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Proposed Rule

Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2008

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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 update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for Federal fiscal year (FY) 2008 (for discharges occurring on or after October 1, 2007 and on or before September 30, 2008) as required under section 1886(j)(3)(C) of the Social Security Act (the Act). Section 1886(j)(5) of the Act requires the Secretary to publish in the Federal Register on or before the August 1 that precedes the start of each fiscal year, the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the methodology and data used in computing the prospective payment rates for that fiscal year.

We are proposing to revise existing policies regarding the PPS within the authority granted under section 1886(j) of the Act.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 2, 2007.

ADDRESSES:

In commenting, please refer to file code CMS-1551-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-1551-P, P.O. Box 8012, Baltimore, MD 21244-8012. Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By 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-1551-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-8012.

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.

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

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FOR FURTHER INFORMATION CONTACT:

Pete Diaz, (410) 786-1235, for information regarding the 75 percent rule. Susanne Seagrave, (410) 786-0044, for information regarding the payment policies. Zinnia Ng, (410) 786-4587, for information regarding the wage index and prospective payment rate calculation.

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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-1551-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 will 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.

Table of Contents

I. Background

A. Historical Overview of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) for Fiscal Years (FYs) 2002 through 2007

B. Requirements for Updating the IRF PPS Rates

C. Operational Overview of the Current IRF PPS

D. Brief Summary of Proposed Revisions to the IRF PPS for FY 2008

II. 75 Percent Rule Policy

III. Classification System for the Inpatient Rehabilitation Facility Prospective Payment System

IV. Proposed FY 2008 IRF PPS Federal Prospective Payment Rates

A. Proposed FY 2008 IRF Market Basket Increase Factor and Labor-Related Share

B. Proposed Area Wage Adjustment

C. Description of the Proposed IRF Standard Payment Conversion Factor and Proposed Payment Rates for FY 2008

D. Example of the Methodology for Adjusting the Proposed Federal Prospective Payment Rates

V. Update to Payments for High-Cost Outliers Under the IRF PPS

A. Proposed Update to the Outlier Threshold Amount for FY 2008

B. Update to the IRF Cost-to-Charge Ratio Ceilings

VI. Clarification to the Regulations Text for Special Payment Provisions for Patients That Are Transferred

VII. Provisions of a Proposed Regulation

VIII. Collection of Information Requirement

IX. Response to Public Comments

X. Regulatory Impact Analysis

A. Overall Impact

B. Anticipated Effects of the Proposed Rule

C. Anticipated Effects of the 75 Percent Rule Policy

D. Alternatives Considered

E. Accounting Statement

F. Conclusion

Regulation Text

Addendum Start Printed Page 26231

Acronyms

Because of the many terms to which we refer by acronym in this proposed rule, we are listing the acronyms used and their corresponding terms in alphabetical order below.

ASCA—Administrative Simplification Compliance Act of 2002, Pub. L. 107-105

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

BBRA—Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113

BIPA—Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106-554

CBSA—Core-Based Statistical Area

CCR—Cost-to-Charge Ratio

CFR—Code of Federal Regulations

CMG—Case-Mix Group

DRA—Deficit Reduction Act of 2005, Pub. L. 109-171

DSH—Disproportionate Share Hospital

ECI—Employment Cost Indexes

FI—Fiscal Intermediary

FR—Federal Register

FY—Federal Fiscal Year

GDP—Gross Domestic Product

HHH—Hubert H. Humphrey Building

HIPAA—Health Insurance Portability and Accountability Act, Pub. L. 104-191

IFMC—Iowa Foundation for Medical Care

IPPS—Inpatient Prospective Payment System

IRF—Inpatient Rehabilitation Facility

IRF-PAI—Inpatient Rehabilitation Facility-Patient Assessment Instrument

IRF PPS—Inpatient Rehabilitation Facility Prospective Payment System

IRVEN—Inpatient Rehabilitation Validation and Entry

LIP—Low-Income Percentage

MEDPAR—Medicare Provider Analysis and Review

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

MSA—Metropolitan Statistical Area

NAICS—North American Industrial Classification System

OMB—Office of Management and Budget

PAI—Patient Assessment Instrument

PPS—Prospective Payment System

RAND—RAND Corporation

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

RIA—Regulation Impact Analysis

RIC—Rehabilitation Impairment Category

RPL—Rehabilitation, Psychiatric, and Long-Term Care Hospital Market Basket

SCHIP—State Children's Health Insurance Program

SIC—Standard Industrial Code

TEFRA—Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248

I. Background

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

A. Historical Overview of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) for Fiscal Years (FYs) 2002 through 2007

Section 4421 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33), as amended by section 125 of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA, Pub. L. 106-113), and by section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA, Pub. L. 106-554), provides for the implementation of a per discharge prospective payment system (PPS), through section 1886(j) of the Social Security Act (the Act), for inpatient rehabilitation hospitals and inpatient rehabilitation units of a hospital (hereinafter referred to as IRFs).

Payments under the IRF PPS encompass inpatient operating and capital costs of furnishing covered rehabilitation services (that is, routine, ancillary, and capital costs) but not costs of approved educational activities, bad debts, and other services or items outside the scope of the IRF PPS. Although a complete discussion of the IRF PPS provisions appears in the August 7, 2001 final rule (66 FR 41316) as revised in the FY 2006 IRF PPS final rule (70 FR 47880), we are providing below a general description of the IRF PPS for fiscal years (FYs) 2002 through 2005.

Under the IRF PPS from FY 2002 through FY 2005, as described in the August 7, 2001 final rule, the Federal prospective payment rates were computed across 100 distinct case-mix groups (CMGs). We constructed 95 CMGs using rehabilitation impairment categories (RICs), functional status (both motor and cognitive), and age (in some cases, cognitive status and age may not be a factor in defining a CMG). In addition, we constructed five special CMGs to account for very short stays and for patients who expire in the IRF.

For each of the CMGs, we developed relative weighting factors to account for a patient's clinical characteristics and expected resource needs. Thus, the weighting factors accounted for the relative difference in resource use across all CMGs. Within each CMG, we created tiers based on the estimated effects that certain comorbidities would have on resource use.

We established the Federal PPS rates using a standardized payment conversion factor (formerly referred to as the budget neutral conversion factor). For a detailed discussion of the budget neutral conversion factor, please refer to our August 1, 2003 final rule (68 FR 45674, 45684 through 45685). In the FY 2006 IRF PPS final rule (70 FR 47880), we discussed in detail the methodology for determining the standard payment conversion factor.

We applied the relative weighting factors to the standard payment conversion factor to compute the unadjusted Federal prospective payment rates. Under the IRF PPS from FYs 2002 through 2005, we then applied adjustments for geographic variations in wages (wage index), the percentage of low-income patients, and location in a rural area (if applicable) to the IRF's unadjusted Federal prospective payment rates. In addition, we made adjustments to account for short-stay transfer cases, interrupted stays, and high cost outliers.

For cost reporting periods that began on or after January 1, 2002 and before October 1, 2002, we determined the final prospective payment amounts using the transition methodology prescribed in section 1886(j)(1) of the Act. Under this provision, IRFs transitioning into the PPS were paid a blend of the Federal IRF PPS rate and the payment that the IRF would have received had the IRF PPS not been implemented. This provision also allowed IRFs to elect to bypass this blended payment and immediately be paid 100 percent of the Federal IRF PPS rate. The transition methodology expired as of cost reporting periods beginning on or after October 1, 2002 (FY 2003), and payments for all IRFs now consist of 100 percent of the Federal IRF PPS rate.

We established a CMS Web site as a primary information resource for the IRF PPS. The Web site URL is http://www.cms.hhs.gov/​InpatientRehabFacPPS/​ and may be accessed to download or view publications, software, data specifications, educational materials, and other information pertinent to the IRF PPS.

Section 1886(j) of the Act confers broad statutory authority to propose refinements to the IRF PPS. We finalized the refinements described in this section in the FY 2006 IRF PPS final rule (70 FR 47880). The provisions of the FY 2006 IRF PPS final rule became effective for discharges beginning on or after October 1, 2005. We published correcting amendments to the FY 2006 IRF PPS final rule in the Federal Register on September 30, 2005 (70 FR 57166). Any reference to the FY 2006 IRF PPS final rule in this proposed rule also includes the provisions effective in the correcting amendments. Start Printed Page 26232

In the FY 2006 final rule (70 FR 47880 and 70 FR 57166), we finalized a number of refinements to the IRF PPS case-mix classification system (the CMGs and the corresponding relative weights) and the case-level and facility-level adjustments. These refinements were based on analyses by the RAND Corporation (RAND), a non-partisan economic and social policy research group, using calendar year 2002 and FY 2003 data. These were the first significant refinements to the IRF PPS since its implementation. In conducting the analysis, RAND used claims and clinical data for services furnished after the IRF PPS implementation. These newer data sets were more complete, and reflected improved coding of comorbidities and patient severity by IRFs. The researchers were able to use new data sources for imputing missing values and more advanced statistical approaches to complete their analyses. The RAND reports supporting the refinements made to the IRF PPS are available on the CMS Web site at: http://www.cms.hhs.gov/​InpatientRehabFacPPS/​09_​Research.asp.

The final key policy changes, effective for discharges occurring on or after October 1, 2005, are discussed in detail in the FY 2006 IRF PPS final rule (70 FR 47880 and 70 FR 57166). The following is a brief summary of the key policy changes:

  • Adopted the Office of Management and Budget's (OMB's) Core-Based Statistical Area (CBSA) market area definitions in a budget neutral manner.
  • Implemented a budget-neutral three-year hold harmless policy for IRFs that had been classified as rural in FY 2005, but became urban in FY 2006.
  • Implemented a payment adjustment to account for changes in coding that did not reflect real changes in case mix. We reduced the standard payment amount by 1.9 percent to account for such changes in coding following implementation of the IRF PPS.
  • Modified the CMGs, tier comorbidities, and relative weights in a budget-neutral manner. The five special CMGs remained the same as they had been before FY 2006 and continued to account for very short stays and for patients who expire in the IRF.
  • Implemented a teaching status adjustment in a budget neutral manner for IRFs, similar to the one adopted for inpatient psychiatric facilities.
  • Revised and rebased the market basket and labor-related share to reflect the operating and capital cost structures for rehabilitation, psychiatric, and long-term care (RPL) hospitals to update IRF payment rates.
  • Updated the rural adjustment from 19.14 percent to 21.3 percent in a budget neutral manner.
  • Updated the low-income percentage (LIP) adjustment from an exponent of 0.484 to an exponent of 0.6229 in a budget neutral manner.
  • Updated the outlier threshold amount from $11,211 to $5,129.

As noted above, a detailed discussion of the final key policy changes for FY 2006 appears in the FY 2006 IRF PPS final rule (70 FR 47880 and 70 FR 57166).

In the FY 2007 final rule (71 FR 48354) we made the following revisions and updates:

  • Updated the relative weight and average length of stay tables based on re-analysis of the data by CMS and our contractor, the RAND Corporation.
  • Reduced the standard payment amount by 2.6 percent to account more fully for coding changes that do not reflect real changes in case mix.
  • Updated the IRF PPS payment rates by the FY 2007 estimates of the market basket and the labor-related share.
  • Updated the IRF PPS payment rates by the FY 2007 wage indexes.
  • Applied the second year of the hold harmless policy in a budget neutral manner.
  • Updated the outlier threshold from $5,129 to $5,534.
  • Updated the urban and rural national cost-to-charge ratio ceilings for the purposes of determining outlier payments under the IRF PPS and clarified the methodology described in the regulations text.
  • Revised the regulation text in § 412.23(b)(2)(i) and § 412.23(b)(2)(ii) to reflect the statutory changes in section 5005 of the Deficit Reduction Act of 2005 (DRA, Pub. L. 109-171). The regulation text change prolongs the overall duration of the phased transition to the full 75 percent threshold established in § 412.23(b)(2)(i) and § 412.23(b)(2)(ii), by extending the transition's 60 percent phase for an additional 12 months. In addition to the above DRA requirements pertaining to the applicable compliance percentage requirements under § 412.23(b)(2), we also permitted a comorbidity that meets the criteria as specified in (b)(2)(i) to continue to be used before the 75 percent compliance threshold must be met.

B. Requirements for Updating the IRF PPS Rates

On August 7, 2001, we published a final rule titled “Medicare Program; Prospective Payment System for Inpatient Rehabilitation Facilities” in the Federal Register (66 FR 41316) that established a PPS for IRFs as authorized under section 1886(j) of the Act and codified at subpart P of part 412 of the Medicare regulations. In the August 7, 2001 final rule, we set forth the per discharge Federal prospective payment rates for FY 2002, which provided payment for inpatient operating and capital costs of furnishing covered rehabilitation services (that is, routine, ancillary, and capital costs) but not costs of approved educational activities, bad debts, and other services or items that are outside the scope of the IRF PPS. The provisions of the August 7, 2001 final rule were effective for cost reporting periods beginning on or after January 1, 2002. On July 1, 2002, we published a correcting amendment to the August 7, 2001 final rule in the Federal Register (67 FR 44073). Any references to the August 7, 2001 final rule in this proposed rule include the provisions effective in the correcting amendment.

Section 1886(j)(5) of the Act and § 412.628 of the regulations require the Secretary to publish in the Federal Register, on or before the August 1 that precedes the start of each new FY, the classifications and weighting factors for the IRF CMGs and a description of the methodology and data used in computing the prospective payment rates for the upcoming FY. On August 1, 2002, we published a notice in the Federal Register (67 FR at 49928) to update the IRF Federal prospective payment rates from FY 2002 to FY 2003 using the methodology as described in § 412.624. As stated in the August 1, 2002 notice, we used the same classifications and weighting factors for the IRF CMGs that were set forth in the August 7, 2001 final rule to update the IRF Federal prospective payment rates from FY 2002 to FY 2003. We continued to update the prospective payment rates in accordance with the methodology set forth in the August 7, 2001 final rule for each succeeding FY up to and including FY 2005. For FY 2006, however, we published a final rule that revised several IRF PPS policies (70 FR 47880). The provisions of the FY 2006 IRF PPS final rule became effective for discharges occurring on or after October 1, 2005. We published correcting amendments to the FY 2006 IRF PPS final rule in the Federal Register (70 FR 57166). Any reference to the FY 2006 IRF PPS final rule in this proposed rule includes the provisions effective in the correcting amendments.

In the final rule for FY 2007, we updated the IRF Federal prospective payment rates. In addition, we updated the cost-to-charge ratio ceilings and the outlier threshold. We implemented a 2.6 Start Printed Page 26233percent reduction to the FY 2007 standard payment amount to account more fully for changes in coding practices that do not reflect real changes in case mix. We revised the tier comorbidities and the relative weights to ensure that IRF PPS payments reflect, as closely as possible, the costs of caring for patients in IRFs. The final FY 2007 Federal prospective payment rates were effective for discharges occurring on or after October 1, 2006 and on or before September 30, 2007.

C. Operational Overview of the Current IRF PPS

As described in the August 7, 2001 final rule, upon the admission and discharge of a Medicare Part A fee-for-service patient, the IRF is required to complete the appropriate sections of a patient assessment instrument, the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI). All required data must be electronically encoded into the IRF-PAI software product. Generally, the software product includes patient grouping programming called the GROUPER software. The GROUPER software uses specific Patient Assessment Instrument (PAI) data elements to classify (or group) patients into distinct CMGs and account for the existence of any relevant comorbidities.

The GROUPER software produces a five-digit CMG number. The first digit is an alpha-character that indicates the comorbidity tier. The last four digits represent the distinct CMG number. (Free downloads of the Inpatient Rehabilitation Validation and Entry (IRVEN) software product, including the GROUPER software, are available on the CMS Web site at http://www.cms.hhs.gov/​InpatientRehabFacPPS/​06_​Software.asp).

Once a patient is discharged, the IRF completes the Medicare claim (UB-92 or its equivalent) using the five-digit CMG number and sends it to the appropriate Medicare fiscal intermediary (FI). Claims submitted to Medicare must comply with both the Administrative Simplification Compliance Act (ASCA, Pub. L. 107-105), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Pub. L. 104-191). Section 3 of the ASCA amends section 1862(a) of the Act by adding paragraph (22) which requires the Medicare program, subject to section 1862(h) of the Act, to deny payment under Part A or Part B for any expenses for items or services “for which a claim is submitted other than in an electronic form specified by the Secretary.” Section 1862(h) of the Act, in turn, provides that the Secretary shall waive such denial in two types of cases and may also waive such denial “in such unusual cases as the Secretary finds appropriate.” See also the final rule on Electronic Submission of Medicare Claims (70 FR 71008, November 25, 2005). Section 3 of the ASCA operates in the context of the administrative simplification provisions of HIPAA, which include, among others, the requirements for transaction standards and code sets codified as 45 CFR parts 160 and 162, subparts A and I through R (generally known as the Transactions Rule). The Transactions Rule requires covered entities, including covered providers, to conduct covered electronic transactions according to the applicable transaction standards. (See the program claim memoranda issued and published by CMS at: http://www.cms.hhs.gov/​ElectronicBillingEDITrans/​ and listed in the addenda to the Medicare Intermediary Manual, Part 3, section 3600. Instructions for the limited number of claims submitted to Medicare on paper are published by CMS at: http://www.cms.hhs.gov/​manuals/​downloads/​clm104c25.pdf.

The Medicare FI processes the claim through its software system. This software system includes pricing programming called the PRICER software. The PRICER software uses the CMG number, along with other specific claim data elements and provider-specific data, to adjust the IRF's prospective payment for interrupted stays, transfers, short stays, and deaths, and then applies the applicable adjustments to account for the IRF's wage index, percentage of low-income patients, rural location, and outlier payments. For discharges occurring on or after October 1, 2005, the IRF PPS payment also reflects the new teaching status adjustment that became effective as of FY 2006, as discussed in the FY 2006 IRF PPS final rule (70 FR 47880).

D. Brief Summary of Proposed Revisions to the IRF PPS for FY 2008

In this proposed rule, we are proposing to make the following revisions, updates, and clarifications:

  • Update the FY 2008 IRF PPS payment rates by the proposed market basket, as discussed in section IV.A.
  • Update the FY 2008 IRF PPS payment rates by the proposed wage index and the labor related share in a budget neutral manner, as discussed in section IV.A and B.
  • Update the pre-reclassified and pre-floor wage indexes based on the applicable Office of Management and Budget (OMB) bulletins that add or delete Core-Based Statistical Areas (CBSAs) numbers and title changes, as discussed in section IV.B.
  • Implement the final year of the 3-year hold harmless policy adopted in the FY 2006 IRF PPS final rule (70 FR 47880, 47923 through 47926) in a budget neutral manner, as discussed in section IV.B.
  • Update the outlier threshold amount for FY 2008 to $7,522, as discussed in section V.A.
  • Update the cost-to-charge ratio ceiling and the national average urban and rural cost-to-charge ratios for purposes of determining outlier payments under the IRF PPS, as discussed in section V.B.
  • Clarify the regulations text for the special payment provisions for patients that are transferred, as discussed in section VI.

II. 75 Percent Rule Policy

[If you choose to comment on issues in this section, please include the caption “75 Percent Rule Policy” at the beginning of your comments.]

In order to be excluded from the acute care inpatient hospital PPS specified in § 412.1(a)(1) and instead be paid under the IRF PPS, a hospital or rehabilitation unit of an acute care hospital must meet the requirements for classification as an IRF stipulated in subpart B of part 412. As discussed in previous Federal Register publications (68 FR 26786 (May 16, 2003), 68 FR 53266 (September 9, 2003), 69 FR 25752 (May 7, 2004), 70 FR 36640 (June 24, 2005), and 71 FR 48354 (August 18, 2006)), § 412.23(b)(2) specifies one criterion which Medicare uses for classifying a hospital or unit of a hospital as an IRF. The criterion is that a minimum percentage of a facility's total inpatient population must require intensive rehabilitative services for the treatment of at least one of 13 medical conditions listed in § 412.23(b)(2)(iii) in order for the facility to be classified as an IRF. In addition, for cost reporting periods beginning on or after July 1, 2004, and before July 1, 2008, a patient with a comorbidity as defined at § 412.602 may be included in the inpatient population that counts toward the required applicable percentage if certain requirements are met. The minimum percentage is known as the “compliance threshold.”

Prior to the May 7, 2004 final rule (69 FR 25752), § 412.23(b)(2) stipulated that the compliance threshold was 75 percent. Therefore, the compliance threshold was commonly referred to as the “75 percent rule.” In addition, prior to the May 7, 2004 final rule the regulation only specified 10 medical conditions. However, in the May 7, 2004 final rule we revised § 412.23(b)(2), and Start Printed Page 26234that revision increased the number of medical conditions to 13, as well as temporarily lowered the compliance threshold while at the same time specified a transition period at the end of which IRFs would once again have to meet a compliance threshold of 75 percent. Also, the revised regulation specified that during the compliance threshold transition period a patient's comorbidity may be used to determine if a provider met the compliance threshold provided certain applicable requirements were met.

In § 412.602 a comorbidity is defined as a specific patient condition that is secondary to the patient's principal diagnosis. A patient's principal diagnosis is the primary reason for the patient being admitted to an IRF, and this diagnosis is used to determine if the patient had a medical condition that can be counted towards meeting the compliance threshold. As specified in the May 7, 2004 final rule, in order for an inpatient with a certain comorbidity to be included in the inpatient population that counts toward the applicable percentage the following criteria must be met:

  • The patient is admitted for inpatient rehabilitation for a condition that is not one of the conditions listed in § 412.23(b)(2)(iii).
  • The patient also has a comorbidity that falls in one of the conditions listed in § 412.23(b)(2)(iii).
  • The comorbidity has caused significant decline in functional ability in the individual such that, even in the absence of the admitting condition, the individual would require the intensive rehabilitation treatment that is unique to inpatient rehabilitation facilities paid under the IRF PPS and that cannot be appropriately performed in another care setting covered under this Title.

In accordance with the May 7, 2004 final rule, IRFs would have to meet a compliance threshold of 75 percent for cost reporting periods starting on or after July 1, 2007. However, Section 5005 of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171 modified the applicable time periods when the various compliance thresholds, as originally specified in the May 7, 2004 final rule, must be met.) The net effect of the DRA was extension of the compliance threshold transition period. Due to the DRA, the transition period was extended to include cost reporting periods starting on or after July 1, 2004, and before July 1, 2008. Therefore, in order to conform the regulations to the DRA, we revised § 412.23(b)(2) and stipulated that an IRF with a cost reporting period starting on or after July 1, 2008, instead of July 1, 2007, must meet the 75 percent compliance threshold. In addition, we also permitted a comorbidity that meets the criteria as specified in (b)(2)(i) to continue to be used to determine the compliance threshold for cost reporting periods beginning before July 1, 2008 instead of July 1, 2007. (For a complete description of all the changes made, see the FY 2007 IRF PPS final rule (71 FR 48354)).

For cost reporting periods beginning on or after July 1, 2008, comorbidities will not be eligible for inclusion in the calculations used to determine if the provider meets the 75 percent compliance threshold specified in § 412.23(b)(2)(ii). As the 75 percent rule is only partially phased in at this time and there are limitations to the policy conclusions that can be drawn from currently available claim and patient assessment data, this rule maintains existing policy. However, in the May 7, 2004 final rule (69 FR 25762), we encouraged research evaluating the continued use of comorbidities in determining compliance with the 75 percent rule. Therefore, we are soliciting comments supporting current policy or other options, including use of some or all of the existing comorbidities in calculating the compliance percentage for an additional fixed period of one or more years or to integrate the inclusion of some or all of the existing comorbidities on a permanent basis. In addition, we are soliciting comments that include clinical data based on scientifically sound research that provide evidence on these and other options.

III. Classification System for the Inpatient Rehabilitation Facility Prospective Payment System

[If you choose to comment on issues in this section, please include the caption “Classification System for the Inpatient Rehabilitation Facility Prospective Payment System” at the beginning of your comments.]

For the FY 2008 IRF PPS, we will use the same case-mix classification system that we used for FY 2007, as set forth in the FY 2007 IRF PPS final rule (71 FR 48354). Table 1 below, “Relative Weights and Average Lengths of Stay for Case-Mix Groups”, presents the CMGs, the comorbidity tiers, the corresponding relative weights, and the average length of stay value for each CMG and tier. The average length of stay for each CMG is used to determine when an IRF discharge meets the definition of a short-stay transfer, which results in a per diem case level adjustment. Because these data elements are not changing, Table 1 shown below is identical to Table 4 that was published in the FY 2007 IRF PPS final rule (71 FR 48354, 48364 through 48370). The methodology we used to construct the data elements in Table 1 is described in detail in the FY 2007 IRF PPS final rule (71 FR 48354).

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IV. Proposed FY 2008 IRF PPS Federal Prospective Payment Rates

[If you choose to comment on issues in this section, please include the caption “Proposed FY 2008 IRF PPS Federal Prospective Payment Rates” at the beginning of your comments.]

A. Proposed FY 2008 IRF PPS Market Basket Increase Factor and Labor-Related Share

Section 1886(j)(3)(C) of the Act requires the Secretary to establish an increase factor that reflects changes over Start Printed Page 26243time in the prices of an appropriate mix of goods and services included in the covered IRF services, which is referred to as a market basket index. In updating the FY 2008 payment rates outlined in this proposed rule, CMS applied an appropriate increase factor to the FY 2007 IRF PPS payment rates that is based on the rehabilitation, psychiatric, and long-term care hospital (RPL) market basket. In constructing the RPL market basket, we used the methodology set forth in the FY 2006 IRF PPS final rule (70 FR 47880, 47908 through 47915).

As discussed in that final rule, the RPL market basket primarily uses the Bureau of Labor Statistics' (BLS) data as price proxies, which are grouped in one of the three BLS categories: Producer Price Indexes (PPI), Consumer Price Indexes (CPI), and Employment Cost Indexes (ECI). We evaluated and selected these particular price proxies using the criteria of reliability, timeliness, availability, and relevance, and believe they continue to be the best measures of price changes for the cost categories.

As discussed in the FY 2007 IRF PPS proposed rule, beginning April 2006 with the publication of March 2006 data, the BLS” ECI has used a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SIC). We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the RPL market basket and did not make any changes. This proposed rule's estimated FY 2008 IRF market basket increase factor and labor-related share will be updated for the final rule based on the most recent data available from the BLS.

We will use the same methodology described in the FY 2006 IRF PPS final rule to compute the FY 2008 IRF market basket increase factor and labor-related share. For this proposed rule, the FY 2008 IRF market basket increase factor is 3.3 percent. This is based on Global Insight, Inc.’s forecast for the first quarter of 2007 (2007q1) with historical data through the fourth quarter of 2006 (2006q4). We propose to update the market basket with more recent data for the final rule to the extent it is available. However, we note that the President's budget includes a proposal for a zero percent update in the IRF market basket for FY 2008, and that the provisions outlined in this proposed rule would need to reflect any legislation that the Congress enacts to adopt this proposal.

In addition, we have used the methodology described in the FY 2006 IRF PPS final rule to update the labor-related share for FY 2008. In FY 2004, we updated the 1992 market basket data to 1997 based on the methodology described in the August 1, 2003 final rule (68 FR 45688 through 45689). As discussed in the FY 2006 IRF PPS final rule (70 FR 47880, 47915 through 47917), we rebased and revised the market basket for FY 2006 using the 2002-based cost structures for IRFs, IPFs, and LTCHs to determine the FY 2006 labor-related share. For FY 2007, we used the same methodology discussed in the FY 2006 IRF PPS final rule (70 FR 47880, 47908 through 47917) to determine the FY 2007 IRF labor-related share. For FY 2008, we continue to use the same methodology discussed in the FY 2006 IRF PPS final rule. As shown in Table 2, the total FY 2008 RPL labor-related share is 75.846 percent in this proposed rule. We propose to update the labor-related share with more recent data for the final rule to the extent it is available.

Table 2.—Proposed FY 2008 IRF Labor-Related Share Relative Importance

Cost categoryProposed FY 2008 IRF labor-related relative importance
Wages and salaries52.640
Employee benefits14.149
Professional fees2.907
All other labor intensive services2.147
Subtotal71.843
Labor-related share of capital costs4.003
Total75.846
SOURCE: Global Insight, Inc, 1st Qtr, 2007; @USMACRO/CONTROL0307 @CISSIM/TL0207.SIM Historical Data through 4th QTR, 2006

B. Proposed Area Wage Adjustment

Section 1886(j)(6) of the Act requires the Secretary to adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs attributable to wages and wage-related costs by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for those facilities. The Secretary is required to update the wage index on the basis of information available to the Secretary on the wages and wage-related costs to furnish rehabilitation services. Any adjustments or updates made under section 1886(j)(6) of the Act for a FY are made in a budget neutral manner.

In the FY 2007 IRF PPS final rule, we maintained the methodology described in the FY 2006 IRF PPS final rule to determine the wage index, labor market area definitions, and hold harmless policy consistent with the rationale outlined in that final rule (70 FR 47880, 47917 through 47933). In the FY 2006 IRF PPS final rule, we adopted a 3-year hold harmless policy specifically for rural IRFs whose labor market designations changed from rural to urban under the CBSA-based labor market area designations. This policy specifically applied to IRFs that had been previously designated rural and which, effective for discharges on or after October 1, 2005, would otherwise have become ineligible for the 19.14 percent rural adjustment. For FY 2008, the third and final year of the 3-year phase-out of the budget-neutral hold harmless policy, we will no longer apply an adjustment for IRFs that meet the criteria described in the FY 2006 final rule (70 FR 47880, 47923 through 47926).

For FY 2008, we propose to maintain the policies and methodologies described in the FY 2007 IRF PPS final rule relating to the labor market area definitions, the wage index methodology for areas with wage data, and hold harmless policy consistent with the rationale outlined in the FY 2006 IRF PPS final rule (70 FR 47880, 47917 through 47933). Therefore, this proposed rule continues to use the Core-Based Statistical Area (CBSA) labor market area definitions and the pre-reclassification and pre-floor hospital wage index based on 2003 cost report data. In addition, the budget neutral hold harmless policy established in the FY 2006 final rule will expire for discharges occurring on or after October 1, 2007.

In adopting the CBSA geographic designations in FY 2006, we provided a one-year transition with a blended wage index for all providers. For FY 2006, the wage index for each provider consisted of a blend of 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index (both using FY 2001 hospital data). We referred to the blended wage index as the FY 2006 IRF PPS transition wage index. As discussed in the FY 2006 IRF PPS final rule (70 FR 47880, 47926), subsequent to the expiration of this one-year transition on September 30, 2006, we used the full CBSA-based wage index values as published in the Addendum of the FY 2007 IRF PPS final rule (71 FR 48354) and in the Addendum of this proposed rule. Start Printed Page 26244

When adopting OMB's new labor market designations, we identified some geographic areas where there were no hospitals and, thus, no hospital wage index data on which to base the calculation of the IRF PPS wage index (70 FR 47880).

In this proposed rule, we are proposing to revise our methodology to determine a proxy for rural areas without hospital wage data. Under the CBSA labor market areas, there are no rural hospitals in rural Massachusetts and rural Puerto Rico. Because there was no rural proxy for more recent rural data within those areas, we used the FY 2006 wage index value in both FY 2006 and FY 2007 for rural Massachusetts and rural Puerto Rico.

Due to the use of the same wage index value (from FY 2006) for these areas for two fiscal years, we believe it is appropriate at this point to consider alternatives in our methodology to update the wage index for rural areas without rural hospital wage index data. We believe that the best imputed proxy would 1) use pre-floor, pre-reclassified hospital data, 2) be easy to evaluate, 3) use the most local data, and 4) be easily updateable from year-to-year. Since the implementation of the IRF PPS, we have used the pre-floor, pre-reclassified hospital wage data that is easy to evaluate and is updateable from year-to-year. In addition, the IRF PPS wage index is based on hospitals' cost report data, which reflects local available data. Therefore, we believe the imputed proxy for a rural area without hospital wage data is consistent with our past methodology and other post-acute PPS wage index policy. Although our current methodology uses rural pre-floor, pre-reclassified hospital wage data, this method is not updateable from year-to-year.

Therefore, in cases where there is a rural area without rural hospital wage data, we propose using the average wage index from all contiguous CBSAs to represent a reasonable proxy for the rural area within a State. While this approach does not use rural data, it does use pre-floor, pre-reclassified hospital wage data, it is easy to evaluate, it is updateable from year-to-year, and it uses the most local data available.

In determining an imputed rural wage index, we interpret the term “contiguous” to mean sharing a border. For example, in the case of Massachusetts, the entire rural area consists of Dukes and Nantucket counties. We have determined that the borders of Dukes and Nantucket counties are local and contiguous with Barnstable and Bristol counties. Under the proposed methodology, the wage indexes for the counties of Barnstable (CBSA 12700: 1.2539) and Bristol (CBSA 39300: 1.0783) are averaged, resulting in an imputed rural wage index of 1.1661 for rural Massachusetts for FY 2008. While we believe that this policy could be readily applied to other rural areas that lack hospital wage data (possibly due to hospitals converting to a different provider type, such as a CAH, that does not submit the appropriate wage data), we may re-examine this policy should a similar situation arise in the future.

However, we do not believe that this policy is appropriate for Puerto Rico. There are sufficient economic differences between hospitals in the United States and those in Puerto Rico (including the payment of hospitals in Puerto Rico using blended Federal/Commonwealth-specific rates) that a separate and distinct policy for Puerto Rico is necessary. Consequently, any alternative methodology for imputing a wage index for rural Puerto Rico would need to take into account these economic differences and the payment rates hospitals receive in Puerto Rico. Our policy of imputing a rural wage index based on the wage index(es) of CBSAs contiguous to the rural area in question does not recognize the unique circumstances of Puerto Rico. While we have not yet identified an alternative methodology for imputing a wage index for rural Puerto Rico, we will continue to evaluate the feasibility of using existing hospital wage data and, possibly, wage data from other sources. By maintaining our current policy for Puerto Rico, we will maintain consistency with other post-acute care PPS wage index policies. Accordingly, we propose to continue using the most recent wage index previously available for Puerto Rico; that is, a wage index of 0.4047. We solicit comments on our proposal to maintain the current wage index policy for rural Puerto Rico.

In the FY 2006 IRF PPS final rule (70 FR 47880, 47920), we notified the public that the Office of Management and Budget (OMB) published a bulletin that changed the titles to certain CBSAs after the publication of our FY 2006 IRF PPS proposed rule (70 FR 30186). Since the publication of the FY 2006 IRF PPS final rule, OMB published additional bulletins that updated the CBSAs. Specifically, OMB added or deleted certain CBSA numbers and revised certain titles. Accordingly, in this proposed rule, we are proposing to clarify that this and all subsequent IRF PPS rules and notices are considered to incorporate the CBSA changes published in the most recent OMB bulletin that applies to the hospital wage data used to determine the current IRF PPS wage index. The OMB bulletins may be accessed online at http://www.whitehouse.gov/​omb/​bulletins/​index.html.

To calculate the wage-adjusted facility payment for the payment rates set forth in this proposed rule, we multiply the unadjusted Federal prospective payment by the proposed FY 2008 RPL labor-related share (75.846 percent) to determine the labor-related portion of the Federal prospective payments. We then multiply this labor-related portion by the applicable proposed IRF wage index shown in Table 1 for urban areas and Table 2 for rural areas in the Addendum.

Adjustments or updates to the IRF wage index made under section 1886(j)(6) of the Act must be made in a budget neutral manner; therefore, we calculated a budget neutral wage adjustment factor as established in the August 1, 2003 final rule and codified at § 412.624(e)(1), and described in the steps below. We propose to use the following steps to ensure that the FY 2008 IRF standard payment conversion factor reflects the update to the proposed wage indexes (based on the FY 2003 pre-reclassified and pre-floor hospital wage data) and the proposed labor-related share in a budget neutral manner:

Step 1 Determine the total amount of the estimated FY 2007 IRF PPS rates, using the FY 2007 standard payment conversion factor and the labor-related share and the wage indexes from FY 2007 (as published in the FY 2007 IRF PPS final rule).

Step 2 Calculate the total amount of estimated IRF PPS payments, using the FY 2007 standard payment conversion factor and the proposed FY 2008 labor-related share and proposed CBSA urban and rural wage indexes.

Step 3 Divide the amount calculated in step 1 by the amount calculated in step 2, which equals the FY 2008 budget neutral wage adjustment factor of 1.0026.

Step 4 Apply the FY 2008 budget neutral wage adjustment factor from step 3 to the FY 2007 IRF PPS standard payment conversion factor after the application of the estimated market basket update to determine the FY 2008 standard payment conversion factor.

C. Description of the Proposed IRF Standard Payment Conversion Factor and Proposed Payment Rates for FY 2008

To calculate the proposed standard payment conversion factor for FY 2008 and as illustrated in Table 3 below, we begin by applying the estimated market Start Printed Page 26245basket increase factor (3.3 percent) to the standard payment conversion factor for FY 2007 ($12,981), which equals $13,409. We then apply the proposed combined budget neutrality factor for the wage index and labor related share and final year of the hold harmless policy of 1.0040 (1.0026 * 1.0014 = 1.0040), which would result in a proposed standard payment conversion factor of $13,463.

Table 3.—Calculations To Determine the Proposed FY 2008 Standard Payment Conversion Factor

Explanation for adjustmentCalculations
FY 2007 Standard Payment Conversion Factor12,981
Proposed FY 2008 Market Basket Increase Factor× 1.033
Subtotal= 13,409
Proposed Budget Neutrality Factor for the Wage Index, Labor-Related Share, and the Hold Harmless Provision× 1.0040
Proposed FY 2008 Standard Payment Conversion Factor= $13,463

After the application of the relative weights, the resulting proposed unadjusted IRF prospective payment rates for FY 2008 are shown below in Table 4, “Proposed FY 2008 Payment Rates.”

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D. Example of the Methodology for Adjusting the Proposed Federal Prospective Payment Rates

Table 5 illustrates the proposed methodology for adjusting the Federal prospective payments (as described in sections IV.A through C of this proposed rule). The examples below are based on two hypothetical Medicare beneficiaries, both classified into CMG 0110 (without comorbidities). The unadjusted Federal prospective payment rate for CMG 0110 (without comorbidities) can be found in Table 4 above.

One beneficiary is in Facility A, an IRF located in rural Spencer County, Indiana, and another beneficiary is in Facility B, an IRF located in urban Harrison County, Indiana. Facility A, a non-teaching hospital, has a disproportionate share hospital (DSH) percentage of 5 percent (which results in a LIP adjustment of 1.0309), a wage index of 0.8538, and an applicable rural adjustment of 21.3 percent. Facility B, a teaching hospital, has a DSH percentage of 15 percent (which results in a LIP adjustment of 1.0910), a wage index of 0.9118, and an applicable teaching status adjustment of 0.109.

To calculate each IRF's labor and non-labor portion of the Federal prospective payment, we begin by taking the unadjusted Federal prospective payment rate for CMG 0110 (without comorbidities) from Table 4 above. Then, we multiply the estimated labor-related share (75.846) described in section IV.A by the unadjusted Federal prospective payment rate. To determine the non-labor portion of the Federal prospective payment rate, we subtract the labor portion of the Federal payment from the unadjusted Federal prospective payment.

To compute the wage-adjusted Federal prospective payment, we multiply the result of the labor portion of the Federal payment by the appropriate wage index found in the Addendum in Tables 1 and 2, which will result in the wage-adjusted amount. Next, we compute the wage-adjusted Federal payment by adding the wage-adjusted amount to the non-labor portion.

To adjust the Federal prospective payment by the facility-level adjustments, there are several steps. First, we take the wage-adjusted Federal prospective payment and multiply it by the appropriate rural and LIP adjustments (if applicable). Then, to determine the appropriate amount of additional payment for the teaching status adjustment (if applicable), we multiply the teaching status adjustment (0.109, in this example) by the wage-adjusted and rural-adjusted amount (if applicable). Finally, we add the additional teaching status payments (if applicable) to the wage, rural, and LIP-adjusted Federal prospective payment rate. Table 5 illustrates the components of the proposed adjusted payment calculation.

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Thus, the proposed adjusted payment for Facility A would be $32,405.16 and the proposed adjusted payment for Facility B would be $32,635.56.

V. Update to Payments for High-Cost Outliers Under the IRF PPS

[If you choose to comment on issues in this section, please include the caption “High-Cost Outliers Under the IRF PPS” at the beginning of your comments.]

A. Proposed Update to the Outlier Threshold Amount for FY 2008

Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments in addition to the basic IRF prospective payments for cases incurring extraordinarily high costs. A case qualifies for an outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold. We calculate the adjusted outlier threshold by adding the IRF PPS payment for the case (that is, the CMG payment adjusted by all of the relevant facility-level adjustments) and the adjusted threshold amount (also adjusted by all of the relevant facility-level adjustments). Then, we calculate the estimated cost of a case by multiplying the IRF's overall cost-to-charge ratio (CCR) by the Medicare allowable covered charge. If the estimated cost of the case is higher than the adjusted outlier threshold, we make an outlier payment for the case equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold.

In the August 7, 2001 final rule (66 FR 41316, 41362 through 41363), we discussed our rationale for setting the outlier threshold amount for the IRF PPS so that estimated outlier payments would equal 3 percent of total estimated payments. Subsequently, we updated the IRF outlier threshold amount in the FYs 2006 and 2007 IRF PPS final rules (70 FR 47880 and 71 FR 48354) to maintain estimated outlier payments at 3 percent of total estimated payments, Start Printed Page 26250and we also stated that we would continue to analyze the estimated outlier payments for subsequent years and adjust the outlier threshold amount as appropriate to maintain the 3 percent target.

For this proposed rule, we performed an updated analysis of FY 2005 claims and IRF-PAI data using the same methodology we used to set the initial outlier threshold amount when we first implemented the IRF PPS in the August 7, 2001 final rule (66 FR 41316), which is also the same methodology we used to update the outlier threshold amounts for FYs 2006 and 2007. Using the updated FY 2005 claims and IRF-PAI data, we estimate that IRF outlier payments as a percentage of total estimated payments for FY 2007 increased from 3 percent using the FY 2004 data to approximately 3.8 percent using the updated FY 2005 data. We are still investigating the reasons for the change in estimated outlier payments between FY 2004 and FY 2005, and will carefully evaluate all possible reasons for this change.

Based on the updated analysis using FY 2005 data, and consistent with the broad statutory authority conferred upon the Secretary in sections 1886(j)(4)(A)(i) and 1886(j)(4)(A)(ii) of the Act, we propose to update the outlier threshold amount to $7,522 to decrease estimated outlier payments from approximately 3.8 to 3 percent of total estimated aggregate IRF payments for FY 2008.

The outlier threshold amount for FY 2008 is subject to change in the final rule based on analysis of updated data.

B. Update to the IRF Cost-to-Charge Ratio Ceilings

In accordance with the methodology stated in the August 1, 2003 final rule (68 FR 45692 through 45694), we apply a ceiling to IRFs' cost-to-charge ratios (CCRs). Using the methodology described in that final rule, we propose to update the national urban and rural CCRs for IRFs. We apply the national urban and rural CCRs in the following situations:

  • New IRFs that have not yet submitted their first Medicare cost report.
  • IRFs whose overall CCR is in excess of 3 standard deviations above the corresponding national geometric mean, which we propose to set at 1.55 (based on the current estimate) for FY 2008.
  • Other IRFs for whom accurate data with which to calculate an overall CCR are not available.

Specifically, for FY 2008, we estimate a proposed national CCR of 0.589 for rural IRFs and 0.475 for urban IRFs. For new facilities, we use these national ratios until the data become available for us to compute the facility's actual CCR using the first tentative settled or final settled cost report data, which we will then use for the subsequent cost reporting period. We note that the proposed national average rural and urban CCRs and our estimate of 3 standard deviations above the corresponding national geometric mean in this section are subject to change in the final rule based on updated analysis and data.

C. Adjustment of IRF Outlier Payments

In the August 1, 2003 final rule (68 FR 45674, 45693 through 45694), we finalized a proposal to make IRF outlier payments subject to reconciliation when IRFs' cost reports are settled, consistent with the policy adopted for IPPS hospitals in the June 9, 2003 IPPS final rule (68 FR 34494, 34501). The revised methodology provides for retroactive adjustments to IRF outlier payments to account for differences between the CCRs from the latest settled cost report and the actual CCRs computed at the time the cost report that coincides with the date of discharge is settled using the cost and charge data from that cost report. This revised methodology addresses vulnerabilities found in the IPPS and the IRF outlier payment policies, which may have resulted in outlier payments that were too high or too low. Along these lines, we are analyzing IRF outlier payments from the beginning of the IRF PPS through FY 2005, obtained from IRFs' cost report filings, to identify specific payment vulnerabilities in the IRF outlier payment policy.

Under this policy, which is outlined in § 412.624(e)(5), which in turn references § 412.84(i) and § 412.84(m) of the IPPS regulations, outlier payments will be processed on an interim basis throughout the year using IRFs' CCRs based on the best information available at the time. When an IRF's cost report is settled, any reconciliation of outlier payments by fiscal intermediaries will be based on the relationship between an IRF's costs and charges at the time a particular discharge actually occurred. This revised methodology ensures that the final outlier payments reflect an accurate assessment of the actual costs the IRF incurred for treating the case.

We have not yet issued instructions to the fiscal intermediaries regarding IRF outlier reconciliation because we have been analyzing the data and assessing the systems changes necessary to conduct the reconciliation. Thus, we will soon issue instructions to fiscal intermediaries to begin reconciling IRF outlier payments upon settlement of IRF cost reports.

VI. Clarification to the Regulation Text for Special Payment Provisions for Patients That Are Transferred

[If you choose to comment on issues in this section, please include the caption “Clarification to the Regulation Text for Special Payment Provisions for Patients that are Transferred” at the beginning of your comments.]

Section 125(a)(3) of the BBRA amended Section 1886(j)(1) of the Act by adding a paragraph (E) that states “Construction relating to transfer authority—Nothing in this subsection shall be construed as preventing the Secretary from providing for an adjustment to payments to take into account the early transfer of a patient from a rehabilitation facility to another site of care.” In the FY 2002 proposed and final IRF PPS rules, we proposed and adopted the transfer payment policy under § 412.624(f). The transfer policy provides payments that more accurately reflect facility resources used and services delivered for patients that transfer to another site of care as discussed in the FY 2002 IRF PPS final rule (66 FR 41316, 41353 through 41355). We are proposing to revise our regulations text to clarify our existing policy under § 412.624(f).

In the FY 2002 IRF PPS final rule (66 FR 41316, 41353 through 41355), we discuss our rationale, criteria for defining a transfer case, and the methodology to determine the unadjusted Federal prospective payment for the transfer case. In addition, we discuss several adjustments that we apply to the unadjusted Federal prospective payment rate. The final adjustments described in the FY 2002 IRF PPS final rule (65 FR 66304, 66347 through 66357) include the area wage adjustment, rural adjustment, the LIP adjustment, and the high-cost outlier adjustment. In our FY 2006 IRF PPS final rule (70 FR 47880), we refined the facility level adjustments and also adopted a teaching status adjustment.

We define a transfer under § 412.602 to mean the release of a Medicare inpatient from an IRF to another IRF, a short-term, acute-care prospective payment hospital, a long-term care hospital as described in § 412.23(e), or a nursing home that qualifies to receive Medicare or Medicaid payment. In order to receive a transfer payment under § 412.624(f), a patient must be transferred to another site of care as defined in § 412.602 and had to have stayed in the IRF for less than the average length of stay for the case-mix Start Printed Page 26251group (CMG). Table 1 in this proposed rule presents the CMGs, the comorbidity tiers, the corresponding relative weights, and the average length of stay value for each CMG and tier. We use the average length of stay for each CMG to determine when an IRF discharge meets the definition of a transfer, which results in a per diem case level adjustment.

Since the implementation of the IRF PPS, we determine whether a claim meets the high-cost outlier policy under § 412.624(e)(5), as revised in the FY 2007 IRF PPS final rule (71 FR 48354, 48382 through 48383). A case qualifies for an outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold, in which case we make an outlier payment equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold. Since the implementation of the IRF PPS, we have provided an additional high-cost outlier payment to both transfer cases and full CMG cases when applicable. We propose to clarify the regulations text to articulate the transfer policy more clearly. Specifically, we propose to add the phrase “subject to paragraph (e)(5)” at the end of the paragraph under § 412.624(f)(2)(v). The proposed revised § 412.624(f)(2)(v) will read, “By applying the adjustment described in paragraphs (e)(1), (e)(2), (e)(3), (e)(4), and (e)(7) of this section to the unadjusted payment amount determined in paragraph (f)(2)(iv) of this section to equal the adjusted transfer payment amount, subject to paragraph (e)(5).”

VII. Provisions of the Proposed Regulation

[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.]

We are proposing to make revisions to the regulation text in order to implement the proposed policy changes for IRFs for FY 2007 and subsequent fiscal years. Specifically, we are proposing to make conforming changes in 42 CFR part 412. We discuss these proposed revisions and others in detail below.

A. Section 412.624 Methodology for Calculating the Federal Prospective Payment Rates

In this section, we are proposing to revise the current regulations text in paragraph (f)(2)(v) to clarify that we determine whether a high-cost outlier payment would be applicable for transfer cases. We emphasize that this is not a change to our current methodology for determining whether a high-cost outlier payment applies to transfer cases.

B. Additional Proposed Changes

  • Update the FY 2008 IRF PPS payment rates by the proposed market basket, as discussed in section IV.A.
  • Update the FY 2008 IRF PPS payment rates by the proposed wage index and the labor related share in a budget neutral manner, as discussed in section IV.A and B.
  • Update the pre-reclassified and pre-floor wage indexes based on the CBSA changes published in the most recent OMB bulletins that apply to the hospital wage data used to determine the current IRF PPS wage index, as discussed in section IV.B.
  • Implement the final year of the three-year hold harmless policy adopted in the FY 2006 IRF PPS final rule (70 FR 47880, 447923 through 47926) in a budget neutral manner, as discussed in section IV.B.
  • Update the outlier threshold amount for FY 2008 to $7,522, as discussed in section V.A.
  • Update the cost-to-charge ratio ceiling and the national average urban and rural cost-to-charge ratios for purposes of determining outlier payments under the IRF PPS, as discussed in section V.B.

VIII. Collection of Information Requirements

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995.

IX. Response to Public Comments

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

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

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any one year). This proposed rule is a major rule, as defined in Title 5, United States Code, section 804(2), because we estimate the impact to the Medicare program, and the annual effects to the overall economy, would be more than $100 million. We estimate that the total impact of these proposed changes for estimated FY 2008 payments compared to estimated FY 2007 payments would be an increase of approximately $150 million (this reflects a $200 million increase from the update to the payment rates and a $50 million decrease due to the proposed update to the outlier threshold amount to decrease estimated outlier payments from approximately 3.8 percent in FY 2007 to 3 percent in FY 2008).

The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government jurisdictions. Most IRFs and most other providers and suppliers are considered small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any one year. (For details, see the Small Business Administration's final rule that set forth size standards for health care industries, at 65 FR 69432, November 17, 2000.) Because we lack data on individual hospital receipts, we cannot determine the number of small proprietary IRFs or the proportion of IRFs' revenue that is derived from Medicare payments. Therefore, we assume that all IRFs (an approximate total of 1,200 IRFs, of which approximately 60 percent are nonprofit facilities) are considered small entities and that Medicare payment constitutes the majority of their revenues. The Department of Health and Human Start Printed Page 26252Services generally uses a revenue impact of 3 to 5 percent as a significance threshold under the RFA. As shown in Table 6, we estimate that the net revenue impact of this proposed rule on all IRFs is to increase estimated payments by about 2.4 percent, with an estimated increase in payments of 3 percent or higher for some categories of IRFs (such as rural freestanding IRFs, urban IRFs in the East North Central and Mountain regions, and rural IRFs in the Middle Atlantic and East South Central regions). Thus, we anticipate that this proposed rule may have a significant impact on a substantial number of small entities. However, the estimated impact of this proposed rule is a net increase in revenues across all categories of IRFs, so we believe that this proposed rule would not impose a significant burden on small entities. Medicare fiscal intermediaries and carriers are not considered to be small entities. Individuals and States are not included in the definition of a small entity.

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. As discussed in detail below, the rates and policies set forth in this proposed rule would not have an adverse impact on rural hospitals based on the data of the 199 rural units and 20 rural hospitals in our database of 1,234 IRFs for which data were available.

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 whose mandates require spending in any one year of $100 million in 1995, updated annually for inflation. That threshold level is currently approximately $120 million. This proposed rule would not mandate any requirements for State, local, or tribal governments, nor would it affect private sector costs.

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

B. Anticipated Effects of the Proposed Rule

We discuss below the impacts of this proposed rule on the budget and on IRFs.

1. Basis and Methodology of Estimates

This proposed rule sets forth updates of the IRF PPS rates contained in the FY 2007 final rule, proposes an update to the outlier threshold for high-cost cases, and proposes an adjustment to the wage index methodology.

Based on the above, we estimate that the FY 2008 impact would be a net increase of $150 million in payments to IRF providers (this reflects a $200 million estimated increase from the proposed update to the payment rates and a $50 million estimated decrease due to the proposed update to the outlier threshold amount to decrease the estimated outlier payments from approximately 3.8 percent in FY 2007 to 3 percent in FY 2008). The impact analysis in Table 6 of this proposed rule represents the projected effects of the proposed policy changes in the IRF PPS for FY 2008 compared with estimated IRF PPS payments in FY 2007 without the proposed policy changes. 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 proposed changes, except where noted, and we do not make adjustments for future changes in such variables as number of discharges or case-mix, except where noted.

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 because of other changes in the forecasted impact time period. Some examples could be legislative changes made by the Congress to the Medicare program that would impact program funding, or changes specifically related to IRFs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the BIPA, the MMA, the DRA, or new statutory provisions. Although these changes may not be specific to the IRF 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 IRFs.

In updating the rates for FY 2008, we proposed a number of standard annual revisions and clarifications mentioned elsewhere in this proposed rule (for example, the update to the wage and market basket indexes used to adjust the Federal rates). We estimate that these proposed revisions would increase payments to IRFs by approximately $200 million.

The aggregate change in estimated payments associated with this proposed rule is estimated to be an increase in payments to IRFs of $150 million for FY 2008. The market basket increase of $200 million and the $50 million decrease due to the proposed update to the outlier threshold amount to decrease estimated outlier payments from approximately 3.8 percent in FY 2007 to 3.0 percent in FY 2008 would result in a net change in estimated payments from FY 2007 to FY 2008 of $150 million.

The effects of the proposed changes that affect IRF PPS payment rates are shown in Table 6. The following proposed changes that affect the IRF PPS payment rates are discussed separately below:

  • The effects of the proposed update to the outlier threshold amount to decrease total estimated outlier payments from approximately 3.8 to 3 percent of total estimated payments for FY 2008, consistent with section 1886(j)(4) of the Act.
  • The effects of the annual market basket update (using the RPL market basket) to IRF PPS payment rates, as required by sections 1886(j)(3)(A)(i) and 1886(j)(3)(C) of the Act.
  • The effects of applying the budget-neutral labor-related share and wage index adjustment, including a proposal to revise our methodology to determine a proxy for rural areas without hospital wage data (as described in section IV of this proposed rule), as required under section 1886(j)(6) of the Act.
  • The effects of the final year of the 3-year budget-neutral hold-harmless policy for IRFs that were rural under § 412.602 during FY 2005, but are urban under § 412.602 beginning FY 2006 and lose the rural adjustment, resulting in a decrease in the estimated IRF PPS payments if not for the hold harmless policy.
  • The total proposed change in estimated payments based on the FY 2008 proposed policies relative to estimated FY 2007 payments without the proposed policies.

2. Description of Table 6

The table below categorizes IRFs by geographic location, including urban or rural location and location with respect to CMS's nine census divisions (as defined on the cost report) of the country. In addition, the table divides IRFs into those that are separate Start Printed Page 26253rehabilitation hospitals (otherwise called freestanding hospitals in this section), those that are rehabilitation units of a hospital (otherwise called hospital units in this section), rural or urban facilities, ownership (otherwise called for-profit, non-profit, and government), and by teaching status. The top row of the table shows the overall impact on the 1,234 IRFs included in the analysis.

The next 12 rows of Table 6 contain IRFs categorized according to their geographic location, designation as either a freestanding hospital or a unit of a hospital, and by type of ownership; all urban, which is further divided into urban units of a hospital, urban freestanding hospitals, and by type of ownership; and all rural, which is further divided into rural units of a hospital, rural freestanding hospitals, and by type of ownership. There are 1,015 IRFs located in urban areas included in our analysis. Among these, there are 816 IRF units of hospitals located in urban areas and 199 freestanding IRF hospitals located in urban areas. There are 219 IRFs located in rural areas included in our analysis. Among these, there are 199 IRF units of hospitals located in rural areas and 20 freestanding IRF hospitals located in rural areas. There are 419 for-profit IRFs. Among these, there are 340 IRFs in urban areas and 79 IRFs in rural areas. There are 748 non-profit IRFs. Among these, there are 624 urban IRFs and 124 rural IRFs. There are 67 government-owned IRFs. Among these, there are 51 urban IRFs and 16 rural IRFs.

The remaining three parts of Table 6 show IRFs grouped by their geographic location within a region, and the last part groups IRFs by teaching status. First, IRFs located in urban areas are categorized with respect to their location within a particular one of the nine CMS geographic regions. Second, IRFs located in rural areas are categorized with respect to their location within a particular one of the nine CMS geographic regions. In some cases, especially for rural IRFs located in the New England, Mountain, and Pacific regions, the number of IRFs represented is small. Finally, IRFs are grouped by teaching status, including non-teaching IRFs, IRFs with an intern and resident to average daily census (ADC) ratio less than 10 percent, IRFs with an intern and resident to ADC ratio greater than or equal to 10 percent and less than or equal to 19 percent, and IRFs with an intern and resident to ADC ratio greater than 19 percent.

The estimated impacts of each proposed change to the facility categories listed above are shown in the columns of Table 6. The description of each column is as follows:

Column (1) shows the facility classification categories described above.

Column (2) shows the number of IRFs in each category.

Column (3) shows the number of cases in each category.

Column (4) shows the estimated effect of the proposed adjustment to the outlier threshold amount so that estimated outlier payments decrease from approximately 3.8 percent in FY 2007 to 3 percent of total estimated payments for FY 2008.

Column (5) shows the estimated effect of the market basket update to the IRF PPS payment rates.

Column (6) shows the estimated effect of the update to the IRF labor-related share, wage index, and the final year of the hold harmless policy, in a budget neutral manner.

Column (7) compares our estimates of the payments per discharge, incorporating all of the proposed changes reflected in this proposed rule for FY 2008, to our estimates of payments per discharge in FY 2007 (without these proposed changes). The average estimated increase for all IRFs is approximately 2.4 percent. This estimated increase includes the effects of the 3.3 percent market basket update. It also includes the 0.9 percent overall estimated decrease in estimated IRF outlier payments from the proposed update to the outlier threshold amount. Because we are making the remainder of the proposed changes outlined in this proposed rule in a budget-neutral manner, they would not affect total estimated IRF payments in the aggregate. However, as described in more detail in each section, they would affect the estimated distribution of payments among providers.

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Start Printed Page 26255

3. Impact of the Proposed Update to the Outlier Threshold Amount (Column 4, Table 6)

In the FY 2007 IRF PPS final rule (71 FR 48354), we used FY 2004 patient-level claims data (the best, most complete data available at that time) to set the outlier threshold amount for FY 2007 so that estimated outlier payments would equal 3 percent of total estimated payments for FY 2007. For this proposed rule, we are proposing to update our analysis using FY 2005 data. Using the updated FY 2005 data, we now estimate that IRF outlier payments as a percentage of total estimated payments for FY 2007 increased from 3 percent using the FY 2004 data to approximately 3.8 percent using the updated FY 2005 data. Thus, we are proposing to adjust the outlier threshold amount for FY 2008 to $7,522 to set total estimated outlier payments equal to 3 percent of total estimated payments in FY 2008. The proposed estimated change in total payments between FY 2007 and FY 2008, therefore, includes a 0.9 percent (rounded from 0.85 percent) overall estimated decrease in payments because the estimated outlier portion of total payments is estimated to decrease from approximately 3.8 percent to 3 percent.

The impact of this proposed update (as shown in column 4 of Table 6) is to decrease estimated overall payments to IRFs by 0.9 percent. We do not estimate that any group of IRFs would experience an increase in payments from this proposed update. We estimate the largest decrease in payments to be a 1.7 percent decrease in estimated payments to rural IRFs in the Mountain region.

4. Impact of the Proposed Market Basket Update to the IRF PPS Payment Rates (Column 5, Table 6)

In column 5 of Table 6, we present the estimated effects of the proposed market basket update to the IRF PPS payment rates. In the aggregate, and across all hospital groups, the proposed update would result in a 3.3 percent increase in overall estimated payments to IRFs.

5. Impact of the Proposed CBSA Wage Index, Labor-Related Share, and the Hold Harmless Policy for FY 2008 (Column 6, Table 6).

In column 6 of Table 6, we present the effects of the proposed budget neutral update of the wage index, labor-related share, and the final year of the hold harmless policy. In FY 2006, we provided a 1-year blended wage index and a 3-year phase out of the rural adjustment for IRFs that changed designation because of the change from MSAs to CBSAs (referenced as the hold harmless policy). We applied the blended wage index to all IRFs and the hold harmless policy to those IRFs that qualify, as described in § 412.624(e)(7), in order to mitigate the impact of the change from the MSA-based labor area definitions to the CBSA-based labor area definitions for IRFs.

As discussed in the FY 2007 IRF PPS final rule (71 FR 48345), the blended wage index expired in FY 2007 and will not be applied for discharges occurring on or after October 1, 2006. In addition, FY 2008 is the third and final year of the hold harmless policy, and we are continuing to apply this policy as described in the FY 2006 final rule in a budget neutral manner.

As discussed in this proposed rule, we are proposing to revise our methodology to impute a rural wage index value for rural areas without hospital wage data and update the wage index based on the CBSA-based labor market area definitions in a budget neutral manner. We are also applying the third and final year of the hold harmless policy in a budget neutral manner. Thus, in the aggregate, the estimated impact of the proposed update to the wage index and labor-related share is zero percent.

In the aggregate and for all urban IRFs, we do not estimate that these proposed changes would affect overall estimated payments to IRFs. However, we estimate that these proposed changes would have small distributional effects. We estimate a 0.2 percent increase in estimated payments to rural IRFs. We estimate the largest increase in payments to be a 0.7 percent increase for urban IRFs in the Mountain region and for rural IRFs in the Middle Atlantic region. We estimate the largest decrease in payments to be a 0.9 percent decrease for rural IRFs in the New England region.

C. Anticipated Effects of the 75 Percent Rule Policy

The existing policy for classifying a facility as an IRF, which is described in § 412.23(b)(2), allows the inclusion of comorbidities meeting certain requirements in the calculations used to determine the compliance percentage for cost reporting periods beginning on or after July 1, 2004, and before July 1, 2008. However, for cost reporting periods beginning on or after July 1, 2008, comorbidities will not be eligible for inclusion in the calculations used to determine if the provider meets the 75 percent compliance threshold. As discussed in section II of this proposed rule, we are not proposing to change existing policy. On or after July 1, 2008, we anticipate that IRFs would make adjustments to their admission and coding practices to continue to meet the compliance threshold. Data limitations and two important sources of uncertainty prevent a precise estimate of the effect of this policy at this time. One source of uncertainty is what proportion of patients who would no longer be treated in IRFs would instead be treated by other, lower-cost post-acute care settings such as skilled nursing facilities or home health agencies. Another source of uncertainty is determining how providers will make adjustments on or after July 1, 2008. While we cannot make a precise estimate at this time, we anticipate modest decreases in Medicare payments beginning on or after July 1, 2008.

D. Alternatives Considered

Because we have determined that this proposed rule would have a significant economic impact on IRFs and on a substantial number of small entities, we will discuss the alternative changes to the IRF PPS that we considered.

Section 1886(j)(3)(C) of the Act requires the Secretary to update the IRF PPS payment rates by an increase factor that reflects changes over time in the prices of an appropriate mix of goods and services included in the covered IRF services. As discussed above, we estimate the RPL market basket increase factor for FY 2008 to be 3.3 percent. This increase factor represents the majority of the impact on IRF providers shown in Table 6. Thus, we believe this estimated net increase in payments across all categories of IRFs represents a benefit to IRF providers and, thus, to IRFs that are small entities.

We considered maintaining the existing outlier threshold amount for FY 2008 because this proposed update would have a negative impact on IRF providers and, therefore, on small entities. If we maintain the FY 2007 outlier threshold amount, more outlier cases would have qualified for the additional outlier payments in FY 2008. However, analysis of updated FY 2005 data indicates that estimated outlier payments would not equal 3 percent of estimated total payments for FY 2008 unless we proposed to update the outlier threshold amount. Also, we estimate that the effect of this proposal on estimated payments to IRFs is small (less than 1 percent).

E. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf), in Table 8 below, we Start Printed Page 26256have 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 IRF PPS as a result of the proposed changes presented in this proposed rule based on the data for 1,234 IRFs in our database. All estimated expenditures are classified as transfers to Medicare providers (that is, IRFs).

Table 8.—Accounting Statement: Classification of Estimated Expenditures, from the 2007 IRF PPS Rate Year to the 2008 IRF PPS Rate Year (in Millions)

CategoryTransfers
Annualized Monetized Transfers$150 million.
From Whom To Whom?Federal Government to IRF Medicare Providers.

F. Conclusion (Column 7, Table 6)

Overall, the estimated payments per discharge for IRFs in FY 2008 are projected to increase by 2.4 percent, compared with those in FY 2007, as reflected in column 7 of Table 6. We estimate that IRFs in urban areas would experience a 2.4 percent increase in estimated payments per discharge compared with FY 2007. We estimate that IRFs in rural areas would experience a 2.7 percent increase in estimated payments per discharge compared with FY 2007. We estimate that rehabilitation units and freestanding rehabilitation hospitals in urban areas would both experience a 2.4 percent increase in estimated payments per discharge. We estimate that rehabilitation units in rural areas would experience a 2.6 percent increase in estimated payments per discharge, while freestanding rehabilitation hospitals in rural areas would experience a 3.1 percent increase in estimated payments per discharge.

Overall, we estimate that the largest payment increase would be 3.4 percent among rural IRFs in the Middle Atlantic region. We do not estimate that any group of IRFs would experience an overall decrease in payments from the proposed changes in this proposed rule.

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 in 42 CFR Part 412

End List of Subjects

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

Start Part

PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

1. The authority citation for part 412 continues to read as follows:

Start Authority

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

End Authority

Subpart P—Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units

2. Section 412.624 is amended by revising paragraph (f)(2)(v) to read as follows:

Methodology for calculating the Federal prospective payment rates.
* * * * *

(f) * * *

(2) * * *

(v) By applying the adjustment described in paragraphs (e)(1), (e)(2), (e)(3), (e)(4), and (e)(7) of this section to the unadjusted payment amount determined in paragraph (f)(2)(iv) of this section to equal the adjusted transfer payment amount, subject to paragraph (e)(5) of this section.

Start Signature

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

Dated: March 22, 2007.

Leslie V. Norwalk,

Acting Administrator, Centers for Medicare & Medicaid Services.

Approved: April 3, 2007.

Michael O. Leavitt,

Secretary.

End Signature Start Printed Page 26257

The following addendum will not appear in the Code of Federal Regulations.

Addendum

This addendum contains the tables referred to throughout the preamble of this proposed rule. The tables presented below are as follows:

End Part

Table 1.—Proposed Inpatient Rehabilitation Facility Wage Index for Urban Areas for Discharges Occurring from October 1, 2007 through September 30, 2008

Table 2.—Proposed Inpatient Rehabilitation Facility Wage Index for Rural Areas for Discharges Occurring from October 1, 2007 through September 30, 2008

Table 1.—Proposed Inpatient Rehabilitation Facility Wage Index for Urban Areas for Discharges Occurring From October 1, 2007 Through September 30, 2008

CBSA codeUrban area (constituent counties)Wage index
10180Abilene, TX0.8000
 Callahan County, TX
 Jones County, TX
 Taylor County, TX
10380Aguadilla-Isabela-San Sebastián, PR0.3915
 Aguada Municipio, PR
 Aguadilla Municipio, PR
 Añasco Municipio, PR
 Isabela Municipio, PR
 Lares Municipio, PR
 Moca Municipio, PR
 Rincón Municipio, PR
 San Sebastián Municipio, PR
10420Akron, OH0.8654
 Portage County, OH
 Summit County, OH
10500Albany, GA0.8991
 Baker County, GA
 Dougherty County, GA
 Lee County, GA
 Terrell County, GA
 Worth County, GA
10580Albany-Schenectady-Troy, NY0.8720
 Albany County, NY
 Rensselaer County, NY
 Saratoga County, NY
 Schenectady County, NY
 Schoharie County, NY
10740Albuquerque, NM0.9458
 Bernalillo County, NM
 Sandoval County, NM
 Torrance County, NM
 Valencia County, NM
10780Alexandria, LA0.8006
 Grant Parish, LA
 Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ0.9947
 Warren County, NJ
 Carbon County, PA
 Lehigh County, PA
 Northampton County, PA
11020Altoona, PA0.8812
 Blair County, PA
11100Amarillo, TX0.9169
 Armstrong County, TX
 Carson County, TX
 Potter County, TX
 Randall County, TX
11180Ames, IA0.9760
 Story County, IA
11260Anchorage, AK1.2023
 Anchorage Municipality, AK
 Matanuska-Susitna Borough, AK
11300Anderson, IN0.8681
 Madison County, IN
11340Anderson, SC0.9017
 Anderson County, SC
11460Ann Arbor, MI1.0826
 Washtenaw County, MI
11500Anniston-Oxford, AL0.7770
 Calhoun County, AL
Start Printed Page 26258
11540Appleton, WI0.9455
 Calumet County, WI
 Outagamie County, WI
11700Asheville, NC0.9216
 Buncombe County, NC
 Haywood County, NC
 Henderson County, NC
 Madison County, NC
12020Athens-Clarke County, GA0.9856
 Clarke County, GA
 Madison County, GA
 Oconee County, GA
 Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA0.9762
 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, NJ1.1831
 Atlantic County, NJ
12220Auburn-Opelika, AL0.8096
 Lee County, AL
12260Augusta-Richmond County, GA-SC0.9667
 Burke County, GA
 Columbia County, GA
 McDuffie County, GA
 Richmond County, GA
 Aiken County, SC
 Edgefield County, SC
12420Austin-Round Rock, TX0.9344
 Bastrop County, TX
 Caldwell County, TX
 Hays County, TX
 Travis County, TX
 Williamson County, TX
12540Bakersfield, CA1.0725
 Kern County, CA
12580Baltimore-Towson, MD1.0088
 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, ME0.9711
Start Printed Page 26259
 Penobscot County, ME
12700Barnstable Town, MA1.2539
 Barnstable County, MA
12940Baton Rouge, LA0.8084
 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, MI0.9762
 Calhoun County, MI
13020Bay City, MI0.9251
 Bay County, MI
13140Beaumont-Port Arthur, TX0.8595
 Hardin County, TX
 Jefferson County, TX
 Orange County, TX
13380Bellingham, WA1.1104
 Whatcom County, WA
13460Bend, OR1.0743
 Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.0903
 Frederick County, MD
 Montgomery County, MD
13740Billings, MT0.8712
 Carbon County, MT
 Yellowstone County, MT
13780Binghamton, NY0.8786
 Broome County, NY
 Tioga County, NY
13820Birmingham-Hoover, AL0.8894
 Bibb County, AL
 Blount County, AL
 Chilton County, AL
 Jefferson County, AL
 St. Clair County, AL
 Shelby County, AL
 Walker County, AL
13900Bismarck, ND0.7240
 Burleigh County, ND
 Morton County, ND
13980Blacksburg-Christiansburg-Radford, VA0.8213
 Giles County, VA
 Montgomery County, VA
 Pulaski County, VA
 Radford City, VA
14020Bloomington, IN0.8533
 Greene County, IN
 Monroe County, IN
 Owen County, IN
14060Bloomington-Normal, IL0.8944
 McLean County, IL
14260Boise City-Nampa, ID0.9401
 Ada County, ID
 Boise County, ID
 Canyon County, ID
 Gem County, ID
 Owyhee County, ID
14484Boston-Quincy, MA1.1679
 Norfolk County, MA
 Plymouth County, MA
 Suffolk County, MA
14500Boulder, CO1.0350
 Boulder County, CO
14540Bowling Green, KY0.8148
 Edmonson County, KY
Start Printed Page 26260
 Warren County, KY
14740Bremerton-Silverdale, WA1.0913
 Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.2659
 Fairfield County, CT
15180Brownsville-Harlingen, TX0.9430
 Cameron County, TX
15260Brunswick, GA1.0164
 Brantley County, GA
 Glynn County, GA
 McIntosh County, GA
15380Buffalo-Niagara Falls, NY0.9424
 Erie County, NY
 Niagara County, NY
15500Burlington, NC0.8674
 Alamance County, NC
15540Burlington-South Burlington, VT0.9474
 Chittenden County, VT
 Franklin County, VT
 Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.0970
 Middlesex County, MA
15804Camden, NJ1.0392
 Burlington County, NJ
 Camden County, NJ
 Gloucester County, NJ
15940Canton-Massillon, OH0.9031
 Carroll County, OH
 Stark County, OH
15980Cape Coral-Fort Myers, FL0.9342
 Lee County, FL
16180Carson City, NV1.0025
 Carson City, NV
16220Casper, WY0.9145
 Natrona County, WY
16300Cedar Rapids, IA0.8888
 Benton County, IA
 Jones County, IA
 Linn County, IA
16580Champaign-Urbana, IL0.9644
 Champaign County, IL
 Ford County, IL
 Piatt County, IL
16620Charleston, WV0.8542
 Boone County, WV
 Clay County, WV
 Kanawha County, WV
 Lincoln County, WV
 Putnam County, WV
16700Charleston-North Charleston, SC0.9145
 Berkeley County, SC
 Charleston County, SC
 Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC0.9554
 Anson County, NC
 Cabarrus County, NC
 Gaston County, NC
 Mecklenburg County, NC
 Union County, NC
 York County, SC
16820Charlottesville, VA1.0125
 Albemarle County, VA
 Fluvanna County, VA
 Greene County, VA
 Nelson County, VA
 Charlottesville City, VA
16860Chattanooga, TN-GA0.8948
 Catoosa County, GA
 Dade County, GA
 Walker County, GA
Start Printed Page 26261
 Hamilton County, TN
 Marion County, TN
 Sequatchie County, TN
16940Cheyenne, WY0.9060
 Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.0751
 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, CA1.1053
 Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN0.9601
 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-KY0.8436
 Christian County, KY
 Trigg County, KY
 Montgomery County, TN
 Stewart County, TN
17420Cleveland, TN0.8109
 Bradley County, TN
 Polk County, TN
17460Cleveland-Elyria-Mentor, OH0.9400
 Cuyahoga County, OH
 Geauga County, OH
 Lake County, OH
 Lorain County, OH
 Medina County, OH
17660Coeur d'Alene, ID0.9344
 Kootenai County, ID
17780College Station-Bryan, TX0.9045
 Brazos County, TX
 Burleson County, TX
 Robertson County, TX
17820Colorado Springs, CO0.9701
 El Paso County, CO
 Teller County, CO
17860Columbia, MO0.8542
 Boone County, MO
 Howard County, MO
17900Columbia, SC0.8933
 Calhoun County, SC
 Fairfield County, SC
 Kershaw County, SC
 Lexington County, SC
 Richland County, SC
 Saluda County, SC
17980Columbus, GA-AL0.8239
 Russell County, AL
 Chattahoochee County, GA
 Harris County, GA
 Marion County, GA
Start Printed Page 26262
 Muscogee County, GA
18020Columbus, IN0.9318
 Bartholomew County, IN
18140Columbus, OH1.0107
 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, TX0.8564
 Aransas County, TX
 Nueces County, TX
 San Patricio County, TX
18700Corvallis, OR1.1546
 Benton County, OR
19060Cumberland, MD-WV0.8446
 Allegany County, MD
 Mineral County, WV
19124Dallas-Plano-Irving, TX1.0075
 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, GA0.9093
 Murray County, GA
 Whitfield County, GA
19180Danville, IL0.9266
 Vermilion County, IL
19260Danville, VA0.8451
 Pittsylvania County, VA
 Danville City, VA
19340Davenport-Moline-Rock Island, IA-IL0.8846
 Henry County, IL
 Mercer County, IL
 Rock Island County, IL
 Scott County, IA
19380Dayton, OH0.9037
 Greene County, OH
 Miami County, OH
 Montgomery County, OH
 Preble County, OH
19460Decatur, AL0.8159
 Lawrence County, AL
 Morgan County, AL
19500Decatur, IL0.8172
 Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.9263
 Volusia County, FL
19740Denver-Aurora, CO1.0930
 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-West Des Moines, IA0.9214
 Dallas County, IA
 Guthrie County, IA
 Madison County, IA
Start Printed Page 26263
 Polk County, IA
 Warren County, IA
19804Detroit-Livonia-Dearborn, MI1.0281
 Wayne County, MI
20020Dothan, AL0.7381
 Geneva County, AL
 Henry County, AL
 Houston County, AL
20100Dover, DE0.9847
 Kent County, DE
20220Dubuque, IA0.9133
 Dubuque County, IA
20260Duluth, MN-WI1.0042
 Carlton County, MN
 St. Louis County, MN
 Douglas County, WI
20500Durham, NC0.9826
 Chatham County, NC
 Durham County, NC
 Orange County, NC
 Person County, NC
20740Eau Claire, WI0.9630
 Chippewa County, WI
 Eau Claire County, WI
20764Edison, NJ1.1190
 Middlesex County, NJ
 Monmouth County, NJ
 Ocean County, NJ
 Somerset County, NJ
20940El Centro, CA0.9076
 Imperial County, CA
21060Elizabethtown, KY0.8697
 Hardin County, KY
 Larue County, KY
21140Elkhart-Goshen, IN0.9426
 Elkhart County, IN
21300Elmira, NY0.8240
 Chemung County, NY
21340El Paso, TX0.9053
 El Paso County, TX
21500Erie, PA0.8827
 Erie County, PA
21604Essex County, MA1.0418
 Essex County, MA
21660Eugene-Springfield, OR1.0876
 Lane County, OR
21780Evansville, IN-KY0.9071
 Gibson County, IN
 Posey County, IN
 Vanderburgh County, IN
 Warrick County, IN
 Henderson County, KY
 Webster County, KY
21820Fairbanks, AK1.1059
 Fairbanks North Star Borough, AK
21940Fajardo, PR0.4036
 Ceiba Municipio, PR
 Fajardo Municipio, PR
 Luquillo Municipio, PR
22020Fargo, ND-MN0.8250
 Cass County, ND
 Clay County, MN
22140Farmington, NM0.8589
 San Juan County, NM
22180Fayetteville, NC0.8945
 Cumberland County, NC
 Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.8865
 Benton County, AR
 Madison County, AR
Start Printed Page 26264
 Washington County, AR
 McDonald County, MO
22380Flagstaff, AZ1.1601
 Coconino County, AZ
22420Flint, MI1.0969
 Genesee County, MI
22500Florence, SC0.8388
 Darlington County, SC
 Florence County, SC
22520Florence-Muscle Shoals, AL0.7843
 Colbert County, AL
 Lauderdale County, AL
22540Fond du Lac, WI1.0063
 Fond du Lac County, WI
22660Fort Collins-Loveland, CO0.9544
 Larimer County, CO
22744Fort Lauderdale-Pompano Beach-Deerfield Beach, FL1.0133
 Broward County, FL
22900Fort Smith, AR-OK0.7731
 Crawford County, AR
 Franklin County, AR
 Sebastian County, AR
 Le Flore County, OK
 Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.8643
 Okaloosa County, FL
23060Fort Wayne, IN0.9517
 Allen County, IN
 Wells County, IN
 Whitley County, IN
23104Fort Worth-Arlington, TX0.9569
 Johnson County, TX
 Parker County, TX
 Tarrant County, TX
 Wise County, TX
23420Fresno, CA1.0943
 Fresno County, CA
23460Gadsden, AL0.8066
 Etowah County, AL
23540Gainesville, FL0.9277
 Alachua County, FL
 Gilchrist County, FL
23580Gainesville, GA0.8958
 Hall County, GA
23844Gary, IN0.9334
 Jasper County, IN
 Lake County, IN
 Newton County, IN
 Porter County, IN
24020Glens Falls, NY0.8324
 Warren County, NY
 Washington County, NY
24140Goldsboro, NC0.9171
 Wayne County, NC
24220Grand Forks, ND-MN0.7949
 Polk County, MN
 Grand Forks County, ND
24300Grand Junction, CO0.9668
 Mesa County, CO
24340Grand Rapids-Wyoming, MI0.9455
 Barry County, MI
 Ionia County, MI
 Kent County, MI
 Newaygo County, MI
24500Great Falls, MT0.8598
 Cascade County, MT
24540Greeley, CO0.9602
 Weld County, CO
24580Green Bay, WI0.9787
 Brown County, WI
Start Printed Page 26265
 Kewaunee County, WI
 Oconto County, WI
24660Greensboro-High Point, NC0.8866
 Guilford County, NC
 Randolph County, NC
 Rockingham County, NC
24780Greenville, NC0.9432
 Greene County, NC
 Pitt County, NC
24860Greenville, SC0.9804
 Greenville County, SC
 Laurens County, SC
 Pickens County, SC
25020Guayama, PR0.3235
 Arroyo Municipio, PR
 Guayama Municipio, PR
 Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.8915
 Hancock County, MS
 Harrison County, MS
 Stone County, MS
25180Hagerstown-Martinsburg, MD-WV0.9038
 Washington County, MD
 Berkeley County, WV
 Morgan County, WV
25260Hanford-Corcoran, CA1.0282
 Kings County, CA
25420Harrisburg-Carlisle, PA0.9402
 Cumberland County, PA
 Dauphin County, PA
 Perry County, PA
25500Harrisonburg, VA0.9073
 Rockingham County, VA
 Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.0894
 Hartford County, CT
 Litchfield County, CT
 Middlesex County, CT
 Tolland County, CT
25620Hattiesburg, MS0.7430
 Forrest County, MS
 Lamar County, MS
 Perry County, MS
25860Hickory-Lenoir-Morganton, NC0.9010
 Alexander County, NC
 Burke County, NC
 Caldwell County, NC
 Catawba County, NC
25980Hinesville-Fort Stewart, GA 10.9178
 Liberty County, GA
 Long County, GA
26100Holland-Grand Haven, MI0.9163
 Ottawa County, MI
26180Honolulu, HI1.1096
 Honolulu County, HI
26300Hot Springs, AR0.8782
 Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.8082
 Lafourche Parish, LA
 Terrebonne Parish, LA
26420Houston-Sugar Land-Baytown, TX1.0008
 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
Start Printed Page 26266
 Waller County, TX
26580Huntington-Ashland, WV-KY-OH0.8997
 Boyd County, KY
 Greenup County, KY
 Lawrence County, OH
 Cabell County, WV
 Wayne County, WV
26620Huntsville, AL0.9007
 Limestone County, AL
 Madison County, AL
26820Idaho Falls, ID0.9088
 Bonneville County, ID
 Jefferson County, ID
26900Indianapolis-Carmel, IN0.9895
 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, IA0.9714
 Johnson County, IA
 Washington County, IA
27060Ithaca, NY0.9928
 Tompkins County, NY
27100Jackson, MI0.9560
 Jackson County, MI
27140Jackson, MS0.8271
 Copiah County, MS
 Hinds County, MS
 Madison County, MS
 Rankin County, MS
 Simpson County, MS
27180Jackson, TN0.8853
 Chester County, TN
 Madison County, TN
27260Jacksonville, FL0.9165
 Baker County, FL
 Clay County, FL
 Duval County, FL
 Nassau County, FL
 St. Johns County, FL
27340Jacksonville, NC0.8231
 Onslow County, NC
27500Janesville, WI0.9655
 Rock County, WI
27620Jefferson City, MO0.8332
 Callaway County, MO
 Cole County, MO
 Moniteau County, MO
 Osage County, MO
27740Johnson City, TN0.8043
 Carter County, TN
 Unicoi County, TN
 Washington County, TN
27780Johnstown, PA0.8620
 Cambria County, PA
27860Jonesboro, AR0.7662
 Craighead County, AR
 Poinsett County, AR
27900Joplin, MO0.8605
 Jasper County, MO
 Newton County, MO
28020Kalamazoo-Portage, MI1.0704
 Kalamazoo County, MI
 Van Buren County, MI
Start Printed Page 26267
28100Kankakee-Bradley, IL1.0083
 Kankakee County, IL
28140Kansas City, MO-KS0.9495
 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, WA1.0343
 Benton County, WA
 Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.8901
 Bell County, TX
 Coryell County, TX
 Lampasas County, TX
28700Kingsport-Bristol-Bristol, TN-VA0.7985
 Hawkins County, TN
 Sullivan County, TN
 Bristol City, VA
 Scott County, VA
 Washington County, VA
28740Kingston, NY0.9367
 Ulster County, NY
28940Knoxville, TN0.8249
 Anderson County, TN
 Blount County, TN
 Knox County, TN
 Loudon County, TN
 Union County, TN
29020Kokomo, IN0.9669
 Howard County, IN
 Tipton County, IN
29100La Crosse, WI-MN0.9426
 Houston County, MN
 La Crosse County, WI
29140Lafayette, IN0.8931
 Benton County, IN
 Carroll County, IN
 Tippecanoe County, IN
29180Lafayette, LA0.8289
 Lafayette Parish, LA
 St. Martin Parish, LA
29340Lake Charles, LA0.7914
 Calcasieu Parish, LA
 Cameron Parish, LA
29404Lake County-Kenosha County, IL-WI1.0570
 Lake County, IL
 Kenosha County, WI
29460Lakeland, FL0.8879
 Polk County, FL
29540Lancaster, PA0.9589
 Lancaster County, PA
29620Lansing-East Lansing, MI1.0088
 Clinton County, MI
 Eaton County, MI
 Ingham County, MI
29700Laredo, TX0.7811
 Webb County, TX
29740Las Cruces, NM0.9273
 Dona Ana County, NM
Start Printed Page 26268
29820Las Vegas-Paradise, NV1.1430
 Clark County, NV
29940Lawrence, KS0.8365
 Douglas County, KS
30020Lawton, OK0.8065
 Comanche County, OK
30140Lebanon, PA0.8679
 Lebanon County, PA
30300Lewiston, ID-WA0.9853
 Nez Perce County, ID
 Asotin County, WA
30340Lewiston-Auburn, ME0.9126
 Androscoggin County, ME
30460Lexington-Fayette, KY0.9181
 Bourbon County, KY
 Clark County, KY
 Fayette County, KY
 Jessamine County, KY
 Scott County, KY
 Woodford County, KY
30620Lima, OH0.9042
 Allen County, OH
30700Lincoln, NE1.0092
 Lancaster County, NE
 Seward County, NE
30780Little Rock-North Little Rock, AR0.8890
 Faulkner County, AR
 Grant County, AR
 Lonoke County, AR
 Perry County, AR
 Pulaski County, AR
 Saline County, AR
30860Logan, UT-ID0.9022
 Franklin County, ID
 Cache County, UT
30980Longview, TX0.8788
 Gregg County, TX
 Rusk County, TX
 Upshur County, TX
31020Longview, WA1.0011
 Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale, CA1.1760
 Los Angeles County, CA
31140Louisville, KY-IN0.9118
 Clark County, IN
 Floyd County, IN
 Harrison County, IN
 Washington County, IN
 Bullitt County, KY
 Henry County, KY
 Jefferson County, KY
 Meade County, KY
 Nelson County, KY
 Oldham County, KY
 Shelby County, KY
 Spencer County, KY
 Trimble County, KY
31180Lubbock, TX0.8613
 Crosby County, TX
 Lubbock County, TX
31340Lynchburg, VA0.8694
 Amherst County, VA
 Appomattox County, VA
 Bedford County, VA
 Campbell County, VA
 Bedford City, VA
 Lynchburg City, VA
31420Macon, GA0.9519
 Bibb County, GA
 Crawford County, GA
Start Printed Page 26269
 Jones County, GA
 Monroe County, GA
 Twiggs County, GA
31460Madera, CA0.8154
 Madera County, CA
31540Madison, WI1.0840
 Columbia County, WI
 Dane County, WI
 Iowa County, WI
31700Manchester-Nashua, NH1.0243
 Hillsborough County, NH
 Merrimack County, NH
31900Mansfield, OH0.9271
 Richland County, OH
32420Mayagüez, PR0.3848
 Hormigueros Municipio, PR
 Mayagüez Municipio, PR
32580McAllen-Edinburg-Pharr, TX0.8773
 Hidalgo County, TX
32780Medford, OR1.0818
 Jackson County, OR
32820Memphis, TN-MS-AR0.9373
 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, CA1.1471
 Merced County, CA
33124Miami-Miami Beach-Kendall, FL0.9812
 Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9118
 LaPorte County, IN
33260Midland, TX0.9786
 Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0218
 Milwaukee County, WI
 Ozaukee County, WI
 Washington County, WI
 Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.0946
 Anoka County, MN
 Carver County, MN
 Chisago County, MN
 Dakota County, MN
 Hennepin County, MN
 Isanti County, MN
 Ramsey County, MN
 Scott County, MN
 Sherburne County, MN
 Washington County, MN
 Wright County, MN
 Pierce County, WI
 St. Croix County, WI
33540Missoula, MT0.8928
 Missoula County, MT
33660Mobile, AL0.7913
 Mobile County, AL
33700Modesto, CA1.1729
 Stanislaus County, CA
33740Monroe, LA0.7997
 Ouachita Parish, LA
 Union Parish, LA
33780Monroe, MI0.9707
 Monroe County, MI
33860Montgomery, AL0.8009
 Autauga County, AL
Start Printed Page 26270
 Elmore County, AL
 Lowndes County, AL
 Montgomery County, AL
34060Morgantown, WV0.8423
 Monongalia County, WV
 Preston County, WV
34100Morristown, TN0.7933
 Grainger County, TN
 Hamblen County, TN
 Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.0517
 Skagit County, WA
34620Muncie, IN0.8562
 Delaware County, IN
34740Muskegon-Norton Shores, MI0.9941
 Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.8810
 Horry County, SC
34900Napa, CA1.3374
 Napa County, CA
34940Naples-Marco Island, FL0.9941
 Collier County, FL
34980Nashville-Davidson—Murfreesboro, TN0.9847
 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, NY1.2662
 Nassau County, NY
 Suffolk County, NY
35084Newark-Union, NJ-PA1.1892
 Essex County, NJ
 Hunterdon County, NJ
 Morris County, NJ
 Sussex County, NJ
 Union County, NJ
 Pike County, PA
35300New Haven-Milford, CT1.1953
 New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.8831
 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-NJ1.3177
 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, MI0.8915
 Berrien County, MI
Start Printed Page 26271
35980Norwich-New London, CT1.1932
 New London County, CT
36084Oakland-Fremont-Hayward, CA1.5819
 Alameda County, CA
 Contra Costa County, CA
36100Ocala, FL0.8867
 Marion County, FL
36140Ocean City, NJ1.0472
 Cape May County, NJ
36220Odessa, TX1.0073
 Ector County, TX
36260Ogden-Clearfield, UT0.8995
 Davis County, UT
 Morgan County, UT
 Weber County, UT
36420Oklahoma City, OK0.8843
 Canadian County, OK
 Cleveland County, OK
 Grady County, OK
 Lincoln County, OK
 Logan County, OK
 McClain County, OK
 Oklahoma County, OK
36500Olympia, WA1.1081
 Thurston County, WA
36540Omaha-Council Bluffs, NE-IA0.9450
 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, FL0.9452
 Lake County, FL
 Orange County, FL
 Osceola County, FL
 Seminole County, FL
36780Oshkosh-Neenah, WI0.9315
 Winnebago County, WI
36980Owensboro, KY0.8748
 Daviess County, KY
 Hancock County, KY
 McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.1546
 Ventura County, CA
37340Palm Bay-Melbourne-Titusville, FL0.9443
 Brevard County, FL
37460Panama City-Lynn Haven, FL0.8027
 Bay County, FL
37620Parkersburg-Marietta, WV-OH0.7977
 Washington County, OH
 Pleasants County, WV
 Wirt County, WV
 Wood County, WV
37700Pascagoula, MS0.8215
 George County, MS
 Jackson County, MS
37860Pensacola-Ferry Pass-Brent, FL0.8000
 Escambia County, FL
 Santa Rosa County, FL
37900Peoria, IL0.8982
 Marshall County, IL
 Peoria County, IL
 Stark County, IL
 Tazewell County, IL
 Woodford County, IL
37964Philadelphia, PA1.0996
 Bucks County, PA
Start Printed Page 26272
 Chester County, PA
 Delaware County, PA
 Montgomery County, PA
 Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0287
 Maricopa County, AZ
 Pinal County, AZ
38220Pine Bluff, AR0.8383
 Cleveland County, AR
 Jefferson County, AR
 Lincoln County, AR
38300Pittsburgh, PA0.8674
 Allegheny County, PA
 Armstrong County, PA
 Beaver County, PA
 Butler County, PA
 Fayette County, PA
 Washington County, PA
 Westmoreland County, PA
38340Pittsfield, MA1.0266
 Berkshire County, MA
38540Pocatello, ID0.9400
 Bannock County, ID
 Power County, ID
38660Ponce, PR0.4842
 Juana Díaz Municipio, PR
 Ponce Municipio, PR
 Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME0.9908
 Cumberland County, ME
 Sagadahoc County, ME
 York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.1416
 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, FL0.9833
 Martin County, FL
 St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.0911
 Dutchess County, NY
 Orange County, NY
39140Prescott, AZ0.9836
 Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.0783
 Bristol County, MA
 Bristol County, RI
 Kent County, RI
 Newport County, RI
 Providence County, RI
 Washington County, RI
39340Provo-Orem, UT0.9537
 Juab County, UT
 Utah County, UT
39380Pueblo, CO0.8753
 Pueblo County, CO
39460Punta Gorda, FL0.9405
 Charlotte County, FL
39540Racine, WI0.9356
 Racine County, WI
39580Raleigh-Cary, NC0.9864
 Franklin County, NC
 Johnston County, NC
 Wake County, NC
39660Rapid City, SD0.8833
 Meade County, SD
Start Printed Page 26273
 Pennington County, SD
39740Reading, PA0.9622
 Berks County, PA
39820Redding, CA1.3198
 Shasta County, CA
39900Reno-Sparks, NV1.1963
 Storey County, NV
 Washoe County, NV
40060Richmond, VA0.9177
 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, CA1.0904
 Riverside County, CA
 San Bernardino County, CA
40220Roanoke, VA0.8647
 Botetourt County, VA
 Craig County, VA
 Franklin County, VA
 Roanoke County, VA
 Roanoke City, VA
 Salem City, VA
40340Rochester, MN1.1408
 Dodge County, MN
 Olmsted County, MN
 Wabasha County, MN
40380Rochester, NY0.8994
 Livingston County, NY
 Monroe County, NY
 Ontario County, NY
 Orleans County, NY
 Wayne County, NY
40420Rockford, IL0.9989
 Boone County, IL
 Winnebago County, IL
40484Rockingham County-Strafford County, NH1.0159
 Rockingham County, NH
 Strafford County, NH
40580Rocky Mount, NC0.8854
 Edgecombe County, NC
 Nash County, NC
40660Rome, GA0.9193
 Floyd County, GA
40900Sacramento—Arden-Arcade—Roseville, CA1.3372
 El Dorado County, CA
 Placer County, CA
 Sacramento County, CA
 Yolo County, CA
40980Saginaw-Saginaw Township North, MI0.8874
 Saginaw County, MI
41060St. Cloud, MN1.0362
 Benton County, MN
 Stearns County, MN
Start Printed Page 26274
41100St. George, UT0.9265
 Washington County, UT
41140St. Joseph, MO-KS1.0118
 Doniphan County, KS
 Andrew County, MO
 Buchanan County, MO
 DeKalb County, MO
41180St. Louis, MO-IL0.9005
 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, OR1.0438
 Marion County, OR
 Polk County, OR
41500Salinas, CA1.4337
 Monterey County, CA
41540Salisbury, MD0.8953
 Somerset County, MD
 Wicomico County, MD
41620Salt Lake City, UT0.9402
 Salt Lake County, UT
 Summit County, UT
 Tooele County, UT
41660San Angelo, TX0.8362
 Irion County, TX
 Tom Green County, TX
41700San Antonio, TX0.8844
 Atascosa County, TX
 Bandera County, TX
 Bexar County, TX
 Comal County, TX
 Guadalupe County, TX
 Kendall County, TX
 Medina County, TX
 Wilson County, TX
41740San Diego-Carlsbad-San Marcos, CA1.1354
 San Diego County, CA
41780Sandusky, OH0.9302
 Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.5165
 Marin County, CA
 San Francisco County, CA
 San Mateo County, CA
41900San Germán-Cabo Rojo, PR0.4885
 Cabo Rojo Municipio, PR
 Lajas Municipio, PR
 Sabana Grande Municipio, PR
 San Germán Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.5543
 San Benito County, CA
 Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.4452
 Aguas Buenas Municipio, PR
 Aibonito Municipio, PR
 Arecibo Municipio, PR
 Barceloneta Municipio, PR
Start Printed Page 26275
 Barranquitas Municipio, PR
 Bayamón Municipio, PR
 Caguas Municipio, PR
 Camuy Municipio, PR
 Canóvanas Municipio, PR
 Carolina Municipio, PR
 Cataño Municipio, PR
 Cayey Municipio, PR
 Ciales Municipio, PR
 Cidra Municipio, PR
 Comerío 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
 Loíza Municipio, PR
 Manatí Municipio, PR
 Maunabo Municipio, PR
 Morovis Municipio, PR
 Naguabo Municipio, PR
 Naranjito Municipio, PR
 Orocovis Municipio, PR
 Quebradillas Municipio, PR
 Río 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, CA1.1598
 San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.1473
 Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.1091
 Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.5457
 Santa Cruz County, CA
42140Santa Fe, NM1.0824
 Santa Fe County, NM
42220Santa Rosa-Petaluma, CA1.4464
 Sonoma County, CA
42260Sarasota-Bradenton-Venice, FL0.9868
 Manatee County, FL
 Sarasota County, FL
42340Savannah, GA0.9351
 Bryan County, GA
 Chatham County, GA
 Effingham County, GA
42540Scranton—Wilkes-Barre, PA0.8347
 Lackawanna County, PA
 Luzerne County, PA
 Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.1434
 King County, WA
 Snohomish County, WA
42680Sebastian-Vero Beach, FL0.9573
 Indian River County, FL
43100Sheboygan, WI0.9026
 Sheboygan County, WI
43300Sherman-Denison, TX0.8502
 Grayson County, TX
43340Shreveport-Bossier City, LA0.8865
Start Printed Page 26276
 Bossier Parish, LA
 Caddo Parish, LA
 De Soto Parish, LA
43580Sioux City, IA-NE-SD0.9200
 Woodbury County, IA
 Dakota County, NE
 Dixon County, NE
 Union County, SD
43620Sioux Falls, SD0.9559
 Lincoln County, SD
 McCook County, SD
 Minnehaha County, SD
 Turner County, SD
43780South Bend-Mishawaka, IN-MI0.9842
 St. Joseph County, IN
 Cass County, MI
43900Spartanburg, SC0.9174
 Spartanburg County, SC
44060Spokane, WA1.0447
 Spokane County, WA
44100Springfield, IL0.8890
 Menard County, IL
 Sangamon County, IL
44140Springfield, MA1.0079
 Franklin County, MA
 Hampden County, MA
 Hampshire County, MA
44180Springfield, MO0.8469
 Christian County, MO
 Dallas County, MO
 Greene County, MO
 Polk County, MO
 Webster County, MO
44220Springfield, OH0.8593
 Clark County, OH
44300State College, PA0.8784
 Centre County, PA
44700Stockton, CA1.1442
 San Joaquin County, CA
44940Sumter, SC0.8083
 Sumter County, SC
45060Syracuse, NY0.9691
 Madison County, NY
 Onondaga County, NY
 Oswego County, NY
45104Tacoma, WA1.0789
 Pierce County, WA
45220Tallahassee, FL0.8942
 Gadsden County, FL
 Jefferson County, FL
 Leon County, FL
 Wakulla County, FL
45300Tampa-St. Petersburg-Clearwater, FL0.9144
 Hernando County, FL
 Hillsborough County, FL
 Pasco County, FL
 Pinellas County, FL
45460Terre Haute, IN0.8765
 Clay County, IN
 Sullivan County, IN
 Vermillion County, IN
 Vigo County, IN
45500Texarkana, TX-Texarkana, AR0.8104
 Miller County, AR
 Bowie County, TX
45780Toledo, OH0.9586
 Fulton County, OH
 Lucas County, OH
 Ottawa County, OH
 Wood County, OH
Start Printed Page 26277
45820Topeka, KS0.8730
 Jackson County, KS
 Jefferson County, KS
 Osage County, KS
 Shawnee County, KS
 Wabaunsee County, KS
45940Trenton-Ewing, NJ1.0835
 Mercer County, NJ
46060Tucson, AZ0.9202
 Pima County, AZ
46140Tulsa, OK0.8103
 Creek County, OK
 Okmulgee County, OK
 Osage County, OK
 Pawnee County, OK
 Rogers County, OK
 Tulsa County, OK
 Wagoner County, OK
46220Tuscaloosa, AL0.8542
 Greene County, AL
 Hale County, AL
 Tuscaloosa County, AL
46340Tyler, TX0.8811
 Smith County, TX
46540Utica-Rome, NY0.8396
 Herkimer County, NY
 Oneida County, NY
46660Valdosta, GA0.8369
 Brooks County, GA
 Echols County, GA
 Lanier County, GA
 Lowndes County, GA
46700Vallejo-Fairfield, CA1.5137
 Solano County, CA
47020Victoria, TX0.8560
 Calhoun County, TX
 Goliad County, TX
 Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ0.9832
 Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.8790
 Currituck County, NC
 Gloucester County, VA
 Isle of Wight County, VA
 James City County, VA
 Mathews County, VA
 Surry County, VA
 York County, VA
 Chesapeake City, VA
 Hampton City, VA
 Newport News City, VA
 Norfolk City, VA
 Poquoson City, VA
 Portsmouth City, VA
 Suffolk City, VA
 Virginia Beach City, VA
 Williamsburg City, VA
47300Visalia-Porterville, CA0.9968
 Tulare County, CA
47380Waco, TX0.8633
 McLennan County, TX
47580Warner Robins, GA0.8380
 Houston County, GA
47644Warren-Troy-Farmington Hills, MI1.0054
 Lapeer County, MI
 Livingston County, MI
 Macomb County, MI
 Oakland County, MI
 St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA-MD-WV1.1054
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 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, IA0.8408
 Black Hawk County, IA
 Bremer County, IA
 Grundy County, IA
48140Wausau, WI0.9722
 Marathon County, WI
48260Weirton-Steubenville, WV-OH0.8063
 Jefferson County, OH
 Brooke County, WV
 Hancock County, WV
48300Wenatchee, WA1.0346
 Chelan County, WA
 Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL0.9649
 Palm Beach County, FL
48540Wheeling, WV-OH0.7010
 Belmont County, OH
 Marshall County, WV
 Ohio County, WV
48620Wichita, KS0.9063
 Butler County, KS
 Harvey County, KS
 Sedgwick County, KS
 Sumner County, KS
48660Wichita Falls, TX0.8311
 Archer County, TX
 Clay County, TX
 Wichita County, TX
48700Williamsport, PA0.8139
 Lycoming County, PA
48864Wilmington, DE-MD-NJ1.0684
 New Castle County, DE
 Cecil County, MD
 Salem County, NJ
48900Wilmington, NC0.9835
 Brunswick County, NC
 New Hanover County, NC
 Pender County, NC
49020Winchester, VA-WV1.0091
 Frederick County, VA
 Winchester City, VA
 Hampshire County, WV
49180Winston-Salem, NC0.9276
 Davie County, NC
 Forsyth County, NC
 Stokes County, NC
 Yadkin County, NC
49340Worcester, MA1.0722
 Worcester County, MA
49420Yakima, WA0.9847
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 Yakima County, WA
49500Yauco, PR0.3854
 Guánica Municipio, PR
 Guayanilla Municipio, PR
 Peñuelas Municipio, PR
 Yauco Municipio, PR
49620York-Hanover, PA0.9397
 York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.8802
 Mahoning County, OH
 Trumbull County, OH
 Mercer County, PA
49700Yuba City, CA1.0730
 Sutter County, CA
 Yuba County, CA
49740Yuma, AZ0.9109
 Yuma County, AZ
1 At this time, there are no hospitals located in this CBSA-based urban area on which to base a wage index. Therefore, the wage index value is based on the methodology described in the August 15, 2005 final rule (70 FR 47880). The wage index value for this area is the average wage index for all urban areas within the state.

Table 2.—Proposed Inpatient Rehabilitation Facility Wage Index for Rural Areas for Discharges Occurring From October 1, 2007 Through September 30, 2008

CBSA codeNonurban areaWage index
01Alabama0.7591
02Alaska1.0661
03Arizona0.8908
04Arkansas0.7307
05California1.1454
06Colorado0.9325
07Connecticut1.1709
08Delaware0.9705
10Florida0.8594
11Georgia0.7593
12Hawaii1.0448
13Idaho0.8120
14Illinois0.8320
15Indiana0.8538
16Iowa0.8681
17Kansas0.7998
18Kentucky0.7768
19Louisiana0.7438
20Maine0.8443
21Maryland0.8926
22Massachusetts 21.1661
23Michigan0.9062
24Minnesota0.9153
25Mississippi0.7738
26Missouri0.7927
27Montana0.8590
28Nebraska0.8677
29Nevada0.8944
30New Hampshire1.0853
31New Jersey 1
32New Mexico0.8332
33New York0.8232
34North Carolina0.8588
35North Dakota0.7215
36Ohio0.8658
37Oklahoma0.7629
38Oregon0.9753
39Pennsylvania0.8320
40Puerto Rico 30.4047
41Rhode Island 1
42South Carolina0.8566
43South Dakota0.8480
44Tennessee0.7827
45Texas0.7965
46Utah0.8140
47Vermont0.9744
48Virgin Islands0.8467
49Virginia0.7940
50Washington1.0263
51West Virginia0.7607
52Wisconsin0.9553
53Wyoming0.9295
65Guam0.9611
1 All counties within the State are classified as urban.
2 Massachusetts has areas designated as rural; however, no short-term, acute care hospitals are located in the area(s) for FY 2008. As discussed in the preamble in Section IV.B, we are proposing to impute a wage index value for rural Massachusettes based on the average wage index from all contiguous CBSAs.
3 Puerto Rico has areas designated as rural; however, no short-term, acute care hospitals are located in the area(s) for FY 2008. As discussed in the preamble in Section IV.B, we are proposing to continue to use the most recent wage index previously available for Puerto Rico as discussed in the FY 2006 IRF PPS final rule (70 FR 47880).
End Supplemental Information

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[FR Doc. 07-2241 Filed 5-2-07; 8:45 am]

BILLING CODE 4120-01-P