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Proposed Rule

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2007 and Deficit Reduction Act of 2005 Changes to Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical Equipment; Proposed Rule

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Information about this document as published in the Federal Register.

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AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

This proposed rule would set forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health agencies. In addition, this proposed rule would set forth policy changes related to Medicare payment for certain durable medical equipment for the purpose of implementing sections 1834(a)(5) and 1834(a)(7) of the Social Security Act, as amended by section 5101 of the Deficit Reduction Act of 2005. We are also inviting comments on a number of issues including payments based on reporting quality data and health information technology, as well as how to improve data transparency for consumers.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 25, 2006.

ADDRESSES:

In commenting, please refer to file code CMS-1304-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

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

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/​eRulemaking. Click on the link “Submit electronic comments on CMS regulations with an open comment period.” (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1304-P, P.O. Box 8014, Baltimore, MD 21244-8014.

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

3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1304-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

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

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

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

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

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

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FOR FURTHER INFORMATION CONTACT:

Randy Throndset, (410) 786-0131, or Sharon Ventura, (410) 786-1985 (for issues related to the home health prospective payment system).

Doug Brown, (410) 786-0028 (for issues related to reporting quality data).

Alexis Meholic, (410) 786-2300 (for issues related to implementation of section 5101 of the Deficit Reduction Act of 2005).

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SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1304-P and the specific “issue identifier” that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.cms.hhs.gov/​eRulemaking. Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments.

Comments received timely would also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

I. Background

[If you choose to comment on issues in this section, please include the caption “BACKGROUND” at the beginning of your comments.]

A. Statutory Background

The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on August 5, 1997, significantly changed the way Medicare pays for Medicare home health services. Until the implementation of a home health prospective payment system (HH PPS) on October 1, 2000, home health agencies (HHAs) received payment under a cost-based reimbursement system. Section 4603 of the BBA governed the development of the HH PPS.

Section 4603(a) of the BBA provides the authority for the development of a PPS for all Medicare-covered home health services provided under a plan of care that were paid on a reasonable cost basis by adding section 1895, entitled “Prospective Payment For Home Health Services,” to the Social Security Act (the Act).

Section 1895(b)(1) of the Act requires the Secretary to establish a PPS for all Start Printed Page 44083costs of home health services paid under Medicare.

Section 1895(b)(3)(A) of the Act requires that (1) the computation of a standard prospective payment amount include all costs of home health services covered and paid for on a reasonable cost basis and be initially based on the most recent audited cost report data available to the Secretary, and (2) the prospective payment amounts be standardized to eliminate the effects of case-mix and wage levels among HHAs.

Section 1895(b)(3)(B) of the Act addresses the annual update to the standard prospective payment amounts by the home health applicable increase percentage as specified in the statute.

Section 1895(b)(4) of the Act governs the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the standard prospective payment amount to be adjusted for case-mix and geographic differences in wage levels. Section 1895(b)(4)(B) of the Act requires the establishment of an appropriate case-mix adjustment factor that explains a significant amount of the variation in cost among different units of services. Similarly, section 1895(b)(4)(C) of the Act requires the establishment of wage-adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services in a geographic area compared to the national average applicable level. These wage-adjustment factors may be the factors used by the Secretary for the different area wage levels for purposes of section 1886(d)(3)(E) of the Act.

Section 1895(b)(5) of the Act gives the Secretary the option to grant additions or adjustments to the payment amount otherwise made in the case of outliers because of unusual variations in the type or amount of medically necessary care. Total outlier payments in a given fiscal year cannot exceed 5 percent of total payments projected or estimated.

On December 8, 2003, the Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-173). This legislation affected how we make updates to HH payment rates.

Section 701 of the MMA changed the yearly update cycle of the HH PPS rates from that of a fiscal year to a calendar year update cycle for 2004 and any subsequent year. Generally, section 701(a) of the MMA changed the references in the statute to refer to the calendar year for 2004 and any subsequent year. The changes resulted in updates to the HH PPS rates described as “fiscal year” updates for 2002 and 2003 and as “calendar year” updates for 2004 and any subsequent year (section 1895(b)(3)(B)(i) of the Act). Beginning on January 1, 2005, HH PPS would now be updated on a calendar year update cycle.

In addition to changing the update cycle for HH PPS rates, section 701 of the MMA made adjustments to the home health applicable increase percentage for 2004, 2005, and 2006. Specifically, section 701(a)(2)(D) of the MMA left unchanged the home health market basket update for the last calendar year quarter of 2003 and the first calendar year quarter of 2004 (section 1895(b)(3)(B)(ii)(II) of the Act). Furthermore, section 701(b)(4) of the MMA set the home health applicable percentage increase for the last 3 quarters of 2004 as the home health market basket (3.1 percent) minus 0.8 percentage point (section 1895(b)(3)(B)(ii)(III) of the Act). We implemented this provision through Pub. 100-20, One Time Notification, Transmittal 59, issued February 20, 2004. Section 701(b)(4) of the MMA also provided that updates for CY 2005 and CY 2006 would equal the applicable home health market basket percentage increase minus 0.8 percentage point. Lastly, section 701(b)(3) of the MMA revised the statute to provide that HH PPS rates for CY 2007 and any subsequent year would be updated by that year's home health market basket percentage increase (section 1895(b)(3)(B)(ii)(IV) of the Act).

On February 8, 2006, the Congress enacted the Deficit Reduction Act (DRA) of 2005 (Pub. L. 109-171). This legislation made additional changes to HH PPS.

Section 5201 of the DRA changed the CY 2006 update from the applicable home health market basket percentage increase minus 0.8 percentage point to a 0 percent update.

Section 5201 of the DRA amended section 421(a) of the MMA. The amended section 421(a) of the MMA requires for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) on or after January 1, 2006 and before January 1, 2007, that the Secretary increase the payment amount otherwise made under section 1895 of the Act for those services by 5 percent. The statute waives budget neutrality for purposes of this increase as it specifically requires that the Secretary not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute.

The 0 percent update to the payment rates and the rural add-on provisions of the DRA were implemented through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006.

In addition, section 5201(c) of the DRA amends the statute to add section 1895(b)(3)(B)(v) to the Act, requiring HHAs to submit data for purposes of measuring health care quality. This requirement is applicable for 2007 and each subsequent year. For 2007 and each subsequent year, in the case of a HHA that does not submit quality data, the home health market basket percentage increase would be reduced by 2 percentage points.

B. Updates

On July 3, 2000, we published a final rule (65 FR 41128) in the Federal Register to implement the HH PPS legislation. That final rule established requirements for the new PPS for HHAs as required by section 4603 of the BBA, and as subsequently amended by section 5101 of the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for Fiscal Year 1999 (Pub. L. 105-277), enacted on October 21, 1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113), enacted on November 29, 1999. The requirements include the implementation of a PPS for HHAs, consolidated billing requirements, and a number of other related changes. The PPS described in that rule replaced the retrospective reasonable-cost-based system that was used by Medicare for the payment of home health services under Part A and Part B.

On November 9, 2005, we published a final rule (70 FR 68132), which set forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health agencies. As part of that final rule, we adopted revised area labor market Metropolitan Statistical Area designations for CY 2006. In implementing the new area labor market designations, we allowed for a one-year transition period. This transition consists of a blend of 50 percent of the new area labor market designations' wage index and 50 percent of the previous area labor market designations' wage index. In addition, we revised the fixed dollar loss ratio, which is used in the calculation of outlier payments.

C. System for Payment of Home Health Services

Generally, Medicare makes payment under the HH PPS on the basis of a Start Printed Page 44084national standardized 60-day episode payment, adjusted for case mix and wage index. For episodes with four or fewer visits, Medicare pays on the basis of a national per-visit amount by discipline, referred to as a low utilization payment adjustment (LUPA). Medicare also adjusts the 60-day episode payment for certain intervening events that give rise to a partial episode payment adjustment (PEP adjustment) or a significant change in condition adjustment (SCIC). For certain cases that exceed a specific cost threshold, an outlier adjustment may also be available. For a complete and full description of the HH PPS as required by the BBA and as amended by OCESAA and BBRA, see the July 3, 2000 HH PPS final rule (65 FR 41128).

D. Changes in Payment for Oxygen and Oxygen Equipment and Other Durable Medical Equipment (Capped Rental Items)

The Medicare payment rules for durable medical equipment (DME) are set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D of our regulations. General payment rules for DME are set forth in section 1834(a)(1) of the Act and § 414.210 of our regulations, and § 414.210 also contains paragraphs relating to maintenance and servicing of items and replacement of items. Specific rules for oxygen and oxygen equipment are set forth in section 1834(a)(5) of the Act and § 414.226 of our regulations, and specific rules for capped rental items are set forth in section 1834(a)(7) of the Act and § 414.229 of our regulations. Rules for determining a period of continuous use for the rental of DME are set forth in § 414.230 of our regulations. The Medicare payment basis for DME is equal to 80 percent of either the lower of the actual charge or the fee schedule amount for the item. The beneficiary coinsurance is equal to 20 percent of either the lower of the actual charge or the fee schedule amount for the item.

In accordance with the rules set forth in section 1834(a)(5) of the Act and § 414.226 of our regulations, since 1989, suppliers have been paid monthly for furnishing oxygen and oxygen equipment to Medicare beneficiaries. Suppliers have also been paid an add-on fee for furnishing portable oxygen equipment to patients when medically necessary. Before the enactment of the DRA, these monthly payments continued for the duration of use of the equipment, provided that Medicare Part B coverage and eligibility criteria were met. Medicare covers three types of oxygen delivery systems: (1) Stationary or portable oxygen concentrators, which concentrate oxygen in room air; (2) stationary or portable liquid oxygen systems, which use oxygen stored as a very cold liquid in cylinders and tanks; and (3) stationary or portable gaseous oxygen systems, which administer compressed oxygen directly from cylinders. Both liquid and gaseous oxygen systems require delivery of oxygen contents.

Medicare payment for furnishing oxygen and oxygen equipment is made on a monthly basis and the fee schedule amounts vary by State. Payment for oxygen contents for both stationary and portable equipment is included in the fee schedule allowances for stationary equipment. Medicare fee schedules for home oxygen equipment are modality neutral; meaning that in a given State, there is one fee schedule amount that applies to all stationary systems and one fee schedule amount that applies to all portable systems.

Effective January 1, 2006, section 5101(b) of the DRA amended the Act at section 1834(a)(5) of the Act, limiting to 36 months the total number of continuous months for which Medicare will pay for oxygen equipment on a rental basis. At the end of the 36-month period, this section mandates that the supplier transfer title to the stationary and portable oxygen equipment to the beneficiary. Section 5101(b) of the DRA does not, however, limit the number of months for which Medicare will pay for oxygen contents for beneficiary-owned stationary or portable gaseous or liquid systems, and payment will continue to be made as long as the oxygen remains medically necessary. Section 5101(b) of the DRA also provides that payment for reasonable and necessary maintenance and servicing of beneficiary-owned oxygen equipment will be made for parts and labor not covered by a supplier's or manufacturer's warranty. In the case of beneficiaries using oxygen equipment on December 31, 2005, the 36-month rental period prescribed by the DRA begins on January 1, 2006.

In accordance with the rules set forth in section 1834(a)(7) of the Act and § 414.229 of our regulations, before the enactment of the DRA, suppliers of capped rental items (that is, other DME not described in paragraphs (2) through (6) of section 1834(a) of the Act) were paid on a rental or purchase option basis. Payment for most items in the capped rental category was made on a monthly rental basis, with rental payments being capped at 15 months or 13 months, depending on whether the beneficiary chose to continue renting the item or to take over ownership of the item through the “purchase option.” For all capped rental items, the supplier was required to inform the beneficiary of his or her purchase option, during the 10th rental month, to enter into a purchase agreement under which the supplier would transfer title to the item to the beneficiary on the first day after the 13th continuous month during which payment was made for the rental of the item. Therefore, if the beneficiary chose the purchase option, rental payments to the supplier would continue through the 13th month of continuous use of the equipment, after which time title to the equipment would transfer from the supplier to the beneficiary. Medicare would also make payment for any reasonable and necessary repair or maintenance and servicing of the equipment following the transfer of title. If the beneficiary did not choose the purchase option, rental payments would continue through the 15th month of continuous use. In these cases, suppliers would maintain title to the equipment but would have to continue furnishing the item to the beneficiary as long as medically necessity continued. Beginning 6 months after the 15th month of continuous use in which payment was made, Medicare would also make semi-annual maintenance and servicing payments to suppliers. These payments were approximately equal to 10 percent of the purchase price for the equipment as determined by the statute. Total Medicare payments made through the 13th and 15th months of rental equal 105 and 120 percent, respectively, of the purchase price for the equipment.

In the case of power-driven wheelchairs, since 1989 payment has also been made on a lump-sum purchase basis at the time that the item is initially furnished to the beneficiary if the beneficiary chooses to obtain the item in this manner. Most beneficiaries choose to obtain power-driven wheelchairs via this lump-sum purchase option.

Effective for items for which the first rental month occurs on or after January 1, 2006, section 5101(a) of the DRA of 2005 amended section 1834(a)(7) of the Act, limiting to 13 months the total number of continuous months for which Medicare will pay for DME in this category. After a 13-month period of continuous use during which rental payments are made, the statute requires that the supplier transfer title to the equipment to the beneficiary. Beneficiaries may still elect to obtain power-driven wheelchairs on a lump-sum purchase agreement basis. In all cases, payment for reasonable and necessary maintenance and servicing of beneficiary-owned equipment will be made for parts and labor not covered by Start Printed Page 44085the supplier's or manufacturer's warranty.

II. Provisions of the Proposed Regulations

[If you choose to comment on issues in this section, please include the caption “PROVISIONS OF THE PROPOSED REGULATIONS” at the beginning of your comments.]

A. National Standardized 60-Day Episode Rate

Medicare HH PPS has been effective since October 1, 2000. As set forth in the final rule published July 3, 2000 in the Federal Register (65 FR 41128), the unit of payment under Medicare HH PPS is a national standardized 60-day episode rate. As set forth in § 484.220, we adjust the national standardized 60-day episode rate by a case mix grouping and a wage index value based on the site of service for the beneficiary. The proposed CY 2007 HH PPS rates use the same case-mix methodology and application of the wage index adjustment to the labor portion of the HH PPS rates as set forth in the July 3, 2000 final rule. In the October 22, 2004 final rule, we rebased and revised the home health market basket, resulting in a labor-related share of 76.775 percent and a non-labor portion of 23.225 percent (69 FR 62126). We multiply the national 60-day episode rate by the patient's applicable case-mix weight. We divide the case-mix adjusted amount into a labor and non-labor portion. We multiply the labor portion by the applicable wage index based on the site of service of the beneficiary.

As required by section 1895(b)(3)(B) of the Act, we have updated the HH PPS rates annually in a separate Federal Register document. Section 484.225 sets forth the specific annual percentage update. To reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201 of the DRA, in § 484.225, we are proposing to revise paragraph (g) as follows:

(g) For 2007 and subsequent calendar years, the unadjusted national rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount unless the HHA has not submitted quality data in which case the unadjusted national rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount minus 2 percentage points.

For CY 2007, we are proposing to use again the design and case-mix methodology described in section III.G of the HH PPS July 3, 2000 final rule (65 FR 41192 through 41203). For CY 2007, we are proposing to base the wage index adjustment to the labor portion of the PPS rates on the most recent pre-floor and pre-reclassified hospital wage index as discussed in section II.F. of this proposed rule (not including any reclassifications under section 1886(d)(8)(B) of the Act).

As discussed in the July 3, 2000 HH PPS final rule, for episodes with four or fewer visits, Medicare pays the national per-visit amount by discipline, referred to as a LUPA. We update the national per-visit amounts by discipline annually by the applicable home health market basket percentage. We adjust the national per-visit amount by the appropriate wage index based on the site of service for the beneficiary as set forth in § 484.230. We propose to adjust the labor portion of the updated national per-visit amounts by discipline used to calculate the LUPA by the most recent pre-floor and pre-reclassified hospital wage index, as discussed in section II.F of this proposed rule.

Medicare pays the 60-day case-mix and wage-adjusted episode payment on a split percentage payment approach. The split percentage payment approach includes an initial percentage payment and a final percentage payment as set forth in § 484.205(b)(1) and § 484.205(b)(2). We may base the initial percentage payment on the submission of a request for anticipated payment (RAP) and the final percentage payment on the submission of the claim for the episode, as discussed in § 409.43. The claim for the episode that the HHA submits for the final percentage payment determines the total payment amount for the episode and whether we make an applicable adjustment to the 60-day case-mix and wage-adjusted episode payment. The end date of the 60-day episode as reported on the claim determines which calendar year rates Medicare would use to pay the claim.

We may also adjust the 60-day case-mix and wage-adjusted episode payment based on the information submitted on the claim to reflect the following:

  • A low utilization payment provided on a per-visit basis as set forth in § 484.205(c) and § 484.230.
  • A partial episode payment adjustment as set forth in § 484.205(d) and § 484.235.
  • A significant change in condition adjustment as set forth in § 484.205(e) and § 484.237.
  • An outlier payment as set forth in § 484.205(f) and § 484.240.

This proposed rule reflects the proposed updated CY 2007 rates that would be effective January 1, 2007.

B. Proposed CY 2007 Update to the Home Health Market Basket Index

Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the DRA, requires for CY 2007 that the standard prospective payment amounts be increased by a factor equal to the applicable home health market basket update.

  • Proposed CY 2007 Adjustments.

In calculating the annual update for the CY 2007 60-day episode rates, we are proposing to first look at the CY 2006 rates as a starting point. The CY 2006 national 60-day episode rate, as modified by section 5201(a)(4) of the DRA (and implemented through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006) is $2,264.28.

In order to calculate the CY 2007 national 60-day episode rate, we are proposing to multiply the CY 2006 national 60-day episode rate ($2,264.28) by the proposed estimated home health market basket update of 3.1 percent for CY 2007. The proposed estimated home health market basket percentage increase reflects changes over time in the prices of an appropriate mix of goods and services included in covered home health services. The estimated home health market basket percentage increase is generally used to update the HH PPS rates on an annual basis.

We would increase the 60-day episode payment rate for CY 2007 (episodes ending on or after January 1, 2007, and before January 1, 2008) by the proposed estimated home health market basket update (3.1 percent) ($2,264.28 × 1.031) to yield the proposed updated CY 2007 national 60-day episode rate ($2,334.47) (see Table 1 below).Start Printed Page 44086

Table 1.—Proposed National 60-Day Episode Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007, Before Case-Mix Adjustment

Total CY 2006 prospective payment amount per 60-day episodeMultiply by the proposed estimated home health market basket update (3.1 Percent) 1Proposed CY 2007 updated national 60-day episode rate
$2,264.28× 1.031$2,334.47
1 The estimated home health market basket update of 3.1 percent for CY 2007 is based on Global Insight, Inc, 2nd Qtr, 2006 forecast with historical data through 1st Qtr, 2006.

National Per-visit Amounts Used To Pay LUPAs and Compute Imputed Costs Used in Outlier Calculations

As discussed previously in this proposed rule, the policies governing the LUPAs and outlier calculations set forth in the July 3, 2000 HH PPS final rule would continue during CY 2007. In calculating the annual update for the CY 2007 national per-visit amounts we use to pay LUPAs and to compute the imputed costs in outlier calculations, we are proposing to look again at the CY 2006 rates as a starting point. We then are proposing to multiply those amounts by the proposed estimated home health market basket update (3.1 percent) for CY 2007 to yield the updated per-visit amounts for each home health discipline for CY 2007 (episodes ending on or after January 1, 2007, and before January 1, 2008) (see Table 2 below).

Table 2.—Proposed National Per-Visit Amounts for LUPAs and Outlier Calculations Updated by the Estimated Home Health Market Basket Update for CY 2007

Home health discipline typeFinal CY 2006 per-visit amounts per 60-day episode for LUPAsMultiply by the proposed estimated home health market basket (3.1 percent) 1Proposed CY 2007 per-visit payment amount per discipline for LUPAs
Home health aide$44.76× 1.031$46.15
Medical social services158.45× 1.031163.36
Occupational therapy108.81× 1.031112.18
Physical therapy108.08× 1.031111.43
Skilled nursing98.85× 1.031101.91
Speech-language pathology117.44× 1.031121.08
1 The estimated home health market basket update of 3.1 percent for CY 2007 is based on Global Insight, Inc, 2nd Qtr, 2006 forecast with historical data through 1st Qtr, 2006.

C. Rural Add-On

As stated above, section 5201(b) of the DRA requires, for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) with respect to episodes and visits beginning on or after January 1, 2006 and before January 1, 2007, that the Secretary increase by 5 percent the payment amount otherwise made under section 1895 of the Act. The statute waives budget neutrality related to this provision as it specifically states that the Secretary shall not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute.

While the rural add-on would primarily affect those episodes paid based on CY 2006 rates, it would also affect a number of episodes that would be paid based on CY 2007 rates. For example, an episode that begins on December 20, 2006 and ends on February 17, 2007, for services furnished in a rural area, would be paid based on CY 2007 rates because the episode ends on or after January 1, 2007 and before January 1, 2008; and the episode would also receive the rural add-on because the episode begins on or after January 1, 2006 and before January 1, 2007.

The applicable case-mix and wage index adjustment is subsequently applied to the 60-day episode amount for the provision of home health services where the site of service is the non-Metropolitan Statistical Area (MSA) of the beneficiary. Similarly, the applicable wage index adjustment is subsequently applied to the LUPA per-visit amounts adjusted for the provision of home health services where the site of service for the beneficiary is a non-MSA area. We implemented this provision for CY 2006 on February 13, 2006 through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006. The 5 percent rural add-on is noted in tables 3 and 4 below.Start Printed Page 44087

Table 3.—Proposed Payment Amounts for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket Update for CY 2007 With Rural Add-On, Before Case-Mix Adjustment

Proposed CY 2007 total prospective payment amount per 60-day episode5 percent rural add-onProposed CY 2007 payment amount per 60-day episode beginning in CY 2006 and before January 1, 2007 and ending in CY 2007 for a beneficiary who resides in a non-MSA area
2,334.47× 1.05$2,451.20

Table 4.—Proposed National Per-Visit Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket Update for CY 2007 With Rural Add-On

Home health discipline typeProposed CY 2007 per-visit amountsMultiply by the 5 percent rural add-onProposed CY 2007 per-visit payment amount per discipline for 60-day episodes beginning on or after January 1 in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-msa area
Home health aide$46.15× 1.05$48.46
Medical social services163.36× 1.05171.53
Occupational therapy112.18× 1.05117.79
Physical therapy111.43× 1.05117.00
Skilled nursing101.91× 1.05107.01
Speech-language pathology121.08× 1.05127.13

Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to the Act, requiring that “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.” In addition, section 1895(b)(3)(B)(v)(I) of the Act, as also added by section 5201(c)(2) of the DRA, dictates that “for 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.”

The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required the use of a standardized assessment instrument for quality oversight of HHAs. A standardized assessment instrument provides an HHA with a uniform mechanism to assess the needs of their patients and provide CMS with a uniform mechanism to assess the HHA's ability to adequately address those needs. To fulfill the OBRA 87 mandate, CMS required that, as part of their comprehensive assessment process, HHAs collect and report Outcome and Assessment Information Set (OASIS) data and later mandated the submission of this data as an HHA condition of participation at 42 CFR 484.20 and 484.55.

The OASIS data provide consumers and HHAs with ten, publicly-reported home health quality measures which have been endorsed by the National Quality Forum (NQF). Reporting this quality data has also required the development of several supporting mechanisms such as the HAVEN software used to encode and transmit data using a CMS standard electronic record layout, edit specifications, and data dictionary. The HAVEN software, which includes the OASIS, has become a standard practice within HHA operations. These early investments in data infrastructure and supporting software that CMS and HHAs have made over the past several years in order to create this quality reporting structure, have made quality reporting and measurement an important component of the HHA industry. The ten measures are:

(1) Improvement in ambulation/locomotion.

(2) Improvement in bathing.

(3) Improvement in transferring.

(4) Improvement in management of oral medications.

(5) Improvement in pain interfering with activity.

(6) Acute care hospitalization.

(7) Emergent care.

(8) Improvement in dyspnea.

(9) Improvement in urinary incontinence.

(10) Discharge to community.

We propose to use OASIS data and the ten quality measures based on those data as the appropriate measure on home health quality. Continuing to use the OASIS instrument would minimize the burden to providers and ensure that costs associated with the development and testing of a new reporting mechanism are not incurred. We believe that at this time the noted ten quality measures are the most appropriate measure of home health quality. Accordingly, for the calendar year (CY) 2007, we propose that the OASIS data, specifically, the ten quality measures, be submitted by HHAs, to meet the requirement that each HHA submit data appropriate for the measurement of health care quality, as determined by the Secretary.

Additionally, section 1895(b)(3)(B)(v)(II) of the Act provides the Secretary with the discretion to submit the required data in a form, Start Printed Page 44088manner, and time specified by him. For CY 2007, we are proposing to consider OASIS data submitted by HHAs to CMS for episodes beginning on or after July 1, 2005 and before July 1, 2006 as meeting the reporting requirement. This reporting time period will allow a full 12 months of data and will provide CMS the time necessary to analyze and make any necessary payment adjustments to the CY 2007 payment rates. HHAs that meet the reporting requirement would be eligible for the full home health market basket percentage increase.

During the next few years, we will be pursuing the development of patient level process measures for home health agencies, as well as continuing to refine the current OASIS tool in response to recommendations from a Technical Expert Panel conducted to review the data elements that make up the OASIS tool. These process measures will refer to specific care practices that are, or are not, followed by the home health agency for each patient. An example of this type of measure may be: the percentage of patients at risk of falls for whom prevention of falls was addressed in the care plan. We expect to introduce these additional measures over 2008 and 2009 so as to complement the existing OASIS outcome measures. During the years leading to calendar year 2010 payments, we will test and refine these measures to determine if they can more accurately reflect the level of quality care being provided at HHAs without being overly burdensome with the data collection instrument. Some process measures are in the very early stages of development. To the extent that evidence-based data are available on which to determine the appropriate measure specifications, and adequate risk-adjustments are made, we anticipate collecting and reporting these measures as part of each agency's home health quality plan. We believe that future modifications to the current OASIS tool including reducing the numbers of questions on the tool, refining possible responses, as well as adding new process measures will be made. In all cases, we anticipate that any future quality measures should be evidence-based, clearly linked to improved outcomes, and able to be reliably captured with the least burden to the provider. We are also beginning work in order to measure patient experience (in the form of a patient satisfaction survey) of care in the home health setting.

We recognize, however, that the conditions of participation (42 CFR part 484) that require OASIS submission also provide for exclusions from this requirement. Generally, agencies are not subject to the OASIS submission requirement, and thus do not receive Medicare payments, for patients that are not Medicare Beneficiaries or the patients are not receiving Medicare-covered home health services. Under the conditions of participation, agencies are excluded from the OASIS reporting requirement on individual patients if:

  • Those patients are receiving only non-skilled services,
  • Neither Medicare nor Medicaid is paying for home health care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement),
  • Those patients are receiving pre- or post-partum services,
  • Those patients are under the age of 18 years.

We believe that the rationale behind the exclusion of these agencies from submitting OASIS on patients excluded from OASIS submission as a condition of participation is equally applicable to HHAs for purposes of meeting the DRA quality requirement. If an agency is not submitting OASIS for patients excluded from OASIS submission as a condition of participation, we believe that the submission of OASIS for quality measures for Medicare payment purposes is also not necessary. Therefore, we propose that HHAs do not need to submit quality measures for DRA reporting purposes, for those patients who are excluded from OASIS submission as a condition of participation.

Additionally, we propose that agencies newly certified (on or after May 31, 2006 for payments to be made in CY 2007) be excluded from the DRA reporting requirement as data submission and analysis will not be possible for an agency certified this late in the reporting time period. We propose that in future years, agencies that certify on or after May 31 of the preceding year involved be excluded from any payment penalty under the DRA for the following calendar year. For example, if HHA “X” were to enroll in the Medicare Program on May 30 2007, CMS would expect them to submit the required quality data (unless covered by another exclusion protocol) on or before June 30 2006 (the end of the reporting period for payments effectuated in calendar year 2007. However, if HHA “X” were to enroll in the Medicare Program on May 31, 2006, CMS would automatically exclude them from the requirements under the DRA and the agency would be entitled to the full market basket increase for calendar year 2007. We note these exclusions only affect reporting requirements under the DRA and do not affect the agency's OASIS reporting responsibilities under the conditions of participation.

We propose to require that all HHAs, unless covered by these specific exclusions, meet the reporting requirement, or be subject to a 2 percent reduction in the home health market basket percentage increase in accordance with section 1895(b)(3)(B)(v)(I) of the Act. The 2 percent reduction would apply to all episodes ending on or before December 31, 2007. We provide the reduced payment rates in tables 5, 6, 7, and 8 below.

Table 5.—For HHAs That Do Not Submit the Required Quality Data—Proposed National 60-Day Episode Amount Updated by the Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points, Before Case-Mix Adjustment

Total CY 2006 prospective payment amount per 60-day episodeMultiply by the proposed estimated home health market basket update (3.1 percent 1 minus 2 percent)Proposed CY 2007 updated national 60-day episode rate for HHAs that do not submit required quality data
$2,264.28× 1.011$2,289.19
1 The estimated home health market basket update of 3.1 percent for CY 2007 is based on Global Insight, Inc, 2nd Qtr, 2006 forecast with historical data through 1st Qtr, 2006.
Start Printed Page 44089

Table 6.—For HHAs That Do Not Submit the Required Quality Data—Proposed National Per-Visit Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points

Home health discipline typeFinal CY 2006 per-visit amounts per 60-day episodeMultiply by the proposed estimated home health market basket update (3.1 percent 1 minus 2 percent)Proposed CY 2007 per-visit payment amount per discipline for HHAs that do not submit required quality data
Home health aide$44.76× 1.011$45.25
Medical social services158.45× 1.011160.19
Occupational therapy108.81× 1.011110.01
Physical therapy108.08× 1.011109.27
Skilled nursing98.85× 1.01199.94
Speech-language pathology117.44× 1.011118.73
1 The estimated home health market basket update of 3.1 percent for CY 2007 is based on Global Insight, Inc, 2nd Qtr, 2006 forecast with historical data through 1st Qtr, 2006.

Table 7.—For HHAs That Do Not Submit the Required Quality Data—Proposed Payment Amount for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2 Percentage Points, With Rural Add-On, Before Case-Mix Adjustment

Proposed CY 2007 updated national 60-day episode rate for HHAs that do not submit required quality data5 percent rural add-onProposed CY 2007 payment amount per 60-day episode beginning in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-MSA area for HHAs that do not submit required quality data
$2,289.19× 1.05$2,403.65

Table 8.—For HHAs That Do Not Submit the Required Quality Data—Proposed Per-Visit Payment Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2 Percentage Points, With Rural Add-On

Home health discipline typeProposed CY 2007 per-visit amounts for HHAs that do not submit required quality data5 percent rural add-onProposed CY 2007 per-visit payment amounts for episodes beginning in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-MSA area for HHAs that do not submit required quality data
Home health aide$45.25× 1.05$47.51
Medical social services160.19× 1.05168.20
Occupational therapy110.01× 1.05115.51
Physical therapy109.27× 1.05114.73
Skilled nursing99.94× 1.05104.93
Speech-language pathology118.73× 1.05124.67

Section 1895(b)(3)(B)(v)(III) of the Act further requires that the “Secretary shall establish procedures for making data submitted under subclause (II) available to the public.” Additionally, the statute requires that “such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.” To meet the requirement for making such data public, we are proposing to continue to use the CMS Home Health Compare Web site whereby HHAs are listed geographically. Currently the 10 proposed quality measures are posted on the CMS Home Health Compare Web site. Consumers can search for all Medicare-approved home health providers that serve their city or zip code and then find the agencies offering the types of services they need as well as the proposed quality measures. See http://www.medicare.gov/​HHCompare/​Home/​. HHAs currently have access (through the Home Health Compare contractor) to their own agency's quality data (updated periodically) and we propose to continue this process thus enabling each agency to know how it is performing before public posting of agency quality data on the CMS Home Health Compare Web site.

Currently, the CMS Home Health Compare Web site does not publicly Start Printed Page 44090report data when agencies have fewer than 20 episodes of care within a reporting period. In light of the DRA requirements we recognize the need to provide the required data to the public and propose to make these statistics available through expansion of the CMS Home Health Compare Web site.

In the July 27, 2005 Medicare Payment Advisory Commission (MedPAC) testimony before the U.S. Senate Committee on Finance, MedPAC expressed support for the concept of differential payments for Medicare providers, which could create incentives to improve quality. To support this initiative, MedPAC stated that “outcome measures from CMS' Outcome-based Quality Indicators” (currently collected through the OASIS instrument) “could form the starter set.” MedPAC further states “* * * the Agency for Healthcare Research and Quality concur(s) that a set of these measures is reliable and adequately risk adjusted.”

The MedPAC testimony recognizes that while the goal of care for many home health patients is improving health and functioning, for some patients the goal of the HHA is to simply stabilize their conditions and prevent further decline. Additionally, the MedPAC testimony reflects that measures of structure and process could also be considered.

Various home health outcome measures are now in common use and have been studied for some time. A number of these measures have been endorsed by the National Quality Forum (NQF) and are evidence-based, well accepted, and not unduly burdensome. When determining outcome measures that would be most appropriate it is important to measure aspects of care that providers can control and are adequately risk-adjusted. Home-based care presents particular difficulties for provider control because patient conditions are compounded by a variety of home environment and support system issues.

We are currently pursuing the development of patient-level process measures for HHAs, as well as refining the current OASIS tool in response to recommendations from a Technical Expert Panel conducted to review the data elements that make up the OASIS tool. These additional measures would complement the existing OASIS outcome measures and would assist us in identifying processes of care that lead to improvements for certain populations of patients. These process measures are currently in the very early stages of development. As we stated previously, to the extent that evidence-based data are available on which to determine the appropriate measure specifications, and adequate risk-adjustments are made, we anticipate collecting and reporting these measures as part of our home health quality plan. Possible modifications to the current OASIS tool include reducing the numbers of questions on the tool, refining possible responses, as well as adding new process measures.

We are soliciting comments on how to make the outcome measures more useful. We would also like comments on measures of home health care processes for which there is evidence or improved care to beneficiaries. In all cases, measures should be evidence-based, clearly linked to improved outcomes, and able to be reliably captured with the least burden to the provider. We are also considering measures of patient experience of care in the home health setting, as well as efficiency measures, and soliciting comment on the use of the measures and their importance in the home health setting. We would address any changes to the HH PPS quality data submission requirement in future rulemaking.

It is also our intent to provide guidance on the specifications, definitions, and reporting requirements of any additional measures through the standard protocol for measure development.

We are proposing to revise the regulations at 42 CFR § 484.225 to reflect these new payment requirements which require submission of quality data.

E. Outliers and Fixed Dollar Loss Ratio

Outlier payments are payments made in addition to regular 60-day case-mix and wage-adjusted episode payments for episodes that incur unusually large costs due to patient home health care needs. Outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. The episode's estimated cost is the sum of the national wage-adjusted per-visit payment amounts for all visits delivered during the episode. The outlier threshold for each case-mix group, PEP adjustment, or total SCIC adjustment is defined as the 60-day episode payment amount, PEP adjustment, or total SCIC adjustment for that group plus a fixed dollar loss amount. Both components of the outlier threshold are wage-adjusted.

The wage-adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. The FDL is computed by multiplying the wage-adjusted 60-day episode payment amount by the FDL ratio, which is a proportion expressed in terms of the national standardized episode payment amount. The outlier payment is defined to be a proportion of the wage-adjusted estimated costs beyond the wage-adjusted threshold. The proportion of additional costs paid as outlier payments is referred to as the loss-sharing ratio.

Section 1895(b)(5) of the Act requires that estimated total outlier payments are no more than 5 percent of total estimated HH PPS payments. In response to the concerns about potential financial losses that might result from unusually expensive cases expressed in comments to the October 28, 1999 proposed rule (64 FR 58133), the July 2000 final rule set the target for estimated outlier payments at the 5 percent level. The FDL ratio and the loss-sharing ratio were then selected so that estimated total outlier payments would meet the 5 percent target.

For a given level of outlier payments, there is a trade-off between the values selected for the FDL ratio and the loss-sharing ratio. A high FDL ratio reduces the number of episodes that can receive outlier payments, but makes it possible to select a higher loss-sharing ratio and, therefore, increase outlier payments for outlier episodes. Alternatively, a lower FDL ratio means that more episodes can qualify for outlier payments, but outlier payments per episode must be lower. As a result of public comments on the October 28, 1999 proposed rule, in our July 2000 final rule, we made the decision to attempt to cover a relatively high proportion of the costs of outlier cases for the most expensive episodes that would qualify for outlier payments within the 5 percent constraint.

In the July 2000 final rule, we chose a value of 0.80 for the loss-sharing ratio, which preserves incentives for agencies to attempt to provide care efficiently for outlier cases. A loss-sharing ratio of 0.80 was also consistent with the loss-sharing ratios used in other Medicare PPS outlier policies. Furthermore, we estimated the value of the FDL ratio that would yield estimated total outlier payments that were 5 percent of total home health PPS payments. The resulting value for the FDL ratio, for the July 2000 final rule, was 1.13.

Our CY 2005 update to the HH PPS rates (69 FR 62124) changed the FDL ratio from the original 1.13 to 0.70 to allow more home health episodes to qualify for outlier payments and to better meet the estimated 5 percent target of outlier payments to total HH PPS payments. We stated in that CY 2005 update that we planned to continue to monitor the outlier expenditures on a yearly basis and to make adjustments as necessary (69 FR Start Printed Page 4409162129). To do so, we planned on using the best Medicare data available at the time of publication. For the CY 2005 update, we used CY 2003 home health claims data.

Our CY 2006 update to the HH PPS rates (70 FR 68132) changed the FDL ratio from 0.70 to 0.65 to allow even more home health episodes to qualify for outlier payments and to better meet the estimated 5 percent target of outlier payments to total HH PPS payments. For the CY 2006 update, we used CY 2004 home health claims data.

At this time, we do not have sufficient data to propose any update to the FDL ratio for the CY 2007 update to the HH PPS rates. However, depending on the availability of more recent data at the time of publication of the HH PPS rate update for the CY 2007 final rule, we may, if necessary, implement an update to the FDL ratio for the CY 2007 update to the HH PPS rates. If so, we plan on using the same methodology performed in updating to the current FDL ratio described in the June 2, 2004 proposed rule using any more recent available data.

F. Hospital Wage Index—Revised OMB Definition for Geographical Statistical Areas

Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the Secretary to establish area wage adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services and to provide appropriate adjustments to the episode payment amounts under HH PPS to account for area wage differences. We apply the appropriate wage index value to the labor portion (76.775 percent; see 60 FR 62126) of the HH PPS rates based on the geographic area in which the beneficiary received home health services as discussed in section II.A of this proposed rule. Generally, we determine each HHA's labor market area based on definitions of Metropolitan Statistical Areas (MSAs) issued by the Office of Management and Budget (OMB).

We acknowledged in our October 22, 2004 final rule that on June 6, 2003, the OMB issued an OMB Bulletin (No. 03-04) announcing revised definitions for MSAs, new definitions for Micropolitan Statistical Areas and Combined Statistical Areas, and guidance on using the statistical definitions. A copy of the Bulletin may be obtained at the following Internet address: http://www.whitehouse.gov/​omb/​bulletins/​b03-04.html. At that time, we did not propose to apply these new definitions known as Core-Based Statistical Areas (CBSAs). In the November 9, 2005 final rule, we adopted the OMB-revised definitions to adjust the CY 2006 HH PPS payment rates and revised the regulations at § 484.202 to reflect this proposed change. The Hospital Inpatient PPS (IPPS) also applied these revised definitions as discussed in the August 11, 2004 IPPS final rule (68 FR 49207).

1. Background

As discussed previously and set forth in the July 3, 2000 final rule, the statute provides that the wage adjustment factors may be the factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustment factors. As discussed in the July 3, 2000 final rule, we are proposing to again use the pre-floor and pre-reclassified hospital wage index data to adjust the labor portion of the HH PPS rates based on the geographic area in which the beneficiary receives the home health services. We believe the use of the pre-floor and pre-reclassified hospital wage index data results in the appropriate adjustment to the labor portion of the costs as required by statute. For the CY 2007 update to the home health payment rates, we would continue to use the most recent pre-floor and pre-reclassified hospital wage index available at the time of publication. See Addenda A and B of this proposed rule, respectively, for the rural and urban hospital wage indices using the CBSA designations. For HH PPS rates addressed in this proposed rule, we use preliminary 2007 pre-floor and pre-reclassified hospital wage index data. We are proposing to incorporate updated hospital wage index data for the 2007 pre-floor and pre-reclassified hospital wage index for use in the final rule for the CY 2007 HH PPS update (not including any reclassifications under section 1886(d)(8)(B) of the Act).

As implemented under the HH PPS in the July 3, 2000 HH PPS final rule, each HHA's labor market is determined based on definitions of MSAs issued by OMB. In general, an urban area is defined as an MSA or New England County Metropolitan Area (NECMA) as defined by OMB. Under § 412.62(f)(1)(iii), a rural area is defined as any area outside of the urban area. The urban and rural area geographic classifications are defined in § 412.62(f)(1)(ii) and § 412.62(f)(1)(iii), respectively, and have been used under HH PPS since it was implemented.

Under the HH PPS, the wage index value is based upon the site of service (defined by section 1861(m) of the Act as the beneficiary's place of residence) for the beneficiary. As has been our longstanding practice, any area not included in an MSA (urban area) is considered to be nonurban (§ 412.64(b)(1)(ii)(C)) and receives the statewide rural wage index value (see, for example, 65 FR 41173).

2. Current Labor Market Areas Based on MSAs, Including CBSAs

In the August 11, 2004 IPPS final rule (69 FR 49206 through 49034), revised labor market area definitions were adopted at § 412.64(b), which were effective October 1, 2004 for acute care hospitals. The new definitions, including CBSAs, were announced by OMB in late 2000 and were also discussed in greater detail in the July 14, 2005 HH PPS proposed rule in which we proposed to move from MSA-based to CBSA-based wage area designations. For the purposes of this proposed rule, the term “MSA-based” refers to wage index values and designations based on the previous MSA designations. Conversely, the term “CBSA-based” refers to wage index values and designations based on the new OMB revised MSA designations which now include CBSAs. Recently other payment systems such as the inpatient rehabilitation facility PPS, the skilled nursing facility PPS, and Medicare payment for hospice care have been updated to use the new revised labor market area definitions.

Based on public comments received in response to the July 14, 2005 HH PPS proposed rule, we decided to adopt a 1-year transition policy consisting of a 50/50 blend of the CBSA-based wage index values and the MSA-based wage index values. This transition policy is discussed in the November 9, 2005 HH PPS final rule (70 FR 68132, 68138). In the final rule, we also noted that for CY 2007, the HH PPS wage index adjustment would be solely based on a CBSA-based wage index.

3. Proposed Revision to the HH PPS Labor Market Areas

For CY 2007, we are proposing to end the 1 year transition policy (implemented for CY 2006) of using a 50/50 blend of MSA-based and CBSA-based wage area designations. For CY 2007, we are proposing to use 100 percent of the CBSA-based wage area designations for purposes of determining the HH PPS wage index adjustment.

In adopting the CBSA designations, we identified some geographic areas where there were no hospitals, and thus no hospital wage data on which to base the calculation of the CY 2006 home health wage index. For CY 2006, we adopted a policy in the HH PPS final rule (70 FR 68132) to use the CY 2005 Start Printed Page 44092pre-floor, pre-reclassified hospital wage index value for rural areas when no rural hospital wage data is available. We also adopted the policy that for urban labor markets without an urban hospital from which a hospital wage index can be derived, all of the urban CBSAs within the State would be used to calculate a statewide urban average wage index to use as a reasonable proxy for these areas. As we stated in the CY 2006 Home Health PPS Final Rule, we believe that this approach serves as a proxy for hospital wage data and provides an appropriate standard that accounts for area wage differences.

For this CY 2007 proposed rule, we are again proposing to apply our policy to use the CY 2005 pre-floor/pre-reclassified hospital wage index for rural areas where no hospital wage data is available.

We have not received any concerns from the industry regarding our policy to calculate a statewide urban average wage index, using all of the urban CBSAs wage index values within the State, for urban labor markets without an urban hospital from which a hospital wage index can be derived. Consequently, for this CY 2007 proposed rule, we again propose to apply our policy to calculate a statewide urban average wage index for urban areas with no hospital wage data available. For this CY 2007 proposed rule, the following areas will be affected by these policies:

Rural Massachusetts—proposed assigned wage index value of 1.0216;

Rural Puerto Rico—proposed assigned wage index value of 0.4047; and

Hinesville, GA (CBSA 25980)—proposed assigned wage index value of 0.9163.

We recognize that since the publication of the CY 2006 HH PPS final rule, representatives of the home health industry have expressed concerns with the policy we apply for rural areas where no hospital wage data is available, particularly as applied to rural Massachusetts facilities. In response to these concerns and in recognition that there may be additional rural areas in the future similarly impacted by a lack of hospital wage data on which to derive a hospital wage index, we are considering alternative methodologies to the methodology proposed above, for imputing a rural wage index for areas in States where no hospital wage data are available. We believe that an evaluation of alternative methodologies for imputing a rural wage index in these areas should adhere to four basic policy criteria. First, an alternative methodology should retain our current longstanding policy to use pre-floor, pre-reclassified hospital wage data to compute wage index values for post acute care facilities, including home health agencies. Second, any methodology to impute a rural wage index should use rural wage data to derive the rural wage index value. Third, any methodology to impute a rural wage index should be easy to evaluate. Fourth, any methodology to impute a rural wage index would be able to update wage data from year-to-year.

We are specifically considering one alternative to the proposal that meets all of the above policy criteria. Under this alternative, we would impute a rural wage index value by using a simple average CBSA-based rural wage index value at the Census Division level. Census Divisions are defined by the U.S. Census Bureau and may be found at (http://www.census.gov/​geo/​www/​us_​regdiv.pdf). As stated above, for CY 2007, hospital wage data are not available to compute a rural wage index for HHAs in rural Massachusetts, and this alternative methodology could be applied in this case. Massachusetts is located in Census Division I (New England). The states in this Census Division, and their respective rural wage index values (using hospital cost report wage data for FY 2003) include: Connecticut (1.1753), Maine (0.8410), New Hampshire (1.0800), Vermont (0.9944), Rhode Island (all five counties classified as urban) and Massachusetts. Using this alternative methodology, the states in Census Division I for which rural wage index values are available, as shown above, would be used resulting in a simple average rural wage index value of 1.0227. Although this methodology results in a rural Massachusetts wage index that is currently greater than the value under the current proposed policy (1.0216), we believe this methodology may be able to accurately reflect future increases and/or decreases of wage data for the States within the applicable census division. Wage indices are intended to be redistributive and should not increase total Medicare spending. We believe that the alternative methodology could be a reasonable proxy as it uses current rural wage index values (using rural hospital wage data) from States within the same census bureau divisions, with similar economics.

As defined by the Census Bureau: “Census divisions are grouping of states and the District of Columbia that are subdivisions of the four census regions.” The Census Bureau further specifically states: “Puerto Rico and the Island Areas are not part of any census region or census division.” Therefore, because the Census Bureau does not recognize Puerto Rico as part of any of the Census Bureau divisions, we do not believe that it is appropriate to compute the wage index for rural Puerto Rico using the methodology described in the alternative described above. Consequently, as stated above, we propose to continue to apply the CY 2005 wage index (0.4047) for Puerto Rico to payments for home health services provided to beneficiaries who reside in rural areas of Puerto Rico for CY 2007.

We solicit comments on maintaining our current policy for establishing wage index values for rural and urban areas without hospitals, the alternative approach outlined above in developing wage index values for rural areas without hospitals for CY 2007 and subsequent years, as well as suggestions for determining the wage index for rural Puerto Rico. We note that there are sufficient economic differences between the hospitals in the United States and those in Puerto Rico, and that hospitals in Puerto Rico are paid on a blended Federal/Commonwealth-specific rates. Consequently, any alternative approach/methodology to computing a wage index for rural Puerto Rico would need to take into account those differences. We will also continue to evaluate existing hospital wage data and, possibly, wage data from other sources, such as the Bureau of Labor Statistics, to determine if other methodologies of imputing a wage index value where hospital wage data are not available may be feasible.

G. Payment for Oxygen, Oxygen Equipment and Capped Rental DME Items

This proposed rule would amend our regulations at § 414.226 by revising the payment rules for oxygen and oxygen equipment in paragraph (a), adding a new paragraph (f) that provides that the beneficiary assumes ownership of oxygen equipment on the first day that begins after the 36th continuous month in which rental payments are made, and adding a new paragraph (g) that contains new supplier requirements that we believe are necessary in light of the amendments made to section 1834(a)(5) of the Act by section 5101(b) of the DRA. This proposed rule would amend our regulations at § 414.226 by adding a new paragraph (c) that establishes new classes and national payment amounts for oxygen and oxygen equipment based on our authority in section 1834(a)(9)(D) of the Act. We are also revising paragraph (b) of this section to incorporate the special payment rules for oxygen equipment mandated by Start Printed Page 44093section 1834(a)(21) of the Act. The provisions of section 1834(a)(21), which we believe are self-implementing, resulted in adjustments to Medicare payment amounts for oxygen contents and stationary oxygen equipment as well as portable oxygen equipment in 2005, which were implemented through program instructions. We are now seeking to codify these changes to make our regulations consistent with the payment methodology for these items in 2005 and 2006, and because the payment reductions mandated by section 1834(a)(21) are incorporated into our proposal, as more fully discussed in section I below, to create new payment classes for oxygen and oxygen equipment. This proposed rule would redesignate old paragraph (c) of this section as paragraph (d) and would amend this paragraph to indicate under what situations payments would be made for the items and services described in new paragraph (c). Finally, this proposed rule would redesignate old paragraph (d) of this section as paragraph (e) and would make technical changes to this paragraph so that the cross-references are accurate in light of the other changes we are proposing to make to § 414.226.

This proposed rule would also amend our regulations at § 414.229 by revising the payment rules for capped rental durable medical equipment (DME) items (also called capped rental items) in paragraph (a), revising paragraph (f) to provide for new payment rules for capped rental items furnished beginning on or after January 1, 2006, revising paragraph (g) to provide for supplier requirements that we believe are necessary in light of the amendments made to section 1834(a)(7)(A) of the Act by section 5101(a) of the DRA, and adding a new paragraph (h) to address the lump-sum purchase option for power-driven wheelchairs furnished on or after January 1, 2006. The language in current paragraphs (f) and (g) of this section is obsolete, and therefore, we would propose to delete this language.

This proposed rule would amend our regulations at § 414.210 by revising the maintenance and servicing rules in paragraph (e) and the replacement of equipment rules in paragraph (f) to further implement the new supplier requirements that we are proposing below.

Finally, we are proposing to revise § 414.230(b) to incorporate section 5101(b)(2)(B) of the DRA, which provides that for all beneficiaries receiving oxygen equipment paid for under section 1834(a) on December 31, 2005, the period of continuous use begins on January 1, 2006. We are also proposing to revise § 414.230(f), which governs when a new period of continuous use begins if a beneficiary receives new equipment, to account for the fact that oxygen equipment is paid on a modality neutral basis.

Section 5101(a) of the DRA changes the Medicare payment methodology for capped rental equipment to beneficiary ownership after 13 months of continuous use, for those beneficiaries who need the equipment for more than 13 months. This section also makes the transfer of title for the capped rental items a requirement rather than a beneficiary option after 13 months of continuous use. The changes made by this section of the DRA apply to capped rental items, including rented power-driven wheelchairs, for which the first rental month occurs on or after January 1, 2006. We are proposing to update § 414.229 of our regulations to reflect these new statutory requirements. However, for capped rental items and rented power-driven wheelchairs for which the first rental month occurred before January 1, 2006, the existing rules in § 414.229 would continue to apply. In addition, as was the case before enactment of the DRA, beneficiaries may elect to obtain power-driven wheelchairs furnished on or after January 1, 2006, on a lump-sum purchase basis.

Section 5101(b) of the DRA changes the Medicare payment methodology for oxygen equipment from continuous rental to beneficiary ownership after 36 months of continuous use, for those beneficiaries who medically need the oxygen equipment for more than 36 months. For beneficiaries who were receiving oxygen equipment on December 31, 2005 for which payment was made under section 1834(a) of the Act, the 36-month rental period began on January 1, 2006. For beneficiaries who begin to rent oxygen equipment on or after January 1, 2006, the 36-month rental period commences at the time they begin to rent the equipment. We are proposing to update § 414.226 of our regulations to incorporate these new requirements.

In light of the changes made by sections 5101(a) and (b) of the DRA, we believe it is necessary to propose additional supplier requirements in order to maintain beneficiary protections and access to oxygen, oxygen equipment, and capped rental DME items under section 1834(a) of the Act. For both capped rental DME items and oxygen equipment, the DRA amendments make the transfer of title from the supplier to the beneficiary a requirement rather than an option after the statutorily-prescribed rental period ends for each category of items. Therefore, suppliers and beneficiaries should be aware that title to these items will automatically transfer to the beneficiary if the medical need for the equipment continues for a period of continuous use that is longer than 36 months for oxygen equipment and 13 months for capped rental items. We are concerned that there may be incentives for suppliers to avoid having to transfer title to equipment to beneficiaries as required by the DRA. For example, we are aware of cases where a supplier has informed beneficiaries that it would decline to accept assignment for capped rental items and would charge beneficiaries who elected the purchase option the full retail price for the item during the 13th rental month (which was right before the supplier would be required to transfer title under the purchase option). In these cases, the beneficiary would become financially liable for the total retail price for the equipment in the 13th month if they elected the purchase option. We are making several proposals relating to the furnishing of oxygen equipment and capped rental items which we believe protect beneficiaries from these types of abusive practices and which we believe are reasonable for a supplier to comply with. Our authority to promulgate these requirements stems from our authority to administer the payment rules at section 1834(a)(5) of the Act for oxygen equipment and section 1834(a)(7) of the Act for capped rental items, as well as the general authority provided in section 1871 of the Act for prescribing regulations necessary for administering the Medicare program. Other than the length of the rental periods, which the DRA made effective beginning on January 1, 2006 for all oxygen equipment and for capped rental items for which the first rental period began on or after that date, we are proposing that the requirements presented in this section of the regulations would be effective on January 1, 2007, and would apply to suppliers that furnish oxygen equipment or capped rental items on a rental basis.

We believe that a supplier of an item that is subject to these new payment rules that furnishes the item in the first month for which a rental payment is made has an obligation to continue furnishing the item to the beneficiary for the entire period of medical need in which payments are made, up to and including the time when title to the equipment transfers to the beneficiary. We believe it is reasonable for the beneficiary to have an expectation that he or she will not be forced to change Start Printed Page 44094equipment or suppliers during the period of medical need unless he or she wants to. Therefore, we are proposing that unless an exception applies, the supplier that furnishes oxygen equipment or a capped rental item for the first month of the statutorily prescribed rental period must continue to furnish the oxygen equipment or the capped rental item for as long as the equipment remains medically necessary, up to and including the last month for which a rental payment is made by Medicare. We believe that this proposal is necessary to ensure beneficiary access to equipment during a period of medical need, which we believe could be jeopardized if suppliers have the option to take back the rented equipment just before the rental period expires in order to retain title to that equipment. We propose that this requirement would be subject to the following exceptions: (1) Cases where the item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act; (2) cases where a beneficiary relocates on either a temporary or permanent basis to an area that is outside the normal service area of the initial supplier; (3) cases where the beneficiary chooses to obtain equipment from a different supplier; and (4) other cases where CMS or the carrier determine that an exception is warranted. We have proposed rules in connection with the first exception in our Notice of Proposed Rulemaking for Competitive Acquisition for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other Issues. These proposed rules are addressed beginning on page 25662 of the May 1, 2006, Federal Register. If the second exception applies, we propose that the supplier or beneficiary would need to arrange for another supplier in the new area to furnish the item on either a temporary or permanent basis. This proposed exception is consistent with what currently happens when beneficiaries move outside a supplier's service area on either a temporary or permanent basis. The third exception is intended to protect a beneficiary's right to obtain the equipment from the supplier of his or her choice. Finally, we are proposing to allow other exceptions to this proposed requirement on a case-by-case basis at the discretion of CMS or the Medicare contractor. CMS will be monitoring the case-by-case determinations made by the Medicare contractor.

We are concerned that there might be potential incentives for a supplier to replace more valuable or newer equipment used by the beneficiary with less valuable or older equipment from its inventory at some point before the 36th rental month for oxygen equipment or 13th rental month for capped rental DME expires in order to avoid losing title to the more valuable equipment. In order to avoid such potential situations, we propose that the supplier may not provide different equipment from that which was initially furnished to the beneficiary at any time during the 36-month period for oxygen equipment or 13th rental month for capped rental DME unless one of the following exceptions applies: (1) The equipment is lost, stolen, or irreparably damaged; (2) the equipment is being repaired while loaner equipment is in use; (3) there is a change in the beneficiary's medical condition such that the equipment initially furnished is no longer appropriate or medically necessary; or (4) the carrier determines that a change in equipment is warranted. However, we are proposing that a change from one oxygen equipment modality to another without physician documentation that such a change is medically necessary for the individual would not be considered a change in equipment that is warranted under the fourth exception stated above since there is no medical basis for the change. In those cases where the equipment is replaced, we propose that the replacement item must be equipment that is, at minimum, in the same condition as the equipment being replaced. This proposal is intended to safeguard beneficiary access to quality oxygen equipment and capped rental items throughout the duration of the rental period.

Under Medicare, suppliers who furnish items of DME can accept assignment on all claims for Medicare services or on a claim-by-claim basis. Assignment is an agreement between the supplier and the beneficiary under which the supplier agrees to request direct payment from Medicare for the item, to accept 80 percent of the Medicare allowed payment amount for the item from the carrier, and to charge the beneficiary not more than the remaining 20 percent of the Medicare approved payment amount, plus any unmet deductible. If a supplier elects not to accept assignment, Medicare pays the beneficiary 80 percent of the Medicare allowed payment amount, after subtracting any unmet deductible, and there is no limit under Title XVIII of the Act on the amount the supplier can charge the beneficiary for rental of the DME item. The beneficiary, in these situations, is financially responsible for the difference between 80 percent of the Medicare allowed payment amount and the amount the supplier charges for the rental of the DME item.

Section 1842(h) allows suppliers to sign a participation agreement where the supplier agrees voluntarily, before a calendar year, to accept assignment for all Medicare items and services furnished to a beneficiary for the following calendar year. Current supplier participation agreements are renewable annually. However, the agreements do not apply for a full period of medical need for specific beneficiaries in cases where such need extends for more than a calendar year. Nor do current participation agreements apply to periods of medical need where such a period overlaps calendar years. In the latter case, while a supplier may renew its participation agreement annually, a beneficiary would not know before choosing a supplier whether the supplier would be willing to accept assignment of all claims during the 13-month or 36-month rental period.

In order for the beneficiary to make an informed choice, we propose that before furnishing the oxygen equipment or a capped rental item, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the equipment during the period of medical necessity, up to and including the 36th month of continuous use for oxygen equipment or the 13th rental month of continuous use for capped rental DME in which rental payments could potentially be made. We believe that it is reasonable for the supplier to disclose to each beneficiary its intentions regarding assignment of claims for all months during a rental period as this decision has a direct financial effect on the beneficiary. A supplier's intentions could be expressed in the form of a written agreement between the supplier and a beneficiary. This proposal would require suppliers to give beneficiaries advance notice of the possible extent of their financial liability during the period of medical need in which monthly rental payments are made for the equipment, so that they can use this information to help select a supplier. Additionally, to promote informed beneficiary choices, we plan to post information on a CMS and/or CMS contractor Web site(s) indicating supplier specific information on oxygen equipment and capped rental items such as (1) the percentage of beneficiaries for whom each supplier accepted assignment during a prior period of time (for example, a quarter), and/or (2) the percentage of cases in which the supplier accepted assignment Start Printed Page 44095during the beneficiary's entire rental period. We believe that these proposals create reasonable rules for suppliers that furnish oxygen equipment and capped rental items and ensure that beneficiaries have information necessary to make informed choices that could have significant financial consequences for them.

H. Payment for Oxygen Contents for Beneficiary-Owned Oxygen Equipment

Section 1834(a)(5) of the Act, as amended by section 5101(b)(1) of the DRA, requires that Medicare continue to make monthly payments for the delivery and refilling of oxygen contents for the period of medical need after beneficiaries own their own gaseous or liquid oxygen stationary or portable equipment. Before the enactment of the DRA, Medicare made monthly payments for the delivery and refilling of oxygen contents for beneficiaries who own their own stationary and/or portable equipment (equipment they obtained on a purchase basis before June 1, 1989, out-of-pocket, or before they enrolled in Medicare Part B). In accordance with the DRA, we propose that after the supplier transfers title to the stationary and/or portable oxygen equipment to the beneficiary, Medicare would continue to make separate monthly payments for gaseous or liquid oxygen contents until medical necessity ends. We are also proposing that if the beneficiary-owned equipment is replaced, and Medicare pays for the replacement in accordance with proposed revised § 414.210(f) (see section K of this proposed rule for a more complete discussion of our proposed oxygen equipment replacement policies), a new 36-month rental period start and the payment for oxygen contents would be included in the monthly rental payments. We are proposing that all oxygen content payment amounts would be based on new rates developed in accordance with our proposal to establish new payment classes, as discussed in section I below.

In transferring title to gaseous or liquid oxygen equipment used during the 36-month rental period, we propose that suppliers must transfer title for all equipment that will meet the beneficiary's continued medical need, including those oxygen cylinders or vessels that are refilled at the supplier's place of business. Customary practice by suppliers for refilling oxygen contents is to deliver to the beneficiary cylinders filled with contents and take back the empty cylinders to the supplier's place of business to refill the oxygen contents. Under our proposal, title would transfer for both sets of cylinders, meaning the ones that are being used by the beneficiary for the month and the ones that the supplier refills in its business location and delivers for use during the next subsequent month. This policy would apply to both gaseous and liquid oxygen stationary equipment and portable systems. Similarly, in those cases where the beneficiary uses an oxygen equipment system which includes a compressor which fills portable gaseous cylinders in the beneficiary's home, we propose that suppliers must transfer title for this equipment to the beneficiary.

Concerns have been raised regarding beneficiary access to, and safety issues associated with, the delivery of oxygen contents for beneficiary-owned stationary and portable gaseous or liquid equipment. We believe that these concerns are based on the misconception that beneficiaries become responsible for filling their own cylinders. To the contrary, there are numerous State and Federal regulations governing the safe handling, filling, and transport of oxygen and those regulations are unaffected by the DRA oxygen provisions. We expect that suppliers will continue to furnish replacement contents for beneficiary-owned gaseous and liquid systems in the same way that they have furnished replacement contents for beneficiary-owned equipment in the past. For example, suppliers that deliver a one-month supply of gaseous cylinders to a beneficiary's home at the same time that they are picking up empty cylinders that the beneficiary used during the previous month could continue this practice under section 5101(b) of the DRA.

I. Classes of Oxygen and Oxygen Equipment

Based on information from paid Medicare claims with dates of service in calendar year 2004, distribution of usage among the four general categories of oxygen systems was: (a) 69 percent of beneficiaries used both a stationary concentrator (which does not require delivery of oxygen contents) and a portable system that requires delivery of gaseous or liquid oxygen, (b) 5 percent of beneficiaries used a stationary system that requires delivery of gaseous or liquid oxygen and a portable system that requires delivery of gaseous or liquid oxygen, (c) 24 percent of beneficiaries used a stationary concentrator system only, and (d) 2 percent of beneficiaries used only a stationary system that requires delivery of liquid or gaseous oxygen. The prevalent use of stationary concentrator systems is due, in part, to the fact that this system is the most cost-effective and dependable of the stationary oxygen modalities. The main reason that the concentrator system is the most cost-effective system is that the oxygen is concentrated from room air, and therefore, the high cost of delivering contents to the beneficiary's residence is removed when this system is used. Medicare's current payment structure results in two separate payments for beneficiaries using both stationary and portable systems, both of which are modality neutral, meaning that the payment amount does not differ depending on the type of oxygen delivery system (gaseous, liquid, or concentrator) that is furnished. One payment, hereinto referred to as the “stationary payment,” includes payment for the rental of stationary equipment, delivery of stationary oxygen contents (for gaseous or liquid systems), and delivery of portable oxygen contents (for gaseous or liquid systems). A separate add-on payment, hereinto referred to as the “portable add-on,” is also made in cases where the beneficiary is renting portable oxygen equipment. As a result of this payment methodology which has been in place since 1989, suppliers have a financial incentive to furnish low cost concentrator systems as opposed to more expensive gaseous or liquid systems because the monthly payment is the same regardless of which system is used. Finally, in implementing section 1834(a)(5) and (9) of the Act, monthly payment amounts were established through regulations at § 414.226 for (1) stationary and portable oxygen contents (for beneficiaries who use stationary and, if applicable, portable equipment), and (2) portable oxygen contents only (for beneficiaries who only use portable oxygen equipment).

The current average statewide monthly payment amounts are:

Equipment & contentsOxygen contents only
Stationary pmt$199Stationary & portable$156
Portable add-on32Portable only21
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Based on our data, 36 percent of Medicare beneficiaries continue using oxygen equipment for more than three years, that is, beyond the 36th month after which title for the equipment would transfer to the beneficiary in accordance with the DRA.

We have heard concerns about the appropriateness of the current payment structure for oxygen and oxygen equipment in light of changes in the technologies for oxygen delivery systems that have occurred since 1989, and these concerns have been amplified in light of the recent changes made by the DRA. The specific concerns pertain to beneficiary access to (1) portable oxygen contents after title to the equipment transfers to the beneficiary, (2) devices that allow a beneficiary to fill portable tanks at home (otherwise referred to in the oxygen equipment industry as transfilling systems), and (3) portable oxygen concentrators. As we implement the DRA provisions for oxygen equipment and propose to promulgate additional supplier requirements, we want to ensure that the Medicare payment methodology results in payments for oxygen and oxygen equipment that are accurate, do not impede beneficiary access to innovations in technology, and do not create inappropriate incentives for suppliers.

Some believe that Medicare's stationary payment for equipment and contents (average of $199) is “too high” and that Medicare's payment for portable oxygen contents only for beneficiary-owned portable equipment (average of $21) is “too low”. While some contend that the overall payment (stationary payment plus portable add-on) for oxygen and oxygen equipment is adequate as long as the beneficiary continues to rent the equipment, they are concerned about the adequacy of Medicare's $21 monthly payment for furnishing oxygen contents for beneficiary-owned portable equipment. Some believe that Medicare's current average monthly payment of $156 for oxygen contents, which includes payment for both stationary and portable systems, is high enough to create an incentive for suppliers to furnish stationary oxygen systems that require the ongoing delivery of oxygen contents, rather than stationary concentrator systems that do not require delivery of oxygen contents.

Some technologies provide an attachment to a stationary oxygen concentrator that allows beneficiaries to fill their own portable tanks at home. Delivery of portable oxygen contents to the beneficiary's home is, therefore, not necessary since this equipment refills the beneficiary's rented or owned portable oxygen tanks. This transfilling technology eliminates the need for frequent and costly trips by a supplier to a beneficiary's home to refill portable oxygen tanks and would save the Medicare program and beneficiaries who use portable equipment the expense of paying for delivery of portable oxygen contents. We note that we are not aware that a similar “transfilling” technology has been developed that would be capable of filling stationary tanks in the beneficiary's home. Therefore, there remains a need for ongoing delivery of gaseous or liquid oxygen contents for stationary equipment. In accordance with the DRA, after 36 months of continuous use, title for the transfilling equipment and accompanying portable oxygen tanks would transfer to the beneficiary who would then own a portable equipment system that self-generates oxygen in their home. However, some are concerned that current Medicare payment rules that allow payment for oxygen contents for stationary equipment creates an incentive for suppliers to furnish stationary oxygen equipment that require liquid or gaseous oxygen deliveries, rather than concentrators and transfilling equipment that self-generate oxygen in the beneficiary's home. In addition, portable oxygen concentrators are now available that meet both the beneficiary's stationary and portable oxygen needs. Some have raised concern about whether the combination of the Medicare stationary payment and portable add-on payment (approximately $231 per month), which is what is currently paid for portable oxygen concentrators, is sufficient to facilitate use of this new technology which, like a transfilling system, eliminates the need for delivery of oxygen contents, but is more expensive than a “standard” or “non-portable” concentrator.

In light of these concerns, we are proposing regulatory changes to address the Medicare payment rates for oxygen and oxygen equipment. We are proposing to address these issues by using our authority under section 1834(a)(9)(D) of the Act to establish separate classes and monthly payment rates for items of oxygen and oxygen equipment. Specifically, there are two changes we are proposing for oxygen and oxygen equipment:

1. We propose to establish a new class and monthly payment amount for oxygen generating portable oxygen equipment (for example, portable concentrators and transfilling systems).

2. We propose to establish separate classes and monthly payment amounts for gaseous and liquid oxygen contents that must be delivered for beneficiary-owned stationary and portable oxygen equipment.

The first change involves creating a new separate class for portable oxygen systems that generate their own oxygen and therefore eliminate the need for delivery of oxygen contents (for example, portable concentrator systems or transfilling systems). A higher monthly payment amount would be allowed, as described below, for these systems to account for the increased, up-front costs to the supplier of furnishing these more expensive concentrator or transfilling systems, which would be partially offset by the reduced payments that the supplier would receive from the Medicare program and beneficiaries due to the fact that these systems do not require the delivery of oxygen contents.

The second change involves creating two separate classes (stationary contents only and portable contents only) and monthly payment rates for furnishing oxygen contents for beneficiary-owned stationary and portable systems. Currently, the combined average monthly payment amount of $156 for furnishing oxygen contents for beneficiary-owned stationary and portable systems includes payment for both stationary contents and portable contents. The current fee schedule amounts for oxygen contents are based on calendar year data from 1986 for the combined average Medicare monthly payment for both stationary and portable contents divided by number of rental months for stationary liquid and gaseous oxygen equipment. As a result, the current combined stationary/portable contents payment results in Medicare payments for portable contents even in those cases where the beneficiary does not use portable oxygen equipment. Under our proposal to create one payment class for oxygen contents used for stationary equipment, and a separate class for oxygen contents used for portable equipment, new national monthly payment amounts for stationary contents delivery and portable contents delivery would be established by splitting the combined payment of $156 into two new payments as explained below. This change would increase the monthly payment for furnishing portable oxygen contents and would address the concerns that the monthly payment rate of $21 is too low for the delivery and filling of portable tanks after the beneficiary assumes ownership of the equipment in accordance with the DRA.Start Printed Page 44097

In order to achieve budget neutrality for the new classes of oxygen and increase payment amounts for furnishing portable contents, we would need to reduce other Medicare oxygen payment rates. Budget neutrality would require that Medicare's total spending for all modalities of stationary and portable systems, including contents, be the same under the proposed change as they would be without the change.

We would propose to achieve budget neutrality by reducing the current monthly payment amounts (the stationary payment) for stationary oxygen equipment and oxygen contents (for stationary or portable equipment) made during the rental period. This reduction in payment is necessary to offset increased payments for the changes identified above and to meet the requirement in section 1834(a)(9)(D)(ii) that the classes and payments be established in a budget neutral fashion. In most cases, suppliers furnish Medicare beneficiaries with stationary oxygen concentrators. These devices can be purchased for $1,000 or less and the current, average Medicare payment of $199 pays suppliers $1,990 over 10 months. We believe that these facts indicate that making a reduction (from $199 on average to $177) in Medicare payment for this relatively inexpensive oxygen equipment in order to pay oxygen suppliers adequately for furnishing portable oxygen contents and more expensive portable oxygen equipment technologies is warranted. With this approach, the proposed new classes, as well as proposed new national monthly payment rates, would be as follows:

1. Stationary Payment: $177.

2. Portable Add-On: $32.

3. Oxygen Generating Portable Equipment Add-On (portable concentrators or transfilling systems): $64.

4. Stationary Contents Delivery: $101.

5. Portable Contents Delivery: $55.

We provide a detailed discussion of the payment rate calculations/adjustments in the paragraphs that follow. Under the proposed new oxygen and oxygen equipment class structure described above, in those cases where the beneficiary needs both stationary and portable oxygen, monthly payments of $241 or $209 (proposed revised stationary payment of $177 plus one of two proposed portable equipment payments, $32 or $64) would be made during rental months 1 through 36. The stationary payment (which includes payment for stationary equipment, as well as oxygen contents for stationary and portable systems) of $177 would be made during rental months 1 through 36 for beneficiaries who only need stationary oxygen and oxygen equipment. Monthly payments of $101 for stationary oxygen contents and/or $55 for portable oxygen contents would be made in cases where beneficiaries own their stationary and/or portable oxygen equipment. As explained in more detail in the paragraphs that follow, the $101 payment is for stationary oxygen contents only and is derived from the current payment of $156, which is made for both stationary and portable oxygen contents. The $55 payment for portable oxygen contents only is also derived from the current payment of $156 that is made for both stationary and portable oxygen contents and would replace the current statewide portable oxygen contents fees (average of $21), which was based on a relatively small number of claims and allowed services compared to the number of claims and allowed services that were used in computing the statewide fees (average of $156) for a combination of stationary and portable oxygen contents.

As noted above, the proposed national payment rates for delivery of oxygen contents for beneficiary owned gaseous/liquid equipment were derived from the current average payment for a combined oxygen contents delivery of $156. We propose to establish $101, or 65 percent of $156, as the monthly payment rate for delivery of larger, heavier, beneficiary-owned stationary gaseous oxygen cylinders or liquid oxygen vessels and $55, or 35 percent of $156, as the monthly payment rate for delivery of smaller, lighter, beneficiary-owned portable gaseous oxygen cylinders or liquid oxygen vessels. The 65/35 split is based on our understanding that there are higher costs associated with delivering stationary tanks (cylinders of gaseous oxygen and vessels of liquid oxygen) which are approximately twice as large as the portable tanks. Such costs include supplier overhead costs, including the costs to purchase, maintain, and dispatch trucks, obtain insurance, and purchase fuel. The 65/35 split is intended to account for the difference in costs associated with the size of the tanks. Larger tanks take up more space on the trucks, take longer to fill, are harder to move, and result in increased fuel costs.

We estimate that the increase from $21 to $55 in the monthly payment rate for delivery of oxygen contents for beneficiary-owned portable equipment will result in increased expenditures of approximately $22 million over a 24 month period, or $11 million annually. This figure is based on current data on utilization of portable oxygen by Medicare beneficiaries.

The add-on payment amount of $64 for the oxygen generating portable equipment class was calculated based on data indicating long term savings generated from use of equipment that eliminated the need for payment of $55 per month for portable oxygen contents. The first step in calculating the proposed $64 payment for oxygen generating portable equipment involves the computation of a national, enhanced, modality neutral monthly payment amount of $241 for new technology systems (stationary concentrators and transfilling systems, as well as portable concentrators), which was derived from the sum of the current average stationary payment ($199), the current average portable add-on payment ($32), and an additional $10 to pay suppliers for furnishing more expensive equipment that eliminates the need for delivery of portable oxygen contents. Specifically, we calculated the modality neutral increased payment (that is, $10 above the current combination of the stationary payment and portable add-on payment) by estimating potential savings that the Medicare program would realize as a result of not having to pay for delivery of oxygen contents for beneficiary-owned portable oxygen systems in the fourth and fifth years of use. We calculated the increased payment to be equal to potential savings from not delivering oxygen contents. In calculating this increased payment, we are only factoring in savings from the fourth and fifth years of use since we assume that most beneficiaries will elect to obtain replacement equipment after the 5-year reasonable useful lifetime for their equipment has expired. Since our data indicates that 35.8 percent of beneficiaries will use oxygen equipment for more than three years, and that approximately 74 percent of these beneficiaries use portable equipment, the $10 amount is calculated based on the following formula, and is rounded to the nearest dollar:

We estimate that the additional $10 payment per month for oxygen generating portable equipment (transfilling units and portable concentrators) will result in increased expenditures of approximately $15 million over a 36 month period, or $5 million annually. This figure is based on current data on utilization of stationary and portable oxygen by Medicare beneficiaries over 36 months.

The second step in calculating the proposed $64 add-on payment for the Start Printed Page 44098proposed new class of oxygen generating portable equipment involves subtracting the proposed new stationary payment. Therefore, the national monthly payment of $241 computed in the first step above would be reduced by $177, the proposed new adjusted stationary payment amount, to arrive at the proposed add-on payment of $64 for just the oxygen generating portable equipment. In addition, to offset the increased annual payments of approximately $16 million that will result from increased payments for portable oxygen contents ($11 million) and newer technology oxygen generating portable equipment ($5 million), we would propose to decrease the current stationary payment by $22 ($199 − $177). We estimate that this offset would result in annual Medicare savings of approximately $16 million, and would therefore offset the increased payments for new technology oxygen generating portable equipment and delivery of oxygen contents for other beneficiary-owned portable equipment. We are proposing that these fees be established on a nationwide basis due to the fact that the variation in the current statewide fee schedule amounts for oxygen and oxygen equipment, as well as the portable equipment add-on payment, are currently only 3 percent and 5 percent, respectively.

We are proposing that the $64 add-on payment would be made for oxygen generating portable equipment only if the equipment eliminates the need for delivery or portable oxygen contents. However, if transfilling equipment is used in connection with a stationary oxygen concentrator (whether as an integrated system component or as a separate part) to both deliver stationary oxygen and fill portable oxygen tanks, Medicare would make both a $177 stationary payment for the stationary oxygen concentrator and stationary oxygen contents, and a separate $64 oxygen generating portable equipment payment for the portable oxygen transfilling equipment.

There are also portable oxygen transfilling products that are not part of or used in conjunction with a stationary oxygen concentrator. These products are only used to fill portable oxygen tanks in the beneficiary's home. If the beneficiary is using one of these products, Medicare would make a $64 oxygen generating portable equipment payment. If the patient is also renting any type of stationary oxygen equipment (gaseous, liquid, or concentrator), Medicare would make a separate, additional $177 stationary equipment payment for that equipment.

If a portable oxygen concentrator is furnished, Medicare would make the $64 oxygen generating portable equipment add-on payment if the portable oxygen concentrator is used as both the beneficiary's stationary oxygen equipment and portable oxygen equipment. In this case, the portable oxygen concentrator equipment would fall under both the stationary oxygen equipment class and the oxygen generating portable equipment class. Therefore, the $177 stationary payment would also be made in this situation, since the equipment being furnished meets the beneficiary's needs for both stationary and portable oxygen equipment. In this case, it would be necessary for the supplier to use two HCPCS codes to bill for this device since it is being used as both the stationary and portable oxygen equipment for the beneficiary. If the beneficiary owns any type of stationary equipment (concentrator, liquid, or gaseous), and is also furnished with a portable oxygen concentrator, only the oxygen generating payment of $64 would be made (that is, the supplier would not also receive the $177 payment) and the portable oxygen concentrator equipment would fall under the oxygen generating portable equipment class because it is only being used to meet the beneficiary's need for portable oxygen equipment. Finally, if, the beneficiary is renting any type of stationary equipment (concentrator, liquid, or gaseous), and is also furnished with a portable oxygen concentrator, the oxygen generating add-on payment of $64 would be paid for the portable oxygen concentrator and the stationary payment of $177 would be paid separately for the stationary oxygen equipment and contents.

In summary, we are proposing new payment classes for oxygen contents for beneficiary-owned stationary equipment, oxygen contents for beneficiary-owned portable equipment, and oxygen generating portable equipment. Payments for oxygen contents for beneficiary-owned portable equipment and oxygen generating portable equipment would exceed what is currently paid for these items to ensure access to portable oxygen regardless of the type of equipment used. These increased payments would be offset by a reduction in the stationary payment. The six broad categories of oxygen equipment used by beneficiaries are as follows:

A. Concentrator and liquid or gaseous portable equipment

B. Concentrator and/or oxygen generating portable equipment

C. Liquid or gaseous stationary equipment and liquid or gaseous portable equipment

D. Liquid or gaseous stationary equipment and oxygen generating portable equipment

E. Concentrator only

F. Liquid or gaseous stationary equipment only

Based on our proposed new payment classes, Medicare payment under these six categories would be as follows:

CategoryEquipment rental and contentsContents for beneficiary-owned equipment
A$209 ($177 + $32)$55
B241 ($177 + $64)0
C209 ($177 + $32)156 ($101 + $55)
D241 ($177 + $64)101
E1770
F177101

We are proposing to revise our regulations in order to implement these new payment classes and payment amounts, effective for claims with dates of service on or after January 1, 2007.

J. Payment for Maintenance and Servicing of Oxygen and Oxygen Equipment and Capped Rental Items

Immediately following passage of the DRA, concerns were raised regarding the ability of a beneficiary to obtain maintenance and servicing of his or her DME once he or she has taken title to it. We believe that these concerns are largely based on misconceptions that the beneficiary will “be on his or her own” in terms of maintenance and Start Printed Page 44099servicing of equipment and submission of claims for payment for these services. We believe that these concerns are unfounded because Medicare payment has traditionally been made for reasonable and necessary repair and maintenance of beneficiary-owned DME. In addition, section 1834(a)(5)(F)(ii)(II)(bb) of the Act, as amended by section 5101(b)(1)(B) of the DRA, requires that Medicare continue to pay for reasonable and necessary maintenance and servicing for parts and labor that is not covered under a manufacturer's or supplier's warranty in amounts determined to be appropriate by the Secretary.

Medicare has also traditionally paid for loaner equipment used while the beneficiary's equipment is being repaired, or in some cases, when the beneficiary does not have access to the equipment (for example, in cases when a natural disaster such as a hurricane forces the beneficiary to be evacuated from his or her home). We are proposing to continue Medicare payment for such loaner equipment.

We are not aware of instances where beneficiaries have encountered problems in finding suppliers to provide maintenance and servicing of beneficiary-owned DME. Section 414.210(e) of our regulations currently provides that reasonable and necessary charges for maintenance and servicing of DME are those charges made for parts and labor not otherwise covered under a manufacturer's or supplier's warranty. This definition has been applied in paying claims for maintenance and servicing of beneficiary-owned DME for several years, and the wording of this regulatory definition is parallel to that used in amended sections 1834(a)(7)(A)(iv) and (a)(5)(F)(ii)(II)(bb) of the Act in describing the “maintenance and servicing” payments that are permitted for capped rental DME and oxygen equipment after title has transferred to the beneficiary. We are proposing to continue use of this existing regulatory definition to define “maintenance and servicing” in section 5101 of the DRA. We would, however, also propose to apply our existing policy of not covering certain routine maintenance or periodic servicing of purchased equipment, such as testing, cleaning, regulating, changing filters, and general inspection of beneficiary-owned DME that can be done by the beneficiary or caregiver, to beneficiary-owned oxygen equipment and to continue that policy for beneficiary-owned capped rental equipment. As specified in current program instructions at section 110.2.B of chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02), “the owner [of the equipment] is expected to perform such routine maintenance rather than a retailer or some other person who charges the beneficiary.” We expect that the supplier, when transferring title to the equipment to the beneficiary, would also provide to the beneficiary any operating manuals published by the manufacturer which describe the servicing an owner may perform to properly maintain the equipment. We also believe that these owner manuals are commonly available at the various manufacturer Web sites. In addition, the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier standards at § 424.57(c)(12) require suppliers to provide the beneficiary with necessary information and instructions on how to use DME items safely and effectively. We believe that after receiving this information, and after becoming familiar with the equipment during the 13 or 36 month rental period, the beneficiary and/or caregiver should be very knowledgeable regarding the routine maintenance required for the item. All non-routine maintenance of beneficiary-owned oxygen equipment and capped rental items which would need to be performed by authorized technicians would be covered as reasonable and necessary maintenance and servicing. Examples of the types of maintenance that would be covered are currently listed in program instructions at section 110.2.B of chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02) and include “breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary.”

We are proposing that maintenance and servicing of beneficiary-owned oxygen equipment and capped rental items would be reasonable and necessary if it is non-routine maintenance and servicing necessary to make the equipment serviceable. Payment is currently made under the Medicare program for parts and labor associated with repairing beneficiary-owned DME. Medicare allowed payment amounts for replacement parts are currently paid based on the carrier's individual consideration of the item. With regard to replacement parts for beneficiary-owned oxygen equipment or capped rental equipment, we propose that the carrier pay for the parts in a lump sum amount based on its consideration of the cost of the item, as is consistent with what our carriers currently do when evaluating maintenance and servicing claims for other beneficiary-owned DME. Currently, payment for labor is based on 15-minute increments in amounts that are established by the carriers and updated on an annual basis by the same factor specified in section 1834(a)(14) of the Act, which is used to update fee schedule amounts for DME. We are proposing that the carriers use the same fee for labor that is currently used in paying for labor associated with repairing, maintaining, and servicing other beneficiary-owned DME, as we are not aware of any past problems associated with access to these services paid at these rates. We believe that the current methods and fees used by carriers in paying for maintenance and servicing of beneficiary-owned DME are reasonable given that we are not aware of any past problems associated with access to these services paid at these rates. In most cases, neither the Medicare program nor the beneficiary actually pays the full amount for repairing or maintaining an item since manufacturer warranties that cover all or part of these costs are widespread. For example, some manufacturers of commonly used oxygen concentrators offer full warranties that cover all parts and labor for 5 years. Rules in § 414.210(f) regarding replacement of DME that has been in continuous use for the equipment's reasonable useful lifetime provide that the beneficiary can elect to obtain replacement equipment after the reasonable useful lifetime for the equipment has expired. Therefore, we believe that the beneficiary should incur little, if any, expense for repair or maintenance of necessary equipment in cases where manufacturer warranties exist that cover parts and labor necessary to repair a new item during a 5-year period.

K. Payment for Replacement of Beneficiary-Owned Oxygen Equipment, Capped Rental Items, and Associated Supplies and Accessories

Medicare has traditionally paid for replacement beneficiary-owned DME after the expiration of the equipment's useful lifetime (see § 414.210(f) and § 414.229(g) of our regulations), and for replacement supplies and accessories used in conjunction with beneficiary-owned DME when these supplies and accessories are necessary for the effective use of the DME (see § 110.3 of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02)). Examples of supplies include drugs and administration sets used with infusion pumps. Examples of accessories include masks and tubing used with respiratory equipment. We are proposing to apply these policies to beneficiary-owned oxygen equipment, as well as the Start Printed Page 44100supplies and accessories used in conjunction with this equipment, and to continue to apply these policies to beneficiary-owned capped rental items, as well as the supplies and accessories used in conjunction with these items.

Specifically, we are proposing to update § 414.210(f) and § 414.229(g) of our regulations to reflect that payment may be made for the replacement of beneficiary-owned oxygen equipment and capped rental DME in cases where the item is lost, stolen, or irreparably damaged, or in cases where the item has been in continuous use for its reasonable useful lifetime. We propose that payment for the replacement be made on a rental basis in accordance with the payment rules in § 414.226 for oxygen equipment and § 414.229 for capped rental items. We also propose to revise § 414.229 to reflect that these proposed changes to the replacement policy for beneficiary-owned capped rental items only apply to those items for which the first rental month occurs on or after January 1, 2007 since the DRA does not apply to capped rental items for which the first rental month occurs before January 1, 2006. The current rules will remain in place for capped rental items to which the DRA does not apply.

We are aware that some manufacturer warranties may cover replacement of oxygen or capped rental equipment within a certain time period after the item is furnished. As was our policy prior to the enactment of DRA (see § 110.2.C of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02)), we are proposing that Medicare not pay for the replacement of beneficiary-owned oxygen equipment or capped rental items covered by a manufacturer's or supplier's warranty. In cases where equipment replacement is not covered by a manufacturer's or supplier's warranty, we propose that the supplier must still replace beneficiary-owned oxygen equipment or beneficiary-owned capped rental items at no cost to the beneficiary or to the Medicare program if: (1) The total accumulated costs, as illustrated in the example below, to repair the item after transfer of title to the beneficiary exceed 60 percent of the replacement cost; and (2) the item has been in continuous use for less than its reasonable useful lifetime, as established in accordance with the procedures set forth in proposed revised § 414.210(f). For example, a capped rental item that can be replaced for $1,000 (total of fee schedule payments after 13 rental months) and for which title has transferred to the beneficiary in accordance with section 1834(a)(7)(A)(ii) of the Act can be used to illustrate what we mean when we use the term “accumulated costs” above. In this example, if Medicare has paid a total of $500 for 3 repairs necessary to make the item functional, and a fourth repair costing $200 is needed in order to make the item functional, the accumulated costs for repair in this case will equal $700, which exceeds $600 or 60 percent of the $1,000 cost to replace the item. In this case, and therefore the supplier would be required to furnish a replacement item. The greater than 60 percent of cost threshold for replacement is consistent with the threshold repair costs that can result in the replacement of prosthetics (artificial limbs) in accordance with section 1834(h)(1)(G) of the Act. We believe this threshold should apply to oxygen equipment and capped rental items as well, because artificial limbs, like these items, are built to withstand repeated use.

We propose that the supplier be responsible for the cost of the replacement equipment because we believe that the item in this case did not last for the entire reasonable useful lifetime. After the beneficiary acquires title to the item, the supplier that transferred title would be responsible for furnishing the replacement item. We are proposing this provision to safeguard the beneficiary from receiving, and the Medicare program from paying for, substandard equipment, and to avoid creating an incentive for suppliers to increase the number of claims submitted for repairs in an effort to recover revenue lost as a result of DRA section 5101. We believe that this requirement is not unreasonable since suppliers should be furnishing items in good working order and are otherwise bound by regulations at § 424.57(c)(15) to accept returns from beneficiaries of substandard items. Exceptions to this rule may be granted by CMS or the carrier as appropriate (for example, the supplier would not be responsible for replacing an item in need of repair due to beneficiary neglect or abuse).

L. Periods of Continuous Use

Rules that apply in determining a period of continuous use for rental of DME are found at § 414.230 of our regulations. We are proposing that these rules would continue to apply in implementing section 5101 of the DRA, with one exception. The rules in § 414.230(f) provide that a new period of continuous use begins for new or additional equipment prescribed by a physician and found to be medically necessary, even if the new or additional equipment is similar to the old equipment.

Medicare payments for stationary and portable oxygen and oxygen equipment are currently modality neutral, which means that the same payment amounts apply to the different types of oxygen equipment furnished to Medicare beneficiaries. Since there is no distinction made between oxygen equipment modalities for payment purposes under the Medicare program, we do not believe that it is necessary or appropriate to begin a new period of continuous use when the beneficiary changes from one oxygen equipment modality to another. We are proposing to revise § 414.230(f) of our regulations to designate the existing language in this section as paragraph (f)(1) and to add a new paragraph (f)(2) to reflect this exception, effective for oxygen equipment furnished on or after January 1, 2007. We are also proposing to revise § 414.230(b) to incorporate section 5101(b)(2)(B) of the DRA, which provides that for all beneficiaries receiving oxygen equipment paid for under section 1834(a) on December 31, 2005, the period of continuous use begins on January 1, 2006.

M. Health Care Information Transparency and Health Information Technology

(If you choose to comment on issues in this section, please include the caption “Health Care Information Transparency and Health Information Technology” at the beginning of your comment.)

In the April 25, 2006 Inpatient Prospective Payment Systems proposed rule (71 FR 23996), we discussed in detail the Health Care Information Transparency Initiative and our efforts to promote effective use of health information technology (HIT) as a means to help improve health care quality and improve efficiency. Specifically, with regard to the transparency initiative, we discussed several potential options for making pricing and quality information available to the public (71 FR 24120 through 24121). We solicited comments on ways the Department can encourage transparency in health care quality and pricing whether through its leadership on voluntary initiatives or through regulatory requirements. We also sought comments on the Department's statutory authority to impose such requirements. In addition, we discussed the potential for HIT to facilitate improvements in the quality and efficiency of health care services (71 FR 24100 through 24101). We solicited comments on our statutory authority to encourage the adoption and Start Printed Page 44101use of HIT. The 2007 Budget states that “the Administration supports the adoption of health information technology (IT) as a normal cost of doing business to ensure patients receive high quality care.” We also sought comments on the appropriate role of HIT in potential value-based purchasing programs, beyond the intrinsic incentives of a PPS to provide efficient care, encourage the avoidance of unnecessary costs, and increase quality of care. In addition, we sought comments on promotion of the use of effective HIT and how CMS can encourage its use in HHAs.

We intend to consider both the health care information transparency initiative and the use of HIT as we refine and update all Medicare payment systems. Therefore, we seek comments on these initiatives as applied to HH PPS in this proposed rule, including the Department's statutory authority to impose any such requirements. We may address these initiatives in the final HH PPS rule. For example, a HIT proposal could include adding a requirement that HHAs use HIT that is compliant with and certified by the Certification Commission for Health Information Technology (CCHIT) in the areas in which the technology is available. As noted previously, we currently collect home health quality information and propose to collect additional quality data and report it on the CMS Home Health Compare Web site. We note that we are in the process of seeking input on these initiatives in various proposed Medicare payment rules being issued this year.

III. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:

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

We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements:

Section 414.226—Oxygen and Oxygen Equipment

This section proposes to require a supplier to disclose to the beneficiary whether or not the supplier will accept assignment of all monthly rental claims for oxygen equipment for the duration of the 36-month rental period.

The burden associated with this requirement is the time and effort put forth by the supplier to disclose this information. While this information collection is subject to the PRA, we believe this requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, the burden associated with this requirement is exempt from the PRA.

Section 414.229—Other Durable Medical Equipment-Capped Rental Items

This section proposes to require a supplier to disclose to the beneficiary whether or not the supplier will accept assignment of all monthly rental claims for capped rental DME for the duration of the 13-month rental period.

The burden associated with this requirement is the time and effort put forth by the supplier to disclose this information. While this information collection is subject to the PRA, we believe this requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, the burden associated with this requirement is exempt from the PRA.

We have submitted a copy of this proposed rule to OMB for its review of the information collection requirements described above. These requirements are not effective until they have been approved by OMB.

If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attn: Melissa Musotto, [CMS-1304-P], Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and

Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Carolyn Lovette, CMS Desk Officer, CMS-1304-P, carolyn_lovett@omb.eop.gov. Fax (202) 395-6974.

IV. Response to Comments

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

V. Regulatory Impact Analysis

[If you choose to comment on issues in this section, please include the caption “REGULATORY IMPACT ANALYSIS” at the beginning of your comments.]

A. Overall Impact

We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the 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 proposed rule would be 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 update set forth in this proposed rule would apply to Medicare payments under HH PPS in CY 2007. Accordingly, the following analysis describes the impact in CY 2007 only. We estimate that there would be an additional $420 million in CY 2007 expenditures attributable to the CY 2007 proposed estimated home health market basket update of 3.1 percent.

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 small government agencies. Most hospitals and most other providers and suppliers Start Printed Page 44102are small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any 1 year. For purposes of the RFA, approximately 75 percent of HHAs are considered small businesses according to the Small Business Administration's size standards with total revenues of $11.5 million or less in any 1 year. Individuals and States are not included in the definition of a small entity. As stated above, this proposed rule would provide an update to all HHAs for CY 2007 as required by statute. This proposed rule would have a significant positive effect upon small entities that are HHAs.

Based on our analysis of 2003 claims data, we also estimate that approximately 90 percent of registered DME suppliers are considered small businesses according to the Small Business Administration's size standards. The size standard for NAICS code, 532291, Home Health Equipment Rental is $6 million. (see http://www.sba.gov/​size/​sizetable2002.html, read May 9, 2005.) This proposed rule would reduce payments for oxygen equipment and capped rental items; and therefore, would have a significant negative effect upon small entities that are DME suppliers overall. However, as explained in detail below, we believe that Medicare payments would still be adequate for the items affected by this rule and that suppliers whose primary line of business involves furnishing these items will remain profitable.

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 have determined that this proposed rule would not have a significant economic impact on the operations of a substantial number of small rural hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) 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 $120 million. We believe this proposed rule would not mandate expenditures in that amount.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this rule under the threshold criteria of Executive Order 13132, Federalism. We have determined that this proposed rule would not have substantial direct effects on the rights, roles, and responsibilities of States.

B. Anticipated Effects

1. Home Health PPS

This proposed rule would update the HH PPS rates contained in Pub. 100-20, One Time Notification, Transmittal 211, published February 10, 2006. We updated the rates in the CY 2006 final rule (70 FR 68132, November 9, 2005) through Transmittal 211 to take account of the DRA changes, specifically the 0 percent update and the rural add-on. The impact analysis of this proposed rule presents the projected effects of the proposed change from the CY 2006 transition wage index (50/50 blend of MSA-based and CBSA-based designations) to the CY 2007 proposed CBSA-based designations in determining the wage index used to calculate the HH PPS rates for CY 2007. 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.

This analysis incorporates the latest estimates of growth in service use and payments under the Medicare home health benefit, based on the latest available Medicare claims from 2004. 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 of such possible events are newly-legislated general Medicare program funding changes made by the Congress, or changes specifically related to HHAs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, the MMA, the DRA, or new statutory provisions. Although these changes may not be specific to HH 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 HHAs.

Our discussion for this proposed rule will focus on the impact of changes in the wage index, most notably the adoption of the full CBSA designations. The impacts of the updated wage data are shown in Table 9 below. The breakdown of the various impacts displayed in the table follows.

The rows display the estimated effect of the proposed changes on different categories. The first row of figures represents the estimated effects on all facilities. The next 2 rows show the effect on urban and rural facilities. This is followed, in the next 4 rows, by impacts on urban and rural facilities based on whether they are a hospital-based or freestanding facility. The next 20 rows show the effect on urban and rural facilities based on the census region in which they are located.

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

The second column in the table shows the number of facilities in the impact database. A facility is considered urban if it is located in a CBSA and, conversely, rural if it is not located in a CBSA.

The third column of the table shows the effect of the proposed annual update to the wage index. This represents the effect of using the most recent wage data available to determine the proposed estimated home health market basket update. The total impact of this change is −0.1 percent; however, there are distributional effects of the change.

The fourth column of the table shows the effect of all the changes on the proposed CY 2007 payments. The proposed estimated market basket update of 3.1 percentage points is constant for all providers and, though not shown individually, is included in this column. It is projected that total aggregate payments would increase by 3.0 percent, 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, HHAs in the rural Pacific show the largest estimated increase in payment at 10.3 percent, while HHAs in the rural Mountain census division show the smallest increase in payments at 0.5 percent. Rural HHAs do somewhat better than urban HHAs, seeing an estimated increase in payments of 3.3 percent and 2.9 percent respectively. Amongst the different type of facility categories, freestanding rural HHAs do Start Printed Page 44103best, with an estimated increase in payments of 3.5 percent. Hospital-based urban HHAs are next with an estimated increase in payments of 3.2 percent with hospital-based rural and freestanding urban HHAs with estimated increases of 3.1 percent and 2.8 percent, respectively.

Table 9.—Projected Impact of CY 2007 Update to the HH PPS

Number of facilitiesUpdated wage data (percent)Total CY 2007 change (percent)
Total7,370−0.13.0
Urban2,097−0.22.9
Rural5,2730.23.3
Hospital based urban1,9880.13.2
Freestanding urban3,285−0.32.8
Hospital based rural1,2010.03.1
Freestanding rural8960.43.5
Urban by region:
New England254−1.12.0
Middle Atlantic4230.03.1
South Atlantic913−0.52.6
East North Central8860.33.5
East South Central222−0.42.7
West North Central3040.33.4
West South Central1,300−0.62.4
Mountain2811.74.8
Pacific6490.23.3
Outlying41−4.8−1.8
Rural by region:
New England43−0.72.3
Middle Atlantic820.33.4
South Atlantic239−0.62.5
East North Central2841.54.6
East South Central215−0.32.8
West North Central4880.33.4
West South Central475−0.32.8
Mountain173−2.50.5
Pacific886.910.3
Outlying107.711.1

The impact of the proposed wage index for CY 2007 is shown in Addendum C to this document. Addendum C to this document shows a side-by-side comparison, by State and county code, of the CY 2006 transition wage index, which was a 50/50 blend of MSA-based and CBSA-based pre-floor, pre-reclassified hospital wage indexes, and the proposed CY 2007 pre-floor, pre-reclassified hospital wage index for the CY 2007 HH PPS update. In the last column of Addendum C to this document, we show the percentage change in the wage index from CY 2006 to the proposed wage index for CY 2007.

We estimate that there would be an additional $420 million in CY 2007 expenditures attributable to the CY 2007 proposed estimated market basket (3.1 percent) increase. Thus, the anticipated expenditures outlined in this proposed rule would exceed the $100 million annual threshold for a major rule as defined in Title 5, USC, section 804(2).

This proposed rule would have a positive effect on providers of Medicare home health services by increasing their Medicare payment rates. It is anticipated that very few HHAs will not submit the quality data required by section 1895(b)(3)(B)(v)(II)of the Act necessary to receive the full market basket percentage increase. Submission of OASIS data is a Medicare condition of participation for HHAs. Therefore, one would expect that no HHA would be subject to the 2 percent reduction in payments in CY 2007. As indicated in the rule, most HHAs that do not report OASIS provide pediatric, non-Medicare, or personal care only. However, CMS is aware of instances of non-compliance among a very small portion of HHAs with regard to OASIS submission.

For the purposes of the CY 2007 impact analysis, we anticipate that less than 1 percent of HHAs, involving less than 1 percent of total Medicare HH payments, would fail to submit quality data and hence would be subject to the 2 percent reduction. This is not enough to impact the estimated $420 million in additional expenditures. Finally, we do not believe there is a differential impact due to the aggregate nature of the update. We do not anticipate specific effects on other providers.

2. Oxygen and Oxygen Equipment Provisions

As mandated by the DRA of 2005, this proposed rule limits to 36 months the total number of continuous months for which Medicare would pay for oxygen equipment, after which the title to the oxygen equipment would be transferred from the supplier to the beneficiary. Since Medicare currently pays for oxygen equipment on a monthly basis for as long as it is medically necessary, this change would result in savings to Medicare. In addition, the DRA mandates that Medicare continue to make monthly payments for furnishing contents for beneficiary-owned oxygen equipment.

Close to a million patients now receive oxygen therapy. Although monthly rental payments already have been reduced by 30 percent by section 4552 of the Balanced Budget Act of 1997 and approximately 10 percent by section 302(c)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare allowed charges rose to $2.78 billion by 2004, a 71 percent increase since 1998 that reflects the growing use. Before the Start Printed Page 44104amendments to section 1834(a)(5) of the Act made by the DRA, Medicare continued to make rental payments for as long as medical necessity continued, even when the total payments greatly exceeded the cost of purchasing the equipment and the supplier retained title to the equipment. We believe the DRA amendments to the Act will result in a loss of revenue to suppliers that will no longer receive payments for oxygen equipment after the 36th month of continuous use.

Based on data for items furnished in calendar year 2004, oxygen concentrators accounted for over 93 percent of Medicare utilization for stationary oxygen systems, in terms of both allowed charges and allowed services. Since oxygen concentrators can typically be purchased for $1,000 or less, we believe that 36 months of payment at approximately $200 per month would ensure the supplier is reimbursed for its cost for furnishing the equipment. The $200 allowed payment amount may be re-adjusted in the future to assure that payments are adequate, but not excessive. This could be accomplished though the competitive acquisition programs mandated by section 1847 of the Act or in accordance with our authority for adjusting fee schedule amounts at section 1842(b)(8) and (9) of the Act. Based on our data, approximately 36 percent of Medicare beneficiaries use oxygen equipment for more than 3 years and approximately 20 percent of Medicare beneficiaries use oxygen equipment for more than 5 years. In section K of the “provisions of the proposed regulation section of this preamble,” we propose to allow beneficiaries to obtain replacement oxygen equipment in cases where their equipment has been in continuous use for the reasonable useful lifetime of the equipment. Unless CMS or its carriers establish a specific reasonable useful lifetime for oxygen equipment, the default lifetime for DME of 5 years would apply. The main effect of this rule on suppliers is that they will not be able to receive payment for the equipment beyond 36 months for approximately 36 percent of Medicare patients. They will also not be able to receive payment for furnishing the same item to subsequent patients in these cases since they lose title to the equipment. In the case of oxygen concentrator systems and portable oxygen transfilling systems, delivery of oxygen contents is not necessary, and therefore, payment will not be made for the furnishing of contents for these types of beneficiary owned equipment. Under the old payment rules, payment for oxygen concentrators used for stationary equipment purposes would have continued at approximately $200 per month for the entire period of medical need. Section 5101(b) of the DRA mandates that payment for oxygen equipment end and that title to the equipment transfer after 36 months of continuous use.

In the case of liquid and gaseous oxygen systems, suppliers will continue to be paid for furnishing oxygen contents for beneficiary-owned systems. The current statewide monthly payment amounts for oxygen and oxygen equipment that would be paid during the 36-month period of continuous use for beneficiaries who only use stationary equipment range from $194.48 to $200.41, with the average statewide fee being $199.36. The current statewide monthly payment amount for furnishing oxygen contents for beneficiary owned equipment range from $137.54 to $198.12, with the average statewide fee being $156.07. The average decrease in Medicare fee schedule amounts that may result from the DRA changes for liquid and gaseous systems after the 36-month period (that is, shift from monthly payments for equipment and contents to monthly payments for contents only), is expected to be $43.29 ($199.36−$156.07). Therefore, this is the level of monthly reimbursement that would be lost after the 36-month period for suppliers that furnish oxygen and oxygen equipment to beneficiaries in these situations and who continue to furnish contents to these beneficiaries. Based on current fee schedule amounts for all oxygen and oxygen equipment, this equates to an average reduction in payment (from $199.36 to $156.07) of approximately 22 percent.

At the current monthly statewide fee schedule rates, which range from $194.48 to $200.41, suppliers of oxygen equipment are expected to be paid from $7,001.28 to $7,214.76 over 36 months. By comparison, a medical center operated by the Department of Veterans Affairs (VA) in Tampa, Florida, is the largest VA center in terms of number of veterans on oxygen therapy and services approximately 1,000 patients on oxygen by contracting with a locally based manufacturer to purchase the oxygen concentrators for $895 each. The medical center contracts with a local supplier for $90 to deliver and set up the concentrator to the patient's home. This local supplier also provides service and maintenance of the equipment at any time throughout the year for $48 per service episode. If the equipment needs to be replaced, the local supplier will furnish another concentrator for a $90 fee. The VA total payments over 5 years for an oxygen concentrator used by a veteran in this center plus payment for ten episodes of maintenance and servicing, assuming servicing every 6 months, would be $1,435, compared to total Medicare allowed charges of $7,164, on average, for a Medicare beneficiary. Based on this comparison, the Medicare payment amounts and methodology appear to be more than adequate.

We do not anticipate that transfer of ownership for oxygen equipment to the beneficiary after 36 months of continuous use would be a significant financial burden to suppliers because the effect is limited to a maximum of 36 percent of a supplier's Medicare business and because suppliers of oxygen equipment primarily furnish lower cost oxygen concentrators. We also do not anticipate a significant change in the rate of assignment of claims for oxygen equipment based on our belief that suppliers will be adequately reimbursed for furnishing the oxygen equipment.

Finally, if new oxygen and oxygen equipment classes and payment amounts are established in accordance with the proposed provisions in section I of this rule, there could potentially be a shift in utilization between the various oxygen equipment modalities, which could impact supplier revenues and sales volume for certain oxygen equipment manufacturers. However, since use of the authority to create such classes under section 1834(a)(9)(D) of the Act requires that these changes be budget-neutral, there would not a significant impact on overall Medicare payments to suppliers.

3. Capped Rental DME

This proposed rule, which limits to 13 months the total number of continuous months for which Medicare would pay for capped rental DME, after which the ownership of the capped rental item would be transferred from the supplier to the beneficiary, would result in significant savings for the Medicare program. Savings would be realized through: (1) The gradual elimination of rental payments for the 14th and 15th months of continuous use; and (2) changing the semi-annual payment for maintenance and servicing to payment only when reasonable and necessary maintenance and servicing is needed. We anticipate that suppliers may lose money due to the loss of 1 to 2 months rental in cases where beneficiaries need the item for more than 13 months and would not have otherwise selected the purchase option currently described in § 414.229(d). The average of the 2006 fee schedule amounts for all capped rental Start Printed Page 44105items for months 14 and 15 is approximately $152. We do not believe suppliers will suffer financially as a result of this provision based on data which shows that in 2004, 97 percent of suppliers accepted assignment for beneficiaries who chose the purchase option (§ 414.229(d)) in the 11th month of a capped rental period. This is an indication that suppliers were willing to accept the Medicare payment as payment in full for the capped rental item, even though they had been informed that the beneficiary would take over ownership of the item after the 13th month of continuous use. Therefore, we do not anticipate that transfer of ownership for capped rental equipment to the beneficiary after 13 months of continuous use would be a significant financial burden to suppliers.

For items for which the first rental payment falls on or after January 1, 2006, Medicare would only pay for maintenance and servicing as necessary. In a June 2002 report (OEI-03-00-00410), the Office of Inspector General (OIG) indicated that only 9 percent of the capped rental equipment with a June 2000 service date actually received any servicing between June and December 2000. Out of the $7.3 million Medicare paid for maintenance services from June 2000, we estimate that $6.5 million was paid for equipment that received no actual servicing. The OIG recommended to CMS in 2002 that we eliminate the semi-annual maintenance payment currently allowed for capped rental equipment and pay only for repairs when needed.

The combination of these two factors provides strong evidence that the Medicare rules for paying for maintenance and servicing of capped rental equipment furnished before January 1, 2006, were not cost-effective.

Impact on Beneficiaries

The DRA provisions and this proposed rule would result in savings for Medicare beneficiaries using oxygen equipment and capped rental items. For capped rental items, Medicare payments will be made for 13 continuous months and for oxygen equipment, payments will be made for 36 continuous months. After the rental period for each category of equipment expires, ownership of the equipment will transfer from the suppliers to the beneficiaries. Beneficiaries will continue to be financially responsible for a 20 percent coinsurance payment during the 13 or 36 month rental periods for capped rental items and oxygen equipment, respectively. However, beneficiaries will no longer have to make a monthly 20 percent coinsurance payment for the equipment after they own it. This will result in significant savings to beneficiaries.

For example, before the DRA, Medicare and the beneficiary made continuous payments for the rental of oxygen equipment that totaled about $200 per month. Of this amount, the beneficiary paid coinsurance of $40 which would equal $480 for a single year's rental, $1,440 over 36 months, and $2,400 over 5 years. After the DRA, beneficiaries will only pay a coinsurance amount for up to 36 months for the rental of oxygen equipment, after which time they will own the equipment. Thus, the DRA oxygen provisions result in savings of approximately $480 if beneficiaries use the equipment for 4 years, and $960 if they use the equipment for 5 years.

For capped rental items, beneficiaries will save coinsurance by not being responsible for any equipment payment after the 13th rental month or the semi-annual maintenance and servicing payment that was approximately equal to 10 percent of the purchase price for the equipment. Before the DRA, Medicare and the beneficiary would pay up to 15 months for capped rental items, and Medicare and the beneficiary would also pay for maintenance and servicing every six months. Thus, beneficiaries will save coinsurance payments related to both the equipment itself and the maintenance and servicing of that equipment.

The proposed rule would assure beneficiaries that suppliers that furnish the equipment for the first month would continue to furnish the equipment for the entire 36-month period of continuous use for oxygen equipment or the 13-month period of continuous use for capped rental.

Beneficiaries would also be assured that their oxygen and capped rental equipment would not be impermissibly swapped by the supplier at any time during the rental period. Under the proposed rule, we propose that a supplier may not provide different rented equipment to the beneficiary at any time during the 36 rental months for oxygen equipment or the 13 rental months for capped rental DME unless one of the following exceptions apply: The equipment is lost, stolen, or irreparably damaged; the equipment is being repaired while loaner equipment is in use; there is a change in the beneficiary's medical condition; or the carrier determines that a change in equipment is otherwise warranted.

We are proposing that suppliers inform beneficiaries whether they will accept or not accept assignment on all monthly rental claims during the 13-month rental period for capped rental items or the 36-month rental period for oxygen equipment in an upfront manner.

The proposed rule would also assure beneficiaries that following the transfer of title, the supplier would replace the item at no cost to the beneficiary in cases where the accumulated costs of repair exceed 60 percent of the cost of replacement, if the reasonable useful lifetime of the item (currently a default period of 5 years) has not expired.

C. Accounting Statement

As required by OMB Circular A-4 (available at ), http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf) in Table 10 below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments under the HH PPS as a result of the changes presented in this final rule based on the data for 7,370 HHAs in our database. All expenditures are classified as transfers to Medicare providers (that is, HHAs).

Table 10.—Accounting Statement: Classification of Estimated Expenditures, From CY 2006 to CY 2007

[In millions]

CategoryTransfers
Annualized monetized transfers$420
From whom to whom?Federal Government to HHAs.

In Table 11 below, we have prepared an accounting statement showing the classification of the expenditures associated with the DME provisions of this final rule. This table provides our best estimate of the decrease in Medicare payments under the DME benefit as a result of the changes presented in this final rule based on the 2004 allowed charge data for oxygen and capped rental DME in our database. All expenditures are classified as transfers to the Medicare program and its beneficiaries.

Table 11.—Accounting Statement: Classification of Estimated Expenditures

[In millions]

CategoryTransfers
Monetized transfers in FY 2007$80
Start Printed Page 44106
Monetized transfers in FY 2008130
Monetized transfers in FY 2009170
Monetized transfers in FY 2010220
Monetized transfers in FY 2011280
From whom to whom?Suppliers to Federal Government and beneficiaries.

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

End List of Subjects

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

Start Part

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices

1. The authority citation for part 414 continues to read as follows:

Start Authority

Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)).

End Authority

2. Amend § 414.210 as follows:

A. Revise paragraph (e).

B. Revise the introductory text to paragraph (f).

C. Revise paragraph (f)(2)

D. Add new paragraphs (f)(3) and (f)(4).

The revisions read as follows:

General payment rules.
* * * * *

(e) Maintenance and servicing.—(1) General rule. Except as provided in paragraph (e)(2) of this section, the carrier pays the reasonable and necessary charges for maintenance and servicing of beneficiary-owned equipment. Reasonable and necessary charges are those made for parts and labor not otherwise covered under a manufacturer's or supplier's warranty. Payment is made for replacement parts in a lump sum based on the carrier's consideration of the item. The carrier establishes a reasonable fee for labor associated with repairing, maintaining, and servicing the item. Payment is not made for maintenance and servicing of a rented item other than the maintenance and servicing fee for other durable medical equipment as described in § 414.229(e).

(2) Exception. For items purchased on or after June 1, 1989, no payment is made under the provisions of paragraph (e)(1) of this section for the maintenance and servicing of:

(i) Items requiring frequent and substantial servicing, as defined in § 414.222(a);

(ii) Capped rental items, as defined in § 414.229(a), that are not beneficiary-owned in accordance with § 414.229(d) or § 414.229(h); and

(iii) Oxygen equipment, as described in § 414.226, that is not beneficiary-owned in accordance with § 414.226(e).

(3) Supplier replacement of beneficiary-owned equipment based on accumulated repair costs. A supplier that transfers title to oxygen equipment or a capped rental item to a beneficiary in accordance with § 414.226(f) or § 414.229(f)(2) is responsible for furnishing replacement equipment at no cost to the beneficiary or to the Medicare program if the total repair costs that accumulate for the equipment after transfer of title exceed 60 percent of the cost to replace the equipment and the equipment has been in use for less than its reasonable useful lifetime, as determined under § 414.210(f)(1).

(f) Payment for replacement of equipment. If a beneficiary-owned item of DME or a prosthetic or orthotic device paid for under this subpart has been in continuous use by the patient for the equipment's reasonable useful lifetime or if the carrier determines that the item is lost, stolen, or irreparably damaged, the patient may elect to obtain a new piece of equipment.

* * * * *

(2) If the beneficiary elects to obtain replacement oxygen equipment, payment is made in accordance with § 414.226(a).

(3) If the beneficiary elects to obtain a replacement capped rental item, payment is made in accordance with § 414.229(a)(2) or (a)(3).

(4) For all other beneficiary-owned items, if the beneficiary elects to obtain replacement equipment, payment is made on a purchase basis.

3. Amend § 414.226 by—

A. Revising paragraph (a) and the heading of paragraph (b).

B. Revising paragraph (b)(3).

C. Adding paragraphs (b)(4) and (b)(5).

D. Redesignating paragraph (d) as paragraph (e).

E. Redesignating paragraph (c) as paragraph (d).

F. Revising newly redesignated paragraph (d).

G. Adding a new paragraph (c).

H. Revising newly redesignated paragraph (e)(1) introductory text.

I. Revising newly redesignated paragraph (e)(1)(i).

. Revising newly redesignated paragraph (e)(2)(i).

K. Revising newly redesignated paragraph (e)(2)(ii).

L. Adding new paragraphs (f) and (g).

The revisions and additions read as follows:

Oxygen and oxygen equipment.

(a) Payment rules. (1) Oxygen equipment. Payment for rental of oxygen equipment is made based on a monthly fee schedule amount during the period of medical need, but for no longer than a period of continuous use of 36 months. A period of continuous use is determined under the provisions in § 414.230.

(2) Oxygen contents. Payment for purchase of oxygen contents is made based on a monthly fee schedule amount until medical necessity ends.

(b) Monthly fee schedule amount for items furnished prior to 2007.

* * * * *

(3) For 1991 through 2006, the fee schedule amounts for items described in paragraphs (b)(1)(iii) and (iv) of this section are determined using the methodology contained in § 414.220 (d), (e), and (f).

(4) For 1991 through 2006, the fee schedule amounts for items described in paragraphs (b)(1)(i) and (ii) of this section are determined using the methodology contained in § 414.220 (d), (e), and (f).

(5) For 2005 and 2006, the fee schedule amounts determined under paragraph (b)(4) of this section are reduced using the methodology described in § 1834(a)(21)(A) of the Act.

(c) Monthly fee schedule amount for items furnished for years after 2006. (1) Monthly fee schedule amounts are separately calculated for the following items:

(i) Stationary oxygen equipment (including stationary concentrators) and oxygen contents (stationary and portable). Start Printed Page 44107

(ii) Portable equipment only (gaseous or liquid tanks).

(iii) Oxygen generating portable equipment only.

(iv) Stationary oxygen contents only.

(v) Portable oxygen contents only.

(2) The nationwide fee schedule amount for items described in paragraph (c)(1)(i) of this section is equal to the average fee schedule amount established under paragraph (b)(5) of this section reduced by $22.

(3) The nationwide fee schedule amount for items described in paragraph (c)(1)(ii) of this section is equal to the average of the fee schedule amounts established under paragraph (b)(5) of this section.

(4) The nationwide fee schedule amount for items described in paragraph (c)(1)(iii) of this section is equal to the sum of the average of the fee schedule amounts established under paragraph (b)(5) of this section for items described in paragraph (b)(1)(i) of this section and the average of the fee schedule amounts established under paragraph (b)(5) of this section for items described in paragraph (b)(1)(ii) of this section, increased by $10, and reduced by the nationwide fee schedule amount established under paragraph (c)(2) of this section.

(5) The nationwide fee schedule amount for items described in paragraph (c)(1)(iv) of this section is equal to 65 percent of the average fee schedule amount established under paragraph (b)(3) of this section for items described in paragraph (b)(1)(iii) of this section.

(6) The nationwide fee schedule amount for items described in paragraph (c)(1)(v) of this section is equal to 35 percent of the average fee schedule amount established under paragraph (b)(3) of this section for items described in paragraph (b)(1)(iii) of this section.

(d) Application of monthly fee schedule amounts. (1) The fee schedule amount for items described in paragraph (c)(1)(i) of this section is paid when the beneficiary rents stationary oxygen equipment.

(2) Subject to the limitation set forth in paragraph (e)(2) of this section, the fee schedule amount for items described in paragraph (c)(1)(ii) and (iii) of this section is paid when the beneficiary rents portable oxygen equipment.

(3) The fee schedule amount for items described in paragraph (c)(1)(iv) of this section is paid when the beneficiary owns stationary oxygen equipment that requires delivery of gaseous or liquid oxygen contents.

(4) The fee schedule amount for items described in paragraph (c)(1)(v) of this section is paid when the beneficiary owns portable oxygen equipment described in paragraph (c)(1)(ii) of this section, or rents portable oxygen equipment described in paragraph (c)(1)(ii) of this section and does not rent stationary oxygen equipment.

(e) Volume adjustments. (1) The fee schedule amount for an item described in paragraph (c)(1)(i) of this section is adjusted as follows:

(i) If the attending physician prescribes an oxygen flow rate exceeding four liters per minute, the fee schedule amount is increased by 50 percent, subject to the limit in paragraph (e)(2) of this section.

* * * * *

(2) * * *

(i) The sum of the monthly fee schedule amount for the items described in paragraphs (c)(1)(i) and (ii) or (iii) of this section; or

(ii) The adjusted fee schedule amount described in paragraph (e)(1)(i) of this section.

* * * * *

(f) Ownership of equipment. On the first day that begins after the 36th continuous month in which payment is made for oxygen equipment under paragraph (a)(1) of this section, the supplier must transfer title to the oxygen equipment to the beneficiary.

(g) Additional supplier requirements for rentals that begin on or after January 1, 2007. (1) The supplier that furnishes oxygen equipment for the first month during which payment is made under this section must continue to furnish the equipment until medical necessity ends, or the 36-month period of continuous use ends, whichever is earlier, unless-(i) The item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act;

(ii) The beneficiary relocates to an area that is outside the normal service area of the supplier that initially furnished the equipment;

(iii) The beneficiary elects to obtain oxygen equipment from a different supplier prior to the expiration of the 36-month rental period; or

(iv) CMS or the carrier determines that an exception should apply in an individual case based on the circumstances.

(2) Oxygen equipment furnished under this section may not be replaced by the supplier prior to the expiration of the 36-month rental period unless:

(i) The equipment is lost, stolen, or irreparably damaged;

(ii) The furnishing of loaner equipment is necessary while the equipment is being repaired;

(iii) The equipment is no longer medically necessary; or

(iv) The equipment is replaced in accordance with § 414.210(e)(3) or (f).

(3) Before furnishing oxygen equipment, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. A supplier's intentions could be expressed in the form of a written agreement between the supplier and the beneficiary.

4. Amend § 414.229 by—

A. Revising paragraphs (a), (f) and (g).

B. Adding paragraph (h).

The revisions and additions read as follows:

Other durable medical equipment-capped rental items.

(a) General payment rule. Payment is made for other durable medical equipment that is not subject to the payment provisions set forth in §§ 414.220 through 414.228 as follows:

(1) For items furnished prior to January 1, 2006, payment is made on a rental or purchase option basis in accordance with the rules set forth in paragraphs (b) through (e) of this section.

(2) For items other than power-driven wheelchairs furnished on or after January 1, 2006, payment is made in accordance with the rules set forth in paragraph (f) of this section.

(3) For power-driven wheelchairs furnished on or after January 1, 2006, payment is made in accordance with the rules set forth in paragraphs (f) or (h) of this section.

* * * * *

(f) Rules for Capped Rental Items Furnished Beginning on or after January 1, 2006. (1) For items furnished on or after January 1, 2006, payment is made based on a monthly rental fee schedule amount during the period of medical need, but for no longer than a period of continuous use of 13 months. A period of continuous use is determined under the provisions in § 414.230.

(2) The supplier must transfer title to the item to the beneficiary on the first day that begins after the 13th continuous month in which payments are made under paragraph (f)(1) of this section.

(3) Payment for maintenance and servicing of beneficiary-owned equipment is made in accordance with § 414.210(e).

(g) Additional supplier requirements for capped rental items that are furnished beginning on or after January 1, 2007. (1) The supplier that furnishes an item for the first month during which payment is made using the methodology described in paragraph (f)(1) of this Start Printed Page 44108section must continue to furnish the equipment until medical necessity ends, or the 13-month period of continuous use ends, whichever is earlier, unless—

(i) The item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act;

(ii) The beneficiary relocates to an area that is outside the normal service area of the supplier that initially furnished the equipment;

(iii) The beneficiary elects to obtain the equipment from a different supplier prior to the expiration of the 13-month rental period; or

(iv) CMS or the carrier determines that an exception should apply in an individual case based on the circumstances.

(2) A capped rental item furnished under this section may not be replaced by the supplier prior to the expiration of the 13-month rental period unless:

(i) The item is lost, stolen, or irreparably damaged;

(ii) The furnishing of a loaner item is necessary while the item is being repaired;

(iii) The item is no longer medically necessary; or

(iv) The item is replaced in accordance with § 414.210(e)(3) or (f).

(3) Before furnishing a capped rental item, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. A supplier's intentions could be expressed in the form of a written agreement between the supplier and the beneficiary.

(h) Purchase of power-driven wheelchairs furnished on or after January 1, 2006. Suppliers must offer beneficiaries the option to purchase power-driven wheelchairs at the time the equipment is initially furnished. Payment is made on a lump-sum purchase basis if the beneficiary chooses this option.

5. Amend § 414.230 by—

A. Revising paragraphs (b)(1) and (b)(2).

B. Revising paragraph (f).

The revisions read as follows:

Determining a period of continuous use.
* * * * *

(b) Continuous use. (1) A period of continuous use begins with the first month of medical need and lasts until a beneficiary's medical need for a particular item of durable medical equipment ends.

(2) In the case of a beneficiary receiving oxygen equipment on December 31, 2005, the period of continuous use for the equipment begins on January 1, 2006.

* * * * *

(f) New equipment. (1) If a beneficiary changes equipment or requires additional equipment based on a physician's prescription, and the new or additional equipment is found to be necessary, a new period of continuous use begins for the new or additional equipment. A new period of continuous use does not begin for base equipment that is modified by an addition.

(2) A new period of continuous use does not begin when a beneficiary changes from one oxygen equipment modality to another.

* * * * *
End Part Start Part

PART 484—HOME HEALTH SERVICES

6. The authority citation for part 484 continues to read as follows:

Start Authority

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

End Authority

7. Amend § 484.225 as follows:

A. Revise paragraph (f).

B. Redesignate paragraph (g) as paragraph (h).

C. Add new paragraph (g).

D. Revise newly redesignated paragraph (h).

E. Add new paragraph (i).

The revisions and additions read as follows:

Annual update of the unadjusted national prospective 60-day episode payment rate.
* * * * *

(f) For calendar year 2005, the unadjusted national prospective 60-day episode payment rate is equal to the rate from the previous calendar year, increased by the applicable home health market basket minus 0.8 percentage points.

(g) For calendar year 2006, the unadjusted national prospective 60-day episode payment rate is equal to the rate from calendar year 2005.

(h) For 2007 and subsequent calendar years, in the case of a home health agency that submits home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount.

(i) For 2007 and subsequent calendar years, in the case of a home health agency that does not submit home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount minus 2 percentage points. Any reduction of the percentage change will apply only to the calendar year involved and will not be taken into account in computing the prospective payment amount for a subsequent calendar year.

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

Start Signature

Dated: June 16, 2006.

Mark B. McClellan,

Administrator, Centers for Medicare & Medicaid Services.

Approved: July 14, 2006.

Michael O. Leavitt,

Secretary.

End Signature Start Printed Page 44109

Addendum A.—Proposed CY 2007 Wage Index for Rural Areas by CBSA; Applicable Pre-Floor and Pre-Reclassified Hospital Wage Index

CBSA codeNonurban AreaWage index
01Alabama0.7652
02Alaska1.0680
03Arizona0.8924
04Arkansas0.7335
05California1.1302
06Colorado0.9342
07Connecticut1.1753
08Delaware0.9723
10Florida0.8595
11Georgia0.7560
12Hawaii1.0467
13Idaho0.8134
14Illinois0.8327
15Indiana0.8477
16Iowa0.8697
17Kansas0.8000
18Kentucky0.7780
19Louisiana0.7450
20Maine0.8410
21Maryland0.8942
22Massachusetts11.0216
23Michigan0.9052
24Minnesota0.9167
25Mississippi0.7565
26Missouri0.7934
27Montana0.8605
28Nebraska0.8693
29Nevada0.8960
30New Hampshire1.0800
31New Jersey1
32New Mexico0.8347
33New York0.8250
34North Carolina0.8599
35North Dakota0.7228
36Ohio0.8674
37Oklahoma0.7640
38Oregon0.9770
39Pennsylvania0.8332
40Puerto Rico 10.4047
41Rhode Island 1
42South Carolina0.8583
43South Dakota0.8496
44Tennessee0.7841
45Texas0.7973
46Utah0.8154
47Vermont0.9944
48Virgin Islands0.7615
49Virginia0.7954
50Washington1.0281
51West Virginia0.7620
52Wisconsin0.9468
53Wyoming0.9311
65Guam0.9611
1 All counties within the State are classified as urban, with the exception of Massaschusetts and Puerto Pico. Massachusetts and Puerto Rico have areas designated as rural, however, no short-term, acute care hospitals are located in the area(s) for CY 2007.

Addendum B.—Proposed CY 2007 Wage Index for Urban Areas by CBSA; Applicable Pre-Floor and Pre-Reclassified Hospital Wage Index

CBSA codeUrban area (constituent counties)Wage index
10180Abilene, TX0.8014
Callahan County, TX
Jones County, TX
Taylor County, TX
10380Aguadilla-Isabela-San Sebastian, PR0.3922
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, OH0.8639
Portage County, OH
Summit County, OH
10500Albany, GA0.8962
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580Albany-Schenectady-Troy, NY0.8735
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740Albuquerque, NM0.9474
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780Alexandria, LA0.8020
Grant Parish, LA
Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ0.9910
Warren County, NJ
Carbon County, PA
Start Printed Page 44110
Lehigh County, PA
Northampton County, PA
11020Altoona, PA0.8727
Blair County, PA
11100Amarillo, TX0.9177
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180Ames, IA0.9777
Story County, IA
11260Anchorage, AK1.2045
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300Anderson, IN0.8790
Madison County, IN
11340Anderson, SC0.8959
Anderson County, SC
11460Ann Arbor, MI1.0838
Washtenaw County, MI
11500Anniston-Oxford, AL0.7868
Calhoun County, AL
11540Appleton, WI0.9472
Calumet County, WI
Outagamie County, WI
11700Asheville, NC0.9093
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020Athens-Clarke County, GA0.9857
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA0.9772
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, NJ1.1751
Atlantic County, NJ
12220Auburn-Opelika, AL0.8110
Lee County, AL
12260Augusta-Richmond County, GA-SC0.9678
Burke County, GA
Start Printed Page 44111
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420Austin-Round Rock, TX0.9360
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540Bakersfield, CA1.0605
Kern County, CA
12580Baltimore-Towson, MD1.0106
Anne Arundel County, MD
Baltimore County, MD
Carroll County, MD
Harford County, MD
Howard County, MD
Queen Anne's County, MD
Baltimore City, MD
12620Bangor, ME0.9719
Penobscot County, ME
12700Barnstable Town, MA1.2561
Barnstable County, MA
12940Baton Rouge, LA0.8099
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, MI0.9746
Calhoun County, MI
13020Bay City, MI0.9271
Bay County, MI
13140Beaumont-Port Arthur, TX0.8610
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380Bellingham, WA1.1124
Whatcom County, WA
13460Bend, OR1.0762
Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.0923
Frederick County, MD
Montgomery County, MD
13740Billings, MT0.8728
Carbon County, MT
Yellowstone County, MT
13780Binghamton, NY0.8798
Broome County, NY
Tioga County, NY
13820Birmingham-Hoover, AL0.8919
Bibb County, AL
Blount County, AL
Chilton County, AL
Jefferson County, AL
St. Clair County, AL
Shelby County, AL
Walker County, AL
13900Bismarck, ND0.7253
Burleigh County, ND
Morton County, ND
13980Blacksburg-Christiansburg-Radford, VA0.8227
Giles County, VA
Montgomery County, VA
Start Printed Page 44112
Pulaski County, VA
Radford City, VA
14020Bloomington, IN0.8548
Greene County, IN
Monroe County, IN
Owen County, IN
14060Bloomington-Normal, IL0.8960
McLean County, IL
14260Boise City-Nampa, ID0.9417
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484Boston-Quincy, MA1.1693
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500Boulder, CO1.0368
Boulder County, CO
14540Bowling Green, KY0.8162
Edmonson County, KY
Warren County, KY
14740Bremerton-Silverdale, WA1.0932
Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.2681
Fairfield County, CT
15180Brownsville-Harlingen, TX0.9446
Cameron County, TX
15260Brunswick, GA1.0097
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380Buffalo-Niagara Falls, NY0.9483
Erie County, NY
Niagara County, NY
15500Burlington, NC0.8689
Alamance County, NC
15540Burlington-South Burlington, VT0.9491
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.0918
Middlesex County, MA
15804Camden, NJ1.0411
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940Canton-Massillon, OH0.9047
Carroll County, OH
Stark County, OH
15980Cape Coral-Fort Myers, FL0.9359
Lee County, FL
16180Carson City, NV1.0043
Carson City, NV
16220Casper, WY0.9161
Natrona County, WY
16300Cedar Rapids, IA0.8903
Benton County, IA
Jones County, IA
Linn County, IA
16580Champaign-Urbana, IL0.9661
Champaign County, IL
Ford County, IL
Piatt County, IL
16620Charleston, WV0.8558
Boone County, WV
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Start Printed Page 44113
Putnam County, WV
16700Charleston-North Charleston, SC0.9156
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC0.9564
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820Charlottesville, VA1.0143
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860Chattanooga, TN-GA0.8963
Catoosa County, GA
Dade County, GA
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940Cheyenne, WY0.9076
Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.0745
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, CA1.1073
Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN0.9617
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-KY0.8451
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420Cleveland, TN0.8124
Bradley County, TN
Polk County, TN
17460Cleveland-Elyria-Mentor, OH0.9385
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
17660Coeur d'Alene, ID0.9360
Kootenai County, ID
Start Printed Page 44114
17780College Station-Bryan, TX0.9061
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820Colorado Springs, CO0.9718
El Paso County, CO
Teller County, CO
17860Columbia, MO0.8557
Boone County, MO
Howard County, MO
17900Columbia, SC0.8028
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980Columbus, GA-AL0.8254
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Muscogee County, GA
18020Columbus, IN0.9334
Bartholomew County, IN
18140Columbus, OH1.0122
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, TX0.8579
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700Corvallis, OR1.1566
Benton County, OR
19060Cumberland, MD-WV0.8859
Allegany County, MD
Mineral County, WV
19124Dallas-Plano-Irving, TX1.0093
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, GA0.9061
Murray County, GA
Whitfield County, GA
19180Danville, IL0.9283
Vermilion County, IL
19260Danville, VA0.8466
Pittsylvania County, VA
Danville City, VA
19340Davenport-Moline-Rock Island, IA-IL0.8557
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380Dayton, OH0.9053
Greene County, OH
Miami County, OH
Montgomery County, OH
Preble County, OH
Start Printed Page 44115
19460Decatur, AL0.8220
Lawrence County, AL
Morgan County, AL
19500Decatur, IL0.8187
Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.9280
Volusia County, FL
19740Denver-Aurora, CO1.0947
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, IA0.9136
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Warren County, IA
19804Detroit-Livonia-Dearborn, MI1.0223
Wayne County, MI
20020Dothan, AL0.7438
Geneva County, AL
Henry County, AL
Houston County, AL
20100Dover, DE0.9865
Kent County, DE
20220Dubuque, IA0.9150
Dubuque County, IA
20260Duluth, MN-WI1.0070
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500Durham, NC0.9843
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740Eau Claire, WI0.9647
Chippewa County, WI
Eau Claire County, WI
20764Edison, NJ1.1207
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940El Centro, CA0.9092
Imperial County, CA
21060Elizabethtown, KY0.8713
Hardin County, KY
Larue County, KY
21140Elkhart-Goshen, IN0.9442
Elkhart County, IN
21300Elmira, NY0.8213
Chemung County, NY
21340El Paso, TX0.9069
El Paso County, TX
21500Erie, PA0.8704
Erie County, PA
21604Essex County, MA1.0437
Essex County, MA
21660Eugene-Springfield, OR1.0896
Lane County, OR
21780Evansville, IN-KY0.8830
Gibson County, IN
Start Printed Page 44116
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820Fairbanks, AK1.1079
Fairbanks North Star Borough, AK
21940Fajardo, PR0.4044
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020Fargo, ND-MN0.8265
Cass County, ND
Clay County, MN
22140Farmington, NM0.8604
San Juan County, NM
22180Fayetteville, NC0.8961
Cumberland County, NC
Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.8761
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
22380Flagstaff, AZ1.1621
Coconino County, AZ
22420Flint, MI1.0988
Genesee County, MI
22500Florence, SC0.8421
Darlington County, SC
Florence County, SC
22520Florence-Muscle Shoals, AL0.7967
Colbert County, AL
Lauderdale County, AL
22540Fond du Lac, WI1.0081
Fond du Lac County, WI
22660Fort Collins-Loveland, CO0.9561
Larimer County, CO
22744Fort Lauderdale-Pompano Beach-Deerfield1.0151
Beach, FL
Broward County, FL
22900Fort Smith, AR-OK0.7745
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.8658
Okaloosa County, FL
23060Fort Wayne, IN0.9504
Allen County, IN
Wells County, IN
Whitley County, IN
23104Fort Worth-Arlington, TX0.9587
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420Fresno, CA1.0965
Fresno County, CA
23460Gadsden, AL0.8080
Etowah County, AL
23540Gainesville, FL0.9312
Alachua County, FL
Gilchrist County, FL
23580Gainesville, GA0.8974
Hall County, GA
23844Gary, IN0.9281
Jasper County, IN
Lake County, IN
Start Printed Page 44117
Newton County, IN
Porter County, IN
24020Glens Falls, NY0.8339
Warren County, NY
Washington County, NY
24140Goldsboro, NC0.9187
Wayne County, NC
24220Grand Forks, ND-MN0.7963
Polk County, MN
Grand Forks County, ND
24300Grand Junction, CO0.9685
Mesa County, CO
24340Grand Rapids-Wyoming, MI0.9470
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500Great Falls, MT0.8613
Cascade County, MT
24540Greeley, CO0.9619
Weld County, CO
24580Green Bay, WI0.9804
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660Greensboro-High Point, NC0.8735
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780Greenville, NC0.9449
Greene County, NC
Pitt County, NC
24860Greenville, SC0.9733
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020Guayama, PR0.3241
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.8931
Hancock County, MS
Harrison County, MS
Stone County, MS
25180Hagerstown-Martinsburg, MD-WV0.9054
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260Hanford-Corcoran, CA1.0142
Kings County, CA
25420Harrisburg-Carlisle, PA0.9419
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500Harrisonburg, VA0.9090
Rockingham County, VA
Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.0916
Hartford County, CT
Litchfield County, CT
Middlesex County, CT
Tolland County, CT
25620Hattiesburg, MS0.7443
Forrest County, MS
Lamar County, MS
Perry County, MS
25860Hickory-Lenoir-Morganton, NC0.9021
Alexander County, NC
Burke County, NC
Caldwell County, NC
Start Printed Page 44118
Catawba County, NC
25980 \2Hinesville-Fort Stewart, GA0.9163
Liberty County, GA
Long County, GA
26100Holland-Grand Haven, MI0.9205
Ottawa County, MI
26180Honolulu, HI1.1067
Honolulu County, HI
26300Hot Springs, AR0.8797
Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.8003
Lafourche Parish, LA
Terrebonne Parish, LA
26420Houston-Baytown-Sugar Land, TX1.0026
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-OH0.9013
Boyd County, KY
Greenup County, KY
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620Huntsville, AL0.9051
Limestone County, AL
Madison County, AL
26820Idaho Falls, ID0.9104
Bonneville County, ID
Jefferson County, ID
26900Indianapolis, IN0.9766
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, IA0.9731
Johnson County, IA
Washington County, IA
27060Ithaca, NY0.9831
Tompkins County, NY
27100Jackson, MI0.9577
Jackson County, MI
27140Jackson, MS0.8286
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180Jackson, TN0.8869
Chester County, TN
Madison County, TN
27260Jacksonville, FL0.9042
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340Jacksonville, NC0.8245
Start Printed Page 44119
Onslow County, NC
27500Janesville, WI0.9672
Rock County, WI
27620Jefferson City, MO0.8347
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740Johnson City, TN0.8057
Carter County, TN
Unicoi County, TN
Washington County, TN
27780Johnstown, PA0.8635
Cambria County, PA
27860Jonesboro, AR0.7609
Craighead County, AR
Poinsett County, AR
27900Joplin, MO0.8620
Jasper County, MO
Newton County, MO
28020Kalamazoo-Portage, MI1.0723
Kalamazoo County, MI
Van Buren County, MI
28100Kankakee-Bradley, IL0.9990
Kankakee County, IL
28140Kansas City, MO-KS0.9514
Franklin County, KS
Johnson County, KS
Leavenworth County, KS
Linn County, KS
Miami County, KS
Wyandotte County, KS
Bates County, MO
Caldwell County, MO
Cass County, MO
Clay County, MO
Clinton County, MO
Jackson County, MO
Lafayette County, MO
Platte County, MO
Ray County, MO
28420Kennewick-Richland-Pasco, WA1.0361
Benton County, WA
Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.9098
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700Kingsport-Bristol-Bristol, TN-VA0.7975
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740Kingston, NY0.9383
Ulster County, NY
28940Knoxville, TN0.8263
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020Kokomo, IN0.9460
Howard County, IN
Tipton County, IN
29100La Crosse, WI-MN0.9442
Houston County, MN
La Crosse County, WI
29140Lafayette, IN0.8972
Benton County, IN
Start Printed Page 44120
Carroll County, IN
Tippecanoe County, IN
29180Lafayette, LA0.8293
Lafayette Parish, LA
St. Martin Parish, LA
29340Lake Charles, LA0.7928
Calcasieu Parish, LA
Cameron Parish, LA
29404Lake County-Kenosha County, IL-WI1.0406
Lake County, IL
Kenosha County, WI
29460Lakeland, FL0.8895
Polk County, FL
29540Lancaster, PA0.9644
Lancaster County, PA
29620Lansing-East Lansing, MI1.0102
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700Laredo, TX0.7825
Webb County, TX
29740Las Cruces, NM0.9290
Dona Ana County, NM
29820Las Vegas-Paradise, NV1.1450
Clark County, NV
29940Lawrence, KS0.8353
Douglas County, KS
30020Lawton, OK0.8080
Comanche County, OK
30140Lebanon, PA0.8695
Lebanon County, PA
30300Lewiston, ID-WA0.9871
Nez Perce County, ID
Asotin County, WA
30340Lewiston-Auburn, ME0.9148
Androscoggin County, ME
30460Lexington-Fayette, KY0.9191
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620Lima, OH0.9058
Allen County, OH
30700Lincoln, NE1.0110
Lancaster County, NE
Seward County, NE
30780Little Rock-North Little Rock, AR0.8906
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860Logan, UT-ID0.9038
Franklin County, ID
Cache County, UT
30980Longview, TX0.8803
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020Longview, WA1.0029
Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale, CA1.1752
Los Angeles County, CA
31140Louisville, KY-IN0.9135
Clark County, IN
Floyd County, IN
Harrison County, IN
Start Printed Page 44121
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, TX0.8628
Crosby County, TX
Lubbock County, TX
31340Lynchburg, VA0.8710
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420Macon, GA0.9518
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460Madera, CA0.8169
Madera County, CA
31540Madison, WI1.0736
Columbia County, WI
Dane County, WI
Iowa County, WI
31700Manchester-Nashua, NH1.0261
Hillsborough County, NH
Merrimack County, NH
31900Mansfield, OH0.9287
Richland County, OH
32420Mayaguez, PR0.3857
Hormigueros Municipio, PR
Mayaguez Municipio, PR
32580McAllen-Edinburg-Pharr, TX0.8788
Hidalgo County, TX
32780Medford, OR1.0837
Jackson County, OR
32820Memphis, TN-MS-AR0.9361
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, CA1.1415
Merced County, CA
33124Miami-Miami Beach-Kendall, FL0.9830
Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9093
LaPorte County, IN
33260Midland, TX0.9803
Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0236
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.0965
Anoka County, MN
Carver County, MN
Chisago County, MN
Start Printed Page 44122
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, MT0.8944
Missoula County, MT
33660Mobile, AL0.7947
Mobile County, AL
33700Modesto, CA1.1590
Stanislaus County, CA
33740Monroe, LA0.8011
Ouachita Parish, LA
Union Parish, LA
33780Monroe, MI0.9725
Monroe County, MI
33860Montgomery, AL0.8023
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060Morgantown, WV0.8438
Monongalia County, WV
Preston County, WV
34100Morristown, TN0.7944
Grainger County, TN
Hamblen County, TN
Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.0536
Skagit County, WA
34620Muncie, IN0.8299
Delaware County, IN
34740Muskegon-Norton Shores, MI0.9957
Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.8824
Horry County, SC
34900Napa, CA1.3496
Napa County, CA
34940Naples-Marco Island, FL0.9959
Collier County, FL
34980Nashville-Davidson--Murfreesboro, TN0.9862
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, NY1.2681
Nassau County, NY
Suffolk County, NY
35084Newark-Union, NJ-PA1.1890
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300New Haven-Milford, CT1.1974
Start Printed Page 44123
New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.8858
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-NJ1.3208
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, MI0.8931
Berrien County, MI
35980Norwich-New London, CT1.1953
New London County, CT
36084Oakland-Fremont-Hayward, CA1.5420
Alameda County, CA
Contra Costa County, CA
36100Ocala, FL0.8883
Marion County, FL
36140Ocean City, NJ1.0490
Cape May County, NJ
36220Odessa, TX1.0119
Ector County, TX
36260Ogden-Clearfield, UT0.9011
Davis County, UT
Morgan County, UT
Weber County, UT
36420Oklahoma City, OK0.8853
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500Olympia, WA1.1100
Thurston County, WA
36540Omaha-Council Bluffs, NE-IA0.9467
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, FL0.9422
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780Oshkosh-Neenah, WI0.9332
Winnebago County, WI
36980Owensboro, KY0.8763
Daviess County, KY
Hancock County, KY
McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.1591
Ventura County, CA
Start Printed Page 44124
37340Palm Bay-Melbourne-Titusville, FL0.9448
Brevard County, FL
37460Panama City-Lynn Haven, FL0.8087
Bay County, FL
37620Parkersburg-Marietta, WV-OH0.7940
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700Pascagoula, MS0.8230
George County, MS
Jackson County, MS
37860Pensacola-Ferry Pass-Brent, FL0.8014
Escambia County, FL
Santa Rosa County, FL
37900Peoria, IL0.8998
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964Philadelphia, PA1.1018
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0305
Maricopa County, AZ
Pinal County, AZ
38220Pine Bluff, AR0.8398
Cleveland County, AR
Jefferson County, AR
Lincoln County, AR
38300Pittsburgh, PA0.8685
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340Pittsfield, MA1.0284
Berkshire County, MA
38540Pocatello, ID0.9417
Bannock County, ID
Power County, ID
38660Ponce, PR0.4851
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME0.9926
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.1436
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, FL0.9851
Martin County, FL
St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.0913
Dutchess County, NY
Orange County, NY
39140Prescott, AZ0.9853
Start Printed Page 44125
Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.0804
Bristol County, MA
Bristol County, RI
Kent County, RI
Newport County, RI
Providence County, RI
Washington County, RI
39340Provo-Orem, UT0.9554
Juab County, UT
Utah County, UT
39380Pueblo, CO0.8552
Pueblo County, CO
39460Punta Gorda, FL0.9421
Charlotte County, FL
39540Racine, WI0.9192
Racine County, WI
39580Raleigh-Cary, NC0.9879
Franklin County, NC
Johnston County, NC
Wake County, NC
39660Rapid City, SD1.0351
Meade County, SD
Pennington County, SD
39740Reading, PA0.9639
Berks County, PA
39820Redding, CA1.3221
Shasta County, CA
39900Reno-Sparks, NV1.1984
Storey County, NV
Washoe County, NV
40060Richmond, VA0.9193
Amelia County, VA
Caroline County, VA
Charles City County, VA
Chesterfield County, VA
Cumberland County, VA
Dinwiddie County, VA
Goochland County, VA
Hanover County, VA
Henrico County, VA
King and Queen County, VA
King William County, VA
Louisa County, VA
New Kent County, VA
Powhatan County, VA
Prince George County, VA
Sussex County, VA
Colonial Heights City, VA
Hopewell City, VA
Petersburg City, VA
Richmond City, VA
40140Riverside-San Bernardino-Ontario, CA1.0934
Riverside County, CA
San Bernardino County, CA
40220Roanoke, VA0.8662
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340Rochester, MN1.1260
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380Rochester, NY0.9005
Livingston County, NY
Monroe County, NY
Ontario County, NY
Start Printed Page 44126
Orleans County, NY
Wayne County, NY
40420Rockford, IL1.0007
Boone County, IL
Winnebago County, IL
40484Rockingham County-Strafford County, NH1.0177
Rockingham County, NH
Strafford County, NH
40580Rocky Mount, NC0.8869
Edgecombe County, NC
Nash County, NC
40660Rome, GA0.9316
Floyd County, GA
40900Sacramento-Arden-Arcade-Roseville, CA1.3373
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980Saginaw-Saginaw Township North, MI0.8889
Saginaw County, MI
41060St. Cloud, MN1.0380
Benton County, MN
Stearns County, MN
41100St. George, UT0.9281
Washington County, UT
41140St. Joseph, MO-KS1.0136
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180St. Louis, MO-IL0.9013
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
Macoupin County, IL
Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
Jefferson County, MO
Lincoln County, MO
St. Charles County, MO
St. Louis County, MO
Warren County, MO
Washington County, MO
St. Louis City, MO
41420Salem, OR1.0457
Marion County, OR
Polk County, OR
41500Salinas, CA1.4459
Monterey County, CA
41540Salisbury, MD0.8969
Somerset County, MD
Wicomico County, MD
41620Salt Lake City, UT0.9418
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660San Angelo, TX0.8377
Irion County, TX
Tom Green County, TX
41700San Antonio, TX0.8860
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
Kendall County, TX
Start Printed Page 44127
Medina County, TX
Wilson County, TX
41740San Diego-Carlsbad-San Marcos, CA1.1374
San Diego County, CA
41780Sandusky, OH0.9319
Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.5071
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900San German-Cabo Rojo, PR0.4893
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San German Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.5293
San Benito County, CA
Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.4397
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayamon Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canovanas Municipio, PR
Carolina Municipio, PR
Catano Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comerio Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR
Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
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, CA1.1619
San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.1294
Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.1075
Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.5531
Santa Cruz County, CA
42140Santa Fe, NM1.0843
Santa Fe County, NM
Start Printed Page 44128
42220Santa Rosa-Petaluma, CA1.4489
Sonoma County, CA
42260Sarasota-Bradenton-Venice, FL0.9885
Manatee County, FL
Sarasota County, FL
42340Savannah, GA0.9087
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540Scranton--Wilkes-Barre, PA0.8521
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.1454
King County, WA
Snohomish County, WA
42680Sebastian-Vero Beach, FL0.9590
43100Sheboygan, WI0.9042
Sheboygan County, WI
43300Sherman-Denison, TX0.8517
Grayson County, TX
43340Shreveport-Bossier City, LA0.8881
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580Sioux City, IA-NE-SD0.9217
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620Sioux Falls, SD0.9587
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780South Bend-Mishawaka, IN-MI0.9690
St. Joseph County, IN
Cass County, MI
43900Spartanburg, SC0.9190
Spartanburg County, SC
44060Spokane, WA1.0465
Spokane County, WA
44100Springfield, IL0.8905
Menard County, IL
Sangamon County, IL
44140Springfield, MA1.0080
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180Springfield, MO0.8484
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220Springfield, OH0.8462
Clark County, OH
44300State College, PA0.8799
Centre County, PA
44700Stockton, CA1.1462
San Joaquin County, CA
44940Sumter, SC0.8098
Sumter County, SC
45060Syracuse, NY0.9709
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104Tacoma, WA1.0808
Pierce County, WA
45220Tallahassee, FL0.9299
Start Printed Page 44129
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300Tampa-St. Petersburg-Clearwater, FL0.9160
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460Terre Haute, IN0.8661
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500Texarkana, TX-Texarkana, AR0.8118
Miller County, AR
Bowie County, TX
45780Toledo, OH0.9599
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820Topeka, KS0.8746
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940Trenton-Ewing, NJ1.0877
Mercer County, NJ
46060Tucson, AZ0.9219
Pima County, AZ
46140Tulsa, OK0.8104
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
Wagoner County, OK
46220Tuscaloosa, AL0.8641
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340Tyler, TX0.8827
Smith County, TX
46540Utica-Rome, NY0.8402
Herkimer County, NY
Oneida County, NY
46660Valdosta, GA0.8344
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700Vallejo-Fairfield, CA1.5164
Solano County, CA
47020Victoria, TX0.8575
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ0.9849
Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.8805
Currituck County, NC
Gloucester County, VA
Isle of Wight County, VA
James City County, VA
Mathews County, VA
Surry County, VA
York County, VA
Start Printed Page 44130
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, CA0.9986
Tulare County, CA
47380Waco, TX0.8648
McLennan County, TX
47580Warner Robins, GA0.8394
Houston County, GA
47644Warren-Farmington Hills-Troy, MI1.0126
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA-MD-WV1.1074
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Arlington County, VA
Clarke County, VA
Fairfax County, VA
Fauquier County, VA
Loudoun County, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940Waterloo-Cedar Falls, IA0.8422
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140Wausau, WI0.9740
Marathon County, WI
48260Weirton-Steubenville, WV-OH0.8078
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300Wenatchee, WA1.0365
Chelan County, WA
Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL0.9657
Palm Beach County, FL
48540Wheeling, WV-OH0.7022
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620Wichita, KS0.9079
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660Wichita Falls, TX0.8326
Archer County, TX
Clay County, TX
Wichita County, TX
Start Printed Page 44131
48700Williamsport, PA0.8126
Lycoming County, PA
48864Wilmington, DE-MD-NJ1.0703
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900Wilmington, NC0.9853
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020Winchester, VA-WV1.0109
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180Winston-Salem, NC0.9293
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340Worcester, MA1.0741
Worcester County, MA
49420Yakima, WA0.9865
Yakima County, WA
49500Yauco, PR0.3861
Guanica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620York-Hanover, PA0.9414
York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.8817
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700Yuba City, CA1.0749
Sutter County, CA
Yuba County, CA
49740Yuma, AZ0.9125
Yuma County, AZ
2 At this time, there are no hospitals in these urban areas on which to base a wage index. Therefore, the urban wage index value is based on the average wage index of all urban areas within the State.

Addendum C.—Comparison of HH PPS Transition Wage Index for CY 2006 and Pre-Floor and Pre-Reclassified Hospital Wage Index for CY 2007

SSA state/county codeCounty nameCBSA No.CY 2006 HH PPS transition wage indexProposed CY 2007 CBSA-based wage indexPercent change CY 2006-CY 2007
01000Autauga County, Alabama338600.86180.8023-6.90
01010Baldwin County, Alabama999010.76540.7652-0.03
01020Barbour County, Alabama999010.74390.76522.86
01030Bibb County, Alabama138200.81960.89198.82
01040Blount County, Alabama138200.89800.8919-0.68
01050Bullock County, Alabama999010.74390.76522.86
01060Butler County, Alabama999010.74390.76522.86
01070Calhoun County, Alabama115000.76820.78682.42
01080Chambers County, Alabama999010.74390.76522.86
01090Cherokee County, Alabama999010.74390.76522.86
01100Chilton County, Alabama138200.81960.89198.82
01110Choctaw County, Alabama999010.74390.76522.86
01120Clarke County, Alabama999010.74390.76522.86
01130Clay County, Alabama999010.74390.76522.86
01140Cleburne County, Alabama999010.74390.76522.86
01150Coffee County, Alabama999010.74390.76522.86
01160Colbert County, Alabama225200.82720.7967-3.69
01170Conecuh County, Alabama999010.74390.76522.86
Start Printed Page 44132
01180Coosa County, Alabama999010.74390.76522.86
01190Covington County, Alabama999010.74390.76522.86
01200Crenshaw County, Alabama999010.74390.76522.86
01210Cullman County, Alabama999010.74390.76522.86
01220Dale County, Alabama999010.75740.76521.03
01230Dallas County, Alabama999010.74390.76522.86
01240De Kalb County, Alabama999010.74390.76522.86
01250Elmore County, Alabama338600.86180.8023-6.90
01260Escambia County, Alabama999010.74390.76522.86
01270Etowah County, Alabama234600.79380.80801.79
01280Fayette County, Alabama999010.74390.76522.86
01290Franklin County, Alabama999010.74390.76522.86
01300Geneva County, Alabama200200.75770.7438-1.83
01310Greene County, Alabama462200.80390.86417.49
01320Hale County, Alabama462200.80390.86417.49
01330Henry County, Alabama200200.75770.7438-1.83
01340Houston County, Alabama200200.77110.7438-3.54
01350Jackson County, Alabama999010.74390.76522.86
01360Jefferson County, Alabama138200.89800.8919-0.68
01370Lamar County, Alabama999010.74390.76522.86
01380Lauderdale County, Alabama225200.82720.7967-3.69
01390Lawrence County, Alabama194600.84690.8220-2.94
01400Lee County, Alabama122200.81000.81100.12
01410Limestone County, Alabama266200.91460.9051-1.04
01420Lowndes County, Alabama338600.80250.8023-0.02
01430Macon County, Alabama999010.74390.76522.86
01440Madison County, Alabama266200.91460.9051-1.04
01450Marengo County, Alabama999010.74390.76522.86
01460Marion County, Alabama999010.74390.76522.86
01470Marshall County, Alabama999010.74390.76522.86
01480Mobile County, Alabama336600.78760.79470.90
01490Monroe County, Alabama999010.74390.76522.86
01500Montgomery County, Alabama338600.86180.8023-6.90
01510Morgan County, Alabama194600.84690.8220-2.94
01520Perry County, Alabama999010.74390.76522.86
01530Pickens County, Alabama999010.74390.76522.86
01540Pike County, Alabama999010.74390.76522.86
01550Randolph County, Alabama999010.74390.76522.86
01560Russell County, Alabama179800.85600.8254-3.57
01570St Clair County, Alabama138200.89800.8919-0.68
01580Shelby County, Alabama138200.89800.8919-0.68
01590Sumter County, Alabama999010.74390.76522.86
01600Talladega County, Alabama999010.74390.76522.86
01610Tallapoosa County, Alabama999010.74390.76522.86
01620Tuscaloosa County, Alabama462200.87050.8641-0.74
01630Walker County, Alabama138200.81960.89198.82
01640Washington County, Alabama999010.74390.76522.86
01650Wilcox County, Alabama999010.74390.76522.86
01660Winston County, Alabama999010.74390.76522.86
02013Aleutians County East, Alaska999021.19331.0680-10.50
02016Aleutians County West, Alaska999021.19331.0680-10.50
02020Anchorage County, Alaska112601.18401.20451.73
02030Angoon County, Alaska999021.19331.0680-10.50
02040Barrow-North Slope County, Alaska999021.19331.0680-10.50
02050Bethel County, Alaska999021.19331.0680-10.50
02060Bristol Bay Borough County, Alaska999021.19331.0680-10.50
02068Denali County, Alaska999021.19331.0680-10.50
02070Bristol Bay County, Alaska999021.19331.0680-10.50
02080Cordova-Mc Carthy County, Alaska999021.19331.0680-10.50
02090Fairbanks County, Alaska218201.16481.1079-4.88
02100Haines County, Alaska999021.19331.0680-10.50
02110Juneau County, Alaska999021.19331.0680-10.50
02120Kenai-Cook Inlet County, Alaska999021.19331.0680-10.50
02122Kenai Peninsula Borough, Alaska999021.19331.0680-10.50
02130Ketchikan County, Alaska999021.19331.0680-10.50
02140Kobuk County, Alaska999021.19331.0680-10.50
02150Kodiak County, Alaska999021.19331.0680-10.50
Start Printed Page 44133
02160Kuskokwin County, Alaska999021.19331.0680-10.50
02164Lake and Peninsula Borough, Alaska999021.19331.0680-10.50
02170Matanuska County, Alaska112601.18921.20451.29
02180Nome County, Alaska999021.19331.0680-10.50
02185North Slope Borough, Alaska999021.19331.0680-10.50
02188Northwest Arctic Borough, Alaska999021.19331.0680-10.50
02190Outer Ketchikan County, Alaska999021.19331.0680-10.50
02200Prince Of Wales County, Alaska999021.19331.0680-10.50
02201Prince of Wales-Outer Ketchikan Census Area,AK999021.19331.0680-10.50
02210Seward County, Alaska999021.19331.0680-10.50
02220Sitka County, Alaska999021.19331.0680-10.50
02230Skagway-Yakutat County, Alaska999021.19331.0680-10.50
02231Skagway-Yakutat-Angoon Census Area, Alaska999021.19331.0680-10.50
02232Skagway-Hoonah-Angoon Census Area, Alaska999021.19331.0680-10.50
02240Southeast Fairbanks County, Alaska999021.19331.0680-10.50
02250Upper Yukon County, Alaska999021.19331.0680-10.50
02260Valdz-Chitna-Whitier County, Alaska999021.19331.0680-10.50
02261Valdex-Cordove Census Area, Alaska999021.19331.0680-10.50
02270Wade Hampton County, Alaska999021.19331.0680-10.50
02280Wrangell-Petersburg County, Alaska999021.19331.0680-10.50
02282Yakutat Borough, Alaska999021.19331.0680-10.50
02290Yukon-Koyukuk County, Alaska999021.19331.0680-10.50
03000Apache County, Arizona999030.89070.89240.19
03010Cochise County, Arizona999030.89070.89240.19
03020Coconino County, Arizona223801.19691.1621-2.91
03030Gila County, Arizona999030.89070.89240.19
03040Graham County, Arizona999030.89070.89240.19
03050Greenlee County, Arizona999030.89070.89240.19
03055La Paz County, Arizona999030.89070.89240.19
03060Maricopa County, Arizona380601.01271.03051.76
03070Mohave County, Arizona999030.99620.8924-10.42
03080Navajo County, Arizona999030.89070.89240.19
03090Pima County, Arizona460600.90070.92192.35
03100Pinal County, Arizona380601.01271.03051.76
03110Santa Cruz County, Arizona999030.89070.89240.19
03120Yavapai County, Arizona391400.94570.98534.19
03130Yuma County, Arizona497400.91260.9125-0.01
04000Arkansas County, Arkansas999040.76050.7335-3.55
04010Ashley County, Arkansas999040.76050.7335-3.55
04020Baxter County, Arkansas999040.76050.7335-3.55
04030Benton County, Arkansas222200.86610.87611.15
04040Boone County, Arkansas999040.76050.7335-3.55
04050Bradley County, Arkansas999040.76050.7335-3.55
04060Calhoun County, Arkansas999040.76050.7335-3.55
04070Carroll County, Arkansas999040.76050.7335-3.55
04080Chicot County, Arkansas999040.76050.7335-3.55
04090Clark County, Arkansas999040.76050.7335-3.55
04100Clay County, Arkansas999040.76050.7335-3.55
04110Cleburne County, Arkansas999040.76050.7335-3.55
04120Cleveland County, Arkansas382200.82120.83982.26
04130Columbia County, Arkansas999040.76050.7335-3.55
04140Conway County, Arkansas999040.76050.7335-3.55
04150Craighead County, Arkansas278600.79110.7609-3.82
04160Crawford County, Arkansas229000.82380.7745-5.98
04170Crittenden County, Arkansas328200.94070.9361-0.49
04180Cross County, Arkansas999040.76050.7335-3.55
04190Dallas County, Arkansas999040.76050.7335-3.55
04200Desha County, Arkansas999040.76050.7335-3.55
04210Drew County, Arkansas999040.76050.7335-3.55
04220Faulkner County, Arkansas307800.87470.89061.82
04230Franklin County, Arkansas229000.79870.7745-3.03
04240Fulton County, Arkansas999040.76050.7335-3.55
04250Garland County, Arkansas263000.83750.87975.04
04260Grant County, Arkansas307800.82460.89068.00
04270Greene County, Arkansas999040.76050.7335-3.55
04280Hempstead County, Arkansas999040.76050.7335-3.55
04290Hot Spring County, Arkansas999040.76050.7335-3.55
Start Printed Page 44134
04300Howard County, Arkansas999040.76050.7335-3.55
04310Independence County, Arkansas999040.76050.7335-3.55
04320Izard County, Arkansas999040.76050.7335-3.55
04330Jackson County, Arkansas999040.76050.7335-3.55
04340Jefferson County, Arkansas382200.86800.8398-3.25
04350Johnson County, Arkansas999040.76050.7335-3.55
04360Lafayette County, Arkansas999040.76050.7335-3.55
04370Lawrence County, Arkansas999040.76050.7335-3.55
04380Lee County, Arkansas999040.76050.7335-3.55
04390Lincoln County, Arkansas382200.82120.83982.26
04400Little River County, Arkansas999040.76050.7335-3.55
04410Logan County, Arkansas999040.76050.7335-3.55
04420Lonoke County, Arkansas307800.87470.89061.82
04430Madison County, Arkansas222200.82030.87616.80
04440Marion County, Arkansas999040.76050.7335-3.55
04450Miller County, Arkansas455000.82830.8118-1.99
04460Mississippi County, Arkansas999040.76050.7335-3.55
04470Monroe County, Arkansas999040.76050.7335-3.55
04480Montgomery County, Arkansas999040.76050.7335-3.55
04490Nevada County, Arkansas999040.76050.7335-3.55
04500Newton County, Arkansas999040.76050.7335-3.55
04510Ouachita County, Arkansas999040.76050.7335-3.55
04520Perry County, Arkansas307800.82460.89068.00
04530Phillips County, Arkansas999040.76050.7335-3.55
04540Pike County, Arkansas999040.76050.7335-3.55
04550Poinsett County, Arkansas278600.78280.7609-2.80
04560Polk County, Arkansas999040.76050.7335-3.55
04570Pope County, Arkansas999040.76050.7335-3.55
04580Prairie County, Arkansas999040.76050.7335-3.55
04590Pulaski County, Arkansas307800.87470.89061.82
04600Randolph County, Arkansas999040.76050.7335-3.55
04610St Francis County, Arkansas999040.76050.7335-3.55
04620Saline County, Arkansas307800.87470.89061.82
04630Scott County, Arkansas999040.76050.7335-3.55
04640Searcy County, Arkansas999040.76050.7335-3.55
04650Sebastian County, Arkansas229000.82380.7745-5.98
04660Sevier County, Arkansas999040.76050.7335-3.55
04670Sharp County, Arkansas999040.76050.7335-3.55
04680Stone County, Arkansas999040.76050.7335-3.55
04690Union County, Arkansas999040.76050.7335-3.55
04700Van Buren County, Arkansas999040.76050.7335-3.55
04710Washington County, Arkansas222200.86610.87611.15
04720White County, Arkansas999040.76050.7335-3.55
04730Woodruff County, Arkansas999040.76050.7335-3.55
04740Yell County, Arkansas999040.76050.7335-3.55
05000Alameda County, California360841.53461.54200.48
05010Alpine County, California999051.09151.13023.55
05020Amador County, California999051.09151.13023.55
05030Butte County, California170201.05111.10735.35
05040Calaveras County, California999051.09151.13023.55
05050Colusa County, California999051.09151.13023.55
05060Contra Costa County, California360841.53461.54200.48
05070Del Norte County, California999051.09151.13023.55
05080Eldorado County, California409001.30561.33732.43
05090Fresno County, California234201.04831.09654.60
05100Glenn County, California999051.09151.13023.55
05110Humboldt County, California999051.09151.13023.55
05120Imperial County, California209400.98410.9092-7.61
05130Inyo County, California999051.09151.13023.55
05140Kern County, California125401.04701.06051.29
05150Kings County, California252601.04061.0142-2.54
05160Lake County, California999051.09151.13023.55
05170Lassen County, California999051.09151.13023.55
05200Los Angeles County, California310841.17831.1752-0.26
05210Los Angeles County, California310841.17831.1752-0.26
05300Madera County, California314600.95710.8169-14.65
05310Marin County, California418841.49941.50710.51
Start Printed Page 44135
05320Mariposa County, California999051.09151.13023.55
05330Mendocino County, California999051.09151.13023.55
05340Merced County, California329001.11091.14152.75
05350Modoc County, California999051.09151.13023.55
05360Mono County, California999051.09151.13023.55
05370Monterey County, California415001.41281.44592.34
05380Napa County, California349001.33131.34961.37
05390Nevada County, California999051.09151.13023.55
05400Orange County, California420441.15591.1294-2.29
05410Placer County, California409001.30561.33732.43
05420Plumas County, California999051.09151.13023.55
05430Riverside County, California401401.10271.0934-0.84
05440Sacramento County, California409001.30561.33732.43
05450San Benito County, California419401.29371.529318.21
05460San Bernardino County, California401401.10271.0934-0.84
05470San Diego County, California417401.14131.1374-0.34
05480San Francisco County, California418841.49941.50710.51
05490San Joaquin County, California447001.13071.14621.37
05500San Luis Obispo County, California420201.13491.16192.38
05510San Mateo County, California418841.49941.50710.51
05520Santa Barbara County, California420601.16941.1075-5.29
05530Santa Clara County, California419401.51091.52931.22
05540Santa Cruz County, California421001.51661.55312.41
05550Shasta County, California398201.22031.32218.34
05560Sierra County, California999051.09151.13023.55
05570Siskiyou County, California999051.09151.13023.55
05580Solano County, California467001.44601.51644.87
05590Sonoma County, California422201.34931.44897.38
05600Stanislaus County, California337001.18851.1590-2.48
05610Sutter County, California497001.09211.0749-1.57
05620Tehama County, California999051.09151.13023.55
05630Trinity County, California999051.09151.13023.55
05640Tulare County, California473001.01230.9986-1.35
05650Tuolumne County, California999051.09151.13023.55
05660Ventura County, California371001.16221.1591-0.27
05670Yolo County, California409001.14601.337316.69
05680Yuba County, California497001.09211.0749-1.57
06000Adams County, Colorado197401.07231.09472.09
06010Alamosa County, Colorado999060.93800.9342-0.41
06020Arapahoe County, Colorado197401.07231.09472.09
06030Archuleta County, Colorado999060.93800.9342-0.41
06040Baca County, Colorado999060.93800.9342-0.41
06050Bent County, Colorado999060.93800.9342-0.41
06060Boulder County, Colorado145000.97341.03686.51
06070Chaffee County, Colorado999060.93800.9342-0.41
06080Cheyenne County, Colorado999060.93800.9342-0.41
06090Clear Creek County, Colorado197401.00521.09478.90
06100Conejos County, Colorado999060.93800.9342-0.41
06110Costilla County, Colorado999060.93800.9342-0.41
06120Crowley County, Colorado999060.93800.9342-0.41
06130Custer County, Colorado999060.93800.9342-0.41
06140Delta County, Colorado999060.93800.9342-0.41
06150Denver County, Colorado197401.07231.09472.09
06160Dolores County, Colorado999060.93800.9342-0.41
06170Douglas County, Colorado197401.07231.09472.09
06180Eagle County, Colorado999060.93800.9342-0.41
06190Elbert County, Colorado197401.00521.09478.90
06200El Paso County, Colorado178200.94680.97182.64
06210Fremont County, Colorado999060.93800.9342-0.41
06220Garfield County, Colorado999060.93800.9342-0.41
06230Gilpin County, Colorado197401.00521.09478.90
06240Grand County, Colorado999060.93800.9342-0.41
06250Gunnison County, Colorado999060.93800.9342-0.41
06260Hinsdale County, Colorado999060.93800.9342-0.41
06270Huerfano County, Colorado999060.93800.9342-0.41
06280Jackson County, Colorado999060.93800.9342-0.41
06290Jefferson County, Colorado197401.07231.09472.09
Start Printed Page 44136
06300Kiowa County, Colorado999060.93800.9342-0.41
06310Kit Carson County, Colorado999060.93800.9342-0.41
06320Lake County, Colorado999060.93800.9342-0.41
06330La Plata County, Colorado999060.93800.9342-0.41
06340Larimer County, Colorado226601.01220.9561-5.54
06350Las Animas County, Colorado999060.93800.9342-0.41
06360Lincoln County, Colorado999060.93800.9342-0.41
06370Logan County, Colorado999060.93800.9342-0.41
06380Mesa County, Colorado243000.95500.96851.41
06390Mineral County, Colorado999060.93800.9342-0.41
06400Moffat County, Colorado999060.93800.9342-0.41
06410Montezuma County, Colorado999060.93800.9342-0.41
06420Montrose County, Colorado999060.93800.9342-0.41
06430Morgan County, Colorado999060.93800.9342-0.41
06440Otero County, Colorado999060.93800.9342-0.41
06450Ouray County, Colorado999060.93800.9342-0.41
06460Park County, Colorado197401.00521.09478.90
06470Phillips County, Colorado999060.93800.9342-0.41
06480Pitkin County, Colorado999060.93800.9342-0.41
06490Prowers County, Colorado999060.93800.9342-0.41
06500Pueblo County, Colorado393800.86230.8552-0.82
06510Rio Blanco County, Colorado999060.93800.9342-0.41
06520Rio Grande County, Colorado999060.93800.9342-0.41
06530Routt County, Colorado999060.93800.9342-0.41
06540Saguache County, Colorado999060.93800.9342-0.41
06550San Juan County, Colorado999060.93800.9342-0.41
06560San Miguel County, Colorado999060.93800.9342-0.41
06570Sedgwick County, Colorado999060.93800.9342-0.41
06580Summit County, Colorado999060.93800.9342-0.41
06590Teller County, Colorado178200.94240.97183.12
06600Washington County, Colorado999060.93800.9342-0.41
06610Weld County, Colorado245400.95700.96190.51
06620Yuma County, Colorado999060.93800.9342-0.41
06630Broomfield County, Colorado197401.07231.09472.09
07000Fairfield County, Connecticut148601.23941.26812.32
07010Hartford County, Connecticut255401.10731.0916-1.42
07020Litchfield County, Connecticut255401.10731.0916-1.42
07030Middlesex County, Connecticut255401.10731.0916-1.42
07040New Haven County, Connecticut353001.20421.1974-0.56
07050New London County, Connecticut359801.13451.19535.36
07060Tolland County, Connecticut255401.10731.0916-1.42
07070Windham County, Connecticut999071.17301.17530.20
08000Kent County, Delaware201000.97760.98650.91
08010New Castle County, Delaware488641.04991.07031.94
08020Sussex County, Delaware999080.95790.97231.50
09000Washington Dc County, Dist Of Col478941.09511.10741.12
10000Alachua County, Florida235400.93880.9312-0.81
10010Baker County, Florida272600.89840.90420.65
10020Bay County, Florida374600.80050.80871.02
10030Bradford County, Florida999100.86230.8595-0.32
10040Brevard County, Florida373400.98390.9448-3.97
10050Broward County, Florida227441.04321.0151-2.69
10060Calhoun County, Florida999100.86230.8595-0.32
10070Charlotte County, Florida394600.92550.94211.79
10080Citrus County, Florida999100.86230.8595-0.32
10090Clay County, Florida272600.92950.9042-2.72
10100Collier County, Florida349401.01390.9959-1.78
10110Columbia County, Florida999100.86230.8595-0.32
10120Dade County, Florida331240.97500.98300.82
10130De Soto County, Florida999100.86230.8595-0.32
10140Dixie County, Florida999100.86230.8595-0.32
10150Duval County, Florida272600.92950.9042-2.72
10160Escambia County, Florida378600.80960.8014-1.01
10170Flagler County, Florida999100.89470.8595-3.93
10180Franklin County, Florida999100.86230.8595-0.32
10190Gadsden County, Florida452200.86880.92997.03
10200Gilchrist County, Florida235400.90330.93123.09
Start Printed Page 44137
10210Glades County, Florida999100.86230.8595-0.32
10220Gulf County, Florida999100.86230.8595-0.32
10230Hamilton County, Florida999100.86230.8595-0.32
10240Hardee County, Florida999100.86230.8595-0.32
10250Hendry County, Florida999100.86230.8595-0.32
10260Hernando County, Florida453000.92330.9160-0.79
10270Highlands County, Florida999100.86230.8595-0.32
10280Hillsborough County, Florida453000.92330.9160-0.79
10290Holmes County, Florida999100.86230.8595-0.32
10300Indian River County, Florida426800.90560.95905.90
10310Jackson County, Florida999100.86230.8595-0.32
10320Jefferson County, Florida452200.86830.92997.09
10330Lafayette County, Florida999100.86230.8595-0.32
10340Lake County, Florida367400.94640.9422-0.44
10350Lee County, Florida159800.93560.93590.03
10360Leon County, Florida452200.86880.92997.03
10370Levy County, Florida999100.86230.8595-0.32
10380Liberty County, Florida999100.86230.8595-0.32
10390Madison County, Florida999100.86230.8595-0.32
10400Manatee County, Florida422600.96390.98852.55
10410Marion County, Florida361000.89250.8883-0.47
10420Martin County, Florida389401.01230.9851-2.69
10430Monroe County, Florida999100.86230.8595-0.32
10440Nassau County, Florida272600.92950.9042-2.72
10450Okaloosa County, Florida230200.88720.8658-2.41
10460Okeechobee County, Florida999100.86230.8595-0.32
10470Orange County, Florida367400.94640.9422-0.44
10480Osceola County, Florida367400.94640.9422-0.44
10490Palm Beach County, Florida484241.00670.9657-4.07
10500Pasco County, Florida453000.92330.9160-0.79
10510Pinellas County, Florida453000.92330.9160-0.79
10520Polk County, Florida294600.89120.8895-0.19
10530Putnam County, Florida999100.86230.8595-0.32
10540Johns County, Florida272600.92950.9042-2.72
10550St Lucie County, Florida389401.01230.9851-2.69
10560Santa Rosa County, Florida378600.80960.8014-1.01
10570Sarasota County, Florida422600.96390.98852.55
10580Seminole County, Florida367400.94640.9422-0.44
10590Sumter County, Florida999100.86230.8595-0.32
10600Suwannee County, Florida999100.86230.8595-0.32
10610Taylor County, Florida999100.86230.8595-0.32
10620Union County, Florida999100.86230.8595-0.32
10630Volusia County, Florida196600.93120.9280-0.34
10640Wakulla County, Florida452200.86830.92997.09
10650Walton County, Florida999100.86230.8595-0.32
10660Washington County, Florida999100.86230.8595-0.32
11000Appling County, Georgia999110.79140.7560-4.47
11010Atkinson County, Georgia999110.79140.7560-4.47
11011Bacon County, Georgia999110.79140.7560-4.47
11020Baker County, Georgia105000.83970.89626.73
11030Baldwin County, Georgia999110.79140.7560-4.47
11040Banks County, Georgia999110.79140.7560-4.47
11050Barrow County, Georgia120600.97930.9772-0.21
11060Bartow County, Georgia120600.97930.9772-0.21
11070Ben Hill County, Georgia999110.79140.7560-4.47
11080Berrien County, Georgia999110.79140.7560-4.47
11090Bibb County, Georgia314200.93600.95181.69
11100Bleckley County, Georgia999110.79140.7560-4.47
11110Brantley County, Georgia152600.87391.009715.54
11120Brooks County, Georgia466600.85160.8344-2.02
11130Bryan County, Georgia423400.94610.9087-3.95
11140Bulloch County, Georgia999110.79140.7560-4.47
11150Burke County, Georgia122600.89570.96788.05
11160Butts County, Georgia120600.89800.97728.82
11161Calhoun County, Georgia999110.79140.7560-4.47
11170Camden County, Georgia999110.79140.7560-4.47
11180Candler County, Georgia999110.79140.7560-4.47
Start Printed Page 44138
11190Carroll County, Georgia120600.97930.9772-0.21
11200Catoosa County, Georgia168600.90880.8963-1.38
11210Charlton County, Georgia999110.79140.7560-4.47
11220Chatham County, Georgia423400.94610.9087-3.95
11230Chattahoochee County, Georgia179800.85600.8254-3.57
11240Chattooga County, Georgia999110.79140.7560-4.47
11250Cherokee County, Georgia120600.97930.9772-0.21
11260Clarke County, Georgia120200.98550.98570.02
11270Clay County, Georgia999110.79140.7560-4.47
11280Clayton County, Georgia120600.97930.9772-0.21
11281Clinch County, Georgia999110.79140.7560-4.47
11290Cobb County, Georgia120600.97930.9772-0.21
11291Coffee County, Georgia999110.79140.7560-4.47
11300Colquitt County, Georgia999110.79140.7560-4.47
11310Columbia County, Georgia122600.97780.9678-1.02
11311Cook County, Georgia999110.79140.7560-4.47
11320Coweta County, Georgia120600.97930.9772-0.21
11330Crawford County, Georgia314200.88050.95188.10
11340Crisp County, Georgia999110.79140.7560-4.47
11341Dade County, Georgia168600.90880.8963-1.38
11350Dawson County, Georgia120600.89800.97728.82
11360Decatur County, Georgia999110.79140.7560-4.47
11370De Kalb County, Georgia120600.97930.9772-0.21
11380Dodge County, Georgia999110.79140.7560-4.47
11381Dooly County, Georgia999110.79140.7560-4.47
11390Dougherty County, Georgia105000.86280.89623.87
11400Douglas County, Georgia120600.97930.9772-0.21
11410Early County, Georgia999110.79140.7560-4.47
11420Echols County, Georgia466600.85160.8344-2.02
11421Effingham County, Georgia423400.94610.9087-3.95
11430Elbert County, Georgia999110.79140.7560-4.47
11440Emanuel County, Georgia999110.79140.7560-4.47
11441Evans County, Georgia999110.79140.7560-4.47
11450Fannin County, Georgia999110.79140.7560-4.47
11451Fayette County, Georgia120600.97930.9772-0.21
11460Floyd County, Georgia406600.87900.93165.98
11461Forsyth County, Georgia120600.97930.9772-0.21
11462Franklin County, Georgia999110.79140.7560-4.47
11470Fulton County, Georgia120600.97930.9772-0.21
11471Gilmer County, Georgia999110.79140.7560-4.47
11480Glascock County, Georgia999110.79140.7560-4.47
11490Glynn County, Georgia152600.87391.009715.54
11500Gordon County, Georgia999110.79140.7560-4.47
11510Grady County, Georgia999110.79140.7560-4.47
11520Greene County, Georgia999110.79140.7560-4.47
11530Gwinnett County, Georgia120600.97930.9772-0.21
11540Habersham County, Georgia999110.79140.7560-4.47
11550Hall County, Georgia235800.85200.89745.33
11560Hancock County, Georgia999110.79140.7560-4.47
11570Haralson County, Georgia120600.89800.97728.82
11580Harris County, Georgia179800.85600.8254-3.57
11581Hart County, Georgia999110.79140.7560-4.47
11590Heard County, Georgia120600.89800.97728.82
11591Henry County, Georgia120600.97930.9772-0.21
11600Houston County, Georgia475800.89610.8394-6.33
11601Irwin County, Georgia999110.79140.7560-4.47
11610Jackson County, Georgia999110.79140.7560-4.47
11611Jasper County, Georgia120600.89800.97728.82
11612Jeff Davis County, Georgia999110.79140.7560-4.47
11620Jefferson County, Georgia999110.79140.7560-4.47
11630Jenkins County, Georgia999110.79140.7560-4.47
11640Johnson County, Georgia999110.79140.7560-4.47
11650Jones County, Georgia314200.93600.95181.69
11651Lamar County, Georgia120600.89800.97728.82
11652Lanier County, Georgia466600.85160.8344-2.02
11660Laurens County, Georgia999110.79140.7560-4.47
11670Lee County, Georgia105000.86280.89623.87
Start Printed Page 44139
11680Liberty County, Georgia259800.89730.91632.12
11690Lincoln County, Georgia999110.79140.7560-4.47
11691Long County, Georgia259800.89730.91632.12
11700Lowndes County, Georgia466600.85160.8344-2.02
11701Lumpkin County, Georgia999110.79140.7560-4.47
11702Mc Duffie County, Georgia122600.97780.9678-1.02
11703Mc Intosh County, Georgia152600.87391.009715.54
11710Macon County, Georgia999110.79140.7560-4.47
11720Madison County, Georgia120200.98550.98570.02
11730Marion County, Georgia179800.83630.8254-1.30
11740Meriwether County, Georgia120600.89800.97728.82
11741Miller County, Georgia999110.79140.7560-4.47
11750Mitchell County, Georgia999110.79140.7560-4.47
11760Monroe County, Georgia314200.88050.95188.10
11770Montgomery County, Georgia999110.79140.7560-4.47
11771Morgan County, Georgia999110.79140.7560-4.47
11772Murray County, Georgia191400.86230.90615.08
11780Muscogee County, Georgia179800.85600.8254-3.57
11790Newton County, Georgia120600.97930.9772-0.21
11800Oconee County, Georgia120200.98550.98570.02
11801Oglethorpe County, Georgia120200.90110.98579.39
11810Paulding County, Georgia120600.97930.9772-0.21
11811Peach County, Georgia999110.84700.7560-10.74
11812Pickens County, Georgia120600.97930.9772-0.21
11820Pierce County, Georgia999110.79140.7560-4.47
11821Pike County, Georgia120600.89800.97728.82
11830Polk County, Georgia999110.79140.7560-4.47
11831Pulaski County, Georgia999110.79140.7560-4.47
11832Putnam County, Georgia999110.79140.7560-4.47
11833Quitman County, Georgia999110.79140.7560-4.47
11834Rabun County, Georgia999110.79140.7560-4.47
11835Randolph County, Georgia999110.79140.7560-4.47
11840Richmond County, Georgia122600.97780.9678-1.02
11841Rockdale County, Georgia120600.97930.9772-0.21
11842Schley County, Georgia999110.79140.7560-4.47
11850Screven County, Georgia999110.79140.7560-4.47
11851Seminole County, Georgia999110.79140.7560-4.47
11860Spalding County, Georgia120600.97930.9772-0.21
11861Stephens County, Georgia999110.79140.7560-4.47
11862Stewart County, Georgia999110.79140.7560-4.47
11870Sumter County, Georgia999110.79140.7560-4.47
11880Talbot County, Georgia999110.79140.7560-4.47
11881Taliaferro County, Georgia999110.79140.7560-4.47
11882Tattnall County, Georgia999110.79140.7560-4.47
11883Taylor County, Georgia999110.79140.7560-4.47
11884Telfair County, Georgia999110.79140.7560-4.47
11885Terrell County, Georgia105000.83970.89626.73
11890Thomas County, Georgia999110.79140.7560-4.47
11900Tift County, Georgia999110.79140.7560-4.47
11901Toombs County, Georgia999110.79140.7560-4.47
11902Towns County, Georgia999110.79140.7560-4.47
11903Treutlen County, Georgia999110.79140.7560-4.47
11910Troup County, Georgia999110.79140.7560-4.47
11911Turner County, Georgia999110.79140.7560-4.47
11912Twiggs County, Georgia314200.93600.95181.69
11913Union County, Georgia999110.79140.7560-4.47
11920Upson County, Georgia999110.79140.7560-4.47
11921Walker County, Georgia168600.90880.8963-1.38
11930Walton County, Georgia120600.97930.9772-0.21
11940Ware County, Georgia999110.79140.7560-4.47
11941Warren County, Georgia999110.79140.7560-4.47
11950Washington County, Georgia999110.79140.7560-4.47
11960Wayne County, Georgia999110.79140.7560-4.47
11961Webster County, Georgia999110.79140.7560-4.47
11962Wheeler County, Georgia999110.79140.7560-4.47
11963White County, Georgia999110.79140.7560-4.47
11970Whitfield County, Georgia191400.86230.90615.08
Start Printed Page 44140
11971Wilcox County, Georgia999110.79140.7560-4.47
11972Wilkes County, Georgia999110.79140.7560-4.47
11973Wilkinson County, Georgia999110.79140.7560-4.47
11980Worth County, Georgia105000.83970.89626.73
12005Kalawao County, Hawaii999121.05511.0467-0.80
12010Hawaii County, Hawaii999121.05511.0467-0.80
12020Honolulu County, Hawaii261801.12141.1067-1.31
12040Kauai County, Hawaii999121.05511.0467-0.80
12050Maui County, Hawaii999121.05511.0467-0.80
13000Ada County, Idaho142600.90520.94174.03
13010Adams County, Idaho999130.85670.8134-5.05
13020Bannock County, Idaho385400.93510.94170.71
13030Bear Lake County, Idaho999130.85670.8134-5.05
13040Benewah County, Idaho999130.85670.8134-5.05
13050Bingham County, Idaho999130.85670.8134-5.05
13060Blaine County, Idaho999130.85670.8134-5.05
13070Boise County, Idaho142600.90750.94173.77
13080Bonner County, Idaho999130.85670.8134-5.05
13090Bonneville County, Idaho268200.92590.9104-1.67
13100Boundary County, Idaho999130.85670.8134-5.05
13110Butte County, Idaho999130.85670.8134-5.05
13120Camas County, Idaho999130.85670.8134-5.05
13130Canyon County, Idaho142600.90520.94174.03
13140Caribou County, Idaho999130.85670.8134-5.05
13150Cassia County, Idaho999130.85670.8134-5.05
13160Clark County, Idaho999130.85670.8134-5.05
13170Clearwater County, Idaho999130.85670.8134-5.05
13180Custer County, Idaho999130.85670.8134-5.05
13190Elmore County, Idaho999130.85670.8134-5.05
13200Franklin County, Idaho308600.91310.9038-1.02
13210Fremont County, Idaho999130.85670.8134-5.05
13220Gem County, Idaho142600.90750.94173.77
13230Gooding County, Idaho999130.85670.8134-5.05
13240Idaho County, Idaho999130.85670.8134-5.05
13250Jefferson County, Idaho268200.92590.9104-1.67
13260Jerome County, Idaho999130.85670.8134-5.05
13270Kootenai County, Idaho176600.93720.9360-0.13
13280Latah County, Idaho999130.85670.8134-5.05
13290Lemhi County, Idaho999130.85670.8134-5.05
13300Lewis County, Idaho999130.85670.8134-5.05
13310Lincoln County, Idaho999130.85670.8134-5.05
13320Madison County, Idaho999130.85670.8134-5.05
13330Minidoka County, Idaho999130.85670.8134-5.05
13340Nez Perce County, Idaho303000.94920.98713.99
13350Oneida County, Idaho999130.85670.8134-5.05
13360Owyhee County, Idaho142600.90750.94173.77
13370Payette County, Idaho999130.85670.8134-5.05
13380Power County, Idaho385400.92240.94172.09
13390Shoshone County, Idaho999130.85670.8134-5.05
13400Teton County, Idaho999130.85670.8134-5.05
13410Twin Falls County, Idaho999130.85670.8134-5.05
13420Valley County, Idaho999130.85670.8134-5.05
13430Washington County, Idaho999130.85670.8134-5.05
14000Adams County, Illinois999140.82860.83270.49
14010Alexander County, Illinois999140.82860.83270.49
14020Bond County, Illinois411800.86280.90134.46
14030Boone County, Illinois404200.99841.00070.23
14040Brown County, Illinois999140.82860.83270.49
14050Bureau County, Illinois999140.82860.83270.49
14060Calhoun County, Illinois411800.86280.90134.46
14070Carroll County, Illinois999140.82860.83270.49
14080Cass County, Illinois999140.82860.83270.49
14090Champaign County, Illinois165800.95940.96610.70
14100Christian County, Illinois999140.82860.83270.49
14110Clark County, Illinois999140.82860.83270.49
14120Clay County, Illinois999140.82860.83270.49
14130Clinton County, Illinois411800.89580.90130.61
Start Printed Page 44141
14140Coles County, Illinois999140.82860.83270.49
14141Cook County, Illinois169741.07871.0745-0.39
14150Crawford County, Illinois999140.82860.83270.49
14160Cumberland County, Illinois999140.82860.83270.49
14170De Kalb County, Illinois169741.07871.0745-0.39
14180De Witt County, Illinois999140.82860.83270.49
14190Douglas County, Illinois999140.82860.83270.49
14250Du Page County, Illinois169741.07871.0745-0.39
14310Edgar County, Illinois999140.82860.83270.49
14320Edwards County, Illinois999140.82860.83270.49
14330Effingham County, Illinois999140.82860.83270.49
14340Fayette County, Illinois999140.82860.83270.49
14350Ford County, Illinois165800.89480.96617.97
14360Franklin County, Illinois999140.82860.83270.49
14370Fulton County, Illinois999140.82860.83270.49
14380Gallatin County, Illinois999140.82860.83270.49
14390Greene County, Illinois999140.82860.83270.49
14400Grundy County, Illinois169741.07871.0745-0.39
14410Hamilton County, Illinois999140.82860.83270.49
14420Hancock County, Illinois999140.82860.83270.49
14421Hardin County, Illinois999140.82860.83270.49
14440Henderson County, Illinois999140.82860.83270.49
14450Henry County, Illinois193400.87240.8557-1.91
14460Iroquois County, Illinois999140.82860.83270.49
14470Jackson County, Illinois999140.82860.83270.49
14480Jasper County, Illinois999140.82860.83270.49
14490Jefferson County, Illinois999140.82860.83270.49
14500Jersey County, Illinois411800.89580.90130.61
14510Jo Daviess County, Illinois999140.82860.83270.49
14520Johnson County, Illinois999140.82860.83270.49
14530Kane County, Illinois169741.07871.0745-0.39
14540Kankakee County, Illinois281001.07210.9990-6.82
14550Kendall County, Illinois169741.07871.0745-0.39
14560Knox County, Illinois999140.82860.83270.49
14570Lake County, Illinois294041.06061.0406-1.89
14580La Salle County, Illinois999140.82860.83270.49
14590Lawrence County, Illinois999140.82860.83270.49
14600Lee County, Illinois999140.82860.83270.49
14610Livingston County, Illinois999140.82860.83270.49
14620Logan County, Illinois999140.82860.83270.49
14630Mc Donough County, Illinois999140.82860.83270.49
14640Mc Henry County, Illinois169741.07871.0745-0.39
14650Mclean County, Illinois140600.90750.8960-1.27
14660Macon County, Illinois195000.80670.81871.49
14670Macoupin County, Illinois411800.86280.90134.46
14680Madison County, Illinois411800.89580.90130.61
14690Marion County, Illinois999140.82860.83270.49
14700Marshall County, Illinois379000.85860.89984.80
14710Mason County, Illinois999140.82860.83270.49
14720Massac County, Illinois999140.82860.83270.49
14730Menard County, Illinois441000.87920.89051.29
14740Mercer County, Illinois193400.85130.85570.52
14750Monroe County, Illinois411800.89580.90130.61
14760Montgomery County, Illinois999140.82860.83270.49
14770Morgan County, Illinois999140.82860.83270.49
14780Moultrie County, Illinois999140.82860.83270.49
14790Ogle County, Illinois999140.91280.8327-8.78
14800Peoria County, Illinois379000.88700.89981.44
14810Perry County, Illinois999140.82860.83270.49
14820Piatt County, Illinois165800.89480.96617.97
14830Pike County, Illinois999140.82860.83270.49
14831Pope County, Illinois999140.82860.83270.49
14850Pulaski County, Illinois999140.82860.83270.49
14860Putnam County, Illinois999140.82860.83270.49
14870Randolph County, Illinois999140.82860.83270.49
14880Richland County, Illinois999140.82860.83270.49
14890Rock Island County, Illinois193400.87240.8557-1.91
Start Printed Page 44142
14900St Clair County, Illinois411800.89580.90130.61
14910Saline County, Illinois999140.82860.83270.49
14920Sangamon County, Illinois441000.87920.89051.29
14921Schuyler County, Illinois999140.82860.83270.49
14940Scott County, Illinois999140.82860.83270.49
14950Shelby County, Illinois999140.82860.83270.49
14960Stark County, Illinois379000.85860.89984.80
14970Stephenson County, Illinois999140.82860.83270.49
14980Tazewell County, Illinois379000.88700.89981.44
14981Union County, Illinois999140.82860.83270.49
14982Vermilion County, Illinois191800.86650.92837.13
14983Wabash County, Illinois999140.82860.83270.49
14984Warren County, Illinois999140.82860.83270.49
14985Washington County, Illinois999140.82860.83270.49
14986Wayne County, Illinois999140.82860.83270.49
14987White County, Illinois999140.82860.83270.49
14988Whiteside County, Illinois999140.82860.83270.49
14989Will County, Illinois169741.07871.0745-0.39
14990Williamson County, Illinois999140.82860.83270.49
14991Winnebago County, Illinois404200.99841.00070.23
14992Woodford County, Illinois379000.88700.89981.44
15000Adams County, Indiana999150.91650.8477-7.51
15010Allen County, Indiana230600.97500.9504-2.52
15020Bartholomew County, Indiana180200.91640.93341.86
15030Benton County, Indiana291400.87380.89722.68
15040Blackford County, Indiana999150.86820.8477-2.36
15050Boone County, Indiana269000.98930.9766-1.28
15060Brown County, Indiana269000.93300.97664.67
15070Carroll County, Indiana291400.87380.89722.68
15080Cass County, Indiana999150.86820.8477-2.36
15090Clark County, Indiana311400.92720.9135-1.48
15100Clay County, Indiana454600.83210.86614.09
15110Clinton County, Indiana999150.86800.8477-2.34
15120Crawford County, Indiana999150.86820.8477-2.36
15130Daviess County, Indiana999150.86820.8477-2.36
15140Dearborn County, Indiana171400.96750.9617-0.60
15150Decatur County, Indiana999150.86820.8477-2.36
15160De Kalb County, Indiana999150.91650.8477-7.51
15170Delaware County, Indiana346200.89300.8299-7.07
15180Dubois County, Indiana999150.86820.8477-2.36
15190Elkhart County, Indiana211400.96270.9442-1.92
15200Fayette County, Indiana999150.86820.8477-2.36
15210Floyd County, Indiana311400.92720.9135-1.48
15220Fountain County, Indiana999150.86820.8477-2.36
15230Franklin County, Indiana171400.91770.96174.79
15240Fulton County, Indiana999150.86820.8477-2.36
15250Gibson County, Indiana217800.87260.88301.19
15260Grant County, Indiana999150.86820.8477-2.36
15270Greene County, Indiana140200.85930.8548-0.52
15280Hamilton County, Indiana269000.98930.9766-1.28
15290Hancock County, Indiana269000.98930.9766-1.28
15300Harrison County, Indiana311400.92720.9135-1.48
15310Hendricks County, Indiana269000.98930.9766-1.28
15320Henry County, Indiana999150.86820.8477-2.36
15330Howard County, Indiana290200.95080.9460-0.50
15340Huntington County, Indiana999150.91650.8477-7.51
15350Jackson County, Indiana999150.86820.8477-2.36
15360Jasper County, Indiana238440.90670.92812.36
15370Jay County, Indiana999150.86820.8477-2.36
15380Jefferson County, Indiana999150.86820.8477-2.36
15390Jennings County, Indiana999150.86820.8477-2.36
15400Johnson County, Indiana269000.98930.9766-1.28
15410Knox County, Indiana999150.86820.8477-2.36
15420Kosciusko County, Indiana999150.86820.8477-2.36
15430Lagrange County, Indiana999150.86820.8477-2.36
15440Lake County, Indiana238440.93950.9281-1.21
15450La Porte County, Indiana331400.90690.90930.26
Start Printed Page 44143
15460Lawrence County, Indiana999150.86820.8477-2.36
15470Madison County, Indiana113000.92260.8790-4.73
15480Marion County, Indiana269000.98930.9766-1.28
15490Marshall County, Indiana999150.86820.8477-2.36
15500Martin County, Indiana999150.86820.8477-2.36
15510Miami County, Indiana999150.86820.8477-2.36
15520Monroe County, Indiana140200.84470.85481.20
15530Montgomery County, Indiana999150.86820.8477-2.36
15540Morgan County, Indiana269000.98930.9766-1.28
15550Newton County, Indiana238440.90670.92812.36
15560Noble County, Indiana999150.86820.8477-2.36
15570Ohio County, Indiana171400.96750.9617-0.60
15580Orange County, Indiana999150.86820.8477-2.36
15590Owen County, Indiana140200.85930.8548-0.52
15600Parke County, Indiana999150.86820.8477-2.36
15610Perry County, Indiana999150.86820.8477-2.36
15620Pike County, Indiana999150.86820.8477-2.36
15630Porter County, Indiana238440.93950.9281-1.21
15640Posey County, Indiana217800.87130.88301.34
15650Pulaski County, Indiana999150.86820.8477-2.36
15660Putnam County, Indiana269000.93300.97664.67
15670Randolph County, Indiana999150.86820.8477-2.36
15680Ripley County, Indiana999150.86820.8477-2.36
15690Rush County, Indiana999150.86820.8477-2.36
15700St Joseph County, Indiana437800.97880.9690-1.00
15710Scott County, Indiana999150.89590.8477-5.38
15720Shelby County, Indiana269000.98930.9766-1.28
15730Spencer County, Indiana999150.86820.8477-2.36
15740Starke County, Indiana999150.86820.8477-2.36
15750Steuben County, Indiana999150.86820.8477-2.36
15760Sullivan County, Indiana454600.85220.86611.63
15770Switzerland County, Indiana999150.86820.8477-2.36
15780Tippecanoe County, Indiana291400.87360.89722.70
15790Tipton County, Indiana290200.95080.9460-0.50
15800Union County, Indiana999150.86820.8477-2.36
15810Vanderburgh County, Indiana217800.87130.88301.34
15820Vermillion County, Indiana454600.83210.86614.09
15830Vigo County, Indiana454600.83210.86614.09
15840Wabash County, Indiana999150.86820.8477-2.36
15850Warren County, Indiana999150.86820.8477-2.36
15860Warrick County, Indiana217800.87130.88301.34
15870Washington County, Indiana311400.89950.91351.56
15880Wayne County, Indiana999150.86820.8477-2.36
15890Wells County, Indiana230600.97500.9504-2.52
15900White County, Indiana999150.86820.8477-2.36
15910Whitley County, Indiana230600.97500.9504-2.52
16000Adair County, Iowa999160.85520.86971.70
16010Adams County, Iowa999160.85520.86971.70
16020Allamakee County, Iowa999160.85520.86971.70
16030Appanoose County, Iowa999160.85520.86971.70
16040Audubon County, Iowa999160.85520.86971.70
16050Benton County, Iowa163000.87100.89032.22
16060Black Hawk County, Iowa479400.85570.8422-1.58
16070Boone County, Iowa999160.85520.86971.70
16080Bremer County, Iowa479400.85760.8422-1.80
16090Buchanan County, Iowa999160.85520.86971.70
16100Buena Vista County, Iowa999160.85520.86971.70
16110Butler County, Iowa999160.85520.86971.70
16120Calhoun County, Iowa999160.85520.86971.70
16130Carroll County, Iowa999160.85520.86971.70
16140Cass County, Iowa999160.85520.86971.70
16150Cedar County, Iowa999160.85520.86971.70
16160Cerro Gordo County, Iowa999160.85520.86971.70
16170Cherokee County, Iowa999160.85520.86971.70
16180Chickasaw County, Iowa999160.85520.86971.70
16190Clarke County, Iowa999160.85520.86971.70
16200Clay County, Iowa999160.85520.86971.70
Start Printed Page 44144
16210Clayton County, Iowa999160.85520.86971.70
16220Clinton County, Iowa999160.85520.86971.70
16230Crawford County, Iowa999160.85520.86971.70
16240Dallas County, Iowa197800.96690.9136-5.51
16250Davis County, Iowa999160.85520.86971.70
16260Decatur County, Iowa999160.85520.86971.70
16270Delaware County, Iowa999160.85520.86971.70
16280Des Moines County, Iowa999160.85520.86971.70
16290Dickinson County, Iowa999160.85520.86971.70
16300Dubuque County, Iowa202200.90240.91501.40
16310Emmet County, Iowa999160.85520.86971.70
16320Fayette County, Iowa999160.85520.86971.70
16330Floyd County, Iowa999160.85520.86971.70
16340Franklin County, Iowa999160.85520.86971.70
16350Fremont County, Iowa999160.85520.86971.70
16360Greene County, Iowa999160.85520.86971.70
16370Grundy County, Iowa479400.85760.8422-1.80
16380Guthrie County, Iowa197800.91320.91360.04
16390Hamilton County, Iowa999160.85520.86971.70
16400Hancock County, Iowa999160.85520.86971.70
16410Hardin County, Iowa999160.85520.86971.70
16420Harrison County, Iowa365400.90770.94674.30
16430Henry County, Iowa999160.85520.86971.70
16440Howard County, Iowa999160.85520.86971.70
16450Humboldt County, Iowa999160.85520.86971.70
16460Ida County, Iowa999160.85520.86971.70
16470Iowa County, Iowa999160.85520.86971.70
16480Jackson County, Iowa999160.85520.86971.70
16490Jasper County, Iowa999160.85520.86971.70
16500Jefferson County, Iowa999160.85520.86971.70
16510Johnson County, Iowa269800.97470.9731-0.16
16520Jones County, Iowa163000.87100.89032.22
16530Keokuk County, Iowa999160.85520.86971.70
16540Kossuth County, Iowa999160.85520.86971.70
16550Lee County, Iowa999160.85520.86971.70
16560Linn County, Iowa163000.88250.89030.88
16570Louisa County, Iowa999160.85520.86971.70
16580Lucas County, Iowa999160.85520.86971.70
16590Lyon County, Iowa999160.85520.86971.70
16600Madison County, Iowa197800.91320.91360.04
16610Mahaska County, Iowa999160.85520.86971.70
16620Marion County, Iowa999160.85520.86971.70
16630Marshall County, Iowa999160.85520.86971.70
16640Mills County, Iowa365400.90770.94674.30
16650Mitchell County, Iowa999160.85520.86971.70
16660Monona County, Iowa999160.85520.86971.70
16670Monroe County, Iowa999160.85520.86971.70
16680Montgomery County, Iowa999160.85520.86971.70
16690Muscatine County, Iowa999160.85520.86971.70
16700O Brien County, Iowa999160.85520.86971.70
16710Osceola County, Iowa999160.85520.86971.70
16720Page County, Iowa999160.85520.86971.70
16730Palo Alto County, Iowa999160.85520.86971.70
16740Plymouth County, Iowa999160.85520.86971.70
16750Pocahontas County, Iowa999160.85520.86971.70
16760Polk County, Iowa197800.96690.9136-5.51
16770Pottawattamie County, Iowa365400.95600.9467-0.97
16780Poweshiek County, Iowa999160.85520.86971.70
16790Ringgold County, Iowa999160.85520.86971.70
16800Sac County, Iowa999160.85520.86971.70
16810Scott County, Iowa193400.87240.8557-1.91
16820Shelby County, Iowa999160.85520.86971.70
16830Sioux County, Iowa999160.85520.86971.70
16840Story County, Iowa111800.90650.97777.85
16850Tama County, Iowa999160.85520.86971.70
16860Taylor County, Iowa999160.85520.86971.70
16870Union County, Iowa999160.85520.86971.70
Start Printed Page 44145
16880Van Buren County, Iowa999160.85520.86971.70
16890Wapello County, Iowa999160.85520.86971.70
16900Warren County, Iowa197800.96690.9136-5.51
16910Washington County, Iowa269800.91710.97316.11
16920Wayne County, Iowa999160.85520.86971.70
16930Webster County, Iowa999160.85520.86971.70
16940Winnebago County, Iowa999160.85520.86971.70
16950Winneshiek County, Iowa999160.85520.86971.70
16960Woodbury County, Iowa435800.93990.9217-1.94
16970Worth County, Iowa999160.85520.86971.70
16980Wright County, Iowa999160.85520.86971.70
17000Allen County, Kansas999170.80380.8000-0.47
17010Anderson County, Kansas999170.80380.8000-0.47
17020Atchison County, Kansas999170.80380.8000-0.47
17030Barber County, Kansas999170.80380.8000-0.47
17040Barton County, Kansas999170.80380.8000-0.47
17050Bourbon County, Kansas999170.80380.8000-0.47
17060Brown County, Kansas999170.80380.8000-0.47
17070Butler County, Kansas486200.91640.9079-0.93
17080Chase County, Kansas999170.80380.8000-0.47
17090Chautauqua County, Kansas999170.80380.8000-0.47
17100Cherokee County, Kansas999170.80380.8000-0.47
17110Cheyenne County, Kansas999170.80380.8000-0.47
17120Clark County, Kansas999170.80380.8000-0.47
17130Clay County, Kansas999170.80380.8000-0.47
17140Cloud County, Kansas999170.80380.8000-0.47
17150Coffey County, Kansas999170.80380.8000-0.47
17160Comanche County, Kansas999170.80380.8000-0.47
17170Cowley County, Kansas999170.80380.8000-0.47
17180Crawford County, Kansas999170.80380.8000-0.47
17190Decatur County, Kansas999170.80380.8000-0.47
17200Dickinson County, Kansas999170.80380.8000-0.47
17210Doniphan County, Kansas411400.87801.013615.44
17220Douglas County, Kansas299400.85370.8353-2.16
17230Edwards County, Kansas999170.80380.8000-0.47
17240Elk County, Kansas999170.80380.8000-0.47
17250Ellis County, Kansas999170.80380.8000-0.47
17260Ellsworth County, Kansas999170.80380.8000-0.47
17270Finney County, Kansas999170.80380.8000-0.47
17280Ford County, Kansas999170.80380.8000-0.47
17290Franklin County, Kansas281400.87580.95148.63
17300Geary County, Kansas999170.80380.8000-0.47
17310Gove County, Kansas999170.80380.8000-0.47
17320Graham County, Kansas999170.80380.8000-0.47
17330Grant County, Kansas999170.80380.8000-0.47
17340Gray County, Kansas999170.80380.8000-0.47
17350Greeley County, Kansas999170.80380.8000-0.47
17360Greenwood County, Kansas999170.80380.8000-0.47
17370Hamilton County, Kansas999170.80380.8000-0.47
17380Harper County, Kansas999170.80380.8000-0.47
17390Harvey County, Kansas486200.91640.9079-0.93
17391Haskell County, Kansas999170.80380.8000-0.47
17410Hodgeman County, Kansas999170.80380.8000-0.47
17420Jackson County, Kansas458200.84800.87463.14
17430Jefferson County, Kansas458200.84800.87463.14
17440Jewell County, Kansas999170.80380.8000-0.47
17450Johnson County, Kansas281400.94830.95140.33
17451Kearny County, Kansas999170.80380.8000-0.47
17470Kingman County, Kansas999170.80380.8000-0.47
17480Kiowa County, Kansas999170.80380.8000-0.47
17490Labette County, Kansas999170.80380.8000-0.47
17500Lane County, Kansas999170.80380.8000-0.47
17510Leavenworth County, Kansas281400.94830.95140.33
17520Lincoln County, Kansas999170.80380.8000-0.47
17530Linn County, Kansas281400.87580.95148.63
17540Logan County, Kansas999170.80380.8000-0.47
17550Lyon County, Kansas999170.80380.8000-0.47
Start Printed Page 44146
17560Mc Pherson County, Kansas999170.80380.8000-0.47
17570Marion County, Kansas999170.80380.8000-0.47
17580Marshall County, Kansas999170.80380.8000-0.47
17590Meade County, Kansas999170.80380.8000-0.47
17600Miami County, Kansas281400.94830.95140.33
17610Mitchell County, Kansas999170.80380.8000-0.47
17620Montgomery County, Kansas999170.80380.8000-0.47
17630Morris County, Kansas999170.80380.8000-0.47
17640Morton County, Kansas999170.80380.8000-0.47
17650Nemaha County, Kansas999170.80380.8000-0.47
17660Neosho County, Kansas999170.80380.8000-0.47
17670Ness County, Kansas999170.80380.8000-0.47
17680Norton County, Kansas999170.80380.8000-0.47
17690Osage County, Kansas458200.84800.87463.14
17700Osborne County, Kansas999170.80380.8000-0.47
17710Ottawa County, Kansas999170.80380.8000-0.47
17720Pawnee County, Kansas999170.80380.8000-0.47
17730Phillips County, Kansas999170.80380.8000-0.47
17740Pottawatomie County, Kansas999170.80380.8000-0.47
17750Pratt County, Kansas999170.80380.8000-0.47
17760Rawlins County, Kansas999170.80380.8000-0.47
17770Reno County, Kansas999170.80380.8000-0.47
17780Republic County, Kansas999170.80380.8000-0.47
17790Rice County, Kansas999170.80380.8000-0.47
17800Riley County, Kansas999170.80380.8000-0.47
17810Rooks County, Kansas999170.80380.8000-0.47
17820Rush County, Kansas999170.80380.8000-0.47
17830Russell County, Kansas999170.80380.8000-0.47
17840Saline County, Kansas999170.80380.8000-0.47
17841Scott County, Kansas999170.80380.8000-0.47
17860Sedgwick County, Kansas486200.91640.9079-0.93
17870Seward County, Kansas999170.80380.8000-0.47
17880Shawnee County, Kansas458200.89200.8746-1.95
17890Sheridan County, Kansas999170.80380.8000-0.47
17900Sherman County, Kansas999170.80380.8000-0.47
17910Smith County, Kansas999170.80380.8000-0.47
17920Stafford County, Kansas999170.80380.8000-0.47
17921Stanton County, Kansas999170.80380.8000-0.47
17940Stevens County, Kansas999170.80380.8000-0.47
17950Sumner County, Kansas486200.85970.90795.61
17960Thomas County, Kansas999170.80380.8000-0.47
17970Trego County, Kansas999170.80380.8000-0.47
17980Wabaunsee County, Kansas458200.84800.87463.14
17981Wallace County, Kansas999170.80380.8000-0.47
17982Washington County, Kansas999170.80380.8000-0.47
17983Wichita County, Kansas999170.80380.8000-0.47
17984Wilson County, Kansas999170.80380.8000-0.47
17985Woodson County, Kansas999170.80380.8000-0.47
17986Wyandotte County, Kansas281400.94830.95140.33
18000Adair County, Kentucky999180.78120.7780-0.41
18010Allen County, Kentucky999180.78120.7780-0.41
18020Anderson County, Kentucky999180.78120.7780-0.41
18030Ballard County, Kentucky999180.78120.7780-0.41
18040Barren County, Kentucky999180.78120.7780-0.41
18050Bath County, Kentucky999180.78120.7780-0.41
18060Bell County, Kentucky999180.78120.7780-0.41
18070Boone County, Kentucky171400.96750.9617-0.60
18080Bourbon County, Kentucky304600.90320.91911.76
18090Boyd County, Kentucky265800.94770.9013-4.90
18100Boyle County, Kentucky999180.78120.7780-0.41
18110Bracken County, Kentucky171400.87370.961710.07
18120Breathitt County, Kentucky999180.78120.7780-0.41
18130Breckinridge County, Kentucky999180.78120.7780-0.41
18140Bullitt County, Kentucky311400.92720.9135-1.48
18150Butler County, Kentucky999180.78120.7780-0.41
18160Caldwell County, Kentucky999180.78120.7780-0.41
18170Calloway County, Kentucky999180.78120.7780-0.41
Start Printed Page 44147
18180Campbell County, Kentucky171400.96750.9617-0.60
18190Carlisle County, Kentucky999180.78120.7780-0.41
18191Carroll County, Kentucky999180.78120.7780-0.41
18210Carter County, Kentucky999180.86220.7780-9.77
18220Casey County, Kentucky999180.78120.7780-0.41
18230Christian County, Kentucky173000.82840.84512.02
18240Clark County, Kentucky304600.90320.91911.76
18250Clay County, Kentucky999180.78120.7780-0.41
18260Clinton County, Kentucky999180.78120.7780-0.41
18270Crittenden County, Kentucky999180.78120.7780-0.41
18271Cumberland County, Kentucky999180.78120.7780-0.41
18290Daviess County, Kentucky369800.87800.8763-0.19
18291Edmonson County, Kentucky145400.80350.81621.58
18310Elliott County, Kentucky999180.78120.7780-0.41
18320Estill County, Kentucky999180.78120.7780-0.41
18330Fayette County, Kentucky304600.90320.91911.76
18340Fleming County, Kentucky999180.78120.7780-0.41
18350Floyd County, Kentucky999180.78120.7780-0.41
18360Franklin County, Kentucky999180.78120.7780-0.41
18361Fulton County, Kentucky999180.78120.7780-0.41
18362Gallatin County, Kentucky171400.96750.9617-0.60
18390Garrard County, Kentucky999180.78120.7780-0.41
18400Grant County, Kentucky171400.96750.9617-0.60
18410Graves County, Kentucky999180.78120.7780-0.41
18420Grayson County, Kentucky999180.78120.7780-0.41
18421Green County, Kentucky999180.78120.7780-0.41
18440Greenup County, Kentucky265800.94770.9013-4.90
18450Hancock County, Kentucky369800.83190.87635.34
18460Hardin County, Kentucky210600.83300.87134.60
18470Harlan County, Kentucky999180.78120.7780-0.41
18480Harrison County, Kentucky999180.78120.7780-0.41
18490Hart County, Kentucky999180.78120.7780-0.41
18500Henderson County, Kentucky217800.87130.88301.34
18510Henry County, Kentucky311400.85550.91356.78
18511Hickman County, Kentucky999180.78120.7780-0.41
18530Hopkins County, Kentucky999180.78120.7780-0.41
18540Jackson County, Kentucky999180.78120.7780-0.41
18550Jefferson County, Kentucky311400.92720.9135-1.48
18560Jessamine County, Kentucky304600.90320.91911.76
18570Johnson County, Kentucky999180.78120.7780-0.41
18580Kenton County, Kentucky171400.96750.9617-0.60
18590Knott County, Kentucky999180.78120.7780-0.41
18600Knox County, Kentucky999180.78120.7780-0.41
18610Larue County, Kentucky210600.83300.87134.60
18620Laurel County, Kentucky999180.78120.7780-0.41
18630Lawrence County, Kentucky999180.78120.7780-0.41
18640Lee County, Kentucky999180.78120.7780-0.41
18650Leslie County, Kentucky999180.78120.7780-0.41
18660Letcher County, Kentucky999180.78120.7780-0.41
18670Lewis County, Kentucky999180.78120.7780-0.41
18680Lincoln County, Kentucky999180.78120.7780-0.41
18690Livingston County, Kentucky999180.78120.7780-0.41
18700Logan County, Kentucky999180.78120.7780-0.41
18710Lyon County, Kentucky999180.78120.7780-0.41
18720Mc Cracken County, Kentucky999180.78120.7780-0.41
18730Mc Creary County, Kentucky999180.78120.7780-0.41
18740Mc Lean County, Kentucky369800.83190.87635.34
18750Madison County, Kentucky999180.83770.7780-7.13
18760Magoffin County, Kentucky999180.78120.7780-0.41
18770Marion County, Kentucky999180.78120.7780-0.41
18780Marshall County, Kentucky999180.78120.7780-0.41
18790Martin County, Kentucky999180.78120.7780-0.41
18800Mason County, Kentucky999180.78120.7780-0.41
18801Meade County, Kentucky311400.85550.91356.78
18802Menifee County, Kentucky999180.78120.7780-0.41
18830Mercer County, Kentucky999180.78120.7780-0.41
18831Metcalfe County, Kentucky999180.78120.7780-0.41
Start Printed Page 44148
18850Monroe County, Kentucky999180.78120.7780-0.41
18860Montgomery County, Kentucky999180.78120.7780-0.41
18861Morgan County, Kentucky999180.78120.7780-0.41
18880Muhlenberg County, Kentucky999180.78120.7780-0.41
18890Nelson County, Kentucky311400.85550.91356.78
18900Nicholas County, Kentucky999180.78120.7780-0.41
18910Ohio County, Kentucky999180.78120.7780-0.41
18920Oldham County, Kentucky311400.92720.9135-1.48
18930Owen County, Kentucky999180.78120.7780-0.41
18931Owsley County, Kentucky999180.78120.7780-0.41
18932Pendleton County, Kentucky171400.96750.9617-0.60
18960Perry County, Kentucky999180.78120.7780-0.41
18970Pike County, Kentucky999180.78120.7780-0.41
18971Powell County, Kentucky999180.78120.7780-0.41
18972Pulaski County, Kentucky999180.78120.7780-0.41
18973Robertson County, Kentucky999180.78120.7780-0.41
18974Rockcastle County, Kentucky999180.78120.7780-0.41
18975Rowan County, Kentucky999180.78120.7780-0.41
18976Russell County, Kentucky999180.78120.7780-0.41
18977Scott County, Kentucky304600.90320.91911.76
18978Shelby County, Kentucky311400.85550.91356.78
18979Simpson County, Kentucky999180.78120.7780-0.41
18980Spencer County, Kentucky311400.85550.91356.78
18981Taylor County, Kentucky999180.78120.7780-0.41
18982Todd County, Kentucky999180.78120.7780-0.41
18983Trigg County, Kentucky173000.80710.84514.71
18984Trimble County, Kentucky311400.85550.91356.78
18985Union County, Kentucky999180.78120.7780-0.41
18986Warren County, Kentucky145400.80350.81621.58
18987Washington County, Kentucky999180.78120.7780-0.41
18988Wayne County, Kentucky999180.78120.7780-0.41
18989Webster County, Kentucky217800.82860.88306.57
18990Whitley County, Kentucky999180.78120.7780-0.41
18991Wolfe County, Kentucky999180.78120.7780-0.41
18992Woodford County, Kentucky304600.90320.91911.76
19000Acadia County, Louisiana999190.78310.7450-4.87
19010Allen County, Louisiana999190.73760.74501.00
19020Ascension County, Louisiana129400.86180.8099-6.02
19030Assumption County, Louisiana999190.73760.74501.00
19040Avoyelles County, Louisiana999190.73760.74501.00
19050Beauregard County, Louisiana999190.73760.74501.00
19060Bienville County, Louisiana999190.73760.74501.00
19070Bossier County, Louisiana433400.87490.88811.51
19080Caddo County, Louisiana433400.87490.88811.51
19090Calcasieu County, Louisiana293400.78460.79281.05
19100Caldwell County, Louisiana999190.73760.74501.00
19110Cameron County, Louisiana293400.75870.79284.49
19120Catahoula County, Louisiana999190.73760.74501.00
19130Claiborne County, Louisiana999190.73760.74501.00
19140Concordia County, Louisiana999190.73760.74501.00
19150De Soto County, Louisiana433400.80500.888110.32
19160East Baton Rouge County, Louisiana129400.86180.8099-6.02
19170East Carroll County, Louisiana999190.73760.74501.00
19180East Feliciana County, Louisiana129400.79670.80991.66
19190Evangeline County, Louisiana999190.73760.74501.00
19200Franklin County, Louisiana999190.73760.74501.00
19210Grant County, Louisiana107800.76870.80204.33
19220Iberia County, Louisiana999190.73760.74501.00
19230Iberville County, Louisiana129400.79670.80991.66
19240Jackson County, Louisiana999190.73760.74501.00
19250Jefferson County, Louisiana353800.89950.8858-1.52
19260Jefferson Davis County, Louisiana999190.73760.74501.00
19270Lafayette County, Louisiana291800.83400.8293-0.56
19280Lafourche County, Louisiana263800.78940.80031.38
19290La Salle County, Louisiana999190.73760.74501.00
19300Lincoln County, Louisiana999190.73760.74501.00
19310Livingston County, Louisiana129400.86180.8099-6.02
Start Printed Page 44149
19320Madison County, Louisiana999190.73760.74501.00
19330Morehouse County, Louisiana999190.73760.74501.00
19340Natchitoches County, Louisiana999190.73760.74501.00
19350Orleans County, Louisiana353800.89950.8858-1.52
19360Ouachita County, Louisiana337400.80380.8011-0.34
19370Plaquemines County, Louisiana353800.89950.8858-1.52
19380Pointe Coupee County, Louisiana129400.79670.80991.66
19390Rapides County, Louisiana107800.80330.8020-0.16
19400Red River County, Louisiana999190.73760.74501.00
19410Richland County, Louisiana999190.73760.74501.00
19420Sabine County, Louisiana999190.73760.74501.00
19430St Bernard County, Louisiana353800.89950.8858-1.52
19440St Charles County, Louisiana353800.89950.8858-1.52
19450St Helena County, Louisiana129400.79670.80991.66
19460St James County, Louisiana999190.82030.7450-9.18
19470St John Baptist County, Louisiana353800.89950.8858-1.52
19480St Landry County, Louisiana999190.78310.7450-4.87
19490St Martin County, Louisiana291800.83400.8293-0.56
19500St Mary County, Louisiana999190.73760.74501.00
19510St Tammany County, Louisiana353800.89950.8858-1.52
19520Tangipahoa County, Louisiana999190.73760.74501.00
19530Tensas County, Louisiana999190.73760.74501.00
19540Terrebonne County, Louisiana263800.78940.80031.38
19550Union County, Louisiana337400.76860.80114.23
19560Vermilion County, Louisiana999190.73760.74501.00
19570Vernon County, Louisiana999190.73760.74501.00
19580Washington County, Louisiana999190.73760.74501.00
19590Webster County, Louisiana999190.80740.7450-7.73
19600West Baton Rouge County, Louisiana129400.86180.8099-6.02
19610West Carroll County, Louisiana999190.73760.74501.00
19620West Feliciana County, Louisiana129400.79670.80991.66
19630Winn County, Louisiana999190.73760.74501.00
20000Androscoggin County, Maine303400.93310.9148-1.96
20010Aroostook County, Maine999200.88430.8410-4.90
20020Cumberland County, Maine388601.03820.9926-4.39
20030Franklin County, Maine999200.88430.8410-4.90
20040Hancock County, Maine999200.88430.8410-4.90
20050Kennebec County, Maine999200.88430.8410-4.90
20060Knox County, Maine999200.88430.8410-4.90
20070Lincoln County, Maine999200.88430.8410-4.90
20080Oxford County, Maine999200.88430.8410-4.90
20090Penobscot County, Maine126200.99930.9719-2.74
20100Piscataquis County, Maine999200.88430.8410-4.90
20110Sagadahoc County, Maine388601.03820.9926-4.39
20120Somerset County, Maine999200.88430.8410-4.90
20130Waldo County, Maine999200.88430.8410-4.90
20140Washington County, Maine999200.88430.8410-4.90
20150York County, Maine388601.03820.9926-4.39
21000Allegany County, Maryland190600.93170.8859-4.92
21010Anne Arundel County, Maryland125800.98971.01062.11
21020Baltimore County, Maryland125800.98971.01062.11
21030Baltimore City County, Maryland125800.98971.01062.11
21040Calvert County, Maryland478941.09511.10741.12
21050Caroline County, Maryland999210.92920.8942-3.77
21060Carroll County, Maryland125800.98971.01062.11
21070Cecil County, Maryland488641.04991.07031.94
21080Charles County, Maryland478941.09511.10741.12
21090Dorchester County, Maryland999210.92920.8942-3.77
21100Frederick County, Maryland136441.12301.0923-2.73
21110Garrett County, Maryland999210.92920.8942-3.77
21120Harford County, Maryland125800.98971.01062.11
21130Howard County, Maryland125800.98971.01062.11
21140Kent County, Maryland999210.92920.8942-3.77
21150Montgomery County, Maryland136441.12301.0923-2.73
21160Prince Georges County, Maryland478941.09511.10741.12
21170Queen Annes County, Maryland125800.98971.01062.11
21180St Marys County, Maryland999210.92920.8942-3.77
Start Printed Page 44150
21190Somerset County, Maryland415400.91470.8969-1.95
21200Talbot County, Maryland999210.92920.8942-3.77
21210Washington County, Maryland251800.96790.9054-6.46
21220Wicomico County, Maryland415400.91470.8969-1.95
21230Worcester County, Maryland999210.92920.8942-3.77
22000Barnstable County, Massachusetts127001.26001.2561-0.31
22010Berkshire County, Massachusetts383401.01811.02841.01
22020Bristol County, Massachusetts393001.10721.0804-2.42
22030Dukes County, Massachusetts999221.02161.02160.00
22040Essex County, Massachusetts216041.08581.0437-3.88
22060Franklin County, Massachusetts441401.02321.0080-0.63
22070Hampden County, Massachusetts441401.02561.0080-1.72
22080Hampshire County, Massachusetts441401.02561.0080-1.72
22090Middlesex County, Massachusetts157641.11751.0918-2.30
22120Nantucket County, Massachusetts999221.02161.02160.00
22130Norfolk County, Massachusetts144841.13681.16932.86
22150Plymouth County, Massachusetts144841.13681.16932.86
22160Suffolk County, Massachusetts144841.13681.16932.86
22170Worcester County, Massachusetts493401.11031.0741-3.26
23000Alcona County, Michigan999230.88600.90522.17
23010Alger County, Michigan999230.88600.90522.17
23020Allegan County, Michigan999230.91700.9052-1.29
23030Alpena County, Michigan999230.88600.90522.17
23040Antrim County, Michigan999230.88600.90522.17
23050Arenac County, Michigan999230.88600.90522.17
23060Baraga County, Michigan999230.88600.90522.17
23070Barry County, Michigan243400.91070.94703.99
23080Bay County, Michigan130200.92920.9271-0.23
23090Benzie County, Michigan999230.88600.90522.17
23100Berrien County, Michigan356600.88790.89310.59
23110Branch County, Michigan999230.88600.90522.17
23120Calhoun County, Michigan129800.98260.9746-0.81
23130Cass County, Michigan437800.93060.96904.13
23140Charlevoix County, Michigan999230.88600.90522.17
23150Cheboygan County, Michigan999230.88600.90522.17
23160Chippewa County, Michigan999230.88600.90522.17
23170Clare County, Michigan999230.88600.90522.17
23180Clinton County, Michigan296200.97941.01023.14
23190Crawford County, Michigan999230.88600.90522.17
23200Delta County, Michigan999230.88600.90522.17
23210Dickinson County, Michigan999230.88600.90522.17
23220Eaton County, Michigan296200.97941.01023.14
23230Emmet County, Michigan999230.88600.90522.17
23240Genesee County, Michigan224201.06551.09883.13
23250Gladwin County, Michigan999230.88600.90522.17
23260Gogebic County, Michigan999230.88600.90522.17
23270Grand Traverse County, Michigan999230.88600.90522.17
23280Gratiot County, Michigan999230.88600.90522.17
23290Hillsdale County, Michigan999230.88600.90522.17
23300Houghton County, Michigan999230.88600.90522.17
23310Huron County, Michigan999230.88600.90522.17
23320Ingham County, Michigan296200.97941.01023.14
23330Ionia County, Michigan243400.91070.94703.99
23340Iosco County, Michigan999230.88600.90522.17
23350Iron County, Michigan999230.88600.90522.17
23360Isabella County, Michigan999230.88600.90522.17
23370Jackson County, Michigan271000.93040.95772.93
23380Kalamazoo County, Michigan280201.02621.07234.49
23390Kalkaska County, Michigan999230.88600.90522.17
23400Kent County, Michigan243400.94180.94700.55
23410Keweenaw County, Michigan999230.88600.90522.17
23420Lake County, Michigan999230.88600.90522.17
23430Lapeer County, Michigan476441.00091.01261.17
23440Leelanau County, Michigan999230.88600.90522.17
23450Lenawee County, Michigan999230.98010.9052-7.64
23460Livingston County, Michigan476441.02891.0126-1.58
23470Luce County, Michigan999230.88600.90522.17
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23480Mackinac County, Michigan999230.88600.90522.17
23490Macomb County, Michigan476441.00091.01261.17
23500Manistee County, Michigan999230.88600.90522.17
23510Marquette County, Michigan999230.88600.90522.17
23520Mason County, Michigan999230.88600.90522.17
23530Mecosta County, Michigan999230.88600.90522.17
23540Menominee County, Michigan999230.88600.90522.17
23550Midland County, Michigan999230.90680.9052-0.18
23560Missaukee County, Michigan999230.88600.90522.17
23570Monroe County, Michigan337800.98080.9725-0.85
23580Montcalm County, Michigan999230.88600.90522.17
23590Montmorency County, Michigan999230.88600.90522.17
23600Muskegon County, Michigan347400.95550.99574.21
23610Newaygo County, Michigan243400.91070.94703.99
23620Oakland County, Michigan476441.00091.01261.17
23630Oceana County, Michigan999230.88600.90522.17
23640Ogemaw County, Michigan999230.88600.90522.17
23650Ontonagon County, Michigan999230.88600.90522.17
23660Osceola County, Michigan99923