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Medicare Program; Hospice Wage Index

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Start Preamble Start Printed Page 60072


Health Care Financing Administration (HCFA), HHS.




This notice announces the annual update to the hospice wage index as required by statute. This update is effective October 1, 2000 through September 30, 2001. The wage index is used to reflect local differences in wage levels. The hospice wage index methodology and values are based on recommendations of a negotiated rulemaking advisory committee and were originally published in the Federal Register on August 8, 1997.


This notice is effective on October 1, 2000.

Start Further Info


Carol Blackford, (410) 786-5909.

End Further Info End Preamble Start Supplemental Information


I. Background

A. Statute and Regulations

Hospice Care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care (relief of pain and other uncomfortable symptoms). The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling and respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care.

Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. The statutory authority for payment to hospices participating in the Medicare program is contained in section 1814(i) of the Act.

Our existing regulations under 42 CFR part 418 (issued on December 16, 1983, effective for hospice services furnished on or after November 1, 1983) establish eligibility requirements and payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Subpart G of Part 418 provides for payment to hospices based on one of four prospectively determined rates for each day in which a qualified Medicare beneficiary is under the care of a hospice. The four rate categories are routine home care, continuous home care, inpatient respite care, and general inpatient care. Payment rates are established for each category.

The regulations at § 418.306(c), which require the rates to be adjusted by a wage index, were revised in the August 8, 1997 final rule (62 FR 42860). This rule implemented a new methodology for calculating the hospice wage index based on the recommendations of a negotiated rulemaking committee. The committee reached consensus on the methodology. We included the resulting committee statement, describing that consensus, as an appendix to the August 8, 1997 final rule (62 FR 42883). The provisions of the final hospice wage index rule are as follows:

  • The revised hospice wage index will be calculated using the most current available hospital wage data.
  • The revised hospice wage index was phased in over a 3-year transition period. For the first year of the transition period, October 1, 1997 through September 30, 1998, a blended index was calculated by adding two-thirds of the 1983 index value for an area to one-third of the revised wage index value for that area. During the second year of the transition period, October 1, 1998 through September 30, 1999, the calculation was similar, except that the blend was one-third of the 1983 index value and two-thirds of the revised wage index value for that area. We fully implemented the revised wage index during the third transition period, October 1, 1999 through September 30, 2000.
  • All hospice wage index values of 0.8 or greater are subject to a budget-neutrality adjustment to ensure that we do not pay more in the aggregate than we would have paid under the original wage index. The budget-neutrality adjustment is calculated by multiplying the hospice wage index for a given area by the budget-neutrality adjustment factor. The budget-neutrality adjustment is to be applied annually, both during and after the transition period.
  • All hospice wage index values below 0.8 receive the greater of the following adjustments: the wage index floor, a 15-percent increase, subject to a maximum wage index value of 0.8; or, the budget-neutrality adjustment.
  • The wage index is to be updated annually, in the Federal Register, based on the most current available hospital wage data. These data will include any changes to the definitions of Metropolitan Statistical Areas (MSA).

Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice rates for fiscal years (FYs) 1998 through 2002. Hospice rates were to be updated by a factor equal to the market basket index, minus 1 percentage point. However, section 131(a) of the Balanced Budget Refinement Act of 1999 (BBRA) changed the payment rates for FYs 2001 and 2002 by increasing the FY 2001 rate by 0.5 percent and the FY 2002 rate by 0.75 percent. Section 131(b) of the BBRA states that any additional payments made under section 131(a) of the BBRA shall not be included in updating the hospice rates after those 2 years.

B. Update to the Hospice Wage Index

This annual update is effective October 1, 2000 through September 30, 2001. In accordance with the agreement signed by the Health Care Financing Administration (HCFA) and all other members of the Hospice Wage Index Negotiated Rulemaking Committee, we are using the most current HCFA hospital data available, including any changes to the definitions of MSAs. The FY 2000 hospital wage index was the most current hospital wage data available when the FY 2001 wage index values were calculated. We used the pre-reclassified and pre-floor hospital area wage index data.

All wage index values are adjusted by a budget-neutrality factor of 1.065425 and are subject to the wage index floor adjustment, if applicable. We have completed all of the calculations described above and included them in the wage index values reflected in both Tables A and B below. A detailed description of the method used to compute the hospice wage index is contained in both the September 4, 1996 proposed rule (61 FR 46579) and the August 8, 1997 final rule (62 FR 42860).

After the publication of the FY 2000 hospice wage index updates, we received a number of questions about the methodology used to calculate the hospice wage indices. We would like to take this opportunity to further explain the methodology used in determining the hospice wage indices. Start Printed Page 60073

1. Metropolitan Statistical Areas

As explained in the September 4, 1996 hospice wage index proposed rule, each hospice=s labor market area would be established by the MSA definitions issued by the Office of Management and Budget (OMB) on December 28, 1992 based on the 1990 census, and updated periodically by OMB. Any changes to the MSA definitions would be effective annually and announced in the final rule updating the hospice wage index.

2. MSA Wage Index Values Lower Than Rural Values

As explained above, any area not included in an MSA is considered to be nonurban and receives the statewide rural rate. We are aware that in the past, a number of MSAs have had wage index values that were lower than their rural statewide value. This difference is due to variations in local wage data as compared to national wage data. The hospice wage index is computed by dividing the hourly wage rate for an MSA or nonurban area by a national hourly wage rate. Nonurban areas could receive a higher wage index value than urban areas in the same state if the hourly wage rate in the nonurban area increased at a greater rate.

C. Tables

Table A.—Hospice Wage Index for Urban Areas

MSA code No.Urban area (constituent counties or county equivalents) 1Wage index 2
0040Abilene, TX0.8715
Taylor, TX
0060Aguadilla, PR0.4386
Aguada, PR
Aguadilla, PR
Moca, PR
0080Akron, OH1.0829
Portage, OH
Summit, OH
0120Albany, GA1.1052
Dougherty, GA
Lee, GA
0160Albany-Schenectady-Troy, NY0.9328
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200Albuquerque, NM0.9056
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220Alexandria, LA0.8385
Rapides, LA
0240Allentown-Bethlehem-Easton, PA1.0897
Carbon, PA
Lehigh, PA
Northampton, PA
0280Altoona, PA0.9954
Blair, PA
0320Amarillo, TX0.8929
Potter, TX
Randall, TX
0380Anchorage, AK1.3701
Anchorage, AK
0440Ann Arbor, MI1.2235
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450Anniston, AL0.9017
Calhoun, AL
0460Appleton-Oshkosh-Neenah, WI0.9496
Calumet, WI
Outagamie, WI
Winnebago, WI
0470Arecibo, PR0.5537
Arecibo, PR
Camuy, PR
Hatillo, PR
0480Asheville, NC0.9466
Buncombe, NC
Madison, NC
0500Athens, GA1.0340
Clarke, GA
Madison, GA
Oconee, GA
0520Atlanta, GA1.0709
Barrow, GA
Bartow, GA
Carroll, GA
Cherokee, GA
Clayton, GA
Cobb, GA
Coweta, GA
DeKalb, GA
Douglas, GA
Fayette, GA
Forsyth, GA
Fulton, GA
Gwinnett, GA
Henry, GA
Newton, GA
Paulding, GA
Pickens, GA
Rockdale, GA
Spalding, GA
Walton, GA
0560Atlantic-Cape May, NJ1.2051
Atlantic, NJ
Cape May, NJ
0580Aubrn-Opelika, AL0.8256
Lee, AL
0600Augusta-Aiken, GA-SC0.9603
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640Austin-San Marcos, TX0.9676
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680Bakersfield, CA1.0248
Kern, CA
0720Baltimore, MD1.0539
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733Bangor, ME1.0239
Penobscot, ME
0743Barnstable-Yarmouth, MA1.4173
Barnstable, MA
0760Baton Rouge, LA0.9278
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840Beaumont-Port Arthur, TX0.9129
Hardin, TX
Jefferson, TX
Orange, TX
0860Bellingham, WA1.2141
Whatcom, WA
0870Benton Harbor, MI0.9011
Berrien, MI
0875Bergen-Passaic, NJ1.2816
Bergen, NJ
Passaic, NJ
0880Billings, MT1.0696
Yellowstone, MT
0920Biloxi-Gulfport-Pascagoula, MS0.8383
Hancock, MS
Harrison, MS
Jackson, MS
0960Binghamton, NY0.9324
Broome, NY
Tioga, NY
1000Birmingham, AL0.9584
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010Bismarck, ND0.8267
 Burleigh, ND
Morton, ND
1020Bloomington, IN0.9155
Monroe, IN
1040Bloomington-Normal, IL0.9582
McLean, IL
1080Boise City, ID0.9654
Ada, ID
Canyon, ID
1123Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH1.2102
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
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Strafford, NH
1125Boulder-Longmont, CO1.0596
Boulder, CO
1145Brazoria, TX0.9074
Brazoria, TX
1150Bremerton, WA1.1733
Kitsap, WA
1240Brownsville-Harlingen-San Benito, TX0.9816
Cameron, TX
1260Bryan-College Station, TX0.9057
Brazos, TX
1280Buffalo-Niagara Falls, NY1.0233
Erie, NY
Niagara, NY
1303Burlington, VT1.1250
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310Caguas, PR0.5245
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320Canton-Massillon, OH0.9346
Carroll, OH
Stark, OH
1350Casper, WY0.9802
Natrona, WY
1360Cedar Rapids, IA0.9609
Linn, IA
1400Champaign-Urbana, IL0.9764
Champaign, IL
1440Charleston-North Charleston, SC0.9577
Berkeley, SC
Charleston, SC
Dorchester, SC
1480Charleston, WV0.9691
Kanawha, WV
Putnam, WV
1520Charlotte-Gastonia-Rock Hill, NC-SC1.0051
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540Charlottesville, VA1.1267
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560Chattanooga, TN-GA1.0369
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580Cheyenne, WY0.8711
Laramie, WY
1600Chicago, IL1.1585
Cook, IL
DeKalb, IL
Du Page, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620Chico-Paradise, CA1.1071
Butte, CA
1640Cincinnati, OH-KY-IN1.0035
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Kenton, KY
Pendleton, KY
Dearborn, IN
Ohio, IN
1660Clarksville-Hopkinsville, TN-KY0.8619
Christian, KY
Montgomery, TN
1680Cleveland-Lorain-Elyria, OH1.0323
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720Colorado Springs, CO0.9821
El Paso, CO
1740Columbia, MO0.9488
Boone, MO
1760Columbia, SC0.9970
Lexington, SC
Richland, SC
1800Columbus, GA-AL0.9068
Chattahochee, GA
Harris, GA
Muscogee, GA
Russell, AL
1840Columbus, OH1.0556
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880Corpus Christi, TX0.9271
Nueces, TX
San Patricio, TX
1890Corvallis, Oregon1.1813
Benton, OR
1900Cumberland, MD-WV0.9378
Allegany, MD
Mineral, WV
1920Dallas, TX1.0236
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950Danville, VA0.9277
Danville City, VA
Pittsylvania, VA
1960Davenport-Moline-Rock Island, IA-IL1.0080
Scott, IA
Henry, IL
Rock Island, IL
2000Dayton-Springfield, OH0.9576
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020Daytona Beach, FL0.9248
Flagler, FL
Volusia, FL
2030Decatur, AL0.9248
Lawrence, AL
Morgan, AL
2040Decatur, IL0.8867
Macon, IL
2080Denver, CO1.0857
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120Des Moines, IA0.9328
Dallas, IA
Polk, IA
Warren, IA
2160Detroit, MI1.1104
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180Dothan, AL0.8309
Dale, AL
Houston, AL
2190Dover, DE0.9947
Kent, DE
2200Dubuque, IA0.9079
Dubuque, IA
2240Duluth-Superior, MN-WI1.0831
St. Louis, MN
Douglas, WI
2281Dutchess County, NY1.1243
Dutchess, NY
2290Eau Claire, WI0.9544
Chippewa, WI
Eau Claire, WI
2320El Paso, TX0.9533
El Paso, TX
2330Elkhart-Goshen, IN0.9994
Elkhart, IN
2335Elmira, NY0.9092
Chemung, NY
2340Enid, OK0.8474
Garfield, OK
2360Erie, PA0.9614
Erie, PA
2400Eugene-Springfield, OR1.1298
Lane, OR
Start Printed Page 60075
2440Evansville-Henderson, IN-KY0.8847
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520Fargo-Moorhead, ND-MN0.9185
Clay, MN
Cass, ND
2560Fayetteville, NC0.9051
Cumberland, NC
2580Fayetteville-Springdale-Rogers, AR0.8283
Benton, AR
Washington, AR
2620Flagstaff, AZ-UT1.1026
Coconino, AZ
Kane, UT
2640Flint, MI1.1742
Genesee, MI
2650Florence, AL0.8447
Colbert, AL
Lauderdale, AL
2655Florence, SC0.9183
Florence, SC
2670Fort Collins-Loveland, CO1.0977
Larimer, CO
2680Ft. Lauderdale, FL1.0839
Broward, FL
2700Fort Myers-Cape Coral, FL0.9537
Lee, FL
2710Fort Pierce-Port St. Lucie, FL1.0653
Martin, FL
St. Lucie, FL
2720Fort Smith, AR-OK0.8357
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750Fort Walton Beach, FL0.9284
Okaloosa, FL
2760Fort Wayne, IN0.9692
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800Fort Worth-Arlington, TX1.0480
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840Fresno, CA1.0935
Fresno, CA
Madera, CA
2880Gadsden, AL0.9258
Etowah, AL
2900Gainesville, FL1.0764
Alachua, FL
2920Galveston-Texas City, TX1.0370
Galveston, TX
2960Gary, IN1.0005
Lake, IN
Porter, IN
2975Glens Falls, NY0.9170
Warren, NY
Washington, NY
2980Goldsboro, NC0.8879
Wayne, NC
2985Grand Forks, ND-MN0.9693
Grand Forks, ND
Polk, MN
2995Grand Junction, CO0.9790
Mesa, CO
3000Grand Rapids-Muskegon-Holland, MI1.0799
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040Great Falls, MT1.1144
Cascade, MT
3060Greeley, CO1.0359
Weld, CO
3080Green Bay, WI0.9731
Brown, WI
3120Greensboro-Winston-Salem-High Point, NC0.9629
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150Greenville, NC1.0123
Pitt, NC
3160Greenville-Spartanburg-Anderson, SC0.9790
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180Hagerstown, MD0.9422
Washington, MD
3200Hamilton-Middletown, OH0.9532
Butler, OH
3240Harrisburg-Lebanon-Carlisle, PA1.0567
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283Hartford, CT1.2483
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285Hattiesburg, MS0.8134
Forrest, MS
Lamar, MS
3290Hickory-Morganton-Lenoir, NC0.9709
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320Honolulu, HI1.2228
Honolulu, HI
3350Houma, LA0.8350
Lafourche, LA
Terrebonne, LA
3360Houston, TX1.0002
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400Huntington-Ashland, WV-KY-OH1.0396
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440Huntsville, AL0.9400
Limestone, AL
Madison, AL
3480Indianapolis, IN1.0434
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500Iowa City, IA1.0237
Johnson, IA
3520Jackson, MI0.9419
Jackson, MI
3560Jackson, MS0.8936
Hinds, MS
Madison, MS
Rankin, MS
3580Jackson, TN0.9164
Madison, TN
Chester, TN
3600Jacksonville, FL0.9544
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605Jacksonville, NC0.8367
Onslow, NC
3610Jamestown, NY0.8372
Chautauqua, NY
3620Janesville-Beloit, WI1.0289
Rock, WI
3640Jersey City, NJ1.2440
Hudson, NJ
3660Johnson City-Kingsport-Bristol, TN-VA0.9433
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680Johnstown, PA0.9206
Cambria, PA
Somerset, PA
Start Printed Page 60076
3700Jonesboro, AR0.8000
Craighead, AR
3710Joplin, MO0.8181
Jasper, MO
Newton, MO
3720Kalamazoo-Battlecreek, MI1.0635
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740Kankakee, IL0.9162
Kankakee, IL
3760Kansas City, KS-MO0.9932
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800Kenosha, WI0.9625
Kenosha, WI
3810Killeen-Temple, TX1.0583
Bell, TX
Coryell, TX
3840Knoxville, TN0.9802
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850Kokomo, IN0.9503
Howard, IN
Tipton, IN
3870La Crosse, WI-MN0.9519
Houston, MN
La Crosse, WI
3880Lafayette, LA0.8886
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920Lafayette, IN0.9386
Clinton, IN
Tippecanoe, IN
3960Lake Charles, LA0.8488
Calcasieu, LA
3980Lakeland-Winter Haven, FL0.9393
Polk, FL
4000Lancaster, PA0.9862
Lancaster, PA
4040Lansing-East Lansing, MI1.0631
Clinton, MI
Eaton, MI
Ingham, MI
4080Laredo, TX0.8868
Webb, TX
4100Las Cruces, NM0.9153
Dona Ana, NM
4120Las Vegas, NV-AZ1.1996
Mohave, AZ
Clarke, NV
Nye, NV
4150Lawrence, KS0.8761
Douglas, KS
4200Lawton, OK1.0157
Comanche, OK
4243Lewiston-Auburn, ME0.9482
Androscoggin, ME
4280Lexington, KY0.9090
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320Lima, OH0.9489
Allen, OH
Auglaize, OH
4360Lincoln, NE1.0304
Lancaster, NE
4400Little Rock-North Little Rock, AR0.9179
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420Longview-Marshall, TX0.9311
Gregg, TX
Harrison, TX
Upshur, TX
4480Los Angeles-Long Beach, CA1.2841
Los Angeles, CA
4520Louisville, KY-IN0.9996
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600Lubbock, TX0.8962
Lubbock, TX
4640Lynchburg, VA0.9392
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680Macon, GA0.9089
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720Madison, WI1.0367
Dane, WI
4800Mansfield, OH0.9031
Crawford, OH
Richland, OH
4840Mayaguez, PR0.5376
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880McAllen-Edinburg-Mission, TX0.8652
Hidalgo, TX
4890Medford-Ashland, OR1.1180
Jackson, OR
4900Melbourne-Titusville-Palm Bay, FL0.9905
Brevard, Fl
4920Memphis, TN-AR-MS0.8784
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940Merced, CA1.0950
Merced, CA
5000Miami, FL1.0904
Dade, FL
5015Middlesex-Somerset-Hunterdon, NJ1.1851
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080Milwaukee-Waukesha, WI1.0490
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120Minneapolis-St. Paul, MN-WI1.1645
Anoka, MN
Carver, MN
Chisago, MN Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherbune, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5140Missoula, MT0.9681
Missoula, MT
5160Mobile, AL0.8809
Baldwin, AL
Mobile, AL
5170Modesto, CA1.0774
Stanislaus, CA
5190Monmouth-Ocean, NJ1.1996
Monmouth, NJ
Ocean, NJ
5200Monroe, LA0.8760
Ouachita, LA
5240Montgomery, AL0.8208
Autauga, AL
Elmore, AL
Montgomery, AL
5280Muncie, IN1.1544
Delaware, IN
5330Myrtle Beach, SC0.9088
Horry, SC
5345Naples, FL1.0484
Collier, FL
5360Nashville, TN1.0068
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Start Printed Page 60077
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380Nassau-Suffolk, NY1.4997
Nassau, NY
Suffolk, NY
5483New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT1.3166
Fairfield, CT
New Haven, CT
5523New London-Norwich, CT1.3242
New London, CT
5560New Orleans, LA0.9685
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600New York, NY1.5469
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640Newark, NJ1.2409
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660Newburgh, NY-PA1.1624
Orange, NY
Pike, PA
5720Norfolk-Virginia Beach-Newport News, VA-NC0.8993
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
James City, VA
Isle of Wight, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City VA
Williamsburg City, VA
York, VA
5775Oakland, CA1.6044
Alameda, CA
Contra Costa, CA
5790Ocala, FL1.0245
Marion, FL
5800Odessa-Midland, TX0.9455
Ector, TX
Midland, TX
5880Oklahoma City, OK0.9150
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910Olympia, WA1.1648
Thurston, WA
5920Omaha, NE-IA1.1140
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945Orange County, CA1.2349
Orange, CA
5960Orlando, FL1.0437
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990Owensboro, KY0.8635
Daviess, KY
6015Panama City, FL0.9770
Bay, FL
6020Parkersburg-Marietta, WV-OH0.8896
Washington, OH
Wood, WV
6080Pensacola, FL0.8995
Escambia, FL
Santa Rosa, FL
6120Peoria-Pekin, IL0.8896
Peoria, IL
Tazewell, IL
Woodford, IL
6160Philadelphia, PA-NJ1.1891
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200Phoenix-Mesa, AZ1.0084
Maricopa, AZ
Pinal, AZ
6240Pine Bluff, AR0.8202
Jefferson, AR
6280Pittsburgh, PA1.0265
Allegheny, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323Pittsfield, MA1.0927
Berkshire, MA
6340Pocatello, ID0.9561
Bannock, ID
6360Ponce, PR0.5717
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403Portland, ME1.0096
Cumberland, ME
Sagadahoc, ME
York, ME
6440Portland-Vancouver, OR-WA1.1694
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483Providence-Warwick-Pawtucket, RI1.1391
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520Provo-Orem, UT1.0461
Utah, UT
6560Pueblo, CO0.9433
Pueblo, CO
6580Punta Gorda, FL0.9509
Charlotte, FL
6600Racine, WI0.9820
Racine, WI
6640Raleigh-Durham-Chapel Hill, NC1.0170
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660Rapid City, SD0.8911
Pennington, SD
6680Reading, PA1.0054
Berks, PA
6690Redding, CA1.2002
Shasta, CA
6720Reno, NV1.1353
Washoe, NV
6740Richland-Kennewick-Pasco, WA1.1959
Benton, WA
Franklin, WA
6760Richmond-Petersburg, VA1.0171
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780Riverside-San Bernardino, CA1.1945
Riverside, CA
San Bernardino, CA
Start Printed Page 60078
6800Roanoke, VA0.8672
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820Rochester, MN1.2178
Olmsted, MN
6840Rochester, NY0.9786
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880Rockford, IL0.9359
Boone, IL
Ogle, IL
Winnebago, IL
6895Rocky Mount, NC0.9307
Edgecombe, NC
Nash, NC
6920Sacramento, CA1.3089
El Dorado, CA
Placer, CA
Sacramento, CA
6960Saginaw-Bay City-Midland, MI0.9895
Bay, MI
Midland, MI
Saginaw, MI
6980St. Cloud, MN1.0038
Benton, MN
Stearns, MN
7000St. Joseph, MO0.9529
Andrew, MO
Buchanan, MO
7040St. Louis, MO-IL0.9645
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
7080Salem, OR1.0601
Marion, OR
Polk, OR
7120Salinas, CA1.5674
Monterey, CA
7160Salt Lake City-Ogden, UT1.0500
Davis, UT
Salt Lake, UT
Weber, UT
7200San Angelo, TX0.8359
Tom Green, TX
7240San Antonio, TX0.8862
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320San Diego, CA1.2712
7360San Francisco, CA1.4918
Marin, CA
San Francisco, CA
San Mateo, CA
7400San Jose, CA1.4500
Santa Clara, CA
7440San Juan-Bayamon, PR0.5357
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Ceiba, PR
Comerio, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Morovis, PR
Naguabo, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trujillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Yabucoa, PR
7460San Luis Obispo-Atascadero-Paso Robles, CA1.1156
San Luis Obispo, CA
7480Santa Barbara-Santa Maria-Lompoc, CA1.1528
Santa Barbara, CA
7485Santa Cruz-Watsonville, CA1.4840
Santa Cruz, CA
7490Santa Fe, NM1.1121
Los Alamos, NM
Santa Fe, NM
7500Santa Rosa, CA1.3852
Sonoma, CA
7510Sarasota-Bradenton, FL1.0554
Manatee, FL
Sarasota, FL
7520Savannah, GA1.0605
Bryan, GA
Chatham, GA
Effingham, GA
7560Scranton—Wilkes-Barre—Hazleton, PA0.8921
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600Seattle-Bellevue-Everett, WA1.2030
Island, WA
King, WA
Snohomish, WA
7610Sharon, PA0.8826
Mercer, PA
7620Sheboygan, WI0.8740
Sheboygan, WI
7640Sherman-Denison, TX0.9940
Grayson, TX
7680Shreveport-Bossier City, LA0.9642
Bossier, LA
Caddo, LA
Webster, LA
7720Sioux City, IA-NE0.9108
Woodbury, IA
Dakota, NE
7760Sioux Falls, SD0.9351
Lincoln, SD
Minnehaha, SD
7800South Bend, IN1.0435
St. Joseph, IN
7840Spokane, WA1.1507
Spokane, WA
7880Springfield, IL0.9252
Menard, IL
Sangamon, IL
7920Springfield, MO0.8515
Christian, MO
Greene, MO
Webster, MO
8003Springfield, MA1.1377
Hampden, MA
Hampshire, MA
8840Washington, DC-MD-VA-WV1.1778
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpeper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
King George, VA
Loudoun, VA
Manassas City, VA
Start Printed Page 60079
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
8920Waterloo-Cedar Falls, IA0.9075
Black Hawk, IA
8940Wausau, WI1.0064
Marathon, WI
8960West Palm Beach-Boca Raton, FL1.0668
Palm Beach, FL
9000Wheeling, WV-OH0.8144
Belmont, OH
Marshall, WV
Ohio, WV
9040Wichita, KS1.0038
Butler, KS
Harvey, KS
Sedgwick, KS
9080Wichita Falls, TX0.8154
Archer, TX
Wichita, TX
8050State College, PA0.9737
Centre, PA
8080Steubenville-Weirton, OH-WV0.9179
Jefferson, OH
Brooke, WV
Hancock, WV
8120Stockton-Lodi, CA1.1207
San Joaquin, CA
8140Sumter, SC0.8778
Sumter, SC
8160Syracuse, NY1.1377
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200Tacoma, WA1.2230
Pierce, WA
8240Tallahassee, FL0.9040
Gadsden, FL
Leon, FL
8280Tampa-St. Petersburg-Clearwater, FL0.9637
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320Terre Haute, IN0.9132
Clay, IN
Vermillion, IN
Vigo, IN
8360Texarkana, AR-Texarkana, TX0.8668
Miller, AR
Bowie, TX
8400Toledo, OH1.0458
Fulton, OH
Lucas, OH
Wood, OH
8440Topeka, KS0.9937
Shawnee, KS
8480Trenton, NJ1.0764
Mercer, NJ
8520Tucson, AZ0.9315
Pima, AZ
8560Tulsa, OK0.8616
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600Tuscaloosa, AL0.8593
Tuscaloosa, AL
8640Tyler, TX0.9983
8680Utica-Rome, NY0.8842
Herkimer, NY
Oneida, NY
8720Vallejo-Fairfield-Napa, CA1.4220
Napa, CA
Solano, CA
8735Ventura, CA1.2206
8750Victoria, TX0.8927
8760Vineland-Millville-Bridgeton, NJ1.1206
Cumberland, NJ
8780Visalia-Turlare-Porterville, CA1.1093
Tulare, CA
8800Waco, TX0.8604
McLennan, TX
9140Williamsport, PA0.9003
Lycoming, PA
9160Wilmington-Newark, DE-MD1.2013
New Castle, DE
Cecil, MD
9200Wilmington, NC1.0343
Brunswick, NC
New Hanover, NC
9260Yakima, WA1.1009
Yakima, WA
9270Yolo, CA1.0356
Yolo, CA
9280York, PA0.9919
York, PA
9320Youngstown-Warren, OH1.0651
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340Yuba City, CA1.1361
Sutter, CA
Yuba, CA
9360Yuma, AZ1.0574
Yuma, AZ
1 This column lists each MSA area name (in italics) and each county, or county equivalent, in the MSA area. Counties not listed in this Table are considered to be Rural Areas. Wage Index values for these areas are found in Table B.
2 Wage index values are based on FY 1996 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget-neutrality adjustment of 1.065425. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget-neutrality adjustment. We have completed all of these adjustments and included them in the wage index values reflected in this table.

Table B.—Wage Index for Rural Areas

MSA code No.Nonurban areaWage index 1
Start Printed Page 60080
9930New Hampshire1.0554
9931New Jersey 2
9932New Mexico0.8927
9933New York0.9202
9934North Carolina0.8832
9935North Dakota0.8148
9940Puerto Rico0.4886
9941Rhode Island 2
9942South Carolina0.8805
9943South Dakota0.8073
9948Virgin Islands0.7252
9951West Virginia0.8597
1 Wage index values are based on FY 1996 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget-neutrality adjustment of 1.065425. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget-neutrality adjustment. We have completed all of these adjustments and have included them in the wage index values reflected in this table.
2 All counties within the State are classified as urban.

II. Regulatory Impact Statement

We have examined the impacts of this notice as required by Executive Order 12866, the Unfunded Mandate Reform Act, and the Regulatory Flexibility Act (RFA) (Pub. L. 96-354). In this notice, we identified an impact on hospices as a result of changes in the way we compute the hospice wage index. The change in the methodology for computing the wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). We recognize that the BBRA adjusted hospice payments upward by 0.5 percent; however, we did not do a separate analysis of the impact of this payment adjustment. We used the new rates adjusted by the BBRA when estimating the payments to be made under the new wage index and when calculating the budget-neutrality adjustment factor. Overall, we believe the changes included in this notice to be insignificant.

1. Executive Order 12866 and RFA

Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects; distributive impacts; and equity). We have determined that this notice is not an economically significant rule under this Executive Order. The RFA requires agencies to analyze options for regulatory relief for small businesses. For purposes of the RFA, States and individuals are not considered small entities. However, most providers, physicians, and health care suppliers are small entities, either by nonprofit status or by having revenues of $5 million or less annually. Approximately 73 percent of Medicare certified hospices are identified as voluntary, government, or other agencies, and, therefore, are considered small entities. Because the National Hospice Organization estimates that approximately 70 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis.

As discussed below, the estimated decreases in payment to hospices overall are very slight. The most significant change is an increase in estimated payments to rural areas in East and West South Central, at 4.8 and 9.1 percent, respectively. The effects of this notice on West South Central alone, indicate that 54 of the 85 hospices in urban West South Central can be considered small entities that will experience an 9.1-percent increase in Medicare payments. Therefore, we anticipate this notice will have a significant, albeit positive, impact on a substantial number of small entities. However, the methodology for the hospice wage index was previously determined by consensus through a negotiated rulemaking committee that included representatives of national hospice associations; rural, urban, large and small hospices; multi-site hospices; and consumer groups. Based on the options considered, the committee determined that the methodology described in the committee statement, and adopted into regulation in the August 8, 1997 final rule, was favorable for the hospice community as well as for beneficiaries. Therefore, we believe that mitigating any negative effects on small entities has been taken into consideration.

2. Congressional Review

Section 804(2) of Title 5, United States Code (U.S.C.) (as added by section 251 of Pub. L. 104-121), specifies that a “major rule” is any rule that the Office of Management and Budget finds is likely to result in—

  • An annual effect on the economy of $100 million or more;
  • A major increase in costs or prices for consumers, individual industries, Federal, State, or local government agencies, or geographic regions; or
  • Significant adverse effects on competition, employment, investment, productivity, innovation, or on the ability of United States-based enterprises to compete with foreign-based enterprises in domestic and export markets.

We estimate that the impact of this notice will not be $100 million or more; therefore, this notice is not a major rule as defined in Title 5, United States Code, section 804(2) and is not being forwarded to the Congress for a 60-day review period.

3. Unfunded Mandate

The Unfunded Mandate Reform Act of 1995 also requires (in section 202) that agencies prepare an assessment of anticipated costs and benefits for any rule that may result in an expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more in any one year. The notice has no consequential effect on State, local, or tribal governments. We believe the private sector costs of this notice fall below the threshold as well.

4. Rural Hospital Impact

Section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any notice that may have a significant impact on the operations of a substantial number of small rural hospitals. Such an analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside an MSA and has fewer than 50 beds.

Because this notice has no direct impact on small hospitals, in accordance with 5 U.S.C. 604, the Start Printed Page 60081Secretary certifies that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals.

5. Federalism

We have reviewed this notice under the threshold criteria of Executive Order 13132, Federalism, and have determined that this notice will not have any negative impact on the rights, roles, and responsibilities of State, local, or tribal governments.

A. Anticipated Effects

We have compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2001 wage index and determined the current hospice rates to be budget-neutral. As mentioned above, the negotiated rulemaking committee agreement required that we not pay more under the new wage index in the aggregate than we would have paid under the original wage index.

This impact analysis compares hospice payments under the FY 2000 hospice wage index to the estimated payments using the FY 2001 wage index. The data used in developing the quantitative analysis for this notice were obtained from the March 2000 update of the national claims history file of all bills submitted during FY 1999. We deleted bills from hospices that have since closed.

Table C demonstrates the results of our analysis. In Column 2 of Table C, we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 of Table C indicates payments that were made using the FY 2000 wage index. Column 4 of Table C is based on FY 1999 claims and estimates payments to be made to hospices using the FY 2001 wage index. The final column, which compares Columns 3 and 4, shows the percent change in estimated hospice payments made based on the category of the hospice.

Table C categorizes hospices by various geographic and provider characteristics. The first row displays the results of the impact analysis for all Medicare certified hospices. The second and third rows of the table categorize hospices according to their geographic location (urban and rural). Our analysis indicated that there are 1,351 hospices located in urban areas and 798 hospices located in rural areas. The next two groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The sixth grouping shows the impact on hospices based on the size of the hospice's program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice's program on the number of routine home care days provided in 1999. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding.

The results of our analysis shows that the greatest increases in payment are for rural areas in the West and East South Central Regions, with a 9.1 percent and 4.8 percent increase, respectively. The greatest decreases in payment are for urban areas in the New England and Mountain regions, each with a 0.4 percent decrease, and for rural areas in the Middle Atlantic and Pacific regions, each with a 0.4 percent decrease.

The breakdown by size, type of ownership, and facility base showed an increase in payments to all hospice programs. Small hospice programs showed significant increases of about 10 percent, while larger programs experienced only a negligible increase. Government-owned hospices showed the greatest estimated increase of 2.7 percent, while payments to voluntary hospices are expected to increase by 0.4 percent. In terms of hospice base, freestanding hospices showed the greatest estimated payment increase while home health agencies showed the smallest amount of payment increase.

Table C.—Impact of Hospice Wage Index Change

Number of hospices (1)Number of routine home care days in thousands (2)Payments using FY 2000 wage index in thousands (3)Estimated payments using FY 2001 wage index in thousands (4)Percent change in Hospice payments (5)
(By geographic location):
All Hospices2,14921,3542,490,7022,504,4390.6
Urban Hospices1,35118,1202,185,7802,190,5900.2
Rural Hospices7983,234304,922313,8492.9
By Region—Urban:
New England9464289,44789,051−0.4
Middle Atlantic1702,245290,927291,8940.3
South Atlantic1854,030509,079511,5830.5
East North Central2242,862334,861336,6940.5
East South Central941,169123,023123,5300.4
West North Central961,061113,167113,4980.3
West South Central1882,408261,632261,287−0.1
Puerto Rico2924316,47016,5240.3
By Region—Rural:
New England26727,6667,8111.9
Middle Atlantic3516817,28217,214−0.4
South Atlantic11768163,90465,0051.7
East North Central13656153,80154,5411.4
East South Central8152448,15950,4814.8
West North Central17440937,62238,9693.6
West South Central8536229.64032.3519.1
Start Printed Page 60082
Puerto Rico3231,4761,5072.1
Routine home care days:
0-1,754 days43739036,70040,60910.6
1,754-4,373 days5021,504150,829154,3992.4
4,373-9,681 days5563,669388,427390,2690.5
9,681 + days65315,4491,875,3391,879,9690.2
Type of ownership:
Hospice base:
Home health agency7165,357625,165627,4400.4
Skilled nursing facility2112617,64217,7480.6

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

Start Authority

Authority: Section 1814(i) of the Social Security Act (42 U.S.C. 1395f (i)(1)).

End Authority Start Signature

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

Dated: August 21, 2000.

Nancy-Ann Min DeParle,

Administrator, Health Care Financing Administration.

Dated: September 22, 2000.

Donna E. Shalala,


End Signature End Supplemental Information

[FR Doc. 00-25547 Filed 10-2-00; 12:23 pm]