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Rule

Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2006

Action

Final Rule.

Summary

In this final rule we update the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for fiscal year (FY) 2006. Annual updates to the PPS rates are required by section 1888(e) of the Social Security Act (the Act), as amended by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), relating to Medicare payments and consolidated billing for SNFs. This final rule also responds to public comments submitted on the proposed rule published on May 19, 2005(70 FR 29070), and promulgates provisions set forth in that proposed rule, along with several additional technical revisions to the regulations.

Unified Agenda

 

Table of Contents Back to Top

Tables Back to Top

DATES: Back to Top

Effective Date: This final rule becomes effective on October 1, 2005.

FOR FURTHER INFORMATION CONTACT: Back to Top

Ellen Gay, (410) 786-4528 (for information related to the case-mix classification methodology, and for information related to swing-bed providers).

Jeanette Kranacs, (410) 786-9385 (for information related to the development of the payment rates, and for information related to the wage index).

Bill Ullman, (410) 786-5667 (for information related to coverage requirements, level of care determinations, consolidated billing, and general information).

SUPPLEMENTARY INFORMATION: Back to Top

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

Table of Contents Back to Top

I. 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 SNF PPS

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. General Overview of the SNF PPS

1. Payment Provisions—Federal Rates

2. Payment Provisions—Initial Transition Period

G. Use of the SNF Market Basket Index

II. Summary of the Provisions of the FY 2006 Proposed Rule

III. Analysis of and Response to Public Comments on the FY 2006 Proposed Rule

A. General Comments on the FY 2006 Proposed Rule

1. Public Comment Schedule for the FY 2006 Proposed Rule

B. Update of Federal Payment Rates Under the SNF PPS

1. Costs and Services Covered by the Federal Rates

2. Methodology Used for the Calculation of the Federal Rates

C. Case-Mix Adjustment and Other Clinical Issues

1. Proposed Refinements to the RUG-III Case-Mix Classification System

2. Proposed Increases to the RUG-III Case-Mix Weight Values

3. Implementation Issues

4. Additional Clinical and Related Issues

a. Proposed Changes to the MDS Coding Requirements (“Look-Back” Period, 5-day Grace Periods for PPS MDS Assessments, and Projection of Anticipated Therapy Services during the 5-day PPS Assessment (Section T))

b. Long-Term Payment and Quality Incentive Proposals

c. Proposal to Clarify “Direct” and “Indirect” Employment Relationships for Nurse Practitioners and Clinical Nurse Specialists

d. Completion of Other Medicare Required Assessments (OMRAs)

e. Concurrent Therapy

5. Case-Mix Adjusted Federal Rates and Associated Indexes

D. Wage Index Adjustment to Federal Rates

1. Proposal to Incorporate the Revised OMB Definitions for Metropolitan Statistical Areas and Combined Statistical Areas

2. Determining the Labor-Related Portion of the SNF PPS Rate

3. Calculating the Budget Neutrality Factor

E. Updates to the Federal Rates

F. Relationship of Case-Mix Classification System to Existing SNF Level-of-Care Criteria

1. Proposals on the 9 New Rehabilitation Plus Extensive Services Groups

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

H. SNF Market Basket Index

1. Background

2. Use of the SNF Market Basket Percentage

3. Market Basket Forecast Error Adjustment

4. Federal Rate Update Factor

I. Consolidated Billing

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

K. Qualifying Three-Day Inpatient Hospital Stay Requirement

IV. Provisions of the Final Rule

V. Waiver of Proposed Rulemaking

VI. Collection of Information Requirements

VII. Regulatory Impact Analysis

A. Overall Impact

B. Anticipated Effects

C. Accounting Statement

D. Alternatives Considered Regulation Text

VIII. Addendum

In addition, because of the many terms to which we refer by abbreviation in this final rule, we are listing these abbreviations and their corresponding terms in alphabetical order below:

ADLActivity of Daily Living

ARDAssessment Reference Date

BBABalanced Budget Act of 1997, Pub. L. 105-33

BBRAMedicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, Pub. L. 106-113

BEA(U.S. Department of Commerce) Bureau of Economic Analysis

BIPAMedicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Pub. L. 106-554

CAHCritical Access Hospital

CBSACore-Based Statistical Area

CFRCode of Federal Regulations

CMSCenters for Medicare Medicaid Services

CMSAConsolidated Metropolitan Statistical Area

CPT(Physicians') Current Procedural Terminology

DRGDiagnosis Related Group

FIFiscal Intermediary

FRFederal Register

FYFiscal Year

GAOGovernment Accountability Office

HCPCSHealthcare Common Procedure Coding System

ICD-9-CMInternational Classification of Diseases, Ninth Edition, Clinical Modification

IFCInterim Final Rule With Comment Period

MDSMinimum Data Set

MEDPARMedicare Provider Analysis and Review File

MMAMedicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173

MSAMetropolitan Statistical Area

NECMANew England County Metropolitan Area

OIGOffice of Inspector General

OMRA Other Medicare Required Assessment

PMSAPrimary Metropolitan Statistical Area

PPIProducer Price Index

PPSProspective Payment System

PRMProvider Reimbursement Manual

RAIResident Assessment Instrument

RAPResident Assessment Protocol

RAVENResident Assessment Validation Entry

RFARegulatory Flexibility Act, 96

RIARegulatory Impact Analysis

RUGResource Utilization Group

SCHIP State Children's Health Insurance Program

SNFSkilled Nursing Facility

STMStaff Time Measurement

UMRAUnfunded Mandates Reform Act, Pub. L. 104-4

I. Background Back to Top

On May 19, 2005, we published a proposed rule in the Federal Register (70 FR 29070, hereafter referred to as the FY 2006 SNF PPS proposed rule), setting forth the proposed updates to the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for FY 2006. Annual updates to the PPS rates are required by section 1888(e) of the Social Security Act (the Act), as amended by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA, Pub. L. 106-113), the Medicare, Medicaid, and SCHIP Benefits Improvement and rotection Act of 2000 (BIPA, Pub. L. 106-554), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, 100), relating to Medicare payments and consolidated billing for SNFs. In the FY 2006 SNF PPS proposed rule, we invited public comments on a number of proposed revisions and technical corrections to the regulations.

A. Current System for Payment of SNF Services Under Part A of the Medicare Program

Section 4432 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33) 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. We are updating the per diem payment rates for SNFs for FY 2006. Major elements of the SNF PPS include:

  • Rates. Per diem Federal rates were established for urban and rural areas using allowable costs from FY 1995 cost reports. These rates also included an estimate of the cost of 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. The rates were adjusted annually using a SNF market basket index. Rates were case-mix adjusted using a classification system (Resource Utilization Groups, version III (RUG-III)) based on beneficiary assessments (using the Minimum Data Set (MDS) version 2.0) (In section III.C of this final rule, we discuss refinements to the case-mix classification system). The rates were also adjusted by the hospital wage index to account for geographic variation in wages. (In section III.D of this final rule, we discuss the wage index adjustment in detail.) Correction notices were published in the Federal Register on October 7, 2004 (69 FR 60158) and on December 30, 2004 (69 FR 78445) that announced corrections to several of the wage factors. Additionally, as noted in the July 30, 2004 update notice (69 FR 45775), section 101 of BBRA and certain sections of BIPA also affect the payment rate.
  • Transition. The SNF PPS included an initial 3-year, phased transition that blended a facility-specific payment rate with the Federal case-mix adjusted rate. For each cost reporting period after a facility migrated to the new system, the facility-specific portion of the blend decreased and the Federal portion increased in 25 percentage point increments. For most facilities, the facility-specific rate was based on allowable costs from FY 1995; however, since the last year of the transition was FY 2001, all facilities were paid at the full Federal rate by the following fiscal year (FY 2002). Therefore, as discussed in section I.F.2 of this final rule, we are no longer including adjustment factors related to facility-specific rates for the coming fiscal year.
  • Coverage. The establishment of the SNF PPS did not change Medicare's fundamental requirements for SNF coverage. However, because the RUG-III 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 involving level of care determinations with the outputs of beneficiary assessment and RUG-III classifying activities. We discuss this coordination in greater detail in section III.F of this final rule. Moreover, the Part A SNF benefit has not only level of care requirements, but also a set of technical, or “posthospital” requirements as well. In section III.K of this final rule, we discuss one aspect of the technical requirement for a qualifying prior inpatient hospital stay of at least 3 consecutive days, on which we invited public comment in the FY 2006 SNF PPS proposed rule.
  • Consolidated Billing. The SNF PPS includes a consolidated billing provision that requires a SNF to submit consolidated Medicare claims for almost all of the services that the resident receives during the course of a covered Part A stay. (In addition, this provision places with the SNF the Medicare billing responsibility for physical and occupational therapy, and speech-language pathology services that the resident receives during a noncovered stay.) The statute excludes from the consolidated billing provision a few services—primarily those of physicians and certain other types of practitioners—which remain separately billable to Part B by the outside entity that furnishes them. We discuss this provision in greater detail in section III.I of this final rule.
  • 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 III.J of this final rule.
  • Technical corrections. We are also taking this opportunity to make certain technical corrections in the text of the regulations, as discussed in greater detail in section IV. of this final rule.

B. Requirements of the Balanced Budget Act of 1997 (BBA) for Updating the SNF PPS

Section 1888(e)(4)(H) of the Act requires that we publish in the Federal Register:

1. The unadjusted Federal per diem rates to be applied to days of covered SNF services furnished during the FY.

2. The case-mix classification system to be applied with respect to these services during the FY.

3. The factors to be applied in making the area wage adjustment with respect to these services.

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 RUG-III classification structure (see section III.F of this final rule).

Along with a number of other revisions discussed later in this preamble, this final rule provides the annual updates to the Federal rates as mandated by the Act.

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

There were several provisions in the BBRA that resulted in adjustments to the SNF PPS. These provisions were described in detail in the final rule that we published in the Federal Register on July 31, 2000(65 FR 46770). In particular, sections 101(a) and (b) of the BBRA provided for a temporary 20 percent increase in the per diem adjusted payment rates for 15 specified RUG-III groups (SE3, SE2, SE1, SSC, SSB, SSA, CC2, CC1, CB2,CB1, CA2, CA1, RHC, RMC, and RMB). Under section 101(c) of the BBRA, this temporary increase remains in effect until the later of October 1, 2000, or the implementation of case-mix refinements in the PPS. (We discuss refinements to the case-mix classification system in section III.C of this final rule.) In addition, section 101(d) of the BBRA included a 4 percent across-the-board increase in the adjusted Federal per diem payment rates each year for FYs 2001 and 2002, exclusive of the 20 percent increase.

We included further information on all of the provisions of the BBRA that affect the SNF PPS in Program Memoranda A-99-53 and A-99-61 (December 1999), and Program Memorandus AB-00-18 (March 2000). In addition, 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 July 31, 2001 final rule (66 FR 39562), we made conforming changes to the regulations in § 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 included several provisions that resulted in adjustments to the PPS for SNFs. These provisions were described in detail in the final rule that we published in the Federal Register on July 31, 2001 (66 FR 39562), as follows:

  • Section 203 of the BIPA exempted critical access hospital (CAH) swing-beds from the SNF PPS; we included further information on this provision in Program MemorandumA-01-09 (January 16, 2001).
  • Section 311 of the BIPA eliminated the 1 percent reduction in the SNF market basket that the statutory update formula had previously specified for FY 2001, and changed the 1 percent reduction specified for FYs 2002 and 2003 to a 0.5 percent reduction. This section also required us to conduct a study of alternative case-mix classification systems for the SNF PPS, and to submit a report to the Congress on the results of the study.
  • Section 312 of the BIPA provided for a temporary 16.66 percent increase 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. This section also required 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. GAO issued this report (GAO-03-176) in November 2002.
  • Section 313 of the BIPA repealed the consolidated billing requirement for services (other than physical and occupational therapy, and speech-language pathology services) furnished to SNF residents during noncovered stays, effective January 1, 2001.
  • Section 314 of the BIPA adjusted the payment rates for all of the 14 rehabilitation RUGs (RUC, RUB, RUA, RVC, RVB,RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, and RLA), in order to correct an anomaly under which the existing payment rates for three particular rehabilitation RUGs—RHC, RMC, and RMB—were higher than the rates for some other, more intensive rehabilitation RUGs. Under the BIPA adjustment, the temporary increase that sections 101(a) and (b) of the BBRA had applied to the RHC, RMC, and RMB rehabilitation RUGs was revised from 20 percent to 6.7 percent, and the BIPA adjustment also applied this temporary 6.7 percent increase to each of the other 11 rehabilitation RUGs. Under this provision, the temporary increase remained at 20 percent for each of the 12 non-rehabilitation RUGs specified in section 101(b) of the BBRA (SE3, SE2, SE1,SSC, SSB, SSA, CC2, CC1, CB2, CB1, CA2, and CA1).
  • 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.

We included further information on several of these provisions in Program Memorandum A-01-08(January 16, 2001).

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

A provision of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) resulted in a further adjustment to the PPS for SNFs. Specifically, section 511 of the MMA amended paragraph (12) of section 1888(e) of the Act to provide for a temporary 128 percent increase in the PPS per diem payment for any SNF resident with Acquired Immune Deficiency Syndrome (AIDS), effective with services furnished on or after October 1, 2004. As discussed in Transmittal No. 160 (Change Request No. 3291, April 30, 2004, available online at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp), this add-on applies to claims with diagnosis code 042. Like the temporary add-on payments created by section 101(a) of the BBRA (as amended by section 314 of the BIPA), this special AIDS add-on was not intended to remain in effect indefinitely. As amended by section 511 of the MMA, section 1888(e)(12)(B) of the Act specifies that this temporary increase for patients with AIDS is to remain in effect only until “* * * such date as the Secretary certifies that there is an appropriate adjustment in the case mix * * * to compensate for the increased costs associated with [such] residents * * *.” As discussed in the FY 2006 SNF PPS proposed rule (70 FR 29080), we are not addressing the issue of such certification at this time and, accordingly, the temporary add-on payments created by section 511 of the MMA will remain in effect during FY 2006.

The law further provided that the 128 percent increase in payment under the AIDS add-on is to be “* * * determined without regard to any increase” under section 101 of the BBRA (as amended by section 314 of the BIPA). As explained in the MMA Conference report, this means that if a resident qualifies for the temporary 128 percent increase in payment under the special AIDS add-on, “the BBRA temporary RUG add-on does not apply in this case * * *.” (H.R. Conf. Rep. No. 108-391 at 662).

In addition, section 410 of the MMA contained a provision that affects the SNF consolidated billing requirement's treatment of certain services furnished as of January 1, 2005, by rural health clinics (RHCs) andFederally qualified health centers (FQHCs). This provision was discussed in Transmittal No. 390 (Change Request No. 3575), issued on December 10, 2004, which is available online at http://www.cms.hhs.gov/ manuals/transmittals/comm_date_dsc.asp.

F. General Overview of the SNF PPS

We implemented the Medicare SNF PPS for cost reporting periods beginning on or after July 1, 1998. Under the PPS, we pay SNFs through prospective, case-mix adjusted per diem payment rates applicable to all covered SNF services.These payment rates cover all the costs of furnishing covered skilled nursing services (routine, ancillary, and capital-related costs) other than costs associated with approved educational activities. Covered SNF services include post-hospital services for which benefits are provided under Part A and all items and services that, before July 1, 1998, had been paid under Part B (other than physician and certain other services specifically excluded under the BBA) but furnished to Medicare beneficiaries in a SNF during a covered Part A stay. A complete 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 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 PPS (the 15-month period beginning July 1, 1998) using a SNF market basket, and then standardized for the costs of facility differences in case-mix and for geographic variations in wages. The database used to compute the Federal payment rates excluded 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. In accordance with the formula prescribed in the BBA, 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. This classification system,Resource Utilization Groups, version III (RUG-III), uses beneficiary assessment data from the Minimum Data Set (MDS) completed by SNFs to assign beneficiaries to one of 44 RUG-III groups. The May 12, 1998 interim final rule(63 FR 26252) included a complete and detailed description of the RUG-III classification system. A further discussion of the case-mix classification system, including the issue of case-mix refinements, appears in section III.C of this final rule.

The Federal rates in this final rule reflect an update to the rates that we published for FY 2005 equal to the full change in the SNF market basket index. According to section 1888(e)(4)(E)(ii)(IV) of the Act, for FY 2006, we have adjusted the current rates by the full SNF market basket index.

2. Payment Provisions—Initial Transition Period

The SNF PPS included an initial, phased transition from a facility-specific rate (which reflected the individual facility's historical cost experience) to the Federal case-mix adjusted rate. The transition extended through the facility's first three cost reporting periods under the PPS, up to, and potentially including, the one that began in FY 2001. (Further, once section 102 of the BBRA took effect, a facility could elect to bypass the remainder of its transition period and go directly to being paid entirely under the Federal rates.) Accordingly, starting with cost reporting periods beginning in FY 2002, we base payments entirely on the Federal rates and, as mentioned previously in this final rule, we no longer include adjustment factors related to facility-specific rates for the coming fiscal year.

G. Use of the SNF 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 the covered SNF services. The SNF market basket index is used to update the Federal rates on an annual basis. The final rule published on July 31, 2001(66 FR 39562) revised and rebased the market basket to reflect 1997 total cost data. The SNF market basket index is discussed in greater detail in section III.H of this final rule.

In addition, as explained in the FY 2004 final rule(68 FR 46058, August 4, 2003) and in section III.H of this final rule, the annual update of the payment rates includes, as appropriate, an adjustment to account for market basket forecast error. This adjustment takes into account the forecast error from the most recently available fiscal year for which there are final data, and is applied whenever the difference between the forecasted and actual change in the market basket exceeds a 0.25 percentage point threshold. For FY 2004 (the most recently available fiscal year for which there are final data), the estimated increase in the market basket index was 3.0 percentage points, while the actual increase also was 3.0 percentage points. Therefore, the payment rates for FY 2006 do not include a forecast error adjustment, as there is no difference between the estimated and actual amounts of change. Table 1 below shows the forecasted and actual market basket amounts for FY 2004.

Table 1.—FY 2004 Forecast Error Correction for CMS SNF Market Basket Back to Top
Index Forecasted FY 2004 increase* Actual FY 2004 increase** FY 2004 forecast error correction***
* Published in August 4, 2003 Federal Register; based on second quarter 2003 Global Insight/DRI-WEFA forecast.
** Based on the second quarter 2005 Global Insight/DRI-WEFA forecast.
*** The FY 2004 forecast error correction will be applied to the FY 2006 PPS update. Any forecast error less than 0.25 percentage points is not reflected in the update.
SNF 3.0 3.0 0.0

II. Summary of the Provisions of the FY 2006 Proposed Rule Back to Top

The FY 2006 SNF PPS proposed rule included proposed updates to the FY 2006 Federal payment rates used under the SNF PPS. In accordance with section 1888(e)(4)(E)(ii)(IV) of the Act, the updates reflect the full SNF market basket percentage change for the fiscal year. We also proposed to introduce, as of January 1, 2006, a refined case-mix classification system that would add nine newRehabilitation plus Extensive Services groups at the top of the existing RUG hierarchy. The FY 2006 SNF PPS proposed rule discussed and invited public comment on a number of other clinical issues as well, involving alternative ways to improve quality and efficiency and ensure accurate payments under the SNF PPS.

We also proposed to incorporate OMB's revised definitions for Metropolitan Statistical Areas and its new definitions of Micropolitan Statistical Areas and CombinedStatistical Areas, and we invited comments on the appropriateness of implementing this change through a transition period similar to that adopted under the inpatient hospital PPS (IPPS). Further, we invited public comments on additional HCPCS codes that could represent the type of “high-cost, low probability” services within certain designated service categories (that is, chemotherapy and its administration, radioisotope services, and customized prosthetic devices) that section 103 of the BBRA has authorized us to exclude from the SNF consolidated billing provision. We also invited comments on the apparent hospital practice of having patients spend time in observation status prior to a formal inpatient admission, and on the potential implications of this practice for the SNF benefit's qualifying 3-day hospital stay requirement.

In addition to discussing these general issues in the FY 2006 SNF PPS proposed rule, we also proposed making the following specific revisions to the existing text of the regulations:

  • In § 424.3, we would make a technical correction to the definition of “HCPCS”.
  • In § 424.20, we would revise paragraph (e)(2) to clarify the distinction between “direct” and“indirect” employment relationships in terms of the ability of nurse practitioners and clinical nurse specialists to perform SNF certifications and recertifications.

More detailed information on each of these issues, to the extent that we received public comments on them, appears in the discussion contained in the following sections of this preamble.

III. Analysis of and Responses to Public Comments on the FY 2006 Proposed Rule Back to Top

In response to the publication of the FY 2006 SNF PPS proposed rule, we received 149 timely items of correspondence from the public. We received numerous comments from various trade associations and major organizations. Comments also originated from nursing homes, hospitals, and other providers, suppliers, and practitioners, nursing home resident advocacy groups, health care consulting firms, and private citizens. The following discussion, arranged by subject area, includes a summary of the public comments that we received, and our responses to the comments appear under the appropriate heading.

A. General Comments on the FY 2006 SNF PPS Proposed Rule

1. Public Comment Schedule for the FY 2006 SNF PPS Proposed Rule

Comment: A few commenters noted that the July 12, 2005, closing date for the public comment period fell less than 60 days after the proposed rule's May 19, 2005, publication date in the Federal Register, and expressed concern about abbreviating the comment period available for the proposed rule. They asserted that a timeframe of less than 60 days was burdensome, and affected their ability to furnish comprehensive responses. They asked us to provide the full 60-day comment period in the future.

Response: We note that in accordance with the requirements of section 1871(b)(1) of the Act, “notice of the proposed regulation in the Federal Register” was provided as of May 13, 2005. At that same time, the document was also posted on the CMS website. Accordingly, the contents of the proposed rule were, in fact, available to the public for the full 60-day comment period.

B. Update of Federal Payment Rates Under the SNF PPS

This final rule sets forth a schedule of Federal prospective payment rates applicable to Medicare Part A SNF services beginning October 1, 2005. The schedule incorporates per diem Federal rates that provide Part A payment for all costs of services furnished to a beneficiary in a SNF during a Medicare-covered stay. In the proposed rule, we proposed case-mix refinements, including the introduction of 9 new RUGs. As part of this process, we proposed to update and recalibrate the therapy and nursing case-mix indexes associated with all RUGs. We also proposed to increase both the nursing and therapy case-mix indexes and provide additional funding to the system in order to account for the variation in non-therapy ancillary costs.

Comment: Several commenters expressed concern regarding the overall fiscal impact of the proposed changes and recommended that the aggregate expenditure levels be increased, either by further increasing the case-mix weights or by increasing the baseline expenditure levels.Other commenters stated that they had been unable to reconcile their independent analyses with the information contained in the proposed rule, and were concerned that the impact of the proposed rate structure would exceed the CMS projections. In other cases, commenters submitted technical questions on the accuracy of the methodology used in developing our proposals, and urged that these methodological issues be addressed for the final rule.

Response: Throughout the comment period, we examined the data presented in the proposed rule, updated the analyses to reflect the most recent available data, and corrected minor technical errors. We received information from industry representatives and others, which helped us to verify the accuracy of the data used in the rate calculations, and then to ensure that the resulting rates correctly reflected the policies specified in the proposed rule. To accomplish these objectives, we made several adjustments to our models to better reflect the methodologies described in the proposed rule.

For example, for our modeling in the proposed rule, we used a therapy case-mix index that originally had been created for use in our FY 2001 refinements proposal, and utilized the same therapy case-mix weights for the new groups as for the original rehabilitation groups; that is, the therapy case-mix weight for the ultra high rehabilitation and combined ultra high rehabilitation/extensive care RUG groups were the same. As part of our ongoing review, we also tested several adjustments to our model, including recalibration of the therapy case-mix weights, using different sets of decision rules, to create separate therapy weights for the nine new groups. The purpose of this exercise was to test whether the adjusted model(s) better reflected the policy outlined in the proposed rule.

Using the adjusted therapy case-mix weights, we repeated the payment simulation described in the proposed rule. We then recalculated the payment adjustment needed to ensure parity when comparing the aggregate expenditure levels of the 44-group and 53-group RUG models. We found that, in recalibrating both the nursing and therapy case-mix weights, applying the payment adjustment solely to the nursing case-mix weights was no longer appropriate. Thus, we tested a second adjustment to the model that modified the payment simulation provision to apply the payment adjustment to both the nursing and therapy case-mix weights. We posted the analyses on our CMS web site.

Industry representatives and others used these data to replicate these analyses, to suggest alternative methodologies, and to develop their formal comments on the proposed rule. Thus, the information exchange through the CMS website was productive, and was beneficial in terms of finalizing our analysis.

Comment: A commenter questioned the methodology used to recalibrate the therapy case-mix weights, and also expressed concerns about the small staff time measurement (STM) sample size used to create separate therapy weights for each of the RUG-III groups.

Response: As part of the ongoing analysis described above, we reviewed the methodology used to create the case-mix weights for the initial introduction of the SNF PPS in 1998, and the ABT recalibration that was published in our FY 2001 proposed rule. We found that, as mentioned by a commenter, we were relying on extremely small sample sizes for several of the combined rehabilitation and extensive care groups. In addition, we found several variations in the decision rules used in the two sets of analyses. We were able to adjust for these methodological differences by recreating the therapy case-mix indexes using the original decision rules.

Once these methodological changes were made, we examined the model to determine the potential impact of using small sample sizes to establish therapy case-mix weights for all 23 rehabilitation groups; that is, 14 existing rehabilitation groups and 9 combined rehabilitation and extensive care groups. We concluded that we could not fully adjust for these small sample sizes when recalibrating the therapy case-mix weights, either as proposed or as noted on our website. Therefore, we have determined that retaining the same therapy case-mix weights that are being used in the 44-group RUG model would best reflect our policy objectives as stated in the proposed rule. These weights will be applied to the RUG groups based on the rehabilitation level. For example, a therapy case-mix weight of 2.25 will be used for the RUC, RUB, RUA,RUX, and RUL groups.

Once the case-mix weight structure was determined, we developed the final rates in accordance with the procedures outlined in the proposed rule. As we updated the nursing case-mix index only, we then applied the payment simulation to the nursing case-mix weights by adding 8.65 percent to maintain parity between the 44-group and 53-group models. Then, a final adjustment of 8.51 percent was made to the nursing weights to reflect the variability in non-therapy ancillary utilization.

In conducting these analyses, it was clear that relying on data collected before the introduction of the SNF PPS is not a permanent solution. We intend to revisit the structural development of the case-mix weights as part of our upcoming STM study, in which we will survey SNFs and collect data to better reflect current practice patterns and resource use in the SNF PPS. In addition, we intend to investigate alternative methods of updating the payment system as part of our ongoing program monitoring and evaluation activities.

1. Costs and Services Covered by the Federal Rates

The Federal rates apply to all costs (routine, ancillary, and capital-related costs) of covered SNF services other than costs associated with approved educational activities as defined in § 413.85. Under section 1888(e)(2) 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 underPart 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 FederalRates

The FY 2006 rates reflect an update using the full amount of the latest market basket index. The FY 2006 market basket increase factor is 3.1 percent. A complete description of the multi-step process was initially delineated in the May 12, 1998 interim final rule (63 FR 26252), and was further revised in subsequent rules. We note that in accordance with section 101(a) of the BBRA and section 314 of the BIPA, the existing, temporary increase in the per diem adjusted payment rates of 20 percent for certain specified clinically complex RUGs (and 6.7 percent for rehabilitation RUGs) remains in effect until January 1, 2006, when the refined RUG-53 classification system is implemented.

We used the SNF market basket to adjust each per diem component of the Federal rates forward to reflect price increases occurring between the midpoint of the Federal fiscal year beginning October 1, 2004, and endingSeptember 30, 2005, and the midpoint of the Federal fiscal year beginning October 1, 2005, and ending September 30, 2006, to which the payment rates apply. In accordance with section 1888(e)(4)(E)(ii)(IV) of the Act, the payment rates for FY 2005 are updated by a factor equal to the full market basket index percentage increase to determine the payment rates for FY 2006.The rates are further adjusted by a wage index budget neutrality factor, described later in this section. The unadjusted rates are the same under both the 44-group RUG-III classification system and the refined RUG-53 classification system.Tables 2 and 3 below reflect the updated components of the unadjusted Federal rates for FY 2006.

Table 2.—FY 2006 Unadjusted Federal Rate Per Diem—Urban Back to Top
Rate component Nursing—case-mix Therapy—case-mix Therapy—non-case-mix Non-case-mix
Per Diem Amount $137.59 $103.64 $13.65 $70.22
Table 3.—FY 2006 Unadjusted Federal Rate Per Diem—Rural Back to Top
Rate component Nursing—case-mix Therapy—case-mix Therapy—non-case-mix Non-case-mix
Per Diem Amount $131.45 $119.51 $14.58 $71.52

C. Case-Mix Adjustment and Other Clinical Issues

1. Proposed Refinements to the RUG-III Case-MixClassification System

Under the BBA, we must publish the SNF PPS case-mix classification methodology applicable for the next Federal fiscal year before August 1 of each year. In the FY 2006SNF PPS proposed rule, we proposed to implement refinements in the existing 44-group RUG-III case-mix classification system that would add 9 new Rehabilitation plus ExtensiveServices groups at the top of the existing hierarchy. A full discussion of our proposal can be found in this year's proposed rule for FY 2006 (70 FR 29075-81). The following is a discussion of the comments that we received on this issue.

Comment: A number of commenters viewed the introduction of the proposed refinements in a positive light, both as a means to address the needs of a specific heavy-care population and as a way to remove the uncertainty over the past several years surrounding the pending expiration of the BBRA's temporary add-on payments, which had made it difficult for SNFs to predict with any certainty what their payments would be from one year to the next. Other commenters questioned why we introduced RUG refinements through the regulatory process before finalizing a long term research project and submitting a report to the Congress on the results of that research.Several commenters suggested that it would be more appropriate to wait until the upcoming STM study is completed, so that we could take advantage of more recent data on practice patterns and resource use. Still others were concerned that the proposed refinements do not go far enough to reimburse SNFs adequately for non-therapy ancillaries, and questioned why we proposed a series of incremental changes to the existing RUG-III system rather than developing a comprehensive replacement to the currentSNF PPS.

Response: The RUG refinements and the SNF PPS report to the Congress on alternative systems have often been viewed as two components of a single project. However, while there is a definite relationship, the RUG refinements and the SNF PPS report to the Congress are, and should be viewed as, end products of two separate Congressional mandates.

The BBRA legislation authorized temporary payment adjustments that were intended to serve as short term, interim adjustments to the payment rates and RUG-III case-mix classification system as published in our July 30, 1999 final rule (64 FR 41644). In fact, while the legislation included a contingency plan to maintain the temporary payments until refinements to better account for “medically complex” patients were introduced, the Congress clearly envisioned that these temporary payments would expire on October 1, 2000. Given this short time frame, it seems clear that the “refinements” could be expected to be modest in scope. We believe the rulemaking process was the most appropriate vehicle for introducing any refinement policy changes, as it affords all stakeholders the opportunity to comment before any policy recommendations are finalized.

In contrast, section 311(e) of the BIPA directed us to conduct a study of the different systems for categorizing patients in Medicare SNFs, and to issue a report with any appropriate recommendations to the Congress. Based upon the broad language describing the purpose of this study, and the multi-year timeframe provided for conducting it, we believe that the Congress clearly intended for this study to address more comprehensive changes, by evaluating a number of different classification systems and considering the full range of patient types. The results of this broader research will be discussed in a report that will be released to the Congress once it has been completed.

However, we believe the need for ongoing evaluation and change should not preclude the more immediate introduction of incremental adjustments and improvements to the SNF PPS. We intend to use the report to Congress to outline a series of next steps, including the need for a new STM study, that support our ongoing efforts to enhance the accuracy and efficiency of the SNF PPS.

We note that many of the concerns advanced by the commenters are similar to the ones that some commenters expressed in response to the SNF PPS proposed rule for FY 2004 (68 FR 26758, May 16, 2003), when we last invited public comments on the issue of case-mix refinements. However, as we subsequently observed in the final rule for FY 2004, other commenters were at that same time urging us “* * * to move quickly to identify and implement short-term incremental improvements to provide more appropriate reimbursement for patients with heavy non-therapy ancillary needs” (68 FR 46041, August 4, 2003). As discussed in this year's FY 2006 proposed rule, we believe the refinements that we have developed offer an effective means of enabling the SNF PPS to make more accurate payments for non-therapy ancillary services (thus ensuring continued access to quality care for the very vulnerable heavy-care population), while at the same time avoiding the drawbacks in terms of added complexity that were inherent in previous proposals to address this issue (70 FR 29079). Accordingly, we are implementing the case-mix refinements as set forth in the proposed rule.

Comment: Commenters suggested we expand the proposedRUG-53 classification system by, for instance, creating an additional Rehabilitation RUG between Medium and High and the expansion of the Extensive Services category to include criteria such as cardiac respiratory conditions that require monitoring and the administration of aerosol medications.

Response: During future analysis, most notably our upcoming STM study, we will evaluate whether the RUG categories should be further modified.

In addition, we have discovered that in the FY 2006 SNF PPS proposed rule, we inadvertently misidentified some RUG classification categories corresponding to Rehab High, Rehab Medium, and Rehab Low in Table 3a (“Crosswalk Between Existing RUG-III Rehabilitation Groups and the Proposed Extensive Plus Rehabilitation Groups”). Accordingly, in this final rule, we are reprinting the retitled and corrected Table 3a, as set forth below.

Table 3a.—Crosswalk Between Existing RUG-III Rehabilitation Groups and the New Rehabilitation Plus Extensive Services Groups Back to Top
Current rehabilitation groups New rehabilitation plus extensive services groups
Rehab Ultra • RUC—ADL 16-18 • RUB—ADL 9-15 • RUA—ADL 4-8 • RUX—ADL 16-18. • RUL—ADL 7-15.
Rehab Very High • RVC—ADL 16-18 • RVB—ADL 9-15 • RVA—ADL 4-8 • RVX—ADL 16-18. • RVL—ADL 7-15.
Rehab High • RHC—ADL 13-18 • RHB—ADL 8-12 • RHA—ADL 4-7 • RHX—ADL 13-18. • RHL—ADL 7-12.
Rehab Medium • RMC—ADL 15-18 • RMB—ADL 8-14 • RMA—ADL 4-7 • RMX—ADL 15-18. • RML—ADL 7-14.
Rehab Low • RLB—ADL 14-18 • RLA—ADL 4-13 • RLX—ADL 7-18.

2. Proposed Increases to the RUG-III Case-Mix Weight Values

To help address the high degree of variability in the use of non-therapy ancillary services that we have identified both within and across groups, in the FY 2006SNF PPS proposed rule, we proposed to increase the case-mix weights for all 53 RUGs (that is, the 44 existing RUG-III groups, as well as the proposed 9 new Rehabilitation plus Extensive Services groups). Specifically, we proposed to apply an increase of 8.4 percent to the component of the case-mix weights that includes both nursing and non-therapy ancillary costs (producing a 3 percent increase in aggregate spending), and to do so in a manner that would integrate the increase into base line spending levels and continue it in future years (70 FR 29079). (As noted previously in section III.B, the proposed 8.4 percent increase to the nursing component of the case-mix weights is now 8.51 percent in this final rule.) The following is a discussion of the comments that we received on this issue.

Comment: A number of commenters were concerned about the adequacy of payment for non-therapy ancillary services, and questioned whether the proposed increase in the nursing case-mix weights fully addresses the issue. Several commenters recommended that the case-mix weights should be adjusted by more than the 8.4 percent presented in the proposed rule. Others suggested that, rather than adjusting the case-mix weights by a factor comparable to outlier pools (that is, 3 percent of aggregate spending) established for other prospective payment systems, we implement a SNF outlier pool that could more specifically target high-cost cases. A few commenters also recommended that we adopt a payment adjustment for hospital-based SNFs, either as part of an outlier policy or as an adjustment to the base rates that would address not only the different levels of non-therapy ancillary utilization between hospital-based and freestanding facilities, but the overall cost structure differences related to differences in patient characteristics and care needs. In addition, several commenters recommended creating a variable per diem payment mechanism similar to the mechanism used for inpatient psychiatric hospitals, where higher payments could be made for the early (and presumably more costly) days of a SNF stay. Finally, a few commenters expressed concern that the effect of the refinements would be to redirect dollars away from beneficiaries needing complex medical services.

Response: As discussed here and in our proposed rule, the variability in non-therapy ancillary utilization increased the difficulty of any refinement to the RUG-III system without increasing the system complexity to such a degree that it would become both burdensome and confusing to the facility staff responsible for administering the system. In evaluating potential options, we recognized that this across-the-board increase in the nursing component is only an incremental improvement, but it is a change that did not give rise to the concerns about undue complexity noted above.

Moreover, while the introduction of these refinements fulfills our obligations under section 101 of the BBRA, we note it is just the first of an ongoing series of analyses aimed at enhancing the SNF PPS payment structure. For example, we are already examining the potential for an outlier program to further enhance program accuracy and beneficiary access to care.

The introduction of this incremental change is part of this ongoing process that will also include update activities such as the upcoming STM study and investigation of potential alternatives to the RUG system itself. However, the commitment to long term analysis and refinement should not preclude the introduction of more immediate methodological and policy updates.

While most commenters viewed the adoption of the nine new groups as beneficial, a few commenters were concerned that money was being redirected away from the complex medical RUGs. We are confident that the introduction of these refinements benefits heavy-care beneficiaries. However, as shown in Table 12 of this final rule, changes in the FY 2006 rate structure reflect an interrelationship between many factors, including the elimination of the BBRA add-ons, changes in the wage index, and the introduction of the refinements.

Comment: Some commenters suggested that the underfunding in the Medicaid system should be addressed at the same time as the Medicare RUGs refinement, and expressed concern about the impact that Medicare payment rate reductions would have in combination with changes in State Medicaid payments.

Response: While Medicare and Medicaid are independent programs that are subject to different ratesetting and budgetary mechanisms, we recognize their interrelationship, particularly for those States that utilize variations of Medicare's RUG case-mix classification system. We further recognize that Medicaid needs to establish rates that accurately reflect the cost of Medicaid services. In order to assist in realizing that objective, we plan to use our upcoming STM study to look at the entire RUG payment system, including facilities that are predominatelyMedicaid-based. Additionally, the Pay for Performance quality initiatives discussed in the FY 2006 proposed rule could apply to both covered Part A and noncovered (Part B) stays of dual-eligibles.

3. Implementation Issues

In order to enable nursing homes and Medicare contractors to have sufficient lead time to prepare for the changes associated with implementing the RUG-III case-mix refinements, in the FY 2006 SNF PPS proposed rule we proposed an effective date for the refinements of January 1, 2006, rather than the start of the fiscal year on October 1, 2005. (Under the terms of section 101(c) of the BBRA, the temporary add-on payments enacted by sections 101(a) and (b) of the BBRA for certain designatedRUG-III groups would expire on the date that these refinements take effect.) The following is a discussion of the comments that we received on this issue.

Comment: Generally, commenters were supportive of the delay in implementing the case-mix refinements. However, some commenters were concerned that the January 2006 date does not provide adequate preparation time, especially for the software vendors and facilities that will need to update their MDS data systems. They pointed out the need for adequate lead time to ensure a smooth transition. In addition, a few commenters wanted to know which date would determine when the new RUG classification would need to be reported on the claim (for example the Assessment ReferenceDate (ARD, item A3a), the Minimum Data Set (MDS) completion date (item R2b), the service date, or the admission date), as well as whether the MDS edits will provide a 44-group RUG for corrected MDSs. Finally, a few commenters noted that the RAVEN software would need to be updated prior to any changes to the existing RUG-III classification system.

Response: We agree that software vendors and SNFs must have enough time to design, test, and implement the system changes needed to support these refinements. For this reason, we have scheduled a software vendor conference call on August 4, 2005 to review the data specifications, and respond to questions on the changes. Further information on this vendor teleconference is posted on ourQuality Improvement Evaluation System (QIES) website at the following address: http://www.qtso.com/vendor.html. We will also make available the new software specifications at http://www.cms.hhs.gov/medicaid/mds20/mdssoftw.asp and vendors should implement the appropriate software by November 22, 2005. This timeline provides the vendors over 3 months to update their programs for SNFs. We also plan to release training materials and billing instructions in sufficient time so that SNFs will be able to transition to the refined RUG model.

As stated in the proposed rule, we will begin to apply the RUG case-mix refinement on January 1, 2006. Even though payments are determined by the MDS, the CMS claims processing systems operate on a date of service basis. Thus, the new rates need to go into effect as of January 1, 2006, rather than by the ARD date. This procedure is consistent with the billing procedures used at the start of each rate year. Providers are always instructed to prepare separate bills for services prior to and on or after October 1. This ensures that the claim is paid using the correct rate.

We believe that by scheduling implementation for January 1, 2006, rather than October 1, 2005 (the beginning of FY 2006), we are allowing ample time for providers to adjust to the refined RUG case-mix classification system and to train and educate their staff. This date also allows vendors sufficient time to update their programs to meet our requirements. Finally, by providing a date certain, all systems (State, CMS, FI, providers) can be configured uniformly, thus limiting potential billing errors.

The provider shall bill the appropriate RUG category based on the calendar date of service. For days of service before January 1, 2006, the provider shall record the 44-group RUG on the claim. For days of service beginning on January 1, 2006, the provider shall record the 53-group RUG on the claim.

If for some unforeseen reason, a software vendor is not able to update its program by mid-November, the State system “Final Validation Report” to the provider will list both the 44-group RUG and the 53-group RUG for SNF PPS assessments with ARDs of 11/22/2005 through 1/13/2006. These are the potential transition assessments that could be used for days of service both before January 1, 2006 and for days of service in 2006. For example, a 60-day SNF PPS MDS can be completed as early as day 50 of the beneficiary's SNF Part A stay. If the resident's 50th day of the stay is November 22, 2005 and the provider chooses this date as the ARD for the 60-day PPS MDS, the 44-group RUG would be billed from day 61 (December 3, 2005) to day 89 (December 31, 2005) and the 53-group RUG would be billed for day 90 (January 1, 2006).

For assessments with ARDs before November 22, 2005, only the 44-group RUG is appropriate for billing and the “Final Validation Report” will only report the 44-group RUG when the facility submits an incorrect 44-group RUG on the assessment. For assessments with ARDs after January 13, 2006, only the 53-group RUG is appropriate for billing and the “Final Validation Report” will only report the 53-groupRUG when the facility submits an incorrect 53-group RUG on the assessment. For assessments with ARDs from November 22, 2005 through January 13, 2006, the MDS may be submitted with either the 44-group RUG or the 53-group RUG.

Correction assessments (Modifications or Significant Correction Assessments) will be processed in the same manner as other assessments. The RUG grouper (44-group vs. 53-group RUG) that will be calculated and accepted will be determined by the ARD of the Modification or SignificantCorrection Assessment.

We believe that these steps provide adequate support, and will proceed with the implementation of the refinements effective January 1, 2006.

4. Additional Clinical and Related Issues

In addition to the proposed case-mix refinements, the FY 2006 SNF PPS proposed rule discussed and invited public comment on a number of other clinical and related issues involving alternative ways to improve quality and efficiency and continue to ensure accurate payments under the SNF PPS.

a. Proposed Changes to the MDS Coding Requirements (“Look Back” Period, 5-Day Grace Periods for PPS MDS Assessments, and Projection of Anticipated Therapy Services During the 5-Day PPS Assessment (Section T))

In the FY 2006 SNF PPS proposed rule, we invited public comment on possible changes in MDS coding requirements, such as decreasing the length of the “look-back” period (to restrict coding of certain high intensity services to those actually received in the SNF), decreasing or eliminating the grace periods associated with PPS MDS assessments (specifically with reference to the 5-day PPS MDS assessment), and possibly eliminating the projection of anticipated therapy services during the 5-day PPS assessment (70 FR 29080).

Comment: We received numerous comments on several potential changes to the MDS and the case-mix classification system that we proposed. The overwhelming majority of commenters opposed the elimination of two current policies: The availability of grace days when completing the MDS, and the method of estimating therapy services during the first 15 days of a SNF admission. However, a few commenters supported eliminating the method of estimating therapy services, mentioning findings by the GAO and the Data Assessment and Verification Project (DAVE) that demonstrated a mismatch between the estimated and actual amount of therapy provided, and expressing concern that there may be some abuse of this policy. In addition, a few commenters suggested limiting the use of grace days to the 5-day and 14-day assessments. We also received numerous comments on the change in the MDS assessment “look back” period to restrict MDS reporting to services furnished in the SNF rather than during the preceding hospital stay. While some commenters supported the change in terms of SNF reimbursement policy, most commenters believed there were strong care planning reasons for retaining the current policy. Specifically, the commenters were concerned that facility staff would be unable to perform an accurate assessment of the resident, and that the elimination of the data would result in an underestimate of resource needs and negatively affect the development of an individualized care plan. A number of commenters also recommended that the type of changes discussed in the proposed rule needed to be coordinated with other CMS initiatives, including the development of MDS 3.0 and the upcoming STM study.

Response: After reviewing the comments, we agree that the changes discussed above should be addressed as part of a comprehensive examination of both the MDS 3.0 design initiative and the case-mix classification system. Therefore, we will not implement changes at this time, but will continue to study these and other issues during the upcoming STM study and MDS 3.0 design initiative.

b. Long-Term Payment and Quality Incentive Proposals

In the FY 2006 SNF PPS proposed rule, we discussed and invited comment on various long-term payment and quality incentives (70 FR 29080-29081). The following is a discussion of the comments that we received on these issues.

Comment: Commenters generally responded positively to our discussion of these issues. Regarding Pay for Performance initiatives, the overwhelming majority of commenters believed that its design should be a collaborative process between CMS, industry representatives, and other stakeholders to ensure development of a fair and equitable program. In some cases, the comments we received contained detailed suggestions on the design, validation, and use of quality measures in such a program. A few commenters also suggested specific funding structures. Other commenters suggested that additional work is needed to evaluate the interaction between performance measures used for payment and the design structure of an MDS 3.0 assessment tool. Commenters also expressed interest in the integrated post acute payment system, and were supportive of the idea that reimbursement under such a system could be more closely linked to actual patient need. Similarly, the majority of commenters believed that the development of electronic health records has a real potential for improving the accuracy and efficiency of the system. Commenters were also very supportive of enhanced discharge planning, and saw it as a way of achieving improved outcomes in terms of quality of care as well as quality of life for facility residents.

Response: We agree with the commenters that the most effective way of designing any of these initiatives would be through a collaborative process. To that end, we have begun work on a SNF Pay for Performance model, and have already had informal discussions with stakeholders, where we asked them for their input and comments on specific design issues. These issues included the type of measures that would be most appropriate, and the importance of ensuring that they reflect the needs of the entire population, from post acute patients to chronic, long-term care patients. We also informed the stakeholders that we have contracted with Abt Associates to design a demonstration model, and we asked for their feedback on the type of model that would be most effective in fostering quality of care. We plan to follow up with a general meeting early this fall, where we will discuss design issues and potential quality measures in greater detail. We expect to follow similar procedures as we undertake development of the various other initiatives discussed here and in the proposed rule.

c. Proposal To Clarify “Direct” and “Indirect” Employment Relationships for Nurse Practitioners and Clinical NurseSpecialists

The Medicare statute specifies that a nurse practitioner (NP) or a clinical nurse specialist (CNS) can perform the required level of care certifications and recertifications in a SNF only if the NP or CNS “ * * * does not have a direct or indirect employment relationship with the facility * * *” (section 1814(a)(2) of the Act). In the FY 2006 SNF PPS proposed rule, we proposed revising our policies at § 424.20(e)(2) of the regulations to distinguish more clearly between “direct” and “indirect” employment relationships in terms of the ability of NPs and CNSs to perform SNF certifications and recertifications. We noted that NPs and CNSs who are employed by SNFs not only perform the types of delegated physician tasks that are permitted under the long-term care facility requirements for participation at 42 CFR 483.40(e), but typically perform general nursing services as well. In those situations where no direct employment relationship exists between an NP or CNS and the SNF, we proposed that an indirect employment relationship exists for any NP or CNS who performs these general nursing services for the SNF under the regulations at 42 CFR 409.21 (70 FR 29082).

Comment: Many commenters expressed concern that our proposal to define “indirect” employment in terms of the provision of general nursing services was overly restrictive. They argued that adopting this approach would inhibit NPs and CNSs from engaging in their full scope of practice, and would limit SNF residents' access to their services. It was also asserted that our proposed definition actually goes well beyond the intent of the Congressional restriction on indirect employment relationships, as it could encompass even those NPs and CNSs who operate in independent practice and have no employment relationship whatsoever with the SNF, either directly or through another entity. In addition, some commenters suggested that our proposed approach represents a double standard, in that it would not subject physicians to similar restrictions.

Response: Regarding the concerns about unduly impeding the scope of practice for NPs and CNSs and limiting resident access to their services, we note that under section 1814(a)(2) of the Act, the statutory prohibition against an NP or CNS having a direct or indirect employment relationship with the SNF applies solely in terms of performing the required certification and recertifications of the beneficiary's need for Part A SNF services, and does not carry over to any other context. This means that while the presence of such an employment relationship would serve to preclude an NP or CNS from performing the required SNF certification and recertifications, it would not additionally prevent the NP or CNS from furnishing the full range of direct patient care to the SNF's residents. Further, regarding the issue of the differential treatment of physicians (who are not subject to this restriction), we note that the statute itself specifically applies the restriction to NPs and CNSs, but not to physicians.

In essence, we believe that a direct employment relationship is one in which the SNF itself exercises the right of direction and control over the NP or CNS that characterizes an employment relationship under the common law test (see the regulations at 20 CFR 404.1005, 404.1007, and 404.1009), while an indirect employment relationship is one in which another entity exercises this right on the SNF's behalf. However, we agree that an indirect employment relationship should not be defined so broadly as to encompass an NP or CNS who is operating in independent practice and, thus, has no employer-employee relationship whatsoever, either with the SNF or with any other entity. Moreover, we believe this term should not encompass situations where an entity other than the SNF, although employing the NP or CNS, does not do so on the SNF's behalf. For example, it is common for an NP or CNS who is employed by a group practice to see SNF residents on behalf of one of the group practice's physicians. There may be instances where the group practice enters into an agreement with the SNF that includes having the group practice's NP or CNS employee furnish general nursing services to the SNF's residents. As these general nursing services would fall within the package of bundled services for which the SNF is financially and professionally responsible, the group practice under such an agreement essentially would be exercising its authority as the NP's or CNS's employer on the SNF's behalf, so that an indirect employment relationship would exist between the SNF and the NP or CNS.

By contrast, if the group practice's agreement with the SNF does not involve the provision of bundled nursing services (for example, it is solely for the purpose of gaining admitting privileges for the group practice's physicians, or for providing excluded NP or CNS services to the SNF's residents), then the group practice's exercise of its authority as the NP's or CNS's employer would not be done on the SNF's behalf. Consequently, an indirect employment relationship would not arise under such an agreement, and the NP or CNS would not be precluded from either furnishing the separately billable NP or CNS services to the SNF's residents, or from completing the required certifications and recertifications. Similarly, an indirect employment relationship would not arise in those instances where the only services that the NP or CNS furnishes to the SNF's residents under the agreement are delegated physician tasks under 42 CFR 483.40(e).

Accordingly, in response to comments, we are modifying this aspect of the proposed rule in the regulations at § 424.20 to specify that in contrast to a direct employment relationship with a SNF (in which the SNF itself exercises the right of direction and control over the NP or CNS that characterizes an employment relationship under the common law test), an indirect employment relationship exists in situations where an NP or CNS meets both of the following conditions: (1) The NP or CNS has a direct employment relationship with an entity other than the SNF itself; and (2) The NP's or CNS's employer enters into an agreement with the SNF for the provision of bundled general nursing services to the SNF's residents. Under this definition, an NP or CNS who is employed by an entity other than the SNF can still perform SNF certifications and recertifications, as long as his or her employer has not entered into such an agreement with the SNF.

d. Completion of Other Medicare Required Assessments (OMRAs)

In the FY 2006 SNF PPS proposed rule, we noted that one of the requirements governing the completion of Other Medicare Required Assessments (OMRAs) specifies that an OMRA “is due” 8 to 10 days after the cessation of all therapy (occupational and physical therapies and speech-language pathology services) in all situations where the beneficiary was assigned a rehabilitation RUG on the previous assessment. We then went on to clarify how the last day of therapy is determined in this context.

Comment: Most commenters supported introduction of the clarification, while a small number of commenters expressed concern about the wording. Others expressed concerns on issues that are not directly related to the OMRA language, including comments expressing concern about the limited ability to capture the “short-stay patients discharged before the five-day assessment,” and suggesting that we introduce either an at-admission or an at-discharge assessment, or that we eliminate the 5-day assessment.

Response: After reviewing the comments, we agree that we can further clarify our discussion of OMRA assessments in the proposed rule. Therefore, we wish to clarify that in our previous statements that the OMRA “is due” 8 to 10 days after the cessation of all therapy, and that therapeutic leave days are counted in determining the OMRA “due date,” the due date to which we refer is, in fact, the Assessment Reference Date (ARD). Thus, it is the ARD of the OMRA that must be set 8 to 10 days after the cessation of all therapy, and therapeutic leave days are counted when setting the OMRA ARD. Further, we note that we will keep the commenters' additional suggestions in this area in mind as we pursue our ongoing efforts to improve the accuracy and efficiency of the SNF PPS and the MDS processing system.

e. Concurrent Therapy

In the FY 2006 SNF PPS proposed rule, we solicited public comment on whether additional guidance might be warranted to help prevent the inappropriate provision of concurrent therapy in situations where it is not clinically justified (70 FR 29082-29083). The following is a discussion of the comments that we received on this issue.

Comment: A majority of commenters support the continuation of concurrent therapy as a delivery mode for rehabilitation services when properly furnished by the therapist. Many commenters suggested that CMS establish guidelines or develop examples that would provide guidance on the appropriate use of concurrent therapy, while a few commenters pointed out that CMS already has authority to conduct medical reviews and opposed further regulation. We also received some comments that suggested ways to decrease confusion among therapists, including educational outreach with the assistance of the professional associations, and establishing a single set of guidelines for Medicare Part A and Medicare Part B. Several commenters reported abuse and some reported that staff are being coerced to maximize minutes and reimbursement. One commenter expressed concern that, in the absence of concurrent therapy, some patients might not receive any services. However, another commenter suggested that the overuse of concurrent therapy could mean that a beneficiary might never receive necessary individualized care.

Response: We addressed the practice of concurrent therapy in the FY 2006 SNF PPS proposed rule in order to reiterate Medicare policy and to solicit public comment. Our concern was two-fold: That therapists' professional judgment was being overridden by pressures to be more productive by treating multiple beneficiaries concurrently; and that the Medicare policy that allows for the treatment of multiple beneficiaries was being used inappropriately and could lead to diminished quality of care. We wished to convey that the therapist's professional judgment should not be compromised and concurrent therapy should be performed only when it is clinically appropriate to render care to more than one individual (other than group therapy) at the same time. We agree that, at times, such care can be provided concurrently with another therapy patient, as long as the decision to do so is driven by valid clinical considerations. As requested by several commenters and based on the reports of overuse and/or abuse of concurrent therapy, we will continue to monitor these issues. We intend to work with professional organizations to determine the type of guidelines and educational materials that would be most helpful to therapists and other stakeholders. In addition, we also intend to address concurrent and group therapy utilization patterns during our STM study scheduled to start later this calendar year.

5. Case-Mix Adjusted Federal Rates and Associated Indexes

We have established January 1, 2006, as the beginning date for the use of the case-mix refinements. Accordingly, from October 1, 2005, through December 31, 2005, we will make payment based entirely on the existing 44-group RUG-III classification system. Tables 4, 5, 6, and 7 reflect the corresponding rate information for the existing 44-group RUG-III classification system to be used during this time.

Beginning on January 1, 2006, we will make payment based entirely on the refined RUG-53 classification system (and, thus, would not include the add-on payments). Tables 4a, 5a, 6a, and 7a reflect the corresponding rate information for the RUG-53 classification system.

As part of our ongoing analysis of the 53-group model, we updated the nursing case-mix weights presented in the proposed rule using 2001 data, the most current data available. In addition, based on comments, we adjusted the 53-group model to retain the existing therapy case-mix weights for the 23 Rehabilitation and combined Rehabilitation/Extensive Care groups. We then used the updated case-mix data to repeat the payment simulation described in the proposed rule. The payment simulation showed that adjustments were needed to maintain parity between the 44-group and 53-group models. Thus, we modified the payment simulation model to apply the payment adjustment to both the nursing and therapy case-mix weights proportionally by the aggregate number of days in therapy RUGs versus non-therapy RUGs. This parity was achieved by increasing the nursing case-mix weight by 8.65 percent. Finally, using the methodology described in the proposed rule, we calculated an 8.51 percent nursing case-mix weight adjustment factor to use to address variability in non-therapy ancillary costs. The steps taken to calculate the 53-group model nursing case-mix weights are shown on the SNF PPS website, at www.cms.hhs.gov/providers/snfpps.

Tables 4 and 5 reflect the updated SNF Federal rates for FY 2006 for the existing 44-group RUG-III classification system. Tables 4a and 5a reflect the updated SNF Federal rates for FY 2006 for the RUG-53 classification system. The first nine groups listed in Tables 4a and 5a are for the new Rehabilitation plus Extensive Services groups.

Table 4.—RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes—Urban Back to Top
RUG III category Nursing index Therapy index Nursing component Therapy component Non-case mix therapy component Non-case mix component Total rate
RUC 1.30 2.25 178.87 233.19 70.22 482.28
RUB 0.95 2.25 130.71 233.19 70.22 434.12
RUA 0.78 2.25 107.32 233.19 70.22 410.73
RVC 1.13 1.41 155.48 146.13 70.22 371.83
RVB 1.04 1.41 143.09 146.13 70.22 359.44
RVA 0.81 1.41 111.45 146.13 70.22 327.80
RHC 1.26 0.94 173.36 97.42 70.22 341.00
RHB 1.06 0.94 145.85 97.42 70.22 313.49
RHA 0.87 0.94 119.70 97.42 70.22 287.34
RMC 1.35 0.77 185.75 79.80 70.22 335.77
RMB 1.09 0.77 149.97 79.80 70.22 299.99
RMA 0.96 0.77 132.09 79.80 70.22 282.11
RLB 1.11 0.43 152.72 44.57 70.22 267.51
RLA 0.80 0.43 110.07 44.57 70.22 224.86
SE3 1.70 233.90 13.65 70.22 317.77
SE2 1.39 191.25 13.65 70.22 275.12
SE1 1.17 160.98 13.65 70.22 244.85
SSC 1.13 155.48 13.65 70.22 239.35
SSB 1.05 144.47 13.65 70.22 228.34
SSA 1.01 138.97 13.65 70.22 222.84
CC2 1.12 154.10 13.65 70.22 237.97
CC1 0.99 136.21 13.65 70.22 220.08
CB2 0.91 125.21 13.65 70.22 209.08
CB1 0.84 115.58 13.65 70.22 199.45
CA2 0.83 114.20 13.65 70.22 198.07
CA1 0.75 103.19 13.65 70.22 187.06
IB2 0.69 94.94 13.65 70.22 178.81
IB1 0.67 92.19 13.65 70.22 176.06
IA2 0.57 78.43 13.65 70.22 162.30
IA1 0.53 72.92 13.65 70.22 156.79
BB2 0.68 93.56 13.65 70.22 177.43
BB1 0.65 89.43 13.65 70.22 173.30
BA2 0.56 77.05 13.65 70.22 160.92
BA1 0.48 66.04 13.65 70.22 149.91
PE2 0.79 108.70 13.65 70.22 192.57
PE1 0.77 105.94 13.65 70.22 189.81
PD2 0.72 99.06 13.65 70.22 182.93
PD1 0.70 96.31 13.65 70.22 180.18
PC2 0.65 89.43 13.65 70.22 173.30
PC1 0.64 88.06 13.65 70.22 171.93
PB2 0.51 70.17 13.65 70.22 154.04
PB1 0.50 68.80 13.65 70.22 152.67
PA2 0.49 67.42 13.65 70.22 151.29
PA1 0.46 63.29 13.65 70.22 147.16
Table 4a.—RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes—Urban Back to Top
RUG-53 category Nursing index Therapy index Nursing component Therapy component Non-case mix therapy component Non-case mix component Total rate
RUX 1.90 2.25 261.42 233.19 70.22 564.83
RUL 1.40 2.25 192.63 233.19 70.22 496.04
RVX 1.54 1.41 211.89 146.13 70.22 428.24
RVL 1.33 1.41 182.99 146.13 70.22 399.34
RHX 1.42 0.94 195.38 97.42 70.22 363.02
RHL 1.37 0.94 188.50 97.42 70.22 356.14
RMX 1.93 0.77 265.55 79.80 70.22 415.57
RML 1.68 0.77 231.15 79.80 70.22 381.17
RLX 1.31 0.43 180.24 44.57 70.22 295.03
RUC 1.28 2.25 176.12 233.19 70.22 479.53
RUB 0.99 2.25 136.21 233.19 70.22 439.62
RUA 0.84 2.25 115.58 233.19 70.22 418.99
RVC 1.23 1.41 169.24 146.13 70.22 385.59
RVB 1.09 1.41 149.97 146.13 70.22 366.32
RVA 0.82 1.41 112.82 146.13 70.22 329.17
RHC 1.22 0.94 167.86 97.42 70.22 335.50
RHB 1.11 0.94 152.72 97.42 70.22 320.36
RHA 0.94 0.94 129.33 97.42 70.22 296.97
RMC 1.15 0.77 158.23 79.80 70.22 308.25
RMB 1.09 0.77 149.97 79.80 70.22 299.99
RMA 1.04 0.77 143.09 79.80 70.22 293.11
RLB 1.14 0.43 156.85 44.57 70.22 271.64
RLA 0.85 0.43 116.95 44.57 70.22 231.74
SE3 1.86 255.92 13.65 70.22 339.79
SE2 1.49 205.01 13.65 70.22 288.88
SE1 1.26 173.36 13.65 70.22 257.23
SSC 1.23 169.24 13.65 70.22 253.11
SSB 1.13 155.48 13.65 70.22 239.35
SSA 1.10 151.35 13.65 70.22 235.22
CC2 1.22 167.86 13.65 70.22 251.73
CC1 1.06 145.85 13.65 70.22 229.72
CB2 0.98 134.84 13.65 70.22 218.71
CB1 0.91 125.21 13.65 70.22 209.08
CA2 0.90 123.83 13.65 70.22 207.70
CA1 0.80 110.07 13.65 70.22 193.94
IB2 0.74 101.82 13.65 70.22 185.69
IB1 0.72 99.06 13.65 70.22 182.93
IA2 0.61 83.93 13.65 70.22 167.80
IA1 0.56 77.05 13.65 70.22 160.92
BB2 0.73 100.44 13.65 70.22 184.31
BB1 0.69 94.94 13.65 70.22 178.81
BA2 0.60 82.55 13.65 70.22 166.42
BA1 0.52 71.55 13.65 70.22 155.42
PE2 0.85 116.95 13.65 70.22 200.82
PE1 0.82 112.82 13.65 70.22 196.69
PD2 0.78 107.32 13.65 70.22 191.19
PD1 0.76 104.57 13.65 70.22 188.44
PC2 0.71 97.69 13.65 70.22 181.56
PC1 0.69 94.94 13.65 70.22 178.81
PB2 0.55 75.67 13.65 70.22 159.54
PB1 0.54 74.30 13.65 70.22 158.17
PA2 0.53 72.92 13.65 70.22 156.79
PA1 0.50 68.80 13.65 70.22 152.67
Table 5.—RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes—Rural Back to Top
RUG III category Nursing index Therapy index Nursing component Therapy component Non-case mix therapy component Non-case mix component Total rate
RUC 1.30 2.25 170.89 268.90 71.52 511.31
RUB 0.95 2.25 124.88 268.90 71.52 465.30
RUA 0.78 2.25 102.53 268.90 71.52 442.95
RVC 1.13 1.41 148.54 168.51 71.52 388.57
RVB 1.04 1.41 136.71 168.51 71.52 376.74
RVA 0.81 1.41 106.47 168.51 71.52 346.50
RHC 1.26 0.94 165.63 112.34 71.52 349.49
RHB 1.06 0.94 139.34 112.34 71.52 323.20
RHA 0.87 0.94 114.36 112.34 71.52 298.22
RMC 1.35 0.77 177.46 92.02 71.52 341.00
RMB 1.09 0.77 143.28 92.02 71.52 306.82
RMA 0.96 0.77 126.19 92.02 71.52 289.73
RLB 1.11 0.43 145.91 51.39 71.52 268.82
RLA 0.80 0.43 105.16 51.39 71.52 228.07
SE3 1.70 223.47 14.58 71.52 309.57
SE2 1.39 182.72 14.58 71.52 268.82
SE1 1.17 153.80 14.58 71.52 239.90
SSC 1.13 148.54 14.58 71.52 234.64
SSB 1.05 138.02 14.58 71.52 224.12
SSA 1.01 132.76 14.58 71.52 218.86
CC2 1.12 147.22 14.58 71.52 233.32
CC1 0.99 130.14 14.58 71.52 216.24
CB2 0.91 119.62 14.58 71.52 205.72
CB1 0.84 110.42 14.58 71.52 196.52
CA2 0.83 109.10 14.58 71.52 195.20
CA1 0.75 98.59 14.58 71.52 184.69
IB2 0.69 90.70 14.58 71.52 176.80
IB1 0.67 88.07 14.58 71.52 174.17
IA2 0.57 74.93 14.58 71.52 161.03
IA1 0.53 69.67 14.58 71.52 155.77
BB2 0.68 89.39 14.58 71.52 175.49
BB1 0.65 85.44 14.58 71.52 171.54
BA2 0.56 73.61 14.58 71.52 159.71
BA1 0.48 63.10 14.58 71.52 149.20
PE2 0.79 103.85 14.58 71.52 189.95
PE1 0.77 101.22 14.58 71.52 187.32
PD2 0.72 94.64 14.58 71.52 180.74
PD1 0.70 92.02 14.58 71.52 178.12
PC2 0.65 85.44 14.58 71.52 171.54
PC1 0.64 84.13 14.58 71.52 170.23
PB2 0.51 67.04 14.58 71.52 153.14
PB1 0.50 65.73 14.58 71.52 151.83
PA2 0.49 64.41 14.58 71.52 150.51
PA1 0.46 60.47 14.58 71.52 146.57
Table 5a.—RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes—Rural Back to Top
RUG-53 category Nursing index Therapy index Nursing component Therapy component Non-case mix therapy comp Non-case mix component Total rate
RUX 1.90 2.25 249.76 268.90 71.52 590.18
RUL 1.40 2.25 184.03 268.90 71.52 524.45
RVX 1.54 1.41 202.43 168.51 71.52 442.46
RVL 1.33 1.41 174.83 168.51 71.52 414.86
RHX 1.42 0.94 186.66 112.34 71.52 370.52
RHL 1.37 0.94 180.09 112.34 71.52 363.95
RMX 1.93 0.77 253.70 92.02 71.52 417.24
RML 1.68 0.77 220.84 92.02 71.52 384.38
RLX 1.31 0.43 172.20 51.39 71.52 295.11
RUC 1.28 2.25 168.26 268.90 71.52 508.68
RUB 0.99 2.25 130.14 268.90 71.52 470.56
RUA 0.84 2.25 110.42 268.90 71.52 450.84
RVC 1.23 1.41 161.68 168.51 71.52 401.71
RVB 1.09 1.41 143.28 168.51 71.52 383.31
RVA 0.82 1.41 107.79 168.51 71.52 347.82
RHC 1.22 0.94 160.37 112.34 71.52 344.23
RHB 1.11 0.94 145.91 112.34 71.52 329.77
RHA 0.94 0.94 123.56 112.34 71.52 307.42
RMC 1.15 0.77 151.17 92.02 71.52 314.71
RMB 1.09 0.77 143.28 92.02 71.52 306.82
RMA 1.04 0.77 136.71 92.02 71.52 300.25
RLB 1.14 0.43 149.85 51.39 71.52 272.76
RLA 0.85 0.43 111.73 51.39 71.52 234.64
SE3 1.86 244.50 14.58 71.52 330.60
SE2 1.49 195.86 14.58 71.52 281.96
SE1 1.26 165.63 14.58 71.52 251.73
SSC 1.23 161.68 14.58 71.52 247.78
SSB 1.13 148.54 14.58 71.52 234.64
SSA 1.10 144.60 14.58 71.52 230.70
CC2 1.22 160.37 14.58 71.52 246.47
CC1 1.06 139.34 14.58 71.52 225.44
CB2 0.98 128.82 14.58 71.52 214.92
CB1 0.91 119.62 14.58 71.52 205.72
CA2 0.90 118.31 14.58 71.52 204.41
CA1 0.80 105.16 14.58 71.52 191.26
IB2 0.74 97.27 14.58 71.52 183.37
IB1 0.72 94.64 14.58 71.52 180.74
IA2 0.61 80.18 14.58 71.52 166.28
IA1 0.56 73.61 14.58 71.52 159.71
BB2 0.73 95.96 14.58 71.52 182.06
BB1 0.69 90.70 14.58 71.52 176.80
BA2 0.60 78.87 14.58 71.52 164.97
BA1 0.52 68.35 14.58 71.52 154.45
PE2 0.85 111.73 14.58 71.52 197.83
PE1 0.82 107.79 14.58 71.52 193.89
PD2 0.78 102.53 14.58 71.52 188.63
PD1 0.76 99.90 14.58 71.52 186.00
PC2 0.71 93.33 14.58 71.52 179.43
PC1 0.69 90.70 14.58 71.52 176.80
PB2 0.55 72.30 14.58 71.52 158.40
PB1 0.54 70.98 14.58 71.52 157.08
PA2 0.53 69.67 14.58 71.52 155.77
PA1 0.50 65.73 14.58 71.52 151.83

D. 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 continuing that practice for FY 2006.

1. Proposal To Incorporate the Revised OMB Definitions for Metropolitan Statistical Areas and Combined Statistical Areas

In the FY 2006 SNF PPS proposed rule, we proposed to incorporate into the SNF PPS the revised OMB definitions for Metropolitan Statistical Areas, as well as the new definitions of Micropolitan Statistical Areas and CombinedStatistical Areas. For a full discussion of this proposal, see our FY 2006 proposed rule (70 FR 29090-94). We also invited comments on the appropriateness of implementing this change through a transition period similar to that adopted under the inpatient hospital PPS (IPPS)(70 FR 29095). The following is a discussion of the comments that we received on this issue.

Comment: A number of commenters questioned the continued use of the hospital wage index, and suggested that, rather than using the hospital wage index to implement the OMB designations, CMS postpone action until a SNF-specific wage index can be created. Commenters also recommended adopting policies included in the IPPS, such as the creation of a geographic reclassification policy for SNFs and the introduction of a “rural floor” (ensuring that no urban wage index value is lower than the State-wide rural wage index.

Response: As part of our ongoing program analysis, we periodically reevaluate the suitability of establishing a SNF-specific wage index and a provider reclassification methodology. However, as we noted in the FY 2004 SNF PPS final rule when this issue was raised previously (68 FR 46046, August 4, 2003), in view of 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 do not expect to propose a SNF-specific wage index until we can demonstrate that it would significantly improve our ability to determine payment for facilities and justify the resources required to collect the data, as well as the increased burden on providers.

In addition, we note that the development of the hospital wage data can also be scrutinized and evaluated by the SNF industry when commenting on the hospital proposed rule that is published each spring. Therefore, because of the problems associated with the current SNF-specific data, and our inability to demonstrate that a SNF-specific wage index would be more reflective of the wages and salaries paid in a specific area, we continue to believe that hospital wage data are the most appropriate data for adjusting payments made to SNFs.

We also noted in the FY 2004 final rule that while section 315 of the BIPA does authorize the SNF PPS to use a reclassification methodology that would allow providers to seek geographic reclassification, it specifically provides that such reclassification cannot be implemented until we have collected the data necessary to establish a SNF-specific wage index. At that time, we also invited input from the industry that could demonstrate that the adoption of a “rural floor” would provide a more accurate wage index. To date, however, we have not received evidence that such an approach would, in fact, accomplish this result. Accordingly, we are not adopting these suggested changes at this time.

Comment: Several commenters recommended that we withdraw or postpone implementation of this provision because the fiscal impact of the wage index changes have a disproportionate effect on different facilities or in different localities. One commenter also questioned whether CMS has the legislative authority to implement the OMB designations, as the SNF PPS structure distinguishes between urban and rural providers, but doesn't include a category for micropolitan areas.

Response: The statute provides the Secretary with broad authority to select an appropriate wage index, and we believe that the adoption of these OMB designations is consistent with and in compliance with the statutory authority. We further understand that impact on providers based on the wage index adjustments (which, by statute, must be accomplished in a budget neutral manner) will always vary as an inherent aspect of such adjustments, and would occur regardless of whether we continue to use the current MSA designations or use the more accurate CBSA designations established by OMB in June 2003. Therefore, we continue to believe that an appropriate wage index includes the CBSA designations described in the proposed rule.

Comment: A large number of commenters urged CMS to develop a transition policy to minimize the fiscal impact of the transition to the OMB designations. Many commenters urged CMS to adopt broad protections for facilities against changes in the wage index due to the adoption of the newOMB designations. Commenters offered various recommendations about how to provide such protection. Some advocated transition mechanisms such as blending wage index factors specifically for those facilities that would experience a wage index decrease (similar to the approach adopted under the IPPS), with a one to four year phase-in period to allow SNFs to make appropriate adjustments in their operations. In addition, many commenters recommended caps on gains and losses or a hold harmless provision for SNFs facing significant wage index reductions under the proposal.

Response: In the FY 2006 SNF PPS proposed rule, while we did not view it as appropriate or necessary to propose a transition period, we provided various transition options and specifically invited comments on our proposed approaches. We continue to recognize that some SNFs will experience decreases in their applicable wage index as a result of the conversion from the MSA to the CBSA structure. We also agree that it is appropriate to assist providers in adapting to these changes in a manner that provides the most benefit to the largest number of providers. Therefore, based in part upon the comments, we now agree that a transition period for SNFs would be appropriate and beneficial.

In evaluating transition options, we looked for approaches that would provide relief to the largest percentage of adversely affected SNFs with the least impact to the rest of the facilities, who either received small increases or remained the same. One possible approach that we considered would involve creating a floor (for example, at a 2 percent decrease), to be funded by also imposing a ceiling (for example, at a 5 percent gain). Instead, we have decided to use a 1-year transition with a blended wage index for all providers. The wage index for each provider will consist 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 wage data). We refer to this blended wage index as the FY 2006 SNF PPS transition wage index and these values can be found in the Addendum in Table A. This option achieves our objective of creating a transition policy that provides relief to the largest percentage of adversely affected SNFs with the least impact to the rest of the facilities. In addition, the 50/50 blend option allows us to achieve a high degree of stability in the unadjusted base rates. The adoption of this option results in only minimal change to the budget neutrality factor, from 1.0011 to 1.0012. In fact, the unadjusted base rates applicable to all SNFs actually show a slight increase.

Accordingly, as noted above, after consideration of these comments, we have modified the wage index proposal to include the transition policy discussed above. This transition policy is for a one-year period. It goes into effect October 1, 2005, and remains in effect throughSeptember 30, 2006. Thus, the transition will end at the start of FY 2007.

In addition, we solicited comments on approaches to calculating the wage index values for areas without hospitals for FY 2006 and subsequent years. We received no comments on our approach and we will implement the methodology described in the FY 2006 SNF PPS proposed rule(70 FR 29096).

2. Determining the Labor-Related Portion of the SNF PPSRate

The wage index adjustment is applied to the labor-related portion of the Federal rate, which is 75.922 percent of the total rate, as explained in section III.H.1 of this final rule. This percentage reflects the labor-related relative importance for FY 2006. The labor-related relative importance is calculated from the SNF market basket, and approximates the labor-related portion of the total costs after taking into account historical and projected price changes between the base year and FY 2006. The price proxies that move the different cost categories in the market basket do not necessarily change at the same rate, and the relative importance captures these changes. Accordingly, the relative importance figure more closely reflects the cost share weights for FY 2006 than the base year weights from the SNF market basket.

We calculate the labor-related relative importance for FY 2006 in four steps. First, we compute the FY 2006 price index level for the total market basket and each cost category of the market basket. Second, we calculate a ratio for each cost category by dividing the FY 2006 price index level for that cost category by the total market basket price index level. Third, we determine the FY 2006 relative importance for each cost category by multiplying this ratio by the base year (FY 1997) weight. Finally, we sum the FY 2006 relative importance for each of the labor-related cost categories (wages and salaries, employee benefits, nonmedical professional fees, labor-intensive services, and capital-related expenses) to produce the FY 2006 labor-related relative importance. Tables 6 and 7 show the Federal rates by labor-related and non-labor-related components for the existing 44-group RUG-III classification system. Tables 6a and 7a show the Federal rates by labor-related and non-labor-related components for the refined 53-group RUG classification system.

Table 6.—RUG-44Case-Mix Adjusted Federal Rates for Urban SNFs by Labor and Non-Labor Component Back to Top
RUG III category Total rate Labor portion Non-labor portion
RUC 482.28 366.16 116.12
RUB 434.12 329.59 104.53
RUA 410.73 311.83 98.90
RVC 371.83 282.30 89.53
RVB 359.44 272.89 86.55
RVA 327.80 248.87 78.93
RHC 341.00 258.89 82.11
RHB 313.49 238.01 75.48
RHA 287.34 218.15 69.19
RMC 335.77 254.92 80.85
RMB 299.99 227.76 72.23
RMA 282.11 214.18 67.93
RLB 267.51 203.10 64.41
RLA 224.86 170.72 54.14
SE3 317.77 241.26 76.51
SE2 275.12 208.88 66.24
SE1 244.85 185.90 58.95
SSC 239.35 181.72 57.63
SSB 228.34 173.36 54.98
SSA 222.84 169.18 53.66
CC2 237.97 180.67 57.30
CC1 220.08 167.09 52.99
CB2 209.08 158.74 50.34
CB1 199.45 151.43 48.02
CA2 198.07 150.38 47.69
CA1 187.06 142.02 45.04
IB2 178.81 135.76 43.05
IB1 176.06 133.67 42.39
IA2 162.30 123.22 39.08
IA1 156.79 119.04 37.75
BB2 177.43 134.71 42.72
BB1 173.30 131.57 41.73
BA2 160.92 122.17 38.75
BA1 149.91 113.81 36.10
PE2 192.57 146.20 46.37
PE1 189.81 144.11 45.70
PD2 182.93 138.88 44.05
PD1 180.18 136.80 43.38
PC2 173.30 131.57 41.73
PC1 171.93 130.53 41.40
PB2 154.04 116.95 37.09
PB1 152.67 115.91 36.76
PA2 151.29 114.86 36.43
PA1 147.16 111.73 35.43
Table 6a.—RUG-53 Case-Mix Adjusted Federal Rates for Urban SNFs by Labor and Non-Labor Component Back to Top
RUG-53 category Total rate Labor portion Non-labor portion
RUX 564.83 428.83 136.00
RUL 496.04 376.60 119.44
RVX 428.24 325.13 103.11
RVL 399.34 303.19 96.15
RHX 363.02 275.61 87.41
RHL 356.14 270.39 85.75
RMX 415.57 315.51 100.06
RML 381.17 289.39 91.78
RLX 295.03 223.99 71.04
RUC 479.53 364.07 115.46
RUB 439.62 333.77 105.85
RUA 418.99 318.11 100.88
RVC 385.59 292.75 92.84
RVB 366.32 278.12 88.20
RVA 329.17 249.91 79.26
RHC 335.50 254.72 80.78
RHB 320.36 243.22 77.14
RHA 296.97 225.47 71.50
RMC 308.25 234.03 74.22
RMB 299.99 227.76 72.23
RMA 293.11 222.53 70.58
RLB 271.64 206.23 65.41
RLA 231.74 175.94 55.80
SE3 339.79 257.98 81.81
SE2 288.88 219.32 69.56
SE1 257.23 195.29 61.94
SSC 253.11 192.17 60.94
SSB 239.35 181.72 57.63
SSA 235.22 178.58 56.64
CC2 251.73 191.12 60.61
CC1 229.72 174.41 55.31
CB2 218.71 166.05 52.66
CB1 209.08 158.74 50.34
CA2 207.70 157.69 50.01
CA1 193.94 147.24 46.70
IB2 185.69 140.98 44.71
IB1 182.93 138.88 44.05
IA2 167.80 127.40 40.40
IA1 160.92 122.17 38.75
BB2 184.31 139.93 44.38
BB1 178.81 135.76 43.05
BA2 166.42 126.35 40.07
BA1 155.42 118.00 37.42
PE2 200.82 152.47 48.35
PE1 196.69 149.33 47.36
PD2 191.19 145.16 46.03
PD1 188.44 143.07 45.37
PC2 181.56 137.84 43.72
PC1 178.81 135.76 43.05
PB2 159.54 121.13 38.41
PB1 158.17 120.09 38.08
PA2 156.79 119.04 37.75
PA1 152.67 115.91 36.76
Table 7.—RUG-44 Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component Back to Top
RUG III category Total rate Labor portion Non-labor portion
RUC 511.31 388.20 123.11
RUB 465.30 353.27 112.03
RUA 442.95 336.30 106.65
RVC 388.57 295.01 93.56
RVB 376.74 286.03 90.71
RVA 346.50 263.07 83.43
RHC 349.49 265.34 84.15
RHB 323.20 245.38 77.82
RHA 298.22 226.41 71.81
RMC 341.00 258.89 82.11
RMB 306.82 232.94 73.88
RMA 289.73 219.97 69.76
RLB 268.82 204.09 64.73
RLA 228.07 173.16 54.91
SE3 309.57 235.03 74.54
SE2 268.82 204.09 64.73
SE1 239.90 182.14 57.76
SSC 234.64 178.14 56.50
SSB 224.12 170.16 53.96
SSA 218.86 166.16 52.70
CC2 233.32 177.14 56.18
CC1 216.24 164.17 52.07
CB2 205.72 156.19 49.53
CB1 196.52 149.20 47.32
CA2 195.20 148.20 47.00
CA1 184.69 140.22 44.47
IB2 176.80 134.23 42.57
IB1 174.17 132.23 41.94
IA2 161.03 122.26 38.77
IA1 155.77 118.26 37.51
BB2 175.49 133.24 42.25
BB1 171.54 130.24 41.30
BA2 159.71 121.26 38.45
BA1 149.20 113.28 35.92
PE2 189.95 144.21 45.74
PE1 187.32 142.22 45.10
PD2 180.74 137.22 43.52
PD1 178.12 135.23 42.89
PC2 171.54 130.24 41.30
PC1 170.23 129.24 40.99
PB2 153.14 116.27 36.87
PB1 151.83 115.27 36.56
PA2 150.51 114.27 36.24
PA1 146.57 111.28 35.29
Table 7a.—RUG-53 Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component Back to Top
RUG-53 category Total rate Labor portion Non-labor portion
RUX 590.18 448.08 142.10
RUL 524.45 398.17 126.28
RVX 442.46 335.92 106.54
RVL 414.86 314.97 99.89
RHX 370.52 281.31 89.21
RHL 363.95 276.32 87.63
RMX 417.24 316.78 100.46
RML 384.38 291.83 92.55
RLX 295.11 224.05 71.06
RUC 508.68 386.20 122.48
RUB 470.56 357.26 113.30
RUA 450.84 342.29 108.55
RVC 401.71 304.99 96.72
RVB 383.31 291.02 92.29
RVA 347.82 264.07 83.75
RHC 344.23 261.35 82.88
RHB 329.77 250.37 79.40
RHA 307.42 233.40 74.02
RMC 314.71 238.93 75.78
RMB 306.82 232.94 73.88
RMA 300.25 227.96 72.29
RLB 272.76 207.08 65.68
RLA 234.64 178.14 56.50
SE3 330.60 251.00 79.60
SE2 281.96 214.07 67.89
SE1 251.73 191.12 60.61
SSC 247.78 188.12 59.66
SSB 234.64 178.14 56.50
SSA 230.70 175.15 55.55
CC2 246.47 187.12 59.35
CC1 225.44 171.16 54.28
CB2 214.92 163.17 51.75
CB1 205.72 156.19 49.53
CA2 204.41 155.19 49.22
CA1 191.26 145.21 46.05
IB2 183.37 139.22 44.15
IB1 180.74 137.22 43.52
IA2 166.28 126.24 40.04
IA1 159.71 121.26 38.45
BB2 182.06 138.22 43.84
BB1 176.80 134.23 42.57
BA2 164.97 125.25 39.72
BA1 154.45 117.26 37.19
PE2 197.83 150.20 47.63
PE1 193.89 147.21 46.68
PD2 188.63 143.21 45.42
PD1 186.00 141.21 44.79
PC2 179.43 136.23 43.20
PC1 176.80 134.23 42.57
PB2 158.40 120.26 38.14
PB1 157.08 119.26 37.82
PA2 155.77 118.26 37.51
PA1 151.83 115.27 36.56

3. Calculating the Budget Neutrality Factor

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 lesser than would otherwise be made in the absence of the wage adjustment. For FY 2006 (Federal rates effective October 1, 2005), we are applying the wage index applicable to SNF payments using the most recent hospital wage data applicable to FY 2006 payments (as discussed previously in section III.D.1 of this final rule), and applying an adjustment to fulfill the budget neutrality requirement. This requirement is met by multiplying each of the components of the unadjusted Federal rates by a factor equal to the ratio of the volume weighted mean wage adjustment factor (using the wage index from the previous year) to the volume weighted mean wage adjustment factor, using the wage index for the fiscal year beginning October 1, 2005. The same volume weights are used in both the numerator and denominator and were derived from 1997 Medicare Provider Analysis and Review File (MEDPAR) data. The wage adjustment factor used in this calculation is defined as the labor share of the rate component multiplied by the wage index plus the non-labor share. The budget neutrality factor has been recalculated to reflect the addition of a transition policy. Effective October 1, 2005, we will adopt a budget neutrality factor of 1.0012.In order to give the public a sense of the magnitude of this adjustment, last year's factor was 1.0011.

E. Updates to the Federal Rates

In accordance with section 1888(e)(4)(E) of the Act, the final payment rates listed here reflect an update equal to the full SNF market basket, which equals 3.1 percent.

We will continue to disseminate the rates, wage index, and case-mix classification methodology in the Federal Register before August 1 preceding the start of each succeeding fiscal year. Along with a number of other revisions discussed elsewhere in this preamble, this final rule provides the annual updates to the Federal rates as required by statute.

F. Relationship of Case-Mix Classification System to Existing SNF Level-of-Care Criteria

As discussed in § 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 § 409.30. This designation reflects an administrative presumption that we initially adopted under the original 44-group RUG-III classification system. Under the presumption, any beneficiary correctly assigned to one of the upper 26 of the 44 RUG-III groups in the initial 5-day, Medicare-required assessment is automatically classified as meeting the SNF level of care definition up to the assessment reference date (ARD) for that assessment.

A beneficiary assigned to any of the lower 18 of the 44 RUG-III 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 26 groups during the immediate post-hospital period require a covered level of care, which would be significantly less likely for those beneficiaries assigned to one of the lower 18 groups.

1. Proposals on the 9 New Rehabilitation Plus Extensive Services Groups

In the FY 2006 SNF PPS proposed rule, we noted that the 9 new Rehabilitation plus Extensive Services groups that we proposed to add at the top of the existing RUG-III hierarchy would effectively encompass care “* * * that is at least as intensive as that identified by any of the upper 26 RUG-III groups under the original, 44-group RUG-III classification system.” Accordingly, with the adoption of those 9 new groups as discussed elsewhere in this final rule (and as proposed), we hereby designate as representing a covered level of care under the administrative presumption the upper 35 groups of the refined case-mix classification system (including the upper 26 groups that were previously so designated under the original 44-group system, plus the additional 9 Rehabilitation plus ExtensiveServices groups that we are now adopting), consisting of the following RUG classifications:

  • All groups within the new Rehabilitation plusExtensive Services category;
  • All groups within the Ultra High Rehabilitation category;
  • All groups within the Very High Rehabilitation category;
  • All groups within the High Rehabilitation category;
  • All groups within the Medium Rehabilitation category;
  • All groups within the Low Rehabilitation category;
  • All groups within the Extensive Services category;
  • All groups within the Special Care category; and
  • All groups within the Clinically Complex category.

Comment: Commenters consistently supported the extension of the administrative presumption to the nine new RUG groups.

Response: We appreciate the commenters' support, and will implement this provision as proposed without modification.

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

As explained in section II., from October 1, 2005, through December 31, 2005, we will make payment based entirely on the existing 44-group RUG-III classification system (including any associated add-on payments). Using the model SNF (XYZ) described in Table 10, the following shows the adjustments made to the Federal per diem rate to compute the provider's actual per diem PPS for the time period mentioned above using the existing 44-group RUG-III classification system.

Beginning January 1, 2006, we will make payment based on the refined RUG-53 classification system (and, thus, would not include the add-on payments). Table 10a shows an example of the actual per diem PPS payments under the RUG-53 classification system.

The Labor and Non-labor columns are derived from Tables 6 or 6a. In addition, the adjustment for residents with AIDS enacted in section 511 of the MMA is reflected in Tables 10 and 10a.

Table 10.—RUG-44, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation), Wage Index: 0.8710 (See Transition Wage Index in Table A) Back to Top
RUG group Labor Wage index Adjusted labor Non-labor Adjusted rate Percent adjustment Medicare days Payment
*Reflects a 6.7 percent adjustment from section 314 of the BIPA.
**Reflects a 128 percent adjustment from section 511 of the MMA. Section 101(a) of the BBRA no longer applies because of the MMA section 511 adjustment.
***Reflects a 20 percent adjustment from section 101(a) of the BBRA.
RVC $282.30 0.8710 $245.88 $89.53 $335.41 *$357.88 14 $5,010
RHA 218.15 0.8710 190.01 69.19 259.20 *276.57 16 4,425
CC2 180.67 0.8710 157.36 57.30 214.66 **489.42 10 4,894
SSC 181.72 0.8710 158.28 57.63 215.91 ***259.09 30 7,773
IA2 123.22 0.8710 107.32 39.08 146.40 146.40 30 4,392
Total 100 26,494
Table 10a.—RUG-53, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation) Wage Index: 0.8710 (See Transition Wage Index in Table A) Back to Top
RUG group Labor Wage index Adjusted labor Non-labor Adjusted rate Percent adjustment Medicare days Payment
* Reflects a 128 percent adjustment from section 511 of the MMA.
RVX $325.13 0.871 $283.19 $103.11 $386.30 $386.30 14 $5,408
RHA 225.47 0.871 196.38 71.50 267.88 267.88 16 4,286
CC2 191.12 0.871 166.47 60.61 227.08 517.73 10 5,177
RLX 223.99 0.871 195.10 71.04 266.14 266.14 30 7,984
IA2 127.40 0.871 110.97 40.40 151.37 151.37 30 4,541
Total 100 27,396

H. SNF Market Basket Index

1. Background

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 final rule 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. In the July 31, 2001 Federal Register (66 FR 39562), we included a complete discussion on the rebasing of the SNF market basket to FY 1997. There are 21 separate cost categories and respective price proxies.These cost categories were illustrated in Table 10.A, Table 10.B, and Appendix A, along with other relevant information, in the July 31, 2001 Federal Register.

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 11 summarizes the updated labor-related share for FY 2006.

Table 11.—Labor-related Relative Importance, FY2005 and FY2006 Back to Top
Relative importance, labor-related, FY 2005 (97 index) Relative importance, labor-related, FY 2006 (97 index)
Source: Global Insights, Inc., formerly DRI-WEFA, 2nd Quarter, 2005.
Wages and salaries 54.356 54.391
Employee benefits 11.506 11.648
Nonmedical professional fees 2.708 2.739
Labor-intensive services 4.114 4.128
Capital-related 3.092 3.016
Total 75.776 75.922

2. Use of the SNF 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, as described in the previous section, from the average index level of the prior fiscal year to the average index level of the current fiscal year. For the Federal rates established in this final rule, this percentage increase in the SNF market basket index is used to compute the update factor occurring between FY 2005 and FY 2006. We used the Global Insights, Inc. (formerlyDRI-WEFA), 2nd quarter 2005 forecasted percentage increase in the FY 1997-based SNF market basket index for routine, ancillary, and capital-related expenses, described in the previous section, to compute the update factor.

Comment: The current SNF market basket is based on FY 1997 Medicare cost report data. Several commenters requested that CMS utilize more up-to-date cost reports in the SNF market basket in order to produce more accurate and representative weights for the various cost categories, such as compensation and pharmaceuticals. They also requested that CMS review the price proxies used in the market basket, specifically the Employment Cost Index (ECI) for wages and salaries for Private Nursing Homes. This price proxy includes wage price data for SNFs as well as for other nursing and long-term care facilities. One commenter claimed the staffing mix in a SNF is much different than in these other types of facilities. Finally, a few commenters suggested that CMS collect SNF-specific labor data provided by the SNF industry.

Response: CMS is considering revising and rebasing the SNF market basket in the near future. We would expect to use the most recent and complete SNF Medicare cost reports available. Moreover, we would use the SNF Medicare cost reports to develop as many viable cost category weights (such as wages and salaries, benefits, contract labor, and pharmaceuticals) as possible. We also plan to review alternative price proxies based on our criteria of relevance, reliability, timeliness, and public availability. We will include a detailed discussion of our analysis when we propose a revised and rebased SNF market basket, and will also provide an opportunity for public comment.

Comment: Several commenters requested that the SNF rebasing follow the same frequency planned for IPPS hospital rebasing, currently set at every four years.

Response: As noted above, we intend to revise and rebase the SNF market basket in the near future, and we would use the most recent and complete SNF Medicare cost reports available to do this. We will keep the commenters' suggestions in mind in considering whether to establish a schedule for rebasing the SNF market basket.

Comment: Several commenters requested that the SNF market basket be revised to reflect industry data and CMS's own data, which show that prescription drugs represent more than 10 percent of SNF costs. They cite the CMS Health Care Financing Review, which shows that Medicare SNF facility charges for pharmaceuticals from 1997 to 2001 represent over 10 percent of total Medicare SNF facility charges. Also, one commenter stated the pharmaceutical cost weight was derived using a combination of nursing facility and hospital cost reports.

Response: The market basket is intended to reflect the average change in the price of a basket of goods and services that SNFs purchase in order to furnish patient care. The current market basket is based on the purchasing behavior of SNFs in 1997. Preliminary analysis shows that both the FY 2002 and FY 2003 pharmaceutical cost weights(the cost of pharmaceuticals as a percent of total costs), based on freestanding SNF Medicare cost reports, are slightly below 3 percent, compared to 3 percent in the 1997-based SNF market basket. It would be inappropriate for the market basket weight to reflect trends in charges, which have little relationship to the actual costs incurred.

The pharmaceutical cost weight in the 1997-based SNF market basket is based on Medicare cost reports of freestanding SNF facilities. As discussed in the SNF PPS proposed rule for FY 2002, hospital cost report data were not used to derive this cost weight (66 FR 24013, May 10, 2001).

Comment: In view of the concern regarding the adequacy of the pharmaceutical cost weight included in the SNF market basket, we received a comment recommending that we identify discrepancies between the forecasted and actual cost of pharmaceuticals, and develop an adjustment mechanism similar to the forecast error correction policy described previously in section I.G of this final rule.

Response: As part of the forecast error correction, the difference between the projected and actual pharmaceutical price increases is incorporated. Therefore, it would be inappropriate to develop a separate mechanism.

Comment: One commenter suggested that CMS should study the effect of adding a separate weight for professional liability insurance (PLI), and should work with the SNF industry to determine how the weight should be calculated and how to develop an appropriate price index.

Response: We intend to review both SNF cost reports and other industry data to determine the feasibility of developing a weight and price proxy for PLI for SNFs. We look forward to working with the SNF industry on this effort, and have already received feedback about the nature of PLI for SNFs.

3. 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 46067), the regulations at 42 CFR 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 that occurred in FY 2004, and took into account the cumulative forecast error for the period from FY 2000 through FY 2002. Subsequent adjustments in succeeding FYs take into account the forecast error from the most recently available fiscal year for which there is final data, and are applied whenever the difference between the forecasted and actual change in the market basket exceeds a 0.25 percentage point threshold. As discussed previously in section I.G of this final rule, as the difference between the estimated and actual amounts of increase in the market basket index for FY 2004 (the most recently available fiscal year for which there is final data) did not exceed the 0.25 percentage point threshold, the payment rates for FY 2006 do not include a forecast error adjustment.

4. Federal Rate Update Factor

Section 1888(e)(4)(E)(ii)(IV) of the Act requires that the update factor used to establish the FY 2006 Federal rates be at a level equal to the full 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, 2004 through September 30, 2005 to the average market basket level for the period of October 1, 2005 throughSeptember 30, 2006. Using this process, the market basket update factor for FY 2006 SNF Federal rates is 3.1 percent.We used this revised update factor to compute the Federal portion of the SNF PPS rate shown in Tables 2 and 3.

I. Consolidated Billing

As established by section 4432(b) of the BBA, the consolidated billing requirement 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.Section 103 of the BBRA amended this provision by further excluding a number of high-cost, low probability services(identified by Healthcare Common Procedure Coding System(HCPCS) codes) within several broader categories that otherwise remained subject to the provision. Section 313 of the BIPA further amended this provision by repealing itsPart B aspect, that is, its applicability to services furnished to a resident during a SNF stay that Medicare does not cover. (However, physical and 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.) In addition, section 313 of the BIPA specified that consolidated billing applies only to services furnished to those individuals residing in an institution (or portion of an institution) that is actually certified by Medicare as a SNF. Further, as noted in section I.E. of this final rule, section 410 of the MMA revised the SNF consolidated billing requirement as to certain services furnished on or afterJanuary 1, 2005, by rural health clinics (RHCs) andFederally qualified health centers (FQHCs).

To date, the Congress has enacted no further legislation affecting the consolidated billing provision.However, as we noted in the April 10, 2000 proposed rule(65 FR 19232), section 1888(e)(2)(A)(iii) of the Act, as added by section 103 of the BBRA, not only identified for exclusion from this provision a number of particular service codes within four specified categories (that is, chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices), but “ * * * also gives the Secretary the authority to designate additional, individual services for exclusion within each of the specified service categories.” In the FY 2001 proposed rule, we also noted that the BBRAConference Report (H.R. Conf. Rep. No. 106-479 at 854) characterizes the individual services that this legislation targets for exclusion as “* * * high-cost, low probability events that could have devastating financial impacts because their costs far exceed the payment [SNFs] receive under the prospective payment system * * *.” According to the conferees, section 103(a) “is an attempt to exclude from the PPS certain services and costly items that are provided infrequently in SNFs * * *.” By contrast, we noted that the Congress declined to designate for exclusion any of the remaining services within those four categories(thus leaving all of those services subject to SNF consolidated billing), because they are relatively inexpensive and are furnished routinely in SNFs.

As we further explained in the July 31, 2000 final rule (65 FR 46790), any additional service codes that we might designate for exclusion under our discretionary authority must meet the same criteria that the Congress used in identifying the original codes excluded from consolidated billing under section 103(a) of the BBRA:They must fall within one of the four service categories specified in the BBRA, and they also must meet the same standards of high cost and low probability in the SNF setting. Accordingly, we characterized this statutory authority to identify additional service codes for exclusion“* * * as essentially affording the flexibility to revise the list of excluded codes in response to changes of major significance that may occur over time (for example, the development of new medical technologies or other advances in the state of medical practice)”(65 FR 46791). In view of the amount of time that has elapsed since we last invited comments on this issue, we invited public comments in the FY 2006 SNF PPS proposed rule on codes in any of these four service categories which represent recent medical advances that might meet the BBRA criteria for exclusion from SNF consolidated billing (70 FR 29098).

Comment: Commenters proposed for exclusion particular services that fell within the four specified categories specified by section 103 of the BBRA (chemotherapy items, chemotherapy administration services, radioisotope services, and customized prosthetic devices).

Response: We will further examine whether these particular services should be excluded as we complete work on the 2006 annual updated list of the specific HCPCS codes that are excluded from consolidated billing, which we plan to issue this fall.

Comment: Noting that some chemotherapy drugs have two HCPCS codes assigned—both a C code and a J code—two commenters pointed out that a number of the chemotherapy medications that we exclude by J code also have C codes assigned to them. They asserted that hospital outpatient departments are mandated to use C codes when billingMedicare for some chemotherapy medications under the hospital outpatient prospective payment system and asked that we add the corresponding C codes for the following codes: J9040, J9060, J9065, J9070, J9093, J9100, J9130,J9150, J9181, J9200, J9208, J9211, J9265, and J9280.

Response: It is our understanding that hospital outpatient departments can, in fact, use J codes when billing Medicare for chemotherapy medications. Accordingly, at this time we see no need to add the corresponding C codes when the J code chemotherapy medications are already excluded.

Comment: Although the FY 2006 SNF PPS proposed rule specifically invited comments on possible exclusions within the specific service categories identified in the BBRA legislation, a number of commenters took this opportunity to reiterate concerns about other aspects of consolidated billing. For example, we received a number of comments concerning the possible exclusion of additional categories of services from SNF consolidated billing, beyond those specified in the BBRA. The commenters identified services such as barium swallows, video fluoroscopies, hyperbaric oxygen therapy, sterile larvae therapy, ultrasonic procedures and duplex scans, PET scans, and nuclear medicine as appropriate candidates for exclusion. In addition, a number of commenters recommended a further set of services for exclusion. These additional services are durable medical equipment (including, but not limited to, wound care devices and diabetic shoes), total parenteral nutrition (TPN), and specialized bariatric equipment.

Response: As we noted previously in the final rule of August 4, 2003 (68 FR 46060), the original set of consolidated billing exclusions at section 1888(e)(2)(A)(ii) of the Act (as enacted by section 4432(b) of the BBA) broadly excluded entire categories of services from consolidated billing (primarily, those of physicians and certain other types of medical practitioners). By contrast, the set of statutory exclusions at section 1888(e)(2)(A)(iii) of the Act, as subsequently enacted by section 103 of the BBRA, was more specifically targeted within a number of broader service categories. In the FY 2006 SNF PPS proposed rule, we noted that the original BBRA legislation (as well as the implementing regulations) provides the Secretary the authority to designate additional, individual services for exclusion within each of the BBRA-specified service categories. However, the statute does not provide the Secretary the authority to create additional categories of excluded services beyond those specified in the law. Therefore, based on the statute, we cannot exclude services and items from consolidated billing unless they fall into the categories of services provided in the statute.

Comment: Some commenters cited the existing list of exclusions (in § 411.15(p)(3)(iii)) for certain high-intensity outpatient hospital services, and expressed the view that these exclusions should not be limited to only those services that actually require the intensity of a hospital setting, but rather, should also encompass services furnished in other, nonhospital settings as well. As examples, they cited services such as magnetic resonance imaging (MRIs) and computerized axial tomography (CT) scans furnished in freestanding imaging centers, and radiation therapy furnished in physician's clinics or ambulatory care centers, all of which may be cheaper and more accessible in certain particular localities (such as rural settings) than those furnished by hospitals.

Response: As we noted in the May 12, 1998 interim final rule (63 FR 26298), in the July 31, 2000 final rule (65 FR 46790 through 46791), and again in the August 4, 2003 final rule (68 FR 46061), the exclusion of certain outpatient hospital services (in § 411.15(p)(3)(iii)) is targeted specifically at those services “* * * that, under commonly accepted standards of medical practice, lie exclusively within the purview of hospitals * * *” (emphasis added); that is, services which generally require the intensity of the hospital setting in order to be furnished safely and effectively. We have determined that this high level of outpatient hospital care is beyond the scope of SNF comprehensive care plans and should be excluded from consolidated billing. However, this exclusion does not encompass services furnished in any other health care setting. Thus, to the extent that advances in medical practice over time may make it feasible to perform such a service more widely in a less intensive, nonhospital setting, this would not argue in favor of excluding the nonhospital performance of the service from consolidated billing under these regulations, but rather, would call into question whether the service should continue to be excluded from consolidated billing at all, even when performed in the hospital setting. In addition, we note that unlike the outpatient hospital exclusions in § 411.15(p)(3)(iii), the statutory exclusions enacted by the BBRA for certain chemotherapy and other services apply regardless of the setting (hospital versus freestanding) in which the services are furnished. However, we do not have the authority to add services such as MRIs, CT scans, or radiation therapy to the existing statutory list administratively.

Comment: Several commenters also proposed expanding the list of excluded services by redefining categories of service that are currently excluded from consolidated billing. For example, while the BBRA excludes specific chemotherapy services by HCPCS codes, these commenters recommended not only adding to the list of excluded chemotherapy pharmaceuticals, but expanding the exclusion to encompass all related services associated with a chemotherapy treatment, such as supplies and other pharmaceuticals used to treat side effects. In addition, several commenters recommended exclusion of oral chemotherapy agents that are not separately billable to Medicare Part B for any beneficiary, and are currently covered only as part of the overall package of services furnished under the Part A inpatient hospital or SNF benefits.

Response: In the FY 2006 SNF PPS proposed rule, we noted that the BBRA's list of services excluded by HCPCS code is a targeted list, narrowly carving out only certain individual “high-cost, low probability” services within a number of broader service categories—such as chemotherapy services—that otherwise remained subject to consolidated billing. As we noted in the FY 2006 SNF PPS proposed rule, the BBRA provides the Secretary the authority to designate additional, individual services for exclusion within each of the service categories that it specifies. However, the statute does not provide authority to exclude other services that, while related, fall outside of the specified service categories themselves. For example, although anti-nausea drugs are commonly used in conjunction with chemotherapy, they are not in themselves chemotherapeutic agents and, consequently, do not fall within one of the excluded categories designated in the BBRA. Further, we believe that the Congress was clear in its intent regarding the particular items and services to be excluded from consolidated billing, by use of the HCPCS codes specified in the Act. Regarding the suggestion to exclude from consolidated billing those oral chemotherapy agents that are not separately billable to Part B (and are currently covered only under the Part A inpatient hospital and SNF benefits), we note that expanding the existing statutory drug coverage available under Part B to include those drugs is not within our authority.

We note that some chemotherapy pharmaceuticals that commenters proposed for exclusion have already been added to the list of HCPCS codes excluded from the consolidated billing provisions. The most recent annual update regarding HCPCS exclusions from consolidated billing can be found in Transmittal No. 360 (Change Request (CR) No. 3542), issued on November 5, 2004, which is available online at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp.

Comment: A few commenters requested an expansion of the existing Part B dialysis exclusion to encompass dialysis services furnished directly by the SNF. In addition, several commenters noted that erythropoietin (EPO or Aranesp) currently is excluded from consolidated billing only when furnished in conjunction with the Part B dialysis benefit, and they recommended expanding this exclusion to encompass its use in connection with other, non-dialysis forms of treatment (such as chemotherapy).

Response: As we noted previously in the final rule published on August 4, 2003 (68 FR 46062), under section 1888(e)(2)(A)(ii) of the Act, the exclusion of dialysis services from consolidated billing applies only to those services that meet the requirements for coverage under the separate Part B dialysis benefit at section 1861(s)(2)(F) of the Act. The Part B benefit allows for home dialysis and dialysis performed on the premises of a certified dialysis facility. By contrast, if the SNF itself elects to furnish dialysis services to a resident during a covered Part A stay (either directly with its own resources, or under an “arrangement” with a certified dialysis facility in which the SNF itself does the billing), the services are no longer considered Part B dialysis services, but instead are Part A SNF services. Accordingly, they would no longer be subject to the statutory exclusion of Part B dialysis services from consolidated billing, and would instead be bundled into the comprehensive PPS per diem payment that the SNF receives for the package of services that it furnishes during the resident's covered Part A stay.

Similarly, under section 1888(e)(2)(A)(ii) of the Act, the exclusion of EPO from consolidated billing applies only to those services that meet the requirements for coverage under the separate Part B EPO benefit at section 1861(s)(2)(O) of the Act. Section 1861(s)(2)(O) of the Act permits coverage of EPO and items related to its administration for those dialysis patients who can self-administer the drug, subject to methods and standards established by the Secretary for its safe and effective use (as described in § 405.2163(g) and (h)). Since EPO that is used for non-dialysis patients does not fall within the scope of section 1861(s)(2)(O) of the Act, that usage does not fall within the scope of the EPO exclusion from consolidated billing.

Comment: One commenter requested that we amend 42 CFR§ 409.20(a)(3) and 409.23 to add recreational therapy to the current list of rehabilitation services (i.e., physical and occupational therapy and speech-language pathology services).

Response: The purpose of the two above-cited sections of the regulations is to implement section 1861(h)(3) of the Act, which currently specifies that “* * * ‘extended care services’ means the following items and services furnished to an inpatient of a skilled nursing facility * * * (3) physical or occupational therapy or speech-language pathology services furnished by the skilled nursing facility or by others under arrangements with them made by the facility * * *.” Notably, recreational therapy is not included in this statutory definition and we cannot adopt the commenter's request to revise the regulations.

J. 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, as noted previously in section I.A. of this final rule, the services furnished by non-CAH rural hospitals are paid under the SNF PPS. In the July 31, 2001 final rule (66 FR 39562), we announced the conversion of swing-bed rural hospitals to the SNF PPS, effective with the start of the provider's first cost reporting period beginning on or after July 1, 2002. We selected this 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.

As of June 30, 2003, all swing-bed rural hospitals have come under the SNF PPS. Therefore, the SNF PPS rates and wage indexes outlined in earlier sections of this final rule for SNFs also apply to all swing-bed rural hospitals. A complete discussion of assessment schedules, the MDS and the transmission software, Raven-SB for Swing Beds can be found in the July 31, 2001 final rule (66 FR 39562). The latest changes in the MDS for swing-bed rural hospitals are listed on our SNF PPS web site, http://www.cms.hhs.gov/providers/snfpps/default.asp.

K. Qualifying Three-Day Inpatient Hospital Stay Requirement

In the FY 2006 SNF PPS proposed rule, we noted that one of the prerequisites for Part A coverage under the Medicare SNF benefit is a qualifying hospital stay of at least 3 consecutive days, and that under current policy, only time following the formal inpatient admission to the hospital counts toward meeting this requirement. We invited comments on having patients spend time in observation status prior to a formal inpatient admission, and on the potential implications of this practice for the SNF benefit's qualifying 3-day hospital stay requirement.

Comment: Of the comments that we received on this issue, most expressed support for the idea that hospital time spent in observation status immediately preceding a formal inpatient admission should count toward satisfying the SNF benefit's statutory qualifying three-day hospital stay requirement, while some advocated eliminating the statutory requirement altogether. Still others recommended counting all time spent in the hospital (not only in observation status, but also in the emergency room as well), while some others supported counting the observation time but were opposed to counting time spent in the emergency room. Other commenters raised related issues regarding the availability of information in this area, such as the inability of existing CMS operating systems (including the claims and cost reporting systems) to accommodate the counting of observation time for this purpose without further modification, and the inability of SNFs to distinguish between observation and emergency room time spent in the hospital. Some of these commenters also suggested taking certain additional measures, such as requiring the hospital to certify that a beneficiary has met the SNF benefit's qualifying 3-day stay requirement (and to assume the financial liability for any related coverage denials), and examining ways in which SNFs can obtain better information from hospitals about the specific nature and duration of a patient's hospital stay.

Response: Regarding the comments that expressed support for repealing the statutory 3-day qualifying hospital stay requirement altogether, we note that such an action would require legislation by the Congress to amend the law itself and, thus, is beyond the scope of this final rule. Further, we do not share the belief expressed by some commenters that time spent in the emergency room is essentially comparable to observation time in this context. As we noted in the FY 2006 SNF PPS proposed rule, except for scheduled admissions, the emergency room generally serves as the overall point of entry into the hospital for most patients; thus, the mere presence of time spent in the emergency room prior to formal admission would not, in itself, serve to identify the degree of severity of a particular patient's condition during that time.

With regard to the comments that suggested other possible modifications to the 3-day inpatient hospital stay requirement, we note that we are continuing to review this issue, but are not yet ready to make a final determination at this time. As we observed in the FY 2006 SNF PPS proposed rule, the SNF benefit was never intended to cover long-term, relatively low-level “custodial” care; rather, the Congress envisioned this benefit more narrowly, in terms of serving as a less expensive alternative to what would otherwise be the final, convalescent portion of an acute care stay of several days as an inpatient at a hospital. Thus, any potential changes in the SNF benefit's qualifying hospital stay requirement would need to be carefully evaluated, in order to ensure that they accurately reflect Congressional intent in establishing the qualifying hospital stay requirement, and would not result in altering the unique nature of the SNF benefit in a manner that is inconsistent with that intent.

IV. Provisions of the Final Rule Back to Top

In section III. above, “Analysis of and Responses to Public Comments on the FY 2006 SNF PPS Proposed Rule,” we have added a statement at the end of each issue indicating our final decision either to adopt the provisions as set forth in the FY 2006 SNF PPS proposed rule or to make modifications based on public comments. However, all other changes, including clarifying and technical changes that are not issue-specific will be addressed in this section below.

Specifically, we are making the following technical correction in the regulations text, as discussed in the FY 2006 SNF PPS proposed rule: we are correcting the definition of “HCPCS” that appears in § 424.3, by removing the acronym “CMS” and adding the word “Healthcare” in its place.

Further, we note that we are taking this opportunity to make two additional technical corrections in Part 409 of the regulations. The first involves updating an obsolete citation that appears in several places in § 409.60(c). This section of the regulations sets forth several administrative presumptions that serve to help determine the end of a benefit period in a SNF, and it makes repeated references to an obsolete citation (§ 405.330) for the provision dealing with limitation of liability for care that is custodial or not reasonable and necessary. Accordingly, we are hereby updating that obsolete citation by replacing it with the current citation, § 411.400.

The other correction to Part 409 involves the regulations at 42 CFR 409.31(b)(2), which describe one aspect of the SNF level of care requirements. In a final rule published on August 22, 2003 (68 FR 50855), we added § 409.31(b)(2)(iii) regarding Medicare+Choice (M+C) enrollees. However, in republishing § 409.31(b)(2)(ii), we inadvertently omitted several words that previously had appeared in the text. Accordingly, we are now taking this opportunity to restore the missing language, so that § 409.31(b)(2)(ii) is revised to reflect its original complete and accurate language.

Finally, we note that in the FY 2004 final rule (68 FR 46060, 46070, August 4, 2003), we added two radiopharmaceuticals, Zevalin and Bexxar, to the list of chemotherapy drugs that are excluded from consolidated billing (and, thus, are separately billable to Part B when furnished to a SNF resident during a covered Part A stay). The final rule specified that regulation text at 42 CFR 411.15(p)(2)(xii) and 42 CFR 489.20(s)(12) list the Healthcare Common Procedure Coding System (HCPCS) codes for Zevalin (A9522 and A9523) “as of January 1, 2004.” At the time the FY 2004 final rule was published, the codes for Bexxar were not yet available (see 68 FR 46060) but were about to be issued. Accordingly, we are now adding the initial Bexxar HCPCS codes to 42 CFR 411.15(p)(2)(xii) and 42 CFR 489.20(s)(12) effective “as of January 1, 2004.” These codes for Bexxar are A9533 and A9534. As we clarified in the September 29, 2003 Federal Register (68 FR 55883), the HCPCS codes to be utilized in connection with Bexxar and Zevalin include any successor codes that may replace (or supplement) the codes currently listed in the regulation. Such successor codes are disseminated through program instructions.

V. Waiver of Proposed Rulemaking Back to Top

Regarding the technical corrections to Parts 409, 411, and 489 of the regulations that we discuss in the preceding section, we note that we would ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before revisions in the regulations text would take effect; 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. We find it unnecessary to undertake notice and comment rulemaking in connection with these particular revisions, as they merely provide technical corrections to the regulations, without making any substantive changes. Therefore, for good cause, we waive notice and comment procedures for the revisions that we are making to the regulations text in Parts 409, 411, and 489.

VI. Collection of Information Requirements Back to Top

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

VII. Regulatory Impact Analysis Back to Top

A. Overall Impact

We have examined the impacts of this final rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA, September 16, 1980, 96), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This final rule is a major rule, as defined in Title 5, United States Code, section 804(2), because we estimate the impact to the Medicare program, and the annual effects to the overall economy, would be more than $100 million.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most SNFs and most other providers and suppliers are small entities, either by their nonprofit status or by having revenues of $11.5 million or less in any 1 year. For purposes of the RFA, approximately 53 percent of SNFs are considered small businesses according to the Small Business Administration's latest size standards, with total revenues of $11.5 million or less in any 1 year (for further information, see 65 FR 69432, November 17, 2000). Individuals and States are not included in the definition of a small entity. In addition, approximately 29 percent of SNFs are nonprofit organizations.

This final rule updates the SNF PPS rates published in the FY 2005 update notice on July 30, 2004 (69 FR 45775) and the associated correction notices published on October 7, 2004 (69 FR 60158), and December 30, 2004(69 FR 78445).

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. We anticipate that the impact on swing-bed facilities will be similar to the impact on rural hospital-based facilities, which benefit from the case-mix refinement (seeTable 12 below).

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million or more. This final rule will not have a substantial effect on the governments mentioned, or on private sector costs.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this final rule will not have a substantial effect on State and local governments.

B. Anticipated Effects

This final rule sets forth updates of the SNF PPS rates contained in the FY 2005 update notice (69 FR 45775) and the associated correction notices (69 FR 60158 and 69 FR 78445), and implements a refinement to the RUG-III case-mix classification system to be incorporated into the Medicare SNF PPS effective January 1, 2006.

As described in Section III., providers will continue to be paid under the current 44-group RUG-III system from October 1, 2005 through December 31, 2005. Beginning January 1, 2006, providers will be paid under the refinedRUG-53 system.

Based on the above, we estimate the FY 2006 impact will be a net increase of $20 million in payments to SNF providers (this reflects a $1.02 billion reduction from the expiration of temporary payment increases, offset by a $510 million increase from the refined case-mix classification system and a $530 million increase from the update to the payment rates, as explained in greater detail later in this section). The impact analysis in Table 12 of this final rule represents the projected effects of the policy changes in the SNF PPS from FY 2005 to FY 2006. We estimate the effects by estimating payments while holding all other payment variables constant. We use the best data available, but we do not attempt to predict behavioral responses to these changes, and we do not make adjustments for future changes in such variables as days or case-mix.

We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples are 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 the BBA, the BBRA, the BIPA, the MMA, 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 the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact uponSNFs.

In accordance with section 1888(e)(4)(E) of the Act, we are updating the payment rates for FY 2006. The BBRA, BIPA, and MMA provided for several temporary adjustments to the SNF PPS payment rates that together, using the most recent data available, accounted for an estimated impact of $1.4 billion per year.

We note that in accordance with section 101(a) of the BBRA and section 314 of the BIPA, the existing, temporary increase in the per diem adjusted payment rates of 20 percent for certain specified clinically complex RUGs(and 6.7 percent for other, rehabilitation RUGs) would expire with the implementation of the case-mix refinements in the SNF PPS. As explained in section II. of this final rule, section 511 of the MMA, which provides for a 128 percent increase in the PPS per diem payment for any SNF resident with Acquired Immune Deficiency Syndrome (AIDS), remains in effect. However, we have not provided a separate impact analysis for the MMA provision. Our latest estimates indicate that there are less than 2,000 beneficiaries who qualify for the AIDS add-on payment. The impact to Medicare is included in the “total” column of Table 12.

In updating the rates for FY 2006, we made a number of standard annual revisions and clarifications mentioned elsewhere in this final rule (for example, the update to the wage and market basket indexes used for adjusting the Federal rates). These revisions would increase payments to SNFs by approximately $530 million.

The aggregate change in payments associated with this final rule is estimated to be an increase in payments to SNFs of $20 million for FY 2006. The decrease of $1.02 billion due to the elimination of the temporary add-ons, together with the additional payment due to the refined case-mix classification system of $510 million and the market basket increase of $530 million, results in a net change in payments of $20 million. There are two areas of change that produce this impact on SNFs:

1. The implementation of a refined case-mix classification system under section 1888(e)(4)(G)(i) of the Act and, consequently, the expiration of the temporary 20 percent/6.7 percent add-ons to the Federal rates for the specified RUG groups.

2. The total change in payments from FY 2005 levels to FY 2006 levels. This includes all of the previously noted changes in addition to the effect of the update to the rates.

The impacts are shown in Table 12. 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, and census region.

The first row of figures in the first column describes the estimated effects of the various changes on all facilities. The next 6 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 designations. The next 20 rows show the effects on urban versus rural status by census region.

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 of the table shows the effect of using the new OMB geographic designations based on CBSAs.During the FY 2006 transition to CBSAs, SNFs will receive a transition-based wage index value consisting 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 (seeTable A in the Addendum), as described in Section III.D.1 of this final rule.

The fifth column of the table shows the effect of the elimination of the add-on for specified RUG groups. As expected, this results in a decrease in payments for all providers.

The sixth column of the table shows the effect of the refinements to the case-mix classification system.Table 12 shows that there is a positive 3 percent overall impact from the case-mix refinements. Distributional effects are noted for specific providers. For example, hospital-based facilities are expected to receive greater than an 7.7 percent increase in payment, compared with freestanding facilities that show an increase in payments of between 2.2 percent and 2.6 percent. Additionally, rural Census regions show increases in payments of 3.4 percent.

The seventh column of the table shows the effect of all of the changes on the FY 2006 payments. As the market basket increase of 3.1 percentage points is constant for all providers, it is not shown individually; however, we note that the “Total FY 2006 change” column does incorporate this increase. It is projected that aggregate payments will increase by $20 million, assuming facilities do not change their care delivery and billing practices in response.

As can be seen from this table, the combined effects of all of the changes would vary by specific types of providers and by location. For example, though facilities in the urban New England and rural South Atlantic regions experience payment decreases of 0.4 percent and 0.4 percent, respectively, some providers (such as those in the rural Pacific and rural New England regions) show increases of 4.1 percent and 2.4 percent, respectively. Payment increases for facilities in the Rural Pacific area of the country are the highest for any provider category.

Table 12.—Projected Impact to the SNF PPS for FY 2006 Back to Top
Number of facilities Update wage data (percent) MSA to CBSA (percent) Eliminate add-on to certain RUGs (percent) Case-mix refinements (percent) Total FY 2006 change (percent)
Total 15,675 0.0 0.0 −6.0 3.0 0.1
Urban 10,599 0.0 0.0 −6.0 2.9 0.0
Rural 5,076 0.1 0.1 −6.0 3.4 0.7
Hospital based urban 1,097 0.0 0.0 −6.3 7.8 4.6
Freestanding urban 8,693 0.0 0.0 −5.9 2.2 −0.6
Hospital based rural 1,160 0.0 0.1 −6.8 7.7 4.1
Freestanding rural 3,372 0.1 0.1 −5.9 2.6 0.1
Urban by Region            
New England 917 −0.2 −0.1 −6.4 3.2 −0.4
Middle Atlantic 1,499 0.2 0.0 −6.1 3.0 0.2
South Atlantic 1,739 −0.3 0.0 −5.9 2.9 −0.3
East North Central 2,009 −0.4 0.0 −5.7 2.9 −0.2
East South Central 531 0.3 0.0 −6.0 2.6 0.0
West North Central 836 −0.6 0.0 −5.9 3.6 0.3
West South Central 1,093 −0.1 0.1 −5.8 2.6 0.0
Mountain 467 −0.3 0.1 −5.6 2.9 0.2
Pacific 1,501 1.2 0.0 −6.2 2.9 1.0
Rural by Region            
New England 139 2.0 0.0 −5.7 3.0 2.4
Middle Atlantic 283 −0.1 0.1 −6.0 3.6 0.7
South Atlantic 612 −0.3 0.0 −6.2 3.0 −0.4
East North Central 947 0.3 0.0 −5.9 3.8 1.4
East South Central 571 0.1 0.1 −6.3 2.6 −0.4
West North Central 1,219 −0.5 0.1 −6.2 4.1 0.7
West South Central 823 0.2 0.0 −6.2 2.7 −0.2
Mountain 298 0.6 −0.2 −5.9 3.8 1.4
Pacific 182 1.6 0.0 −4.2 3.6 4.1
Ownership            
Government 693 0.0 0.2 −6.5 4.8 1.6
Proprietary 9,317 0.0 0.0 −5.9 2.3 −0.6
Voluntary 3,493 −0.1 0.0 −6.0 4.9 1.9

Comment: Several commenters asked that we provide additional data and files to help them model the impact on providers.

Response: CMS worked to make additional data and updated analyses readily available throughout the comment period, and posted these additional data and analyses to the CMS website as soon as they became available.

Comment: A few commenters expressed concern that the proposed FY 2006 market basket update was included in our impact analysis. They contended that the market basket update reflects changes in price levels that have already taken place and, in their view, reimburses them for expenses they have already incurred. By including the market basket update in the impact analysis, these commenters argue that we have understated the actual impact of the FY 2006 changes.

Response: The impact analyses presented here and in the proposed rule utilize the same methodology that has been in effect since the introduction of the SNF PPS.Specifically, we determine the impact analysis by estimating aggregate payments attributable to each major component of the rate, including the market basket adjustment, while holding all other payment variables constant. By including the FY 2006 market basket variable in the analysis, and then comparing the expenditures to the FY 2005 levels (which also include a market basket update factor), we obtain a more accurate picture of aggregate spending changes.

Comment: Several commenters expressed concern regarding the overall fiscal impact of the proposed changes and recommended that the aggregate expenditure levels be increased. Other commenters stated that they had been unable to reconcile their independent analyses with the information contained in the proposed rule, and were concerned that the impact of the proposed rate structure would exceed the CMS projections.

Response: As mentioned in Section III., throughout the comment period, we reexamined the data presented in the proposed rule, updated the analyses to reflect the most recent available data, and corrected minor technical errors. We also received information from industry representatives and others, which helped us to verify the accuracy of the data used in the rate calculations, and then to ensure that the resulting rates correctly reflected the policies specified in the proposed rule. We then repeated the payment simulation described in the proposed rule. Next we recalculated the payment adjustment needed to ensure parity when comparing the aggregate expenditure levels of the 44-group and 53-group RUG models. As a final step, we applied an 8.51 percent increase to the nursing weights to reflect variation in non-therapy ancillary costs.

The impact analyses presented here and in the proposed rule utilize the same methodology that has been in effect since the introduction of the SNF PPS. The numbers presented in the impact analysis section represent the impact to the Federal Government which is calculated as total payments net of coinsurance. However, when considering total payments (not total impact), such as determining any adjustment to the nursing weights to reflect the variation in non-therapy ancillary costs, we use total payments including the coinsurance amounts.

We further note that, while the market basket increases are mandated in the statute, the Congress established an oversight mechanism to adjust or eliminate the updates based on MedPAC's annual analysis and recommendations. For FY 2006, MedPAC recommended a zero update. Had the Congress accepted that recommendation and enacted a change, the market basket adjustment would have been zero, and we would have included that factor in our impact analyses.

C. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 13 below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule. This table provides our best estimate of the change in Medicare payments under the SNF PPS as a result of the policies in this final rule based on the data for 15,675 SNFs in our database. All expenditures are classified as transfers to Medicare providers (that is, SNFs).

Table 13.—Accounting Statement: Classification of EstimatedExpenditures, From the 2005 SNF PPS Rate Year to the 2006 SNF PPS RateYear (in Millions) Back to Top
Category Transfers
Annualized Monetized Transfers $20 million.
From Whom To Whom? Federal Government to SNF Medicare Providers.

D. Alternatives Considered

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 be used for computing the 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, such as a case-mix classification methodology, the MDS assessment schedule, 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 fiscal year through the Federal Register, and to do so before the August 1 that precedes the start of the new fiscal year.

Because we have determined that this final rule will have a significant economic impact on SNFs, we will discuss the alternatives we considered. We reviewed the options considered in the proposed rule and took into consideration comments received during the public comment period as discussed in the preamble.

As discussed previously in section II. of this final rule, we will implement refinements to the RUG-III case-mix classification system under section 1888(e)(4)(G)(i) of the Act. At the same time, we continue to evaluate longer-range, more comprehensive changes in the case-mix classification system. One alternative that we considered was to defer refinements at this time until our evaluation of longer-range, more comprehensive changes is complete. However, we believe that these refinements will serve to improve the distribution of payments under the PPS in a manner that more accurately accounts for the care needs of the most medically complex patients. While our additional research may identify more comprehensive modifications, it is not currently known when the results of this research would become available. Therefore, we have decided to implement the refinements discussed elsewhere in this final rule.

As discussed in section III.D, we considered several budget neutral options that would most effectively implement the adoption of the CBSA designation. Among the alternatives that we considered were the options discussed in the proposed rule and new options that took into consideration comments received during the public comment period, as discussed elsewhere in this final rule.

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

List of Subjects Back to Top

begin regulatory text

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

PART 409—HOSPITAL INSURANCE BENEFITS Back to Top

1.The authority citation for part 409 continues to read as follows:

Authority:

Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Subpart D—Requirements for Coverage of Posthospital SNF Care Back to Top

2.Amend § 409.31 by—

A. Republishing paragraph (b)(2) introductory text.

B. Revising paragraph (b)(2)(ii) to read as follows:

§ 409.31 Level of care requirement.

* * * * *

(b) * * *

(2) Those services must be furnished for a condition—

(i) * * *

(ii) Which arose while the beneficiary was receiving care in a SNF or swing-bed hospital for a condition for which he or she received inpatient hospital or inpatient CAH services; or

* * * * *

Subpart F—Scope of Hospital Insurance Benefits Back to Top

3.Amend § 409.60(c) by removing the references to “§ 405.330” and adding “§ 411.400” in its place.

PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT Back to Top

1.The authority citation for part 411 continues to read as follows:

Authority:

Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Subpart A—General Exclusions and Exclusion of ParticularServices Back to Top

2.Amend § 411.15 by—

A. Republishing paragraph (p)(2) introductory text.

B. Revising paragraph (p)(2)(xii) to read as follows:

§ 411.15 Particular services excluded from coverage.

* * * * *

(p) * * *

(2) Exceptions. The following services are not excluded from coverage, provided that the claim for payment includes the SNF's Medicare provider number in accordance with § 424.32(a)(5) of this chapter:

* * * * *

(xii) Those chemotherapy items identified, as of July 1, 1999, by HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206-J9208; J9211; J9230-J9245; andJ9265-J9600; and, as of January 1, 2004, by HCPCS codesA9522, A9523, A9533, and A9534.

* * * * *

PART 424—CONDITIONS FOR MEDICARE PAYMENT Back to Top

1.The authority citation for part 424 continues to read as follows:

Authority:

Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Subpart B—Certification and Plan of Treatment Requirements Back to Top

§ 424.3 Definitions.

2.In § 424.3, in the definition of “HCPCS” remove the word “CMS” and add the word “Healthcare” in its place.

3.In § 424.20, paragraph (e)(2) is revised to read as follows:

§ 424.20 Requirements for posthospital SNF care.

* * * * *

(e) * * *

(2) A nurse practitioner or clinical nurse specialist, neither of whom has a direct or indirect employment relationship with the facility but who is working in collaboration with a physician. For purposes of this section—

(i) Collaboration means a process whereby a nurse practitioner or clinical nurse specialist works with a doctor of medicine or osteopathy to deliver health care services. The services are delivered within the scope of the nurse's professional expertise, with medical direction and appropriate supervision as provided for in guidelines jointly developed by the nurse and the physician or other mechanisms defined by Federal regulations and the law of the State in which the services are performed.

(ii) A direct employment relationship with the facility is one in which the nurse practitioner or clinical nurse specialist meets the common law definition of the facility's “employee,” as specified in § 404.1005, § 404.1007, and § 404.1009 of title 20 of the regulations. When a nurse practitioner or clinical nurse specialist meets this definition with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under § 409.21 of this subchapter, the facility is considered to have an indirect employment relationship with the nurse practitioner or clinical nurse specialist. An indirect employment relationship does not exist if the agreement between the entity and the facility involves only the performance of delegated physician tasks under § 483.40(e) of this chapter.

* * * * *

PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL Back to Top

1.The authority citation for part 489 continues to read as follows:

Authority:

Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

Subpart B—Essentials of Provider Agreements Back to Top

2.Section 489.20 is amended by:

A. Republishing the introductory text and the paragraph (s) introductory text.

B. Revising paragraph (s)(12).

§ 489.20 Basic commitments.

The provider agrees to the following:

* * * * *

(s) In the case of an SNF, either to furnish directly or make arrangements (as defined in § 409.3 of this chapter) for all Medicare-covered services furnished to a resident (as defined in § 411.15(p)(3) of this chapter) of the SNF, except the following:

* * * * *

(12) Those chemotherapy items identified, as of July 1,1999, by HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206-J9208; J9211; J9230-J9245; and J9265-J9600; and, as of January 1, 2004, by HCPCS codes A9522, A9523, A9533, and A9534.

* * * * *

end regulatory text

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

Dated: July 19, 2005.

Mark B. McClellan,

Administrator, Centers for Medicare Medicaid Services.

Approved: July 27, 2005.

Michael O. Leavitt,

Secretary.

Addendum—FY 2006 Transition Wage Index and CBSA Tables Back to Top

In this addendum, we provide the tables referred to in the preamble to this final rule. Tables 8 and 9 provide the CBSA-based wage index values for urban and rural providers. Though we will use the transition-based wage index values presented in Table A for FY 2006, CBSA-based wage index values will be used for FY 2007 when the transition will expire. Tables 8 and 9 serve the purpose of showing a possible format of how the CBSA-based wage index values will be presented for FY 2007.

Table A provides the following information: Social Security Administration (SSA) State and County Code; State and County name; existing MSA-based labor market area designation; MSA-based urban/rural geographic designation; FY 2006 MSA-based wage index; FY 2006 CBSA-based wage index; CBSA-based labor market area; CBSA-based urban/rural geographic designation (which will be used for the FY 2006 transition); and the FY 2006 transition wage index (based on 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index).

Table 8.—FY 2006 Wage Index For Urban Areas Based On CBSA Labor Market Areas Back to Top
CBSA code Urban area (constituent counties) Wage index
1At this time, there are no hospitals located in these urban areas on which to base a wage index.
10180 Abilene, TX 0.7896
Callahan County, TX  
Jones County, TX  
Taylor County, TX  
10380 Aguadilla-Isabela-San Sebastian, PR 0.4738
Aguada Municipio, PR  
Aguadilla Municipio, PR  
Anasco Municipio, PR  
Isabela Municipio, PR  
Lares Municipio, PR  
Moca Municipio, PR  
Rincon Municipio, PR  
San Sebastian Municipio, PR  
10420 Akron, OH 0.8982
Portage County, OH  
Summit County, OH  
10500 Albany, GA 0.8628
Baker County, GA  
Dougherty County, GA  
Lee County, GA  
Terrell County, GA  
Worth County, GA  
10580 Albany-Schenectady-Troy, NY 0.8589
Albany County, NY  
Rensselaer County, NY  
Saratoga County, NY  
Schenectady County, NY  
Schoharie County, NY  
10740 Albuquerque, NM 0.9684
Bernalillo County, NM  
Sandoval County, NM  
Torrance County, NM  
Valencia County, NM  
10780 Alexandria, LA 0.8033
Grant Parish, LA  
Rapides Parish, LA  
10900 Allentown-Bethlehem-Easton, PA-NJ 0.9818
Warren County, NJ  
Carbon County, PA  
Lehigh County, PA  
Northampton County, PA  
11020 Altoona, PA 0.8944
Blair County, PA  
11100 Amarillo, TX 0.9156
Armstrong County, TX  
Carson County, TX  
Potter County, TX  
Randall County, TX  
11180 Ames, IA 0.9536
Story County, IA  
11260 Anchorage, AK 1.1895
Anchorage Municipality, AK  
Matanuska-Susitna Borough, AK  
11300 Anderson, IN 0.8586
Madison County, IN  
11340 Anderson, SC 0.8997
Anderson County, SC  
11460 Ann Arbor, MI 1.0859
Washtenaw County, MI  
11500 Anniston-Oxford, AL 0.7682
Calhoun County, AL  
11540 Appleton, WI 0.9288
Calumet County, WI  
Outagamie County, WI  
11700 Asheville, NC 0.9285
Buncombe County, NC  
Haywood County, NC  
Henderson County, NC  
Madison County, NC  
12020 Athens-Clarke County, GA 0.9855
Clarke County, GA  
Madison County, GA  
Oconee County, GA  
Oglethorpe County, GA  
12060 Atlanta-Sandy Springs-Marietta, GA 0.9793
Barrow County, GA  
Bartow County, GA  
Butts County, GA  
Carroll County, GA  
Cherokee County, GA  
Clayton County, GA  
Cobb County, GA  
Coweta County, GA  
Dawson County, GA  
DeKalb County, GA  
Douglas County, GA  
Fayette County, GA  
Forsyth County, GA  
Fulton County, GA  
Gwinnett County, GA  
Haralson County, GA  
Heard County, GA  
Henry County, GA  
Jasper County, GA  
Lamar County, GA  
Meriwether County, GA  
Newton County, GA  
Paulding County, GA  
Pickens County, GA  
Pike County, GA  
Rockdale County, GA  
Spalding County, GA  
Walton County, GA  
12100 Atlantic City, NJ 1.1615
Atlantic County, NJ  
12220 Auburn-Opelika, AL 0.8100
Lee County, AL  
12260 Augusta-Richmond County, GA-SC 0.9748
Burke County, GA  
Columbia County, GA  
McDuffie County, GA  
Richmond County, GA  
Aiken County, SC  
Edgefield County, SC  
12420 Austin-Round Rock, TX 0.9437
Bastrop County, TX  
Caldwell County, TX  
Hays County, TX  
Travis County, TX  
Williamson County, TX  
12540 Bakersfield, CA 1.0470
Kern County, CA  
12580 Baltimore-Towson, MD 0.9897
Anne Arundel County, MD  
Baltimore County, MD  
Carroll County, MD  
Harford County, MD  
Howard County, MD  
Queen Anne's County, MD  
Baltimore City, MD  
12620 Bangor, ME 0.9993
Penobscot County, ME  
12700 Barnstable Town, MA 1.2600
Barnstable County, MA  
12940 Baton Rouge, LA 0.8593
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 0.9508
Calhoun County, MI  
13020 Bay City, MI 0.9343
Bay County, MI  
13140 Beaumont-Port Arthur, TX 0.8412
Hardin County, TX  
Jefferson County, TX  
Orange County, TX  
13380 Bellingham, WA 1.1731
Whatcom County, WA  
13460 Bend, OR 1.0786
Deschutes County, OR  
13644 Bethesda-Frederick-Gaithersburg, MD 1.1483
Frederick County, MD  
Montgomery County, MD  
13740 Billings, MT 0.8834
Carbon County, MT  
Yellowstone County, MT  
13780 Binghamton, NY 0.8562
Broome County, NY  
Tioga County, NY  
13820 Birmingham-Hoover, AL 0.8959
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 0.7574
Burleigh County, ND  
Morton County, ND  
13980 Blacksburg-Christiansburg-Radford, VA 0.7954
Giles County, VA  
Montgomery County, VA  
Pulaski County, VA  
Radford City, VA  
14020 Bloomington, IN 0.8447
Greene County, IN  
Monroe County, IN  
Owen County, IN  
14060 Bloomington-Normal, IL 0.9075
McLean County, IL  
14260 Boise City-Nampa, ID 0.9052
Ada County, ID  
Boise County, ID  
Canyon County, ID  
Gem County, ID  
Owyhee County, ID  
14484 Boston-Quincy, MA 1.1558
Norfolk County, MA  
Plymouth County, MA  
Suffolk County, MA  
14500 Boulder, CO 0.9734
Boulder County, CO  
14540 Bowling Green, KY 0.8211
Edmonson County, KY  
Warren County, KY  
14740 Bremerton-Silverdale, WA 1.0675
Kitsap County, WA  
14860 Bridgeport-Stamford-Norwalk, CT 1.2592
Fairfield County, CT  
15180 Brownsville-Harlingen, TX 0.9804
Cameron County, TX  
15260 Brunswick, GA 0.9311
Brantley County, GA  
Glynn County, GA  
McIntosh County, GA  
15380 Buffalo-Niagara Falls, NY 0.9511
Erie County, NY  
Niagara County, NY  
15500 Burlington, NC 0.8905
Alamance County, NC  
15540 Burlington-South Burlington, VT 0.9410
Chittenden County, VT  
Franklin County, VT  
Grand Isle County, VT  
15764 Cambridge-Newton-Framingham, MA 1.1172
Middlesex County, MA  
15804 Camden, NJ 1.0517
Burlington County, NJ  
Camden County, NJ  
Gloucester County, NJ  
15940 Canton-Massillon, OH 0.8935
Carroll County, OH  
Stark County, OH  
15980 Cape Coral-Fort Myers, FL 0.9356
Lee County, FL  
16180 Carson City, NV 1.0234
Carson City, NV  
16220 Casper, WY 0.9026
Natrona County, WY  
16300 Cedar Rapids, IA 0.8825
Benton County, IA  
Jones County, IA  
Linn County, IA  
16580 Champaign-Urbana, IL 0.9594
Champaign County, IL  
Ford County, IL  
Piatt County, IL  
16620 Charleston, WV 0.8445
Boone County, WV  
Clay County, WV  
Kanawha County, WV  
Lincoln County, WV  
Putnam County, WV  
16700 Charleston-North Charleston, SC 0.9245
Berkeley County, SC  
Charleston County, SC  
Dorchester County, SC  
16740 Charlotte-Gastonia-Concord, NC-SC 0.9750
Anson County, NC  
Cabarrus County, NC  
Gaston County, NC  
Mecklenburg County, NC  
Union County, NC  
York County, SC  
16820 Charlottesville, VA 1.0187
Albemarle County, VA  
Fluvanna County, VA  
Greene County, VA  
Nelson County, VA  
Charlottesville City, VA  
16860 Chattanooga, TN-GA 0.9088
Catoosa County, GA  
Dade County, GA  
Walker County, GA  
Hamilton County, TN  
Marion County, TN  
Sequatchie County, TN  
16940 Cheyenne, WY 0.8775
Laramie County, WY  
16974 Chicago-Naperville-Joliet, IL 1.0790
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 1.0511
Butte County, CA  
17140 Cincinnati-Middletown, OH-KY-IN 0.9615
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 0.8284
Christian County, KY  
Trigg County, KY  
Montgomery County, TN  
Stewart County, TN  
17420 Cleveland, TN 0.8139
Bradley County, TN  
Polk County, TN  
17460 Cleveland-Elyria-Mentor, OH 0.9213
Cuyahoga County, OH  
Geauga County, OH  
Lake County, OH  
Lorain County, OH  
Medina County, OH  
17660 Coeur d'Alene, ID 0.9647
Kootenai County, ID  
17780 College Station-Bryan, TX 0.8900
Brazos County, TX  
Burleson County, TX  
Robertson County, TX  
17820 Colorado Springs, CO 0.9468
El Paso County, CO  
Teller County, CO  
17860 Columbia, MO 0.8345
Boone County, MO  
Howard County, MO  
17900 Columbia, SC 0.9057
Calhoun County, SC  
Fairfield County, SC  
Kershaw County, SC  
Lexington County, SC  
Richland County, SC  
Saluda County, SC  
17980 Columbus, GA-AL 0.8560
Russell County, AL  
Chattahoochee County, GA  
Harris County, GA  
Marion County, GA  
Muscogee County, GA  
18020 Columbus, IN 0.9588
Bartholomew County, IN  
18140 Columbus, OH 0.9860
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 0.8550
Aransas County, TX  
Nueces County, TX  
San Patricio County, TX  
18700 Corvallis, OR 1.0729
Benton County, OR  
19060 Cumberland, MD-WV 0.9317
Allegany County, MD  
Mineral County, WV  
19124 Dallas-Plano-Irving, TX 1.0228
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 0.9079
Murray County, GA  
Whitfield County, GA  
19180 Danville, IL 0.9028
Vermilion County, IL  
19260 Danville, VA 0.8489
Pittsylvania County, VA  
Danville City, VA  
19340 Davenport-Moline-Rock Island, IA-IL 0.8724
Henry County, IL  
Mercer County, IL  
Rock Island County, IL  
Scott County, IA  
19380 Dayton, OH 0.9064
Greene County, OH  
Miami County, OH  
Montgomery County, OH  
Preble County, OH  
19460 Decatur, AL 0.8469
Lawrence County, AL  
Morgan County, AL  
19500 Decatur, IL 0.8067
Macon County, IL  
19660 Deltona-Daytona Beach-Ormond Beach, FL 0.9299
Volusia County, FL  
19740 Denver-Aurora, CO 1.0723
Adams County, CO  
Arapahoe County, CO  
Broomfield County, CO  
Clear Creek County, CO  
Denver County, CO  
Douglas County, CO  
Elbert County, CO  
Gilpin County, CO  
Jefferson County, CO  
Park County, CO  
19780 Des Moines, IA 0.9669
Dallas County, IA  
Guthrie County, IA  
Madison County, IA  
Polk County, IA  
Warren County, IA  
19804 Detroit-Livonia-Dearborn, MI 1.0424
Wayne County, MI  
20020 Dothan, AL 0.7721
Geneva County, AL  
Henry County, AL  
Houston County, AL  
20100 Dover, DE 0.9776
Kent County, DE  
20220 Dubuque, IA 0.9024
Dubuque County, IA  
20260 Duluth, MN-WI 1.0213
Carlton County, MN  
St. Louis County, MN  
Douglas County, WI  
20500 Durham, NC 1.0244
Chatham County, NC  
Durham County, NC  
Orange County, NC  
Person County, NC  
20740 Eau Claire, WI 0.9201
Chippewa County, WI  
Eau Claire County, WI  
20764 Edison, NJ 1.1249
Middlesex County, NJ  
Monmouth County, NJ  
Ocean County, NJ  
Somerset County, NJ  
20940 El Centro, CA 0.8906
Imperial County, CA  
21060 Elizabethtown, KY 0.8802
Hardin County, KY  
Larue County, KY  
21140 Elkhart-Goshen, IN 0.9627
Elkhart County, IN  
21300 Elmira, NY 0.8250
Chemung County, NY  
21340 El Paso, TX 0.8977
El Paso County, TX  
21500 Erie, PA 0.8737
Erie County, PA  
21604 Essex County, MA 1.0538
Essex County, MA  
21660 Eugene-Springfield, OR 1.0818
Lane County, OR  
21780 Evansville, IN-KY 0.8713
Gibson County, IN  
Posey County, IN  
Vanderburgh County, IN  
Warrick County, IN  
Henderson County, KY  
Webster County, KY  
21820 Fairbanks, AK 1.1408
Fairbanks North Star Borough, AK  
21940 Fajardo, PR 0.4153
Ceiba Municipio, PR  
Fajardo Municipio, PR  
Luquillo Municipio, PR  
22020 Fargo, ND-MN 0.8486
Cass County, ND  
Clay County, MN  
22140 Farmington, NM 0.8509
San Juan County, NM  
22180 Fayetteville, NC 0.9416
Cumberland County, NC  
Hoke County, NC  
22220 Fayetteville-Springdale-Rogers, AR-MO 0.8661
Benton County, AR  
Madison County, AR  
Washington County, AR  
McDonald County, MO  
22380 Flagstaff, AZ 1.2092
Coconino County, AZ  
22420 Flint, MI 1.0655
Genesee County, MI  
22500 Florence, SC 0.8947
Darlington County, SC  
Florence County, SC  
22520 Florence-Muscle Shoals, AL 0.8272
Colbert County, AL  
Lauderdale County, AL  
22540 Fond du Lac, WI 0.9640
Fond du Lac County, WI  
22660 Fort Collins-Loveland, CO 1.0122
Larimer County, CO  
22744 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL 1.0432
Broward County, FL  
22900 Fort Smith, AR-OK 0.8230
Crawford County, AR  
Franklin County, AR  
Sebastian County, AR  
Le Flore County, OK  
Sequoyah County, OK  
23020 Fort Walton Beach-Crestview-Destin, FL 0.8872
Okaloosa County, FL  
23060 Fort Wayne, IN 0.9793
Allen County, IN  
Wells County, IN  
Whitley County, IN  
23104 Fort Worth-Arlington, TX 0.9486
Johnson County, TX  
Parker County, TX  
Tarrant County, TX  
Wise County, TX  
23420 Fresno, CA 1.0538
Fresno County, CA  
23460 Gadsden, AL 0.7938
Etowah County, AL  
23540 Gainesville, FL 0.9388
Alachua County, FL  
Gilchrist County, FL  
23580 Gainesville, GA 0.8874
Hall County, GA  
23844 Gary, IN 0.9395
Jasper County, IN  
Lake County, IN  
Newton County, IN  
Porter County, IN  
24020 Glens Falls, NY 0.8559
Warren County, NY  
Washington County, NY  
24140 Goldsboro, NC 0.8775
Wayne County, NC  
24220 Grand Forks, ND-MN 0.7901
Polk County, MN  
Grand Forks County, ND  
24300 Grand Junction, CO 0.9550
Mesa County, CO  
24340 Grand Rapids-Wyoming, MI 0.9390
Barry County, MI  
Ionia County, MI  
Kent County, MI  
Newaygo County, MI  
24500 Great Falls, MT 0.9052
Cascade County, MT  
24540 Greeley, CO 0.9570
Weld County, CO  
24580 Green Bay, WI 0.9483
Brown County, WI  
Kewaunee County, WI  
Oconto County, WI  
24660 Greensboro-High Point, NC 0.9104
Guilford County, NC  
Randolph County, NC  
Rockingham County, NC  
24780 Greenville, NC 0.9425
Greene County, NC  
Pitt County, NC  
24860 Greenville, SC 1.0027
Greenville County, SC  
Laurens County, SC  
Pickens County, SC  
25020 Guayama, PR 0.3181
Arroyo Municipio, PR  
Guayama Municipio, PR  
Patillas Municipio, PR  
25060 Gulfport-Biloxi, MS 0.8929
Hancock County, MS  
Harrison County, MS  
Stone County, MS  
25180 Hagerstown-Martinsburg, MD-WV 0.9489
Washington County, MD  
Berkeley County, WV  
Morgan County, WV  
25260 Hanford-Corcoran, CA 1.0036
Kings County, CA  
25420 Harrisburg-Carlisle, PA 0.9313
Cumberland County, PA  
Dauphin County, PA  
Perry County, PA  
25500 Harrisonburg, VA 0.9088
Rockingham County, VA  
Harrisonburg City, VA  
25540 Hartford-West Hartford-East Hartford, CT 1.1073
Hartford County, CT  
Litchfield County, CT  
Middlesex County, CT  
Tolland County, CT  
25620 Hattiesburg, MS 0.7601
Forrest County, MS  
Lamar County, MS  
Perry County, MS  
25860 Hickory-Lenoir-Morganton, NC 0.8921
Alexander County, NC  
Burke County, NC  
Caldwell County, NC  
Catawba County, NC  
25980 Hinesville-Fort Stewart, GA1
Liberty County, GA  
Long County, GA  
26100 Holland-Grand Haven, MI 0.9055
Ottawa County, MI  
26180 Honolulu, HI 1.1214
Honolulu County, HI  
26300 Hot Springs, AR 0.9005
Garland County, AR  
26380 Houma-Bayou Cane-Thibodaux, LA 0.7894
Lafourche Parish, LA  
Terrebonne Parish, LA  
26420 Houston-Baytown-Sugar Land, TX 0.9992
Austin County, TX  
Brazoria County, TX  
Chambers County, TX  
Fort Bend County, TX  
Galveston County, TX  
Harris County, TX  
Liberty County, TX  
Montgomery County, TX  
San Jacinto County, TX  
Waller County, TX  
26580 Huntington-Ashland, WV-KY-OH 0.9477
Boyd County, KY  
Greenup County, KY  
Lawrence County, OH  
Cabell County, WV  
Wayne County, WV  
26620 Huntsville, AL 0.9146
Limestone County, AL  
Madison County, AL  
26820 Idaho Falls, ID 0.9420
Bonneville County, ID  
Jefferson County, ID  
26900 Indianapolis, IN 0.9920
Boone County, IN  
Brown County, IN  
Hamilton County, IN  
Hancock County, IN  
Hendricks County, IN  
Johnson County, IN  
Marion County, IN  
Morgan County, IN  
Putnam County, IN  
Shelby County, IN  
26980 Iowa City, IA 0.9747
Johnson County, IA  
Washington County, IA  
27060 Ithaca, NY 0.9793
Tompkins County, NY  
27100 Jackson, MI 0.9304
Jackson County, MI  
27140 Jackson, MS 0.8311
Copiah County, MS  
Hinds County, MS  
Madison County, MS  
Rankin County, MS  
Simpson County, MS  
27180 Jackson, TN 0.8964
Chester County, TN  
Madison County, TN  
27260 Jacksonville, FL 0.9290
Baker County, FL  
Clay County, FL  
Duval County, FL  
Nassau County, FL  
St. Johns County, FL  
27340 Jacksonville, NC 0.8236
Onslow County, NC  
27500 Janesville, WI 0.9538
Rock County, WI  
27620 Jefferson City, MO 0.8387
Callaway County, MO  
Cole County, MO  
Moniteau County, MO  
Osage County, MO  
27740 Johnson City, TN 0.7937
Carter County, TN  
Unicoi County, TN  
Washington County, TN  
27780 Johnstown, PA 0.8354
Cambria County, PA  
27860 Jonesboro, AR 0.7911
Craighead County, AR  
Poinsett County, AR  
27900 Joplin, MO 0.8582
Jasper County, MO  
Newton County, MO  
28020 Kalamazoo-Portage, MI 1.0381
Kalamazoo County, MI  
Van Buren County, MI  
28100 Kankakee-Bradley, IL 1.0721
Kankakee County, IL  
28140 Kansas City, MO-KS 0.9476
Franklin County, KS  
Johnson County, KS  
Leavenworth County, KS  
Linn County, KS  
Miami County, KS  
Wyandotte County, KS  
Bates County, MO  
Caldwell County, MO  
Cass County, MO  
Clay County, MO  
Clinton County, MO  
Jackson County, MO  
Lafayette County, MO  
Platte County, MO  
Ray County, MO  
28420 Kennewick-Richland-Pasco, WA 1.0619
Benton County, WA  
Franklin County, WA  
28660 Killeen-Temple-Fort Hood, TX 0.8526
Bell County, TX  
Coryell County, TX  
Lampasas County, TX  
28700 Kingsport-Bristol-Bristol, TN-VA 0.8054
Hawkins County, TN  
Sullivan County, TN  
Bristol City, VA  
Scott County, VA  
Washington County, VA  
28740 Kingston, NY 0.9255
Ulster County, NY  
28940 Knoxville, TN 0.8441
Anderson County, TN  
Blount County, TN  
Knox County, TN  
Loudon County, TN  
Union County, TN  
29020 Kokomo, IN 0.9508
Howard County, IN  
Tipton County, IN  
29100 La Crosse, WI-MN 0.9564
Houston County, MN  
La Crosse County, WI  
29140 Lafayette, IN 0.8736
Benton County, IN  
Carroll County, IN  
Tippecanoe County, IN  
29180 Lafayette, LA 0.8428
Lafayette Parish, LA  
St. Martin Parish, LA  
29340 Lake Charles, LA 0.7833
Calcasieu Parish, LA  
Cameron Parish, LA  
29404 Lake County-Kenosha County, IL-WI 1.0429
Lake County, IL  
Kenosha County, WI  
29460 Lakeland, FL 0.8912
Polk County, FL  
29540 Lancaster, PA 0.9694
Lancaster County, PA  
29620 Lansing-East Lansing, MI 0.9794
Clinton County, MI  
Eaton County, MI  
Ingham County, MI  
29700 Laredo, TX 0.8068
Webb County, TX  
29740 Las Cruces, NM 0.8467
Dona Ana County, NM  
29820 Las Vegas-Paradise, NV 1.1437
Clark County, NV  
29940 Lawrence, KS 0.8537
Douglas County, KS  
30020 Lawton, OK 0.7872
Comanche County, OK  
30140 Lebanon, PA 0.8459
Lebanon County, PA  
30300 Lewiston, ID-WA 0.9886
Nez Perce County, ID  
Asotin County, WA  
30340 Lewiston-Auburn, ME 0.9331
Androscoggin County, ME  
30460 Lexington-Fayette, KY 0.9075
Bourbon County, KY  
Clark County, KY  
Fayette County, KY  
Jessamine County, KY  
Scott County, KY  
Woodford County, KY  
30620 Lima, OH 0.9225
Allen County, OH  
30700 Lincoln, NE 1.0214
Lancaster County, NE  
Seward County, NE  
30780 Little Rock-North Little Rock, AR 0.8747
Faulkner County, AR  
Grant County, AR  
Lonoke County, AR  
Perry County, AR  
Pulaski County, AR  
Saline County, AR  
30860 Logan, UT-ID 0.9164
Franklin County, ID  
Cache County, UT  
30980 Longview, TX 0.8730
Gregg County, TX  
Rusk County, TX  
Upshur County, TX  
31020 Longview, WA 0.9579
Cowlitz County, WA  
31084 Los Angeles-Long Beach-Glendale, CA 1.1783
Los Angeles County, CA  
31140 Louisville, KY-IN 0.9251
Clark County, IN  
Floyd County, IN  
Harrison County, IN  
Washington County, IN  
Bullitt County, KY  
Henry County, KY  
Jefferson County, KY  
Meade County, KY  
Nelson County, KY  
Oldham County, KY  
Shelby County, KY  
Spencer County, KY  
Trimble County, KY  
31180 Lubbock, TX 0.8783
Crosby County, TX  
Lubbock County, TX  
31340 Lynchburg, VA 0.8691
Amherst County, VA  
Appomattox County, VA  
Bedford County, VA  
Campbell County, VA  
Bedford City, VA  
Lynchburg City, VA  
31420 Macon, GA 0.9443
Bibb County, GA  
Crawford County, GA  
Jones County, GA  
Monroe County, GA  
Twiggs County, GA  
31460 Madera, CA 0.8713
Madera County, CA  
31540 Madison, WI 1.0659
Columbia County, WI  
Dane County, WI  
Iowa County, WI  
31700 Manchester-Nashua, NH 1.0354
Hillsborough County, NH  
Merrimack County, NH  
31900 Mansfield, OH1
Richland County, OH  
32420 Mayaguez, PR 0.4020
Hormigueros Municipio, PR  
Mayaguez Municipio, PR  
32580 McAllen-Edinburg-Pharr, TX 0.8934
Hidalgo County, TX  
32780 Medford, OR 1.0225
Jackson County, OR  
32820 Memphis, TN-MS-AR 0.9397
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 1.1109
Merced County, CA  
33124 Miami-Miami Beach-Kendall, FL 0.9750
Miami-Dade County, FL  
33140 Michigan City-La Porte, IN 0.9399
LaPorte County, IN  
33260 Midland, TX 0.9514
Midland County, TX  
33340 Milwaukee-Waukesha-West Allis, WI 1.0146
Milwaukee County, WI  
Ozaukee County, WI  
Washington County, WI  
Waukesha County, WI  
33460 Minneapolis-St. Paul-Bloomington, MN-WI 1.1075
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 0.9473
Missoula County, MT  
33660 Mobile, AL 0.7891
Mobile County, AL  
33700 Modesto, CA 1.1885
Stanislaus County, CA  
33740 Monroe, LA 0.8031
Ouachita Parish, LA  
Union Parish, LA  
33780 Monroe, MI 0.9468
Monroe County, MI  
33860 Montgomery, AL 0.8618
Autauga County, AL  
Elmore County, AL  
Lowndes County, AL  
Montgomery County, AL  
34060 Morgantown, WV 0.8420
Monongalia County, WV  
Preston County, WV  
34100 Morristown, TN 0.7961
Grainger County, TN  
Hamblen County, TN  
Jefferson County, TN  
34580 Mount Vernon-Anacortes, WA 1.0454
Skagit County, WA  
34620 Muncie, IN 0.8930
Delaware County, IN  
34740 Muskegon-Norton Shores, MI 0.9664
Muskegon County, MI  
34820 Myrtle Beach-Conway-North Myrtle Beach, SC 0.8934
Horry County, SC  
34900 Napa, CA 1.2643
Napa County, CA  
34940 Naples-Marco Island, FL 1.0139
Collier County, FL  
34980 Nashville-Davidson--Murfreesboro, TN 0.9741
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 1.2719
Nassau County, NY  
Suffolk County, NY  
35084 Newark-Union, NJ-PA 1.1883
Essex County, NJ  
Hunterdon County, NJ  
Morris County, NJ  
Sussex County, NJ  
Union County, NJ  
Pike County, PA  
35300 New Haven-Milford, CT 1.1887
New Haven County, CT  
35380 New Orleans-Metairie-Kenner, LA 0.8995
Jefferson Parish, LA  
Orleans Parish, LA  
Plaquemines Parish, LA  
St. Bernard Parish, LA  
St. Charles Parish, LA  
St. John the Baptist Parish, LA  
St. Tammany Parish, LA  
35644 New York-Wayne-White Plains, NY-NJ 1.3188
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 0.8879
Berrien County, MI  
35980 Norwich-New London, CT 1.1345
New London County, CT  
36084 Oakland-Fremont-Hayward, CA 1.5346
Alameda County, CA  
Contra Costa County, CA  
36100 Ocala, FL 0.8925
Marion County, FL  
36140 Ocean City, NJ 1.1011
Cape May County, NJ  
36220 Odessa, TX 0.9884
Ector County, TX  
36260 Ogden-Clearfield, UT 0.9029
Davis County, UT  
Morgan County, UT  
Weber County, UT  
36420 Oklahoma City, OK 0.9031
Canadian County, OK  
Cleveland County, OK  
Grady County, OK  
Lincoln County, OK  
Logan County, OK  
McClain County, OK  
Oklahoma County, OK  
36500 Olympia, WA 1.0927
Thurston County, WA  
36540 Omaha-Council Bluffs, NE-IA 0.9560
Harrison County, IA  
Mills County, IA  
Pottawattamie County, IA  
Cass County, NE  
Douglas County, NE  
Sarpy County, NE  
Saunders County, NE  
Washington County, NE  
36740 Orlando, FL 0.9464
Lake County, FL  
Orange County, FL  
Osceola County, FL  
Seminole County, FL  
36780 Oshkosh-Neenah, WI 0.9183
Winnebago County, WI  
36980 Owensboro, KY 0.8780
Daviess County, KY  
Hancock County, KY  
McLean County, KY  
37100 Oxnard-Thousand Oaks-Ventura, CA 1.1622
Ventura County, CA  
37340 Palm Bay-Melbourne-Titusville, FL 0.9839
Brevard County, FL  
37460 Panama City-Lynn Haven, FL 0.8005
Bay County, FL  
37620 Parkersburg-Marietta, WV-OH 0.8270
Washington County, OH  
Pleasants County, WV  
Wirt County, WV  
Wood County, WV  
37700 Pascagoula, MS 0.8156
George County, MS  
Jackson County, MS  
37860 Pensacola-Ferry Pass-Brent, FL 0.8096
Escambia County, FL  
Santa Rosa County, FL  
37900 Peoria, IL 0.8870
Marshall County, IL  
Peoria County, IL  
Stark County, IL  
Tazewell County, IL  
Woodford County, IL  
37964 Philadelphia, PA 1.1038
Bucks County, PA  
Chester County, PA  
Delaware County, PA  
Montgomery County, PA  
Philadelphia County, PA  
38060 Phoenix-Mesa-Scottsdale, AZ 1.0127
Maricopa County, AZ  
Pinal County, AZ  
38220 Pine Bluff, AR 0.8680
Cleveland County, AR  
Jefferson County, AR  
Lincoln County, AR  
38300 Pittsburgh, PA 0.8845
Allegheny County, PA  
Armstrong County, PA  
Beaver County, PA  
Butler County, PA  
Fayette County, PA  
Washington County, PA  
Westmoreland County, PA  
38340 Pittsfield, MA 1.0181
Berkshire County, MA  
38540 Pocatello, ID 0.9351
Bannock County, ID  
Power County, ID  
38660 Ponce, PR 0.4939
Juana Diaz Municipio, PR  
Ponce Municipio, PR  
Villalba Municipio, PR  
38860 Portland-South Portland-Biddeford, ME 1.0382
Cumberland County, ME  
Sagadahoc County, ME  
York County, ME  
38900 Portland-Vancouver-Beaverton, OR-WA 1.1266
Clackamas County, OR  
Columbia County, OR  
Multnomah County, OR  
Washington County, OR  
Yamhill County, OR  
Clark County, WA  
Skamania County, WA  
38940 Port St. Lucie-Fort Pierce, FL 1.0123
Martin County, FL  
St. Lucie County, FL  
39100 Poughkeepsie-Newburgh-Middletown, NY 1.0891
Dutchess County, NY  
Orange County, NY  
39140 Prescott, AZ 0.9869
Yavapai County, AZ  
39300 Providence-New Bedford-Fall River, RI-MA 1.0966
Bristol County, MA  
Bristol County, RI  
Kent County, RI  
Newport County, RI  
Providence County, RI  
Washington County, RI  
39340 Provo-Orem, UT 0.9500
Juab County, UT  
Utah County, UT  
39380 Pueblo, CO 0.8623
Pueblo County, CO  
39460 Punta Gorda, FL 0.9255
Charlotte County, FL  
39540 Racine, WI 0.8997
Racine County, WI  
39580 Raleigh-Cary, NC 0.9691
Franklin County, NC  
Johnston County, NC  
Wake County, NC  
39660 Rapid City, SD 0.8987
Meade County, SD  
Pennington County, SD  
39740 Reading, PA 0.9686
Berks County, PA  
39820 Redding, CA 1.2203
Shasta County, CA  
39900 Reno-Sparks, NV 1.0982
Storey County, NV  
Washoe County, NV  
40060 Richmond, VA 0.9328
Amelia County, VA  
Caroline County, VA  
Charles City County, VA  
Chesterfield County, VA  
Cumberland County, VA  
Dinwiddie County, VA  
Goochland County, VA  
Hanover County, VA  
Henrico County, VA  
King and Queen County, VA  
King William County, VA  
Louisa County, VA  
New Kent County, VA  
Powhatan County, VA  
Prince George County, VA  
Sussex County, VA  
Colonial Heights City, VA  
Hopewell City, VA  
Petersburg City, VA  
Richmond City, VA  
40140 Riverside-San Bernardino-Ontario, CA 1.1027
Riverside County, CA  
San Bernardino County, CA  
40220 Roanoke, VA 0.8374
Botetourt County, VA  
Craig County, VA  
Franklin County, VA  
Roanoke County, VA  
Roanoke City, VA  
Salem City, VA  
40340 Rochester, MN 1.1131
Dodge County, MN  
Olmsted County, MN  
Wabasha County, MN  
40380 Rochester, NY 0.9121
Livingston County, NY  
Monroe County, NY  
Ontario County, NY  
Orleans County, NY  
Wayne County, NY  
40420 Rockford, IL 0.9984
Boone County, IL  
Winnebago County, IL  
40484 Rockingham County-Strafford County, NH 1.0374
Rockingham County, NH  
Strafford County, NH  
40580 Rocky Mount, NC 0.8915
Edgecombe County, NC  
Nash County, NC  
40660 Rome, GA 0.9414
Floyd County, GA  
40900 Sacramento--Arden-Arcade--Roseville, CA 1.2969
El Dorado County, CA  
Placer County, CA  
Sacramento County, CA  
Yolo County, CA  
40980 Saginaw-Saginaw Township North, MI 0.9088
Saginaw County, MI  
41060 St. Cloud, MN 0.9965
Benton County, MN  
Stearns County, MN  
41100 St. George, UT 0.9392
Washington County, UT  
41140 St. Joseph, MO-KS 0.9519
Doniphan County, KS  
Andrew County, MO  
Buchanan County, MO  
DeKalb County, MO  
41180 St. Louis, MO-IL 0.8954
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 1.0442
Marion County, OR  
Polk County, OR  
41500 Salinas, CA 1.4128
Monterey County, CA  
41540 Salisbury, MD 0.9064
Somerset County, MD  
Wicomico County, MD  
41620 Salt Lake City, UT 0.9421
Salt Lake County, UT  
Summit County, UT  
Tooele County, UT  
41660 San Angelo, TX 0.8271
Irion County, TX  
Tom Green County, TX  
41700 San Antonio, TX 0.8980
Atascosa County, TX  
Bandera County, TX  
Bexar County, TX  
Comal County, TX  
Guadalupe County, TX  
Kendall County, TX  
Medina County, TX  
Wilson County, TX  
41740 San Diego-Carlsbad-San Marcos, CA 1.1413
San Diego County, CA  
41780 Sandusky, OH 0.9019
Erie County, OH  
41884 San Francisco-San Mateo-Redwood City, CA 1.4994
Marin County, CA  
San Francisco County, CA  
San Mateo County, CA  
41900 San German-Cabo Rojo, PR 0.4650
Cabo Rojo Municipio, PR  
Lajas Municipio, PR  
Sabana Grande Municipio, PR  
San German Municipio, PR  
41940 San Jose-Sunnyvale-Santa Clara, CA 1.5099
San Benito County, CA  
Santa Clara County, CA  
41980 San Juan-Caguas-Guaynabo, PR 0.4621
Aguas Buenas Municipio, PR  
Aibonito Municipio, PR  
Arecibo Municipio, PR  
Barceloneta Municipio, PR  
Barranquitas Municipio, PR  
Bayamon Municipio, PR  
Caguas Municipio, PR  
Camuy Municipio, PR  
Canovanas Municipio, PR  
Carolina Municipio, PR  
Catano Municipio, PR  
Cayey Municipio, PR  
Ciales Municipio, PR  
Cidra Municipio, PR  
Comerio Municipio, PR  
Corozal Municipio, PR  
Dorado Municipio, PR  
Florida Municipio, PR  
Guaynabo Municipio, PR  
Gurabo Municipio, PR  
Hatillo Municipio, PR  
Humacao Municipio, PR  
Juncos Municipio, PR  
Las Piedras Municipio, PR  
Loiza Municipio, PR  
ManatiMunicipio, PR  
Maunabo Municipio, PR  
Morovis Municipio, PR  
Naguabo Municipio, PR  
Naranjito Municipio, PR  
Orocovis Municipio, PR  
Quebradillas Municipio, PR  
Rio Grande Municipio, PR  
San Juan Municipio, PR  
San Lorenzo Municipio, PR  
Toa Alta Municipio, PR  
Toa Baja Municipio, PR  
Trujillo Alto Municipio, PR  
Vega Alta Municipio, PR  
Vega Baja Municipio, PR  
Yabucoa Municipio, PR  
42020 San Luis Obispo-Paso Robles, CA 1.1349
San Luis Obispo County, CA  
42044 Santa Ana-Anaheim-Irvine, CA 1.1559
Orange County, CA  
42060 Santa Barbara-Santa Maria-Goleta, CA 1.1694
Santa Barbara County, CA  
42100 Santa Cruz-Watsonville, CA 1.5166
Santa Cruz County, CA  
42140 Santa Fe, NM 1.0920
Santa Fe County, NM  
42220 Santa Rosa-Petaluma, CA 1.3493
Sonoma County, CA  
42260 Sarasota-Bradenton-Venice, FL 0.9639
Manatee County, FL  
Sarasota County, FL  
42340 Savannah, GA 0.9461
Bryan County, GA  
Chatham County, GA  
Effingham County, GA  
42540 Scranton--Wilkes-Barre, PA 0.8540
Lackawanna County, PA  
Luzerne County, PA  
Wyoming County, PA  
42644 Seattle-Bellevue-Everett, WA 1.1577
King County, WA  
Snohomish County, WA  
43100 Sheboygan, WI 0.8911
Sheboygan County, WI  
43300 Sherman-Denison, TX 0.9507
Grayson County, TX  
43340 Shreveport-Bossier City, LA 0.8760
Bossier Parish, LA  
Caddo Parish, LA  
De Soto Parish, LA  
43580 Sioux City, IA-NE-SD 0.9381
Woodbury County, IA  
Dakota County, NE  
Dixon County, NE  
Union County, SD  
43620 Sioux Falls, SD 0.9635
Lincoln County, SD  
McCook County, SD  
Minnehaha County, SD  
Turner County, SD  
43780 South Bend-Mishawaka, IN-MI 0.9788
St. Joseph County, IN  
Cass County, MI  
43900 Spartanburg, SC 0.9172
Spartanburg County, SC  
44060 Spokane, WA 1.0905
Spokane County, WA  
44100 Springfield, IL 0.8792
Menard County, IL  
Sangamon County, IL  
44140 Springfield, MA 1.0248
Franklin County, MA  
Hampden County, MA  
Hampshire County, MA  
44180 Springfield, MO 0.8237
Christian County, MO  
Dallas County, MO  
Greene County, MO  
Polk County, MO  
Webster County, MO  
44220 Springfield, OH 0.8396
Clark County, OH  
44300 State College, PA 0.8356
Centre County, PA  
44700 Stockton, CA 1.1307
San Joaquin County, CA  
44940 Sumter, SC 0.8377
Sumter County, SC  
45060 Syracuse, NY 0.9574
Madison County, NY  
Onondaga County, NY  
Oswego County, NY  
45104 Tacoma, WA 1.0742
Pierce County, WA  
45220 Tallahassee, FL 0.8688
Gadsden County, FL  
Jefferson County, FL  
Leon County, FL  
Wakulla County, FL  
45300 Tampa-St. Petersburg-Clearwater, FL 0.9233
Hernando County, FL  
Hillsborough County, FL  
Pasco County, FL  
Pinellas County, FL  
45460 Terre Haute, IN 0.8304
Clay County, IN  
Sullivan County, IN  
Vermillion County, IN  
Vigo County, IN  
45500 Texarkana, TX-Texarkana, AR 0.8283
Miller County, AR  
Bowie County, TX  
45780 Toledo, OH 0.9574
Fulton County, OH  
Lucas County, OH  
Ottawa County, OH  
Wood County, OH  
45820 Topeka, KS 0.8920
Jackson County, KS  
Jefferson County, KS  
Osage County, KS  
Shawnee County, KS  
Wabaunsee County, KS  
45940 Trenton-Ewing, NJ 1.0834
Mercer County, NJ  
46060 Tucson, AZ 0.9007
Pima County, AZ  
46140 Tulsa, OK 0.8543
Creek County, OK  
Okmulgee County, OK  
Osage County, OK  
Pawnee County, OK  
Rogers County, OK  
Tulsa County, OK  
Wagoner County, OK  
46220 Tuscaloosa, AL 0.8645
Greene County, AL  
Hale County, AL  
Tuscaloosa County, AL  
46340 Tyler, TX 0.9168
Smith County, TX  
46540 Utica-Rome, NY 0.8358
Herkimer County, NY  
Oneida County, NY  
46660 Valdosta, GA 0.8866
Brooks County, GA  
Echols County, GA  
Lanier County, GA  
Lowndes County, GA  
46700 Vallejo-Fairfield, CA 1.4936
Solano County, CA  
46940 Vero Beach, FL 0.9434
Indian River County, FL  
47020 Victoria, TX 0.8160
Calhoun County, TX  
Goliad County, TX  
Victoria County, TX  
47220 Vineland-Millville-Bridgeton, NJ 0.9827
Cumberland County, NJ  
47260 Virginia Beach-Norfolk-Newport News, VA-NC 0.8799
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 1.0123
Tulare County, CA  
47380 Waco, TX 0.8518
McLennan County, TX  
47580 Warner Robins, GA 0.8645
Houston County, GA  
47644 Warren-Farmington Hills-Troy, MI 0.9871
Lapeer County, MI  
Livingston County, MI  
Macomb County, MI  
Oakland County, MI  
St. Clair County, MI  
47894 Washington-Arlington-Alexandria, DC-VA-MD-WV 1.0926
District of Columbia, DC  
Calvert County, MD  
Charles County, MD  
Prince George's County, MD  
Arlington County, VA  
Clarke County, VA  
Fairfax County, VA  
Fauquier County, VA  
Loudoun County, VA  
Prince William County, VA  
Spotsylvania County, VA  
Stafford County, VA  
Warren County, VA  
Alexandria City, VA  
Fairfax City, VA  
Falls Church City, VA  
Fredericksburg City, VA  
Manassas City, VA  
Manassas Park City, VA  
Jefferson County, WV  
47940 Waterloo-Cedar Falls, IA 0.8557
Black Hawk County, IA  
Bremer County, IA  
Grundy County, IA  
48140 Wausau, WI 0.9590
Marathon County, WI  
48260 Weirton-Steubenville, WV-OH 0.7819
Jefferson County, OH  
Brooke County, WV  
Hancock County, WV  
48300 Wenatchee, WA 1.0070
Chelan County, WA  
Douglas County, WA  
48424 West Palm Beach-Boca Raton-Boynton Beach, FL 1.0067
Palm Beach County, FL  
48540 Wheeling, WV-OH 0.7161
Belmont County, OH  
Marshall County, WV  
Ohio County, WV  
48620 Wichita, KS 0.9153
Butler County, KS  
Harvey County, KS  
Sedgwick County, KS  
Sumner County, KS  
48660 Wichita Falls, TX 0.8285
Archer County, TX  
Clay County, TX  
Wichita County, TX  
48700 Williamsport, PA 0.8364
Lycoming County, PA  
48864 Wilmington, DE-MD-NJ 1.0471
New Castle County, DE  
Cecil County, MD  
Salem County, NJ  
48900 Wilmington, NC 0.9582
Brunswick County, NC  
New Hanover County, NC  
Pender County, NC  
49020 Winchester, VA-WV 1.0214
Frederick County, VA  
Winchester City, VA  
Hampshire County, WV  
49180 Winston-Salem, NC 0.8944
Davie County, NC  
Forsyth County, NC  
Stokes County, NC  
Yadkin County, NC  
49340 Worcester, MA 1.1028
Worcester County, MA  
49420 Yakima, WA 1.0155
Yakima County, WA  
49500 Yauco, PR 0.4408
Guanica Municipio, PR  
Guayanilla Municipio, PR  
Penuelas Municipio, PR  
Yauco Municipio, PR  
49620 York-Hanover, PA 0.9347
York County, PA  
49660 Youngstown-Warren-Boardman, OH-PA 0.8603
Mahoning County, OH  
Trumbull County, OH  
Mercer County, PA  
49700 Yuba City, CA 1.0921
Sutter County, CA  
Yuba County, CA  
49740 Yuma, AZ 0.9126
Yuma County, AZ  
Table 9.—FY 2006 Wage Index Based on CBSA Labor Market Areas for Rural Areas Back to Top
CBSA code Nonurban area Wage index
1All counties within the State are classified as urban, with the exception of Massachusetts and Puerto Rico. Massachusetts and Puerto Rico have areas designated as rural; however, no short-term, acute care hospitals are located in the area(s) for FY 2006. Because more recent data is not available for those areas, we are using last year's wage index value.
1 Alabama 0.7446
2 Alaska 1.1977
3 Arizona 0.8768
4 Arkansas 0.7466
5 California 1.1054
6 Colorado 0.9380
7 Connecticut 1.1730
8 Delaware 0.9579
10 Florida 0.8568
11 Georgia 0.7662
12 Hawaii 1.0551
13 Idaho 0.8037
14 Illinois 0.8271
15 Indiana 0.8624
16 Iowa 0.8509
17 Kansas 0.8035
18 Kentucky 0.7766
19 Louisiana 0.7411
20 Maine 0.8843
21 Maryland 0.9353
22 Massachusetts1 1.2016
23 Michigan 0.8895
24 Minnesota 0.9132
25 Mississippi 0.7674
26 Missouri 0.7900
27 Montana 0.8762
28 Nebraska 0.8657
29 Nevada 0.9065
30 New Hampshire 1.0817
31 New Jersey1
32 New Mexico 0.8635
33 New York 0.8154
34 North Carolina 0.8540
35 North Dakota 0.7261
36 Ohio 0.8826
37 Oklahoma 0.7581
38 Oregon 0.9826
39 Pennsylvania 0.8291
40 Puerto Rico1 0.4047
41 Rhode Island1
42 South Carolina 0.8638
43 South Dakota 0.8560
44 Tennessee 0.7895
45 Texas 0.8003
46 Utah 0.8118
47 Vermont 0.9830
48 Virgin Islands 0.7615
49 Virginia 0.8013
50 Washington 1.0510
51 West Virginia 0.7717
52 Wisconsin 0.9509
53 Wyoming 0.9257
65 Guam 0.9611
Table A.—FY 2006 SNF PPS Transition Wage Index Table Back to Top
SSA state/county code County name MSA No. MSA urban/rural 2006 MSA-based WI 2006 CBSA-based WI CBSA No. CBSA urban/rural Transition wage index *
* Transition wage index value should be used with the CBSA urban/rural designation for rate calculation purposes.
1At this time, there are no hospitals located in these CBSA-based urban areas on which to base a wage index. Therefore, the transition wage index value is based on the average transition wage index for all urban areas within the state.
01000 Autauga County, Alabama 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
01010 Baldwin County, Alabama 5160 Urban 0.7861 0.7446 99901 Rural 0.7654
01020 Barbour County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01030 Bibb County, Alabama 01 Rural 0.7432 0.8959 13820 Urban 0.8196
01040 Blount County, Alabama 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
01050 Bullock County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01060 Butler County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01070 Calhoun County, Alabama 0450 Urban 0.7682 0.7682 11500 Urban 0.7682
01080 Chambers County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01090 Cherokee County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01100 Chilton County, Alabama 01 Rural 0.7432 0.8959 13820 Urban 0.8196
01110 Choctaw County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01120 Clarke County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01130 Clay County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01140 Cleburne County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01150 Coffee County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01160 Colbert County, Alabama 2650 Urban 0.8272 0.8272 22520 Urban 0.8272
01170 Conecuh County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01180 Coosa County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01190 Covington County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01200 Crenshaw County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01210 Cullman County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01220 Dale County, Alabama 2180 Urban 0.7701 0.7446 99901 Rural 0.7574
01230 Dallas County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01240 De Kalb County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01250 Elmore County, Alabama 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
01260 Escambia County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01270 Etowah County, Alabama 2880 Urban 0.7938 0.7938 23460 Urban 0.7938
01280 Fayette County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01290 Franklin County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01300 Geneva County, Alabama 01 Rural 0.7432 0.7721 20020 Urban 0.7577
01310 Greene County, Alabama 01 Rural 0.7432 0.8645 46220 Urban 0.8039
01320 Hale County, Alabama 01 Rural 0.7432 0.8645 46220 Urban 0.8039
01330 Henry County, Alabama 01 Rural 0.7432 .7721 20020 Urban 0.7577
01340 Houston County, Alabama 2180 Urban 0.7701 0.7721 20020 Urban 0.7711
01350 Jackson County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01360 Jefferson County, Alabama 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
01370 Lamar County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01380 Lauderdale County, Alabama 2650 Urban 0.8272 0.8272 22520 Urban 0.8272
01390 Lawrence County, Alabama 2030 Urban 0.8469 0.8469 19460 Urban 0.8469
01400 Lee County, Alabama 0580 Urban 0.8100 0.8100 12220 Urban 0.8100
01410 Limestone County, Alabama 3440 Urban 0.9146 0.9146 26620 Urban 0.9146
01420 Lowndes County, Alabama 01 Rural 0.7432 0.8618 33860 Urban 0.8025
01430 Macon County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01440 Madison County, Alabama 3440 Urban 0.9146 0.9146 26620 Urban 0.9146
01450 Marengo County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01460 Marion County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01470 Marshall County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01480 Mobile County, Alabama 5160 Urban 0.7861 0.7891 33660 Urban 0.7876
01490 Monroe County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01500 Montgomery County, Alabama 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
01510 Morgan County, Alabama 2030 Urban 0.8469 0.8469 19460 Urban 0.8469
01520 Perry County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01530 Pickens County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01540 Pike County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01550 Randolph County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01560 Russell County, Alabama 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
01570 St Clair County, Alabama 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
01580 Shelby County, Alabama 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
01590 Sumter County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01600 Talladega County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01610 Tallapoosa County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01620 Tuscaloosa County, Alabama 8600 Urban 0.8764 0.8645 46220 Urban 0.8705
01630 Walker County, Alabama 01 Rural 0.7432 0.8959 13820 Urban 0.8196
01640 Washington County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01650 Wilcox County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01660 Winston County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
02013 Aleutians County East, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02016 Aleutians County West, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02020 Anchorage County, Alaska 0380 Urban 1.1784 1.1895 11260 Urban 1.1840
02030 Angoon County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02040 Barrow-North Slope County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02050 Bethel County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02060 Bristol Bay Borough County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02068 Denali County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02070 Bristol Bay County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02080 Cordova-Mc Carthy County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02090 Fairbanks County, Alaska 02 Rural 1.1888 1.1408 21820 Urban 1.1648
02100 Haines County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02110 Juneau County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02120 Kenai-Cook Inlet County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02122 Kenai Peninsula Borough, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02130 Ketchikan County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02140 Kobuk County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02150 Kodiak County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02160 Kuskokwin County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02164 Lake and Peninsula Borough, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02170 Matanuska County, Alaska 02 Rural 1.1888 1.1895 11260 Urban 1.1892
02180 Nome County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02185 North Slope Borough, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02188 Northwest Arctic Borough, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02190 Outer Ketchikan County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02200 Prince Of Wales County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02201 Prince of Wales-Outer Ketchikan Census Area, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02210 Seward County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02220 Sitka County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02230 Skagway-Yakutat County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02231 Skagway-Yakutat-Angoon Census Area, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02232 Skagway-Hoonah-Angoon Census Area, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02240 Southeast Fairbanks County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02250 Upper Yukon County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02260 Valdz-Chitna-Whitier County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02261 Valdex-Cordove Census Area, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02270 Wade Hampton County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02280 Wrangell-Petersburg County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02282 Yakutat Borough, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02290 Yukon-Koyukuk County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
03000 Apache County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03010 Cochise County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03020 Coconino County, Arizona 2620 Urban 1.1845 1.2092 22380 Urban 1.1969
03030 Gila County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03040 Graham County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03050 Greenlee County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03055 La Paz County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03060 Maricopa County, Arizona 6200 Urban 1.0127 1.0127 38060 Urban 1.0127
03070 Mohave County, Arizona 4120 Urban 1.1155 0.8768 99903 Rural 0.9962
03080 Navajo County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03090 Pima County, Arizona 8520 Urban 0.9007 0.9007 46060 Urban 0.9007
03100 Pinal County, Arizona 6200 Urban 1.0127 1.0127 38060 Urban 1.0127
03110 Santa Cruz County, Arizona 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03120 Yavapai County, Arizona 03 Rural 0.9045 0.9869 39140 Urban 0.9457
03130 Yuma County, Arizona 9360 Urban 0.9126 0.9126 49740 Urban 0.9126
04000 Arkansas County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04010 Ashley County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04020 Baxter County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04030 Benton County, Arkansas 2580 Urban 0.8661 0.8661 22220 Urban 0.8661
04040 Boone County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04050 Bradley County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04060 Calhoun County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04070 Carroll County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04080 Chicot County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04090 Clark County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04100 Clay County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04110 Cleburne County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04120 Cleveland County, Arkansas 04 Rural 0.7744 0.8680 38220 Urban 0.8212
04130 Columbia County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04140 Conway County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04150 Craighead County, Arkansas 3700 Urban 0.7911 0.7911 27860 Urban 0.7911
04160 Crawford County, Arkansas 2720 Urban 0.8246 0.8230 22900 Urban 0.8238
04170 Crittenden County, Arkansas 4920 Urban 0.9416 0.9397 32820 Urban 0.9407
04180 Cross County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04190 Dallas County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04200 Desha County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04210 Drew County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04220 Faulkner County, Arkansas 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
04230 Franklin County, Arkansas 04 Rural 0.7744 0.8230 22900 Urban 0.7987
04240 Fulton County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04250 Garland County, Arkansas 04 Rural 0.7744 0.9005 26300 Urban 0.8375
04260 Grant County, Arkansas 04 Rural 0.7744 0.8747 30780 Urban 0.8246
04270 Greene County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
4280 Hempstead County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04290 Hot Spring County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04300 Howard County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04310 Independence County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04320 Izard County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04330 Jackson County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04340 Jefferson County, Arkansas 6240 Urban 0.8680 0.8680 38220 Urban 0.8680
04350 Johnson County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04360 Lafayette County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04370 Lawrence County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04380 Lee County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04390 Lincoln County, Arkansas 04 Rural 0.7744 0.8680 38220 Urban 0.8212
04400 Little River County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04410 Logan County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04420 Lonoke County, Arkansas 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
04430 Madison County, Arkansas 04 Rural 0.7744 0.8661 22220 Urban 0.8203
04440 Marion County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04450 Miller County, Arkansas 8360 Urban 0.8283 0.8283 45500 Urban 0.8283
04460 Mississippi County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04470 Monroe County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04480 Montgomery County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04490 Nevada County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04500 Newton County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04510 Ouachita County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04520 Perry County, Arkansas 04 Rural 0.7744 0.8747 30780 Urban 0.8246
04530 Phillips County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04540 Pike County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04550 Poinsett County, Arkansas 04 Rural 0.7744 0.7911 27860 Urban 0.7828
04560 Polk County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04570 Pope County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04580 Prairie County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04590 Pulaski County, Arkansas 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
04600 Randolph County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04610 St Francis County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04620 Saline County, Arkansas 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
04630 Scott County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04640 Searcy County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04650 Sebastian County, Arkansas 2720 Urban 0.8246 0.8230 22900 Urban 0.8238
04660 Sevier County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04670 Sharp County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04680 Stone County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04690 Union County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04700 Van Buren County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04710 Washington County, Arkansas 2580 Urban 0.8661 0.8661 22220 Urban 0.8661
04720 White County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04730 Woodruff County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04740 Yell County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
05000 Alameda County, California 5775 Urban 1.5346 1.5346 36084 Urban 1.5346
05010 Alpine County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05020 Amador County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05030 Butte County, California 1620 Urban 1.0511 1.0511 17020 Urban 1.0511
05040 Calaveras County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05050 Colusa County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05060 Contra Costa County, California 5775 Urban 1.5346 1.5346 36084 Urban 1.5346
05070 Del Norte County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05080 Eldorado County, California 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
05090 Fresno County, California 2840 Urban 1.0428 1.0538 23420 Urban 1.0483
05100 Glenn County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05110 Humboldt County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05120 Imperial County, California 05 Rural 1.0775 0.8906 20940 Urban 0.9841
05130 Inyo County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05140 Kern County, California 0680 Urban 1.0470 1.0470 12540 Urban 1.0470
05150 Kings County, California 05 Rural 1.0775 1.0036 25260 Urban 1.0406
05160 Lake County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05170 Lassen County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05200 Los Angeles County, California 4480 Urban 1.1783 1.1783 31084 Urban 1.1783
05210 Los Angeles County, California 4480 Urban 1.1783 1.1783 31084 Urban 1.1783
05300 Madera County, California 2840 Urban 1.0428 0.8713 31460 Urban 0.9571
05310 Marin County, California 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
05320 Mariposa County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05330 Mendocino County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05340 Merced County, California 4940 Urban 1.1109 1.1109 32900 Urban 1.1109
05350 Modoc County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05360 Mono County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05370 Monterey County, California 7120 Urban 1.4128 1.4128 41500 Urban 1.4128
05380 Napa County, California 8720 Urban 1.3983 1.2643 34900 Urban 1.3313
05390 Nevada County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05400 Orange County, California 5945 Urban 1.1559 1.1559 42044 Urban 1.1559
05410 Placer County, California 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
05420 Plumas County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05430 Riverside County, California 6780 Urban 1.1027 1.1027 40140 Urban 1.1027
05440 Sacramento County, California 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
05450 San Benito County, California 05 Rural 1.0775 1.5099 41940 Urban 1.2937
05460 San Bernardino County, California 6780 Urban 1.1027 1.1027 40140 Urban 1.1027
05470 San Diego County, California 7320 Urban 1.1413 1.1413 41740 Urban 1.1413
05480 San Francisco County, California 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
05490 San Joaquin County, California 8120 Urban 1.1307 1.1307 44700 Urban 1.1307
05500 San Luis Obispo County, California 7460 Urban 1.1349 1.1349 42020 Urban 1.1349
05510 San Mateo County, California 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
05520 Santa Barbara County, California 7480 Urban 1.1694 1.1694 42060 Urban 1.1694
05530 Santa Clara County, California 7400 Urban 1.5118 1.5099 41940 Urban 1.5109
05540 Santa Cruz County, California 7485 Urban 1.5166 1.5166 42100 Urban 1.5166
05550 Shasta County, California 6690 Urban 1.2203 1.2203 39820 Urban 1.2203
05560 Sierra County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05570 Siskiyou County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05580 Solano County, California 8720 Urban 1.3983 1.4936 46700 Urban 1.4460
05590 Sonoma County, California 7500 Urban 1.3493 1.3493 42220 Urban 1.3493
05600 Stanislaus County, California 5170 Urban 1.1885 1.1885 33700 Urban 1.1885
05610 Sutter County, California 9340 Urban 1.0921 1.0921 49700 Urban 1.0921
05620 Tehama County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05630 Trinity County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05640 Tulare County, California 8780 Urban 1.0123 1.0123 47300 Urban 1.0123
05650 Tuolumne County, California 05 Rural 1.0775 1.1054 99905 Rural 1.0915
05660 Ventura County, California 8735 Urban 1.1622 1.1622 37100 Urban 1.1622
05670 Yolo County, California 9270 Urban 0.9950 1.2969 40900 Urban 1.1460
05680 Yuba County, California 9340 Urban 1.0921 1.0921 49700 Urban 1.0921
06000 Adams County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
06010 Alamosa County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06020 Arapahoe County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
06030 Archuleta County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06040 Baca County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06050 Bent County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06060 Boulder County, Colorado 1125 Urban 0.9734 0.9734 14500 Urban 0.9734
06070 Chaffee County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06080 Cheyenne County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06090 Clear Creek County, Colorado 06 Rural 0.9380 1.0723 19740 Urban 1.0052
06100 Conejos County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06110 Costilla County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06120 Crowley County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06130 Custer County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06140 Delta County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06150 Denver County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
06160 Dolores County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06170 Douglas County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
06180 Eagle County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06190 Elbert County, Colorado 06 Rural 0.9380 1.0723 19740 Urban 1.0052
06200 El Paso County, Colorado 1720 Urban 0.9468 0.9468 17820 Urban 0.9468
06210 Fremont County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06220 Garfield County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06230 Gilpin County, Colorado 06 Rural 0.9380 1.0723 19740 Urban 1.0052
06240 Grand County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06250 Gunnison County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06260 Hinsdale County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06270 Huerfano County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06280 Jackson County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06290 Jefferson County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
06300 Kiowa County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06310 Kit Carson County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06320 Lake County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06330 La Plata County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06340 Larimer County, Colorado 2670 Urban 1.0122 1.0122 22660 Urban 1.0122
06350 Las Animas County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06360 Lincoln County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06370 Logan County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06380 Mesa County, Colorado 2995 Urban 0.9550 0.9550 24300 Urban 0.9550
06390 Mineral County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06400 Moffat County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06410 Montezuma County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06420 Montrose County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06430 Morgan County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06440 Otero County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06450 Ouray County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06460 Park County, Colorado 06 Rural 0.9380 1.0723 19740 Urban 1.0052
06470 Phillips County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06480 Pitkin County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06490 Prowers County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06500 Pueblo County, Colorado 6560 Urban 0.8623 0.8623 39380 Urban 0.8623
06510 Rio Blanco County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06520 Rio Grande County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06530 Routt County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06540 Saguache County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06550 San Juan County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06560 San Miguel County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06570 Sedgwick County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06580 Summit County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06590 Teller County, Colorado 06 Rural 0.9380 0.9468 17820 Urban 0.9424
06600 Washington County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06610 Weld County, Colorado 3060 Urban 0.9570 0.9570 24540 Urban 0.9570
06620 Yuma County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06630 Broomfield County, Colorado 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
07000 Fairfield County, Connecticut 5483 Urban 1.2196 1.2592 14860 Urban 1.2394
07010 Hartford County, Connecticut 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
07020 Litchfield County, Connecticut 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
07030 Middlesex County, Connecticut 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
07040 New Haven County, Connecticut 5483 Urban 1.2196 1.1887 35300 Urban 1.2042
07050 New London County, Connecticut 5523 Urban 1.1345 1.1345 35980 Urban 1.1345
07060 Tolland County, Connecticut 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
07070 Windham County, Connecticut 07 Rural 1.1730 1.1730 99907 Rural 1.1730
08000 Kent County, Delaware 2190 Urban 0.9776 0.9776 20100 Urban 0.9776
08010 New Castle County, Delaware 9160 Urban 1.0527 1.0471 48864 Urban 1.0499
08020 Sussex County, Delaware 08 Rural 0.9579 0.9579 99908 Rural 0.9579
09000 Washington Dc County, Dist Of Col 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
10000 Alachua County, Florida 2900 Urban 0.9388 0.9388 23540 Urban 0.9388
10010 Baker County, Florida 10 Rural 0.8677 0.9290 27260 Urban 0.8984
10020 Bay County, Florida 6015 Urban 0.8005 0.8005 37460 Urban 0.8005
10030 Bradford County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10040 Brevard County, Florida 4900 Urban 0.9839 0.9839 37340 Urban 0.9839
10050 Broward County, Florida 2680 Urban 1.0432 1.0432 22744 Urban 1.0432
10060 Calhoun County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10070 Charlotte County, Florida 6580 Urban 0.9255 0.9255 39460 Urban 0.9255
10080 Citrus County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10090 Clay County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10100 Collier County, Florida 5345 Urban 1.0139 1.0139 34940 Urban 1.0139
10110 Columbia County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10120 Dade County, Florida 5000 Urban 0.9750 0.9750 33124 Urban 0.9750
10130 De Soto County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10140 Dixie County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10150 Duval County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10160 Escambia County, Florida 6080 Urban 0.8096 0.8096 37860 Urban 0.8096
10170 Flagler County, Florida 2020 Urban 0.9325 0.8568 99910 Rural 0.8947
10180 Franklin County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10190 Gadsden County, Florida 8240 Urban 0.8688 0.8688 45220 Urban 0.8688
10200 Gilchrist County, Florida 10 Rural 0.8677 0.9388 23540 Urban 0.9033
10210 Glades County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10220 Gulf County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10230 Hamilton County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10240 Hardee County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10250 Hendry County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10260 Hernando County, Florida 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
10270 Highlands County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10280 Hillsborough County, Florida 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
10290 Holmes County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10300 Indian River County, Florida 10 Rural 0.8677 0.9434 46940 Urban 0.9056
10310 Jackson County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10320 Jefferson County, Florida 10 Rural 0.8677 0.8688 45220 Urban 0.8683
10330 Lafayette County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10340 Lake County, Florida 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
10350 Lee County, Florida 2700 Urban 0.9356 0.9356 15980 Urban 0.9356
10360 Leon County, Florida 8240 Urban 0.8688 0.8688 45220 Urban 0.8688
10370 Levy County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10380 Liberty County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10390 Madison County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10400 Manatee County, Florida 7510 Urban 0.9639 0.9639 42260 Urban 0.9639
10410 Marion County, Florida 5790 Urban 0.8925 0.8925 36100 Urban 0.8925
10420 Martin County, Florida 2710 Urban 1.0123 1.0123 38940 Urban 1.0123
10430 Monroe County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10440 Nassau County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10450 Okaloosa County, Florida 2750 Urban 0.8872 0.8872 23020 Urban 0.8872
10460 Okeechobee County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10470 Orange County, Florida 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
10480 Osceola County, Florida 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
10490 Palm Beach County, Florida 8960 Urban 1.0067 1.0067 48424 Urban 1.0067
10500 Pasco County, Florida 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
10510 Pinellas County, Florida 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
10520 Polk County, Florida 3980 Urban 0.8912 0.8912 29460 Urban 0.8912
10530 Putnam County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10540 Johns County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10550 St Lucie County, Florida 2710 Urban 1.0123 1.0123 38940 Urban 1.0123
10560 Santa Rosa County, Florida 6080 Urban 0.8096 0.8096 37860 Urban 0.8096
10570 Sarasota County, Florida 7510 Urban 0.9639 0.9639 42260 Urban 0.9639
10580 Seminole County, Florida 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
10590 Sumter County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10600 Suwannee County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10610 Taylor County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10620 Union County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10630 Volusia County, Florida 2020 Urban 0.9325 0.9299 19660 Urban 0.9312
10640 Wakulla County, Florida 10 Rural 0.8677 0.8688 45220 Urban 0.8683
10650 Walton County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10660 Washington County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
11000 Appling County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11010 Atkinson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11011 Bacon County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11020 Baker County, Georgia 11 Rural 0.8166 0.8628 10500 Urban 0.8397
11030 Baldwin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11040 Banks County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11050 Barrow County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11060 Bartow County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11070 Ben Hill County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11080 Berrien County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11090 Bibb County, Georgia 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
11100 Bleckley County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11110 Brantley County, Georgia 11 Rural 0.8166 0.9311 15260 Urban 0.8739
11120 Brooks County, Georgia 11 Rural 0.8166 0.8866 46660 Urban 0.8516
11130 Bryan County, Georgia 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
11140 Bulloch County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11150 Burke County, Georgia 11 Rural 0.8166 0.9748 12260 Urban 0.8957
11160 Butts County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11161 Calhoun County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11170 Camden County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11180 Candler County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11190 Carroll County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11200 Catoosa County, Georgia 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
11210 Charlton County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11220 Chatham County, Georgia 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
11230 Chattahoochee County, Georgia 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
11240 Chattooga County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11250 Cherokee County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11260 Clarke County, Georgia 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
11270 Clay County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11280 Clayton County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11281 Clinch County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11290 Cobb County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11291 Coffee County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11300 Colquitt County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11310 Columbia County, Georgia 0600 Urban 0.9808 0.9748 12260 Urban 0.9778
11311 Cook County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11320 Coweta County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11330 Crawford County, Georgia 11 Rural 0.8166 0.9443 31420 Urban 0.8805
11340 Crisp County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11341 Dade County, Georgia 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
11350 Dawson County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11360 Decatur County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11370 De Kalb County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11380 Dodge County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11381 Dooly County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11390 Dougherty County, Georgia 0120 Urban 0.8628 0.8628 10500 Urban 0.8628
11400 Douglas County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11410 Early County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11420 Echols County, Georgia 11 Rural 0.8166 0.8866 46660 Urban 0.8516
11421 Effingham County, Georgia 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
11430 Elbert County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11440 Emanuel County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11441 Evans County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11450 Fannin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11451 Fayette County, Georgia 0520 Urban 9793 0.9793 12060 Urban 0.9793
11460 Floyd County, Georgia 11 Rural 0.8166 0.9414 40660 Urban 0.8790
11461 Forsyth County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11462 Franklin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11470 Fulton County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11471 Gilmer County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11480 Glascock County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11490 Glynn County, Georgia 11 Rural 0.8166 0.9311 15260 Urban 0.8739
11500 Gordon County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11510 Grady County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11520 Greene County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11530 Gwinnett County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11540 Habersham County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11550 Hall County, Georgia 11 Rural 0.8166 0.8874 23580 Urban 0.8520
11560 Hancock County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11570 Haralson County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11580 Harris County, Georgia 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
11581 Hart County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11590 Heard County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11591 Henry County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11600 Houston County, Georgia 4680 Urban 0.9277 0.8645 47580 Urban 0.8961
11601 Irwin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11610 Jackson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11611 Jasper County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11612 Jeff Davis County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11620 Jefferson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11630 Jenkins County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11640 Johnson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11650 Jones County, Georgia 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
11651 Lamar County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11652 Lanier County, Georgia 11 Rural 0.8166 0.8866 46660 Urban 0.8516
11660 Laurens County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11670 Lee County, Georgia 0120 Urban 0.8628 0.8628 10500 Urban 0.8628
11680 Liberty County, Georgia 11 Rural 0.8166 (1) 25980 Urban 0.8973
11690 Lincoln County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11691 Long County, Georgia 11 Rural 0.8166 (1) 25980 Urban 0.8973
11700 Lowndes County, Georgia 11 Rural 0.8166 0.8866 46660 Urban 0.8516
11701 Lumpkin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11702 Mc Duffie County, Georgia 0600 Urban 0.9808 0.9748 12260 Urban 0.9778
11703 Mc Intosh County, Georgia 11 Rural 0.8166 0.9311 15260 Urban 0.8739
11710 Macon County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11720 Madison County, Georgia 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
11730 Marion County, Georgia 11 Rural 0.8166 0.8560 17980 Urban 0.8363
11740 Meriwether County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11741 Miller County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11750 Mitchell County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11760 Monroe County, Georgia 11 Rural 0.8166 0.9443 31420 Urban 0.8805
11770 Montgomery County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11771 Morgan County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11772 Murray County, Georgia 11 Rural 0.8166 0.9079 19140 Urban 0.8623
11780 Muscogee County, Georgia 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
11790 Newton County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11800 Oconee County, Georgia 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
11801 Oglethorpe County, Georgia 11 Rural 0.8166 0.9855 12020 Urban 0.9011
11810 Paulding County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11811 Peach County, Georgia 4680 Urban 0.9277 0.7662 99911 Rural 0.8470
11812 Pickens County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11820 Pierce County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11821 Pike County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11830 Polk County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11831 Pulaski County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11832 Putnam County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11833 Quitman County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11834 Rabun County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11835 Randolph County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11840 Richmond County, Georgia 0600 Urban 0.9808 0.9748 12260 Urban 10.9778
11841 Rockdale County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11842 Schley County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11850 Screven County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11851 Seminole County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11860 Spalding County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11861 Stephens County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11862 Stewart County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11870 Sumter County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11880 Talbot County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11881 Taliaferro County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11882 Tattnall County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11883 Taylor County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11884 Telfair County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11885 Terrell County, Georgia 11 Rural 0.8166 0.8628 10500 Urban 0.8397
11890 Thomas County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11900 Tift County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11901 Toombs County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11902 Towns County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11903 Treutlen County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11910 Troup County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11911 Turner County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11912 Twiggs County, Georgia 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
11913 Union County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11920 Upson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11921 Walker County, Georgia 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
11930 Walton County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11940 Ware County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11941 Warren County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11950 Washington County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11960 Wayne County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11961 Webster County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11962 Wheeler County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11963 White County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11970 Whitfield County, Georgia 11 Rural 0.8166 0.9079 19140 Urban 0.8623
11971 Wilcox County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11972 Wilkes County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11973 Wilkinson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11980 Worth County, Georgia 11 Rural 0.8166 0.8628 10500 Urban 0.8397
12005 Kalawao County, Hawaii 12 Rural 1.0551 1.0551 99912 Rural 1.0551
12010 Hawaii County, Hawaii 12 Rural 1.0551 1.0551 99912 Rural 1.0551
12020 Honolulu County, Hawaii 3320 Urban 1.1214 1.1214 26180 Urban 1.1214
12040 Kauai County, Hawaii 12 Rural 1.0551 1.0551 99912 Rural 1.0551
12050 Maui County, Hawaii 12 Rural 1.0551 1.0551 99912 Rural 1.0551
13000 Ada County, Idaho 1080 Urban 0.9052 0.9052 14260 Urban 0.9052
13010 Adams County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13020 Bannock County, Idaho 6340 Urban 0.9351 0.9351 38540 Urban 0.9351
13030 Bear Lake County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13040 Benewah County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13050 Bingham County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13060 Blaine County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13070 Boise County, Idaho 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13080 Bonner County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13090 Bonneville County, Idaho 13 Rural 0.9097 0.9420 26820 Urban 0.9259
13100 Boundary County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13110 Butte County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13120 Camas County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13130 Canyon County, Idaho 1080 Urban 0.9052 0.9052 14260 Urban 0.9052
13140 Caribou County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13150 Cassia County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13160 Clark County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13170 Clearwater County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13180 Custer County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13190 Elmore County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13200 Franklin County, Idaho 13 Rural 0.9097 0.9164 30860 Urban 0.9131
13210 Fremont County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13220 Gem County, Idaho 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13230 Gooding County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13240 Idaho County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13250 Jefferson County, Idaho 13 Rural 0.9097 0.9420 26820 Urban 0.9259
13260 Jerome County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13270 Kootenai County, Idaho 13 Rural 0.9097 0.9647 17660 Urban 0.9372
13280 Latah County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13290 Lemhi County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13300 Lewis County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13310 Lincoln County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13320 Madison County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13330 Minidoka County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13340 Nez Perce County, Idaho 13 Rural 0.9097 0.9886 30300 Urban 0.9492
13350 Oneida County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13360 Owyhee County, Idaho 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13370 Payette County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13380 Power County, Idaho 13 Rural 0.9097 0.9351 38540 Urban 0.9224
13390 Shoshone County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13400 Teton County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13410 Twin Falls County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13420 Valley County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13430 Washington County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
14000 Adams County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14010 Alexander County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14020 Bond County, Illinois 14 Rural 0.8301 0.8954 41180 Urban 0.8628
14030 Boone County, Illinois 6880 Urban 0.9984 0.9984 40420 Urban 0.9984
14040 Brown County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14050 Bureau County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14060 Calhoun County, Illinois 14 Rural 0.8301 0.8954 41180 Urban 0.8628
14070 Carroll County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14080 Cass County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14090 Champaign County, Illinois 1400 Urban 0.9594 0.9594 16580 Urban 0.9594
14100 Christian County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14110 Clark County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14120 Clay County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14130 Clinton County, Illinois 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
14140 Coles County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14141 Cook County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14150 Crawford County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14160 Cumberland County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14170 De Kalb County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14180 De Witt County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14190 Douglas County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14250 Du Page County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14310 Edgar County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14320 Edwards County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14330 Effingham County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14340 Fayette County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14350 Ford County, Illinois 14 Rural 0.8301 0.9594 16580 Urban 0.8948
14360 Franklin County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14370 Fulton County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14380 Gallatin County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14390 Greene County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14400 Grundy County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14410 Hamilton County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14420 Hancock County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14421 Hardin County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14440 Henderson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14450 Henry County, Illinois 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
14460 Iroquois County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14470 Jackson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14480 Jasper County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14490 Jefferson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14500 Jersey County, Illinois 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
14510 Jo Daviess County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14520 Johnson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14530 Kane County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14540 Kankakee County, Illinois 3740 Urban 1.0721 1.0721 28100 Urban 1.0721
14550 Kendall County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14560 Knox County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14570 Lake County, Illinois 1600 Urban 1.0783 1.0429 29404 Urban 1.0606
14580 La Salle County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14590 Lawrence County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14600 Lee County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14610 Livingston County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14620 Logan County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14630 Mc Donough County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14640 Mc Henry County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14650 Mclean County, Illinois 1040 Urban 0.9075 0.9075 14060 Urban 0.9075
14660 Macon County, Illinois 2040 Urban 0.8067 0.8067 19500 Urban 0.8067
14670 Macoupin County, Illinois 14 Rural 0.8301 0.8954 41180 Urban 0.8628
14680 Madison County, Illinois 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
14690 Marion County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14700 Marshall County, Illinois 14 Rural 0.8301 0.8870 37900 Urban 0.8586
14710 Mason County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14720 Massac County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14730 Menard County, Illinois 7880 Urban 0.8792 0.8792 44100 Urban 0.8792
14740 Mercer County, Illinois 14 Rural 0.8301 0.8724 19340 Urban 0.8513
14750 Monroe County, Illinois 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
14760 Montgomery County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14770 Morgan County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14780 Moultrie County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14790 Ogle County, Illinois 6880 Urban 0.9984 0.8271 99914 Rural 0.9128
14800 Peoria County, Illinois 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
14810 Perry County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14820 Piatt County, Illinois 14 Rural 0.8301 0.9594 16580 Urban 0.8948
14830 Pike County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14831 Pope County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14850 Pulaski County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14860 Putnam County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14870 Randolph County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14880 Richland County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14890 Rock Island County, Illinois 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
14900 St Clair County, Illinois 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
14910 Saline County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14920 Sangamon County, Illinois 7880 Urban 0.8792 0.8792 44100 Urban 0.8792
14921 Schuyler County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14940 Scott County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14950 Shelby County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14960 Stark County, Illinois 14 Rural 0.8301 0.8870 37900 Urban 0.8586
14970 Stephenson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14980 Tazewell County, Illinois 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
14981 Union County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14982 Vermilion County, Illinois 14 Rural 0.8301 0.9028 19180 Urban 0.8665
14983 Wabash County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14984 Warren County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14985 Washington County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14986 Wayne County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14987 White County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14988 Whiteside County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14989 Will County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14990 Williamson County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14991 Winnebago County, Illinois 6880 Urban 0.9984 0.9984 40420 Urban 0.9984
14992 Woodford County, Illinois 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
15000 Adams County, Indiana 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
15010 Allen County, Indiana 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
15020 Bartholomew County, Indiana 15 Rural 0.8739 0.9588 18020 Urban 0.9164
15030 Benton County, Indiana 15 Rural 0.8739 0.8736 29140 Urban 0.8738
15040 Blackford County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15050 Boone County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15060 Brown County, Indiana 15 Rural 0.8739 0.9920 26900 Urban 0.9330
15070 Carroll County, Indiana 15 Rural 0.8739 0.8736 29140 Urban 0.8738
15080 Cass County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15090 Clark County, Indiana 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
15100 Clay County, Indiana 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
15110 Clinton County, Indiana 3920 Urban 0.8736 0.8624 99915 Rural 0.8680
15120 Crawford County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15130 Daviess County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15140 Dearborn County, Indiana 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
15150 Decatur County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15160 De Kalb County, Indiana 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
15170 Delaware County, Indiana 5280 Urban 0.8930 0.8930 34620 Urban 0.8930
15180 Dubois County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15190 Elkhart County, Indiana 2330 Urban 0.9627 0.9627 21140 Urban 0.9627
15200 Fayette County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15210 Floyd County, Indiana 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
15220 Fountain County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15230 Franklin County, Indiana 15 Rural 0.8739 0.9615 17140 Urban 0.9177
15240 Fulton County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15250 Gibson County, Indiana 15 Rural 0.8739 0.8713 21780 Urban 0.8726
15260 Grant County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15270 Greene County, Indiana 15 Rural 0.8739 0.8447 14020 Urban 0.8593
15280 Hamilton County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15290 Hancock County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15300 Harrison County, Indiana 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
15310 Hendricks County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15320 Henry County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15330 Howard County, Indiana 3850 Urban 0.9508 0.9508 29020 Urban 0.9508
15340 Huntington County, Indiana 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
15350 Jackson County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15360 Jasper County, Indiana 15 Rural 0.8739 0.9395 23844 Urban 0.9067
15370 Jay County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15380 Jefferson County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15390 Jennings County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15400 Johnson County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15410 Knox County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15420 Kosciusko County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15430 Lagrange County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15440 Lake County, Indiana 2960 Urban 0.9395 0.9395 23844 Urban 0.9395
15450 La Porte County, Indiana 15 Rural 0.8739 0.9399 33140 Urban 0.9069
15460 Lawrence County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15470 Madison County, Indiana 3480 Urban 0.9865 0.8586 11300 Urban 0.9226
15480 Marion County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15490 Marshall County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15500 Martin County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15510 Miami County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15520 Monroe County, Indiana 1020 Urban 0.8447 0.8447 14020 Urban 0.8447
15530 Montgomery County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15540 Morgan County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15550 Newton County, Indiana 15 Rural 0.8739 0.9395 23844 Urban 0.9067
15560 Noble County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15570 Ohio County, Indiana 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
15580 Orange County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15590 Owen County, Indiana 15 Rural 0.8739 0.8447 14020 Urban 0.8593
15600 Parke County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15610 Perry County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15620 Pike County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15630 Porter County, Indiana 2960 Urban 0.9395 0.9395 23844 Urban 0.9395
15640 Posey County, Indiana 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
15650 Pulaski County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15660 Putnam County, Indiana 15 Rural 0.8739 0.9920 26900 Urban 0.9330
15670 Randolph County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15680 Ripley County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15690 Rush County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15700 St Joseph County, Indiana 7800 Urban 0.9788 0.9788 43780 Urban 0.9788
15710 Scott County, Indiana 4520 Urban 0.9293 0.8624 99915 Rural 0.8959
15720 Shelby County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15730 Spencer County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15740 Starke County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15750 Steuben County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15760 Sullivan County, Indiana 15 Rural 0.8739 0.8304 45460 Urban 0.8522
15770 Switzerland County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15780 Tippecanoe County, Indiana 3920 Urban 0.8736 0.8736 29140 Urban 0.8736
15790 Tipton County, Indiana 3850 Urban 0.9508 0.9508 29020 Urban 0.9508
15800 Union County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15810 Vanderburgh County, Indiana 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
15820 Vermillion County, Indiana 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
15830 Vigo County, Indiana 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
15840 Wabash County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15850 Warren County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15860 Warrick County, Indiana 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
15870 Washington County, Indiana 15 Rural 0.8739 0.9251 31140 Urban 0.8995
15880 Wayne County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15890 Wells County, Indiana 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
15900 White County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15910 Whitley County, Indiana 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
16000 Adair County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16010 Adams County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16020 Allamakee County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16030 Appanoose County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16040 Audubon County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16050 Benton County, Iowa 16 Rural 0.8594 0.8825 16300 Urban 0.8710
16060 Black Hawk County, Iowa 8920 Urban 0.8557 0.8557 47940 Urban 0.8557
16070 Boone County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16080 Bremer County, Iowa 16 Rural 0.8594 0.8557 47940 Urban 0.8576
16090 Buchanan County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16100 Buena Vista County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16110 Butler County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16120 Calhoun County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16130 Carroll County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16140 Cass County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16150 Cedar County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16160 Cerro Gordo County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16170 Cherokee County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16180 Chickasaw County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16190 Clarke County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16200 Clay County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16210 Clayton County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16220 Clinton County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16230 Crawford County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16240 Dallas County, Iowa 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16250 Davis County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16260 Decatur County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16270 Delaware County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16280 Des Moines County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16290 Dickinson County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16300 Dubuque County, Iowa 2200 Urban 0.9024 0.9024 20220 Urban 0.9024
16310 Emmet County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16320 Fayette County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16330 Floyd County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16340 Franklin County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16350 Fremont County, Iowa 6 Rural 0.8594 0.8509 99916 Rural 0.8552
16360 Greene County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16370 Grundy County, Iowa 16 Rural 0.8594 0.8557 47940 Urban 0.8576
16380 Guthrie County, Iowa 16 Rural 0.8594 0.9669 19780 Urban 0.9132
16390 Hamilton County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16400 Hancock County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16410 Hardin County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16420 Harrison County, Iowa 16 Rural 0.8594 0.9560 36540 Urban 0.9077
16430 Henry County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16440 Howard County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16450 Humboldt County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16460 Ida County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16470 Iowa County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16480 Jackson County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16490 Jasper County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16500 Jefferson County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16510 Johnson County, Iowa 3500 Urban 0.9747 0.9747 26980 Urban 0.9747
16520 Jones County, Iowa 16 Rural 0.8594 0.8825 16300 Urban 0.8710
16530 Keokuk County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16540 Kossuth County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16550 Lee County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16560 Linn County, owa 1360 Urban 0.8825 0.8825 16300 Urban 0.8825
16570 Louisa County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16580 Lucas County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16590 Lyon County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16600 Madison County, Iowa 16 Rural 0.8594 0.9669 19780 Urban 0.9132
16610 Mahaska County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16620 Marion County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16630 Marshall County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16640 Mills County, Iowa 16 Rural 0.8594 0.9560 36540 Urban 0.9077
16650 Mitchell County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16660 Monona County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16670 Monroe County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16680 Montgomery County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16690 Muscatine County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16700 O Brien County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16710 Osceola County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16720 Page County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16730 Palo Alto County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16740 Plymouth County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16750 Pocahontas County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16760 Polk County, Iowa 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16770 Pottawattamie County, Iowa 5920 Urban 0.9560 0.9560 36540 Urban 0.9560
16780 Poweshiek County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16790 Ringgold County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16800 Sac County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16810 Scott County, Iowa 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
16820 Shelby County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16830 Sioux County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16840 Story County, Iowa 16 Rural 0.8594 0.9536 11180 Urban 0.9065
16850 Tama County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16860 Taylor County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16870 Union County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16880 Van Buren County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16890 Wapello County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16900 Warren County, Iowa 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16910 Washington County, Iowa 16 Rural 0.8594 0.9747 26980 Urban 0.9171
16920 Wayne County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16930 Webster County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16940 Winnebago County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16950 Winneshiek County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16960 Woodbury County, Iowa 7720 Urban 0.9416 0.9381 43580 Urban 0.9399
16970 Worth County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16980 Wright County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
17000 Allen County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17010 Anderson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17020 Atchison County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17030 Barber County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17040 Barton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17050 Bourbon County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17060 Brown County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17070 Butler County, Kansas 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
17080 Chase County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17090 Chautauqua County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17100 Cherokee County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17110 Cheyenne County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17120 Clark County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17130 Clay County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17140 Cloud County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17150 Coffey County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17160 Comanche County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17170 Cowley County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17180 Crawford County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17190 Decatur County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17200 Dickinson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17210 Doniphan County, Kansas 17 Rural 0.8040 0.9519 41140 Urban 0.8780
17220 Douglas County, Kansas 4150 Urban 0.8537 0.8537 29940 Urban 0.8537
17230 Edwards County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17240 Elk County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17250 Ellis County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17260 Ellsworth County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17270 Finney County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17280 Ford County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17290 Franklin County, Kansas 17 Rural 0.8040 0.9476 28140 Urban 0.8758
17300 Geary County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17310 Gove County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17320 Graham County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17330 Grant County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17340 Gray County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17350 Greeley County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17360 Greenwood County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17370 Hamilton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17380 Harper County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17390 Harvey County, Kansas 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
17391 Haskell County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17410 Hodgeman County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17420 Jackson County, Kansas 17 Rural 0.8040 0.8920 45820 Urban 0.8480
17430 Jefferson County, Kansas 17 Rural 0.8040 0.8920 45820 Urban 0.8480
17440 Jewell County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17450 Johnson County, Kansas 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
17451 Kearny County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17470 Kingman County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17480 Kiowa County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17490 Labette County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17500 Lane County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17510 Leavenworth County, Kansas 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
17520 Lincoln County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17530 Linn County, Kansas 17 Rural 0.8040 0.9476 28140 Urban 0.8758
17540 Logan County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17550 Lyon County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17560 Mc Pherson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17570 Marion County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17580 Marshall County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17590 Meade County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17600 Miami County, Kansas 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
17610 Mitchell County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17620 Montgomery County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17630 Morris County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17640 Morton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17650 Nemaha County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17660 Neosho County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17670 Ness County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17680 Norton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17690 Osage County, Kansas 17 Rural 0.8040 0.8920 45820 Urban 0.8480
17700 Osborne County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17710 Ottawa County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17720 Pawnee County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17730 Phillips County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17740 Pottawatomie County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17750 Pratt County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17760 Rawlins County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17770 Reno County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17780 Republic County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17790 Rice County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17800 Riley County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17810 Rooks County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17820 Rush County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17830 Russell County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17840 Saline County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17841 Scott County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17860 Sedgwick County, Kansas 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
17870 Seward County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17880 Shawnee County, Kansas 8440 Urban 0.8920 0.8920 45820 Urban 0.8920
17890 Sheridan County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17900 Sherman County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17910 Smith County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17920 Stafford County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17921 Stanton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17940 Stevens County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17950 Sumner County, Kansas 17 Rural 0.8040 0.9153 48620 Urban 0.8597
17960 Thomas County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17970 Trego County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17980 Wabaunsee County, Kansas 17 Rural 0.8040 0.8920 45820 Urban 0.8480
17981 Wallace County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17982 Washington County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17983 Wichita County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17984 Wilson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17985 Woodson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17986 Wyandotte County, Kansas 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
18000 Adair County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18010 Allen County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18020 Anderson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18030 Ballard County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18040 Barren County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18050 Bath County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18060 Bell County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18070 Boone County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18080 Bourbon County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
18090 Boyd County, Kentucky 3400 Urban 0.9477 0.9477 26580 Urban 0.9477
18100 Boyle County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18110 Bracken County, Kentucky 18 Rural 0.7858 0.9615 17140 Urban 0.8737
18120 Breathitt County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18130 Breckinridge County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18140 Bullitt County, Kentucky 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
18150 Butler County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18160 Caldwell County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18170 Calloway County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18180 Campbell County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18190 Carlisle County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18191 Carroll County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18210 Carter County, Kentucky 3400 Urban 0.9477 0.7766 99918 Rural 0.8622
18220 Casey County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18230 Christian County, Kentucky 1660 Urban 0.8284 0.8284 17300 Urban 0.8284
18240 Clark County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
18250 Clay County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18260 Clinton County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18270 Crittenden County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18271 Cumberland County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18290 Daviess County, Kentucky 5990 Urban 0.8780 0.8780 36980 Urban 0.8780
18291 Edmonson County, Kentucky 18 Rural 0.7858 0.8211 14540 Urban 0.8035
18310 Elliott County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18320 Estill County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18330 Fayette County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
18340 Fleming County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18350 Floyd County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18360 Franklin County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18361 Fulton County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18362 Gallatin County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18390 Garrard County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18400 Grant County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18410 Graves County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18420 Grayson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18421 Green County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18440 Greenup County, Kentucky 3400 Urban 0.9477 0.9477 26580 Urban 0.9477
18450 Hancock County, Kentucky 18 Rural 0.7858 0.8780 36980 Urban 0.8319
18460 Hardin County, Kentucky 18 Rural 0.7858 0.8802 21060 Urban 0.8330
18470 Harlan County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18480 Harrison County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18490 Hart County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18500 Henderson County, Kentucky 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
18510 Henry County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18511 Hickman County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18530 Hopkins County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18540 Jackson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18550 Jefferson County, Kentucky 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
18560 Jessamine County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
18570 Johnson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18580 Kenton County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18590 Knott County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18600 Knox County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18610 Larue County, Kentucky 18 Rural 0.7858 0.8802 21060 Urban 0.8330
18620 Laurel County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18630 Lawrence County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18640 Lee County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18650 Leslie County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18660 Letcher County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18670 Lewis County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18680 Lincoln County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18690 Livingston County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18700 Logan County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18710 Lyon County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18720 Mc Cracken County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18730 Mc Creary County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18740 Mc Lean County, Kentucky 18 Rural 0.7858 0.8780 36980 Urban 0.8319
18750 Madison County, Kentucky 4280 Urban 0.8988 0.7766 99918 Rural 0.8377
18760 Magoffin County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18770 Marion County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18780 Marshall County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18790 Martin County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18800 Mason County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18801 Meade County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18802 Menifee County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18830 Mercer County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18831 Metcalfe County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18850 Monroe County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18860 Montgomery County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18861 Morgan County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18880 Muhlenberg County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18890 Nelson County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18900 Nicholas County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18910 Ohio County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18920 Oldham County, Kentucky 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
18930 Owen County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18931 Owsley County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18932 Pendleton County, Kentucky 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
18960 Perry County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18970 Pike County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18971 Powell County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18972 Pulaski County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18973 Robertson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18974 Rockcastle County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18975 Rowan County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18976 Russell County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18977 Scott County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
18978 Shelby County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18979 Simpson County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18980 Spencer County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18981 Taylor County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18982 Todd County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18983 Trigg County, Kentucky 18 Rural 0.7858 0.8284 17300 Urban 0.8071
18984 Trimble County, Kentucky 18 Rural 0.7858 0.9251 31140 Urban 0.8555
18985 Union County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18986 Warren County, Kentucky 18 Rural 0.7858 0.8211 14540 Urban 0.8035
18987 Washington County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18988 Wayne County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18989 Webster County, Kentucky 18 Rural 0.7858 0.8713 21780 Urban 0.8286
18990 Whitley County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18991 Wolfe County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18992 Woodford County, Kentucky 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
19000 Acadia County, Louisiana 3880 Urban 0.8251 0.7411 99919 Rural 0.7831
19010 Allen County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19020 Ascension County, Louisiana 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
19030 Assumption County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19040 Avoyelles County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19050 Beauregard County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19060 Bienville County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19070 Bossier County, Louisiana 7680 Urban 0.8737 0.8760 43340 Urban 0.8749
19080 Caddo County, Louisiana 7680 Urban 0.8737 0.8760 43340 Urban 0.8749
19090 Calcasieu County, Louisiana 3960 Urban 0.7858 0.7833 29340 Urban 0.7846
19100 Caldwell County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19110 Cameron County, Louisiana 19 Rural 0.7340 0.7833 29340 Urban 0.7587
19120 Catahoula County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19130 Claiborne County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19140 Concordia County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19150 De Soto County, Louisiana 19 Rural 0.7340 0.8760 43340 Urban 0.8050
19160 East Baton Rouge County, Louisiana 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
19170 East Carroll County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19180 East Feliciana County, Louisiana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
19190 Evangeline County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19200 Franklin County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19210 Grant County, Louisiana 19 Rural 0.7340 0.8033 10780 Urban 0.7687
19220 Iberia County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19230 Iberville County, Louisiana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
19240 Jackson County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19250 Jefferson County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19260 Jefferson Davis County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19270 Lafayette County, Louisiana 3880 Urban 0.8251 0.8428 29180 Urban 0.8340
19280 Lafourche County, Louisiana 3350 Urban 0.7894 0.7894 26380 Urban 0.7894
19290 La Salle County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19300 Lincoln County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19310 Livingston County, Louisiana 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
19320 Madison County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19330 Morehouse County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19340 Natchitoches County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19350 Orleans County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19360 Ouachita County, Louisiana 5200 Urban 0.8044 0.8031 33740 Urban 0.8038
19370 Plaquemines County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19380 Pointe Coupee County, Louisiana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
19390 Rapides County, Louisiana 0220 Urban 0.8033 0.8033 10780 Urban 0.8033
19400 Red River County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19410 Richland County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19420 Sabine County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19430 St Bernard County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19440 St Charles County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19450 St Helena County, Louisiana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
19460 St James County, Louisiana 5560 Urban 0.8995 0.7411 99919 Rural 0.8203
19470 St John Baptist County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19480 St Landry County, Louisiana 3880 Urban 0.8251 0.7411 99919 Rural 0.7831
19490 St Martin County, Louisiana 3880 Urban 0.8251 0.8428 29180 Urban 0.8340
19500 St Mary County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19510 St Tammany County, Louisiana 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
19520 Tangipahoa County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19530 Tensas County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19540 Terrebonne County, Louisiana 3350 Urban 0.7894 0.7894 26380 Urban 0.7894
19550 Union County, Louisiana 19 Rural 0.7340 0.8031 33740 Urban 0.7686
19560 Vermilion County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19570 Vernon County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19580 Washington County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19590 Webster County, Louisiana 7680 Urban 0.8737 0.7411 99919 Rural 0.8074
19600 West Baton Rouge County, Louisiana 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
19610 West Carroll County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
19620 West Feliciana County, Louisiana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
19630 Winn County, Louisiana 19 Rural 0.7340 0.7411 99919 Rural 0.7376
20000 Androscoggin County, Maine 4243 Urban 0.9331 0.9331 30340 Urban 0.9331
20010 Aroostook County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20020 Cumberland County, Maine 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
20030 Franklin County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20040 Hancock County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20050 Kennebec County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20060 Knox County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20070 Lincoln County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20080 Oxford County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20090 Penobscot County, Maine 0733 Urban 0.9993 0.9993 12620 Urban 0.9993
20100 Piscataquis County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20110 Sagadahoc County, Maine 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
20120 Somerset County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20130 Waldo County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20140 Washington County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20150 York County, Maine 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
21000 Allegany County, Maryland 1900 Urban 0.9317 0.9317 19060 Urban 0.9317
21010 Anne Arundel County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21020 Baltimore County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21030 Baltimore City County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21040 Calvert County, Maryland 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
21050 Caroline County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21060 Carroll County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21070 Cecil County, Maryland 9160 Urban 1.0527 1.0471 48864 Urban 1.0499
21080 Charles County, Maryland 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
21090 Dorchester County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21100 Frederick County, Maryland 8840 Urban 1.0976 1.1483 13644 Urban 1.1230
21110 Garrett County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21120 Harford County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21130 Howard County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21140 Kent County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21150 Montgomery County, Maryland 8840 Urban 1.0976 1.1483 13644 Urban 1.1230
21160 Prince Georges County, Maryland 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
21170 Queen Annes County, Maryland 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
21180 St Marys County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21190 Somerset County, Maryland 21 Rural 0.9230 0.9064 41540 Urban 0.9147
21200 Talbot County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
21210 Washington County, Maryland 3180 Urban 0.9869 0.9489 25180 Urban 0.9679
21220 Wicomico County, Maryland 21 Rural 0.9230 0.9064 41540 Urban 0.9147
21230 Worcester County, Maryland 21 Rural 0.9230 0.9353 99921 Rural 0.9292
22000 Barnstable County, Massachusetts 0743 Urban 1.2600 1.2600 12700 Urban 1.2600
22010 Berkshire County, Massachusetts 6323 Urban 1.0181 1.0181 38340 Urban 1.0181
22020 Bristol County, Massachusetts 1123 Urban 1.1178 1.0966 39300 Urban 1.1072
22030 Dukes County, Massachusetts 22 Rural 1.0216 1.0216 99922 Rural 1.0216
22040 Essex County, Massachusetts 1123 Urban 1.1178 1.0538 21604 Urban 1.0858
22060 Franklin County, Massachusetts 22 Rural 1.0216 1.0248 44140 Urban 1.0232
22070 Hampden County, Massachusetts 8003 Urban 1.0263 1.0248 44140 Urban 1.0256
22080 Hampshire County, Massachusetts 8003 Urban 1.0263 1.0248 44140 Urban 1.0256
22090 Middlesex County, Massachusetts 1123 Urban 1.1178 1.1172 15764 Urban 1.1175
22120 Nantucket County, Massachusetts 22 Rural 1.0216 1.0216 99922 Rural 1.0216
22130 Norfolk County, Massachusetts 1123 Urban 1.1178 1.1558 14484 Urban 1.1368
22150 Plymouth County, Massachusetts 1123 Urban 1.1178 1.1558 14484 Urban 1.1368
22160 Suffolk County, Massachusetts 1123 Urban 1.1178 1.1558 14484 Urban 1.1368
22170 Worcester County, Massachusetts 1123 Urban 1.1178 1.1028 49340 Urban 1.1103
23000 Alcona County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23010 Alger County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23020 Allegan County, Michigan 3000 Urban 0.9445 0.8895 99923 Rural 0.9170
23030 Alpena County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23040 Antrim County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23050 Arenac County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23060 Baraga County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23070 Barry County, Michigan 23 Rural 0.8824 0.9390 24340 Urban 0.9107
23080 Bay County, Michigan 6960 Urban 0.9241 0.9343 13020 Urban 0.9292
23090 Benzie County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23100 Berrien County, Michigan 0870 Urban 0.8879 0.8879 35660 Urban 0.8879
23110 Branch County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23120 Calhoun County, Michigan 3720 Urban 1.0143 0.9508 12980 Urban 0.9826
23130 Cass County, Michigan 23 Rural 0.8824 0.9788 43780 Urban 0.9306
23140 Charlevoix County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23150 Cheboygan County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23160 Chippewa County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23170 Clare County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23180 Clinton County, Michigan 4040 Urban 0.9794 0.9794 29620 Urban 0.9794
23190 Crawford County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23200 Delta County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23210 Dickinson County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23220 Eaton County, Michigan 4040 Urban 0.9794 0.9794 29620 Urban 0.9794
23230 Emmet County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23240 Genesee County, Michigan 2640 Urban 1.0655 1.0655 22420 Urban 1.0655
23250 Gladwin County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23260 Gogebic County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23270 Grand Traverse County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23280 Gratiot County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23290 Hillsdale County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23300 Houghton County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23310 Huron County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23320 Ingham County, Michigan 4040 Urban 0.9794 0.9794 29620 Urban 0.9794
23330 Ionia County, Michigan 23 Rural 0.8824 0.9390 24340 Urban 0.9107
23340 Iosco County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23350 Iron County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23360 Isabella County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23370 Jackson County, Michigan 3520 Urban 0.9304 0.9304 27100 Urban 0.9304
23380 Kalamazoo County, Michigan 3720 Urban 1.0143 1.0381 28020 Urban 1.0262
23390 Kalkaska County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23400 Kent County, Michigan 3000 Urban 0.9445 0.9390 24340 Urban 0.9418
23410 Keweenaw County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23420 Lake County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23430 Lapeer County, Michigan 2160 Urban 1.0147 0.9871 47644 Urban 1.0009
23440 Leelanau County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23450 Lenawee County, Michigan 0440 Urban 1.0707 0.8895 99923 Rural 0.9801
23460 Livingston County, Michigan 0440 Urban 1.0707 0.9871 47644 Urban 1.0289
23470 Luce County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23480 Mackinac County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23490 Macomb County, Michigan 2160 Urban 1.0147 0.9871 47644 Urban 1.0009
23500 Manistee County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23510 Marquette County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23520 Mason County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23530 Mecosta County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23540 Menominee County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23550 Midland County, Michigan 6960 Urban 0.9241 0.8895 99923 Rural 0.9068
23560 Missaukee County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23570 Monroe County, Michigan 2160 Urban 1.0147 0.9468 33780 Urban 0.9808
23580 Montcalm County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23590 Montmorency County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23600 Muskegon County, Michigan 3000 Urban 0.9445 0.9664 34740 Urban 0.9555
23610 Newaygo County, Michigan 23 Rural 0.8824 0.9390 24340 Urban 0.9107
23620 Oakland County, Michigan 2160 Urban 1.0147 0.9871 47644 Urban 1.0009
23630 Oceana County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23640 Ogemaw County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23650 Ontonagon County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23660 Osceola County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23670 Oscoda County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23680 Otsego County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23690 Ottawa County, Michigan 3000 Urban 0.9445 0.9055 26100 Urban 0.9250
23700 Presque Isle County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23710 Roscommon County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23720 Saginaw County, Michigan 6960 Urban 0.9241 0.9088 40980 Urban 0.9165
23730 St Clair County, Michigan 2160 Urban 1.0147 0.9871 47644 Urban 1.0009
23740 St Joseph County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23750 Sanilac County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23760 Schoolcraft County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23770 Shiawassee County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23780 Tuscola County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
23790 Van Buren County, Michigan 3720 Urban 1.0143 1.0381 28020 Urban 1.0262
23800 Washtenaw County, Michigan 0440 Urban 1.0707 1.0859 11460 Urban 1.0783
23810 Wayne County, Michigan 2160 Urban 1.0147 1.0424 19804 Urban 1.0286
23830 Wexford County, Michigan 23 Rural 0.8824 0.8895 99923 Rural 0.8860
24000 Aitkin County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24010 Anoka County, Minnesota 5120 Urban 1.1075 1.1075 33460 Urban 1.1075
24020 Becker County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24030 Beltrami County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24040 Benton County, Minnesota 6980 Urban 0.9965 0.9965 41060 Urban 0.9965
24050 Big Stone County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24060 Blue Earth County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24070 Brown County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24080 Carlton County, Minnesota 24 Rural 0.9132 1.0213 20260 Urban 0.9673
24090 Carver County, Minnesota 5120 Urban 1.1075 1.1075 33460 Urban 1.1075
24100 Cass County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24110 Chippewa County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24120 Chisago County, Minnesota 5120 Urban 1.1075 1.1075 33460 Urban 1.1075
24130 Clay County, Minnesota 2520 Urban 0.8486 0.8486 22020 Urban 0.8486
24140 Clearwater County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24150 Cook County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24160 Cottonwood County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24170 Crow Wing County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24180 Dakota County, Minnesota 5120 Urban 1.1075 1.1075 33460 Urban 1.1075
24190 Dodge County, Minnesota 24 Rural 0.9132 1.1131 40340 Urban 1.0132
24200 Douglas County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24210 Faribault County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24220 Fillmore County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24230 Freeborn County, Minnesota 24 Rural 0.9132 0.9132 99924 Rural 0.9132
24240 Goodhue County, Minnesota 24 Rural 0.9132<