[Federal Register Volume 77, Number 149 (Thursday, August 2, 2012)]
[Notices]
[Pages 46214-46255]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-18719]



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Vol. 77

Thursday,

No. 149

August 2, 2012

Part IV





Department of Health and Human Services





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Center for Medicare & Medicaid Services





Medicare Program; Prospective Payment System and Consolidated Billing 
for Skilled Nursing Facilities for FY 2013; Notice

  Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / 
Notices  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1432-N]
RIN 0938-AR20


Medicare Program; Prospective Payment System and Consolidated 
Billing for Skilled Nursing Facilities for FY 2013

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

ACTION: Notice.

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SUMMARY: This notice updates the payment rates used under the 
prospective payment system (PPS) for skilled nursing facilities (SNFs), 
for fiscal year (FY) 2013.

DATES: Effective Date: This notice is effective on October 1, 2012.

FOR FURTHER INFORMATION CONTACT: Penny Gershman, (410) 786-6643 (for 
information related to clinical issues).
    John Kane, (410) 786-0557 (for information related to the 
development of the payment rates and case-mix indexes).
    Kia Sidbury, (410) 786-7816 (for information related to the wage 
index).
    Bill Ullman, (410) 786-5667 (for information related to level of 
care determinations, consolidated billing, and general information).

SUPPLEMENTARY INFORMATION: To assist readers in referencing sections 
contained in this document, we are providing the following Table of 
Contents.

Table of Contents

I. Executive Summary
II. Background
    A. Current System for Payment of SNF Services Under Part A of 
the Medicare Program
    B. Requirements of the Balanced Budget Act of 1997 (BBA) for 
Updating the Prospective Payment System for Skilled Nursing 
Facilities
    C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement 
Act of 1999 (BBRA)
    D. The Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000 (BIPA)
    E. The Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA)
    F. The Affordable Care Act
    G. Skilled Nursing Facility Prospective Payment--General 
Overview
    1. Payment Provisions--Federal Rate
    2. FY 2013 Rate Updates Using the Skilled Nursing Facility 
Market Basket Index
III. FY 2013 Annual Update of Payment Rates Under the Prospective 
Payment System for Skilled Nursing Facilities
    A. Federal Prospective Payment System
    1. Costs and Services Covered by the Federal Rates
    2. Methodology Used for the Calculation of the Federal Rates
    B. Case-Mix Adjustments
    C. Wage Index Adjustment to Federal Rates
    D. Updates to Federal Rates
    E. Relationship of Case-Mix Classification System to Existing 
Skilled Nursing Facility Level-of-Care Criteria
    F. Example of Computation of Adjusted PPS Rates and SNF Payment
IV. Monitoring Impact of FY 2012 Policy Changes and Certain SNF 
Practices
    A. RUG Distributions
    B. Group Therapy Allocation
    C. MDS 3.0 Changes
V. The Skilled Nursing Facility Market Basket Index
    A. Use of the Skilled Nursing Facility Market Basket Percentage
    B. Market Basket Forecast Error Adjustment
    C. Multifactor Productivity Adjustment
    D. Federal Rate Update Factor
VI. Consolidated Billing
VII. Application of the SNF PPS to SNF Services Furnished by Swing-
Bed Hospitals
VIII. Collection of Information Requirements
IX. Waiver of Proposed Rulemaking
X. Economic Analyses

Acronyms

    In addition, because of the many terms to which we refer by acronym 
in this notice, we are listing these abbreviations and their 
corresponding terms in alphabetical order below:
AIDS Acquired Immune Deficiency Syndrome
ARD Assessment Reference Date
BBA Balanced Budget Act of 1997, Public Law 105-33
BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 
1999, Public Law 106-113
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000, Public Law 106-554
CAH Critical Access Hospital
CBSA Core-Based Statistical Area
CFR Code of Federal Regulations
CMI Case-Mix Index
CMS Centers for Medicare & Medicaid Services
COT Change of Therapy
EOT End of Therapy
EOT-R End of Therapy--Resumption
FQHC Federally Qualified Health Center
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
HCPCS Healthcare Common Procedure Coding System
HR-III Hybrid Resource Utilization Groups, Version 3
IHS IGI (Information Handling Services) Global Insight, Inc.
MDS Minimum Data Set
MFP Multifactor Productivity
MIPPA Medicare Improvements for Patients and Providers Act of 2008, 
Public Law 110-275
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, Public Law 108-173
MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Public 
Law 110-173
MPAF Medicare PPS Assessment Form
MSA Metropolitan Statistical Area
OCN OMB Control Number
OMB Office of Management and Budget
OMRA Other Medicare-Required Assessment
PPS Prospective Payment System
RAI Resident Assessment Instrument
RAVEN Resident Assessment Validation Entry
RFA Regulatory Flexibility Act, Public Law 96-354
RHC Rural Health Clinic
RIA Regulatory Impact Analysis
RUG-III Resource Utilization Groups, Version 3
RUG-IV Resource Utilization Groups, Version 4
RUG-53 Refined 53-Group RUG-III Case-Mix Classification System
SCHIP State Children's Health Insurance Program
SNF Skilled Nursing Facility
STM Staff Time Measurement
STRIVE Staff Time and Resource Intensity Verification
UMRA Unfunded Mandates Reform Act, Public Law 104-4

I. Executive Summary

A. Purpose

    This notice updates the SNF prospective payment rates for FY 2013 
as required under section 1888(e)(4)(E) of the Act. It also responds to 
section 1888(e)(4)(H) of the Act, which requires the Secretary to 
``provide for publication in the Federal Register'' before the August 1 
that precedes the start of each fiscal year, the unadjusted Federal per 
diem rates, the case-mix classification system, and the factors to be 
applied in making the area wage adjustment used in computing the 
prospective payment rates for that fiscal year.

B. Summary of Major Provisions

    This notice does not contain any proposals for new policies 
applicable to the SNF PPS. In accordance with sections 
1888(e)(4)(E)(ii)(IV) and (e)(5) of the Act, the Federal rates in this 
notice reflect an update to the rates that we published in the final 
rule for FY 2012 (76 FR 48486, August 8, 2011) and the associated 
correction notice (76 FR 59265, September 26, 2011), equal to the full 
change in the SNF market basket index, adjusted by the forecast error 
correction, if applicable, and the Multifactor Productivity adjustment 
for FY 2013.

C. Summary of Cost and Benefits

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------------------------------------------------------------------------
   Provision  description          Total costs         Total benefits
------------------------------------------------------------------------
FY 2013 SNF PPS payment rate  The overall economic  This notice
 update.                       impact of this        accomplishes the
                               notice is an          required update of
                               estimated $670        the SNF PPS payment
                               million in            rates for FY 2013
                               increased payments    in accordance with
                               to SNFs during FY     the formula
                               2013.                 prescribed by law.
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II. Background

    Annual updates to the prospective payment system (PPS) rates for 
skilled nursing facilities (SNFs) are required by section 1888(e) of 
the Social Security Act (the Act), as added by section 4432 of the 
Balanced Budget Act of 1997 (BBA, Pub. L. 105-33, enacted on August 5, 
1997), and amended by subsequent legislation as discussed elsewhere in 
this preamble. Our most recent annual update occurred in a final rule 
(76 FR 48486, August 8, 2011) that set forth updates to the SNF PPS 
payment rates for FY 2012. We subsequently published a correction 
notice (76 FR 59265, September 26, 2011) with respect to those payment 
rate updates.

A. Current System for Payment of Skilled Nursing Facility Services 
Under Part A of the Medicare Program

    Section 4432 of the BBA amended section 1888 of the Act to provide 
for the implementation of a per diem PPS for SNFs, covering all costs 
(routine, ancillary, and capital-related) of covered SNF services 
furnished to beneficiaries under Part A of the Medicare program, 
effective for cost reporting periods beginning on or after July 1, 
1998. In this notice, we update the per diem payment rates for SNFs for 
FY 2013. Major elements of the SNF PPS include:
     Rates. As discussed in section II.G.1. of this notice, we 
established per diem Federal rates for urban and rural areas using 
allowable costs from FY 1995 cost reports. These rates also included a 
``Part B add-on'' (an estimate of the cost of those services that, 
before July 1, 1998, were paid under Part B, but furnished to Medicare 
beneficiaries in a SNF during a Part A covered stay). We adjust the 
rates annually using a SNF market basket index, and we adjust them by 
the hospital inpatient wage index to account for geographic variation 
in wages. We also apply a case-mix adjustment to account for the 
relative resource utilization of different patient types. As further 
discussed in section II.G.1. of this notice, for FY 2013 this 
adjustment will utilize the Resource Utilization Groups, version 4 
(RUG-IV) case-mix classification system, and will use information 
obtained from the required resident assessments using version 3.0 of 
the Minimum Data Set (MDS 3.0). (The Office of Management and Budget 
(OMB) has approved the resident assessment under OMB Control Number 
(OCN) 0938-0739.) Additionally, as noted elsewhere in this preamble, 
the payment rates at various times have also reflected specific 
legislative provisions for certain temporary adjustments.
     Transition. Under sections 1888(e)(1)(A) and (e)(11) of 
the Act, the SNF PPS included an initial, three-phase transition that 
blended a facility-specific rate (reflecting the individual facility's 
historical cost experience) with the Federal case-mix adjusted rate. 
The transition extended through the facility's first three cost 
reporting periods under the PPS, up to and including the one that began 
in FY 2001. Thus, the SNF PPS is no longer operating under the 
transition, as all facilities have been paid at the full Federal rate 
effective with cost reporting periods beginning in FY 2002. As we now 
base payments entirely on the adjusted Federal per diem rates, we no 
longer include adjustment factors related to facility-specific rates 
for the coming FY.
     Coverage. The establishment of the SNF PPS did not change 
Medicare's fundamental requirements for SNF coverage. However, because 
the case-mix classification is based, in part, on the beneficiary's 
need for skilled nursing care and therapy, we have attempted, where 
possible, to coordinate claims review procedures with the existing 
resident assessment process and case-mix classification system. As 
further discussed in section III.E. of this notice, in FY 2013, this 
approach includes an administrative presumption that utilizes a 
beneficiary's initial classification in one of the upper 52 RUGs of the 
66-group RUG-IV case-mix classification system to assist in making 
certain SNF level of care determinations. In the July 30, 1999 final 
rule (64 FR 41670), we indicated that we would announce any changes to 
the guidelines for Medicare level of care determinations related to 
modifications in the case-mix classification structure (see section 
III.E. of this notice for a more detailed discussion of the 
relationship between the case-mix classification system and SNF level 
of care determinations).
     Consolidated Billing. The SNF PPS includes a consolidated 
billing provision that requires a SNF to submit consolidated Medicare 
bills to its fiscal intermediary or Medicare Administrative Contractor 
for almost all of the services that its residents receive during the 
course of a covered Part A stay. In addition, this provision places 
with the SNF the Medicare billing responsibility for physical therapy, 
occupational therapy, and speech-language pathology services that the 
resident receives during a noncovered stay. The statute excludes a 
small list of services from the consolidated billing provision 
(primarily those of physicians and certain other types of 
practitioners), which remain separately billable under Part B when 
furnished to a SNF's Part A resident. A more detailed discussion of 
this provision appears in section VI. of this notice.
     Application of the SNF PPS to SNF services furnished by 
swing-bed hospitals. Section 1883 of the Act permits certain small, 
rural hospitals to enter into a Medicare swing-bed agreement, under 
which the hospital can use its beds to provide either acute or SNF 
care, as needed. For critical access hospitals (CAHs), Part A pays on a 
reasonable cost basis for SNF services furnished under a swing-bed 
agreement. However, in accordance with section 1888(e)(7) of the Act, 
these services furnished by non-CAH rural hospitals are paid under the 
SNF PPS, effective with cost reporting periods beginning on or after 
July 1, 2002. A more detailed discussion of this provision appears in 
section VII. of this notice.

B. Requirements of the Balanced Budget Act of 1997 (BBA) for Updating 
the Prospective Payment System for Skilled Nursing Facilities

    As added by section 4432(a) of the BBA, section 1888(e)(4)(H) of 
the Act requires that we provide for publication annually in the 
Federal Register:
    1. The unadjusted Federal per diem rates to be applied to days of 
covered SNF services furnished during the upcoming FY.
    2. The case-mix classification system to be applied with respect to 
these services during the upcoming FY.
    3. The factors to be applied in making the area wage adjustment 
with respect to these services.

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    This notice provides these required annual updates to the Federal 
rates.

C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 
1999 (BBRA)

    There were several provisions in the BBRA (Pub. L. 106-113, enacted 
on November 29, 1999) that resulted in adjustments to the SNF PPS. We 
described these provisions in detail in the SNF PPS final rule for FY 
2001 (65 FR 46770, July 31, 2000). In particular, section 101(a) of the 
BBRA provided for a temporary 20 percent increase in the per diem 
adjusted payment rates for 15 specified groups in the original, 44-
group Resource Utilization Groups, version 3 (RUG-III) case-mix 
classification system. In accordance with section 101(c)(2) of the 
BBRA, this temporary payment adjustment expired on January 1, 2006, 
upon the implementation of a refined, 53-group version of the RUG-III 
system, RUG-53 (see section II.G.1. of this notice). We included 
further information on BBRA provisions that affected the SNF PPS in 
Program Memoranda A-99-53 and A-99-61 (December 1999).
    Also, section 103 of the BBRA designated certain additional 
services for exclusion from the consolidated billing requirement, as 
discussed in section VI. of this notice. Further, for swing-bed 
hospitals with more than 49 (but less than 100) beds, section 408 of 
the BBRA provided for the repeal of certain statutory restrictions on 
length of stay and aggregate payment for patient days, effective with 
the end of the SNF PPS transition period described in section 
1888(e)(2)(E) of the Act. In the final rule for FY 2002 (66 FR 39562, 
July 31, 2001), we made conforming changes to the regulations at Sec.  
413.114(d), effective for services furnished in cost reporting periods 
beginning on or after July 1, 2002, to reflect section 408 of the BBRA.

D. The Medicare, Medicaid, and SCHIP Benefits Improvement and 
Protection Act of 2000 (BIPA)

    The BIPA (Pub. L. 106-554, enacted December 21, 2000) also included 
several provisions that resulted in adjustments to the SNF PPS. We 
described these provisions in detail in the final rule for FY 2002 (66 
FR 39562, July 31, 2001). In particular:
     Section 203 of the BIPA exempted CAH swing beds from the 
SNF PPS. We included further information on this provision in Program 
Memorandum A-01-09 (Change Request 1509), issued January 16, 
2001, which is available online at www.cms.gov/transmittals/downloads/a0109.pdf.
     Section 311 of the BIPA revised the statutory update 
formula for the SNF market basket, and also directed us to conduct a 
study of alternative case-mix classification systems for the SNF PPS. 
In 2006, we submitted a report to the Congress on this study, which is 
available online at www.cms.gov/SNFPPS/Downloads/RC_2006_PC-PPSSNF.pdf.
     Section 312 of the BIPA provided for a temporary increase 
of 16.66 percent in the nursing component of the case-mix adjusted 
Federal rate for services furnished on or after April 1, 2001, and 
before October 1, 2002; accordingly, this add-on is no longer in 
effect. This section also directed the Government Accountability Office 
(GAO) to conduct an audit of SNF nursing staff ratios and submit a 
report to the Congress on whether the temporary increase in the nursing 
component should be continued. The report (GAO-03-176), which GAO 
issued in November 2002, is available online at www.gao.gov/new.items/d03176.pdf.
     Section 313 of the BIPA repealed the consolidated billing 
requirement for services (other than physical therapy, occupational 
therapy, and speech-language pathology services) furnished to SNF 
residents during noncovered stays, effective January 1, 2001. (A more 
detailed discussion of this provision appears in section VI. of this 
notice.)
     Section 314 of the BIPA corrected an anomaly involving 
three of the RUGs that section 101(a) of the BBRA had designated to 
receive the temporary payment adjustment discussed above in section 
I.C. of this notice. (As noted previously, in accordance with section 
101(c)(2) of the BBRA, this temporary payment adjustment expired upon 
the implementation of case-mix refinements on January 1, 2006.)
     Section 315 of the BIPA authorized us to establish a 
geographic reclassification procedure that is specific to SNFs, but 
only after collecting the data necessary to establish a SNF wage index 
that is based on wage data from nursing homes. To date, this has proven 
to be unfeasible due to the volatility of existing SNF wage data and 
the significant amount of resources that would be required to improve 
the quality of that data.
    We included further information on several of the BIPA provisions 
in Program Memorandum A-01-08 (Change Request 1510), issued 
January 16, 2001, which is available online at www.cms.gov/transmittals/downloads/a0108.pdf.

E. The Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003 (MMA)

    The MMA (Pub. L. 108-173, enacted on December 8, 2003) included a 
provision that resulted in a further adjustment to the SNF PPS. 
Specifically, section 511 of the MMA amended section 1888(e)(12) of the 
Act, to provide for a temporary increase of 128 percent in the PPS per 
diem payment for any SNF residents with Acquired Immune Deficiency 
Syndrome (AIDS), effective with services furnished on or after October 
1, 2004. This special AIDS add-on was to remain in effect until ``* * * 
the Secretary certifies that there is an appropriate adjustment in the 
case mix * * * to compensate for the increased costs associated with 
[such] residents * * *.'' The AIDS add-on is also discussed in Program 
Transmittal 160 (Change Request 3291), issued on 
April 30, 2004, which is available online at www.cms.gov/transmittals/downloads/r160cp.pdf. In the SNF PPS final rule for FY 2010 (74 FR 
40288, August 11, 2009), we did not address the certification of the 
AIDS add-on in that final rule's implementation of the case-mix 
refinements for RUG-IV, thus allowing the temporary add-on payment 
created by section 511 of the MMA to remain in effect.
    For the limited number of SNF residents that qualify for the AIDS 
add-on, implementation of this provision results in a significant 
increase in payment. For example, using FY 2010 data, we identified 
less than 3,800 SNF residents with a diagnosis code of 042 (Human 
Immunodeficiency Virus (HIV) Infection). For FY 2013, an urban facility 
with a resident with AIDS in RUG-IV group ``HC2'' would have a case-mix 
adjusted payment of $408.88 (see Table 4) before the application of the 
MMA adjustment. After an increase of 128 percent, this urban facility 
would receive a case-mix adjusted payment of approximately $932.25.
    In addition, section 410 of the MMA contained a provision that 
excluded from consolidated billing certain services furnished to SNF 
residents by rural health clinics (RHCs) and Federally Qualified Health 
Centers (FQHCs). (Further information on this provision appears in 
section VI. of this notice.)

F. The Affordable Care Act

    On March 23, 2010, the Patient Protection and Affordable Care Act, 
Pub. L. 111-148, was enacted. Following the enactment of Public Law 
111-148, the Health Care and Education Reconciliation Act of 2010 (Pub. 
L. 111-

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152, enacted on March 30, 2010) amended certain provisions of Public 
Law 111-148 and certain sections of the statute and, in certain 
instances, included ``freestanding'' provisions (Pub. L. 111-148 and 
Pub. L. 111-152 are collectively referred to in this notice as the 
``Affordable Care Act''). Section 10325 of the Affordable Care Act 
included a provision involving the SNF PPS. Section 10325 of the 
Affordable Care Act postponed the implementation of the RUG-IV case-mix 
classification system published in the FY 2010 SNF PPS final rule (74 
FR 40288, August 11, 2009), requiring that the Secretary not implement 
the RUG-IV case-mix classification system before October 1, 2011. 
Notwithstanding this postponement of overall RUG-IV implementation, 
section 10325 of the Affordable Care Act further specified that the 
Secretary implement, effective October 1 2010, the changes related to 
concurrent therapy and the look-back period that were finalized as 
components of RUG-IV (see 74 FR 40315-19, 40322-24, August 11, 2009). 
As we noted in the FY 2011 SNF PPS notice with comment period (75 FR 
42889), implementing the particular combination of RUG-III and RUG-IV 
features specified in section 10325 of the Affordable Care Act would 
require developing a revised grouper, something that could not be 
accomplished by that provision's effective date (October 1, 2010) 
without risking serious disruption to providers, suppliers, and State 
agencies. Accordingly, in the FY 2011 notice with comment period (75 FR 
42889), we announced our intention to proceed on an interim basis with 
implementation of the full RUG-IV case-mix classification system as of 
October 1, 2010, followed by a retroactive claims adjustment, using a 
hybrid RUG-III (HR-III) system reflecting the Affordable Care Act 
configuration, once we had developed a revised grouper that could 
accommodate it.
    However, section 202 of the Medicare and Medicaid Extenders Act of 
2010 (Pub. L. 111-309, enacted on December 15, 2010) subsequently 
repealed section 10325 of the Affordable Care Act. We have, therefore, 
left in place permanently the implementation of the full RUG-IV system 
as of FY 2011, as finalized in the FY 2010 SNF PPS final rule (74 FR 
40288). In addition, we note that implementation of version 3.0 of the 
Minimum Data Set (MDS 3.0) proceeded as originally scheduled, with an 
effective date of October 1, 2010. The MDS 3.0 RAI Manual and MDS 3.0 
Item Set are published on the MDS 3.0 Training Materials Web site, at 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Accordingly, 
as discussed above, effective October 1, 2010, we implemented and began 
paying claims under the RUG-IV system that was finalized in the FY 2010 
SNF PPS final rule.
    We note that a parity adjustment was applied to the RUG-53 nursing 
case-mix weights when the RUG-III system was initially refined in 2006, 
in order to ensure that the implementation of the refinements would not 
cause any change in overall payment levels (70 FR 45031, August 4, 
2005). Similarly, a parity adjustment was applied to the RUG-IV nursing 
case-mix weights for FY 2011 when the new classification system was 
implemented. A detailed discussion of the parity adjustment in the 
specific context of the RUG-IV payment rates appears in the FY 2010 SNF 
PPS proposed rule (74 FR 22236-38, May 12, 2009) and final rule (74 FR 
40338-40339, August 11, 2009), and in the FY 2011 notice with comment 
period (75 FR 42892-42893).
    For FY 2012, the RUG-IV parity adjustment was recalibrated in order 
to restore the intended parity in overall payments between the RUG-IV 
and RUG-53 case mix classification systems, as discussed in the FY 2012 
SNF PPS proposed rule (76 FR 26370-26373, May 6, 2011) and final rule 
(76 FR 48492-48500, 48537-48538 August 8, 2011).

G. Skilled Nursing Facility Prospective Payment--General Overview

    We implemented the Medicare SNF PPS effective with cost reporting 
periods beginning on or after July 1, 1998. This methodology uses 
prospective, case-mix adjusted per diem payment rates applicable to all 
covered SNF services. These payment rates cover all costs of furnishing 
covered SNF services (routine, ancillary, and capital-related costs) 
other than costs associated with approved educational activities and 
bad debts. Covered SNF services include post-hospital services for 
which benefits are provided under Part A, as well as those items and 
services (other than physician and certain other services specifically 
excluded under the BBA) which, before July 1, 1998, had been paid under 
Part B but furnished to Medicare beneficiaries in a SNF during a 
covered Part A stay. A comprehensive discussion of these provisions 
appears in the May 12, 1998 interim final rule (63 FR 26252).
1. Payment Provisions--Federal Rate
    The PPS uses per diem Federal payment rates based on mean SNF costs 
in a base year (FY 1995) updated for inflation to the first effective 
period of the PPS. We developed the Federal payment rates using 
allowable costs from hospital-based and freestanding SNF cost reports 
for reporting periods beginning in FY 1995. The data used in developing 
the Federal rates also incorporated an estimate of the amounts that 
would be payable under Part B for covered SNF services furnished to 
individuals during the course of a covered Part A stay in a SNF.
    In developing the rates for the initial period, we updated costs to 
the first effective year of the PPS (the 15-month period beginning July 
1, 1998) using a SNF market basket index, and then standardized for the 
costs of facility differences in case mix and for geographic variations 
in wages. In compiling the database used to compute the Federal payment 
rates, we excluded those providers that received new provider 
exemptions from the routine cost limits, as well as costs related to 
payments for exceptions to the routine cost limits. Using the formula 
that the BBA prescribed, we set the Federal rates at a level equal to 
the weighted mean of freestanding costs plus 50 percent of the 
difference between the freestanding mean and weighted mean of all SNF 
costs (hospital-based and freestanding) combined. We computed and 
applied separately the payment rates for facilities located in urban 
and rural areas. In addition, we adjusted the portion of the Federal 
rate attributable to wage-related costs by a wage index.
    The Federal rate also incorporates adjustments to account for 
facility case-mix, using a classification system that accounts for the 
relative resource utilization of different patient types. The RUG-IV 
classification system uses beneficiary assessment data from the MDS 3.0 
completed by SNFs to assign beneficiaries to one of 66 RUG-IV groups. 
The original RUG-III case-mix classification system used beneficiary 
assessment data from the MDS, version 2.0 (MDS 2.0) completed by SNFs 
to assign beneficiaries to one of 44 RUG-III groups. Then, under 
incremental refinements that became effective on January 1, 2006, we 
added nine new groups--comprising a new Rehabilitation plus Extensive 
Services category--at the top of the RUG-III hierarchy. The May 12, 
1998 interim final rule (63 FR 26252) included a detailed description 
of the original 44-group RUG-III case-mix classification system. A 
comprehensive description of

[[Page 46218]]

the refined RUG-53 system appeared in the proposed and final rules for 
FY 2006 (70 FR 29070, May 19, 2005, and 70 FR 45026, August 4, 2005), 
and a detailed description of the current 66-group RUG-IV system 
appeared in the proposed and final rules for FY 2010 (74 FR 22208, May 
12, 2009, and 74 FR 40288, August 11, 2009).
    Further, in accordance with sections 1888(e)(4)(E)(ii)(IV) and 
(e)(5) of the Act, the Federal rates in this notice reflect an update 
to the rates that we published in the final rule for FY 2012 (76 FR 
48486, August 8, 2011) and the associated correction notice (76 FR 
59265, September 26, 2011), equal to the full change in the SNF market 
basket index, adjusted by the forecast error correction, if applicable, 
and the Multifactor Productivity (MFP) adjustment for FY 2013. A more 
detailed discussion of the SNF market basket index and related issues 
appears in sections II.G.2. and V. of this notice.
2. FY 2013 Rate Updates Using the Skilled Nursing Facility Market 
Basket Index
    Section 1888(e)(5) of the Act requires us to establish a SNF market 
basket index that reflects changes over time in the prices of an 
appropriate mix of goods and services included in covered SNF services. 
We use the SNF market basket index, adjusted in the manner described 
below, to update the Federal rates on an annual basis. In the SNF PPS 
final rule for FY 2008 (72 FR 43425 through 43430, August 3, 2007), we 
revised and rebased the market basket, which included updating the base 
year from FY 1997 to FY 2004. The FY 2013 market basket increase is 2.5 
percent, which is based on IHS Global Insight, Inc. (IGI) second 
quarter 2012 forecast with historical data through first quarter 2012.
    In addition, as explained in the final rule for FY 2004 (66 FR 
46058, August 4, 2003) and in section V.B. of this notice, the annual 
update of the payment rates includes, as appropriate, an adjustment to 
account for market basket forecast error. As described in the final 
rule for FY 2008, the threshold percentage that serves to trigger an 
adjustment to account for market basket forecast error is 0.5 
percentage point effective for FY 2008 and subsequent years. This 
adjustment takes into account the forecast error from the most recently 
available FY for which there is final data, and applies whenever the 
difference between the forecasted and actual change in the market 
basket exceeds a 0.5 percentage point threshold. For FY 2011 (the most 
recently available FY for which there is final data), the estimated 
increase in the market basket index was 2.3 percentage points, while 
the actual increase was 2.2 percentage points, resulting in the actual 
increase being 0.1 percentage point lower than the estimated increase. 
Accordingly, as the difference between the estimated and actual amount 
of change does not exceed the 0.5 percentage point threshold, the 
payment rates for FY 2013 do not include a forecast error adjustment. 
As we stated in the final rule for FY 2004 that first promulgated the 
forecast error adjustment (68 FR 46058, August 4, 2003), the adjustment 
will ``* * * reflect both upward and downward adjustments, as 
appropriate.'' Table 1 shows the forecasted and actual market basket 
amounts for FY 2011.

            Table 1--Difference Between the Forecasted and Actual Market Basket Increases for FY 2011
----------------------------------------------------------------------------------------------------------------
                                                                Forecasted FY
                            Index                               2011  increase   Actual FY 2011      FY 2011
                                                                      *           increase **       difference
----------------------------------------------------------------------------------------------------------------
SNF..........................................................             2.3              2.2             -0.1
----------------------------------------------------------------------------------------------------------------
* Published in Federal Register; based on second quarter 2010 IGI forecast (2004-based index).
** Based on the second quarter 2012 IGI forecast, with historical data through the first quarter 2012 (2004-
  based index).

    Furthermore, effective FY 2012, as required by section 3401(b) of 
the Affordable Care Act, the market basket percentage is reduced by a 
productivity adjustment equal to ``the 10-year moving average of 
changes in annual economy-wide private nonfarm business multi-factor 
productivity (as projected by the Secretary for the 10-year period 
ending with the applicable fiscal year, year, cost-reporting period or 
other annual period)'' (the MFP adjustment). As discussed in greater 
detail in section V.C of this notice, the MFP adjustment for FY 2013 is 
0.7 percent.

III. FY 2013 Annual Update of Payment Rates Under the Prospective 
Payment System for Skilled Nursing Facilities

A. Federal Prospective Payment System

    This notice sets forth a schedule of Federal prospective payment 
rates applicable to Medicare Part A SNF services beginning October 1, 
2012. The schedule incorporates per diem Federal rates that provide 
Part A payment for almost all costs of services furnished to a 
beneficiary in a SNF during a Part A Medicare-covered stay.
1. Costs and Services Covered by the Federal Rates
    In accordance with section 1888(e)(2)(B) of the Act, the Federal 
rates apply to all costs (routine, ancillary, and capital-related) of 
covered SNF services other than costs associated with approved 
educational activities as defined in Sec.  413.85. Under section 
1888(e)(2)(A)(i) of the Act, covered SNF services include post-hospital 
SNF services for which benefits are provided under Part A (the hospital 
insurance program), as well as all items and services (other than those 
services excluded by statute) that, before July 1, 1998, were paid 
under Part B (the supplementary medical insurance program) but 
furnished to Medicare beneficiaries in a SNF during a Part A covered 
stay. (These excluded service categories are discussed in greater 
detail in section V.B.2 of the May 12, 1998 interim final rule (63 FR 
26295 through 26297)).
2. Methodology Used for the Calculation of the Federal Rates
    The FY 2013 rates reflect an update using the latest market basket 
index, reduced by the MFP adjustment. The FY 2013 market basket 
increase factor is 2.5 percent, which as discussed in section V.C of 
this notice, is reduced by a 0.7 percent MFP adjustment. A complete 
description of the multi-step process used to calculate Federal rates 
initially appeared in the May 12, 1998 interim final rule (63 FR 
26252), as further revised in subsequent rules. As explained above in 
section II.C of this notice, under section 101(c)(2) of the BBRA, the 
previous temporary increases in the per diem adjusted payment rates for 
certain designated RUGs (as specified in section 101(a) of the BBRA and 
section 314 of the BIPA) are no longer in effect due to the 
implementation of case-mix refinements as of January 1, 2006. However, 
the

[[Page 46219]]

temporary increase of 128 percent in the per diem adjusted payment 
rates for SNF residents with AIDS, enacted by section 511 of the MMA, 
remains in effect.
    We used the SNF market basket to adjust each per diem component of 
the Federal rates forward to reflect cost increases occurring between 
the midpoint of the Federal FY beginning October 1, 2011, and ending 
September 30, 2012, and the midpoint of the Federal FY beginning 
October 1, 2012, and ending September 30, 2013, to which the payment 
rates apply. In accordance with sections 1888(e)(4)(E)(ii)(IV) and 
(e)(5) of the Act, we update the payment rates for FY 2013 by a factor 
equal to the market basket index percentage change, as discussed in 
sections II.G.2 and V. of this notice. As further explained in sections 
II.G.2 and V. of this notice, as applicable, we adjust the market 
basket index by the forecast error from the most recently available FY 
for which there is final data and apply this adjustment whenever the 
difference between the forecasted and actual change in the market 
basket exceeds a 0.5 percentage point threshold. In addition, as 
further explained in sections II.G.2 and V. of this notice, effective 
FY 2012 and each subsequent fiscal year, we are required to reduce the 
market basket percentage by the MFP adjustment. We further adjust the 
rates by a wage index budget neutrality factor, described later in this 
section. Tables 2 and 3 reflect the updated components of the 
unadjusted Federal rates for FY 2013, prior to adjustment for case-mix.

                             Table 2--FY 2013 Unadjusted Federal Rate Per Diem Urban
----------------------------------------------------------------------------------------------------------------
                                              Nursing-- case-  Therapy-- case-   Therapy-- Non-
               Rate component                       mix              mix            case-mix       Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount.............................         $163.58          $123.22           $16.23           $83.48
----------------------------------------------------------------------------------------------------------------


                             Table 3--FY 2013 Unadjusted Federal Rate Per Diem Rural
----------------------------------------------------------------------------------------------------------------
                                              Nursing-- case-  Therapy-- case-   Therapy-- non-
               Rate component                       mix              mix            case-mix       Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount.............................         $156.28          $142.08           $17.33           $85.03
----------------------------------------------------------------------------------------------------------------

B. Case-Mix Adjustments

1. Background
    Section 1888(e)(4)(G)(i) of the Act requires the Secretary to make 
an adjustment to account for case mix. The statute specifies that the 
adjustment is to reflect both a resident classification system that the 
Secretary establishes to account for the relative resource use of 
different patient types, as well as resident assessment and other data 
that the Secretary considers appropriate. In first implementing the SNF 
PPS (63 FR 26252, May 12, 1998), we developed the RUG-III case-mix 
classification system, which tied the amount of payment to resident 
resource use in combination with resident characteristic information. 
Staff time measurement (STM) studies conducted in 1990, 1995, and 1997 
provided information on resource use (time spent by staff members on 
residents) and resident characteristics that enabled us not only to 
establish RUG-III, but also to create case-mix indexes (CMIs).
    Although the establishment of the SNF PPS did not change Medicare's 
fundamental requirements for SNF coverage, there is a correlation 
between level of care and provider payment. One of the elements 
affecting the SNF PPS per diem rates is the case-mix adjustment derived 
from a classification system based on comprehensive resident 
assessments using the MDS. Case-mix classification is based, in part, 
on the beneficiary's need for skilled nursing care and therapy. The 
case-mix classification system uses clinical data from the MDS, and 
wage-adjusted staff time measurement data, to assign a case-mix group 
to each patient record that is then used to calculate a per diem 
payment under the SNF PPS. Because the MDS is used as basis for payment 
as well as a clinical document, we have provided extensive training on 
proper coding and the time frames for MDS completion in our Resident 
Assessment Instrument (RAI) Manual. For an MDS to be considered valid 
for use in determining payment, the MDS assessment must be completed in 
compliance with the instructions in the RAI Manual in effect at the 
time the assessment is completed. For payment and quality monitoring 
purposes, the RAI Manual consists of both the Manual instructions and 
the interpretive guidance and policy clarifications posted on the 
appropriate MDS Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.
    The original RUG-III grouper logic was based on clinical data 
collected in 1990, 1995, and 1997. As discussed in the SNF PPS proposed 
rule for FY 2010 (74 FR 22208, May 12, 2009), we subsequently conducted 
a multi-year data collection and analysis under the Staff Time and 
Resource Intensity Verification (STRIVE) project to update the case-mix 
classification system for FY 2011. The resulting RUG-IV case-mix 
classification system reflected the data collected in 2006-2007 during 
the STRIVE project, and was finalized in the FY 2010 SNF PPS final rule 
(74 FR 40288, August 11, 2009) to take effect in FY 2011 concurrently 
with an updated new resident assessment instrument, the MDS 3.0, which 
collects the clinical data used for case-mix classification under RUG-
IV.
    Under the BBA, each update of the SNF PPS payment rates must 
include the case-mix classification methodology applicable for the 
coming Federal FY. As indicated in section II.G of this notice, the 
payment rates set forth herein reflect the use of the RUG-IV case-mix 
classification system from October 1, 2012, through September 30, 2013.
    We list the case-mix adjusted RUG-IV payment rates, provided 
separately for urban and rural SNFs, in Tables 4 and 5 with 
corresponding case-mix values. These tables do not reflect the AIDS 
add-on enacted by section 511 of the MMA, which we apply only after 
making all other adjustments (such as wage and case-mix).

[[Page 46220]]



                                      Table 4--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                     Non-case     Non-case
                       RUG-IV category                           Nursing      Therapy      Nursing      Therapy    mix therapy      mix       Total rate
                                                                  index        index      component    component       comp      component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX..........................................................         2.67         1.87      $436.76      $230.42  ...........       $83.48      $750.66
RUL..........................................................         2.57         1.87       420.40       230.42  ...........        83.48       734.30
RVX..........................................................         2.61         1.28       426.94       157.72  ...........        83.48       668.14
RVL..........................................................         2.19         1.28       358.24       157.72  ...........        83.48       599.44
RHX..........................................................         2.55         0.85       417.13       104.74  ...........        83.48       605.35
RHL..........................................................         2.15         0.85       351.70       104.74  ...........        83.48       539.92
RMX..........................................................         2.47         0.55       404.04        67.77  ...........        83.48       555.29
RML..........................................................         2.19         0.55       358.24        67.77  ...........        83.48       509.49
RLX..........................................................         2.26         0.28       369.69        34.50  ...........        83.48       487.67
RUC..........................................................         1.56         1.87       255.18       230.42  ...........        83.48       569.08
RUB..........................................................         1.56         1.87       255.18       230.42  ...........        83.48       569.08
RUA..........................................................         0.99         1.87       161.94       230.42  ...........        83.48       475.84
RVC..........................................................         1.51         1.28       247.01       157.72  ...........        83.48       488.21
RVB..........................................................         1.11         1.28       181.57       157.72  ...........        83.48       422.77
RVA..........................................................         1.10         1.28       179.94       157.72  ...........        83.48       421.14
RHC..........................................................         1.45         0.85       237.19       104.74  ...........        83.48       425.41
RHB..........................................................         1.19         0.85       194.66       104.74  ...........        83.48       382.88
RHA..........................................................         0.91         0.85       148.86       104.74  ...........        83.48       337.08
RMC..........................................................         1.36         0.55       222.47        67.77  ...........        83.48       373.72
RMB..........................................................         1.22         0.55       199.57        67.77  ...........        83.48       350.82
RMA..........................................................         0.84         0.55       137.41        67.77  ...........        83.48       288.66
RLB..........................................................         1.50         0.28       245.37        34.50  ...........        83.48       363.35
RLA..........................................................         0.71         0.28       116.14        34.50  ...........        83.48       234.12
ES3..........................................................         3.58  ...........       585.62  ...........        16.23        83.48       685.33
ES2..........................................................         2.67  ...........       436.76  ...........        16.23        83.48       536.47
ES1..........................................................         2.32  ...........       379.51  ...........        16.23        83.48       479.22
HE2..........................................................         2.22  ...........       363.15  ...........        16.23        83.48       462.86
HE1..........................................................         1.74  ...........       284.63  ...........        16.23        83.48       384.34
HD2..........................................................         2.04  ...........       333.70  ...........        16.23        83.48       433.41
HD1..........................................................         1.60  ...........       261.73  ...........        16.23        83.48       361.44
HC2..........................................................         1.89  ...........       309.17  ...........        16.23        83.48       408.88
HC1..........................................................         1.48  ...........       242.10  ...........        16.23        83.48       341.81
HB2..........................................................         1.86  ...........       304.26  ...........        16.23        83.48       403.97
HB1..........................................................         1.46  ...........       238.83  ...........        16.23        83.48       338.54
LE2..........................................................         1.96  ...........       320.62  ...........        16.23        83.48       420.33
LE1..........................................................         1.54  ...........       251.91  ...........        16.23        83.48       351.62
LD2..........................................................         1.86  ...........       304.26  ...........        16.23        83.48       403.97
LD1..........................................................         1.46  ...........       238.83  ...........        16.23        83.48       338.54
LC2..........................................................         1.56  ...........       255.18  ...........        16.23        83.48       354.89
LC1..........................................................         1.22  ...........       199.57  ...........        16.23        83.48       299.28
LB2..........................................................         1.45  ...........       237.19  ...........        16.23        83.48       336.90
LB1..........................................................         1.14  ...........       186.48  ...........        16.23        83.48       286.19
CE2..........................................................         1.68  ...........       274.81  ...........        16.23        83.48       374.52
CE1..........................................................         1.50  ...........       245.37  ...........        16.23        83.48       345.08
CD2..........................................................         1.56  ...........       255.18  ...........        16.23        83.48       354.89
CD1..........................................................         1.38  ...........       225.74  ...........        16.23        83.48       325.45
CC2..........................................................         1.29  ...........       211.02  ...........        16.23        83.48       310.73
CC1..........................................................         1.15  ...........       188.12  ...........        16.23        83.48       287.83
CB2..........................................................         1.15  ...........       188.12  ...........        16.23        83.48       287.83
CB1..........................................................         1.02  ...........       166.85  ...........        16.23        83.48       266.56
CA2..........................................................         0.88  ...........       143.95  ...........        16.23        83.48       243.66
CA1..........................................................         0.78  ...........       127.59  ...........        16.23        83.48       227.30
BB2..........................................................         0.97  ...........       158.67  ...........        16.23        83.48       258.38
BB1..........................................................         0.90  ...........       147.22  ...........        16.23        83.48       246.93
BA2..........................................................         0.70  ...........       114.51  ...........        16.23        83.48       214.22
BA1..........................................................         0.64  ...........       104.69  ...........        16.23        83.48       204.40
PE2..........................................................         1.50  ...........       245.37  ...........        16.23        83.48       345.08
PE1..........................................................         1.40  ...........       229.01  ...........        16.23        83.48       328.72
PD2..........................................................         1.38  ...........       225.74  ...........        16.23        83.48       325.45
PD1..........................................................         1.28  ...........       209.38  ...........        16.23        83.48       309.09
PC2..........................................................         1.10  ...........       179.94  ...........        16.23        83.48       279.65
PC1..........................................................         1.02  ...........       166.85  ...........        16.23        83.48       266.56
PB2..........................................................         0.84  ...........       137.41  ...........        16.23        83.48       237.12
PB1..........................................................         0.78  ...........       127.59  ...........        16.23        83.48       227.30
PA2..........................................................         0.59  ...........        96.51  ...........        16.23        83.48       196.22
PA1..........................................................         0.54  ...........        88.33  ...........        16.23        83.48       188.04
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 46221]]


                                      Table 5--RUG-IV Case-Mix Adjusted Federal Rates and Associated Indexes Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                     Non-case     Non-case
                       RUG-IV category                           Nursing      Therapy      Nursing      Therapy    mix therapy      mix       Total rate
                                                                  index        index      component    component       comp      component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX..........................................................         2.67         1.87      $417.27      $265.69  ...........       $85.03      $767.99
RUL..........................................................         2.57         1.87       401.64       265.69  ...........        85.03       752.36
RVX..........................................................         2.61         1.28       407.89       181.86  ...........        85.03       674.78
RVL..........................................................         2.19         1.28       342.25       181.86  ...........        85.03       609.14
RHX..........................................................         2.55         0.85       398.51       120.77  ...........        85.03       604.31
RHL..........................................................         2.15         0.85       336.00       120.77  ...........        85.03       541.80
RMX..........................................................         2.47         0.55       386.01        78.14  ...........        85.03       549.18
RML..........................................................         2.19         0.55       342.25        78.14  ...........        85.03       505.42
RLX..........................................................         2.26         0.28       353.19        39.78  ...........        85.03       478.00
RUC..........................................................         1.56         1.87       243.80       265.69  ...........        85.03       594.52
RUB..........................................................         1.56         1.87       243.80       265.69  ...........        85.03       594.52
RUA..........................................................         0.99         1.87       154.72       265.69  ...........        85.03       505.44
RVC..........................................................         1.51         1.28       235.98       181.86  ...........        85.03       502.87
RVB..........................................................         1.11         1.28       173.47       181.86  ...........        85.03       440.36
RVA..........................................................         1.10         1.28       171.91       181.86  ...........        85.03       438.80
RHC..........................................................         1.45         0.85       226.61       120.77  ...........        85.03       432.41
RHB..........................................................         1.19         0.85       185.97       120.77  ...........        85.03       391.77
RHA..........................................................         0.91         0.85       142.21       120.77  ...........        85.03       348.01
RMC..........................................................         1.36         0.55       212.54        78.14  ...........        85.03       375.71
RMB..........................................................         1.22         0.55       190.66        78.14  ...........        85.03       353.83
RMA..........................................................         0.84         0.55       131.28        78.14  ...........        85.03       294.45
RLB..........................................................         1.50         0.28       234.42        39.78  ...........        85.03       359.23
RLA..........................................................         0.71         0.28       110.96        39.78  ...........        85.03       235.77
ES3..........................................................         3.58  ...........       559.48  ...........        17.33        85.03       661.84
ES2..........................................................         2.67  ...........       417.27  ...........        17.33        85.03       519.63
ES1..........................................................         2.32  ...........       362.57  ...........        17.33        85.03       464.93
HE2..........................................................         2.22  ...........       346.94  ...........        17.33        85.03       449.30
HE1..........................................................         1.74  ...........       271.93  ...........        17.33        85.03       374.29
HD2..........................................................         2.04  ...........       318.81  ...........        17.33        85.03       421.17
HD1..........................................................         1.60  ...........       250.05  ...........        17.33        85.03       352.41
HC2..........................................................         1.89  ...........       295.37  ...........        17.33        85.03       397.73
HC1..........................................................         1.48  ...........       231.29  ...........        17.33        85.03       333.65
HB2..........................................................         1.86  ...........       290.68  ...........        17.33        85.03       393.04
HB1..........................................................         1.46  ...........       228.17  ...........        17.33        85.03       330.53
LE2..........................................................         1.96  ...........       306.31  ...........        17.33        85.03       408.67
LE1..........................................................         1.54  ...........       240.67  ...........        17.33        85.03       343.03
LD2..........................................................         1.86  ...........       290.68  ...........        17.33        85.03       393.04
LD1..........................................................         1.46  ...........       228.17  ...........        17.33        85.03       330.53
LC2..........................................................         1.56  ...........       243.80  ...........        17.33        85.03       346.16
LC1..........................................................         1.22  ...........       190.66  ...........        17.33        85.03       293.02
LB2..........................................................         1.45  ...........       226.61  ...........        17.33        85.03       328.97
LB1..........................................................         1.14  ...........       178.16  ...........        17.33        85.03       280.52
CE2..........................................................         1.68  ...........       262.55  ...........        17.33        85.03       364.91
CE1..........................................................         1.50  ...........       234.42  ...........        17.33        85.03       336.78
CD2..........................................................         1.56  ...........       243.80  ...........        17.33        85.03       346.16
CD1..........................................................         1.38  ...........       215.67  ...........        17.33        85.03       318.03
CC2..........................................................         1.29  ...........       201.60  ...........        17.33        85.03       303.96
CC1..........................................................         1.15  ...........       179.72  ...........        17.33        85.03       282.08
CB2..........................................................         1.15  ...........       179.72  ...........        17.33        85.03       282.08
CB1..........................................................         1.02  ...........       159.41  ...........        17.33        85.03       261.77
CA2..........................................................         0.88  ...........       137.53  ...........        17.33        85.03       239.89
CA1..........................................................         0.78  ...........       121.90  ...........        17.33        85.03       224.26
BB2..........................................................         0.97  ...........       151.59  ...........        17.33        85.03       253.95
BB1..........................................................         0.90  ...........       140.65  ...........        17.33        85.03       243.01
BA2..........................................................         0.70  ...........       109.40  ...........        17.33        85.03       211.76
BA1..........................................................         0.64  ...........       100.02  ...........        17.33        85.03       202.38
PE2..........................................................         1.50  ...........       234.42  ...........        17.33        85.03       336.78
PE1..........................................................         1.40  ...........       218.79  ...........        17.33        85.03       321.15
PD2..........................................................         1.38  ...........       215.67  ...........        17.33        85.03       318.03
PD1..........................................................         1.28  ...........       200.04  ...........        17.33        85.03       302.40
PC2..........................................................         1.10  ...........       171.91  ...........        17.33        85.03       274.27
PC1..........................................................         1.02  ...........       159.41  ...........        17.33        85.03       261.77
PB2..........................................................         0.84  ...........       131.28  ...........        17.33        85.03       233.64
PB1..........................................................         0.78  ...........       121.90  ...........        17.33        85.03       224.26
PA2..........................................................         0.59  ...........        92.21  ...........        17.33        85.03       194.57
PA1..........................................................         0.54  ...........        84.39  ...........        17.33        85.03       186.75
--------------------------------------------------------------------------------------------------------------------------------------------------------


[[Page 46222]]

C. Wage Index Adjustment to Federal Rates

    Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the 
Federal rates to account for differences in area wage levels, using a 
wage index that we find appropriate. Since the inception of a PPS for 
SNFs, we have used hospital wage data in developing a wage index to be 
applied to SNFs. We are maintaining that practice for FY 2013, as we 
continue to believe that in the absence of SNF-specific wage data, 
using the hospital inpatient wage index is appropriate and reasonable 
for the SNF PPS. As explained in the update notice for FY 2005 (69 FR 
45786, July 30, 2004), the SNF 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; moreover, the collection of the occupational wage 
data also excludes any wage data related to SNFs. Therefore, we believe 
that using the updated wage data exclusive of the occupational mix 
adjustment continues to be appropriate for SNF payments.
    Finally, we continue to use the same methodology discussed in the 
SNF PPS final rule for FY 2008 (72 FR 43423) to address those 
geographic areas in which there are no hospitals and, thus, no hospital 
wage index data on which to base the calculation of the FY 2013 SNF PPS 
wage index. For rural geographic areas that do not have hospitals and, 
therefore, lack hospital wage data on which to base an area wage 
adjustment, we use the average wage index from all contiguous Core-
Based Statistical Areas (CBSAs) as a reasonable proxy. For FY 2013, 
there are no rural geographic areas that do not have hospitals, and 
thus this methodology will not be applied. For rural Puerto Rico, we do 
not apply this methodology due to the distinct economic circumstances 
that exist there, but instead continue using the most recent wage index 
previously available for that area. For urban areas without specific 
hospital wage index data, we use the average wage indexes of all of the 
urban areas within the State to serve as a reasonable proxy for the 
wage index of that urban CBSA. For FY 2013, the only urban area without 
wage index data available is CBSA 25980, Hinesville-Fort Stewart, GA.
    To calculate the SNF PPS wage index adjustment, we apply the wage 
index adjustment to the labor-related portion of the Federal rate, 
which is 68.383 percent of the total rate. This percentage reflects the 
labor-related relative importance for FY 2013, using the revised and 
rebased FY 2004-based market basket. The labor-related relative 
importance for FY 2012 was 68.693, as shown in Table 13. We calculate 
the labor-related relative importance from the SNF market basket, and 
it approximates the labor-related portion of the total costs after 
taking into account historical and projected price changes between the 
base year and FY 2013. The price proxies that move the different cost 
categories in the market basket do not necessarily change at the same 
rate, and the relative importance captures these changes. Accordingly, 
the relative importance figure more closely reflects the cost share 
weights for FY 2013 than the base year weights from the SNF market 
basket.
    We calculate the labor-related relative importance for FY 2013 in 
four steps. First, we compute the FY 2013 price index level for the 
total market basket and each cost category of the market basket. 
Second, we calculate a ratio for each cost category by dividing the FY 
2013 price index level for that cost category by the total market 
basket price index level. Third, we determine the FY 2013 relative 
importance for each cost category by multiplying this ratio by the base 
year (FY 2004) weight. Finally, we add the FY 2013 relative importance 
for each of the labor-related cost categories (wages and salaries, 
employee benefits, non-medical professional fees, labor-intensive 
services, and a portion of capital-related expenses) to produce the FY 
2013 labor-related relative importance. Tables 6 and 7 below show the 
RUG-IV case-mix adjusted Federal rates by labor-related and non-labor-
related components.

 Table 6--RUG-IV Case-Mix Adjusted Federal Rates for Urban SNFs by Labor
                         and Non-Labor Component
------------------------------------------------------------------------
                                                                  Non-
              RUG-IV category                 Total     Labor     labor
                                              rate     portion   portion
------------------------------------------------------------------------
RUX.......................................   $750.66   $513.32   $237.34
RUL.......................................    734.30    502.14    232.16
RVX.......................................    668.14    456.89    211.25
RVL.......................................    599.44    409.92    189.52
RHX.......................................    605.35    413.96    191.39
RHL.......................................    539.92    369.21    170.71
RMX.......................................    555.29    379.72    175.57
RML.......................................    509.49    348.40    161.09
RLX.......................................    487.67    333.48    154.19
RUC.......................................    569.08    389.15    179.93
RUB.......................................    569.08    389.15    179.93
RUA.......................................    475.84    325.39    150.45
RVC.......................................    488.21    333.85    154.36
RVB.......................................    422.77    289.10    133.67
RVA.......................................    421.14    287.99    133.15
RHC.......................................    425.41    290.91    134.50
RHB.......................................    382.88    261.82    121.06
RHA.......................................    337.08    230.51    106.57
RMC.......................................    373.72    255.56    118.16
RMB.......................................    350.82    239.90    110.92
RMA.......................................    288.66    197.39     91.27
RLB.......................................    363.35    248.47    114.88
RLA.......................................    234.12    160.10     74.02
ES3.......................................    685.33    468.65    216.68
ES2.......................................    536.47    366.85    169.62
ES1.......................................    479.22    327.71    151.51
HE2.......................................    462.86    316.52    146.34
HE1.......................................    384.34    262.82    121.52
HD2.......................................    433.41    296.38    137.03
HD1.......................................    361.44    247.16    114.28
HC2.......................................    408.88    279.60    129.28
HC1.......................................    341.81    233.74    108.07
HB2.......................................    403.97    276.25    127.72
HB1.......................................    338.54    231.50    107.04
LE2.......................................    420.33    287.43    132.90
LE1.......................................    351.62    240.45    111.17
LD2.......................................    403.97    276.25    127.72
LD1.......................................    338.54    231.50    107.04
LC2.......................................    354.89    242.68    112.21
LC1.......................................    299.28    204.66     94.62
LB2.......................................    336.90    230.38    106.52
LB1.......................................    286.19    195.71     90.48
CE2.......................................    374.52    256.11    118.41
CE1.......................................    345.08    235.98    109.10
CD2.......................................    354.89    242.68    112.21
CD1.......................................    325.45    222.55    102.90
CC2.......................................    310.73    212.49     98.24
CC1.......................................    287.83    196.83     91.00
CB2.......................................    287.83    196.83     91.00
CB1.......................................    266.56    182.28     84.28
CA2.......................................    243.66    166.62     77.04
CA1.......................................    227.30    155.43     71.87
BB2.......................................    258.38    176.69     81.69
BB1.......................................    246.93    168.86     78.07
BA2.......................................    214.22    146.49     67.73
BA1.......................................    204.40    139.77     64.63
PE2.......................................    345.08    235.98    109.10
PE1.......................................    328.72    224.79    103.93
PD2.......................................    325.45    222.55    102.90
PD1.......................................    309.09    211.37     97.72
PC2.......................................    279.65    191.23     88.42
PC1.......................................    266.56    182.28     84.28
PB2.......................................    237.12    162.15     74.97
PB1.......................................    227.30    155.43     71.87
PA2.......................................    196.22    134.18     62.04
PA1.......................................    188.04    128.59     59.45
------------------------------------------------------------------------


 Table 7--RUG-IV Case-Mix Adjusted Federal Rates for Rural SNFs by Labor
                         and Non-Labor Component
------------------------------------------------------------------------
                                                                  Non-
              RUG-IV category                 Total     Labor     labor
                                              rate     portion   portion
------------------------------------------------------------------------
RUX.......................................   $767.99   $525.17   $242.82
RUL.......................................    752.36    514.49    237.87
RVX.......................................    674.78    461.43    213.35
RVL.......................................    609.14    416.55    192.59
RHX.......................................    604.31    413.25    191.06
RHL.......................................    541.80    370.50    171.30
RMX.......................................    549.18    375.55    173.63
RML.......................................    505.42    345.62    159.80

[[Page 46223]]

 
RLX.......................................    478.00    326.87    151.13
RUC.......................................    594.52    406.55    187.97
RUB.......................................    594.52    406.55    187.97
RUA.......................................    505.44    345.64    159.80
RVC.......................................    502.87    343.88    158.99
RVB.......................................    440.36    301.13    139.23
RVA.......................................    438.80    300.06    138.74
RHC.......................................    432.41    295.69    136.72
RHB.......................................    391.77    267.90    123.87
RHA.......................................    348.01    237.98    110.03
RMC.......................................    375.71    256.92    118.79
RMB.......................................    353.83    241.96    111.87
RMA.......................................    294.45    201.35     93.10
RLB.......................................    359.23    245.65    113.58
RLA.......................................    235.77    161.23     74.54
ES3.......................................    661.84    452.59    209.25
ES2.......................................    519.63    355.34    164.29
ES1.......................................    464.93    317.93    147.00
HE2.......................................    449.30    307.24    142.06
HE1.......................................    374.29    255.95    118.34
HD2.......................................    421.17    288.01    133.16
HD1.......................................    352.41    240.99    111.42
HC2.......................................    397.73    271.98    125.75
HC1.......................................    333.65    228.16    105.49
HB2.......................................    393.04    268.77    124.27
HB1.......................................    330.53    226.03    104.50
LE2.......................................    408.67    279.46    129.21
LE1.......................................    343.03    234.57    108.46
LD2.......................................    393.04    268.77    124.27
LD1.......................................    330.53    226.03    104.50
LC2.......................................    346.16    236.71    109.45
LC1.......................................    293.02    200.38     92.64
LB2.......................................    328.97    224.96    104.01
LB1.......................................    280.52    191.83     88.69
CE2.......................................    364.91    249.54    115.37
CE1.......................................    336.78    230.30    106.48
CD2.......................................    346.16    236.71    109.45
CD1.......................................    318.03    217.48    100.55
CC2.......................................    303.96    207.86     96.10
CC1.......................................    282.08    192.89     89.19
CB2.......................................    282.08    192.89     89.19
CB1.......................................    261.77    179.01     82.76
CA2.......................................    239.89    164.04     75.85
CA1.......................................    224.26    153.36     70.90
BB2.......................................    253.95    173.66     80.29
BB1.......................................    243.01    166.18     76.83
BA2.......................................    211.76    144.81     66.95
BA1.......................................    202.38    138.39     63.99
PE2.......................................    336.78    230.30    106.48
PE1.......................................    321.15    219.61    101.54
PD2.......................................    318.03    217.48    100.55
PD1.......................................    302.40    206.79     95.61
PC2.......................................    274.27    187.55     86.72
PC1.......................................    261.77    179.01     82.76
PB2.......................................    233.64    159.77     73.87
PB1.......................................    224.26    153.36     70.90
PA2.......................................    194.57    133.05     61.52
PA1.......................................    186.75    127.71     59.04
------------------------------------------------------------------------

    Section 1888(e)(4)(G)(ii) of the Act also requires that we apply 
this wage index in a manner that does not result in aggregate payments 
that are greater or less than would otherwise be made in the absence of 
the wage adjustment. For FY 2013 (Federal rates effective October 1, 
2012), we apply an adjustment to fulfill the budget neutrality 
requirement. We meet this requirement by multiplying each of the 
components of the unadjusted Federal rates by a budget neutrality 
factor equal to the ratio of the weighted average wage adjustment 
factor for FY 2012 to the weighted average wage adjustment factor for 
FY 2013. For this calculation, we use the same 2011 claims utilization 
data for both the numerator and denominator of this ratio. We define 
the wage adjustment factor used in this calculation as the labor share 
of the rate component multiplied by the wage index plus the non-labor 
share of the rate component. The budget neutrality factor for this year 
is 1.0004. The wage index applicable to FY 2013 is set forth in Tables 
A and B, which appear in the Addendum of this notice, and is also 
available on the CMS Web site at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/WageIndex.html.
    In the SNF PPS final rule for FY 2006 (70 FR 45026, August 4, 
2005), we adopted the changes discussed in the OMB Bulletin No. 03-04 
(June 6, 2003), available online at www.whitehouse.gov/omb/bulletins/b03-04.html, which announced revised definitions for Metropolitan 
Statistical Areas (MSAs), and the creation of Micropolitan Statistical 
Areas and Combined Statistical Areas. In addition, OMB published 
subsequent bulletins regarding CBSA changes, including changes in CBSA 
numbers and titles. As indicated in the FY 2008 SNF PPS final rule (72 
FR 43423, August 3, 2007), this and all subsequent SNF PPS rules and 
notices are considered to incorporate the CBSA changes published in the 
most recent OMB bulletin that applies to the hospital wage data used to 
determine the current SNF PPS wage index. The OMB bulletins are 
available online at http://www.whitehouse.gov/omb/bulletins/index.html.
    In adopting the OMB CBSA geographic designations, we provided for a 
1-year transition with a blended wage index for all providers. For FY 
2006, the wage index for each provider consisted of a blend of 50 
percent of the FY 2006 MSA-based wage index and 50 percent of the FY 
2006 CBSA-based wage index (both using FY 2002 hospital data). We 
referred to the blended wage index as the FY 2006 SNF PPS transition 
wage index. As discussed in the SNF PPS final rule for FY 2006 (70 FR 
45041), subsequent to the expiration of this 1-year transition on 
September 30, 2006, we used the full CBSA-based wage index values, as 
now presented in Tables A and B in the Addendum of this notice.

D. Updates to the Federal Rates

    In accordance with section 1888(e)(4)(E) of the Act as amended by 
section 311 of the BIPA, and section 1888(e)(5)(B) of the Act as 
amended by section 3401(b) of the Affordable Care Act, the payment 
rates in this notice reflect an update equal to the full SNF market 
basket, estimated at 2.5 percentage points, reduced by the MFP 
adjustment. As discussed in sections II.G.2 and V.C of this notice, the 
annual update for FY 2013 includes a 0.7 percentage point reduction to 
account for the MFP adjustment described in the latter section, for a 
net update of 1.8 percent.

E. Relationship of Case-Mix Classification System to Existing Skilled 
Nursing Facility Level-of-Care Criteria

    As discussed in Sec.  413.345, we include in each update of the 
Federal payment rates in the Federal Register the designation of those 
specific RUGs under the classification system that represent the 
required SNF level of care, as provided in Sec.  409.30. As set forth 
in the FY 2011 SNF PPS update notice (75 FR 42910, July 22, 2010), this 
designation reflects an administrative presumption under the 66-group 
RUG-IV system that beneficiaries who are correctly assigned to one of 
the upper 52 RUG-IV groups on the initial 5-day, Medicare-required 
assessment are automatically classified as meeting the SNF level of 
care definition up to and including the assessment reference date on 
the 5-day Medicare-required assessment.
    A beneficiary assigned to any of the lower 14 RUG-IV groups is not 
automatically classified as either meeting or not meeting the 
definition, but instead receives an individual level of care 
determination using the existing administrative criteria. This 
presumption recognizes the strong likelihood that beneficiaries 
assigned to one of the upper 52 RUG-IV groups during the immediate 
post-hospital period require a covered level of care, which would be 
less likely for those beneficiaries assigned to one of the lower 14 
RUG-IV groups.
    In this notice, we continue to designate the upper 52 RUG-IV groups 
for purposes of this administrative presumption, consisting of all 
groups encompassed by the following RUG-IV categories:
     Rehabilitation plus Extensive Services;
     Ultra High Rehabilitation;
     Very High Rehabilitation;

[[Page 46224]]

     High Rehabilitation;
     Medium Rehabilitation;
     Low Rehabilitation;
     Extensive Services;
     Special Care High;
     Special Care Low; and,
     Clinically Complex.
    However, we note that this administrative presumption policy does 
not supersede the SNF's responsibility to ensure that its decisions 
relating to level of care are appropriate and timely, including a 
review to confirm that the services prompting the beneficiary's 
assignment to one of the upper 52 RUG-IV groups (which, in turn, serves 
to trigger the administrative presumption) are themselves medically 
necessary. As we explained in the FY 2000 SNF PPS final rule (64 FR 
41667, July 30, 1999), the administrative presumption:

* * * is itself rebuttable in those individual cases in which the 
services actually received by the resident do not meet the basic 
statutory criterion of being reasonable and necessary to diagnose or 
treat a beneficiary's condition (according to section 1862(a)(1) of 
the Act). Accordingly, the presumption would not apply, for example, 
in those situations in which a resident's assignment to one of the 
upper * * * groups is itself based on the receipt of services that 
are subsequently determined to be not reasonable and necessary.

    Moreover, we want to stress the importance of careful monitoring 
for changes in each patient's condition to determine the continuing 
need for Part A SNF benefits after the assessment reference date of the 
5-day assessment.

F. Example of Computation of Adjusted PPS Rates and SNF Payment

    Using the hypothetical SNF XYZ described below, Table 8 shows the 
adjustments made to the Federal per diem rates to compute the 
provider's actual per diem PPS payment under the described scenario. 
SNF XYZ's 12-month cost reporting period begins October 1, 2012. As 
illustrated in Table 8, SNF XYZ's total PPS payment would equal 
$41,149.70. We derive the Labor and Non-labor columns from Table 6.

                               Table 8--RUG-IV SNF XYZ: Located in Cedar Rapids, IA (Urban CBSA 16300) Wage Index: 0.8944
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              Adjusted                  Adjusted     Percent      Medicare
                  RUG-IV group                       Labor      Wage index     labor      Non-labor       rate      adjustment      days       Payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
RVX.............................................      $456.89       0.8944      $408.64      $211.25      $619.89      $619.89           14    $8,678.46
ES2.............................................       366.85       0.8944       328.11       169.62       497.73       497.73           30    14,931.90
RHA.............................................       230.51       0.8944       206.17       106.57       312.74       312.74           16     5,003.84
CC2 *...........................................       212.49       0.8944       190.05        98.24       288.29       657.30           10     6,573.00
BA2.............................................       146.49       0.8944       131.02        67.73       198.75       198.75           30     5,962.50
                                                                                                                               -------------------------
                                                  ...........  ...........  ...........  ...........  ...........  ...........          100    41,149.70
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Reflects a 128 percent adjustment from section 511 of the MMA.

IV. Monitoring Impact of FY 2012 Policy Changes and Certain SNF 
Practices

    In the FY 2012 SNF PPS final rule, we stated we would monitor the 
impact of certain FY 2012 policy changes on various aspects of the SNF 
PPS (76 FR 48498, August 8, 2011). Specifically, we have been 
monitoring the impact of the following FY 2012 policy changes:
     Recalibration of the FY 2011 SNF parity adjustment to 
align overall payments under RUG-IV with those under RUG-III.
     Allocation of group therapy time to pay more appropriately 
for group therapy services based on resource utilization and cost.
     Implementation of changes to the MDS 3.0 patient 
assessment instrument, most notably the introduction of the Change-of-
Therapy (COT) Other Medicare Required Assessment (OMRA).
    We have posted quarterly memos to the SNF PPS Web site which 
highlight some of the trends we have observed over a given time period. 
These memos may be accessed through the SNF PPS Web site at the 
following address: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/SNF_Monitoring.zip.
    Below, we provide a summary of the initial results derived from 
this monitoring effort.

A. RUG Distributions

    As stated in the FY 2012 SNF PPS final rule (76 FR 48493), the 
recalibration of the FY 2011 parity adjustment used 8 months of FY 2011 
data as the basis for the recalibration. We observed that case-mix 
utilization patterns continued to be consistent over the final 4 months 
of FY 2011 and would not have resulted in a significant difference in 
the calculated amount of the recalibrated parity adjustment. We have 
posted data illustrating the RUG-IV distribution of days for the 
entirety of FY 2011, as compared to the days distribution used to 
calculate the parity adjustment in the FY 2012 final rule, and the 
distribution of days for the first half of FY 2012, all of which may be 
found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/SNF_Monitoring.zip.
    Additionally, case-mix utilization observed during FY 2012 has not 
shown unanticipated changes in patient classification. Overall patient 
case mix is not significantly different from that observed in FY 2011. 
Table 9 below illustrates a breakdown of the SNF case-mix distribution 
of service days by the major RUG classification categories for the full 
year of FY 2011 and for the first half of FY 2012.

      Table 9--SNF Case-Mix Distributions by Major RUG-IV Category
------------------------------------------------------------------------
                                           FY 2011      Q1 & Q2  FY 2012
                                          (percent)         (percent)
------------------------------------------------------------------------
Rehabilitation Plus Extensive                      2.5               1.8
 Services...........................
Rehabilitation......................              87.9              88.5
Extensive Services..................               0.6               0.7
Special Care........................               4.6               5.0
Clinically Complex..................               2.5               2.3

[[Page 46225]]

 
Behavioral Symptoms and Cognitive                  0.4               0.3
 Performance........................
Reduced Physical Function...........               1.5               1.5
------------------------------------------------------------------------

As illustrated in Table 9, there have been small decreases in both the 
Rehabilitation Plus Extensive Services category and in the overall 
percentage of service days in a rehabilitation group, and increases in 
some of the medically-based RUG categories, most notably Special Care.
    It should be noted that the recalibration of the parity adjustment 
applied only to those RUG-IV groups connected to therapy 
(Rehabilitation Plus Extensive Services and Rehabilitation). This 
caused a shift in the hierarchy of nursing case-mix weights among the 
various RUG-IV groups. Since SNFs are permitted to ``index maximize'' 
when determining a resident's RUG classification (i.e., of those RUGs 
for which the resident qualifies, SNFs are permitted to choose the one 
with the highest per diem payment), it is possible that the 
aforementioned case-mix distribution shifts reflect residents that had 
previously been classified into therapy groups but now index maximize 
into nursing groups instead.
    While the overall percentage of resident days that classify into 
therapy groups has decreased slightly during the first half of FY 2012 
(possibly due in part to index maximization), the data show an increase 
in the percentage of service days at the highest therapy level (Ultra 
High Rehabilitation) in the first half of FY 2012. This is illustrated 
in Table 10 below.

 Table 10--SNF Case-Mix Distribution for Therapy RUG-IV Groups, by Minor
                        RUG-IV Therapy Categories
------------------------------------------------------------------------
                                           FY 2011      Q1 &  Q2 FY 2012
                                          (percent)         (percent)
------------------------------------------------------------------------
Ultra-High Rehabilitation (>= 720                 44.9              46.2
 minutes of therapy per week).......
Very-High Rehabilitation (500-719                 26.9              26.7
 minutes of therapy per week).......
High Rehabilitation (325-499 minutes              10.8              10.7
 of therapy per week)...............
Medium Rehabilitation (150-324                     7.6               6.6
 minutes of therapy per week).......
Low Rehabilitation (45-149 minutes                 0.1               0.1
 of therapy per week)...............
------------------------------------------------------------------------

>Although there have been decreases in the percentage of service days 
which classify into the Very High, High and Medium therapy RUG-IV 
categories, some of the decrease may be due to index maximization into 
the Special Care category.

B. Group Therapy Allocation

    To account more accurately for resource utilization and cost and to 
equalize the payment incentives across therapy modes, we allocated 
group therapy time beginning in FY 2012. We anticipated that this 
policy would result in some change to the type of therapy mode used for 
SNF residents. As noted in the section above, we have not observed any 
significant difference in patient case mix. However, as illustrated 
below in Table 11, providers have significantly changed the mode of 
therapy since our STRIVE study (2006-2007).

                                       Table 11--Mode of Therapy Provision
----------------------------------------------------------------------------------------------------------------
                                                                                                        Q1 &  Q2
                                                                   STRIVE (percent)       FY 2011       FY 2012
                                                                                         (percent)     (percent)
----------------------------------------------------------------------------------------------------------------
Individual.......................................................                74              91.8   99.5
Concurrent.......................................................                25               0.8    0.4
Group............................................................                <1               7.4    0.1
----------------------------------------------------------------------------------------------------------------

During FY 2011, we implemented the allocation of concurrent therapy 
without the allocation of group therapy and providers shifted from 
concurrent therapy to group therapy. During FY 2012, we implemented the 
allocation of group therapy, and data from the first and second 
quarters of FY 2012 indicate that facilities are providing individual 
therapy almost exclusively.

C. COT OMRA

    In FY 2012, we introduced a new assessment called the COT OMRA to 
capture more accurately the therapy services provided to SNF residents. 
Effective for services provided on or after October 1, 2011, SNFs are 
required to complete a COT OMRA for patients classified into a RUG-IV 
therapy category (and for patients receiving therapy services who are 
classified into a nursing RUG because of index maximization), whenever 
the intensity of therapy changes to such a degree that it would no 
longer reflect the RUG-IV classification and payment assigned for the 
patient based on the most recent assessment used for Medicare payment 
(76 FR 48525). An evaluation of the

[[Page 46226]]

necessity for a COT OMRA must be completed at the end of each COT 
observation period, which is a successive 7-day window beginning on the 
day following the ARD set for the most recent scheduled or unscheduled 
PPS assessment (or beginning the day therapy resumes in cases where an 
EOT-R OMRA is completed), and ending every seven calendar days 
thereafter. In cases where the resident's therapy has changed to such a 
degree that it is no longer consistent with the resident's current RUG-
IV classification, then the SNF must complete a COT OMRA to reclassify 
the resident into the appropriate RUG-IV category. The new RUG-IV group 
resulting from the COT OMRA is billed starting the first day of the 7-
day COT observation period for which the COT OMRA was completed and 
remains at this level until a new assessment is done that changes the 
patient's RUG-IV classification.
    Table 12 below shows the distribution of all MDS assessment types 
as a percentage of all MDS assessments. We note that the first half of 
FY 2012 included a transition period for the new policies and, 
therefore, may not be entirely representative of all of FY 2012.

             Table 12--Distribution of MDS Assessment Types
------------------------------------------------------------------------
                                           FY 2011      Q1 &  Q2 FY 2012
                                          (percent)         (percent)
------------------------------------------------------------------------
Scheduled PPS assessment............                95                84
Start-of-Therapy (SOT) OMRA.........                 2                 2
End-of-Therapy (EOT) OMRA (w/o                       3                 3
 Resumption)........................
Combined SOT/EOT OMRA...............                 0                 0
End-of-Therapy OMRA (w/Resumption)                 N/A                 0
 (EOT-R OMRA).......................
Combined SOT/EOT-R OMRA.............               N/A                 0
Change-of-Therapy (COT) OMRA........               N/A                11
------------------------------------------------------------------------

Prior to the implementation of the COT OMRA, scheduled PPS assessments 
comprised the vast majority of completed assessments. With the 
implementation of the COT OMRA for FY 2012, scheduled PPS assessments 
still comprise the vast majority of completed MDS assessments, though 
the COT OMRA is the most frequently completed OMRA. Information related 
to our continuing monitoring activities will be posted on the SNF PPS 
Web site at the following address: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/SNF_Monitoring.zip.
    Finally, while not related to the above-cited FY 2012 policy 
changes, our ongoing monitoring of the quality of care in SNFs also 
causes us to have concerns that some SNFs are using the practice of 
asking patients to sign binding arbitration agreements that require as 
a condition of admission that a patient resolve disputes with the 
facility through binding arbitration. We plan to monitor this closely 
and take action consistent with current rules and guidelines (including 
CMS Survey & Certification Letter S&C-03-10 dated January 9, 2003, 
available online at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCletter03-10.pdf), 
and consider rulemaking or any additional steps that may be 
appropriate.

V. The Skilled Nursing Facility Market Basket Index

    Section 1888(e)(5)(A) of the Act requires us to establish a SNF 
market basket index (input price index), that reflects changes over 
time in the prices of an appropriate mix of goods and services included 
in the SNF PPS. This notice incorporates the latest available 
projections of the SNF market basket index. Accordingly, we have 
developed a SNF market basket index that encompasses the most commonly 
used cost categories for SNF routine services, ancillary services, and 
capital-related expenses.
    Each year, we calculate a revised labor-related share based on the 
relative importance of labor-related cost categories in the input price 
index. Table 13 summarizes the updated labor-related share for FY 2013.

                        Table 13--Labor-Related Relative Importance, FY 2012 and FY 2013
----------------------------------------------------------------------------------------------------------------
                                                                Relative importance,      Relative importance,
                                                               labor-related, FY 2012    labor-related, FY 2013
                                                                   11:2 forecast *          12:2 forecast **
----------------------------------------------------------------------------------------------------------------
Wages and salaries..........................................                   50.129                    49.847
Employee benefits...........................................                   11.502                    11.532
Nonmedical professional fees................................                     1.31                     1.307
Labor-intensive services....................................                    3.394                     3.364
Capital-related (.391)......................................                    2.358                     2.333
                                                             ---------------------------------------------------
    Total...................................................                   68.693                    68.383
----------------------------------------------------------------------------------------------------------------
* Published in the Federal Register; based on the second-quarter 2011 IHS Global Insight Inc. forecast.
** Based on the second-quarter 2012 IHS Global Insight forecast, with historical data through the first-quarter
  2012.

A. Use of the Skilled Nursing Facility Market Basket Percentage

    Section 1888(e)(5)(B) of the Act defines the SNF market basket 
percentage as the percentage change in the SNF market basket index from 
the midpoint of the previous FY to the midpoint of the current FY. For 
the Federal rates established in this notice, we use the percentage 
change in the SNF market basket index to compute the update factor for 
FY 2013. This is based

[[Page 46227]]

on the IGI (formerly DRI-WEFA) second quarter 2012 forecast (with 
historical data through the first quarter 2012) of the FY 2013 
percentage increase in the FY 2004-based SNF market basket index for 
routine, ancillary, and capital-related expenses, which is used to 
compute the update factor in this notice. As discussed in section V.C 
of this notice, this market basket percentage change is reduced by the 
MFP adjustment as required by section 1888(e)(5)(B)(ii) of the Act. 
Finally, as discussed in section II.A of this notice, we no longer 
compute update factors to adjust a facility-specific portion of the SNF 
PPS rates, because the initial 3-phase transition period from facility-
specific to full Federal rates that started with cost reporting periods 
beginning in July 1998 has expired.

B. Market Basket Forecast Error Adjustment

    As discussed in the June 10, 2003, supplemental proposed rule (68 
FR 34768) and finalized in the August 4, 2003, final rule (68 FR 46057 
through 46059), the regulations at Sec.  413.337(d)(2) provide for an 
adjustment to account for market basket forecast error. The initial 
adjustment applied to the update of the FY 2003 rate for FY 2004, and 
took into account the cumulative forecast error for the period from FY 
2000 through FY 2002, resulting in an increase of 3.26 percent. 
Subsequent adjustments in succeeding FYs take into account the forecast 
error from the most recently available FY for which there is final 
data, and apply whenever the difference between the forecasted and 
actual change in the market basket exceeds a specified threshold. We 
originally used a 0.25 percentage point threshold for this purpose; 
however, for the reasons specified in the FY 2008 SNF PPS final rule 
(72 FR 43425, August 3, 2007), we adopted a 0.5 percentage point 
threshold effective with FY 2008. As discussed previously in section 
II.G.2 of this notice, as the difference between the estimated and 
actual amounts of increase in the market basket index for FY 2011 (the 
most recently available FY for which there is final data) does not 
exceed the 0.5 percentage point threshold, the payment rates for FY 
2013 do not include a forecast error adjustment.

C. Multifactor Productivity Adjustment

    Section 3401(b) of the Affordable Care Act requires that, in FY 
2012 (and in subsequent FYs), the market basket percentage under the 
SNF payment system as described in section 1888(e)(5)(B)(i) is to be 
reduced annually by the productivity adjustment described in section 
1886(b)(3)(B)(xi)(II) of the Act. Specifically, section 3401(a) of the 
Affordable Care Act amends section 1886(b)(3)(B) of the Act to add 
clause (xi)(II), which sets forth the definition of this productivity 
adjustment. The statute defines the productivity adjustment to be equal 
to the 10-year moving average of changes in annual economy-wide private 
nonfarm business multi-factor productivity (MFP) (as projected by the 
Secretary for the 10-year period ending with the applicable fiscal 
year, year, cost reporting period, or other annual period) (the ``MFP 
adjustment''). The Bureau of Labor Statistics (BLS) is the agency that 
publishes the official measure of private nonfarm business MFP. Please 
see http://www.bls.gov/mfp to obtain the BLS historical published MFP 
data.
    The projection of MFP is currently produced by IGI, an economic 
forecasting firm. In order to generate a forecast of MFP, IGI 
replicated the MFP measure calculated by the BLS, using a series of 
proxy variables derived from IGI's U.S. macroeconomic models. This 
process is described in greater detail in section III.F.3 of the FY 
2012 SNF PPS final rule (76 FR 48527-48529, August 8, 2011).
1. Incorporating the Multifactor Productivity Adjustment Into the 
Market Basket Update
    According to section 1888(e)(5)(A) of the Act, the Secretary 
``shall establish a skilled nursing facility market basket index that 
reflects changes over time in the prices of an appropriate mix of goods 
and services included in covered skilled nursing facility services.'' 
As described in section II.G.2 of this notice, we estimate the SNF PPS 
market basket percentage for FY 2013 under section 1888(e)(5)(B)(i) of 
the Act based on the FY 2004-based SNF market basket. Section 3401(b) 
of the Affordable Care Act amends section 1888(e)(5)(B) of the Act, in 
part, by adding a new clause (ii), which requires that for FY 2012 and 
each subsequent FY, after determining the market basket percentage 
described in section 1888(e)(5)(B)(i) of the Act, ``the Secretary shall 
reduce such percentage by the productivity adjustment described in 
section 1886(b)(3)(B)(xi)(II)'' (which we refer to as the MFP 
adjustment). Section 1888(e)(5)(B)(ii) of the Act further states that 
the reduction of the market basket percentage by the MFP adjustment may 
result in the market basket percentage being less than zero for a FY, 
and may result in payment rates under section 1888(e) of the Act for a 
FY being less than such payment rates for the preceding FY. Thus, if 
the application of the MFP adjustment to the market basket percentage 
calculated under section 1888(e)(5)(B)(i) results in an MFP-adjusted 
market basket percentage that is less than zero, then the annual update 
to the unadjusted Federal per diem rates under section 
1888(e)(4)(E)(ii) would be negative, and such rates would decrease 
relative to the prior FY.
    For the FY 2013 update, the MFP adjustment is calculated as the 10-
year moving average of changes in MFP for the period ending September 
30, 2013. In accordance with section 1888(e)(5)(B)(i) of the Act, the 
market basket percentage for FY 2013 for the SNF PPS is based on IGI's 
second quarter 2012 forecast of the FY 2004-based SNF market basket 
update, which is estimated to be 2.5 percent. In accordance with 
section 1888(e)(5)(B)(ii) of the Act (as added by section 3401(b) of 
the Affordable Care Act), this market basket percentage is then reduced 
by the MFP adjustment (the 10-year moving average of changes in MFP for 
the period ending September 30, 2013) of 0.7 percent, which is 
calculated as described above and based on IGI's second quarter 2012 
forecast. The resulting MFP-adjusted market basket update is equal to 
1.8 percent, or 2.5 percent less 0.7 percentage point.

D. Federal Rate Update Factor

    Section 1888(e)(4)(E)(ii)(IV) of the Act requires that the update 
factor used to establish the FY 2013 unadjusted Federal rates be at a 
level equal to the market basket percentage change. Accordingly, to 
establish the update factor, we determined the total growth from the 
average market basket level for the period of October 1, 2011 through 
September 30, 2012 to the average market basket level for the period of 
October 1, 2012 through September 30, 2013. Using this process, the 
market basket update factor for FY 2013 SNF PPS unadjusted Federal 
rates is 2.5 percent. As required by section 1888(e)(5)(B) of the Act, 
this market basket percentage is then reduced by the MFP adjustment 
(the 10-year moving average of changes in MFP for the period ending 
September 30, 2013) of 0.7 percent as described in section V.C. The 
resulting MFP-adjusted market basket update is equal to 1.8 percent, or 
2.5 percent less 0.7 percentage point. We used this MFP-adjusted market 
basket update factor to compute the SNF PPS rate shown in Tables 2 and 
3.

[[Page 46228]]

VI. Consolidated Billing

    Section 4432(b) of the BBA established a consolidated billing 
requirement that places with the SNF the Medicare billing 
responsibility for virtually all of the services that the SNF's 
residents receive, except for a small number of services that the 
statute specifically identifies as being excluded from this provision. 
As noted previously in section II of this notice, subsequent 
legislation enacted a number of modifications in the consolidated 
billing provision.
    Specifically, section 103 of the BBRA amended this provision by 
further excluding a number of individual ``high-cost, low-probability'' 
services, identified by Healthcare Common Procedure Coding System 
(HCPCS) codes, within several broader categories (chemotherapy and its 
administration, radioisotope services, and customized prosthetic 
devices) that otherwise remained subject to the provision. We discuss 
this BBRA amendment in greater detail in the proposed and final rules 
for FY 2001 (65 FR 19231 through 19232, April 10, 2000, and 65 FR 46790 
through 46795, July 31, 2000), as well as in Program Memorandum AB-00-
18 (Change Request 1070), issued March 2000, which is 
available online at www.cms.gov/transmittals/downloads/ab001860.pdf.
    Section 313 of the BIPA further amended this provision by repealing 
its Part B aspect; that is, its applicability to services furnished to 
a resident during a SNF stay that Medicare Part A does not cover. 
(However, physical therapy, occupational therapy, and speech-language 
pathology services remain subject to consolidated billing, regardless 
of whether the resident who receives these services is in a covered 
Part A stay.) We discuss this BIPA amendment in greater detail in the 
proposed and final rules for FY 2002 (66 FR 24020 through 24021, May 
10, 2001, and 66 FR 39587 through 39588, July 31, 2001).
    In addition, section 410 of the MMA amended this provision by 
excluding certain practitioner and other services furnished to SNF 
residents by RHCs and FQHCs. We discuss this MMA amendment in greater 
detail in the update notice for FY 2005 (69 FR 45818 through 45819, 
July 30, 2004), as well as in Medicare Learning Network (MLN) Matters 
article MM3575, which is available online at http://www.cms.gov/MLNMattersArticles/downloads/MM3575.pdf.
    Further, while not substantively revising the consolidated billing 
requirement itself, a related provision was enacted in the Medicare 
Improvements for Patients and Providers Act of 2008 (MIPPA, Pub. L. 
110-275). Specifically, section 149 of MIPPA amended section 
1834(m)(4)(C)(ii) of the Act to add subclause (VII), which adds SNFs 
(as defined in section 1819(a) of the Act) to the list of entities that 
can serve as a telehealth ``originating site'' (that is, the location 
at which an eligible individual can receive, through a 
telecommunications system, services of a physician or other 
practitioner who is located elsewhere at a ``distant site'').
    As explained in the Medicare Physician Fee Schedule (PFS) final 
rule for calendar year (CY) 2009 (73 FR 69726, 69879, November 19, 
2008), a telehealth originating site receives a facility fee which is 
always separately payable under Part B outside of any other payment 
methodology. Section 149(b) of MIPPA amended section 1888(e)(2)(A)(ii) 
of the Act to exclude telehealth services furnished under section 
1834(m)(4)(C)(ii)(VII) of the Act from the definition of ``covered 
skilled nursing facility services'' that are paid under the SNF PPS. 
Thus, a SNF `` * * * can receive separate payment for a telehealth 
originating site facility fee even in those instances where it also 
receives a bundled per diem payment under the SNF PPS for a resident's 
covered Part A stay'' (73 FR 69881). By contrast, under section 
1834(m)(2)(A) of the Act, a telehealth distant site service is payable 
under Part B to an eligible physician or practitioner only to the same 
extent that it would have been so payable if furnished without the use 
of a telecommunications system. Thus, as explained in the CY 2009 
Physician Fee Schedule final rule (73 FR 69726, 69880), eligible 
distant site physicians or practitioners can receive payment for a 
telehealth service that they furnish

* * * only if the service is separately payable under the PFS when 
furnished in a face-to-face encounter at that location. For example, 
we pay distant site physicians or practitioners for furnishing 
services via telehealth only if such services are not included in a 
bundled payment to the facility that serves as the originating site 
(73 FR 69880).

This means that in those situations where a SNF serves as the 
telehealth originating site, the distant site professional services 
would be separately payable under Part B only to the extent that they 
are not already included in the SNF PPS bundled per diem payment and 
subject to consolidated billing. Thus, for a type of practitioner whose 
services are not otherwise excluded from consolidated billing when 
furnished during a face-to-face encounter, the use of a telehealth 
distant site would not serve to unbundle those services. In fact, 
consolidated billing does exclude the professional services of 
physicians, along with those of most of the other types of telehealth 
practitioners that the law specifies at section 1842(b)(18)(C) of the 
Act; that is, physician assistants, nurse practitioners, clinical nurse 
specialists, certified registered nurse anesthetists, certified nurse 
midwives, and clinical psychologists (see section 1888(e)(2)(A)(ii) of 
the Act and 42 CFR 411.15(p)(2)). However, the services of clinical 
social workers, registered dietitians and nutrition professionals 
remain subject to consolidated billing when furnished to a SNF's Part A 
resident and, thus, cannot qualify for separate Part B payment as 
telehealth distant site services in this situation. Additional 
information on this provision appears in MLN Matters article 
MM6215, which is available online at http://www.cms.gov/MLNMattersArticles/downloads/MM6215.pdf. To date, the Congress has 
enacted no further legislation affecting the consolidated billing 
provision.

VII. Application of the SNF PPS to SNF Services Furnished by Swing-Bed 
Hospitals

    In accordance with section 1888(e)(7) of the Act, as amended by 
section 203 of the BIPA, Part A pays critical access hospitals (CAHs) 
on a reasonable cost basis for SNF services furnished under a swing-bed 
agreement. However, effective with cost reporting periods beginning on 
or after July 1, 2002, the swing-bed services of non-CAH rural 
hospitals are paid under the SNF PPS. As explained in the final rule 
for FY 2002 (66 FR 39562, July 31, 2001), we selected this effective 
date consistent with the statutory provision to integrate swing-bed 
rural hospitals into the SNF PPS by the end of the SNF transition 
period, June 30, 2002.
    Accordingly, all non-CAH swing-bed rural hospitals have come under 
the SNF PPS as of June 30, 2003. Therefore, all rates and wage indexes 
outlined in earlier sections of this notice for the SNF PPS also apply 
to all non-CAH swing-bed rural hospitals. A complete discussion of 
assessment schedules, the MDS and the transmission software (RAVEN-SB 
for Swing Beds) appears in the final rule for FY 2002 (66 FR 39562, 
July 31, 2001) and in the final rule for FY 2010 (74 FR 40288, August 
11, 2009). As finalized in the FY 2010 SNF PPS final rule (74 FR 40356-
57), effective October 1, 2010, non-CAH swing-bed rural hospitals are 
required to complete an MDS 3.0 swing-bed

[[Page 46229]]

assessment which is limited to the required demographic, payment, and 
quality items. The latest changes in the MDS for swing-bed rural 
hospitals appear on the SNF PPS Web site, http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html.

VIII. Collection of Information Requirements

    This notice does not impose any new or revised information 
collection or recordkeeping requirements. The information collection 
requirements referenced in this notice with regard to resident 
assessment information used to determine facility payments are 
currently approved under OCN 0938-0739 (which relates to the Medicare 
PPS Assessment Form (MPAF) information collection) and OCN 0938-0872 
(which relates to the Minimum Data Set for Swing-Bed Hospitals), 
neither of which is affected by this notice. This notice, OCN: 0938-
0739, and OCN: 0938-0872 do not impose any burden requiring additional 
Office of Management and Budget review under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

IX. Waiver of Notice and Comment

    We would ordinarily publish a notice of proposed rulemaking in the 
Federal Register to provide a period for public comment, followed by a 
final rule. However, we can waive this procedure 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 the 
finding and its reasons in the notice issued. In this instance, we have 
found good cause to waive notice and comment rulemaking and are issuing 
this update notice.
    We believe it is unnecessary to undertake notice and comment 
rulemaking in this instance, as the statute requires annual updates to 
the SNF PPS rates, the methodologies used to update the rates in this 
notice have been previously subject to public comment and finalized, 
and this notice initiates no policy changes with regard to the SNF PPS, 
but simply reflects application of previously established 
methodologies. Therefore, we find good cause to waive notice and 
comment procedures.

X. Economic Analyses

A. Regulatory Impact Analysis

1. Introduction
    We have examined the impacts of this notice as required by 
Executive Order 12866 on Regulatory Planning and Review (September 30, 
1993), Executive Order 13563 on Improving Regulation and Regulatory 
Review (January 18, 2011), the Regulatory Flexibility Act (RFA) 
(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Act, 
section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA, March 
22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 
4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)).
    Executive Orders 12866 and 13563 direct 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). Executive 
Order 13563 emphasizes the importance of quantifying both costs and 
benefits, of reducing costs, of harmonizing rules, and of promoting 
flexibility. This notice has been designated an economically 
significant rule, under section 3(f)(1) of Executive Order 12866. 
Accordingly, we have prepared a regulatory impact analysis (RIA) as 
further discussed below. Also, the rule has been reviewed by the Office 
of Management and Budget.
2. Statement of Need
    This notice updates the SNF prospective payment rates for FY 2013 
as required under section 1888(e)(4)(E) of the Act. It also responds to 
section 1888(e)(4)(H) of the Act, which requires the Secretary to 
``provide for publication in the Federal Register'' before August 1 
that precedes the start of each fiscal year, the unadjusted Federal per 
diem rates, the case-mix classification system, and the factors to be 
applied in making the area wage adjustment. As these statutory 
provisions prescribe a detailed methodology for calculating and 
disseminating payment rates under the SNF PPS, we do not have the 
discretion to adopt an alternative approach.
3. Overall Impacts
    This notice sets forth updates of the SNF PPS rates contained in 
the final rule for FY 2012 (76 FR 48486, August 8, 2011). Based on the 
above, we estimate that the aggregate impact would be an increase of 
$670 million in payments to SNFs, resulting from the MFP-adjusted 
market basket update to the payment rates. The impact analysis of this 
notice represents the projected effects of the changes in the SNF PPS 
from FY 2012 to FY 2013. Although the best data available are utilized, 
there is no attempt to predict behavioral responses to these changes, 
or to make adjustments for future changes in such variables as days or 
case-mix.
    Certain events may occur to limit the scope or accuracy of our 
impact analysis, as this analysis is future-oriented and, thus, very 
susceptible to forecasting errors due to certain events that may occur 
within the assessed impact time period. Some examples of possible 
events may include newly-legislated general Medicare program funding 
changes by the Congress, or changes specifically related to SNFs. In 
addition, changes to the Medicare program may continue to be made as a 
result of previously-enacted legislation, or new statutory provisions. 
Although these changes may not be specific to the SNF PPS, the nature 
of the Medicare program is such that the changes may interact and, 
thus, the complexity of the interaction of these changes could make it 
difficult to predict accurately the full scope of the impact upon SNFs.
    In accordance with section 1888(e)(4)(E) and (e)(5) of the Act, we 
update the FY 2012 payment rates by a factor equal to the market basket 
index percentage change adjusted by the FY 2011 forecast error 
adjustment (if applicable) and the MFP adjustment to determine the 
payment rates for FY 2013. As discussed previously, for FY 2012 and 
each subsequent FY, as required by section 1888(e)(5)(B) of the Act as 
amended by section 3401(b) of the Affordable Care Act, the market 
basket percentage is reduced by the MFP adjustment. The special AIDS 
add-on established by section 511 of the MMA remains in effect until 
``* * * such date as the Secretary certifies that there is an 
appropriate adjustment in the case mix * * * .'' We have not provided a 
separate impact analysis for the MMA provision. Our latest estimates 
indicate that there are fewer than 3,800 beneficiaries who qualify for 
the AIDS add-on payment. The impact to Medicare is included in the 
``total'' column of Table 14. In updating the rates for FY 2013, we 
made a number of standard annual revisions and clarifications mentioned 
elsewhere in this notice (for example, the update to the wage and 
market basket indexes used for adjusting the Federal rates).
    The update set forth in this notice applies to payments in FY 2013. 
Accordingly, the analysis that follows only describes the impact of 
this single year. In accordance with the requirements of the Act, we 
will publish a notice or rule for each subsequent FY that will provide 
for an update to the payment rates and include an associated impact 
analysis.

[[Page 46230]]

4. Detailed Economic Analysis
    The FY 2013 impacts appear in Table 14. The breakdown of the 
various categories of data in the table follows.
    The first column shows the breakdown of all SNFs by urban or rural 
status, hospital-based or freestanding status, census region, and 
ownership.
    The first row of figures describes the estimated effects of the 
various changes on all facilities. The next six rows show the effects 
on facilities split by hospital-based, freestanding, urban, and rural 
categories. The urban and rural designations are based on the location 
of the facility under the CBSA designation. The next nineteen rows show 
the effects on facilities by urban versus rural status by census 
region. The last three rows show the effects on facilities by ownership 
(i.e., government, profit, and non-profit status).
    The second column in the table shows the number of facilities in 
the impact database.
    The third column of the table shows the effect of the annual update 
to the wage index. This represents the effect of using the most recent 
wage data available. The total impact of this change is zero percent; 
however, there are distributional effects of the change.
    The fourth column shows the effect of all of the changes on the FY 
2013 payments. The update of 1.8 percent (consisting of the market 
basket increase of 2.5 percentage points, reduced by the 0.7 percentage 
point MFP adjustment) is constant for all providers and, though not 
shown individually, is included in the total column. It is projected 
that aggregate payments will increase by 1.8 percent, assuming 
facilities do not change their care delivery and billing practices in 
response.
    As can be seen from Table 14, the combined effects of all of the 
changes vary by specific types of providers and by location. Though all 
facilities would experience payment increases, the amount of the 
overall increase varies due to the impact of the wage index update. The 
wage index change can adjust the overall impact of the 1.8 percent 
update upward or downward. For example, providers in the urban New 
England region would experience a 2.6 percent increase in FY 2013 total 
payments. The increase for this region differs from the aggregate 1.8 
percent update due to the distributional effect of the wage index 
update as shown in the third column.

                          Table 14--RUG-IV Projected Impact to the SNF PPS for FY 2013
----------------------------------------------------------------------------------------------------------------
                                                                     Number of                     Total FY 2013
                                                                   facilities FY    Update wage       change
                                                                       2013       data (percent)     (percent)
----------------------------------------------------------------------------------------------------------------
Group:
    Total.......................................................          15,407             0.0             1.8
    Urban.......................................................          10,568             0.1             1.9
    Rural.......................................................           4,839            -0.3             1.5
    Hospital based urban........................................             761            -0.1             1.7
    Freestanding urban..........................................           9,807             0.1             1.9
    Hospital based rural........................................             428            -0.1             1.7
    Freestanding rural..........................................           4,411            -0.3             1.5
Urban by region:
    New England.................................................             811             0.8             2.6
    Middle Atlantic.............................................           1,456             0.0             1.8
    South Atlantic..............................................           1,747            -0.3             1.5
    East North Central..........................................           2,043             0.2             2.0
    East South Central..........................................             518            -1.0             0.8
    West North Central..........................................             870             0.5             2.3
    West South Central..........................................           1,224            -0.3             1.5
    Mountain....................................................             482            -0.9             0.9
    Pacific.....................................................           1,411             0.9             2.7
    Outlying....................................................               6             0.2             2.0
Rural by region:
    New England.................................................             152            -0.9             0.9
    Middle Atlantic.............................................             262            -0.1             1.7
    South Atlantic..............................................             611            -0.7             1.1
    East North Central..........................................             935             0.3             2.1
    East South Central..........................................             558            -0.4             1.4
    West North Central..........................................           1,120            -0.9             0.9
    West South Central..........................................             822             0.3             2.1
    Mountain....................................................             250             0.3             2.1
    Pacific.....................................................             129            -1.4             0.3
Ownership:
    Government..................................................             805             0.1             1.9
    Profit......................................................          10,742             0.0             1.8
    Non-profit..................................................           3,860             0.1             1.9
----------------------------------------------------------------------------------------------------------------
Note: The Total column includes the 2.5 percent market basket increase, reduced by the 0.7 percentage point MFP
  adjustment. Additionally, we found no SNFs in rural outlying areas.

5. Alternatives Considered
    As described above, we estimate that the aggregate impact for FY 
2013 would be an increase of $670 million in payments to SNFs, 
resulting from the MFP-adjusted market basket update to the payment 
rates.
    Section 1888(e) of the Act establishes the SNF PPS for the payment 
of Medicare SNF services for cost reporting periods beginning on or 
after July 1, 1998. This section of the statute prescribes a detailed 
formula for calculating payment rates under the SNF PPS, and does not 
provide for the use of any alternative methodology. It specifies that 
the base year cost data to

[[Page 46231]]

be used for computing the SNF PPS payment rates must be from FY 1995 
(October 1, 1994, through September 30, 1995). In accordance with the 
statute, we also incorporated a number of elements into the SNF PPS 
(for example, case-mix classification methodology, a market basket 
index, a wage index, and the urban and rural distinction used in the 
development or adjustment of the Federal rates). Further, section 
1888(e)(4)(H) of the Act specifically requires us to disseminate the 
payment rates for each new FY through the Federal Register, and to do 
so before the August 1 that precedes the start of the new FY. 
Accordingly, we are not pursuing alternatives with respect to the 
payment methodology as discussed above.
6. Accounting Statement
    As required by OMB Circular A-4 (available online at 
www.whitehouse.gov/sites/default/files/omb/assets/regulatory_matters_pdf/a-4.pdf), in Table 15, we have prepared an accounting statement 
showing the classification of the expenditures associated with the 
provisions of this notice. Table 15 provides our best estimate of the 
possible changes in Medicare payments under the SNF PPS as a result of 
the policies in this notice, based on the data for 15,407 SNFs in our 
database. All expenditures are classified as transfers to Medicare 
providers (that is, SNFs).

       TABLE 15--Accounting Statement: Classification of Estimated
   Expenditures, From the 2012 SNF PPS Fiscal Year to the 2013 SNF PPS
                               Fiscal Year
------------------------------------------------------------------------
             Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers....  670 million.*
From Whom To Whom?................  Federal Government to SNF Medicare
                                     Providers.
------------------------------------------------------------------------
* The net increase of $670 million in transfer payments is a result of
  the MFP-adjusted market basket increase of $670 million.

7. Conclusion
    This notice sets forth updates of the SNF PPS rates contained in 
the final rule for FY 2012 (76 FR 48486, August 8, 2011). Based on the 
above, we estimate the overall estimated payments for SNFs in FY 2013 
are projected to increase by $670 million, or 1.8 percent, compared 
with those in FY 2012. We estimate that in FY 2013 under RUG-IV, SNFs 
in urban and rural areas would experience, on average, a 1.9 and 1.5 
percent increase, respectively, in estimated payments compared with FY 
2012. Providers in the urban Pacific region would experience the 
largest estimated increase in payments of approximately 2.7 percent. 
Rural Pacific providers would experience the smallest estimated 
increase in payments of 0.3 percent.

B. Regulatory Flexibility Act Analysis

    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. For purposes of the RFA, small entities 
include small businesses, non-profit organizations, and small 
governmental jurisdictions. Most SNFs and most other providers and 
suppliers are small entities, either by their non-profit status or by 
having revenues of $13.5 million or less in any 1 year. For purposes of 
the RFA, approximately 91 percent of SNFs are considered small 
businesses according to the Small Business Administration's latest size 
standards, with total revenues of $13.5 million or less in any 1 year. 
(For details, see the Small Business Administration's Web site at 
http://www.sba.gov/category/navigation-structure/contracting/contracting-officials/eligibility-size-standards). Individuals and 
States are not included in the definition of a small entity. In 
addition, approximately 25 percent of SNFs classified as small entities 
are non-profit organizations. Finally, the estimated number of small 
business entities does not distinguish provider establishments that are 
within a single firm and, therefore, the number of SNFs classified as 
small entities may be higher than the estimate above.
    This notice sets forth updates of the SNF PPS rates contained in 
the final rule for FY 2012 (76 FR 48486, August 8, 2011). Based on the 
above, we estimate that the aggregate impact would be an increase of 
$670 million in payments to SNFs, resulting from the MFP-adjusted 
market basket update to the payment rates. While it is projected in 
Table 14 that all providers would experience a net increase in 
payments, we note that some individual providers may experience larger 
increases in payments than others due to the distributional impact of 
the FY 2013 wage indexes and the degree of Medicare utilization.
    Guidance issued by the Department of Health and Human Services on 
the proper assessment of the impact on small entities in rulemakings, 
utilizes a cost or revenue impact of 3 to 5 percent as a significance 
threshold under the RFA. According to MedPAC, Medicare covers 
approximately 12 percent of total patient days in freestanding 
facilities and 23 percent of facility revenue (March 2012). However, it 
is worth noting that the distribution of days and payments is highly 
variable. That is, the majority of SNFs have significantly lower 
Medicare utilization. As a result, for most facilities, when all payers 
are included in the revenue stream, the overall impact on total 
revenues should be substantially less than those impacts presented in 
Table 14. As indicated in Table 14, the effect on facilities is 
projected to be an aggregate positive impact of 1.8 percent. 
Additionally, as discussed in the FY 2012 final rule (76 FR 48539), 
given the high proportion of SNFs that constitute small entities, any 
discussion of the impacts on the SNF industry as a whole may be 
directly characterized as an analysis of the impact of this notice on 
small entities. As the overall impact on the industry as a whole, and 
thus on small entities specifically, is less than the 3 to 5 percent 
threshold discussed above, the Secretary has determined that this 
notice would not have a significant impact on a substantial number of 
small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a Metropolitan 
Statistical Area and has fewer than 100 beds. This notice would affect 
small rural hospitals that (a) furnish SNF services under a swing-bed 
agreement or (b) have a hospital-based SNF. We anticipate that the 
impact on small rural hospitals would be similar to the impact on SNF 
providers overall. Moreover, as noted in the FY 2012 final rule (76 FR 
48539), the category of small rural hospitals would be included within 
the analysis of the impact of this

[[Page 46232]]

notice on small entities in general. As indicated in Table 14, the 
effect on facilities is projected to be an aggregate positive impact of 
1.8 percent. As a result, the Secretary has determined that this notice 
would not have a significant impact on a substantial number of small 
rural hospitals.

C. Unfunded Mandates Reform Act Analysis

    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2012, that 
threshold is approximately $139 million. This notice would not impose 
spending costs on State, local, or tribal governments in the aggregate, 
or by the private sector, of $139 million.

D. Federalism Analysis

    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that impose substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. This notice would have no substantial direct effect on 
State and local governments, preempt State law, or otherwise have 
Federalism implications.

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

    Dated: April 17, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: July 24, 2012.
Kathleen Sebelius,
Secretary.

Addendum--FY 2013 CBSA Wage Index Tables

    In this addendum, we provide the wage index tables referred to in 
the preamble to this notice. Tables A and B display the CBSA-based wage 
index values for urban and rural providers.

 Table A--FY 2013 Wage Index for Urban Areas Based on CBSA Labor Market
                                  Areas
------------------------------------------------------------------------
                                        Urban area
           CBSA code              (constituent counties)    Wage index
------------------------------------------------------------------------
10180..........................  Abilene, TX............          0.8324
                                 Callahan County, TX
                                 Jones County, TX
                                 Taylor County, TX
10380..........................  Aguadilla-Isabela-San            0.3532
                                  Sebasti[aacute]n, PR.
                                 Aguada Municipio, PR
                                 Aguadilla Municipio, PR
                                 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..............          0.8729
                                 Portage County, OH
                                 Summit County, OH
10500..........................  Albany, GA.............          0.8435
                                 Baker County, GA
                                 Dougherty County, GA
                                 Lee County, GA
                                 Terrell County, GA
                                 Worth County, GA
10580..........................  Albany-Schenectady-              0.8647
                                  Troy, NY.
                                 Albany County, NY
                                 Rensselaer County, NY
                                 Saratoga County, NY
                                 Schenectady County, NY
                                 Schoharie County, NY
10740..........................  Albuquerque, NM........          0.9542
                                 Bernalillo County, NM
                                 Sandoval County, NM
                                 Torrance County, NM
                                 Valencia County, NM
10780..........................  Alexandria, LA.........          0.7857
                                 Grant Parish, LA
                                 Rapides Parish, LA
10900..........................  Allentown-Bethlehem-             0.9084
                                  Easton, PA-NJ.
                                 Warren County, NJ
                                 Carbon County, PA
                                 Lehigh County, PA
                                 Northampton County, PA
11020..........................  Altoona, PA............          0.8898
                                 Blair County, PA
11100..........................  Amarillo, TX...........          0.8506
                                 Armstrong County, TX
                                 Carson County, TX
                                 Potter County, TX
                                 Randall County, TX

[[Page 46233]]

 
11180..........................  Ames, IA...............          0.9595
                                 Story County, IA
11260..........................  Anchorage, AK..........          1.2147
                                 Anchorage Municipality,
                                  AK
                                 Matanuska-Susitna
                                  Borough, AK
11300..........................  Anderson, IN...........          0.9547
                                 Madison County, IN
11340..........................  Anderson, SC...........          0.8929
                                 Anderson County, SC
11460..........................  Ann Arbor, MI..........          1.0115
                                 Washtenaw County, MI
11500..........................  Anniston-Oxford, AL....          0.7539
                                 Calhoun County, AL
11540..........................  Appleton, WI...........          0.9268
                                 Calumet County, WI
                                 Outagamie County, WI
11700..........................  Asheville, NC..........          0.8555
                                 Buncombe County, NC
                                 Haywood County, NC
                                 Henderson County, NC
                                 Madison County, NC
12020..........................  Athens-Clarke County,            0.9488
                                  GA.
                                 Clarke County, GA
                                 Madison County, GA
                                 Oconee County, GA
                                 Oglethorpe County, GA
12060..........................  Atlanta-Sandy Springs-           0.9517
                                  Marietta, GA.
                                 Barrow County, GA
                                 Bartow County, GA
                                 Butts County, GA
                                 Carroll County, GA
                                 Cherokee County, GA
                                 Clayton County, GA
                                 Cobb County, GA
                                 Coweta County, GA
                                 Dawson County, GA
                                 DeKalb County, GA
                                 Douglas County, GA
                                 Fayette County, GA
                                 Forsyth County, GA
                                 Fulton County, GA
                                 Gwinnett County, GA
                                 Haralson County, GA
                                 Heard County, GA
                                 Henry County, GA
                                 Jasper County, GA
                                 Lamar County, GA
                                 Meriwether County, GA
                                 Newton County, GA
                                 Paulding County, GA
                                 Pickens County, GA
                                 Pike County, GA
                                 Rockdale County, GA
                                 Spalding County, GA
                                 Walton County, GA
12100..........................  Atlantic City-                   1.1977
                                  Hammonton, NJ.
                                 Atlantic County, NJ
12220..........................  Auburn-Opelika, AL.....          0.7437
                                 Lee County, AL
12260..........................  Augusta-Richmond                 0.9373
                                  County, GA-SC.
                                 Burke County, GA
                                 Columbia County, GA
                                 McDuffie County, GA
                                 Richmond County, GA
                                 Aiken County, SC
                                 Edgefield County, SC
12420..........................  Austin-Round Rock, TX..          0.9746
                                 Bastrop County, TX
                                 Caldwell County, TX
                                 Hays County, TX
                                 Travis County, TX

[[Page 46234]]

 
                                 Williamson County, TX
12540..........................  Bakersfield, CA........          1.1611
                                 Kern County, CA
12580..........................  Baltimore-Towson, MD...          1.0147
                                 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.............          1.0184
                                 Penobscot County, ME
12700..........................  Barnstable Town, MA....          1.2843
                                 Barnstable County, MA
12940..........................  Baton Rouge, LA........          0.8147
                                 Ascension Parish, LA
                                 East Baton Rouge
                                  Parish, LA
                                 East Feliciana Parish,
                                  LA
                                 Iberville Parish, LA
                                 Livingston Parish, LA
                                 Pointe Coupee Parish,
                                  LA
                                 St. Helena Parish, LA
                                 West Baton Rouge
                                  Parish, LA
                                 West Feliciana Parish,
                                  LA
12980..........................  Battle Creek, MI.......          0.9912
                                 Calhoun County, MI
13020..........................  Bay City, MI...........          0.9181
                                 Bay County, MI
13140..........................  Beaumont-Port Arthur,            0.8533
                                  TX.
                                 Hardin County, TX
                                 Jefferson County, TX
                                 Orange County, TX
13380..........................  Bellingham, WA.........          1.1415
                                 Whatcom County, WA
13460..........................  Bend, OR...............          1.1119
                                 Deschutes County, OR
13644..........................  Bethesda-Frederick-              1.0374
                                  Gaithersburg, MD.
                                 Frederick County, MD
                                 Montgomery County, MD
13740..........................  Billings, MT...........          0.8737
                                 Carbon County, MT
                                 Yellowstone County, MT
13780..........................  Binghamton, NY.........          0.8707
                                 Broome County, NY
                                 Tioga County, NY
13820..........................  Birmingham-Hoover, AL..          0.8516
                                 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...........          0.7261
                                 Burleigh County, ND
                                 Morton County, ND
13980..........................  Blacksburg-                      0.8348
                                  Christiansburg-
                                  Radford, VA.
                                 Giles County, VA
                                 Montgomery County, VA
                                 Pulaski County, VA
                                 Radford City, VA
14020..........................  Bloomington, IN........          0.8752
                                 Greene County, IN
                                 Monroe County, IN
                                 Owen County, IN
14060..........................  Bloomington-Normal, IL.          0.9502
                                 McLean County, IL
14260..........................  Boise City-Nampa, ID...          0.8897
                                 Ada County, ID
                                 Boise County, ID

[[Page 46235]]

 
                                 Canyon County, ID
                                 Gem County, ID
                                 Owyhee County, ID
14484..........................  Boston-Quincy, MA......          1.2378
                                 Norfolk County, MA
                                 Plymouth County, MA
                                 Suffolk County, MA
14500..........................  Boulder, CO............          1.0574
                                 Boulder County, CO
14540..........................  Bowling Green, KY......          0.8665
                                 Edmonson County, KY
                                 Warren County, KY
14740..........................  Bremerton-Silverdale,            1.0829
                                  WA.
                                 Kitsap County, WA
14860..........................  Bridgeport-Stamford-             1.3170
                                  Norwalk, CT.
                                 Fairfield County, CT
15180..........................  Brownsville-Harlingen,           0.8612
                                  TX.
                                 Cameron County, TX
15260..........................  Brunswick, GA..........          0.8792
                                 Brantley County, GA
                                 Glynn County, GA
                                 McIntosh County, GA
15380..........................  Buffalo-Niagara Falls,           0.9999
                                  NY.
                                 Erie County, NY
                                 Niagara County, NY
15500..........................  Burlington, NC.........          0.8485
                                 Alamance County, NC
15540..........................  Burlington-South                 0.9997
                                  Burlington, VT.
                                 Chittenden County, VT
                                 Franklin County, VT
                                 Grand Isle County, VT
15764..........................  Cambridge-Newton-                1.1262
                                  Framingham, MA.
                                 Middlesex County, MA
15804..........................  Camden, NJ.............          1.0474
                                 Burlington County, NJ
                                 Camden County, NJ
                                 Gloucester County, NJ
15940..........................  Canton-Massillon, OH...          0.8834
                                 Carroll County, OH
                                 Stark County, OH
15980..........................  Cape Coral-Fort Myers,           0.9153
                                  FL.
                                 Lee County, FL
16020..........................  Cape Girardeau-Jackson,          0.8860
                                  MO-IL.
                                 Alexander County, IL
                                 Bollinger County, MO
                                 Cape Girardeau County,
                                  MO
16180..........................  Carson City, NV........          1.0559
                                 Carson City, NV
16220..........................  Casper, WY.............          1.0143
                                 Natrona County, WY.....
16300..........................  Cedar Rapids, IA.......          0.8944
                                 Benton County, IA......
                                 Jones County, IA.......
                                 Linn County, IA........
16580..........................  Champaign-Urbana, IL...          0.9907
                                 Champaign County, IL...
                                 Ford County, IL........
                                 Piatt County, IL.......
16620..........................  Charleston, WV.........          0.8050
                                 Boone County, WV.......
                                 Clay County, WV........
                                 Kanawha County, WV.....
                                 Lincoln County, WV.....
                                 Putnam County, WV......
16700..........................  Charleston-North                 0.8820
                                  Charleston-
                                  Summerville, SC.
                                 Berkeley County, SC....
                                 Charleston County, SC..
                                 Dorchester County, SC..

[[Page 46236]]

 
16740..........................  Charlotte-Gastonia-              0.9215
                                  Concord, NC-SC.
                                 Anson County, NC.......
                                 Cabarrus County, NC....
                                 Gaston County, NC......
                                 Mecklenburg County, NC.
                                 Union County, NC.......
                                 York County, SC........
16820..........................  Charlottesville, VA....          0.9195
                                 Albemarle County, VA...
                                 Fluvanna County, VA....
                                 Greene County, VA......
                                 Nelson County, VA......
                                 Charlottesville City,
                                  VA.
16860..........................  Chattanooga, TN-GA.....          0.8678
                                 Catoosa County, GA.....
                                 Dade County, GA........
                                 Walker County, GA......
                                 Hamilton County, TN....
                                 Marion County, TN......
                                 Sequatchie County, TN..
16940..........................  Cheyenne, WY...........          0.9730
                                 Laramie County, WY.....
16974..........................  Chicago-Naperville-              1.0600
                                  Joliet, IL.
                                 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..............          1.1197
                                 Butte County, CA.......
17140..........................  Cincinnati-Middletown,           0.9508
                                  OH-KY-IN.
                                 Dearborn County, IN....
                                 Franklin County, IN....
                                 Ohio County, IN........
                                 Boone County, KY.......
                                 Bracken County, KY.....
                                 Campbell County, KY....
                                 Gallatin County, KY....
                                 Grant County, KY.......
                                 Kenton County, KY......
                                 Pendleton County, KY...
                                 Brown County, OH.......
                                 Butler County, OH......
                                 Clermont County, OH....
                                 Hamilton County, OH....
                                 Warren County, OH......
17300..........................  Clarksville, TN-KY.....          0.8082
                                 Christian County, KY...
                                 Trigg County, KY.......
                                 Montgomery County, TN..
                                 Stewart County, TN.....
17420..........................  Cleveland, TN..........          0.7592
                                 Bradley County, TN.....
                                 Polk County, TN........
17460..........................  Cleveland-Elyria-                0.9082
                                  Mentor, OH.
                                 Cuyahoga County, OH....
                                 Geauga County, OH......
                                 Lake County, OH........
                                 Lorain County, OH......
                                 Medina County, OH......
17660..........................  Coeur d'Alene, ID......          0.9218
                                 Kootenai County, ID....
17780..........................  College Station-Bryan,           0.9584
                                  TX.
                                 Brazos County, TX......
                                 Burleson County, TX....
                                 Robertson County, TX...

[[Page 46237]]

 
17820..........................  Colorado Springs, CO...          0.9364
                                 El Paso County, CO.....
                                 Teller County, CO......
17860..........................  Columbia, MO...........          0.8339
                                 Boone County, MO.......
                                 Howard County, MO......
17900..........................  Columbia, SC...........          0.8560
                                 Calhoun County, SC.....
                                 Fairfield County, SC...
                                 Kershaw County, SC.....
                                 Lexington County, SC...
                                 Richland County, SC....
                                 Saluda County, SC......
17980..........................  Columbus, GA-AL........          0.8857
                                 Russell County, AL.....
                                 Chattahoochee County,
                                  GA.
                                 Harris County, GA......
                                 Marion County, GA......
                                 Muscogee County, GA....
18020..........................  Columbus, IN...........          0.9564
                                 Bartholomew County, IN.
18140..........................  Columbus, OH...........          0.9763
                                 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.....          0.8591
                                 Aransas County, TX.....
                                 Nueces County, TX......
                                 San Patricio County, TX
18700..........................  Corvallis, OR..........          1.0715
                                 Benton County, OR......
18880..........................  Crestview-Fort Walton            0.8916
                                  Beach-Destin, FL.
                                 Okaloosa County, FL....
19060..........................  Cumberland, MD-WV......          0.8836
                                 Allegany County, MD....
                                 Mineral County, WV.....
19124..........................  Dallas-Plano-Irving, TX          0.9835
                                 Collin County, TX......
                                 Dallas County, TX......
                                 Delta County, TX.......
                                 Denton County, TX......
                                 Ellis County, TX.......
                                 Hunt County, TX........
                                 Kaufman County, TX.....
                                 Rockwall County, TX....
19140..........................  Dalton, GA.............          0.8828
                                 Murray County, GA......
                                 Whitfield County, GA...
19180..........................  Danville, IL...........          0.9977
                                 Vermilion County, IL...
19260..........................  Danville, VA...........          0.8218
                                 Pittsylvania County, VA
                                 Danville City, VA......
19340..........................  Davenport-Moline-Rock            0.9145
                                  Island, IA-IL.
                                 Henry County, IL.......
                                 Mercer County, IL......
                                 Rock Island County, IL.
                                 Scott County, IA.......
19380..........................  Dayton, OH.............          0.9136
                                 Greene County, OH......
                                 Miami County, OH.......
                                 Montgomery County, OH..
                                 Preble County, OH......

[[Page 46238]]

 
19460..........................  Decatur, AL............          0.7261
                                 Lawrence County, AL....
                                 Morgan County, AL......
19500..........................  Decatur, IL............          0.7993
                                 Macon County, IL.......
19660..........................  Deltona-Daytona Beach-           0.8716
                                  Ormond Beach, FL.
                                 Volusia County, FL.....
19740..........................  Denver-Aurora-                   1.0469
                                  Broomfield, CO.
                                 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-West Des              0.9616
                                  Moines, IA.
                                 Dallas County, IA......
                                 Guthrie County, IA.....
                                 Madison County, IA.....
                                 Polk County, IA........
                                 Warren County, IA......
19804..........................  Detroit-Livonia-                 0.9361
                                  Dearborn, MI.
                                 Wayne County, MI.......
20020..........................  Dothan, AL.............          0.7398
                                 Geneva County, AL......
                                 Henry County, AL.......
                                 Houston County, AL.....
20100..........................  Dover, DE..............          0.9893
                                 Kent County, DE........
20220..........................  Dubuque, IA............          0.8662
                                 Dubuque County, IA.....
20260..........................  Duluth, MN-WI..........          1.0741
                                 Carlton County, MN.....
                                 St. Louis County, MN...
                                 Douglas County, WI.....
20500..........................  Durham-Chapel Hill, NC.          0.9525
                                 Chatham County, NC.....
                                 Durham County, NC......
                                 Orange County, NC......
                                 Person County, NC......
20740..........................  Eau Claire, WI.........          0.9705
                                 Chippewa County, WI....
                                 Eau Claire County, WI..
20764..........................  Edison-New Brunswick,            1.0806
                                  NJ.
                                 Middlesex County, NJ...
                                 Monmouth County, NJ....
                                 Ocean County, NJ.......
                                 Somerset County, NJ....
20940..........................  El Centro, CA..........          0.8602
                                 Imperial County, CA....
21060..........................  Elizabethtown, KY......          0.8294
                                 Hardin County, KY......
                                 Larue County, KY.......
21140..........................  Elkhart-Goshen, IN.....          0.9097
                                 Elkhart County, IN.....
21300..........................  Elmira, NY.............          0.8205
                                 Chemung County, NY.....
21340..........................  El Paso, TX............          0.8426
                                 El Paso County, TX.....
21500..........................  Erie, PA...............          0.7823
                                 Erie County, PA........
21660..........................  Eugene-Springfield, OR.          1.1454
                                 Lane County, OR........

[[Page 46239]]

 
21780..........................  Evansville, IN-KY......          0.8401
                                 Gibson County, IN......
                                 Posey County, IN.......
                                 Vanderburgh County, IN.
                                 Warrick County, IN.....
                                 Henderson County, KY...
                                 Webster County, KY.....
21820..........................  Fairbanks, AK..........          1.0816
                                 Fairbanks North Star
                                  Borough, AK.
21940..........................  Fajardo, PR............          0.3663
                                 Ceiba Municipio, PR....
                                 Fajardo Municipio, PR..
                                 Luquillo Municipio, PR.
22020..........................  Fargo, ND-MN...........          0.8108
                                 Cass County, ND........
                                 Clay County, MN........
22140..........................  Farmington, NM.........          0.9323
                                 San Juan County, NM....
22180..........................  Fayetteville, NC.......          0.8971
                                 Cumberland County, NC..
                                 Hoke County, NC........
22220..........................  Fayetteville-Springdale-         0.9288
                                  Rogers, AR-MO.
                                 Benton County, AR......
                                 Madison County, AR.....
                                 Washington County, AR..
                                 McDonald County, MO....
22380..........................  Flagstaff, AZ..........          1.2369
                                 Coconino County, AZ....
22420..........................  Flint, MI..............          1.1257
                                 Genesee County, MI.....
22500..........................  Florence, SC...........          0.8087
                                 Darlington County, SC..
                                 Florence County, SC....
22520..........................  Florence-Muscle Shoals,          0.7679
                                  AL.
                                 Colbert County, AL.....
                                 Lauderdale County, AL..
22540..........................  Fond du Lac, WI........          0.9158
                                 Fond du Lac County, WI.
22660..........................  Fort Collins-Loveland,           0.9833
                                  CO.
                                 Larimer County, CO.....
22744..........................  Fort Lauderdale-Pompano          1.0363
                                  Beach-Deerfield Beach,
                                  FL.
                                 Broward County, FL.....
22900..........................  Fort Smith, AR-OK......          0.7848
                                 Crawford County, AR....
                                 Franklin County, AR....
                                 Sebastian County, AR...
                                 Le Flore County, OK....
                                 Sequoyah County, OK....
23060..........................  Fort Wayne, IN.........          0.9633
                                 Allen County, IN.......
                                 Wells County, IN.......
                                 Whitley County, IN.....
23104..........................  Fort Worth-Arlington,            0.9516
                                  TX.
                                 Johnson County, TX.....
                                 Parker County, TX......
                                 Tarrant County, TX.....
                                 Wise County, TX........
23420..........................  Fresno, CA.............          1.1593
                                 Fresno County, CA......
23460..........................  Gadsden, AL............          0.7697
                                 Etowah County, AL......
23540..........................  Gainesville, FL........          0.9631
                                 Alachua County, FL.....
                                 Gilchrist County, FL...
23580..........................  Gainesville, GA........          0.9327
                                 Hall County, GA........
23844..........................  Gary, IN...............          0.9259
                                 Jasper County, IN......
                                 Lake County, IN........
                                 Newton County, IN......
                                 Porter County, IN......

[[Page 46240]]

 
24020..........................  Glens Falls, NY........          0.8340
                                 Warren County, NY......
                                 Washington County, NY..
24140..........................  Goldsboro, NC..........          0.8560
                                 Wayne County, NC.......
24220..........................  Grand Forks, ND-MN.....          0.7250
                                 Polk County, MN........
                                 Grand Forks County, ND.
24300..........................  Grand Junction, CO.....          0.9415
                                 Mesa County, CO........
24340..........................  Grand Rapids-Wyoming,            0.9125
                                  MI.
                                 Barry County, MI.......
                                 Ionia County, MI.......
                                 Kent County, MI........
                                 Newaygo County, MI.....
24500..........................  Great Falls, MT........          0.7927
                                 Cascade County, MT.....
24540..........................  Greeley, CO............          0.9593
                                 Weld County, CO........
24580..........................  Green Bay, WI..........          0.9793
                                 Brown County, WI.......
                                 Kewaunee County, WI....
                                 Oconto County, WI......
24660..........................  Greensboro-High Point,           0.8638
                                  NC.
                                 Guilford County, NC....
                                 Randolph County, NC....
                                 Rockingham County, NC..
24780..........................  Greenville, NC.........          0.9694
                                 Greene County, NC......
                                 Pitt County, NC........
24860..........................  Greenville-Mauldin-              0.9737
                                  Easley, SC.
                                 Greenville County, SC..
                                 Laurens County, SC.....
                                 Pickens County, SC.....
25020..........................  Guayama, PR............          0.3696
                                 Arroyo Municipio, PR...
                                 Guayama Municipio, PR..
                                 Patillas Municipio, PR.
25060..........................  Gulfport-Biloxi, MS....          0.8544
                                 Hancock County, MS.....
                                 Harrison County, MS....
                                 Stone County, MS.......
25180..........................  Hagerstown-Martinsburg,          0.9422
                                  MD-WV.
                                 Washington County, MD..
                                 Berkeley County, WV....
                                 Morgan County, WV......
25260..........................  Hanford-Corcoran, CA...          1.0992
                                 Kings County, CA.......
25420..........................  Harrisburg-Carlisle, PA          0.9525
                                 Cumberland County, PA..
                                 Dauphin County, PA.....
                                 Perry County, PA.......
25500..........................  Harrisonburg, VA.......          0.9087
                                 Rockingham County, VA..
                                 Harrisonburg City, VA..
25540..........................  Hartford-West Hartford-          1.0869
                                  East Hartford, CT.
                                 Hartford County, CT....
                                 Middlesex County, CT...
                                 Tolland County, CT.....
25620..........................  Hattiesburg, MS........          0.8035
                                 Forrest County, MS.....
                                 Lamar County, MS.......
                                 Perry County, MS.......
25860..........................  Hickory-Lenoir-                  0.8677
                                  Morganton, NC.
                                 Alexander County, NC...
                                 Burke County, NC.......
                                 Caldwell County, NC....
                                 Catawba County, NC.....
25980..........................  Hinesville-Fort                  0.8843
                                  Stewart, GA\1\.
                                 Liberty County, GA.....
                                 Long County, GA........

[[Page 46241]]

 
26100..........................  Holland-Grand Haven, MI          0.8024
                                 Ottawa County, MI......
26180..........................  Honolulu, HI...........          1.2156
                                 Honolulu County, HI....
26300..........................  Hot Springs, AR........          0.8944
                                 Garland County, AR.....
26380..........................  Houma-Bayou Cane-                0.7928
                                  Thibodaux, LA.
                                 Lafourche Parish, LA...
                                 Terrebonne Parish, LA..
26420..........................  Houston-Sugar Land-              0.9933
                                  Baytown, TX.
                                 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-          0.8635
                                  KY-OH.
                                 Boyd County, KY........
                                 Greenup County, KY.....
                                 Lawrence County, OH....
                                 Cabell County, WV......
                                 Wayne County, WV.......
26620..........................  Huntsville, AL.........          0.8667
                                 Limestone County, AL...
                                 Madison County, AL.....
26820..........................  Idaho Falls, ID........          0.9114
                                 Bonneville County, ID..
                                 Jefferson County, ID...
26900..........................  Indianapolis-Carmel, IN          0.9870
                                 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..........          1.0120
                                 Johnson County, IA.....
                                 Washington County, IA..
27060..........................  Ithaca, NY.............          0.9249
                                 Tompkins County, NY....
27100..........................  Jackson, MI............          0.8511
                                 Jackson County, MI.....
27140..........................  Jackson, MS............          0.8177
                                 Copiah County, MS......
                                 Hinds County, MS.......
                                 Madison County, MS.....
                                 Rankin County, MS......
                                 Simpson County, MS.....
27180..........................  Jackson, TN............          0.7672
                                 Chester County, TN.....
                                 Madison County, TN.....
27260..........................  Jacksonville, FL.......          0.8883
                                 Baker County, FL.......
                                 Clay County, FL........
                                 Duval County, FL.......
                                 Nassau County, FL......
                                 St. Johns County, FL...
27340..........................  Jacksonville, NC.......          0.7957
                                 Onslow County, NC......
27500..........................  Janesville, WI.........          0.9458
                                 Rock County, WI........

[[Page 46242]]

 
27620..........................  Jefferson City, MO.....          0.8263
                                 Callaway County, MO....
                                 Cole County, MO........
                                 Moniteau County, MO....
                                 Osage County, MO.......
27740..........................  Johnson City, TN.......          0.7359
                                 Carter County, TN......
                                 Unicoi County, TN......
                                 Washington County, TN..
27780..........................  Johnstown, PA..........          0.8116
                                 Cambria County, PA.....
27860..........................  Jonesboro, AR..........          0.8084
                                 Craighead County, AR...
                                 Poinsett County, AR....
27900..........................  Joplin, MO.............          0.7828
                                 Jasper County, MO......
                                 Newton County, MO......
28020..........................  Kalamazoo-Portage, MI..          0.9834
                                 Kalamazoo County, MI...
                                 Van Buren County, MI...
28100..........................  Kankakee-Bradley, IL...          1.0127
                                 Kankakee County, IL....
28140..........................  Kansas City, MO-KS.....          0.9614
                                 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-Pasco-                 0.9708
                                  Richland, WA.
                                 Benton County, WA......
                                 Franklin County, WA....
28660..........................  Killeen-Temple-Fort              0.9102
                                  Hood, TX.
                                 Bell County, TX........
                                 Coryell County, TX.....
                                 Lampasas County, TX....
28700..........................  Kingsport-Bristol-               0.7325
                                  Bristol, TN-VA.
                                 Hawkins County, TN.....
                                 Sullivan County, TN....
                                 Bristol City, VA.......
                                 Scott County, VA.......
                                 Washington County, VA..
28740..........................  Kingston, NY...........          0.8953
                                 Ulster County, NY......
28940..........................  Knoxville, TN..........          0.7575
                                 Anderson County, TN....
                                 Blount County, TN......
                                 Knox County, TN........
                                 Loudon County, TN......
                                 Union County, TN.......
29020..........................  Kokomo, IN.............          0.8756
                                 Howard County, IN......
                                 Tipton County, IN......
29100..........................  La Crosse, WI-MN.......          1.0070
                                 Houston County, MN.....
                                 La Crosse County, WI...
29140..........................  Lafayette, IN..........          0.9316
                                 Benton County, IN......
                                 Carroll County, IN.....
                                 Tippecanoe County, IN..

[[Page 46243]]

 
29180..........................  Lafayette, LA..........          0.8565
                                 Lafayette Parish, LA...
                                 St. Martin Parish, LA..
29340..........................  Lake Charles, LA.......          0.7813
                                 Calcasieu Parish, LA...
                                 Cameron Parish, LA.....
29404..........................  Lake County-Kenosha              1.0558
                                  County, IL-WI.
                                 Lake County, IL........
                                 Kenosha County, WI.....
29420..........................  Lake Havasu City-                0.9760
                                  Kingman, AZ.
                                 Mohave County, AZ......
29460..........................  Lakeland-Winter Haven,           0.8262
                                  FL.
                                 Polk County, FL........
29540..........................  Lancaster, PA..........          0.9452
                                 Lancaster County, PA...
29620..........................  Lansing-East Lansing,            1.0065
                                  MI.
                                 Clinton County, MI.....
                                 Eaton County, MI.......
                                 Ingham County, MI......
29700..........................  Laredo, TX.............          0.7486
                                 Webb County, TX........
29740..........................  Las Cruces, NM.........          0.9044
                                 Dona Ana County, NM....
29820..........................  Las Vegas-Paradise, NV.          1.2076
                                 Clark County, NV.......
29940..........................  Lawrence, KS...........          0.8676
                                 Douglas County, KS.....
30020..........................  Lawton, OK.............          0.8351
                                 Comanche County, OK....
30140..........................  Lebanon, PA............          0.7994
                                 Lebanon County, PA.....
30300..........................  Lewiston, ID-WA........          0.9326
                                 Nez Perce County, ID...
                                 Asotin County, WA......
30340..........................  Lewiston-Auburn, ME....          0.9178
                                 Androscoggin County, ME
30460..........................  Lexington-Fayette, KY..          0.9023
                                 Bourbon County, KY.....
                                 Clark County, KY.......
                                 Fayette County, KY.....
                                 Jessamine County, KY...
                                 Scott County, KY.......
                                 Woodford County, KY....
30620..........................  Lima, OH...............          0.9226
                                 Allen County, OH.......
30700..........................  Lincoln, NE............          0.9726
                                 Lancaster County, NE...
                                 Seward County, NE......
30780..........................  Little Rock-North                0.8595
                                  Little Rock-Conway, AR.
                                 Faulkner County, AR....
                                 Grant County, AR.......
                                 Lonoke County, AR......
                                 Perry County, AR.......
                                 Pulaski County, AR.....
                                 Saline County, AR......
30860..........................  Logan, UT-ID...........          0.8456
                                 Franklin County, ID....
                                 Cache County, UT.......
30980..........................  Longview, TX...........          0.8550
                                 Gregg County, TX.......
                                 Rusk County, TX........
                                 Upshur County, TX......
31020..........................  Longview, WA...........          1.0081
                                 Cowlitz County, WA.....
31084..........................  Los Angeles-Long Beach-          1.2293
                                  Glendale, CA.
                                 Los Angeles County, CA.

[[Page 46244]]

 
31140..........................  Louisville-Jefferson             0.8862
                                  County, KY-IN.
                                 Clark County, IN.......
                                 Floyd County, IN.......
                                 Harrison County, IN....
                                 Washington County, IN..
                                 Bullitt County, KY.....
                                 Henry County, KY.......
                                 Meade County, KY.......
                                 Nelson County, KY......
                                 Oldham County, KY......
                                 Shelby County, KY......
                                 Spencer County, KY.....
                                 Trimble County, KY.....
31180..........................  Lubbock, TX............          0.8870
                                 Crosby County, TX......
                                 Lubbock County, TX.....
31340..........................  Lynchburg, VA..........          0.8615
                                 Amherst County, VA.....
                                 Appomattox County, VA..
                                 Bedford County, VA.....
                                 Campbell County, VA....
                                 Bedford City, VA.......
                                 Lynchburg City, VA.....
31420..........................  Macon, GA..............          0.8584
                                 Bibb County, GA........
                                 Crawford County, GA....
                                 Jones County, GA.......
                                 Monroe County, GA......
                                 Twiggs County, GA......
31460..........................  Madera-Chowchilla, CA..          0.8050
                                 Madera County, CA......
31540..........................  Madison, WI............          1.1264
                                 Columbia County, WI....
                                 Dane County, WI........
                                 Iowa County, WI........
31700..........................  Manchester-Nashua, NH..          1.0042
                                 Hillsborough County, NH
31740..........................  Manhattan, KS..........          0.7839
                                 Geary County, KS.......
                                 Pottawatomie County, KS
                                 Riley County, KS.......
31860..........................  Mankato-North Mankato,           0.9413
                                  MN.
                                 Blue Earth County, MN..
                                 Nicollet County, MN....
31900..........................  Mansfield, OH..........          0.8993
                                 Richland County, OH....
32420..........................  Mayag[uuml]ez, PR......          0.3586
                                 Hormigueros Municipio,
                                  PR.
                                 Mayag[uuml]ez
                                  Municipio, PR.
32580..........................  McAllen-Edinburg-                0.8603
                                  Mission, TX.
                                 Hidalgo County, TX.....
32780..........................  Medford, OR............          1.0400
                                 Jackson County, OR.....
32820..........................  Memphis, TN-MS-AR......          0.9049
                                 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.............          1.2996
                                 Merced County, CA......
33124..........................  Miami-Miami Beach-               1.0130
                                  Kendall, FL.
                                 Miami-Dade County, FL..
33140..........................  Michigan City-La Porte,          0.9694
                                  IN.
                                 LaPorte County, IN.....
33260..........................  Midland, TX............          1.0640
                                 Midland County, TX.....

[[Page 46245]]

 
33340..........................  Milwaukee-Waukesha-West          0.9931
                                  Allis, WI.
                                 Milwaukee County, WI...
                                 Ozaukee County, WI.....
                                 Washington County, WI..
                                 Waukesha County, WI....
33460..........................  Minneapolis-St. Paul-            1.1336
                                  Bloomington, MN-WI.
                                 Anoka County, MN.......
                                 Carver County, MN......
                                 Chisago County, MN.....
                                 Dakota County, MN......
                                 Hennepin County, MN....
                                 Isanti County, MN......
                                 Ramsey County, MN......
                                 Scott County, MN.......
                                 Sherburne County, MN...
                                 Washington County, MN..
                                 Wright County, MN......
                                 Pierce County, WI......
                                 St. Croix County, WI...
33540..........................  Missoula, MT...........          0.9001
                                 Missoula County, MT....
33660..........................  Mobile, AL.............          0.7467
                                 Mobile County, AL......
33700..........................  Modesto, CA............          1.2841
                                 Stanislaus County, CA..
33740..........................  Monroe, LA.............          0.7717
                                 Ouachita Parish, LA....
                                 Union Parish, LA.......
33780..........................  Monroe, MI.............          0.8472
                                 Monroe County, MI......
33860..........................  Montgomery, AL.........          0.7858
                                 Autauga County, AL.....
                                 Elmore County, AL......
                                 Lowndes County, AL.....
                                 Montgomery County, AL..
34060..........................  Morgantown, WV.........          0.8284
                                 Monongalia County, WV..
                                 Preston County, WV.....
34100..........................  Morristown, TN.........          0.6768
                                 Grainger County, TN....
                                 Hamblen County, TN.....
                                 Jefferson County, TN...
34580..........................  Mount Vernon-Anacortes,          1.0340
                                  WA.
                                 Skagit County, WA......
34620..........................  Muncie, IN.............          0.8734
                                 Delaware County, IN....
34740..........................  Muskegon-Norton Shores,          1.1007
                                  MI.
                                 Muskegon County, MI....
34820..........................  Myrtle Beach-North               0.8717
                                  Myrtle Beach-Conway,
                                  SC.
                                 Horry County, SC.......
34900..........................  Napa, CA...............          1.6045
                                 Napa County, CA........
34940..........................  Naples-Marco Island, FL          0.9265
                                 Collier County, FL.....
34980..........................  Nashville-Davidson--             0.9061
                                  Murfreesboro-Franklin,
                                  TN.
                                 Cannon County, TN......
                                 Cheatham County, TN....
                                 Davidson County, TN....
                                 Dickson County, TN.....
                                 Hickman County, TN.....
                                 Macon County, TN.......
                                 Robertson County, TN...
                                 Rutherford County, TN..
                                 Smith County, TN.......
                                 Sumner County, TN......
                                 Trousdale County, TN...
                                 Williamson County, TN..
                                 Wilson County, TN......
35004..........................  Nassau-Suffolk, NY.....          1.2698
                                 Nassau County, NY......
                                 Suffolk County, NY.....

[[Page 46246]]

 
35084..........................  Newark-Union, NJ-PA....          1.1223
                                 Essex County, NJ.......
                                 Hunterdon County, NJ...
                                 Morris County, NJ......
                                 Sussex County, NJ......
                                 Union County, NJ.......
                                 Pike County, PA........
35300..........................  New Haven-Milford, CT..          1.2061
                                 New Haven County, CT...
35380..........................  New Orleans-Metairie-            0.8932
                                  Kenner, LA.
                                 Jefferson Parish, LA...
                                 Orleans Parish, LA.....
                                 Plaquemines Parish, LA.
                                 St. Bernard Parish, LA.
                                 St. Charles Parish, LA.
                                 St. John the Baptist
                                  Parish, LA.
                                 St. Tammany Parish, LA.
35644..........................  New York-White Plains-           1.2914
                                  Wayne, NY-NJ.
                                 Bergen County, NJ......
                                 Hudson County, NJ......
                                 Passaic County, NJ.....
                                 Bronx County, NY.......
                                 Kings County, NY.......
                                 New York County, NY....
                                 Putnam County, NY......
                                 Queens County, NY......
                                 Richmond County, NY....
                                 Rockland County, NY....
                                 Westchester County, NY.
35660..........................  Niles-Benton Harbor, MI          0.8237
                                 Berrien County, MI.....
35840..........................  North Port-Bradenton-            0.9375
                                  Sarasota-Venice, FL.
                                 Manatee County, FL.....
                                 Sarasota County, FL....
35980..........................  Norwich-New London, CT.          1.1376
                                 New London County, CT..
36084..........................  Oakland-Fremont-                 1.6654
                                  Hayward, CA.
                                 Alameda County, CA.....
                                 Contra Costa County, CA
36100..........................  Ocala, FL..............          0.8455
                                 Marion County, FL......
36140..........................  Ocean City, NJ.........          1.0307
                                 Cape May County, NJ....
36220..........................  Odessa, TX.............          0.9741
                                 Ector County, TX.......
36260..........................  Ogden-Clearfield, UT...          0.9031
                                 Davis County, UT.......
                                 Morgan County, UT......
                                 Weber County, UT.......
36420..........................  Oklahoma City, OK......          0.8810
                                 Canadian County, OK....
                                 Cleveland County, OK...
                                 Grady County, OK.......
                                 Lincoln County, OK.....
                                 Logan County, OK.......
                                 McClain County, OK.....
                                 Oklahoma County, OK....
36500..........................  Olympia, WA............          1.1397
                                 Thurston County, WA....
36540..........................  Omaha-Council Bluffs,            1.0037
                                  NE-IA.
                                 Harrison County, IA....
                                 Mills County, IA.......
                                 Pottawattamie County,
                                  IA.
                                 Cass County, NE........
                                 Douglas County, NE.....
                                 Sarpy County, NE.......
                                 Saunders County, NE....
                                 Washington County, NE..

[[Page 46247]]

 
36740..........................  Orlando-Kissimmee, FL..          0.9082
                                 Lake County, FL........
                                 Orange County, FL......
                                 Osceola County, FL.....
                                 Seminole County, FL....
36780..........................  Oshkosh-Neenah, WI.....          0.9433
                                 Winnebago County, WI...
36980..........................  Owensboro, KY..........          0.8117
                                 Daviess County, KY.....
                                 Hancock County, KY.....
                                 McLean County, KY......
37100..........................  Oxnard-Thousand Oaks-            1.3079
                                  Ventura, CA.
                                 Ventura County, CA.....
37340..........................  Palm Bay-Melbourne-              0.8838
                                  Titusville, FL.
                                 Brevard County, FL.....
37380..........................  Palm Coast, FL.........          0.9880
                                 Flagler County, FL.....
37460..........................  Panama City-Lynn Haven-          0.7976
                                  Panama City Beach, FL.
                                 Bay County, FL.........
37620..........................  Parkersburg-Marietta-            0.7487
                                  Vienna, WV-OH.
                                 Washington County, OH..
                                 Pleasants County, WV...
                                 Wirt County, WV........
                                 Wood County, WV........
37700..........................  Pascagoula, MS.........          0.7662
                                 George County, MS......
                                 Jackson County, MS.....
37764..........................  Peabody, MA............          1.0551
                                 Essex County, MA.......
37860..........................  Pensacola-Ferry Pass-            0.7819
                                  Brent, FL.
                                 Escambia County, FL....
                                 Santa Rosa County, FL..
37900..........................  Peoria, IL.............          0.8882
                                 Marshall County, IL....
                                 Peoria County, IL......
                                 Stark County, IL.......
                                 Tazewell County, IL....
                                 Woodford County, IL....
37964..........................  Philadelphia, PA.......          1.0806
                                 Bucks County, PA.......
                                 Chester County, PA.....
                                 Delaware County, PA....
                                 Montgomery County, PA..
                                 Philadelphia County, PA
38060..........................  Phoenix-Mesa-                    1.0477
                                  Scottsdale, AZ.
                                 Maricopa County, AZ....
                                 Pinal County, AZ.......
38220..........................  Pine Bluff, AR.........          0.7847
                                 Cleveland County, AR...
                                 Jefferson County, AR...
                                 Lincoln County, AR.....
38300..........................  Pittsburgh, PA.........          0.8585
                                 Allegheny County, PA...
                                 Armstrong County, PA...
                                 Beaver County, PA......
                                 Butler County, PA......
                                 Fayette County, PA.....
                                 Washington County, PA..
                                 Westmoreland County, PA
38340..........................  Pittsfield, MA.........          1.0721
                                 Berkshire County, MA...
38540..........................  Pocatello, ID..........          0.9555
                                 Bannock County, ID.....
                                 Power County, ID.......
38660..........................  Ponce, PR..............          0.4314
                                 Juana D[iacute]az
                                  Municipio, PR.
                                 Ponce Municipio, PR....
                                 Villalba Municipio, PR.

[[Page 46248]]

 
38860..........................  Portland-South Portland-         0.9975
                                  Biddeford, ME.
                                 Cumberland County, ME..
                                 Sagadahoc County, ME...
                                 York County, ME........
38900..........................  Portland-Vancouver-              1.1673
                                  Beaverton, OR-WA.
                                 Clackamas County, OR...
                                 Columbia County, OR....
                                 Multnomah County, OR...
                                 Washington County, OR..
                                 Yamhill County, OR.....
                                 Clark County, WA.......
                                 Skamania County, WA....
38940..........................  Port St. Lucie, FL.....          0.9577
                                 Martin County, FL......
                                 St. Lucie County, FL...
39100..........................  Poughkeepsie-Newburgh-           1.1325
                                  Middletown, NY.
                                 Dutchess County, NY....
                                 Orange County, NY......
39140..........................  Prescott, AZ...........          1.2009
                                 Yavapai County, AZ.....
39300..........................  Providence-New Bedford-          1.0699
                                  Fall River, RI-MA.
                                 Bristol County, MA.....
                                 Bristol County, RI.....
                                 Kent County, RI........
                                 Newport County, RI.....
                                 Providence County, RI..
                                 Washington County, RI..
39340..........................  Provo-Orem, UT.........          0.9133
                                 Juab County, UT........
                                 Utah County, UT........
39380..........................  Pueblo, CO.............          0.8518
                                 Pueblo County, CO......
39460..........................  Punta Gorda, FL........          0.8590
                                 Charlotte County, FL...
39540..........................  Racine, WI.............          0.9158
                                 Racine County, WI......
39580..........................  Raleigh-Cary, NC.......          0.9488
                                 Franklin County, NC....
                                 Johnston County, NC....
                                 Wake County, NC........
39660..........................  Rapid City, SD.........          0.9823
                                 Meade County, SD.......
                                 Pennington County, SD..
39740..........................  Reading, PA............          0.9072
                                 Berks County, PA.......
39820..........................  Redding, CA............          1.4555
                                 Shasta County, CA......
39900..........................  Reno-Sparks, NV........          1.0328
                                 Storey County, NV......
                                 Washoe County, NV......

[[Page 46249]]

 
40060..........................  Richmond, VA...........          0.9695
                                 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                    1.1396
                                  Bernardino-Ontario, CA.
                                 Riverside County, CA...
                                 San Bernardino County,
                                  CA.
40220..........................  Roanoke, VA............          0.9088
                                 Botetourt County, VA...
                                 Craig County, VA.......
                                 Franklin County, VA....
                                 Roanoke County, VA.....
                                 Roanoke City, VA.......
                                 Salem City, VA.........
40340..........................  Rochester, MN..........          1.0708
                                 Dodge County, MN.......
                                 Olmsted County, MN.....
                                 Wabasha County, MN.....
40380..........................  Rochester, NY..........          0.8704
                                 Livingston County, NY..
                                 Monroe County, NY......
                                 Ontario County, NY.....
                                 Orleans County, NY.....
                                 Wayne County, NY.......
40420..........................  Rockford, IL...........          0.9935
                                 Boone County, IL.......
                                 Winnebago County, IL...
40484..........................  Rockingham County-               1.0234
                                  Strafford County, NH.
                                 Rockingham County, NH..
                                 Strafford County, NH...
40580..........................  Rocky Mount, NC........          0.8898
                                 Edgecombe County, NC...
                                 Nash County, NC........
40660..........................  Rome, GA...............          0.8844
                                 Floyd County, GA.......
40900..........................  Sacramento-Arden-Arcade-         1.4752
                                  Roseville, CA.
                                 El Dorado County, CA...
                                 Placer County, CA......
                                 Sacramento County, CA..
                                 Yolo County, CA........
40980..........................  Saginaw-Saginaw                  0.8820
                                  Township North, MI.
                                 Saginaw County, MI.....
41060..........................  St. Cloud, MN..........          1.1010
                                 Benton County, MN......
                                 Stearns County, MN.....
41100..........................  St. George, UT.........          0.8870
                                 Washington County, UT..
41140..........................  St. Joseph, MO-KS......          0.9856
                                 Doniphan County, KS....
                                 Andrew County, MO......
                                 Buchanan County, MO....
                                 DeKalb County, MO......

[[Page 46250]]

 
41180..........................  St. Louis, MO-IL.......          0.9420
                                 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..............          1.1069
                                 Marion County, OR......
                                 Polk County, OR........
41500..........................  Salinas, CA............          1.6074
                                 Monterey County, CA....
41540..........................  Salisbury, MD..........          0.9260
                                 Somerset County, MD....
                                 Wicomico County, MD....
41620..........................  Salt Lake City, UT.....          0.9063
                                 Salt Lake County, UT...
                                 Summit County, UT......
                                 Tooele County, UT......
41660..........................  San Angelo, TX.........          0.8221
                                 Irion County, TX.......
                                 Tom Green County, TX...
41700..........................  San Antonio, TX........          0.8936
                                 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           1.1922
                                  Marcos, CA.
                                 San Diego County, CA...
41780..........................  Sandusky, OH...........          0.8347
                                 Erie County, OH........
41884..........................  San Francisco-San Mateo-         1.6327
                                  Redwood City, CA.
                                 Marin County, CA.......
                                 San Francisco County,
                                  CA.
                                 San Mateo County, CA...
41900..........................  San Germ[aacute]n-Cabo           0.4804
                                  Rojo, PR.
                                 Cabo Rojo Municipio, PR
                                 Lajas Municipio, PR....
                                 Sabana Grande
                                  Municipio, PR.
                                 San Germ[aacute]n
                                  Municipio, PR.
41940..........................  San Jose-Sunnyvale-              1.7396
                                  Santa Clara, CA.
                                 San Benito County, CA..
                                 Santa Clara County, CA.

[[Page 46251]]

 
41980..........................  San Juan-Caguas-                 0.4318
                                  Guaynabo, PR.
                                 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             1.3081
                                  Robles, CA.
                                 San Luis Obispo County,
                                  CA.
42044..........................  Santa Ana-Anaheim-               1.2038
                                  Irvine, CA.
                                 Orange County, CA......
42060..........................  Santa Barbara-Santa              1.2670
                                  Maria-Goleta, CA.
                                 Santa Barbara County,
                                  CA.
42100..........................  Santa Cruz-Watsonville,          1.8062
                                  CA.
                                 Santa Cruz County, CA..
42140..........................  Santa Fe, NM...........          1.0400
                                 Santa Fe County, NM....
42220..........................  Santa Rosa-Petaluma, CA          1.6440
                                 Sonoma County, CA......
42340..........................  Savannah, GA...........          0.8968
                                 Bryan County, GA.......
                                 Chatham County, GA.....
                                 Effingham County, GA...
42540..........................  Scranton--Wilkes-Barre,          0.8260
                                  PA.
                                 Lackawanna County, PA..
                                 Luzerne County, PA.....
                                 Wyoming County, PA.....
42644..........................  Seattle-Bellevue-                1.1771
                                  Everett, WA.
                                 King County, WA........
                                 Snohomish County, WA...
42680..........................  Sebastian-Vero Beach,            0.8850
                                  FL.
                                 Indian River County, FL
43100..........................  Sheboygan, WI..........          0.9515
                                 Sheboygan County, WI...

[[Page 46252]]

 
43300..........................  Sherman-Denison, TX....          0.8544
                                 Grayson County, TX.....
43340..........................  Shreveport-Bossier               0.8412
                                  City, LA.
                                 Bossier Parish, LA.....
                                 Caddo Parish, LA.......
                                 De Soto Parish, LA.....
43580..........................  Sioux City, IA-NE-SD...          0.9010
                                 Woodbury County, IA....
                                 Dakota County, NE......
                                 Dixon County, NE.......
                                 Union County, SD.......
43620..........................  Sioux Falls, SD........          0.8338
                                 Lincoln County, SD.....
                                 McCook County, SD......
                                 Minnehaha County, SD...
                                 Turner County, SD......
43780..........................  South Bend-Mishawaka,            0.9531
                                  IN-MI.
                                 St. Joseph County, IN..
                                 Cass County, MI........
43900..........................  Spartanburg, SC........          0.9186
                                 Spartanburg County, SC.
44060..........................  Spokane, WA............          1.0824
                                 Spokane County, WA.....
44100..........................  Springfield, IL........          0.9179
                                 Menard County, IL......
                                 Sangamon County, IL....
44140..........................  Springfield, MA........          1.0377
                                 Franklin County, MA....
                                 Hampden County, MA.....
                                 Hampshire County, MA...
44180..........................  Springfield, MO........          0.8581
                                 Christian County, MO...
                                 Dallas County, MO......
                                 Greene County, MO......
                                 Polk County, MO........
                                 Webster County, MO.....
44220..........................  Springfield, OH........          0.9236
                                 Clark County, OH.......
44300..........................  State College, PA......          0.9510
                                 Centre County, PA......
44600..........................  Steubenville-Weirton,            0.7640
                                  OH-WV.
                                 Jefferson County, OH...
                                 Brooke County, WV......
                                 Hancock County, WV.....
44700..........................  Stockton, CA...........          1.3356
                                 San Joaquin County, CA.
44940..........................  Sumter, SC.............          0.7454
                                 Sumter County, SC......
45060..........................  Syracuse, NY...........          0.9829
                                 Madison County, NY.....
                                 Onondaga County, NY....
                                 Oswego County, NY......
45104..........................  Tacoma, WA.............          1.1741
                                 Pierce County, WA......
45220..........................  Tallahassee, FL........          0.8521
                                 Gadsden County, FL.....
                                 Jefferson County, FL...
                                 Leon County, FL........
                                 Wakulla County, FL.....
45300..........................  Tampa-St. Petersburg-            0.9032
                                  Clearwater, FL.
                                 Hernando County, FL....
                                 Hillsborough County, FL
                                 Pasco County, FL.......
                                 Pinellas County, FL....
45460..........................  Terre Haute, IN........          0.9113
                                 Clay County, IN........
                                 Sullivan County, IN....
                                 Vermillion County, IN..
                                 Vigo County, IN........

[[Page 46253]]

 
45500..........................  Texarkana, TX-                   0.7967
                                  Texarkana, AR.
                                 Miller County, AR......
                                 Bowie County, TX.......
45780..........................  Toledo, OH.............          0.9034
                                 Fulton County, OH......
                                 Lucas County, OH.......
                                 Ottawa County, OH......
                                 Wood County, OH........
45820..........................  Topeka, KS.............          0.8969
                                 Jackson County, KS.....
                                 Jefferson County, KS...
                                 Osage County, KS.......
                                 Shawnee County, KS.....
                                 Wabaunsee County, KS...
45940..........................  Trenton-Ewing, NJ......          1.0360
                                 Mercer County, NJ......
46060..........................  Tucson, AZ.............          0.9065
                                 Pima County, AZ........
46140..........................  Tulsa, OK..............          0.8139
                                 Creek County, OK.......
                                 Okmulgee County, OK....
                                 Osage County, OK.......
                                 Pawnee County, OK......
                                 Rogers County, OK......
                                 Tulsa County, OK.......
                                 Wagoner County, OK.....
46220..........................  Tuscaloosa, AL.........          0.8533
                                 Greene County, AL......
                                 Hale County, AL........
                                 Tuscaloosa County, AL..
46340..........................  Tyler, TX..............          0.8361
                                 Smith County, TX.......
46540..........................  Utica-Rome, NY.........          0.8653
                                 Herkimer County, NY....
                                 Oneida County, NY......
46660..........................  Valdosta, GA...........          0.7918
                                 Brooks County, GA......
                                 Echols County, GA......
                                 Lanier County, GA......
                                 Lowndes County, GA.....
46700..........................  Vallejo-Fairfield, CA..          1.5844
                                 Solano County, CA......
47020..........................  Victoria, TX...........          0.8992
                                 Calhoun County, TX.....
                                 Goliad County, TX......
                                 Victoria County, TX....
47220..........................  Vineland-Millville-              1.0596
                                  Bridgeton, NJ.
                                 Cumberland County, NJ..
47260..........................  Virginia Beach-Norfolk-          0.9208
                                  Newport News, VA-NC.
                                 Currituck County, NC...
                                 Gloucester County, VA..
                                 Isle of Wight County,
                                  VA.
                                 James City County, VA..
                                 Mathews County, VA.....
                                 Surry County, VA.......
                                 York County, VA........
                                 Chesapeake City, VA....
                                 Hampton City, VA.......
                                 Newport News City, VA..
                                 Norfolk City, VA.......
                                 Poquoson City, VA......
                                 Portsmouth City, VA....
                                 Suffolk City, VA.......
                                 Virginia Beach City, VA
                                 Williamsburg City, VA..
47300..........................  Visalia-Porterville, CA          1.0349
                                 Tulare County, CA......
47380..........................  Waco, TX...............          0.8458
                                 McLennan County, TX....

[[Page 46254]]

 
47580..........................  Warner Robins, GA......          0.8197
                                 Houston County, GA.....
47644..........................  Warren-Troy-Farmington           0.9543
                                  Hills, MI.
                                 Lapeer County, MI......
                                 Livingston County, MI..
                                 Macomb County, MI......
                                 Oakland County, MI.....
                                 St. Clair County, MI...
47894..........................  Washington-Arlington-            1.0659
                                  Alexandria, DC-VA-MD-
                                  WV.
                                 District of Columbia,
                                  DC.
                                 Calvert County, MD.....
                                 Charles County, MD.....
                                 Prince George's County,
                                  MD.
                                 Arlington County, VA...
                                 Clarke County, VA......
                                 Fairfax County, VA.....
                                 Fauquier County, VA....
                                 Loudoun County, VA.....
                                 Prince William County,
                                  VA.
                                 Spotsylvania County, VA
                                 Stafford County, VA....
                                 Warren County, VA......
                                 Alexandria City, VA....
                                 Fairfax City, VA.......
                                 Falls Church City, VA..
                                 Fredericksburg City, VA
                                 Manassas City, VA......
                                 Manassas Park City, VA.
                                 Jefferson County, WV...
47940..........................  Waterloo-Cedar Falls,            0.8422
                                  IA.
                                 Black Hawk County, IA..
                                 Bremer County, IA......
                                 Grundy County, IA......
48140..........................  Wausau, WI.............          0.8921
                                 Marathon County, WI....
48300..........................  Wenatchee-East                   1.0037
                                  Wenatchee, WA.
                                 Chelan County, WA......
                                 Douglas County, WA.....
48424..........................  West Palm Beach-Boca             0.9661
                                  Raton-Boynton Beach,
                                  FL.
                                 Palm Beach County, FL..
48540..........................  Wheeling, WV-OH........          0.6863
                                 Belmont County, OH.....
                                 Marshall County, WV....
                                 Ohio County, WV........
48620..........................  Wichita, KS............          0.8681
                                 Butler County, KS......
                                 Harvey County, KS......
                                 Sedgwick County, KS....
                                 Sumner County, KS......
48660..........................  Wichita Falls, TX......          0.9048
                                 Archer County, TX......
                                 Clay County, TX........
                                 Wichita County, TX.....
48700..........................  Williamsport, PA.......          0.8230
                                 Lycoming County, PA....
48864..........................  Wilmington, DE-MD-NJ...          1.0687
                                 New Castle County, DE..
                                 Cecil County, MD.......
                                 Salem County, NJ.......
48900..........................  Wilmington, NC.........          0.9155
                                 Brunswick County, NC...
                                 New Hanover County, NC.
                                 Pender County, NC......
49020..........................  Winchester, VA-WV......          0.9249
                                 Frederick County, VA...
                                 Winchester City, VA....
                                 Hampshire County, WV...

[[Page 46255]]

 
49180..........................  Winston-Salem, NC......          0.8660
                                 Davie County, NC.......
                                 Forsyth County, NC.....
                                 Stokes County, NC......
                                 Yadkin County, NC......
49340..........................  Worcester, MA..........          1.1205
                                 Worcester County, MA...
49420..........................  Yakima, WA.............          1.0097
                                 Yakima County, WA......
49500..........................  Yauco, PR..............          0.4059
                                 Gu[aacute]nica
                                  Municipio, PR.
                                 Guayanilla Municipio,
                                  PR.
                                 Pe[ntilde]uelas
                                  Municipio, PR.
                                 Yauco Municipio, PR....
49620..........................  York-Hanover, PA.......          0.9557
                                 York County, PA........
49660..........................  Youngstown-Warren-               0.8283
                                  Boardman, OH-PA.
                                 Mahoning County, OH....
                                 Trumbull County, OH....
                                 Mercer County, PA......
49700..........................  Yuba City, CA \1\......          1.2004
                                 Sutter County, CA......
                                 Yuba County, CA........
49740..........................  Yuma, AZ...............         0.9517
                                 Yuma County, AZ........
------------------------------------------------------------------------
\1\ At this time, there are no hospitals located in this urban area on
  which to base a wage index.


 Table B--FY 2013 Wage Index Based on CBSA Labor Market Areas for Rural
                                  Areas
------------------------------------------------------------------------
         State  code                  Nonurban  area         Wage  index
------------------------------------------------------------------------
 1..........................  Alabama......................       0.7121
 2..........................  Alaska.......................       1.2807
 3..........................  Arizona......................       0.9182
 4..........................  Arkansas.....................       0.7350
 5..........................  California...................       1.2567
 6..........................  Colorado.....................       1.0208
 7..........................  Connecticut..................       1.1128
 8..........................  Delaware.....................       1.0171
10..........................  Florida......................       0.8062
11..........................  Georgia......................       0.7421
12..........................  Hawaii.......................       1.0728
13..........................  Idaho........................       0.7583
14..........................  Illinois.....................       0.8438
15..........................  Indiana......................       0.8472
16..........................  Iowa.........................       0.8351
17..........................  Kansas.......................       0.7997
18..........................  Kentucky.....................       0.7877
19..........................  Louisiana....................       0.7718
20..........................  Maine........................       0.8300
21..........................  Maryland.....................       0.8797
22..........................  Massachusetts................       1.3540
23..........................  Michigan.....................       0.8387
24..........................  Minnesota....................       0.9053
25..........................  Mississippi..................       0.7537
26..........................  Missouri.....................       0.7622
27..........................  Montana......................       0.8600
28..........................  Nebraska.....................       0.8733
29..........................  Nevada.......................       0.9739
30..........................  New Hampshire................       1.0372
31..........................  New Jersey \1\...............  ...........
32..........................  New Mexico...................       0.8879
33..........................  New York.....................       0.8199
34..........................  North Carolina...............       0.8271
35..........................  North Dakota.................       0.6891
36..........................  Ohio.........................       0.8470
37..........................  Oklahoma.....................       0.7783
38..........................  Oregon.......................       0.9500
39..........................  Pennsylvania.................       0.8380
40..........................  Puerto Rico \1\..............       0.4047
41..........................  Rhode Island \1\.............  ...........
42..........................  South Carolina...............       0.8338
43..........................  South Dakota.................       0.8124
44..........................  Tennessee....................       0.7559
45..........................  Texas........................       0.7978
46..........................  Utah.........................       0.8516
47..........................  Vermont......................       0.9725
48..........................  Virgin Islands...............       0.7185
49..........................  Virginia.....................       0.7728
50..........................  Washington...................       1.0092
51..........................  West Virginia................       0.7333
52..........................  Wisconsin....................       0.9142
53..........................  Wyoming......................       0.9238
65..........................  Guam.........................       0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
  exception of Puerto Rico. Puerto Rico has areas designated as rural;
  however, no short-term, acute care hospitals are located in the
  area(s) for FY 2013. The Puerto Rico wage index is the same as FY
  2012.

[FR Doc. 2012-18719 Filed 7-27-12; 4:15 pm]
BILLING CODE P