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Medicare Program; Hospice Wage Index Fiscal Year 2003

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Start Preamble Start Printed Page 56092


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




This notice announces the annual update to the hospice wage index as required by statute. This update is effective October 1, 2002 through September 30, 2003. 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.


October 1, 2002.

Start Further Info


Lynn Riley, (410) 786-1286.

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 inpatient 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 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 published in the Federal Register (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 1983 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 Medicare, Medicaid, and SCHIP 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.

Section 321(a) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1814(i)(1)(C)(ii)(VI) of the Act by increasing Medicare hospice rates for FY 2001 by 5 percentage points. This amendment was applicable to hospice care furnished on or after April 1, 2001. Section 321(b) of the BIPA further stipulated that the 5-percent increase in Medicare hospice rates during the period beginning on April 1, 2001 through September 30, 2001 were to be treated as the payment rates in effect during FY 2001. This means that the 5-percent increase was made to the base that is updated annually according to a statutorily dictated percentage of the market basket update, as provided in section 1814(i) of the Act. The new Medicare rates for this time period were announced through HCFA Program Memorandum (PM) A-01-04 on January 16, 2001.

Also, section 321(d) of the BIPA specified that the Secretary of Health and Human Services use 1.0043 as the hospice wage index value for the Wichita, Kansas MSA in calculating payments for a hospice program providing hospice care in this MSA during FY 2000.

Payment rates for FY 2003 will be updated according to section 1814(i) of the Act. The FY 2003 rates will be the full market basket percentage increase for the FY. This rate update will be implemented through a separate PM and is not part of this notice. Start Printed Page 56093

B. Update to the Hospice Wage Index

This annual update is effective October 1, 2002 through September 30, 2003. In accordance with the agreement we signed with other members of the Hospice Wage Index Negotiated Rulemaking Committee, we are using the most current hospital data available to us, including any changes to the definitions of MSAs. The FY 2002 hospital wage index was the most current hospital wage data available when the FY 2003 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 1.063422 and are subject to the wage index floor adjustment, if applicable. We have completed all of the calculations described above and have 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 published in the Federal Register (61 FR 46579) and the August 8, 1997 final rule published in the Federal Register (62 FR 42860).

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 by OMB based on the decennial census. 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, TX Taylor, TX0.8470
0060Aguadilla, PR Aguada, PR Aguadilla, PR Moca, PR0.5385
0080Akron, OH Portage, OH Summit, OH1.0502
0120Albany, GA Dougherty, GA Lee, GA1.1315
0160Albany-Schenectady-Troy, NY Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY0.9039
0200Albuquerque, NM Bernalillo, NM Sandoval, NM Valencia, NM1.0378
0220Alexandria, LA Rapides, LA0.8538
0240Allentown-Bethlehem-Easton, PA Carbon, PA Lehigh, PA Northampton, PA1.0716
0280Altoona, PA Blair, PA0.9705
0320Amarillo, TX Potter, TX Randall, TX0.9263
0380Anchorage, AK Anchorage, AK1.3367
0440Ann Arbor, MI Lenawee, MI Livingston, MI Washtenaw, MI1.1802
0450Anniston, AL Calhoun, AL0.8801
Start Printed Page 56094
0460Appleton-Oshkosh-Neenah, WI Calumet, WI Outagamie, WI Winnebago, WI0.9827
0470Arecibo, PR Arecibo, PR Camuy, PR Hatillo, PR0.8507
0480Asheville, NC Buncombe, NC Madison, NC0.9783
0500Athens, GA Clarke, GA Madison, GA Oconee, GA1.0466
0520Atlanta, GA 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, GA1.0696
0560Atlantic-Cape May, NJ Atlantic, NJ Cape May, NJ1.2009
0580Auburn-Opelika, AL Lee, AL0.8752
0600Augusta-Aiken, GA-SC Columbia, GA McDuffie, GA Richmond, GA Aiken, SC Edgefield, SC1.0602
0640Austin-San Marcos, TX Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX1.0241
0680Bakersfield, CA Kern, CA1.0123
0720Baltimore, MD Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD1.0481
0733Bangor, ME Penobscot, ME1.0201
0743Barnstable-Yarmouth, MA Barnstable, MA1.4490
Start Printed Page 56095
0760Baton Rouge, LA Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA0.8666
0840Beaumont-Port Arthur, TX Hardin, TX Jefferson, TX Orange, TX0.8977
0860Bellingham, WA Whatcom, WA1.2576
0870Benton Harbor, MI Berrien, MI0.9451
0875Bergen-Passaic, NJ Bergen, NJ Passaic, NJ1.2430
0880Billings, MT Yellowstone, MT0.9945
0920Biloxi-Gulfport-Pascagoula, MS Hancock, MS Harrison, MS Jackson, MS0.8975
0960Binghamton, NY Broome, NY Tioga, NY0.8982
1000Birmingham, AL Blount, AL Jefferson, AL St. Clair, AL Shelby, AL0.9367
1010Bismarck, ND Burleigh, ND Morton, ND0.8490
1020Bloomington, IN Monroe, IN0.9403
1040Bloomington-Normal, IL McLean, IL0.9611
1080Boise City, ID Ada, ID Canyon, ID0.9624
1123Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH1.2105
1125Boulder-Longmont, CO Boulder, CO1.0420
1145Brazoria, TX Brazoria, TX0.8730
1150Bremerton, WA Kitsap, WA1.1440
1240Brownsville-Harlingen-San Benito, TX Cameron, TX0.9584
1260Bryan-College Station, TX Brazos, TX0.9920
1280Buffalo-Niagara Falls, NY Erie, NY Niagara, NY1.0059
1303Burlington, VT Chittenden, VT Franklin, VT Grand Isle, VT1.0510
Start Printed Page 56096
1310Caguas, PR Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR0.5404
1320Canton-Massillon, OH Carroll, OH Stark, OH0.9524
1350Casper, WY Natrona, WY1.0098
1360Cedar Rapids, IA Linn, IA0.9251
1400Champaign-Urbana, IL Champaign, IL0.9896
1440Charleston-North Charleston, SC Berkeley, SC Charleston, SC Dorchester, SC0.9790
1480Charleston, WV Kanawha, WV Putnam, WV0.9852
1520Charlotte-Gastonia-Rock Hill, NC-SC Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC0.9928
1540Charlottesville, VA Albermale, VA Charlottesville City, VA Fluvanna, VA Greene, VA1.1236
1560Chattanooga, TN-GA Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN0.9963
1580Cheyenne, WY Laramie, WY0.8814
1600Chicago, IL Cook, IL DeKalb, IL Du Page, IL Grundy, IL Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL1.1747
1620Chico-Paradise, CA Butte, CA1.0481
1640Cincinnati, OH-KY-IN Brown, OH Clermont, OH Hamilton, OH Warren, OH Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Dearborn, IN Ohio, IN1.0074
Start Printed Page 56097
1660Clarksville-Hopkinsville, TN-KY Christian, KY Montgomery, TN0.8866
1680Cleveland-Lorain-Elyria, OH Ashtabula, OH Cuyahoga, OH Geauga, OH Lake, OH Lorain, OH Medina, OH1.0057
1720Colorado Springs, CO El Paso, CO1.0362
1740Columbia, MO Boone, MO0.9237
1760Columbia, SC Lexington, SC Richland, SC1.0094
1800Columbus, GA-AL Chattahoochee, GA Harris, GA Muscogee, GA Russell, AL0.8975
1840Columbus, OH Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH1.0172
1880Corpus Christi, TX Nueces, TX San Patricio, TX0.8870
1890Corvallis, Oregon Benton, OR1.2385
1900Cumberland, MD-WV Allegany, MD Mineral, WV0.8833
1920Dallas, TX Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX1.0566
1950Danville, VA Danville City, VA Pittsylvania, VA0.9159
1960Davenport-Moline-Rock Island, IA-IL Scott, IA Henry, IL Rock Island, IL0.9186
2000Dayton-Springfield, OH Clark, OH Greene, OH Miami, OH Montgomery, OH0.9810
2020Daytona Beach, FL Flagler, FL Volusia, FL0.9541
2030Decatur, AL Lawrence, AL Morgan, AL0.9332
2040Decatur, IL Macon, IL0.8494
Start Printed Page 56098
2080Denver, CO Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO1.0983
2120Des Moines, IA Dallas, IA Polk, IA Warren, IA0.9336
2160Detroit, MI Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI1.1152
2180Dothan, AL Dale, AL Houston, AL0.8452
2190Dover, DE Kent, DE1.0949
2200Dubuque, IA Dubuque, IA0.9059
2240Duluth-Superior, MN-WI St. Louis, MN Douglas, WI1.0936
2281Dutchess County, NY Dutchess, NY1.1200
2290Eau Claire, WI Chippewa, WI Eau Claire, WI0.9463
2320El Paso, TX El Paso, TX0.9799
2330Elkhart-Goshen, IN Elkhart, IN1.0249
2335Elmira, NY Chemung, NY0.8949
2340Enid, OK Garfield, OK0.8887
2360Erie, PA Erie, PA0.9269
2400Eugene-Springfield, OR Lane, OR1.2199
2440Evansville-Henderson, IN-KY Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY0.9054
2520Fargo-Moorhead, ND-MN Clay, MN Cass, ND0.9855
2560Fayetteville, NC Cumberland, NC0.9600
2580Fayetteville-Springdale-Rogers, AR Benton, AR Washington, AR0.8981
2620Flagstaff, AZ-UT Coconino, AZ Kane, UT1.1225
2640Flint, MI Genesee, MI1.1605
2650Florence, AL Colbert, AL Lauderdale, AL0.8343
2655Florence, SC Florence, SC0.9275
2670Fort Collins-Loveland, CO Larimer, CO1.0682
2680Ft. Lauderdale, FL Broward, FL1.0946
Start Printed Page 56099
2700Fort Myers-Cape Coral, FL Lee, FL0.9969
2710Fort Pierce-Port St. Lucie, FL Martin, FL St. Lucie, FL1.0862
2720Fort Smith, AR-OK Crawford, AR Sebastian, AR Sequoyah, OK0.8564
2750Fort Walton Beach, FL Okaloosa, FL0.9573
2760Fort Wayne, IN Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN0.9787
2800Fort Worth-Arlington, TX Hood, TX Johnson, TX Parker, TX Tarrant, TX0.9990
2840Fresno, CA Fresno, CA Madera, CA1.0617
2880Gadsden, AL Etowah, AL0.9350
2900Gainesville, FL Alachua, FL1.0082
2920Galveston-Texas City, TX Galveston, TX1.0967
2960Gary, IN Lake, IN Porter, IN1.0134
2975Glens Falls, NY Warren, NY Washington, NY0.8865
2980Goldsboro, NC Wayne, NC0.9261
2985Grand Forks, ND-MN Grand Forks, ND Polk, MN0.9644
2995Grand Junction, CO Mesa, CO1.0176
3000Grand Rapids-Muskegon-Holland, MI Allegan, MI Kent, MI Muskegon, MI Ottawa, MI1.0685
3040Great Falls, MT Cascade, MT0.9433
3060Greeley, CO Weld, CO1.0097
3080Green Bay, WI Brown, WI0.9792
3120Greensboro-Winston-Salem-High Point, NC Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC1.0144
3150Greenville, NC Pitt, NC0.9878
Start Printed Page 56100
3160Greenville-Spartanburg-Anderson, SC Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC0.9802
3180Hagerstown, MD Washington, MD0.8896
3200Hamilton-Middletown, OH Butler, OH0.9876
3240Harrisburg-Lebanon-Carlisle, PA Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA1.0023
3283Hartford, CT Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT1.2264
3285Hattiesburg, MS Forrest, MS Lamar, MS0.8000
3290Hickory-Morganton-Lenoir, NC Alexander, NC Burke, NC Caldwell, NC Catawba, NC0.9961
3320Honolulu, HI Honolulu, HI1.2271
3350Houma, LA Lafourche, LA Terrebonne, LA0.8481
3360Houston, TX Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX1.0242
3400Huntington-Ashland, WV-KY-OH Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV1.0226
3440Huntsville, AL Limestone, AL Madison, AL0.9446
3480Indianapolis, IN Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN1.0313
3500Iowa City, IA Johnson, IA1.0484
3520Jackson, MI Jackson, MI0.9844
3560Jackson, MS Hinds, MS Madison, MS Rankin, MS0.9030
3580Jackson, TN Madison, TN Chester, TN0.9585
Start Printed Page 56101
3600Jacksonville, FL Clay, FL Duval, FL Nassau, FL St. Johns, FL0.9808
3605Jacksonville, NC Onslow, NC0.8105
3610Jamestown, NY Chautauqua, NY0.8561
3620Janesville-Beloit, WI Rock, WI1.0357
3640Jersey City, NJ Hudson, NJ1.1887
3660Johnson City-Kingsport-Bristol, TN-VA Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA0.9164
3680Johnstown, PA Cambria, PA Somerset, PA0.9276
3700Jonesboro, AR Craighead, AR0.8959
3710Joplin, MO Jasper, MO Newton, MO0.9280
3720Kalamazoo-Battlecreek, MI Calhoun, MI Kalamazoo, MI Van Buren, MI1.1314
3740Kankakee, IL Kankakee, IL1.0516
3760Kansas City, KS-MO Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO1.0141
3800Kenosha, WI Kenosha, WI1.0175
3810Killeen-Temple, TX Bell, TX Coryell, TX0.9008
3840Knoxville, TN Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN0.9454
3850Kokomo, IN Howard, IN Tipton, IN0.9705
3870La Crosse, WI-MN Houston, MN La Crosse, WI0.9837
3880Lafayette, LA Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA0.9086
Start Printed Page 56102
3920Lafayette, IN Clinton, IN Tippecanoe, IN0.9700
3960Lake Charles, LA Calcasieu, LA0.8257
3980Lakeland-Winter Haven, FL Polk, FL0.9642
4000Lancaster, PA Lancaster, PA0.9886
4040Lansing-East Lansing, MI Clinton, MI Eaton, MI Ingham, MI1.0265
4080Laredo, TX Webb, TX0.8347
4100Las Cruces, NM Dona Ana, NM0.9168
4120Las Vegas, NV-AZ Mohave, AZ Clarke, NV Nye, NV1.1891
4150Lawrence, KS Douglas, KS0.8307
4200Lawton, OK Comanche, OK0.9233
4243Lewiston-Auburn, ME Androscoggin, ME0.9876
4280Lexington, KY Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY0.9349
4320Lima, OH Allen, OH Auglaize, OH1.0071
4360Lincoln, NE Lancaster, NE1.0818
4400Little Rock-North Little Rock, AR Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR0.9523
4420Longview-Marshall, TX Gregg, TX Harrison, TX Upshur, TX0.9115
4480Los Angeles-Long Beach, CA Los Angeles, CA1.2706
4520Louisville, KY-IN Clark, IN Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY1.0133
4600Lubbock, TX Lubbock, TX0.8985
4640Lynchburg, VA Amherst, VA Bedford, VA Bedford City, VA Campbell, VA Lynchburg City, VA0.9680
Start Printed Page 56103
4680Macon, GA Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA0.9525
4720Madison, WI Dane, WI1.0993
4800Mansfield, OH Crawford, OH Richland, OH0.9260
4840Mayaguez, PR Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR0.5589
4880McAllen-Edinburg-Mission, TX Hidalgo, TX0.8909
4890Medford-Ashland, OR Jackson, OR1.0968
4900Melbourne-Titusville-Palm Bay, FL Brevard, Fl1.0542
4920Memphis, TN-AR-MS Crittenden, AR DeSoto, MS Fayette, TN Shelby, TN Tipton, TN0.9547
4940Merced, CA Merced, CA1.0578
5000Miami, FL Dade, FL1.0581
5015Middlesex-Somerset-Hunterdon, NJ Hunterdon, NJ Middlesex, NJ Somerset, NJ1.2196
5080Milwaukee-Waukesha, WI Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI1.0603
5120Minneapolis-St. Paul, MN-WI 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, WI1.1623
5140Missoula, MT Missoula, MT0.9958
5160Mobile, AL Baldwin, AL Mobile, AL0.8595
5170Modesto, CA Stanislaus, CA1.1506
5190Monmouth-Ocean, NJ Monmouth, NJ Ocean, NJ1.1539
5200Monroe, LA Ouachita, LA0.8721
Start Printed Page 56104
5240Montgomery, AL Autauga, AL Elmore, AL Montgomery, AL0.8000
5280Muncie, IN Delaware, IN1.0569
5330Myrtle Beach, SC Horry, SC0.9327
5345Naples, FL Collier, FL1.0314
5360Nashville, TN Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford TN Sumner, TN Williamson, TN Wilson, TN1.0373
5380Nassau-Suffolk, NY Nassau, NY Suffolk, NY1.4508
5483New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT Fairfield, CT New Haven, CT1.3014
5523New London-Norwich, CT New London, CT1.2257
5560New Orleans, LA Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA0.9609
5600New York, NY Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY1.5342
5640Newark, NJ Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ1.2359
5660Newburgh, NY-PA Orange, NY Pike, PA1.1818
5720Norfolk-Virginia Beach-Newport News, VA-NC Currituck, NC Chesapeake City, VA Gloucester, VA Hampton City, VA Isle of Wight, VA James City, 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, VA0.9123
Start Printed Page 56105
5775Oakland, CA Alameda, CA Contra Costa, CA1.6291
5790Ocala, FL Marion, FL1.0162
5800Odessa-Midland, TX Ector, TX Midland, TX1.0745
5880Oklahoma City, OK Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK0.9245
5910Olympia, WA Thurston, WA1.2070
5920Omaha, NE-IA Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE1.0328
5945Orange County, CA Orange, CA1.1828
5960Orlando, FL Lake, FL Orange, FL Osceola, FL Seminole, FL1.0254
5990Owensboro, KY Daviess, KY0.8863
6015Panama City, FL Bay, FL0.9636
6020Parkersburg-Marietta, WV-OH Washington, OH Wood, WV0.8649
6080Pensacola, FL Escambia, FL Santa Rosa, FL0.8891
6120Peoria-Pekin, IL Peoria, IL Tazewell, IL Woodford, IL0.9329
6160Philadelphia, PA-NJ Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA1.1641
6200Phoenix-Mesa, AZ Maricopa, AZ Pinal, AZ1.0249
6240Pine Bluff, AR Jefferson, AR0.8396
6280Pittsburgh, PA Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA1.0166
6323Pittsfield, MA Berkshire, MA1.0930
6340Pocatello, ID Bannock, ID1.0047
Start Printed Page 56106
6360Ponce, PR Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR0.6001
6403Portland, ME Cumberland, ME Sagadahoc, ME York, ME1.0025
6440Portland-Vancouver, OR-WA Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA1.1816
6483Providence-Warwick-Pawtucket, RI Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI1.1490
6520Provo-Orem, UT Utah, UT1.0467
6560Pueblo, CO Pueblo, CO0.9150
6580Punta Gorda, FL Charlotte, FL0.9587
6600Racine, WI Racine, WI0.9925
6640Raleigh-Durham-Chapel Hill, NC Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC1.0441
6660Rapid City, SD Pennington, SD0.9431
6680Reading, PA Berks, PA1.0191
6690Redding, CA Shasta, CA1.1862
6720Reno, NV Washoe, NV1.1082
6740Richland-Kennewick-Pasco, WA Benton, WA Franklin, WA1.1655
6760Richmond-Petersburg, VA 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, VA1.0292
6780Riverside-San Bernardino, CA Riverside, CA San Bernardino, CA1.1817
Start Printed Page 56107
6800Roanoke, VA Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA0.8902
6820Rochester, MN Olmsted, MN1.2189
6840Rochester, NY Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY0.9940
6880Rockford, IL Boone, IL Ogle, IL Winnebago, IL0.9788
6895Rocky Mount, NC Edgecombe, NC Nash, NC0.9687
6920Sacramento, CA El Dorado, CA Placer, CA Sacramento, CA1.2581
6960Saginaw-Bay City-Midland, MI Bay, MI Midland, MI Saginaw, MI1.0198
6980St. Cloud, MN Benton, MN Stearns, MN1.0476
7000St. Joseph, MO Andrew, MO Buchanan, MO0.8391
7040St. Louis, MO-IL 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, IL0.9497
7080Salem, OR Marion, OR Polk, OR1.0646
7120Salinas, CA Monterey, CA1.5615
7160Salt Lake City-Ogden, UT Davis, UT Salt Lake, UT Weber, UT1.0489
7200San Angelo, TX Tom Green, TX0.8713
7240San Antonio, TX Bexar, TX Comal, TX Guadalupe, TX Wilson, TX0.9128
7320San Diego, CA San Diego, CA1.1979
7360San Francisco, CA Marin, CA San Francisco, CA San Mateo, CA1.5037
Start Printed Page 56108
7400San Jose, CA Santa Clara, CA1.5093
7440San Juan-Bayamon, PR Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR0.5476
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, CA San Luis Obispo, CA1.1687
7480Santa Barbara-Santa Maria-Lompoc, CA Santa Barbara, CA1.1487
7485Santa Cruz-Watsonville, CA Santa Cruz, CA1.4856
7490Santa Fe, NM Los Alamos, NM Santa Fe, NM1.0841
7500Santa Rosa, CA Sonoma, CA1.3861
7510Sarasota-Bradenton, FL Manatee, FL Sarasota, FL1.0730
7520Savannah, GA Bryan, GA Chatham, GA Effingham, GA1.0653
7560Scranton-Wilkes-Barre-Hazleton, PA Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA0.9234
7600Seattle-Bellevue-Everett, WA Island, WA King, WA Snohomish, WA1.2082
7610Sharon, PA Mercer, PA0.8429
7620Sheboygan, WI Sheboygan, WI0.8961
7640Sherman-Denison, TX Grayson, TX0.9967
7680Shreveport-Bossier City, LA Bossier, LA Caddo, LA Webster, LA0.9624
Start Printed Page 56109
7720Sioux City, IA-NE Woodbury, IA Dakota, NE0.9323
7760Sioux Falls, SD Lincoln, SD Minnehaha, SD0.9719
7800South Bend, IN St. Joseph, IN1.0627
7840Spokane, WA Spokane, WA1.1345
7880Springfield, IL Menard, IL Sangamon, IL0.9226
7920Springfield, MO Christian, MO Greene, MO Webster, MO0.9110
8003Springfield, MA Hampden, MA Hampshire, MA1.1571
8050State College, PA Centre, PA0.9712
8080Steubenville-Weirton, OH-WV Jefferson, OH Brooke, WV Hancock, WV0.9185
8120Stockton-Lodi, CA San Joaquin, CA1.1501
8140Sumter, SC Sumter, SC0.8288
8160Syracuse, NY Cayuga, NY Madison, NY Onondaga, NY Oswego, NY1.0231
8200Tacoma, WA Pierce, WA1.2353
8240Tallahassee, FL Gadsden, FL Leon, FL0.9068
8280Tampa-St. Petersburg-Clearwater, FL Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL0.9491
8320Terre Haute, IN Clay, IN Vermillion, IN Vigo, IN0.9073
8360Texarkana, AR-Texarkana, TX Miller, AR Bowie, TX0.8855
8400Toledo, OH Fulton, OH Lucas, OH Wood, OH1.0431
8440Topeka, KS Shawnee, KS0.9477
8480Trenton, NJ Mercer, NJ1.1077
8520Tucson, AZ Pima, AZ0.9536
8560Tulsa, OK Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK0.9467
8600Tuscaloosa, AL Tuscaloosa, AL0.8689
8640Tyler, TX Smith, TX1.0252
Start Printed Page 56110
8680Utica-Rome, NY Herkimer, NY Oneida, NY0.8857
8720Vallejo-Fairfield-Napa, CA Napa, CA Solano, CA1.4422
8735Ventura, CA Ventura, CA1.1691
8750Victoria, TX Victoria, TX0.8856
8760Vineland-Millville-Bridgeton, NJ Cumberland, NJ1.1103
8780Visalia-Tulare-Porterville, CA Tulare, CA1.0239
8800Waco, TX McLennan, TX0.8645
8840Washington, DC-MD-VA-WV District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA1.1657
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 Manassas Park City, VA Prince William, VA Spotsylvania, VA Stafford, VA Warren, VA Berkeley, WV Jefferson, WV
8920Waterloo-Cedar Falls, IA Black Hawk, IA0.8551
8940Wausau, WI Marathon, WI1.0311
8960West Palm Beach-Boca Raton, FL Palm Beach, FL1.0397
9000Wheeling, WV-OH Belmont, OH Marshall, WV Ohio, WV0.8491
9040Wichita, KS Butler, KS Harvey, KS Sedgwick, KS1.0215
9080Wichita Falls, TX Archer, TX Wichita, TX0.8366
9140Williamsport, PA Lycoming, PA0.9175
9160Wilmington-Newark, DE-MD New Castle, DE Cecil, MD1.1567
9200Wilmington, NC Brunswick, NC New Hanover, NC1.0006
9260Yakima, WA Yakima, WA1.1237
9270Yolo, CA Yolo, CA1.0316
Start Printed Page 56111
9280York, PA York, PA1.0040
9320Youngstown-Warren, OH Columbiana, OH Mahoning, OH Trumbull, OH1.0170
9340Yuba City, CA Sutter, CA Yuba, CA1.1016
9360Yuma, AZ Yuma, AZ0.9559
1 This column lists each MSA area name 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 1998 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 1.063422. 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 3
9930New Hampshire1.0399
9931New Jersey 4
9932New Mexico0.9226
9933New York0.9089
9934North Carolina0.9076
9935North Dakota0.8379
9940Puerto Rico0.5520
9941Rhode Island 4
9942South Carolina0.9052
9943South Dakota0.8360
9948Virgin Islands0.7759
Start Printed Page 56112
9951West Virginia0.8579
3 Wage index values are based on FY 1998 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 1.063422. 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.
4 All counties within the State are classified as urban.

II. Waiver of Proposed Rulemaking

We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a notice such as this take effect. We can waive this procedure, however, if we find good cause that a notice and comment procedure is impracticable, unnecessary, or contrary to the public interest and incorporate a statement of the finding and its reasons in the notice issued.

We find it unnecessary to undertake notice and comment rulemaking as the statute requires annual updates to the hospice payment rates. The methodologies used to determine the wage index have been previously subject to public comments, and this notice merely reflects the application of those previously established methodologies. Therefore, for good cause, we waive notice and comment procedures.

III. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this notice as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of 1995 (Pub.L. 104-4), and Executive Order 13132. In this notice, we identified the impact on hospices as a result of updating the hospice wage index for FY 2003. 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). This notice only updates the hospice wage index in accordance with that methodology. We believe these changes to be insignificant. As Table C below indicates, we estimate that total hospice payments will increase from last year by 0.3 percent, or $12,731,000.

Executive Order 12866 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). We have determined that this notice is not an economically significant rule under this Executive Order.

The RFA requires agencies to determine whether a rule will have a significant economic impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospital and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $5 million or less annually. (For details, see the Small Business Administration's regulation that set forth size standards for health care industries (65 FR 69432)). For purposes of the RFA, most hospices are small entities. 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 and Palliative Care Organization estimates that approximately 79 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 effects of this notice indicate that on a regional basis, urban hospices in the Middle Atlantic, East North Central, West North Central, West South Central, and Pacific regions will experience a slight decrease in payments. The payment decreases range from a minimum of 0.1 percent (East North Central region) to a maximum of 0.5 percent (Middle Atlantic region). The mid-range of the decrease in estimated payments for urban hospices falls within the Pacific urban region with a 0.3-percent decrease. Rural hospices in the Pacific region will also experience a slight decrease in payment of 0.7 percent. Therefore, based on an analysis of the wage index changes for FY 2003, hospices in the urban areas of the North Central (East and West), South Central (West), and Middle Atlantic regions will be impacted the most. This payment decrease to these small entities indicates that this notice will have an impact on a substantial number of small entities. However, nationwide, hospices will receive an overall slight increase in estimated payments. We estimate that total hospice payments will increase by 0.3 percent, or $12,731,000. Urban hospices will receive an increase in estimated payments of 0.1 percent and rural hospices will receive an increase in estimated payments of 2.1 percent. Rural hospices, with exception of the Pacific region, received the largest increase in payments for FY 2003. We estimate that rural hospice payments overall will increase by $9,860,000. Specifically, rural hospices in Puerto Rico are estimated to receive a 13.6-percent increase in payments for FY 2003. This anomaly is due to an increase in hospital wage data for FY 2002.

Under the Medicare hospice benefit, hospices can provide four different levels of care days. The majority of the days provided by a hospice are routine home care days. Therefore, the number of routine home care days can be used as a proxy for the size of the hospice, that is, the more days of care provided, the larger the hospice. Using routine home care days as a proxy for size, our analysis indicates that, overall, the impact of the wage index update on small hospices will be positive. For example, the smallest hospices (those that provide only up to 1,754 days of routine home care) will experience an approximately 4.2 percent increase in hospice payments as a result of the wage Start Printed Page 56113update. Overall, hospices will experience a positive increase in payments. Therefore, we certify that this rule will not have a significant impact on a substantial number of small entities, in accordance with the RFA. Furthermore, the wage index methodology 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 all of the options considered, the committee agreed on the methodology described in the committee statement, and it was adopted into regulation in the August 8, 1997 final rule. The committee also agreed that this was favorable for the hospice community, as well as for beneficiaries. In developing the process for updating the wage index in the 1997 final rule, we fully considered the impact of this methodology on small entities and attempted to mitigate any potential negative effects.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside an MSA and has fewer than 100 beds. We have determined that this rule will not have a significant impact on the operations of a substantial number of small rural hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in an expenditure in any 1 year by State, local, and tribal governments, in the aggregate, or by the private sector, of $110 million or more. This 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. We have determined that this rule will not have a significant impact on the operations of a substantial number of small rural hospitals.

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

B. Anticipated Effects

We have compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2003 wage index and determined the current hospice rates to be budget-neutral. This impact analysis compares hospice payments using the FY 2002 hospice wage index to the estimated payments using the FY 2003 wage index. The data used in developing the quantitative analysis for this notice were obtained from the March 2002 update of the national claims history file of all bills submitted during FY 2001. We deleted bills from hospices that have since closed.

Table C below 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 2002 wage index. Column 4 of Table C is based on FY 2001 claims (for hospices in business during that time period) and estimates payments to be made to hospices using the FY 2003 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 1,327 hospices located in urban areas and 854 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 2001. 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 South Central, Mountain and Puerto Rico regions, with a 7.2 percent, 2.5 percent, and 13.6 percent increase, respectively. The greatest decreases in payment are for urban areas in the Middle Atlantic and Pacific regions.

The breakdown by size, type of ownership, and facility base showed an increase in payments to almost all hospice programs. Small hospice programs showed significant increases of about 4 percent, while larger programs experienced only a negligible increase. In terms of hospice base, hospital-based hospices showed the greatest estimated payment increase while hospices affiliated with skilled nursing facilities showed the smallest amount of payment increase.

Table C.—Impact of Hospice Wage Index Change

By Geographic LocationNumber of HospicesNumber of Routine Home Care Days in ThousandsPayments using FY 2002 Wage Index in ThousandsEstimated Payments using FY 2003 Wage Index in ThousandsPercent Change in Hospice Payments
All Hospices2,18128,2493,684,0273,696,7580.3
Urban Hospices1,32723,7053,207,2083,210,0780.1
Rural Hospices8544,545476,820486,6802.1
By Region—Urban:
New England87755116,018116,6110.5
Middle Atlantic1662,651380,513378,736-0.5
South Atlantic1845,216755,293759,2510.5
Start Printed Page 56114
East North Central2243,861515,761515,007-0.1
East South Central981,639191,446192,4980.5
West North Central971,443170,906170,654-0.1
West South Central1833,337415,324414,764-0.1
Puerto Rico2828321,60422,0352.0
By Region—Rural:
New England27849,9429,9950.5
Middle Atlantic3420022,72122,7700.2
South Atlantic12793299,489101,2821.8
East North Central13967572,90473,1090.3
East South Central8879278,89780,3631.9
West North Central18049953,25153,9311.3
West South Central10570764,84669,5257.2
Puerto Rico4281,9112,17113.6
Routine Home Care Days:
0-1,754 Days34230935,32436,8114.2
1,754-4,373 Days4451,337149,372151,6001.5
4,373-9,681 Days5433,698433,227437,2930.9
Type of Ownership:
Hospice Base:
Home Health Agency6616,184808,876810,7400.2
Skilled Nursing Facility1715823,61723,604-0.1

C. Conclusion

Our impact analysis compared hospice payments using the FY 2002 wage index to the estimated payments using the FY 2003 wage index. Through the analysis, we estimate that total hospice payments will increase from last year by 0.3 percent, or $12,731.000. Additionally, we compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2003 wage index and determined the current hospice wage index to be budget neutral, as required by the negotiated rulemaking committee. We have determined that this rule is not an economically significant rule under Executive Order 12866. We do believe that this rule will not have a significant economic impact on a substantial number of small entities, but took any negative effects into consideration during the negotiated rulemaking process. We have determined that this rule will not have a significant impact on the operations of a substantial number of small rural hospitals. Finally, this rule will have no consequential effect on State, local, or tribal governments.

OMB Review

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

Start Authority

Authority: Section 1814(i) of the Social Security Act (42 U.S.C. 1395f (i)(1))(Catalog of Federal Domestic Assistance Program No. 93.773 Medicare—Hospital Insurance Program; and No. 93.774, Medicare—Supplementary Medical Insurance Program)

End Authority Start Signature

Dated: June 20, 2002.

Thomas A. Scully,

Administrator, Centers for Medicare & Medicaid Services.

Dated: July 23, 2002.

Tommy G. Thompson,


End Signature End Supplemental Information

[FR Doc. 02-22018 Filed 8-29-02; 8:45 am]