Federal Register, Volume 73 Issue 213 (Monday, November 3, 2008)

[Federal Register Volume 73, Number 213 (Monday, November 3, 2008)]
[Notices]
[Pages 65351-65384]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-26142]

=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1555-N]
RIN 0938-AP20

Medicare Program; Home Health Prospective Payment System Rate
Update for Calendar Year 2009

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

ACTION: Notice.

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

SUMMARY: This notice 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, effective on
January 1, 2009.

DATES: Effective Date: This notice is effective on January 1, 2009.

FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131.

I. Background

A. Requirements of the Balanced Budget Act of 1997 for Establishing the
Prospective Payment System for Home Health Services

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. Section 4603 of the BBA mandated the
development of the home health prospective payment system (HH PPS).
Until the implementation of a HH PPS on October 1, 2000, home health
agencies (HHAs) received payment under a cost-based reimbursement
system.
Section 4603(a) of the BBA mandated the development of a HH 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 of the
Social Security Act (the Act), entitled ``Prospective Payment For Home
Health Services''. Section 1895(b)(1) of the Act requires the Secretary
to establish a HH 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 for 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 change adjustment factor that adjusts for
significant variation in costs 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 home health
services furnished in a geographic area compared to the applicable
national average level. These wage-adjustment factors may be used by
the Secretary for the different geographic 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
make additions or adjustments to the payment amount otherwise paid 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 (FY) may not exceed 5 percent of total payments projected
or estimated.
In accordance with the statute, we published a final rule (65 FR
41128) in the Federal Register on July 3, 2000 to implement the HH PPS
legislation. The July 2000 final rule established requirements for the
new HH PPS for home health services as required by section 4603 of the
BBA, 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 HH PPS for home health services, consolidated
billing requirements, and a number of other related changes. The HH 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.
For a complete and full description of the HH PPS as required by
the BBA, see the July 2000 HH PPS final rule (65 FR 41128 through
41214).

B. Deficit Reduction Act of 2005

On February 8, 2006, the Deficit Reduction Act of 2005 (Pub. L.
109-171) (DRA) was enacted. This legislation affected updates to HH
payment rates for calendar year (CY) 2006. The DRA also required HHAs
to submit home health care quality data and created a linkage between
those data and payment, beginning in CY 2007.
Specifically, 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. In addition, section 5201
of the DRA amends section 421(a) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173,
enacted on December 8, 2003). The amended section 421(a) of the MMA
requires that for home health services furnished in a rural area (as
defined in section 1886(d)(2)(D) of the Act) on or after January 1,
2006 and before January 1, 2007, that the Secretary increase the
payment amount otherwise made under section 1895 of the Act for home
health services by 5 percent. The statute waives budget neutrality for
purposes of this increase since it specifically states that the
Secretary must 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 a CMS transmittal (Pub.
100-20, One Time Notification, Transmittal 211) issued on February 10,
2006.
In addition, section 5201 of the DRA requires HHAs to submit data
for purposes of measuring health care quality, and links the quality
data submission to payment. This requirement is applicable for CY 2007
and each subsequent year. If an HHA does not submit quality data, the
home health market basket percentage increase will be reduced 2
percentage points. In accordance with the statute,

[[Page 65352]]

we published a final rule (71 FR 65884, 65935) in the Federal Register
on November 9, 2006 to implement the pay-for-reporting requirement of
the DRA, codified at 42 CFR 484.225(h) and (i). In addition, the
November 2006 final rule ended the 1-year transition period that
consisted 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. We also 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 rate that is adjusted
for the applicable case-mix and wage index. The national standardized
60-day episode payment rate includes the six home health disciplines
(skilled nursing, home health aide, physical therapy, speech-language
pathology, occupational therapy, and medical social services) and non-
routine medical supplies. Durable medical equipment covered under home
health is paid for outside the HH PPS payment. To adjust for case-mix,
the HH PPS uses a 153-category case-mix classification to assign
patients to a home health resource group (HHRG). Clinical needs,
functional status, and service utilization are computed from responses
to selected data elements in the OASIS assessment instrument.
For episodes with four or fewer visits, Medicare pays on the basis
of a national per-visit amount by discipline; an episode consisting of
four or fewer visits within a 60-day period is referred to as a LUPA.
Medicare also adjusts the national standardized 60-day episode payment
rate for certain intervening events that are subject to a partial
episode payment adjustment (PEP adjustment). For certain cases that
exceed a specific cost threshold, an outlier adjustment may also be
available.

D. Updates to the HH PPS

As required by section 1895(b)(3)(B) of the Act, we have
historically updated the HH PPS rates annually in a separate Federal
Register document. We published a final rule with comment period in the
Federal Register on August 29, 2007 (72 FR 49762) that set forth a
refinement and rate update to the Medicare prospective payment system
for home health services. As part of the CY 2008 HH PPS final rule with
comment period, we rebased and revised the home health market basket to
reflect FY 2003 Medicare cost report data, the latest available and
most complete data on the structure of HHA costs. In the rebased and
revised home health market basket, the labor-related share was 77.082
(an increase from the previous labor-related share of 76.775). The non-
labor-related share is 22.918 (a decrease from the previous nonlabor-
related share of 23.225). The increase in the labor-related share using
the FY 2003 home health market basket was primarily due to the increase
in the benefit cost weight.
The CY 2008 HH PPS final rule with comment period also implemented
refinements to the payment system. Extensive research was conducted to
investigate ways to improve the performance of the case-mix model. This
research was the basis for our decision to refine the case-mix model.
We refined the case-mix model to reflect different resource costs for
early home health episodes versus later home health episodes and to
expand the case-mix variables included in the payment model. For 2008,
we used a 4-equation case-mix model that recognizes and differentiates
payment for episodes of care based on whether a patient is in an early
(1st or 2nd episode in a sequence of adjacent episodes) or later (the
3rd episode and beyond in a sequence of adjacent episodes) episode of
care as well as recognizing whether a patient was a high therapy (14 or
more therapy visits) or low therapy (13 or fewer therapy visits) case.
We defined episodes as adjacent if they were separated by no more than
a 60-day period between claims. Analysis of the performance of the
case-mix model for later episodes revealed two important differences
for episodes occurring later in the home health treatment compared to
earlier episodes: Higher resource use per episode and a different
relationship between clinical conditions and resource use. We use
additional variables to include scores for certain wound and skin
conditions; more diagnosis groups such as pulmonary, cardiac, and
cancer diagnoses; and certain secondary diagnoses. The 4-equation model
results in 153 case-mix groups.
In addition, we replaced the previous single therapy threshold of
10 visits with three therapy thresholds at 6, 14, and 20 visits. The
payment for additional therapy visits between the three thresholds
increases gradually, incorporating a declining, rather than a constant,
amount per added therapy visit. This approach does not reduce total
payments to home health providers because the payment model still
predicts total resource cost. The combined effect of the new therapy
thresholds and payment gradations reduces the undesirable emphasis in
treatment planning on a single therapy visit threshold and restores the
primacy of clinical considerations in treatment planning for
rehabilitation patients.
In the CY 2008 HH PPS final rule with comment period, we further
adjusted for case-mix that was not due to a change in the underlying
health status of the home health users. Section 1895(b)(3)(B) of the
Act requires that in compensating for case-mix change, a payment
reduction must be applied to the standardized payment amount. For the
CY 2008 HH PPS final rule with comment period, we conducted several
analyses to determine if any portion of the total change in case-mix
could be considered to be real change. Real change is a change in the
underlying health status of the home health user population. The
results of the analysis indicated that while a small amount (8.03
percent) of measured case-mix change was real, most of the change was
unrelated to the underlying health status of home health users.
Using 100 percent of the home health interim payment system (HH
IPS) file for our baseline (12 months ending September 30, 2000), the
average case-mix weight per episode was 1.0960. (The HH IPS was the
previous cost-based payment system under which HHAs were paid, prior to
the HH PPS.) The 2005 20 percent sample file yielded an average CMI
(case mix indicator) of 1.2361. Therefore, the change measurement was
(1.2361 - 1.0960)/ 1.0960 = 12.78 percent. We adjusted this result
downward by 8.03 percent (the percentage of total change in case-mix
considered to be real) to get a final case-mix change measure of 11.75
percent (0.1278 * (1-0.0803) = 0.1175). To account for the 11.75
percent increase in case-mix which was not due to a change in the
underlying health status of Medicare home health patients, we
implemented a 2.75 percent reduction of the national standardized 60-
day episode payment rate for 3 years beginning in 2008 and solicited
comments on extending that adjustment period to a fourth year based on
a 2.71 percent reduction for 2011 (see 72 FR 49833).
Additionally, we modified a number of existing HH PPS payment
adjustments. Specifically, we increased the payment for low utilization
payment adjustment (LUPA) episodes that occur as the only episode or
the initial episode during a sequence of adjacent episodes, by $87.93.
We also eliminated the significant change in condition (SCIC)

[[Page 65353]]

payment adjustment for various reasons. Specifically, we ended the
policy because of the apparent difficulty HHAs had in interpreting the
SCIC policy, the association between negative margins and SCIC
episodes, the decline in the occurrence of SCICs, and the estimated
minimal impact on outlays from eliminating the SCIC policy.
In the development of the HH PPS, non-routine medical supplies
(NRS) were accounted for by attributing $49.62 to the standardized
episode payment. In the CY 2008 HH PPS final rule with comment period,
we applied a severity adjustment to the NRS portion of the HH PPS
standardized episode payment. Specifically, we adopted a six-severity-
group approach to account for NRS costs (see 72 FR 49851-49852) based
on measurable conditions that are feasible to administer. This change
offers HHAs some protection against episodes with extremely high NRS
costs. Finally, we did not modify the existing Partial Episode Payment
(PEP) Adjustment.
Section 1895(b)(5) of the Act also allows for the provision of an
addition or adjustment to account for outlier episodes, which are those
episodes that incur unusually large costs due to heavy patient care
needs. Under the HH PPS, outlier payments are made for episodes for
which the estimated cost exceeds a threshold amount. 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. Section 1895(b)(5) of the Act requires that the estimated
total outlier payments may not exceed 5 percent of total estimated HH
PPS payments. In the CY 2008 HH PPS final rule with comment period, we
adjusted the FDL ratio to 0.89, based on the most recently available
data, analysis, trends, and unknown effects of the refinements on
outliers (see 72 FR 49857).
Finally, we expanded the list of quality measures identified in the
update notice for CY 2007. In CY 2007, we specified 10 OASIS quality
measures from the OASIS data set as appropriate for public reporting of
measurements of health care quality. For CY 2008, we added two more
quality measures from the OASIS data set for public reporting. All
twelve publicly reported measures are National Quality Forum (NQF)-
endorsed measures. The additional measures for 2008 were as follows:
Emergent Care for Wound Infection, Deteriorating Wound
Status; and
Improvement in the Status of Surgical Wounds (see 72 FR
49861).
Accordingly, for CY 2008, we considered the existing OASIS data set
submitted by HHAs to CMS for episodes beginning on or after July 1,
2006, and before July 1, 2007, as meeting the reporting requirement for
quality measures for CY 2008.

II. Comments Received From CY 2008 HH PPS Final Rule With Comment
Period

In the CY 2008 HH PPS final rule with comment period, we
implemented a 2.75 percent payment reduction of the national
standardized 60-day episode payment rate for three years beginning in
CY 2008 and a fourth year reduction of 2.71 percent for CY 2011. We
sought comments only on the 2.71 percent case-mix change adjustment for
2011. We received approximately 44 items of correspondence from the
public, only a few of which were directly related to the 2.71 percent
adjustment to the HH PPS 60-day episode payment rate in the fourth
year. The provision for the 2.71 percent adjustment was added as the
fourth year's reduction to the rates to account for the additional
change in case-mix, that was indicated in the analysis for the CY 2008
final rule with comment period, that is not considered real; i.e., that
is not related to an underlying change in patient health status.
Comments originated from trade associations, HHAs, hospitals, and
health care professionals such as physicians, nurses, social workers,
and physical and occupational therapists. Because this is an update
notice, we are not changing policy. However, in order to provide more
meaningful and substantive responses we will respond to the above
mentioned comments in future rulemaking. This approach allows us to
respond comprehensively as more current data become available, while
also affording the public ample opportunity to comment on possible
future policy changes.
At this time, CMS is maintaining our existing policy as implemented
in the CY 2008 final rule with comment period and will impose a 2.75
percent reduction to the national standardized 60-day episode rate for
CY 2009. We will continue to monitor any changes in case-mix and may
revise the percentage reductions to the HH PPS rates in future
rulemaking.

III. Provisions of This Notice

A. National Standardized 60-Day Episode Rate

The Medicare HH PPS has been in effect 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 relative weight and a wage index value based on the site of
service for the beneficiary. In the CY 2008 HH PPS final rule with
comment period, we refined the case-mix methodology and also rebased
and revised the home health market basket. The labor-related share of
the case-mix adjusted 60-day episode rate is 77.082 percent and the
non-labor-related share is 22.918 percent. The CY 2009 HH PPS rates use
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
CY 2008 HH PPS final rule with comment period. 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. We add the wage-adjusted portion to
the non-labor portion yielding the case-mix and wage-adjusted 60-day
episode rate subject to any additional applicable adjustments.
In accordance with section 1895(b)(3)(B) of the Act, we have
updated the HH PPS rates annually in a separate Federal Register
document. The HH PPS regulations at Sec. 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 added Sec.
484.225, paragraphs (h) and (i), in the November 9, 2006 final rule to
reflect the requirement for submission of quality data, as follows:
(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.
For CY 2009, we will base the wage index adjustment to the labor
portion of

[[Page 65354]]

the HH PPS rates on the most recent pre-floor and pre-reclassified
hospital wage index. 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 ``low
utilization payment adjustment'' (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 the CY 2008 HH PPS final rule with
comment period. We are also updating the amounts of the LUPA add-on and
the NRS conversion factor by the applicable home health market basket
update of 2.9 percent for CY 2009.
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:
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.
An outlier payment as set forth in Sec. 484.205(e) and
Sec. 484.240.

B. CY 2009 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 2009 that the standard prospective payment amounts
be increased by a factor equal to the applicable home health market
basket update for those HHAs that submit quality data as required by
the Secretary.
The applicable home health market basket update will be reduced by
2 percentage points for those HHAs that fail to submit the required
quality data. This requirement has been codified in regulations at 42
CFR 484.225. The HH PPS market basket update for CY 2009 is 2.9
percent. This is based on Global Insights Inc.'s, third quarter 2008
forecast, utilizing historical data through the second quarter of 2008.
A detailed description of how we derived the HHA market basket is
available in the CY 2008 Home Health PPS proposed rule (72 FR 25356,
25435).
CY 2009 Adjustments
In order to calculate the CY 2009 national standardized 60-day
episode rate, we first increase the CY 2008 national standardized 60-
day episode payment rate of $2,270.32 by the home health market basket
update of 2.9% for CY 2009.
Given this updated rate, we then take a reduction of 2.75 percent
to account for the change in case-mix that is not related to the real
change in patient acuity levels, as discussed above. The resulting
updated CY 2009 national standardized 60-day episode rate for an HHA
that submits the required quality data is shown in Table 1. The updated
CY 2009 national standardized 60-day episode rate for an HHA that does
not submit the required quality data is shown in Table 2.

Table 1--National 60-Day Episode Amounts Updated by the Home Health Market Basket Update for CY 2009, Before
Case-Mix Adjustment, Wage Index Adjustment Based on the Site of Service for the Beneficiary
----------------------------------------------------------------------------------------------------------------
Multiply by the Updated National Reduce by 2.75
Total CY 2008 National Home Health Market Standardized 60- Percent for CY 2009 National
Standardized 60-Day Episode Basket Update (2.9 Day Episode Nominal Change in Standardized 60-Day
Payment Rate Percent) \1\ Payment Case-Mix Episode Payment
----------------------------------------------------------------------------------------------------------------
$2,270.32...................... x 1.029........... $2,336.16......... x 0.9725.......... $2,271.92
----------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc.,
3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.

Table 2--For HHAs That Do Not Submit the Required Quality Data--National 60-Day Episode Amounts Updated by the
Home Health Market Basket Update for CY 2009, Before Case-Mix Adjustment, Wage Index Adjustment Based on the
Site of Service for the Beneficiary
----------------------------------------------------------------------------------------------------------------
Updated National
Multiply by the Standardized 60- CY 2009 National
Total CY 2008 National Home Health Market Day Episode Reduce by 2.75 Standardized 60-Day
Standardized 60-Day Episode Basket Update (2.9 Payment for HHAs Percent for Episode Payment for
Payment Rate Percent) \1\ minus that do not submit Nominal Change in HHAs that do not
2 percent required quality Case-Mix submit required
data quality data
----------------------------------------------------------------------------------------------------------------
$2,270.32...................... x 1.009........... $2,290.75......... x 0.9725.......... $2,227.75
----------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc.,
3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.

[[Page 65355]]

National Per-Visit Amounts Used To Pay LUPAs and Compute
Imputed Costs Used in Outlier Calculations
As discussed previously in the CY 2008 HH PPS final rule with
comment period, the policies governing LUPAs and the outlier
calculations set forth in the July 3, 2000 HH PPS final rule will
continue (65 FR 41128). Also, we implemented a LUPA add-on amount of
$87.93 for initial and only episode LUPAs during CY 2008. In
calculating the CY 2009 national per-visit amounts used to calculate
payments for LUPA episodes and to compute the imputed costs in outlier
calculations, we start with the CY 2008 per-visit amounts. We increase
the CY 2008 per-visit amounts for each home health discipline for CY
2009 by the home health market basket update (2.9 percent). LUPA rates
are not reduced due to the nominal increase in case-mix since they are
per-visit rates and hence are not subject to changes in case-mix.

Table 3--National Per-Visit Amounts for LUPAs (Not including the Increase in Payment for a Beneficiary's Only Episode or the Initial Episode in a
Sequence of Adjacent Episodes) and Outlier Calculations Updated by the Home Health Market Basket Update for CY 2009, Before Wage Index Adjustment Based
on the Site of Service for the Beneficiary
--------------------------------------------------------------------------------------------------------------------------------------------------------
For HHAs that DO submit the required quality For HHAs that DO NOT submit the required
------------------------------------------------------------ data quality data
--------------------------------------------------------------------------------------------
Multiply by the Home Multiply by the Home
Home Health Discipline CY 2008 per-visit Health Market Basket CY 2009 per-visit Health Market Basket CY 2009 per-visit
payment Update (2.9 Percent) payment Update (2.9 percent) payment
\1\ \1\ minus 2 percent
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home Health Aide................... $47.51................ x 1.029.............. $48.89............... x 1.009.............. $47.94
Medical Social Services............ 168.17................ x 1.029.............. 173.05............... x 1.009.............. 169.68
Occupational Therapy............... 115.48................ x 1.029.............. 118.83............... x 1.009.............. 116.52
Physical Therapy................... 114.71................ x 1.029.............. 118.04............... x 1.009.............. 115.74
Skilled Nursing.................... 104.91................ x 1.029.............. 107.95............... x 1.009.............. 105.85
Speech-Language Pathology.......... 124.65................ x 1.029.............. 128.26............... x 1.009.............. 125.77
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical
data through 2nd Qtr 2008.

Payment for LUPA episodes changed in CY 2008 in that for LUPAs that
occur as initial episodes in a sequence of adjacent episodes or as the
only episode, an additional payment amount is added to the LUPA
payment. The Table 3 per-visit rates noted above are before that
additional payment is added to the LUPA payment, and are the per-visit
rates paid to all other LUPA episodes and used in computing outlier
payments. LUPA episodes that occur as the only episode or initial
episode in a sequence of adjacent episodes are adjusted by adding an
additional amount to the LUPA payment before adjusting for wage index.
For CY 2008, that amount was $87.93. This additional LUPA amount is
updated in the same manner as the national standardized 60-day episode
payment amount and the per-visit rates (i.e. by the home health market
basket percentage update). Consequently, for CY 2009, the additional
amount paid to LUPAs that occur as initial episodes in a sequence of
adjacent episodes or as the only episode is 90.48 ($87.93 x 1.029).
Beginning in CY 2008, to ensure that the variation in non-routine
medical supplies (NRS) is more appropriately reflected in the HH PPS,
we replaced the original portion ($49.62) of the HH PPS base rate that
accounted for NRS, with a system that pays for NRS based on 6 severity
groups. For a complete description of the analysis and research behind
the development of this system for the payment of NRS, we refer readers
to the CY 2008 HH PPS proposed rule (72 FR 25426-25434). Following
public comment on the initial proposal made in the proposed rule, we
made several modifications using a file of more recent data. The
revisions resulted in some scoring changes, and the addition of the
sixth severity group to the original five severity groups, to provide
more adequate reimbursement for episodes with a high utilization of
NRS. As we did in the CY 2008 HH PPS final rule with comment, payments
for NRS are updated by the home health market basket and reduced by the
2.75 percent reduction to the rates through the updating of the NRS
conversion factor. NRS payments are computed by multiplying the
relative weight for a particular severity level by the NRS conversion
factor. For this notice, the NRS conversion factor is updated by the
home health market basket update of 2.9 percent and reduced by the 2.75
percent reduction to the rates. The NRS conversion factor for CY 2008
was $52.35. Consequently, for CY 2009, the NRS conversion factor is
$52.39 (52.35 x (1.029 x (1-0.0275))). The payment amounts for the
various severity levels based on the updated conversion factor are
calculated in Table 4.

Table 4--Relative Weights for the 6-Severity NRS System
----------------------------------------------------------------------------------------------------------------
Relative NRS payment
Severity level Points (scoring) weight amount
----------------------------------------------------------------------------------------------------------------
1............................................. 0............................... 0.2698 $14.13
2............................................. 1 to 14......................... 0.9742 51.04
3............................................. 15 to 27........................ 2.6712 139.94
4............................................. 28 to 48........................ 3.9686 207.91
5............................................. 49 to 98........................ 6.1198 320.62
6............................................. 99+............................. 10.5254 551.43
----------------------------------------------------------------------------------------------------------------

[[Page 65356]]

C. 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, starting with the initial reporting year from
July 2005 through June 2006 and each year thereafter, ``each home
health agency shall submit to the Secretary such data that the
Secretary determines are appropriate for the measurement of health care
quality.'' In response to the DRA requirements, CMS published
information about the quality measures in the Federal Register as a
proposed rule on August 3, 2006 (71 FR 44082-44090) and as a final rule
on November 9, 2006 (71 FR 65903). We proposed, and made final, the
decision to use the subset of OASIS data that is publicly reported on
Home Health Compare, as the appropriate measures of home health
quality.
Therefore, OASIS assessments submitted by HHAs to CMS in compliance
with HHA conditions of participation for dates of service beginning
July 1, 2007 and ending June 30, 2008 will fulfill the HH PPS quality
reporting requirement for CY 2009 payments. This reporting time period
allows for 12 full months of data and provides us the time necessary to
analyze and make any necessary payment adjustments to the CY 2009
payment rates. The required quality measures for meeting the submission
requirements for CY 2009 are the same as those required for meeting the
submission requirements for CY 2008. These measures are:
Improvement in Ambulation/Locomotion,
Improvement in Bathing,
Improvement in Transferring,
Improvement in Management of Oral Medication,
Improvement in Pain Interfering with Activity,
Acute Care Hospitalization,
Emergent Care,
Discharge to Community,
Improvement in Dyspnea,
Improvement in Urinary incontinence,
Improvement in surgical wounds, and
Emergent Care for wound deterioration.
HHAs that meet the reporting requirements are eligible for the full
home health market basket percentage increase. Consistent with our
previous policy, home health agencies that are certified on or after
May 1, 2007 for payments to be made in CY 2009 will be excluded from
the quality reporting requirement in CY 2009 because data submission
and analysis will not be possible for an agency certified this late in
the reporting time period. At the earliest time possible after
obtaining the CCN number, reporting is mandatory. These exclusions only
affect quality reporting requirements and do not affect the agency's
OASIS reporting responsibilities under the CoP submission requirement.
Additionally, section 1895(b)(3)(B)(v)(I) of the Act requires that
all HHAs, unless covered by specific exclusions, meet the reporting
requirement, or be subject to a 2 percent reduction in the home health
market basket percentage increase. CMS will reconcile the OASIS
submissions with claims data in order to verify full compliance with
the quality reporting requirements on an annual cycle July 1 through
June 30. The 2 percent reduction applies to all HHAs who have not
submitted an OASIS assessment in the required time frame for payments
beginning in January 2007 and each year thereafter. We will reconcile
the OASIS submissions with claims data in order to verify full
compliance with the quality reporting requirements. Section
1895(b)(3)(B)(v)(III) of the Act further requires that ``[t]he
Secretary shall establish procedures for making data submitted under
subclause (II) available to the public. 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 will continue to use the Home Health Compare Web site, which
lists HHAs geographically. Currently, the Home Health Compare Web site
lists 12 quality measures from the OASIS set, and these 12 measures are
all NQF-endorsed measures for public reporting. Consumers can search
for all Medicare-approved home health providers that serve their city
or zip code (which would include the quality measures) and then find
the agencies offering the types of services they need. See http://www.medicare.gov/HHCompare/Home.asp. HHAs currently have pre-
publication access every November to their own agency's quality data
(collected and periodically updated by a contractor), which enables
each agency to know how it is performing before public posting of data
on the Home Health Compare Web site. In addition, each agency formally
receives quarterly updates via the CASPER system known as Outcome Based
Quality Improvement (OBQI) and Outcome Based Quality Monitoring (OBQM)
and a report describing the agency patient characteristics based on
OASIS. Continuing to use the OASIS instrument ensures that providers
will not have an additional burden of reporting through a separate
mechanism and that the costs associated with the development and
testing of a new reporting mechanism can be avoided. For CY 2009, we
will continue to require that the HHA submit OASIS data appropriate for
the measurement of health care quality.
Over the past year, CMS has tested new patient level best practice
and process measures for home health agencies, and has continued to
refine the current OASIS instrument. CMS is testing the new measure the
NQF has developed a Global Measure for Flu/Pneumonia vaccination across
care settings. We anticipate making further modifications to the
current OASIS items, including refinements to response categories. Any
new data elements go through OMB process and measures go through the
NQF consensus development process, prior to proposing them through the
rulemaking process. Additionally, section 1895(b)(3)(B)(v)(II) of the
Act requires each HHA to submit appropriate health care quality data in
a form, manner, and at a time specified by the Secretary. Such measures
would be evidence-based, clearly linked to improved outcomes, and
reliably captured with the least burden to the provider. Data element
revisions and measures across settings of care will be integral to CMS'
vision of addressing national quality care priorities and use of a
future single instrument for quality, payment, clinical relevance, and
risk adjustment.

D. Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) Home Health Care

As part of the U.S. Department of Health and Human Services (DHHS)
Transparency Initiative, CMS plans to implement a process to measure
and publicly report patient experiences with home health care using a
survey developed by the Agency for Healthcare Research and Quality's
(AHRQ's) Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) program. The CAHPS Home Health Care survey is part of a
family of CAHPS[supreg] surveys that ask patients to report on and rate
their experiences with health care. This notice provides an update on
the development of the CAHPS Home Health Care survey, as initially
discussed in the May 4, 2007 proposed rule (72 FR 25356, 25452). The
CAHPS[supreg] Home Health Care survey presents home health patients
with a set of standardized questions about their

[[Page 65357]]

home health care providers and the quality of their home health care.
Prior to this survey, there was no national standard for collecting
information about patient experience that would allow comparisons
across all home health agencies.
The survey captures topics such as patients' interactions with home
health staff, provider care and communication, and patient
characteristics. The survey allows the patient to give an overall
rating of the agency, and asks if the patient would recommend the
agency to family and friends.
AHRQ conducted a field test to determine the length and content of
the CAHPS Home Health Care Survey. CMS has submitted the survey to the
National Quality Forum (NQF) for consideration and approval in their
consensus process. NQF endorsement represents the consensus opinion of
many healthcare providers, consumer groups, professional organizations,
purchasers, federal agencies, and research and quality organizations.
The final survey will be submitted to the Office of Management and
Budget (OMB) for their approval under the Paperwork Reduction Act (PRA)
process.
CMS is working with a contractor to develop protocols and
guidelines for implementation of CAHPS Home Health Care survey.
Administration of the survey will be conducted by multiple, independent
survey vendors working under contract with home health agencies to
facilitate data collection and reporting. During 2008, vendor training
materials are being developed, and implementation procedures for data
submission and processing will be finalized. Recruitment and training
of vendors who wish to be approved to collect survey data will begin in
2009. The CAHPS Home Health Care survey will be implemented similar to
the CAHPS Hospital survey where vendors are approved to conduct the
survey and trained prior to agency participation in the survey. Home
health agencies interested in learning about the survey are encouraged
to view the CAHPS Home Health Care Survey Web site: http://www.homehealthCAHPS.org. They can also call toll-free: 1-866-354-0985
or send an email to the project team at [email protected] for more
information.
More information about the national implementation will be
available next year in the Home Health Rule: The Home Health
Prospective Payment System Refinement and Rate Update for Calendar Year
2010.

E. Outliers and the Fixed Dollar Loss Ratio

In addition to the regular 60-day case-mix and wage-adjusted
episode payments, the HH PPS allows for outlier payments for episodes
that incur unusually high costs. As noted in section I.A., of this
notice, outlier payments are made for episodes for which the estimated
cost exceeds a threshold amount. Section 1895(b)(5) of the Act requires
that the estimated total outlier payments be no more than 5 percent of
total estimated HH PPS payments for a given year. For a full
description of our outlier policy, we refer to the CY 2008 HH PPS final
rule with comment period (72 FR 49855-49857).
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. Annually, we review the percentage of
outlier payments and adjust the FDL ratio as appropriate.
Past experience has shown that outlier payments have been
increasing as a percent of total payments from 4.1 percent in CY 2005,
to 5.0 percent in CY 2006, to 6.4 percent in CY 2007. More recent
analysis estimates outlier payments to increase to approximately 8.1
percent in CY 2008 (an increase of slightly more than 27 percent).
In the CY 2008 final rule with comment period, in the interest of
using the latest data and best analysis available, we performed
supplemental analysis on the most recent data available in order to
best estimate the FDL ratio. That analysis derived a final FDL ratio of
0.89 for CY 2008.
In order to determine the appropriate value for the FDL ratio for
CY 2009 we performed an updated analysis using the most recent,
complete available data (CY 2007), applying a methodology similar to
that which we used to update the FDL ratio in the CY 2008 HH PPS final
rule with comment. That updated analysis projects that in CY 2009 we
will expend an estimated 10.26 percent of total estimated HH PPS
payments in outlier payments, more than double our 5 percent statutory
limit. However, our analysis also revealed that this growth in outlier
payments is primarily the result of excessive growth in a few specific
areas of the country. Specifically, we have noticed statistical
anomalies in outlier payments, as a percentage of total HH PPS
payments, in areas such as Miami-Dade, Florida, where outlier payments
to providers far exceed the national average and the 5 percent target
for outlier payments. Using similar analysis to what was performed for
the CY 2009 final rule with comment; we estimated that we would need to
raise our FDL ratio from 0.89 to 2.71 for CY 2009. This is a dramatic
change that appears to be driven by statistical anomalies in outlier
payments in areas such as Miami-Dade, Florida. In addition, the size of
these statistical anomalies raises concerns about the medical necessity
of the outlier episodes in some areas. We will be examining outlier
payments in these areas in more detail and will take action to remedy
inappropriate outlier payments as necessary.
Therefore, we believe that raising the FDL ratio to 2.71 is not
justified at this time, given the statistical outlier data anomalies
that we have identified in certain areas, and the actions that are
underway to address excessive, suspect outlier payments that are
occurring in these areas. We believe the most reasonable policy to
achieve paying no more than 5 percent outlier payments as a percentage
of total estimated HH PPS payments is through the combined effects of
maintaining the current (CY 2008) FDL ratio of 0.89 in CY 2009 and the
actions being taken to remedy any inappropriate outlier payments in
these areas of the country where outlier data anomalies exist. Any
further update to the FDL ratio, if any, will not occur until future
rulemaking when we expect to have a better understanding of appropriate
outlier payments, particularly in those areas of the country with
extremely high outlier payments as a percentage of total HH PPS
payments.

F. Hospital Wage Index

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. As discussed previously, we apply the
appropriate wage index value to the labor portion (77.082 percent) of
the HH PPS rates based on the site of service for the beneficiary
(defined by section 1861(m) of the Act as the beneficiary's place of
residence). 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 have consistently used the
pre-floor, pre-reclassified hospital wage index data to adjust the
labor portion of the HH PPS rates. We believe the use of the pre-floor,
pre-reclassified hospital wage index data results in the appropriate
adjustment to

[[Page 65358]]

the labor portion of the costs as required by statute.
In the November 9, 2005 final rule for CY 2006 (70 FR 68132), we
adopted revised labor market area definitions based on Core-Based
Statistical Areas (CBSAs). At the time, we noted that these were the
same labor market area definitions (based on OMB's new CBSA
designations) implemented under the Hospital Inpatient Prospective
Payment System (IPPS). In adopting the CBSA designations, we identified
some geographic areas where there are no hospitals and, thus, no
hospital wage data on which to base the calculation of the home health
wage index. We continue to use the methodology discussed in the
November 9, 2006 final rule for CY 2007 (71 FR 65884) to address the
geographic areas that lack hospital wage data on which to base the
calculation of their home health wage index. For rural areas that do
not have IPPS hospitals, we use the average wage index from all
contiguous CBSAs as a reasonable proxy. This methodology is used to
calculate the wage index for rural Massachusetts. However, we could not
apply this methodology to rural Puerto Rico due to the distinct
economic circumstances that exist there, but instead continue using the
most recent wage index previously available for that area (from CY
2005). For urban areas without IPPS hospitals, we use the average wage
index of all urban areas within the State as a reasonable proxy for the
wage index for that CBSA. The only urban area without IPPS hospital
wage data is Hinesville-Fort Stewart, Georgia (CBSA 25980).
1. Clarification of New England Deemed Counties
We are taking this opportunity to address the change in the
treatment of ``New England deemed counties'' (that is, those counties
in New England listed at 42 CFR 412.64(b)(1)(ii)(B) that were deemed to
be part of urban areas under section 601(g) of the Social Security
Amendments of 1983) that was made in the FY 2008 IPPS final rule with
comment period (72 FR 47337 through 47338, August 22, 2007). These
counties include the following: Litchfield County, Connecticut; York
County, Maine; Sagadahoc County, Maine; Merrimack County, New
Hampshire; and Newport County, Rhode Island. Of these five ``New
England deemed counties,'' three (York County, ME; Sagadahoc County,
ME; and Newport County, RI) are also included in metropolitan
statistical areas defined by OMB and are considered urban under both
the current IPPS and HH PPS labor market area definitions in Sec.
412.64(b)(1)(ii)(A). The remaining two, Litchfield County, CT, and
Merrimack County, NH, are geographically located in areas that are
considered rural under the current IPPS (and HH PPS) labor market area
definitions, but have been previously deemed urban under the IPPS in
certain circumstances, as discussed below.
In the FY 2008 IPPS final rule with comment period, Sec.
412.64(b)(1)(ii)(B) was revised such that the two ``New England deemed
counties'' that are still considered rural under the OMB definitions
(Litchfield County, CT and Merrimack County, NH), are no longer
considered urban effective for discharges occurring on or after October
1, 2007, and therefore, are considered rural in accordance with Sec.
412.64(b)(1)(ii)(C). However, for purposes of payment under the IPPS,
acute-care hospitals located within those areas are treated as being
reclassified to their deemed urban area effective for discharges
occurring on or after October 1, 2007 (see 72 FR 47337 through 47338).
We note that the HH PPS does not provide for such geographic
reclassification. Also, in the FY 2008 IPPS final rule with comment
period (72 FR 47338), we explained that we have limited this policy
change for the ``New England deemed counties'' only to IPPS hospitals,
and any change to non-IPPS provider wage indexes would be addressed in
the respective payment system rules. Accordingly, we are taking this
opportunity to clarify the treatment of ``New England deemed counties''
under the HH PPS in this notice.
As discussed above, the HH PPS has consistently used the IPPS
definition of ``urban'' and ``rural'' with regard to the wage index
used in the HH PPS. Historical changes to the labor market area/
geographic classifications and annual updates to the wage index values
under the HH PPS are made effective January 1 each year. When we
established the most recent HH PPS payment rate update, effective for
HH services provided on or after January 1, 2008 through December 31,
2008, we considered the ``New England deemed counties'' (including
Litchfield County, CT and Merrimack County, NH) as urban for CY 2008,
as evidenced by the inclusion of Litchfield County as one of the
constituent counties of urban CBSA 25540 (Hartford-West Hartford-East
Hartford, CT), and the inclusion of Merrimack County as one of the
constituent counties of urban CBSA 31700 (Manchester-Nashua, NH).
At 42 CFR 484.202, the terms ``rural'' and ``urban'' are defined
according to the definitions of those terms as used in the IPPS.
Applying the IPPS definitions, Litchfield County, CT and Merrimack
County, NH are not considered ``urban'' under Sec. 412.64(b)(1)(ii)(A)
through (B) as revised under the FY 2008 IPPS final rule and,
therefore, are considered ``rural'' under Sec. 412.64(b)(1)(ii)(C).
Accordingly, reflecting our policy to use the IPPS definitions of
``urban'' and ``rural,'' these two counties will be considered
``rural'' under the HH PPS effective with the next update of the HH PPS
payment rates on January 1, 2009, and will no longer be included in
urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT) and urban
CBSA 31700 (Manchester-Nashua, NH), respectively. We note that this
policy is consistent with our policy of not taking into account IPPS
geographic reclassifications in determining payments under the HH PPS.
2. Multi-Campus Hospital Wage Index Data
In the CY 2008 HH PPS final rule with comment period, we
established HH PPS wage index values for CY 2008 calculated from the
same data (collected from cost reports submitted by hospitals for cost
reporting periods beginning during FY 2004) used to compute the FY 2008
acute care hospital inpatient wage index, without taking into account
geographic reclassification under sections 1886(d)(8) and (d)(10) of
the Act. However, the IPPS policy that apportions the wage data for
multi-campus hospitals was not finalized before the HH PPS final rule
with comment period.
We are continuing to use IPPS wage data for this CY 2009 update
notice because we believe that in the absence of home health-specific
wage data, using the hospital inpatient wage data is appropriate and
reasonable for the HH PPS. We note that the IPPS wage data used to
determine the CY 2009 HH wage index values reflect our policy that was
adopted under the IPPS beginning in FY 2008, which apportions the wage
data for multi-campus hospitals located in different labor market
areas, or Core-Based Statistical Areas (CBSAs), to each CBSA where the
campuses are located (see the FY 2008 IPPS final rule with comment
period (72 FR 47317 through 47320)). Specifically, for the CY 2009 HH
PPS, the wage index was computed using IPPS wage data (published by
hospitals for cost reporting periods beginning in 2005, as with the FY
2009 IPPS wage index), which allocated salaries and hours to the
campuses of two multi-campus hospitals with campuses that are located
in different labor areas; one is Massachusetts and the other is
Illinois. The wage index

[[Page 65359]]

values for the CY 2009 HH PPS in the following CBSAs are affected by
this policy: Boston-Quincy, MA (CBSA 14484), Providence-New Bedford-
Falls River, RI-MA (CBSA 39300), Chicago-Naperville-Joliet, IL (CBSA
16974) and Lake County-Kenosha County, IL-WI (CBSA 29404) (please refer
to Addendum B in this notice).
As previously discussed in the July 3, 2000 final rule (65 FR
41128), 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. Since publication of
the July 3, 2000 final rule, we continue to believe that the use of the
pre-floor and pre-reclassified hospital wage index data results in the
appropriate and reasonable adjustment to the labor portion of the costs
as required by statute. The HH PPS does not use the hospital area wage
index's occupational mix adjustment, as this adjustment serves
specifically to define the occupational categories more clearly in a
hospital setting. See Addenda A and B of this notice, respectively, for
the rural and urban pre-floor, pre-reclassified hospital wage indexes
for 2009. The 2009 wage index is based on data collected from hospital
cost reports submitted for cost reporting periods beginning during FY
2005. These data reflect the multi-campus and New England deemed
counties policies discussed above.
Under the HH PPS, we use the wage index value associated with the
labor market in which the beneficiary's home is located. 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).

IV. Waiver of Proposed Rulemaking

We ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide a period for public comment before the
provisions of a notice such as this take effect. We can waive this
procedure, however, if we find good cause that a notice-and-comment
procedure is impracticable, unnecessary, or contrary to the public
interest and incorporate a statement of finding and its reasons in the
notice issued.
We find that it is unnecessary, impracticable and contrary to the
public interest to undertake proposed notice and comment rulemaking in
this Notice. We believe it is unnecessary because the statute requires
annual updates to the HH PPS rates and the methodologies used to update
the rates have been previously subject to public comment; we are simply
applying the methodology to the most recent data. With respect to the
update of the outlier FDL ratio, we find that insofar as we have
deviated from our usual methodology in this calendar year, such change
is an analytical change. Moreover, we believe that the difficulty of
deriving a new methodology to address the limited data discrepancies in
localized areas of the country makes issuing a notice of proposed
rulemaking in this instance impracticable. Moreover, it would be
contrary to the public interest to undertake notice and comment
rulemaking as it would impose a hardship on home health agencies and
their patients by delaying publication of this update in order to
solicit comments. Since it would pose additional harm to those home
health agencies across the country that would be deemed ineligible for
outlier payments because of these localized data discrepancies,
applying the FDL analysis that we have used in past years is likewise
contrary to the public interest for CY 2009. Therefore, we find good
cause to waive notice and comment procedures for CY 2009.

V. Collection of Information Requirements

This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 501 et seq. ).

VI. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this notice 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), Executive Order 13132 on
Federalism, and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Order 12866, as amended, 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 rules with economically significant
effects ($100 million or more in any 1 year). This notice, as defined
by Executive Order 12866, is not an economically significant rule. This
notice would not be considered major under the Congressional Review
Act. The update set forth in this notice applies to Medicare payments
under HH PPS in CY 2009. Accordingly, the following analysis describes
the impact in CY 2009 only.
We estimate that the net impact in this notice, including a 2.75
percent reduction to the payment rate to account for the case-mix
change adjustment, is estimated to be approximately $30 million in CY
2009 expenditures. This total estimated $30 million impact reflects the
distributional effects of an updated wage index (-$20 million) as well
as the 2.9 percent home health market basket increase (an estimated
additional $490 million in CY 2009 expenditures attributable only to
the CY 2009 home health market basket update), and the 2.75 percent
decrease (-$440 million for the second year of a 4-year phase-in) to
the HH PPS national standardized 60-day episode rate to account for the
case-mix change adjustment under the HH PPS. The $30 million is
reflected in column 3 of Table 5 as a 0.15 percent increase in
expenditures when comparing the current CY 2008 system to the CY 2009
system.
The RFA requires agencies to analyze options for regulatory relief
of small entities. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small governmental
jurisdictions. Most hospitals and most other providers and suppliers
are small entities, either by nonprofit status or by having revenues of
$7 million to $34.5 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 $13.5 million or less in any 1 year. Individuals and
States are not included in the definition of a small entity. As stated
above, this notice will have an estimated positive effect upon small
entities that are HHAs (see Section IV.B ``Anticipated Effects'', of
this rule, for supporting analysis).
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 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital

[[Page 65360]]

as a hospital that is located outside of a Metropolitan Statistical
Area and has fewer than 100 beds. We have determined that this notice
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 also
requires that agencies assess anticipated costs and benefits before
issuing any rule that may result in expenditure in any 1 year by State,
local, or tribal governments, in the aggregate, or by the private
sector, of $100 million adjusted for inflation. Using the Gross
Domestic Price Deflator, the inflation adjusted threshold for 2008 is
approximately $130 million. We believe this notice will not mandate
expenditures in that amount.
Executive Order 13132 established 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 notice under the threshold criteria
of Executive Order 13132, Federalism. We have determined that this
notice would not have substantial direct effects on the rights, roles,
and responsibilities of States.

B. Anticipated Effects

This notice updates the HH PPS rates contained in the CY 2008 HH
PPS final rule with comment period. We use the latest data and best
analysis 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 2006. 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.
Table 5 represents how home health agencies are likely to be
affected by the policy changes described in this notice. Column one of
this table classifies HHAs according to a number of characteristics
including provider type, geographic region, and urban versus rural
location. For the purposes of analyzing impacts on payments, we
performed four simulations and compared them to each other. Based on
our estimate that outliers, as a percentage of total HH PPS payments,
will be at least 5 percent in CY 2008, the 2008 baseline, for the
purposes of these simulations, we assumed that the full 5 percent
outlay for outliers will be paid. The first simulation estimates 2008
payments under the current system (to include the 2008 wage index and
2008 payment rates). The second simulation estimates CY 2008 payments
under the current system, but with the CY 2009 wage index. The second
simulation produces an estimate of the effect of the CY 2009 wage index
only. The third simulation estimates the effect of the CY 2009 payments
using the CY 2009 payment rates and the CY 2008 wage index. The fourth
simulation estimates CY 2009 payments using the new CY 2009 payment
rates and CY 2009 wage index.
These four simulations allow us to demonstrate the effects of the
new CY 2009 wage index and a new 2009 payment rates as a percentage
change in estimated expenditures. Specifically, the second column of
Table 5 shows the percent change due to the effects of the CY 2009 wage
index. The third column of Table 5 shows the percent change due to the
combined effects of the CY 2009 wage index and the CY 2009 home health
market basket update and the case-mix reduction.
Column three shows the percentage change in estimated total
payments in moving from the current CY 2008 to the revised CY 2009
system outlined in this notice. Our estimate of the change in total
payments between CY 2008 and CY 2009 is an increase of approximately
0.15 percent.
In general, most HHAs are estimated to see increases in total
payments from CY 2008 to CY 2009. The increases range from -0.01
percent for other voluntary/non-profit freestanding agencies to 0.25
percent for facility-based governmental HHAs.
The only rural HHA's estimated to see a decrease are free-standing,
other voluntary/non-profit HHAs. The decrease is estimated to be 0.07
percent. In total, payments are estimated to increase 0.17 percent to
HHAs in rural areas and 0.19 percent to HHAs in urban areas. The only
urban HHAs estimated to see a decrease are facility-based voluntary/
non-profits with an estimated decrease of 0.05 percent. Overall,
payments are estimated to increase 0.15 percent to HHAs in urban areas.
HHAs in the South and the West are expected to experience increases
of 0.08 percent and 1.56 percent respectively from CY 2008 to CY 2009.
The North and the Midwest are estimated to experience decreases of 0.08
percent and 0.44 percent respectively. It is estimated that New
England, East South Central, West South Central, West North Central and
Pacific HHAs will experience percentage increases of 0.36 percent, 0.02
percent, 0.34 percent, 0.61 percent, and 2.21 percent respectively.
Conversely, Mid Atlantic, South Atlantic, East North Central, and
Mountain area HHAs are expected to experience decreases of 0.32
percent, 0.18 percent, 0.70 percent, and 0.09 percent respectively. In
general, all HHAs of varying facility size are expected to experience
increases (ranging from 0.04 percent to 0.53 percent) in total payments
from CY 2008 to CY 2009.

[[Page 65361]]

Table 5--Impact by Agency Type
------------------------------------------------------------------------
Percent change
due to the
effects of the
Percent change updated wage
due to the index, the 2.9%
Group effects of the home health
updated wage market basket
index only update, and the
2.75% reduction
to the rates
------------------------------------------------------------------------
Type of Facility
------------------------------------------------------------------------
Free-Standing/Other Vol/NP.......... -0.22 -0.01
Free-Standing/Other Proprietary..... -0.09 0.24
Free-Standing/Other Government...... -0.11 0.07
Facility-Based Vol/NP............... -0.16 0.01
Facility-Based Proprietary.......... -0.01 0.14
Facility-Based Government........... 0.10 0.25
Subtotal: Freestanding.......... -0.12 0.17
Subtotal: Facility-based........ -0.12 0.05
Subtotal: Vol/PNP............... -0.19 0.00
Subtotal: Proprietary........... -0.09 0.24
Subtotal: Government............ -0.01 0.16
-----------------------------------
Total....................... -0.12 0.15
------------------------------------------------------------------------
Type of Facility (Rural * Only)
------------------------------------------------------------------------
Free-Standing/Other Vol/NP.......... -0.22 -0.07
Free-Standing/Other Proprietary..... 0.07 0.23
Free-Standing/Other Government...... -0.16 0.01
Facility-Based Vol/NP............... 0.06 0.21
Facility-Based Proprietary.......... 0.20 0.33
Facility-Based Government........... 0.09 0.23
------------------------------------------------------------------------
Type of Facility (Urban * Only)
------------------------------------------------------------------------
Free-Standing/Other Vol/NP.......... -0.22 0.00
Free-Standing/Other Proprietary..... -0.12 0.25
Free-Standing/Other Government...... -0.06 0.16
Facility-Based Vol/NP............... -0.22 0.05
Facility-Based Proprietary.......... -0.16 0.01
Facility-Based Government........... 0.11 0.28
------------------------------------------------------------------------
Type of Facility (Urban * or Rural *)
------------------------------------------------------------------------
Rural*.............................. 0.01 0.17
Urban*.............................. -0.15 0.15
-----------------------------------
Total........................... -0.12 0.15
------------------------------------------------------------------------
Facility Location: Region *
------------------------------------------------------------------------
North............................... -0.30 -0.08
South............................... -0.25 0.08
Midwest............................. -0.58 -0.44
West................................ 1.20 1.56
Other............................... -0.09 0.07
-----------------------------------
Total........................... -0.12 0.15
------------------------------------------------------------------------
Facility Location: Area of the Country
------------------------------------------------------------------------
New England......................... 0.15 0.36
Mid Atlantic........................ -0.55 -0.32
South Atlantic...................... -0.65 -0.18
East South Central.................. -0.11 0.02
West South Central.................. 0.06 0.34
East North Central.................. -0.84 -0.70
West North Central.................. 0.45 0.61
Mountain............................ -0.31 -0.09
Pacific............................. 1.80 2.21
Other............................... -0.09 0.07
-----------------------------------
Total........................... -0.12 0.15

[[Page 65362]]

Facility Size (Number of First Episodes)
------------------------------------------------------------------------
1 to 5.............................. -0.29 0.34
6 to 9.............................. -0.41 0.17
10 to 14............................ -0.38 0.17
15 to 19............................ -0.39 0.19
20 to 29............................ -0.25 0.28
30 to 49............................ -0.10 0.37
50 to 99............................ 0.06 0.50
100 to 199.......................... 0.07 0.36
200 or More......................... -0.17 0.04
-----------------------------------
Total........................... -0.12 0.15
------------------------------------------------------------------------
Note: Based on a 20 percent sample of CY 2006 claims linked to OASIS
assessments.
* Urban/rural status, for the purposes of these simulations, is based on
the wage index on which episode payment is based. The wage index is
based on the site of service of the beneficiary.

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

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

Dated: October 9, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.

Approved: October 24, 2008.
Michael O. Leavitt,
Secretary.

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

Addendum A--CY 2009 Wage Index for Rural Areas by CBSA; Applicable Pre-
floor and Pre-Reclassified Hospital Wage Index

------------------------------------------------------------------------
Wage
CBSA code Nonurban area index
------------------------------------------------------------------------
01........................ Alabama.......................... 0.7587
02........................ Alaska........................... 1.1898
03........................ Arizona.......................... 0.8453
04........................ Arkansas......................... 0.7473
05........................ California....................... 1.2275
06........................ Colorado......................... 0.9570
07........................ Connecticut...................... 1.1016
08........................ Delaware......................... 0.9962
10........................ Florida.......................... 0.8504
11........................ Georgia.......................... 0.7612
12........................ Hawaii........................... 1.0999
13........................ Idaho............................ 0.7651
14........................ Illinois......................... 0.8386
15........................ Indiana.......................... 0.8473
16........................ Iowa............................. 0.8804
17........................ Kansas........................... 0.8052
18........................ Kentucky......................... 0.7803
19........................ Louisiana........................ 0.7447
20........................ Maine............................ 0.8644
21........................ Maryland......................... 0.8883
22........................ Massachusetts\1\................. 1.1670
23........................ Michigan......................... 0.8887
24........................ Minnesota........................ 0.9059
25........................ Mississippi...................... 0.7584
26........................ Missouri......................... 0.7982
27........................ Montana.......................... 0.8658
28........................ Nebraska......................... 0.8730
29........................ Nevada........................... 0.9382
30........................ New Hampshire.................... 1.0219
31........................ New Jersey \1\................... .........
32........................ New Mexico....................... 0.8812
33........................ New York......................... 0.8145
34........................ North Carolina................... 0.8576
35........................ North Dakota..................... 0.7205
36........................ Ohio............................. 0.8588
37........................ Oklahoma......................... 0.7732
38........................ Oregon........................... 1.0218
39........................ Pennsylvania..................... 0.8365
40........................ Puerto Rico \1\.................. 0.4047
41........................ Rhode Island \1\................. .........
42........................ South Carolina................... 0.8538
43........................ South Dakota..................... 0.8603
44........................ Tennessee........................ 0.7789
45........................ Texas............................ 0.7894
46........................ Utah............................. 0.8267
47........................ Vermont.......................... 1.0079
48........................ Virgin Islands................... 0.6971
49........................ Virginia......................... 0.7861
50........................ Washington....................... 1.0181
51........................ West Virginia.................... 0.7503
52........................ Wisconsin........................ 0.9373
53........................ Wyoming.......................... 0.9315
65........................ Guam............................. 0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
exception of Massachusetts and Puerto Rico. Massachusetts and Puerto
Rico have areas designated as rural, however, no short-term, acute
care hospitals are located in the area(s) for CY 2009.

Addendum B--CY 2009 Wage Index for Urban Areas by CBSA; Applicable Pre-
Floor and Pre-Reclassified Hospital Wage Index

------------------------------------------------------------------------
Wage
CBSA code Urban area (constituent counties) index
------------------------------------------------------------------------
10180............ Abilene, TX................................. 0.8097
Callahan County, TX........................
Jones County, TX...........................
Taylor County, TX..........................
10380............ Aguadilla-Isabela-San Sebasti[aacute]n, PR.. 0.3399
Aguada Municipio, PR.......................
Aguadilla Municipio, PR....................

[[Page 65363]]

A[ntilde]asco Municipio, PR................
Isabela Municipio, PR......................
Lares Municipio, PR........................
Moca Municipio, PR.........................
Rinc[oacute]n Municipio, PR................
San Sebasti[aacute]n Municipio, PR.........
10420............ Akron, OH................................... 0.8917
Portage County, OH.........................
Summit County, OH..........................
10500............ Albany, GA.................................. 0.8703
Baker County, GA...........................
Dougherty County, GA.......................
Lee County, GA.............................
Terrell County, GA.........................
Worth County, GA...........................
10580............ Albany-Schenectady-Troy, NY................. 0.8707
Albany County, NY..........................
Rensselaer County, NY......................
Saratoga County, NY........................
Schenectady County, NY.....................
Schoharie County, NY.......................
10740............ Albuquerque, NM............................. 0.9210
Bernalillo County, NM......................
Sandoval County, NM........................
Torrance County, NM........................
Valencia County, NM........................
10780............ Alexandria, LA.............................. 0.8130
Grant Parish, LA...........................
Rapides Parish, LA.........................
10900............ Allentown-Bethlehem-Easton, PA-NJ........... 0.9499
Warren County, NJ..........................
Carbon County, PA..........................
Lehigh County, PA..........................
Northampton County, PA.....................
11020............ Altoona, PA................................. 0.8521
Blair County, PA...........................
11100............ Amarillo, TX................................ 0.8927
Armstrong County, TX.......................
Carson County, TX..........................
Potter County, TX..........................
Randall County, TX.........................
11180............ Ames, IA.................................... 0.9487
Story County, IA...........................
11260............ Anchorage, AK............................... 1.1931
Anchorage Municipality, AK.................
Matanuska-Susitna Borough, AK..............
11300............ Anderson, IN................................ 0.8760
Madison County, IN.........................
11340............ Anderson, SC................................ 0.9570
Anderson County, SC........................
11460............ Ann Arbor, MI............................... 1.0445
Washtenaw County, MI.......................
11500............ Anniston-Oxford, AL......................... 0.7927
Calhoun County, AL.........................
11540............ Appleton, WI................................ 0.9440
Calumet County, WI.........................
Outagamie County, WI.......................
11700............ Asheville, NC............................... 0.9142
Buncombe County, NC........................
Haywood County, NC.........................
Henderson County, NC.......................
Madison County, NC.........................
12020............ Athens-Clarke County, GA.................... 0.9591
Clarke County, GA..........................
Madison County, GA.........................
Oconee County, GA..........................
Oglethorpe County, GA......................
12060............ Atlanta-Sandy Springs-Marietta, GA.......... 0.9754
Barrow County, GA..........................
Bartow County, GA..........................
Butts County, GA...........................
Carroll County, GA.........................
Cherokee County, GA........................

[[Page 65364]]

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........................... 1.1973
Atlantic County, NJ........................
12220............ Auburn-Opelika, AL.......................... 0.7544
Lee County, AL.............................
12260............ Augusta-Richmond County, GA-SC.............. 0.9615
Burke County, GA...........................
Columbia County, GA........................
McDuffie County, GA........................
Richmond County, GA........................
Aiken County, SC...........................
Edgefield County, SC.......................
12420............ Austin-Round Rock, TX....................... 0.9536
Bastrop County, TX.........................
Caldwell County, TX........................
Hays County, TX............................
Travis County, TX..........................
Williamson County, TX......................
12540............ Bakersfield, CA............................. 1.1189
Kern County, CA............................
12580............ Baltimore-Towson, MD........................ 1.0055
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.................................. 1.0174
Penobscot County, ME.......................
12700............ Barnstable Town, MA......................... 1.2643
Barnstable County, MA......................
12940............ Baton Rouge, LA............................. 0.8163
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............................ 1.0120
Calhoun County, MI.........................
13020............ Bay City, MI................................ 0.9248
Bay County, MI.............................
13140............ Beaumont-Port Arthur, TX.................... 0.8479
Hardin County, TX..........................
Jefferson County, TX.......................
Orange County, TX..........................
13380............ Bellingham, WA.............................. 1.1640

[[Page 65365]]

Whatcom County, WA.........................
13460............ Bend, OR.................................... 1.1375
Deschutes County, OR.......................
13644............ Bethesda-Frederick-Gaithersburg, MD......... 1.0548
Frederick County, MD.......................
Montgomery County, MD......................
13740............ Billings, MT................................ 0.8805
Carbon County, MT..........................
Yellowstone County, MT.....................
13780............ Binghamton, NY.............................. 0.8574
Broome County, NY..........................
Tioga County, NY...........................
13820............ Birmingham-Hoover, AL....................... 0.8792
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................................ 0.7148
Burleigh County, ND........................
Morton County, ND..........................
13980............ Blacksburg-Christiansburg-Radford, VA....... 0.8155
Giles County, VA...........................
Montgomery County, VA......................
Pulaski County, VA.........................
Radford City, VA...........................
14020............ Bloomington, IN............................. 0.8979
Greene County, IN..........................
Monroe County, IN..........................
Owen County, IN............................
14060............ Bloomington-Normal, IL...................... 0.9323
McLean County, IL..........................
14260............ Boise City-Nampa, ID........................ 0.9268
Ada County, ID.............................
Boise County, ID...........................
Canyon County, ID..........................
Gem County, ID.............................
Owyhee County, ID..........................
14484............ Boston-Quincy, MA........................... 1.1897
Norfolk County, MA.........................
Plymouth County, MA........................
Suffolk County, MA.........................
14500............ Boulder, CO................................. 1.0302
Boulder County, CO.........................
14540............ Bowling Green, KY........................... 0.8388
Edmonson County, KY........................
Warren County, KY..........................
14600............ Bradenton-Sarasota-Venice, FL............... 0.9900
14740............ Bremerton-Silverdale, WA.................... 1.0770
Kitsap County, WA..........................
14860............ Bridgeport-Stamford-Norwalk, CT............. 1.2868
Fairfield County, CT.......................
15180............ Brownsville-Harlingen, TX................... 0.8916
Cameron County, TX.........................
15260............ Brunswick, GA............................... 0.9567
Brantley County, GA........................
Glynn County, GA...........................
McIntosh County, GA........................
15380............ Buffalo-Niagara Falls, NY................... 0.9537
Erie County, NY............................
Niagara County, NY.........................
15500............ Burlington, NC.............................. 0.8736
Alamance County, NC........................
15540............ Burlington-South Burlington, VT............. 0.9254
Chittenden County, VT......................
Franklin County, VT........................
Grand Isle County, VT......................
15764............ Cambridge-Newton-Framingham, MA............. 1.1086
Middlesex County, MA.......................
15804............ Camden, NJ.................................. 1.0346
Burlington County, NJ......................

[[Page 65366]]

Camden County, NJ..........................
Gloucester County, NJ......................
15940............ Canton-Massillon, OH........................ 0.8841
Carroll County, OH.........................
Stark County, OH...........................
15980............ Cape Coral-Fort Myers, FL................... 0.9396
Lee County, FL.............................
16180............ Carson City, NV............................. 1.0128
Carson City, NV............................
16220............ Casper, WY.................................. 0.9579
Natrona County, WY.........................
16300............ Cedar Rapids, IA............................ 0.8919
Benton County, IA..........................
Jones County, IA...........................
Linn County, IA............................
16580............ Champaign-Urbana, IL........................ 0.9461
Champaign County, IL.......................
Ford County, IL............................
Piatt County, IL...........................
16620............ Charleston, WV.............................. 0.8275
Boone County, WV...........................
Clay County, WV............................
Kanawha County, WV.........................
Lincoln County, WV.........................
Putnam County, WV..........................
16700............ Charleston-North Charleston, SC............. 0.9209
Berkeley County, SC........................
Charleston County, SC......................
Dorchester County, SC......................
16740............ Charlotte-Gastonia-Concord, NC-SC........... 0.9595
Anson County, NC...........................
Cabarrus County, NC........................
Gaston County, NC..........................
Mecklenburg County, NC.....................
Union County, NC...........................
York County, SC............................
16820............ Charlottesville, VA......................... 0.9816
Albemarle County, VA.......................
Fluvanna County, VA........................
Greene County, VA..........................
Nelson County, VA..........................
Charlottesville City, VA...................
16860............ Chattanooga, TN-GA.......................... 0.8878
Catoosa County, GA.........................
Dade County, GA............................
Walker County, GA..........................
Hamilton County, TN........................
Marion County, TN..........................
Sequatchie County, TN......................
16940............ Cheyenne, WY................................ 0.9276
Laramie County, WY.........................
16974............ Chicago-Naperville-Joliet, IL............... 1.0399
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................................... 1.0897
Butte County, CA...........................
17140............ Cincinnati-Middletown, OH-KY-IN............. 0.9687
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.......................

[[Page 65367]]

Brown County, OH...........................
Butler County, OH..........................
Clermont County, OH........................
Hamilton County, OH........................
Warren County, OH..........................
17300............ Clarksville, TN-KY.......................... 0.8298
Christian County, KY.......................
Trigg County, KY...........................
Montgomery County, TN......................
Stewart County, TN.........................
17420............ Cleveland, TN............................... 0.8010
Bradley County, TN.........................
Polk County, TN............................
17460............ Cleveland-Elyria-Mentor, OH................. 0.9241
Cuyahoga County, OH........................
Geauga County, OH..........................
Lake County, OH............................
Lorain County, OH..........................
Medina County, OH..........................
17660............ Coeur d'Alene, ID........................... 0.9322
Kootenai County, ID........................
17780............ College Station-Bryan, TX................... 0.9346
Brazos County, TX..........................
Burleson County, TX........................
Robertson County, TX.......................
17820............ Colorado Springs, CO........................ 0.9977
El Paso County, CO.........................
Teller County, CO..........................
17860............ Columbia, MO................................ 0.8540
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............................. 0.8739
Russell County, AL.........................
Chattahoochee County, GA...................
Harris County, GA..........................
Marion County, GA..........................
Muscogee County, GA........................
18020............ Columbus, IN................................ 0.9739
Bartholomew County, IN.....................
18140............ Columbus, OH................................ 0.9943
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.......................... 0.8598
Aransas County, TX.........................
Nueces County, TX..........................
San Patricio County, TX....................
18700............ Corvallis, OR............................... 1.1304
Benton County, OR..........................
19060............ Cumberland, MD-WV........................... 0.7816
Allegany County, MD........................
Mineral County, WV.........................
19124............ Dallas-Plano-Irving, TX..................... 0.9945
Collin County, TX..........................
Dallas County, TX..........................
Delta County, TX...........................
Denton County, TX..........................
Ellis County, TX...........................
Hunt County, TX............................
Kaufman County, TX.........................
Rockwall County, TX........................

[[Page 65368]]

19140............ Dalton, GA.................................. 0.8705
Murray County, GA..........................
Whitfield County, GA.......................
19180............ Danville, IL................................ 0.9374
Vermilion County, IL.......................
19260............ Danville, VA................................ 0.8395
Pittsylvania County, VA....................
Danville City, VA..........................
19340............ Davenport-Moline-Rock Island, IA-IL......... 0.8435
Henry County, IL...........................
Mercer County, IL..........................
Rock Island County, IL.....................
Scott County, IA...........................
19380............ Dayton, OH.................................. 0.9203
Greene County, OH..........................
Miami County, OH...........................
Montgomery County, OH......................
Preble County, OH..........................
19460............ Decatur, AL................................. 0.7803
Lawrence County, AL........................
Morgan County, AL..........................
19500............ Decatur, IL................................. 0.8145
Macon County, IL...........................
19660............ Deltona-Daytona Beach-Ormond Beach, FL...... 0.8890
Volusia County, FL.........................
19740............ Denver-Aurora, CO........................... 1.0818
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.............................. 0.9535
Dallas County, IA..........................
Guthrie County, IA.........................
Madison County, IA.........................
Polk County, IA............................
Warren County, IA..........................
19804............ Detroit-Livonia-Dearborn, MI................ 0.9958
Wayne County, MI...........................
20020............ Dothan, AL.................................. 0.7613
Geneva County, AL..........................
Henry County, AL...........................
Houston County, AL.........................
20100............ Dover, DE................................... 1.0325
Kent County, DE............................
20220............ Dubuque, IA................................. 0.8380
Dubuque County, IA.........................
20260............ Duluth, MN-WI............................... 1.0363
Carlton County, MN.........................
St. Louis County, MN.......................
Douglas County, WI.........................
20500............ Durham, NC.................................. 0.9732
Chatham County, NC.........................
Durham County, NC..........................
Orange County, NC..........................
Person County, NC..........................
20740............ Eau Claire, WI.............................. 0.9668
Chippewa County, WI........................
Eau Claire County, WI......................
20764............ Edison, NJ.................................. 1.1283
Middlesex County, NJ.......................
Monmouth County, NJ........................
Ocean County, NJ...........................
Somerset County, NJ........................
20940............ El Centro, CA............................... 0.8746
Imperial County, CA........................
21060............ Elizabethtown, KY........................... 0.8525
Hardin County, KY..........................

[[Page 65369]]

Larue County, KY...........................
21140............ Elkhart-Goshen, IN.......................... 0.9568
Elkhart County, IN.........................
21300............ Elmira, NY.................................. 0.8247
Chemung County, NY.........................
21340............ El Paso, TX................................. 0.8694
El Paso County, TX.........................
21500............ Erie, PA.................................... 0.8713
Erie County, PA............................
21660............ Eugene-Springfield, OR...................... 1.1061
Lane County, OR............................
21780............ Evansville, IN-KY........................... 0.8690
Gibson County, IN..........................
Posey County, IN...........................
Vanderburgh County, IN.....................
Warrick County, IN.........................
Henderson County, KY.......................
Webster County, KY.........................
21820............ Fairbanks, AK............................... 1.1297
Fairbanks North Star Borough, AK...........
21940............ Fajardo, PR................................. 0.4061
Ceiba Municipio, PR........................
Fajardo Municipio, PR......................
Luquillo Municipio, PR.....................
22020............ Fargo, ND-MN................................ 0.8166
Cass County, ND............................
Clay County, MN............................
22140............ Farmington, NM.............................. 0.8051
San Juan County, NM........................
22180............ Fayetteville, NC............................ 0.9340
Cumberland County, NC......................
Hoke County, NC............................
22220............ Fayetteville-Springdale-Rogers, AR-MO....... 0.8970
Benton County, AR..........................
Madison County, AR.........................
Washington County, AR......................
McDonald County, MO........................
22380............ Flagstaff, AZ............................... 1.1743
Coconino County, AZ........................
22420............ Flint, MI................................... 1.1425
Genesee County, MI.........................
22500............ Florence, SC................................ 0.8130
Darlington County, SC......................
Florence County, SC........................
22520............ Florence-Muscle Shoals, AL.................. 0.7871
Colbert County, AL.........................
Lauderdale County, AL......................
22540............ Fond du Lac, WI............................. 0.9293
Fond du Lac County, WI.....................
22660............ Fort Collins-Loveland, CO................... 0.9867
Larimer County, CO.........................
22744............ Fort Lauderdale-Pompano Beach-Deerfield 0.9946
Beach, FL.
Broward County, FL.........................
22900............ Fort Smith, AR-OK........................... 0.7697
Crawford County, AR........................
Franklin County, AR........................
Sebastian County, AR.......................
Le Flore County, OK........................
Sequoyah County, OK........................
23020............ Fort Walton Beach-Crestview-Destin, FL...... 0.8769
Okaloosa County, FL........................
23060............ Fort Wayne, IN.............................. 0.9176
Allen County, IN...........................
Wells County, IN...........................
Whitley County, IN.........................
23104............ Fort Worth-Arlington, TX.................... 0.9709
Johnson County, TX.........................
Parker County, TX..........................
Tarrant County, TX.........................
Wise County, TX............................
23420............ Fresno, CA.................................. 1.1009
Fresno County, CA..........................
23460............ Gadsden, AL................................. 0.7983

[[Page 65370]]

Etowah County, AL..........................
23540............ Gainesville, FL............................. 0.9312
Alachua County, FL.........................
Gilchrist County, FL.......................
23580............ Gainesville, GA............................. 0.9109
Hall County, GA............................
23844............ Gary, IN.................................... 0.9250
Jasper County, IN..........................
Lake County, IN............................
Newton County, IN..........................
Porter County, IN..........................
24020............ Glens Falls, NY............................. 0.8473
Warren County, NY..........................
Washington County, NY......................
24140............ Goldsboro, NC............................... 0.9143
Wayne County, NC...........................
24220............ Grand Forks, ND-MN.......................... 0.7565
Polk County, MN............................
Grand Forks County, ND.....................
24300............ Grand Junction, CO.......................... 0.9812
Mesa County, CO............................
24340............ Grand Rapids-Wyoming, MI.................... 0.9184
Barry County, MI...........................
Ionia County, MI...........................
Kent County, MI............................
Newaygo County, MI.........................
24500............ Great Falls, MT............................. 0.8784
Cascade County, MT.........................
24540............ Greeley, CO................................. 0.9684
Weld County, CO............................
24580............ Green Bay, WI............................... 0.9709
Brown County, WI...........................
Kewaunee County, WI........................
Oconto County, WI..........................
24660............ Greensboro-High Point, NC................... 0.9011
Guilford County, NC........................
Randolph County, NC........................
Rockingham County, NC......................
24780............ Greenville, NC.............................. 0.9448
Greene County, NC..........................
Pitt County, NC............................
24860............ Greenville, SC.............................. 0.9961
Greenville County, SC......................
Laurens County, SC.........................
Pickens County, SC.........................
25020............ Guayama, PR................................. 0.3249
Arroyo Municipio, PR.......................
Guayama Municipio, PR......................
Patillas Municipio, PR.....................
25060............ Gulfport-Biloxi, MS......................... 0.9029
Hancock County, MS.........................
Harrison County, MS........................
Stone County, MS...........................
25180............ Hagerstown-Martinsburg, MD-WV............... 0.8997
Washington County, MD......................
Berkeley County, WV........................
Morgan County, WV..........................
25260............ Hanford-Corcoran, CA........................ 1.0870
Kings County, CA...........................
25420............ Harrisburg-Carlisle, PA..................... 0.9153
Cumberland County, PA......................
Dauphin County, PA.........................
Perry County, PA...........................
25500............ Harrisonburg, VA............................ 0.8894
Rockingham County, VA......................
Harrisonburg City, VA......................
25540............ Hartford-West Hartford-East Hartford, CT.... 1.1069
Hartford County, CT........................
Litchfield County, CT......................
Middlesex County, CT.......................
Tolland County, CT.........................
25620............ Hattiesburg, MS............................. 0.7337
Forrest County, MS.........................

[[Page 65371]]

Lamar County, MS...........................
Perry County, MS...........................
25860............ Hickory-Lenoir-Morganton, NC................ 0.8976
Alexander County, NC.......................
Burke County, NC...........................
Caldwell County, NC........................
Catawba County, NC.........................
25980 \1\........ Hinesville-Fort Stewart, GA................. 0.9110
Liberty County, GA.........................
Long County, GA............................
26100............ Holland-Grand Haven, MI..................... 0.9008
Ottawa County, MI..........................
26180............ Honolulu, HI................................ 1.1811
Honolulu County, HI........................
26300............ Hot Springs, AR............................. 0.9113
Garland County, AR.........................
26380............ Houma-Bayou Cane-Thibodaux, LA.............. 0.7758
Lafourche Parish, LA.......................
Terrebonne Parish, LA......................
26420............ Houston-Baytown-Sugar Land, TX.............. 0.9838
Austin County, TX..........................
Brazoria County, TX........................
Chambers County, TX........................
Fort Bend County, TX.......................
Galveston County, TX.......................
Harris County, TX..........................
Liberty County, TX.........................
Montgomery County, TX......................
San Jacinto County, TX.....................
Waller County, TX..........................
26580............ Huntington-Ashland, WV-KY-OH................ 0.9254
Boyd County, KY............................
Greenup County, KY.........................
Lawrence County, OH........................
Cabell County, WV..........................
Wayne County, WV...........................
26620............ Huntsville, AL.............................. 0.9082
Limestone County, AL.......................
Madison County, AL.........................
26820............ Idaho Falls, ID............................. 0.9080
Bonneville County, ID......................
Jefferson County, ID.......................
26900............ Indianapolis, IN............................ 0.9908
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............................... 0.9483
Johnson County, IA.........................
Washington County, IA......................
27060............ Ithaca, NY.................................. 0.9614
Tompkins County, NY........................
27100............ Jackson, MI................................. 0.9309
Jackson County, MI.........................
27140............ Jackson, MS................................. 0.8067
Copiah County, MS..........................
Hinds County, MS...........................
Madison County, MS.........................
Rankin County, MS..........................
Simpson County, MS.........................
27180............ Jackson, TN................................. 0.8523
Chester County, TN.........................
Madison County, TN.........................
27260............ Jacksonville, FL............................ 0.8999
Baker County, FL...........................
Clay County, FL............................
Duval County, FL...........................

[[Page 65372]]

Nassau County, FL..........................
St. Johns County, FL.......................
27340............ Jacksonville, NC............................ 0.8177
Onslow County, NC..........................
27500............ Janesville, WI.............................. 0.9662
Rock County, WI............................
27620............ Jefferson City, MO.......................... 0.8775
Callaway County, MO........................
Cole County, MO............................
Moniteau County, MO........................
Osage County, MO...........................
27740............ Johnson City, TN............................ 0.7971
Carter County, TN..........................
Unicoi County, TN..........................
Washington County, TN......................
27780............ Johnstown, PA............................... 0.7920
Cambria County, PA.........................
27860............ Jonesboro, AR............................... 0.7916
Craighead County, AR.......................
Poinsett County, AR........................
27900............ Joplin, MO.................................. 0.9406
Jasper County, MO..........................
Newton County, MO..........................
28020............ Kalamazoo-Portage, MI....................... 1.0801
Kalamazoo County, MI.......................
Van Buren County, MI.......................
28100............ Kankakee-Bradley, IL........................ 1.0485
Kankakee County, IL........................
28140............ Kansas City, MO-KS.......................... 0.9610
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................ 0.9911
Benton County, WA..........................
Franklin County, WA........................
28660............ Killeen-Temple-Fort Hood, TX................ 0.8765
Bell County, TX............................
Coryell County, TX.........................
Lampasas County, TX........................
28700............ Kingsport-Bristol-Bristol, TN-VA............ 0.7743
Hawkins County, TN.........................
Sullivan County, TN........................
Bristol City, VA...........................
Scott County, VA...........................
Washington County, VA......................
28740............ Kingston, NY................................ 0.9375
Ulster County, NY..........................
28940............ Knoxville, TN............................... 0.7881
Anderson County, TN........................
Blount County, TN..........................
Knox County, TN............................
Loudon County, TN..........................
Union County, TN...........................
29020............ Kokomo, IN.................................. 0.9349
Howard County, IN..........................
Tipton County, IN..........................
29100............ La Crosse, WI-MN............................ 0.9758
Houston County, MN.........................
La Crosse County, WI.......................
29140............ Lafayette, IN............................... 0.9221
Benton County, IN..........................

[[Page 65373]]

Carroll County, IN.........................
Tippecanoe County, IN......................
29180............ Lafayette, LA............................... 0.8374
Lafayette Parish, LA.......................
St. Martin Parish, LA......................
29340............ Lake Charles, LA............................ 0.7556
Calcasieu Parish, LA.......................
Cameron Parish, LA.........................
29404............ Lake County-Kenosha County, IL-WI........... 1.0389
Lake County, IL............................
Kenosha County, WI.........................
29420............ Lake Havasu City-Kingman, AZ................ 0.9797
29460............ Lakeland, FL................................ 0.8530
Polk County, FL............................
29540............ Lancaster, PA............................... 0.9363
Lancaster County, PA.......................
29620............ Lansing-East Lansing, MI.................... 0.9931
Clinton County, MI.........................
Eaton County, MI...........................
Ingham County, MI..........................
29700............ Laredo, TX.................................. 0.8366
Webb County, TX............................
29740............ Las Cruces, NM.............................. 0.8929
Dona Ana County, NM........................
29820............ Las Vegas-Paradise, NV...................... 1.1971
Clark County, NV...........................
29940............ Lawrence, KS................................ 0.8343
Douglas County, KS.........................
30020............ Lawton, OK.................................. 0.8211
Comanche County, OK........................
30140............ Lebanon, PA................................. 0.8954
Lebanon County, PA.........................
30300............ Lewiston, ID-WA............................. 0.9465
Nez Perce County, ID.......................
Asotin County, WA..........................
30340............ Lewiston-Auburn, ME......................... 0.9200
Androscoggin County, ME....................
30460............ Lexington-Fayette, KY....................... 0.9110
Bourbon County, KY.........................
Clark County, KY...........................
Fayette County, KY.........................
Jessamine County, KY.......................
Scott County, KY...........................
Woodford County, KY........................
30620............ Lima, OH.................................... 0.9427
Allen County, OH...........................
30700............ Lincoln, NE................................. 0.9759
Lancaster County, NE.......................
Seward County, NE..........................
30780............ Little Rock-North Little Rock, AR........... 0.8672
Faulkner County, AR........................
Grant County, AR...........................
Lonoke County, AR..........................
Perry County, AR...........................
Pulaski County, AR.........................
Saline County, AR..........................
30860............ Logan, UT-ID................................ 0.8765
Franklin County, ID........................
Cache County, UT...........................
30980............ Longview, TX................................ 0.8370
Gregg County, TX...........................
Rusk County, TX............................
Upshur County, TX..........................
31020............ Longview, WA................................ 1.1207
Cowlitz County, WA.........................
31084............ Los Angeles-Long Beach-Glendale, CA......... 1.2208
Los Angeles County, CA.....................
31140............ Louisville, KY-IN........................... 0.9249
Clark County, IN...........................
Floyd County, IN...........................
Harrison County, IN........................
Washington County, IN......................
Bullitt County, KY.........................

[[Page 65374]]

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................................. 0.8731
Crosby County, TX..........................
Lubbock County, TX.........................
31340............ Lynchburg, VA............................... 0.8774
Amherst County, VA.........................
Appomattox County, VA......................
Bedford County, VA.........................
Campbell County, VA........................
Bedford City, VA...........................
Lynchburg City, VA.........................
31420............ Macon, GA................................... 0.9570
Bibb County, GA............................
Crawford County, GA........................
Jones County, GA...........................
Monroe County, GA..........................
Twiggs County, GA..........................
31460............ Madera, CA.................................. 0.7939
Madera County, CA..........................
31540............ Madison, WI................................. 1.0967
Columbia County, WI........................
Dane County, WI............................
Iowa County, WI............................
31700............ Manchester-Nashua, NH....................... 1.0359
Hillsborough County, NH....................
Merrimack County, NH.......................
31900............ Mansfield, OH............................... 0.9330
Richland County, OH........................
32420............ Mayag[uuml]ez, PR........................... 0.3940
Hormigueros Municipio, PR..................
Mayag[uuml]ez Municipio, PR................
32580............ McAllen-Edinburg-Pharr, TX.................. 0.9009
Hidalgo County, TX.........................
32780............ Medford, OR................................. 1.0244
Jackson County, OR.........................
32820............ Memphis, TN-MS-AR........................... 0.9232
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.................................. 1.2243
Merced County, CA..........................
33124............ Miami-Miami Beach-Kendall, FL............... 0.9830
Miami-Dade County, FL......................
33140............ Michigan City-La Porte, IN.................. 0.9159
LaPorte County, IN.........................
33260............ Midland, TX................................. 0.9827
Midland County, TX.........................
33340............ Milwaukee-Waukesha-West Allis, WI........... 1.0080
Milwaukee County, WI.......................
Ozaukee County, WI.........................
Washington County, WI......................
Waukesha County, WI........................
33460............ Minneapolis-St. Paul-Bloomington, MN-WI..... 1.1150
Anoka County, MN...........................
Carver County, MN..........................
Chisago County, MN.........................
Dakota County, MN..........................
Hennepin County, MN........................
Isanti County, MN..........................
Ramsey County, MN..........................
Scott County, MN...........................

[[Page 65375]]

Sherburne County, MN.......................
Washington County, MN......................
Wright County, MN..........................
Pierce County, WI..........................
St. Croix County, WI.......................
33540............ Missoula, MT................................ 0.8973
Missoula County, MT........................
33660............ Mobile, AL.................................. 0.7908
Mobile County, AL..........................
33700............ Modesto, CA................................. 1.2194
Stanislaus County, CA......................
33740............ Monroe, LA.................................. 0.7900
Ouachita Parish, LA........................
Union Parish, LA...........................
33780............ Monroe, MI.................................. 0.8941
Monroe County, MI..........................
33860............ Montgomery, AL.............................. 0.8283
Autauga County, AL.........................
Elmore County, AL..........................
Lowndes County, AL.........................
Montgomery County, AL......................
34060............ Morgantown, WV.............................. 0.8528
Monongalia County, WV......................
Preston County, WV.........................
34100............ Morristown, TN.............................. 0.7254
Grainger County, TN........................
Hamblen County, TN.........................
Jefferson County, TN.......................
34580............ Mount Vernon-Anacortes, WA.................. 1.0292
Skagit County, WA..........................
34620............ Muncie, IN.................................. 0.8489
Delaware County, IN........................
34740............ Muskegon-Norton Shores, MI.................. 1.0055
Muskegon County, MI........................
34820............ Myrtle Beach-Conway-North Myrtle Beach, SC.. 0.8652
Horry County, SC...........................
34900............ Napa, CA.................................... 1.4520
Napa County, CA............................
34940............ Naples-Marco Island, FL..................... 0.9672
Collier County, FL.........................
34980............ Nashville-Davidson-Murfreesboro, TN......... 0.9504
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.......................... 1.2453
Nassau County, NY..........................
Suffolk County, NY.........................
35084............ Newark-Union, NJ-PA......................... 1.1731
Essex County, NJ...........................
Hunterdon County, NJ.......................
Morris County, NJ..........................
Sussex County, NJ..........................
Union County, NJ...........................
Pike County, PA............................
35300............ New Haven-Milford, CT....................... 1.1742
New Haven County, CT.......................
35380............ New Orleans-Metairie-Kenner, LA............. 0.9103
Jefferson Parish, LA.......................
Orleans Parish, LA.........................
Plaquemines Parish, LA.....................
St. Bernard Parish, LA.....................
St. Charles Parish, LA.....................
St. John the Baptist Parish, LA............

[[Page 65376]]

St. Tammany Parish, LA.....................
35644............ New York-Wayne-White Plains, NY-NJ.......... 1.2885
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..................... 0.9066
Berrien County, MI.........................
35980............ Norwich-New London, CT...................... 1.1398
New London County, CT......................
36084............ Oakland-Fremont-Hayward, CA................. 1.6092
Alameda County, CA.........................
Contra Costa County, CA....................
36100............ Ocala, FL................................... 0.8512
Marion County, FL..........................
36140............ Ocean City, NJ.............................. 1.1496
Cape May County, NJ........................
36220............ Odessa, TX.................................. 0.9475
Ector County, TX...........................
36260............ Ogden-Clearfield, UT........................ 0.9153
Davis County, UT...........................
Morgan County, UT..........................
Weber County, UT...........................
36420............ Oklahoma City, OK........................... 0.8724
Canadian County, OK........................
Cleveland County, OK.......................
Grady County, OK...........................
Lincoln County, OK.........................
Logan County, OK...........................
McClain County, OK.........................
Oklahoma County, OK........................
36500............ Olympia, WA................................. 1.1537
Thurston County, WA........................
36540............ Omaha-Council Bluffs, NE-IA................. 0.9441
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................................. 0.9111
Lake County, FL............................
Orange County, FL..........................
Osceola County, FL.........................
Seminole County, FL........................
36780............ Oshkosh-Neenah, WI.......................... 0.9474
Winnebago County, WI.......................
36980............ Owensboro, KY............................... 0.8685
Daviess County, KY.........................
Hancock County, KY.........................
McLean County, KY..........................
37100............ Oxnard-Thousand Oaks-Ventura, CA............ 1.1951
Ventura County, CA.........................
37340............ Palm Bay-Melbourne-Titusville, FL........... 0.9332
Brevard County, FL.........................
37380............ Palm Coast, FL.............................. 0.8963
Flagler County, FL.........................
37460............ Panama City-Lynn Haven, FL.................. 0.8360
Bay County, FL.............................
37620............ Parkersburg-Marietta, WV-OH................. 0.7867
Washington County, OH......................
Pleasants County, WV.......................
Wirt County, WV............................
Wood County, WV............................

[[Page 65377]]

37700............ Pascagoula, MS.............................. 0.8102
George County, MS..........................
Jackson County, MS.........................
37764............ Peabody, MA................................. 1.0747
Essex County, MA...........................
37860............ Pensacola-Ferry Pass-Brent, FL.............. 0.8242
Escambia County, FL........................
Santa Rosa County, FL......................
37900............ Peoria, IL.................................. 0.9038
Marshall County, IL........................
Peoria County, IL..........................
Stark County, IL...........................
Tazewell County, IL........................
Woodford County, IL........................
37964............ Philadelphia, PA............................ 1.0979
Bucks County, PA...........................
Chester County, PA.........................
Delaware County, PA........................
Montgomery County, PA......................
Philadelphia County, PA....................
38060............ Phoenix-Mesa-Scottsdale, AZ................. 1.0379
Maricopa County, AZ........................
Pinal County, AZ...........................
38220............ Pine Bluff, AR.............................. 0.7926
Cleveland County, AR.......................
Jefferson County, AR.......................
Lincoln County, AR.........................
38300............ Pittsburgh, PA.............................. 0.8678
Allegheny County, PA.......................
Armstrong County, PA.......................
Beaver County, PA..........................
Butler County, PA..........................
Fayette County, PA.........................
Washington County, PA......................
Westmoreland County, PA....................
38340............ Pittsfield, MA.............................. 1.0445
Berkshire County, MA.......................
38540............ Pocatello, ID............................... 0.9343
Bannock County, ID.........................
Power County, ID...........................
38660............ Ponce, PR................................... 0.4289
Juana D[iacute]az Municipio, PR............
Ponce Municipio, PR........................
Villalba Municipio, PR.....................
38860............ Portland-South Portland-Biddeford, ME....... 0.9942
Cumberland County, ME......................
Sagadahoc County, ME.......................
York County, ME............................
38900............ Portland-Vancouver-Beaverton, OR-WA......... 1.1456
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.............. 0.9870
Martin County, FL..........................
St. Lucie County, FL.......................
39100............ Poughkeepsie-Newburgh-Middletown, NY........ 1.0920
Dutchess County, NY........................
Orange County, NY..........................
39140............ Prescott, AZ................................ 1.0221
Yavapai County, AZ.........................
39300............ Providence-New Bedford-Fall River, RI-MA.... 1.0696
Bristol County, MA.........................
Bristol County, RI.........................
Kent County, RI............................
Newport County, RI.........................
Providence County, RI......................
Washington County, RI......................
39340............ Provo-Orem, UT.............................. 0.9381
Juab County, UT............................

[[Page 65378]]

Utah County, UT............................
39380............ Pueblo, CO.................................. 0.8713
Pueblo County, CO..........................
39460............ Punta Gorda, FL............................. 0.8976
Charlotte County, FL.......................
39540............ Racine, WI.................................. 0.9054
Racine County, WI..........................
39580............ Raleigh-Cary, NC............................ 0.9817
Franklin County, NC........................
Johnston County, NC........................
Wake County, NC............................
39660............ Rapid City, SD.............................. 0.9598
Meade County, SD...........................
Pennington County, SD......................
39740............ Reading, PA................................. 0.9242
Berks County, PA...........................
39820............ Redding, CA................................. 1.3731
Shasta County, CA..........................
39900............ Reno-Sparks, NV............................. 1.0317
Storey County, NV..........................
Washoe County, NV..........................
40060............ Richmond, VA................................ 0.9363
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-Ontario, CA........ 1.1468
Riverside County, CA.......................
San Bernardino County, CA..................
40220............ Roanoke, VA................................. 0.8660
Botetourt County, VA.......................
Craig County, VA...........................
Franklin County, VA........................
Roanoke County, VA.........................
Roanoke City, VA...........................
Salem City, VA.............................
40340............ Rochester, MN............................... 1.1214
Dodge County, MN...........................
Olmsted County, MN.........................
Wabasha County, MN.........................
40380............ Rochester, NY............................... 0.8811
Livingston County, NY......................
Monroe County, NY..........................
Ontario County, NY.........................
Orleans County, NY.........................
Wayne County, NY...........................
40420............ Rockford, IL................................ 0.9835
Boone County, IL...........................
Winnebago County, IL.......................
40484............ Rockingham County-Strafford County, NH...... 0.9926
Rockingham County, NH......................
Strafford County, NH.......................
40580............ Rocky Mount, NC............................. 0.9031
Edgecombe County, NC.......................
Nash County, NC............................
40660............ Rome, GA.................................... 0.9134
Floyd County, GA...........................

[[Page 65379]]

40900............ Sacramento--Arden-Arcade--Roseville, CA..... 1.3572
El Dorado County, CA.......................
Placer County, CA..........................
Sacramento County, CA......................
Yolo County, CA............................
40980............ Saginaw-Saginaw Township North, MI.......... 0.8702
Saginaw County, MI.........................
41060............ St. Cloud, MN............................... 1.0976
Benton County, MN..........................
Stearns County, MN.........................
41100............ St. George, UT.............................. 0.9021
Washington County, UT......................
41140............ St. Joseph, MO-KS........................... 1.0380
Doniphan County, KS........................
Andrew County, MO..........................
Buchanan County, MO........................
DeKalb County, MO..........................
41180............ St. Louis, MO-IL............................ 0.9006
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................................... 1.0884
Marion County, OR..........................
Polk County, OR............................
41500............ Salinas, CA................................. 1.4987
Monterey County, CA........................
41540............ Salisbury, MD............................... 0.9246
Somerset County, MD........................
Wicomico County, MD........................
41620............ Salt Lake City, UT.......................... 0.9158
Salt Lake County, UT.......................
Summit County, UT..........................
Tooele County, UT..........................
41660............ San Angelo, TX.............................. 0.8424
Irion County, TX...........................
Tom Green County, TX.......................
41700............ San Antonio, TX............................. 0.8856
Atascosa County, TX........................
Bandera County, TX.........................
Bexar County, TX...........................
Comal County, TX...........................
Guadalupe County, TX.......................
Kendall County, TX.........................
Medina County, TX..........................
Wilson County, TX..........................
41740............ San Diego-Carlsbad-San Marcos, CA........... 1.1538
San Diego County, CA.......................
41780............ Sandusky, OH................................ 0.8870
Erie County, OH............................
41884............ San Francisco-San Mateo-Redwood City, CA.... 1.5529
Marin County, CA...........................
San Francisco County, CA...................
San Mateo County, CA.......................
41900............ San Germ[aacute]n-Cabo Rojo, PR............. 0.4756
Cabo Rojo Municipio, PR....................
Lajas Municipio, PR........................
Sabana Grande Municipio, PR................
San Germ[aacute]n Municipio, PR............
41940............ San Jose-Sunnyvale-Santa Clara, CA.......... 1.6141

[[Page 65380]]

San Benito County, CA......................
Santa Clara County, CA.....................
41980............ San Juan-Caguas-Guaynabo, PR................ 0.4393
Aguas Buenas Municipio, PR.................
Aibonito Municipio, PR.....................
Arecibo Municipio, PR......................
Barceloneta Municipio, PR..................
Barranquitas Municipio, PR.................
Bayam[oacute]n Municipio, PR...............
Caguas Municipio, PR.......................
Camuy Municipio, PR........................
Can[oacute]vanas Municipio, PR.............
Carolina Municipio, PR.....................
Cata[ntilde]o Municipio, PR................
Cayey Municipio, PR........................
Ciales Municipio, PR.......................
Cidra Municipio, PR........................
Comer[iacute]o 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..................
Lo[iacute]za Municipio, PR.................
Manat[iacute] Municipio, PR................
Maunabo Municipio, PR......................
Morovis Municipio, PR......................
Naguabo Municipio, PR......................
Naranjito Municipio, PR....................
Orocovis Municipio, PR.....................
Quebradillas Municipio, PR.................
R[iacute]o Grande Municipio, PR............
San Juan Municipio, PR.....................
San Lorenzo Municipio, PR..................
Toa Alta Municipio, PR.....................
Toa Baja Municipio, PR.....................
Trujillo Alto Municipio, PR................
Vega Alta Municipio, PR....................
Vega Baja Municipio, PR....................
Yabucoa Municipio, PR......................
42020............ San Luis Obispo-Paso Robles, CA............. 1.2441
San Luis Obispo County, CA.................
42044............ Santa Ana-Anaheim-Irvine, CA................ 1.1993
Orange County, CA..........................
42060............ Santa Barbara-Santa Maria-Goleta, CA........ 1.1909
Santa Barbara County, CA...................
42100............ Santa Cruz-Watsonville, CA.................. 1.6429
Santa Cruz County, CA......................
42140............ Santa Fe, NM................................ 1.0610
Santa Fe County, NM........................
42220............ Santa Rosa-Petaluma, CA..................... 1.5528
Sonoma County, CA..........................
42340............ Savannah, GA................................ 0.9152
Bryan County, GA...........................
Chatham County, GA.........................
Effingham County, GA.......................
42540............ Scranton--Wilkes-Barre, PA.................. 0.8333
Lackawanna County, PA......................
Luzerne County, PA.........................
Wyoming County, PA.........................
42644............ Seattle-Bellevue-Everett, WA................ 1.1755
King County, WA............................
Snohomish County, WA.......................
42680............ Sebastian-Vero Beach, FL.................... 0.9217
43100............ Sheboygan, WI............................... 0.8920
Sheboygan County, WI.......................
43300............ Sherman-Denison, TX......................... 0.9024
Grayson County, TX.........................
43340............ Shreveport-Bossier City, LA................. 0.8442

[[Page 65381]]

Bossier Parish, LA.........................
Caddo Parish, LA...........................
De Soto Parish, LA.........................
43580............ Sioux City, IA-NE-SD........................ 0.8915
Woodbury County, IA........................
Dakota County, NE..........................
Dixon County, NE...........................
Union County, SD...........................
43620............ Sioux Falls, SD............................. 0.9354
Lincoln County, SD.........................
McCook County, SD..........................
Minnehaha County, SD.......................
Turner County, SD..........................
43780............ South Bend-Mishawaka, IN-MI................. 0.9761
St. Joseph County, IN......................
Cass County, MI............................
43900............ Spartanburg, SC............................. 0.9025
Spartanburg County, SC.....................
44060............ Spokane, WA................................. 1.0559
Spokane County, WA.........................
44100............ Springfield, IL............................. 0.9102
Menard County, IL..........................
Sangamon County, IL........................
44140............ Springfield, MA............................. 1.0405
Franklin County, MA........................
Hampden County, MA.........................
Hampshire County, MA.......................
44180............ Springfield, MO............................. 0.8424
Christian County, MO.......................
Dallas County, MO..........................
Greene County, MO..........................
Polk County, MO............................
Webster County, MO.........................
44220............ Springfield, OH............................. 0.8876
Clark County, OH...........................
44300............ State College, PA........................... 0.8937
Centre County, PA..........................
44700............ Stockton, CA................................ 1.2015
San Joaquin County, CA.....................
44940............ Sumter, SC.................................. 0.8257
Sumter County, SC..........................
45060............ Syracuse, NY................................ 0.9787
Madison County, NY.........................
Onondaga County, NY........................
Oswego County, NY..........................
45104............ Tacoma, WA.................................. 1.1241
Pierce County, WA..........................
45220............ Tallahassee, FL............................. 0.8964
Gadsden County, FL.........................
Jefferson County, FL.......................
Leon County, FL............................
Wakulla County, FL.........................
45300............ Tampa-St. Petersburg-Clearwater, FL......... 0.8852
Hernando County, FL........................
Hillsborough County, FL....................
Pasco County, FL...........................
Pinellas County, FL........................
45460............ Terre Haute, IN............................. 0.9085
Clay County, IN............................
Sullivan County, IN........................
Vermillion County, IN......................
Vigo County, IN............................
45500............ Texarkana, TX-Texarkana, AR................. 0.8144
Miller County, AR..........................
Bowie County, TX...........................
45780............ Toledo, OH.................................. 0.9407
Fulton County, OH..........................
Lucas County, OH...........................
Ottawa County, OH..........................
Wood County, OH............................
45820............ Topeka, KS.................................. 0.8756
Jackson County, KS.........................
Jefferson County, KS.......................

[[Page 65382]]

Osage County, KS...........................
Shawnee County, KS.........................
Wabaunsee County, KS.......................
45940............ Trenton-Ewing, NJ........................... 1.0604
Mercer County, NJ..........................
46060............ Tucson, AZ.................................. 0.9229
Pima County, AZ............................
46140............ Tulsa, OK................................... 0.8445
Creek County, OK...........................
Okmulgee County, OK........................
Osage County, OK...........................
Pawnee County, OK..........................
Rogers County, OK..........................
Tulsa County, OK...........................
Wagoner County, OK.........................
46220............ Tuscaloosa, AL.............................. 0.8496
Greene County, AL..........................
Hale County, AL............................
Tuscaloosa County, AL......................
46340............ Tyler, TX................................... 0.8804
Smith County, TX...........................
46540............ Utica-Rome, NY.............................. 0.8404
Herkimer County, NY........................
Oneida County, NY..........................
46660............ Valdosta, GA................................ 0.8027
Brooks County, GA..........................
Echols County, GA..........................
Lanier County, GA..........................
Lowndes County, GA.........................
46700............ Vallejo-Fairfield, CA....................... 1.4359
Solano County, CA..........................
47020............ Victoria, TX................................ 0.8124
Calhoun County, TX.........................
Goliad County, TX..........................
Victoria County, TX........................
47220............ Vineland-Millville-Bridgeton, NJ............ 1.0366
Cumberland County, NJ......................
47260............ Virginia Beach-Norfolk-Newport News, VA-NC.. 0.8884
Currituck County, NC.......................
Gloucester County, VA......................
Isle of Wight County, VA...................
James City County, VA......................
Mathews County, VA.........................
Surry County, VA...........................
York County, VA............................
Chesapeake City, VA........................
Hampton City, VA...........................
Newport News City, VA......................
Norfolk City, VA...........................
Poquoson City, VA..........................
Portsmouth City, VA........................
Suffolk City, VA...........................
Virginia Beach City, VA....................
Williamsburg City, VA......................
47300............ Visalia-Porterville, CA..................... 1.0144
Tulare County, CA..........................
47380............ Waco, TX.................................... 0.8596
McLennan County, TX........................
47580............ Warner Robins, GA........................... 0.8989
Houston County, GA.........................
47644............ Warren-Farmington Hills-Troy, MI............ 0.9904
Lapeer County, MI..........................
Livingston County, MI......................
Macomb County, MI..........................
Oakland County, MI.........................
St. Clair County, MI.......................
47894............ Washington-Arlington-Alexandria, DC-VA-MD-WV 1.0827
District of Columbia, DC...................
Calvert County, MD.........................
Charles County, MD.........................
Prince George's County, MD.................
Arlington County, VA.......................
Clarke County, VA..........................

[[Page 65383]]

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.................... 0.8490
Black Hawk County, IA......................
Bremer County, IA..........................
Grundy County, IA..........................
48140............ Wausau, WI.................................. 0.9615
Marathon County, WI........................
48260............ Weirton-Steubenville, WV-OH................. 0.8079
Jefferson County, OH.......................
Brooke County, WV..........................
Hancock County, WV.........................
48300............ Wenatchee, WA............................... 0.9544
Chelan County, WA..........................
Douglas County, WA.........................
48424............ West Palm Beach-Boca Raton-Boynton Beach, FL 0.9757
Palm Beach County, FL......................
48540............ Wheeling, WV-OH............................. 0.6955
Belmont County, OH.........................
Marshall County, WV........................
Ohio County, WV............................
48620............ Wichita, KS................................. 0.9069
Butler County, KS..........................
Harvey County, KS..........................
Sedgwick County, KS........................
Sumner County, KS..........................
48660............ Wichita Falls, TX........................... 0.8832
Archer County, TX..........................
Clay County, TX............................
Wichita County, TX.........................
48700............ Williamsport, PA............................ 0.8096
Lycoming County, PA........................
48864............ Wilmington, DE-MD-NJ........................ 1.0696
New Castle County, DE......................
Cecil County, MD...........................
Salem County, NJ...........................
48900............ Wilmington, NC.............................. 0.9089
Brunswick County, NC.......................
New Hanover County, NC.....................
Pender County, NC..........................
49020............ Winchester, VA-WV........................... 0.9801
Frederick County, VA.......................
Winchester City, VA........................
Hampshire County, WV.......................
49180............ Winston-Salem, NC........................... 0.9016
Davie County, NC...........................
Forsyth County, NC.........................
Stokes County, NC..........................
Yadkin County, NC..........................
49340............ Worcester, MA............................... 1.0836
Worcester County, MA.......................
49420............ Yakima, WA.................................. 0.9948
Yakima County, WA..........................
49500............ Yauco, PR................................... 0.3432
Gu[aacute]nica Municipio, PR...............
Guayanilla Municipio, PR...................
Pe[ntilde]uelas Municipio, PR..............
Yauco Municipio, PR........................
49620............ York-Hanover, PA............................ 0.9518
York County, PA............................
49660............ Youngstown-Warren-Boardman, OH-PA........... 0.8915

[[Page 65384]]

Mahoning County, OH........................
Trumbull County, OH........................
Mercer County, PA..........................
49700............ Yuba City, CA............................... 1.1137
Sutter County, CA..........................
Yuba County, CA............................
49740............ Yuma, AZ.................................... 0.9281
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.

[FR Doc. E8-26142 Filed 10-30-08; 4:15 pm]
BILLING CODE 4120-01-P