   California.
05130...........................  Inyo County, California.        99905       1.0915       1.1454          4.94
05140...........................  Kern County, California.        12540       1.0470       1.0725          2.44
05150...........................  Kings County, California        25260       1.0406       1.0282         -1.19
05160...........................  Lake County, California.        99905       1.0915       1.1454          4.94
05170...........................  Lassen County,                  99905       1.0915       1.1454          4.94
                                   California.
05200...........................  Los Angeles County,             31084       1.1783       1.1760         -0.20
                                   California.
05210...........................  Los Angeles County,             31084       1.1783       1.1760         -0.20
                                   California.
05300...........................  Madera County,                  31460       0.9571       0.8154        -14.81
                                   California.
05310...........................  Marin County, California        41884       1.4994       1.5165          1.14
05320...........................  Mariposa County,                99905       1.0915       1.1454          4.94
                                   California.
05330...........................  Mendocino County,               99905       1.0915       1.1454          4.94
                                   California.
05340...........................  Merced County,                  32900       1.1109       1.1471          3.26
                                   California.

[[Page 65962]]

 
05350...........................  Modoc County, California        99905       1.0915       1.1454          4.94
05360...........................  Mono County, California.        99905       1.0915       1.1454          4.94
05370...........................  Monterey County,                41500       1.4128       1.4337          1.48
                                   California.
05380...........................  Napa County, California.        34900       1.3313       1.3374          0.46
05390...........................  Nevada County,                  99905       1.0915       1.1454          4.94
                                   California.
05400...........................  Orange County,                  42044       1.1559       1.1473         -0.74
                                   California.
05410...........................  Placer County,                  40900       1.3056       1.3372          2.42
                                   California.
05420...........................  Plumas County,                  99905       1.0915       1.1454          4.94
                                   California.
05430...........................  Riverside County,               40140       1.1027       1.0904         -1.12
                                   California.
05440...........................  Sacramento County,              40900       1.3056       1.3372          2.42
                                   California.
05450...........................  San Benito County,              41940       1.2937       1.5543         20.14
                                   California.
05460...........................  San Bernardino County,          40140       1.1027       1.0904         -1.12
                                   California.
05470...........................  San Diego County,               41740       1.1413       1.1354         -0.52
                                   California.
05480...........................  San Francisco County,           41884       1.4994       1.5165          1.14
                                   California.
05490...........................  San Joaquin County,             44700       1.1307       1.1442          1.19
                                   California.
05500...........................  San Luis Obispo County,         42020       1.1349       1.1598          2.19
                                   California.
05510...........................  San Mateo County,               41884       1.4994       1.5165          1.14
                                   California.
05520...........................  Santa Barbara County,           42060       1.1694       1.1091         -5.16
                                   California.
05530...........................  Santa Clara County,             41940       1.5109       1.5543          2.87
                                   California.
05540...........................  Santa Cruz County,              42100       1.5166       1.5457          1.92
                                   California.
05550...........................  Shasta County,                  39820       1.2203       1.3198          8.15
                                   California.
05560...........................  Sierra County,                  99905       1.0915       1.1454          4.94
                                   California.
05570...........................  Siskiyou County,                99905       1.0915       1.1454          4.94
                                   California.
05580...........................  Solano County,                  46700       1.4460       1.5137          4.68
                                   California.
05590...........................  Sonoma County,                  42220       1.3493       1.4464          7.20
                                   California.
05600...........................  Stanislaus County,              33700       1.1885       1.1729         -1.31
                                   California.
05610...........................  Sutter County,                  49700       1.0921       1.0730         -1.75
                                   California.
05620...........................  Tehama County,                  99905       1.0915       1.1454          4.94
                                   California.
05630...........................  Trinity County,                 99905       1.0915       1.1454          4.94
                                   California.
05640...........................  Tulare County,                  47300       1.0123       0.9968         -1.53
                                   California.
05650...........................  Tuolumne County,                99905       1.0915       1.1454          4.94
                                   California.
05660...........................  Ventura County,                 37100       1.1622       1.1546         -0.65
                                   California.
05670...........................  Yolo County, California.        40900       1.1460       1.3372         16.68
05680...........................  Yuba County, California.        49700       1.0921       1.0730         -1.75
06000...........................  Adams County, Colorado..        19740       1.0723       1.0930          1.93
06010...........................  Alamosa County, Colorado        99906       0.9380       0.9325         -0.59
06020...........................  Arapahoe County,                19740       1.0723       1.0930          1.93
                                   Colorado.
06030...........................  Archuleta County,               99906       0.9380       0.9325         -0.59
                                   Colorado.
06040...........................  Baca County, Colorado...        99906       0.9380       0.9325         -0.59
06050...........................  Bent County, Colorado...        99906       0.9380       0.9325         -0.59
06060...........................  Boulder County, Colorado        14500       0.9734       1.0350          6.33
06070...........................  Chaffee County, Colorado        99906       0.9380       0.9325         -0.59
06080...........................  Cheyenne County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06090...........................  Clear Creek County,             19740       1.0052       1.0930          8.73
                                   Colorado.
06100...........................  Conejos County, Colorado        99906       0.9380       0.9325         -0.59
06110...........................  Costilla County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06120...........................  Crowley County, Colorado        99906       0.9380       0.9325         -0.59
06130...........................  Custer County, Colorado.        99906       0.9380       0.9325         -0.59
06140...........................  Delta County, Colorado..        99906       0.9380       0.9325         -0.59
06150...........................  Denver County, Colorado.        19740       1.0723       1.0930          1.93
06160...........................  Dolores County, Colorado        99906       0.9380       0.9325         -0.59
06170...........................  Douglas County, Colorado        19740       1.0723       1.0930          1.93
06180...........................  Eagle County, Colorado..        99906       0.9380       0.9325         -0.59
06190...........................  Elbert County, Colorado.        19740       1.0052       1.0930          8.73
06200...........................  El Paso County, Colorado        17820       0.9468       0.9701          2.46
06210...........................  Fremont County, Colorado        99906       0.9380       0.9325         -0.59
06220...........................  Garfield County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06230...........................  Gilpin County, Colorado.        19740       1.0052       1.0930          8.73
06240...........................  Grand County, Colorado..        99906       0.9380       0.9325         -0.59
06250...........................  Gunnison County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06260...........................  Hinsdale County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06270...........................  Huerfano County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06280...........................  Jackson County, Colorado        99906       0.9380       0.9325         -0.59
06290...........................  Jefferson County,               19740       1.0723       1.0930          1.93
                                   Colorado.
06300...........................  Kiowa County, Colorado..        99906       0.9380       0.9325         -0.59
06310...........................  Kit Carson County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06320...........................  Lake County, Colorado...        99906       0.9380       0.9325         -0.59
06330...........................  La Plata County,                99906       0.9380       0.9325         -0.59
                                   Colorado.

[[Page 65963]]

 
06340...........................  Larimer County, Colorado        22660       1.0122       0.9544         -5.71
06350...........................  Las Animas County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06360...........................  Lincoln County, Colorado        99906       0.9380       0.9325         -0.59
06370...........................  Logan County, Colorado..        99906       0.9380       0.9325         -0.59
06380...........................  Mesa County, Colorado...        24300       0.9550       0.9668          1.24
06390...........................  Mineral County, Colorado        99906       0.9380       0.9325         -0.59
06400...........................  Moffat County, Colorado.        99906       0.9380       0.9325         -0.59
06410...........................  Montezuma County,               99906       0.9380       0.9325         -0.59
                                   Colorado.
06420...........................  Montrose County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06430...........................  Morgan County, Colorado.        99906       0.9380       0.9325         -0.59
06440...........................  Otero County, Colorado..        99906       0.9380       0.9325         -0.59
06450...........................  Ouray County, Colorado..        99906       0.9380       0.9325         -0.59
06460...........................  Park County, Colorado...        19740       1.0052       1.0930          8.73
06470...........................  Phillips County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06480...........................  Pitkin County, Colorado.        99906       0.9380       0.9325         -0.59
06490...........................  Prowers County, Colorado        99906       0.9380       0.9325         -0.59
06500...........................  Pueblo County, Colorado.        39380       0.8623       0.8753          1.51
06510...........................  Rio Blanco County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06520...........................  Rio Grande County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06530...........................  Routt County, Colorado..        99906       0.9380       0.9325         -0.59
06540...........................  Saguache County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06550...........................  San Juan County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06560...........................  San Miguel County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06570...........................  Sedgwick County,                99906       0.9380       0.9325         -0.59
                                   Colorado.
06580...........................  Summit County, Colorado.        99906       0.9380       0.9325         -0.59
06590...........................  Teller County, Colorado.        17820       0.9424       0.9701          2.94
06600...........................  Washington County,              99906       0.9380       0.9325         -0.59
                                   Colorado.
06610...........................  Weld County, Colorado...        24540       0.9570       0.9602          0.33
06620...........................  Yuma County, Colorado...        99906       0.9380       0.9325         -0.59
06630...........................  Broomfield County,              19740       1.0723       1.0930          1.93
                                   Colorado.
07000...........................  Fairfield County,               14860       1.2394       1.2659          2.14
                                   Connecticut.
07010...........................  Hartford County,                25540       1.1073       1.0894         -1.62
                                   Connecticut.
07020...........................  Litchfield County,              25540       1.1073       1.0894         -1.62
                                   Connecticut.
07030...........................  Middlesex County,               25540       1.1073       1.0894         -1.62
                                   Connecticut.
07040...........................  New Haven County,               35300       1.2042       1.1953         -0.74
                                   Connecticut.
07050...........................  New London County,              35980       1.1345       1.1932          5.17
                                   Connecticut.
07060...........................  Tolland County,                 25540       1.1073       1.0894         -1.62
                                   Connecticut.
07070...........................  Windham County,                 99907       1.1730       1.1709         -0.18
                                   Connecticut.
08000...........................  Kent County, Delaware...        20100       0.9776       0.9847          0.73
08010...........................  New Castle County,              48864       1.0499       1.0684          1.76
                                   Delaware.
08020...........................  Sussex County, Delaware.        99908       0.9579       0.9705          1.32
09000...........................  Washington DC County,           47894       1.0951       1.1054          0.94
                                   Dist Of Col.
10000...........................  Alachua County, Florida.        23540       0.9388       0.9277         -1.18
10010...........................  Baker County, Florida...        27260       0.8984       0.9165          2.01
10020...........................  Bay County, Florida.....        37460       0.8005       0.8027          0.27
10030...........................  Bradford County, Florida        99910       0.8623       0.8594         -0.34
10040...........................  Brevard County, Florida.        37340       0.9839       0.9443         -4.02
10050...........................  Broward County, Florida.        22744       1.0432       1.0133         -2.87
10060...........................  Calhoun County, Florida.        99910       0.8623       0.8594         -0.34
10070...........................  Charlotte County,               39460       0.9255       0.9405          1.62
                                   Florida.
10080...........................  Citrus County, Florida..        99910       0.8623       0.8594         -0.34
10090...........................  Clay County, Florida....        27260       0.9295       0.9165         -1.40
10100...........................  Collier County, Florida.        34940       1.0139       0.9941         -1.95
10110...........................  Columbia County, Florida        99910       0.8623       0.8594         -0.34
10120...........................  Dade County, Florida....        33124       0.9750       0.9812          0.64
10130...........................  De Soto County, Florida.        99910       0.8623       0.8594         -0.34
10140...........................  Dixie County, Florida...        99910       0.8623       0.8594         -0.34
10150...........................  Duval County, Florida...        27260       0.9295       0.9165         -1.40
10160...........................  Escambia County, Florida        37860       0.8096       0.8000         -1.19
10170...........................  Flagler County, Florida.        99910       0.8947       0.8594         -3.95
10180...........................  Franklin County, Florida        99910       0.8623       0.8594         -0.34
10190...........................  Gadsden County, Florida.        45220       0.8688       0.8942          2.92
10200...........................  Gilchrist County,               23540       0.9033       0.9277          2.70
                                   Florida.
10210...........................  Glades County, Florida..        99910       0.8623       0.8594         -0.34
10220...........................  Gulf County, Florida....        99910       0.8623       0.8594         -0.34
10230...........................  Hamilton County, Florida        99910       0.8623       0.8594         -0.34
10240...........................  Hardee County, Florida..        99910       0.8623       0.8594         -0.34
10250...........................  Hendry County, Florida..        99910       0.8623       0.8594         -0.34

[[Page 65964]]

 
10260...........................  Hernando County, Florida        45300       0.9233       0.9144         -0.96
10270...........................  Highlands County,               99910       0.8623       0.8594         -0.34
                                   Florida.
10280...........................  Hillsborough County,            45300       0.9233       0.9144         -0.96
                                   Florida.
10290...........................  Holmes County, Florida..        99910       0.8623       0.8594         -0.34
10300...........................  Indian River County,            42680       0.9056       0.9573          5.71
                                   Florida.
10310...........................  Jackson County, Florida.        99910       0.8623       0.8594         -0.34
10320...........................  Jefferson County,               45220       0.8683       0.8942          2.98
                                   Florida.
10330...........................  Lafayette County,               99910       0.8623       0.8594         -0.34
                                   Florida.
10340...........................  Lake County, Florida....        36740       0.9464       0.9452         -0.13
10350...........................  Lee County, Florida.....        15980       0.9356       0.9342         -0.15
10360...........................  Leon County, Florida....        45220       0.8688       0.8942          2.92
10370...........................  Levy County, Florida....        99910       0.8623       0.8594         -0.34
10380...........................  Liberty County, Florida.        99910       0.8623       0.8594         -0.34
10390...........................  Madison County, Florida.        99910       0.8623       0.8594         -0.34
10400...........................  Manatee County, Florida.        42260       0.9639       0.9868          2.38
10410...........................  Marion County, Florida..        36100       0.8925       0.8867         -0.65
10420...........................  Martin County, Florida..        38940       1.0123       0.9833         -2.86
10430...........................  Monroe County, Florida..        99910       0.8623       0.8594         -0.34
10440...........................  Nassau County, Florida..        27260       0.9295       0.9165         -1.40
10450...........................  Okaloosa County, Florida        23020       0.8872       0.8643         -2.58
10460...........................  Okeechobee County,              99910       0.8623       0.8594         -0.34
                                   Florida.
10470...........................  Orange County, Florida..        36740       0.9464       0.9452         -0.13
10480...........................  Osceola County, Florida.        36740       0.9464       0.9452         -0.13
10490...........................  Palm Beach County,              48424       1.0067       0.9649         -4.15
                                   Florida.
10500...........................  Pasco County, Florida...        45300       0.9233       0.9144         -0.96
10510...........................  Pinellas County, Florida        45300       0.9233       0.9144         -0.96
10520...........................  Polk County, Florida....        29460       0.8912       0.8879         -0.37
10530...........................  Putnam County, Florida..        99910       0.8623       0.8594         -0.34
10540...........................  Johns County, Florida...        27260       0.9295       0.9165         -1.40
10550...........................  St Lucie County, Florida        38940       1.0123       0.9833         -2.86
10560...........................  Santa Rosa County,              37860       0.8096       0.8000         -1.19
                                   Florida.
10570...........................  Sarasota County, Florida        42260       0.9639       0.9868          2.38
10580...........................  Seminole County, Florida        36740       0.9464       0.9452         -0.13
10590...........................  Sumter County, Florida..        99910       0.8623       0.8594         -0.34
10600...........................  Suwannee County, Florida        99910       0.8623       0.8594         -0.34
10610...........................  Taylor County, Florida..        99910       0.8623       0.8594         -0.34
10620...........................  Union County, Florida...        99910       0.8623       0.8594         -0.34
10630...........................  Volusia County, Florida.        19660       0.9312       0.9263         -0.53
10640...........................  Wakulla County, Florida.        45220       0.8683       0.8942          2.98
10650...........................  Walton County, Florida..        99910       0.8623       0.8594         -0.34
10660...........................  Washington County,              99910       0.8623       0.8594         -0.34
                                   Florida.
11000...........................  Appling County, Georgia.        99911       0.7914       0.7593         -4.06
11010...........................  Atkinson County, Georgia        99911       0.7914       0.7593         -4.06
11011...........................  Bacon County, Georgia...        99911       0.7914       0.7593         -4.06
11020...........................  Baker County, Georgia...        10500       0.8397       0.8991          7.07
11030...........................  Baldwin County, Georgia.        99911       0.7914       0.7593         -4.06
11040...........................  Banks County, Georgia...        99911       0.7914       0.7593         -4.06
11050...........................  Barrow County, Georgia..        12060       0.9793       0.9762         -0.32
11060...........................  Bartow County, Georgia..        12060       0.9793       0.9762         -0.32
11070...........................  Ben Hill County, Georgia        99911       0.7914       0.7593         -4.06
11080...........................  Berrien County, Georgia.        99911       0.7914       0.7593         -4.06
11090...........................  Bibb County, Georgia....        31420       0.9360       0.9519          1.70
11100...........................  Bleckley County, Georgia        99911       0.7914       0.7593         -4.06
11110...........................  Brantley County, Georgia        15260       0.8739       1.0164         16.31
11120...........................  Brooks County, Georgia..        46660       0.8516       0.8369         -1.73
11130...........................  Bryan County, Georgia...        42340       0.9461       0.9351         -1.16
11140...........................  Bulloch County, Georgia.        99911       0.7914       0.7593         -4.06
11150...........................  Burke County, Georgia...        12260       0.8957       0.9667          7.93
11160...........................  Butts County, Georgia...        12060       0.8980       0.9762          8.71
11161...........................  Calhoun County, Georgia.        99911       0.7914       0.7593         -4.06
11170...........................  Camden County, Georgia..        99911       0.7914       0.7593         -4.06
11180...........................  Candler County, Georgia.        99911       0.7914       0.7593         -4.06
11190...........................  Carroll County, Georgia.        12060       0.9793       0.9762         -0.32
11200...........................  Catoosa County, Georgia.        16860       0.9088       0.8948         -1.54
11210...........................  Charlton County, Georgia        99911       0.7914       0.7593         -4.06
11220...........................  Chatham County, Georgia.        42340       0.9461       0.9351         -1.16
11230...........................  Chattahoochee County,           17980       0.8560       0.8239         -3.75
                                   Georgia.
11240...........................  Chattooga County,               99911       0.7914       0.7593         -4.06
                                   Georgia.

[[Page 65965]]

 
11250...........................  Cherokee County, Georgia        12060       0.9793       0.9762         -0.32
11260...........................  Clarke County, Georgia..        12020       0.9855       0.9856          0.01
11270...........................  Clay County, Georgia....        99911       0.7914       0.7593         -4.06
11280...........................  Clayton County, Georgia.        12060       0.9793       0.9762         -0.32
11281...........................  Clinch County, Georgia..        99911       0.7914       0.7593         -4.06
11290...........................  Cobb County, Georgia....        12060       0.9793       0.9762         -0.32
11291...........................  Coffee County, Georgia..        99911       0.7914       0.7593         -4.06
11300...........................  Colquitt County, Georgia        99911       0.7914       0.7593         -4.06
11310...........................  Columbia County, Georgia        12260       0.9778       0.9667         -1.14
11311...........................  Cook County, Georgia....        99911       0.7914       0.7593         -4.06
11320...........................  Coweta County, Georgia..        12060       0.9793       0.9762         -0.32
11330...........................  Crawford County, Georgia        31420       0.8805       0.9519          8.11
11340...........................  Crisp County, Georgia...        99911       0.7914       0.7593         -4.06
11341...........................  Dade County, Georgia....        16860       0.9088       0.8948         -1.54
11350...........................  Dawson County, Georgia..        12060       0.8980       0.9762          8.71
11360...........................  Decatur County, Georgia.        99911       0.7914       0.7593         -4.06
11370...........................  De Kalb County, Georgia.        12060       0.9793       0.9762         -0.32
11380...........................  Dodge County, Georgia...        99911       0.7914       0.7593         -4.06
11381...........................  Dooly County, Georgia...        99911       0.7914       0.7593         -4.06
11390...........................  Dougherty County,               10500       0.8628       0.8991          4.21
                                   Georgia.
11400...........................  Douglas County, Georgia.        12060       0.9793       0.9762         -0.32
11410...........................  Early County, Georgia...        99911       0.7914       0.7593         -4.06
11420...........................  Echols County, Georgia..        46660       0.8516       0.8369         -1.73
11421...........................  Effingham County,               42340       0.9461       0.9351         -1.16
                                   Georgia.
11430...........................  Elbert County, Georgia..        99911       0.7914       0.7593         -4.06
11440...........................  Emanuel County, Georgia.        99911       0.7914       0.7593         -4.06
11441...........................  Evans County, Georgia...        99911       0.7914       0.7593         -4.06
11450...........................  Fannin County, Georgia..        99911       0.7914       0.7593         -4.06
11451...........................  Fayette County, Georgia.        12060       0.9793       0.9762         -0.32
11460...........................  Floyd County, Georgia...        40660       0.8790       0.9193          4.58
11461...........................  Forsyth County, Georgia.        12060       0.9793       0.9762         -0.32
11462...........................  Franklin County, Georgia        99911       0.7914       0.7593         -4.06
11470...........................  Fulton County, Georgia..        12060       0.9793       0.9762         -0.32
11471...........................  Gilmer County, Georgia..        99911       0.7914       0.7593         -4.06
11480...........................  Glascock County, Georgia        99911       0.7914       0.7593         -4.06
11490...........................  Glynn County, Georgia...        15260       0.8739       1.0164         16.31
11500...........................  Gordon County, Georgia..        99911       0.7914       0.7593         -4.06
11510...........................  Grady County, Georgia...        99911       0.7914       0.7593         -4.06
11520...........................  Greene County, Georgia..        99911       0.7914       0.7593         -4.06
11530...........................  Gwinnett County, Georgia        12060       0.9793       0.9762         -0.32
11540...........................  Habersham County,               99911       0.7914       0.7593         -4.06
                                   Georgia.
11550...........................  Hall County, Georgia....        23580       0.8520       0.8958          5.14
11560...........................  Hancock County, Georgia.        99911       0.7914       0.7593         -4.06
11570...........................  Haralson County, Georgia        12060       0.8980       0.9762          8.71
11580...........................  Harris County, Georgia..        17980       0.8560       0.8239         -3.75
11581...........................  Hart County, Georgia....        99911       0.7914       0.7593         -4.06
11590...........................  Heard County, Georgia...        12060       0.8980       0.9762          8.71
11591...........................  Henry County, Georgia...        12060       0.9793       0.9762         -0.32
11600...........................  Houston County, Georgia.        47580       0.8961       0.8380         -6.48
11601...........................  Irwin County, Georgia...        99911       0.7914       0.7593         -4.06
11610...........................  Jackson County, Georgia.        99911       0.7914       0.7593         -4.06
11611...........................  Jasper County, Georgia..        12060       0.8980       0.9762          8.71
11612...........................  Jeff Davis County,              99911       0.7914       0.7593         -4.06
                                   Georgia.
11620...........................  Jefferson County,               99911       0.7914       0.7593         -4.06
                                   Georgia.
11630...........................  Jenkins County, Georgia.        99911       0.7914       0.7593         -4.06
11640...........................  Johnson County, Georgia.        99911       0.7914       0.7593         -4.06
11650...........................  Jones County, Georgia...        31420       0.9360       0.9519          1.70
11651...........................  Lamar County, Georgia...        12060       0.8980       0.9762          8.71
11652...........................  Lanier County, Georgia..        46660       0.8516       0.8369         -1.73
11660...........................  Laurens County, Georgia.        99911       0.7914       0.7593         -4.06
11670...........................  Lee County, Georgia.....        10500       0.8628       0.8991          4.21
11680...........................  Liberty County, Georgia.        25980       0.8973       0.9178          2.28
11690...........................  Lincoln County, Georgia.        99911       0.7914       0.7593         -4.06
11691...........................  Long County, Georgia....        25980       0.8973       0.9178          2.28
11700...........................  Lowndes County, Georgia.        46660       0.8516       0.8369         -1.73
11701...........................  Lumpkin County, Georgia.        99911       0.7914       0.7593         -4.06
11702...........................  Mc Duffie County,               12260       0.9778       0.9667         -1.14
                                   Georgia.
11703...........................  Mc Intosh County,               15260       0.8739       1.0164         16.31
                                   Georgia.

[[Page 65966]]

 
11710...........................  Macon County, Georgia...        99911       0.7914       0.7593         -4.06
11720...........................  Madison County, Georgia.        12020       0.9855       0.9856          0.01
11730...........................  Marion County, Georgia..        17980       0.8363       0.8239         -1.48
11740...........................  Meriwether County,              12060       0.8980       0.9762          8.71
                                   Georgia.
11741...........................  Miller County, Georgia..        99911       0.7914       0.7593         -4.06
11750...........................  Mitchell County, Georgia        99911       0.7914       0.7593         -4.06
11760...........................  Monroe County, Georgia..        31420       0.8805       0.9519          8.11
11770...........................  Montgomery County,              99911       0.7914       0.7593         -4.06
                                   Georgia.
11771...........................  Morgan County, Georgia..        99911       0.7914       0.7593         -4.06
11772...........................  Murray County, Georgia..        19140       0.8623       0.9093          5.45
11780...........................  Muscogee County, Georgia        17980       0.8560       0.8239         -3.75
11790...........................  Newton County, Georgia..        12060       0.9793       0.9762         -0.32
11800...........................  Oconee County, Georgia..        12020       0.9855       0.9856          0.01
11801...........................  Oglethorpe County,              12020       0.9011       0.9856          9.38
                                   Georgia.
11810...........................  Paulding County, Georgia        12060       0.9793       0.9762         -0.32
11811...........................  Peach County, Georgia...        99911       0.8470       0.7593        -10.35
11812...........................  Pickens County, Georgia.        12060       0.9793       0.9762         -0.32
11820...........................  Pierce County, Georgia..        99911       0.7914       0.7593         -4.06
11821...........................  Pike County, Georgia....        12060       0.8980       0.9762          8.71
11830...........................  Polk County, Georgia....        99911       0.7914       0.7593         -4.06
11831...........................  Pulaski County, Georgia.        99911       0.7914       0.7593         -4.06
11832...........................  Putnam County, Georgia..        99911       0.7914       0.7593         -4.06
11833...........................  Quitman County, Georgia.        99911       0.7914       0.7593         -4.06
11834...........................  Rabun County, Georgia...        99911       0.7914       0.7593         -4.06
11835...........................  Randolph County, Georgia        99911       0.7914       0.7593         -4.06
11840...........................  Richmond County, Georgia        12260       0.9778       0.9667         -1.14
11841...........................  Rockdale County, Georgia        12060       0.9793       0.9762         -0.32
11842...........................  Schley County, Georgia..        99911       0.7914       0.7593         -4.06
11850...........................  Screven County, Georgia.        99911       0.7914       0.7593         -4.06
11851...........................  Seminole County, Georgia        99911       0.7914       0.7593         -4.06
11860...........................  Spalding County, Georgia        12060       0.9793       0.9762         -0.32
11861...........................  Stephens County, Georgia        99911       0.7914       0.7593         -4.06
11862...........................  Stewart County, Georgia.        99911       0.7914       0.7593         -4.06
11870...........................  Sumter County, Georgia..        99911       0.7914       0.7593         -4.06
11880...........................  Talbot County, Georgia..        99911       0.7914       0.7593         -4.06
11881...........................  Taliaferro County,              99911       0.7914       0.7593         -4.06
                                   Georgia.
11882...........................  Tattnall County, Georgia        99911       0.7914       0.7593         -4.06
11883...........................  Taylor County, Georgia..        99911       0.7914       0.7593         -4.06
11884...........................  Telfair County, Georgia.        99911       0.7914       0.7593         -4.06
11885...........................  Terrell County, Georgia.        10500       0.8397       0.8991          7.07
11890...........................  Thomas County, Georgia..        99911       0.7914       0.7593         -4.06
11900...........................  Tift County, Georgia....        99911       0.7914       0.7593         -4.06
11901...........................  Toombs County, Georgia..        99911       0.7914       0.7593         -4.06
11902...........................  Towns County, Georgia...        99911       0.7914       0.7593         -4.06
11903...........................  Treutlen County, Georgia        99911       0.7914       0.7593         -4.06
11910...........................  Troup County, Georgia...        99911       0.7914       0.7593         -4.06
11911...........................  Turner County, Georgia..        99911       0.7914       0.7593         -4.06
11912...........................  Twiggs County, Georgia..        31420       0.9360       0.9519          1.70
11913...........................  Union County, Georgia...        99911       0.7914       0.7593         -4.06
11920...........................  Upson County, Georgia...        99911       0.7914       0.7593         -4.06
11921...........................  Walker County, Georgia..        16860       0.9088       0.8948         -1.54
11930...........................  Walton County, Georgia..        12060       0.9793       0.9762         -0.32
11940...........................  Ware County, Georgia....        99911       0.7914       0.7593         -4.06
11941...........................  Warren County, Georgia..        99911       0.7914       0.7593         -4.06
11950...........................  Washington County,              99911       0.7914       0.7593         -4.06
                                   Georgia.
11960...........................  Wayne County, Georgia...        99911       0.7914       0.7593         -4.06
11961...........................  Webster County, Georgia.        99911       0.7914       0.7593         -4.06
11962...........................  Wheeler County, Georgia.        99911       0.7914       0.7593         -4.06
11963...........................  White County, Georgia...        99911       0.7914       0.7593         -4.06
11970...........................  Whitfield County,               19140       0.8623       0.9093          5.45
                                   Georgia.
11971...........................  Wilcox County, Georgia..        99911       0.7914       0.7593         -4.06
11972...........................  Wilkes County, Georgia..        99911       0.7914       0.7593         -4.06
11973...........................  Wilkinson County,               99911       0.7914       0.7593         -4.06
                                   Georgia.
11980...........................  Worth County, Georgia...        10500       0.8397       0.8991          7.07
12005...........................  Kalawao County, Hawaii..        99912       1.0551       1.0448         -0.98
12010...........................  Hawaii County, Hawaii...        99912       1.0551       1.0448         -0.98
12020...........................  Honolulu County, Hawaii.        26180       1.1214       1.1096         -1.05
12040...........................  Kauai County, Hawaii....        99912       1.0551       1.0448         -0.98

[[Page 65967]]

 
12050...........................  Maui County, Hawaii.....        99912       1.0551       1.0448         -0.98
13000...........................  Ada County, Idaho.......        14260       0.9052       0.9401          3.86
13010...........................  Adams County, Idaho.....        99913       0.8567       0.8120         -5.22
13020...........................  Bannock County, Idaho...        38540       0.9351       0.9400          0.52
13030...........................  Bear Lake County, Idaho.        99913       0.8567       0.8120         -5.22
13040...........................  Benewah County, Idaho...        99913       0.8567       0.8120         -5.22
13050...........................  Bingham County, Idaho...        99913       0.8567       0.8120         -5.22
13060...........................  Blaine County, Idaho....        99913       0.8567       0.8120         -5.22
13070...........................  Boise County, Idaho.....        14260       0.9075       0.9401          3.59
13080...........................  Bonner County, Idaho....        99913       0.8567       0.8120         -5.22
13090...........................  Bonneville County, Idaho        26820       0.9259       0.9088         -1.85
13100...........................  Boundary County, Idaho..        99913       0.8567       0.8120         -5.22
13110...........................  Butte County, Idaho.....        99913       0.8567       0.8120         -5.22
13120...........................  Camas County, Idaho.....        99913       0.8567       0.8120         -5.22
13130...........................  Canyon County, Idaho....        14260       0.9052       0.9401          3.86
13140...........................  Caribou County, Idaho...        99913       0.8567       0.8120         -5.22
13150...........................  Cassia County, Idaho....        99913       0.8567       0.8120         -5.22
13160...........................  Clark County, Idaho.....        99913       0.8567       0.8120         -5.22
13170...........................  Clearwater County, Idaho        99913       0.8567       0.8120         -5.22
13180...........................  Custer County, Idaho....        99913       0.8567       0.8120         -5.22
13190...........................  Elmore County, Idaho....        99913       0.8567       0.8120         -5.22
13200...........................  Franklin County, Idaho..        30860       0.9131       0.9022         -1.19
13210...........................  Fremont County, Idaho...        99913       0.8567       0.8120         -5.22
13220...........................  Gem County, Idaho.......        14260       0.9075       0.9401          3.59
13230...........................  Gooding County, Idaho...        99913       0.8567       0.8120         -5.22
13240...........................  Idaho County, Idaho.....        99913       0.8567       0.8120         -5.22
13250...........................  Jefferson County, Idaho.        26820       0.9259       0.9088         -1.85
13260...........................  Jerome County, Idaho....        99913       0.8567       0.8120         -5.22
13270...........................  Kootenai County, Idaho..        17660       0.9372       0.9344         -0.30
13280...........................  Latah County, Idaho.....        99913       0.8567       0.8120         -5.22
13290...........................  Lemhi County, Idaho.....        99913       0.8567       0.8120         -5.22
13300...........................  Lewis County, Idaho.....        99913       0.8567       0.8120         -5.22
13310...........................  Lincoln County, Idaho...        99913       0.8567       0.8120         -5.22
13320...........................  Madison County, Idaho...        99913       0.8567       0.8120         -5.22
13330...........................  Minidoka County, Idaho..        99913       0.8567       0.8120         -5.22
13340...........................  Nez Perce County, Idaho.        30300       0.9492       0.9853          3.80
13350...........................  Oneida County, Idaho....        99913       0.8567       0.8120         -5.22
13360...........................  Owyhee County, Idaho....        14260       0.9075       0.9401          3.59
13370...........................  Payette County, Idaho...        99913       0.8567       0.8120         -5.22
13380...........................  Power County, Idaho.....        38540       0.9224       0.9400          1.91
13390...........................  Shoshone County, Idaho..        99913       0.8567       0.8120         -5.22
13400...........................  Teton County, Idaho.....        99913       0.8567       0.8120         -5.22
13410...........................  Twin Falls County, Idaho        99913       0.8567       0.8120         -5.22
13420...........................  Valley County, Idaho....        99913       0.8567       0.8120         -5.22
13430...........................  Washington County, Idaho        99913       0.8567       0.8120         -5.22
14000...........................  Adams County, Illinois..        99914       0.8286       0.8320          0.41
14010...........................  Alexander County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14020...........................  Bond County, Illinois...        41180       0.8628       0.9005          4.37
14030...........................  Boone County, Illinois..        40420       0.9984       0.9989          0.05
14040...........................  Brown County, Illinois..        99914       0.8286       0.8320          0.41
14050...........................  Bureau County, Illinois.        99914       0.8286       0.8320          0.41
14060...........................  Calhoun County, Illinois        41180       0.8628       0.9005          4.37
14070...........................  Carroll County, Illinois        99914       0.8286       0.8320          0.41
14080...........................  Cass County, Illinois...        99914       0.8286       0.8320          0.41
14090...........................  Champaign County,               16580       0.9594       0.9644          0.52
                                   Illinois.
14100...........................  Christian County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14110...........................  Clark County, Illinois..        99914       0.8286       0.8320          0.41
14120...........................  Clay County, Illinois...        99914       0.8286       0.8320          0.41
14130...........................  Clinton County, Illinois        41180       0.8958       0.9005          0.52
14140...........................  Coles County, Illinois..        99914       0.8286       0.8320          0.41
14141...........................  Cook County, Illinois...        16974       1.0787       1.0751         -0.33
14150...........................  Crawford County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14160...........................  Cumberland County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14170...........................  De Kalb County, Illinois        16974       1.0787       1.0751         -0.33
14180...........................  De Witt County, Illinois        99914       0.8286       0.8320          0.41
14190...........................  Douglas County, Illinois        99914       0.8286       0.8320          0.41
14250...........................  Du Page County, Illinois        16974       1.0787       1.0751         -0.33
14310...........................  Edgar County, Illinois..        99914       0.8286       0.8320          0.41

[[Page 65968]]

 
14320...........................  Edwards County, Illinois        99914       0.8286       0.8320          0.41
14330...........................  Effingham County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14340...........................  Fayette County, Illinois        99914       0.8286       0.8320          0.41
14350...........................  Ford County, Illinois...        16580       0.8948       0.9644          7.78
14360...........................  Franklin County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14370...........................  Fulton County, Illinois.        99914       0.8286       0.8320          0.41
14380...........................  Gallatin County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14390...........................  Greene County, Illinois.        99914       0.8286       0.8320          0.41
14400...........................  Grundy County, Illinois.        16974       1.0787       1.0751         -0.33
14410...........................  Hamilton County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14420...........................  Hancock County, Illinois        99914       0.8286       0.8320          0.41
14421...........................  Hardin County, Illinois.        99914       0.8286       0.8320          0.41
14440...........................  Henderson County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14450...........................  Henry County, Illinois..        19340       0.8724       0.8846          1.40
14460...........................  Iroquois County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14470...........................  Jackson County, Illinois        99914       0.8286       0.8320          0.41
14480...........................  Jasper County, Illinois.        99914       0.8286       0.8320          0.41
14490...........................  Jefferson County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14500...........................  Jersey County, Illinois.        41180       0.8958       0.9005          0.52
14510...........................  Jo Daviess County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14520...........................  Johnson County, Illinois        99914       0.8286       0.8320          0.41
14530...........................  Kane County, Illinois...        16974       1.0787       1.0751         -0.33
14540...........................  Kankakee County,                28100       1.0721       1.0083         -5.95
                                   Illinois.
14550...........................  Kendall County, Illinois        16974       1.0787       1.0751         -0.33
14560...........................  Knox County, Illinois...        99914       0.8286       0.8320          0.41
14570...........................  Lake County, Illinois...        29404       1.0606       1.0570         -0.34
14580...........................  La Salle County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14590...........................  Lawrence County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14600...........................  Lee County, Illinois....        99914       0.8286       0.8320          0.41
14610...........................  Livingston County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14620...........................  Logan County, Illinois..        99914       0.8286       0.8320          0.41
14630...........................  Mc Donough County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14640...........................  Mc Henry County,                16974       1.0787       1.0751         -0.33
                                   Illinois.
14650...........................  Mclean County, Illinois.        14060       0.9075       0.8944         -1.44
14660...........................  Macon County, Illinois..        19500       0.8067       0.8172          1.30
14670...........................  Macoupin County,                41180       0.8628       0.9005          4.37
                                   Illinois.
14680...........................  Madison County, Illinois        41180       0.8958       0.9005          0.52
14690...........................  Marion County, Illinois.        99914       0.8286       0.8320          0.41
14700...........................  Marshall County,                37900       0.8586       0.8982          4.61
                                   Illinois.
14710...........................  Mason County, Illinois..        99914       0.8286       0.8320          0.41
14720...........................  Massac County, Illinois.        99914       0.8286       0.8320          0.41
14730...........................  Menard County, Illinois.        44100       0.8792       0.8890          1.11
14740...........................  Mercer County, Illinois.        19340       0.8513       0.8846          3.91
14750...........................  Monroe County, Illinois.        41180       0.8958       0.9005          0.52
14760...........................  Montgomery County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14770...........................  Morgan County, Illinois.        99914       0.8286       0.8320          0.41
14780...........................  Moultrie County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14790...........................  Ogle County, Illinois...        99914       0.9128       0.8320         -8.85
14800...........................  Peoria County, Illinois.        37900       0.8870       0.8982          1.26
14810...........................  Perry County, Illinois..        99914       0.8286       0.8320          0.41
14820...........................  Piatt County, Illinois..        16580       0.8948       0.9644          7.78
14830...........................  Pike County, Illinois...        99914       0.8286       0.8320          0.41
14831...........................  Pope County, Illinois...        99914       0.8286       0.8320          0.41
14850...........................  Pulaski County, Illinois        99914       0.8286       0.8320          0.41
14860...........................  Putnam County, Illinois.        99914       0.8286       0.8320          0.41
14870...........................  Randolph County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14880...........................  Richland County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14890...........................  Rock Island County,             19340       0.8724       0.8846          1.40
                                   Illinois.
14900...........................  St Clair County,                41180       0.8958       0.9005          0.52
                                   Illinois.
14910...........................  Saline County, Illinois.        99914       0.8286       0.8320          0.41
14920...........................  Sangamon County,                44100       0.8792       0.8890          1.11
                                   Illinois.
14921...........................  Schuyler County,                99914       0.8286       0.8320          0.41
                                   Illinois.
14940...........................  Scott County, Illinois..        99914       0.8286       0.8320          0.41
14950...........................  Shelby County, Illinois.        99914       0.8286       0.8320          0.41
14960...........................  Stark County, Illinois..        37900       0.8586       0.8982          4.61
14970...........................  Stephenson County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14980...........................  Tazewell County,                37900       0.8870       0.8982          1.26
                                   Illinois.
14981...........................  Union County, Illinois..        99914       0.8286       0.8320          0.41

[[Page 65969]]

 
14982...........................  Vermilion County,               19180       0.8665       0.9266          6.94
                                   Illinois.
14983...........................  Wabash County, Illinois.        99914       0.8286       0.8320          0.41
14984...........................  Warren County, Illinois.        99914       0.8286       0.8320          0.41
14985...........................  Washington County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14986...........................  Wayne County, Illinois..        99914       0.8286       0.8320          0.41
14987...........................  White County, Illinois..        99914       0.8286       0.8320          0.41
14988...........................  Whiteside County,               99914       0.8286       0.8320          0.41
                                   Illinois.
14989...........................  Will County, Illinois...        16974       1.0787       1.0751         -0.33
14990...........................  Williamson County,              99914       0.8286       0.8320          0.41
                                   Illinois.
14991...........................  Winnebago County,               40420       0.9984       0.9989          0.05
                                   Illinois.
14992...........................  Woodford County,                37900       0.8870       0.8982          1.26
                                   Illinois.
15000...........................  Adams County, Indiana...        99915       0.9165       0.8538         -6.84
15010...........................  Allen County, Indiana...        23060       0.9750       0.9517         -2.39
15020...........................  Bartholomew County,             18020       0.9164       0.9318          1.68
                                   Indiana.
15030...........................  Benton County, Indiana..        29140       0.8738       0.8931          2.21
15040...........................  Blackford County,               99915       0.8682       0.8538         -1.66
                                   Indiana.
15050...........................  Boone County, Indiana...        26900       0.9893       0.9895          0.02
15060...........................  Brown County, Indiana...        26900       0.9330       0.9895          6.06
15070...........................  Carroll County, Indiana.        29140       0.8738       0.8931          2.21
15080...........................  Cass County, Indiana....        99915       0.8682       0.8538         -1.66
15090...........................  Clark County, Indiana...        31140       0.9272       0.9118         -1.66
15100...........................  Clay County, Indiana....        45460       0.8321       0.8765          5.34
15110...........................  Clinton County, Indiana.        99915       0.8680       0.8538         -1.64
15120...........................  Crawford County, Indiana        99915       0.8682       0.8538         -1.66
15130...........................  Daviess County, Indiana.        99915       0.8682       0.8538         -1.66
15140...........................  Dearborn County, Indiana        17140       0.9675       0.9601         -0.76
15150...........................  Decatur County, Indiana.        99915       0.8682       0.8538         -1.66
15160...........................  De Kalb County, Indiana.        99915       0.9165       0.8538         -6.84
15170...........................  Delaware County, Indiana        34620       0.8930       0.8562         -4.12
15180...........................  Dubois County, Indiana..        99915       0.8682       0.8538         -1.66
15190...........................  Elkhart County, Indiana.        21140       0.9627       0.9426         -2.09
15200...........................  Fayette County, Indiana.        99915       0.8682       0.8538         -1.66
15210...........................  Floyd County, Indiana...        31140       0.9272       0.9118         -1.66
15220...........................  Fountain County, Indiana        99915       0.8682       0.8538         -1.66
15230...........................  Franklin County, Indiana        17140       0.9177       0.9601          4.62
15240...........................  Fulton County, Indiana..        99915       0.8682       0.8538         -1.66
15250...........................  Gibson County, Indiana..        21780       0.8726       0.9071          3.95
15260...........................  Grant County, Indiana...        99915       0.8682       0.8538         -1.66
15270...........................  Greene County, Indiana..        14020       0.8593       0.8533         -0.70
15280...........................  Hamilton County, Indiana        26900       0.9893       0.9895          0.02
15290...........................  Hancock County, Indiana.        26900       0.9893       0.9895          0.02
15300...........................  Harrison County, Indiana        31140       0.9272       0.9118         -1.66
15310...........................  Hendricks County,               26900       0.9893       0.9895          0.02
                                   Indiana.
15320...........................  Henry County, Indiana...        99915       0.8682       0.8538         -1.66
15330...........................  Howard County, Indiana..        29020       0.9508       0.9669          1.69
15340...........................  Huntington County,              99915       0.9165       0.8538         -6.84
                                   Indiana.
15350...........................  Jackson County, Indiana.        99915       0.8682       0.8538         -1.66
15360...........................  Jasper County, Indiana..        23844       0.9067       0.9334          2.94
15370...........................  Jay County, Indiana.....        99915       0.8682       0.8538         -1.66
15380...........................  Jefferson County,               99915       0.8682       0.8538         -1.66
                                   Indiana.
15390...........................  Jennings County, Indiana        99915       0.8682       0.8538         -1.66
15400...........................  Johnson County, Indiana.        26900       0.9893       0.9895          0.02
15410...........................  Knox County, Indiana....        99915       0.8682       0.8538         -1.66
15420...........................  Kosciusko County,               99915       0.8682       0.8538         -1.66
                                   Indiana.
15430...........................  Lagrange County, Indiana        99915       0.8682       0.8538         -1.66
15440...........................  Lake County, Indiana....        23844       0.9395       0.9334         -0.65
15450...........................  La Porte County, Indiana        33140       0.9069       0.9118          0.54
15460...........................  Lawrence County, Indiana        99915       0.8682       0.8538         -1.66
15470...........................  Madison County, Indiana.        11300       0.9226       0.8681         -5.91
15480...........................  Marion County, Indiana..        26900       0.9893       0.9895          0.02
15490...........................  Marshall County, Indiana        99915       0.8682       0.8538         -1.66
15500...........................  Martin County, Indiana..        99915       0.8682       0.8538         -1.66
15510...........................  Miami County, Indiana...        99915       0.8682       0.8538         -1.66
15520...........................  Monroe County, Indiana..        14020       0.8447       0.8533          1.02
15530...........................  Montgomery County,              99915       0.8682       0.8538         -1.66
                                   Indiana.
15540...........................  Morgan County, Indiana..        26900       0.9893       0.9895          0.02
15550...........................  Newton County, Indiana..        23844       0.9067       0.9334          2.94
15560...........................  Noble County, Indiana...        99915       0.8682       0.8538         -1.66

[[Page 65970]]

 
15570...........................  Ohio County, Indiana....        17140       0.9675       0.9601         -0.76
15580...........................  Orange County, Indiana..        99915       0.8682       0.8538         -1.66
15590...........................  Owen County, Indiana....        14020       0.8593       0.8533         -0.70
15600...........................  Parke County, Indiana...        99915       0.8682       0.8538         -1.66
15610...........................  Perry County, Indiana...        99915       0.8682       0.8538         -1.66
15620...........................  Pike County, Indiana....        99915       0.8682       0.8538         -1.66
15630...........................  Porter County, Indiana..        23844       0.9395       0.9334         -0.65
15640...........................  Posey County, Indiana...        21780       0.8713       0.9071          4.11
15650...........................  Pulaski County, Indiana.        99915       0.8682       0.8538         -1.66
15660...........................  Putnam County, Indiana..        26900       0.9330       0.9895          6.06
15670...........................  Randolph County, Indiana        99915       0.8682       0.8538         -1.66
15680...........................  Ripley County, Indiana..        99915       0.8682       0.8538         -1.66
15690...........................  Rush County, Indiana....        99915       0.8682       0.8538         -1.66
15700...........................  St Joseph County,               43780       0.9788       0.9842          0.55
                                   Indiana.
15710...........................  Scott County, Indiana...        99915       0.8959       0.8538         -4.70
15720...........................  Shelby County, Indiana..        26900       0.9893       0.9895          0.02
15730...........................  Spencer County, Indiana.        99915       0.8682       0.8538         -1.66
15740...........................  Starke County, Indiana..        99915       0.8682       0.8538         -1.66
15750...........................  Steuben County, Indiana.        99915       0.8682       0.8538         -1.66
15760...........................  Sullivan County, Indiana        45460       0.8522       0.8765          2.85
15770...........................  Switzerland County,             99915       0.8682       0.8538         -1.66
                                   Indiana.
15780...........................  Tippecanoe County,              29140       0.8736       0.8931          2.23
                                   Indiana.
15790...........................  Tipton County, Indiana..        29020       0.9508       0.9669          1.69
15800...........................  Union County, Indiana...        99915       0.8682       0.8538         -1.66
15810...........................  Vanderburgh County,             21780       0.8713       0.9071          4.11
                                   Indiana.
15820...........................  Vermillion County,              45460       0.8321       0.8765          5.34
                                   Indiana.
15830...........................  Vigo County, Indiana....        45460       0.8321       0.8765          5.34
15840...........................  Wabash County, Indiana..        99915       0.8682       0.8538         -1.66
15850...........................  Warren County, Indiana..        99915       0.8682       0.8538         -1.66
15860...........................  Warrick County, Indiana.        21780       0.8713       0.9071          4.11
15870...........................  Washington County,              31140       0.8995       0.9118          1.37
                                   Indiana.
15880...........................  Wayne County, Indiana...        99915       0.8682       0.8538         -1.66
15890...........................  Wells County, Indiana...        23060       0.9750       0.9517         -2.39
15900...........................  White County, Indiana...        99915       0.8682       0.8538         -1.66
15910...........................  Whitley County, Indiana.        23060       0.9750       0.9517         -2.39
16000...........................  Adair County, Iowa......        99916       0.8552       0.8681          1.51
16010...........................  Adams County, Iowa......        99916       0.8552       0.8681          1.51
16020...........................  Allamakee County, Iowa..        99916       0.8552       0.8681          1.51
16030...........................  Appanoose County, Iowa..        99916       0.8552       0.8681          1.51
16040...........................  Audubon County, Iowa....        99916       0.8552       0.8681          1.51
16050...........................  Benton County, Iowa.....        16300       0.8710       0.8888          2.04
16060...........................  Black Hawk County, Iowa.        47940       0.8557       0.8408         -1.74
16070...........................  Boone County, Iowa......        99916       0.8552       0.8681          1.51
16080...........................  Bremer County, Iowa.....        47940       0.8576       0.8408         -1.96
16090...........................  Buchanan County, Iowa...        99916       0.8552       0.8681          1.51
16100...........................  Buena Vista County, Iowa        99916       0.8552       0.8681          1.51
16110...........................  Butler County, Iowa.....        99916       0.8552       0.8681          1.51
16120...........................  Calhoun County, Iowa....        99916       0.8552       0.8681          1.51
16130...........................  Carroll County, Iowa....        99916       0.8552       0.8681          1.51
16140...........................  Cass County, Iowa.......        99916       0.8552       0.8681          1.51
16150...........................  Cedar County, Iowa......        99916       0.8552       0.8681          1.51
16160...........................  Cerro Gordo County, Iowa        99916       0.8552       0.8681          1.51
16170...........................  Cherokee County, Iowa...        99916       0.8552       0.8681          1.51
16180...........................  Chickasaw County, Iowa..        99916       0.8552       0.8681          1.51
16190...........................  Clarke County, Iowa.....        99916       0.8552       0.8681          1.51
16200...........................  Clay County, Iowa.......        99916       0.8552       0.8681          1.51
16210...........................  Clayton County, Iowa....        99916       0.8552       0.8681          1.51
16220...........................  Clinton County, Iowa....        99916       0.8552       0.8681          1.51
16230...........................  Crawford County, Iowa...        99916       0.8552       0.8681          1.51
16240...........................  Dallas County, Iowa.....        19780       0.9669       0.9214         -4.71
16250...........................  Davis County, Iowa......        99916       0.8552       0.8681          1.51
16260...........................  Decatur County, Iowa....        99916       0.8552       0.8681          1.51
16270...........................  Delaware County, Iowa...        99916       0.8552       0.8681          1.51
16280...........................  Des Moines County, Iowa.        99916       0.8552       0.8681          1.51
16290...........................  Dickinson County, Iowa..        99916       0.8552       0.8681          1.51
16300...........................  Dubuque County, Iowa....        20220       0.9024       0.9133          1.21
16310...........................  Emmet County, Iowa......        99916       0.8552       0.8681          1.51
16320...........................  Fayette County, Iowa....        99916       0.8552       0.8681          1.51

[[Page 65971]]

 
16330...........................  Floyd County, Iowa......        99916       0.8552       0.8681          1.51
16340...........................  Franklin County, Iowa...        99916       0.8552       0.8681          1.51
16350...........................  Fremont County, Iowa....        99916       0.8552       0.8681          1.51
16360...........................  Greene County, Iowa.....        99916       0.8552       0.8681          1.51
16370...........................  Grundy County, Iowa.....        47940       0.8576       0.8408         -1.96
16380...........................  Guthrie County, Iowa....        19780       0.9132       0.9214          0.90
16390...........................  Hamilton County, Iowa...        99916       0.8552       0.8681          1.51
16400...........................  Hancock County, Iowa....        99916       0.8552       0.8681          1.51
16410...........................  Hardin County, Iowa.....        99916       0.8552       0.8681          1.51
16420...........................  Harrison County, Iowa...        36540       0.9077       0.9450          4.11
16430...........................  Henry County, Iowa......        99916       0.8552       0.8681          1.51
16440...........................  Howard County, Iowa.....        99916       0.8552       0.8681          1.51
16450...........................  Humboldt County, Iowa...        99916       0.8552       0.8681          1.51
16460...........................  Ida County, Iowa........        99916       0.8552       0.8681          1.51
16470...........................  Iowa County, Iowa.......        99916       0.8552       0.8681          1.51
16480...........................  Jackson County, Iowa....        99916       0.8552       0.8681          1.51
16490...........................  Jasper County, Iowa.....        99916       0.8552       0.8681          1.51
16500...........................  Jefferson County, Iowa..        99916       0.8552       0.8681          1.51
16510...........................  Johnson County, Iowa....        26980       0.9747       0.9714         -0.34
16520...........................  Jones County, Iowa......        16300       0.8710       0.8888          2.04
16530...........................  Keokuk County, Iowa.....        99916       0.8552       0.8681          1.51
16540...........................  Kossuth County, Iowa....        99916       0.8552       0.8681          1.51
16550...........................  Lee County, Iowa........        99916       0.8552       0.8681          1.51
16560...........................  Linn County, Iowa.......        16300       0.8825       0.8888          0.71
16570...........................  Louisa County, Iowa.....        99916       0.8552       0.8681          1.51
16580...........................  Lucas County, Iowa......        99916       0.8552       0.8681          1.51
16590...........................  Lyon County, Iowa.......        99916       0.8552       0.8681          1.51
16600...........................  Madison County, Iowa....        19780       0.9132       0.9214          0.90
16610...........................  Mahaska County, Iowa....        99916       0.8552       0.8681          1.51
16620...........................  Marion County, Iowa.....        99916       0.8552       0.8681          1.51
16630...........................  Marshall County, Iowa...        99916       0.8552       0.8681          1.51
16640...........................  Mills County, Iowa......        36540       0.9077       0.9450          4.11
16650...........................  Mitchell County, Iowa...        99916       0.8552       0.8681          1.51
16660...........................  Monona County, Iowa.....        99916       0.8552       0.8681          1.51
16670...........................  Monroe County, Iowa.....        99916       0.8552       0.8681          1.51
16680...........................  Montgomery County, Iowa.        99916       0.8552       0.8681          1.51
16690...........................  Muscatine County, Iowa..        99916       0.8552       0.8681          1.51
16700...........................  O Brien County, Iowa....        99916       0.8552       0.8681          1.51
16710...........................  Osceola County, Iowa....        99916       0.8552       0.8681          1.51
16720...........................  Page County, Iowa.......        99916       0.8552       0.8681          1.51
16730...........................  Palo Alto County, Iowa..        99916       0.8552       0.8681          1.51
16740...........................  Plymouth County, Iowa...        99916       0.8552       0.8681          1.51
16750...........................  Pocahontas County, Iowa.        99916       0.8552       0.8681          1.51
16760...........................  Polk County, Iowa.......        19780       0.9669       0.9214         -4.71
16770...........................  Pottawattamie County,           36540       0.9560       0.9450         -1.15
                                   Iowa.
16780...........................  Poweshiek County, Iowa..        99916       0.8552       0.8681          1.51
16790...........................  Ringgold County, Iowa...        99916       0.8552       0.8681          1.51
16800...........................  Sac County, Iowa........        99916       0.8552       0.8681          1.51
16810...........................  Scott County, Iowa......        19340       0.8724       0.8846          1.40
16820...........................  Shelby County, Iowa.....        99916       0.8552       0.8681          1.51
16830...........................  Sioux County, Iowa......        99916       0.8552       0.8681          1.51
16840...........................  Story County, Iowa......        11180       0.9065       0.9760          7.67
16850...........................  Tama County, Iowa.......        99916       0.8552       0.8681          1.51
16860...........................  Taylor County, Iowa.....        99916       0.8552       0.8681          1.51
16870...........................  Union County, Iowa......        99916       0.8552       0.8681          1.51
16880...........................  Van Buren County, Iowa..        99916       0.8552       0.8681          1.51
16890...........................  Wapello County, Iowa....        99916       0.8552       0.8681          1.51
16900...........................  Warren County, Iowa.....        19780       0.9669       0.9214         -4.71
16910...........................  Washington County, Iowa.        26980       0.9171       0.9714          5.92
16920...........................  Wayne County, Iowa......        99916       0.8552       0.8681          1.51
16930...........................  Webster County, Iowa....        99916       0.8552       0.8681          1.51
16940...........................  Winnebago County, Iowa..        99916       0.8552       0.8681          1.51
16950...........................  Winneshiek County, Iowa.        99916       0.8552       0.8681          1.51
16960...........................  Woodbury County, Iowa...        43580       0.9399       0.9200         -2.12
16970...........................  Worth County, Iowa......        99916       0.8552       0.8681          1.51
16980...........................  Wright County, Iowa.....        99916       0.8552       0.8681          1.51
17000...........................  Allen County, Kansas....        99917       0.8038       0.7998         -0.50
17010...........................  Anderson County, Kansas.        99917       0.8038       0.7998         -0.50

[[Page 65972]]

 
17020...........................  Atchison County, Kansas.        99917       0.8038       0.7998         -0.50
17030...........................  Barber County, Kansas...        99917       0.8038       0.7998         -0.50
17040...........................  Barton County, Kansas...        99917       0.8038       0.7998         -0.50
17050...........................  Bourbon County, Kansas..        99917       0.8038       0.7998         -0.50
17060...........................  Brown County, Kansas....        99917       0.8038       0.7998         -0.50
17070...........................  Butler County, Kansas...        48620       0.9164       0.9063         -1.10
17080...........................  Chase County, Kansas....        99917       0.8038       0.7998         -0.50
17090...........................  Chautauqua County,              99917       0.8038       0.7998         -0.50
                                   Kansas.
17100...........................  Cherokee County, Kansas.        99917       0.8038       0.7998         -0.50
17110...........................  Cheyenne County, Kansas.        99917       0.8038       0.7998         -0.50
17120...........................  Clark County, Kansas....        99917       0.8038       0.7998         -0.50
17130...........................  Clay County, Kansas.....        99917       0.8038       0.7998         -0.50
17140...........................  Cloud County, Kansas....        99917       0.8038       0.7998         -0.50
17150...........................  Coffey County, Kansas...        99917       0.8038       0.7998         -0.50
17160...........................  Comanche County, Kansas.        99917       0.8038       0.7998         -0.50
17170...........................  Cowley County, Kansas...        99917       0.8038       0.7998         -0.50
17180...........................  Crawford County, Kansas.        99917       0.8038       0.7998         -0.50
17190...........................  Decatur County, Kansas..        99917       0.8038       0.7998         -0.50
17200...........................  Dickinson County, Kansas        99917       0.8038       0.7998         -0.50
17210...........................  Doniphan County, Kansas.        41140       0.8780       1.0118         15.24
17220...........................  Douglas County, Kansas..        29940       0.8537       0.8365         -2.01
17230...........................  Edwards County, Kansas..        99917       0.8038       0.7998         -0.50
17240...........................  Elk County, Kansas......        99917       0.8038       0.7998         -0.50
17250...........................  Ellis County, Kansas....        99917       0.8038       0.7998         -0.50
17260...........................  Ellsworth County, Kansas        99917       0.8038       0.7998         -0.50
17270...........................  Finney County, Kansas...        99917       0.8038       0.7998         -0.50
17280...........................  Ford County, Kansas.....        99917       0.8038       0.7998         -0.50
17290...........................  Franklin County, Kansas.        28140       0.8758       0.9495          8.42
17300...........................  Geary County, Kansas....        99917       0.8038       0.7998         -0.50
17310...........................  Gove County, Kansas.....        99917       0.8038       0.7998         -0.50
17320...........................  Graham County, Kansas...        99917       0.8038       0.7998         -0.50
17330...........................  Grant County, Kansas....        99917       0.8038       0.7998         -0.50
17340...........................  Gray County, Kansas.....        99917       0.8038       0.7998         -0.50
17350...........................  Greeley County, Kansas..        99917       0.8038       0.7998         -0.50
17360...........................  Greenwood County, Kansas        99917       0.8038       0.7998         -0.50
17370...........................  Hamilton County, Kansas.        99917       0.8038       0.7998         -0.50
17380...........................  Harper County, Kansas...        99917       0.8038       0.7998         -0.50
17390...........................  Harvey County, Kansas...        48620       0.9164       0.9063         -1.10
17391...........................  Haskell County, Kansas..        99917       0.8038       0.7998         -0.50
17410...........................  Hodgeman County, Kansas.        99917       0.8038       0.7998         -0.50
17420...........................  Jackson County, Kansas..        45820       0.8480       0.8730          2.95
17430...........................  Jefferson County, Kansas        45820       0.8480       0.8730          2.95
17440...........................  Jewell County, Kansas...        99917       0.8038       0.7998         -0.50
17450...........................  Johnson County, Kansas..        28140       0.9483       0.9495          0.13
17451...........................  Kearny County, Kansas...        99917       0.8038       0.7998         -0.50
17470...........................  Kingman County, Kansas..        99917       0.8038       0.7998         -0.50
17480...........................  Kiowa County, Kansas....        99917       0.8038       0.7998         -0.50
17490...........................  Labette County, Kansas..        99917       0.8038       0.7998         -0.50
17500...........................  Lane County, Kansas.....        99917       0.8038       0.7998         -0.50
17510...........................  Leavenworth County,             28140       0.9483       0.9495          0.13
                                   Kansas.
17520...........................  Lincoln County, Kansas..        99917       0.8038       0.7998         -0.50
17530...........................  Linn County, Kansas.....        28140       0.8758       0.9495          8.42
17540...........................  Logan County, Kansas....        99917       0.8038       0.7998         -0.50
17550...........................  Lyon County, Kansas.....        99917       0.8038       0.7998         -0.50
17560...........................  Mc Pherson County,              99917       0.8038       0.7998         -0.50
                                   Kansas.
17570...........................  Marion County, Kansas...        99917       0.8038       0.7998         -0.50
17580...........................  Marshall County, Kansas.        99917       0.8038       0.7998         -0.50
17590...........................  Meade County, Kansas....        99917       0.8038       0.7998         -0.50
17600...........................  Miami County, Kansas....        28140       0.9483       0.9495          0.13
17610...........................  Mitchell County, Kansas.        99917       0.8038       0.7998         -0.50
17620...........................  Montgomery County,              99917       0.8038       0.7998         -0.50
                                   Kansas.
17630...........................  Morris County, Kansas...        99917       0.8038       0.7998         -0.50
17640...........................  Morton County, Kansas...        99917       0.8038       0.7998         -0.50
17650...........................  Nemaha County, Kansas...        99917       0.8038       0.7998         -0.50
17660...........................  Neosho County, Kansas...        99917       0.8038       0.7998         -0.50
17670...........................  Ness County, Kansas.....        99917       0.8038       0.7998         -0.50
17680...........................  Norton County, Kansas...        99917       0.8038       0.7998         -0.50
17690...........................  Osage County, Kansas....        45820       0.8480       0.8730          2.95

[[Page 65973]]

 
17700...........................  Osborne County, Kansas..        99917       0.8038       0.7998         -0.50
17710...........................  Ottawa County, Kansas...        99917       0.8038       0.7998         -0.50
17720...........................  Pawnee County, Kansas...        99917       0.8038       0.7998         -0.50
17730...........................  Phillips County, Kansas.        99917       0.8038       0.7998         -0.50
17740...........................  Pottawatomie County,            99917       0.8038       0.7998         -0.50
                                   Kansas.
17750...........................  Pratt County, Kansas....        99917       0.8038       0.7998         -0.50
17760...........................  Rawlins County, Kansas..        99917       0.8038       0.7998         -0.50
17770...........................  Reno County, Kansas.....        99917       0.8038       0.7998         -0.50
17780...........................  Republic County, Kansas.        99917       0.8038       0.7998         -0.50
17790...........................  Rice County, Kansas.....        99917       0.8038       0.7998         -0.50
17800...........................  Riley County, Kansas....        99917       0.8038       0.7998         -0.50
17810...........................  Rooks County, Kansas....        99917       0.8038       0.7998         -0.50
17820...........................  Rush County, Kansas.....        99917       0.8038       0.7998         -0.50
17830...........................  Russell County, Kansas..        99917       0.8038       0.7998         -0.50
17840...........................  Saline County, Kansas...        99917       0.8038       0.7998         -0.50
17841...........................  Scott County, Kansas....        99917       0.8038       0.7998         -0.50
17860...........................  Sedgwick County, Kansas.        48620       0.9164       0.9063         -1.10
17870...........................  Seward County, Kansas...        99917       0.8038       0.7998         -0.50
17880...........................  Shawnee County, Kansas..        45820       0.8920       0.8730         -2.13
17890...........................  Sheridan County, Kansas.        99917       0.8038       0.7998         -0.50
17900...........................  Sherman County, Kansas..        99917       0.8038       0.7998         -0.50
17910...........................  Smith County, Kansas....        99917       0.8038       0.7998         -0.50
17920...........................  Stafford County, Kansas.        99917       0.8038       0.7998         -0.50
17921...........................  Stanton County, Kansas..        99917       0.8038       0.7998         -0.50
17940...........................  Stevens County, Kansas..        99917       0.8038       0.7998         -0.50
17950...........................  Sumner County, Kansas...        48620       0.8597       0.9063          5.42
17960...........................  Thomas County, Kansas...        99917       0.8038       0.7998         -0.50
17970...........................  Trego County, Kansas....        99917       0.8038       0.7998         -0.50
17980...........................  Wabaunsee County, Kansas        45820       0.8480       0.8730          2.95
17981...........................  Wallace County, Kansas..        99917       0.8038       0.7998         -0.50
17982...........................  Washington County,              99917       0.8038       0.7998         -0.50
                                   Kansas.
17983...........................  Wichita County, Kansas..        99917       0.8038       0.7998         -0.50
17984...........................  Wilson County, Kansas...        99917       0.8038       0.7998         -0.50
17985...........................  Woodson County, Kansas..        99917       0.8038       0.7998         -0.50
17986...........................  Wyandotte County, Kansas        28140       0.9483       0.9495          0.13
18000...........................  Adair County, Kentucky..        99918       0.7812       0.7768         -0.56
18010...........................  Allen County, Kentucky..        99918       0.7812       0.7768         -0.56
18020...........................  Anderson County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18030...........................  Ballard County, Kentucky        99918       0.7812       0.7768         -0.56
18040...........................  Barren County, Kentucky.        99918       0.7812       0.7768         -0.56
18050...........................  Bath County, Kentucky...        99918       0.7812       0.7768         -0.56
18060...........................  Bell County, Kentucky...        99918       0.7812       0.7768         -0.56
18070...........................  Boone County, Kentucky..        17140       0.9675       0.9601         -0.76
18080...........................  Bourbon County, Kentucky        30460       0.9032       0.9181          1.65
18090...........................  Boyd County, Kentucky...        26580       0.9477       0.8997         -5.06
18100...........................  Boyle County, Kentucky..        99918       0.7812       0.7768         -0.56
18110...........................  Bracken County, Kentucky        17140       0.8737       0.9601          9.89
18120...........................  Breathitt County,               99918       0.7812       0.7768         -0.56
                                   Kentucky.
18130...........................  Breckinridge County,            99918       0.7812       0.7768         -0.56
                                   Kentucky.
18140...........................  Bullitt County, Kentucky        31140       0.9272       0.9118         -1.66
18150...........................  Butler County, Kentucky.        99918       0.7812       0.7768         -0.56
18160...........................  Caldwell County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18170...........................  Calloway County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18180...........................  Campbell County,                17140       0.9675       0.9601         -0.76
                                   Kentucky.
18190...........................  Carlisle County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18191...........................  Carroll County, Kentucky        99918       0.7812       0.7768         -0.56
18210...........................  Carter County, Kentucky.        99918       0.8622       0.7768         -9.90
18220...........................  Casey County, Kentucky..        99918       0.7812       0.7768         -0.56
18230...........................  Christian County,               17300       0.8284       0.8436          1.83
                                   Kentucky.
18240...........................  Clark County, Kentucky..        30460       0.9032       0.9181          1.65
18250...........................  Clay County, Kentucky...        99918       0.7812       0.7768         -0.56
18260...........................  Clinton County, Kentucky        99918       0.7812       0.7768         -0.56
18270...........................  Crittenden County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18271...........................  Cumberland County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18290...........................  Daviess County, Kentucky        36980       0.8780       0.8748         -0.36
18291...........................  Edmonson County,                14540       0.8035       0.8148          1.41
                                   Kentucky.
18310...........................  Elliott County, Kentucky        99918       0.7812       0.7768         -0.56
18320...........................  Estill County, Kentucky.        99918       0.7812       0.7768         -0.56

[[Page 65974]]

 
18330...........................  Fayette County, Kentucky        30460       0.9032       0.9181          1.65
18340...........................  Fleming County, Kentucky        99918       0.7812       0.7768         -0.56
18350...........................  Floyd County, Kentucky..        99918       0.7812       0.7768         -0.56
18360...........................  Franklin County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18361...........................  Fulton County, Kentucky.        99918       0.7812       0.7768         -0.56
18362...........................  Gallatin County,                17140       0.9675       0.9601         -0.76
                                   Kentucky.
18390...........................  Garrard County, Kentucky        99918       0.7812       0.7768         -0.56
18400...........................  Grant County, Kentucky..        17140       0.9675       0.9601         -0.76
18410...........................  Graves County, Kentucky.        99918       0.7812       0.7768         -0.56
18420...........................  Grayson County, Kentucky        99918       0.7812       0.7768         -0.56
18421...........................  Green County, Kentucky..        99918       0.7812       0.7768         -0.56
18440...........................  Greenup County, Kentucky        26580       0.9477       0.8997         -5.06
18450...........................  Hancock County, Kentucky        36980       0.8319       0.8748          5.16
18460...........................  Hardin County, Kentucky.        21060       0.8330       0.8697          4.41
18470...........................  Harlan County, Kentucky.        99918       0.7812       0.7768         -0.56
18480...........................  Harrison County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18490...........................  Hart County, Kentucky...        99918       0.7812       0.7768         -0.56
18500...........................  Henderson County,               21780       0.8713       0.9071          4.11
                                   Kentucky.
18510...........................  Henry County, Kentucky..        31140       0.8555       0.9118          6.58
18511...........................  Hickman County, Kentucky        99918       0.7812       0.7768         -0.56
18530...........................  Hopkins County, Kentucky        99918       0.7812       0.7768         -0.56
18540...........................  Jackson County, Kentucky        99918       0.7812       0.7768         -0.56
18550...........................  Jefferson County,               31140       0.9272       0.9118         -1.66
                                   Kentucky.
18560...........................  Jessamine County,               30460       0.9032       0.9181          1.65
                                   Kentucky.
18570...........................  Johnson County, Kentucky        99918       0.7812       0.7768         -0.56
18580...........................  Kenton County, Kentucky.        17140       0.9675       0.9601         -0.76
18590...........................  Knott County, Kentucky..        99918       0.7812       0.7768         -0.56
18600...........................  Knox County, Kentucky...        99918       0.7812       0.7768         -0.56
18610...........................  Larue County, Kentucky..        21060       0.8330       0.8697          4.41
18620...........................  Laurel County, Kentucky.        99918       0.7812       0.7768         -0.56
18630...........................  Lawrence County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18640...........................  Lee County, Kentucky....        99918       0.7812       0.7768         -0.56
18650...........................  Leslie County, Kentucky.        99918       0.7812       0.7768         -0.56
18660...........................  Letcher County, Kentucky        99918       0.7812       0.7768         -0.56
18670...........................  Lewis County, Kentucky..        99918       0.7812       0.7768         -0.56
18680...........................  Lincoln County, Kentucky        99918       0.7812       0.7768         -0.56
18690...........................  Livingston County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18700...........................  Logan County, Kentucky..        99918       0.7812       0.7768         -0.56
18710...........................  Lyon County, Kentucky...        99918       0.7812       0.7768         -0.56
18720...........................  Mc Cracken County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18730...........................  Mc Creary County,               99918       0.7812       0.7768         -0.56
                                   Kentucky.
18740...........................  Mc Lean County, Kentucky        36980       0.8319       0.8748          5.16
18750...........................  Madison County, Kentucky        99918       0.8377       0.7768         -7.27
18760...........................  Magoffin County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18770...........................  Marion County, Kentucky.        99918       0.7812       0.7768         -0.56
18780...........................  Marshall County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18790...........................  Martin County, Kentucky.        99918       0.7812       0.7768         -0.56
18800...........................  Mason County, Kentucky..        99918       0.7812       0.7768         -0.56
18801...........................  Meade County, Kentucky..        31140       0.8555       0.9118          6.58
18802...........................  Menifee County, Kentucky        99918       0.7812       0.7768         -0.56
18830...........................  Mercer County, Kentucky.        99918       0.7812       0.7768         -0.56
18831...........................  Metcalfe County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18850...........................  Monroe County, Kentucky.        99918       0.7812       0.7768         -0.56
18860...........................  Montgomery County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18861...........................  Morgan County, Kentucky.        99918       0.7812       0.7768         -0.56
18880...........................  Muhlenberg County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18890...........................  Nelson County, Kentucky.        31140       0.8555       0.9118          6.58
18900...........................  Nicholas County,                99918       0.7812       0.7768         -0.56
                                   Kentucky.
18910...........................  Ohio County, Kentucky...        99918       0.7812       0.7768         -0.56
18920...........................  Oldham County, Kentucky.        31140       0.9272       0.9118         -1.66
18930...........................  Owen County, Kentucky...        99918       0.7812       0.7768         -0.56
18931...........................  Owsley County, Kentucky.        99918       0.7812       0.7768         -0.56
18932...........................  Pendleton County,               17140       0.9675       0.9601         -0.76
                                   Kentucky.
18960...........................  Perry County, Kentucky..        99918       0.7812       0.7768         -0.56
18970...........................  Pike County, Kentucky...        99918       0.7812       0.7768         -0.56
18971...........................  Powell County, Kentucky.        99918       0.7812       0.7768         -0.56
18972...........................  Pulaski County, Kentucky        99918       0.7812       0.7768         -0.56
18973...........................  Robertson County,               99918       0.7812       0.7768         -0.56
                                   Kentucky.

[[Page 65975]]

 
18974...........................  Rockcastle County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18975...........................  Rowan County, Kentucky..        99918       0.7812       0.7768         -0.56
18976...........................  Russell County, Kentucky        99918       0.7812       0.7768         -0.56
18977...........................  Scott County, Kentucky..        30460       0.9032       0.9181          1.65
18978...........................  Shelby County, Kentucky.        31140       0.8555       0.9118          6.58
18979...........................  Simpson County, Kentucky        99918       0.7812       0.7768         -0.56
18980...........................  Spencer County, Kentucky        31140       0.8555       0.9118          6.58
18981...........................  Taylor County, Kentucky.        99918       0.7812       0.7768         -0.56
18982...........................  Todd County, Kentucky...        99918       0.7812       0.7768         -0.56
18983...........................  Trigg County, Kentucky..        17300       0.8071       0.8436          4.52
18984...........................  Trimble County, Kentucky        31140       0.8555       0.9118          6.58
18985...........................  Union County, Kentucky..        99918       0.7812       0.7768         -0.56
18986...........................  Warren County, Kentucky.        14540       0.8035       0.8148          1.41
18987...........................  Washington County,              99918       0.7812       0.7768         -0.56
                                   Kentucky.
18988...........................  Wayne County, Kentucky..        99918       0.7812       0.7768         -0.56
18989...........................  Webster County, Kentucky        21780       0.8286       0.9071          9.47
18990...........................  Whitley County, Kentucky        99918       0.7812       0.7768         -0.56
18991...........................  Wolfe County, Kentucky..        99918       0.7812       0.7768         -0.56
18992...........................  Woodford County,                30460       0.9032       0.9181          1.65
                                   Kentucky.
19000...........................  Acadia County, Louisiana        99919       0.7831       0.7438         -5.02
19010...........................  Allen County, Louisiana.        99919       0.7376       0.7438          0.84
19020...........................  Ascension County,               12940       0.8618       0.8084         -6.20
                                   Louisiana.
19030...........................  Assumption County,              99919       0.7376       0.7438          0.84
                                   Louisiana.
19040...........................  Avoyelles County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19050...........................  Beauregard County,              99919       0.7376       0.7438          0.84
                                   Louisiana.
19060...........................  Bienville County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19070...........................  Bossier County,                 43340       0.8749       0.8865          1.33
                                   Louisiana.
19080...........................  Caddo County, Louisiana.        43340       0.8749       0.8865          1.33
19090...........................  Calcasieu County,               29340       0.7846       0.7914          0.87
                                   Louisiana.
19100...........................  Caldwell County,                99919       0.7376       0.7438          0.84
                                   Louisiana.
19110...........................  Cameron County,                 29340       0.7587       0.7914          4.31
                                   Louisiana.
19120...........................  Catahoula County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19130...........................  Claiborne County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19140...........................  Concordia County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19150...........................  De Soto County,                 43340       0.8050       0.8865         10.12
                                   Louisiana.
19160...........................  East Baton Rouge County,        12940       0.8618       0.8084         -6.20
                                   Louisiana.
19170...........................  East Carroll County,            99919       0.7376       0.7438          0.84
                                   Louisiana.
19180...........................  East Feliciana County,          12940       0.7967       0.8084          1.47
                                   Louisiana.
19190...........................  Evangeline County,              99919       0.7376       0.7438          0.84
                                   Louisiana.
19200...........................  Franklin County,                99919       0.7376       0.7438          0.84
                                   Louisiana.
19210...........................  Grant County, Louisiana.        10780       0.7687       0.8006          4.15
19220...........................  Iberia County, Louisiana        99919       0.7376       0.7438          0.84
19230...........................  Iberville County,               12940       0.7967       0.8084          1.47
                                   Louisiana.
19240...........................  Jackson County,                 99919       0.7376       0.7438          0.84
                                   Louisiana.
19250...........................  Jefferson County,               35380       0.8995       0.8831         -1.82
                                   Louisiana.
19260...........................  Jefferson Davis County,         99919       0.7376       0.7438          0.84
                                   Louisiana.
19270...........................  Lafayette County,               29180       0.8340       0.8289         -0.61
                                   Louisiana.
19280...........................  Lafourche County,               26380       0.7894       0.8082          2.38
                                   Louisiana.
19290...........................  La Salle County,                99919       0.7376       0.7438          0.84
                                   Louisiana.
19300...........................  Lincoln County,                 99919       0.7376       0.7438          0.84
                                   Louisiana.
19310...........................  Livingston County,              12940       0.8618       0.8084         -6.20
                                   Louisiana.
19320...........................  Madison County,                 99919       0.7376       0.7438          0.84
                                   Louisiana.
19330...........................  Morehouse County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19340...........................  Natchitoches County,            99919       0.7376       0.7438          0.84
                                   Louisiana.
19350...........................  Orleans County,                 35380       0.8995       0.8831         -1.82
                                   Louisiana.
19360...........................  Ouachita County,                33740       0.8038       0.7997         -0.51
                                   Louisiana.
19370...........................  Plaquemines County,             35380       0.8995       0.8831         -1.82
                                   Louisiana.
19380...........................  Pointe Coupee County,           12940       0.7967       0.8084          1.47
                                   Louisiana.
19390...........................  Rapides County,                 10780       0.8033       0.8006         -0.34
                                   Louisiana.
19400...........................  Red River County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19410...........................  Richland County,                99919       0.7376       0.7438          0.84
                                   Louisiana.
19420...........................  Sabine County, Louisiana        99919       0.7376       0.7438          0.84
19430...........................  St Bernard County,              35380       0.8995       0.8831         -1.82
                                   Louisiana.
19440...........................  St Charles County,              35380       0.8995       0.8831         -1.82
                                   Louisiana.
19450...........................  St Helena County,               12940       0.7967       0.8084          1.47
                                   Louisiana.
19460...........................  St James County,                99919       0.8203       0.7438         -9.33
                                   Louisiana.
19470...........................  St John Baptist County,         35380       0.8995       0.8831         -1.82
                                   Louisiana.
19480...........................  St Landry County,               99919       0.7831       0.7438         -5.02
                                   Louisiana.

[[Page 65976]]

 
19490...........................  St Martin County,               29180       0.8340       0.8289         -0.61
                                   Louisiana.
19500...........................  St Mary County,                 99919       0.7376       0.7438          0.84
                                   Louisiana.
19510...........................  St Tammany County,              35380       0.8995       0.8831         -1.82
                                   Louisiana.
19520...........................  Tangipahoa County,              99919       0.7376       0.7438          0.84
                                   Louisiana.
19530...........................  Tensas County, Louisiana        99919       0.7376       0.7438          0.84
19540...........................  Terrebonne County,              26380       0.7894       0.8082          2.38
                                   Louisiana.
19550...........................  Union County, Louisiana.        33740       0.7686       0.7997          4.05
19560...........................  Vermilion County,               99919       0.7376       0.7438          0.84
                                   Louisiana.
19570...........................  Vernon County, Louisiana        99919       0.7376       0.7438          0.84
19580...........................  Washington County,              99919       0.7376       0.7438          0.84
                                   Louisiana.
19590...........................  Webster County,                 99919       0.8074       0.7438         -7.88
                                   Louisiana.
19600...........................  West Baton Rouge County,        12940       0.8618       0.8084         -6.20
                                   Louisiana.
19610...........................  West Carroll County,            99919       0.7376       0.7438          0.84
                                   Louisiana.
19620...........................  West Feliciana County,          12940       0.7967       0.8084          1.47
                                   Louisiana.
19630...........................  Winn County, Louisiana..        99919       0.7376       0.7438          0.84
20000...........................  Androscoggin County,            30340       0.9331       0.9126         -2.20
                                   Maine.
20010...........................  Aroostook County, Maine.        99920       0.8843       0.8443         -4.52
20020...........................  Cumberland County, Maine        38860       1.0382       0.9908         -4.57
20030...........................  Franklin County, Maine..        99920       0.8843       0.8443         -4.52
20040...........................  Hancock County, Maine...        99920       0.8843       0.8443         -4.52
20050...........................  Kennebec County, Maine..        99920       0.8843       0.8443         -4.52
20060...........................  Knox County, Maine......        99920       0.8843       0.8443         -4.52
20070...........................  Lincoln County, Maine...        99920       0.8843       0.8443         -4.52
20080...........................  Oxford County, Maine....        99920       0.8843       0.8443         -4.52
20090...........................  Penobscot County, Maine.        12620       0.9993       0.9711         -2.82
20100...........................  Piscataquis County,             99920       0.8843       0.8443         -4.52
                                   Maine.
20110...........................  Sagadahoc County, Maine.        38860       1.0382       0.9908         -4.57
20120...........................  Somerset County, Maine..        99920       0.8843       0.8443         -4.52
20130...........................  Waldo County, Maine.....        99920       0.8843       0.8443         -4.52
20140...........................  Washington County, Maine        99920       0.8843       0.8443         -4.52
20150...........................  York County, Maine......        38860       1.0382       0.9908         -4.57
21000...........................  Allegany County,                19060       0.9317       0.8446         -9.35
                                   Maryland.
21010...........................  Anne Arundel County,            12580       0.9897       1.0088          1.93
                                   Maryland.
21020...........................  Baltimore County,               12580       0.9897       1.0088          1.93
                                   Maryland.
21030...........................  Baltimore City County,          12580       0.9897       1.0088          1.93
                                   Maryland.
21040...........................  Calvert County, Maryland        47894       1.0951       1.1054          0.94
21050...........................  Caroline County,                99921       0.9292       0.8926         -3.94
                                   Maryland.
21060...........................  Carroll County, Maryland        12580       0.9897       1.0088          1.93
21070...........................  Cecil County, Maryland..        48864       1.0499       1.0684          1.76
21080...........................  Charles County, Maryland        47894       1.0951       1.1054          0.94
21090...........................  Dorchester County,              99921       0.9292       0.8926         -3.94
                                   Maryland.
21100...........................  Frederick County,               13644       1.1230       1.0903         -2.91
                                   Maryland.
21110...........................  Garrett County, Maryland        99921       0.9292       0.8926         -3.94
21120...........................  Harford County, Maryland        12580       0.9897       1.0088          1.93
21130...........................  Howard County, Maryland.        12580       0.9897       1.0088          1.93
21140...........................  Kent County, Maryland...        99921       0.9292       0.8926         -3.94
21150...........................  Montgomery County,              13644       1.1230       1.0903         -2.91
                                   Maryland.
21160...........................  Prince Georges County,          47894       1.0951       1.1054          0.94
                                   Maryland.
21170...........................  Queen Annes County,             12580       0.9897       1.0088          1.93
                                   Maryland.
21180...........................  St Marys County,                99921       0.9292       0.8926         -3.94
                                   Maryland.
21190...........................  Somerset County,                41540       0.9147       0.8953         -2.12
                                   Maryland.
21200...........................  Talbot County, Maryland.        99921       0.9292       0.8926         -3.94
21210...........................  Washington County,              25180       0.9679       0.9038         -6.62
                                   Maryland.
21220...........................  Wicomico County,                41540       0.9147       0.8953         -2.12
                                   Maryland.
21230...........................  Worcester County,               99921       0.9292       0.8926         -3.94
                                   Maryland.
22000...........................  Barnstable County,              12700       1.2600       1.2539         -0.48
                                   Massachusetts.
22010...........................  Berkshire County,               38340       1.0181       1.0266          0.83
                                   Massachusetts.
22020...........................  Bristol County,                 39300       1.1072       1.0783         -2.61
                                   Massachusetts.
22030...........................  Dukes County,                   99922       1.0216       1.1661         14.14
                                   Massachusetts.
22040...........................  Essex County,                   21604       1.0858       1.0418         -4.05
                                   Massachusetts.
22060...........................  Franklin County,                44140       1.0232       1.0079         -0.64
                                   Massachusetts.
22070...........................  Hampden County,                 44140       1.0256       1.0079         -1.73
                                   Massachusetts.
22080...........................  Hampshire County,               44140       1.0256       1.0079         -1.73
                                   Massachusetts.
22090...........................  Middlesex County,               15764       1.1175       1.0970         -1.83
                                   Massachusetts.
22120...........................  Nantucket County,               99922       1.0216       1.1661         14.14
                                   Massachusetts.
22130...........................  Norfolk County,                 14484       1.1368       1.1679          2.74
                                   Massachusetts.
22150...........................  Plymouth County,                14484       1.1368       1.1679          2.74
                                   Massachusetts.
22160...........................  Suffolk County,                 14484       1.1368       1.1679          2.74
                                   Massachusetts.

[[Page 65977]]

 
22170...........................  Worcester County,               49340       1.1103       1.0722         -3.43
                                   Massachusetts.
23000...........................  Alcona County, Michigan.        99923       0.8860       0.9062          2.28
23010...........................  Alger County, Michigan..        99923       0.8860       0.9062          2.28
23020...........................  Allegan County, Michigan        99923       0.9170       0.9062         -1.18
23030...........................  Alpena County, Michigan.        99923       0.8860       0.9062          2.28
23040...........................  Antrim County, Michigan.        99923       0.8860       0.9062          2.28
23050...........................  Arenac County, Michigan.        99923       0.8860       0.9062          2.28
23060...........................  Baraga County, Michigan.        99923       0.8860       0.9062          2.28
23070...........................  Barry County, Michigan..        24340       0.9107       0.9455          3.82
23080...........................  Bay County, Michigan....        13020       0.9292       0.9251         -0.44
23090...........................  Benzie County, Michigan.        99923       0.8860       0.9062          2.28
23100...........................  Berrien County, Michigan        35660       0.8879       0.8915          0.41
23110...........................  Branch County, Michigan.        99923       0.8860       0.9062          2.28
23120...........................  Calhoun County, Michigan        12980       0.9826       0.9762         -0.65
23130...........................  Cass County, Michigan...        43780       0.9306       0.9842          5.76
23140...........................  Charlevoix County,              99923       0.8860       0.9062          2.28
                                   Michigan.
23150...........................  Cheboygan County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23160...........................  Chippewa County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23170...........................  Clare County, Michigan..        99923       0.8860       0.9062          2.28
23180...........................  Clinton County, Michigan        29620       0.9794       1.0088          3.00
23190...........................  Crawford County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23200...........................  Delta County, Michigan..        99923       0.8860       0.9062          2.28
23210...........................  Dickinson County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23220...........................  Eaton County, Michigan..        29620       0.9794       1.0088          3.00
23230...........................  Emmet County, Michigan..        99923       0.8860       0.9062          2.28
23240...........................  Genesee County, Michigan        22420       1.0655       1.0969          2.95
23250...........................  Gladwin County, Michigan        99923       0.8860       0.9062          2.28
23260...........................  Gogebic County, Michigan        99923       0.8860       0.9062          2.28
23270...........................  Grand Traverse County,          99923       0.8860       0.9062          2.28
                                   Michigan.
23280...........................  Gratiot County, Michigan        99923       0.8860       0.9062          2.28
23290...........................  Hillsdale County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23300...........................  Houghton County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23310...........................  Huron County, Michigan..        99923       0.8860       0.9062          2.28
23320...........................  Ingham County, Michigan.        29620       0.9794       1.0088          3.00
23330...........................  Ionia County, Michigan..        24340       0.9107       0.9455          3.82
23340...........................  Iosco County, Michigan..        99923       0.8860       0.9062          2.28
23350...........................  Iron County, Michigan...        99923       0.8860       0.9062          2.28
23360...........................  Isabella County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23370...........................  Jackson County, Michigan        27100       0.9304       0.9560          2.75
23380...........................  Kalamazoo County,               28020       1.0262       1.0704          4.31
                                   Michigan.
23390...........................  Kalkaska County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23400...........................  Kent County, Michigan...        24340       0.9418       0.9455          0.39
23410...........................  Keweenaw County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23420...........................  Lake County, Michigan...        99923       0.8860       0.9062          2.28
23430...........................  Lapeer County, Michigan.        47644       1.0009       1.0054          0.45
23440...........................  Leelanau County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23450...........................  Lenawee County, Michigan        99923       0.9801       0.9062         -7.54
23460...........................  Livingston County,              47644       1.0289       1.0054         -2.28
                                   Michigan.
23470...........................  Luce County, Michigan...        99923       0.8860       0.9062          2.28
23480...........................  Mackinac County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23490...........................  Macomb County, Michigan.        47644       1.0009       1.0054          0.45
23500...........................  Manistee County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23510...........................  Marquette County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23520...........................  Mason County, Michigan..        99923       0.8860       0.9062          2.28
23530...........................  Mecosta County, Michigan        99923       0.8860       0.9062          2.28
23540...........................  Menominee County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23550...........................  Midland County, Michigan        99923       0.9068       0.9062         -0.07
23560...........................  Missaukee County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23570...........................  Monroe County, Michigan.        33780       0.9808       0.9707         -1.03
23580...........................  Montcalm County,                99923       0.8860       0.9062          2.28
                                   Michigan.
23590...........................  Montmorency County,             99923       0.8860       0.9062          2.28
                                   Michigan.
23600...........................  Muskegon County,                34740       0.9555       0.9941          4.04
                                   Michigan.
23610...........................  Newaygo County, Michigan        24340       0.9107       0.9455          3.82
23620...........................  Oakland County, Michigan        47644       1.0009       1.0054          0.45
23630...........................  Oceana County, Michigan.        99923       0.8860       0.9062          2.28
23640...........................  Ogemaw County, Michigan.        99923       0.8860       0.9062          2.28
23650...........................  Ontonagon County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23660...........................  Osceola County, Michigan        99923       0.8860       0.9062          2.28

[[Page 65978]]

 
23670...........................  Oscoda County, Michigan.        99923       0.8860       0.9062          2.28
23680...........................  Otsego County, Michigan.        99923       0.8860       0.9062          2.28
23690...........................  Ottawa County, Michigan.        26100       0.9250       0.9163         -0.94
23700...........................  Presque Isle County,            99923       0.8860       0.9062          2.28
                                   Michigan.
23710...........................  Roscommon County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23720...........................  Saginaw County, Michigan        40980       0.9165       0.8874         -3.18
23730...........................  St Clair County,                47644       1.0009       1.0054          0.45
                                   Michigan.
23740...........................  St Joseph County,               99923       0.8860       0.9062          2.28
                                   Michigan.
23750...........................  Sanilac County, Michigan        99923       0.8860       0.9062          2.28
23760...........................  Schoolcraft County,             99923       0.8860       0.9062          2.28
                                   Michigan.
23770...........................  Shiawassee County,              99923       0.8860       0.9062          2.28
                                   Michigan.
23780...........................  Tuscola County, Michigan        99923       0.8860       0.9062          2.28
23790...........................  Van Buren County,               28020       1.0262       1.0704          4.31
                                   Michigan.
23800...........................  Washtenaw County,               11460       1.0783       1.0826          0.40
                                   Michigan.
23810...........................  Wayne County, Michigan..        19804       1.0286       1.0281         -0.05
23830...........................  Wexford County, Michigan        99923       0.8860       0.9062          2.28
24000...........................  Aitkin County, Minnesota        99924       0.9132       0.9153          0.23
24010...........................  Anoka County, Minnesota.        33460       1.1075       1.0946         -1.16
24020...........................  Becker County, Minnesota        99924       0.9132       0.9153          0.23
24030...........................  Beltrami County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24040...........................  Benton County, Minnesota        41060       0.9965       1.0362          3.98
24050...........................  Big Stone County,               99924       0.9132       0.9153          0.23
                                   Minnesota.
24060...........................  Blue Earth County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24070...........................  Brown County, Minnesota.        99924       0.9132       0.9153          0.23
24080...........................  Carlton County,                 20260       0.9673       1.0042          3.81
                                   Minnesota.
24090...........................  Carver County, Minnesota        33460       1.1075       1.0946         -1.16
24100...........................  Cass County, Minnesota..        99924       0.9132       0.9153          0.23
24110...........................  Chippewa County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24120...........................  Chisago County,                 33460       1.1075       1.0946         -1.16
                                   Minnesota.
24130...........................  Clay County, Minnesota..        22020       0.8486       0.8250         -2.78
24140...........................  Clearwater County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24150...........................  Cook County, Minnesota..        99924       0.9132       0.9153          0.23
24160...........................  Cottonwood County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24170...........................  Crow Wing County,               99924       0.9132       0.9153          0.23
                                   Minnesota.
24180...........................  Dakota County, Minnesota        33460       1.1075       1.0946         -1.16
24190...........................  Dodge County, Minnesota.        40340       1.0132       1.1408         12.59
24200...........................  Douglas County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24210...........................  Faribault County,               99924       0.9132       0.9153          0.23
                                   Minnesota.
24220...........................  Fillmore County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24230...........................  Freeborn County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24240...........................  Goodhue County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24250...........................  Grant County, Minnesota.        99924       0.9132       0.9153          0.23
24260...........................  Hennepin County,                33460       1.1075       1.0946         -1.16
                                   Minnesota.
24270...........................  Houston County,                 29100       0.9564       0.9426         -1.44
                                   Minnesota.
24280...........................  Hubbard County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24290...........................  Isanti County, Minnesota        33460       1.1075       1.0946         -1.16
24300...........................  Itasca County, Minnesota        99924       0.9132       0.9153          0.23
24310...........................  Jackson County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24320...........................  Kanabec County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24330...........................  Kandiyohi County,               99924       0.9132       0.9153          0.23
                                   Minnesota.
24340...........................  Kittson County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24350...........................  Koochiching County,             99924       0.9132       0.9153          0.23
                                   Minnesota.
24360...........................  Lac Qui Parle County,           99924       0.9132       0.9153          0.23
                                   Minnesota.
24370...........................  Lake County, Minnesota..        99924       0.9132       0.9153          0.23
24380...........................  Lake Of Woods County,           99924       0.9132       0.9153          0.23
                                   Minnesota.
24390...........................  Le Sueur County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24400...........................  Lincoln County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24410...........................  Lyon County, Minnesota..        99924       0.9132       0.9153          0.23
24420...........................  Mc Leod County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24430...........................  Mahnomen County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24440...........................  Marshall County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24450...........................  Martin County, Minnesota        99924       0.9132       0.9153          0.23
24460...........................  Meeker County, Minnesota        99924       0.9132       0.9153          0.23
24470...........................  Mille Lacs County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24480...........................  Morrison County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24490...........................  Mower County, Minnesota.        99924       0.9132       0.9153          0.23
24500...........................  Murray County, Minnesota        99924       0.9132       0.9153          0.23
24510...........................  Nicollet County,                99924       0.9132       0.9153          0.23
                                   Minnesota.

[[Page 65979]]

 
24520...........................  Nobles County, Minnesota        99924       0.9132       0.9153          0.23
24530...........................  Norman County, Minnesota        99924       0.9132       0.9153          0.23
24540...........................  Olmsted County,                 40340       1.1131       1.1408          2.49
                                   Minnesota.
24550...........................  Otter Tail County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24560...........................  Pennington County,              99924       0.9132       0.9153          0.23
                                   Minnesota.
24570...........................  Pine County, Minnesota..        99924       0.9132       0.9153          0.23
24580...........................  Pipestone County,               99924       0.9132       0.9153          0.23
                                   Minnesota.
24590...........................  Polk County, Minnesota..        24220       0.7901       0.7949          0.61
24600...........................  Pope County, Minnesota..        99924       0.9132       0.9153          0.23
24610...........................  Ramsey County, Minnesota        33460       1.1075       1.0946         -1.16
24620...........................  Red Lake County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24630...........................  Redwood County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24640...........................  Renville County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24650...........................  Rice County, Minnesota..        99924       0.9132       0.9153          0.23
24660...........................  Rock County, Minnesota..        99924       0.9132       0.9153          0.23
24670...........................  Roseau County, Minnesota        99924       0.9132       0.9153          0.23
24680...........................  St Louis County,                20260       1.0213       1.0042         -1.67
                                   Minnesota.
24690...........................  Scott County, Minnesota.        33460       1.1075       1.0946         -1.16
24700...........................  Sherburne County,               33460       1.1075       1.0946         -1.16
                                   Minnesota.
24710...........................  Sibley County, Minnesota        99924       0.9132       0.9153          0.23
24720...........................  Stearns County,                 41060       0.9965       1.0362          3.98
                                   Minnesota.
24730...........................  Steele County, Minnesota        99924       0.9132       0.9153          0.23
24740...........................  Stevens County,                 99924       0.9132       0.9153          0.23
                                   Minnesota.
24750...........................  Swift County, Minnesota.        99924       0.9132       0.9153          0.23
24760...........................  Todd County, Minnesota..        99924       0.9132       0.9153          0.23
24770...........................  Traverse County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24780...........................  Wabasha County,                 40340       1.0132       1.1408         12.59
                                   Minnesota.
24790...........................  Wadena County, Minnesota        99924       0.9132       0.9153          0.23
24800...........................  Waseca County, Minnesota        99924       0.9132       0.9153          0.23
24810...........................  Washington County,              33460       1.1075       1.0946         -1.16
                                   Minnesota.
24820...........................  Watonwan County,                99924       0.9132       0.9153          0.23
                                   Minnesota.
24830...........................  Wilkin County, Minnesota        99924       0.9132       0.9153          0.23
24840...........................  Winona County, Minnesota        99924       0.9132       0.9153          0.23
24850...........................  Wright County, Minnesota        33460       1.1075       1.0946         -1.16
24860...........................  Yellow Medicine County,         99924       0.9132       0.9153          0.23
                                   Minnesota.
25000...........................  Adams County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25010...........................  Alcorn County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25020...........................  Amite County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25030...........................  Attala County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25040...........................  Benton County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25050...........................  Bolivar County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25060...........................  Calhoun County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25070...........................  Carroll County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25080...........................  Chickasaw County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25090...........................  Choctaw County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25100...........................  Claiborne County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25110...........................  Clarke County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25120...........................  Clay County, Mississippi        99925       0.7654       0.7738          1.10
25130...........................  Coahoma County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25140...........................  Copiah County,                  27140       0.7973       0.8271          3.74
                                   Mississippi.
25150...........................  Covington County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25160...........................  Desoto County,                  32820       0.9407       0.9373         -0.36
                                   Mississippi.
25170...........................  Forrest County,                 25620       0.7601       0.7430         -2.25
                                   Mississippi.
25180...........................  Franklin County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25190...........................  George County,                  37700       0.7895       0.8215          4.05
                                   Mississippi.
25200...........................  Greene County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25210...........................  Grenada County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25220...........................  Hancock County,                 25060       0.8818       0.8915          1.10
                                   Mississippi.
25230...........................  Harrison County,                25060       0.8818       0.8915          1.10
                                   Mississippi.
25240...........................  Hinds County,                   27140       0.8347       0.8271         -0.91
                                   Mississippi.
25250...........................  Holmes County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25260...........................  Humphreys County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25270...........................  Issaquena County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25280...........................  Itawamba County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25290...........................  Jackson County,                 37700       0.8431       0.8215         -2.56
                                   Mississippi.
25300...........................  Jasper County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25310...........................  Jefferson County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25320...........................  Jefferson Davis County,         99925       0.7654       0.7738          1.10
                                   Mississippi.

[[Page 65980]]

 
25330...........................  Jones County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25340...........................  Kemper County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25350...........................  Lafayette County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25360...........................  Lamar County,                   25620       0.7601       0.7430         -2.25
                                   Mississippi.
25370...........................  Lauderdale County,              99925       0.7654       0.7738          1.10
                                   Mississippi.
25380...........................  Lawrence County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25390...........................  Leake County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25400...........................  Lee County, Mississippi.        99925       0.7654       0.7738          1.10
25410...........................  Leflore County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25420...........................  Lincoln County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25430...........................  Lowndes County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25440...........................  Madison County,                 27140       0.8347       0.8271         -0.91
                                   Mississippi.
25450...........................  Marion County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25460...........................  Marshall County,                32820       0.8516       0.9373         10.06
                                   Mississippi.
25470...........................  Monroe County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25480...........................  Montgomery County,              99925       0.7654       0.7738          1.10
                                   Mississippi.
25490...........................  Neshoba County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25500...........................  Newton County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25510...........................  Noxubee County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25520...........................  Oktibbeha County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25530...........................  Panola County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25540...........................  Pearl River County,             99925       0.7654       0.7738          1.10
                                   Mississippi.
25550...........................  Perry County,                   25620       0.7618       0.7430         -2.47
                                   Mississippi.
25560...........................  Pike County, Mississippi        99925       0.7654       0.7738          1.10
25570...........................  Pontotoc County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25580...........................  Prentiss County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25590...........................  Quitman County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25600...........................  Rankin County,                  27140       0.8347       0.8271         -0.91
                                   Mississippi.
25610...........................  Scott County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25620...........................  Sharkey County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25630...........................  Simpson County,                 27140       0.7973       0.8271          3.74
                                   Mississippi.
25640...........................  Smith County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25650...........................  Stone County,                   25060       0.8282       0.8915          7.64
                                   Mississippi.
25660...........................  Sunflower County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25670...........................  Tallahatchie County,            99925       0.7654       0.7738          1.10
                                   Mississippi.
25680...........................  Tate County, Mississippi        32820       0.8516       0.9373         10.06
25690...........................  Tippah County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25700...........................  Tishomingo County,              99925       0.7654       0.7738          1.10
                                   Mississippi.
25710...........................  Tunica County,                  32820       0.8516       0.9373         10.06
                                   Mississippi.
25720...........................  Union County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25730...........................  Walthall County,                99925       0.7654       0.7738          1.10
                                   Mississippi.
25740...........................  Warren County,                  99925       0.7654       0.7738          1.10
                                   Mississippi.
25750...........................  Washington County,              99925       0.7654       0.7738          1.10
                                   Mississippi.
25760...........................  Wayne County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
25770...........................  Webster County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25780...........................  Wilkinson County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25790...........................  Winston County,                 99925       0.7654       0.7738          1.10
                                   Mississippi.
25800...........................  Yalobusha County,               99925       0.7654       0.7738          1.10
                                   Mississippi.
25810...........................  Yazoo County,                   99925       0.7654       0.7738          1.10
                                   Mississippi.
26000...........................  Adair County, Missouri..        99926       0.7930       0.7927         -0.04
26010...........................  Andrew County, Missouri.        41140       0.9519       1.0118          6.29
26020...........................  Atchison County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26030...........................  Audrain County, Missouri        99926       0.7930       0.7927         -0.04
26040...........................  Barry County, Missouri..        99926       0.7930       0.7927         -0.04
26050...........................  Barton County, Missouri.        99926       0.7930       0.7927         -0.04
26060...........................  Bates County, Missouri..        28140       0.8718       0.9495          8.91
26070...........................  Benton County, Missouri.        99926       0.7930       0.7927         -0.04
26080...........................  Bollinger County,               99926       0.7930       0.7927         -0.04
                                   Missouri.
26090...........................  Boone County, Missouri..        17860       0.8345       0.8542          2.36
26100...........................  Buchanan County,                41140       0.9519       1.0118          6.29
                                   Missouri.
26110...........................  Butler County, Missouri.        99926       0.7930       0.7927         -0.04
26120...........................  Caldwell County,                28140       0.8718       0.9495          8.91
                                   Missouri.
26130...........................  Callaway County,                27620       0.8173       0.8332          1.95
                                   Missouri.
26140...........................  Camden County, Missouri.        99926       0.7930       0.7927         -0.04
26150...........................  Cape Girardeau County,          99926       0.7930       0.7927         -0.04
                                   Missouri.
26160...........................  Carroll County, Missouri        99926       0.7930       0.7927         -0.04
26170...........................  Carter County, Missouri.        99926       0.7930       0.7927         -0.04
26180...........................  Cass County, Missouri...        28140       0.9483       0.9495          0.13

[[Page 65981]]

 
26190...........................  Cedar County, Missouri..        99926       0.7930       0.7927         -0.04
26200...........................  Chariton County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26210...........................  Christian County,               44180       0.8244       0.8469          2.73
                                   Missouri.
26220...........................  Clark County, Missouri..        99926       0.7930       0.7927         -0.04
26230...........................  Clay County, Missouri...        28140       0.9483       0.9495          0.13
26240...........................  Clinton County, Missouri        28140       0.9483       0.9495          0.13
26250...........................  Cole County, Missouri...        27620       0.8173       0.8332          1.95
26260...........................  Cooper County, Missouri.        99926       0.7930       0.7927         -0.04
26270...........................  Crawford County,                41180       0.8457       0.9005          6.48
                                   Missouri.
26280...........................  Dade County, Missouri...        99926       0.7930       0.7927         -0.04
26290...........................  Dallas County, Missouri.        44180       0.8098       0.8469          4.58
26300...........................  Daviess County, Missouri        99926       0.7930       0.7927         -0.04
26310...........................  De Kalb County, Missouri        41140       0.8739       1.0118         15.78
26320...........................  Dent County, Missouri...        99926       0.7930       0.7927         -0.04
26330...........................  Douglas County, Missouri        99926       0.7930       0.7927         -0.04
26340...........................  Dunklin County, Missouri        99926       0.7930       0.7927         -0.04
26350...........................  Franklin County,                41180       0.8958       0.9005          0.52
                                   Missouri.
26360...........................  Gasconade County,               99926       0.7930       0.7927         -0.04
                                   Missouri.
26370...........................  Gentry County, Missouri.        99926       0.7930       0.7927         -0.04
26380...........................  Greene County, Missouri.        44180       0.8244       0.8469          2.73
26390...........................  Grundy County, Missouri.        99926       0.7930       0.7927         -0.04
26400...........................  Harrison County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26410...........................  Henry County, Missouri..        99926       0.7930       0.7927         -0.04
26411...........................  Hickory County, Missouri        99926       0.7930       0.7927         -0.04
26412...........................  Holt County, Missouri...        99926       0.7930       0.7927         -0.04
26440...........................  Howard County, Missouri.        17860       0.8152       0.8542          4.78
26450...........................  Howell County, Missouri.        99926       0.7930       0.7927         -0.04
26460...........................  Iron County, Missouri...        99926       0.7930       0.7927         -0.04
26470...........................  Jackson County, Missouri        28140       0.9483       0.9495          0.13
26480...........................  Jasper County, Missouri.        27900       0.8582       0.8605          0.27
26490...........................  Jefferson County,               41180       0.8958       0.9005          0.52
                                   Missouri.
26500...........................  Johnson County, Missouri        99926       0.7930       0.7927         -0.04
26510...........................  Knox County, Missouri...        99926       0.7930       0.7927         -0.04
26520...........................  Laclede County, Missouri        99926       0.7930       0.7927         -0.04
26530...........................  Lafayette County,               28140       0.9483       0.9495          0.13
                                   Missouri.
26540...........................  Lawrence County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26541...........................  Lewis County, Missouri..        99926       0.7930       0.7927         -0.04
26560...........................  Lincoln County, Missouri        41180       0.8958       0.9005          0.52
26570...........................  Linn County, Missouri...        99926       0.7930       0.7927         -0.04
26580...........................  Livingston County,              99926       0.7930       0.7927         -0.04
                                   Missouri.
26590...........................  Mc Donald County,               22220       0.8310       0.8865          6.68
                                   Missouri.
26600...........................  Macon County, Missouri..        99926       0.7930       0.7927         -0.04
26601...........................  Madison County, Missouri        99926       0.7930       0.7927         -0.04
26620...........................  Maries County, Missouri.        99926       0.7930       0.7927         -0.04
26630...........................  Marion County, Missouri.        99926       0.7930       0.7927         -0.04
26631...........................  Mercer County, Missouri.        99926       0.7930       0.7927         -0.04
26650...........................  Miller County, Missouri.        99926       0.7930       0.7927         -0.04
26660...........................  Mississippi County,             99926       0.7930       0.7927         -0.04
                                   Missouri.
26670...........................  Moniteau County,                27620       0.8173       0.8332          1.95
                                   Missouri.
26680...........................  Monroe County, Missouri.        99926       0.7930       0.7927         -0.04
26690...........................  Montgomery County,              99926       0.7930       0.7927         -0.04
                                   Missouri.
26700...........................  Morgan County, Missouri.        99926       0.7930       0.7927         -0.04
26710...........................  New Madrid County,              99926       0.7930       0.7927         -0.04
                                   Missouri.
26720...........................  Newton County, Missouri.        27900       0.8582       0.8605          0.27
26730...........................  Nodaway County, Missouri        99926       0.7930       0.7927         -0.04
26740...........................  Oregon County, Missouri.        99926       0.7930       0.7927         -0.04
26750...........................  Osage County, Missouri..        27620       0.8173       0.8332          1.95
26751...........................  Ozark County, Missouri..        99926       0.7930       0.7927         -0.04
26770...........................  Pemiscot County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26780...........................  Perry County, Missouri..        99926       0.7930       0.7927         -0.04
26790...........................  Pettis County, Missouri.        99926       0.7930       0.7927         -0.04
26800...........................  Phelps County, Missouri.        99926       0.7930       0.7927         -0.04
26810...........................  Pike County, Missouri...        99926       0.7930       0.7927         -0.04
26820...........................  Platte County, Missouri.        28140       0.9483       0.9495          0.13
26821...........................  Polk County, Missouri...        44180       0.8098       0.8469          4.58
26840...........................  Pulaski County, Missouri        99926       0.7930       0.7927         -0.04
26850...........................  Putnam County, Missouri.        99926       0.7930       0.7927         -0.04
26860...........................  Ralls County, Missouri..        99926       0.7930       0.7927         -0.04

[[Page 65982]]

 
26870...........................  Randolph County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26880...........................  Ray County, Missouri....        28140       0.9483       0.9495          0.13
26881...........................  Reynolds County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26900...........................  Ripley County, Missouri.        99926       0.7930       0.7927         -0.04
26910...........................  St Charles County,              41180       0.8958       0.9005          0.52
                                   Missouri.
26911...........................  St Clair County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26930...........................  St Francois County,             99926       0.7930       0.7927         -0.04
                                   Missouri.
26940...........................  St Louis County,                41180       0.8958       0.9005          0.52
                                   Missouri.
26950...........................  St Louis City County,           41180       0.8958       0.9005          0.52
                                   Missouri.
26960...........................  Ste Genevieve County,           99926       0.7930       0.7927         -0.04
                                   Missouri.
26970...........................  Saline County, Missouri.        99926       0.7930       0.7927         -0.04
26980...........................  Schuyler County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26981...........................  Scotland County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26982...........................  Scott County, Missouri..        99926       0.7930       0.7927         -0.04
26983...........................  Shannon County, Missouri        99926       0.7930       0.7927         -0.04
26984...........................  Shelby County, Missouri.        99926       0.7930       0.7927         -0.04
26985...........................  Stoddard County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26986...........................  Stone County, Missouri..        99926       0.7930       0.7927         -0.04
26987...........................  Sullivan County,                99926       0.7930       0.7927         -0.04
                                   Missouri.
26988...........................  Taney County, Missouri..        99926       0.7930       0.7927         -0.04
26989...........................  Texas County, Missouri..        99926       0.7930       0.7927         -0.04
26990...........................  Vernon County, Missouri.        99926       0.7930       0.7927         -0.04
26991...........................  Warren County, Missouri.        41180       0.8958       0.9005          0.52
26992...........................  Washington County,              41180       0.8457       0.9005          6.48
                                   Missouri.
26993...........................  Wayne County, Missouri..        99926       0.7930       0.7927         -0.04
26994...........................  Webster County, Missouri        44180       0.8244       0.8469          2.73
26995...........................  Worth County, Missouri..        99926       0.7930       0.7927         -0.04
26996...........................  Wright County, Missouri.        99926       0.7930       0.7927         -0.04
27000...........................  Beaverhead County,              99927       0.8762       0.8590         -1.96
                                   Montana.
27010...........................  Big Horn County, Montana        99927       0.8762       0.8590         -1.96
27020...........................  Blaine County, Montana..        99927       0.8762       0.8590         -1.96
27030...........................  Broadwater County,              99927       0.8762       0.8590         -1.96
                                   Montana.
27040...........................  Carbon County, Montana..        13740       0.8798       0.8712         -0.98
27050...........................  Carter County, Montana..        99927       0.8762       0.8590         -1.96
27060...........................  Cascade County, Montana.        24500       0.9052       0.8598         -5.02
27070...........................  Chouteau County, Montana        99927       0.8762       0.8590         -1.96
27080...........................  Custer County, Montana..        99927       0.8762       0.8590         -1.96
27090...........................  Daniels County, Montana.        99927       0.8762       0.8590         -1.96
27100...........................  Dawson County, Montana..        99927       0.8762       0.8590         -1.96
27110...........................  Deer Lodge County,              99927       0.8762       0.8590         -1.96
                                   Montana.
27113...........................  Yellowstone National            99927       0.8762       0.8590         -1.96
                                   Park, Montana.
27120...........................  Fallon County, Montana..        99927       0.8762       0.8590         -1.96
27130...........................  Fergus County, Montana..        99927       0.8762       0.8590         -1.96
27140...........................  Flathead County, Montana        99927       0.8762       0.8590         -1.96
27150...........................  Gallatin County, Montana        99927       0.8762       0.8590         -1.96
27160...........................  Garfield County, Montana        99927       0.8762       0.8590         -1.96
27170...........................  Glacier County, Montana.        99927       0.8762       0.8590         -1.96
27180...........................  Golden Valley County,           99927       0.8762       0.8590         -1.96
                                   Montana.
27190...........................  Granite County, Montana.        99927       0.8762       0.8590         -1.96
27200...........................  Hill County, Montana....        99927       0.8762       0.8590         -1.96
27210...........................  Jefferson County,               99927       0.8762       0.8590         -1.96
                                   Montana.
27220...........................  Judith Basin County,            99927       0.8762       0.8590         -1.96
                                   Montana.
27230...........................  Lake County, Montana....        99927       0.8762       0.8590         -1.96
27240...........................  Lewis And Clark County,         99927       0.8762       0.8590         -1.96
                                   Montana.
27250...........................  Liberty County, Montana.        99927       0.8762       0.8590         -1.96
27260...........................  Lincoln County, Montana.        99927       0.8762       0.8590         -1.96
27270...........................  Mc Cone County, Montana.        99927       0.8762       0.8590         -1.96
27280...........................  Madison County, Montana.        99927       0.8762       0.8590         -1.96
27290...........................  Meagher County, Montana.        99927       0.8762       0.8590         -1.96
27300...........................  Mineral County, Montana.        99927       0.8762       0.8590         -1.96
27310...........................  Missoula County, Montana        33540       0.9473       0.8928         -5.75
27320...........................  Musselshell County,             99927       0.8762       0.8590         -1.96
                                   Montana.
27330...........................  Park County, Montana....        99927       0.8762       0.8590         -1.96
27340...........................  Petroleum County,               99927       0.8762       0.8590         -1.96
                                   Montana.
27350...........................  Phillips County, Montana        99927       0.8762       0.8590         -1.96
27360...........................  Pondera County, Montana.        99927       0.8762       0.8590         -1.96
27370...........................  Powder River County,            99927       0.8762       0.8590         -1.96
                                   Montana.
27380...........................  Powell County, Montana..        99927       0.8762       0.8590         -1.96

[[Page 65983]]

 
27390...........................  Prairie County, Montana.        99927       0.8762       0.8590         -1.96
27400...........................  Ravalli County, Montana.        99927       0.8762       0.8590         -1.96
27410...........................  Richland County, Montana        99927       0.8762       0.8590         -1.96
27420...........................  Roosevelt County,               99927       0.8762       0.8590         -1.96
                                   Montana.
27430...........................  Rosebud County, Montana.        99927       0.8762       0.8590         -1.96
27440...........................  Sanders County, Montana.        99927       0.8762       0.8590         -1.96
27450...........................  Sheridan County, Montana        99927       0.8762       0.8590         -1.96
27460...........................  Silver Bow County,              99927       0.8762       0.8590         -1.96
                                   Montana.
27470...........................  Stillwater County,              99927       0.8762       0.8590         -1.96
                                   Montana.
27480...........................  Sweet Grass County,             99927       0.8762       0.8590         -1.96
                                   Montana.
27490...........................  Teton County, Montana...        99927       0.8762       0.8590         -1.96
27500...........................  Toole County, Montana...        99927       0.8762       0.8590         -1.96
27510...........................  Treasure County, Montana        99927       0.8762       0.8590         -1.96
27520...........................  Valley County, Montana..        99927       0.8762       0.8590         -1.96
27530...........................  Wheatland County,               99927       0.8762       0.8590         -1.96
                                   Montana.
27540...........................  Wibaux County, Montana..        99927       0.8762       0.8590         -1.96
27550...........................  Yellowstone County,             13740       0.8834       0.8712         -1.38
                                   Montana.
28000...........................  Adams County, Nebraska..        99928       0.8657       0.8677          0.23
28010...........................  Antelope County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28020...........................  Arthur County, Nebraska.        99928       0.8657       0.8677          0.23
28030...........................  Banner County, Nebraska.        99928       0.8657       0.8677          0.23
28040...........................  Blaine County, Nebraska.        99928       0.8657       0.8677          0.23
28050...........................  Boone County, Nebraska..        99928       0.8657       0.8677          0.23
28060...........................  Box Butte County,               99928       0.8657       0.8677          0.23
                                   Nebraska.
28070...........................  Boyd County, Nebraska...        99928       0.8657       0.8677          0.23
28080...........................  Brown County, Nebraska..        99928       0.8657       0.8677          0.23
28090...........................  Buffalo County, Nebraska        99928       0.8657       0.8677          0.23
28100...........................  Burt County, Nebraska...        99928       0.8657       0.8677          0.23
28110...........................  Butler County, Nebraska.        99928       0.8657       0.8677          0.23
28120...........................  Cass County, Nebraska...        36540       0.9560       0.9450         -1.15
28130...........................  Cedar County, Nebraska..        99928       0.8657       0.8677          0.23
28140...........................  Chase County, Nebraska..        99928       0.8657       0.8677          0.23
28150...........................  Cherry County, Nebraska.        99928       0.8657       0.8677          0.23
28160...........................  Cheyenne County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28170...........................  Clay County, Nebraska...        99928       0.8657       0.8677          0.23
28180...........................  Colfax County, Nebraska.        99928       0.8657       0.8677          0.23
28190...........................  Cuming County, Nebraska.        99928       0.8657       0.8677          0.23
28200...........................  Custer County, Nebraska.        99928       0.8657       0.8677          0.23
28210...........................  Dakota County, Nebraska.        43580       0.9399       0.9200         -2.12
28220...........................  Dawes County, Nebraska..        99928       0.8657       0.8677          0.23
28230...........................  Dawson County, Nebraska.        99928       0.8657       0.8677          0.23
28240...........................  Deuel County, Nebraska..        99928       0.8657       0.8677          0.23
28250...........................  Dixon County, Nebraska..        43580       0.9019       0.9200          2.01
28260...........................  Dodge County, Nebraska..        99928       0.8657       0.8677          0.23
28270...........................  Douglas County, Nebraska        36540       0.9560       0.9450         -1.15
28280...........................  Dundy County, Nebraska..        99928       0.8657       0.8677          0.23
28290...........................  Fillmore County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28300...........................  Franklin County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28310...........................  Frontier County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28320...........................  Furnas County, Nebraska.        99928       0.8657       0.8677          0.23
28330...........................  Gage County, Nebraska...        99928       0.8657       0.8677          0.23
28340...........................  Garden County, Nebraska.        99928       0.8657       0.8677          0.23
28350...........................  Garfield County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28360...........................  Gosper County, Nebraska.        99928       0.8657       0.8677          0.23
28370...........................  Grant County, Nebraska..        99928       0.8657       0.8677          0.23
28380...........................  Greeley County, Nebraska        99928       0.8657       0.8677          0.23
28390...........................  Hall County, Nebraska...        99928       0.8657       0.8677          0.23
28400...........................  Hamilton County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28410...........................  Harlan County, Nebraska.        99928       0.8657       0.8677          0.23
28420...........................  Hayes County, Nebraska..        99928       0.8657       0.8677          0.23
28430...........................  Hitchcock County,               99928       0.8657       0.8677          0.23
                                   Nebraska.
28440...........................  Holt County, Nebraska...        99928       0.8657       0.8677          0.23
28450...........................  Hooker County, Nebraska.        99928       0.8657       0.8677          0.23
28460...........................  Howard County, Nebraska.        99928       0.8657       0.8677          0.23
28470...........................  Jefferson County,               99928       0.8657       0.8677          0.23
                                   Nebraska.
28480...........................  Johnson County, Nebraska        99928       0.8657       0.8677          0.23
28490...........................  Kearney County, Nebraska        99928       0.8657       0.8677          0.23
28500...........................  Keith County, Nebraska..        99928       0.8657       0.8677          0.23

[[Page 65984]]

 
28510...........................  Keya Paha County,               99928       0.8657       0.8677          0.23
                                   Nebraska.
28520...........................  Kimball County, Nebraska        99928       0.8657       0.8677          0.23
28530...........................  Knox County, Nebraska...        99928       0.8657       0.8677          0.23
28540...........................  Lancaster County,               30700       1.0214       1.0092         -1.19
                                   Nebraska.
28550...........................  Lincoln County, Nebraska        99928       0.8657       0.8677          0.23
28560...........................  Logan County, Nebraska..        99928       0.8657       0.8677          0.23
28570...........................  Loup County, Nebraska...        99928       0.8657       0.8677          0.23
28580...........................  Mc Pherson County,              99928       0.8657       0.8677          0.23
                                   Nebraska.
28590...........................  Madison County, Nebraska        99928       0.8657       0.8677          0.23
28600...........................  Merrick County, Nebraska        99928       0.8657       0.8677          0.23
28610...........................  Morrill County, Nebraska        99928       0.8657       0.8677          0.23
28620...........................  Nance County, Nebraska..        99928       0.8657       0.8677          0.23
28630...........................  Nemaha County, Nebraska.        99928       0.8657       0.8677          0.23
28640...........................  Nuckolls County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28650...........................  Otoe County, Nebraska...        99928       0.8657       0.8677          0.23
28660...........................  Pawnee County, Nebraska.        99928       0.8657       0.8677          0.23
28670...........................  Perkins County, Nebraska        99928       0.8657       0.8677          0.23
28680...........................  Phelps County, Nebraska.        99928       0.8657       0.8677          0.23
28690...........................  Pierce County, Nebraska.        99928       0.8657       0.8677          0.23
28700...........................  Platte County, Nebraska.        99928       0.8657       0.8677          0.23
28710...........................  Polk County, Nebraska...        99928       0.8657       0.8677          0.23
28720...........................  Redwillow County,               99928       0.8657       0.8677          0.23
                                   Nebraska.
28730...........................  Richardson County,              99928       0.8657       0.8677          0.23
                                   Nebraska.
28740...........................  Rock County, Nebraska...        99928       0.8657       0.8677          0.23
28750...........................  Saline County, Nebraska.        99928       0.8657       0.8677          0.23
28760...........................  Sarpy County, Nebraska..        36540       0.9560       0.9450         -1.15
28770...........................  Saunders County,                36540       0.9109       0.9450          3.74
                                   Nebraska.
28780...........................  Scotts Bluff County,            99928       0.8657       0.8677          0.23
                                   Nebraska.
28790...........................  Seward County, Nebraska.        30700       0.9436       1.0092          6.95
28800...........................  Sheridan County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28810...........................  Sherman County, Nebraska        99928       0.8657       0.8677          0.23
28820...........................  Sioux County, Nebraska..        99928       0.8657       0.8677          0.23
28830...........................  Stanton County, Nebraska        99928       0.8657       0.8677          0.23
28840...........................  Thayer County, Nebraska.        99928       0.8657       0.8677          0.23
28850...........................  Thomas County, Nebraska.        99928       0.8657       0.8677          0.23
28860...........................  Thurston County,                99928       0.8657       0.8677          0.23
                                   Nebraska.
28870...........................  Valley County, Nebraska.        99928       0.8657       0.8677          0.23
28880...........................  Washington County,              36540       0.9560       0.9450         -1.15
                                   Nebraska.
28890...........................  Wayne County, Nebraska..        99928       0.8657       0.8677          0.23
28900...........................  Webster County, Nebraska        99928       0.8657       0.8677          0.23
28910...........................  Wheeler County, Nebraska        99928       0.8657       0.8677          0.23
28920...........................  York County, Nebraska...        99928       0.8657       0.8677          0.23
29000...........................  Churchill County, Nevada        99929       0.9376       0.8944         -4.61
29010...........................  Clark County, Nevada....        29820       1.1296       1.1430          1.19
29020...........................  Douglas County, Nevada..        99929       0.9376       0.8944         -4.61
29030...........................  Elko County, Nevada.....        99929       0.9376       0.8944         -4.61
29040...........................  Esmeralda County, Nevada        99929       0.9376       0.8944         -4.61
29050...........................  Eureka County, Nevada...        99929       0.9376       0.8944         -4.61
29060...........................  Humboldt County, Nevada.        99929       0.9376       0.8944         -4.61
29070...........................  Lander County, Nevada...        99929       0.9376       0.8944         -4.61
29080...........................  Lincoln County, Nevada..        99929       0.9376       0.8944         -4.61
29090...........................  Lyon County, Nevada.....        99929       0.9376       0.8944         -4.61
29100...........................  Mineral County, Nevada..        99929       0.9376       0.8944         -4.61
29110...........................  Nye County, Nevada......        99929       1.0110       0.8944        -11.53
29120...........................  Carson City County,             16180       0.9961       1.0025          0.64
                                   Nevada.
29130...........................  Pershing County, Nevada.        99929       0.9376       0.8944         -4.61
29140...........................  Storey County, Nevada...        39900       1.0335       1.1963         15.75
29150...........................  Washoe County, Nevada...        39900       1.0982       1.1963          8.93
29160...........................  White Pine County,              99929       0.9376       0.8944         -4.61
                                   Nevada.
30000...........................  Belknap County, New             99930       1.0817       1.0853          0.33
                                   Hampshire.
30010...........................  Carroll County, New             99930       1.0817       1.0853          0.33
                                   Hampshire.
30020...........................  Cheshire County, New            99930       1.0817       1.0853          0.33
                                   Hampshire.
30030...........................  Coos County, New                99930       1.0817       1.0853          0.33
                                   Hampshire.
30040...........................  Grafton County, New             99930       1.0817       1.0853          0.33
                                   Hampshire.
30050...........................  Hillsboro County, New           31700       1.0766       1.0243         -4.86
                                   Hampshire.
30060...........................  Merrimack County, New           31700       1.0766       1.0243         -4.86
                                   Hampshire.
30070...........................  Rockingham County, New          40484       1.0776       1.0159         -5.73
                                   Hampshire.
30080...........................  Strafford County, New           40484       1.0776       1.0159         -5.73
                                   Hampshire.

[[Page 65985]]

 
30090...........................  Sullivan County, New            99930       1.0817       1.0853          0.33
                                   Hampshire.
31000...........................  Atlantic County, New            12100       1.1556       1.1831          2.38
                                   Jersey.
31100...........................  Bergen County, New              35644       1.2420       1.3177          6.10
                                   Jersey.
31150...........................  Burlington County, New          15804       1.0720       1.0392         -3.06
                                   Jersey.
31160...........................  Camden County, New              15804       1.0720       1.0392         -3.06
                                   Jersey.
31180...........................  Cape May County, New            36140       1.1254       1.0472         -6.95
                                   Jersey.
31190...........................  Cumberland County, New          47220       0.9827       0.9832          0.05
                                   Jersey.
31200...........................  Essex County, New Jersey        35084       1.1859       1.1892          0.28
31220...........................  Gloucester County, New          15804       1.0720       1.0392         -3.06
                                   Jersey.
31230...........................  Hudson County, New              35644       1.2263       1.3177          7.45
                                   Jersey.
31250...........................  Hunterdon County, New           35084       1.1525       1.1892          3.18
                                   Jersey.
31260...........................  Mercer County, New              45940       1.0834       1.0835          0.01
                                   Jersey.
31270...........................  Middlesex County, New           20764       1.1208       1.1190         -0.16
                                   Jersey.
31290...........................  Monmouth County, New            20764       1.1255       1.1190         -0.58
                                   Jersey.
31300...........................  Morris County, New              35084       1.1859       1.1892          0.28
                                   Jersey.
31310...........................  Ocean County, New Jersey        20764       1.1255       1.1190         -0.58
31320...........................  Passaic County, New             35644       1.2420       1.3177          6.10
                                   Jersey.
31340...........................  Salem County, New Jersey        48864       1.0697       1.0684         -0.12
31350...........................  Somerset County, New            20764       1.1208       1.1190         -0.16
                                   Jersey.
31360...........................  Sussex County, New              35084       1.1859       1.1892          0.28
                                   Jersey.
31370...........................  Union County, New Jersey        35084       1.1859       1.1892          0.28
31390...........................  Warren County, New              10900       1.0826       0.9947         -8.12
                                   Jersey.
32000...........................  Bernalillo County, New          10740       0.9684       0.9458         -2.33
                                   Mexico.
32010...........................  Catron County, New              99932       0.8599       0.8332         -3.11
                                   Mexico.
32020...........................  Chaves County, New              99932       0.8599       0.8332         -3.11
                                   Mexico.
32025...........................  Cibola County, New              99932       0.8599       0.8332         -3.11
                                   Mexico.
32030...........................  Colfax County, New              99932       0.8599       0.8332         -3.11
                                   Mexico.
32040...........................  Curry County, New Mexico        99932       0.8599       0.8332         -3.11
32050...........................  De Baca County, New             99932       0.8599       0.8332         -3.11
                                   Mexico.
32060...........................  Dona Ana County, New            29740       0.8467       0.9273          9.52
                                   Mexico.
32070...........................  Eddy County, New Mexico.        99932       0.8599       0.8332         -3.11
32080...........................  Grant County, New Mexico        99932       0.8599       0.8332         -3.11
32090...........................  Guadalupe County, New           99932       0.8599       0.8332         -3.11
                                   Mexico.
32100...........................  Harding County, New             99932       0.8599       0.8332         -3.11
                                   Mexico.
32110...........................  Hidalgo County, New             99932       0.8599       0.8332         -3.11
                                   Mexico.
32120...........................  Lea County, New Mexico..        99932       0.8599       0.8332         -3.11
32130...........................  Lincoln County, New             99932       0.8599       0.8332         -3.11
                                   Mexico.
32131...........................  Los Alamos County, New          99932       0.9692       0.8332        -14.03
                                   Mexico.
32140...........................  Luna County, New Mexico.        99932       0.8599       0.8332         -3.11
32150...........................  Mc Kinley County, New           99932       0.8599       0.8332         -3.11
                                   Mexico.
32160...........................  Mora County, New Mexico.        99932       0.8599       0.8332         -3.11
32170...........................  Otero County, New Mexico        99932       0.8599       0.8332         -3.11
32180...........................  Quay County, New Mexico.        99932       0.8599       0.8332         -3.11
32190...........................  Rio Arriba County, New          99932       0.8599       0.8332         -3.11
                                   Mexico.
32200...........................  Roosevelt County, New           99932       0.8599       0.8332         -3.11
                                   Mexico.
32210...........................  Sandoval County, New            10740       0.9684       0.9458         -2.33
                                   Mexico.
32220...........................  San Juan County, New            22140       0.8536       0.8589          0.62
                                   Mexico.
32230...........................  San Miguel County, New          99932       0.8599       0.8332         -3.11
                                   Mexico.
32240...........................  Santa Fe County, New            42140       1.0834       1.0824         -0.09
                                   Mexico.
32250...........................  Sierra County, New              99932       0.8599       0.8332         -3.11
                                   Mexico.
32260...........................  Socorro County, New             99932       0.8599       0.8332         -3.11
                                   Mexico.
32270...........................  Taos County, New Mexico.        99932       0.8599       0.8332         -3.11
32280...........................  Torrance County, New            10740       0.9124       0.9458          3.66
                                   Mexico.
32290...........................  Union County, New Mexico        99932       0.8599       0.8332         -3.11
32300...........................  Valencia County, New            10740       0.9684       0.9458         -2.33
                                   Mexico.
33000...........................  Albany County, New York.        10580       0.8574       0.8720          1.70
33010...........................  Allegany County, New            99933       0.8275       0.8232         -0.52
                                   York.
33020...........................  Bronx County, New York..        35644       1.3326       1.3177         -1.12
33030...........................  Broome County, New York.        13780       0.8562       0.8786          2.62
33040...........................  Cattaraugus County, New         99933       0.8275       0.8232         -0.52
                                   York.
33050...........................  Cayuga County, New York.        99933       0.8823       0.8232         -6.70
33060...........................  Chautauqua County, New          99933       0.7849       0.8232          4.88
                                   York.
33070...........................  Chemung County, New York        21300       0.8250       0.8240         -0.12
33080...........................  Chenango County, New            99933       0.8275       0.8232         -0.52
                                   York.
33090...........................  Clinton County, New York        99933       0.8275       0.8232         -0.52
33200...........................  Columbia County, New            99933       0.8275       0.8232         -0.52
                                   York.
33210...........................  Cortland County, New            99933       0.8275       0.8232         -0.52
                                   York.
33220...........................  Delaware County, New            99933       0.8275       0.8232         -0.52
                                   York.

[[Page 65986]]

 
33230...........................  Dutchess County, New            39100       1.0683       1.0911          2.13
                                   York.
33240...........................  Erie County, New York...        15380       0.9511       0.9424         -0.91
33260...........................  Essex County, New York..        99933       0.8275       0.8232         -0.52
33270...........................  Franklin County, New            99933       0.8275       0.8232         -0.52
                                   York.
33280...........................  Fulton County, New York.        99933       0.8275       0.8232         -0.52
33290...........................  Genesee County, New York        99933       0.8602       0.8232         -4.30
33300...........................  Greene County, New York.        99933       0.8275       0.8232         -0.52
33310...........................  Hamilton County, New            99933       0.8275       0.8232         -0.52
                                   York.
33320...........................  Herkimer County, New            46540       0.8358       0.8396          0.45
                                   York.
33330...........................  Jefferson County, New           99933       0.8275       0.8232         -0.52
                                   York.
33331...........................  Kings County, New York..        35644       1.3326       1.3177         -1.12
33340...........................  Lewis County, New York..        99933       0.8275       0.8232         -0.52
33350...........................  Livingston County, New          40380       0.9085       0.8994         -1.00
                                   York.
33360...........................  Madison County, New York        45060       0.9533       0.9691          1.66
33370...........................  Monroe County, New York.        40380       0.9085       0.8994         -1.00
33380...........................  Montgomery County, New          99933       0.8357       0.8232         -1.50
                                   York.
33400...........................  Nassau County, New York.        35004       1.2719       1.2662         -0.45
33420...........................  New York County, New            35644       1.3326       1.3177         -1.12
                                   York.
33500...........................  Niagara County, New York        15380       0.9511       0.9424         -0.91
33510...........................  Oneida County, New York.        46540       0.8358       0.8396          0.45
33520...........................  Onondaga County, New            45060       0.9533       0.9691          1.66
                                   York.
33530...........................  Ontario County, New York        40380       0.9085       0.8994         -1.00
33540...........................  Orange County, New York.        39100       1.1049       1.0911         -1.25
33550...........................  Orleans County, New York        40380       0.9085       0.8994         -1.00
33560...........................  Oswego County, New York.        45060       0.9533       0.9691          1.66
33570...........................  Otsego County, New York.        99933       0.8275       0.8232         -0.52
33580...........................  Putnam County, New York.        35644       1.3326       1.3177         -1.12
33590...........................  Queens County, New York.        35644       1.3326       1.3177         -1.12
33600...........................  Rensselaer County, New          10580       0.8574       0.8720          1.70
                                   York.
33610...........................  Richmond County, New            35644       1.3326       1.3177         -1.12
                                   York.
33620...........................  Rockland County, New            35644       1.3326       1.3177         -1.12
                                   York.
33630...........................  St Lawrence County, New         99933       0.8275       0.8232         -0.52
                                   York.
33640...........................  Saratoga County, New            10580       0.8574       0.8720          1.70
                                   York.
33650...........................  Schenectady County, New         10580       0.8574       0.8720          1.70
                                   York.
33660...........................  Schoharie County, New           10580       0.8574       0.8720          1.70
                                   York.
33670...........................  Schuyler County, New            99933       0.8275       0.8232         -0.52
                                   York.
33680...........................  Seneca County, New York.        99933       0.8275       0.8232         -0.52
33690...........................  Steuben County, New York        99933       0.8275       0.8232         -0.52
33700...........................  Suffolk County, New York        35004       1.2719       1.2662         -0.45
33710...........................  Sullivan County, New            99933       0.8275       0.8232         -0.52
                                   York.
33720...........................  Tioga County, New York..        13780       0.8562       0.8786          2.62
33730...........................  Tompkins County, New            27060       0.9094       0.9928          9.17
                                   York.
33740...........................  Ulster County, New York.        28740       0.8825       0.9367          6.14
33750...........................  Warren County, New York.        24020       0.8559       0.8324         -2.75
33760...........................  Washington County, New          24020       0.8559       0.8324         -2.75
                                   York.
33770...........................  Wayne County, New York..        40380       0.9085       0.8994         -1.00
33800...........................  Westchester County, New         35644       1.3326       1.3177         -1.12
                                   York.
33900...........................  Wyoming County, New York        99933       0.8275       0.8232         -0.52
33910...........................  Yates County, New York..        99933       0.8275       0.8232         -0.52
34000...........................  Alamance County, N              15500       0.8962       0.8674         -3.21
                                   Carolina.
34010...........................  Alexander County, N             25860       0.8921       0.9010          1.00
                                   Carolina.
34020...........................  Alleghany County, N             99934       0.8501       0.8588          1.02
                                   Carolina.
34030...........................  Anson County, N Carolina        16740       0.9106       0.9554          4.92
34040...........................  Ashe County, N Carolina.        99934       0.8501       0.8588          1.02
34050...........................  Avery County, N Carolina        99934       0.8501       0.8588          1.02
34060...........................  Beaufort County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34070...........................  Bertie County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34080...........................  Bladen County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34090...........................  Brunswick County, N             48900       0.9582       0.9835          2.64
                                   Carolina.
34100...........................  Buncombe County, N              11700       0.9511       0.9216         -3.10
                                   Carolina.
34110...........................  Burke County, N Carolina        25860       0.8921       0.9010          1.00
34120...........................  Cabarrus County, N              16740       0.9733       0.9554         -1.84
                                   Carolina.
34130...........................  Caldwell County, N              25860       0.8921       0.9010          1.00
                                   Carolina.
34140...........................  Camden County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34150...........................  Carteret County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34160...........................  Caswell County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34170...........................  Catawba County, N               25860       0.8921       0.9010          1.00
                                   Carolina.
34180...........................  Chatham County, N               20500       1.0139       0.9826         -3.09
                                   Carolina.

[[Page 65987]]

 
34190...........................  Cherokee County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34200...........................  Chowan County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34210...........................  Clay County, N Carolina.        99934       0.8501       0.8588          1.02
34220...........................  Cleveland County, N             99934       0.8501       0.8588          1.02
                                   Carolina.
34230...........................  Columbus County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34240...........................  Craven County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34250...........................  Cumberland County, N            22180       0.9416       0.8945         -5.00
                                   Carolina.
34251...........................  Currituck County, N             47260       0.8799       0.8790         -0.10
                                   Carolina.
34270...........................  Dare County, N Carolina.        99934       0.8501       0.8588          1.02
34280...........................  Davidson County, N              99934       0.8779       0.8588         -2.18
                                   Carolina.
34290...........................  Davie County, N Carolina        49180       0.8981       0.9276          3.28
34300...........................  Duplin County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34310...........................  Durham County, N                20500       1.0139       0.9826         -3.09
                                   Carolina.
34320...........................  Edgecombe County, N             40580       0.8915       0.8854         -0.68
                                   Carolina.
34330...........................  Forsyth County, N               49180       0.8981       0.9276          3.28
                                   Carolina.
34340...........................  Franklin County, N              39580       0.9863       0.9864          0.01
                                   Carolina.
34350...........................  Gaston County, N                16740       0.9733       0.9554         -1.84
                                   Carolina.
34360...........................  Gates County, N Carolina        99934       0.8501       0.8588          1.02
34370...........................  Graham County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34380...........................  Granville County, N             99934       0.8501       0.8588          1.02
                                   Carolina.
34390...........................  Greene County, N                24780       0.8944       0.9432          5.46
                                   Carolina.
34400...........................  Guilford County, N              24660       0.9061       0.8866         -2.15
                                   Carolina.
34410...........................  Halifax County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34420...........................  Harnett County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34430...........................  Haywood County, N               11700       0.8874       0.9216          3.85
                                   Carolina.
34440...........................  Henderson County, N             11700       0.8874       0.9216          3.85
                                   Carolina.
34450...........................  Hertford County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34460...........................  Hoke County, N Carolina.        22180       0.8939       0.8945          0.07
34470...........................  Hyde County, N Carolina.        99934       0.8501       0.8588          1.02
34480...........................  Iredell County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34490...........................  Jackson County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34500...........................  Johnston County, N              39580       0.9863       0.9864          0.01
                                   Carolina.
34510...........................  Jones County, N Carolina        99934       0.8501       0.8588          1.02
34520...........................  Lee County, N Carolina..        99934       0.8501       0.8588          1.02
34530...........................  Lenoir County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34540...........................  Lincoln County, N               99934       0.9128       0.8588         -5.92
                                   Carolina.
34550...........................  Mc Dowell County, N             99934       0.8501       0.8588          1.02
                                   Carolina.
34560...........................  Macon County, N Carolina        99934       0.8501       0.8588          1.02
34570...........................  Madison County, N               11700       0.9511       0.9216         -3.10
                                   Carolina.
34580...........................  Martin County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34590...........................  Mecklenburg County, N           16740       0.9733       0.9554         -1.84
                                   Carolina.
34600...........................  Mitchell County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34610...........................  Montgomery County, N            99934       0.8501       0.8588          1.02
                                   Carolina.
34620...........................  Moore County, N Carolina        99934       0.8501       0.8588          1.02
34630...........................  Nash County, N Carolina.        40580       0.8915       0.8854         -0.68
34640...........................  New Hanover County, N           48900       0.9582       0.9835          2.64
                                   Carolina.
34650...........................  Northampton County, N           99934       0.8501       0.8588          1.02
                                   Carolina.
34660...........................  Onslow County, N                27340       0.8236       0.8231         -0.06
                                   Carolina.
34670...........................  Orange County, N                20500       1.0139       0.9826         -3.09
                                   Carolina.
34680...........................  Pamlico County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34690...........................  Pasquotank County, N            99934       0.8501       0.8588          1.02
                                   Carolina.
34700...........................  Pender County, N                48900       0.9022       0.9835          9.01
                                   Carolina.
34710...........................  Perquimans County, N            99934       0.8501       0.8588          1.02
                                   Carolina.
34720...........................  Person County, N                20500       0.9353       0.9826          5.06
                                   Carolina.
34730...........................  Pitt County, N Carolina.        24780       0.9425       0.9432          0.07
34740...........................  Polk County, N Carolina.        99934       0.8501       0.8588          1.02
34750...........................  Randolph County, N              24660       0.9061       0.8866         -2.15
                                   Carolina.
34760...........................  Richmond County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34770...........................  Robeson County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34780...........................  Rockingham County, N            24660       0.8783       0.8866          0.95
                                   Carolina.
34790...........................  Rowan County, N Carolina        99934       0.9128       0.8588         -5.92
34800...........................  Rutherford County, N            99934       0.8501       0.8588          1.02
                                   Carolina.
34810...........................  Sampson County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34820...........................  Scotland County, N              99934       0.8501       0.8588          1.02
                                   Carolina.
34830...........................  Stanly County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34840...........................  Stokes County, N                49180       0.8981       0.9276          3.28
                                   Carolina.
34850...........................  Surry County, N Carolina        99934       0.8501       0.8588          1.02
34860...........................  Swain County, N Carolina        99934       0.8501       0.8588          1.02

[[Page 65988]]

 
34870...........................  Transylvania County, N          99934       0.8501       0.8588          1.02
                                   Carolina.
34880...........................  Tyrrell County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34890...........................  Union County, N Carolina        16740       0.9733       0.9554         -1.84
34900...........................  Vance County, N Carolina        99934       0.8501       0.8588          1.02
34910...........................  Wake County, N Carolina.        39580       0.9863       0.9864          0.01
34920...........................  Warren County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34930...........................  Washington County, N            99934       0.8501       0.8588          1.02
                                   Carolina.
34940...........................  Watauga County, N               99934       0.8501       0.8588          1.02
                                   Carolina.
34950...........................  Wayne County, N Carolina        24140       0.8775       0.9171          4.51
34960...........................  Wilkes County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34970...........................  Wilson County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
34980...........................  Yadkin County, N                49180       0.8981       0.9276          3.28
                                   Carolina.
34981...........................  Yancey County, N                99934       0.8501       0.8588          1.02
                                   Carolina.
35000...........................  Adams County, N Dakota..        99935       0.7261       0.7215         -0.63
35010...........................  Barnes County, N Dakota.        99935       0.7261       0.7215         -0.63
35020...........................  Benson County, N Dakota.        99935       0.7261       0.7215         -0.63
35030...........................  Billings County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35040...........................  Bottineau County, N             99935       0.7261       0.7215         -0.63
                                   Dakota.
35050...........................  Bowman County, N Dakota.        99935       0.7261       0.7215         -0.63
35060...........................  Burke County, N Dakota..        99935       0.7261       0.7215         -0.63
35070...........................  Burleigh County, N              13900       0.7574       0.7240         -4.41
                                   Dakota.
35080...........................  Cass County, N Dakota...        22020       0.8486       0.8250         -2.78
35090...........................  Cavalier County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35100...........................  Dickey County, N Dakota.        99935       0.7261       0.7215         -0.63
35110...........................  Divide County, N Dakota.        99935       0.7261       0.7215         -0.63
35120...........................  Dunn County, N Dakota...        99935       0.7261       0.7215         -0.63
35130...........................  Eddy County, N Dakota...        99935       0.7261       0.7215         -0.63
35140...........................  Emmons County, N Dakota.        99935       0.7261       0.7215         -0.63
35150...........................  Foster County, N Dakota.        99935       0.7261       0.7215         -0.63
35160...........................  Golden Valley County, N         99935       0.7261       0.7215         -0.63
                                   Dakota.
35170...........................  Grand Forks County, N           24220       0.7901       0.7949          0.61
                                   Dakota.
35180...........................  Grant County, N Dakota..        99935       0.7261       0.7215         -0.63
35190...........................  Griggs County, N Dakota.        99935       0.7261       0.7215         -0.63
35200...........................  Hettinger County, N             99935       0.7261       0.7215         -0.63
                                   Dakota.
35210...........................  Kidder County, N Dakota.        99935       0.7261       0.7215         -0.63
35220...........................  La Moure County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35230...........................  Logan County, N Dakota..        99935       0.7261       0.7215         -0.63
35240...........................  Mc Henry County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35250...........................  Mc Intosh County, N             99935       0.7261       0.7215         -0.63
                                   Dakota.
35260...........................  Mc Kenzie County, N             99935       0.7261       0.7215         -0.63
                                   Dakota.
35270...........................  Mc Lean County, N Dakota        99935       0.7261       0.7215         -0.63
35280...........................  Mercer County, N Dakota.        99935       0.7261       0.7215         -0.63
35290...........................  Morton County, N Dakota.        13900       0.7574       0.7240         -4.41
35300...........................  Mountrail County, N             99935       0.7261       0.7215         -0.63
                                   Dakota.
35310...........................  Nelson County, N Dakota.        99935       0.7261       0.7215         -0.63
35320...........................  Oliver County, N Dakota.        99935       0.7261       0.7215         -0.63
35330...........................  Pembina County, N Dakota        99935       0.7261       0.7215         -0.63
35340...........................  Pierce County, N Dakota.        99935       0.7261       0.7215         -0.63
35350...........................  Ramsey County, N Dakota.        99935       0.7261       0.7215         -0.63
35360...........................  Ransom County, N Dakota.        99935       0.7261       0.7215         -0.63
35370...........................  Renville County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35380...........................  Richland County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35390...........................  Rolette County, N Dakota        99935       0.7261       0.7215         -0.63
35400...........................  Sargent County, N Dakota        99935       0.7261       0.7215         -0.63
35410...........................  Sheridan County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35420...........................  Sioux County, N Dakota..        99935       0.7261       0.7215         -0.63
35430...........................  Slope County, N Dakota..        99935       0.7261       0.7215         -0.63
35440...........................  Stark County, N Dakota..        99935       0.7261       0.7215         -0.63
35450...........................  Steele County, N Dakota.        99935       0.7261       0.7215         -0.63
35460...........................  Stutsman County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
35470...........................  Towner County, N Dakota.        99935       0.7261       0.7215         -0.63
35480...........................  Traill County, N Dakota.        99935       0.7261       0.7215         -0.63
35490...........................  Walsh County, N Dakota..        99935       0.7261       0.7215         -0.63
35500...........................  Ward County, N Dakota...        99935       0.7261       0.7215         -0.63
35510...........................  Wells County, N Dakota..        99935       0.7261       0.7215         -0.63
35520...........................  Williams County, N              99935       0.7261       0.7215         -0.63
                                   Dakota.
36000...........................  Adams County, Ohio......        99936       0.8874       0.8658         -2.43
36010...........................  Allen County, Ohio......        30620       0.9172       0.9042         -1.42

[[Page 65989]]

 
36020...........................  Ashland County, Ohio....        99936       0.8874       0.8658         -2.43
36030...........................  Ashtabula County, Ohio..        99936       0.9005       0.8658         -3.85
36040...........................  Athens County, Ohio.....        99936       0.8874       0.8658         -2.43
36050...........................  Auglaize County, Ohio...        99936       0.8973       0.8658         -3.51
36060...........................  Belmont County, Ohio....        48540       0.7161       0.7010         -2.11
36070...........................  Brown County, Ohio......        17140       0.9675       0.9601         -0.76
36080...........................  Butler County, Ohio.....        17140       0.9283       0.9601          3.43
36090...........................  Carroll County, Ohio....        15940       0.8935       0.9031          1.07
36100...........................  Champaign County, Ohio..        99936       0.8874       0.8658         -2.43
36110...........................  Clark County, Ohio......        44220       0.8688       0.8593         -1.09
36120...........................  Clermont County, Ohio...        17140       0.9675       0.9601         -0.76
36130...........................  Clinton County, Ohio....        99936       0.8874       0.8658         -2.43
36140...........................  Columbiana County, Ohio.        99936       0.8837       0.8658         -2.03
36150...........................  Coshocton County, Ohio..        99936       0.8874       0.8658         -2.43
36160...........................  Crawford County, Ohio...        99936       0.9359       0.8658         -7.49
36170...........................  Cuyahoga County, Ohio...        17460       0.9198       0.9400          2.20
36190...........................  Darke County, Ohio......        99936       0.8874       0.8658         -2.43
36200...........................  Defiance County, Ohio...        99936       0.8874       0.8658         -2.43
36210...........................  Delaware County, Ohio...        18140       0.9867       1.0107          2.43
36220...........................  Erie County, Ohio.......        41780       0.8970       0.9302          3.70
36230...........................  Fairfield County, Ohio..        18140       0.9867       1.0107          2.43
36240...........................  Fayette County, Ohio....        99936       0.8874       0.8658         -2.43
36250...........................  Franklin County, Ohio...        18140       0.9867       1.0107          2.43
36260...........................  Fulton County, Ohio.....        45780       0.9574       0.9586          0.13
36270...........................  Gallia County, Ohio.....        99936       0.8874       0.8658         -2.43
36280...........................  Geauga County, Ohio.....        17460       0.9198       0.9400          2.20
36290...........................  Greene County, Ohio.....        19380       0.9022       0.9037          0.17
36300...........................  Guernsey County, Ohio...        99936       0.8874       0.8658         -2.43
36310...........................  Hamilton County, Ohio...        17140       0.9675       0.9601         -0.76
36330...........................  Hancock County, Ohio....        99936       0.8874       0.8658         -2.43
36340...........................  Hardin County, Ohio.....        99936       0.8874       0.8658         -2.43
36350...........................  Harrison County, Ohio...        99936       0.8874       0.8658         -2.43
36360...........................  Henry County, Ohio......        99936       0.8874       0.8658         -2.43
36370...........................  Highland County, Ohio...        99936       0.8874       0.8658         -2.43
36380...........................  Hocking County, Ohio....        99936       0.8874       0.8658         -2.43
36390...........................  Holmes County, Ohio.....        99936       0.8874       0.8658         -2.43
36400...........................  Huron County, Ohio......        99936       0.8874       0.8658         -2.43
36410...........................  Jackson County, Ohio....        99936       0.8874       0.8658         -2.43
36420...........................  Jefferson County, Ohio..        48260       0.7819       0.8063          3.12
36430...........................  Knox County, Ohio.......        99936       0.8874       0.8658         -2.43
36440...........................  Lake County, Ohio.......        17460       0.9198       0.9400          2.20
36450...........................  Lawrence County, Ohio...        26580       0.9477       0.8997         -5.06
36460...........................  Licking County, Ohio....        18140       0.9867       1.0107          2.43
36470...........................  Logan County, Ohio......        99936       0.8874       0.8658         -2.43
36480...........................  Lorain County, Ohio.....        17460       0.9198       0.9400          2.20
36490...........................  Lucas County, Ohio......        45780       0.9574       0.9586          0.13
36500...........................  Madison County, Ohio....        18140       0.9867       1.0107          2.43
36510...........................  Mahoning County, Ohio...        49660       0.8726       0.8802          0.87
36520...........................  Marion County, Ohio.....        99936       0.8874       0.8658         -2.43
36530...........................  Medina County, Ohio.....        17460       0.9198       0.9400          2.20
36540...........................  Meigs County, Ohio......        99936       0.8874       0.8658         -2.43
36550...........................  Mercer County, Ohio.....        99936       0.8874       0.8658         -2.43
36560...........................  Miami County, Ohio......        19380       0.9022       0.9037          0.17
36570...........................  Monroe County, Ohio.....        99936       0.8874       0.8658         -2.43
36580...........................  Montgomery County, Ohio.        19380       0.9022       0.9037          0.17
36590...........................  Morgan County, Ohio.....        99936       0.8874       0.8658         -2.43
36600...........................  Morrow County, Ohio.....        18140       0.9391       1.0107          7.62
36610...........................  Muskingum County, Ohio..        99936       0.8874       0.8658         -2.43
36620...........................  Noble County, Ohio......        99936       0.8874       0.8658         -2.43
36630...........................  Ottawa County, Ohio.....        45780       0.9248       0.9586          3.65
36640...........................  Paulding County, Ohio...        99936       0.8874       0.8658         -2.43
36650...........................  Perry County, Ohio......        99936       0.8874       0.8658         -2.43
36660...........................  Pickaway County, Ohio...        18140       0.9867       1.0107          2.43
36670...........................  Pike County, Ohio.......        99936       0.8874       0.8658         -2.43
36680...........................  Portage County, Ohio....        10420       0.8982       0.8654         -3.65
36690...........................  Preble County, Ohio.....        19380       0.8993       0.9037          0.49
36700...........................  Putnam County, Ohio.....        99936       0.8874       0.8658         -2.43
36710...........................  Richland County, Ohio...        31900       0.9891       0.9271         -6.27

[[Page 65990]]

 
36720...........................  Ross County, Ohio.......        99936       0.8874       0.8658         -2.43
36730...........................  Sandusky County, Ohio...        99936       0.8874       0.8658         -2.43
36740...........................  Scioto County, Ohio.....        99936       0.8874       0.8658         -2.43
36750...........................  Seneca County, Ohio.....        99936       0.8874       0.8658         -2.43
36760...........................  Shelby County, Ohio.....        99936       0.8874       0.8658         -2.43
36770...........................  Stark County, Ohio......        15940       0.8935       0.9031          1.07
36780...........................  Summit County, Ohio.....        10420       0.8982       0.8654         -3.65
36790...........................  Trumbull County, Ohio...        49660       0.8726       0.8802          0.87
36800...........................  Tuscarawas County, Ohio.        99936       0.8874       0.8658         -2.43
36810...........................  Union County, Ohio......        18140       0.9391       1.0107          7.62
36820...........................  Van Wert County, Ohio...        99936       0.8874       0.8658         -2.43
36830...........................  Vinton County, Ohio.....        99936       0.8874       0.8658         -2.43
36840...........................  Warren County, Ohio.....        17140       0.9675       0.9601         -0.76
36850...........................  Washington County, Ohio.        37620       0.8270       0.7977         -3.54
36860...........................  Wayne County, Ohio......        99936       0.8874       0.8658         -2.43
36870...........................  Williams County, Ohio...        99936       0.8874       0.8658         -2.43
36880...........................  Wood County, Ohio.......        45780       0.9574       0.9586          0.13
36890...........................  Wyandot County, Ohio....        99936       0.8874       0.8658         -2.43
37000...........................  Adair County, Oklahoma..        99937       0.7512       0.7629          1.56
37010...........................  Alfalfa County, Oklahoma        99937       0.7512       0.7629          1.56
37020...........................  Atoka County, Oklahoma..        99937       0.7512       0.7629          1.56
37030...........................  Beaver County, Oklahoma.        99937       0.7512       0.7629          1.56
37040...........................  Beckham County, Oklahoma        99937       0.7512       0.7629          1.56
37050...........................  Blaine County, Oklahoma.        99937       0.7512       0.7629          1.56
37060...........................  Bryan County, Oklahoma..        99937       0.7512       0.7629          1.56
37070...........................  Caddo County, Oklahoma..        99937       0.7512       0.7629          1.56
37080...........................  Canadian County,                36420       0.9028       0.8843         -2.05
                                   Oklahoma.
37090...........................  Carter County, Oklahoma.        99937       0.7512       0.7629          1.56
37100...........................  Cherokee County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37110...........................  Choctaw County, Oklahoma        99937       0.7512       0.7629          1.56
37120...........................  Cimarron County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37130...........................  Cleveland County,               36420       0.9028       0.8843         -2.05
                                   Oklahoma.
37140...........................  Coal County, Oklahoma...        99937       0.7512       0.7629          1.56
37150...........................  Comanche County,                30020       0.7872       0.8065          2.45
                                   Oklahoma.
37160...........................  Cotton County, Oklahoma.        99937       0.7512       0.7629          1.56
37170...........................  Craig County, Oklahoma..        99937       0.7512       0.7629          1.56
37180...........................  Creek County, Oklahoma..        46140       0.8565       0.8103         -5.39
37190...........................  Custer County, Oklahoma.        99937       0.7512       0.7629          1.56
37200...........................  Delaware County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37210...........................  Dewey County, Oklahoma..        99937       0.7512       0.7629          1.56
37220...........................  Ellis County, Oklahoma..        99937       0.7512       0.7629          1.56
37230...........................  Garfield County,                99937       0.8124       0.7629         -6.09
                                   Oklahoma.
37240...........................  Garvin County, Oklahoma.        99937       0.7512       0.7629          1.56
37250...........................  Grady County, Oklahoma..        36420       0.8237       0.8843          7.36
37260...........................  Grant County, Oklahoma..        99937       0.7512       0.7629          1.56
37270...........................  Greer County, Oklahoma..        99937       0.7512       0.7629          1.56
37280...........................  Harmon County, Oklahoma.        99937       0.7512       0.7629          1.56
37290...........................  Harper County, Oklahoma.        99937       0.7512       0.7629          1.56
37300...........................  Haskell County, Oklahoma        99937       0.7512       0.7629          1.56
37310...........................  Hughes County, Oklahoma.        99937       0.7512       0.7629          1.56
37320...........................  Jackson County, Oklahoma        99937       0.7512       0.7629          1.56
37330...........................  Jefferson County,               99937       0.7512       0.7629          1.56
                                   Oklahoma.
37340...........................  Johnston County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37350...........................  Kay County, Oklahoma....        99937       0.7512       0.7629          1.56
37360...........................  Kingfisher County,              99937       0.7512       0.7629          1.56
                                   Oklahoma.
37370...........................  Kiowa County, Oklahoma..        99937       0.7512       0.7629          1.56
37380...........................  Latimer County, Oklahoma        99937       0.7512       0.7629          1.56
37390...........................  Le Flore County,                22900       0.7836       0.7731         -1.34
                                   Oklahoma.
37400...........................  Lincoln County, Oklahoma        36420       0.8237       0.8843          7.36
37410...........................  Logan County, Oklahoma..        36420       0.9028       0.8843         -2.05
37420...........................  Love County, Oklahoma...        99937       0.7512       0.7629          1.56
37430...........................  Mc Clain County,                36420       0.9028       0.8843         -2.05
                                   Oklahoma.
37440...........................  Mc Curtain County,              99937       0.7512       0.7629          1.56
                                   Oklahoma.
37450...........................  Mc Intosh County,               99937       0.7512       0.7629          1.56
                                   Oklahoma.
37460...........................  Major County, Oklahoma..        99937       0.7512       0.7629          1.56
37470...........................  Marshall County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37480...........................  Mayes County, Oklahoma..        99937       0.7512       0.7629          1.56
37490...........................  Murray County, Oklahoma.        99937       0.7512       0.7629          1.56

[[Page 65991]]

 
37500...........................  Muskogee County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37510...........................  Noble County, Oklahoma..        99937       0.7512       0.7629          1.56
37520...........................  Nowata County, Oklahoma.        99937       0.7512       0.7629          1.56
37530...........................  Okfuskee County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37540...........................  Oklahoma County,                36420       0.9028       0.8843         -2.05
                                   Oklahoma.
37550...........................  Okmulgee County,                46140       0.7993       0.8103          1.38
                                   Oklahoma.
37560...........................  Osage County, Oklahoma..        46140       0.8565       0.8103         -5.39
37570...........................  Ottawa County, Oklahoma.        99937       0.7512       0.7629          1.56
37580...........................  Pawnee County, Oklahoma.        46140       0.7993       0.8103          1.38
37590...........................  Payne County, Oklahoma..        99937       0.7512       0.7629          1.56
37600...........................  Pittsburg County,               99937       0.7512       0.7629          1.56
                                   Oklahoma.
37610...........................  Pontotoc County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37620...........................  Pottawatomie County,            99937       0.8303       0.7629         -8.12
                                   Oklahoma.
37630...........................  Pushmataha County,              99937       0.7512       0.7629          1.56
                                   Oklahoma.
37640...........................  Roger Mills County,             99937       0.7512       0.7629          1.56
                                   Oklahoma.
37650...........................  Rogers County, Oklahoma.        46140       0.8565       0.8103         -5.39
37660...........................  Seminole County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37670...........................  Sequoyah County,                22900       0.8238       0.7731         -6.15
                                   Oklahoma.
37680...........................  Stephens County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
37690...........................  Texas County, Oklahoma..        99937       0.7512       0.7629          1.56
37700...........................  Tillman County, Oklahoma        99937       0.7512       0.7629          1.56
37710...........................  Tulsa County, Oklahoma..        46140       0.8565       0.8103         -5.39
37720...........................  Wagoner County, Oklahoma        46140       0.8565       0.8103         -5.39
37730...........................  Washington County,              99937       0.7512       0.7629          1.56
                                   Oklahoma.
37740...........................  Washita County, Oklahoma        99937       0.7512       0.7629          1.56
37750...........................  Woods County, Oklahoma..        99937       0.7512       0.7629          1.56
37760...........................  Woodward County,                99937       0.7512       0.7629          1.56
                                   Oklahoma.
38000...........................  Baker County, Oregon....        99938       0.9939       0.9753         -1.87
38010...........................  Benton County, Oregon...        18700       1.0729       1.1546          7.61
38020...........................  Clackamas County, Oregon        38900       1.1266       1.1416          1.33
38030...........................  Clatsop County, Oregon..        99938       0.9939       0.9753         -1.87
38040...........................  Columbia County, Oregon.        38900       1.1266       1.1416          1.33
38050...........................  Coos County, Oregon.....        99938       0.9939       0.9753         -1.87
38060...........................  Crook County, Oregon....        99938       0.9939       0.9753         -1.87
38070...........................  Curry County, Oregon....        99938       0.9939       0.9753         -1.87
38080...........................  Deschutes County, Oregon        13460       1.0419       1.0743          3.11
38090...........................  Douglas County, Oregon..        99938       0.9939       0.9753         -1.87
38100...........................  Gilliam County, Oregon..        99938       0.9939       0.9753         -1.87
38110...........................  Grant County, Oregon....        99938       0.9939       0.9753         -1.87
38120...........................  Harney County, Oregon...        99938       0.9939       0.9753         -1.87
38130...........................  Hood River County,              99938       0.9939       0.9753         -1.87
                                   Oregon.
38140...........................  Jackson County, Oregon..        32780       1.0225       1.0818          5.80
38150...........................  Jefferson County, Oregon        99938       0.9939       0.9753         -1.87
38160...........................  Josephine County, Oregon        99938       0.9939       0.9753         -1.87
38170...........................  Klamath County, Oregon..        99938       0.9939       0.9753         -1.87
38180...........................  Lake County, Oregon.....        99938       0.9939       0.9753         -1.87
38190...........................  Lane County, Oregon.....        21660       1.0818       1.0876          0.54
38200...........................  Lincoln County, Oregon..        99938       0.9939       0.9753         -1.87
38210...........................  Linn County, Oregon.....        99938       0.9939       0.9753         -1.87
38220...........................  Malheur County, Oregon..        99938       0.9939       0.9753         -1.87
38230...........................  Marion County, Oregon...        41420       1.0442       1.0438         -0.04
38240...........................  Morrow County, Oregon...        99938       0.9939       0.9753         -1.87
38250...........................  Multnomah County, Oregon        38900       1.1266       1.1416          1.33
38260...........................  Polk County, Oregon.....        41420       1.0442       1.0438         -0.04
38270...........................  Sherman County, Oregon..        99938       0.9939       0.9753         -1.87
38280...........................  Tillamook County, Oregon        99938       0.9939       0.9753         -1.87
38290...........................  Umatilla County, Oregon.        99938       0.9939       0.9753         -1.87
38300...........................  Union County, Oregon....        99938       0.9939       0.9753         -1.87
38310...........................  Wallowa County, Oregon..        99938       0.9939       0.9753         -1.87
38320...........................  Wasco County, Oregon....        99938       0.9939       0.9753         -1.87
38330...........................  Washington County,              38900       1.1266       1.1416          1.33
                                   Oregon.
38340...........................  Wheeler County, Oregon..        99938       0.9939       0.9753         -1.87
38350...........................  Yamhill County, Oregon..        38900       1.1266       1.1416          1.33
39000...........................  Adams County,                   99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39010...........................  Allegheny County,               38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39070...........................  Armstrong County,               38300       0.8582       0.8674          1.07
                                   Pennsylvania.
39080...........................  Beaver County,                  38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39100...........................  Bedford County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.

[[Page 65992]]

 
39110...........................  Berks County,                   39740       0.9686       0.9622         -0.66
                                   Pennsylvania.
39120...........................  Blair County,                   11020       0.8944       0.8812         -1.48
                                   Pennsylvania.
39130...........................  Bradford County,                99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39140...........................  Bucks County,                   37964       1.0980       1.0996          0.15
                                   Pennsylvania.
39150...........................  Butler County,                  38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39160...........................  Cambria County,                 27780       0.8220       0.8620          4.87
                                   Pennsylvania.
39180...........................  Cameron County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39190...........................  Carbon County,                  10900       0.9832       0.9947          1.17
                                   Pennsylvania.
39200...........................  Centre County,                  44300       0.8356       0.8784          5.12
                                   Pennsylvania.
39210...........................  Chester County,                 37964       1.0980       1.0996          0.15
                                   Pennsylvania.
39220...........................  Clarion County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39230...........................  Clearfield County,              99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39240...........................  Clinton County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39250...........................  Columbia County,                99939       0.8408       0.8320         -1.05
                                   Pennsylvania.
39260...........................  Crawford County,                99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39270...........................  Cumberland County,              25420       0.9273       0.9402          1.39
                                   Pennsylvania.
39280...........................  Dauphin County,                 25420       0.9273       0.9402          1.39
                                   Pennsylvania.
39290...........................  Delaware County,                37964       1.0980       1.0996          0.15
                                   Pennsylvania.
39310...........................  Elk County, Pennsylvania        99939       0.8305       0.8320          0.18
39320...........................  Erie County,                    21500       0.8737       0.8827          1.03
                                   Pennsylvania.
39330...........................  Fayette County,                 38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39340...........................  Forest County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39350...........................  Franklin County,                99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39360...........................  Fulton County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39370...........................  Greene County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39380...........................  Huntingdon County,              99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39390...........................  Indiana County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39400...........................  Jefferson County,               99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39410...........................  Juniata County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39420...........................  Lackawanna County,              42540       0.8532       0.8347         -2.17
                                   Pennsylvania.
39440...........................  Lancaster County,               29540       0.9694       0.9589         -1.08
                                   Pennsylvania.
39450...........................  Lawrence County,                99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39460...........................  Lebanon County,                 30140       0.8846       0.8679         -1.89
                                   Pennsylvania.
39470...........................  Lehigh County,                  10900       0.9832       0.9947          1.17
                                   Pennsylvania.
39480...........................  Luzerne County,                 42540       0.8532       0.8347         -2.17
                                   Pennsylvania.
39510...........................  Lycoming County,                48700       0.8364       0.8139         -2.69
                                   Pennsylvania.
39520...........................  Mc Kean County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39530...........................  Mercer County,                  49660       0.8198       0.8802          7.37
                                   Pennsylvania.
39540...........................  Mifflin County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39550...........................  Monroe County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39560...........................  Montgomery County,              37964       1.0980       1.0996          0.15
                                   Pennsylvania.
39580...........................  Montour County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
90 Nor..........................  thampton County,                10900       0.9832       0.9947          1.17
                                   Pennsylvania.
39600...........................  Northumberland County,          99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39610...........................  Perry County,                   25420       0.9273       0.9402          1.39
                                   Pennsylvania.
39620...........................  Philadelphia County,            37964       1.0980       1.0996          0.15
                                   Pennsylvania.
39630...........................  Pike County,                    35084       1.1545       1.1892          3.01
                                   Pennsylvania.
39640...........................  Potter County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39650...........................  Schuylkill County,              99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39670...........................  Snyder County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39680...........................  Somerset County,                99939       0.8189       0.8320          1.60
                                   Pennsylvania.
39690...........................  Sullivan County,                99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39700...........................  Susquehanna County,             99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39710...........................  Tioga County,                   99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39720...........................  Union County,                   99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39730...........................  Venango County,                 99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39740...........................  Warren County,                  99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39750...........................  Washington County,              38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39760...........................  Wayne County,                   99939       0.8305       0.8320          0.18
                                   Pennsylvania.
39770...........................  Westmoreland County,            38300       0.8853       0.8674         -2.02
                                   Pennsylvania.
39790...........................  Wyoming County,                 42540       0.8532       0.8347         -2.17
                                   Pennsylvania.
39800...........................  York County,                    49620       0.9347       0.9397          0.53
                                   Pennsylvania.
40010...........................  Adjuntas County, Puerto         99940       0.3826       0.4047          5.78
                                   Rico.
40020...........................  Aguada County, Puerto           10380       0.4807       0.3915        -18.56
                                   Rico.
40030...........................  Aguadilla County, Puerto        10380       0.4807       0.3915        -18.56
                                   Rico.
40040...........................  Aguas Buenas County,            41980       0.4687       0.4452         -5.01
                                   Puerto Rico.
40050...........................  Aibonito County, Puerto         41980       0.4113       0.4452          8.24
                                   Rico.
40060...........................  Anasco County, Puerto           10380       0.4491       0.3915        -12.83
                                   Rico.

[[Page 65993]]

 
40070...........................  Arecibo County, Puerto          41980       0.4367       0.4452          1.95
                                   Rico.
40080...........................  Arroyo County, Puerto           25020       0.3393       0.3235         -4.66
                                   Rico.
40090...........................  Barceloneta County,             41980       0.4687       0.4452         -5.01
                                   Puerto Rico.
40100...........................  Barranquitas County,            41980       0.4113       0.4452          8.24
                                   Puerto Rico.
40110...........................  Bayamon County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40120...........................  Cabo Rojo County, Puerto        41900       0.4447       0.4885          9.85
                                   Rico.
40130...........................  Caguas County, Puerto           41980       0.4371       0.4452          1.85
                                   Rico.
40140...........................  Camuy County, Puerto            41980       0.4367       0.4452          1.95
                                   Rico.
40145...........................  Canovanas County, Puerto        41980       0.4687       0.4452         -5.01
                                   Rico.
40150...........................  Carolina County, Puerto         41980       0.4687       0.4452         -5.01
                                   Rico.
40160...........................  Catano County, Puerto           41980       0.4687       0.4452         -5.01
                                   Rico.
40170...........................  Cayey County, Puerto            41980       0.4371       0.4452          1.85
                                   Rico.
40180...........................  Ceiba County, Puerto            21940       0.4453       0.4036         -9.36
                                   Rico.
40190...........................  Ciales County, Puerto           41980       0.4113       0.4452          8.24
                                   Rico.
40200...........................  Cidra County, Puerto            41980       0.4371       0.4452          1.85
                                   Rico.
40210...........................  Coamo County, Puerto            99940       0.3826       0.4047          5.78
                                   Rico.
40220...........................  Comerio County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40230...........................  Corozal County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40240...........................  Culebra County, Puerto          99940       0.3826       0.4047          5.78
                                   Rico.
40250...........................  Dorado County, Puerto           41980       0.4687       0.4452         -5.01
                                   Rico.
40260...........................  Fajardo County, Puerto          21940       0.4453       0.4036         -9.36
                                   Rico.
40265...........................  Florida County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40270...........................  Guanica County, Puerto          49500       0.4006       0.3854         -3.79
                                   Rico.
40280...........................  Guayama County, Puerto          25020       0.3393       0.3235         -4.66
                                   Rico.
40290...........................  Guayanilla County,              49500       0.4645       0.3854        -17.03
                                   Puerto Rico.
40300...........................  Guaynabo County, Puerto         41980       0.4687       0.4452         -5.01
                                   Rico.
40310...........................  Gurabo County, Puerto           41980       0.4371       0.4452          1.85
                                   Rico.
40320...........................  Hatillo County, Puerto          41980       0.4367       0.4452          1.95
                                   Rico.
40330...........................  Hormigueros County,             32420       0.4132       0.3848         -6.87
                                   Puerto Rico.
40340...........................  Humacao County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40350...........................  Isabela County, Puerto          10380       0.4171       0.3915         -6.14
                                   Rico.
40360...........................  Jayuya County, Puerto           99940       0.3826       0.4047          5.78
                                   Rico.
40370...........................  Juana Diaz County,              38660       0.4910       0.4842         -1.38
                                   Puerto Rico.
40380...........................  Juncos County, Puerto           41980       0.4687       0.4452         -5.01
                                   Rico.
40390...........................  Lajas County, Puerto            41900       0.4127       0.4885         18.37
                                   Rico.
40400...........................  Lares County, Puerto            10380       0.4171       0.3915         -6.14
                                   Rico.
40410...........................  Las Marias County,              99940       0.3826       0.4047          5.78
                                   Puerto Rico.
40420...........................  Las Piedras County,             41980       0.4687       0.4452         -5.01
                                   Puerto Rico.
40430...........................  Loiza County, Puerto            41980       0.4687       0.4452         -5.01
                                   Rico.
40440...........................  Luquillo County, Puerto         21940       0.4453       0.4036         -9.36
                                   Rico.
40450...........................  Manati County, Puerto           41980       0.4687       0.4452         -5.01
                                   Rico.
40460...........................  Maricao County, Puerto          99940       0.3826       0.4047          5.78
                                   Rico.
40470...........................  Maunabo County, Puerto          41980       0.4113       0.4452          8.24
                                   Rico.
40480...........................  Mayaguez County, Puerto         32420       0.4132       0.3848         -6.87
                                   Rico.
40490...........................  Moca County, Puerto Rico        10380       0.4807       0.3915        -18.56
40500...........................  Morovis County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40510...........................  Naguabo County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40520...........................  Naranjito County, Puerto        41980       0.4687       0.4452         -5.01
                                   Rico.
40530...........................  Orocovis County, Puerto         41980       0.4113       0.4452          8.24
                                   Rico.
40540...........................  Patillas County, Puerto         25020       0.3393       0.3235         -4.66
                                   Rico.
40550...........................  Penuelas County, Puerto         49500       0.4645       0.3854        -17.03
                                   Rico.
40560...........................  Ponce County, Puerto            38660       0.4910       0.4842         -1.38
                                   Rico.
40570...........................  Quebradillas County,            41980       0.4113       0.4452          8.24
                                   Puerto Rico.
40580...........................  Rincon County, Puerto           10380       0.4171       0.3915         -6.14
                                   Rico.
40590...........................  Rio Grande County,              41980       0.4687       0.4452         -5.01
                                   Puerto Rico.
40610...........................  Sabana Grande County,           41900       0.4447       0.4885          9.85
                                   Puerto Rico.
40620...........................  Salinas County, Puerto          99940       0.3826       0.4047          5.78
                                   Rico.
40630...........................  San German County,              41900       0.4447       0.4885          9.85
                                   Puerto Rico.
40640...........................  San Juan County, Puerto         41980       0.4687       0.4452         -5.01
                                   Rico.
40650...........................  San Lorenzo County,             41980       0.4371       0.4452          1.85
                                   Puerto Rico.
40660...........................  San Sebastian County,           10380       0.4171       0.3915         -6.14
                                   Puerto Rico.
40670...........................  Santa Isabel County,            99940       0.3826       0.4047          5.78
                                   Puerto Rico.
40680...........................  Toa Alta County, Puerto         41980       0.4687       0.4452         -5.01
                                   Rico.
40690...........................  Toa Baja County, Puerto         41980       0.4687       0.4452         -5.01
                                   Rico.
40700...........................  Trujillo Alto County,           41980       0.4687       0.4452         -5.01
                                   Puerto Rico.
40710...........................  Utuado County, Puerto           99940       0.3826       0.4047          5.78
                                   Rico.
40720...........................  Vega Alta County, Puerto        41980       0.4687       0.4452         -5.01
                                   Rico.
40730...........................  Vega Baja County, Puerto        41980       0.4687       0.4452         -5.01
                                   Rico.

[[Page 65994]]

 
40740...........................  Vieques County, Puerto          99940       0.3826       0.4047          5.78
                                   Rico.
40750...........................  Villalba County, Puerto         38660       0.4910       0.4842         -1.38
                                   Rico.
40760...........................  Yabucoa County, Puerto          41980       0.4687       0.4452         -5.01
                                   Rico.
40770...........................  Yauco County, Puerto            49500       0.4645       0.3854        -17.03
                                   Rico.
41000...........................  Bristol County, Rhode           39300       1.1012       1.0783         -2.08
                                   Island.
41010...........................  Kent County, Rhode              39300       1.1012       1.0783         -2.08
                                   Island.
41020...........................  Newport County, Rhode           39300       1.1012       1.0783         -2.08
                                   Island.
41030...........................  Providence County, Rhode        39300       1.1012       1.0783         -2.08
                                   Island.
41050...........................  Washington County, Rhode        39300       1.1012       1.0783         -2.08
                                   Island.
42000...........................  Abbeville County, S             99942       0.8635       0.8566         -0.80
                                   Carolina.
42010...........................  Aiken County, S Carolina        12260       0.9778       0.9667         -1.14
42020...........................  Allendale County, S             99942       0.8635       0.8566         -0.80
                                   Carolina.
42030...........................  Anderson County, S              11340       0.9306       0.9017         -3.11
                                   Carolina.
42040...........................  Bamberg County, S               99942       0.8635       0.8566         -0.80
                                   Carolina.
42050...........................  Barnwell County, S              99942       0.8635       0.8566         -0.80
                                   Carolina.
42060...........................  Beaufort County, S              99942       0.8635       0.8566         -0.80
                                   Carolina.
42070...........................  Berkeley County, S              16700       0.9245       0.9145         -1.08
                                   Carolina.
42080...........................  Calhoun County, S               17900       0.8844       0.8933          1.01
                                   Carolina.
42090...........................  Charleston County, S            16700       0.9245       0.9145         -1.08
                                   Carolina.
42100...........................  Cherokee County, S              99942       0.9127       0.8566         -6.15
                                   Carolina.
42110...........................  Chester County, S               99942       0.8635       0.8566         -0.80
                                   Carolina.
42120...........................  Chesterfield County, S          99942       0.8635       0.8566         -0.80
                                   Carolina.
42130...........................  Clarendon County, S             99942       0.8635       0.8566         -0.80
                                   Carolina.
42140...........................  Colleton County, S              99942       0.8635       0.8566         -0.80
                                   Carolina.
42150...........................  Darlington County, S            22500       0.8789       0.8388         -4.56
                                   Carolina.
42160...........................  Dillon County, S                99942       0.8635       0.8566         -0.80
                                   Carolina.
42170...........................  Dorchester County, S            16700       0.9245       0.9145         -1.08
                                   Carolina.
42180...........................  Edgefield County, S             12260       0.9778       0.9667         -1.14
                                   Carolina.
42190...........................  Fairfield County, S             17900       0.8844       0.8933          1.01
                                   Carolina.
42200...........................  Florence County, S              22500       0.8995       0.8388         -6.75
                                   Carolina.
42210...........................  Georgetown County, S            99942       0.8635       0.8566         -0.80
                                   Carolina.
42220...........................  Greenville County, S            24860       0.9821       0.9804         -0.17
                                   Carolina.
42230...........................  Greenwood County, S             99942       0.8635       0.8566         -0.80
                                   Carolina.
42240...........................  Hampton County, S               99942       0.8635       0.8566         -0.80
                                   Carolina.
42250...........................  Horry County, S Carolina        34820       0.8934       0.8810         -1.39
42260...........................  Jasper County, S                99942       0.8635       0.8566         -0.80
                                   Carolina.
42270...........................  Kershaw County, S               17900       0.8844       0.8933          1.01
                                   Carolina.
42280...........................  Lancaster County, S             99942       0.8635       0.8566         -0.80
                                   Carolina.
42290...........................  Laurens County, S               24860       0.9329       0.9804          5.09
                                   Carolina.
42300...........................  Lee County, S Carolina..        99942       0.8635       0.8566         -0.80
42310...........................  Lexington County, S             17900       0.9070       0.8933         -1.51
                                   Carolina.
42320...........................  Mc Cormick County, S            99942       0.8635       0.8566         -0.80
                                   Carolina.
42330...........................  Marion County, S                99942       0.8635       0.8566         -0.80
                                   Carolina.
42340...........................  Marlboro County, S              99942       0.8635       0.8566         -0.80
                                   Carolina.
42350...........................  Newberry County, S              99942       0.8635       0.8566         -0.80
                                   Carolina.
42360...........................  Oconee County, S                99942       0.8635       0.8566         -0.80
                                   Carolina.
42370...........................  Orangeburg County, S            99942       0.8635       0.8566         -0.80
                                   Carolina.
42380...........................  Pickens County, S               24860       0.9821       0.9804         -0.17
                                   Carolina.
42390...........................  Richland County, S              17900       0.9070       0.8933         -1.51
                                   Carolina.
42400...........................  Saluda County, S                17900       0.8844       0.8933          1.01
                                   Carolina.
42410...........................  Spartanburg County, S           43900       0.9394       0.9174         -2.34
                                   Carolina.
42420...........................  Sumter County, S                44940       0.8377       0.8083         -3.51
                                   Carolina.
42430...........................  Union County, S Carolina        99942       0.8635       0.8566         -0.80
42440...........................  Williamsburg County, S          99942       0.8635       0.8566         -0.80
                                   Carolina.
42450...........................  York County, S Carolina.        16740       0.9733       0.9554         -1.84
43010...........................  Aurora County, S Dakota.        99943       0.8556       0.8480         -0.89
43020...........................  Beadle County, S Dakota.        99943       0.8556       0.8480         -0.89
43030...........................  Bennett County, S Dakota        99943       0.8556       0.8480         -0.89
43040...........................  Bon Homme County, S             99943       0.8556       0.8480         -0.89
                                   Dakota.
43050...........................  Brookings County, S             99943       0.8556       0.8480         -0.89
                                   Dakota.
43060...........................  Brown County, S Dakota..        99943       0.8556       0.8480         -0.89
43070...........................  Brule County, S Dakota..        99943       0.8556       0.8480         -0.89
43080...........................  Buffalo County, S Dakota        99943       0.8556       0.8480         -0.89
43090...........................  Butte County, S Dakota..        99943       0.8556       0.8480         -0.89
43100...........................  Campbell County, S              99943       0.8556       0.8480         -0.89
                                   Dakota.
43110...........................  Charles Mix County, S           99943       0.8556       0.8480         -0.89
                                   Dakota.
43120...........................  Clark County, S Dakota..        99943       0.8556       0.8480         -0.89
43130...........................  Clay County, S Dakota...        99943       0.8556       0.8480         -0.89

[[Page 65995]]

 
43140...........................  Codington County, S             99943       0.8556       0.8480         -0.89
                                   Dakota.
43150...........................  Corson County, S Dakota.        99943       0.8556       0.8480         -0.89
43160...........................  Custer County, S Dakota.        99943       0.8556       0.8480         -0.89
43170...........................  Davison County, S Dakota        99943       0.8556       0.8480         -0.89
43180...........................  Day County, S Dakota....        99943       0.8556       0.8480         -0.89
43190...........................  Deuel County, S Dakota..        99943       0.8556       0.8480         -0.89
43200...........................  Dewey County, S Dakota..        99943       0.8556       0.8480         -0.89
43210...........................  Douglas County, S Dakota        99943       0.8556       0.8480         -0.89
43220...........................  Edmunds County, S Dakota        99943       0.8556       0.8480         -0.89
43230...........................  Fall River County, S            99943       0.8556       0.8480         -0.89
                                   Dakota.
43240...........................  Faulk County, S Dakota..        99943       0.8556       0.8480         -0.89
43250...........................  Grant County, S Dakota..        99943       0.8556       0.8480         -0.89
43260...........................  Gregory County, S Dakota        99943       0.8556       0.8480         -0.89
43270...........................  Haakon County, S Dakota.        99943       0.8556       0.8480         -0.89
43280...........................  Hamlin County, S Dakota.        99943       0.8556       0.8480         -0.89
43290...........................  Hand County, S Dakota...        99943       0.8556       0.8480         -0.89
43300...........................  Hanson County, S Dakota.        99943       0.8556       0.8480         -0.89
43310...........................  Harding County, S Dakota        99943       0.8556       0.8480         -0.89
43320...........................  Hughes County, S Dakota.        99943       0.8556       0.8480         -0.89
43330...........................  Hutchinson County, S            99943       0.8556       0.8480         -0.89
                                   Dakota.
43340...........................  Hyde County, S Dakota...        99943       0.8556       0.8480         -0.89
43350...........................  Jackson County, S Dakota        99943       0.8556       0.8480         -0.89
43360...........................  Jerauld County, S Dakota        99943       0.8556       0.8480         -0.89
43370...........................  Jones County, S Dakota..        99943       0.8556       0.8480         -0.89
43380...........................  Kingsbury County, S             99943       0.8556       0.8480         -0.89
                                   Dakota.
43390...........................  Lake County, S Dakota...        99943       0.8556       0.8480         -0.89
43400...........................  Lawrence County, S              99943       0.8556       0.8480         -0.89
                                   Dakota.
43410...........................  Lincoln County, S Dakota        43620       0.9635       0.9559         -0.79
43420...........................  Lyman County, S Dakota..        99943       0.8556       0.8480         -0.89
43430...........................  Mc Cook County, S Dakota        43620       0.9093       0.9559          5.12
43440...........................  Mc Pherson County, S            99943       0.8556       0.8480         -0.89
                                   Dakota.
43450...........................  Marshall County, S              99943       0.8556       0.8480         -0.89
                                   Dakota.
43460...........................  Meade County, S Dakota..        39660       0.8769       0.8833          0.73
43470...........................  Mellette County, S              99943       0.8556       0.8480         -0.89
                                   Dakota.
43480...........................  Miner County, S Dakota..        99943       0.8556       0.8480         -0.89
43490...........................  Minnehaha County, S             43620       0.9635       0.9559         -0.79
                                   Dakota.
43500...........................  Moody County, S Dakota..        99943       0.8556       0.8480         -0.89
43510...........................  Pennington County, S            39660       0.8987       0.8833         -1.71
                                   Dakota.
43520...........................  Perkins County, S Dakota        99943       0.8556       0.8480         -0.89
43530...........................  Potter County, S Dakota.        99943       0.8556       0.8480         -0.89
43540...........................  Roberts County, S Dakota        99943       0.8556       0.8480         -0.89
43550...........................  Sanborn County, S Dakota        99943       0.8556       0.8480         -0.89
43560...........................  Shannon County, S Dakota        99943       0.8556       0.8480         -0.89
43570...........................  Spink County, S Dakota..        99943       0.8556       0.8480         -0.89
43580...........................  Stanley County, S Dakota        99943       0.8556       0.8480         -0.89
43590...........................  Sully County, S Dakota..        99943       0.8556       0.8480         -0.89
43600...........................  Todd County, S Dakota...        99943       0.8556       0.8480         -0.89
43610...........................  Tripp County, S Dakota..        99943       0.8556       0.8480         -0.89
43620...........................  Turner County, S Dakota.        43620       0.9093       0.9559          5.12
43630...........................  Union County, S Dakota..        43580       0.8966       0.9200          2.61
43640...........................  Walworth County, S              99943       0.8556       0.8480         -0.89
                                   Dakota.
43650...........................  Washabaugh County, S            99943       0.8556       0.8480         -0.89
                                   Dakota.
43670...........................  Yankton County, S Dakota        99943       0.8556       0.8480         -0.89
43680...........................  Ziebach County, S Dakota        99943       0.8556       0.8480         -0.89
44000...........................  Anderson County,                28940       0.8419       0.8249         -2.02
                                   Tennessee.
44010...........................  Bedford County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44020...........................  Benton County, Tennessee        99944       0.7915       0.7827         -1.11
44030...........................  Bledsoe County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44040...........................  Blount County, Tennessee        28940       0.8419       0.8249         -2.02
44050...........................  Bradley County,                 17420       0.8037       0.8109          0.90
                                   Tennessee.
44060...........................  Campbell County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44070...........................  Cannon County, Tennessee        34980       0.8838       0.9847         11.42
44080...........................  Carroll County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44090...........................  Carter County, Tennessee        27740       0.7972       0.8043          0.89
44100...........................  Cheatham County,                34980       0.9751       0.9847          0.98
                                   Tennessee.
44110...........................  Chester County,                 27180       0.8964       0.8853         -1.24
                                   Tennessee.
44120...........................  Claiborne County,               99944       0.7915       0.7827         -1.11
                                   Tennessee.
44130...........................  Clay County, Tennessee..        99944       0.7915       0.7827         -1.11

[[Page 65996]]

 
44140...........................  Cocke County, Tennessee.        99944       0.7915       0.7827         -1.11
44150...........................  Coffee County, Tennessee        99944       0.7915       0.7827         -1.11
44160...........................  Crockett County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44170...........................  Cumberland County,              99944       0.7915       0.7827         -1.11
                                   Tennessee.
44180...........................  Davidson County,                34980       0.9751       0.9847          0.98
                                   Tennessee.
44190...........................  Decatur County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44200...........................  De Kalb County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44210...........................  Dickson County,                 34980       0.9751       0.9847          0.98
                                   Tennessee.
44220...........................  Dyer County, Tennessee..        99944       0.7915       0.7827         -1.11
44230...........................  Fayette County,                 32820       0.9407       0.9373         -0.36
                                   Tennessee.
44240...........................  Fentress County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44250...........................  Franklin County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44260...........................  Gibson County, Tennessee        99944       0.7915       0.7827         -1.11
44270...........................  Giles County, Tennessee.        99944       0.7915       0.7827         -1.11
44280...........................  Grainger County,                34100       0.7948       0.7933         -0.19
                                   Tennessee.
44290...........................  Greene County, Tennessee        99944       0.7915       0.7827         -1.11
44300...........................  Grundy County, Tennessee        99944       0.7915       0.7827         -1.11
44310...........................  Hamblen County,                 34100       0.7948       0.7933         -0.19
                                   Tennessee.
44320...........................  Hamilton County,                16860       0.9088       0.8948         -1.54
                                   Tennessee.
44330...........................  Hancock County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44340...........................  Hardeman County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44350...........................  Hardin County, Tennessee        99944       0.7915       0.7827         -1.11
44360...........................  Hawkins County,                 28700       0.8031       0.7985         -0.57
                                   Tennessee.
44370...........................  Haywood County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44380...........................  Henderson County,               99944       0.7915       0.7827         -1.11
                                   Tennessee.
44390...........................  Henry County, Tennessee.        99944       0.7915       0.7827         -1.11
44400...........................  Hickman County,                 34980       0.8838       0.9847         11.42
                                   Tennessee.
44410...........................  Houston County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44420...........................  Humphreys County,               99944       0.7915       0.7827         -1.11
                                   Tennessee.
44430...........................  Jackson County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44440...........................  Jefferson County,               34100       0.7948       0.7933         -0.19
                                   Tennessee.
44450...........................  Johnson County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44460...........................  Knox County, Tennessee..        28940       0.8419       0.8249         -2.02
44470...........................  Lake County, Tennessee..        99944       0.7915       0.7827         -1.11
44480...........................  Lauderdale County,              99944       0.7915       0.7827         -1.11
                                   Tennessee.
44490...........................  Lawrence County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44500...........................  Lewis County, Tennessee.        99944       0.7915       0.7827         -1.11
44510...........................  Lincoln County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44520...........................  Loudon County, Tennessee        28940       0.8419       0.8249         -2.02
44530...........................  Mc Minn County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44540...........................  Mc Nairy County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44550...........................  Macon County, Tennessee.        34980       0.8838       0.9847         11.42
44560...........................  Madison County,                 27180       0.8964       0.8853         -1.24
                                   Tennessee.
44570...........................  Marion County, Tennessee        16860       0.9088       0.8948         -1.54
44580...........................  Marshall County,                99944       0.7915       0.7827         -1.11
                                   Tennessee.
44590...........................  Maury County, Tennessee.        99944       0.7915       0.7827         -1.11
44600...........................  Meigs County, Tennessee.        99944       0.7915       0.7827         -1.11
44610...........................  Monroe County, Tennessee        99944       0.7915       0.7827         -1.11
44620...........................  Montgomery County,              17300       0.8284       0.8436          1.83
                                   Tennessee.
44630...........................  Moore County, Tennessee.        99944       0.7915       0.7827         -1.11
44640...........................  Morgan County, Tennessee        99944       0.7915       0.7827         -1.11
44650...........................  Obion County, Tennessee.        99944       0.7915       0.7827         -1.11
44660...........................  Overton County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44670...........................  Perry County, Tennessee.        99944       0.7915       0.7827         -1.11
44680...........................  Pickett County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44690...........................  Polk County, Tennessee..        17420       0.8037       0.8109          0.90
44700...........................  Putnam County, Tennessee        99944       0.7915       0.7827         -1.11
44710...........................  Rhea County, Tennessee..        99944       0.7915       0.7827         -1.11
44720...........................  Roane County, Tennessee.        99944       0.7915       0.7827         -1.11
44730...........................  Robertson County,               34980       0.9751       0.9847          0.98
                                   Tennessee.
44740...........................  Rutherford County,              34980       0.9751       0.9847          0.98
                                   Tennessee.
44750...........................  Scott County, Tennessee.        99944       0.7915       0.7827         -1.11
44760...........................  Sequatchie County,              16860       0.8512       0.8948          5.12
                                   Tennessee.
44770...........................  Sevier County, Tennessee        99944       0.8146       0.7827         -3.92
44780...........................  Shelby County, Tennessee        32820       0.9407       0.9373         -0.36
44790...........................  Smith County, Tennessee.        34980       0.8838       0.9847         11.42
44800...........................  Stewart County,                 17300       0.8110       0.8436          4.02
                                   Tennessee.
44810...........................  Sullivan County,                28700       0.8031       0.7985         -0.57
                                   Tennessee.

[[Page 65997]]

 
44820...........................  Sumner County, Tennessee        34980       0.9751       0.9847          0.98
44830...........................  Tipton County, Tennessee        32820       0.9407       0.9373         -0.36
44840...........................  Trousdale County,               34980       0.8838       0.9847         11.42
                                   Tennessee.
44850...........................  Unicoi County, Tennessee        27740       0.7972       0.8043          0.89
44860...........................  Union County, Tennessee.        28940       0.8419       0.8249         -2.02
44870...........................  Van Buren County,               99944       0.7915       0.7827         -1.11
                                   Tennessee.
44880...........................  Warren County, Tennessee        99944       0.7915       0.7827         -1.11
44890...........................  Washington County,              27740       0.7972       0.8043          0.89
                                   Tennessee.
44900...........................  Wayne County, Tennessee.        99944       0.7915       0.7827         -1.11
44910...........................  Weakley County,                 99944       0.7915       0.7827         -1.11
                                   Tennessee.
44920...........................  White County, Tennessee.        99944       0.7915       0.7827         -1.11
44930...........................  Williamson County,              34980       0.9751       0.9847          0.98
                                   Tennessee.
44940...........................  Wilson County, Tennessee        34980       0.9751       0.9847          0.98
45000...........................  Anderson County, Texas..        99945       0.7967       0.7965         -0.03
45010...........................  Andrews County, Texas...        99945       0.7967       0.7965         -0.03
45020...........................  Angelina County, Texas..        99945       0.7967       0.7965         -0.03
45030...........................  Aransas County, Texas...        18580       0.8241       0.8564          3.92
45040...........................  Archer County, Texas....        48660       0.8325       0.8311         -0.17
45050...........................  Armstrong County, Texas.        11100       0.8544       0.9169          7.32
45060...........................  Atascosa County, Texas..        41700       0.8456       0.8844          4.59
45070...........................  Austin County, Texas....        26420       0.8962       1.0008         11.67
45080...........................  Bailey County, Texas....        99945       0.7967       0.7965         -0.03
45090...........................  Bandera County, Texas...        41700       0.8456       0.8844          4.59
45100...........................  Bastrop County, Texas...        12420       0.9437       0.9344         -0.99
45110...........................  Baylor County, Texas....        99945       0.7967       0.7965         -0.03
45113...........................  Bee County, Texas.......        99945       0.7967       0.7965         -0.03
45120...........................  Bell County, Texas......        28660       0.8526       0.8901          4.40
45130...........................  Bexar County, Texas.....        41700       0.8982       0.8844         -1.54
45140...........................  Blanco County, Texas....        99945       0.7967       0.7965         -0.03
45150...........................  Borden County, Texas....        99945       0.7967       0.7965         -0.03
45160...........................  Bosque County, Texas....        99945       0.7967       0.7965         -0.03
45170...........................  Bowie County, Texas.....        45500       0.8283       0.8104         -2.16
45180...........................  Brazoria County, Texas..        26420       0.9278       1.0008          7.87
45190...........................  Brazos County, Texas....        17780       0.8900       0.9045          1.63
45200...........................  Brewster County, Texas..        99945       0.7967       0.7965         -0.03
45201...........................  Briscoe County, Texas...        99945       0.7967       0.7965         -0.03
45210...........................  Brooks County, Texas....        99945       0.7967       0.7965         -0.03
45220...........................  Brown County, Texas.....        99945       0.7967       0.7965         -0.03
45221...........................  Burleson County, Texas..        17780       0.8416       0.9045          7.47
45222...........................  Burnet County, Texas....        99945       0.7967       0.7965         -0.03
45223...........................  Caldwell County, Texas..        12420       0.9437       0.9344         -0.99
45224...........................  Calhoun County, Texas...        47020       0.8046       0.8560          6.39
45230...........................  Callahan County, Texas..        10180       0.7914       0.8000          1.09
45240...........................  Cameron County, Texas...        15180       0.9804       0.9430         -3.81
45250...........................  Camp County, Texas......        99945       0.7967       0.7965         -0.03
45251...........................  Carson County, Texas....        11100       0.8544       0.9169          7.32
45260...........................  Cass County, Texas......        99945       0.7967       0.7965         -0.03
45270...........................  Castro County, Texas....        99945       0.7967       0.7965         -0.03
45280...........................  Chambers County, Texas..        26420       1.0040       1.0008         -0.32
45281...........................  Cherokee County, Texas..        99945       0.7967       0.7965         -0.03
45290...........................  Childress County, Texas.        99945       0.7967       0.7965         -0.03
45291...........................  Clay County, Texas......        48660       0.8108       0.8311          2.50
45292...........................  Cochran County, Texas...        99945       0.7967       0.7965         -0.03
45300...........................  Coke County, Texas......        99945       0.7967       0.7965         -0.03
45301...........................  Coleman County, Texas...        99945       0.7967       0.7965         -0.03
45310...........................  Collin County, Texas....        19124       1.0217       1.0075         -1.39
45311...........................  Collingsworth County,           99945       0.7967       0.7965         -0.03
                                   Texas.
45312...........................  Colorado County, Texas..        99945       0.7967       0.7965         -0.03
45320...........................  Comal County, Texas.....        41700       0.8982       0.8844         -1.54
45321...........................  Comanche County, Texas..        99945       0.7967       0.7965         -0.03
45330...........................  Concho County, Texas....        99945       0.7967       0.7965         -0.03
45340...........................  Cooke County, Texas.....        99945       0.7967       0.7965         -0.03
45341...........................  Coryell County, Texas...        28660       0.8526       0.8901          4.40
45350...........................  Cottle County, Texas....        99945       0.7967       0.7965         -0.03
45360...........................  Crane County, Texas.....        99945       0.7967       0.7965         -0.03
45361...........................  Crockett County, Texas..        99945       0.7967       0.7965         -0.03
45362...........................  Crosby County, Texas....        31180       0.8357       0.8613          3.06
45370...........................  Culberson County, Texas.        99945       0.7967       0.7965         -0.03

[[Page 65998]]

 
45380...........................  Dallam County, Texas....        99945       0.7967       0.7965         -0.03
45390...........................  Dallas County, Texas....        19124       1.0217       1.0075         -1.39
45391...........................  Dawson County, Texas....        99945       0.7967       0.7965         -0.03
45392...........................  Deaf Smith County, Texas        99945       0.7967       0.7965         -0.03
45400...........................  Delta County, Texas.....        19124       0.9080       1.0075         10.96
45410...........................  Denton County, Texas....        19124       1.0217       1.0075         -1.39
45420...........................  De Witt County, Texas...        99945       0.7967       0.7965         -0.03
45421...........................  Dickens County, Texas...        99945       0.7967       0.7965         -0.03
45430...........................  Dimmit County, Texas....        99945       0.7967       0.7965         -0.03
45431...........................  Donley County, Texas....        99945       0.7967       0.7965         -0.03
45440...........................  Duval County, Texas.....        99945       0.7967       0.7965         -0.03
45450...........................  Eastland County, Texas..        99945       0.7967       0.7965         -0.03
45451...........................  Ector County, Texas.....        36220       0.9813       1.0073          2.65
45460...........................  Edwards County, Texas...        99945       0.7967       0.7965         -0.03
45470...........................  Ellis County, Texas.....        19124       1.0217       1.0075         -1.39
45480...........................  El Paso County, Texas...        21340       0.8977       0.9053          0.85
45490...........................  Erath County, Texas.....        99945       0.7967       0.7965         -0.03
45500...........................  Falls County, Texas.....        99945       0.7967       0.7965         -0.03
45510...........................  Fannin County, Texas....        99945       0.7967       0.7965         -0.03
45511...........................  Fayette County, Texas...        99945       0.7967       0.7965         -0.03
45520...........................  Fisher County, Texas....        99945       0.7967       0.7965         -0.03
45521...........................  Floyd County, Texas.....        99945       0.7967       0.7965         -0.03
45522...........................  Foard County, Texas.....        99945       0.7967       0.7965         -0.03
45530...........................  Fort Bend County, Texas.        26420       1.0040       1.0008         -0.32
45531...........................  Franklin County, Texas..        99945       0.7967       0.7965         -0.03
45540...........................  Freestone County, Texas.        99945       0.7967       0.7965         -0.03
45541...........................  Frio County, Texas......        99945       0.7967       0.7965         -0.03
45542...........................  Gaines County, Texas....        99945       0.7967       0.7965         -0.03
45550...........................  Galveston County, Texas.        26420       0.9814       1.0008          1.98
45551...........................  Garza County, Texas.....        99945       0.7967       0.7965         -0.03
45552...........................  Gillespie County, Texas.        99945       0.7967       0.7965         -0.03
45560...........................  Glasscock County, Texas.        99945       0.7967       0.7965         -0.03
45561...........................  Goliad County, Texas....        47020       0.8046       0.8560          6.39
45562...........................  Gonzales County, Texas..        99945       0.7967       0.7965         -0.03
45563...........................  Gray County, Texas......        99945       0.7967       0.7965         -0.03
45564...........................  Grayson County, Texas...        43300       0.9507       0.8502        -10.57
45570...........................  Gregg County, Texas.....        30980       0.8809       0.8788         -0.24
45580...........................  Grimes County, Texas....        99945       0.7967       0.7965         -0.03
45581...........................  Guadaloupe County, Texas        41700       0.8982       0.8844         -1.54
45582...........................  Hale County, Texas......        99945       0.7967       0.7965         -0.03
45583...........................  Hall County, Texas......        99945       0.7967       0.7965         -0.03
45590...........................  Hamilton County, Texas..        99945       0.7967       0.7965         -0.03
45591...........................  Hansford County, Texas..        99945       0.7967       0.7965         -0.03
45592...........................  Hardeman County, Texas..        99945       0.7967       0.7965         -0.03
45600...........................  Hardin County, Texas....        13140       0.8412       0.8595          2.18
45610...........................  Harris County, Texas....        26420       1.0040       1.0008         -0.32
45620...........................  Harrison County, Texas..        99945       0.8446       0.7965         -5.70
45621...........................  Hartley County, Texas...        99945       0.7967       0.7965         -0.03
45630...........................  Haskell County, Texas...        99945       0.7967       0.7965         -0.03
45631...........................  Hays County, Texas......        12420       0.9437       0.9344         -0.99
45632...........................  Hemphill County, Texas..        99945       0.7967       0.7965         -0.03
45640...........................  Henderson County, Texas.        99945       0.9104       0.7965        -12.51
45650...........................  Hidalgo County, Texas...        32580       0.8934       0.8773         -1.80
45651...........................  Hill County, Texas......        99945       0.7967       0.7965         -0.03
45652...........................  Hockley County, Texas...        99945       0.7967       0.7965         -0.03
45653...........................  Hood County, Texas......        99945       0.8763       0.7965         -9.11
45654...........................  Hopkins County, Texas...        99945       0.7967       0.7965         -0.03
45660...........................  Houston County, Texas...        99945       0.7967       0.7965         -0.03
45661...........................  Howard County, Texas....        99945       0.7967       0.7965         -0.03
45662...........................  Hudspeth County, Texas..        99945       0.7967       0.7965         -0.03
45670...........................  Hunt County, Texas......        19124       1.0217       1.0075         -1.39
45671...........................  Hutchinson County, Texas        99945       0.7967       0.7965         -0.03
45672...........................  Irion County, Texas.....        41660       0.8101       0.8362          3.22
45680...........................  Jack County, Texas......        99945       0.7967       0.7965         -0.03
45681...........................  Jackson County, Texas...        99945       0.7967       0.7965         -0.03
45690...........................  Jasper County, Texas....        99945       0.7967       0.7965         -0.03
45691...........................  Jeff Davis County, Texas        99945       0.7967       0.7965         -0.03
45700...........................  Jefferson County, Texas.        13140       0.8412       0.8595          2.18

[[Page 65999]]

 
45710...........................  Jim Hogg County, Texas..        99945       0.7967       0.7965         -0.03
45711...........................  Jim Wells County, Texas.        99945       0.7967       0.7965         -0.03
45720...........................  Johnson County, Texas...        23104       0.9504       0.9569          0.68
45721...........................  Jones County, Texas.....        10180       0.7914       0.8000          1.09
45722...........................  Karnes County, Texas....        99945       0.7967       0.7965         -0.03
45730...........................  Kaufman County, Texas...        19124       1.0217       1.0075         -1.39
45731...........................  Kendall County, Texas...        41700       0.8456       0.8844          4.59
45732...........................  Kenedy County, Texas....        99945       0.7967       0.7965         -0.03
45733...........................  Kent County, Texas......        99945       0.7967       0.7965         -0.03
45734...........................  Kerr County, Texas......        99945       0.7967       0.7965         -0.03
45740...........................  Kimble County, Texas....        99945       0.7967       0.7965         -0.03
45741...........................  King County, Texas......        99945       0.7967       0.7965         -0.03
45742...........................  Kinney County, Texas....        99945       0.7967       0.7965         -0.03
45743...........................  Kleberg County, Texas...        99945       0.7967       0.7965         -0.03
45744...........................  Knox County, Texas......        99945       0.7967       0.7965         -0.03
45750...........................  Lamar County, Texas.....        99945       0.7967       0.7965         -0.03
45751...........................  Lamb County, Texas......        99945       0.7967       0.7965         -0.03
45752...........................  Lampasas County, Texas..        28660       0.8229       0.8901          8.17
45753...........................  La Salle County, Texas..        99945       0.7967       0.7965         -0.03
45754...........................  Lavaca County, Texas....        99945       0.7967       0.7965         -0.03
45755...........................  Lee County, Texas.......        99945       0.7967       0.7965         -0.03
45756...........................  Leon County, Texas......        99945       0.7967       0.7965         -0.03
45757...........................  Liberty County, Texas...        26420       1.0040       1.0008         -0.32
45758...........................  Limestone County, Texas.        99945       0.7967       0.7965         -0.03
45759...........................  Lipscomb County, Texas..        99945       0.7967       0.7965         -0.03
45760...........................  Live Oak County, Texas..        99945       0.7967       0.7965         -0.03
45761...........................  Llano County, Texas.....        99945       0.7967       0.7965         -0.03
45762...........................  Loving County, Texas....        99945       0.7967       0.7965         -0.03
45770...........................  Lubbock County, Texas...        31180       0.8783       0.8613         -1.94
45771...........................  Lynn County, Texas......        99945       0.7967       0.7965         -0.03
45772...........................  Mc Culloch County, Texas        99945       0.7967       0.7965         -0.03
45780...........................  Mc Lennan County, Texas.        47380       0.8518       0.8633          1.35
45781...........................  Mc Mullen County, Texas.        99945       0.7967       0.7965         -0.03
45782...........................  Madison County, Texas...        99945       0.7967       0.7965         -0.03
45783...........................  Marion County, Texas....        99945       0.7967       0.7965         -0.03
45784...........................  Martin County, Texas....        99945       0.7967       0.7965         -0.03
45785...........................  Mason County, Texas.....        99945       0.7967       0.7965         -0.03
45790...........................  Matagorda County, Texas.        99945       0.7967       0.7965         -0.03
45791...........................  Maverick County, Texas..        99945       0.7967       0.7965         -0.03
45792...........................  Medina County, Texas....        41700       0.8456       0.8844          4.59
45793...........................  Menard County, Texas....        99945       0.7967       0.7965         -0.03
45794...........................  Midland County, Texas...        33260       0.9628       0.9786          1.64
45795...........................  Milam County, Texas.....        99945       0.7967       0.7965         -0.03
45796...........................  Mills County, Texas.....        99945       0.7967       0.7965         -0.03
45797...........................  Mitchell County, Texas..        99945       0.7967       0.7965         -0.03
45800...........................  Montague County, Texas..        99945       0.7967       0.7965         -0.03
45801...........................  Montgomery County, Texas        26420       1.0040       1.0008         -0.32
45802...........................  Moore County, Texas.....        99945       0.7967       0.7965         -0.03
45803...........................  Morris County, Texas....        99945       0.7967       0.7965         -0.03
45804...........................  Motley County, Texas....        99945       0.7967       0.7965         -0.03
45810...........................  Nacogdoches County,             99945       0.7967       0.7965         -0.03
                                   Texas.
45820...........................  Navarro County, Texas...        99945       0.7967       0.7965         -0.03
45821...........................  Newton County, Texas....        99945       0.7967       0.7965         -0.03
45822...........................  Nolan County, Texas.....        99945       0.7967       0.7965         -0.03
45830...........................  Nueces County, Texas....        18580       0.8550       0.8564          0.16
45831...........................  Ochiltree County, Texas.        99945       0.7967       0.7965         -0.03
45832...........................  Oldham County, Texas....        99945       0.7967       0.7965         -0.03
45840...........................  Orange County, Texas....        13140       0.8412       0.8595          2.18
45841...........................  Palo Pinto County, Texas        99945       0.7967       0.7965         -0.03
45842...........................  Panola County, Texas....        99945       0.7967       0.7965         -0.03
45843...........................  Parker County, Texas....        23104       0.9504       0.9569          0.68
45844...........................  Parmer County, Texas....        99945       0.7967       0.7965         -0.03
45845...........................  Pecos County, Texas.....        99945       0.7967       0.7965         -0.03
45850...........................  Polk County, Texas......        99945       0.7967       0.7965         -0.03
45860...........................  Potter County, Texas....        11100       0.9156       0.9169          0.14
45861...........................  Presidio County, Texas..        99945       0.7967       0.7965         -0.03
45870...........................  Rains County, Texas.....        99945       0.7967       0.7965         -0.03
45871...........................  Randall County, Texas...        11100       0.9156       0.9169          0.14

[[Page 66000]]

 
45872...........................  Reagan County, Texas....        99945       0.7967       0.7965         -0.03
45873...........................  Real County, Texas......        99945       0.7967       0.7965         -0.03
45874...........................  Red River County, Texas.        99945       0.7967       0.7965         -0.03
45875...........................  Reeves County, Texas....        99945       0.7967       0.7965         -0.03
45876...........................  Refugio County, Texas...        99945       0.7967       0.7965         -0.03
45877...........................  Roberts County, Texas...        99945       0.7967       0.7965         -0.03
45878...........................  Robertson County, Texas.        17780       0.8416       0.9045          7.47
45879...........................  Rockwall County, Texas..        19124       1.0217       1.0075         -1.39
45880...........................  Runnels County, Texas...        99945       0.7967       0.7965         -0.03
45881...........................  Rusk County, Texas......        30980       0.8331       0.8788          5.49
45882...........................  Sabine County, Texas....        99945       0.7967       0.7965         -0.03
45883...........................  San Augustine County,           99945       0.7967       0.7965         -0.03
                                   Texas.
45884...........................  San Jacinto County,             26420       0.8962       1.0008         11.67
                                   Texas.
45885...........................  San Patricio County,            18580       0.8550       0.8564          0.16
                                   Texas.
45886...........................  San Saba County, Texas..        99945       0.7967       0.7965         -0.03
45887...........................  Schleicher County, Texas        99945       0.7967       0.7965         -0.03
45888...........................  Scurry County, Texas....        99945       0.7967       0.7965         -0.03
45889...........................  Shackelford County,             99945       0.7967       0.7965         -0.03
                                   Texas.
45890...........................  Shelby County, Texas....        99945       0.7967       0.7965         -0.03
45891...........................  Sherman County, Texas...        99945       0.7967       0.7965         -0.03
45892...........................  Smith County, Texas.....        46340       0.9168       0.8811         -3.89
45893...........................  Somervell County, Texas.        99945       0.7967       0.7965         -0.03
45900...........................  Starr County, Texas.....        99945       0.7967       0.7965         -0.03
45901...........................  Stephens County, Texas..        99945       0.7967       0.7965         -0.03
45902...........................  Sterling County, Texas..        99945       0.7967       0.7965         -0.03
45903...........................  Stonewall County, Texas.        99945       0.7967       0.7965         -0.03
45904...........................  Sutton County, Texas....        99945       0.7967       0.7965         -0.03
45905...........................  Swisher County, Texas...        99945       0.7967       0.7965         -0.03
45910...........................  Tarrant County, Texas...        23104       0.9504       0.9569          0.68
45911...........................  Taylor County, Texas....        10180       0.7975       0.8000          0.31
45912...........................  Terrell County, Texas...        99945       0.7967       0.7965         -0.03
45913...........................  Terry County, Texas.....        99945       0.7967       0.7965         -0.03
45920...........................  Throckmorton County,            99945       0.7967       0.7965         -0.03
                                   Texas.
45921...........................  Titus County, Texas.....        99945       0.7967       0.7965         -0.03
45930...........................  Tom Green County, Texas.        41660       0.8271       0.8362          1.10
45940...........................  Travis County, Texas....        12420       0.9437       0.9344         -0.99
45941...........................  Trinity County, Texas...        99945       0.7967       0.7965         -0.03
45942...........................  Tyler County, Texas.....        99945       0.7967       0.7965         -0.03
45943...........................  Upshur County, Texas....        30980       0.8809       0.8788         -0.24
45944...........................  Upton County, Texas.....        99945       0.7967       0.7965         -0.03
45945...........................  Uvalde County, Texas....        99945       0.7967       0.7965         -0.03
45946...........................  Val Verde County, Texas.        99945       0.7967       0.7965         -0.03
45947...........................  Van Zandt County, Texas.        99945       0.7967       0.7965         -0.03
45948...........................  Victoria County, Texas..        47020       0.8160       0.8560          4.90
45949...........................  Walker County, Texas....        99945       0.7967       0.7965         -0.03
45950...........................  Waller County, Texas....        26420       1.0040       1.0008         -0.32
45951...........................  Ward County, Texas......        99945       0.7967       0.7965         -0.03
45952...........................  Washington County, Texas        99945       0.7967       0.7965         -0.03
45953...........................  Webb County, Texas......        29700       0.8068       0.7811         -3.19
45954...........................  Wharton County, Texas...        99945       0.7967       0.7965         -0.03
45955...........................  Wheeler County, Texas...        99945       0.7967       0.7965         -0.03
45960...........................  Wichita County, Texas...        48660       0.8325       0.8311         -0.17
45961...........................  Wilbarger County, Texas.        99945       0.7967       0.7965         -0.03
45962...........................  Willacy County, Texas...        99945       0.7967       0.7965         -0.03
45970...........................  Williamson County, Texas        12420       0.9437       0.9344         -0.99
45971...........................  Wilson County, Texas....        41700       0.8982       0.8844         -1.54
45972...........................  Winkler County, Texas...        99945       0.7967       0.7965         -0.03
45973...........................  Wise County, Texas......        23104       0.8709       0.9569          9.87
45974...........................  Wood County, Texas......        99945       0.7967       0.7965         -0.03
45980...........................  Yoakum County, Texas....        99945       0.7967       0.7965         -0.03
45981...........................  Young County, Texas.....        99945       0.7967       0.7965         -0.03
45982...........................  Zapata County, Texas....        99945       0.7967       0.7965         -0.03
45983...........................  Zavala County, Texas....        99945       0.7967       0.7965         -0.03
46000...........................  Beaver County, Utah.....        99946       0.8440       0.8140         -3.55
46010...........................  Box Elder County, Utah..        99946       0.8440       0.8140         -3.55
46020...........................  Cache County, Utah......        30860       0.8963       0.9022          0.66
46030...........................  Carbon County, Utah.....        99946       0.8440       0.8140         -3.55
46040...........................  Daggett County, Utah....        99946       0.8440       0.8140         -3.55

[[Page 66001]]

 
46050...........................  Davis County, Utah......        36260       0.9185       0.8995         -2.07
46060...........................  Duchesne County, Utah...        99946       0.8440       0.8140         -3.55
46070...........................  Emery County, Utah......        99946       0.8440       0.8140         -3.55
46080...........................  Garfield County, Utah...        99946       0.8440       0.8140         -3.55
46090...........................  Grand County, Utah......        99946       0.8440       0.8140         -3.55
46100...........................  Iron County, Utah.......        99946       0.8440       0.8140         -3.55
46110...........................  Juab County, Utah.......        39340       0.9131       0.9537          4.45
46120...........................  Kane County, Utah.......        99946       0.9982       0.8140        -18.45
46130...........................  Millard County, Utah....        99946       0.8440       0.8140         -3.55
46140...........................  Morgan County, Utah.....        36260       0.8896       0.8995          1.11
46150...........................  Piute County, Utah......        99946       0.8440       0.8140         -3.55
46160...........................  Rich County, Utah.......        99946       0.8440       0.8140         -3.55
46170...........................  Salt Lake County, Utah..        41620       0.9381       0.9402          0.22
46180...........................  San Juan County, Utah...        99946       0.8440       0.8140         -3.55
46190...........................  Sanpete County, Utah....        99946       0.8440       0.8140         -3.55
46200...........................  Sevier County, Utah.....        99946       0.8440       0.8140         -3.55
46210...........................  Summit County, Utah.....        41620       0.9092       0.9402          3.41
46220...........................  Tooele County, Utah.....        41620       0.9092       0.9402          3.41
46230...........................  Uintah County, Utah.....        99946       0.8440       0.8140         -3.55
46240...........................  Utah County, Utah.......        39340       0.9500       0.9537          0.39
46250...........................  Wasatch County, Utah....        99946       0.8440       0.8140         -3.55
46260...........................  Washington County, Utah.        41100       0.9077       0.9265          2.07
46270...........................  Wayne County, Utah......        99946       0.8440       0.8140         -3.55
46280...........................  Weber County, Utah......        36260       0.9185       0.8995         -2.07
47000...........................  Addison County, Vermont.        99947       0.9830       0.9744         -0.87
47010...........................  Bennington County,              99947       0.9830       0.9744         -0.87
                                   Vermont.
47020...........................  Caledonia County,               99947       0.9830       0.9744         -0.87
                                   Vermont.
47030...........................  Chittenden County,              15540       0.9410       0.9474          0.68
                                   Vermont.
47040...........................  Essex County, Vermont...        99947       0.9830       0.9744         -0.87
47050...........................  Franklin County, Vermont        15540       0.9410       0.9474          0.68
47060...........................  Grand Isle County,              15540       0.9410       0.9474          0.68
                                   Vermont.
47070...........................  Lamoille County, Vermont        99947       0.9830       0.9744         -0.87
47080...........................  Orange County, Vermont..        99947       0.9830       0.9744         -0.87
47090...........................  Orleans County, Vermont.        99947       0.9830       0.9744         -0.87
47100...........................  Rutland County, Vermont.        99947       0.9830       0.9744         -0.87
47110...........................  Washington County,              99947       0.9830       0.9744         -0.87
                                   Vermont.
47120...........................  Windham County, Vermont.        99947       0.9830       0.9744         -0.87
47130...........................  Windsor County, Vermont.        99947       0.9830       0.9744         -0.87
48010...........................  St Croix County, Virgin         99948       0.7615       0.8467         11.19
                                   Islands.
48020...........................  St Thomas-John County,          99948       0.7615       0.8467         11.19
                                   Virgin Islands.
49000...........................  Accomack County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49010...........................  Albemarle County,               16820       1.0187       1.0125         -0.61
                                   Virginia.
49011...........................  Alexandria City County,         47894       1.0951       1.1054          0.94
                                   Virginia.
49020...........................  Alleghany County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49030...........................  Amelia County, Virginia.        40060       0.8873       0.9177          3.43
49040...........................  Amherst County, Virginia        31340       0.8691       0.8694          0.03
49050...........................  Appomattox County,              31340       0.8554       0.8694          1.64
                                   Virginia.
49060...........................  Arlington County,               47894       1.0951       1.1054          0.94
                                   Virginia.
49070...........................  Augusta County, Virginia        99949       0.8215       0.7940         -3.35
49080...........................  Bath County, Virginia...        99949       0.8215       0.7940         -3.35
49088...........................  Bedford City County,            31340       0.8691       0.8694          0.03
                                   Virginia.
49090...........................  Bedford County, Virginia        31340       0.8691       0.8694          0.03
49100...........................  Bland County, Virginia..        99949       0.8215       0.7940         -3.35
49110...........................  Botetourt County,               40220       0.8381       0.8647          3.17
                                   Virginia.
49111...........................  Bristol City County,            28700       0.8031       0.7985         -0.57
                                   Virginia.
49120...........................  Brunswick County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49130...........................  Buchanan County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49140...........................  Buckingham County,              99949       0.8215       0.7940         -3.35
                                   Virginia.
49141...........................  Buena Vista City County,        99949       0.8215       0.7940         -3.35
                                   Virginia.
49150...........................  Campbell County,                31340       0.8691       0.8694          0.03
                                   Virginia.
49160...........................  Caroline County,                40060       0.8873       0.9177          3.43
                                   Virginia.
49170...........................  Carroll County, Virginia        99949       0.8215       0.7940         -3.35
49180...........................  Charles City County,            40060       0.9328       0.9177         -1.62
                                   Virginia.
49190...........................  Charlotte County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49191...........................  Charlottesville City            16820       1.0187       1.0125         -0.61
                                   County, Virginia.
49194...........................  Chesapeake County,              47260       0.8799       0.8790         -0.10
                                   Virginia.
49200...........................  Chesterfield County,            40060       0.9328       0.9177         -1.62
                                   Virginia.
49210...........................  Clarke County, Virginia.        47894       1.0951       1.1054          0.94

[[Page 66002]]

 
49211...........................  Clifton Forge City              99949       0.8215       0.7940         -3.35
                                   County, Virginia.
49212...........................  Colonial Heights County,        40060       0.9328       0.9177         -1.62
                                   Virginia.
49213...........................  Covington City County,          99949       0.8215       0.7940         -3.35
                                   Virginia.
49220...........................  Craig County, Virginia..        40220       0.8396       0.8647          2.99
49230...........................  Culpeper County,                99949       0.9495       0.7940        -16.38
                                   Virginia.
49240...........................  Cumberland County,              40060       0.8873       0.9177          3.43
                                   Virginia.
49241...........................  Danville City County,           19260       0.8489       0.8451         -0.45
                                   Virginia.
49250...........................  Dickenson County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49260...........................  Dinniddie County,               40060       0.9328       0.9177         -1.62
                                   Virginia.
49270...........................  Emporia County, Virginia        99949       0.8215       0.7940         -3.35
49280...........................  Essex County, Virginia..        99949       0.8215       0.7940         -3.35
49288...........................  Fairfax City County,            47894       1.0951       1.1054          0.94
                                   Virginia.
49290...........................  Fairfax County, Virginia        47894       1.0951       1.1054          0.94
49291...........................  Falls Church City               47894       1.0951       1.1054          0.94
                                   County, Virginia.
49300...........................  Fauquier County,                47894       1.0951       1.1054          0.94
                                   Virginia.
49310...........................  Floyd County, Virginia..        99949       0.8215       0.7940         -3.35
49320...........................  Fluvanna County,                16820       1.0187       1.0125         -0.61
                                   Virginia.
49328...........................  Franklin City County,           99949       0.8215       0.7940         -3.35
                                   Virginia.
49330...........................  Franklin County,                40220       0.8396       0.8647          2.99
                                   Virginia.
49340...........................  Frederick County,               49020       0.9316       1.0091          8.32
                                   Virginia.
49342...........................  Fredericksburg City             47894       1.0951       1.1054          0.94
                                   County, Virginia.
49343...........................  Galax City County,              99949       0.8215       0.7940         -3.35
                                   Virginia.
49350...........................  Giles County, Virginia..        13980       0.8186       0.8213          0.33
49360...........................  Gloucester County,              47260       0.8799       0.8790         -0.10
                                   Virginia.
49370...........................  Goochland County,               40060       0.9328       0.9177         -1.62
                                   Virginia.
49380...........................  Grayson County, Virginia        99949       0.8215       0.7940         -3.35
49390...........................  Greene County, Virginia.        16820       1.0187       1.0125         -0.61
49400...........................  Greensville County,             99949       0.8215       0.7940         -3.35
                                   Virginia.
49410...........................  Halifax County, Virginia        99949       0.8215       0.7940         -3.35
49411...........................  Hampton City County,            47260       0.8799       0.8790         -0.10
                                   Virginia.
49420...........................  Hanover County, Virginia        40060       0.9328       0.9177         -1.62
49421...........................  Harrisonburg City               25500       0.8753       0.9073          3.66
                                   County, Virginia.
49430...........................  Henrico County, Virginia        40060       0.9328       0.9177         -1.62
49440...........................  Henry County, Virginia..        99949       0.8215       0.7940         -3.35
49450...........................  Highland County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49451...........................  Hopewell City County,           40060       0.9328       0.9177         -1.62
                                   Virginia.
49460...........................  Isle Of Wight County,           47260       0.8799       0.8790         -0.10
                                   Virginia.
49470...........................  James City Co County,           47260       0.8799       0.8790         -0.10
                                   Virginia.
49480...........................  King And Queen County,          40060       0.8873       0.9177          3.43
                                   Virginia.
49490...........................  King George County,             99949       0.9495       0.7940        -16.38
                                   Virginia.
49500...........................  King William County,            40060       0.8873       0.9177          3.43
                                   Virginia.
49510...........................  Lancaster County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49520...........................  Lee County, Virginia....        99949       0.8215       0.7940         -3.35
49522...........................  Lexington County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49530...........................  Loudoun County, Virginia        47894       1.0951       1.1054          0.94
49540...........................  Louisa County, Virginia.        40060       0.8873       0.9177          3.43
49550...........................  Lunenburg County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49551...........................  Lynchburg City County,          31340       0.8691       0.8694          0.03
                                   Virginia.
49560...........................  Madison County, Virginia        99949       0.8215       0.7940         -3.35
49561...........................  Martinsville City               99949       0.8215       0.7940         -3.35
                                   County, Virginia.
49563...........................  Manassas City County,           47894       1.0951       1.1054          0.94
                                   Virginia.
49565...........................  Manassas Park City              47894       1.0951       1.1054          0.94
                                   County, Virginia.
49570...........................  Mathews County, Virginia        47260       0.8799       0.8790         -0.10
49580...........................  Mecklenburg County,             99949       0.8215       0.7940         -3.35
                                   Virginia.
49590...........................  Middlesex County,               99949       0.8215       0.7940         -3.35
                                   Virginia.
49600...........................  Montgomery County,              13980       0.8186       0.8213          0.33
                                   Virginia.
49610...........................  Nansemond, Virginia.....        99949       0.8215       0.7940         -3.35
49620...........................  Nelson County, Virginia.        16820       0.9302       1.0125          8.85
49621...........................  New Kent County,                40060       0.9328       0.9177         -1.62
                                   Virginia.
49622...........................  Newport News City               47260       0.8799       0.8790         -0.10
                                   County, Virginia.
49641...........................  Norfolk City County,            47260       0.8799       0.8790         -0.10
                                   Virginia.
49650...........................  Northampton County,             99949       0.8215       0.7940         -3.35
                                   Virginia.
49660...........................  Northumberland County,          99949       0.8215       0.7940         -3.35
                                   Virginia.
49661...........................  Norton City County,             99949       0.8215       0.7940         -3.35
                                   Virginia.
49670...........................  Nottoway County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49680...........................  Orange County, Virginia.        99949       0.8215       0.7940         -3.35
49690...........................  Page County, Virginia...        99949       0.8215       0.7940         -3.35
49700...........................  Patrick County, Virginia        99949       0.8215       0.7940         -3.35

[[Page 66003]]

 
49701...........................  Petersburg City County,         40060       0.9328       0.9177         -1.62
                                   Virginia.
49710...........................  Pittsylvania County,            19260       0.8489       0.8451         -0.45
                                   Virginia.
49711...........................  Portsmouth City County,         47260       0.8799       0.8790         -0.10
                                   Virginia.
49712...........................  Poquoson City County,           47260       0.8799       0.8790         -0.10
                                   Virginia.
49720...........................  Powhatan County,                40060       0.9328       0.9177         -1.62
                                   Virginia.
49730...........................  Prince Edward County,           99949       0.8215       0.7940         -3.35
                                   Virginia.
49740...........................  Prince George County,           40060       0.9328       0.9177         -1.62
                                   Virginia.
49750...........................  Prince William County,          47894       1.0951       1.1054          0.94
                                   Virginia.
49770...........................  Pulaski County, Virginia        13980       0.8186       0.8213          0.33
49771...........................  Radford City County,            13980       0.8186       0.8213          0.33
                                   Virginia.
49780...........................  Rappahannock County,            99949       0.8215       0.7940         -3.35
                                   Virginia.
49790...........................  Richmond County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49791...........................  Richmond City County,           40060       0.9328       0.9177         -1.62
                                   Virginia.
49800...........................  Roanoke County, Virginia        40220       0.8381       0.8647          3.17
49801...........................  Roanoke City County,            40220       0.8381       0.8647          3.17
                                   Virginia.
49810...........................  Rockbridge County,              99949       0.8215       0.7940         -3.35
                                   Virginia.
49820...........................  Rockingham County,              25500       0.8753       0.9073          3.66
                                   Virginia.
49830...........................  Russell County, Virginia        99949       0.8215       0.7940         -3.35
49838...........................  Salem County, Virginia..        40220       0.8381       0.8647          3.17
49840...........................  Scott County, Virginia..        28700       0.8031       0.7985         -0.57
49850...........................  Shenandoah County,              99949       0.8215       0.7940         -3.35
                                   Virginia.
49860...........................  Smyth County, Virginia..        99949       0.8215       0.7940         -3.35
49867...........................  South Boston City               99949       0.8215       0.7940         -3.35
                                   County, Virginia.
49870...........................  Southampton County,             99949       0.8215       0.7940         -3.35
                                   Virginia.
49880...........................  Spotsylvania County,            47894       1.0951       1.1054          0.94
                                   Virginia.
49890...........................  Stafford County,                47894       1.0951       1.1054          0.94
                                   Virginia.
49891...........................  Staunton City County,           99949       0.8215       0.7940         -3.35
                                   Virginia.
49892...........................  Suffolk City County,            47260       0.8799       0.8790         -0.10
                                   Virginia.
49900...........................  Surry County, Virginia..        47260       0.8608       0.8790          2.11
49910...........................  Sussex County, Virginia.        40060       0.8873       0.9177          3.43
49920...........................  Tazewell County,                99949       0.8215       0.7940         -3.35
                                   Virginia.
49921...........................  Virginia Beach City             47260       0.8799       0.8790         -0.10
                                   County, Virginia.
49930...........................  Warren County, Virginia.        47894       1.0951       1.1054          0.94
49950...........................  Washington County,              28700       0.8031       0.7985         -0.57
                                   Virginia.
49951...........................  Waynesboro City County,         99949       0.8215       0.7940         -3.35
                                   Virginia.
49960...........................  Westmoreland County,            99949       0.8215       0.7940         -3.35
                                   Virginia.
49961...........................  Williamsburg City               47260       0.8799       0.8790         -0.10
                                   County, Virginia.
49962...........................  Winchester City County,         49020       0.9316       1.0091          8.32
                                   Virginia.
49970...........................  Wise County, Virginia...        99949       0.8215       0.7940         -3.35
49980...........................  Wythe County, Virginia..        99949       0.8215       0.7940         -3.35
49981...........................  York County, Virginia...        47260       0.8799       0.8790         -0.10
50000...........................  Adams County, Washington        99950       1.0364       1.0263         -0.97
50010...........................  Asotin County,                  30300       1.0052       0.9853         -1.98
                                   Washington.
50020...........................  Benton County,                  28420       1.0619       1.0343         -2.60
                                   Washington.
50030...........................  Chelan County,                  48300       1.0144       1.0346          1.99
                                   Washington.
50040...........................  Clallam County,                 99950       1.0364       1.0263         -0.97
                                   Washington.
50050...........................  Clark County, Washington        38900       1.1266       1.1416          1.33
50060...........................  Columbia County,                99950       1.0364       1.0263         -0.97
                                   Washington.
50070...........................  Cowlitz County,                 31020       0.9898       1.0011          1.14
                                   Washington.
50080...........................  Douglas County,                 48300       1.0144       1.0346          1.99
                                   Washington.
50090...........................  Ferry County, Washington        99950       1.0364       1.0263         -0.97
50100...........................  Franklin County,                28420       1.0619       1.0343         -2.60
                                   Washington.
50110...........................  Garfield County,                99950       1.0364       1.0263         -0.97
                                   Washington.
50120...........................  Grant County, Washington        99950       1.0364       1.0263         -0.97
50130...........................  Grays Harbor County,            99950       1.0364       1.0263         -0.97
                                   Washington.
50140...........................  Island County,                  99950       1.1039       1.0263         -7.03
                                   Washington.
50150...........................  Jefferson County,               99950       1.0364       1.0263         -0.97
                                   Washington.
50160...........................  King County, Washington.        42644       1.1572       1.1434         -1.19
50170...........................  Kitsap County,                  14740       1.0675       1.0913          2.23
                                   Washington.
50180...........................  Kittitas County,                99950       1.0364       1.0263         -0.97
                                   Washington.
50190...........................  Klickitat County,               99950       1.0364       1.0263         -0.97
                                   Washington.
50200...........................  Lewis County, Washington        99950       1.0364       1.0263         -0.97
50210...........................  Lincoln County,                 99950       1.0364       1.0263         -0.97
                                   Washington.
50220...........................  Mason County, Washington        99950       1.0364       1.0263         -0.97
50230...........................  Okanogan County,                99950       1.0364       1.0263         -0.97
                                   Washington.
50240...........................  Pacific County,                 99950       1.0364       1.0263         -0.97
                                   Washington.
50250...........................  Pend Oreille County,            99950       1.0364       1.0263         -0.97
                                   Washington.
50260...........................  Pierce County,                  45104       1.0742       1.0789          0.44
                                   Washington.

[[Page 66004]]

 
50270...........................  San Juan County,                99950       1.0364       1.0263         -0.97
                                   Washington.
50280...........................  Skagit County,                  34580       1.0336       1.0517          1.75
                                   Washington.
50290...........................  Skamania County,                38900       1.0742       1.1416          6.27
                                   Washington.
50300...........................  Snohomish County,               42644       1.1572       1.1434         -1.19
                                   Washington.
50310...........................  Spokane County,                 44060       1.0905       1.0447         -4.20
                                   Washington.
50320...........................  Stevens County,                 99950       1.0364       1.0263         -0.97
                                   Washington.
50330...........................  Thurston County,                36500       1.0927       1.1081          1.41
                                   Washington.
50340...........................  Wahkiakum County,               99950       1.0364       1.0263         -0.97
                                   Washington.
50350...........................  Walla Walla County,             99950       1.0364       1.0263         -0.97
                                   Washington.
50360...........................  Whatcom County,                 13380       1.1731       1.1104         -5.34
                                   Washington.
50370...........................  Whitman County,                 99950       1.0364       1.0263         -0.97
                                   Washington.
50380...........................  Yakima County,                  49420       1.0155       0.9847         -3.03
                                   Washington.
51000...........................  Barbour County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51010...........................  Berkeley County, W              25180       1.0233       0.9038        -11.68
                                   Virginia.
51020...........................  Boone County, W Virginia        16620       0.8173       0.8542          4.51
51030...........................  Braxton County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51040...........................  Brooke County, W                48260       0.7819       0.8063          3.12
                                   Virginia.
51050...........................  Cabell County, W                26580       0.9477       0.8997         -5.06
                                   Virginia.
51060...........................  Calhoun County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51070...........................  Clay County, W Virginia.        16620       0.8173       0.8542          4.51
51080...........................  Doddridge County, W             99951       0.7809       0.7607         -2.59
                                   Virginia.
51090...........................  Fayette County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51100...........................  Gilmer County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51110...........................  Grant County, W Virginia        99951       0.7809       0.7607         -2.59
51120...........................  Greenbrier County, W            99951       0.7809       0.7607         -2.59
                                   Virginia.
51130...........................  Hampshire County, W             49020       0.9057       1.0091         11.42
                                   Virginia.
51140...........................  Hancock County, W               48260       0.7819       0.8063          3.12
                                   Virginia.
51150...........................  Hardy County, W Virginia        99951       0.7809       0.7607         -2.59
51160...........................  Harrison County, W              99951       0.7809       0.7607         -2.59
                                   Virginia.
51170...........................  Jackson County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51180...........................  Jefferson County, W             47894       1.0951       1.1054          0.94
                                   Virginia.
51190...........................  Kanawha County, W               16620       0.8445       0.8542          1.15
                                   Virginia.
51200...........................  Lewis County, W Virginia        99951       0.7809       0.7607         -2.59
51210...........................  Lincoln County, W               16620       0.8173       0.8542          4.51
                                   Virginia.
51220...........................  Logan County, W Virginia        99951       0.7809       0.7607         -2.59
51230...........................  Mc Dowell County, W             99951       0.7809       0.7607         -2.59
                                   Virginia.
51240...........................  Marion County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51250...........................  Marshall County, W              48540       0.7161       0.7010         -2.11
                                   Virginia.
51260...........................  Mason County, W Virginia        99951       0.7809       0.7607         -2.59
51270...........................  Mercer County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51280...........................  Mineral County, W               19060       0.9317       0.8446         -9.35
                                   Virginia.
51290...........................  Mingo County, W Virginia        99951       0.7809       0.7607         -2.59
51300...........................  Monongalia County, W            34060       0.8160       0.8423          3.22
                                   Virginia.
51310...........................  Monroe County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51320...........................  Morgan County, W                25180       0.8695       0.9038          3.94
                                   Virginia.
51330...........................  Nicholas County, W              99951       0.7809       0.7607         -2.59
                                   Virginia.
51340...........................  Ohio County, W Virginia.        48540       0.7161       0.7010         -2.11
51350...........................  Pendleton County, W             99951       0.7809       0.7607         -2.59
                                   Virginia.
51360...........................  Pleasants County, W             37620       0.8085       0.7977         -1.34
                                   Virginia.
51370...........................  Pocahontas County, W            99951       0.7809       0.7607         -2.59
                                   Virginia.
51380...........................  Preston County, W               34060       0.8160       0.8423          3.22
                                   Virginia.
51390...........................  Putnam County, W                16620       0.8445       0.8542          1.15
                                   Virginia.
51400...........................  Raleigh County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51410...........................  Randolph County, W              99951       0.7809       0.7607         -2.59
                                   Virginia.
51420...........................  Ritchie County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51430...........................  Roane County, W Virginia        99951       0.7809       0.7607         -2.59
51440...........................  Summers County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51450...........................  Taylor County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51460...........................  Tucker County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51470...........................  Tyler County, W Virginia        99951       0.7809       0.7607         -2.59
51480...........................  Upshur County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51490...........................  Wayne County, W Virginia        26580       0.9477       0.8997         -5.06
51500...........................  Webster County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
51510...........................  Wetzel County, W                99951       0.7809       0.7607         -2.59
                                   Virginia.
51520...........................  Wirt County, W Virginia.        37620       0.8085       0.7977         -1.34
51530...........................  Wood County, W Virginia.        37620       0.8270       0.7977         -3.54
51540...........................  Wyoming County, W               99951       0.7809       0.7607         -2.59
                                   Virginia.
52000...........................  Adams County, Wisconsin.        99952       0.9494       0.9553          0.62

[[Page 66005]]

 
52010...........................  Ashland County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52020...........................  Barron County, Wisconsin        99952       0.9494       0.9553          0.62
52030...........................  Bayfield County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52040...........................  Brown County, Wisconsin.        24580       0.9483       0.9787          3.21
52050...........................  Buffalo County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52060...........................  Burnett County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52070...........................  Calumet County,                 11540       0.9264       0.9455          2.06
                                   Wisconsin.
52080...........................  Chippewa County,                20740       0.9201       0.9630          4.66
                                   Wisconsin.
52090...........................  Clark County, Wisconsin.        99952       0.9494       0.9553          0.62
52100...........................  Columbia County,                31540       1.0069       1.0840          7.66
                                   Wisconsin.
52110...........................  Crawford County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52120...........................  Dane County, Wisconsin..        31540       1.0707       1.0840          1.24
52130...........................  Dodge County, Wisconsin.        99952       0.9494       0.9553          0.62
52140...........................  Door County, Wisconsin..        99952       0.9494       0.9553          0.62
52150...........................  Douglas County,                 20260       1.0213       1.0042         -1.67
                                   Wisconsin.
52160...........................  Dunn County, Wisconsin..        99952       0.9494       0.9553          0.62
52170...........................  Eau Claire County,              20740       0.9201       0.9630          4.66
                                   Wisconsin.
52180...........................  Florence County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52190...........................  Fond Du Lac County,             22540       0.9559       1.0063          5.27
                                   Wisconsin.
52200...........................  Forest County, Wisconsin        99952       0.9494       0.9553          0.62
52210...........................  Grant County, Wisconsin.        99952       0.9494       0.9553          0.62
52220...........................  Green County, Wisconsin.        99952       0.9494       0.9553          0.62
52230...........................  Green Lake County,              99952       0.9494       0.9553          0.62
                                   Wisconsin.
52240...........................  Iowa County, Wisconsin..        31540       1.0069       1.0840          7.66
52250...........................  Iron County, Wisconsin..        99952       0.9494       0.9553          0.62
52260...........................  Jackson County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52270...........................  Jefferson County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52280...........................  Juneau County, Wisconsin        99952       0.9494       0.9553          0.62
52290...........................  Kenosha County,                 29404       1.0095       1.0570          4.71
                                   Wisconsin.
52300...........................  Kewaunee County,                24580       0.9481       0.9787          3.23
                                   Wisconsin.
52310...........................  La Crosse County,               29100       0.9564       0.9426         -1.44
                                   Wisconsin.
52320...........................  Lafayette County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52330...........................  Langlade County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52340...........................  Lincoln County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52350...........................  Manitowoc County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52360...........................  Marathon County,                48140       0.9590       0.9722          1.38
                                   Wisconsin.
52370...........................  Marinette County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52380...........................  Marquette County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52381...........................  Menominee County,               99952       0.9494       0.9553          0.62
                                   Wisconsin.
52390...........................  Milwaukee County,               33340       1.0146       1.0218          0.71
                                   Wisconsin.
52400...........................  Monroe County, Wisconsin        99952       0.9494       0.9553          0.62
52410...........................  Oconto County, Wisconsin        24580       0.9481       0.9787          3.23
52420...........................  Oneida County, Wisconsin        99952       0.9494       0.9553          0.62
52430...........................  Outagamie County,               11540       0.9264       0.9455          2.06
                                   Wisconsin.
52440...........................  Ozaukee County,                 33340       1.0146       1.0218          0.71
                                   Wisconsin.
52450...........................  Pepin County, Wisconsin.        99952       0.9494       0.9553          0.62
52460...........................  Pierce County, Wisconsin        33460       1.1075       1.0946         -1.16
52470...........................  Polk County, Wisconsin..        99952       0.9494       0.9553          0.62
52480...........................  Portage County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52490...........................  Price County, Wisconsin.        99952       0.9494       0.9553          0.62
52500...........................  Racine County, Wisconsin        39540       0.8997       0.9356          3.99
52510...........................  Richland County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52520...........................  Rock County, Wisconsin..        27500       0.9538       0.9655          1.23
52530...........................  Rusk County, Wisconsin..        99952       0.9494       0.9553          0.62
52540...........................  St Croix County,                33460       1.1075       1.0946         -1.16
                                   Wisconsin.
52550...........................  Sauk County, Wisconsin..        99952       0.9494       0.9553          0.62
52560...........................  Sawyer County, Wisconsin        99952       0.9494       0.9553          0.62
52570...........................  Shawano County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.
52580...........................  Sheboygan County,               43100       0.8911       0.9026          1.29
                                   Wisconsin.
52590...........................  Taylor County, Wisconsin        99952       0.9494       0.9553          0.62
52600...........................  Trempealeau County,             99952       0.9494       0.9553          0.62
                                   Wisconsin.
52610...........................  Vernon County, Wisconsin        99952       0.9494       0.9553          0.62
52620...........................  Vilas County, Wisconsin.        99952       0.9494       0.9553          0.62
52630...........................  Walworth County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52640...........................  Washburn County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52650...........................  Washington County,              33340       1.0146       1.0218          0.71
                                   Wisconsin.
52660...........................  Waukesha County,                33340       1.0146       1.0218          0.71
                                   Wisconsin.
52670...........................  Waupaca County,                 99952       0.9494       0.9553          0.62
                                   Wisconsin.

[[Page 66006]]

 
52680...........................  Waushara County,                99952       0.9494       0.9553          0.62
                                   Wisconsin.
52690...........................  Winnebago County,               36780       0.9211       0.9315          1.13
                                   Wisconsin.
52700...........................  Wood County, Wisconsin..        99952       0.9494       0.9553          0.62
53000...........................  Albany County, Wyoming..        99953       0.9257       0.9295          0.41
53010...........................  Big Horn County, Wyoming        99953       0.9257       0.9295          0.41
53020...........................  Campbell County, Wyoming        99953       0.9257       0.9295          0.41
53030...........................  Carbon County, Wyoming..        99953       0.9257       0.9295          0.41
53040...........................  Converse County, Wyoming        99953       0.9257       0.9295          0.41
53050...........................  Crook County, Wyoming...        99953       0.9257       0.9295          0.41
53060...........................  Fremont County, Wyoming.        99953       0.9257       0.9295          0.41
53070...........................  Goshen County, Wyoming..        99953       0.9257       0.9295          0.41
53080...........................  Hot Springs County,             99953       0.9257       0.9295          0.41
                                   Wyoming.
53090...........................  Johnson County, Wyoming.        99953       0.9257       0.9295          0.41
53100...........................  Laramie County, Wyoming.        16940       0.8775       0.9060          3.25
53110...........................  Lincoln County, Wyoming.        99953       0.9257       0.9295          0.41
53120...........................  Natrona County, Wyoming.        16220       0.9026       0.9145          1.32
53130...........................  Niobrara County, Wyoming        99953       0.9257       0.9295          0.41
53140...........................  Park County, Wyoming....        99953       0.9257       0.9295          0.41
53150...........................  Platte County, Wyoming..        99953       0.9257       0.9295          0.41
53160...........................  Sheridan County, Wyoming        99953       0.9257       0.9295          0.41
53170...........................  Sublette County, Wyoming        99953       0.9257       0.9295          0.41
53180...........................  Sweetwater County,              99953       0.9257       0.9295          0.41
                                   Wyoming.
53190...........................  Teton County, Wyoming...        99953       0.9257       0.9295          0.41
53200...........................  Uinta County, Wyoming...        99953       0.9257       0.9295          0.41
53210...........................  Washakie County, Wyoming        99953       0.9257       0.9295          0.41
53220...........................  Weston County, Wyoming..        99953       0.9257       0.9295          0.41
65010...........................  Agana County, Guam......        99965       0.9611       0.9611          0.00
65020...........................  Agana Heights County,           99965       0.9611       0.9611          0.00
                                   Guam.
65030...........................  Agat County, Guam.......        99965       0.9611       0.9611          0.00
65040...........................  Asan County, Guam.......        99965       0.9611       0.9611          0.00
65050...........................  Barrigada County, Guam..        99965       0.9611       0.9611          0.00
65060...........................  Chalan Pago County, Guam        99965       0.9611       0.9611          0.00
65070...........................  Dededo County, Guam.....        99965       0.9611       0.9611          0.00
65080...........................  Inarajan County, Guam...        99965       0.9611       0.9611          0.00
65090...........................  Maite County, Guam......        99965       0.9611       0.9611          0.00
65100...........................  Mangilao County, Guam...        99965       0.9611       0.9611          0.00
65110...........................  Merizo County, Guam.....        99965       0.9611       0.9611          0.00
65120...........................  Mongmong County, Guam...        99965       0.9611       0.9611          0.00
65130...........................  Ordot County, Guam......        99965       0.9611       0.9611          0.00
65140...........................  Piti County, Guam.......        99965       0.9611       0.9611          0.00
65150...........................  Santa Rita County, Guam.        99965       0.9611       0.9611          0.00
65160...........................  Sinajana County, Guam...        99965       0.9611       0.9611          0.00
65170...........................  Talofofo County, Guam...        99965       0.9611       0.9611          0.00
65180...........................  Tamuning County, Guam...        99965       0.9611       0.9611          0.00
65190...........................  Toto County, Guam.......        99965       0.9611       0.9611          0.00
65200...........................  Umatac County, Guam.....        99965       0.9611       0.9611          0.00
65210...........................  Yigo County, Guam.......        99965       0.9611       0.9611          0.00
65220...........................  Yona County, Guam.......        99965       0.9611       0.9611          0.00
----------------------------------------------------------------------------------------------------------------

[FR Doc. 06-9068 Filed 11-1-06; 4:00 pm]
BILLING CODE 4120-01-P