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

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Start Preamble Start Printed Page 45026

AGENCY:

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

ACTION:

Final rule.

SUMMARY:

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

DATES:

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

Start Further Info

FOR FURTHER INFORMATION CONTACT:

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

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

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

End Further Info End Preamble Start Supplemental Information

SUPPLEMENTARY INFORMATION:

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

Table of Contents

I. Background

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

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

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

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

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

F. General Overview of the SNF PPS

1. Payment Provisions—Federal Rates

2. Payment Provisions—Initial Transition Period

G. Use of the SNF Market Basket Index

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

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

A. General Comments on the FY 2006 Proposed Rule

1. Public Comment Schedule for the FY 2006 Proposed Rule

B. Update of Federal Payment Rates Under the SNF PPS

1. Costs and Services Covered by the Federal Rates

2. Methodology Used for the Calculation of the Federal Rates

C. Case-Mix Adjustment and Other Clinical Issues

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

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

3. Implementation Issues

4. Additional Clinical and Related Issues

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

b. Long-Term Payment and Quality Incentive Proposals

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

d. Completion of Other Medicare Required Assessments (OMRAs)

e. Concurrent Therapy

5. Case-Mix Adjusted Federal Rates and Associated Indexes

D. Wage Index Adjustment to Federal Rates

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

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

3. Calculating the Budget Neutrality Factor

E. Updates to the Federal Rates

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

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

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

H. SNF Market Basket Index

1. Background

2. Use of the SNF Market Basket Percentage

3. Market Basket Forecast Error Adjustment

4. Federal Rate Update Factor

I. Consolidated Billing

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

K. Qualifying Three-Day Inpatient Hospital Stay Requirement

IV. Provisions of the Final Rule

V. Waiver of Proposed Rulemaking

VI. Collection of Information Requirements

VII. Regulatory Impact Analysis

A. Overall Impact

B. Anticipated Effects

C. Accounting Statement

D. Alternatives Considered Regulation Text

VIII. Addendum

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

ADL Activity of Daily Living

ARD Assessment Reference Date

BBA Balanced Budget Act of 1997, Pub. L. 105-33

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

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

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

CAH Critical Access Hospital

CBSA Core-Based Statistical Area

CFR Code of Federal Regulations

CMS Centers for Medicare & Medicaid Services

CMSA Consolidated Metropolitan Statistical Area

CPT (Physicians') Current Procedural Terminology

DRG Diagnosis Related Group

FI Fiscal Intermediary

FR Federal Register

FY Fiscal Year

GAO Government Accountability Office

HCPCS Healthcare Common Procedure Coding System

ICD-9-CM International Classification of Diseases, Ninth Edition, Clinical Modification

IFC Interim Final Rule With Comment Period

MDS Minimum Data Set

MEDPAR Medicare Provider Analysis and Review File

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

MSA Metropolitan Statistical Area

NECMA New England County Metropolitan Area

OIG Office of Inspector General

OMRA  Other Medicare Required Assessment

PMSA Primary Metropolitan Statistical Area

PPI Producer Price Index

PPS Prospective Payment System

PRM Provider Reimbursement Manual Start Printed Page 45027

RAI Resident Assessment Instrument

RAP Resident Assessment Protocol

RAVEN Resident Assessment Validation Entry

RFA Regulatory Flexibility Act, Pub. L. 96-354

RIA Regulatory Impact Analysis

RUG Resource Utilization Group

SCHIP  State Children's Health Insurance Program

SNF Skilled Nursing Facility

STM Staff Time Measurement

UMRA Unfunded Mandates Reform Act, Pub. L. 104-4

I. Background

On May 19, 2005, we published a proposed rule in the Federal Register (70 FR 29070, hereafter referred to as the FY 2006 SNF PPS proposed rule), setting forth the proposed updates to the payment rates used under the prospective payment system (PPS) for skilled nursing facilities (SNFs), for FY 2006. Annual updates to the PPS rates are required by section 1888(e) of the Social Security Act (the Act), as amended by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA, Pub. L. 106-113), the Medicare, Medicaid, and SCHIP Benefits Improvement and rotection Act of 2000 (BIPA, Pub. L. 106-554), and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, Pub. L. 100-173), relating to Medicare payments and consolidated billing for SNFs. In the FY 2006 SNF PPS proposed rule, we invited public comments on a number of proposed revisions and technical corrections to the regulations.

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

Section 4432 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33) amended section 1888 of the Act to provide for the implementation of a per diem PPS for SNFs, covering all costs (routine, ancillary, and capital-related) of covered SNF services furnished to beneficiaries under Part A of the Medicare program, effective for cost reporting periods beginning on or after July 1, 1998. We are updating the per diem payment rates for SNFs for FY 2006. Major elements of the SNF PPS include:

  • Rates. Per diem Federal rates were established for urban and rural areas using allowable costs from FY 1995 cost reports. These rates also included an estimate of the cost of services that, before July 1, 1998, were paid under Part B but furnished to Medicare beneficiaries in a SNF during a Part A covered stay. The rates were adjusted annually using a SNF market basket index. Rates were case-mix adjusted using a classification system (Resource Utilization Groups, version III (RUG-III)) based on beneficiary assessments (using the Minimum Data Set (MDS) version 2.0) (In section III.C of this final rule, we discuss refinements to the case-mix classification system). The rates were also adjusted by the hospital wage index to account for geographic variation in wages. (In section III.D of this final rule, we discuss the wage index adjustment in detail.) Correction notices were published in the Federal Register on October 7, 2004 (69 FR 60158) and on December 30, 2004 (69 FR 78445) that announced corrections to several of the wage factors. Additionally, as noted in the July 30, 2004 update notice (69 FR 45775), section 101 of BBRA and certain sections of BIPA also affect the payment rate.
  • Transition. The SNF PPS included an initial 3-year, phased transition that blended a facility-specific payment rate with the Federal case-mix adjusted rate. For each cost reporting period after a facility migrated to the new system, the facility-specific portion of the blend decreased and the Federal portion increased in 25 percentage point increments. For most facilities, the facility-specific rate was based on allowable costs from FY 1995; however, since the last year of the transition was FY 2001, all facilities were paid at the full Federal rate by the following fiscal year (FY 2002). Therefore, as discussed in section I.F.2 of this final rule, we are no longer including adjustment factors related to facility-specific rates for the coming fiscal year.
  • Coverage. The establishment of the SNF PPS did not change Medicare's fundamental requirements for SNF coverage. However, because the RUG-III classification is based, in part, on the beneficiary's need for skilled nursing care and therapy, we have attempted, where possible, to coordinate claims review procedures involving level of care determinations with the outputs of beneficiary assessment and RUG-III classifying activities. We discuss this coordination in greater detail in section III.F of this final rule. Moreover, the Part A SNF benefit has not only level of care requirements, but also a set of technical, or “posthospital” requirements as well. In section III.K of this final rule, we discuss one aspect of the technical requirement for a qualifying prior inpatient hospital stay of at least 3 consecutive days, on which we invited public comment in the FY 2006 SNF PPS proposed rule.
  • Consolidated Billing. The SNF PPS includes a consolidated billing provision that requires a SNF to submit consolidated Medicare claims for almost all of the services that the resident receives during the course of a covered Part A stay. (In addition, this provision places with the SNF the Medicare billing responsibility for physical and occupational therapy, and speech-language pathology services that the resident receives during a noncovered stay.) The statute excludes from the consolidated billing provision a few services—primarily those of physicians and certain other types of practitioners—which remain separately billable to Part B by the outside entity that furnishes them. We discuss this provision in greater detail in section III.I of this final rule.
  • Application of the SNF PPS to SNF services furnished by swing-bed hospitals. Section 1883 of the Act permits certain small, rural hospitals to enter into a Medicare swing-bed agreement, under which the hospital can use its beds to provide either acute or SNF care, as needed. For critical access hospitals (CAHs), Part A pays on a reasonable cost basis for SNF services furnished under a swing-bed agreement. However, in accordance with section 1888(e)(7) of the Act, these services furnished by non-CAH rural hospitals are paid under the SNF PPS, effective with cost reporting periods beginning on or after July 1, 2002. A more detailed discussion of this provision appears in section III.J of this final rule.
  • Technical corrections. We are also taking this opportunity to make certain technical corrections in the text of the regulations, as discussed in greater detail in section IV. of this final rule.

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

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

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

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

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

In the July 30, 1999 final rule (64 FR 41670), we indicated that we would announce any changes to the guidelines for Medicare level of care determinations related to modifications in the RUG-III classification structure (see section III.F of this final rule).

Along with a number of other revisions discussed later in this preamble, this final rule provides the Start Printed Page 45028annual updates to the Federal rates as mandated by the Act.

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

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

We included further information on all of the provisions of the BBRA that affect the SNF PPS in Program Memoranda A-99-53 and A-99-61 (December 1999), and Program Memorandus AB-00-18 (March 2000). In addition, for swing-bed hospitals with more than 49 (but less than 100) beds, section 408 of the BBRA provided for the repeal of certain statutory restrictions on length of stay and aggregate payment for patient days, effective with the end of the SNF PPS transition period described in section 1888(e)(2)(E) of the Act. In the July 31, 2001 final rule (66 FR 39562), we made conforming changes to the regulations in § 413.114(d), effective for services furnished in cost reporting periods beginning on or after July 1, 2002, to reflect section 408 of the BBRA.

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

The BIPA included several provisions that resulted in adjustments to the PPS for SNFs. These provisions were described in detail in the final rule that we published in the Federal Register on July 31, 2001 (66 FR 39562), as follows:

  • Section 203 of the BIPA exempted critical access hospital (CAH) swing-beds from the SNF PPS; we included further information on this provision in Program Memorandum A-01-09 (January 16, 2001).
  • Section 311 of the BIPA eliminated the 1 percent reduction in the SNF market basket that the statutory update formula had previously specified for FY 2001, and changed the 1 percent reduction specified for FYs 2002 and 2003 to a 0.5 percent reduction. This section also required us to conduct a study of alternative case-mix classification systems for the SNF PPS, and to submit a report to the Congress on the results of the study.
  • Section 312 of the BIPA provided for a temporary 16.66 percent increase in the nursing component of the case-mix adjusted Federal rate for services furnished on or after April 1, 2001, and before October 1, 2002. This section also required the Government Accountability Office (GAO) to conduct an audit of SNF nursing staff ratios and submit a report to the Congress on whether the temporary increase in the nursing component should be continued. GAO issued this report (GAO-03-176) in November 2002.
  • Section 313 of the BIPA repealed the consolidated billing requirement for services (other than physical and occupational therapy, and speech-language pathology services) furnished to SNF residents during noncovered stays, effective January 1, 2001.
  • Section 314 of the BIPA adjusted the payment rates for all of the 14 rehabilitation RUGs (RUC, RUB, RUA, RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, and RLA), in order to correct an anomaly under which the existing payment rates for three particular rehabilitation RUGs—RHC, RMC, and RMB—were higher than the rates for some other, more intensive rehabilitation RUGs. Under the BIPA adjustment, the temporary increase that sections 101(a) and (b) of the BBRA had applied to the RHC, RMC, and RMB rehabilitation RUGs was revised from 20 percent to 6.7 percent, and the BIPA adjustment also applied this temporary 6.7 percent increase to each of the other 11 rehabilitation RUGs. Under this provision, the temporary increase remained at 20 percent for each of the 12 non-rehabilitation RUGs specified in section 101(b) of the BBRA (SE3, SE2, SE1, SSC, SSB, SSA, CC2, CC1, CB2, CB1, CA2, and CA1).
  • Section 315 of the BIPA authorized us to establish a geographic reclassification procedure that is specific to SNFs, but only after collecting the data necessary to establish a SNF wage index that is based on wage data from nursing homes.

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

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

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

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

In addition, section 410 of the MMA contained a provision that affects the SNF consolidated billing requirement's treatment of certain services furnished as of January 1, 2005, by rural health clinics (RHCs) and Federally qualified health centers (FQHCs). This provision was discussed in Transmittal No. 390 (Change Request No. 3575), issued on December 10, 2004, which is available online at http://www.cms.hhs.gov/​Start Printed Page 45029manuals/​transmittals/​comm_​date_​dsc.asp.

F. General Overview of the SNF PPS

We implemented the Medicare SNF PPS for cost reporting periods beginning on or after July 1, 1998. Under the PPS, we pay SNFs through prospective, case-mix adjusted per diem payment rates applicable to all covered SNF services. These payment rates cover all the costs of furnishing covered skilled nursing services (routine, ancillary, and capital-related costs) other than costs associated with approved educational activities. Covered SNF services include post-hospital services for which benefits are provided under Part A and all items and services that, before July 1, 1998, had been paid under Part B (other than physician and certain other services specifically excluded under the BBA) but furnished to Medicare beneficiaries in a SNF during a covered Part A stay. A complete discussion of these provisions appears in the May 12, 1998 interim final rule (63 FR 26252).

1. Payment Provisions—Federal Rate

The PPS uses per diem Federal payment rates based on mean SNF costs in a base year updated for inflation to the first effective period of the PPS. We developed the Federal payment rates using allowable costs from hospital-based and freestanding SNF cost reports for reporting periods beginning in FY 1995. The data used in developing the Federal rates also incorporated an estimate of the amounts that would be payable under Part B for covered SNF services furnished to individuals during the course of a covered Part A stay in a SNF.

In developing the rates for the initial period, we updated costs to the first effective year of PPS (the 15-month period beginning July 1, 1998) using a SNF market basket, and then standardized for the costs of facility differences in case-mix and for geographic variations in wages. The database used to compute the Federal payment rates excluded providers that received new provider exemptions from the routine cost limits, as well as costs related to payments for exceptions to the routine cost limits. In accordance with the formula prescribed in the BBA, we set the Federal rates at a level equal to the weighted mean of freestanding costs plus 50 percent of the difference between the freestanding mean and weighted mean of all SNF costs (hospital-based and freestanding) combined. We computed and applied separately the payment rates for facilities located in urban and rural areas. In addition, we adjusted the portion of the Federal rate attributable to wage-related costs by a wage index.

The Federal rate also incorporates adjustments to account for facility case-mix, using a classification system that accounts for the relative resource utilization of different patient types. This classification system, Resource Utilization Groups, version III (RUG-III), uses beneficiary assessment data from the Minimum Data Set (MDS) completed by SNFs to assign beneficiaries to one of 44 RUG-III groups. The May 12, 1998 interim final rule (63 FR 26252) included a complete and detailed description of the RUG-III classification system. A further discussion of the case-mix classification system, including the issue of case-mix refinements, appears in section III.C of this final rule.

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

2. Payment Provisions—Initial Transition Period

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

G. Use of the SNF Market Basket Index

Section 1888(e)(5) of the Act requires us to establish a SNF market basket index that reflects changes over time in the prices of an appropriate mix of goods and services included in the covered SNF services. The SNF market basket index is used to update the Federal rates on an annual basis. The final rule published on July 31, 2001 (66 FR 39562) revised and rebased the market basket to reflect 1997 total cost data. The SNF market basket index is discussed in greater detail in section III.H of this final rule.

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

Table 1.—FY 2004 Forecast Error Correction for CMS SNF Market Basket

IndexForecasted FY 2004 increase*Actual FY 2004 increase**FY 2004 forecast error correction***
SNF3.03.00.0
* Published in August 4, 2003 Federal Register; based on second quarter 2003 Global Insight/DRI-WEFA forecast.
** Based on the second quarter 2005 Global Insight/DRI-WEFA forecast.
*** The FY 2004 forecast error correction will be applied to the FY 2006 PPS update. Any forecast error less than 0.25 percentage points is not reflected in the update.
Start Printed Page 45030

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

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

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

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

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

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

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

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

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

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

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

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

B. Update of Federal Payment Rates Under the SNF PPS

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

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

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

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

Using the adjusted therapy case-mix weights, we repeated the payment simulation described in the proposed Start Printed Page 45031rule. We then recalculated the payment adjustment needed to ensure parity when comparing the aggregate expenditure levels of the 44-group and 53-group RUG models. We found that, in recalibrating both the nursing and therapy case-mix weights, applying the payment adjustment solely to the nursing case-mix weights was no longer appropriate. Thus, we tested a second adjustment to the model that modified the payment simulation provision to apply the payment adjustment to both the nursing and therapy case-mix weights. We posted the analyses on our CMS web site.

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

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

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

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

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

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

1. Costs and Services Covered by the Federal Rates

The Federal rates apply to all costs (routine, ancillary, and capital-related costs) of covered SNF services other than costs associated with approved educational activities as defined in § 413.85. Under section 1888(e)(2) of the Act, covered SNF services include post-hospital SNF services for which benefits are provided under Part A (the hospital insurance program), as well as all items and services (other than those services excluded by statute) that, before July 1, 1998, were paid under Part B (the supplementary medical insurance program) but furnished to Medicare beneficiaries in a SNF during a Part A covered stay. (These excluded service categories are discussed in greater detail in section V.B.2 of the May 12, 1998 interim final rule (63 FR 26295 through 26297)).

2. Methodology Used for the Calculation of the Federal Rates

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

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

Table 2.—FY 2006 Unadjusted Federal Rate Per Diem—Urban

Rate componentNursing—case-mixTherapy—case-mixTherapy—non-case-mixNon-case-mix
Per Diem Amount$137.59$103.64$13.65$70.22
Start Printed Page 45032

Table 3.—FY 2006 Unadjusted Federal Rate Per Diem—Rural

Rate componentNursing—case-mixTherapy—case-mixTherapy—non-case-mixNon-case-mix
Per Diem Amount$131.45$119.51$14.58$71.52

C. Case-Mix Adjustment and Other Clinical Issues

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

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

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

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

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

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

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

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

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

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

In addition, we have discovered that in the FY 2006 SNF PPS proposed rule, we inadvertently misidentified some RUG classification categories corresponding to Rehab High, Rehab Medium, and Rehab Low in Table 3a (“Crosswalk Between Existing RUG-III Rehabilitation Groups and the Proposed Extensive Plus Rehabilitation Groups”). Accordingly, in this final rule, we are reprinting the retitled and corrected Table 3a, as set forth below. Start Printed Page 45033

Table 3a.—Crosswalk Between Existing RUG-III Rehabilitation Groups and the New Rehabilitation Plus Extensive Services Groups

Current rehabilitation groupsNew rehabilitation plus extensive services groups
Rehab Ultra• RUC—ADL 16-18 • RUB—ADL 9-15 • RUA—ADL 4-8• RUX—ADL 16-18. • RUL—ADL 7-15.
Rehab Very High• RVC—ADL 16-18 • RVB—ADL 9-15 • RVA—ADL 4-8• RVX—ADL 16-18. • RVL—ADL 7-15.
Rehab High• RHC—ADL 13-18 • RHB—ADL 8-12 • RHA—ADL 4-7• RHX—ADL 13-18. • RHL—ADL 7-12.
Rehab Medium• RMC—ADL 15-18 • RMB—ADL 8-14 • RMA—ADL 4-7• RMX—ADL 15-18. • RML—ADL 7-14.
Rehab Low• RLB—ADL 14-18 • RLA—ADL 4-13• RLX—ADL 7-18.

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

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

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

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

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

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

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

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

Response: While Medicare and Medicaid are independent programs that are subject to different ratesetting and budgetary mechanisms, we recognize their interrelationship, particularly for those States that utilize variations of Medicare's RUG case-mix classification system. We further recognize that Medicaid needs to establish rates that accurately reflect the cost of Medicaid services. In order to Start Printed Page 45034assist in realizing that objective, we plan to use our upcoming STM study to look at the entire RUG payment system, including facilities that are predominately Medicaid-based. Additionally, the Pay for Performance quality initiatives discussed in the FY 2006 proposed rule could apply to both covered Part A and noncovered (Part B) stays of dual-eligibles.

3. Implementation Issues

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

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

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

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

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

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

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

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

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

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

4. Additional Clinical and Related Issues

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

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

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

Comment: We received numerous comments on several potential changes to the MDS and the case-mix Start Printed Page 45035classification system that we proposed. The overwhelming majority of commenters opposed the elimination of two current policies: The availability of grace days when completing the MDS, and the method of estimating therapy services during the first 15 days of a SNF admission. However, a few commenters supported eliminating the method of estimating therapy services, mentioning findings by the GAO and the Data Assessment and Verification Project (DAVE) that demonstrated a mismatch between the estimated and actual amount of therapy provided, and expressing concern that there may be some abuse of this policy. In addition, a few commenters suggested limiting the use of grace days to the 5-day and 14-day assessments. We also received numerous comments on the change in the MDS assessment “look back” period to restrict MDS reporting to services furnished in the SNF rather than during the preceding hospital stay. While some commenters supported the change in terms of SNF reimbursement policy, most commenters believed there were strong care planning reasons for retaining the current policy. Specifically, the commenters were concerned that facility staff would be unable to perform an accurate assessment of the resident, and that the elimination of the data would result in an underestimate of resource needs and negatively affect the development of an individualized care plan. A number of commenters also recommended that the type of changes discussed in the proposed rule needed to be coordinated with other CMS initiatives, including the development of MDS 3.0 and the upcoming STM study.

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

b. Long-Term Payment and Quality Incentive Proposals

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

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

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

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

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

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

Response: Regarding the concerns about unduly impeding the scope of practice for NPs and CNSs and limiting resident access to their services, we note that under section 1814(a)(2) of the Act, the statutory prohibition against an NP or CNS having a direct or indirect employment relationship with the SNF applies solely in terms of performing the Start Printed Page 45036required certification and recertifications of the beneficiary's need for Part A SNF services, and does not carry over to any other context. This means that while the presence of such an employment relationship would serve to preclude an NP or CNS from performing the required SNF certification and recertifications, it would not additionally prevent the NP or CNS from furnishing the full range of direct patient care to the SNF's residents. Further, regarding the issue of the differential treatment of physicians (who are not subject to this restriction), we note that the statute itself specifically applies the restriction to NPs and CNSs, but not to physicians.

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

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

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

d. Completion of Other Medicare Required Assessments (OMRAs)

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

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

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

e. Concurrent Therapy

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

Comment: A majority of commenters support the continuation of concurrent therapy as a delivery mode for rehabilitation services when properly furnished by the therapist. Many commenters suggested that CMS establish guidelines or develop examples that would provide guidance on the appropriate use of concurrent therapy, while a few commenters pointed out that CMS already has authority to conduct medical reviews and opposed further regulation. We also received some comments that suggested ways to decrease confusion among therapists, including educational outreach with the assistance of the professional associations, and establishing a single set of guidelines for Medicare Part A and Medicare Part B. Several commenters reported abuse and some reported that staff are being coerced to maximize minutes and reimbursement. One commenter expressed concern that, in the absence of concurrent therapy, some patients might not receive any services. However, another commenter suggested that the overuse of concurrent therapy Start Printed Page 45037could mean that a beneficiary might never receive necessary individualized care.

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

5. Case-Mix Adjusted Federal Rates and Associated Indexes

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

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

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

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

Table 4.—RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes—Urban

RUG III categoryNursing indexTherapy indexNursing componentTherapy componentNon-case mix therapy componentNon-case mix componentTotal rate
RUC1.302.25178.87233.1970.22482.28
RUB0.952.25130.71233.1970.22434.12
RUA0.782.25107.32233.1970.22410.73
RVC1.131.41155.48146.1370.22371.83
RVB1.041.41143.09146.1370.22359.44
RVA0.811.41111.45146.1370.22327.80
RHC1.260.94173.3697.4270.22341.00
RHB1.060.94145.8597.4270.22313.49
RHA0.870.94119.7097.4270.22287.34
RMC1.350.77185.7579.8070.22335.77
RMB1.090.77149.9779.8070.22299.99
RMA0.960.77132.0979.8070.22282.11
RLB1.110.43152.7244.5770.22267.51
RLA0.800.43110.0744.5770.22224.86
SE31.70233.9013.6570.22317.77
SE21.39191.2513.6570.22275.12
SE11.17160.9813.6570.22244.85
SSC1.13155.4813.6570.22239.35
SSB1.05144.4713.6570.22228.34
SSA1.01138.9713.6570.22222.84
CC21.12154.1013.6570.22237.97
CC10.99136.2113.6570.22220.08
CB20.91125.2113.6570.22209.08
CB10.84115.5813.6570.22199.45
CA20.83114.2013.6570.22198.07
CA10.75103.1913.6570.22187.06
IB20.6994.9413.6570.22178.81
IB10.6792.1913.6570.22176.06
IA20.5778.4313.6570.22162.30
Start Printed Page 45038
IA10.5372.9213.6570.22156.79
BB20.6893.5613.6570.22177.43
BB10.6589.4313.6570.22173.30
BA20.5677.0513.6570.22160.92
BA10.4866.0413.6570.22149.91
PE20.79108.7013.6570.22192.57
PE10.77105.9413.6570.22189.81
PD20.7299.0613.6570.22182.93
PD10.7096.3113.6570.22180.18
PC20.6589.4313.6570.22173.30
PC10.6488.0613.6570.22171.93
PB20.5170.1713.6570.22154.04
PB10.5068.8013.6570.22152.67
PA20.4967.4213.6570.22151.29
PA10.4663.2913.6570.22147.16

Table 4a.—RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes—Urban

RUG-53 categoryNursing indexTherapy indexNursing componentTherapy componentNon-case mix therapy componentNon-case mix componentTotal rate
RUX1.902.25261.42233.1970.22564.83
RUL1.402.25192.63233.1970.22496.04
RVX1.541.41211.89146.1370.22428.24
RVL1.331.41182.99146.1370.22399.34
RHX1.420.94195.3897.4270.22363.02
RHL1.370.94188.5097.4270.22356.14
RMX1.930.77265.5579.8070.22415.57
RML1.680.77231.1579.8070.22381.17
RLX1.310.43180.2444.5770.22295.03
RUC1.282.25176.12233.1970.22479.53
RUB0.992.25136.21233.1970.22439.62
RUA0.842.25115.58233.1970.22418.99
RVC1.231.41169.24146.1370.22385.59
RVB1.091.41149.97146.1370.22366.32
RVA0.821.41112.82146.1370.22329.17
RHC1.220.94167.8697.4270.22335.50
RHB1.110.94152.7297.4270.22320.36
RHA0.940.94129.3397.4270.22296.97
RMC1.150.77158.2379.8070.22308.25
RMB1.090.77149.9779.8070.22299.99
RMA1.040.77143.0979.8070.22293.11
RLB1.140.43156.8544.5770.22271.64
RLA0.850.43116.9544.5770.22231.74
SE31.86255.9213.6570.22339.79
SE21.49205.0113.6570.22288.88
SE11.26173.3613.6570.22257.23
SSC1.23169.2413.6570.22253.11
SSB1.13155.4813.6570.22239.35
SSA1.10151.3513.6570.22235.22
CC21.22167.8613.6570.22251.73
CC11.06145.8513.6570.22229.72
CB20.98134.8413.6570.22218.71
CB10.91125.2113.6570.22209.08
CA20.90123.8313.6570.22207.70
CA10.80110.0713.6570.22193.94
IB20.74101.8213.6570.22185.69
IB10.7299.0613.6570.22182.93
IA20.6183.9313.6570.22167.80
IA10.5677.0513.6570.22160.92
BB20.73100.4413.6570.22184.31
BB10.6994.9413.6570.22178.81
BA20.6082.5513.6570.22166.42
BA10.5271.5513.6570.22155.42
PE20.85116.9513.6570.22200.82
PE10.82112.8213.6570.22196.69
PD20.78107.3213.6570.22191.19
PD10.76104.5713.6570.22188.44
PC20.7197.6913.6570.22181.56
Start Printed Page 45039
PC10.6994.9413.6570.22178.81
PB20.5575.6713.6570.22159.54
PB10.5474.3013.6570.22158.17
PA20.5372.9213.6570.22156.79
PA10.5068.8013.6570.22152.67

Table 5.—RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes—Rural

RUG III categoryNursing indexTherapy indexNursing componentTherapy componentNon-case mix therapy componentNon-case mix componentTotal rate
RUC1.302.25170.89268.9071.52511.31
RUB0.952.25124.88268.9071.52465.30
RUA0.782.25102.53268.9071.52442.95
RVC1.131.41148.54168.5171.52388.57
RVB1.041.41136.71168.5171.52376.74
RVA0.811.41106.47168.5171.52346.50
RHC1.260.94165.63112.3471.52349.49
RHB1.060.94139.34112.3471.52323.20
RHA0.870.94114.36112.3471.52298.22
RMC1.350.77177.4692.0271.52341.00
RMB1.090.77143.2892.0271.52306.82
RMA0.960.77126.1992.0271.52289.73
RLB1.110.43145.9151.3971.52268.82
RLA0.800.43105.1651.3971.52228.07
SE31.70223.4714.5871.52309.57
SE21.39182.7214.5871.52268.82
SE11.17153.8014.5871.52239.90
SSC1.13148.5414.5871.52234.64
SSB1.05138.0214.5871.52224.12
SSA1.01132.7614.5871.52218.86
CC21.12147.2214.5871.52233.32
CC10.99130.1414.5871.52216.24
CB20.91119.6214.5871.52205.72
CB10.84110.4214.5871.52196.52
CA20.83109.1014.5871.52195.20
CA10.7598.5914.5871.52184.69
IB20.6990.7014.5871.52176.80
IB10.6788.0714.5871.52174.17
IA20.5774.9314.5871.52161.03
IA10.5369.6714.5871.52155.77
BB20.6889.3914.5871.52175.49
BB10.6585.4414.5871.52171.54
BA20.5673.6114.5871.52159.71
BA10.4863.1014.5871.52149.20
PE20.79103.8514.5871.52189.95
PE10.77101.2214.5871.52187.32
PD20.7294.6414.5871.52180.74
PD10.7092.0214.5871.52178.12
PC20.6585.4414.5871.52171.54
PC10.6484.1314.5871.52170.23
PB20.5167.0414.5871.52153.14
PB10.5065.7314.5871.52151.83
PA20.4964.4114.5871.52150.51
PA10.4660.4714.5871.52146.57

Table 5a.—RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes—Rural

RUG-53 categoryNursing indexTherapy indexNursing componentTherapy componentNon-case mix therapy compNon-case mix componentTotal rate
RUX1.902.25249.76268.9071.52590.18
RUL1.402.25184.03268.9071.52524.45
RVX1.541.41202.43168.5171.52442.46
RVL1.331.41174.83168.5171.52414.86
RHX1.420.94186.66112.3471.52370.52
RHL1.370.94180.09112.3471.52363.95
Start Printed Page 45040
RMX1.930.77253.7092.0271.52417.24
RML1.680.77220.8492.0271.52384.38
RLX1.310.43172.2051.3971.52295.11
RUC1.282.25168.26268.9071.52508.68
RUB0.992.25130.14268.9071.52470.56
RUA0.842.25110.42268.9071.52450.84
RVC1.231.41161.68168.5171.52401.71
RVB1.091.41143.28168.5171.52383.31
RVA0.821.41107.79168.5171.52347.82
RHC1.220.94160.37112.3471.52344.23
RHB1.110.94145.91112.3471.52329.77
RHA0.940.94123.56112.3471.52307.42
RMC1.150.77151.1792.0271.52314.71
RMB1.090.77143.2892.0271.52306.82
RMA1.040.77136.7192.0271.52300.25
RLB1.140.43149.8551.3971.52272.76
RLA0.850.43111.7351.3971.52234.64
SE31.86244.5014.5871.52330.60
SE21.49195.8614.5871.52281.96
SE11.26165.6314.5871.52251.73
SSC1.23161.6814.5871.52247.78
SSB1.13148.5414.5871.52234.64
SSA1.10144.6014.5871.52230.70
CC21.22160.3714.5871.52246.47
CC11.06139.3414.5871.52225.44
CB20.98128.8214.5871.52214.92
CB10.91119.6214.5871.52205.72
CA20.90118.3114.5871.52204.41
CA10.80105.1614.5871.52191.26
IB20.7497.2714.5871.52183.37
IB10.7294.6414.5871.52180.74
IA20.6180.1814.5871.52166.28
IA10.5673.6114.5871.52159.71
BB20.7395.9614.5871.52182.06
BB10.6990.7014.5871.52176.80
BA20.6078.8714.5871.52164.97
BA10.5268.3514.5871.52154.45
PE20.85111.7314.5871.52197.83
PE10.82107.7914.5871.52193.89
PD20.78102.5314.5871.52188.63
PD10.7699.9014.5871.52186.00
PC20.7193.3314.5871.52179.43
PC10.6990.7014.5871.52176.80
PB20.5572.3014.5871.52158.40
PB10.5470.9814.5871.52157.08
PA20.5369.6714.5871.52155.77
PA10.5065.7314.5871.52151.83

D. Wage Index Adjustment to Federal Rates

Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the Federal rates to account for differences in area wage levels, using a wage index that we find appropriate. Since the inception of a PPS for SNFs, we have used hospital wage data in developing a wage index to be applied to SNFs. We are continuing that practice for FY 2006.

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

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

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

Response: As part of our ongoing program analysis, we periodically reevaluate the suitability of establishing a SNF-specific wage index and a provider reclassification methodology. However, as we noted in the FY 2004 SNF PPS final rule when this issue was Start Printed Page 45041raised previously (68 FR 46046, August 4, 2003), in view of the volatility of existing SNF wage data and the significant amount of resources that would be required to improve the quality of that data, we do not expect to propose a SNF-specific wage index until we can demonstrate that it would significantly improve our ability to determine payment for facilities and justify the resources required to collect the data, as well as the increased burden on providers.

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

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

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

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

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

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

In evaluating transition options, we looked for approaches that would provide relief to the largest percentage of adversely affected SNFs with the least impact to the rest of the facilities, who either received small increases or remained the same. One possible approach that we considered would involve creating a floor (for example, at a 2 percent decrease), to be funded by also imposing a ceiling (for example, at a 5 percent gain). Instead, we have decided to use a 1-year transition with a blended wage index for all providers. The wage index for each provider will consist of a blend of 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index (both using FY 2002 hospital wage data). We refer to this blended wage index as the FY 2006 SNF PPS transition wage index and these values can be found in the Addendum in Table A. This option achieves our objective of creating a transition policy that provides relief to the largest percentage of adversely affected SNFs with the least impact to the rest of the facilities. In addition, the 50/50 blend option allows us to achieve a high degree of stability in the unadjusted base rates. The adoption of this option results in only minimal change to the budget neutrality factor, from 1.0011 to 1.0012. In fact, the unadjusted base rates applicable to all SNFs actually show a slight increase.

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

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

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

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

We calculate the labor-related relative importance for FY 2006 in four steps. Start Printed Page 45042First, we compute the FY 2006 price index level for the total market basket and each cost category of the market basket. Second, we calculate a ratio for each cost category by dividing the FY 2006 price index level for that cost category by the total market basket price index level. Third, we determine the FY 2006 relative importance for each cost category by multiplying this ratio by the base year (FY 1997) weight. Finally, we sum the FY 2006 relative importance for each of the labor-related cost categories (wages and salaries, employee benefits, nonmedical professional fees, labor-intensive services, and capital-related expenses) to produce the FY 2006 labor-related relative importance. Tables 6 and 7 show the Federal rates by labor-related and non-labor-related components for the existing 44-group RUG-III classification system. Tables 6a and 7a show the Federal rates by labor-related and non-labor-related components for the refined 53-group RUG classification system.

Table 6.—RUG-44 Case-Mix Adjusted Federal Rates for Urban SNFs by Labor and Non-Labor Component

RUG III categoryTotal rateLabor portionNon-labor portion
RUC482.28366.16116.12
RUB434.12329.59104.53
RUA410.73311.8398.90
RVC371.83282.3089.53
RVB359.44272.8986.55
RVA327.80248.8778.93
RHC341.00258.8982.11
RHB313.49238.0175.48
RHA287.34218.1569.19
RMC335.77254.9280.85
RMB299.99227.7672.23
RMA282.11214.1867.93
RLB267.51203.1064.41
RLA224.86170.7254.14
SE3317.77241.2676.51
SE2275.12208.8866.24
SE1244.85185.9058.95
SSC239.35181.7257.63
SSB228.34173.3654.98
SSA222.84169.1853.66
CC2237.97180.6757.30
CC1220.08167.0952.99
CB2209.08158.7450.34
CB1199.45151.4348.02
CA2198.07150.3847.69
CA1187.06142.0245.04
IB2178.81135.7643.05
IB1176.06133.6742.39
IA2162.30123.2239.08
IA1156.79119.0437.75
BB2177.43134.7142.72
BB1173.30131.5741.73
BA2160.92122.1738.75
BA1149.91113.8136.10
PE2192.57146.2046.37
PE1189.81144.1145.70
PD2182.93138.8844.05
PD1180.18136.8043.38
PC2173.30131.5741.73
PC1171.93130.5341.40
PB2154.04116.9537.09
PB1152.67115.9136.76
PA2151.29114.8636.43
PA1147.16111.7335.43

Table 6a.—RUG-53 Case-Mix Adjusted Federal Rates for Urban SNFs by Labor and Non-Labor Component

RUG-53 categoryTotal rateLabor portionNon-labor portion
RUX564.83428.83136.00
RUL496.04376.60119.44
RVX428.24325.13103.11
RVL399.34303.1996.15
RHX363.02275.6187.41
RHL356.14270.3985.75
RMX415.57315.51100.06
RML381.17289.3991.78
RLX295.03223.9971.04
RUC479.53364.07115.46
Start Printed Page 45043
RUB439.62333.77105.85
RUA418.99318.11100.88
RVC385.59292.7592.84
RVB366.32278.1288.20
RVA329.17249.9179.26
RHC335.50254.7280.78
RHB320.36243.2277.14
RHA296.97225.4771.50
RMC308.25234.0374.22
RMB299.99227.7672.23
RMA293.11222.5370.58
RLB271.64206.2365.41
RLA231.74175.9455.80
SE3339.79257.9881.81
SE2288.88219.3269.56
SE1257.23195.2961.94
SSC253.11192.1760.94
SSB239.35181.7257.63
SSA235.22178.5856.64
CC2251.73191.1260.61
CC1229.72174.4155.31
CB2218.71166.0552.66
CB1209.08158.7450.34
CA2207.70157.6950.01
CA1193.94147.2446.70
IB2185.69140.9844.71
IB1182.93138.8844.05
IA2167.80127.4040.40
IA1160.92122.1738.75
BB2184.31139.9344.38
BB1178.81135.7643.05
BA2166.42126.3540.07
BA1155.42118.0037.42
PE2200.82152.4748.35
PE1196.69149.3347.36
PD2191.19145.1646.03
PD1188.44143.0745.37
PC2181.56137.8443.72
PC1178.81135.7643.05
PB2159.54121.1338.41
PB1158.17120.0938.08
PA2156.79119.0437.75
PA1152.67115.9136.76

Table 7.—RUG-44 Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component

RUG III categoryTotal rateLabor portionNon-labor portion
RUC511.31388.20123.11
RUB465.30353.27112.03
RUA442.95336.30106.65
RVC388.57295.0193.56
RVB376.74286.0390.71
RVA346.50263.0783.43
RHC349.49265.3484.15
RHB323.20245.3877.82
RHA298.22226.4171.81
RMC341.00258.8982.11
RMB306.82232.9473.88
RMA289.73219.9769.76
RLB268.82204.0964.73
RLA228.07173.1654.91
SE3309.57235.0374.54
SE2268.82204.0964.73
SE1239.90182.1457.76
SSC234.64178.1456.50
SSB224.12170.1653.96
SSA218.86166.1652.70
Start Printed Page 45044
CC2233.32177.1456.18
CC1216.24164.1752.07
CB2205.72156.1949.53
CB1196.52149.2047.32
CA2195.20148.2047.00
CA1184.69140.2244.47
IB2176.80134.2342.57
IB1174.17132.2341.94
IA2161.03122.2638.77
IA1155.77118.2637.51
BB2175.49133.2442.25
BB1171.54130.2441.30
BA2159.71121.2638.45
BA1149.20113.2835.92
PE2189.95144.2145.74
PE1187.32142.2245.10
PD2180.74137.2243.52
PD1178.12135.2342.89
PC2171.54130.2441.30
PC1170.23129.2440.99
PB2153.14116.2736.87
PB1151.83115.2736.56
PA2150.51114.2736.24
PA1146.57111.2835.29

Table 7a.—RUG-53 Case-Mix Adjusted Federal Rates for Rural SNFs by Labor and Non-Labor Component

RUG-53 categoryTotal rateLabor portionNon-labor portion
RUX590.18448.08142.10
RUL524.45398.17126.28
RVX442.46335.92106.54
RVL414.86314.9799.89
RHX370.52281.3189.21
RHL363.95276.3287.63
RMX417.24316.78100.46
RML384.38291.8392.55
RLX295.11224.0571.06
RUC508.68386.20122.48
RUB470.56357.26113.30
RUA450.84342.29108.55
RVC401.71304.9996.72
RVB383.31291.0292.29
RVA347.82264.0783.75
RHC344.23261.3582.88
RHB329.77250.3779.40
RHA307.42233.4074.02
RMC314.71238.9375.78
RMB306.82232.9473.88
RMA300.25227.9672.29
RLB272.76207.0865.68
RLA234.64178.1456.50
SE3330.60251.0079.60
SE2281.96214.0767.89
SE1251.73191.1260.61
SSC247.78188.1259.66
SSB234.64178.1456.50
SSA230.70175.1555.55
CC2246.47187.1259.35
CC1225.44171.1654.28
CB2214.92163.1751.75
CB1205.72156.1949.53
CA2204.41155.1949.22
CA1191.26145.2146.05
IB2183.37139.2244.15
IB1180.74137.2243.52
IA2166.28126.2440.04
IA1159.71121.2638.45
Start Printed Page 45045
BB2182.06138.2243.84
BB1176.80134.2342.57
BA2164.97125.2539.72
BA1154.45117.2637.19
PE2197.83150.2047.63
PE1193.89147.2146.68
PD2188.63143.2145.42
PD1186.00141.2144.79
PC2179.43136.2343.20
PC1176.80134.2342.57
PB2158.40120.2638.14
PB1157.08119.2637.82
PA2155.77118.2637.51
PA1151.83115.2736.56

3. Calculating the Budget Neutrality Factor

Section 1888(e)(4)(G)(ii) of the Act also requires that we apply this wage index in a manner that does not result in aggregate payments that are greater or lesser than would otherwise be made in the absence of the wage adjustment. For FY 2006 (Federal rates effective October 1, 2005), we are applying the wage index applicable to SNF payments using the most recent hospital wage data applicable to FY 2006 payments (as discussed previously in section III.D.1 of this final rule), and applying an adjustment to fulfill the budget neutrality requirement. This requirement is met by multiplying each of the components of the unadjusted Federal rates by a factor equal to the ratio of the volume weighted mean wage adjustment factor (using the wage index from the previous year) to the volume weighted mean wage adjustment factor, using the wage index for the fiscal year beginning October 1, 2005. The same volume weights are used in both the numerator and denominator and were derived from 1997 Medicare Provider Analysis and Review File (MEDPAR) data. The wage adjustment factor used in this calculation is defined as the labor share of the rate component multiplied by the wage index plus the non-labor share. The budget neutrality factor has been recalculated to reflect the addition of a transition policy. Effective October 1, 2005, we will adopt a budget neutrality factor of 1.0012. In order to give the public a sense of the magnitude of this adjustment, last year's factor was 1.0011.

E. Updates to the Federal Rates

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

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

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

As discussed in § 413.345, we include in each update of the Federal payment rates in the Federal Register the designation of those specific RUGs under the classification system that represent the required SNF level of care, as provided in § 409.30. This designation reflects an administrative presumption that we initially adopted under the original 44-group RUG-III classification system. Under the presumption, any beneficiary correctly assigned to one of the upper 26 of the 44 RUG-III groups in the initial 5-day, Medicare-required assessment is automatically classified as meeting the SNF level of care definition up to the assessment reference date (ARD) for that assessment.

A beneficiary assigned to any of the lower 18 of the 44 RUG-III groups is not automatically classified as either meeting or not meeting the definition, but instead receives an individual level of care determination using the existing administrative criteria. This presumption recognizes the strong likelihood that beneficiaries assigned to one of the upper 26 groups during the immediate post-hospital period require a covered level of care, which would be significantly less likely for those beneficiaries assigned to one of the lower 18 groups.

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

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

  • All groups within the new Rehabilitation plus Extensive Services category;
  • All groups within the Ultra High Rehabilitation category;
  • All groups within the Very High Rehabilitation category;
  • All groups within the High Rehabilitation category;
  • All groups within the Medium Rehabilitation category;
  • All groups within the Low Rehabilitation category;
  • All groups within the Extensive Services category;
  • All groups within the Special Care category; and Start Printed Page 45046
  • All groups within the Clinically Complex category.

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

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

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

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

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

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

Table 10.—RUG-44, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation), Wage Index: 0.8710 (See Transition Wage Index in Table A)

RUG groupLaborWage indexAdjusted laborNon-laborAdjusted ratePercent adjustmentMedicare daysPayment
RVC$282.300.8710$245.88$89.53$335.41*$357.8814$5,010
RHA218.150.8710190.0169.19259.20*276.57164,425
CC2180.670.8710157.3657.30214.66**489.42104,894
SSC181.720.8710158.2857.63215.91***259.09307,773
IA2123.220.8710107.3239.08146.40146.40304,392
Total10026,494
 *Reflects a 6.7 percent adjustment from section 314 of the BIPA.
 **Reflects a 128 percent adjustment from section 511 of the MMA. Section 101(a) of the BBRA no longer applies because of the MMA section 511 adjustment.
 ***Reflects a 20 percent adjustment from section 101(a) of the BBRA.

Table 10a.—RUG-53, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation) Wage Index: 0.8710 (See Transition Wage Index in Table A)

RUG groupLaborWage indexAdjusted laborNon-laborAdjusted ratePercent adjustmentMedicare daysPayment
RVX$325.130.871$283.19$103.11$386.30$386.3014$5,408
RHA225.470.871196.3871.50267.88267.88164,286
CC2191.120.871166.4760.61227.08517.73105,177
RLX223.990.871195.1071.04266.14266.14307,984
IA2127.400.871110.9740.40151.37151.37304,541
Total10027,396
* Reflects a 128 percent adjustment from section 511 of the MMA.

H. SNF Market Basket Index

1. Background

Section 1888(e)(5)(A) of the Act requires us to establish a SNF market basket index (input price index) that reflects changes over time in the prices of an appropriate mix of goods and services included in the SNF PPS. This final rule incorporates the latest available projections of the SNF market basket index. Accordingly, we have developed a SNF market basket index that encompasses the most commonly used cost categories for SNF routine services, ancillary services, and capital-related expenses. In the July 31, 2001 Federal Register (66 FR 39562), we included a complete discussion on the rebasing of the SNF market basket to FY 1997. There are 21 separate cost categories and respective price proxies. These cost categories were illustrated in Table 10.A, Table 10.B, and Appendix A, along with other relevant information, in the July 31, 2001 Federal Register.

Each year, we calculate a revised labor-related share based on the relative importance of labor-related cost categories in the input price index. Table 11 summarizes the updated labor-related share for FY 2006.

Table 11.—Labor-related Relative Importance, FY2005 and FY2006

Relative importance, labor-related, FY 2005 (97 index)Relative importance, labor-related, FY 2006 (97 index)
Wages and salaries54.35654.391
Employee benefits11.50611.648
Nonmedical professional fees2.7082.739
Start Printed Page 45047
Labor-intensive services4.1144.128
Capital-related3.0923.016
Total75.77675.922
Source: Global Insights, Inc., formerly DRI-WEFA, 2nd Quarter, 2005.

2. Use of the SNF Market Basket Percentage

Section 1888(e)(5)(B) of the Act defines the SNF market basket percentage as the percentage change in the SNF market basket index, as described in the previous section, from the average index level of the prior fiscal year to the average index level of the current fiscal year. For the Federal rates established in this final rule, this percentage increase in the SNF market basket index is used to compute the update factor occurring between FY 2005 and FY 2006. We used the Global Insights, Inc. (formerly DRI-WEFA), 2nd quarter 2005 forecasted percentage increase in the FY 1997-based SNF market basket index for routine, ancillary, and capital-related expenses, described in the previous section, to compute the update factor.

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

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

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

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

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

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

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

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

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

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

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

3. Market Basket Forecast Error Adjustment

As discussed in the June 10, 2003, supplemental proposed rule (68 FR 34768) and finalized in the August 4, 2003, final rule (68 FR 46067), the regulations at 42 CFR 413.337(d)(2) provide for an adjustment to account for market basket forecast error. The initial Start Printed Page 45048adjustment applied to the update of the FY 2003 rate that occurred in FY 2004, and took into account the cumulative forecast error for the period from FY 2000 through FY 2002. Subsequent adjustments in succeeding FYs take into account the forecast error from the most recently available fiscal year for which there is final data, and are applied whenever the difference between the forecasted and actual change in the market basket exceeds a 0.25 percentage point threshold. As discussed previously in section I.G of this final rule, as the difference between the estimated and actual amounts of increase in the market basket index for FY 2004 (the most recently available fiscal year for which there is final data) did not exceed the 0.25 percentage point threshold, the payment rates for FY 2006 do not include a forecast error adjustment.

4. Federal Rate Update Factor

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

I. Consolidated Billing

As established by section 4432(b) of the BBA, the consolidated billing requirement places with the SNF the Medicare billing responsibility for virtually all of the services that the SNF's residents receive, except for a small number of services that the statute specifically identifies as being excluded from this provision. Section 103 of the BBRA amended this provision by further excluding a number of high-cost, low probability services (identified by Healthcare Common Procedure Coding System (HCPCS) codes) within several broader categories that otherwise remained subject to the provision. Section 313 of the BIPA further amended this provision by repealing its Part B aspect, that is, its applicability to services furnished to a resident during a SNF stay that Medicare does not cover. (However, physical and occupational therapy, and speech-language pathology services remain subject to consolidated billing, regardless of whether the resident who receives these services is in a covered Part A stay.) In addition, section 313 of the BIPA specified that consolidated billing applies only to services furnished to those individuals residing in an institution (or portion of an institution) that is actually certified by Medicare as a SNF. Further, as noted in section I.E. of this final rule, section 410 of the MMA revised the SNF consolidated billing requirement as to certain services furnished on or after January 1, 2005, by rural health clinics (RHCs) and Federally qualified health centers (FQHCs).

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

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

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

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

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

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

Comment: Although the FY 2006 SNF PPS proposed rule specifically invited comments on possible exclusions within the specific service categories identified in the BBRA legislation, a number of commenters took this opportunity to reiterate concerns about other aspects of consolidated billing. Start Printed Page 45049For example, we received a number of comments concerning the possible exclusion of additional categories of services from SNF consolidated billing, beyond those specified in the BBRA. The commenters identified services such as barium swallows, video fluoroscopies, hyperbaric oxygen therapy, sterile larvae therapy, ultrasonic procedures and duplex scans, PET scans, and nuclear medicine as appropriate candidates for exclusion. In addition, a number of commenters recommended a further set of services for exclusion. These additional services are durable medical equipment (including, but not limited to, wound care devices and diabetic shoes), total parenteral nutrition (TPN), and specialized bariatric equipment.

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

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

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

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

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

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

Comment: A few commenters requested an expansion of the existing Part B dialysis exclusion to encompass dialysis services furnished directly by the SNF. In addition, several commenters noted that erythropoietin (EPO or Aranesp) currently is excluded from consolidated billing only when furnished in conjunction with the Part B dialysis benefit, and they Start Printed Page 45050recommended expanding this exclusion to encompass its use in connection with other, non-dialysis forms of treatment (such as chemotherapy).

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

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

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

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

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

In accordance with section 1888(e)(7) of the Act (as amended by section 203 of the BIPA), Part A pays critical access hospitals (CAHs) on a reasonable cost basis for SNF services furnished under a swing-bed agreement. However, as noted previously in section I.A. of this final rule, the services furnished by non-CAH rural hospitals are paid under the SNF PPS. In the July 31, 2001 final rule (66 FR 39562), we announced the conversion of swing-bed rural hospitals to the SNF PPS, effective with the start of the provider's first cost reporting period beginning on or after July 1, 2002. We selected this date consistent with the statutory provision to integrate swing-bed rural hospitals into the SNF PPS by the end of the SNF transition period, June 30, 2002.

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

K. Qualifying Three-Day Inpatient Hospital Stay Requirement

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

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

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

With regard to the comments that suggested other possible modifications to the 3-day inpatient hospital stay requirement, we note that we are continuing to review this issue, but are not yet ready to make a final determination at this time. As we observed in the FY 2006 SNF PPS proposed rule, the SNF benefit was never intended to cover long-term, relatively low-level “custodial” care; Start Printed Page 45051rather, the Congress envisioned this benefit more narrowly, in terms of serving as a less expensive alternative to what would otherwise be the final, convalescent portion of an acute care stay of several days as an inpatient at a hospital. Thus, any potential changes in the SNF benefit's qualifying hospital stay requirement would need to be carefully evaluated, in order to ensure that they accurately reflect Congressional intent in establishing the qualifying hospital stay requirement, and would not result in altering the unique nature of the SNF benefit in a manner that is inconsistent with that intent.

IV. Provisions of the Final Rule

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

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

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

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

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

V. Waiver of Proposed Rulemaking

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

VI. Collection of Information Requirements

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

VII. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this final rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA, September 16, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

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

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

This final rule updates the SNF PPS rates published in the FY 2005 update Start Printed Page 45052notice on July 30, 2004 (69 FR 45775) and the associated correction notices published on October 7, 2004 (69 FR 60158), and December 30, 2004 (69 FR 78445).

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

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

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

B. Anticipated Effects

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

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

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

We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples are newly-legislated general Medicare program funding changes by the Congress, or changes specifically related to SNFs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the BIPA, the MMA, or new statutory provisions. Although these changes may not be specific to the SNF PPS, the nature of the Medicare program is such that the changes may interact, and the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact upon SNFs.

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

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

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

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

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

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

The impacts are shown in Table 12. The breakdown of the various categories of data in the table follows.

The first column shows the breakdown of all SNFs by urban or rural status, hospital-based or freestanding status, and census region.

The first row of figures in the first column describes the estimated effects of the various changes on all facilities. The next 6 rows show the effects on facilities split by hospital-based, freestanding, urban, and rural categories. The urban and rural designations are based on the location of the facility under the CBSA designations. The next 20 rows show the effects on urban versus rural status by census region.

The second column in the table shows the number of facilities in the impact database.

The third column of the table shows the effect of the annual update to the wage index. This represents the effect of using the most recent wage data available. The total impact of this change is zero percent; however, there are distributional effects of the change.

The fourth column of the table shows the effect of using the new OMB geographic designations based on Start Printed Page 45053CBSAs. During the FY 2006 transition to CBSAs, SNFs will receive a transition-based wage index value consisting of a blend of 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index (see Table A in the Addendum), as described in Section III.D.1 of this final rule.

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

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

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

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

Table 12.—Projected Impact to the SNF PPS for FY 2006

Number of facilitiesUpdate wage data (percent)MSA to CBSA (percent)Eliminate add-on to certain RUGs (percent)Case-mix refinements (percent)Total FY 2006 change (percent)
Total15,6750.00.0−6.03.00.1
Urban10,5990.00.0−6.02.90.0
Rural5,0760.10.1−6.03.40.7
Hospital based urban1,0970.00.0−6.37.84.6
Freestanding urban8,6930.00.0−5.92.2−0.6
Hospital based rural1,1600.00.1−6.87.74.1
Freestanding rural3,3720.10.1−5.92.60.1
Urban by Region
New England917−0.2−0.1−6.43.2−0.4
Middle Atlantic1,4990.20.0−6.13.00.2
South Atlantic1,739−0.30.0−5.92.9−0.3
East North Central2,009−0.40.0−5.72.9−0.2
East South Central5310.30.0−6.02.60.0
West North Central836−0.60.0−5.93.60.3
West South Central1,093−0.10.1−5.82.60.0
Mountain467−0.30.1−5.62.90.2
Pacific1,5011.20.0−6.22.91.0
Rural by Region
New England1392.00.0−5.73.02.4
Middle Atlantic283−0.10.1−6.03.60.7
South Atlantic612−0.30.0−6.23.0−0.4
East North Central9470.30.0−5.93.81.4
East South Central5710.10.1−6.32.6−0.4
West North Central1,219−0.50.1−6.24.10.7
West South Central8230.20.0−6.22.7−0.2
Mountain2980.6−0.2−5.93.81.4
Pacific1821.60.0−4.23.64.1
Ownership
Government6930.00.2−6.54.81.6
Proprietary9,3170.00.0−5.92.3−0.6
Voluntary3,493−0.10.0−6.04.91.9

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

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

Comment: A few commenters expressed concern that the proposed FY 2006 market basket update was included in our impact analysis. They contended that the market basket update reflects changes in price levels that have already taken place and, in their view, reimburses them for expenses they have already incurred. By including the market basket update in the impact Start Printed Page 45054analysis, these commenters argue that we have understated the actual impact of the FY 2006 changes.

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

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

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

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

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

C. Accounting Statement

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

Table 13.—Accounting Statement: Classification of Estimated Expenditures, From the 2005 SNF PPS Rate Year to the 2006 SNF PPS Rate Year (in Millions)

CategoryTransfers
Annualized Monetized Transfers$20 million.
From Whom To Whom?Federal Government to SNF Medicare Providers.

D. Alternatives Considered

Section 1888(e) of the Act establishes the SNF PPS for the payment of Medicare SNF services for cost reporting periods beginning on or after July 1, 1998. This section of the statute prescribes a detailed formula for calculating payment rates under the SNF PPS, and does not provide for the use of any alternative methodology. It specifies that the base year cost data to be used for computing the payment rates must be from FY 1995 (October 1, 1994, through September 30, 1995.) In accordance with the statute, we also incorporated a number of elements into the SNF PPS, such as a case-mix classification methodology, the MDS assessment schedule, a market basket index, a wage index, and the urban and rural distinction used in the development or adjustment of the Federal rates. Further, section 1888(e)(4)(H) of the Act specifically requires us to disseminate the payment rates for each new fiscal year through the Federal Register, and to do so before the August 1 that precedes the start of the new fiscal year.

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

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

As discussed in section III.D, we considered several budget neutral options that would most effectively implement the adoption of the CBSA designation. Among the alternatives that we considered were the options discussed in the proposed rule and new options that took into consideration comments received during the public comment period, as discussed elsewhere in this final rule. Start Printed Page 45055

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

Start List of Subjects

List of Subjects

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

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PART 409—HOSPITAL INSURANCE BENEFITS

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

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

End Authority

Subpart D—Requirements for Coverage of Posthospital SNF Care

Start Amendment Part

2. Amend § 409.31 by—

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

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

End Amendment Part
Level of care requirement.
* * * * *

(b) * * *

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

(i) * * *

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

* * * * *

Subpart F—Scope of Hospital Insurance Benefits

Start Amendment Part

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

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PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

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

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

End Authority

Subpart A—General Exclusions and Exclusion of Particular Services

Start Amendment Part

2. Amend § 411.15 by—

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

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

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Particular services excluded from coverage.
* * * * *

(p) * * *

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

* * * * *

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

* * * * *
Start Part

PART 424—CONDITIONS FOR MEDICARE PAYMENT

End Part Start Amendment Part

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

End Amendment Part Start Authority

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

End Authority

Subpart B—Certification and Plan of Treatment Requirements

Definitions.
Start Amendment Part

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

End Amendment Part Start Amendment Part

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

End Amendment Part
Requirements for posthospital SNF care.
* * * * *

(e) * * *

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

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

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

* * * * *
Start Part

PART 489—PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

End Part Start Amendment Part

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

End Amendment Part Start Authority

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

End Authority

Subpart B—Essentials of Provider Agreements

Start Amendment Part

2. Section 489.20 is amended by:

End Amendment Part Start Amendment Part

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

End Amendment Part Start Amendment Part

B. Revising paragraph (s)(12).

End Amendment Part
Basic commitments.

The provider agrees to the following:

* * * * *

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

* * * * *

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

* * * * *

(Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Start Printed Page 45056Insurance Program; and No. 93.774, Medicare—Supplementary Medical Insurance Program)

Start Signature

Dated: July 19, 2005.

Mark B. McClellan,

Administrator, Centers for Medicare & Medicaid Services.

Approved: July 27, 2005.

Michael O. Leavitt,

Secretary.

End Signature Start Printed Page 45057

Addendum—FY 2006 Transition Wage Index and CBSA Tables

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

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

Table 8.—FY 2006 Wage Index For Urban Areas Based On CBSA Labor Market Areas

CBSA codeUrban area (constituent counties)Wage index
10180Abilene, TX0.7896
Callahan County, TX
Jones County, TX
Taylor County, TX
10380Aguadilla-Isabela-San Sebastian, PR0.4738
Aguada Municipio, PR
Aguadilla Municipio, PR
Anasco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Municipio, PR
Rincon Municipio, PR
San Sebastian Municipio, PR
10420Akron, OH0.8982
Portage County, OH
Summit County, OH
10500Albany, GA0.8628
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580Albany-Schenectady-Troy, NY0.8589
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740Albuquerque, NM0.9684
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780Alexandria, LA0.8033
Grant Parish, LA
Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ0.9818
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020Altoona, PA0.8944
Blair County, PA
11100Amarillo, TX0.9156
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180Ames, IA0.9536
Story County, IA
11260Anchorage, AK1.1895
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300Anderson, IN0.8586
Madison County, IN
11340Anderson, SC0.8997
Anderson County, SC
11460Ann Arbor, MI1.0859
Start Printed Page 45058
Washtenaw County, MI
11500Anniston-Oxford, AL0.7682
Calhoun County, AL
11540Appleton, WI0.9288
Calumet County, WI
Outagamie County, WI
11700Asheville, NC0.9285
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020Athens-Clarke County, GA0.9855
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA0.9793
Barrow County, GA
Bartow County, GA
Butts County, GA
Carroll County, GA
Cherokee County, GA
Clayton County, GA
Cobb County, GA
Coweta County, GA
Dawson County, GA
DeKalb County, GA
Douglas County, GA
Fayette County, GA
Forsyth County, GA
Fulton County, GA
Gwinnett County, GA
Haralson County, GA
Heard County, GA
Henry County, GA
Jasper County, GA
Lamar County, GA
Meriwether County, GA
Newton County, GA
Paulding County, GA
Pickens County, GA
Pike County, GA
Rockdale County, GA
Spalding County, GA
Walton County, GA
12100Atlantic City, NJ1.1615
Atlantic County, NJ
12220Auburn-Opelika, AL0.8100
Lee County, AL
12260Augusta-Richmond County, GA-SC0.9748
Burke County, GA
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420Austin-Round Rock, TX0.9437
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540Bakersfield, CA1.0470
Kern County, CA
12580Baltimore-Towson, MD0.9897
Anne Arundel County, MD
Baltimore County, MD
Carroll County, MD
Harford County, MD
Howard County, MD
Queen Anne's County, MD
Start Printed Page 45059
Baltimore City, MD
12620Bangor, ME0.9993
Penobscot County, ME
12700Barnstable Town, MA1.2600
Barnstable County, MA
12940Baton Rouge, LA0.8593
Ascension Parish, LA
East Baton Rouge Parish, LA
East Feliciana Parish, LA
Iberville Parish, LA
Livingston Parish, LA
Pointe Coupee Parish, LA
St. Helena Parish, LA
West Baton Rouge Parish, LA
West Feliciana Parish, LA
12980Battle Creek, MI0.9508
Calhoun County, MI
13020Bay City, MI0.9343
Bay County, MI
13140Beaumont-Port Arthur, TX0.8412
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380Bellingham, WA1.1731
Whatcom County, WA
13460Bend, OR1.0786
Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.1483
Frederick County, MD
Montgomery County, MD
13740Billings, MT0.8834
Carbon County, MT
Yellowstone County, MT
13780Binghamton, NY0.8562
Broome County, NY
Tioga County, NY
13820Birmingham-Hoover, AL0.8959
Bibb County, AL
Blount County, AL
Chilton County, AL
Jefferson County, AL
St. Clair County, AL
Shelby County, AL
Walker County, AL
13900Bismarck, ND0.7574
Burleigh County, ND
Morton County, ND
13980Blacksburg-Christiansburg-Radford, VA0.7954
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020Bloomington, IN0.8447
Greene County, IN
Monroe County, IN
Owen County, IN
14060Bloomington-Normal, IL0.9075
McLean County, IL
14260Boise City-Nampa, ID0.9052
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484Boston-Quincy, MA1.1558
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500Boulder, CO0.9734
Boulder County, CO
Start Printed Page 45060
14540Bowling Green, KY0.8211
Edmonson County, KY
Warren County, KY
14740Bremerton-Silverdale, WA1.0675
Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.2592
Fairfield County, CT
15180Brownsville-Harlingen, TX0.9804
Cameron County, TX
15260Brunswick, GA0.9311
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380Buffalo-Niagara Falls, NY0.9511
Erie County, NY
Niagara County, NY
15500Burlington, NC0.8905
Alamance County, NC
15540Burlington-South Burlington, VT0.9410
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.1172
Middlesex County, MA
15804Camden, NJ1.0517
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940Canton-Massillon, OH0.8935
Carroll County, OH
Stark County, OH
15980Cape Coral-Fort Myers, FL0.9356
Lee County, FL
16180Carson City, NV1.0234
Carson City, NV
16220Casper, WY0.9026
Natrona County, WY
16300Cedar Rapids, IA0.8825
Benton County, IA
Jones County, IA
Linn County, IA
16580Champaign-Urbana, IL0.9594
Champaign County, IL
Ford County, IL
Piatt County, IL
16620Charleston, WV0.8445
Boone County, WV
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700Charleston-North Charleston, SC0.9245
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC0.9750
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820Charlottesville, VA1.0187
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860Chattanooga, TN-GA0.9088
Catoosa County, GA
Dade County, GA
Start Printed Page 45061
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940Cheyenne, WY0.8775
Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.0790
Cook County, IL
DeKalb County, IL
DuPage County, IL
Grundy County, IL
Kane County, IL
Kendall County, IL
McHenry County, IL
Will County, IL
17020Chico, CA1.0511
Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN0.9615
Dearborn County, IN
Franklin County, IN
Ohio County, IN
Boone County, KY
Bracken County, KY
Campbell County, KY
Gallatin County, KY
Grant County, KY
Kenton County, KY
Pendleton County, KY
Brown County, OH
Butler County, OH
Clermont County, OH
Hamilton County, OH
Warren County, OH
17300Clarksville, TN-KY0.8284
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420Cleveland, TN0.8139
Bradley County, TN
Polk County, TN
17460Cleveland-Elyria-Mentor, OH0.9213
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
17660Coeur d'Alene, ID0.9647
Kootenai County, ID
17780College Station-Bryan, TX0.8900
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820Colorado Springs, CO0.9468
El Paso County, CO
Teller County, CO
17860Columbia, MO0.8345
Boone County, MO
Howard County, MO
17900Columbia, SC0.9057
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980Columbus, GA-AL0.8560
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Start Printed Page 45062
Muscogee County, GA
18020Columbus, IN0.9588
Bartholomew County, IN
18140Columbus, OH0.9860
Delaware County, OH
Fairfield County, OH
Franklin County, OH
Licking County, OH
Madison County, OH
Morrow County, OH
Pickaway County, OH
Union County, OH
18580Corpus Christi, TX0.8550
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700Corvallis, OR1.0729
Benton County, OR
19060Cumberland, MD-WV0.9317
Allegany County, MD
Mineral County, WV
19124Dallas-Plano-Irving, TX1.0228
Collin County, TX
Dallas County, TX
Delta County, TX
Denton County, TX
Ellis County, TX
Hunt County, TX
Kaufman County, TX
Rockwall County, TX
19140Dalton, GA0.9079
Murray County, GA
Whitfield County, GA
19180Danville, IL0.9028
Vermilion County, IL
19260Danville, VA0.8489
Pittsylvania County, VA
Danville City, VA
19340Davenport-Moline-Rock Island, IA-IL0.8724
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380Dayton, OH0.9064
Greene County, OH
Miami County, OH
Montgomery County, OH
Preble County, OH
19460Decatur, AL0.8469
Lawrence County, AL
Morgan County, AL
19500Decatur, IL0.8067
Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.9299
Volusia County, FL
19740Denver-Aurora, CO1.0723
Adams County, CO
Arapahoe County, CO
Broomfield County, CO
Clear Creek County, CO
Denver County, CO
Douglas County, CO
Elbert County, CO
Gilpin County, CO
Jefferson County, CO
Park County, CO
19780Des Moines, IA0.9669
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Start Printed Page 45063
Warren County, IA
19804Detroit-Livonia-Dearborn, MI1.0424
Wayne County, MI
20020Dothan, AL0.7721
Geneva County, AL
Henry County, AL
Houston County, AL
20100Dover, DE0.9776
Kent County, DE
20220Dubuque, IA0.9024
Dubuque County, IA
20260Duluth, MN-WI1.0213
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500Durham, NC1.0244
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740Eau Claire, WI0.9201
Chippewa County, WI
Eau Claire County, WI
20764Edison, NJ1.1249
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940El Centro, CA0.8906
Imperial County, CA
21060Elizabethtown, KY0.8802
Hardin County, KY
Larue County, KY
21140Elkhart-Goshen, IN0.9627
Elkhart County, IN
21300Elmira, NY0.8250
Chemung County, NY
21340El Paso, TX0.8977
El Paso County, TX
21500Erie, PA0.8737
Erie County, PA
21604Essex County, MA1.0538
Essex County, MA
21660Eugene-Springfield, OR1.0818
Lane County, OR
21780Evansville, IN-KY0.8713
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820Fairbanks, AK1.1408
Fairbanks North Star Borough, AK
21940Fajardo, PR0.4153
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020Fargo, ND-MN0.8486
Cass County, ND
Clay County, MN
22140Farmington, NM0.8509
San Juan County, NM
22180Fayetteville, NC0.9416
Cumberland County, NC
Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.8661
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
Start Printed Page 45064
22380Flagstaff, AZ1.2092
Coconino County, AZ
22420Flint, MI1.0655
Genesee County, MI
22500Florence, SC0.8947
Darlington County, SC
Florence County, SC
22520Florence-Muscle Shoals, AL0.8272
Colbert County, AL
Lauderdale County, AL
22540Fond du Lac, WI0.9640
Fond du Lac County, WI
22660Fort Collins-Loveland, CO1.0122
Larimer County, CO
22744Fort Lauderdale-Pompano Beach-Deerfield Beach, FL1.0432
Broward County, FL
22900Fort Smith, AR-OK0.8230
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.8872
Okaloosa County, FL
23060Fort Wayne, IN0.9793
Allen County, IN
Wells County, IN
Whitley County, IN
23104Fort Worth-Arlington, TX0.9486
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420Fresno, CA1.0538
Fresno County, CA
23460Gadsden, AL0.7938
Etowah County, AL
23540Gainesville, FL0.9388
Alachua County, FL
Gilchrist County, FL
23580Gainesville, GA0.8874
Hall County, GA
23844Gary, IN0.9395
Jasper County, IN
Lake County, IN
Newton County, IN
Porter County, IN
24020Glens Falls, NY0.8559
Warren County, NY
Washington County, NY
24140Goldsboro, NC0.8775
Wayne County, NC
24220Grand Forks, ND-MN0.7901
Polk County, MN
Grand Forks County, ND
24300Grand Junction, CO0.9550
Mesa County, CO
24340Grand Rapids-Wyoming, MI0.9390
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500Great Falls, MT0.9052
Cascade County, MT
24540Greeley, CO0.9570
Weld County, CO
24580Green Bay, WI0.9483
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660Greensboro-High Point, NC0.9104
Start Printed Page 45065
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780Greenville, NC0.9425
Greene County, NC
Pitt County, NC
24860Greenville, SC1.0027
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020Guayama, PR0.3181
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.8929
Hancock County, MS
Harrison County, MS
Stone County, MS
25180Hagerstown-Martinsburg, MD-WV0.9489
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260Hanford-Corcoran, CA1.0036
Kings County, CA
25420Harrisburg-Carlisle, PA0.9313
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500Harrisonburg, VA0.9088
Rockingham County, VA
Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.1073
Hartford County, CT
Litchfield County, CT
Middlesex County, CT
Tolland County, CT
25620Hattiesburg, MS0.7601
Forrest County, MS
Lamar County, MS
Perry County, MS
25860Hickory-Lenoir-Morganton, NC0.8921
Alexander County, NC
Burke County, NC
Caldwell County, NC
Catawba County, NC
25980Hinesville-Fort Stewart, GA1
Liberty County, GA
Long County, GA
26100Holland-Grand Haven, MI0.9055
Ottawa County, MI
26180Honolulu, HI1.1214
Honolulu County, HI
26300Hot Springs, AR0.9005
Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.7894
Lafourche Parish, LA
Terrebonne Parish, LA
26420Houston-Baytown-Sugar Land, TX0.9992
Austin County, TX
Brazoria County, TX
Chambers County, TX
Fort Bend County, TX
Galveston County, TX
Harris County, TX
Liberty County, TX
Montgomery County, TX
San Jacinto County, TX
Waller County, TX
26580Huntington-Ashland, WV-KY-OH0.9477
Boyd County, KY
Greenup County, KY
Start Printed Page 45066
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620Huntsville, AL0.9146
Limestone County, AL
Madison County, AL
26820Idaho Falls, ID0.9420
Bonneville County, ID
Jefferson County, ID
26900Indianapolis, IN0.9920
Boone County, IN
Brown County, IN
Hamilton County, IN
Hancock County, IN
Hendricks County, IN
Johnson County, IN
Marion County, IN
Morgan County, IN
Putnam County, IN
Shelby County, IN
26980Iowa City, IA0.9747
Johnson County, IA
Washington County, IA
27060Ithaca, NY0.9793
Tompkins County, NY
27100Jackson, MI0.9304
Jackson County, MI
27140Jackson, MS0.8311
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180Jackson, TN0.8964
Chester County, TN
Madison County, TN
27260Jacksonville, FL0.9290
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340Jacksonville, NC0.8236
Onslow County, NC
27500Janesville, WI0.9538
Rock County, WI
27620Jefferson City, MO0.8387
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740Johnson City, TN0.7937
Carter County, TN
Unicoi County, TN
Washington County, TN
27780Johnstown, PA0.8354
Cambria County, PA
27860Jonesboro, AR0.7911
Craighead County, AR
Poinsett County, AR
27900Joplin, MO0.8582
Jasper County, MO
Newton County, MO
28020Kalamazoo-Portage, MI1.0381
Kalamazoo County, MI
Van Buren County, MI
28100Kankakee-Bradley, IL1.0721
Kankakee County, IL
28140Kansas City, MO-KS0.9476
Franklin County, KS
Johnson County, KS
Start Printed Page 45067
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, WA1.0619
Benton County, WA
Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.8526
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700Kingsport-Bristol-Bristol, TN-VA0.8054
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740Kingston, NY0.9255
Ulster County, NY
28940Knoxville, TN0.8441
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020Kokomo, IN0.9508
Howard County, IN
Tipton County, IN
29100La Crosse, WI-MN0.9564
Houston County, MN
La Crosse County, WI
29140Lafayette, IN0.8736
Benton County, IN
Carroll County, IN
Tippecanoe County, IN
29180Lafayette, LA0.8428
Lafayette Parish, LA
St. Martin Parish, LA
29340Lake Charles, LA0.7833
Calcasieu Parish, LA
Cameron Parish, LA
29404Lake County-Kenosha County, IL-WI1.0429
Lake County, IL
Kenosha County, WI
29460Lakeland, FL0.8912
Polk County, FL
29540Lancaster, PA0.9694
Lancaster County, PA
29620Lansing-East Lansing, MI0.9794
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700Laredo, TX0.8068
Webb County, TX
29740Las Cruces, NM0.8467
Dona Ana County, NM
29820Las Vegas-Paradise, NV1.1437
Clark County, NV
29940Lawrence, KS0.8537
Douglas County, KS
30020Lawton, OK0.7872
Comanche County, OK
Start Printed Page 45068
30140Lebanon, PA0.8459
Lebanon County, PA
30300Lewiston, ID-WA0.9886
Nez Perce County, ID
Asotin County, WA
30340Lewiston-Auburn, ME0.9331
Androscoggin County, ME
30460Lexington-Fayette, KY0.9075
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620Lima, OH0.9225
Allen County, OH
30700Lincoln, NE1.0214
Lancaster County, NE
Seward County, NE
30780Little Rock-North Little Rock, AR0.8747
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860Logan, UT-ID0.9164
Franklin County, ID
Cache County, UT
30980Longview, TX0.8730
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020Longview, WA0.9579
Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale, CA1.1783
Los Angeles County, CA
31140Louisville, KY-IN0.9251
Clark County, IN
Floyd County, IN
Harrison County, IN
Washington County, IN
Bullitt County, KY
Henry County, KY
Jefferson County, KY
Meade County, KY
Nelson County, KY
Oldham County, KY
Shelby County, KY
Spencer County, KY
Trimble County, KY
31180Lubbock, TX0.8783
Crosby County, TX
Lubbock County, TX
31340Lynchburg, VA0.8691
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420Macon, GA0.9443
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460Madera, CA0.8713
Madera County, CA
31540Madison, WI1.0659
Columbia County, WI
Start Printed Page 45069
Dane County, WI
Iowa County, WI
31700Manchester-Nashua, NH1.0354
Hillsborough County, NH
Merrimack County, NH
31900Mansfield, OH 1
Richland County, OH
32420Mayaguez, PR0.4020
Hormigueros Municipio, PR
Mayaguez Municipio, PR
32580McAllen-Edinburg-Pharr, TX0.8934
Hidalgo County, TX
32780Medford, OR1.0225
Jackson County, OR
32820Memphis, TN-MS-AR0.9397
Crittenden County, AR
DeSoto County, MS
Marshall County, MS
Tate County, MS
Tunica County, MS
Fayette County, TN
Shelby County, TN
Tipton County, TN
32900Merced, CA1.1109
Merced County, CA
33124Miami-Miami Beach-Kendall, FL0.9750
Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9399
LaPorte County, IN
33260Midland, TX0.9514
Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0146
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.1075
Anoka County, MN
Carver County, MN
Chisago County, MN
Dakota County, MN
Hennepin County, MN
Isanti County, MN
Ramsey County, MN
Scott County, MN
Sherburne County, MN
Washington County, MN
Wright County, MN
Pierce County, WI
St. Croix County, WI
33540Missoula, MT0.9473
Missoula County, MT
33660Mobile, AL0.7891
Mobile County, AL
33700Modesto, CA1.1885
Stanislaus County, CA
33740Monroe, LA0.8031
Ouachita Parish, LA
Union Parish, LA
33780Monroe, MI0.9468
Monroe County, MI
33860Montgomery, AL0.8618
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060Morgantown, WV0.8420
Monongalia County, WV
Preston County, WV
34100Morristown, TN0.7961
Grainger County, TN
Start Printed Page 45070
Hamblen County, TN
Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.0454
Skagit County, WA
34620Muncie, IN0.8930
Delaware County, IN
34740Muskegon-Norton Shores, MI0.9664
Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.8934
Horry County, SC
34900Napa, CA1.2643
Napa County, CA
34940Naples-Marco Island, FL1.0139
Collier County, FL
34980Nashville-Davidson--Murfreesboro, TN0.9741
Cannon County, TN
Cheatham County, TN
Davidson County, TN
Dickson County, TN
Hickman County, TN
Macon County, TN
Robertson County, TN
Rutherford County, TN
Smith County, TN
Sumner County, TN
Trousdale County, TN
Williamson County, TN
Wilson County, TN
35004Nassau-Suffolk, NY1.2719
Nassau County, NY
Suffolk County, NY
35084Newark-Union, NJ-PA1.1883
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300New Haven-Milford, CT1.1887
New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.8995
Jefferson Parish, LA
Orleans Parish, LA
Plaquemines Parish, LA
St. Bernard Parish, LA
St. Charles Parish, LA
St. John the Baptist Parish, LA
St. Tammany Parish, LA
35644New York-Wayne-White Plains, NY-NJ1.3188
Bergen County, NJ
Hudson County, NJ
Passaic County, NJ
Bronx County, NY
Kings County, NY
New York County, NY
Putnam County, NY
Queens County, NY
Richmond County, NY
Rockland County, NY
Westchester County, NY
35660Niles-Benton Harbor, MI0.8879
Berrien County, MI
35980Norwich-New London, CT1.1345
New London County, CT
36084Oakland-Fremont-Hayward, CA1.5346
Alameda County, CA
Contra Costa County, CA
36100Ocala, FL0.8925
Marion County, FL
36140Ocean City, NJ1.1011
Cape May County, NJ
Start Printed Page 45071
36220Odessa, TX0.9884
Ector County, TX
36260Ogden-Clearfield, UT0.9029
Davis County, UT
Morgan County, UT
Weber County, UT
36420Oklahoma City, OK0.9031
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500Olympia, WA1.0927
Thurston County, WA
36540Omaha-Council Bluffs, NE-IA0.9560
Harrison County, IA
Mills County, IA
Pottawattamie County, IA
Cass County, NE
Douglas County, NE
Sarpy County, NE
Saunders County, NE
Washington County, NE
36740Orlando, FL0.9464
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780Oshkosh-Neenah, WI0.9183
Winnebago County, WI
36980Owensboro, KY0.8780
Daviess County, KY
Hancock County, KY
McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.1622
Ventura County, CA
37340Palm Bay-Melbourne-Titusville, FL0.9839
Brevard County, FL
37460Panama City-Lynn Haven, FL0.8005
Bay County, FL
37620Parkersburg-Marietta, WV-OH0.8270
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700Pascagoula, MS0.8156
George County, MS
Jackson County, MS
37860Pensacola-Ferry Pass-Brent, FL0.8096
Escambia County, FL
Santa Rosa County, FL
37900Peoria, IL0.8870
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964Philadelphia, PA1.1038
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0127
Maricopa County, AZ
Pinal County, AZ
38220Pine Bluff, AR0.8680
Cleveland County, AR
Jefferson County, AR
Start Printed Page 45072
Lincoln County, AR
38300Pittsburgh, PA0.8845
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340Pittsfield, MA1.0181
Berkshire County, MA
38540Pocatello, ID0.9351
Bannock County, ID
Power County, ID
38660Ponce, PR0.4939
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME1.0382
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.1266
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, FL1.0123
Martin County, FL
St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.0891
Dutchess County, NY
Orange County, NY
39140Prescott, AZ0.9869
Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.0966
Bristol County, MA
Bristol County, RI
Kent County, RI
Newport County, RI
Providence County, RI
Washington County, RI
39340Provo-Orem, UT0.9500
Juab County, UT
Utah County, UT
39380Pueblo, CO0.8623
Pueblo County, CO
39460Punta Gorda, FL0.9255
Charlotte County, FL
39540Racine, WI0.8997
Racine County, WI
39580Raleigh-Cary, NC0.9691
Franklin County, NC
Johnston County, NC
Wake County, NC
39660Rapid City, SD0.8987
Meade County, SD
Pennington County, SD
39740Reading, PA0.9686
Berks County, PA
39820Redding, CA1.2203
Shasta County, CA
39900Reno-Sparks, NV1.0982
Storey County, NV
Washoe County, NV
40060Richmond, VA0.9328
Amelia County, VA
Caroline County, VA
Start Printed Page 45073
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, CA1.1027
Riverside County, CA
San Bernardino County, CA
40220Roanoke, VA0.8374
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340Rochester, MN1.1131
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380Rochester, NY0.9121
Livingston County, NY
Monroe County, NY
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420Rockford, IL0.9984
Boone County, IL
Winnebago County, IL
40484Rockingham County-Strafford County, NH1.0374
Rockingham County, NH
Strafford County, NH
40580Rocky Mount, NC0.8915
Edgecombe County, NC
Nash County, NC
40660Rome, GA0.9414
Floyd County, GA
40900Sacramento--Arden-Arcade--Roseville, CA1.2969
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980Saginaw-Saginaw Township North, MI0.9088
Saginaw County, MI
41060St. Cloud, MN0.9965
Benton County, MN
Stearns County, MN
41100St. George, UT0.9392
Washington County, UT
41140St. Joseph, MO-KS0.9519
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180St. Louis, MO-IL0.8954
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
Start Printed Page 45074
Macoupin County, IL
Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
Jefferson County, MO
Lincoln County, MO
St. Charles County, MO
St. Louis County, MO
Warren County, MO
Washington County, MO
St. Louis City, MO
41420Salem, OR1.0442
Marion County, OR
Polk County, OR
41500Salinas, CA1.4128
Monterey County, CA
41540Salisbury, MD0.9064
Somerset County, MD
Wicomico County, MD
41620Salt Lake City, UT0.9421
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660San Angelo, TX0.8271
Irion County, TX
Tom Green County, TX
41700San Antonio, TX0.8980
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
Kendall County, TX
Medina County, TX
Wilson County, TX
41740San Diego-Carlsbad-San Marcos, CA1.1413
San Diego County, CA
41780Sandusky, OH0.9019
Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.4994
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900San German-Cabo Rojo, PR0.4650
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San German Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.5099
San Benito County, CA
Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.4621
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayamon Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canovanas Municipio, PR
Carolina Municipio, PR
Catano Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comerio Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR
Start Printed Page 45075
Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
Manati 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, CA1.1349
San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.1559
Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.1694
Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.5166
Santa Cruz County, CA
42140Santa Fe, NM1.0920
Santa Fe County, NM
42220Santa Rosa-Petaluma, CA1.3493
Sonoma County, CA
42260Sarasota-Bradenton-Venice, FL0.9639
Manatee County, FL
Sarasota County, FL
42340Savannah, GA0.9461
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540Scranton--Wilkes-Barre, PA0.8540
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.1577
King County, WA
Snohomish County, WA
43100Sheboygan, WI0.8911
Sheboygan County, WI
43300Sherman-Denison, TX0.9507
Grayson County, TX
43340Shreveport-Bossier City, LA0.8760
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580Sioux City, IA-NE-SD0.9381
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620Sioux Falls, SD0.9635
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780South Bend-Mishawaka, IN-MI0.9788
St. Joseph County, IN
Cass County, MI
Start Printed Page 45076
43900Spartanburg, SC0.9172
Spartanburg County, SC
44060Spokane, WA1.0905
Spokane County, WA
44100Springfield, IL0.8792
Menard County, IL
Sangamon County, IL
44140Springfield, MA1.0248
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180Springfield, MO0.8237
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220Springfield, OH0.8396
Clark County, OH
44300State College, PA0.8356
Centre County, PA
44700Stockton, CA1.1307
San Joaquin County, CA
44940Sumter, SC0.8377
Sumter County, SC
45060Syracuse, NY0.9574
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104Tacoma, WA1.0742
Pierce County, WA
45220Tallahassee, FL0.8688
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300Tampa-St. Petersburg-Clearwater, FL0.9233
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460Terre Haute, IN0.8304
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500Texarkana, TX-Texarkana, AR0.8283
Miller County, AR
Bowie County, TX
45780Toledo, OH0.9574
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820Topeka, KS0.8920
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940Trenton-Ewing, NJ1.0834
Mercer County, NJ
46060Tucson, AZ0.9007
Pima County, AZ
46140Tulsa, OK0.8543
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
Start Printed Page 45077
Wagoner County, OK
46220Tuscaloosa, AL0.8645
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340Tyler, TX0.9168
Smith County, TX
46540Utica-Rome, NY0.8358
Herkimer County, NY
Oneida County, NY
46660Valdosta, GA0.8866
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700Vallejo-Fairfield, CA1.4936
Solano County, CA
46940Vero Beach, FL0.9434
Indian River County, FL
47020Victoria, TX0.8160
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ0.9827
Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.8799
Currituck County, NC
Gloucester County, VA
Isle of Wight County, VA
James City County, VA
Mathews County, VA
Surry County, VA
York County, VA
Chesapeake City, VA
Hampton City, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
47300Visalia-Porterville, CA1.0123
Tulare County, CA
47380Waco, TX0.8518
McLennan County, TX
47580Warner Robins, GA0.8645
Houston County, GA
47644Warren-Farmington Hills-Troy, MI0.9871
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA-MD-WV1.0926
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Arlington County, VA
Clarke County, VA
Fairfax County, VA
Fauquier County, VA
Loudoun County, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
Start Printed Page 45078
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940Waterloo-Cedar Falls, IA0.8557
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140Wausau, WI0.9590
Marathon County, WI
48260Weirton-Steubenville, WV-OH0.7819
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300Wenatchee, WA1.0070
Chelan County, WA
Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL1.0067
Palm Beach County, FL
48540Wheeling, WV-OH0.7161
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620Wichita, KS0.9153
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660Wichita Falls, TX0.8285
Archer County, TX
Clay County, TX
Wichita County, TX
48700Williamsport, PA0.8364
Lycoming County, PA
48864Wilmington, DE-MD-NJ1.0471
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900Wilmington, NC0.9582
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020Winchester, VA-WV1.0214
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180Winston-Salem, NC0.8944
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340Worcester, MA1.1028
Worcester County, MA
49420Yakima, WA1.0155
Yakima County, WA
49500Yauco, PR0.4408
Guanica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620York-Hanover, PA0.9347
York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.8603
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700Yuba City, CA1.0921
Sutter County, CA
Yuba County, CA
49740Yuma, AZ0.9126
Start Printed Page 45079
Yuma County, AZ
1 At this time, there are no hospitals located in these urban areas on which to base a wage index.

Table 9.—FY 2006 Wage Index Based on CBSA Labor Market Areas for Rural Areas

CBSA codeNonurban areaWage index
1Alabama0.7446
2Alaska1.1977
3Arizona0.8768
4Arkansas0.7466
5California1.1054
6Colorado0.9380
7Connecticut1.1730
8Delaware0.9579
10Florida0.8568
11Georgia0.7662
12Hawaii1.0551
13Idaho0.8037
14Illinois0.8271
15Indiana0.8624
16Iowa0.8509
17Kansas0.8035
18Kentucky0.7766
19Louisiana0.7411
20Maine0.8843
21Maryland0.9353
22Massachusetts 11.2016
23Michigan0.8895
24Minnesota0.9132
25Mississippi0.7674
26Missouri0.7900
27Montana0.8762
28Nebraska0.8657
29Nevada0.9065
30New Hampshire1.0817
31New Jersey 1
32New Mexico0.8635
33New York0.8154
34North Carolina0.8540
35North Dakota0.7261
36Ohio0.8826
37Oklahoma0.7581
38Oregon0.9826
39Pennsylvania0.8291
40Puerto Rico10.4047
41Rhode Island 1
42South Carolina0.8638
43South Dakota0.8560
44Tennessee0.7895
45Texas0.8003
46Utah0.8118
47Vermont0.9830
48Virgin Islands0.7615
49Virginia0.8013
50Washington1.0510
51West Virginia0.7717
52Wisconsin0.9509
53Wyoming0.9257
65Guam0.9611
1 All counties within the State are classified as urban, with the exception of Massachusetts and Puerto Rico. Massachusetts and Puerto Rico have areas designated as rural; however, no short-term, acute care hospitals are located in the area(s) for FY 2006. Because more recent data is not available for those areas, we are using last year's wage index value.

Table A.—FY 2006 SNF PPS Transition Wage Index Table

SSA state/county codeCounty nameMSA No.MSA urban/rural2006 MSA-based WI2006 CBSA-based WICBSA No.CBSA urban/ruralTransition wage index *
01000Autauga County, Alabama5240Urban0.86180.861833860Urban0.8618
01010Baldwin County, Alabama5160Urban0.78610.744699901Rural0.7654
01020Barbour County, Alabama01Rural0.74320.744699901Rural0.7439
01030Bibb County, Alabama01Rural0.74320.895913820Urban0.8196
01040Blount County, Alabama1000Urban0.90000.895913820Urban0.8980
01050Bullock County, Alabama01Rural0.74320.744699901Rural0.7439
01060Butler County, Alabama01Rural0.74320.744699901Rural0.7439
01070Calhoun County, Alabama0450Urban0.76820.768211500Urban0.7682
01080Chambers County, Alabama01Rural0.74320.744699901Rural0.7439
01090Cherokee County, Alabama01Rural0.74320.744699901Rural0.7439
01100Chilton County, Alabama01Rural0.74320.895913820Urban0.8196
01110Choctaw County, Alabama01Rural0.74320.744699901Rural0.7439
01120Clarke County, Alabama01Rural0.74320.744699901Rural0.7439
01130Clay County, Alabama01Rural0.74320.744699901Rural0.7439
01140Cleburne County, Alabama01Rural0.74320.744699901Rural0.7439
01150Coffee County, Alabama01Rural0.74320.744699901Rural0.7439
01160Colbert County, Alabama2650Urban0.82720.827222520Urban0.8272
01170Conecuh County, Alabama01Rural0.74320.744699901Rural0.7439
01180Coosa County, Alabama01Rural0.74320.744699901Rural0.7439
01190Covington County, Alabama01Rural0.74320.744699901Rural0.7439
01200Crenshaw County, Alabama01Rural0.74320.744699901Rural0.7439
01210Cullman County, Alabama01Rural0.74320.744699901Rural0.7439
01220Dale County, Alabama2180Urban0.77010.744699901Rural0.7574
01230Dallas County, Alabama01Rural0.74320.744699901Rural0.7439
01240De Kalb County, Alabama01Rural0.74320.744699901Rural0.7439
01250Elmore County, Alabama5240Urban0.86180.861833860Urban0.8618
01260Escambia County, Alabama01Rural0.74320.744699901Rural0.7439
01270Etowah County, Alabama2880Urban0.79380.793823460Urban0.7938
01280Fayette County, Alabama01Rural0.74320.744699901Rural0.7439
01290Franklin County, Alabama01Rural0.74320.744699901Rural0.7439
Start Printed Page 45080
01300Geneva County, Alabama01Rural0.74320.772120020Urban0.7577
01310Greene County, Alabama01Rural0.74320.864546220Urban0.8039
01320Hale County, Alabama01Rural0.74320.864546220Urban0.8039
01330Henry County, Alabama01Rural0.7432.772120020Urban0.7577
01340Houston County, Alabama2180Urban0.77010.772120020Urban0.7711
01350Jackson County, Alabama01Rural0.74320.744699901Rural0.7439
01360Jefferson County, Alabama1000Urban0.90000.895913820Urban0.8980
01370Lamar County, Alabama01Rural0.74320.744699901Rural0.7439
01380Lauderdale County, Alabama2650Urban0.82720.827222520Urban0.8272
01390Lawrence County, Alabama2030Urban0.84690.846919460Urban0.8469
01400Lee County, Alabama0580Urban0.81000.810012220Urban0.8100
01410Limestone County, Alabama3440Urban0.91460.914626620Urban0.9146
01420Lowndes County, Alabama01Rural0.74320.861833860Urban0.8025
01430Macon County, Alabama01Rural0.74320.744699901Rural0.7439
01440Madison County, Alabama3440Urban0.91460.914626620Urban0.9146
01450Marengo County, Alabama01Rural0.74320.744699901Rural0.7439
01460Marion County, Alabama01Rural0.74320.744699901Rural0.7439
01470Marshall County, Alabama01Rural0.74320.744699901Rural0.7439
01480Mobile County, Alabama5160Urban0.78610.789133660Urban0.7876
01490Monroe County, Alabama01Rural0.74320.744699901Rural0.7439
01500Montgomery County, Alabama5240Urban0.86180.861833860Urban0.8618
01510Morgan County, Alabama2030Urban0.84690.846919460Urban0.8469
01520Perry County, Alabama01Rural0.74320.744699901Rural0.7439
01530Pickens County, Alabama01Rural0.74320.744699901Rural0.7439
01540Pike County, Alabama01Rural0.74320.744699901Rural0.7439
01550Randolph County, Alabama01Rural0.74320.744699901Rural0.7439
01560Russell County, Alabama1800Urban0.85600.856017980Urban0.8560
01570St Clair County, Alabama1000Urban0.90000.895913820Urban0.8980
01580Shelby County, Alabama1000Urban0.90000.895913820Urban0.8980
01590Sumter County, Alabama01Rural0.74320.744699901Rural0.7439
01600Talladega County, Alabama01Rural0.74320.744699901Rural0.7439
01610Tallapoosa County, Alabama01Rural0.74320.744699901Rural0.7439
01620Tuscaloosa County, Alabama8600Urban0.87640.864546220Urban0.8705
01630Walker County, Alabama01Rural0.74320.895913820Urban0.8196
01640Washington County, Alabama01Rural0.74320.744699901Rural0.7439
01650Wilcox County, Alabama01Rural0.74320.744699901Rural0.7439
01660Winston County, Alabama01Rural0.74320.744699901Rural0.7439
02013Aleutians County East, Alaska02Rural1.18881.197799902Rural1.1933
02016Aleutians County West, Alaska02Rural1.18881.197799902Rural1.1933
02020Anchorage County, Alaska0380Urban1.17841.189511260Urban1.1840
02030Angoon County, Alaska02Rural1.18881.197799902Rural1.1933
02040Barrow-North Slope County, Alaska02Rural1.18881.197799902Rural1.1933
02050Bethel County, Alaska02Rural1.18881.197799902Rural1.1933
02060Bristol Bay Borough County, Alaska02Rural1.18881.197799902Rural1.1933
02068Denali County, Alaska02Rural1.18881.197799902Rural1.1933
02070Bristol Bay County, Alaska02Rural1.18881.197799902Rural1.1933
02080Cordova-Mc Carthy County, Alaska02Rural1.18881.197799902Rural1.1933
02090Fairbanks County, Alaska02Rural1.18881.140821820Urban1.1648
02100Haines County, Alaska02Rural1.18881.197799902Rural1.1933
02110Juneau County, Alaska02Rural1.18881.197799902Rural1.1933
02120Kenai-Cook Inlet County, Alaska02Rural1.18881.197799902Rural1.1933
02122Kenai Peninsula Borough, Alaska02Rural1.18881.197799902Rural1.1933
02130Ketchikan County, Alaska02Rural1.18881.197799902Rural1.1933
02140Kobuk County, Alaska02Rural1.18881.197799902Rural1.1933
02150Kodiak County, Alaska02Rural1.18881.197799902Rural1.1933
02160Kuskokwin County, Alaska02Rural1.18881.197799902Rural1.1933
02164Lake and Peninsula Borough, Alaska02Rural1.18881.197799902Rural1.1933
02170Matanuska County, Alaska02Rural1.18881.189511260Urban1.1892
02180Nome County, Alaska02Rural1.18881.197799902Rural1.1933
02185North Slope Borough, Alaska02Rural1.18881.197799902Rural1.1933
02188Northwest Arctic Borough, Alaska02Rural1.18881.197799902Rural1.1933
02190Outer Ketchikan County, Alaska02Rural1.18881.197799902Rural1.1933
02200Prince Of Wales County, Alaska02Rural1.18881.197799902Rural1.1933
02201Prince of Wales-Outer Ketchikan Census Area, Alaska02Rural1.18881.197799902Rural1.1933
02210Seward County, Alaska02Rural1.18881.197799902Rural1.1933
02220Sitka County, Alaska02Rural1.18881.197799902Rural1.1933
02230Skagway-Yakutat County, Alaska02Rural1.18881.197799902Rural1.1933
02231Skagway-Yakutat-Angoon Census Area, Alaska02Rural1.18881.197799902Rural1.1933
Start Printed Page 45081
02232Skagway-Hoonah-Angoon Census Area, Alaska02Rural1.18881.197799902Rural1.1933
02240Southeast Fairbanks County, Alaska02Rural1.18881.197799902Rural1.1933
02250Upper Yukon County, Alaska02Rural1.18881.197799902Rural1.1933
02260Valdz-Chitna-Whitier County, Alaska02Rural1.18881.197799902Rural1.1933
02261Valdex-Cordove Census Area, Alaska02Rural1.18881.197799902Rural1.1933
02270Wade Hampton County, Alaska02Rural1.18881.197799902Rural1.1933
02280Wrangell-Petersburg County, Alaska02Rural1.18881.197799902Rural1.1933
02282Yakutat Borough, Alaska02Rural1.18881.197799902Rural1.1933
02290Yukon-Koyukuk County, Alaska02Rural1.18881.197799902Rural1.1933
03000Apache County, Arizona03Rural0.90450.876899903Rural0.8907
03010Cochise County, Arizona03Rural0.90450.876899903Rural0.8907
03020Coconino County, Arizona2620Urban1.18451.209222380Urban1.1969
03030Gila County, Arizona03Rural0.90450.876899903Rural0.8907
03040Graham County, Arizona03Rural0.90450.876899903Rural0.8907
03050Greenlee County, Arizona03Rural0.90450.876899903Rural0.8907
03055La Paz County, Arizona03Rural0.90450.876899903Rural0.8907
03060Maricopa County, Arizona6200Urban1.01271.012738060Urban1.0127
03070Mohave County, Arizona4120Urban1.11550.876899903Rural0.9962
03080Navajo County, Arizona03Rural0.90450.876899903Rural0.8907
03090Pima County, Arizona8520Urban0.90070.900746060Urban0.9007
03100Pinal County, Arizona6200Urban1.01271.012738060Urban1.0127
03110Santa Cruz County, Arizona03Rural0.90450.876899903Rural0.8907
03120Yavapai County, Arizona03Rural0.90450.986939140Urban0.9457
03130Yuma County, Arizona9360Urban0.91260.912649740Urban0.9126
04000Arkansas County, Arkansas04Rural0.77440.746699904Rural0.7605
04010Ashley County, Arkansas04Rural0.77440.746699904Rural0.7605
04020Baxter County, Arkansas04Rural0.77440.746699904Rural0.7605
04030Benton County, Arkansas2580Urban0.86610.866122220Urban0.8661
04040Boone County, Arkansas04Rural0.77440.746699904Rural0.7605
04050Bradley County, Arkansas04Rural0.77440.746699904Rural0.7605
04060Calhoun County, Arkansas04Rural0.77440.746699904Rural0.7605
04070Carroll County, Arkansas04Rural0.77440.746699904Rural0.7605
04080Chicot County, Arkansas04Rural0.77440.746699904Rural0.7605
04090Clark County, Arkansas04Rural0.77440.746699904Rural0.7605
04100Clay County, Arkansas04Rural0.77440.746699904Rural0.7605
04110Cleburne County, Arkansas04Rural0.77440.746699904Rural0.7605
04120Cleveland County, Arkansas04Rural0.77440.868038220Urban0.8212
04130Columbia County, Arkansas04Rural0.77440.746699904Rural0.7605
04140Conway County, Arkansas04Rural0.77440.746699904Rural0.7605
04150Craighead County, Arkansas3700Urban0.79110.791127860Urban0.7911
04160Crawford County, Arkansas2720Urban0.82460.823022900Urban0.8238
04170Crittenden County, Arkansas4920Urban0.94160.939732820Urban0.9407
04180Cross County, Arkansas04Rural0.77440.746699904Rural0.7605
04190Dallas County, Arkansas04Rural0.77440.746699904Rural0.7605
04200Desha County, Arkansas04Rural0.77440.746699904Rural0.7605
04210Drew County, Arkansas04Rural0.77440.746699904Rural0.7605
04220Faulkner County, Arkansas4400Urban0.87470.874730780Urban0.8747
04230Franklin County, Arkansas04Rural0.77440.823022900Urban0.7987
04240Fulton County, Arkansas04Rural0.77440.746699904Rural0.7605
04250Garland County, Arkansas04Rural0.77440.900526300Urban0.8375
04260Grant County, Arkansas04Rural0.77440.874730780Urban0.8246
04270Greene County, Arkansas04Rural0.77440.746699904Rural0.7605
4280Hempstead County, Arkansas04Rural0.77440.746699904Rural0.7605
04290Hot Spring County, Arkansas04Rural0.77440.746699904Rural0.7605
04300Howard County, Arkansas04Rural0.77440.746699904Rural0.7605
04310Independence County, Arkansas04Rural0.77440.746699904Rural0.7605
04320Izard County, Arkansas04Rural0.77440.746699904Rural0.7605
04330Jackson County, Arkansas04Rural0.77440.746699904Rural0.7605
04340Jefferson County, Arkansas6240Urban0.86800.868038220Urban0.8680
04350Johnson County, Arkansas04Rural0.77440.746699904Rural0.7605
04360Lafayette County, Arkansas04Rural0.77440.746699904Rural0.7605
04370Lawrence County, Arkansas04Rural0.77440.746699904Rural0.7605
04380Lee County, Arkansas04Rural0.77440.746699904Rural0.7605
04390Lincoln County, Arkansas04Rural0.77440.868038220Urban0.8212
04400Little River County, Arkansas04Rural0.77440.746699904Rural0.7605
04410Logan County, Arkansas04Rural0.77440.746699904Rural0.7605
04420Lonoke County, Arkansas4400Urban0.87470.874730780Urban0.8747
04430Madison County, Arkansas04Rural0.77440.866122220Urban0.8203
Start Printed Page 45082
04440Marion County, Arkansas04Rural0.77440.746699904Rural0.7605
04450Miller County, Arkansas8360Urban0.82830.828345500Urban0.8283
04460Mississippi County, Arkansas04Rural0.77440.746699904Rural0.7605
04470Monroe County, Arkansas04Rural0.77440.746699904Rural0.7605
04480Montgomery County, Arkansas04Rural0.77440.746699904Rural0.7605
04490Nevada County, Arkansas04Rural0.77440.746699904Rural0.7605
04500Newton County, Arkansas04Rural0.77440.746699904Rural0.7605
04510Ouachita County, Arkansas04Rural0.77440.746699904Rural0.7605
04520Perry County, Arkansas04Rural0.77440.874730780Urban0.8246
04530Phillips County, Arkansas04Rural0.77440.746699904Rural0.7605
04540Pike County, Arkansas04Rural0.77440.746699904Rural0.7605
04550Poinsett County, Arkansas04Rural0.77440.791127860Urban0.7828
04560Polk County, Arkansas04Rural0.77440.746699904Rural0.7605
04570Pope County, Arkansas04Rural0.77440.746699904Rural0.7605
04580Prairie County, Arkansas04Rural0.77440.746699904Rural0.7605
04590Pulaski County, Arkansas4400Urban0.87470.874730780Urban0.8747
04600Randolph County, Arkansas04Rural0.77440.746699904Rural0.7605
04610St Francis County, Arkansas04Rural0.77440.746699904Rural0.7605
04620Saline County, Arkansas4400Urban0.87470.874730780Urban0.8747
04630Scott County, Arkansas04Rural0.77440.746699904Rural0.7605
04640Searcy County, Arkansas04Rural0.77440.746699904Rural0.7605
04650Sebastian County, Arkansas2720Urban0.82460.823022900Urban0.8238
04660Sevier County, Arkansas04Rural0.77440.746699904Rural0.7605
04670Sharp County, Arkansas04Rural0.77440.746699904Rural0.7605
04680Stone County, Arkansas04Rural0.77440.746699904Rural0.7605
04690Union County, Arkansas04Rural0.77440.746699904Rural0.7605
04700Van Buren County, Arkansas04Rural0.77440.746699904Rural0.7605
04710Washington County, Arkansas2580Urban0.86610.866122220Urban0.8661
04720White County, Arkansas04Rural0.77440.746699904Rural0.7605
04730Woodruff County, Arkansas04Rural0.77440.746699904Rural0.7605
04740Yell County, Arkansas04Rural0.77440.746699904Rural0.7605
05000Alameda County, California5775Urban1.53461.534636084Urban1.5346
05010Alpine County, California05Rural1.07751.105499905Rural1.0915
05020Amador County, California05Rural1.07751.105499905Rural1.0915
05030Butte County, California1620Urban1.05111.051117020Urban1.0511
05040Calaveras County, California05Rural1.07751.105499905Rural1.0915
05050Colusa County, California05Rural1.07751.105499905Rural1.0915
05060Contra Costa County, California5775Urban1.53461.534636084Urban1.5346
05070Del Norte County, California05Rural1.07751.105499905Rural1.0915
05080Eldorado County, California6920Urban1.31431.296940900Urban1.3056
05090Fresno County, California2840Urban1.04281.053823420Urban1.0483
05100Glenn County, California05Rural1.07751.105499905Rural1.0915
05110Humboldt County, California05Rural1.07751.105499905Rural1.0915
05120Imperial County, California05Rural1.07750.890620940Urban0.9841
05130Inyo County, California05Rural1.07751.105499905Rural1.0915
05140Kern County, California0680Urban1.04701.047012540Urban1.0470
05150Kings County, California05Rural1.07751.003625260Urban1.0406
05160Lake County, California05Rural1.07751.105499905Rural1.0915
05170Lassen County, California05Rural1.07751.105499905Rural1.0915
05200Los Angeles County, California4480Urban1.17831.178331084Urban1.1783
05210Los Angeles County, California4480Urban1.17831.178331084Urban1.1783
05300Madera County, California2840Urban1.04280.871331460Urban0.9571
05310Marin County, California7360Urban1.49941.499441884Urban1.4994
05320Mariposa County, California05Rural1.07751.105499905Rural1.0915
05330Mendocino County, California05Rural1.07751.105499905Rural1.0915
05340Merced County, California4940Urban1.11091.110932900Urban1.1109
05350Modoc County, California05Rural1.07751.105499905Rural1.0915
05360Mono County, California05Rural1.07751.105499905Rural1.0915
05370Monterey County, California7120Urban1.41281.412841500Urban1.4128
05380Napa County, California8720Urban1.39831.264334900Urban1.3313
05390Nevada County, California05Rural1.07751.105499905Rural1.0915
05400Orange County, California5945Urban1.15591.155942044Urban1.1559
05410Placer County, California6920Urban1.31431.296940900Urban1.3056
05420Plumas County, California05Rural1.07751.105499905Rural1.0915
05430Riverside County, California6780Urban1.10271.102740140Urban1.1027
05440Sacramento County, California6920Urban1.31431.296940900Urban1.3056
05450San Benito County, California05Rural1.07751.509941940Urban1.2937
05460San Bernardino County, California6780Urban1.10271.102740140Urban1.1027
Start Printed Page 45083
05470San Diego County, California7320Urban1.14131.141341740Urban1.1413
05480San Francisco County, California7360Urban1.49941.499441884Urban1.4994
05490San Joaquin County, California8120Urban1.13071.130744700Urban1.1307
05500San Luis Obispo County, California7460Urban1.13491.134942020Urban1.1349
05510San Mateo County, California7360Urban1.49941.499441884Urban1.4994
05520Santa Barbara County, California7480Urban1.16941.169442060Urban1.1694
05530Santa Clara County, California7400Urban1.51181.509941940Urban1.5109
05540Santa Cruz County, California7485Urban1.51661.516642100Urban1.5166
05550Shasta County, California6690Urban1.22031.220339820Urban1.2203
05560Sierra County, California05Rural1.07751.105499905Rural1.0915
05570Siskiyou County, California05Rural1.07751.105499905Rural1.0915
05580Solano County, California8720Urban1.39831.493646700Urban1.4460
05590Sonoma County, California7500Urban1.34931.349342220Urban1.3493
05600Stanislaus County, California5170Urban1.18851.188533700Urban1.1885
05610Sutter County, California9340Urban1.09211.092149700Urban1.0921
05620Tehama County, California05Rural1.07751.105499905Rural1.0915
05630Trinity County, California05Rural1.07751.105499905Rural1.0915
05640Tulare County, California8780Urban1.01231.012347300Urban1.0123
05650Tuolumne County, California05Rural1.07751.105499905Rural1.0915
05660Ventura County, California8735Urban1.16221.162237100Urban1.1622
05670Yolo County, California9270Urban0.99501.296940900Urban1.1460
05680Yuba County, California9340Urban1.09211.092149700Urban1.0921
06000Adams County, Colorado2080Urban1.07231.072319740Urban1.0723
06010Alamosa County, Colorado06Rural0.93800.938099906Rural0.9380
06020Arapahoe County, Colorado2080Urban1.07231.072319740Urban1.0723
06030Archuleta County, Colorado06Rural0.93800.938099906Rural0.9380
06040Baca County, Colorado06Rural0.93800.938099906Rural0.9380
06050Bent County, Colorado06Rural0.93800.938099906Rural0.9380
06060Boulder County, Colorado1125Urban0.97340.973414500Urban0.9734
06070Chaffee County, Colorado06Rural0.93800.938099906Rural0.9380
06080Cheyenne County, Colorado06Rural0.93800.938099906Rural0.9380
06090Clear Creek County, Colorado06Rural0.93801.072319740Urban1.0052
06100Conejos County, Colorado06Rural0.93800.938099906Rural0.9380
06110Costilla County, Colorado06Rural0.93800.938099906Rural0.9380
06120Crowley County, Colorado06Rural0.93800.938099906Rural0.9380
06130Custer County, Colorado06Rural0.93800.938099906Rural0.9380
06140Delta County, Colorado06Rural0.93800.938099906Rural0.9380
06150Denver County, Colorado2080Urban1.07231.072319740Urban1.0723
06160Dolores County, Colorado06Rural0.93800.938099906Rural0.9380
06170Douglas County, Colorado2080Urban1.07231.072319740Urban1.0723
06180Eagle County, Colorado06Rural0.93800.938099906Rural0.9380
06190Elbert County, Colorado06Rural0.93801.072319740Urban1.0052
06200El Paso County, Colorado1720Urban0.94680.946817820Urban0.9468
06210Fremont County, Colorado06Rural0.93800.938099906Rural0.9380
06220Garfield County, Colorado06Rural0.93800.938099906Rural0.9380
06230Gilpin County, Colorado06Rural0.93801.072319740Urban1.0052
06240Grand County, Colorado06Rural0.93800.938099906Rural0.9380
06250Gunnison County, Colorado06Rural0.93800.938099906Rural0.9380
06260Hinsdale County, Colorado06Rural0.93800.938099906Rural0.9380
06270Huerfano County, Colorado06Rural0.93800.938099906Rural0.9380
06280Jackson County, Colorado06Rural0.93800.938099906Rural0.9380
06290Jefferson County, Colorado2080Urban1.07231.072319740Urban1.0723
06300Kiowa County, Colorado06Rural0.93800.938099906Rural0.9380
06310Kit Carson County, Colorado06Rural0.93800.938099906Rural0.9380
06320Lake County, Colorado06Rural0.93800.938099906Rural0.9380
06330La Plata County, Colorado06Rural0.93800.938099906Rural0.9380
06340Larimer County, Colorado2670Urban1.01221.012222660Urban1.0122
06350Las Animas County, Colorado06Rural0.93800.938099906Rural0.9380
06360Lincoln County, Colorado06Rural0.93800.938099906Rural0.9380
06370Logan County, Colorado06Rural0.93800.938099906Rural0.9380
06380Mesa County, Colorado2995Urban0.95500.955024300Urban0.9550
06390Mineral County, Colorado06Rural0.93800.938099906Rural0.9380
06400Moffat County, Colorado06Rural0.93800.938099906Rural0.9380
06410Montezuma County, Colorado06Rural0.93800.938099906Rural0.9380
06420Montrose County, Colorado06Rural0.93800.938099906Rural0.9380
06430Morgan County, Colorado06Rural0.93800.938099906Rural0.9380
06440Otero County, Colorado06Rural0.93800.938099906Rural0.9380
06450Ouray County, Colorado06Rural0.93800.938099906Rural0.9380
Start Printed Page 45084
06460Park County, Colorado06Rural0.93801.072319740Urban1.0052
06470Phillips County, Colorado06Rural0.93800.938099906Rural0.9380
06480Pitkin County, Colorado06Rural0.93800.938099906Rural0.9380
06490Prowers County, Colorado06Rural0.93800.938099906Rural0.9380
06500Pueblo County, Colorado6560Urban0.86230.862339380Urban0.8623
06510Rio Blanco County, Colorado06Rural0.93800.938099906Rural0.9380
06520Rio Grande County, Colorado06Rural0.93800.938099906Rural0.9380
06530Routt County, Colorado06Rural0.93800.938099906Rural0.9380
06540Saguache County, Colorado06Rural0.93800.938099906Rural0.9380
06550San Juan County, Colorado06Rural0.93800.938099906Rural0.9380
06560San Miguel County, Colorado06Rural0.93800.938099906Rural0.9380
06570Sedgwick County, Colorado06Rural0.93800.938099906Rural0.9380
06580Summit County, Colorado06Rural0.93800.938099906Rural0.9380
06590Teller County, Colorado06Rural0.93800.946817820Urban0.9424
06600Washington County, Colorado06Rural0.93800.938099906Rural0.9380
06610Weld County, Colorado3060Urban0.95700.957024540Urban0.9570
06620Yuma County, Colorado06Rural0.93800.938099906Rural0.9380
06630Broomfield County, Colorado2080Urban1.07231.072319740Urban1.0723
07000Fairfield County, Connecticut5483Urban1.21961.259214860Urban1.2394
07010Hartford County, Connecticut3283Urban1.10731.107325540Urban1.1073
07020Litchfield County, Connecticut3283Urban1.10731.107325540Urban1.1073
07030Middlesex County, Connecticut3283Urban1.10731.107325540Urban1.1073
07040New Haven County, Connecticut5483Urban1.21961.188735300Urban1.2042
07050New London County, Connecticut5523Urban1.13451.134535980Urban1.1345
07060Tolland County, Connecticut3283Urban1.10731.107325540Urban1.1073
07070Windham County, Connecticut07Rural1.17301.173099907Rural1.1730
08000Kent County, Delaware2190Urban0.97760.977620100Urban0.9776
08010New Castle County, Delaware9160Urban1.05271.047148864Urban1.0499
08020Sussex County, Delaware08Rural0.95790.957999908Rural0.9579
09000Washington Dc County, Dist Of Col8840Urban1.09761.092647894Urban1.0951
10000Alachua County, Florida2900Urban0.93880.938823540Urban0.9388
10010Baker County, Florida10Rural0.86770.929027260Urban0.8984
10020Bay County, Florida6015Urban0.80050.800537460Urban0.8005
10030Bradford County, Florida10Rural0.86770.856899910Rural0.8623
10040Brevard County, Florida4900Urban0.98390.983937340Urban0.9839
10050Broward County, Florida2680Urban1.04321.043222744Urban1.0432
10060Calhoun County, Florida10Rural0.86770.856899910Rural0.8623
10070Charlotte County, Florida6580Urban0.92550.925539460Urban0.9255
10080Citrus County, Florida10Rural0.86770.856899910Rural0.8623
10090Clay County, Florida3600Urban0.92990.929027260Urban0.9295
10100Collier County, Florida5345Urban1.01391.013934940Urban1.0139
10110Columbia County, Florida10Rural0.86770.856899910Rural0.8623
10120Dade County, Florida5000Urban0.97500.975033124Urban0.9750
10130De Soto County, Florida10Rural0.86770.856899910Rural0.8623
10140Dixie County, Florida10Rural0.86770.856899910Rural0.8623
10150Duval County, Florida3600Urban0.92990.929027260Urban0.9295
10160Escambia County, Florida6080Urban0.80960.809637860Urban0.8096
10170Flagler County, Florida2020Urban0.93250.856899910Rural0.8947
10180Franklin County, Florida10Rural0.86770.856899910Rural0.8623
10190Gadsden County, Florida8240Urban0.86880.868845220Urban0.8688
10200Gilchrist County, Florida10Rural0.86770.938823540Urban0.9033
10210Glades County, Florida10Rural0.86770.856899910Rural0.8623
10220Gulf County, Florida10Rural0.86770.856899910Rural0.8623
10230Hamilton County, Florida10Rural0.86770.856899910Rural0.8623
10240Hardee County, Florida10Rural0.86770.856899910Rural0.8623
10250Hendry County, Florida10Rural0.86770.856899910Rural0.8623
10260Hernando County, Florida8280Urban0.92330.923345300Urban0.9233
10270Highlands County, Florida10Rural0.86770.856899910Rural0.8623
10280Hillsborough County, Florida8280Urban0.92330.923345300Urban0.9233
10290Holmes County, Florida10Rural0.86770.856899910Rural0.8623
10300Indian River County, Florida10Rural0.86770.943446940Urban0.9056
10310Jackson County, Florida10Rural0.86770.856899910Rural0.8623
10320Jefferson County, Florida10Rural0.86770.868845220Urban0.8683
10330Lafayette County, Florida10Rural0.86770.856899910Rural0.8623
10340Lake County, Florida5960Urban0.94640.946436740Urban0.9464
10350Lee County, Florida2700Urban0.93560.935615980Urban0.9356
10360Leon County, Florida8240Urban0.86880.868845220Urban0.8688
10370Levy County, Florida10Rural0.86770.856899910Rural0.8623
Start Printed Page 45085
10380Liberty County, Florida10Rural0.86770.856899910Rural0.8623
10390Madison County, Florida10Rural0.86770.856899910Rural0.8623
10400Manatee County, Florida7510Urban0.96390.963942260Urban0.9639
10410Marion County, Florida5790Urban0.89250.892536100Urban0.8925
10420Martin County, Florida2710Urban1.01231.012338940Urban1.0123
10430Monroe County, Florida10Rural0.86770.856899910Rural0.8623
10440Nassau County, Florida3600Urban0.92990.929027260Urban0.9295
10450Okaloosa County, Florida2750Urban0.88720.887223020Urban0.8872
10460Okeechobee County, Florida10Rural0.86770.856899910Rural0.8623
10470Orange County, Florida5960Urban0.94640.946436740Urban0.9464
10480Osceola County, Florida5960Urban0.94640.946436740Urban0.9464
10490Palm Beach County, Florida8960Urban1.00671.006748424Urban1.0067
10500Pasco County, Florida8280Urban0.92330.923345300Urban0.9233
10510Pinellas County, Florida8280Urban0.92330.923345300Urban0.9233
10520Polk County, Florida3980Urban0.89120.891229460Urban0.8912
10530Putnam County, Florida10Rural0.86770.856899910Rural0.8623
10540Johns County, Florida3600Urban0.92990.929027260Urban0.9295
10550St Lucie County, Florida2710Urban1.01231.012338940Urban1.0123
10560Santa Rosa County, Florida6080Urban0.80960.809637860Urban0.8096
10570Sarasota County, Florida7510Urban0.96390.963942260Urban0.9639
10580Seminole County, Florida5960Urban0.94640.946436740Urban0.9464
10590Sumter County, Florida10Rural0.86770.856899910Rural0.8623
10600Suwannee County, Florida10Rural0.86770.856899910Rural0.8623
10610Taylor County, Florida10Rural0.86770.856899910Rural0.8623
10620Union County, Florida10Rural0.86770.856899910Rural0.8623
10630Volusia County, Florida2020Urban0.93250.929919660Urban0.9312
10640Wakulla County, Florida10Rural0.86770.868845220Urban0.8683
10650Walton County, Florida10Rural0.86770.856899910Rural0.8623
10660Washington County, Florida10Rural0.86770.856899910Rural0.8623
11000Appling County, Georgia11Rural0.81660.766299911Rural0.7914
11010Atkinson County, Georgia11Rural0.81660.766299911Rural0.7914
11011Bacon County, Georgia11Rural0.81660.766299911Rural0.7914
11020Baker County, Georgia11Rural0.81660.862810500Urban0.8397
11030Baldwin County, Georgia11Rural0.81660.766299911Rural0.7914
11040Banks County, Georgia11Rural0.81660.766299911Rural0.7914
11050Barrow County, Georgia0520Urban0.97930.979312060Urban0.9793
11060Bartow County, Georgia0520Urban0.97930.979312060Urban0.9793
11070Ben Hill County, Georgia11Rural0.81660.766299911Rural0.7914
11080Berrien County, Georgia11Rural0.81660.766299911Rural0.7914
11090Bibb County, Georgia4680Urban0.92770.944331420Urban0.9360
11100Bleckley County, Georgia11Rural0.81660.766299911Rural0.7914
11110Brantley County, Georgia11Rural0.81660.931115260Urban0.8739
11120Brooks County, Georgia11Rural0.81660.886646660Urban0.8516
11130Bryan County, Georgia7520Urban0.94610.946142340Urban0.9461
11140Bulloch County, Georgia11Rural0.81660.766299911Rural0.7914
11150Burke County, Georgia11Rural0.81660.974812260Urban0.8957
11160Butts County, Georgia11Rural0.81660.979312060Urban0.8980
11161Calhoun County, Georgia11Rural0.81660.766299911Rural0.7914
11170Camden County, Georgia11Rural0.81660.766299911Rural0.7914
11180Candler County, Georgia11Rural0.81660.766299911Rural0.7914
11190Carroll County, Georgia0520Urban0.97930.979312060Urban0.9793
11200Catoosa County, Georgia1560Urban0.90880.908816860Urban0.9088
11210Charlton County, Georgia11Rural0.81660.766299911Rural0.7914
11220Chatham County, Georgia7520Urban0.94610.946142340Urban0.9461
11230Chattahoochee County, Georgia1800Urban0.85600.856017980Urban0.8560
11240Chattooga County, Georgia11Rural0.81660.766299911Rural0.7914
11250Cherokee County, Georgia0520Urban0.97930.979312060Urban0.9793
11260Clarke County, Georgia0500Urban0.98550.985512020Urban0.9855
11270Clay County, Georgia11Rural0.81660.766299911Rural0.7914
11280Clayton County, Georgia0520Urban0.97930.979312060Urban0.9793
11281Clinch County, Georgia11Rural0.81660.766299911Rural0.7914
11290Cobb County, Georgia0520Urban0.97930.979312060Urban0.9793
11291Coffee County, Georgia11Rural0.81660.766299911Rural0.7914
11300Colquitt County, Georgia11Rural0.81660.766299911Rural0.7914
11310Columbia County, Georgia0600Urban0.98080.974812260Urban0.9778
11311Cook County, Georgia11Rural0.81660.766299911Rural0.7914
11320Coweta County, Georgia0520Urban0.97930.979312060Urban0.9793
11330Crawford County, Georgia11Rural0.81660.944331420Urban0.8805
Start Printed Page 45086
11340Crisp County, Georgia11Rural0.81660.766299911Rural0.7914
11341Dade County, Georgia1560Urban0.90880.908816860Urban0.9088
11350Dawson County, Georgia11Rural0.81660.979312060Urban0.8980
11360Decatur County, Georgia11Rural0.81660.766299911Rural0.7914
11370De Kalb County, Georgia0520Urban0.97930.979312060Urban0.9793
11380Dodge County, Georgia11Rural0.81660.766299911Rural0.7914
11381Dooly County, Georgia11Rural0.81660.766299911Rural0.7914
11390Dougherty County, Georgia0120Urban0.86280.862810500Urban0.8628
11400Douglas County, Georgia0520Urban0.97930.979312060Urban0.9793
11410Early County, Georgia11Rural0.81660.766299911Rural0.7914
11420Echols County, Georgia11Rural0.81660.886646660Urban0.8516
11421Effingham County, Georgia7520Urban0.94610.946142340Urban0.9461
11430Elbert County, Georgia11Rural0.81660.766299911Rural0.7914
11440Emanuel County, Georgia11Rural0.81660.766299911Rural0.7914
11441Evans County, Georgia11Rural0.81660.766299911Rural0.7914
11450Fannin County, Georgia11Rural0.81660.766299911Rural0.7914
11451Fayette County, Georgia0520Urban97930.979312060Urban0.9793
11460Floyd County, Georgia11Rural0.81660.941440660Urban0.8790
11461Forsyth County, Georgia0520Urban0.97930.979312060Urban0.9793
11462Franklin County, Georgia11Rural0.81660.766299911Rural0.7914
11470Fulton County, Georgia0520Urban0.97930.979312060Urban0.9793
11471Gilmer County, Georgia11Rural0.81660.766299911Rural0.7914
11480Glascock County, Georgia11Rural0.81660.766299911Rural0.7914
11490Glynn County, Georgia11Rural0.81660.931115260Urban0.8739
11500Gordon County, Georgia11Rural0.81660.766299911Rural0.7914
11510Grady County, Georgia11Rural0.81660.766299911Rural0.7914
11520Greene County, Georgia11Rural0.81660.766299911Rural0.7914
11530Gwinnett County, Georgia0520Urban0.97930.979312060Urban0.9793
11540Habersham County, Georgia11Rural0.81660.766299911Rural0.7914
11550Hall County, Georgia11Rural0.81660.887423580Urban0.8520
11560Hancock County, Georgia11Rural0.81660.766299911Rural0.7914
11570Haralson County, Georgia11Rural0.81660.979312060Urban0.8980
11580Harris County, Georgia1800Urban0.85600.856017980Urban0.8560
11581Hart County, Georgia11Rural0.81660.766299911Rural0.7914
11590Heard County, Georgia11Rural0.81660.979312060Urban0.8980
11591Henry County, Georgia0520Urban0.97930.979312060Urban0.9793
11600Houston County, Georgia4680Urban0.92770.864547580Urban0.8961
11601Irwin County, Georgia11Rural0.81660.766299911Rural0.7914
11610Jackson County, Georgia11Rural0.81660.766299911Rural0.7914
11611Jasper County, Georgia11Rural0.81660.979312060Urban0.8980
11612Jeff Davis County, Georgia11Rural0.81660.766299911Rural0.7914
11620Jefferson County, Georgia11Rural0.81660.766299911Rural0.7914
11630Jenkins County, Georgia11Rural0.81660.766299911Rural0.7914
11640Johnson County, Georgia11Rural0.81660.766299911Rural0.7914
11650Jones County, Georgia4680Urban0.92770.944331420Urban0.9360
11651Lamar County, Georgia11Rural0.81660.979312060Urban0.8980
11652Lanier County, Georgia11Rural0.81660.886646660Urban0.8516
11660Laurens County, Georgia11Rural0.81660.766299911Rural0.7914
11670Lee County, Georgia0120Urban0.86280.862810500Urban0.8628
11680Liberty County, Georgia11Rural0.8166(1)25980Urban0.8973
11690Lincoln County, Georgia11Rural0.81660.766299911Rural0.7914
11691Long County, Georgia11Rural0.8166(1)25980Urban0.8973
11700Lowndes County, Georgia11Rural0.81660.886646660Urban0.8516
11701Lumpkin County, Georgia11Rural0.81660.766299911Rural0.7914
11702Mc Duffie County, Georgia0600Urban0.98080.974812260Urban0.9778
11703Mc Intosh County, Georgia11Rural0.81660.931115260Urban0.8739
11710Macon County, Georgia11Rural0.81660.766299911Rural0.7914
11720Madison County, Georgia0500Urban0.98550.985512020Urban0.9855
11730Marion County, Georgia11Rural0.81660.856017980Urban0.8363
11740Meriwether County, Georgia11Rural0.81660.979312060Urban0.8980
11741Miller County, Georgia11Rural0.81660.766299911Rural0.7914
11750Mitchell County, Georgia11Rural0.81660.766299911Rural0.7914
11760Monroe County, Georgia11Rural0.81660.944331420Urban0.8805
11770Montgomery County, Georgia11Rural0.81660.766299911Rural0.7914
11771Morgan County, Georgia11Rural0.81660.766299911Rural0.7914
11772Murray County, Georgia11Rural0.81660.907919140Urban0.8623
11780Muscogee County, Georgia1800Urban0.85600.856017980Urban0.8560
11790Newton County, Georgia0520Urban0.97930.979312060Urban0.9793
Start Printed Page 45087
11800Oconee County, Georgia0500Urban0.98550.985512020Urban0.9855
11801Oglethorpe County, Georgia11Rural0.81660.985512020Urban0.9011
11810Paulding County, Georgia0520Urban0.97930.979312060Urban0.9793
11811Peach County, Georgia4680Urban0.92770.766299911Rural0.8470
11812Pickens County, Georgia0520Urban0.97930.979312060Urban0.9793
11820Pierce County, Georgia11Rural0.81660.766299911Rural0.7914
11821Pike County, Georgia11Rural0.81660.979312060Urban0.8980
11830Polk County, Georgia11Rural0.81660.766299911Rural0.7914
11831Pulaski County, Georgia11Rural0.81660.766299911Rural0.7914
11832Putnam County, Georgia11Rural0.81660.766299911Rural0.7914
11833Quitman County, Georgia11Rural0.81660.766299911Rural0.7914
11834Rabun County, Georgia11Rural0.81660.766299911Rural0.7914
11835Randolph County, Georgia11Rural0.81660.766299911Rural0.7914
11840Richmond County, Georgia0600Urban0.98080.974812260Urban10.9778
11841Rockdale County, Georgia0520Urban0.97930.979312060Urban0.9793
11842Schley County, Georgia11Rural0.81660.766299911Rural0.7914
11850Screven County, Georgia11Rural0.81660.766299911Rural0.7914
11851Seminole County, Georgia11Rural0.81660.766299911Rural0.7914
11860Spalding County, Georgia0520Urban0.97930.979312060Urban0.9793
11861Stephens County, Georgia11Rural0.81660.766299911Rural0.7914
11862Stewart County, Georgia11Rural0.81660.766299911Rural0.7914
11870Sumter County, Georgia11Rural0.81660.766299911Rural0.7914
11880Talbot County, Georgia11Rural0.81660.766299911Rural0.7914
11881Taliaferro County, Georgia11Rural0.81660.766299911Rural0.7914
11882Tattnall County, Georgia11Rural0.81660.766299911Rural0.7914
11883Taylor County, Georgia11Rural0.81660.766299911Rural0.7914
11884Telfair County, Georgia11Rural0.81660.766299911Rural0.7914
11885Terrell County, Georgia11Rural0.81660.862810500Urban0.8397
11890Thomas County, Georgia11Rural0.81660.766299911Rural0.7914
11900Tift County, Georgia11Rural0.81660.766299911Rural0.7914
11901Toombs County, Georgia11Rural0.81660.766299911Rural0.7914
11902Towns County, Georgia11Rural0.81660.766299911Rural0.7914
11903Treutlen County, Georgia11Rural0.81660.766299911Rural0.7914
11910Troup County, Georgia11Rural0.81660.766299911Rural0.7914
11911Turner County, Georgia11Rural0.81660.766299911Rural0.7914
11912Twiggs County, Georgia4680Urban0.92770.944331420Urban0.9360
11913Union County, Georgia11Rural0.81660.766299911Rural0.7914
11920Upson County, Georgia11Rural0.81660.766299911Rural0.7914
11921Walker County, Georgia1560Urban0.90880.908816860Urban0.9088
11930Walton County, Georgia0520Urban0.97930.979312060Urban0.9793
11940Ware County, Georgia11Rural0.81660.766299911Rural0.7914
11941Warren County, Georgia11Rural0.81660.766299911Rural0.7914
11950Washington County, Georgia11Rural0.81660.766299911Rural0.7914
11960Wayne County, Georgia11Rural0.81660.766299911Rural0.7914
11961Webster County, Georgia11Rural0.81660.766299911Rural0.7914
11962Wheeler County, Georgia11Rural0.81660.766299911Rural0.7914
11963White County, Georgia11Rural0.81660.766299911Rural0.7914
11970Whitfield County, Georgia11Rural0.81660.907919140Urban0.8623
11971Wilcox County, Georgia11Rural0.81660.766299911Rural0.7914
11972Wilkes County, Georgia11Rural0.81660.766299911Rural0.7914
11973Wilkinson County, Georgia11Rural0.81660.766299911Rural0.7914
11980Worth County, Georgia11Rural0.81660.862810500Urban0.8397
12005Kalawao County, Hawaii12Rural1.05511.055199912Rural1.0551
12010Hawaii County, Hawaii12Rural1.05511.055199912Rural1.0551
12020Honolulu County, Hawaii3320Urban1.12141.121426180Urban1.1214
12040Kauai County, Hawaii12Rural1.05511.055199912Rural1.0551
12050Maui County, Hawaii12Rural1.05511.055199912Rural1.0551
13000Ada County, Idaho1080Urban0.90520.905214260Urban0.9052
13010Adams County, Idaho13Rural0.90970.803799913Rural0.8567
13020Bannock County, Idaho6340Urban0.93510.935138540Urban0.9351
13030Bear Lake County, Idaho13Rural0.90970.803799913Rural0.8567
13040Benewah County, Idaho13Rural0.90970.803799913Rural0.8567
13050Bingham County, Idaho13Rural0.90970.803799913Rural0.8567
13060Blaine County, Idaho13Rural0.90970.803799913Rural0.8567
13070Boise County, Idaho13Rural0.90970.905214260Urban0.9075
13080Bonner County, Idaho13Rural0.90970.803799913Rural0.8567
13090Bonneville County, Idaho13Rural0.90970.942026820Urban0.9259
13100Boundary County, Idaho13Rural0.90970.803799913Rural0.8567
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13110Butte County, Idaho13Rural0.90970.803799913Rural0.8567
13120Camas County, Idaho13Rural0.90970.803799913Rural0.8567
13130Canyon County, Idaho1080Urban0.90520.905214260Urban0.9052
13140Caribou County, Idaho13Rural0.90970.803799913Rural0.8567
13150Cassia County, Idaho13Rural0.90970.803799913Rural0.8567
13160Clark County, Idaho13Rural0.90970.803799913Rural0.8567
13170Clearwater County, Idaho13Rural0.90970.803799913Rural0.8567
13180Custer County, Idaho13Rural0.90970.803799913Rural0.8567
13190Elmore County, Idaho13Rural0.90970.803799913Rural0.8567
13200Franklin County, Idaho13Rural0.90970.916430860Urban0.9131
13210Fremont County, Idaho13Rural0.90970.803799913Rural0.8567
13220Gem County, Idaho13Rural0.90970.905214260Urban0.9075
13230Gooding County, Idaho13Rural0.90970.803799913Rural0.8567
13240Idaho County, Idaho13Rural0.90970.803799913Rural0.8567
13250Jefferson County, Idaho13Rural0.90970.942026820Urban0.9259
13260Jerome County, Idaho13Rural0.90970.803799913Rural0.8567
13270Kootenai County, Idaho13Rural0.90970.964717660Urban0.9372
13280Latah County, Idaho13Rural0.90970.803799913Rural0.8567
13290Lemhi County, Idaho13Rural0.90970.803799913Rural0.8567
13300Lewis County, Idaho13Rural0.90970.803799913Rural0.8567
13310Lincoln County, Idaho13Rural0.90970.803799913Rural0.8567
13320Madison County, Idaho13Rural0.90970.803799913Rural0.8567
13330Minidoka County, Idaho13Rural0.90970.803799913Rural