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Proposed Rule

Medicare Program; Proposed Hospice Wage Index for Fiscal Year 2006

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AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

This proposed rule would set forth the hospice wage index for fiscal year 2006 and identifies the revised labor market and metropolitan statistical areas. This proposed rule would also codify provisions of sections 408 and 946 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 28, 2005.

ADDRESSES:

In commenting, please refer to file code CMS-1286-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of three ways (no duplicates, please):

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/​regulations/​ecomments. (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1286-P, P.O. Box 8012, Baltimore, MD 21244-8012.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members.

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850.

(Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

Submission of comments on paperwork requirements. You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the “Collection of Information Requirements” section in this document.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

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FOR FURTHER INFORMATION CONTACT:

Terri Deutsch, (410) 786-9462.

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SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1286-P and the specific “issue identifier” that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. CMS posts all electronic comments received before the close of the comment period on its public website as soon as possible after they have been received. Hard copy comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

I. Background

A. General

1. Hospice Care

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 for relief of pain and for symptom management. 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 services 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. Section 1824(i) of the Act provides payment for Medicare-participating hospices.

2. Medicare Payment for Hospice Care

Our regulations at 42 CFR part 418 establish eligibility requirements, payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Part 418 subpart G provides for payment in one of four prospectively-determined rate categories (routine home care, continuous home care, inpatient respite care, and general inpatient care) to hospices based on each day a qualified Medicare beneficiary is under a hospice election.

B. Hospice Wage Index

The hospice wage index is used to adjust payment rates for hospice agencies under the Medicare program to reflect local differences in area wage levels. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data and had not been updated since 1983. In 1994, because of disparity in wages from one geographical location to another, a committee was formulated to negotiate a wage index methodology that could be accepted by the industry and the government. This committee, functioning under a process established by the Negotiated Rulemaking Act of 1990, was comprised of national hospice associations; rural, urban, large, and small hospices; multisite hospices; consumer groups; and a government representative. On April 13, 1995, the Hospice Wage Index Negotiated Start Printed Page 22395Rulemaking Committee signed an agreement for the methodology to be used for updating the hospice wage index.

1. Updates to the Hospice Wage Index

In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a new methodology for calculating the hospice wage index based on the recommendations of the negotiated rulemaking committee. The committee statement was included in the appendix of that final rule (62 FR 42883). The provisions of the final rule specified that the revised hospice wage index was to be— (1) calculated using the most current available hospital wage data; and (2) 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. The revised wage index was fully implemented during the third year of the transition period, October 1, 1999 through September 30, 2000.

The annual update to the hospice wage index is published in the Federal Register and is based on the most current available hospital wage data, as well as any changes by the Office of Management and Budget (OMB) to the definitions of Metropolitan Statistical Areas (MSAs). Raw wage index values (inpatient hospital pre-floor and pre-reclassified wage index values) (as described in the August 8, 1997 hospice wage index final rule (62 FR 42860)) are subject to either a budget neutrality adjustment or application of the wage index floor. Raw wage index values of 0.8 or greater are adjusted by the budget neutrality adjustment factor. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated wage index values will equal estimated payments that would have been made for these services if the 1983 wage index values had remained in effect. To achieve this budget neutrality, the raw wage index is multiplied by a budget neutrality adjustment factor. The budget neutrality adjustment factor is computed and applied annually. The budget neutrality adjustment factor is calculated by comparing what we would have paid using current rates and the 1983 wage index to what would be paid using current rates and new wage index.

Raw wage index values below 0.8 are adjusted by the greater of: (1) The hospice budget neutrality adjustment factor; or (2) the hospice wage index floor (a 15 percent increase) subject to a maximum wage index value of 0.8.

C. Hospice Provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

On December 8, 2003, the Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-173). This legislation provided for the following provisions affecting hospice services:

  • Section 408, Recognition of Attending Nurse Practitioners as Attending Physicians to Serve Hospice Patients.
  • Section 512, Coverage of Hospice Consultation Services.
  • Section 946, Authorizing Use of Arrangements to Provide Core Hospice Services in Certain Circumstances.

Section 408 of the MMA amended sections 1861(dd)(3)(B) and 1814(a)(7) of the Act to add nurse practitioners (NPs) to the definition of an attending physician for beneficiaries who have elected the hospice benefit. In other words, if a beneficiary's primary care provider before the determination of the terminal illness and election of the hospice benefit is an NP, the NP can remain as the attending physician, if the beneficiary chooses, after a hospice election. If the beneficiary does not have an attending physician or NP at the time of the terminal diagnosis, the beneficiary may choose to designate either a physician or an NP as his or her attending physician when electing the hospice benefit. Section 408 of the MMA was implemented through an administrative issuance (Change Request (CR) 3226, Transmittals 22 and 304, September 24, 2004).

Section 512 of the MMA provides for a one-time evaluation and consultation to Medicare beneficiaries who have been determined to have a 6-month prognosis if the disease runs its normal course, and who require the expertise of the medical director or physician employed by a hospice in order to be able to make end-of-life decisions. This provision was implemented in the CY 2005 Physician Fee Schedule final rule published in the November 15, 2004 Federal Register (69 FR 66335) and is incorporated in our regulations at § 418.205 and § 418.304(d).

Section 946(a) of the MMA allows a hospice program “in extraordinary, exigent, or other non-routine circumstances, such as unanticipated period of high patient loads, staffing shortages due to illness or other events, or temporary travel of a patient outside a hospice program's service area, * * * “ to enter into arrangements with another hospice program to provide services to beneficiaries. Section 946(b) of the MMA provides that “in the case of hospice care provided by a hospice program under arrangement under section 1861(dd)(5)(D) made by another hospice program, the hospice program that made the arrangements shall bill and be paid for the hospice care.” In section II.B.2 of this proposed rule, we discuss our proposal to revise the regulations to implement payment for hospice services made under arrangements. We will address the implementation of section 946(a) of the MMA in a future rulemaking document.

II. Provisions of the Proposed Rule

A. Hospice Wage Index for FY 2006

1. Revised OMB Definition for Geographical Statistical Areas

As required by § 418.306(c), each hospice's labor market is established using the MSA definitions issued by OMB. In the September 4, 1996 hospice wage index proposed rule (61 FR 46579), we explained that the MSA definitions were issued by OMB on December 28, 1992, based on the 1990 census, and updated by OMB based on the decennial census. In accordance with our regulations, changes to the MSA definitions are announced in a Federal Register notice.

In the August 27, 2004 Federal Register (69 FR 52710), we published a notice with respect to the hospice wage index for FY 2005. In that notice, we acknowledged that on June 6, 2003, OMB issued OMB Bulletin No. 03-04 announcing revised definitions for MSAs, new definitions for Micropolitan Statistical Areas and Combined Statistical Areas, and guidance on using the statistical definitions. (A copy of the Bulletin may be obtained at the following Internet address: http://www.whitehouse.gov/​omb/​bulletins/​b03-04.html.) In addition, we noted that we would not address the new OMB definitions because the wage data used to calculate the FY 2005 hospice wage index (FY 2004 hospital wage data) did not reflect revisions based on the new definitions. We indicated that the new OMB definitions would be addressed in the FY 2006 wage index update.

a. Background

In general, OMB defines an urban area as a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). A rural area is defined Start Printed Page 22396as any area outside of the urban area. Any area not included in an MSA is considered to be nonurban and receives the statewide rural rate.

Under the hospital inpatient prospective payment system (IPPS), the wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located or geographically reclassified under sections 1886(d)(8) and (d)(10) of the Act. In accordance with our regulations for hospice payment, we also use MSAs to define labor market areas, but the application differs from IPPS. Section 1814(i)(2)(D) of the Act requires Medicare to pay for hospice services based on the geographic location where the service is furnished. The wage index value used is based upon the location of the beneficiary's home for routine home care and continuous home care and the location of the hospice agency for general inpatient and respite care.

In this proposed rule, we will address the new OMB definitions and their application to the hospice wage index. Since our regulations require the use of the IPPS wage data as the basis for determining the hospice wage index, we are providing the following summary of the revised geographical statistical areas adopted in the FY 2005 IPPS final rule. (For a more detailed discussion of the changes in the hospital wage index based on the new OMB definitions see the FY 2005 IPPS proposed and final rules published May 18, 2004 (69 FR 28196) and August 11, 2004 (69 FR 48916).)

b. Current Labor Market Areas Based on MSAs

As discussed in the FY 2005 IPPS final rule, “the [hospital] wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located.” In addition, the IPPS final rule (69 FR 49026) defined hospital labor markets as follows:

We currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by OMB. OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital wage index, we use the PMSAs rather than CMSAs because they allow a more precise breakdown of labor costs. If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA.

These different designations use counties as the building blocks upon which they are based. Therefore, hospitals are assigned to either an MSA, PMSA, or NECMA based on whether the county in which the hospital is located is part of that area. For purposes of the IPPS wage index, we combine all of the counties in a State outside a designated MSA, PMSA, or NECMA together to calculate a statewide rural wage index.

c. Core-Based Statistical Areas

In the December 27, 2000 Federal Register (65 FR 82228 through 82238), OMB announced its new standards and in that notice, OMB defined a Core-Based Statistical Area (CBSA), beginning in 2003, as “a geographic entity associated with at least one core of 10,000 or more population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties.” The standards designate and define two categories of CBSAs: MSAs and Micropolitan Statistical Areas (65 FR 82235).

According to OMB, MSAs are based on urbanized areas of 50,000 or more population, and Micropolitan Statistical Areas (referred to in further discussion as Micropolitan Areas) are based on urban clusters of at least 10,000 population but less than 50,000 population. Counties that do not fall within CBSA (either MSA or Micropolitan Areas) are deemed “Outside CBSAs.” In the past, OMB defined MSAs around areas with a minimum core population of 50,000, and smaller areas were “Outside MSAs.”

In its June 6, 2003 bulletin, OMB announced the new CBSAs, comprised of MSAs and the new Micropolitan Areas based on Census 2000 data. The new CBSA designations recognize 49 new (urban) MSAs and 565 new Micropolitan Areas, and revised the composition of many of the existing (urban) MSAs. There are 1,090 counties in MSAs under these new CBSA designations compared with 848 counties in the previous MSAs. Of these 1,090 counties, 737 are in the same MSA as they were before the changes, 65 are in different MSAs, and 288 were not previously designated to any MSA. There are 674 counties in Micropolitan Areas. Of these, 41 were previously in an MSA, while 633 were not previously designated to an MSA.

d. Revised Labor Market Areas

As discussed in the FY 2005 IPPS final rule (69 FR 49027), alternatives to the use of MSAs for the purpose of establishing labor market areas for the Medicare wage index were examined. In the May 27, 1994, IPPS proposed rule (59 FR 27724), the latest research concerning possible future refinements to the labor market areas was presented. Public comments received on the May 27, 1994 proposed rule were described in the June 2, 1995 proposed rule (60 FR 29219). In that rule, it was noted that there was no consensus among commenters on the choice for new labor market areas. Consequently, MSAs have continued to be used to define labor market areas for purposes of the wage index by many Medicare payment systems as noted in previous discussion.

(1) New England County Metropolitan Areas

NECMAs are currently used to define labor markets areas in New England, “* * * because these are county-based designations rather than the 1990 MSA definitions for New England which used minor civil divisions such as cities and towns.” Under the CBSA definition, “OMB has defined the MSAs and Micropolitan Areas in New England on the basis of counties. OMB also established New England City and Town Areas, which are similar to the previous New England MSAs.” Therefore, to maintain consistency in the definition of labor market areas between New England and the rest of the country, IPPS decided to use the New England MSAs under the new CBSA definition.

(2) Metropolitan Divisions

Under OMB's new CBSA designations, a Metropolitan Division is a county or group of counties within a CBSA that contains a core population of at least 2.5 million, representing an employment center, plus adjacent counties associated with the main county or counties through commuting lines. For the hospital wage index the PMSAs are used rather than CMSA to define labor market areas “because they comprise a smaller geographic area with potentially varying labor costs due to different local economies.”

(3) Micropolitan Areas

The IPPS final rule noted the following regarding the use of Micropolitan Areas to define labor markets (69 FR 49029):

One of the major issues with respect to the new definitions is whether to use Micropolitan Areas to define labor market areas for the purpose of the IPPS wage index. Because the new Micropolitan Areas are essentially a third area definition made up mostly of currently rural areas, but also some or all of current MSAs, how these areas are treated will have significant impacts on the calculation and application of the wage index. Treating Micropolitan Areas as separate and distinct labor market areas would affect both the wage indexes of the hospitals in the Micropolitan Areas and the Start Printed Page 22397hospitals in the labor market areas where those hospitals are currently located (both positively and negatively).

Because we currently use MSAs to define urban labor market areas and we group all the hospitals in counties within each State that are not assigned to an MSA together into a statewide rural labor market area, we have used the terms “urban” and “rural” wage indexes in the past for ease of reference. However, the introduction of Micropolitan Areas complicates this terminology because these areas include so many hospitals that are currently included in the statewide rural labor market areas. In order to facilitate the discussion below, we use the term “rural” hospitals to describe hospitals in counties that are not assigned to either an MSA or a Micropolitan Area. This should not be taken to indicate that hospitals in Micropolitan Areas are no longer “rural” hospitals. In fact, we proposed that hospitals in Micropolitan Areas are included in the statewide rural labor market areas, for the reasons outlined below.

2. Annual Update to the Hospice Wage Index

(If you choose to comment on issues in this section, please include the caption “Annual Update to the Hospice Wage Index” at the beginning of your comments)

a. Background

Section 418.306(c) requires that we issue annually in the Federal Register, hospice wage index based on our most current available hospital wage data, including any changes to the definitions of MSAs.

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 FYs 1998 through 2002. Hospice rates were to be updated by a factor equal to the hospital market basket index, minus 1 percentage point. However, neither the BBA nor subsequent legislation specified the hospital market basket adjustment to be used to compute payment for FY 2006. Therefore, payment rates for FY 2006 will be updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which specifies that the update to the payment rates after FY 2002 will be the hospital market basket percentage increase for the fiscal year. This rate update is implemented via administrative issuance to be published July 2005 to provide adequate time to implement system change requirements and is not part of this proposed rule.

The hospice wage index presented in this proposed rule would be effective October 1, 2005 through September 30, 2006. We note that we are not proposing any modifications to the hospice wage index methodology. In accordance with the our regulations and the agreement signed with other members of the Hospice Wage Index Negotiated Rulemaking Committee, we will continue to use the most current hospital data available to adjust for area wage differences. For this proposed rule, the FY 2005 hospital wage index was the most current hospital wage data available when the FY 2006 wage index values were calculated. We continue to use the pre-reclassified and prefloor hospital area wage index data. Payment rates for each of the four levels of care (routine home care, continuous home care, respite care, and general inpatient care) are adjusted annually based upon the hospital market basket for that year and are promulgated administratively to allow for sufficient time for system changes and provider notification. Due to the need to ensure appropriate time for implementing changes, we have not incorporated these payment rates into this proposed rule.

The payment rates are divided into the labor and nonlabor portions. The appropriate wage index value is applied to the labor portion of the hospice rate based on the geographic area in which the beneficiary resides when receiving routine home care or continuous home care. The appropriate wage index value is applied to the labor portion of the hospice rate based on the geographic area of the hospice agency for beneficiaries receiving general inpatient or respite level of care.

We use the previous fiscal year's hospital wage index data to calculate the hospice wage index values. For FY 2006 proposed hospice wage index, we use the FY 2005 hospital prefloor and pre-reclassified hospital wage data. This means that the hospital wage data used for the hospice wage index is not adjusted to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886 (D)(10) of the Act. All wage index values for FY 2006 would be adjusted by either by the proposed FY 2006 budget neutrality adjustment factor, 1.063479, or the wage index floor adjustment. This means, that for wage index values 0.8 or greater, the value is multiplied by the budget neutrality adjustment factor. For wage index values that are below 0.8, either the budget neutrality adjustment factor or the wage index floor, not to exceed 0.8, is applied. In other words, the floor adjustment is the greater of the raw wage index value multiplied by the proposed budget neutrality adjustment factor (1.063479 for FY 2006) or the raw wage index value for that area is multiplied by 15 percent subject to a maximum value of 0.8. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated wage index will equal estimated payments that would have been made for the same services if the wage index adopted for hospices in 1983 had remained in effect. (For a detailed discussion of the methodology used to compute the hospice wage index see the September 4, 1996 proposed rule (61 FR 46579) and the August 8, 1997 final rule (62 FR 42860)). The proposed FY 2006 hospice wage indexes for urban and rural areas are listed in Tables A and B of the Addendum.

b. Implementation of the Revised Labor Market Designations

(If you choose to comment on issues in this section, please include the caption “Implementation of Revised Labor Market Designations” at the beginning of your comments)

For the hospice payment system, § 418.306(c) requires that the hospice wage index be “based on the most current available CMS hospital wage index, including any changes to the definitions of Metropolitan Statistical Areas.” We continue to believe MSAs are a reasonable and appropriate proxy for developing geographic areas for purposes of adjusting for wage differences in hospice. We also note that MSAs are used to define labor market areas for purposes of the wage index for many of the other Medicare payment systems (for example, long term care hospital (LTCH) prospective payment system (PPS), inpatient rehabilitation facility (IRF) PPS, home health agency (HHA) PPS, skilled nursing facility (SNF) PPS, Outpatient PPS and inpatient psychiatric facility (IPF) PPS.

First, historically, Medicare prospective payment systems have used metropolitan area (MA) definitions developed by OMB. For example, in adopting the MSA designation for the IPPS area labor adjustment, the Secretary stated:

[i]n administering a national payment system, we must have a national classification system built on clear, objective standards. Otherwise the program becomes increasingly difficult to administer because the distinction between rural and urban hospitals is blurred. We believe that the MSA system is the only one that currently meets the requirements for use as a classification system in a national payment program. The MSA classification system is a statistical standard developed for use by Federal agencies in the production, analysis, and publication of data on metropolitan areas. The standards have been developed with the aim of producing definitions that will be consistent as possible for all MSAs nationwide.” (49 FR 27426).

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In addition, in numerous instances, the Congress has recognized that the areas developed by OMB may be used for differentiating among geographic areas for Medicare payment purposes. For example, in the IPPS statutory section, section 1886(d)(2)(D) of the Act, the Congress defines an “urban area” as “an area within a Metropolitan Statistical Area (as defined by the Office of Management and Budget) or within such similar area as the Secretary has recognized.” Similarly, in the sections of the statute governing the guidelines to be used by the Medicare Geographic Classification Review Board for purposes of reclassification, sections 1886(d)(10)(A) and (D)(i)(II) of the Act, the Congress directed the Secretary to create guidelines for “determining whether the county in which the hospital is located should be treated as being part of a particular [MSA].” Thus, the Congress has accepted and ratified the use of MSAs as an inherently rational manner of dividing up labor-market areas for purposes of Medicare payments.

The process used by OMB to develop the MSAs creates geographic areas that are based upon characteristics we believe also generally reflect the characteristics of unified labor market areas. For example, the CBSAs reflect a core population plus an adjacent territory that reflects a high degree of social and economic integration. This integration is measured by commuting ties, thus demonstrating that these areas may draw workers from the same general areas. In addition, the most recent CBSAs reflect the most up to date information. OMB reviews its MA definitions preceding each decennial census to reflect recent population changes, and the CBSAs are based on the Census 2000 data. Finally, in the context of the inpatient prospective payment system, we have reviewed alternative methods for determining geographic areas for purposes of the wage index, and in each case, have determined to remain with the OMB designations rather than replace these designations with alternatives.

As stated previously, § 418.306(c) requires the hospice wage index to reflect changes to the definitions of MSA. Therefore, we are proposing to adopt the revised labor market area designations based on OMB's CBSA designations.

For the proposed FY 2006 hospice wage index, we would adopt the CBSA designations as finalized in the FY 2005 IPPS. We believe that OMB's CBSA designations, based on Census 2000 data reflect the most recent available geographic classifications (MA definitions). We are not proposing to change at this time, the methodology derived as a result of the negotiated rulemaking committee. We believe that there are factors which require evaluation to determine if the hospice methodology supports the cost of providing hospice services and if the methodology requires modification.

As discussed in the IPPS final rule (69 FR 49032), when the IPPS adopted the revised labor market areas based on OMB's new CBSA designations on October 1, 2004, IPPS established a transition to the new designations to mitigate the resulting adverse impact on certain hospitals. Section 1814(i)(1)(A) of the Act requires hospice payment to be based on “costs which are reasonable and related to the cost of providing hospice care or which are based on such other tests of reasonableness the Secretary may prescribe in regulations * * *.” Our regulations at § 418.306(c) require us to issue annually in the Federal Register “ a hospice wage index based on the most current available CMS hospital data wage data, including any changes to the definitions of Metropolitan Statistical Areas.” This language would not seem to permit us to establish a transition to the new CBSA designations. In addition, unlike IPPS and other payment systems where each entity uses a single MSA (CBSA), hospice agencies may use various wage indices to compute their payments based upon the location of the beneficiary for routine and continuous home care or the MSA (CBSA) for the location of the agency for respite and general inpatient care. The methodology for applying the hospice floor (15 percent) to wage index values below 0.8 is used to leverage areas where there are significantly low wage index values. Moreover, we do not believe that in the aggregate, hospice agencies would be impacted negatively by the new CBSA designations. The existing methodology of computing the hospice wage index, the annual calculation of the hospice payment rates based upon the market basket index, and the variability of CBSAs that may be attributed to different hospice agencies are sufficient to mitigate adverse effects on individual hospice agencies. While we understand that there are CBSAs that decrease based upon the new definitions, there are those that are positively affected. For example, many counties that have been included in the rural definitions under the MSA designations are now designated as urban areas under the CBSA will generally receive an increase in their wage index. We believe that adjustments made to CBSAs because of negative impact would necessitate adjustment to CBSAs that are positively impacted. Variability and changes in wage indices both positively and negatively have occurred under the MSA designations and occur as a result of geographic differences. As a result, we propose to adopt the CBSA definitions and resulting wage indices without transitions. The impact of the CBSA designations is discussed in section V of this proposed rule.

In adopting the CBSA designations, we identified that there were no IPPS hospitals and thus no hospital wage index data on which to base the calculation of the FY 2006 hospice wage index for rural Massachusetts. Because there is no reasonable proxy for more recent rural data within Massachusetts, we are proposing to use the prefloor, preclassified hospital wage index data for FY 2005 and apply the FY 2006 proposed budget neutrality factor of 1.063479. In the event that future rural areas do not have hospital wage index data to derive a hospice wage index, we propose to use a comparable methodology to derive a wage index. Similarly, if there urban areas without hospital wage index data, we propose to use all of the urban areas within the State as a reasonable proxy. We are soliciting comment on these approaches to calculating the wage index value for areas without hospital wage data for FY 2006 and subsequent years.

To facilitate an understanding of the policies related to the proposed changes in the hospice wage index discussed in section II.A of this proposed rule, we are providing the following tables in the Addendum to this proposed rule:

  • Table A—Proposed Hospice Wage Index for Urban Areas by CBSA.
  • Table B—Proposed Hospice Wage Index for Rural Areas by CBSA.
  • Table C—Comparison of Hospice Wage Index for Urban Areas by MSA and CBSA. This table lists the counties by MSA designation and the wage index if we had retained the use of MSAs. It also presents the CBSA designation for these counties and the corresponding wage index using the CBSA designations. The MSA designations include those counties that were classified as rural and indicated the State rural MSA code and the corresponding CBSA for these counties which under the CBSA designation are now urban. We note that some counties that are classified as rural under the MSA designation would become rural under the new CBSA designation and vice versa.
  • Table D—Comparison of the Hospice Wage Index for Rural Areas by MSA and CBSA. This table compares Start Printed Page 22399the State rural MSA designations and their corresponding wage indices to the CBSA designations and their respective wage indices.
  • Table E—Rural Counties Converting to Urban Counties by State. This table presents the rural counties that under the CBSA designations convert to urban counties. The list includes the county name, State county code, MSA designation, MSA name, CBSA name, and CBSA designation. Please note that these conversions are based on the OMB designations.
  • Table F—Crosswalk of Counties by State from MSA to CBSA. This table crosswalks all counties in each State from MSA to CBSA and includes the State, State county code, MSA designation, MSA name, CBSA designation, and CBSA name. These tables will assist providers in identifying their location and their catchment area(s) by their previous designations and their CBSA designation as well as the wage indices for those areas based upon the previous MSA designations as well as the CBSA designations.

3. Labeling Error in the Hospice Wage Index

We have discovered an error in the labeling of the wage index tables that we have been publishing in the annual hospice wage index update. That labeling error is the listing of Stanly County, North Carolina as one of the areas under MSA 1520 when, in fact, we consider Stanly County, NC to be a rural area in North Carolina. Stanly County wage data have always been correctly treated as rural in the actual creation of the hospice wage index values, and it has only been the listing of Stanly County under MSA 1520 that was in error. Consequently, we are correcting our labeling error from past notices for the hospice and have removed Stanly County from the list of areas that fall under the MSA 1520 wage index. Since this is strictly a ministerial correction that does not affect the actual computation of the wage index values, hospice providers in and beneficiaries who reside in Stanly County and receive routine home and continuous home care in Stanly County will continue to fall under, and use, the wage index for rural North Carolina.

B. Proposed Changes To Implement Hospice-Related Provisions of the MMA

(If you choose to comment on issues in this section, please include the caption “MMA Provisions” at the beginning of your comments)

In section I.C of this proposed rule, we note that section 408 of the MMA was effective upon enactment and initially implemented through administrative issuances. This proposed rule would incorporate the provisions in regulation.

1. Coverage of Nurse Practitioner as Attending Physician in Hospice (Section 408 of the MMA)

Section 408 of the MMA amended sections 1861(dd)(3)(B) and 1814(a)(7) of the Act to add nurse practitioners (NPs) to the definition of an attending physician, for beneficiaries who have elected the hospice benefit. In other words, if a beneficiary's primary care provider is an NP, before the determination of the terminal illness and election of the hospice benefit, the NP can remain as the attending physician, if chosen by the beneficiary. If the beneficiary does not have an attending physician or NP, the beneficiary must be provided with an option of either a physician or an NP (if available and if allowed by State law) to serve as the attending physician. An NP is defined as a registered nurse who performs such services as he or she is legally authorized to perform (in the State in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets the training, education, and experience requirements as the Secretary may prescribe.

As discussed in Change Request 3226 (Transmittals 22 and 304, September 24, 2004), beginning December 8, 2003, Medicare pays for medically reasonable and necessary services provided by NPs to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician. Nurse practitioners are paid 85 percent of the fee schedule amount for their services as attending physicians. Services for the terminal and related conditions provided by an NP—

  • Serving as the attending physician that are medical in nature must be reasonable and necessary and must be services that, in the absence of an NP, would be performed by a physician; and
  • May not be separately billed if the—

++ Services would not be reasonable and necessary if provided by an attending physician;

++ NP is not the patient's attending physician; or

++ Services would be performed by a registered or licensed nurse in the absence of a physician or nurse practitioner.

Since NPs are not physicians, as defined in 1861(r)(1) of the Act, they may not act as medical directors or physicians of the hospice or certify the beneficiary's terminal illness and hospices may not contract for their attending physician services as described in 1861(dd)(2)(B)(i)(III) of the Act. All of these provisions apply to NPs without regard to whether they are hospice employees.

We are proposing to revise § 418.3, 418.22(c)(1)(ii), and § 418.304 to implement the provisions of section 408 of the MMA.

2. Payment for Authorizing Use of Arrangements To Provide Hospice Service Under Certain Circumstances (Section 946 of the MMA)

Section 946(a) of the MMA amended section 1861(dd)(5) of the Act by adding the following: “(D) In extraordinary, exigent, or other non-routine circumstances, such as unanticipated periods of high patient loads, staffing shortages due to illness or other events, or temporary travel of a patient outside a hospice program's service area, a hospice program may enter into arrangements with another hospice program for the provision by that other program of services described in paragraph (2)(A)(ii)(I).” Section 946(a) of the MMA is discussed in this proposed rule to assist the reader in understanding how hospices will be reimbursed for these types of arrangements. We will issue more specific regulations regarding section 946(a) of the MMA in future rulemaking.

Section 946(b) of the MMA amended section 1814(i) of the Act to add the following: “(5) In the case of hospice care provided by a hospice program under arrangements under section 1861(dd)(5)(D) made by another hospice program, the hospice program that made the arrangements shall bill and be paid for the hospice care.” This means that the hospice that establishes the contractual arrangement with the hospice that will be providing services to the beneficiary, continues to bill for and receive payment during the hospice election.

Section 4442 of the BBA amended section 1814(i)(2) of the Act, effective for services furnished on or after October 1, 1997, to require hospice agencies to submit claims for payment for hospice services furnished in an individual's home on the basis of the geographic location at which the service is furnished. Therefore, the methodology for applying the wage index to the labor portion of the payment rates remains the same. This means that the wage index for routine and continuous home care would reflect the place where the service is provided, Start Printed Page 22400which may be outside of the hospice program's service area during periods of temporary travel. We do not propose in this rule to define “temporary travel” since this would depend upon individual needs and abilities determined by the interdisciplinary group, the beneficiary, and his or her family. The wage index for general inpatient care would reflect the MSA for the hospice agency that retains management responsibility. Payment will continue to be made to the hospice agency for which the beneficiary has made the election. We are proposing to revise § 418.302(d) to implement this provision.

III. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995, we are required to provide 30-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:

  • The need for the information collection and its usefulness in carrying out the proper functions of our agency.
  • The accuracy of our estimate of the information collection burden.
  • The quality, utility, and clarity of the information to be collected.
  • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

Section 418.22(c)(1) requires for the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from the individual's attending physician, if the individual has an attending physician, that meets the definition of physician specified in § 410.20 of this subchapter.

While this requirement is subject to the PRA it is currently approved by OMB under control number 0938-0302, “ICRs in Hospice Care Regulation and Supporting Regulations”, with a current expiration date of September 30, 2006.

IV. Response to Comments

Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.

V. Regulatory Impact Analysis

(If you choose to comment on issues in this section, please include the caption “Impact Analysis” at the beginning of your comments)

A. Overall Impact

We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. We estimated the impact on hospices, as a result of the proposed changes to the FY 2006 hospice wage index. As discussed previously, 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 proposed rule updates the hospice wage index in accordance with our regulation and that methodology, incorporating the adoption of the CBSA designations used in the hospital wage index data. Table I reflects the proposed hospice wage index impact using the CBSA designations. Table II indicates the proposed wage index impact using the hospice wage indices under the MSA designations as well as the CBSA designations.

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 an MSA and has fewer than 100 beds. We have determined that this proposed rule would 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 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 proposed rule would have no substantial effect on State, local, or tribal governments or on the private sector.

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. We have reviewed this proposed rule under the threshold criteria of Executive Order 13132, Federalism, and have determined that it would not have an impact on the rights, roles, and responsibilities of State, local, or tribal governments.

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

1. Hospice Size

The impact of hospice wage index changes have been analyzed according to type of hospice, geographic location, type of ownership, hospice base, and hospice size. Hospice size was determined by the number of routine home care days (RHC). Since routine home care days account for over 70 percent of the services provided by a hospice, we used RHC days as a proxy for the size of the hospice agency. In the past, we had, designated the size by four categories: (1) 0 to 1,754 RHC days representing small agencies; (2) 1,754 to 4,373 RHC days or (3) 4,373 to 9,681 RHC days representing medium-sized agencies; and (4) 9,681 RHC days or more representing large agencies.

To determine the statistical distribution of RHC days, based upon the total number of hospice agencies and their respective RHC days using FY 2003 claims processed through March 2004, were used. In determining the statistical distribution, we deleted data for four hospice agencies with RHC days that greatly exceeded the total number of RHC days of other agencies. However, these data have been included in the impact analysis since we recognize that the skewness existed in the “large” agency size distribution using four size categories and does not change with the use of three size categories.

Based upon this analysis, we are using only three size designations to present the impact analyses. We believe that these three designations better describe the size of the hospice. The three categories are: Small agencies having 0 to 3,499 RHC days; medium agencies having 3,500 to 19,999 RHC days; and large agencies having 20,000 or more RHC days.

2. Impact on Hospices

Our discussions for this proposed rule will focus on the impact of adopting the Start Printed Page 22401CBSA designations. Table I indicates the impact of using the proposed CBSA designations. Table II provides a comparison between impact using the MSA and CBSA designations. As discussed above, we use the latest claims file available to us to develop the impact table when we issue the annual yearly wage index update. For the purposes of this proposed rule, we used the 2003 claims that were processed through June 2004 since this was the latest file available. Thus the projections or anticipated payments indicated in Table I do not represent the expenditures that we anticipate for FY 2006. We anticipate that the final rule will more accurately project payment for FY 2006. For the purposes of this proposed rule, we compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2006 wage index and determined the proposed hospice wage index to be budget neutral. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the proposed FY 2006 wage index would equal estimated aggregate payments that would have been made for the same services if the 1983 wage index had remained in effect. Budget neutrality to 1983 does not imply that estimated payments would not increase since the budget neutrality applies only to the wage index portion and not the total payment rate, which accommodates inflation.

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

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 hospices and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any 1 year (for details, see the Small Business Administration's regulation at 65 FR 69432, that sets forth size standards for health care industries). For purposes of the RFA, most hospices are small entities. As indicated in Table I below, there are 2,435 hospices. Approximately 70 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. 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; multisite 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. In developing the process for updating the wage index in the 1997 final rule, we considered the impact of this methodology on small entities and attempted to mitigate any potential negative effects.

As stated previously, the following discussions are limited to demonstrating trends rather than projected dollars if the subsequent final rule to this proposed rule were implemented for FY 2006. We used the CBSA designations and wage indices as well as the data from FY 2003 claims processed through June 2004 in developing the impact analysis. We will recalculate the impacts for the final rule using the FY 2004 claims file. We will discuss the estimated payments for FY 2006 at that time. Since the impact tables are intended to reflect the implementation of the CBSA in contrast with the current MSA designations, the introduction of the wage indices is the only variable used in the computation. It is important to note that the payment rates used reflect the FY 2005 rates. The FY 2006 payment rates will be adjusted to reflect the full FY 2006 hospital market basket, as required by section 1814(i)(1)(C) (ii)(VII) of the Act. As previously noted, we publish these rates through administrative issuances. As discussed in section II.A.1.a. of this proposed rule, hospice agencies may various wage indices to compute their payments based on the geographic location of the beneficiary for routine and continuous home care or the MSA (CBSA) or the location of the hospice agency for respite and general inpatient care. Therefore, we analyze the impact on hospices using the following parameters: geographic location; hospice size; type of ownership; and hospice base).

Our analysis demonstrates that, under this proposed rule, rural hospices would experience an increase in payment that is greater than that of urban hospices. Rural hospices are anticipated to experience a modest increase of 0.8 percent and urban hospices a slight decrease of 0.2 percent. However, the impact overall is anticipated to remain unchanged if the CBSA designations are adopted. This flat trend is also evident when contrasting the findings with projections using the MSA designations. However, the projections using the MSA designations remain flat for urban areas and decrease slightly by 0.1 percent for rural areas.

Of the urban hospices, we anticipate that most of the regions would experience decreases ranging from a 1.4 for the urban New England region to 0.1 decrease for the South Atlantic. A slight increase is anticipated for the West North Central, West South Central, and Pacific urban regions of 0.1, 0.2, and 0.1, respectively. In contrast, the rural regions are expected to receive an increase for all regions ranging from a substantial increase of 21.7 percent for rural Puerto Rico to a 1 percent increase for East North Central. We believe that that aberration for Puerto Rico can be attributed to the increase in the hospital wage indices in the region as well as the large number of rural counties under the MSA designations in Puerto Rico that have been designated as urban counties under the CBSA designations. Rural New England and West North Central regions are expected to remain flat. Only one rural region, the Mid-Atlantic, is anticipated to experience a decrease of 1.5 percent. The anticipated increase for the rural regions using the MSA designations is in contrast, more modest with increases ranging from 0.1 to 0.3 and decreases anticipated for the rural South Atlantic, East North Central, East South Central, and Middle Atlantic of 0.2, 0.3, 0.6, and 0.7, respectively.

As discussed previously, we have designated three hospice sizes based on routine home care days. 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 the impact of the wage index update on small hospices (those Start Printed Page 22402that provide up to 3,499 days of routine home care) will experience a 0.1 percent increase in both the CBSA and MSA projections. The impact remains virtually the same for both the CBSA and MSA designations for all three sizes. As indicated above, a 0.1 percent increase is anticipated for small agencies and remains unchanged for large agencies. There is a scant decrease of 0.1 percent for medium sized agencies (with 3,500 to 19,999 RHC days) using the CBSA designations while it remains unchanged for MSA designations. The lack of variability by agency size indicates that this proposed rule would have no impact on a small number of small entities. Rural Puerto Rico with 6 hospice agencies and 184,000 routine care days, representing the smallest number of hospices and second lowest routine home care days in the rural region, is anticipated to experience a substantial increase of 21.7 percent while rural South Atlantic with 138 hospices and 1,394,000 routine home care days, which represents the highest number of routine home days, will have an increase of 0.6 percent. The rural Mid-Atlantic region with 39 hospices and 280,000 routine home care days is anticipated to decrease by 1.5 percent. Rural New England with 27 hospices representing the second lowest number of agencies with 112,000 routine home care days, and representing the lowest number of rural days, is anticipated to remain unchanged.

Urban Puerto Rico region with 30 hospice agencies with 428,000 routine home care days, representing the lowest number of urban agencies and routine home care days, is anticipated to experience a decrease of 0.5 percent using the CBSA designations in contrast to a 0.2 percent increase using the MSA designation. Urban East North Central with 244 hospice agencies representing the largest number of urban hospice agencies with 5,275,000 routine home care days is anticipated to experience a decrease of 0.3 percent using the CBSA designation and would remain unchanged using the MSA designation. Urban West South Central with the largest number of routine home care days of 5,765,000 is anticipated to experience a 0.2 percent increase using the CBSA designations and 0.4 percent increase using the MSA designations. Based upon these comparisons, the urban regions would expect a slightly larger increase in payment using the MSA designations while the rural areas are anticipated to experience a substantially larger increase using the CBSA designations. However, as indicated above, in the aggregate, hospice agencies overall are anticipated to remain unchanged using either the CBSA or MSA designations.

By type of ownership, proprietary hospice agencies are anticipated to increase by 0.2 percent while voluntary agencies with the largest number of agencies and routine home care days of 1,309 and 23,696,000, respectively, are anticipated to decrease by 0.2 percent and government by 0.3. Since we are unable to determine the ownership type for the unknown category, we are unable to determine the impact of the anticipated decrease of 1.1 percent. By MSA designation, in contrast, voluntary and proprietary hospice agencies are anticipated to remain unchanged with government agencies anticipated to decrease by 0.1 percent.

Freestanding hospice agencies with the largest number of agencies of 1,188 and routine home care days of 29,277,000 are anticipated to remain unchanged when using MSA as well as CBSA designations. Home health-based hospice agencies are anticipated to remain unchanged with the MSA designations but are anticipated to increase by 0.2 percent with CBSA designation. Hospital-based hospice agencies are anticipated to decrease slightly with both MSA and CBSA designations at 0.1 and 0.3 respectively. SNF-based hospice agencies with the lowest number of agencies and routine home care days of 15 and 174,000, respectively, are also anticipated to experience a decrease with both MSA and CBSA designations of 0.6 and 0.9, respectively.

As discussed above, the overall impact for hospice agencies remain unchanged using the CBSA designations with a slight decrease in urban and an increase in rural hospice agencies. While there are more decreases in urban hospice agencies, there is overall increase in the rural agencies. Hospice size remains virtually unchanged when comparing MSA to CBSA designations. Type of ownership and hospice base appear similar between the two designations. As a result, there is no compelling reason to maintain the use of the MSA designations as opposed to the CBSA designations based upon overall hospice agency impact.

3. Anticipated Effects

We have compared estimated payments using the FY 1983 hospice wage index to estimated payments using the proposed FY 2006 wage index and determined the current hospice wage index to be budget neutral. This impact analysis compares hospice payments using the FY 2005 hospice wage index to the estimated payments using the proposed FY 2006 wage index. The data used in developing the quantitative analysis for this proposed rule were obtained from the June 2004 update of the national claims history file of all FY 2003 claims processed through June 2004. We deleted bills from hospices that have since closed. As discussed above, for the purposes of this proposed rule, this file is adequate to demonstrate the impact of using the MSA and proposed CBSA designations and is not intended to project the anticipated expenditures for FY 2006. We will be using an updated file for the final rule which will more accurately indicate the expected expenditures for FY 2006.

Table I demonstrates the results of our analysis. In column 2 of Table I, 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 indicates payments that were made using the FY 2005 wage index. Column 4 is based on claims (for hospices in business during that time period) and estimates payments (with the caveat as discussed above) to be made to hospices using proposed CBSA designations and FY 2006 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 I 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 indicted that there are 1,494 hospices located in urban areas and 941 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 2004. 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.

Table II demonstrates the estimated payments using the CBSA and MSA designations. The groupings as well as columns 1 and 2 are the same as in Start Printed Page 22403Table I. Columns 3 and 4 represent the estimated payments using the CBSA and MSA designations, respectively. Column 5 represents the percentage change in the estimated payments using CBSA designations compared with the estimated payments using the MSA designations.

Our analysis shows that the majority of hospices are in urban areas and provide the vast majority of routine home care days. However, rural hospices are anticipated to receive a larger percent increase in payment of 0.8 percent in contrast to a decrease of 0.2 percent for urban hospices if CBSA designations were used in the proposed FY 2006 wage index. However, overall, there is no anticipated change using the CBSA designations.

Since the impact tables are intended to reflect the implementation of the CBSA as opposed to the current MSA designations, the introduction of the wage indices is the only variable used in the computation. It is important to note that the payment rates used reflect the FY2005 rates. The FY 2006 payment rates would be adjusted to reflect the full FY 2006 hospital market basket, as required by section 1814(i)(1)(C)(ii)(VII) of the Act. We publish these rates through administrative issuances.

Table I.—Impact of Hospice Wage Index Changes Based on Use of CBSA Designations

Number of hospices (1)Number of routine home care days in thousands (2)Payments using FY 2005 wage index in thousands (3)Estimated payments using FY 2006 wage index in thousands (CBSA designations) (4)Percent change in hospice payments (CBSA designations) (5)
By Geographic Location:
All Hospices2,43543,2326,086,7266,084,1940.0
Urban Hospices1,49435,8775,225,2405,215,515−0.2
Rural Hospices9417,355861,486868,6800.8
By Region—Urban:
New England931,051179,129176,671−1.4
Middle Atlantic1733,573551,587549,856−0.3
South Atlantic2097,4421,164,7581,163,315−0.1
East North Central2445,275765,379762,940−0.3
East South Central1092,644346,632345,627−0.3
West North Central1092,442316,698316,9380.1
West South Central2285,765740,895742,5690.2
Mountain1072,821439,997437,091−0.7
Pacific1924,436683,956684,4760.1
Puerto Rico3042836,20836,031−0.5
By Region—Rural:
New England2711214,83514,8320.0
Middle Atlantic3928029,00028,572−1.5
South Atlantic1381,394170,695171,7520.6
East North Central142940113,436113,5410.1
East South Central1141,571179,805180,4340.3
West North Central184889105,953105,9950.0
West South Central1261,096119,455121,5271.7
Mountain10653465,69665,8720.3
Pacific5935547,51247,7720.5
Puerto Rico618415,09818,38121.7
Routine Home Care Days:
0-3499 DAYS (Small)629997125,214125,3300.1
3500-19,999 DAYS (Medium)1,19211,6231,531,0601,529,182−0.1
20,000+ DAYS (Large)61430,6124,430,4524,429,6830.0
Type Of Ownership:
Voluntary1,30923,6963,417,5063,411,195−0.2
Proprietary84017,8432,444,3692,449,6660.2
Government185874116,914116,593−0.3
Unknown101819107,937106,741−1.1
Hospice Base:
Freestanding1,18829,2774,137,9794,136,4040.0
Home Health Agency6237,8021,107,7071,110,1340.2
Hospital5505,470751,268749,156−0.3
Skilled Nursing Facility1517428,53628,273−0.9
Unknown5950961,23760,227−1.6
Note: For purposes of comparing the proposed CBSA designations with the current MSA designations, hospice listings are based on the MSA designations.
FY 2005 payment rates were used for estimated payments for FY 2006. FY 2006 payment rates will be adjusted to reflect the full hospital market basket.
Start Printed Page 22404

Table II.—Comparison of Impact of the Hospice Wage Index Using CBSA and MSA Designations

Number of hospices (1)Number of routine home care days (in thousands) (2)Estimated Payments using FY 2006 wage index and CBSA designations (in thousands) (4)Estimated payments using FY 2006 wage index and MSA designations (in thousands) (6)Percent change in hospice payments (CBSA vs. MSA designations) (7)
By Geographic Location:
All Hospices2,43543,2326,084,1946,086,3140.0
Urban Hospices1,49435,8775,215,5155,224,948−0.2
Rural Hospices9417,355868,680860,3661.0
By Region—Urban:
New England931,051176,671178,262−0.9
Middle Atlantic1733,573549,856548,9150.2
South Atlantic2097,4421,163,3151,165,203−0.2
East North Central2445,275762,940765,293−0.3
East South Central1092,644345,627346,797−0.3
West North Central1092,442316,938317,338−0.1
West South Central2285,765742,569744,193−0.2
Mountain1072,821437,091437,836−0.2
Pacific1924,436684,476684,819−0.1
Puerto Rico3042836,03136,292−0.7
By Region—Rural:
New England2711214,83214,846−0.1
Middle Atlantic3928028,57228,811−0.8
South Atlantic1381,394171,752170,4290.8
East North Central142940113,541113,1510.3
East South Central1141,571180,434178,7430.9
West North Central184889105,995106,186−0.2
West South Central1261,096121,527119,7061.5
Mountain10653465,87265,6950.3
Pacific5935547,77247,6610.2
Puerto Rico618418,38115,14017.6
Routine Home Care Days:
0-3499 DAYS (Small)629997125,330125,398−0.1
3500-19,999 DAYS (Medium)1,19211,6231,529,1821,531,330−0.1
20,000+ DAYS (Large)61430,6124,429,6834,428,5860.0
Type of Ownership
Voluntary1,30923,6963,411,1953,415,970−0.1
Proprietary84017,8432,449,6662,445,1170.2
Government185874116,593116,753−0.1
Unknown101819106,741107,476−0.7
Hospice Base:
Freestanding1,18829,2774,136,4044,137,6890.0
Home Health Agency6237,8021,110,1341,108,2100.2
Hospital5505,470749,156750,172−0.1
Skilled Nursing Facility1517428,27328,351−0.3
Unknown5950960,22760,892−1.1
Note: For purposes of comparing the proposed CBSA designations with the current MSA designations, hospice listings are based on the MSA designations.
FY 2005 payment rates were used for estimated payments for FY 2006. FY 2006 payment rates will be adjusted to reflect the full hospital market basket.
Start List of Subjects

List of Subjects for 42 CFR Part 418

End List of Subjects

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services would amend 42 CFR part 418 as set forth below:

Start Part

PART 418—HOSPICE CARE

1. The authority citation for part 418 continues to read as follows:

Start Authority

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

End Authority

2. Section 418.3 is amended by revising the definition of Attending physician to read as follows:

Definitions.
* * * * *

Attending physician means a—(1)(i) Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs an action; or

(ii) Nurse practitioner who meets the training, education, and experience requirements as the Secretary may prescribe; and

(2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.

* * * * *

3. Section 418.22 is amended by—

A. Republishing the heading of paragraph (c) and paragraph (c)(1).

B. Revising paragraph (c)(1)(ii).

The republication and revisions read as follows:

Certification of terminal illness.
* * * * *
Start Printed Page 22405

(c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from—

(i) * * *

(ii) The individual's attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 410.20 of this subchapter.

* * * * *

4. Section 418.302 is amended by revising paragraph (d) to read as follows:

Payment procedures for hospice care.
* * * * *

(d)(1) The intermediary reimburses the hospice its appropriate payment amount for each day for which an eligible Medicare beneficiary is under the hospice's care.

(2) Effective December 8, 2003, if a hospice makes arrangements with another hospice to provide services under the circumstances specified in section 1861(dd)(5)(D) of the Act, the intermediary reimburses the hospice for which the beneficiary has made an election as described in paragraph (d)(1) of this section.

* * * * *

5. Section 418.304 is amended by—

A. Revising the section heading.

B. Revising the introductory text of paragraph (a).

C. Adding a new paragraph (e).

The revisions and additions read as follows:

Payment for physician and nurse practitioner services.

(a) The following services performed by hospice physicians and nurse practitioners are included in the rates described in § 418.302:

* * * * *

(e)(1) Effective December 8, 2003, Medicare pays for attending physician services provided by nurse practitioners to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician. This applies to nurse practitioners without regard to whether they are hospice employees.

(2) Nurse practitioners may bill and receive payment for services only if the—

(i) Nurse practitioner is the beneficiary's attending physician as defined in § 418.3;

(ii) Services are medically reasonable and necessary; and

(iii) Services are performed by a physician in the absence of the nurse practitioner; and

(iv) Services are not related to the certification of terminal illness specified in § 418.22.

(3) Payment for nurse practitioner services are made at 85 percent of the physician fee schedule amount.

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

Start Signature

Dated: April 7, 2005.

Mark B. McClellan,

Administrator, Centers for Medicare & Medicaid Services.

Approved: April 15, 2005.

Michael O. Leavitt,

Secretary.

End Signature

Addendum

Table A.—Hospice Wage index for Urban Areas by CBSA

CBSA code numberUrban area (Constituent counties or county equivalents) 1Wage index 2
10180Abilene, TX0.8348
Callahan County, TX
Jones County, TX
Taylor County, TX
10380Aguadilla-Isabela-San Sebastian, PR0.4922
Aguada Municipio, PR
Aguadilla Municipio, PR
Anasco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Muncipio, PR
Rincón Municipio, PR
San Sebastián Municipio, PR
10420Akron, OH0.9630
Portage County, OH
Summit County, OH
10500Albany, GA1.1981
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580Albany-Schenectady-Troy, NY0.9199
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740Albuquerque, NM1.1151
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780Alexandria, LA0.8690
Grant Parrish
Start Printed Page 22406
Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ1.0104
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020Altoona, PA0.8999
Blair County, PA
11100Amarillo, TX0.9761
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180Ames, IA1.0081
Story County, IA
11260Anchorage, AK1.2937
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300Anderson, IN0.9266
Madison County, IN
11340Anderson, SC0.9220
Anderson County, SC
11460Ann Arbor, MI1.1722
Washtenaw County, MI
11500Anniston-Oxford, AL0.8381
Calhoun County, AL
11540Appleton, WI0.9711
Calumet County, WI
Outagamie County, WI
11700Asheville, NC0.9774
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020Athens-Clarke County, GA1.0850
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA1.0604
Barrow County, GA
Bartow County, GA
Butts County
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
12100Atlantic City, NJ1.1625
Atlantic County, NJ
Start Printed Page 22407
12220Auburn-Opelika, AL0.8736
Lee County, AL
12260Augusta-Richmond County, GA-SC0.9735
Burke County, GA
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420Austin-Round Rock, TX1.0204
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540Bakersfield, CA1.0673
Kern County, CA
12580Baltimore-Towson, MD1.0536
Anne Arundel County, MD
Baltimore City, MD
Baltimore County, MD
Carroll County, MD
Harford County, MD
Howard County, MD
Queen Anne's County, MD
12620Bangor, ME1.0587
Penobscot County, ME
12700Barnstable Town, MA1.3118
Barnstable County, MA
12940Baton Rouge, LA0.8847
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
12980Battle Creek, MI0.9961
Calhoun County, MI
13020Bay City, MI1.0182
Bay County, MI
13140Beaumont-Port Arthur, TX0.9163
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380Bellingham, WA1.2381
Whatcom County, WA
13460Bend, OR1.1276
Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.1651
Frederick County, MD
Montgomery County, MD
13740Billings, MT0.9530
Carbon County, MT
Yellowstone County, MT
13780Binghamton, NY0.8983
Broome County, NY
Tioga County, NY
13820Birmingham-Hoover, AL0.9738
Bibb County, AL
Blount County, AL
Chilton County, AL
Jefferson County, AL
St. Clair County, AL
Shelby County, AL
13900Bismarck, ND0.8000
Burleigh County, ND
Morton County, ND
Start Printed Page 22408
13980Blacksburg-Christiansburg-Radford, VA0.8456
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020Bloomington, IN0.9132
Greene County, IN
Monroe County, IN
Owen County, IN
14060Bloomington-Normal, IL0.9689
McLean County, IL
14260Boise City, ID0.9946
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee, County, ID
14484Boston-Quincy, MA1.2518
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500Boulder, CO1.0684
Boulder County, CO
14540Bowling Green, KY0.8657
Edmonson County, KY
Warren County, KY
14740Bremerton-Silverdale, WA1.1288
Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.3650
Fairfield County, CT
15180Brownsville-Harlingen, TX1.0768
Cameron County, TX
15260Brunswick, GA1.2690
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380Buffalo-Niagara Falls, NY0.9932
Erie County, NY
Niagara County, NY
15500Burlington, NC0.9536
Alamance County, NC
15540Burlington-South Burlington, VT0.9914
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.1899
Middlesex County, MA
15804Camden, NJ1.1353
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940Canton-Massillon, OH0.9460
Carroll County, OH
Stark County, OH
15980Cape Coral-Fort Myers, FL0.9966
Lee County, FL
16180Carson City, NV1.1009
Carson City, NV
16220Casper, WY0.9830
Natrona County, WY
16300Cedar Rapids, IA0.9545
Benton County, IA
Jones County, IA
Linn County, IA
16580Champaign-Urbana, IL1.0132
Champaign County, IL
Ford County, IL
Piatt County, IL
16620Charleston, WV0.9439
Boone County, WV
Start Printed Page 22409
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700Charleston-North Charleston, SC1.0018
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC1.0361
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820Charlottesville, VA1.0947
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860Chattanooga, TN-GA0.9791
Catoosa County, GA
Dade County, GA
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940Cheyenne, WY0.9550
Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.1558
Cook County, IL
DeKalb County, IL
Du Page County, IL
Grundy County, IL
Kane County, IL
Kendall County, IL
McHenry County, IL
Will County, IL
17020Chico-Paradise, CA1.1211
Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN1.0120
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
17300Clarksville, TN-KY0.8531
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420Cleveland, TN0.8342
Bradley County, TN
Polk County, TN
17460Cleveland-Elyria-Mentor, OH1.0263
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Start Printed Page 22410
Medina County, OH
17660Coeur d'Alene, ID0.9932
Kootenai County, ID
17780College Station-Bryan, TX0.9830
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820Colorado Springs, CO1.0414
El Paso County, CO
Teller County, CO
17860Columbia, MO0.8929
Boone County, MO
Howard County, MO
17900Columbia, SC0.9988
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980Columbus, GA-AL0.9242
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Muscogee County, GA
18020Columbus, IN0.9984
Bartholomew County, IN
18140Columbus, OH1.0355
Delaware County, OH
Fairfield County, OH
Franklin County, OH
Licking County, OH
Madison County, OH
Morrow County, OH
Pickaway County, OH
Union County, OH
18580Corpus Christi, TX0.9196
Aransas, TX
Nueces County, TX
San Patricio County, TX
18700Corvallis, Oregon1.1214
Benton County, OR
19060Cumberland, MD-WV0.9212
Allegany County, MD
Mineral County, WV
19124Dallas-Plano-Irving TX1.0713
Collin County, TX
Dallas County, TX
Delta County, TX
Denton County, TX
Ellis County, TX
Hunt County, TX
Kaufman County, TX
Rockwall County, TX
19140Dalton, GA1.0165
Murray County, GA
Whitfield County, GA
19180Danville, IL0.8925
Vermilion, County, IL
19260Danville, VA0.9192
Danville City, VA
Pittsylvania County, VA
19340Davenport-Moline-Rock Island, IA-IL0.9330
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380Dayton, OH0.9894
Greene County, OH
Start Printed Page 22411
Miami County, OH
Montgomery County, OH
Preble County, OH
19460Decatur, AL0.9459
Lawrence County, AL
Morgan County, AL
19500Decatur, IL0.8638
Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.9463
Volusia County, FL
19740Denver-Aurora, CO1.1596
Adams County, CO
Arapahoe County, CO
Broomfield County, CO
Clear Creek County, CO
Denver County, CO
Douglas County, CO
Elbert County, CO
Jefferson County, CO
Park County, CO
19780Des Moines, IA0.9854
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Warren County, IA
19804Detroit-Livonia-Dearborn, MI1.1006
Wayne County, MI
20020Dothan, AL0.8015
Geneva County, AL
Henry County, AL
Houston County, AL
20100Dover, DE1.0449
Kent County, DE
20220Dubuque, IA0.9303
Dubuque County, IA
20260Duluth, MN-WI1.0996
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500Durham, NC1.1021
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740Eau Claire, WI0.9719
Chippewa County, WI
Eau Claire County, WI
20764Edison, NJ1.1843
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940El Centro, CA0.9418
Imperial County, CA
21060Elizabethtown, KY0.9235
Hardin County, KY
Larue County, KY
21140Elkhart-Goshen, IN0.9867
Elkhart County, IN
21300Elmira, NY0.8981
Chemung County, NY
21340El Paso, TX0.9764
El Paso County, TX
21500Erie, PA0.9251
Erie County, PA
21604Essex County, MA1.1339
Essex County, MA
21660Eugene-Springfield, OR1.1635
Lane County, OR
Start Printed Page 22412
21780Evansville, IN-KY0.8903
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820Fairbanks, AK1.1854
Fairbanks North Star Borough, AK
21940Fajardo, PR0.4530
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020Fargo, ND-MN0.9693
Clay County, MN
Cass County, ND
22140Farmington, NM0.8560
San Juan County, NM
22180Fayetteville, NC0.9957
Cumberland County, NC
Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.9184
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
22380Flagstaff, AZ1.1472
Coconino County, AZ
22420Flint, MI1.1888
Genesee County, MI
22500Florence, SC0.9394
Darlington County, SC
Florence County, SC
22520Florence-Muscle Shoals, AL0.8383
Colbert County, AL
Lauderdale County, AL
22540Fond du Lac, WI1.0525
Fond du Lac County, WI
22660Fort Collins-Loveland, CO1.0867
Larimer County, CO
22744Ft. Lauderdale-Pompano Beach-Deerfield Beach, FL1.0810
Broward County, FL
22900Fort Smith, AR-OK0.8809
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.9344
Okaloosa County, FL
23060Fort Wayne, IN1.0430
Allen County, IN
Wells County, IN
Whitley County, IN
23104Forth Worth-Arlington, TX1.0073
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420Fresno, CA1.1205
Fresno County, CA
23460Gadsden, AL0.8560
Etowah County, AL
23540Gainesville, FL1.0059
Alachua County, FL
Gilchrist County, FL
23580Gainesville, GA1.0164
Hall County, GA
23844Gary, IN0.9901
Jasper County, IN
Start Printed Page 22413
Lake County, IN
Newton County, IN
Porter County, IN
24020Glens Falls, NY0.9004
Warren County, NY
Washington County, NY
24140Goldsboro, NC0.9335
Wayne County, NC
24220Grand Forks, ND-MN0.9668
Grand Forks County, ND
Polk County, MN
24300Grand Junction, CO1.0528
Mesa County, CO
24340Grand Rapids-Wyoming, MI1.0018
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500Great Falls, MT0.9369
Cascade County, MT
24540Greeley, CO1.0043
Weld County, CO
24580Green Bay, WI1.0199
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660Greensboro-High Point, NC0.9773
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780Greenville, NC0.9766
Green County, NC
Pitt County, NC
24860Greenville, SC1.0164
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020Guayama, PR0.4606
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.9518
Hancock County, MS
Harrison County, MS
Stone County, MS
25180Hagerstown-Martinsburg, MD-WV1.0332
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260Hanford-Corcoran, CA0.9886
Kings County, CA
25420Harrisburg—Carlisle, PA0.9953
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500Harrisonburg, VA0.9864
Rockingham County, VA
Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.1756
Hartford County, CT
Middlesex County, CT
Tolland County, CT
25620Hattiesburg, MS0.8000
Forrest County, MS
Lamar County, MS
Perry County, MS
25860Hickory-Morganton-Lenoir, NC1.0105
Alexander County, NC
Burke County, NC
Caldwell County, NC
Start Printed Page 22414
Catawba County, NC
25980Hinesville-Fort Stewart, GA0.8205
Liberty County, GA
Long County, GA
26100Holland-Grand Haven, MI0.9984
Ottawa County, MI
26180Honolulu, HI1.1712
Honolulu County, HI
26300Hot Springs, AR0.9836
Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.8211
Lafourche Parish, LA
Terrebonne Parish, LA
26420Houston-Baytown-Sugar Land, TX1.0606
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
26580Huntington-Ashland, WV-KY-OH1.0171
Boyd County, KY
Greenup County, KY
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620Huntsville, AL0.9413
Limestone County, AL
Madison County, AL
26820Idaho Falls, ID0.9634
Bonneville County, ID
Jefferson County, ID
26900Indianapolis, IN1.0755
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
26980Iowa City, IA1.0267
Johnson County, IA
Washington County, IA
27060Ithaca, NY1.0198
Tompkins County, NY
27100Jackson, MI0.9727
Jackson County, MI
27140Jackson, MS0.8817
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180Jackson, TN0.9465
Chester County, TN
Madison County, TN
27260Jacksonville, FL1.0142
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340Jacksonville, NC0.8934
Start Printed Page 22415
Onslow County, NC
27500Janesville, WI1.0191
Rock County, WI
27620Jefferson City, MO0.8867
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740Johnson City, TN0.8663
Carter County, TN
Unicoi County, TN
Washington County, TN
27780Johnstown, PA0.8912
Cambria County, PA
27860Jonesboro, AR0.8661
Craighead County, AR
Poinsett County, AR
27900Joplin, MO0.9275
Jasper County, MO
Newton County, MO
28020Kalamazoo-Portage, MI1.1354
Kalamazoo County, MI
Van Buren County, MI
28100Kankakee-Bradley, IL1.1276
Kankakee County, IL
28140Kansas City, KS-MO1.0240
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
28420Kennewick-Richland-Pasco, WA1.1188
Benton County, WA
Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.9829
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700Kingsport-Bristol, TN-VA0.8763
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740Kingston, NY0.9571
Ulster County, NY
28940Knoxville, TN0.9091
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020Kokomo, IN0.9556
Howard County, IN
Tipton County, IN
29100La Crosse, WI-MN0.9879
Houston County, MN
La Crosse County, WI
29140Lafayette, IN0.9643
Benton County, IN
Start Printed Page 22416
Carroll County, IN
Tippecanoe, IN
29180Lafayette, LA0.8833
Lafayette County, LA
St. Martin County, LA
29340Lake Charles, LA0.8439
Calcasieu Parish, LA
Cameron Parish
29404Lake County-Kenosha County, IL-WI1.0998
Lake County, IL
Kenosha County, WI
29460Lakeland, FL0.9497
Polk County, FL
29540Lancaster, PA1.0510
Lancaster County, PA
29620Lansing-East Lansing, MI1.0271
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700Laredo, TX0.9302
Webb County, TX
29740Las Cruces, NM0.9342
Dona Ana County, NM
29820Las Vegas-Paradise, NV1.2100
Clarke County, NV
29940Lawrence, KS0.9193
Douglas County, KS
30020Lawton, OK0.8733
Comanche County, OK
30140Lebanon, PA0.9114
Lebanon County, PA
30300Lewiston, ID-WA0.9905
Nez Perce County, ID
Asotin County, WA
30340Lewiston-Auburn, ME1.0169
Androscoggin County, ME
30460Lexington-Fayette, KY0.9953
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620Lima, OH0.9922
Allen County, OH
30700Lincoln, NE1.0856
Lancaster County, NE
30780Little Rock-North Little Rock, AR0.9386
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860Logan, UT-ID0.9671
Franklin County, ID
Cache County, UT
30980Longview, TX0.9360
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020Longview, WA1.0873
Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale-Santa Ana, CA1.2477
Los Angeles County, CA
31140Louisville, KY-IN0.9701
Clark County, IN
Floyd County, IN
Harrison County, IN
Washington County, IN
Start Printed Page 22417
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
31180Lubbock, TX0.9334
Crosby County, TX
Lubbock County, TX
31340Lynchburg, VA0.9589
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420Macon, GA1.0515
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460Madera, CA0.9062
Madera County, CA
31540Madison, WI1.0960
Columbia County, WI
Dane County, WI
Iowa County, WI
31700Manchester-Nashua, NH1.1318
Hillsborough County, NI
31900Mansfield, OH0.9772
Richland County, OH
32420Mayagũez, PR0.5167
Hormigueros Municipio, PR
Mayagũez, PR
32580McAllen-Edinburg-Pharr, TX0.9148
Hidalgo County, TX
32780Medford, OR1.1203
Jackson County, OR
32820Memphis, TN-AR-MS0.9802
Crittenden County, AR
DeSoto County, MS
Marshall County, MS
Tate County, MS
Tunica, County, MS
Fayette County, TN
Shelby County, TN
Tipton County, TN
32900Merced, CA1.1246
Merced County, CA
33124Miami-Miami Beach-Kendall, FL1.0497
Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9924
La Porte County, IN
33260Midland TX0.9980
Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0716
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.1768
Anoka County, MN
Carver County, MN
Chisago County, MN
Dakota County, MN
Hennepin County, MN
Start Printed Page 22418
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
33540Missoula, MT1.0229
Missoula County, MT
33660Mobile, AL0.8503
Mobile County, AL
33700Modesto, CA1.2726
Stanislaus County, CA
33740Monroe, LA0.8405
Ouachita Parish, LA
Union Parish, LA
33780Monroe, MI1.0109
Monroe County, MI
33860Montgomery, AL0.8827
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060Morgantown, WV0.9284
Monongalia County, WV
Preston County, WV
34100Morristown, TN0.8285
Grainger County, TN
Hamblen County, TN
Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.1247
Skagit County, WA
34620Muncie, IN0.9125
Delaware County, IN
34740Muskegon-Norton Shores, MI1.0359
Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.9595
Horry County, SC
34900Napa, CA1.3326
Napa County, CA
34940Naples-Marco Island, FL1.1228
Collier County, FL
34980Nashville-Davidson-Murfreesboro, TN1.0726
Cannon County, TN
Cheatham County, TN
Davidson County, TN
Dickson County, TN
Hickman County, TN
Macon County, TN
Robertson County, TN
Rutherford County, TN
Sumner County, TN
Trousdale County, TN
Williamson County, TN
Wilson County, TN
35004Nassau-Suffolk, NY1.3726
Nassau County, NY
Suffolk County, NY
35084Newark-Union, NJ-PA1.2429
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300New Haven-Milford, CT1.2556
New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.9681
Jefferson Parish, LA
Start Printed Page 22419
Orleans Parish, LA
Plaquemines Parish, LA
St. Bernard Parish, LA
St. Charles Parish, LA
St. John The Baptist Parish, LA
St. Tammany Parish, LA
35644New York-Wayne-White Plains, NY-NJ1.4156
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
35660Niles-Benton Harbor, MI0.9409
Berrien County, MI
35980Norwich-New London Ct1.2332
New London County, CT
36084Oakland-Fremont-Hayward, CA1.6186
Alameda County, CA
Contra Costa County, CA
36100Ocala, FL0.9734
Marion County, FL
36140Ocean City, NJ1.1496
Cape May County, NJ
36220Odessa, TX1.0420
Ector County, TX
36260Ogden-Clearfield, UT0.9801
Davis County, UT
Morgan County, UT
Weber County, UT
36420Oklahoma City, OK0.9552
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500Olympia, WA1.1705
Thurston County, WA
36540Omaha-Council Bluffs, NE-IA1.0373
Harrison County, IA
Mills County, IA
Pottawattamie County, IA
Cass County, NE
Douglas County, NE
Sarpy County, NE
Saunders County, NE
Washington County, NE
36740Orlando, FL1.0360
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780Oshkosh-Neenah, WI0.9677
Winnebago County, WI
36980Owensboro, KY0.8969
Daviess County, KY
Hancock County, KY
McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.1810
Ventura County, CA
37340Palm Bay-Melbourne-Titusville, FL1.0244
Brevard County, FL
37460Panama City-Lynn Haven, FL0.8640
Start Printed Page 22420
Bay County, FL
37620Parkersburg-Marietta, WV-OH0.8814
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700Pascagoula, MS0.8480
George County, MS
Jackson County, MS
37860Pensacola-Ferry Pass-Brent, FL0.8833
Escambia County, FL
Santa Rosa County, FL
37900Peoria, IL0.9450
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964Philadelphia, PA1.1555
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0616
Maricopa County, AZ
Pinal County, AZ
38220Pine Bluff, AR0.9224
Cleveland County, AR
Jefferson County, AR
Lincoln County, AR
38300Pittsburgh, PA0.9291
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340Pittsfield, MA1.1102
Berkshire County, MA
38540Pocatello, ID1.0210
Bannock County, ID
Power County, ID
38660Ponce, PR0.5757
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME1.0754
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.2127
Clackamas County, OR
Columbia County, OR
Multnomah County, OR
Washington County, OR
Yamhill County, OR
Clark County, WA
Skamania County, WA
38940Port St. Lucie-Fort Pierce, FL1.0684
Martin County, FL
St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.2084
Duchess County, NY
Orange County, NY
39140Prescott, AZ1.0520
Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.1623
Bristol County, MA
Start Printed Page 22421
Bristol County, RI
Kent County, RI
Newport County, RI
Providence County, RI
Washington County, RI
39340Provo-Orem, UT1.0197
Juab County, UT
Utah County, UT
39380Pueblo, CO0.9308
Pueblo County, CO
39460Punta Gorda, FL1.0040
Charlotte County, FL
39540Racine, WI0.9619
Racine County, WI
39580Raleigh-Cary, NC1.0695
Franklin County, NC
Johnston County, NC
Wake County, NC
39660Rapid City, SD0.9478
Meade County, SD
Pennington County, SD
39740Reading, PA0.9800
Berks County, PA
39820Redding, CA1.2586
Shasta County, CA
39900Reno-Sparks, NV1.1120
Storey County, NV
Washoe County, NV
40060Richmond, VA0.9994
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
40140Riverside-San Bernardino-Ontario, CA1.1666
Riverside County, CA
San Bernardino County, CA
40220Roanoke, VA0.8949
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340Rochester, MN1.2234
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380Rochester, NY0.9870
Livingston County, NY
Monroe County, NY
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420Rockford, IL1.0237
Start Printed Page 22422
Boone County, IL
Winnebago County, IL
40484Rockingham County, NH1.0870
Rockingham County, NH
Stafford County, NH
40580Rocky Mount, NC0.9569
Edgecombe County, NC
Nash County, NC
40660Rome, Georgia0.9442
Floyd County, GA
40900Sacramento-Arden-Arcade-Roseville, CA1.2443
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980Saginaw-Saginaw Township North, MI1.0437
Saginaw County, MI
41060St. Cloud, MN1.0863
Benton County, MN
Stearns County, MN
41100St. George, UT1.0058
Washington County, UT
41140St. Joseph, MO-KS1.0649
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180St. Louis, MO-IL0.9652
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
St. Louis City, MO
Warren County, MO
Washington County, MO
41420Salem, OR1.1226
Marion County, OR
Polk County, OR
41500Salinas, CA1.4700
Monterey County, CA
41540Salisbury, MD0.9702
Somerset County, MD
Wicomico County, MD
41620Salt Lake City, UT1.0168
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660San Angelo, TX0.8685
Irion County, TX
Tom Green County, TX
41700San Antonio, TX0.9575
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
Kendall County, TX
Medina County, TX
Wilson County, TX
41740San Diego-Carlsbad-San Marcos, CA1.1982
Start Printed Page 22423
San Diego County, CA
41780Sandusky, OH0.9589
Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.5646
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900San Germán-Cabo Rojo, PR0.6026
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San Germán-Cabo Rojo Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.5657
San Benito County, CA
Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.5342
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayamón Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canóvanas 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 Municipiobo, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
Manatí Municipio, 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
42020San Luis Obispo-Paso Robles, CA1.1824
San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.2348
Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.1455
Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.5717
Santa Cruz County, CA
42140Santa Fe, NM1.1601
Santa Fe County, NM
42220Santa Rosa-Petaluma, CA1.3784
Sonoma County, CA
42260Sarasota-Bradenton-Venice, FL1.0240
Start Printed Page 22424
Manatee County, FL
Sarasota County, FL
42340Savannah, GA1.0061
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540Scranton—Wilkes-Barre, PA0.9085
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.2222
King County, WA
Snohomish County, WA
43100Sheboygan, WI0.9516
Sheboygan County, WI
43300Sherman-Denison, TX1.0227
Grayson County, TX
43340Shreveport-Bossier City, LA0.9712
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580Sioux City, IA-NE-SD0.9646
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620Sioux Falls, SD1.0040
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780South Bend-Mishawaka, IN-MI1.0047
St. Joseph County, IN
Cass County, MI
43900Spartanburg, SC1.0123
Spartanburg, SC
44060Spokane, WA1.1337
Spokane County, WA
44100Springfield, IL0.9293
Menard County, IL
Sangamon County, IL
44140Springfield, MA1.0822
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180Springfield, MO0.9100
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220Springfield, OH0.9303
Clark County, OH
44300State College, PA0.8998
Centre County, PA
44700Stockton, CA1.1235
San Joaquin County, CA
44940Sumter, SC0.9061
Sumter County, SC
45060Syracuse, NY1.0069
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104Tacoma, WA1.1781
Pierce County, WA
45220Tallahassee, FL0.9204
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
Start Printed Page 22425
45300Tampa-St. Petersburg-Clearwater, FL0.9597
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460Terre Haute, IN0.9058
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500Texarkana, AR-Texarkana, TX0.8947
Miller County, AR
Bowie County, TX
45780Toledo, OH1.0129
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820Topeka, KS0.9469
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940Trenton-Ewing, NJ1.0928
Mercer County, NJ
46060Tucson, AZ0.9493
Pima County, AZ
46140Tulsa, OK0.9242
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
Wagoner County, OK
46220Tuscaloosa, AL0.8865
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340Tyler, TX1.0105
Smith County, TX
46540Utica-Rome, NY0.8822
Herkimer County, NY
Oneida County, NY
46660Valdosta, GA0.8870
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700Vallejo-Fairfield, CA1.5185
Solano County, CA
46940Vero Beach, FL1.0079
Indian River County, FL
47020Victoria, TX0.9008
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ1.1244
Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.9459
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
Start Printed Page 22426
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
47300Visalia-Tulare-Porterville, CA1.0608
Tulare County, CA
47380Waco, TX0.8663
McLennan County, TX
47580Warner Robins, GA0.9028
Houston County, GA
47644Warren-Farmington Hills-Troy, MI1.0754
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA1.1723
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Alexandria City, VA
Arlington County, VA
Clarke County, VA
Fairfax City, VA
Fairfax County, VA
Falls Church City, VA
Fauquier County, VA
Fredericksburg City, VA
Loudoun County, VA
Manassas City, VA
Manassas Park City, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Jefferson County, WV
47940Waterloo-Cedar Falls, IA0.9181
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140Wausau, WI1.0177
Marathon County, WI
48260Weirton-Steubenville, WV-OH0.8806
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300Wenatchee, WA1.0025
Chelan County, WA
Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL1.1020
Palm Beach County, FL
48540Wheeling, WV-OH0.8000
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620Wichita, KS1.0057
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660Wichita Falls, TX0.8861
Archer County, TX
Clay County, TX
Wichita County, TX
48700Williamsport, PA0.9024
Lycoming County, PA
Start Printed Page 22427
48864Wilmington, DE-MD-NJ1.1750
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900Wilmington, NC0.9823
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020Winchester, VA-WV1.1162
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180Winston-Salem, NC0.9998
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340Worcester, MA1.1694
Worcester County, MA
49420Yakima, WA1.0977
Yakima County, WA
49500Yauco, PR0.5167
Guánica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620York-Hanover, PA0.9731
York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.9823
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700Yuba City, CA1.1021
Sutter County, CA
Yuba County, CA
49740Yuma, AZ0.9434
Yuma County, AZ
1 This column lists each CBSA area name and each county or county equivalent, in the CBSA 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 2000 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 calculated by multiplying the hospital wage index value for a given area by the proposed budget neutrality factor of 1.063479. 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 a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.

Table B.—Hospice Wage Index for Rural Areas by CBSA

CBSA code numberNonurban areaWage index 3
01Alabama0.8112
02Alaska1.2492
03Arizona0.9503
04Arkansas0.8000
05California1.1192
06Colorado0.9963
07Connecticut1.2673
08Delaware1.0106
10Florida0.9118
11Georgia0.8224
12Hawaii1.1190
13Idaho0.8749
14Illinois0.8868
15Indiana0.9202
16Iowa0.9013
17Kansas0.8592
18Kentucky0.8247
19Louisiana0.8000
20Maine0.9613
21Maryland0.9805
22Massachusetts 51.0865
23Michigan0.9344
24Minnesota0.9922
25Mississippi0.8120
26Missouri0.8255
27Montana0.9253
28Nebraska0.9609
29Nevada0.9869
30New Hampshire1.0571
31New Jersey 4
32New Mexico0.9231
33New York0.8668
34North Carolina0.9107
35North Dakota0.8235
36Ohio0.9245
37Oklahoma0.8174
38Oregon1.0543
39Pennsylvania0.8838
40Puerto Rico0.8000
41Rhode Island 4
42South Carolina0.9234
43South Dakota0.8931
44Tennessee0.8369
45Texas0.8472
46Utah0.8813
47Vermont0.9970
48Virgin Islands0.8000
49Virginia0.8560
50Washington1.0967
51West Virginia0.8364
52Wisconsin1.0095
53Wyoming0.9765
Start Printed Page 22428
65Guam1.0221
3 Wage index values are based on FY 2000 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 calculated by multiplying the hospital wage index value for a given area by the proposed budget neutrality factor of 1.063479. 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 a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.
4 All counties within the State are classified as urban. Massachusetts has 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.
5Based on CBSA designations Massachusetts has areas designated as rural. However, no IPPS hospitals are located in those rural area(s) for FY 2006. Because more recent data is not available for those areas, we are using the FY 2005 prefloor, preclassified hospital wage index value, for rural Massachusetts multiplied by the proposed FY 2006 budget neutrality factor of 1.063479.

Table C.—Hospice Wage Index for Urban Areas by MSA and CBSA

MSA code numberWage index 2MSA urban area designations (Constituent counties or county equivalents) 1CBSA code numberWage index 2
00400.8525Abilene, TX101800.8348
Taylor, TX
00600.4938Aguadilla, PR103800.4922
Aguada, PR
Aguadilla, PR
Moca, PR
00800.9638Akron, OH104200.9630
Portage, OH
Summit, OH
01201.1992Albany, GA105001.1981
Dougherty, GA
Lee, GA
01600.9122Albany-Schenectady-Troy, NY105800.9199
Albany, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
01600.9122Albany-Schenectady-Troy, NY105800.9199
Montgomery, NYRural0.8668
02001.1161Albuquerque, NM107401.1151
Bernalillo, NM
Sandoval, NM
Valencia, NM
02200.8697Alexandria, LA107800.8690
Rapides, LA
02401.0150Allentown-Bethlehem-Easton, PA109001.0104
Carbon, PA
Lehigh, PA
Northampton, PA
02800.9007Altoona, PA110200.8999
Blair, PA
03200.9769Amarillo, TX111000.9761
Potter, TX
Randall, TX
03801.2889Anchorage, AK112601.2937
Anchorage, AK
04401.1513Ann Arbor, MI
Lenawee, MIRural0.9344
Livingston, MI476441.0754
04401.1513Ann Arbor, MI114601.1722
Washtenaw, MI
04500.8389Anniston, AL115000.8381
Calhoun, AL
04600.9702Oshkosh-Neenah, WI367800.9677
Start Printed Page 22429
Winnebago, WI
04600.9702Appleton, WI115400.9711
Calumet, WI
Outagamie, WI
04700.4321Arecibo, PR419800.5342
Arecibo, PR
Camuy, PR
Hatillo, PR
04801.0113Asheville, NC117000.9774
Buncombe, NC
Madison, NC
05001.0859Athens, GA120201.0850
Clarke, GA
Madison, GA
Oconee, GA
05201.0613Atlanta, GA120601.0604
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
05601.1610Cape May, NJ361401.1496
Cape May, NJ
05601.1610Atlantic, NJ121001.1625
Atlantic, NJ
05800.8744Aubrn-Opelika, AL122200.8736
Lee, AL
06000.9801Augusta-Aiken, GA-SC122600.9735
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
06401.0213Austin-San Marcos, TX124201.0204
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
06801.0683Bakersfield, CA125401.0673
Kern, CA
07201.0545Baltimore, MD125801.0536
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
07331.0596Bangor, ME126201.0587
Penobscot, ME
07431.3130Barnstable-Yarmouth, MA127001.3118
Barnstable, MA
07600.8892Baton Rouge, LA129400.8847
Ascension, LA
Start Printed Page 22430
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
08400.9171Beaumont-Port Arthur, TX131400.9163
Hardin, TX
Jefferson, TX
Orange, TX
08601.2392Bellingham, WA133801.2381
Whatcom, WA
08700.9417Benton Harbor, MI356600.9409
Berrien, MI
08751.2738Bergen-Passaic, NJ356441.4156
Bergen, NJ
Passaic, NJ
08800.9538Billings, MT137400.9530
Yellowstone, MT
09200.9206Biloxi-Gulfport, MS250600.9518
Hancock, MS
Harrison, MS
09200.9206Pascagoula, MS377000.8480
Jackson, MS
09600.8991Binghamton, NY137800.8983
Broome, NY
Tioga, NY
10000.9791Birmingham, AL138200.9738
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
10100.8000Bismarck, ND139000.8000
Burleigh, ND
Morton, ND
10200.9140Bloomington, IN140200.9132
Monroe, IN
10400.9698Bloomington-Normal, IL140600.9689
McLean, IL
10800.9955Boise City, ID142600.9946
Ada, ID
Canyon, ID
11231.2017Boston, MA144841.2518
Norfolk, MA
Plymouth, MA
Suffolk, MA
11231.2017Worcester-Lawrence-Lowell-Brockton, MA-NH
Bristol, MA
Essex, MA393001.1623
Middlesex, MA216041.1339
Worcester, MA157641.1899
Hillsborough, NH493401.1694
Merrimack, NH317001.1318
Rockingham, NH317001.1318
Strafford, NH317001.1318
404841.0870
11251.0693Boulder, CO145001.0684
Boulder, CO
11251.0693Longmont, CO145001.0684
Boulder, CO
11450.9073Brazoria, TX264201.0606
Brazoria, TX
11501.1298Bremerton, WA147401.1288
Kitsap, WA
12401.0777Brownsville-Harlingeno, TX151801.0768
Cameron, TX
12401.0777San Benito, TX151801.0768
Cameron, TX
12600.9839Bryan-College Station, TX177800.9830
Brazos, TX
12800.9941Buffalo-Niagara Falls, NY153800.9932
Erie, NY
Niagara, NY
Start Printed Page 22431
13030.9923Burlington, VT155400.9914
Chittenden, VT
Franklin, VT
Grand Isle, VT
13100.4670Caguas, PR419800.5342
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
13200.9468Canton-Massillon, OH159400.9460
Carroll, OH
Stark, OH
13500.9839Casper, WY162200.9830
Natrona, WY
13600.9553Cedar Rapids, IA163000.9545
Linn, IA
14001.0141Champaign-Urbana, IL165801.0132
Champaign, IL
14401.0027Charleston-North Charleston, SC167001.0018
Berkeley, SC
Charleston, SC
Dorchester, SC
14800.9448Charleston, WV166200.9439
Kanawha, WV
Putnam, WV
15201.0337Charlotte-Gastonia-Rock Hill, NC-SC
Cabarrus, NC
Gaston, NC167401.0361
Mecklenburg, NC
Union, NC
York, SC
15201.0337Charlotte-Gastonia-Rock Hill, NC-SC
Lincoln, NC
Rowan, NC340.9107
15401.0957Charlottesville, VA168201.0947
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
15600.9800Chattanooga, TN-GA168600.9791
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
15800.9559Cheyenne, WY169400.9550
Laramie, WY
16001.1550Chicago, IL169741.1558
Cook, IL
DeKalb, IL
Du Page, IL
Grundy, IL
Kane, IL
Kendall, IL
McHenry, IL
Will, IL
16001.1550Chicago, IL294041.0998
Lake, IL
16201.1221Chico-Paradise, CA170201.1211
Butte, CA
16401.0213Cincinnati, OH-KY-IN171401.0120
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Start Printed Page 22432
Kenton, KY
Pendleton, KY
Dearborn, IN
Ohio, IN
16600.8539Clarksville, TN-KY173000.8531
Christian, KY
Montgomery, TN
Hopkinsville
16801.0246Cleveland-Elyria, OH174601.0263
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
16801.0246Elyria, OH360.9245
Ashtabula, OH
17201.0423Colorado Springs, CO178201.0414
El Paso, CO
17400.8937Columbia, MO178600.8929
Boone, MO
17601.0059Columbia, SC179000.9988
Lexington, SC
Richland, SC
18000.9250Columbus, GA-AL179800.9242
Chattahochee, GA
Harris, GA
Muscogee, GA
Russell, AL
18401.0381Columbus, OH181401.0355
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
18800.9204Corpus Christi, TX185800.9196
Nueces, TX
San Patricio, TX
18901.1224Corvallis, Oregon187001.1214
Benton, OR
19000.9220Cumberland, MD-WV190600.9212
Allegany, MD
Mineral, WV
19201.0702Dallas, TX191241.0713
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
19201.0702Dallas, TX
Henderson, TX450.8472
19500.9200Danville, VA192600.9192
Danville City, VA
Pittsylvania, VA
19600.9338Davenport-Moline-Rock Island, IA-IL193400.9330
Scott, IA
Henry, IL
Rock Island, IL
20000.9826Dayton, OH193800.9894
Greene, OH
Miami, OH
Montgomery, OH
20000.9826Dayton-Springfield, OH442200.9303
Clark, OH
20200.9473Daytona Beach, FL
Flagler, FL100.9118
Volusia, FL196600.9463
20300.9467Decatur, AL194600.9459
Start Printed Page 22433
Lawrence, AL
Morgan, AL
20400.8645Decatur, IL195000.8638
Macon, IL
20801.1607Denver, CO197401.1596
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
21200.9863Des Moines, IA197800.9854
Dallas, IA
Polk, IA
Warren, IA
21601.0886Detroit, MI198041.1006
Wayne, MI
21601.0886Detroit, MI476441.0754
Lapeer, MI
Macomb, MI
Oakland, MI
St. Clair, MI
21601.0886Detroit, MI337801.0109
Monroe, MI
21800.8085Dothan, AL200200.8015
Houston, AL
21800.8085Dothan, AL200200.8015
Dale, AL
21901.0458Dover, DE201001.0449
Kent, DE
22000.9312Dubuque, IA202200.9303
Dubuque, IA
22401.1023Dulut, MN-WI202601.0996
St. Louis, MN
Douglas, WI
22401.1023Superior, MN-WI202601.0996
St. Louis, MN
Douglas, WI
22811.2408Dutchess County, NY391001.2084
Dutchess, NY
22900.9728Eau Claire, WI207400.9719
Chippewa, WI
Eau Claire, WI
23200.9773El Paso, TX213400.9764
El Paso, TX
23300.9876Elkhart-Goshen, IN211400.9867
Elkhart, IN
23350.8989Elmira, NY213000.8981
Chemung, NY
23400.9581Enid, OK370.8174
Garfield, OK
23600.9260Erie, PA215000.9251
Erie, PA
24001.1645Eugene-Springfield, OR216601.1634
Lane, OR
24400.8936Evansville, IN-KY217800.8903
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
24400.8936Henderson, IN-KY217800.8903
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
25200.9701Fargo, ND-MN220200.9693
Clay, MN
Cass, ND
25200.9701Moorhead, ND-MN220200.9693
Clay, MN
Cass, ND
Start Printed Page 22434
25600.9966Fayetteville, NC221800.9957
Cumberland, NC
25800.9192Fayetteville-Springdale-Rogers, AR222200.9184
Benton, AR
Washington, AR
26201.1295Flagstaff, AZ223801.1472
Coconino, AZ
26201.1295Flagstaff, UT
Kane, UT460.8813
26401.1898Flint, MI224201.1888
Genesee, MI
26500.8391Florence, AL225200.8383
Colbert, AL
Lauderdale, AL
26550.9537Florence, SC225000.9394
Florence, SC
26701.0876Fort Collins-Loveland, CO226601.0867
Larimer, CO
26801.0820Ft. Lauderdale, FL227441.0810
Broward, FL
27000.9975Fort Myers-Cape Coral, FL159800.9966
Lee, FL
27101.0693Fort Pierce-Port St. Lucie, FL389401.0684
Martin, FL
St. Lucie, FL
27200.8838Fort Smith, AR-OK229000.8809
Crawford, AR
Sebastian, AR
Sequoyah, OK
27500.9352Fort Walton Beach, FL230200.9344
Okaloosa, FL
27601.0364Allen, IN230601.0430
Wells, IN
Whitley, IN
27601.0364Fort Wayne, IN150.9202
Adams, IN
De Kalb, IN
Huntington, IN
28001.0133Forth Worth-Arlington, TX231041.0073
Johnson, TX
Parker, TX
Tarrant, TX
28001.0133Hood, TX450.8472
28401.1078Fresno, CA234201.1205
Fresno, CA
28401.1078Madera, CA314600.9062
28800.8568Gadsden, AL234600.8560
Etowah, AL
29001.0068Gainesville, FL235401.0059
Alachua, FL
29201.0009Galveston-Texas City, TX264201.0606
Galveston, TX
29600.9944Gary, IN238440.9901
Lake, IN
Porter, IN
29750.9013Glens Falls, NY240200.9004
Warren, NY
Washington, NY
29800.9344Goldsboro, NC241400.9335
Wayne, NC
29850.9677Grand Forks, ND-MN242200.9668
Grand Forks, ND
Polk, MN
29951.0538Grand Junction, CO243001.0528
Mesa, CO
30001.0132Grand Rapids-Muskegon-Holland, MI
Allegan, MI
Kent, MI230.9344
Muskegon, MI243401.0018
Ottawa, MI347401.0359
Start Printed Page 22435
261000.9984
30400.9378Great Falls, MT245000.9369
Cascade, MT
30601.0053Greeley, CO245401.0043
Weld, CO
30801.0204Green Bay, WI245801.0199
Brown, WI
31200.9912Greensboro-Winston-Salem-High Point, NC
Alamance, NC
Davidson, NC155000.9536
Davie, NC340.9107
Forsyth, NC491800.9998
Guilford, NC491800.9998
Randolph, NC246600.9773
Stokes, NC246600.9773
Yadkin, NC491800.9998
491800.9998
31500.9775Greenville, NC247800.9766
Pitt, NC
31601.0006Greenville-Spartanburg-Anderson, SC
Anderson, SC
Cherokee, SC113400.9220
Greenville, SC420.9234
Pickens, SC248601.0164
Spartanburg, SC248601.0164
439001.0123
31801.0580Hagerstown, MD251801.0332
Washington, MD
32000.9650Hamilton-Middletown, OH171401.0120
Butler, OH
32400.9884Harrisburg-Carlisle, PA254200.9953
Cumberland, PA
Dauphin, PA
Perry, PA
32400.9884Lebanon, PA301400.9114
Lebanon, PA
32831.1766Hartford, CT255401.1756
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
32850.8000Hattiesburg, MS256200.8000
Forrest, MS
Lamar, MS
32901.0114Hickory-Morganton-Lenoir, NC258601.0105
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
33201.1723Honolulu, HI261801.1712
Honolulu, HI
33500.8219Houma, LA263800.8211
Lafourche, LA
Terrebonne, LA
33601.0769Houston, TX264201.0606
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
34001.0180Huntington-Ashland, WV-KY-OH265801.0171
Boyd, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
34001.0180Carter, KY180.8247
34400.9421Huntsville, AL266200.9413
Limestone, AL
Start Printed Page 22436
Madison, AL
34801.0686Indianapolis, IN269001.0755
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Marion, IN
Morgan, IN
Shelby, IN
34801.0686Indianapolis, IN113000.9266
Madison, IN
35001.0276Iowa City, IA269801.0267
Johnson, IA
35200.9735Jackson, MI271000.9727
Jackson, MI
35600.8948Jackson, MS271400.8817
Hinds, MS
Madison, MS
Rankin, MS
35800.9473Jackson, TN271800.9465
Madison, TN
Chester, TN
36001.0163Jacksonville, FL272601.0142
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
36050.8942Jacksonville, NC273400.8934
Onslow, NC
36100.8078Jamestown, NY330.8668
Chautauqua, NY
36201.0200Janesville-Beloit, WI275001.0191
Rock, WI
36401.1627Jersey City, NJ356441.4156
Hudson, NJ
36600.8730Johnson City-Kingsport-Bristol, TN-VA349801.0726
Carter, TN
36600.8730Kingsport-Bristol, TN-VA287000.8763
Hawkins, TN
Sullivan, TN
Bristol City, VA
Scott, VA
Washington, VA
36600.8730Johnson City, TN277400.8663
Unicoi, TN
Washington, TN
36800.8494Johnstown, PA
Cambria, PA277800.8912
Somerset, PA390.8838
37000.8669Jonesboro, AR
Craighead, AR278600.8661
37100.9283Joplin, MO279000.9275
Jasper, MO
Newton, MO
37201.1017Kalamazoo-Battlecreek, MI
Calhoun, MI129800.9961
Kalamazoo, MI280201.1354
Van Buren, MI280201.1354
37401.1286Kankakee, IL281001.1276
Kankakee, IL
37601.0262Kansas City, KS-MO281401.0240
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Start Printed Page 22437
Lafayette, MO
Platte, MO
Ray, MO
38001.0402Kenosha, WI294041.0998
Kenosha, WI
38100.9838Killeen-Temple, TX286600.9829
Bell, TX
Coryell, TX
38400.9056Knoxville, TN289400.9091
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Union, TN
38400.9056Sevier, TN440.8369
38500.9565Kokomo, IN290200.9556
Howard, IN
Tipton, IN
38700.9888La Crosse, WI-MN291000.9879
Houston, MN
La Crosse, WI
38800.8627Lafayette, LA190.8000
Acadia, LA
St. Landry, LA
38800.8627Lafayette, LA291800.8833
Lafayette, LA
St. Martin, LA
39200.9651Lafayette, IN
Clinton, IN150.9202
Tippecanoe, IN291400.9643
39600.8486Lake Charles, LA293400.8439
Calcasieu, LA
39800.9505Lakeland-Winter Haven, FL294600.9497
Polk, FL
40001.0520Lancaster, PA295401.0510
Lancaster, PA
40401.0280Lansing-East Lansing, MI296201.0271
Clinton, MI
Eaton, MI
Ingham, MI
40800.9311Laredo, TX297000.9302
Webb, TX
41000.9350Las Cruces, NM297400.9342
Dona Ana, NM
41201.1838Las Vegas, NV-AZ
Mohave, AZ030.9503
Clarke, NV298201.2100
Nye, NV290.9869
41500.9201Lawrence, KS299400.9193
Douglas, KS
42000.8741Lawton, OK300200.8733
Comanche, OK
42431.0178Lewiston-Auburn, ME303401.0169
Androscoggin, ME
42800.9813Lexington, KY304600.9953
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Scott, KY
Woodford, KY
42800.9813Madison, KY180.8247
43200.9855Lima, OH
Allen, OH306200.9922
Auglaize, OH360.9245
43601.0866Lincoln, NE307001.0856
Lancaster, NE
44000.9395Little Rock-North Little Rock, AR307800.9386
Faulkner, AR
Lonoke, AR
Start Printed Page 22438
Pulaski, AR
Saline, AR
44200.9302Longview-Marshall, TX309800.9360
Gregg, TX
Upshur, TX
44200.9302Harrison, TX450.9245
44801.2488Los Angeles-Long Beach, CA1.2477
Los Angeles, CA31084
45200.9752Louisville, KY-IN311400.9701
Clark, IN
Floyd, IN
Harrison, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
45200.9752Louisville, KY-IN193400.9330
Scott, IN
46000.9343Lubbock, TX311800.9334
Lubbock, TX
46400.9598Lynchburg, VA313400.9589
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
46801.0214Macon, GA314201.0515
Bibb, GA
Jones, GA
Twiggs, GA
46801.0214Macon, GA
Houston, GA475800.9028
Peach, GA110.8224
47201.1065Madison, WI315401.0960
Dane, WI
48000.9692Mansfield, OH
Crawford, OH360.9245
Richland, OH319000.9772
48400.5484Mayaguez, PR419000.6026
Anasco, PR
Cabo Rojo, PR
Sabana Grande, PR
San German, PR
48400.5484Mayaguez, PR324200.5167
Hormigueros, PR
Mayaguez, PR
48800.9156McAllen-Edinburg-Mission, TX325800.9148
Hidalgo, TX
48901.1213Medford-Ashland, OR327801.1203
Jackson, OR
49001.0254Melbourne-Titusville-Palm Bay, FL373401.0244
Brevard, Fl
49200.9829Memphis, TN-AR-MS328200.9802
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
49401.1256Merced, CA329001.1246
Merced, CA
50001.0506Miami, FL331241.0497
Dade, FL
50151.2092Hunterdon, NJ350841.2429
Hunterdon, NJ
50151.2092Middlesex-Somerset, NJ207641.1843
Middlesex, NJ
Somerset, NJ
50801.0725Milwaukee-Waukesha, WI333401.0716
Milwaukee, WI
Ozaukee, WI
Washington, WI
Start Printed Page 22439
Waukesha, WI
51201.1779Minneapolis-St. Paul, MN-WI334601.1768
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
51401.0238Missoula, MT335401.0229
Missoula, MT
51600.8443Mobile, AL
Baldwin, AL010.8112
Mobile, AL336600.8503
51701.2737Modesto, CA337001.2726
Stanislaus, CA
51901.1590Monmouth-Ocean, NJ207641.1843
Monmouth, NJ
Ocean, NJ
52000.8423Monroe, LA337400.8405
Ouachita, LA
52400.8835Montgomery, AL338600.8827
Autauga, AL
Elmore, AL
Montgomery, AL
52800.9133Muncie, IN346200.9125
Delaware, IN
53300.9603Myrtle Beach, SC348200.9595
Horry, SC
53451.1238Naples, FL349401.1228
Collier, FL
53601.0759Nashville, TN349801.0726
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
53801.3739Nassau-Suffolk, NY350041.3726
Nassau, NY
Suffolk, NY
54831.3044New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT
Fairfield, CT
New Haven, CT148601.3650
353001.2556
55231.2343New London-Norwich, CT359801.2332
New London, CT
55600.9690New Orleans, LA353800.9681
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. John The Baptist, LA
St. Tammany, LA
55600.9690St. James, LA190.8000
56001.4461New York, NY356441.4156
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Start Printed Page 22440
Richmond, NY
Rockland, NY
Westchester, NY
56401.2374Newark, NJ350841.2429
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
56401.2374Newark, NJ109001.0104
Warren, NJ
56601.1890Newburgh, NY-PA
Orange, NY391001.2084
Pike, PA350841.2429
57200.9467Norfolk-Virginia Beach-Newport News, VA-NC472600.9459
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
57751.6201Oakland, CA360841.6186
Alameda, CA
Contra Costa, CA
57900.9743Ocala, FL361000.9734
Marion, FL
58001.0253Odessa-Midland, TX
Ector, TX362201.0420
Midland, TX332600.9980
58800.9544Oklahoma City, OK364200.9552
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
58800.9544Pottawatomie, OK370.8174
59101.1715Olympia, WA365001.1705
Thurston, WA
59201.0382Omaha, NE-IA365401.0373
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
59451.2359Orange County, CA420441.2348
Orange, CA
59601.0370Orlando, FL367401.0360
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
59900.8977Owensboro, KY369800.8969
Daviess, KY
60150.8647Panama City, FL374600.8640
Bay, FL
60200.8822Parkersburg-Marietta, WV-OH376200.8814
Washington, OH
Wood, WV
60800.8841Pensacola, FL378600.8833
Escambia, FL
Santa Rosa, FL
61200.9459Peoria-Pekin, IL379000.9450
Start Printed Page 22441
Peoria, IL
Tazewell, IL
Woodford, IL
61601.1521Philadelphia, NJ158041.1353
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
61601.1521Philadelphia, PA379641.1555
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
62001.0625Phoenix-Mesa, AZ380601.0616
Maricopa, AZ
Pinal, AZ
62400.9232Pine Bluff, AR382200.9224
Jefferson, AR
62800.9320Pittsburgh, PA383000.9291
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
63231.1112Pittsfield, MA383401.1102
Berkshire, MA
63401.0220Pocatello, ID385401.0210
Bannock, ID
63600.5697Ponce, PR495000.5167
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Yauco, PR
63600.5697Ponce, PR386600.5757
Ponce, PR
Villalba, PR
64031.0764Portland, ME388601.0754
Cumberland, ME
Sagadahoc, ME
York, ME
64401.2138Portland-Vancouver, OR-WA389001.2127
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
64831.1774Providence-Warwick-Pawtucket, RI393001.1623
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
65201.0232Provo-Orem, UT393401.0197
Utah, UT
65600.9316Pueblo, CO393800.9308
Pueblo, CO
65801.0049Punta Gorda, FL394601.0040
Charlotte, FL
66000.9628Racine, WI395400.9619
Racine, WI
66401.0919Durham-Chapel Hill, NC205001.1021
Chatham, NC
Durham, NC
Orange, NC
66401.0919Raleigh, NC395801.0695
Franklin, NC
Johnston, NC
Start Printed Page 22442
Wake, NC
66600.9486Rapid City, SD396600.9478
Pennington, SD
66800.9809Reading, PA397400.9800
Berks, PA
66901.2598Redding, CA398201.2586
Shasta, CA
67201.1130Reno, NV399001.1120
Washoe, NV
67401.1198Richland-Kennewick-Pasco, WA Benton, WA284201.1188
Franklin, WA
67601.0002Richmond-Petersburg, VA400600.9994
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
67801.1677Riverside-San Bernardino, CA401401.1666
Riverside, CA
San Bernardino, CA
68000.8971Roanoke, VA402200.8949
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
68201.2245Rochester, MN403401.2234
Olmsted, MN
68400.9789Rochester, NY403800.9870
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
68400.9789Genesee, NY330.8668
68801.0246Rockford, IL404201.0237
Boone, IL
Winnebago, IL
68801.0246Ogle, IL140.8868
68950.9578Rocky Mount, NC405800.9569
Edgecombe, NC
Nash, NC
69201.2611Sacramento, CA409001.2443
El Dorado, CA
Placer, CA
Sacramento, CA
69601.0321Saginaw-Bay City-Midland, MI
Bay, MI
Midland, MI130201.0182
Saginaw, MI230.9344
409801.0437
69801.0873St. Cloud, MN410601.0863
Benton, MN
Stearns, MN
70001.0658St. Joseph, MO411401.0649
Andrew, MO
Buchanan, MO
70400.9666St. Louis, MO-IL411800.9652
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
Start Printed Page 22443
St. Louis City, MO
Warren, MO
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
70801.1236Salem, OR414201.1226
Marion, OR
Polk, OR
71201.4714Salinas, CA
Monterey, CA415001.4700
71601.0098Ogden, UT362600.9801
Davis, UT
Weber, UT
71601.0098Salt Lake City, UT416201.0168
Salt Lake, UT
72000.8693San Angelo, TX416600.8685
Tom Green, TX
72400.9604San Antonio, TX417000.9575
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
73201.1993San Diego, CA417401.1982
San Diego, CA
73601.5660San Francisco, CA418841.5646
Marin, CA
San Francisco, CA
San Mateo, CA
74001.5694San Jose, CA419401.5657
Santa Clara, CA
74400.5522San Juan-Bayamon, PR419800.5342
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Comerio, PR
Corozal, PR
Dorado, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, 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
74400.5522San Juan-Bayamon, PR219400.4530
Ceiba, PR
Fajardo, PR
Luguillo, PR
74601.1834San Luis Obispo-Atascadero-Paso Robles, CA420201.1824
San Luis Obispo, CA
74801.1465Santa Barbara-Santa Maria-Lompoc, CA420601.1455
Santa Barbara, CA
74851.5731Santa Cruz-Watsonville, CA421001.5717
Santa Cruz, CA
Start Printed Page 22444
74901.1272Santa Fe, NM
Los Alamos, NM320.9231
Santa Fe, NM421401.1601
75001.3796Santa Rosa, CA422201.3784
Sonoma, CA
75101.0249Sarasota-Bradenton, FL422601.0240
Manatee, FL
Sarasota, FL
75201.0070Savannah, GA423401.0061
Bryan, GA
Chatham, GA
Effingham, GA
75600.9071Scranton—Wilkes-Barre—Hazleton, PA425400.9085
Lackawanna, PA
Luzerne, PA
Wyoming, PA
75600.9071Columbia, PA390.8838
76001.2219Seattle-Bellevue-Everett, WA426441.2222
King, WA
Snohomish, WA
76001.2219Island, WA501.0967
76100.8389Sharon, PA496600.9823
Mercer, PA
76200.9525Sheboygan, WI431000.9516
Sheboygan, WI
76401.0237Sherman-Denison, TX433001.0227
Grayson, TX
76800.9698Shreveport-Bossier City, LA433400.9712
Bossier, LA
Caddo, LA
76800.9698Webster, LA190.8000
77200.9680Sioux City, IA-NE435800.9646
Woodbury, IA
Dakota, NE
77601.0049Sioux Falls, SD436201.0040
Lincoln, SD
Minnehaha, SD
78001.0056South Bend, IN437801.0047
St. Joseph, IN
78401.1347Spokane, WA440601.1337
Spokane, WA
78800.9301Springfield, IL441000.9293
Menard, IL
Sangamon, IL
79200.9151Springfield, MO441800.9100
Christian, MO
Greene, MO
Webster, MO
80031.0828Springfield, MA441401.0822
Hampden, MA
Hampshire, MA
80500.9006State College, PA443000.8998
Centre, PA
80800.8814Steubenville-Weirton, OH-WV482600.8806
Brooke, WV
Hancock, WV
Jefferson, OH
81201.1245Stockton-Lodi, CA447001.1235
San Joaquin, CA
81400.9069Sumter, SC449400.9061
Sumter, SC
81600.9999Syracuse, NY450601.0069
Madison, NY
Onondaga, NY
Oswego, NY
81600.9999Cayuga, NY330.8668
82001.1792Tacoma, WA451041.1781
Pierce, WA
82400.9213Tallahassee, FL452200.9204
Gadsden, FL
Start Printed Page 22445
Leon, FL
82800.9605Tampa-St. Petersburg-Clearwater, FL453000.9597
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
83200.9135Terre Haute, IN454600.9058
Clay, IN
Vermillion, IN
Vigo, IN
83600.8955Texarkana, AR-Texarkana, TX455000.8947
Miller, AR
Bowie, TX
84001.0138Toledo, OH457801.0129
Fulton, OH
Lucas, OH
Wood, OH
84400.9478Topeka, KS458200.9469
Shawnee, KS
84801.0938Trenton, NJ459401.0928
Mercer, NJ
85200.9501Tucson, AZ460600.9493
Pima, AZ
85600.9291Tulsa, OK461400.9242
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
86000.8984Tuscaloosa, AL462200.8865
Tuscaloosa, AL
86401.0114Tyler, TX463401.0105
Smith, TX
86800.8829Utica-Rome, NY465400.8822
Herkimer, NY
Oneida, NY
87201.4388Vallejo-Fairfield-Napa, CA
Napa, CA349001.3326
Solano, CA467001.5185
87351.1821Ventura, CA371001.1810
Ventura, CA
87500.9015Victoria, TX470200.9008
Victoria, TX
87601.1254Vineland-Millville-Bridgeton, NJ472201.1244
Cumberland, NJ
87801.0591Visalia-Tulare-Porterville, CA473001.0608
Tulare, CA
88000.8671Waco, TX473800.8663
McLennan, TX
88401.1678Washington, DC-MD-VA-WV478941.1723
District of Columbia, DC
Calvert, MD
Charles, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Jefferson, WV
Start Printed Page 22446
88401.1678Washington, DC-MD-VA-WV136441.1651
Frederick, MD
Montgomery, MD
88401.1678Culpeper, VA490.8560
King George, VA
88401.1678Washington, DC-MD-VA-WV251801.0332
Berkeley, WV
89200.9189Waterloo-Cedar Falls, IA479400.9181
Black Hawk, IA
89401.0187Wausau, WI481401.0177
Marathon, WI
89601.1030West Palm Beach-Boca Raton, FL484241.1020
Palm Beach, FL
90000.8000Wheeling, WV-OH485400.8000
Belmont, OH
Marshall, WV
Ohio, WV
90401.0097Wichita, KS486201.0057
Butler, KS
Harvey, KS
Sedgwick, KS
90800.8936Wichita Falls, TX486600.8861
Archer, TX
Wichita, TX
91400.9032Williamsport, PA487000.9024
Lycoming, PA
91601.1838Wilmington-Newark, DE-MD488641.1750
New Castle, DE
Cecil, MD
92000.9832Wilmington, NC489000.9823
Brunswick, NC
New Hanover, NC
92601.0987Yakima, WA494201.0977
Yakima, WA
92700.9982Yolo, CA409001.2443
Yolo, CA
92800.9740York, PA496200.9731
York, PA
93201.0130Youngstown-Warren, OH496600.9823
Mahoning, OH
Trumbull, OH
93201.0130Columbiana, OH360.9245
93401.1031Yuba City, CA497001.1021
Sutter, CA
Yuba, CA
93600.9443Yuma, AZ497400.9434
Yuma, AZ
010.8129Bibb, AL138200.9738
Chilton, AL
Walker, AL
010.8129Geneva, AL200200.8015
Henry, AL
010.8129Greene, AL462200.8865
Hale, AL
010.8129Lowndes, AL338600.8827
021.2387Fairbanks North Star AK218201.1854
Matanuska-Susitna, AK112601.2937
030.9729Yavapai, AZ391401.0520
040.8199Cleveland, AR382200.9224
Franklin, AR229000.8809
Garland, AR263000.9836
Grant, AR307800.9386
Lincoln, AR382200.9224
Madison, AR222200.9184
Perry, AR307800.9386
Poinsett, AR278600.8661
051.0960Imperial, CA209400.9418
Kings, CA252600.9886
San Benito, CA419401.5657
060.9972Clear, Creek, CO197401.1596
Start Printed Page 22447
Elbert, CO
Gilpin, CO
Park, CO
060.9972Teller, CO178201.0414
100.9283Baker, FL272601.0142
Gilchrist, FL235401.0059
Indian River, FL469401.0079
100.9283Jefferson, FL452200.9204
Wakulla, FL
110.8778Brooks, GA466600.8870
Echols, GA
Lanier, GA
Lowndes, GA
110.8778Hall, GA235801.0164
Marion, GA179800.9242
Oglethorpe, GA120201.0850
110.8778Long, GA259800.8205
Liberty, GA
110.8778Murray, GA191401.0165
Whitfield, GA
110.8778Baker, GA105001.1981
Terrell, GA
Worth, GA
110.8778Crawford, GA314201.0515
Monroe, GA
110.8778Brantley, GA152601.2690
Glynn, GA
MCIntosh, GA
110.8778Butts, GA120601.0604
Dawson, GA
Haralson, GA
Heard, GA
Jasper, GA
Lamar, GA
Meriwether, GA
Pike, GA
110.8778Burke, GA122600.9735
Floyd, GA0.9442
40660
130.9395Boise, ID142600.9946
Gem, ID
Owyhee, ID
130.9395Bonneville, ID268200.9634
Jefferson, ID
130.9395Franklin, ID308600.9671
Kootenai, ID176600.9932
Nez Perce, ID303000.9905
Power, ID385401.0210
140.8877Bond, IL411800.9652
Calhoun, IL
Macoupin, IL
140.8877Ford, IL165801.0132
Platt
140.8877Marshall, IL379000.9450
Stark, IL37900
140.8877Mercer193400.9330
Vermilion, IL191800.8925
150.9299Bartholomew, IN180200.9984
Franklin, IN171401.0120
Gibson, IN217800.8903
La Porte, IN331400.9924
Sullivan, IN454600.9058
Washington, IN311400.9701
150.9299Brown, IN269001.0755
Putnam, IN
150.9299Benton, IN291400.9643
Carroll, IN
150.9299Greene, IN140200.9132
Owen, IN
150.9299Jasper, IN238440.9901
Start Printed Page 22448
Newton, IN
160.9101Benton, IA163000.9545
Jones, IA
160.9101Bremer, IA479400.9181
Grundy, IA
160.9101Guthrie, IA197800.9854
Madison, IA
160.9101Harrison, IA365401.0373
Mills, IA
160.9101Story, IA111801.0081
Washington, IA269801.0267
170.8608Doniphan, KS411401.0649
Sumner, KS486201.0057
170.8608Franklin, KS281401.0240
Linn, KS
170.8608Jackson, KS458200.9469
Jefferson, KS
Osage, KS
Wabaunsee, KS
180.8349Bracken, KY171401.0120
Trigg, KY173000.8531
Webster, KY217800.8903
180.8349Edmonson, KY145400.8657
Warren, KY
180.8349Hancock, KY369800.8969
Mc Lean, KY
180.8349Hardin, KY210600.9235
Larue, KY
180.8349Henry, KY311400.9701
Meade, KY
Nelson, KY
Shelby, KY
Spencer, KY
Trimble, KY
190.8000Cameron, LA293400.8439
DE Soto, LA433400.9712
Grant, LA107800.8690
Union, LA337400.8405
190.8000East Feliciana, LA129400.8847
Iberville, LA
Pointe Coupee, LA
St. Helena, LA
West Feliciana, LA
210.9770Somerset, MD415400.9702
Wicomico
221.0874Franklin, MA441401.0822
230.9303Barry, MI243401.0018
Ionia, MI
Newaygo, MI
230.9303Cass, MI437801.0047
240.9941Carlton, MN202601.0996
240.9941Dodge, MN403401.2234
Wabasha, MN
250.8072Copiah, MS271400.8817
Simpson, MS
250.8072George, MS377000.8480
Perry, MS256200.8000
Stone, MS250600.9518
250.8072Marshall, MS328200.9802
Tate, MS
Tunica, MS
260.8333Bates, MO281401.0240
Caldwell, MO
260.8333Callaway, MO276200.8867
Cole, MO
Moniteau, MO
Osage, MO
260.8333Crawford, Mo411800.9652
Washington, MO
260.8333Dallas, MO441800.9100
Start Printed Page 22449
Polk, MO
260.8333DeKalb, MO411401.0649
Howard, MO178600.8929
McDonald, MO222200.9184
270.9262Carbon, MT137400.9530
280.9617Dixon, NE435800.9646
Saunders, NE365401.0373
Seward, NE307001.0856
291.0466Storey, NV399001.1120
Carson City, NV161801.1009
320.9079San Juan, NM221400.8560
Torrance, NM107401.1151
330.8944Tompkins, NY270601.0198
Ulster, NY287400.9571
340.9048Anson, NC167401.0361
Greene, NC247800.9766
Hoke, NC221800.9957
Pender, NC489000.9823
Person, NC205001.1021
Rockingham, NC246600.9773
340.9048Haywood, NC117000.9774
Henderson, NC
360.9323Erie, OH417800.9589
Ottawa, OH457801.0129
Preble, OH193800.9894
360.9323Morrow, OH181401.0355
Union, OH
370.8023Grady, OK364200.9552
Lincoln, OK
370.8023Le Flore, OK229000.8809
370.8023Okmulgee, OK461400.9242
Pawnee, OK
381.0697Deschutes, OR134601.1276
390.8886Armstrong, PA383000.9291
400.4654Albonito, PR419800.5342
Barranquitas, PR
Ciales, PR
Maunabo, PR
Orocovis, PR
Quebradillas, PR
400.4654Arroyo, PR250200.4606
Guayama, PR
Patillas, PR
400.4654Guanica, PR495000.5167
Lajas, PR419000.6026
400.4654Isabela, PR103800.4922
Lares, PR
Rincon, PR
San Sebastian, PR
420.9197Calhoun, SC179000.9988
Fairfield, SC
Kershaw, SC
Saluda, SC
420.9197Darlington, SC225000.9394
Laurens, SC248601.0164
430.8934Mc Cook, SD436201.0040
Turner, SD
430.8934Meade, SD396600.9478
Union, SD435800.9646
440.8383Bradley, TN174200.8342
Polk, TN1.0726
440.8383Cannon, TN349801.0726
Hickman, TN
Macon, TN
Smith, TN
Trousdale, TN
440.8383Grainger, TN341000.8285
Hamblen, TN
Jefferson, TN
440.8383Sequatchie, TN168600.9791
Start Printed Page 22450
Stewart, TN173000.8531
450.8420Aransas, TX185800.9196
Calhoun, TX470200.9008
Clay, TX486600.8861
Crosby, TX311800.9334
Delta, TX191241.0713
Goliad, TX470200.9008
Irion, TX416600.8685
Lampasas, TX286600.9829
Rusk, TX309800.9360
Wise, TX231041.0073
450.8420Armstrong, TX111000.9761
Carson, TX
450.8420Callahan, TX101800.8348
Jones, TX
450.8420Atascosa, TX417000.9575
Bandera, TX
Kendall, TX
Medina, TX
450.8420Austin, TX264201.0606
San Jacinto, TX
450.8420Burleson, TX177800.9830
Robertson, TX
460.9413Cache, UT308600.9671
Juab, UT393401.0197
Morgan, UT362600.9801
Washington, UT411001.0058
460.9413Summit, UT416201.0168
Tooele, UT
490.9025Amelia, VA400600.9994
Caroline, VA
Cumberland, VA
King and Queen, VA
King William, VA
Louisa, VA
Sussex, VA
490.9025Appomattox, VA313400.9589
Nelson, VA168201.0947
Surry, VA472600.9459
490.9025Craig, VA402200.8949
Franklin, VA
490.9025Frederick, VA490201.1162
Winchester City, VA
490.9025Giles, VA139800.8456
Montgomery, VA
Pulaski, VA
Radford City, VA
490.9025Rockingham, VA255000.9864
Harrisonburg City, VA
501.0721Asotin, WA303000.9905
Cowlitz, WA310201.0873
Skagit, WA345801.1247
Skamania, WA389001.2127
501.0721Chelan, WA483001.0025
Douglas, WA
510.8604Boone, WV166200.9439
Clay, WV
Lincoln, WV
510.8604Hampshire, WV490201.1162
Morgan, WV251801.0332
510.8604Monongalia, WV340600.9284
Preston, WV
510.8604Pleasants, WV376200.8814
Wirt, WV
521.0110Columbia, WI315401.0960
Iowa, WI
521.0110Fund Du Lac225401.0525
521.0110Kewaunee, WI245801.0199
Start Printed Page 22451
Oconto, WI
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 D.
2 Wage index values are based on FY 2000 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 calculated by multiplying the hospital wage index value for a given area by a budget neutrality factor of 1.064435 for wage indices based on MSA designations and 1.063479 for wage indices based on CBSA designations. 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 a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.

Table D.—Comparison Wage Index for Rural Areas by MSA and CBSA

MSA code numberWage index 3 MSA designationNonurban areaCBSA code numberWage index 3 CBSA designation
99010.8129Alabama010.8112
99021.2387Alaska021.2492
99030.9729Arizona030.9503
99040.8199Arkansas040.8000
99051.0960California051.1192
99060.9972Colorado060.9963
99071.2685Connecticut071.2673
99081.0115Delaware081.0106
99100.9283Florida100.9118
99110.8778Georgia110.8224
99121.1200Hawaii121.1190
99130.9395Idaho130.8749
99140.8877Illinois140.8868
99150.9299Indiana150.9202
99160.9101Iowa160.9013
99170.8608Kansas170.8592
99180.8349Kentucky180.8247
99190.8000Louisiana190.8000
99200.9621Maine300.9613
99210.9770Maryland210.9805
99221.0874Massachusetts 5221.0865
99230.9303Michigan230.9344
99240.9941Minnesota240.9922
99250.8072Mississippi250.8120
99260.8333Missouri260.8255
99270.9262Montana270.9253
99280.9617Nebraska280.9609
9929TBDNevada290.9869
99301.0580New Hampshire301.0571
9931New Jersey 4
99320.9079New Mexico320.9231
99330.8944New York330.8668
99340.9048North Carolina340.9107
99350.8242North Dakota350.8235
99360.9323Ohio360.9245
99370.8023Oklahoma370.8174
99381.0697Oregon381.0543
99390.8886Pennsylvania390.8838
99400.4654Puerto Rico400.8000
9941Rhode Island 4
99420.9197South Carolina420.9234
99430.8934South Dakota430.8931
99440.8383Tennessee440.8369
99450.8420Texas450.8472
99460.9413Utah460.8813
99470.9979Vermont470.9970
99480.8000Virgin Islands480.8000
99490.9025Virginia490.8560
99501.0721Washington501.0967
99510.8604West Virginia510.8364
99521.0110Wisconsin521.0095
99530.9774Wyoming530.9765
Start Printed Page 22452
99651.0230Guam541.0221
3 Wage index values are based on FY 2000 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 calculated by multiplying the hospital wage index value for a given area by a proposed budget neutrality factor of 1.064435 for wage indices based on MSA designations and 1.063479 for wage indices based on CBSA designations. 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 a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.
4 All counties within the State are classified as urban.
5Based on CBSA designations Massachusetts has areas designated as rural. However, no IPPS hospitals are located in those rural area(s) for FY 2006. Because more recent data is not available for those areas, we are using the FY 2005 prefloor, preclassified hospital wage index value, for rural Massachusetts multiplied by the proposed FY 2006 budget neutrality factor of 1.063479.

Table E.—Rural Counties Converting to Urban Counties by State

County nameState county codeMSA codeMSA nameCBSA codeCBSA name
BIBB0103001ALABAMA13820Birmingham-Hoover, AL
CHILTON0110001ALABAMA13820Birmingham-Hoover, AL
GENEVA0130001ALABAMA20020Dothan, AL
GREENE0131001ALABAMA46220Tuscaloosa, AL
HALE0132001ALABAMA46220Tuscaloosa, AL
HENRY0133001ALABAMA20020Dothan, AL
LOWNDES0142001ALABAMA33860Montgomery, AL
WALKER0163001ALABAMA13820Birmingham-Hoover, AL
FAIRBANKS NORTH STAR0209002ALASKA21820Fairbanks, AK
MATANUSKA-SUSITNA0217002ALASKA11260Anchorage, AK
YAVAPAI0312003ARIZONA39140Prescott, AZ
CLEVELAND0412004ARKANSAS38220Pine Bluff, AR
FRANKLIN0423004ARKANSAS22900Fort Smith, AR-OK
GARLAND0425004ARKANSAS26300Hot Springs, AR
GRANT0426004ARKANSAS30780Little Rock-North Little Rock, AR
LINCOLN0439004ARKANSAS38220Pine Bluff, AR
MADISON0443004ARKANSAS2220Fayetteville-Springdale-Rogers, AR-MO
PERRY0452004ARKANSAS30780Little Rock-North Little Rock, AR
POINSETT0455004ARKANSAS27860Jonesboro, AR
IMPERIAL0512005CALIFORNIA20940El Centro, CA
KINGS0515005CALIFORNIA25260Hanford-Corcoran, CA
SAN BENITO0545005CALIFORNIA41940San Jose-Sunnyvale-Santa Clara, CA
CLEAR CREEK0609006COLORADO19740Denver-Aurora, CO
ELBERT0619006COLORADO19740Denver-Aurora, CO
GILPIN0623006COLORADO19740Denver-Aurora, CO
PARK0646006COLORADO19740Denver-Aurora, CO
TELLER0659006COLORADO17820Colorado Springs, CO
BAKER1001010FLORIDA27260Jacksonville, FL
GILCHRIST1020010FLORIDA23540Gainesville, FL
INDIAN RIVER1030010FLORIDA46940Vero Beach, FL
JEFFERSON1032010FLORIDA45220Tallahassee, FL
WAKULLA1064010FLORIDA45220Tallahassee, FL
BAKER1102011GEORGIA10500Albany, GA
BRANTLEY1111011GEORGIA15260Brunswick, GA
BROOKS1112011GEORGIA46660Valdosta, GA
BURKE1115011GEORGIA12260Augusta-Richmond County, GA-SC
BUTTS1116011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
CRAWFORD1133011GEORGIA31420Macon, GA
DAWSON1135011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
ECHOLS1142011GEORGIA46660Valdosta, GA
FLOYD1146011GEORGIA40660Rome, GA
GLYNN1149011GEORGIA15260Brunswick, GA
HALL1155011GEORGIA23580Gainesville, GA
HARALSON1157011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
HEARD1159011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
Start Printed Page 22453
JASPER1161111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
LAMAR1165111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
LANIER1165211GEORGIA46660Valdosta, GA
LIBERTY1168011GEORGIA25980Hinesville-Fort Stewart, GA
LONG1169111GEORGIA25980Hinesville-Fort Stewart, GA
LOWNDES1170011GEORGIA46660Valdosta, GA
MC INTOSH1170311GEORGIA15260Brunswick, GA
MARION1173011GEORGIA17980Columbus, GA-AL
MERIWETHER1174011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
MONROE1176011GEORGIA31420Macon, GA
MURRAY1177211GEORGIA19140Dalton, GA
OGLETHORPE1180111GEORGIA12020Athens-Clarke County, GA
PIKE1182111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
TERRELL1188511GEORGIA10500Albany, GA
WHITFIELD1197011GEORGIA19140Dalton, GA
WORTH1198011GEORGIA10500Albany, GA
BOISE1307013IDAHO14260Boise City-Nampa, ID
BONNEVILLE1309013IDAHO26820Idaho Falls, ID
FRANKLIN1320013IDAHO30860Logan, UT-ID
GEM1322013IDAHO14260Boise City-Nampa, ID
JEFFERSON1325013IDAHO26820Idaho Falls, ID
KOOTENAI1327013IDAHO17660Coeur d'Alene, ID
NEZ PERCE1334013IDAHO30300Lewiston, ID-WA
OWYHEE1336013IDAHO14260Boise City-Nampa, ID
POWER1338013IDAHO38540Pocatello, ID
BOND1402014ILLINOIS41180St. Louis, MO-IL
CALHOUN1406014ILLINOIS41180St. Louis, MO-IL
FORD1435014ILLINOIS16580Champaign-Urbana, IL
MACOUPIN1467014ILLINOIS41180St. Louis, MO-IL
MARSHALL1470014ILLINOIS37900Peoria, IL
MERCER1474014ILLINOIS19340Davenport-Moline-Rock Island, IA-IL
PIATT1482014ILLINOIS16580Champaign-Urbana, IL
STARK1496014ILLINOIS37900Peoria, IL
VERMILION1498214ILLINOIS19180Danville, IL
BARTHOLOMEW1502015INDIANA18020Columbus, IN
BENTON1503015INDIANA29140Lafayette, IN
BROWN1506015INDIANA26900Indianapolis, IN
CARROLL1507015INDIANA29140Lafayette, IN
FRANKLIN1523015INDIANA17140Cincinnati-Middletown, OH-KY-IN
GIBSON1525015INDIANA21780Evansville, IN-KY
GREENE1527015INDIANA14020Bloomington, IN
JASPER1536015INDIANA23844Gary, IN
LA PORTE1545015INDIANA33140Michigan City-La Porte, IN
NEWTON1555015INDIANA23844Gary, IN
OWEN1559015INDIANA14020Bloomington, IN
PUTNAM1566015INDIANA26900Indianapolis, IN
SULLIVAN1576015INDIANA45460Terre Haute, IN
WASHINGTON1587015INDIANA31140Louisville, KY-IN
BENTON1605016IOWA16300Cedar Rapids, IA
BREMER1608016IOWA47940Waterloo-Cedar Falls, IA
GRUNDY1637016IOWA47940Waterloo-Cedar Falls, IA
GUTHRIE1638016IOWA19780Des Moines, IA
HARRISON1642016IOWA36540Omaha-Council Bluffs, NE-IA
JONES1652016IOWA16300Cedar Rapids, IA
MADISON1660016IOWA19780Des Moines, IA
MILLS1664016IOWA36540Omaha-Council Bluffs, NE-IA
STORY1684016IOWA11180Ames, IA
WASHINGTON1691016IOWA26980Iowa City, IA
DONIPHAN1721017KANSAS41140St. Joseph, MO-KS
FRANKLIN1729017KANSAS28140Kansas City, MO-KS
JACKSON1742017KANSAS45820Topeka, KS
JEFFERSON1743017KANSAS45820Topeka, KS
LINN1753017KANSAS28140Kansas City, MO-KS
OSAGE1769017KANSAS45820Topeka, KS
SUMNER1795017KANSAS48620Wichita, KS
Start Printed Page 22454
WABAUNSEE1798017KANSAS45820Topeka, KS
BRACKEN1811018KENTUCKY17140Cincinnati-Middletown, OH-KY-IN
EDMONSON1829118KENTUCKY14540Bowling Green, KY
HANCOCK1845018KENTUCKY36980Owensboro, KY
HARDIN1846018KENTUCKY21060Elizabethtown, KY
HENRY1851018KENTUCKY31140Louisville, KY-IN
LARUE1861018KENTUCKY21060Elizabethtown, KY
MC LEAN1874018KENTUCKY36980Owensboro, KY
MEADE1880118KENTUCKY31140Louisville, KY-IN
NELSON1889018KENTUCKY31140Louisville, KY-IN
SHELBY1897818KENTUCKY31140Louisville, KY-IN
SPENCER1898018KENTUCKY31140Louisville, KY-IN
TRIGG1898318KENTUCKY17300Clarksville, TN-KY
TRIMBLE1898418KENTUCKY31140Louisville, KY-IN
WARREN1898618KENTUCKY14540Bowling Green, KY
WEBSTER1898918KENTUCKY21780Evansville, IN-KY
CAMERON1911019LOUISIANA29340Lake Charles, LA
DE SOTO1915019LOUISIANA43340Shreveport-Bossier City, LA
EAST FELICIANA1918019LOUISIANA12940Baton Rouge, LA
GRANT1921019LOUISIANA10780Alexandria, LA
IBERVILLE1923019LOUISIANA12940Baton Rouge, LA
POINTE COUPEE1938019LOUISIANA12940Baton Rouge, LA
ST. HELENA1945019LOUISIANA12940Baton Rouge, LA
UNION1955019LOUISIANA33740Monroe, LA
WEST FELICIANA1962019LOUISIANA12940Baton Rouge, LA
SOMERSET2119021MARYLAND41540Salisbury, MD
WICOMICO2122021MARYLAND41540Salisbury, MD
FRANKLIN2206022MASSACHUSETTS44140Springfield, MA
BARRY2307023MICHIGAN24340Grand Rapids-Wyoming, MI
CASS2313023MICHIGAN43780South Bend-Mishawaka, IN-MI
IONIA2333023MICHIGAN24340Grand Rapids-Wyoming, MI
NEWAYGO2361023MICHIGAN24340Grand Rapids-Wyoming, MI
CARLTON2408024MINNESOTA20260Duluth, MN-WI
DODGE2419024MINNESOTA40340Rochester, MN
WABASHA2478024MINNESOTA40340Rochester, MN
COPIAH2514025MISSISSIPPI27140Jackson, MS
GEORGE2519025MISSISSIPPI37700Pascagoula, MS
MARSHALL2546025MISSISSIPPI32820Memphis, TN-MS-AR
PERRY2555025MISSISSIPPI25620Hattiesburg, MS
SIMPSON2563025MISSISSIPPI27140Jackson, MS
STONE2565025MISSISSIPPI25060Gulfport-Biloxi, MS
TATE2568025MISSISSIPPI32820Memphis, TN-MS-AR
TUNICA2571025MISSISSIPPI32820Memphis, TN-MS-AR
BATES2606026MISSOURI28140Kansas City, MO-KS
CALDWELL2612026MISSOURI28140Kansas City, MO-KS
CALLAWAY2613026MISSOURI27620Jefferson City, MO
COLE2625026MISSOURI27620Jefferson City, MO
CRAWFORD2627026MISSOURI41180St. Louis, MO-IL
DALLAS2629026MISSOURI44180Springfield, MO
DE KALB2631026MISSOURI41140St. Joseph, MO-KS
HOWARD2644026MISSOURI17860Columbia, MO
MC DONALD2659026MISSOURI22220Fayetteville-Springdale-Rogers, AR-MO
MONITEAU2667026MISSOURI27620Jefferson City, MO
OSAGE2675026MISSOURI27620Jefferson City, MO
POLK2682126MISSOURI44180Springfield, MO
WASHINGTON2699226MISSOURI41180St. Louis, MO-IL
CARBON2704027MONTANA13740Billings, MT
DIXON2825028NEBRASKA43580Sioux City, IA-NE-SD
SAUNDERS2877028NEBRASKA36540Omaha-Council Bluffs, NE-IA
SEWARD2879028NEBRASKA30700Lincoln, NE
STOREY2914029NEVADA39900Reno-Sparks, NV
CARSON CITY2912029NEVADA16180Carson City, NV
SAN JUAN3222032NEW MEXICO22140Farmington, NM
TORRANCE3228032NEW MEXICO10740Albuquerque, NM
TOMPKINS3373033NEW YORK27060Ithaca, NY
ULSTER3374033NEW YORK28740Kingston, NY
ANSON3403034NORTH CAROLINA16740Charlotte-Gastonia-Concord, NC-SC
GREENE3439034NORTH CAROLINA24780Greenville, NC
Start Printed Page 22455
HAYWOOD3443034NORTH CAROLINA11700Asheville, NC
HENDERSON3444034NORTH CAROLINA11700Asheville, NC
HOKE3446034NORTH CAROLINA22180Fayetteville, NC
PENDER3470034NORTH CAROLINA48900Wilmington, NC
PERSON3472034NORTH CAROLINA20500Durham, NC
ROCKINGHAM3478034NORTH CAROLINA24660Greensboro-High Point, NC
ERIE3622036OHIO41780Sandusky, OH
MORROW3660036OHIO18140Columbus, OH
OTTAWA3663036OHIO45780Toledo, OH
PREBLE3669036OHIO19380Dayton, OH
UNION3681036OHIO18140Columbus, OH
GRADY3725037OKLAHOMA36420Oklahoma City, OK
LE FLORE3739037OKLAHOMA22900Fort Smith, AR-OK
LINCOLN3740037OKLAHOMA36420Oklahoma City, OK
OKMULGEE3755037OKLAHOMA46140Tulsa, OK
PAWNEE3758037OKLAHOMA46140Tulsa, OK
DESCHUTES3808038OREGON13460Bend, OR
ARMSTRONG3907039PENNSYLVANIA38300Pittsburgh, PA
CALHOUN4208042SOUTH CAROLINA17900Columbia, SC
DARLINGTON4215042SOUTH CAROLINA22500Florence, SC
FAIRFIELD4219042SOUTH CAROLINA17900Columbia, SC
KERSHAW4227042SOUTH CAROLINA17900Columbia, SC
LAURENS4229042SOUTH CAROLINA24860Greenville, SC
SALUDA4240042SOUTH CAROLINA17900Columbia, SC
MC COOK4343043SOUTH DAKOTA43620Sioux Falls, SD
MEADE4346043SOUTH DAKOTA39660Rapid City, SD
TURNER4362043SOUTH DAKOTA43620Sioux Falls, SD
UNION4363043SOUTH DAKOTA43580Sioux City, IA-NE-SD
BRADLEY4405044TENNESSEE17420Cleveland, TN
CANNON4407044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
GRAINGER4428044TENNESSEE34100Morristown, TN
HAMBLEN4431044TENNESSEE34100Morristown, TN
HICKMAN4440044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
JEFFERSON4444044TENNESSEE34100Morristown, TN
MACON4455044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
POLK4469044TENNESSEE17420Cleveland, TN
SEQUATCHIE4476044TENNESSEE16860Chattanooga, TN-GA
SMITH4479044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
STEWART4480044TENNESSEE17300Clarksville, TN-KY
TROUSDALE4484044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
ARANSAS4503045TEXAS18580Corpus Christi, TX
ARMSTRONG4505045TEXAS11100Amarillo, TX
ATASCOSA4506045TEXAS41700San Antonio, TX
AUSTIN4507045TEXAS26420Houston-Baytown-Sugar Land, TX
BANDERA4509045TEXAS41700San Antonio, TX
BURLESON4522145TEXAS17780College Station-Bryan, TX
CALHOUN4522445TEXAS47020Victoria, TX
CALLAHAN4523045TEXAS10180Abilene, TX
CARSON4525145TEXAS11100Amarillo, TX
CLAY4529145TEXAS48660Wichita Falls, TX
CROSBY4536245TEXAS31180Lubbock, TX
DELTA4540045TEXAS19124Dallas-Plano-Irving, TX
GOLIAD4556145TEXAS47020Victoria, TX
IRION4567245TEXAS41660San Angelo, TX
JONES4572145TEXAS10180Abilene, TX
KENDALL4573145TEXAS41700San Antonio, TX
LAMPASAS4575245TEXAS28660Killeen-Temple-Fort Hood, TX
MEDINA4579245TEXAS41700San Antonio, TX
ROBERTSON4587845TEXAS17780College Station-Bryan, TX
RUSK4588145TEXAS30980Longview, TX
SAN JACINTO4588445TEXAS26420Houston-Baytown-Sugar Land, TX
WISE4597345TEXAS23104Fort Worth-Arlington, TX
CACHE4602046UTAH30860Logan, UT-ID
JUAB4611046UTAH39340Provo-Orem, UT
MORGAN4614046UTAH36260Ogden-Clearfield, UT
Start Printed Page 22456
SUMMIT4621046UTAH41620Salt Lake City, UT
TOOELE4622046UTAH41620Salt Lake City, UT
WASHINGTON4626046UTAH41100St. George, UT
AMELIA4903049VIRGINIA40060Richmond, VA
APPOMATTOX4905049VIRGINIA31340Lynchburg, VA
CAROLINE4916049VIRGINIA40060Richmond, VA
CRAIG4922049VIRGINIA40220Roanoke, VA
CUMBERLAND4924049VIRGINIA40060Richmond, VA
FRANKLIN4933049VIRGINIA40220Roanoke, VA
FREDERICK4934049VIRGINIA49020Winchester, VA-WV
GILES4935049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
KING AND QUEEN4948049VIRGINIA40060Richmond, VA
KING WILLIAM4950049VIRGINIA40060Richmond, VA
LOUISA4954049VIRGINIA40060Richmond, VA
MONTGOMERY4960049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
NELSON4962049VIRGINIA16820Charlottesville, VA
PULASKI4977049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
ROCKINGHAM4982049VIRGINIA25500Harrisonburg, VA
SURRY4990049VIRGINIA47260Virginia Beach-Norfolk-Newport News, VA
SUSSEX4991049VIRGINIA40060Richmond, VA
HARRISONBURG CITY4942149VIRGINIA25500Harrisonburg, VA
RADFORD CITY4977149VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
WINCHESTER CITY4996249VIRGINIA49020Winchester, VA-WV
ASOTIN5001050WASHINGTON30300Lewiston, ID-WA
CHELAN5003050WASHINGTON48300Wenatchee, WA
COWLITZ5007050WASHINGTON31020Longview, WA
DOUGLAS5008050WASHINGTON48300Wenatchee, WA
SKAGIT5028050WASHINGTON34580Mount Vernon-Anacortes, WA a
SKAMANIA5029050WASHINGTON38900Portland-Vancouver-Beaverton, OR-WA
BOONE5102051WEST VIRGINIA16620Charleston, WV
CLAY5107051WEST VIRGINIA16620Charleston, WV
HAMPSHIRE5113051WEST VIRGINIA49020Winchester, VA-WV
LINCOLN5121051WEST VIRGINIA16620Charleston, WV
MONONGALIA5130051WEST VIRGINIA34060Morgantown, WV
MORGAN5132051WEST VIRGINIA25180Hagerstown-Martinsburg, MD-WV
PLEASANTS5136051WEST VIRGINIA37620Parkersburg-Marietta, WV-OH
PRESTON5138051WEST VIRGINIA34060Morgantown, WV
WIRT5152051WEST VIRGINIA37620Parkersburg-Marietta, WV-OH
COLUMBIA5210052WISCONSIN31540Madison, WI
FOND DU LAC5219052WISCONSIN22540Fond du Lac, WI
IOWA5224052WISCONSIN31540Madison, WI
KEWAUNEE5230052WISCONSIN24580Green Bay, WI
OCONTO5241052WISCONSIN24580Green Bay, WI
AIBONITO4005040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
ARROYO4008040PUERTO RICO25020Guayama, PR
BARRANQUITAS4010040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
CIALES4019040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
GUANICA4027040PUERTO RICO49500Yauco, PR
GUAYAMA4028040PUERTO RICO25020Guayama, PR
ISABELA4035040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
LAJAS4039040PUERTO RICO41900San German-Cabo Rojo, PR
LARES4040040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
MAUNABO4047040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
OROCOVIS4053040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
PATILLAS4054040PUERTO RICO25020Guayama, PR
QUEBRADILLAS4057040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
RINCON4058040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
SAN SEBASTIAN4066040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
Start Printed Page 22457

Table F.—Crosswalk of Counties by State From MSA to CBSA

County nameStateState county codeMSA codeMSA nameCBSA codeCBSA name
AUTAUGAAL010005240MONTGOMERY, AL33860Montgomery, AL
BALDWINAL010105160MOBILE, AL*
BARBOURAL0102001ALABAMA*
BIBBAL0103001ALABAMA13820Birmingham-Hoover, AL
BLOUNTAL010401000BIRMINGHAM, AL13820Birmingham-Hoover, AL
BULLOCKAL0105001ALABAMA*
BUTLERAL0106001ALABAMA*
CALHOUNAL010700450ANNISTON, AL11500Anniston-Oxford, AL
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