Skip to Content

Proposed Rule

Medicare Program; Proposed Hospice Wage Index for Fiscal Year 2009

Document Details

Information about this document as published in the Federal Register.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble

AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

This proposed rule proposes the hospice wage index for fiscal year 2009. This proposed rule also proposes to phase-out the Medicare hospice budget neutrality adjustment factor and clarify two wage index issues, pertaining to the definition of rural and urban areas and to multi-campus hospital facilities.

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 27, 2008.

ADDRESSES:

In commenting, please refer to file code CMS-1548-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions for “Comment or Submission” and enter the filecode to find the document accepting comments.

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-1548-P, P.O. Box 8012, Baltimore, MD 21244-1850.

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-1548-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to either of the following addresses:

a. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201.

(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.)

b. 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members.

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.

Start Further Info

FOR FURTHER INFORMATION CONTACT:

Randy Throndset (410) 786-0131 or Katie Lucas (410) 786-7723.

End Further Info End Preamble Start Supplemental Information

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 Start Printed Page 24001referencing the file code CMS-1548-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.regulations.gov. Follow the search instructions 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. General

1. Hospice Care

2. Medicare Payment for Hospice Care

B. Hospice Wage Index

1. Raw Wage Index Values (Pre-Floor, Pre-Reclassified Hospital Wage Index)

2. Changes to Core-Based Statistical Area (CBSA) Designations

3. Definition of Urban and Rural Areas

4. Areas Without Hospital Wage Data

5. CBSA Nomenclature Changes

6. Hospice Payment Rates

II. Provisions of the Proposed Rule

A. Clarification of New England Deemed Counties

B. Wage Data for Multi-Campus Hospitals

C. FY 2009 Proposed Hospice Wage Index With Phase-Out of the Budget Neutrality Adjustment Factor (BNAF)

1. Background

2. Areas Without Hospital Wage Data

3. Phase-Out of the BNAF

a. Effects of phasing-out the BNAF using the published FY 2008 Hospice Wage Index Data

b. Effects of phasing-out the BNAF using the Updated Pre-floor, Pre-reclassified Hospital Wage Index Data (FY 2009 proposal)

D. Summary of the Provisions of the Proposed Rule

III. Collection of Information Requirements

IV. Regulatory Impact Analysis

A. Overall Impact

B. Anticipated Effects

1. Hospice Size

2. Geographic Location

3. Type of Ownership

4. Hospice Base

C. Accounting Statement

Part 418—Hospice Care

I. Background

A. General

1. Hospice Care

Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling services and inpatient respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care.

Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. Section 1814(i) of the Act provides payment for Medicare participating hospices.

2. Medicare Payment for Hospice Care

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

B. Hospice Wage Index

Our regulations at § 418.306(c) require each hospice's labor market to be established using the most current hospital wage data available, including any changes by OMB to the Metropolitan Statistical Areas (MSAs) definitions. OMB revised the MSA definitions beginning in 2003 with new designations called the Core Based Statistical Areas (CBSAs). For the purposes of the hospice benefit, the term “MSA-based” refers to wage index values and designations based on the previous MSA designations before 2003. Conversely, the term “CBSA-based” refers to wage index values and designations based on the OMB revised MSA designations in 2003, which now include CBSAs. In the August 11, 2004 IPPS final rule (69 FR 48916, 49026), revised labor market area definitions were adopted at § 412.64(b), which were effective October 1, 2004 for acute care hospitals. CMS also revised the labor market areas for hospices using the new OMB standards that included CBSAs. In the FY 2006 hospice wage index final rule (70 FR 45130), we implemented a 1-year transition policy using a 50/50 blend of the CBSA-based wage index values and the Metropolitan Statistical Area (MSA)-based wage index values for FY 2006. The one-year transition policy ended on September 30, 2006. For FY 2007 and FY 2008 we used wage index values based on CBSA designations.

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

In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a new methodology for calculating the hospice wage index based on the recommendations of the negotiated rulemaking committee. The committee statement was included in the appendix of that final rule (62 FR 42883). The hospice wage index is updated annually. Our most recent annual update notice published in the Federal Register (72 FR 50214) on August 31, 2007 set forth updates to the hospice wage index for FY 2008. On October 1, 2007, we published a correction notice in the Federal Register (72 FR 55672) to correct technical errors that appeared in the August 31, 2007 final rule. Start Printed Page 24002

1. Raw Wage Index Values (Pre-Floor, Pre-Reclassified Hospital Wage Index)

As described in the August 8, 1997 hospice wage index final rule (62 FR 42860), the pre-floor and pre-reclassified hospital wage index is used as the raw wage index for the hospice benefit. These raw wage index values are then subject to either a budget neutrality adjustment or application of the hospice floor to compute the hospice wage index used to determine payments to hospices.

Pre-floor, pre-reclassified hospital wage index values of 0.8 or greater are adjusted by the BNAF. Pre-floor, pre-reclassified hospital wage index values below 0.8 are adjusted by the greater of: (1) The hospice BNAF; or (2) the hospice floor (which is a 15 percent increase) subject to a maximum wage index value of 0.8. For example, if County A has a pre-floor, pre-reclassified hospital wage index (raw wage index) value of 0.4000, we would perform the following calculations using the budget neutrality factor (which for this example is 1.060988) and the hospice floor to determine County A's hospice wage index:

Pre-floor, pre-reclassified hospital wage index value below 0.8 multiplied by the BNAF: (0.4000 × 1.060988 = 0.4244)

Pre-floor, pre-reclassified hospital wage index value below 0.8 multiplied by the hospice floor: (0.4000 × 1.15 = 0.4600)

Based on these calculations, County A's hospice wage index would be 0.4600.

As decided upon by the Hospice Wage Index Negotiated Rulemaking Committee, budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated hospice values will equal estimated payments that would have been made for these services if the 1983 hospice wage index values had remained in effect, after adjusting the payment rates for inflation.

The BNAF has been computed and applied annually to the labor portion of the hospice payment. Currently, the labor portion of the payment rates is as follows: for Routine Home Care, 68.71 percent; for Continuous Home Care, 68.71 percent; for General Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The non-labor portion is equal to 100 percent minus the labor portion for each level of care. Therefore the non-labor portion of the payment rates is as follows: for Routine Home Care, 31.29 percent; for Continuous Home Care, 31.29 percent; for General Inpatient Care, 35.99 percent; and for Respite Care, 45.87 percent.

2. Changes to Core-Based Statistical Area (CBSA) Designations

The annual update to the hospice wage index is published in the Federal Register and is based on the most current available hospital wage data, as well as any changes by the Office of Management and Budget (OMB) to the definitions of MSAs, which now include CBSA designations. The August 4, 2005 final rule (70 FR 45130) set forth the adoption of the changes discussed in the OMB Bulletin No. 03-04 (June 6, 2003), which announced revised definitions for Micropolitan Statistical Areas and the creation of MSAs and Combined Statistical Areas. In adopting the OMB CBSA geographic designations, we provided for a 1-year transition with a blended hospice wage index for all hospices for FY 2006. For FY 2006, the hospice wage index for each provider consisted of a blend of 50 percent of the FY 2006 MSA-based hospice wage index and 50 percent of the FY 2006 CBSA-based hospice wage index. Fiscal years 2007 and 2008 used the full CBSA-based hospice wage index values as discussed in their respective notices or rules (71 FR 52080 and 72 FR 50214).

3. Definition of Rural and Urban Areas

Each hospice's labor market is determined based on definitions of MSAs issued by OMB. In general, an urban area is defined as an MSA or New England County Metropolitan Area (NECMA) as defined by OMB. Under § 412.64(b)(1)(ii)(C), a rural area is defined as any area outside of the urban area. The urban and rural area geographic classifications are defined in § 412.64(b)(1)(ii)(A) through (C), and have been used for the Medicare hospice benefit since implementation.

4. Areas Without Hospital Wage Data

When adopting OMB's new labor market designations in FY 2006, 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 hospice wage index. Beginning in FY 2006, we adopted a policy to use the FY 2005 pre-floor, pre-reclassified hospital wage index value for rural areas when no hospital wage data were available. We also adopted the policy that for urban labor markets without a hospital from which a hospital wage index data could be derived, all of the CBSAs within the State would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index value to use as a reasonable proxy for these areas. Consequently, in the FY 2006 final rule, the FY 2007 update notice, and the FY 2008 final rule, we applied the average pre-floor, pre-reclassified hospital wage index data from all urban areas in that state to urban areas without a hospital. The only affected CBSA is 25980, Hinesville-Fort Stewart, Georgia.

Under the CBSA labor market areas, there are no hospitals in rural locations in Massachusetts and Puerto Rico. Since there was no rural proxy for more recent rural data within those areas, in the FY 2006 hospice wage index proposed rule (70 FR 22394, 22398), we proposed applying the FY 2005 pre-floor, pre-reclassified hospital wage index value to rural areas where no hospital wage data were available. In the FY 2006 final rule and in the FY 2007 update notice, we applied the FY 2005 pre-floor, pre-reclassified hospital wage index data for areas lacking hospital wage data in both FY 2006 and FY 2007 for rural Massachusetts and rural Puerto Rico.

In the FY 2008 final rule (72 FR 50214, 50217) we considered alternatives to our methodology to update the pre-floor, pre-reclassified hospital wage index for rural areas without hospital wage data. We indicated that we believed that the best imputed proxy for rural areas, would: (1) Use pre-floor, pre-reclassified hospital data; (2) use the most local data available to impute a rural pre-floor, pre-reclassified hospital wage index; (3) be easy to evaluate; and, (4) be easy to update from year-to-year.

Therefore, in FY 2008, in cases where there was a rural area without rural hospital wage data, we used the average pre-floor, pre-reclassified hospital wage index data from all contiguous CBSAs to represent a reasonable proxy for the rural area. This approach does not use rural data, however, the approach uses pre-floor, pre-reclassified hospital wage data, is easy to evaluate, is easy to update from year-to-year, and uses the most local data available. In the FY 2008 rule (72 FR at 50217), we noted that in determining an imputed rural pre-floor, pre-reclassified hospital 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 determined that the borders of Dukes and Nantucket counties are contiguous with Barnstable and Bristol counties. Under the adopted methodology, the pre-floor, pre-reclassified hospital wage index values for the counties of Barnstable (CBSA 12700, Barnstable Town, MA) and Bristol (CBSA 39300, Providence-New Bedford-Fall River, RI-MA) would be Start Printed Page 24003averaged resulting in an imputed pre-floor, pre-reclassified rural hospital wage index for FY 2008. We noted in the FY 2008 final hospice wage index rule that 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 Critical Access Hospital, that does not submit the appropriate wage data), if a similar situation arose in the future, we would re-examine this policy.

We also noted that we do not believe that this policy would be appropriate for Puerto Rico, as 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. Therefore we believe that a separate and distinct policy for Puerto Rico is necessary. Any alternative methodology for imputing a pre-floor, pre-reclassified hospital wage index for rural Puerto Rico would need to take into account the economic differences between hospitals in the United States and those in Puerto Rico. Our policy of imputing a rural pre-floor, pre-reclassified hospital wage index based on the pre-floor, pre-reclassified hospital 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 pre-floor, pre-reclassified hospital 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. For FY 2008, we used the most recent pre-floor, pre-reclassified hospital wage index available for Puerto Rico, which is 0.4047.

5. CBSA Nomenclature Changes

The Office of Management and Budget (OMB) regularly publishes a bulletin that updates the titles of certain CBSAs. In the FY 2008 Final Rule (72 FR 50218) we noted that the FY 2008 rule and all subsequent hospice wage index rules and notices would incorporate CBSA changes from the most recent OMB bulletins. The OMB bulletins may be accessed at http://www.whitehouse.gov/​omb/​bulletins/​index.html.

6. Hospice Payment Rates

Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were to be updated by a factor equal to the market basket index, minus 1 percentage point. However, neither the BBA nor subsequent legislation specified alteration to the market basket adjustment to be used to compute payment for fiscal years beyond 2002. Payment rates for FYs since 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent fiscal years will be the market basket percentage for the fiscal year. It has been longstanding practice to use the inpatient hospital market basket as a proxy for a hospice market basket.

Historically, the rate update has been published through a separate administrative instruction issued annually in July to provide adequate time to implement system change requirements. Providers determine their payments by applying the hospice wage index in this notice to the labor portion of the published hospice rates.

II. Provisions of the Proposed Rule

A. Clarification of New England Deemed Counties

We are taking the opportunity to address the change in the designation of “New England deemed counties,” which are listed in § 412.64(b)(1)(ii)(B). These counties were deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983, yet the OMB designates these counties as rural. In the FY 2008 Inpatient Prospective Payment System (IPPS) final rule, IPPS adopted the OMB designation for the pre-floor, pre-reclassified hospital wage index. The counties include Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. Of these five “New England deemed counties,” three (York County, Sagadahoc County, and Newport County) are also included in metropolitan statistical areas defined by OMB and are considered urban under the current IPPS labor market area definitions in § 412.64(b)(1)(ii)(A).

The remaining two, Litchfield County and Merrimack County, are geographically located in areas that are considered rural under the current IPPS labor market area definitions. However, they have been previously deemed urban under the IPPS in certain circumstances as discussed below. In the FY 2008 IPPS final rule with comment period (72 FR 47130, August 22, 2007), § 412.64(b)(1)(ii)(B) was revised such that the two “New England deemed counties” that are still considered rural by OMB (Litchfield County, CT and Merrimack County, NH) are no longer considered urban effective for discharges occurring on or after October 1, 2007. Therefore, these two counties are considered rural in accordance with § 412.64(b)(1)(ii)(C). However, for purposes of payment under the IPPS, acute care hospitals located within those areas are treated as being reclassified to their deemed urban area effective for discharges occurring on or after October 1, 2007 (see 72 FR 47337 through 47338). We also noted in this discussion that this policy change was limited to the “New England deemed counties” IPPS hospitals only, and that any change to non-IPPS provider wage indexes would be addressed in the respective payment system rules. The hospice program does not provide for such geographic reclassification as the IPPS does, and we are taking this opportunity to clarify treatment of “New England deemed counties” under the hospice program in this proposed rule.

As discussed, our regulations at § 418.306(c) require each hospice's labor market to be established using the most current hospital wage data available. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data. In 1994, a committee functioning under a process established by the Negotiated Rulemaking Act of 1990, was formed to negotiate a hospice wage index methodology that could be accepted by the industry and the government. The revised hospice wage index was based on the recommendations of the Negotiated Rulemaking Advisory Committee. This committee was established to provide advice and make recommendations to the Secretary on the hospice wage index used to adjust payment rates for hospices under the Medicare program, to reflect local differences in area wage levels. The Committee recommended that the revised hospice wage index be based on the most current available data for each fiscal year, which would be used to construct a pre-floor, pre-reclassified hospital wage index under the prospective payment system before adjustments were made to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and (d)(10) of the Act, as well as each hospice's labor market area as established by OMB. The reason the unadjusted hospital wage data were recommended was to avoid further reductions in certain rural statewide wage index values that would result from reclassification. The recommendations are codified in Start Printed Page 24004§ 418.306(c) of our regulations; however, there is no reference to § 412.64.

In other words, while § 412.64 is not explicitly noted, the hospice program has used the urban definition in § 412.64(b)(1)(ii)(A) and (B), and the rural definition as any area outside of an urban area in § 412.64(b)(1)(ii)(C). Historical changes to the labor market area/geographic classifications and annual updates to the hospice wage index values have been made effective October 1 each year. When we established the hospice wage index values effective October 1, 2007 through September 30, 2008, we considered the “New England deemed counties” (including Litchfield County, CT and Merrimack County, NH) as urban for FY 2008 in accordance with the definitions of urban and rural areas in the FY 2008 hospice final rule (72 FR 50216). Therefore, Litchfield County was listed as one of the constituent counties of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and Merrimack County was listed as one of the constituent counties of urban CBSA 31700 (Manchester-Nashua, NH) (72 FR 50236 and 50239, respectively). As noted above, the terms “rural” and “urban” areas are defined in IPPS according to the definitions of those terms in § 412.64(b)(1)(ii)(A) through (C). Litchfield county, CT and Merrimack county, NH are considered rural areas for hospital IPPS purposes in accordance with § 412.64. Under this proposal, effective October 1, 2008, Litchfield county, CT would no longer be considered part of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and Merrimack County, NH would no longer be considered part of urban CBSA 31700 (Manchester-Nashua, NH). Rather, these counties would be considered to be rural areas within their respective states under the hospice payment system. This proposed policy is consistent with our policy of not taking into account IPPS geographic reclassifications in determining payments under the hospice wage index. We propose to amend § 418.306(c) to cross-reference to the definitions of urban and rural in the IPPS regulations in 42 CFR part 412 subpart D.

B. Wage Data for Multi-Campus Hospitals

In the 2007 IPPS final rule, we changed in the way that we treat multi-campus hospital wage data in the creation of the pre-floor, pre-reclassified hospital wage index. The IPPS wage data used to determine the proposed FY 2009 hospice wage index values now apportion the wage data for multi-campus hospitals located in different labor market areas (CBSAs) to the CBSAs where the campuses are located (see 72 FR 47317 through 47320). Historically, the hospice wage index is derived from the pre-floor, pre-reclassified hospital wage index. Consequently, for this proposed rule we propose to continue to use the most recent available pre-floor, pre-reclassified hospital wage index in computing the hospice wage index. The pre-floor, pre-reclassified hospital wage index values for the following CBSAs are affected by this change in how wage data from multi-campus hospitals are used in the computation of the pre-floor, pre-reclassified hospital wage index: Boston-Quincy, MA (CBSA 14484), Providence-New Bedford-Falls River, RI-MA (CBSA 39300), Chicago-Naperville-Joliet, IL (CBSA 16974) and Lake-County-Kenosha County, IL-WI (CBSA 29404).

C. FY 2009 Hospice Wage Index With Phase-Out of the Budget Neutrality Adjustment Factor (BNAF)

[If you choose to comment on issues in this section, please include the caption, “FY 2009 Hospice Wage Index with Phase-out of the Budget Neutrality Adjustment Factor (BNAF)” at the beginning of your comments.]

1. Background

The hospice final rule published in the Federal Register on December 16, 1983 (48 FR 56008) provided for adjustment to hospice payment rates to reflect differences in area wage levels. We apply the appropriate hospice wage index value to the labor portion of the hospice payment rates based on the geographic area where hospice care was furnished. As noted earlier, each hospice's labor market area is based on definitions of Metropolitan Statistical Areas (MSAs) issued by the OMB. For FY 2009, we propose to again use a pre-floor, pre-reclassified hospital wage index based solely on the CBSA designations.

As noted above, our hospice payment rules utilize the wage adjustment factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustments. We are proposing again to use the pre-floor and pre-reclassified hospital wage index data to adjust the labor portion of the hospice payment rates based on the geographic area where the beneficiary receives hospice care. We believe the use of the pre-floor, pre-reclassified hospital wage index data results in the appropriate adjustment to the labor portion of the costs. For the FY 2009 update to hospice payment rates, we propose to continue to use the most recent pre-floor, pre-reclassified hospital wage index available at the time of publication.

2. Areas Without Hospital Wage Data

In adopting the CBSA designations, we identified some geographic areas where there are no hospitals, and thus no hospital wage data on which to base the calculation of the hospice wage index. These areas were described in section I.B.4 of this proposed rule. Beginning in FY 2006, we adopted a policy that, for urban labor markets without an urban hospital from which a pre-floor, pre-reclassified hospital wage index can be derived, all of the urban CBSA pre-floor, pre-reclassified hospital wage index values within the State would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index to use as a reasonable proxy for these areas. Currently, the only CBSA that would be affected by this policy is CBSA 25980, Hinesville, Georgia. We propose to continue this policy for FY 2009.

Currently, the only rural areas where there are no hospitals from which to calculate a pre-floor, pre-reclassified hospital wage index are Massachusetts and Puerto Rico. In August 2007 (72 FR 50217) we adopted the following methodology for imputing rural pre-floor, pre-reclassified hospital wage index values for areas where no hospital wage data are available as an acceptable proxy. We imputed an average pre-floor, pre-reclassified hospital wage index value by averaging the pre-floor, pre-reclassified hospital wage index values from contiguous CBSAs as a reasonable proxy for rural areas with no hospital wage data from which to calculate a pre-floor, pre-reclassified hospital wage index. In determining an imputed rural pre-floor, pre-reclassified hospital wage index, we define “contiguous” as sharing a border. For Massachusetts, rural Massachusetts currently consists of Dukes and Nantucket Counties. We determined that the borders of Dukes and Nantucket counties are “contiguous” with Barnstable and Bristol counties. We are again proposing to apply this methodology for imputing a rural pre-floor, pre-reclassified hospital wage index for those rural areas without rural hospital wage data in FY 2009.

However, as we noted in our final rule at 72 FR 50218, we do not believe that this policy is appropriate for Puerto Rico. We noted that there are sufficient economic differences between the hospitals in the United States and those in Puerto Rico, including the fact that hospitals in Puerto Rico are paid on Start Printed Page 24005blended Federal/Commonwealth-specific rates, to make a separate distinct policy for Puerto Rico necessary. For FY 2009, we again propose to continue to use the most recent pre-floor, pre-reclassified hospital wage index value available for Puerto Rico, which is 0.4047. This pre-floor, pre-reclassified hospital wage index value is then adjusted upward by the hospice floor in the computing of the proposed FY 2009 hospice wage index.

3. Phase-Out of the Budget Neutrality Adjustment Factor (BNAF)

As noted in section 1.B of this proposed rule, the current hospice wage index methodology was developed through a negotiated rule making process and implemented in 1997. The rule making committee sought to address the inaccuracies in the original Bureau of Labor Statistics (BLS)-based hospice wage index, account better for disparities from one geographic location to another, and develop a wage index that would be as accurate, reliable and equitable as possible. The resulting hospice wage index reflects a special adjustment (a BNAF) to ensure payments in the aggregate are budget neutral to payments using the original 1983 hospice wage index. The adjustment, still in place today, results in providers currently receiving about 4 percent more in payments than they would receive if the adjustment factor were not applied. The rationale for maintaining this adjustment is outdated given the time that has elapsed since it was put into place and the growth that is occurring in the hospice benefit. In this section, we propose to phase-out this adjustment over 3 years, reducing it by 25 percent in FY 2009, by an additional 50 percent for a total of 75 percent in FY 2010, and eliminating it completely in FY 2011. We also provide our rationale for the phase-out.

As discussed in section I.B of this proposed rule, the original hospice wage index was based on the 1981 Bureau of Labor Statistics (BLS) hospital data and had not been updated since 1983. During earlier attempts to update the hospice wage index, the hospice industry raised concerns over the adverse financial impact of a new wage index on individual hospices and a possible overall reduction in Medicare payments. Thus, the result was that in the absence of agreement on a new wage index, we continued to use a wage index that was clearly obsolete for geographically adjusting Medicare hospice payments (see “Medicare Program; Notice Containing the Statement Drafted by the Committee Established to Negotiate the Wage Index to be Used to Adjust Hospice Payment Rates Under Medicare,” November 29, 1995, 60 FR 61264).

Changing to a new but more accurate wage index would result in some areas gaining as their wage index value would increase, but in other areas seeing declines in payments as their wage index value dropped. In 1994 we noted that a majority of hospices would have their wage index reduced with the new wage index based on using the pre-floor, pre-reclassified hospital wage index. These reductions would have occurred for two key reasons: (1) Hospices were located in areas where the original hospice wage index was artificially high due to flaws in the 1981 BLS data, and (2) hospices were located in areas where wages had gone down relative to other geographic areas (see “Hospice Services Under Medicare Program: Intent to Form Negotiated Rulemaking Committee,” October 14, 1994, 59 FR 52130).

Because of the negative impact to certain areas that was expected with the change to a new wage index, a committee was formulated in 1994, under the process established by the Negotiated Rulemaking Act of 1990 (Pub. L. 101-648). The Committee was established to negotiate the hospice wage index methodology rather than to go through the usual rulemaking process. On September 4, 1996, we published a proposed rule (61 FR 46579) in which we proposed a methodology to update the hospice wage index used to adjust Medicare hospice payment rates.

In formulating the provisions of that proposed rule, the Committee considered criteria in evaluating the available data sources. The need for fundamental equity of the wage index; data that reflected actual work performed by hospice personnel; compatibility with wage indexes used by CMS for other Medicare providers; and availability of the data for timely implementation were considered.

The Committee agreed that the hospice wage index be derived from the 1993 hospital cost report data and that these data, prior to reclassification, would form the basis for the FY 1997 hospice wage index. That is the pre-floor, pre-reclassified hospital wage index would not be adjusted to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act. The methodology is codified in § 418.306(c). The hospice wage index for subsequent years would be based on pre-floor, pre-reclassified hospital wage index data for a subsequent year.

The Committee was also concerned that while some hospices would see increases, use of the pre-floor, pre-reclassified hospital wage index as the wage index for hospices would result in a net reduction in aggregate Medicare payments for hospices. As noted above, a majority of hospices would have had their wage index lowered by using the new wage index because the prior hospice wage indices were based on outdated data which were artificially high due to flaws in the 1981 BLS data, and because some hospices were located in areas where wages had gone down relative to other geographic areas. The reduction in overall Medicare payments if a new wage index were adopted was noted in the November 29, 1995 final rule (60 FR 61264). Therefore, the Committee also decided that, each year in updating the hospice wage index, aggregate Medicare payments to hospices would remain budget neutral to payments as if the 1983 wage index had been used.

As decided upon by the Hospice Wage Index Negotiated Rulemaking Committee, budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated hospice values will equal estimated payments that would have been made for these services if the 1983 hospice wage index values had remained in effect, after adjusting the payment rates for inflations. Being budget neutral does not take into account annual market basket updates to hospice payment rates. Therefore, although payments to individual hospice programs may change each year, the total payments each year to hospices would not be affected by using the updated hospice wage index because total payments would be budget neutral as if the 1983 wage index had been used. To implement this provision a BNAF would be computed and applied annually.

The BNAF is calculated by computing estimated payments using the most recent completed year of hospice claims data. The units (days or hours) from those claims are multiplied by the updated hospice payment rates to calculate estimated payments. The updated hospice wage index values are then applied to the labor portion of the payments. For this proposed rule, that means estimating payments for FY 2009 using FY 2006 hospice claims data, and applying the estimated updated FY 2009 hospice payment rates (updating the FY 2008 rates by the estimated FY 2009 market basket update). The proposed FY 2009 hospice wage index values are then applied to the labor portion only. The procedure is repeated using the Start Printed Page 24006same claims data and payment rates, but using the 1983 BLS-based wage index instead of the updated pre-floor, pre-reclassified hospital wage index. The total payments are then compared, and the adjustment required to make total payments equal is computed; that adjustment factor is the BNAF. In 1998, the BNAF increased all wage index values by just over 2 percent.

All pre-floor, pre-reclassified hospital wage index values of 0.8 or greater would be adjusted by the BNAF. Also, all pre-floor, pre-reclassified hospital wage index values below 0.8 would receive the greater of the following: (1) A 15-percent increase subject to a maximum hospice wage index value of 0.8; or (2) an adjustment by the BNAF. All hospice wage index values of 0.8 or greater would be adjusted by the BNAF. The BNAF would be calculated and applied annually.

While the Committee sought to adopt a wage index methodology that would be as accurate, reliable, and equitable as possible, the Committee also decided to incorporate a BNAF into the calculation of the hospice wage index that would otherwise apply in order to mitigate adverse financial impacts some hospices would experience through a decrease in their wage index value by transitioning to a pre-floor, pre-reclassified hospital wage index.

In the August 8, 1997 final rule (62 FR 42860), we indicated that the annual updates of the hospice wage index values would be made in accordance with the methodology agreed to by the rulemaking committee. We also noted that in the event that if we decide to change this methodology by which the hospice wage index is computed, it would be reflected in a proposed rule published in the Federal Register. In this proposed rule, we now propose to change this methodology.

In FY 1998, the BNAF was 1.020768; in FY 2008 it was 1.066671. In other words, any pre-floor, pre-reclassified hospital wage index value greater than 0.8 was increased by over 2 percent in FY 1998 and increased by almost 7 percent in FY 2008. In FY 2008, this adjustment resulted in hospice providers receiving about 4 percent more in payments than they would have received if the BNAF had not been applied.

The negotiating committee also recommended that the transition to the new hospice wage index occur over 3 years, from FY 1998 to FY 2001. The intent of both the three year transition and the budget neutrality adjustment was to mitigate the negative financial impact to many hospices resulting from the wage index change. Additionally, the committee sought to ensure that access to hospice care was not jeopardized as a result of the wage index change.

We believe that the rationale for maintaining this adjustment is outdated for several reasons.

First, the original purpose of the BNAF was to prevent reductions in payments to the majority of hospices whose wage index was based on the original hospice wage index which was artificially high due to flaws in the 1981 BLS data. While incorporating a BNAF into hospice wage indices could be rationalized in 1997 as a way to smooth the transition from an old wage index to a new one, since hospices have had plenty of time to adjust to the new wage index, it is difficult to justify maintaining in perpetuity a BNAF which was in part compensating for artificially high data to begin with.

Second, the new wage index adopted in 1997 resulted in increases in wage index values for hospices in certain areas. The BNAF applies to hospices in all areas. Thus, hospices in areas that would have had increases without the BNAF received an artificial boost in the wage index for the past 11 years. We believe that continuation of this excess payment can no longer be justified.

Third, an adjustment factor that is based on 24-year old wage index values is contrary to our goal of using a hospice wage index that is as accurate, reliable and equitable as possible in accounting for geographic variation in wages. We believe that those goals can be better achieved by using the pre-floor, pre-reclassified hospital wage index, without an outdated BNAF, consistent with other providers. For instance, Medicare payments to home health agencies, that utilize a similar labor mix, are adjusted by the pre-floor, pre-reclassified hospital wage index, without any budget neutrality adjustment. We believe that using the unadjusted pre-floor, pre-reclassified hospital wage index provides a good measure of area wage differences for both these home-based reimbursement systems.

Fourth, in the 13 years since concerns about the impact of switching from an old to a new wage index were voiced, the hospice industry and hospice payments have grown substantially. Hospice expenditures in 2006 were $9.2 billion, compared to about $2.2 billion in 1998, a growth rate of almost 20 percent per year. Aggregate hospice expenditures are increasing at a rate of about $1 billion per year. MedPAC projects that expenditures will continue to grow at a rate of 9 percent per year through 2015, outpacing the growth rate of projected expenditures for hospitals, skilled nursing facilities, and physician and home health services. We believe that this growth in Medicare spending for hospice indicates that the original rationale of the BNAF, to cushion the impact of using the new wage index, is no longer justified. These spending growth figures also indicate that any negative financial impact to the hospice industry as a result of eliminating the BNAF is no longer present, and thus the need for a transitional adjustment has passed.

Fifth, 13 years ago the industry also voiced concerns about the negative financial impact on individual hospices that could occur by adopting a new wage index. In August 1994 there were 1,602 hospices; currently there are 2,986 hospices. Clearly any negative financial impact from adopting a new wage index in 1997 is no longer present, or we would not have seen an 86 percent increase in the number of hospices since 1994. The number of Medicare-certified hospices has continued to increase, with a 26 percent increase in the number of hospice providers from 2001 to 2005. This ongoing growth in the industry also suggests that phasing out the BNAF would not have a negative impact on access to care.

Therefore for these reasons, we believe that continuing to apply a BNAF for the purpose of mitigating any adverse financial impact on hospices or negative impact on access to care is no longer necessary. We are proposing to phase out the BNAF over a 3-year period, reducing the BNAF by 25 percent in FY 2009, by 75 percent in FY 2010, and eliminating it in FY 2011. We believe that the proposed 3-year phase-out period will reduce any adverse financial impact that the industry might experience if we eliminated the BNAF in a single year. However, depending on the comments received, updated data, and subsequent analysis, for the final rule we may determine that a different percentage reduction in the BNAF (for any of the years) or a different phase-out timeframe would be more appropriate. Specifically, it may be determined that a more aggressive phase-out alternative (e.g. a 50 percent reduction in the BNAF in FY 2009, a 75 percent reduction in the BNAF in FY 2010, and elimination of the BNAF in FY 2011) is more appropriate. Consequently, we will continue to look at reduction percentages and timeframe alternatives for the phase-out of the BNAF and, for the final rule, will implement what is determined to be the most appropriate option based on the above information. We propose to maintain the hospice floor, which offers protection to Start Printed Page 24007hospices with pre-floor, pre-reclassified hospital wage index values less than 0.8.

We believe that we should have addressed this issue in previous years. We believe that using the BNAF has resulted in Medicare spending for hospice services in excess of what spending should have been in the absence of such an adjustment. However, we are not proposing to reduce Medicare payments to hospices for prior years. We are only proposing to remove the application of the BNAF on a prospective basis, beginning on October 1, 2008.

Section II.C.3.a below discusses the effects of phasing out the BNAF over three years using the data from the published FY 2008 hospice wage index; by basing the analysis on this data, our simulations hold claims data, the wage index values, and payment rates constant, with the only change being the reduction in the BNAF. Section II.C.3.b discusses the effects of reducing the BNAF for FY 2009 using the proposed FY 2009 hospice wage index.

a. Effects of Phasing-Out the BNAF Using the Published FY 2008 Hospice Wage Index

For this proposed rule, we will use the FY 2008 hospice wage index (72 FR 50214, published August 31, 2007) to illustrate the effects of phasing out the BNAF over 3 years. This analysis and discussion is for illustrative purposes only and does not affect any of the hospice wage index values for FY 2008.

The BNAF that was calculated and applied to the 2007 pre-floor, pre-reclassified hospital wage index values was 6.6671 percent. We propose reducing the BNAF by 25 percent for FY 2009, by 75 percent for FY 2010, and eliminating it altogether for FY 2011 and beyond. A 25 percent reduction in the BNAF can be accomplished by blending 75 percent of the FY 2008 hospice wage index that applied the full 6.6671 percent BNAF with 25 percent of the FY 2008 hospice wage index that used no BNAF. This is mathematically equivalent to taking 75 percent of the full BNAF value, or multiplying 0.066671 by 0.75, which equals 0.050003, or 5.0003 percent. The BNAF of 5.0003 percent reflects a 25 percent reduction in the BNAF. The 25 percent reduction in the BNAF of 5.0003 percent would be applied to the pre-floor, pre-reclassified hospital wage index values of 0.8 or greater used in the published FY 2008 hospice wage index.

The hospice floor calculation would still apply to any pre-floor, pre-reclassified hospital wage index values less then 0.8. Currently, the floor calculation has 4 steps. Pre-floor, pre-reclassified hospital wage index values that are less than 0.8 are first multiplied by 1.15; second, the minimum of 0.8 or the pre-floor, pre-reclassified hospital wage index value times 1.15 is chosen as the preliminary hospice wage index value. Third, the pre-floor, pre-reclassified hospital wage index value is multiplied by BNAF. Finally, the greater result of either step 2 or step 3 is chosen as the final hospice wage index value. We propose to leave the hospice floor unchanged, noting that steps 3 and 4 will become unnecessary once the BNAF is eliminated.

For the simulations of the BNAF phase-out for FY 2010 and FY 2011, we used the same pre-floor, pre-reclassified hospital wage index values and claims data as the example above, and simply changed the value of the BNAF to reflect either a 75 percent reduction for FY 2010 or a 100 percent reduction for FY 2011. In both cases we started with the full BNAF of 6.6671 percent. We changed the calculation to take 25 percent of the full BNAF to reflect a 75 percent reduction for FY 2010, or eliminated the BNAF altogether to reflect a 100 percent reduction for FY 2011. For FY 2010, the reduced BNAF or the hospice floor was then applied to the 2008 pre-floor, pre-reclassified hospital wage index as described previously. For FY 2011 and subsequent years, the pre-floor, pre-reclassified hospital wage index values would be unadjusted unless they are less than 0.8, in which case the hospice floor calculation would be applied.

For our simulations, the calculations of the BNAF are as follows:

  • A 75 percent reduction to the BNAF in FY 2010 would be 0.066671 × 0.25 = 0.016668 or 1.6668 percent
  • A 100 percent reduction or elimination of the BNAF in FY 2011 would be 0.066671 × 0.0 = 0.0 or 0 percent

We examined the effects of phasing out the BNAF versus using the full BNAF of 6.6671 percent on the FY 2008 hospice wage index. The FY 2009 BNAF reduction of 25 percent resulted in approximately a 1.55 to 1.57 percent reduction in the hospice wage index value. The FY 2010 BNAF reduction of 75 percent would result in an estimated additional 3.12 to 3.13 percent reduction from the FY 2009 hospice wage index values. The elimination of the BNAF in FY 2011 would result in an estimated final reduction of the FY 2011 hospice wage index values of approximately 1.55 to 1.57 percent compared to FY 2010 hospice wage index values.

Those CBSAs whose pre-floor, pre-reclassified hospital wage index values had the hospice floor calculation applied prior to the BNAF reduction would not be affected by this proposed phase-out of the BNAF. These CBSAs, which typically include rural areas, are protected by the hospice floor calculation. Additionally, those CBSAs whose hospice wage index values were previously 0.8 or greater after the BNAF was applied, but which would have values less than 0.8 after the reduced BNAF was applied would see a smaller reduction in their hospice wage index values since the hospice floor calculation would apply. We have estimated the number of CBSAs that would have their pre-floor, pre-reclassified hospital wage index value eligible for the floor calculation after applying the 25, 75, and 100 percent reductions in the BNAF. Three CBSAs would be affected by the 25 percent reduction, 12 would be affected by the 75 percent reduction, and 22 would be affected by the 100 percent reduction. Because of the protection given by the hospice floor calculation, these CBSAs would see smaller percentage decreases in their hospice wage index values than those CBSAs that are not eligible for the floor calculation. This will benefit those hospices with lower hospice wage index values, which are typically in rural areas.

Finally, the hospice wage index values only apply to the labor portion of the payment rates; the labor portion was described in Section I.B.1 of this proposed rule. Therefore the estimated reduction in payments due to this proposed phase-out of the BNAF would be less than the percentage reductions to the hospice wage index values that would result from reducing or eliminating the BNAF. In addition, the effects of the proposed phase-out of the BNAF could also be mitigated by a hospital market basket update in payments, which in FY 2008 was a 3.3 percent increase in payment rates. We will not have the final market basket update for FY 2009 until the summer, but the current estimate of the hospital market basket update is expected to be around 3.0 percent. This update will be communicated through an administrative instruction and not through rulemaking. The estimated effects on payment described in column 5 of Table 1 in section IV.B of this proposed rule include the projected effect of an estimated 3.0 percent hospital market basket update. CMS may implement updates to the payment rates in future rulemaking. Start Printed Page 24008

b. Effects of Phasing-Out the BNAF Using the Updated Pre-floor, Pre-reclassified Hospital Wage Index Data (FY 2009 Proposal)

For FY 2009, we propose updating the hospice wage index using the 2008 pre-floor, pre-reclassified hospital wage index and the most complete claims data available (FY 2006 claims). Using these data, we computed a full BNAF of 6.5357 percent. For the first year of the BNAF phase-out (FY 2009), the BNAF would be reduced by 25 percent, or 0.065357 × 0.75 = 0.049018, to 4.9018 percent. This would decrease hospice wage index values by approximately 1.53 to 1.54 percent from wage index values with the full BNAF applied. As noted in the previous discussion on the effects of the BNAF reduction in the published FY 2008 hospice wage index, those CBSAs which already have pre-floor, pre-reclassified hospital wage index values that have the hospice floor applied prior to implementing a proposed BNAF reduction would be completely unaffected by this proposed BNAF reduction. Those CBSAs which previously had hospice wage index values above 0.8 after applying the full BNAF, but which now are below 0.8 with the 25 percent reduction in the BNAF would be less affected by the BNAF reduction than those CBSAs which are 0.8 or above after applying the BNAF, as they are protected by the hospice floor calculation. Additionally, as mentioned in section I.B.1 of this proposed rule, the final hospice wage index is only applied to the labor portion of the payment rates, so the actual effect on estimated payment would be less than the anticipated 1.53 to 1.54 percent reduction in the hospice wage index value. Furthermore, that effect may be mitigated by a market basket update. As noted earlier, the market basket update will not be available until the summer, but estimates of the update are at about 3.0 percent.

Column 3 of Table 1 (section IV of this proposed rule) shows the impact of using the most recent wage index data (the 2008 pre-floor, pre-reclassified hospital wage index not including any reclassification under section 1886(d)(8)(B) of the Act) compared to the 2007 pre-floor, pre-reclassified hospital wage index data which was used to derive the FY 2008 hospice wage index. Column 4 of Table 1 in Section IV of this proposed rule shows the impact of incorporating the 25 percent reduction in the BNAF in the proposed FY 2009 hospice wage index along with using the most recent wage index data (2008 pre-floor, pre-reclassified hospital wage index). Finally, column 5 of Table 1 shows the combined effects of using the updated pre-floor, pre-reclassified hospital wage index, the 25 percent reduced BNAF, and an estimated market basket update of 3.0 percent. The proposed FY 2009 rural and urban hospice wage indexes can be found in Addenda A and B of this proposed rule. The pre-floor, pre-reclassified hospital wage index values were adjusted by the 25 percent reduced BNAF or by the hospice floor.

D. Summary of the Provisions of the Proposed Rule

  • We propose to clarify that the hospice benefit will follow the definition of “urban” specified in § 412.64(b)(1)(ii)(A) and (B), and the rural definition as any area outside of an urban area in § 412.64(b)(1)(ii)(C). The regulatory text of § 418.306(c) will be amended to reference § 412.64(b)(1)(ii)(A) through (C). This affects two New England “deemed” counties that meet the OMB definition of rural, but were previously counted as urban; these two counties would now be considered rural. See section II.A of this proposed rule for details.
  • As a basis for the hospice wage index, we propose to continue to use the pre-floor, pre-reclassified hospital wage index, which includes a change to how wage data from multi-campus hospitals are apportioned. See section II.B of this proposed rule for more details.
  • We propose to continue to use a pre-floor, pre-reclassified hospital wage index based solely on the CBSA designations, using the most recent pre-floor and pre-reclassified hospital wage index available at the time of publication. See section II.C.1 of this proposed rule for details.
  • We propose to continue the policy that for urban labor markets without an urban hospital from which a pre-floor, pre-reclassified hospital wage index could be derived, all of the urban CBSA pre-floor, pre-reclassified hospital wage index values within the State would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index to use as a reasonable proxy for these areas. See section II.C.2 of this proposed rule for details.
  • We propose to continue the policy that we impute an average pre-floor, pre-reclassified rural hospital wage index value by averaging the pre-floor, pre-reclassified hospital wage index values from contiguous CBSAs as a reasonable proxy for rural areas with no hospital wage data from which to calculate a pre-floor, pre-reclassified hospital wage index. See section II.C.2 f of this proposed rule or details.
  • We propose to continue to utilize the most recent pre-floor, pre-reclassified hospital wage index value available for Puerto Rico. See section II.C.2 of this proposed rule for details.
  • We propose to phase-out the hospice BNAF over 3 years, reducing it by 25 percent for FY 2009, by 75 percent for FY 2010, and eliminating it completely for FY 2011. See sections II.C.3.a and II.C.3.b of this proposed rule for details. As stated in section II.C.3, based on comments received, updated data, and subsequent analysis, for the final rule we may determine that a different percentage reduction in the BNAF (for any of the years) or a different phase-out timeframe would be more appropriate. Specifically, it may be determined that a more aggressive alternative (e.g., a 50 percent reduction in the BNAF in FY 2009, a 75 percent reduction in the BNAF in FY 2010, and elimination of the BNAF in FY 2011) is more appropriate. Consequently, we will continue to look at reduction percentages and time period alternatives for the phase-out of the BNAF and, for the final rule, will implement what is determined to be the most appropriate option based on the above information.
  • We propose to continue to maintain the hospice floor calculation. See section II.C.3 of this proposed rule for details.

Addendum A reflects the proposed FY 2009 hospice wage index values for urban areas designations. Addendum B reflects the proposed FY 2009 hospice wage index values for rural areas designations.

III. Collection of Information Requirements

This document does not impose any information collection and recordkeeping requirements. Consequently, it does not need to be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 35).

IV. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), Executive Order 13132 on Federalism, and the Congressional Review Act (5 U.S.C. 804(2)). We Start Printed Page 24009estimated the impact on hospices, as a result of the changes to the proposed FY 2009 hospice wage index and of reducing the BNAF by 25 percent. As discussed previously, the methodology for computing the hospice wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). This rule proposes updates to the hospice wage index in accordance with our regulation but proposes to revise the Negotiated Rulemaking Committee methodology of including a BNAF.

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits including potential economic, environmental, public health and safety effects, distributive impacts, and equity. A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We have determined that this proposed rule is an economically significant rule under this Executive Order.

Column 4 of Table 1 shows the combined effects of the proposed 25 percent reduction in the BNAF and of the updated wage data, comparing estimated payments for FY 2009 to estimated payments for FY 2008. We estimate that the total hospice payments for FY 2009 will decrease by $100 million as a result of the application of the 25 percent reduction in the BNAF and the updated wage data. This estimate does not take into account any market basket update, which is currently forecast to be about 3.0 percent. The final market basket update will not be available until some time later this year and will be communicated through an administrative instruction. The estimated effect of a 3.0 percent forecasted market basket update on payments to hospices is approximately $280 million. If we were to take into account an estimated 3.0 percent market basket update, in addition to the 25 percent reduction in the BNAF and the updated wage data, it is estimated that hospice payments would increase by approximately $180 million ($280 million − $100 million = $180 million). The percent change in payments to hospices due to the combined effects of the 25 percent reduction in the BNAF, the updated wage data, and the estimated market basket update of 3.0 percent is reflected in column 5 of the impact table (Table 1).

The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. The great majority of hospices and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $6.5 million to $31.5 million in any one year (for details, see the Small Business Administration's regulation at 65 FR 69432, that sets forth size standards for health care industries). As indicated in Table 1 below, there are 2,986 hospices as of February 2008. Approximately 52.7 percent of Medicare certified hospices are identified as voluntary, government, or other agencies and, therefore, are considered small entities. Most of these and most of the remainder are also small hospice entities because their revenues fall below the SBA size thresholds. We note that the hospice wage index methodology was previously guided by consensus, through a negotiated rulemaking committee that included representatives of national hospice associations, rural, urban, large and small hospices, multi-site hospices, and consumer groups. Based on all of the options considered, the committee agreed on the methodology described in the committee statement, and after notice and comment, it was adopted into regulation in the August 8, 1997 final rule. In developing the process for updating the hospice wage index in the 1997 final rule, we considered the impact of this methodology on small hospice entities and attempted to mitigate any potential negative effects. Small hospice entities are more likely to be in rural areas, which are less affected by the BNAF reduction than entities in urban areas. Generally, hospices in rural areas are protected by the hospice floor, which mitigates the effect of the BNAF reduction. The effects of this rule on hospices, as illustrated in Table 1, are small. Overall, Medicare payments to all hospices will decrease by an estimated 1.1 percent, reflecting the combined effects of the 25 percent reduction in the BNAF and the updated wage data. Within the hospice subgroups, Medicare payments will decrease by no more than 1.6 percent. Furthermore, when including the estimated market basket update of 3.0 percent into these figures, the combined effects of Medicare payment changes to all hospices will result in an increase of approximately 1.9 percent. Overall average hospice revenue effects will be slightly less than these estimates since according the National Hospice and Palliative Care Organization, about 16 percent of hospice caseload is non-Medicare. Longstanding HHS practice in interpreting the RFA is to consider effects economically “significant” only if they reach a threshold of 3 to 5 percent or more. Accordingly, we have determined that this proposed rule does not create a significant economic impact on a substantial number of small entities.

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

Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of about $130 million or more (the threshold in the statute, updated for inflation through 2008). This proposed rule is not anticipated to have an effect on State, local, or tribal governments or on the private sector of $130 million or more.

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

B. Anticipated Effects

This section discusses the impact of the projected effects of the proposed provisions of this rule, including the estimated effects of a projected 3.0 percent market basket update that will be communicated separately through an administrative instruction. The proposed provisions include continuing to use the CBSA-based pre-floor, pre-reclassified hospital wage index (to include the clarification of New England “deemed” counties and a change in the way that multi-campus hospital wage Start Printed Page 24010data are treated in the creation of the pre-floor, pre-reclassified hospital wage index), continuing the use the same policies for treatment of areas (rural and urban) without hospital wage data, and reducing the BNAF by 25 percent for the first year of a 3-year BNAF phase-out. The proposed FY 2009 hospice wage index is based upon the 2008 pre-floor, pre-reclassified hospital wage index and the most complete claims data available (FY 2006) with a 25 percent reduction in the BNAF.

For the purposes of our impacts, our baseline is estimated FY 2008 payments using the 2007 pre-floor, pre-reclassified hospital wage index. Our first comparison (column 3, Table 1) compares our baseline to estimated FY 2009 payments (holding payment rates constant) using the updated wage data (2008 pre-floor, pre-reclassified hospital wage index). Consequently, the estimated effects illustrated in column 3 of Table 1 are for the updated wage data only. The effects of using the updated pre-floor, pre-reclassified hospital wage index data combined with the 25 percent reduction in the BNAF are illustrated in column 4 of Table 1.

Even though the market basket update is not part of this proposed rule, we have included a comparison of the combined effects of the 25 percent BNAF reduction, the updated pre-floor, pre-reclassified hospital wage index, and an estimated 3.0 percent market basket increase for FY 2009 (Table 1, column 5). Presenting this data gives the hospice industry a more complete picture of the effects of the proposed changes in this rule and the market basket update. Certain events may limit the scope or accuracy of our impact analysis, because such an analysis is susceptible to forecasting errors due to other changes in the forecasted impact time period. 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 hospices.

Table 1.—Anticipated Impact on Medicare Hospice Payments of Reducing the BNAF, Updating the Pre-Floor, Pre-Reclassified Hospital Wage Index Data, and Applying an Estimated 3.0 Percent Market Basket Update for the Proposed FY 2009 Hospice Wage Index, Compared to the Published Final FY 2008 Hospice Wage Index

Number of hospices*Number of routine home care days in thousandsPercent change in payments due to the effects of the updated wage data (FY 2009 Proposed Wage Index)Percent change in payments due to the combined effects of the 25% reduction in the BNAF and the updated wage data (FY 2009 Proposed Wage Index)Percent change in payments due to the combined effects of the 25% reduction in the BNAF, the updated wage data (FY 2009 Proposed Wage Index), and estimated market basket update (3.0%)
(1)(2)(3)(4)(5)
ALL HOSPICES2,98661,351−0.1−1.11.9
URBAN HOSPICES1,99652,642−0.1−1.11.8
RURAL HOSPICES9908,709−0.1−0.92.1
BY REGION—URBAN:
NEW ENGLAND1131,7870.3−0.82.2
MIDDLE ATLANTIC2015,250−0.5−1.61.4
SOUTH ATLANTIC28811,388−0.1−1.11.8
EAST NORTH CENTRAL2967,638−0.3−1.41.6
EAST SOUTH CENTRAL1604,365−0.4−1.31.7
WEST NORTH CENTRAL1523,4130.0−1.01.9
WEST SOUTH CENTRAL3397,131−0.2−1.21.7
MOUNTAIN1834,5430.0−1.11.9
PACIFIC2306,3300.8−0.42.6
PUERTO RICO34797−1.1−1.11.9
BY REGION—RURAL:
NEW ENGLAND26147−0.4−1.41.5
MIDDLE ATLANTIC434080.3−0.72.3
SOUTH ATLANTIC1251,7590.0−0.92.0
EAST NORTH CENTRAL1401,1480.0−1.01.9
EAST SOUTH CENTRAL1452,017−0.4−1.11.8
WEST NORTH CENTRAL189945−0.3−1.31.7
WEST SOUTH CENTRAL1651,325−0.6−0.82.2
MOUNTAIN1045800.4−0.62.4
PACIFIC523721.50.43.4
PUERTO RICO170.00.03.0
ROUTINE HOME CARE DAYS:
0-3499 DAYS (small)6311,0600.0−0.92.0
3500-19,999 DAYS (medium)1,44514,385−0.1−1.11.9
20,000+ DAYS (large)91045,906−0.1−1.11.9
TYPE OF OWNERSHIP:
VOLUNTARY1,19427,185−0.2−1.21.8
PROPRIETARY1,41230,0170.0−1.01.9
GOVERNMENT1929860.1−0.82.2
OTHER1883,1630.0−1.02.0
HOSPICE BASE:
FREESTANDING1,80745,473−0.1−1.11.8
HOME HEALTH AGENCY5978,9080.0−1.02.0
HOSPITAL5676,7560.0−1.11.9
Start Printed Page 24011
SKILLED NURSING FACILITY15213−0.6−1.71.2
BNAF = Budget Neutrality Adjustment Factor.
* As of February 2008.

Table 1 shows the results of our analysis. In column 1, we indicate the number of hospices included in our analysis as of February 2008. In column 2, we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 shows the percentage change in estimated Medicare payments from FY 2008 to FY 2009 due to the effects of the updated wage data only. Column 4 shows the percentage change in estimated hospice payments from FY 2008 to FY 2009 due to the combined effects of using the 2008 pre-floor, pre-reclassified hospital wage index and reducing the BNAF by 25 percent. Column 5 shows the percentage change in estimated hospice payments from FY 2008 to FY 2009 due to the combined effects of using updated wage data, a 25 percent BNAF reduction, and a 3.0 percent estimated market basket update.

Table 1 also categorizes hospices by various geographic and provider characteristics. The first row of data displays the aggregate result of the impact for all Medicare-certified hospices. The second and third rows of the table categorize hospices according to their geographic location (urban and rural). Our analysis indicated that there are 1,996 hospices located in urban areas and 990 hospices located in rural areas. The next two row groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The next grouping shows the impact on hospices based on the size of the hospice's program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice's program on the number of routine home care days provided in FY 2006. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding.

As indicated in Table 1 below, there are 2,986 hospices. Approximately 52.7 percent of Medicare-certified hospices are identified as voluntary, government, or other agencies and, therefore, are considered small entities. Because the National Hospice and Palliative Care Organization estimates that approximately 83.7 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis. As noted earlier, those CBSAs which had the hospice floor applied prior to our proposal to reduce the BNAF are unaffected by this proposed change in methodology. Those CBSAs that were not previously less than 0.8 after applying the full BNAF but which now are less than 0.8 after applying the reduced BNAF will see less of a reduction in payments as the floor protects their hospice wage index value.

As stated previously, the following discussions are limited to demonstrating trends rather than projected dollars. We used the pre-floor, pre-reclassified hospital wage indexes as well as the most complete claims data available (FY 2006) in developing the impact analysis. The FY 2009 payment rates will be adjusted to reflect the full hospital market basket, as required by section 1814(i)(1)(C)(ii)(VII) of the Act. As previously noted, we publish these rates through administrative instructions rather than in a proposed rule. The FY 2008 update was 3.3 percent, and the FY 2009 update will not be available until the summer. Currently the FY 2009 update is estimated to be 3.0 percent; however this figure is subject to change. Since the inclusion of the effect of a market basket increase provides a more complete picture of estimated hospice payments for FY 2009, the last column of Table 1 shows the combined impacts of the 25 percent BNAF reduction, the updated wage index, and a projected 3.0 percent market basket update factor.

As discussed in the FY 2006 final rule (70 FR 45129), hospice agencies may use multiple hospice wage index values to compute their payments based on potentially different geographic locations. Before January 1, 2008, the location of the beneficiary was used to determine the CBSA for routine and continuous home care and the location of the hospice agency was used to determine the CBSA for respite and general inpatient care. Beginning January 1, 2008, the hospice wage index utilized is based on the location of the site of service. As the location of the beneficiary's home and the location of the facility may vary, there will still be variability in geographic location for an individual hospice. We anticipate that the location of the various sites will usually correspond with the geographic location of the hospice, and thus we will continue to use the location of the hospice for our analyses of the impact of the proposed changes to the hospice wage index in this rule. For this analysis, we use payments to the hospice in the aggregate based on the location of the hospice.

The impact of hospice wage index changes has been analyzed according to the type of hospice, geographic location, type of ownership, hospice base, and size. Our analysis shows that most hospices are in urban areas and provide the vast majority of routine home care days. Most hospices are medium-sized Start Printed Page 24012followed by large hospices. Hospices are almost equal in numbers by ownership with 1,574 designated as non-profit and 1,412 as proprietary. The vast majority of hospices are freestanding.

1. Hospice Size

Under the Medicare hospice benefit, hospices can provide four different levels of care days. The majority of the days provided by a hospice are routine home care (RHC) days representing about 97 percent of the services provided by a hospice. Therefore, the number of RHC days can be used as a proxy for the size of the hospice, that is, the more days of care provided, the larger the hospice. As discussed in the August 4, 2005 final rule, we currently use three size designations to present the impact analyses. The three categories are: (1) Small agencies having 0 to 3,499 RHC days; (2) medium agencies having 3,500 to 19,999 RHC days; and (3) large agencies having 20,000 or more RHC days. The proposed FY 2009 wage index values without the BNAF reduction are anticipated to have virtually no impact on small hospice providers, with a slight decrease of 0.1 percent anticipated for medium and large hospices (column 3); the proposed FY 2009 wage index values with the 25 percent BNAF reduction and the updated wage data are anticipated to decrease estimated payments by 0.9 percent to small hospices and by 1.1 percent to medium and large hospices (column 4); and finally, the proposed FY 2009 wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update are projected to increase estimated payments by 2.0 percent for small hospices and by 1.9 percent for medium and large hospices (column 5).

2. Geographic Location

Column 3 of Table 1 shows that FY 2009 wage index values without the BNAF reduction will result in little change in estimated payments with rural and urban hospices anticipated to experience a slight decrease of 0.1 percent. For urban hospices, the greatest increase of 0.8 percent is anticipated to be experienced by the Pacific regions, followed by an increase for New England of 0.3 percent and no change for the West North Central and Mountain regions. The remaining urban regions are anticipated to experience a decrease ranging from 0.1 percent in the South Atlantic region 1.1 percent is for Puerto Rico.

Column 3 shows that for rural hospices, Puerto Rico, the South Atlantic, and the East North Central regions are anticipated to experience no change. Four regions are anticipated to experience a decrease ranging from 0.3 percent for the West North Central region to 0.6 percent for West South Central region. The remaining regions are anticipated to experience an increase ranging from 0.3 percent for the Middle Atlantic region to 1.5 percent for the Pacific region.

Column 4 shows the combined effect of the 25 percent BNAF reduction and the updated pre-floor, pre-reclassified hospital wage index values on estimated payments, as compared to the published FY 2008 payments. Overall urban hospices are anticipated to experience a 1.1 percent decrease in payments, while rural hospices expect a 0.9 percent decrease. The estimated percent decrease in payment for urban hospices ranged from 0.4 percent for Pacific hospices to 1.6 percent for Middle Atlantic hospices.

The estimated percent decrease in payment for rural hospices ranged from 0.6 percent for Mountain hospices to 1.4 percent for New England hospices. Rural Puerto Rico's estimated payments were unaffected, and the Pacific region saw a 0.4 percent increase in estimated payments.

Column 5 shows the combined effects of the proposed FY 2009 wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update on estimated payments as compared to the published FY 2008 payments. Overall, urban hospices are anticipated to experience a 1.8 percent increase in payments while rural hospices should experience a 2.1 percent increase in payments. Urban hospices are anticipated to see an increase in estimated payments ranging from 1.4 percent for the Middle Atlantic region to 2.6 percent for the Pacific region. Rural hospices are estimated to see an increase in estimated payments ranging from 1.5 percent for the New England region to 3.4 percent for the Pacific region.

3. Type of Ownership

Column 3 demonstrates the effect of the updated pre-floor, pre-reclassified hospital wage index on FY 2009 estimated payments versus FY 2008 estimated payments. We anticipate that using the updated pre-floor, pre-reclassified hospital wage index data will have no effect on proprietary hospices. While we estimate a slight decrease in estimated payments for voluntary (non-profit) hospices (0.2 percent), other hospices are expected to experience no effect and government hospices are expected to experience a slight increase in payments (0.1 percent).

Column 4 demonstrates the combined effects of using updated pre-floor, pre-reclassified hospital wage index data and of incorporating a 25 percent BNAF reduction. Estimated payments to proprietary hospices are anticipated to decrease by 1.0 percent, while voluntary (non-profit), other, and government hospices are anticipated to experience decreases of 1.2 percent, 1.0 percent, and 0.8 percent, respectively.

Column 5 shows the combined effects of the updated pre-floor, pre-reclassified hospital wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update on estimated payments, comparing FY 2009 to FY 2008. Estimated FY 2009 payments are anticipated to increase for all hospices, regardless of ownership type. Estimated payments are forecast to increase from 1.8 percent for voluntary hospices to 2.2 percent for government hospices.

4. Hospice Base

Column 3 demonstrates the effect of using the updated pre-floor, pre-reclassified hospital wage index values, comparing estimated payments for FY 2009 to FY 2008. Estimated payments are anticipated to decrease by 0.1 percent for freestanding facilities and by 0.6 percent for skilled nursing facilities. Home health and hospital based facilities are anticipated to experience no change in estimated payments.

Column 4 shows the combined effects of reducing the BNAF by 25 percent and updating the pre-floor, pre-reclassified hospital wage index values, comparing FY 2009 to FY 2008 estimated payments. Skilled nursing facility based hospices are estimated to see a 1.7 percent decline, while hospital based hospices and freestanding hospices are each anticipated to experience a 1.1 percent decrease in payments. Home health agency based hospices are expected to experience a 1.0 percent decrease.

Column 5 shows the combined effects of the 25 percent BNAF reduction, the updated pre-floor, pre-reclassified hospital wage index, and the estimated 3.0 percent market basket update on estimated payments, comparing FY 2009 to FY 2008. Estimated increases in payments range from 1.2 percent for skilled nursing facility based hospices to 2.0 percent for home health agency based hospices.

We note that the President's budget includes a proposal for a zero percent payment update for hospices in FY 2009. The impacts outlined in Column 5 of Table 1 in this proposed rule, Start Printed Page 24013which include the effects of a 3.0 percent market basket update, would need to change in the final rule to reflect any legislation that the Congress might enact which would affect the market basket update.

C. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf), in Table 2 below, we have prepared an accounting statement showing the classification of the expenditures associated with the proposed provisions of this rule. This table provides our best estimate of the decrease in Medicare payments under the hospice benefit as a result of the changes presented in this proposed rule on data for 2,086 hospices in our database. All expenditures are classified as transfers to Medicare providers (that is, hospices).

Table 2.—Accounting Statement: Classification of Estimated Expenditures, From FY 2008 to FY 2009 [In millions]

CategoryTransfers
Annualized Monetized Transfers$-100*.
From Whom to WhomFederal Government to Hospices.
* The $100 million reduction in transfers includes the 25 percent reduction in the BNAF and the updated wage data. It does not include the market basket update, which is currently forecast to be about 3.0%.

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 418

End List of Subjects

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

Start Part

PART 418—HOSPICE CARE

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

Start Authority

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

End Authority

Subpart G—Payment for Hospice Care

2. Section § 418.306 is amended by revising paragraph (c) to read as follows:

Determination of payment rates.
* * * * *

(c) Each hospice's labor market is determined based on definitions of Metropolitan Statistical Areas (MSAs) issued by OMB. CMS will issue annually, in the Federal Register, a hospice wage index based on the most current available CMS hospital wage data, including changes to the definition of MSAs. The urban and rural area geographic classifications are defined in § 412.64(b)(1)(ii)(A) through (C) of this chapter. The payment rates established by CMS are adjusted by the intermediary to reflect local differences in wages according to the revised wage data.

* * * * *

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

Note:

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

Start Signature

Dated: March 14, 2008.

Kerry Weems,

Acting Administrator, Centers for Medicare & Medicaid Services.

Approved: April 7, 2008.

Michael O. Leavitt,

Secretary.

End Signature

Addendum A.—Proposed Hospice Wage Index for Urban Areas by CBSA—FY 2009

CBSA codeUrban area (constituent counties) 2Wage index 1
10180Abilene, TX0.8347
 Callahan County, TX
 Jones County, TX
 Taylor County, TX
10380Aguadilla-Isabela-San Sebastián, PR0.3965
 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, OH0.9225
 Portage County, OH
 Summit County, OH
10500Albany, GA0.8931
 Baker County, GA
 Dougherty County, GA
 Lee County, GA
 Terrell County, GA
 Worth County, GA
10580Albany-Schenectady-Troy, NY0.9009
 Albany County, NY
 Rensselaer County, NY
 Saratoga County, NY
 Schenectady County, NY
Start Printed Page 24014
 Schoharie County, NY
10740Albuquerque, NM1.0022
 Bernalillo County, NM
 Sandoval County, NM
 Torrance County, NM
 Valencia County, NM
10780Alexandria, LA0.8370
 Grant Parish, LA
 Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ1.0349
 Warren County, NJ
 Carbon County, PA
 Lehigh County, PA
 Northampton County, PA
11020Altoona, PA0.9040
 Blair County, PA
11100Amarillo, TX0.9563
 Armstrong County, TX
 Carson County, TX
 Potter County, TX
 Randall County, TX
11180Ames, IA1.0538
 Story County, IA
11260Anchorage, AK1.2497
 Anchorage Municipality, AK
 Matanuska-Susitna Borough, AK
11300Anderson, IN0.9260
 Madison County, IN
11340Anderson, SC0.9531
 Anderson County, SC
11460Ann Arbor, MI1.1056
 Washtenaw County, MI
11500Anniston-Oxford, AL0.8315
 Calhoun County, AL
11540Appleton, WI1.0068
 Calumet County, WI
 Outagamie County, WI
11700Asheville, NC0.9635
 Buncombe County, NC
 Haywood County, NC
 Henderson County, NC
 Madison County, NC
12020Athens-Clarke County, GA1.1033
 Clarke County, GA
 Madison County, GA
 Oconee County, GA
 Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA1.0310
 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
Start Printed Page 24015
 Pickens County, GA
 Pike County, GA
 Rockdale County, GA
 Spalding County, GA
 Walton County, GA
12100Atlantic City, NJ1.2796
 Atlantic County, NJ
12220Auburn-Opelika, AL0.8487
 Lee County, AL
12260Augusta-Richmond County, GA-SC1.0118
 Burke County, GA
 Columbia County, GA
 McDuffie County, GA
 Richmond County, GA
 Aiken County, SC
 Edgefield County, SC
12420Austin-Round Rock, TX1.0012
 Bastrop County, TX
 Caldwell County, TX
 Hays County, TX
 Travis County, TX
 Williamson County, TX
12540Bakersfield, CA1.1593
 Kern County, CA
12580Baltimore-Towson, MD1.0631
 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, ME1.0467
 Penobscot County, ME
12700Barnstable Town, MA1.3221
 Barnstable County, MA
12940Baton Rouge, LA0.8428
 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, MI1.0678
 Calhoun County, MI
13020Bay City, MI0.9333
 Bay County, MI
13140Beaumont-Port Arthur, TX0.8949
 Hardin County, TX
 Jefferson County, TX
 Orange County, TX
13380Bellingham, WA1.2036
 Whatcom County, WA
13460Bend, OR1.1478
 Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.1026
 Frederick County, MD
 Montgomery County, MD
13740Billings, MT0.9091
 Carbon County, MT
 Yellowstone County, MT
13780Binghamton, NY0.9388
 Broome County, NY
 Tioga County, NY
13820Birmingham-Hoover, AL0.9334
 Bibb County, AL
 Blount County, AL
 Chilton County, AL
Start Printed Page 24016
 Jefferson County, AL
 St. Clair County, AL
 Shelby County, AL
 Walker County, AL
13900Bismarck, ND0.8000
 Burleigh County, ND
 Morton County, ND
13980Blacksburg-Christiansburg-Radford, VA0.8594
 Giles County, VA
 Montgomery County, VA
 Pulaski County, VA
 Radford City, VA
14020Bloomington, IN0.9352
 Greene County, IN
 Monroe County, IN
 Owen County, IN
14060Bloomington-Normal, IL0.9782
 McLean County, IL
14260Boise City-Nampa, ID0.9929
 Ada County, ID
 Boise County, ID
 Canyon County, ID
 Gem County, ID
 Owyhee County, ID
14484Boston-Quincy, MA1.2370
 Norfolk County, MA
 Plymouth County, MA
 Suffolk County, MA
14500Boulder, CO1.0937
 Boulder County, CO
14540Bowling Green, KY0.8559
 Edmonson County, KY
 Warren County, KY
14740Bremerton-Silverdale, WA1.1438
 Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.3359
 Fairfield County, CT
15180Brownsville-Harlingen, TX0.9351
 Cameron County, TX
15260Brunswick, GA0.9939
 Brantley County, GA
 Glynn County, GA
 McIntosh County, GA
15380Buffalo-Niagara Falls, NY1.0037
 Erie County, NY
 Niagara County, NY
15500Burlington, NC0.9176
 Alamance County, NC
15540Burlington-South Burlington, VT1.0134
 Chittenden County, VT
 Franklin County, VT
 Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.1765
 Middlesex County, MA
15804Camden, NJ1.0921
 Burlington County, NJ
 Camden County, NJ
 Gloucester County, NJ
15940Canton-Massillon, OH0.9373
 Carroll County, OH
 Stark County, OH
15980Cape Coral-Fort Myers, FL0.9857
 Lee County, FL
16180Carson City, NV1.0493
 Carson City, NV
16220Casper, WY0.9845
 Natrona County, WY
16300Cedar Rapids, IA0.9286
 Benton County, IA
 Jones County, IA
 Linn County, IA
Start Printed Page 24017
16580Champaign-Urbana, IL0.9852
 Champaign County, IL
 Ford County, IL
 Piatt County, IL
16620Charleston, WV0.8695
 Boone County, WV
 Clay County, WV
 Kanawha County, WV
 Lincoln County, WV
 Putnam County, WV
16700Charleston-North Charleston, SC0.9571
 Berkeley County, SC
 Charleston County, SC
 Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC0.9987
 Anson County, NC
 Cabarrus County, NC
 Gaston County, NC
 Mecklenburg County, NC
 Union County, NC
 York County, SC
16820Charlottesville, VA0.9732
 Albemarle County, VA
 Fluvanna County, VA
 Greene County, VA
 Nelson County, VA
 Charlottesville City, VA
16860Chattanooga, TN-GA0.9435
 Catoosa County, GA
 Dade County, GA
 Walker County, GA
 Hamilton County, TN
 Marion County, TN
 Sequatchie County, TN
16940Cheyenne, WY0.9764
 Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.1240
 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, CA1.1843
 Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN1.0264
 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-KY0.8655
 Christian County, KY
 Trigg County, KY
 Montgomery County, TN
 Stewart County, TN
17420Cleveland, TN0.8447
 Bradley County, TN
 Polk County, TN
Start Printed Page 24018
17460Cleveland-Elyria-Mentor, OH0.9797
 Cuyahoga County, OH
 Geauga County, OH
 Lake County, OH
 Lorain County, OH
 Medina County, OH
17660Coeur d'Alene, ID0.9999
 Kootenai County, ID
17780College Station-Bryan, TX0.9817
 Brazos County, TX
 Burleson County, TX
 Robertson County, TX
17820Colorado Springs, CO1.0195
 El Paso County, CO
 Teller County, CO
17860Columbia, MO0.9082
 Boone County, MO
 Howard County, MO
17900Columbia, SC0.9231
 Calhoun County, SC
 Fairfield County, SC
 Kershaw County, SC
 Lexington County, SC
 Richland County, SC
 Saluda County, SC
17980Columbus, GA-AL0.9157
 Russell County, AL
 Chattahoochee County, GA
 Harris County, GA
 Marion County, GA
 Muscogee County, GA
18020Columbus, IN1.0004
 Bartholomew County, IN
18140Columbus, OH1.0579
 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, TX0.9009
 Aransas County, TX
 Nueces County, TX
 San Patricio County, TX
18700Corvallis, OR1.1496
 Benton County, OR
19060Cumberland, MD-WV0.8701
 Allegany County, MD
 Mineral County, WV
19124Dallas-Plano-Irving, TX1.0401
 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, GA0.9189
 Murray County, GA
 Whitfield County, GA
19180Danville, IL0.9396
 Vermilion County, IL
19260Danville, VA0.8644
 Pittsylvania County, VA
 Danville City, VA
19340Davenport-Moline-Rock Island, IA-IL0.9263
 Henry County, IL
 Mercer County, IL
Start Printed Page 24019
 Rock Island County, IL
 Scott County, IA
19380Dayton, OH0.9640
 Greene County, OH
 Miami County, OH
 Montgomery County, OH
 Preble County, OH
19460Decatur, AL0.8272
 Lawrence County, AL
 Morgan County, AL
19500Decatur, IL0.8470
 Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.9474
 Volusia County, FL
19740Denver-Aurora, CO1.1243
 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, IA0.9678
 Dallas County, IA
 Guthrie County, IA
 Madison County, IA
 Polk County, IA
 Warren County, IA
19804Detroit-Livonia-Dearborn, MI1.0489
 Wayne County, MI
20020Dothan, AL0.8000
 Geneva County, AL
 Henry County, AL
 Houston County, AL
20100Dover, DE1.0594
 Kent County, DE
20220Dubuque, IA0.9502
 Dubuque County, IA
20260Duluth, MN-WI1.0464
 Carlton County, MN
 St. Louis County, MN
 Douglas County, WI
20500Durham, NC1.0297
 Chatham County, NC
 Durham County, NC
 Orange County, NC
 Person County, NC
20740Eau Claire, WI0.9939
 Chippewa County, WI
 Eau Claire County, WI
20764Edison, NJ1.1729
 Middlesex County, NJ
 Monmouth County, NJ
 Ocean County, NJ
 Somerset County, NJ
20940El Centro, CA0.9351
 Imperial County, CA
21060Elizabethtown, KY0.9138
 Hardin County, KY
 Larue County, KY
21140Elkhart-Goshen, IN1.0082
 Elkhart County, IN
21300Elmira, NY0.8669
 Chemung County, NY
21340El Paso, TX0.9430
 El Paso County, TX
21500Erie, PA0.8911
 Erie County, PA
Start Printed Page 24020
21660Eugene-Springfield, OR1.1468
 Lane County, OR
21780Evansville, IN-KY0.9087
 Gibson County, IN
 Posey County, IN
 Vanderburgh County, IN
 Warrick County, IN
 Henderson County, KY
 Webster County, KY
21820Fairbanks, AK1.1592
 Fairbanks North Star Borough, AK
21940Fajardo, PR0.5031
 Ceiba Municipio, PR
 Fajardo Municipio, PR
 Luquillo Municipio, PR
22020Fargo, ND-MN0.8436
 Cass County, ND
 Clay County, MN
22140Farmington, NM1.0057
 San Juan County, NM
22180Fayetteville, NC0.9827
 Cumberland County, NC
 Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.9171
 Benton County, AR
 Madison County, AR
 Washington County, AR
 McDonald County, MO
22380Flagstaff, AZ1.2260
 Coconino County, AZ
22420Flint, MI1.1770
 Genesee County, MI
22500Florence, SC0.8653
 Darlington County, SC
 Florence County, SC
22520Florence-Muscle Shoals, AL0.8056
 Colbert County, AL
 Lauderdale County, AL
22540Fond du Lac, WI1.0141
 Fond du Lac County, WI
22660Fort Collins-Loveland, CO1.0382
 Larimer County, CO
22744Fort Lauderdale-Pompano Beach-Deerfield Beach, FL1.0730
 Broward County, FL
22900Fort Smith, AR-OK0.8322
 Crawford County, AR
 Franklin County, AR
 Sebastian County, AR
 Le Flore County, OK
 Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.9172
 Okaloosa County, FL
23060Fort Wayne, IN0.9739
 Allen County, IN
 Wells County, IN
 Whitley County, IN
23104Fort Worth-Arlington, TX1.0168
 Johnson County, TX
 Parker County, TX
 Tarrant County, TX
 Wise County, TX
23420Fresno, CA1.1532
 Fresno County, CA
23460Gadsden, AL0.8559
 Etowah County, AL
23540Gainesville, FL0.9647
 Alachua County, FL
 Gilchrist County, FL
23580Gainesville, GA0.9668
 Hall County, GA
23844Gary, IN0.9676
Start Printed Page 24021
 Jasper County, IN
 Lake County, IN
 Newton County, IN
 Porter County, IN
24020Glens Falls, NY0.8661
 Warren County, NY
 Washington County, NY
24140Goldsboro, NC0.9743
 Wayne County, NC
24220Grand Forks, ND-MN0.8267
 Polk County, MN
 Grand Forks County, ND
24300Grand Junction, CO1.0348
 Mesa County, CO
24340Grand Rapids-Wyoming, MI0.9772
 Barry County, MI
 Ionia County, MI
 Kent County, MI
 Newaygo County, MI
24500Great Falls, MT0.9100
 Cascade County, MT
24540Greeley, CO1.0131
 Weld County, CO
24580Green Bay, WI1.0204
 Brown County, WI
 Kewaunee County, WI
 Oconto County, WI
24660Greensboro-High Point, NC0.9452
 Guilford County, NC
 Randolph County, NC
 Rockingham County, NC
24780Greenville, NC0.9863
 Greene County, NC
 Pitt County, NC
24860Greenville, SC1.0343
 Greenville County, SC
 Laurens County, SC
 Pickens County, SC
25020Guayama, PR0.3524
 Arroyo Municipio, PR
 Guayama Municipio, PR
 Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.9203
 Hancock County, MS
 Harrison County, MS
 Stone County, MS
25180Hagerstown-Martinsburg, MD-WV0.9455
 Washington County, MD
 Berkeley County, WV
 Morgan County, WV
25260Hanford-Corcoran, CA1.1014
 Kings County, CA
25420Harrisburg-Carlisle, PA0.9735
 Cumberland County, PA
 Dauphin County, PA
 Perry County, PA
25500Harrisonburg, VA0.9302
 Rockingham County, VA
 Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.1496
 Hartford County, CT
 Middlesex County, CT
 Tolland County, CT
25620Hattiesburg, MS0.8000
 Forrest County, MS
 Lamar County, MS
 Perry County, MS
25860Hickory-Lenoir-Morganton, NC0.9471
 Alexander County, NC
 Burke County, NC
 Caldwell County, NC
Start Printed Page 24022
 Catawba County, NC
25980Hinesville-Fort Stewart, GA 30.9637
 Liberty County, GA
 Long County, GA
26100Holland-Grand Haven, MI0.9447
 Ottawa County, MI
26180Honolulu, HI1.2122
 Honolulu County, HI
26300Hot Springs, AR0.9556
 Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.8279
 Lafourche Parish, LA
 Terrebonne Parish, LA
26420Houston-Sugar Land-Baytown, TX1.0426
 Austin County, TX
 Brazoria County, TX
 Chambers County, TX
 Fort Bend County, TX
 Galveston County, TX
 Harris County, TX
 Liberty County, TX
 Montgomery County, TX
 San Jacinto County, TX
 Waller County, TX
26580Huntington-Ashland, WV-KY-OH0.9484
 Boyd County, KY
 Greenup County, KY
 Lawrence County, OH
 Cabell County, WV
 Wayne County, WV
26620Huntsville, AL0.9594
 Limestone County, AL
 Madison County, AL
26820Idaho Falls, ID0.9718
 Bonneville County, ID
 Jefferson County, ID
26900Indianapolis-Carmel, IN1.0327
 Boone County, IN
 Brown County, IN
 Hamilton County, IN
 Hancock County, IN
 Hendricks County, IN
 Johnson County, IN
 Marion County, IN
 Morgan County, IN
 Putnam County, IN
 Shelby County, IN
26980Iowa City, IA1.0037
 Johnson County, IA
 Washington County, IA
27060Ithaca, NY1.0102
 Tompkins County, NY
27100Jackson, MI0.9786
 Jackson County, MI
27140Jackson, MS0.8404
 Copiah County, MS
 Hinds County, MS
 Madison County, MS
 Rankin County, MS
 Simpson County, MS
27180Jackson, TN0.9101
 Chester County, TN
 Madison County, TN
27260Jacksonville, FL0.9463
 Baker County, FL
 Clay County, FL
 Duval County, FL
 Nassau County, FL
 St. Johns County, FL
27340Jacksonville, NC0.8475
 Onslow County, NC
Start Printed Page 24023
27500Janesville, WI1.0178
 Rock County, WI
27620Jefferson City, MO0.8894
 Callaway County, MO
 Cole County, MO
 Moniteau County, MO
 Osage County, MO
27740Johnson City, TN0.8053
 Carter County, TN
 Unicoi County, TN
 Washington County, TN
27780Johnstown, PA0.8000
 Cambria County, PA
27860Jonesboro, AR0.8172
 Craighead County, AR
 Poinsett County, AR
27900Joplin, MO0.9390
 Jasper County, MO
 Newton County, MO
28020Kalamazoo-Portage, MI1.0944
 Kalamazoo County, MI
 Van Buren County, MI
28100Kankakee-Bradley, IL1.0740
 Kankakee County, IL
28140Kansas City, MO-KS0.9970
 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, WA1.0569
 Benton County, WA
 Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.8653
 Bell County, TX
 Coryell County, TX
 Lampasas County, TX
28700Kingsport-Bristol-Bristol, TN-VA0.8033
 Hawkins County, TN
 Sullivan County, TN
 Bristol City, VA
 Scott County, VA
 Washington County, VA
28740Kingston, NY1.0024
 Ulster County, NY
28940Knoxville, TN0.8430
 Anderson County, TN
 Blount County, TN
 Knox County, TN
 Loudon County, TN
 Union County, TN
29020Kokomo, IN1.0061
 Howard County, IN
 Tipton County, IN
29100La Crosse, WI-MN1.0160
 Houston County, MN
 La Crosse County, WI
29140Lafayette, IN0.9304
 Benton County, IN
 Carroll County, IN
 Tippecanoe County, IN
Start Printed Page 24024
29180Lafayette, LA0.8651
 Lafayette Parish, LA
 St. Martin Parish, LA
29340Lake Charles, LA0.8158
 Calcasieu Parish, LA
 Cameron Parish, LA
29404Lake County-Kenosha County, IL-WI1.1123
 Lake County, IL
 Kenosha County, WI
29420Lake Havasu City - Kingman, AZ0.9790
 Mohave County, AZ
29460Lakeland, FL0.9086
 Polk County, FL
29540Lancaster, PA0.9706
 Lancaster County, PA
29620Lansing-East Lansing, MI1.0615
 Clinton County, MI
 Eaton County, MI
 Ingham County, MI
29700Laredo, TX0.8490
 Webb County, TX
29740Las Cruces, NM0.9101
 Dona Ana County, NM
29820Las Vegas-Paradise, NV1.2377
 Clark County, NV
29940Lawrence, KS0.8630
 Douglas County, KS
30020Lawton, OK0.8418
 Comanche County, OK
30140Lebanon, PA0.8594
 Lebanon County, PA
30300Lewiston, ID-WA0.9917
 Nez Perce County, ID
 Asotin County, WA
30340Lewiston-Auburn, ME0.9644
 Androscoggin County, ME
30460Lexington-Fayette, KY0.9642
 Bourbon County, KY
 Clark County, KY
 Fayette County, KY
 Jessamine County, KY
 Scott County, KY
 Woodford County, KY
30620Lima, OH0.9886
 Allen County, OH
30700Lincoln, NE1.0544
 Lancaster County, NE
 Seward County, NE
30780Little Rock-North Little Rock, AR0.9297
 Faulkner County, AR
 Grant County, AR
 Lonoke County, AR
 Perry County, AR
 Pulaski County, AR
 Saline County, AR
30860Logan, UT-ID0.9633
 Franklin County, ID
 Cache County, UT
30980Longview, TX0.9144
 Gregg County, TX
 Rusk County, TX
 Upshur County, TX
31020Longview, WA1.1358
 Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale, CA1.2348
 Los Angeles County, CA
31140Louisville, KY-IN0.9509
 Clark County, IN
 Floyd County, IN
 Harrison County, IN
 Washington County, IN
Start Printed Page 24025
 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, TX0.9105
 Crosby County, TX
 Lubbock County, TX
31340Lynchburg, VA0.9160
 Amherst County, VA
 Appomattox County, VA
 Bedford County, VA
 Campbell County, VA
 Bedford City, VA
 Lynchburg City, VA
31420Macon, GA1.0009
 Bibb County, GA
 Crawford County, GA
 Jones County, GA
 Monroe County, GA
 Twiggs County, GA
31460Madera, CA0.8465
 Madera County, CA
31540Madison, WI1.1471
 Columbia County, WI
 Dane County, WI
 Iowa County, WI
31700Manchester-Nashua, NH1.0777
 Hillsborough County, NH
31900Mansfield, OH0.9725
 Richland County, OH
32420Mayaguez, PR0.4268
 Hormigueros Municipio, PR
 Mayaguez Municipio, PR
32580McAllen-Edinburg-Pharr, TX0.9570
 Hidalgo County, TX
32780Medford, OR1.0824
 Jackson County, OR
32820Memphis, TN-MS-AR0.9703
 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, CA1.2714
 Merced County, CA
33124Miami-Miami Beach-Kendall, FL1.0492
 Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9351
 LaPorte County, IN
33260Midland, TX1.0508
 Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0715
 Milwaukee County, WI
 Ozaukee County, WI
 Washington County, WI
 Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.1637
 Anoka County, MN
 Carver County, MN
 Chisago County, MN
 Dakota County, MN
 Hennepin County, MN
 Isanti County, MN
Start Printed Page 24026
 Ramsey County, MN
 Scott County, MN
 Sherburne County, MN
 Washington County, MN
 Wright County, MN
 Pierce County, WI
 St. Croix County, WI
33540Missoula, MT0.9392
 Missoula County, MT
33660Mobile, AL0.8427
 Mobile County, AL
33700Modesto, CA1.2548
 Stanislaus County, CA
33740Monroe, LA0.8216
 Ouachita Parish, LA
 Union Parish, LA
33780Monroe, MI0.9875
 Monroe County, MI
33860Montgomery, AL0.8484
 Autauga County, AL
 Elmore County, AL
 Lowndes County, AL
 Montgomery County, AL
34060Morgantown, WV0.8729
 Monongalia County, WV
 Preston County, WV
34100Morristown, TN0.8000
 Grainger County, TN
 Hamblen County, TN
 Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.1045
 Skagit County, WA
34620Muncie, IN0.8617
 Delaware County, IN
34740Muskegon-Norton Shores, MI1.0318
 Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.9057
 Horry County, SC
34900Napa, CA1.5186
 Napa County, CA
34940Naples-Marco Island, FL0.9952
 Collier County, FL
34980Nashville-Davidson—Murfreesboro, TN1.0164
 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, NY1.3260
 Nassau County, NY
 Suffolk County, NY
35084Newark-Union, NJ-PA1.2443
 Essex County, NJ
 Hunterdon County, NJ
 Morris County, NJ
 Sussex County, NJ
 Union County, NJ
 Pike County, PA
35300New Haven-Milford, CT1.2453
 New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.9333
 Jefferson Parish, LA
 Orleans Parish, LA
Start Printed Page 24027
 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-NJ1.3758
 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, MI0.9589
 Berrien County, MI
35980Norwich-New London, CT1.1992
 New London County, CT
36084Oakland-Fremont-Hayward, CA1.6454
 Alameda County, CA
 Contra Costa County, CA
36100Ocala, FL0.9050
 Marion County, FL
36140Ocean City, NJ1.1527
 Cape May County, NJ
36220Odessa, TX1.0534
 Ector County, TX
36260Ogden-Clearfield, UT0.9441
 Davis County, UT
 Morgan County, UT
 Weber County, UT
36420Oklahoma City, OK0.9247
 Canadian County, OK
 Cleveland County, OK
 Grady County, OK
 Lincoln County, OK
 Logan County, OK
 McClain County, OK
 Oklahoma County, OK
36500Olympia, WA1.2076
 Thurston County, WA
36540Omaha-Council Bluffs, NE-IA1.0030
 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, FL0.9678
 Lake County, FL
 Orange County, FL
 Osceola County, FL
 Seminole County, FL
36780Oshkosh-Neenah, WI1.0019
 Winnebago County, WI
36980Owensboro, KY0.9076
 Daviess County, KY
 Hancock County, KY
 McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.2433
 Ventura County, CA
37340Palm Bay-Melbourne-Titusville, FL0.9782
 Brevard County, FL
37380Palm Coast, FL0.9383
 Flagler County, FL
37460Panama City-Lynn Haven, FL0.8720
Start Printed Page 24028
 Bay County, FL
37620Parkersburg-Marietta, WV-OH0.8502
 Washington County, OH
 Pleasants County, WV
 Wirt County, WV
 Wood County, WV
37700Pascagoula, MS0.9071
 George County, MS
 Jackson County, MS
37764Peabody, MA1.1172
 Essex County, MA
37860Pensacola-Ferry Pass-Brent, FL0.8687
 Escambia County, FL
 Santa Rosa County, FL
37900Peoria, IL0.9755
 Marshall County, IL
 Peoria County, IL
 Stark County, IL
 Tazewell County, IL
 Woodford County, IL
37964Philadelphia, PA1.1461
 Bucks County, PA
 Chester County, PA
 Delaware County, PA
 Montgomery County, PA
 Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0767
 Maricopa County, AZ
 Pinal County, AZ
38220Pine Bluff, AR0.8223
 Cleveland County, AR
 Jefferson County, AR
 Lincoln County, AR
38300Pittsburgh, PA0.8943
 Allegheny County, PA
 Armstrong County, PA
 Beaver County, PA
 Butler County, PA
 Fayette County, PA
 Washington County, PA
 Westmoreland County, PA
38340Pittsfield, MA1.0586
 Berkshire County, MA
38540Pocatello, ID0.9929
 Bannock County, ID
 Power County, ID
38660Ponce, PR0.5118
 Juana Díaz Municipio, PR
 Ponce Municipio, PR
 Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME1.0534
 Cumberland County, ME
 Sagadahoc County, ME
 York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.2062
 Clackamas County, OR
 Columbia County, OR
 Multnomah County, OR
 Washington County, OR
 Yamhill County, OR
 Clark County, WA
 Skamania County, WA
38940Port St. Lucie—Fort Pierce, FL1.0507
 Martin County, FL
 St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.1520
 Dutchess County, NY
 Orange County, NY
39140Prescott, AZ1.0511
 Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.1092
Start Printed Page 24029
 Bristol County, MA
 Bristol County, RI
 Kent County, RI
 Newport County, RI
 Providence County, RI
 Washington County, RI
39340Provo-Orem, UT1.0025
 Juab County, UT
 Utah County, UT
39380Pueblo, CO0.9285
 Pueblo County, CO
39460Punta Gorda, FL0.9708
 Charlotte County, FL
39540Racine, WI0.9964
 Racine County, WI
39580Raleigh-Cary, NC1.0321
 Franklin County, NC
 Johnston County, NC
 Wake County, NC
39660Rapid City, SD0.9243
 Meade County, SD
 Pennington County, SD
39740Reading, PA0.9815
 Berks County, PA
39820Redding, CA1.4205
 Shasta County, CA
39900Reno-Sparks, NV1.1240
 Storey County, NV
 Washoe County, NV
40060Richmond, VA0.9887
 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, CA1.1644
 Riverside County, CA
 San Bernardino County, CA
40220Roanoke, VA0.9117
 Botetourt County, VA
 Craig County, VA
 Franklin County, VA
 Roanoke County, VA
 Roanoke City, VA
 Salem City, VA
40340Rochester, MN1.1282
 Dodge County, MN
 Olmsted County, MN
 Wabasha County, MN
40380Rochester, NY0.9292
 Livingston County, NY
 Monroe County, NY
 Ontario County, NY
 Orleans County, NY
 Wayne County, NY
40420Rockford, IL1.0295
Start Printed Page 24030
 Boone County, IL
 Winnebago County, IL
40484Rockingham County-Strafford County, NH1.0607
 Rockingham County, NH
 Strafford County, NH
40580Rocky Mount, NC0.9442
 Edgecombe County, NC
 Nash County, NC
40660Rome, GA0.9485
 Floyd County, GA
40900Sacramento—Arden-Arcade—Roseville, CA1.4167
 El Dorado County, CA
 Placer County, CA
 Sacramento County, CA
 Yolo County, CA
40980Saginaw-Saginaw Township North, MI0.9244
 Saginaw County, MI
41060St. Cloud, MN1.1066
 Benton County, MN
 Stearns County, MN
41100St. George, UT0.9817
 Washington County, UT
41140St. Joseph, MO-KS0.9191
 Doniphan County, KS
 Andrew County, MO
 Buchanan County, MO
 DeKalb County, MO
41180St. Louis, MO-IL0.9466
 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, OR1.1090
 Marion County, OR
 Polk County, OR
41500Salinas, CA1.5499
 Monterey County, CA
41540Salisbury, MD0.9435
 Somerset County, MD
 Wicomico County, MD
41620Salt Lake City, UT0.9860
 Salt Lake County, UT
 Summit County, UT
 Tooele County, UT
41660San Angelo, TX0.9000
 Irion County, TX
 Tom Green County, TX
41700San Antonio, TX0.9267
 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, CA1.2055
 San Diego County, CA
Start Printed Page 24031
41780Sandusky, OH0.9254
 Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.5940
 Marin County, CA
 San Francisco County, CA
 San Mateo County, CA
41900San Germán-Cabo Rojo, PR0.5438
 Cabo Rojo Municipio, PR
 Lajas Municipio, PR
 Sabana Grande Municipio, PR
 San Germán Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.6506
 San Benito County, CA
 Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.5207
 Aguas Buenas Municipio, PR
 Aibonito Municipio, PR
 Arecibo Municipio, PR
 Barceloneta Municipio, PR
 Barranquitas Municipio, PR
 Bayamón Municipio, PR
 Caguas Municipio, PR
 Camuy Municipio, PR
 Canóvanas Municipio, PR
 Carolina Municipio, PR
 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, CA1.3100
 San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.2343
 Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.2288
 Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.6912
 Santa Cruz County, CA
42140Santa Fe, NM1.1260
 Santa Fe County, NM
42220Santa Rosa-Petaluma, CA1.5416
 Sonoma County, CA
42260Sarasota-Bradenton-Venice, FL1.0420
 Manatee County, FL
 Sarasota County, FL
Start Printed Page 24032
42340Savannah, GA0.9579
 Bryan County, GA
 Chatham County, GA
 Effingham County, GA
42540Scranton—Wilkes-Barre, PA0.8872
 Lackawanna County, PA
 Luzerne County, PA
 Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.2139
 King County, WA
 Snohomish County, WA
42680Sebastian-Vero Beach, FL0.9873
 Indian River County, FL
43100Sheboygan, WI0.9415
 Sheboygan County, WI
43300Sherman-Denison, TX0.8728
 Grayson County, TX
43340Shreveport-Bossier City, LA0.8891
 Bossier Parish, LA
 Caddo Parish, LA
 De Soto Parish, LA
43580Sioux City, IA-NE-SD0.9704
 Woodbury County, IA
 Dakota County, NE
 Dixon County, NE
 Union County, SD
43620Sioux Falls, SD1.0032
 Lincoln County, SD
 McCook County, SD
 Minnehaha County, SD
 Turner County, SD
43780South Bend-Mishawaka, IN-MI1.0088
 St. Joseph County, IN
 Cass County, MI
43900Spartanburg, SC0.9884
 Spartanburg County, SC
44060Spokane, WA1.0967
 Spokane County, WA
44100Springfield, IL0.9382
 Menard County, IL
 Sangamon County, IL
44140Springfield, MA1.0874
 Franklin County, MA
 Hampden County, MA
 Hampshire County, MA
44180Springfield, MO0.9121
 Christian County, MO
 Dallas County, MO
 Greene County, MO
 Polk County, MO
 Webster County, MO
44220Springfield, OH0.9120
 Clark County, OH
44300State College, PA0.9198
 Centre County, PA
44700Stockton, CA1.2436
 San Joaquin County, CA
44940Sumter, SC0.9021
 Sumter County, SC
45060Syracuse, NY1.0396
 Madison County, NY
 Onondaga County, NY
 Oswego County, NY
45104Tacoma, WA1.1597
 Pierce County, WA
45220Tallahassee, FL0.9467
 Gadsden County, FL
 Jefferson County, FL
 Leon County, FL
 Wakulla County, FL
45300Tampa-St. Petersburg-Clearwater, FL0.9462
Start Printed Page 24033
 Hernando County, FL
 Hillsborough County, FL
 Pasco County, FL
 Pinellas County, FL
45460Terre Haute, IN0.9237
 Clay County, IN
 Sullivan County, IN
 Vermillion County, IN
 Vigo County, IN
45500Texarkana, TX-Texarkana, AR0.8151
 Miller County, AR
 Bowie County, TX
45780Toledo, OH0.9893
 Fulton County, OH
 Lucas County, OH
 Ottawa County, OH
 Wood County, OH
45820Topeka, KS0.8957
 Jackson County, KS
 Jefferson County, KS
 Osage County, KS
 Shawnee County, KS
 Wabaunsee County, KS
45940Trenton-Ewing, NJ1.1223
 Mercer County, NJ
46060Tucson, AZ0.9698
 Pima County, AZ
46140Tulsa, OK0.8749
 Creek County, OK
 Okmulgee County, OK
 Osage County, OK
 Pawnee County, OK
 Rogers County, OK
 Tulsa County, OK
 Wagoner County, OK
46220Tuscaloosa, AL0.8710
 Greene County, AL
 Hale County, AL
 Tuscaloosa County, AL
46340Tyler, TX0.9561
 Smith County, TX
46540Utica-Rome, NY0.8902
 Herkimer County, NY
 Oneida County, NY
46660Valdosta, GA0.8495
 Brooks County, GA
 Echols County, GA
 Lanier County, GA
 Lowndes County, GA
46700Vallejo-Fairfield, CA1.5385
 Solano County, CA
47020Victoria, TX0.8709
 Calhoun County, TX
 Goliad County, TX
 Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ1.0630
 Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.9250
 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
Start Printed Page 24034
 Suffolk City, VA
 Virginia Beach City, VA
 Williamsburg City, VA
47300Visalia-Porterville, CA1.0586
 Tulare County, CA
47380Waco, TX0.8936
 McLennan County, TX
47580Warner Robins, GA0.9575
 Houston County, GA
47644Warren-Troy-Farmington Hills, MI1.0491
 Lapeer County, MI
 Livingston County, MI
 Macomb County, MI
 Oakland County, MI
 St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA-MD-WV1.1387
 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, IA0.8937
 Black Hawk County, IA
 Bremer County, IA
 Grundy County, IA
48140Wausau, WI1.0153
 Marathon County, WI
48260Weirton-Steubenville, WV-OH0.8312
 Jefferson County, OH
 Brooke County, WV
 Hancock County, WV
48300Wenatchee, WA1.2031
 Chelan County, WA
 Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL1.0205
 Palm Beach County, FL
48540Wheeling, WV-OH0.8000
 Belmont County, OH
 Marshall County, WV
 Ohio County, WV
48620Wichita, KS0.9506
 Butler County, KS
 Harvey County, KS
 Sedgwick County, KS
 Sumner County, KS
48660Wichita Falls, TX0.8308
 Archer County, TX
 Clay County, TX
 Wichita County, TX
48700Williamsport, PA0.8437
 Lycoming County, PA
48864Wilmington, DE-MD-NJ1.1355
 New Castle County, DE
 Cecil County, MD
 Salem County, NJ
48900Wilmington, NC0.9871
Start Printed Page 24035
 Brunswick County, NC
 New Hanover County, NC
 Pender County, NC
49020Winchester, VA-WV1.0399
 Frederick County, VA
 Winchester City, VA
 Hampshire County, WV
49180Winston-Salem, NC0.9565
 Davie County, NC
 Forsyth County, NC
 Stokes County, NC
 Yadkin County, NC
49340Worcester, MA1.1840
 Worcester County, MA
49420Yakima, WA1.0770
 Yakima County, WA
49500Yauco, PR0.3777
 Guánica Municipio, PR
 Guayanilla Municipio, PR
 Peñuelas Municipio, PR
 Yauco Municipio, PR
49620York-Hanover, PA0.9818
 York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.9443
 Mahoning County, OH
 Trumbull County, OH
 Mercer County, PA
49700Yuba City, CA1.1283
 Sutter County, CA
 Yuba County, CA
49740Yuma, AZ0.9953
 Yuma County, AZ
1 Wage index values are based on FY 2004 hospital cost report data before reclassification. These data form the basis for the pre-floor, pre-reclassified hospital wage index. The budget neutrality adjustment or the hospice floor is then applied to the pre-floor, pre-reclassified hospital wage index to derive the hospice wage index. Wage index values greater than or equal to 0.8 are subject to a budget neutrality adjustment. The hospice floor calculation is as follows: Wage index values below 0.8 are adjusted to be the greater of either the a) the 25 percent reduced budget neutrality adjustment OR b) the minimum of the pre-floor, pre-reclassified hospital wage index value x 1.15, or 0.8000. For the proposed FY 2009 hospice wage index, the budget neutrality adjustment was reduced by 25 percent.
2 This column lists each CBSA area name and each county or county equivalent, in the CBSA area. Counties not listed in this Table are considered to be rural areas. Wage index values for these areas are found in Addendum B.
3 Because there are no hospitals in this CBSA, the wage index value is calculated by taking the average of all other urban CBSAs in Georgia.

Addendum B.—Proposed Hospice Wage Index for Rural Areas by CBSA—FY 2009

CBSA codeNon-urban areaWage index
1Alabama0.8000
2Alaska1.2703
3Arizona0.8895
4Arkansas0.8000
5California1.2612
6Colorado1.0180
7Connecticut1.1664
8Delaware1.0204
10Florida0.8880
11Georgia0.8034
12Hawaii1.1132
13Idaho0.8308
14Illinois0.8744
15Indiana0.8996
16Iowa0.8986
17Kansas0.8372
18Kentucky0.8175
19Louisiana0.8000
20Maine0.8891
21Maryland0.9477
22Massachusetts 11.2157
23Michigan0.9392
24Minnesota0.9524
25Mississippi0.8077
26Missouri0.8319
27Montana0.8790
28Nebraska0.9283
29Nevada0.9726
30New Hampshire1.0983
31New Jersey 2
32New Mexico0.9378
33New York0.8673
34North Carolina0.9025
35North Dakota0.8000
36Ohio0.9141
37Oklahoma0.8000
38Oregon1.0392
39Pennsylvania0.8796
40Puerto Rico 30.4654
41Rhode Island 2
42South Carolina0.9080
43South Dakota0.8968
44Tennessee0.8102
45Texas0.8359
46Utah0.8514
47Vermont1.0405
48Virgin Islands0.7855
49Virginia0.8283
50Washington1.0762
51West Virginia0.8000
52Wisconsin1.0141
53Wyoming0.9742
65Guam1.0082
1 There are no hospitals in the rural areas of Massachusetts, so the wage index value used is the average of the contiguous counties.
2 There are no rural areas in this state.
3 Wage index values are obtained using the methodology described in this proposed rule.
End Part End Supplemental Information

[FR Doc. 08-1198 Filed 4-28-08; 4:00 pm]

BILLING CODE 4120-01-P