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Notice

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2009

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Information about this document as published in the Federal Register.

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AGENCY:

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

ACTION:

Notice.

SUMMARY:

This notice sets forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health services, effective on January 1, 2009.

DATES:

Effective Date: This notice is effective on January 1, 2009.

Start Further Info

FOR FURTHER INFORMATION CONTACT:

Randy Throndset, (410) 786-0131.

I. Background

A. Requirements of the Balanced Budget Act of 1997 for Establishing the Prospective Payment System for Home Health Services

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

Section 4603(a) of the BBA mandated the development of a HH PPS for all Medicare-covered home health services provided under a plan of care that were paid on a reasonable cost basis by adding section 1895 of the Social Security Act (the Act), entitled “Prospective Payment For Home Health Services”. Section 1895(b)(1) of the Act requires the Secretary to establish a HH PPS for all costs of home health services paid under Medicare.

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

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

Section 1895(b)(4) of the Act governs the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the standard prospective payment amount to be adjusted for case-mix and geographic differences in wage levels.

Section 1895(b)(4)(B) of the Act requires the establishment of an appropriate case-mix change adjustment factor that adjusts for significant variation in costs among different units of services.

Similarly, section 1895(b)(4)(C) of the Act requires the establishment of wage adjustment factors that reflect the relative level of wages, and wage-related costs applicable to home health services furnished in a geographic area compared to the applicable national average level. These wage-adjustment factors may be used by the Secretary for the different geographic wage levels for purposes of section 1886(d)(3)(E) of the Act.

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

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

For a complete and full description of the HH PPS as required by the BBA, see the July 2000 HH PPS final rule (65 FR 41128 through 41214).

B. Deficit Reduction Act of 2005

On February 8, 2006, the Deficit Reduction Act of 2005 (Pub. L. 109-171) (DRA) was enacted. This legislation affected updates to HH payment rates for calendar year (CY) 2006. The DRA also required HHAs to submit home health care quality data and created a linkage between those data and payment, beginning in CY 2007.

Specifically, section 5201 of the DRA changed the CY 2006 update from the applicable home health market basket percentage increase minus 0.8 percentage points to a 0 percent update. In addition, section 5201 of the DRA amends section 421(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted on December 8, 2003). The amended section 421(a) of the MMA requires that for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) on or after January 1, 2006 and before January 1, 2007, that the Secretary increase the payment amount otherwise made under section 1895 of the Act for home health services by 5 percent. The statute waives budget neutrality for purposes of this increase since it specifically states that the Secretary must not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute.

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

In addition, section 5201 of the DRA requires HHAs to submit data for purposes of measuring health care quality, and links the quality data submission to payment. This requirement is applicable for CY 2007 and each subsequent year. If an HHA does not submit quality data, the home health market basket percentage increase will be reduced 2 percentage points. In accordance with the statute, Start Printed Page 65352we published a final rule (71 FR 65884, 65935) in the Federal Register on November 9, 2006 to implement the pay-for-reporting requirement of the DRA, codified at 42 CFR 484.225(h) and (i). In addition, the November 2006 final rule ended the 1-year transition period that consisted of a blend of 50 percent of the new area labor market designations' wage index and 50 percent of the previous area labor market designations' wage index. We also revised the fixed dollar loss ratio, which is used in the calculation of outlier payments.

C. System for Payment of Home Health Services

Generally, Medicare makes payment under the HH PPS on the basis of a national standardized 60-day episode payment rate that is adjusted for the applicable case-mix and wage index. The national standardized 60-day episode payment rate includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services) and non-routine medical supplies. Durable medical equipment covered under home health is paid for outside the HH PPS payment. To adjust for case-mix, the HH PPS uses a 153-category case-mix classification to assign patients to a home health resource group (HHRG). Clinical needs, functional status, and service utilization are computed from responses to selected data elements in the OASIS assessment instrument.

For episodes with four or fewer visits, Medicare pays on the basis of a national per-visit amount by discipline; an episode consisting of four or fewer visits within a 60-day period is referred to as a LUPA. Medicare also adjusts the national standardized 60-day episode payment rate for certain intervening events that are subject to a partial episode payment adjustment (PEP adjustment). For certain cases that exceed a specific cost threshold, an outlier adjustment may also be available.

D. Updates to the HH PPS

As required by section 1895(b)(3)(B) of the Act, we have historically updated the HH PPS rates annually in a separate Federal Register document. We published a final rule with comment period in the Federal Register on August 29, 2007 (72 FR 49762) that set forth a refinement and rate update to the Medicare prospective payment system for home health services. As part of the CY 2008 HH PPS final rule with comment period, we rebased and revised the home health market basket to reflect FY 2003 Medicare cost report data, the latest available and most complete data on the structure of HHA costs. In the rebased and revised home health market basket, the labor-related share was 77.082 (an increase from the previous labor-related share of 76.775). The non-labor-related share is 22.918 (a decrease from the previous nonlabor-related share of 23.225). The increase in the labor-related share using the FY 2003 home health market basket was primarily due to the increase in the benefit cost weight.

The CY 2008 HH PPS final rule with comment period also implemented refinements to the payment system. Extensive research was conducted to investigate ways to improve the performance of the case-mix model. This research was the basis for our decision to refine the case-mix model. We refined the case-mix model to reflect different resource costs for early home health episodes versus later home health episodes and to expand the case-mix variables included in the payment model. For 2008, we used a 4-equation case-mix model that recognizes and differentiates payment for episodes of care based on whether a patient is in an early (1st or 2nd episode in a sequence of adjacent episodes) or later (the 3rd episode and beyond in a sequence of adjacent episodes) episode of care as well as recognizing whether a patient was a high therapy (14 or more therapy visits) or low therapy (13 or fewer therapy visits) case. We defined episodes as adjacent if they were separated by no more than a 60-day period between claims. Analysis of the performance of the case-mix model for later episodes revealed two important differences for episodes occurring later in the home health treatment compared to earlier episodes: Higher resource use per episode and a different relationship between clinical conditions and resource use. We use additional variables to include scores for certain wound and skin conditions; more diagnosis groups such as pulmonary, cardiac, and cancer diagnoses; and certain secondary diagnoses. The 4-equation model results in 153 case-mix groups.

In addition, we replaced the previous single therapy threshold of 10 visits with three therapy thresholds at 6, 14, and 20 visits. The payment for additional therapy visits between the three thresholds increases gradually, incorporating a declining, rather than a constant, amount per added therapy visit. This approach does not reduce total payments to home health providers because the payment model still predicts total resource cost. The combined effect of the new therapy thresholds and payment gradations reduces the undesirable emphasis in treatment planning on a single therapy visit threshold and restores the primacy of clinical considerations in treatment planning for rehabilitation patients.

In the CY 2008 HH PPS final rule with comment period, we further adjusted for case-mix that was not due to a change in the underlying health status of the home health users. Section 1895(b)(3)(B) of the Act requires that in compensating for case-mix change, a payment reduction must be applied to the standardized payment amount. For the CY 2008 HH PPS final rule with comment period, we conducted several analyses to determine if any portion of the total change in case-mix could be considered to be real change. Real change is a change in the underlying health status of the home health user population. The results of the analysis indicated that while a small amount (8.03 percent) of measured case-mix change was real, most of the change was unrelated to the underlying health status of home health users.

Using 100 percent of the home health interim payment system (HH IPS) file for our baseline (12 months ending September 30, 2000), the average case-mix weight per episode was 1.0960. (The HH IPS was the previous cost-based payment system under which HHAs were paid, prior to the HH PPS.) The 2005 20 percent sample file yielded an average CMI (case mix indicator) of 1.2361. Therefore, the change measurement was (1.2361 − 1.0960)/ 1.0960 = 12.78 percent. We adjusted this result downward by 8.03 percent (the percentage of total change in case-mix considered to be real) to get a final case-mix change measure of 11.75 percent (0.1278 * (1−0.0803) = 0.1175). To account for the 11.75 percent increase in case-mix which was not due to a change in the underlying health status of Medicare home health patients, we implemented a 2.75 percent reduction of the national standardized 60-day episode payment rate for 3 years beginning in 2008 and solicited comments on extending that adjustment period to a fourth year based on a 2.71 percent reduction for 2011 (see 72 FR 49833).

Additionally, we modified a number of existing HH PPS payment adjustments. Specifically, we increased the payment for low utilization payment adjustment (LUPA) episodes that occur as the only episode or the initial episode during a sequence of adjacent episodes, by $87.93. We also eliminated the significant change in condition (SCIC) Start Printed Page 65353payment adjustment for various reasons. Specifically, we ended the policy because of the apparent difficulty HHAs had in interpreting the SCIC policy, the association between negative margins and SCIC episodes, the decline in the occurrence of SCICs, and the estimated minimal impact on outlays from eliminating the SCIC policy.

In the development of the HH PPS, non-routine medical supplies (NRS) were accounted for by attributing $49.62 to the standardized episode payment. In the CY 2008 HH PPS final rule with comment period, we applied a severity adjustment to the NRS portion of the HH PPS standardized episode payment. Specifically, we adopted a six-severity-group approach to account for NRS costs (see 72 FR 49851-49852) based on measurable conditions that are feasible to administer. This change offers HHAs some protection against episodes with extremely high NRS costs. Finally, we did not modify the existing Partial Episode Payment (PEP) Adjustment.

Section 1895(b)(5) of the Act also allows for the provision of an addition or adjustment to account for outlier episodes, which are those episodes that incur unusually large costs due to heavy patient care needs. Under the HH PPS, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. The wage adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. Section 1895(b)(5) of the Act requires that the estimated total outlier payments may not exceed 5 percent of total estimated HH PPS payments. In the CY 2008 HH PPS final rule with comment period, we adjusted the FDL ratio to 0.89, based on the most recently available data, analysis, trends, and unknown effects of the refinements on outliers (see 72 FR 49857).

Finally, we expanded the list of quality measures identified in the update notice for CY 2007. In CY 2007, we specified 10 OASIS quality measures from the OASIS data set as appropriate for public reporting of measurements of health care quality. For CY 2008, we added two more quality measures from the OASIS data set for public reporting. All twelve publicly reported measures are National Quality Forum (NQF)-endorsed measures. The additional measures for 2008 were as follows:

  • Emergent Care for Wound Infection, Deteriorating Wound Status; and
  • Improvement in the Status of Surgical Wounds (see 72 FR 49861).

Accordingly, for CY 2008, we considered the existing OASIS data set submitted by HHAs to CMS for episodes beginning on or after July 1, 2006, and before July 1, 2007, as meeting the reporting requirement for quality measures for CY 2008.

II. Comments Received From CY 2008 HH PPS Final Rule With Comment Period

In the CY 2008 HH PPS final rule with comment period, we implemented a 2.75 percent payment reduction of the national standardized 60-day episode payment rate for three years beginning in CY 2008 and a fourth year reduction of 2.71 percent for CY 2011. We sought comments only on the 2.71 percent case-mix change adjustment for 2011. We received approximately 44 items of correspondence from the public, only a few of which were directly related to the 2.71 percent adjustment to the HH PPS 60-day episode payment rate in the fourth year. The provision for the 2.71 percent adjustment was added as the fourth year's reduction to the rates to account for the additional change in case-mix, that was indicated in the analysis for the CY 2008 final rule with comment period, that is not considered real; i.e., that is not related to an underlying change in patient health status. Comments originated from trade associations, HHAs, hospitals, and health care professionals such as physicians, nurses, social workers, and physical and occupational therapists. Because this is an update notice, we are not changing policy. However, in order to provide more meaningful and substantive responses we will respond to the above mentioned comments in future rulemaking. This approach allows us to respond comprehensively as more current data become available, while also affording the public ample opportunity to comment on possible future policy changes.

At this time, CMS is maintaining our existing policy as implemented in the CY 2008 final rule with comment period and will impose a 2.75 percent reduction to the national standardized 60-day episode rate for CY 2009. We will continue to monitor any changes in case-mix and may revise the percentage reductions to the HH PPS rates in future rulemaking.

III. Provisions of This Notice

A. National Standardized 60-Day Episode Rate

The Medicare HH PPS has been in effect since October 1, 2000. As set forth in the final rule published July 3, 2000 in the Federal Register (65 FR 41128), the unit of payment under the Medicare HH PPS is a national standardized 60-day episode rate. As set forth in § 484.220, we adjust the national standardized 60-day episode rate by a case-mix relative weight and a wage index value based on the site of service for the beneficiary. In the CY 2008 HH PPS final rule with comment period, we refined the case-mix methodology and also rebased and revised the home health market basket. The labor-related share of the case-mix adjusted 60-day episode rate is 77.082 percent and the non-labor-related share is 22.918 percent. The CY 2009 HH PPS rates use the same case-mix methodology and application of the wage index adjustment to the labor portion of the HH PPS rates as set forth in the CY 2008 HH PPS final rule with comment period. We multiply the national 60-day episode rate by the patient's applicable case-mix weight. We divide the case-mix adjusted amount into a labor and non-labor portion. We multiply the labor portion by the applicable wage index based on the site of service of the beneficiary. We add the wage-adjusted portion to the non-labor portion yielding the case-mix and wage-adjusted 60-day episode rate subject to any additional applicable adjustments.

In accordance with section 1895(b)(3)(B) of the Act, we have updated the HH PPS rates annually in a separate Federal Register document. The HH PPS regulations at § 484.225 sets forth the specific annual percentage update. To reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201 of the DRA, we added § 484.225, paragraphs (h) and (i), in the November 9, 2006 final rule to reflect the requirement for submission of quality data, as follows:

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

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

For CY 2009, we will base the wage index adjustment to the labor portion of Start Printed Page 65354the HH PPS rates on the most recent pre-floor and pre-reclassified hospital wage index. As discussed in the July 3, 2000 HH PPS final rule, for episodes with four or fewer visits, Medicare pays the national per-visit amount by discipline, referred to as a “low utilization payment adjustment” (LUPA). We update the national per-visit amounts by discipline annually by the applicable home health market basket percentage. We adjust the national per-visit amount by the appropriate wage index based on the site of service for the beneficiary, as set forth in § 484.230. We will adjust the labor portion of the updated national per-visit amounts by discipline used to calculate the LUPA by the most recent pre-floor and pre-reclassified hospital wage index, as discussed in the CY 2008 HH PPS final rule with comment period. We are also updating the amounts of the LUPA add-on and the NRS conversion factor by the applicable home health market basket update of 2.9 percent for CY 2009.

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

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

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

B. CY 2009 Update to the Home Health Market Basket Index

Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the DRA, requires for CY 2009 that the standard prospective payment amounts be increased by a factor equal to the applicable home health market basket update for those HHAs that submit quality data as required by the Secretary.

The applicable home health market basket update will be reduced by 2 percentage points for those HHAs that fail to submit the required quality data. This requirement has been codified in regulations at 42 CFR 484.225. The HH PPS market basket update for CY 2009 is 2.9 percent. This is based on Global Insights Inc.'s, third quarter 2008 forecast, utilizing historical data through the second quarter of 2008. A detailed description of how we derived the HHA market basket is available in the CY 2008 Home Health PPS proposed rule (72 FR 25356, 25435).

• CY 2009 Adjustments

In order to calculate the CY 2009 national standardized 60-day episode rate, we first increase the CY 2008 national standardized 60-day episode payment rate of $2,270.32 by the home health market basket update of 2.9% for CY 2009.

Given this updated rate, we then take a reduction of 2.75 percent to account for the change in case-mix that is not related to the real change in patient acuity levels, as discussed above. The resulting updated CY 2009 national standardized 60-day episode rate for an HHA that submits the required quality data is shown in Table 1. The updated CY 2009 national standardized 60-day episode rate for an HHA that does not submit the required quality data is shown in Table 2.

Table 1—National 60-Day Episode Amounts Updated by the Home Health Market Basket Update for CY 2009, Before Case-Mix Adjustment, Wage Index Adjustment Based on the Site of Service for the Beneficiary

Total CY 2008 National Standardized 60-Day Episode Payment RateMultiply by the Home Health Market Basket Update (2.9 Percent) 1Updated National Standardized 60-Day Episode PaymentReduce by 2.75 Percent for Nominal Change in Case-MixCY 2009 National Standardized 60-Day Episode Payment
$2,270.32× 1.029$2,336.16× 0.9725$2,271.92
1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.

Table 2—For HHAs That Do Not Submit the Required Quality Data—National 60-Day Episode Amounts Updated by the Home Health Market Basket Update for CY 2009, Before Case-Mix Adjustment, Wage Index Adjustment Based on the Site of Service for the Beneficiary

Total CY 2008 National Standardized 60-Day Episode Payment RateMultiply by the Home Health Market Basket Update (2.9 Percent) 1 minus 2 percentUpdated National Standardized 60-Day Episode Payment for HHAs that do not submit required quality dataReduce by 2.75 Percent for Nominal Change in Case-MixCY 2009 National Standardized 60-Day Episode Payment for HHAs that do not submit required quality data
$2,270.32× 1.009$2,290.75× 0.9725$2,227.75
1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.
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• National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed Costs Used in Outlier Calculations

As discussed previously in the CY 2008 HH PPS final rule with comment period, the policies governing LUPAs and the outlier calculations set forth in the July 3, 2000 HH PPS final rule will continue (65 FR 41128). Also, we implemented a LUPA add-on amount of $87.93 for initial and only episode LUPAs during CY 2008. In calculating the CY 2009 national per-visit amounts used to calculate payments for LUPA episodes and to compute the imputed costs in outlier calculations, we start with the CY 2008 per-visit amounts. We increase the CY 2008 per-visit amounts for each home health discipline for CY 2009 by the home health market basket update (2.9 percent). LUPA rates are not reduced due to the nominal increase in case-mix since they are per-visit rates and hence are not subject to changes in case-mix.

Table 3—National Per-Visit Amounts for LUPAs (Not including the Increase in Payment for a Beneficiary's Only Episode or the Initial Episode in a Sequence of Adjacent Episodes) and Outlier Calculations Updated by the Home Health Market Basket Update for CY 2009, Before Wage Index Adjustment Based on the Site of Service for the Beneficiary

For HHAs that DO submit the required quality dataFor HHAs that DO NOT submit the required quality data
Home Health DisciplineCY 2008 per-visit paymentMultiply by the Home Health Market Basket Update (2.9 Percent) 1CY 2009 per-visit paymentMultiply by the Home Health Market Basket Update (2.9 percent) 1 minus 2 percentCY 2009 per-visit payment
Home Health Aide$47.51× 1.029$48.89× 1.009$47.94
Medical Social Services168.17× 1.029173.05× 1.009169.68
Occupational Therapy115.48× 1.029118.83× 1.009116.52
Physical Therapy114.71× 1.029118.04× 1.009115.74
Skilled Nursing104.91× 1.029107.95× 1.009105.85
Speech-Language Pathology124.65× 1.029128.26× 1.009125.77
1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.

Payment for LUPA episodes changed in CY 2008 in that for LUPAs that occur as initial episodes in a sequence of adjacent episodes or as the only episode, an additional payment amount is added to the LUPA payment. The Table 3 per-visit rates noted above are before that additional payment is added to the LUPA payment, and are the per-visit rates paid to all other LUPA episodes and used in computing outlier payments. LUPA episodes that occur as the only episode or initial episode in a sequence of adjacent episodes are adjusted by adding an additional amount to the LUPA payment before adjusting for wage index. For CY 2008, that amount was $87.93. This additional LUPA amount is updated in the same manner as the national standardized 60-day episode payment amount and the per-visit rates (i.e. by the home health market basket percentage update). Consequently, for CY 2009, the additional amount paid to LUPAs that occur as initial episodes in a sequence of adjacent episodes or as the only episode is 90.48 ($87.93 × 1.029).

Beginning in CY 2008, to ensure that the variation in non-routine medical supplies (NRS) is more appropriately reflected in the HH PPS, we replaced the original portion ($49.62) of the HH PPS base rate that accounted for NRS, with a system that pays for NRS based on 6 severity groups. For a complete description of the analysis and research behind the development of this system for the payment of NRS, we refer readers to the CY 2008 HH PPS proposed rule (72 FR 25426-25434). Following public comment on the initial proposal made in the proposed rule, we made several modifications using a file of more recent data. The revisions resulted in some scoring changes, and the addition of the sixth severity group to the original five severity groups, to provide more adequate reimbursement for episodes with a high utilization of NRS. As we did in the CY 2008 HH PPS final rule with comment, payments for NRS are updated by the home health market basket and reduced by the 2.75 percent reduction to the rates through the updating of the NRS conversion factor. NRS payments are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For this notice, the NRS conversion factor is updated by the home health market basket update of 2.9 percent and reduced by the 2.75 percent reduction to the rates. The NRS conversion factor for CY 2008 was $52.35. Consequently, for CY 2009, the NRS conversion factor is $52.39 (52.35 × (1.029 × (1−0.0275))). The payment amounts for the various severity levels based on the updated conversion factor are calculated in Table 4.

Table 4—Relative Weights for the 6-Severity NRS System

Severity levelPoints (scoring)Relative weightNRS payment amount 
100.2698$14.13
21 to 140.974251.04
315 to 272.6712139.94
428 to 483.9686207.91
549 to 986.1198320.62
699+10.5254551.43
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C. Home Health Care Quality Improvement

Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to the Act, requiring that, starting with the initial reporting year from July 2005 through June 2006 and each year thereafter, “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality.” In response to the DRA requirements, CMS published information about the quality measures in the Federal Register as a proposed rule on August 3, 2006 (71 FR 44082-44090) and as a final rule on November 9, 2006 (71 FR 65903). We proposed, and made final, the decision to use the subset of OASIS data that is publicly reported on Home Health Compare, as the appropriate measures of home health quality.

Therefore, OASIS assessments submitted by HHAs to CMS in compliance with HHA conditions of participation for dates of service beginning July 1, 2007 and ending June 30, 2008 will fulfill the HH PPS quality reporting requirement for CY 2009 payments. This reporting time period allows for 12 full months of data and provides us the time necessary to analyze and make any necessary payment adjustments to the CY 2009 payment rates. The required quality measures for meeting the submission requirements for CY 2009 are the same as those required for meeting the submission requirements for CY 2008. These measures are:

  • Improvement in Ambulation/Locomotion,
  • Improvement in Bathing,
  • Improvement in Transferring,
  • Improvement in Management of Oral Medication,
  • Improvement in Pain Interfering with Activity,
  • Acute Care Hospitalization,
  • Emergent Care,
  • Discharge to Community,
  • Improvement in Dyspnea,
  • Improvement in Urinary incontinence,
  • Improvement in surgical wounds, and
  • Emergent Care for wound deterioration.

HHAs that meet the reporting requirements are eligible for the full home health market basket percentage increase. Consistent with our previous policy, home health agencies that are certified on or after May 1, 2007 for payments to be made in CY 2009 will be excluded from the quality reporting requirement in CY 2009 because data submission and analysis will not be possible for an agency certified this late in the reporting time period. At the earliest time possible after obtaining the CCN number, reporting is mandatory. These exclusions only affect quality reporting requirements and do not affect the agency's OASIS reporting responsibilities under the CoP submission requirement.

Additionally, section 1895(b)(3)(B)(v)(I) of the Act requires that all HHAs, unless covered by specific exclusions, meet the reporting requirement, or be subject to a 2 percent reduction in the home health market basket percentage increase. CMS will reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements on an annual cycle July 1 through June 30. The 2 percent reduction applies to all HHAs who have not submitted an OASIS assessment in the required time frame for payments beginning in January 2007 and each year thereafter. We will reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements. Section 1895(b)(3)(B)(v)(III) of the Act further requires that “[t]he Secretary shall establish procedures for making data submitted under subclause (II) available to the public. Such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.” To meet the requirement for making such data public, we will continue to use the Home Health Compare Web site, which lists HHAs geographically. Currently, the Home Health Compare Web site lists 12 quality measures from the OASIS set, and these 12 measures are all NQF-endorsed measures for public reporting. Consumers can search for all Medicare-approved home health providers that serve their city or zip code (which would include the quality measures) and then find the agencies offering the types of services they need. See http://www.medicare.gov/​HHCompare/​Home.asp. HHAs currently have pre-publication access every November to their own agency's quality data (collected and periodically updated by a contractor), which enables each agency to know how it is performing before public posting of data on the Home Health Compare Web site. In addition, each agency formally receives quarterly updates via the CASPER system known as Outcome Based Quality Improvement (OBQI) and Outcome Based Quality Monitoring (OBQM) and a report describing the agency patient characteristics based on OASIS. Continuing to use the OASIS instrument ensures that providers will not have an additional burden of reporting through a separate mechanism and that the costs associated with the development and testing of a new reporting mechanism can be avoided. For CY 2009, we will continue to require that the HHA submit OASIS data appropriate for the measurement of health care quality.

Over the past year, CMS has tested new patient level best practice and process measures for home health agencies, and has continued to refine the current OASIS instrument. CMS is testing the new measure the NQF has developed a Global Measure for Flu/Pneumonia vaccination across care settings. We anticipate making further modifications to the current OASIS items, including refinements to response categories. Any new data elements go through OMB process and measures go through the NQF consensus development process, prior to proposing them through the rulemaking process. Additionally, section 1895(b)(3)(B)(v)(II) of the Act requires each HHA to submit appropriate health care quality data in a form, manner, and at a time specified by the Secretary. Such measures would be evidence-based, clearly linked to improved outcomes, and reliably captured with the least burden to the provider. Data element revisions and measures across settings of care will be integral to CMS' vision of addressing national quality care priorities and use of a future single instrument for quality, payment, clinical relevance, and risk adjustment.

D. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care

As part of the U.S. Department of Health and Human Services (DHHS) Transparency Initiative, CMS plans to implement a process to measure and publicly report patient experiences with home health care using a survey developed by the Agency for Healthcare Research and Quality's (AHRQ's) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program. The CAHPS Home Health Care survey is part of a family of CAHPS® surveys that ask patients to report on and rate their experiences with health care. This notice provides an update on the development of the CAHPS Home Health Care survey, as initially discussed in the May 4, 2007 proposed rule (72 FR 25356, 25452). The CAHPS® Home Health Care survey presents home health patients with a set of standardized questions about their Start Printed Page 65357home health care providers and the quality of their home health care. Prior to this survey, there was no national standard for collecting information about patient experience that would allow comparisons across all home health agencies.

The survey captures topics such as patients' interactions with home health staff, provider care and communication, and patient characteristics. The survey allows the patient to give an overall rating of the agency, and asks if the patient would recommend the agency to family and friends.

AHRQ conducted a field test to determine the length and content of the CAHPS Home Health Care Survey. CMS has submitted the survey to the National Quality Forum (NQF) for consideration and approval in their consensus process. NQF endorsement represents the consensus opinion of many healthcare providers, consumer groups, professional organizations, purchasers, federal agencies, and research and quality organizations. The final survey will be submitted to the Office of Management and Budget (OMB) for their approval under the Paperwork Reduction Act (PRA) process.

CMS is working with a contractor to develop protocols and guidelines for implementation of CAHPS Home Health Care survey. Administration of the survey will be conducted by multiple, independent survey vendors working under contract with home health agencies to facilitate data collection and reporting. During 2008, vendor training materials are being developed, and implementation procedures for data submission and processing will be finalized. Recruitment and training of vendors who wish to be approved to collect survey data will begin in 2009. The CAHPS Home Health Care survey will be implemented similar to the CAHPS Hospital survey where vendors are approved to conduct the survey and trained prior to agency participation in the survey. Home health agencies interested in learning about the survey are encouraged to view the CAHPS Home Health Care Survey Web site: http://www.homehealthCAHPS.org. They can also call toll-free: 1-866-354-0985 or send an email to the project team at HHCAHPS@rti.org for more information.

More information about the national implementation will be available next year in the Home Health Rule: The Home Health Prospective Payment System Refinement and Rate Update for Calendar Year 2010.

E. Outliers and the Fixed Dollar Loss Ratio

In addition to the regular 60-day case-mix and wage-adjusted episode payments, the HH PPS allows for outlier payments for episodes that incur unusually high costs. As noted in section I.A., of this notice, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. Section 1895(b)(5) of the Act requires that the estimated total outlier payments be no more than 5 percent of total estimated HH PPS payments for a given year. For a full description of our outlier policy, we refer to the CY 2008 HH PPS final rule with comment period (72 FR 49855-49857).

The wage adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. Annually, we review the percentage of outlier payments and adjust the FDL ratio as appropriate.

Past experience has shown that outlier payments have been increasing as a percent of total payments from 4.1 percent in CY 2005, to 5.0 percent in CY 2006, to 6.4 percent in CY 2007. More recent analysis estimates outlier payments to increase to approximately 8.1 percent in CY 2008 (an increase of slightly more than 27 percent).

In the CY 2008 final rule with comment period, in the interest of using the latest data and best analysis available, we performed supplemental analysis on the most recent data available in order to best estimate the FDL ratio. That analysis derived a final FDL ratio of 0.89 for CY 2008.

In order to determine the appropriate value for the FDL ratio for CY 2009 we performed an updated analysis using the most recent, complete available data (CY 2007), applying a methodology similar to that which we used to update the FDL ratio in the CY 2008 HH PPS final rule with comment. That updated analysis projects that in CY 2009 we will expend an estimated 10.26 percent of total estimated HH PPS payments in outlier payments, more than double our 5 percent statutory limit. However, our analysis also revealed that this growth in outlier payments is primarily the result of excessive growth in a few specific areas of the country. Specifically, we have noticed statistical anomalies in outlier payments, as a percentage of total HH PPS payments, in areas such as Miami-Dade, Florida, where outlier payments to providers far exceed the national average and the 5 percent target for outlier payments. Using similar analysis to what was performed for the CY 2009 final rule with comment; we estimated that we would need to raise our FDL ratio from 0.89 to 2.71 for CY 2009. This is a dramatic change that appears to be driven by statistical anomalies in outlier payments in areas such as Miami-Dade, Florida. In addition, the size of these statistical anomalies raises concerns about the medical necessity of the outlier episodes in some areas. We will be examining outlier payments in these areas in more detail and will take action to remedy inappropriate outlier payments as necessary.

Therefore, we believe that raising the FDL ratio to 2.71 is not justified at this time, given the statistical outlier data anomalies that we have identified in certain areas, and the actions that are underway to address excessive, suspect outlier payments that are occurring in these areas. We believe the most reasonable policy to achieve paying no more than 5 percent outlier payments as a percentage of total estimated HH PPS payments is through the combined effects of maintaining the current (CY 2008) FDL ratio of 0.89 in CY 2009 and the actions being taken to remedy any inappropriate outlier payments in these areas of the country where outlier data anomalies exist. Any further update to the FDL ratio, if any, will not occur until future rulemaking when we expect to have a better understanding of appropriate outlier payments, particularly in those areas of the country with extremely high outlier payments as a percentage of total HH PPS payments.

F. Hospital Wage Index

Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the Secretary to establish area wage adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services and to provide appropriate adjustments to the episode payment amounts under the HH PPS to account for area wage differences. As discussed previously, we apply the appropriate wage index value to the labor portion (77.082 percent) of the HH PPS rates based on the site of service for the beneficiary (defined by section 1861(m) of the Act as the beneficiary's place of residence). Generally, we determine each HHA's labor market area based on definitions of Metropolitan Statistical Areas (MSAs) issued by the Office of Management and Budget (OMB). We have consistently used the pre-floor, pre-reclassified hospital wage index data to adjust the labor portion of the HH PPS rates. We believe the use of the pre-floor, pre-reclassified hospital wage index data results in the appropriate adjustment to Start Printed Page 65358the labor portion of the costs as required by statute.

In the November 9, 2005 final rule for CY 2006 (70 FR 68132), we adopted revised labor market area definitions based on Core-Based Statistical Areas (CBSAs). At the time, we noted that these were the same labor market area definitions (based on OMB's new CBSA designations) implemented under the Hospital Inpatient Prospective Payment System (IPPS). 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 home health wage index. We continue to use the methodology discussed in the November 9, 2006 final rule for CY 2007 (71 FR 65884) to address the geographic areas that lack hospital wage data on which to base the calculation of their home health wage index. For rural areas that do not have IPPS hospitals, we use the average wage index from all contiguous CBSAs as a reasonable proxy. This methodology is used to calculate the wage index for rural Massachusetts. However, we could not apply this methodology to rural Puerto Rico due to the distinct economic circumstances that exist there, but instead continue using the most recent wage index previously available for that area (from CY 2005). For urban areas without IPPS hospitals, we use the average wage index of all urban areas within the State as a reasonable proxy for the wage index for that CBSA. The only urban area without IPPS hospital wage data is Hinesville-Fort Stewart, Georgia (CBSA 25980).

1. Clarification of New England Deemed Counties

We are taking this opportunity to address the change in the treatment of “New England deemed counties” (that is, those counties in New England listed at 42 CFR 412.64(b)(1)(ii)(B) that were deemed to be part of urban areas under section 601(g) of the Social Security Amendments of 1983) that was made in the FY 2008 IPPS final rule with comment period (72 FR 47337 through 47338, August 22, 2007). These counties include the following: 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, ME; Sagadahoc County, ME; and Newport County, RI) are also included in metropolitan statistical areas defined by OMB and are considered urban under both the current IPPS and HH PPS labor market area definitions in § 412.64(b)(1)(ii)(A). The remaining two, Litchfield County, CT, and Merrimack County, NH, are geographically located in areas that are considered rural under the current IPPS (and HH PPS) labor market area definitions, but have been previously deemed urban under the IPPS in certain circumstances, as discussed below.

In the FY 2008 IPPS final rule with comment period, § 412.64(b)(1)(ii)(B) was revised such that the two “New England deemed counties” that are still considered rural under the OMB definitions (Litchfield County, CT and Merrimack County, NH), are no longer considered urban effective for discharges occurring on or after October 1, 2007, and therefore, 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 note that the HH PPS does not provide for such geographic reclassification. Also, in the FY 2008 IPPS final rule with comment period (72 FR 47338), we explained that we have limited this policy change for the “New England deemed counties” only to IPPS hospitals, and any change to non-IPPS provider wage indexes would be addressed in the respective payment system rules. Accordingly, we are taking this opportunity to clarify the treatment of “New England deemed counties” under the HH PPS in this notice.

As discussed above, the HH PPS has consistently used the IPPS definition of “urban” and “rural” with regard to the wage index used in the HH PPS. Historical changes to the labor market area/geographic classifications and annual updates to the wage index values under the HH PPS are made effective January 1 each year. When we established the most recent HH PPS payment rate update, effective for HH services provided on or after January 1, 2008 through December 31, 2008, we considered the “New England deemed counties” (including Litchfield County, CT and Merrimack County, NH) as urban for CY 2008, as evidenced by the inclusion of Litchfield County as one of the constituent counties of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and the inclusion of Merrimack County as one of the constituent counties of urban CBSA 31700 (Manchester-Nashua, NH).

At 42 CFR 484.202, the terms “rural” and “urban” are defined according to the definitions of those terms as used in the IPPS. Applying the IPPS definitions, Litchfield County, CT and Merrimack County, NH are not considered “urban” under § 412.64(b)(1)(ii)(A) through (B) as revised under the FY 2008 IPPS final rule and, therefore, are considered “rural” under § 412.64(b)(1)(ii)(C). Accordingly, reflecting our policy to use the IPPS definitions of “urban” and “rural,” these two counties will be considered “rural” under the HH PPS effective with the next update of the HH PPS payment rates on January 1, 2009, and will no longer be included in urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT) and urban CBSA 31700 (Manchester-Nashua, NH), respectively. We note that this policy is consistent with our policy of not taking into account IPPS geographic reclassifications in determining payments under the HH PPS.

2. Multi-Campus Hospital Wage Index Data

In the CY 2008 HH PPS final rule with comment period, we established HH PPS wage index values for CY 2008 calculated from the same data (collected from cost reports submitted by hospitals for cost reporting periods beginning during FY 2004) used to compute the FY 2008 acute care hospital inpatient wage index, without taking into account geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act. However, the IPPS policy that apportions the wage data for multi-campus hospitals was not finalized before the HH PPS final rule with comment period.

We are continuing to use IPPS wage data for this CY 2009 update notice because we believe that in the absence of home health-specific wage data, using the hospital inpatient wage data is appropriate and reasonable for the HH PPS. We note that the IPPS wage data used to determine the CY 2009 HH wage index values reflect our policy that was adopted under the IPPS beginning in FY 2008, which apportions the wage data for multi-campus hospitals located in different labor market areas, or Core-Based Statistical Areas (CBSAs), to each CBSA where the campuses are located (see the FY 2008 IPPS final rule with comment period (72 FR 47317 through 47320)). Specifically, for the CY 2009 HH PPS, the wage index was computed using IPPS wage data (published by hospitals for cost reporting periods beginning in 2005, as with the FY 2009 IPPS wage index), which allocated salaries and hours to the campuses of two multi-campus hospitals with campuses that are located in different labor areas; one is Massachusetts and the other is Illinois. The wage index Start Printed Page 65359values for the CY 2009 HH PPS in the following CBSAs are affected by this policy: 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) (please refer to Addendum B in this notice).

As previously discussed in the July 3, 2000 final rule (65 FR 41128), the statute provides that the wage adjustment factors may be the factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustment factors. Since publication of the July 3, 2000 final rule, we continue to believe that the use of the pre-floor and pre-reclassified hospital wage index data results in the appropriate and reasonable adjustment to the labor portion of the costs as required by statute. The HH PPS does not use the hospital area wage index's occupational mix adjustment, as this adjustment serves specifically to define the occupational categories more clearly in a hospital setting. See Addenda A and B of this notice, respectively, for the rural and urban pre-floor, pre-reclassified hospital wage indexes for 2009. The 2009 wage index is based on data collected from hospital cost reports submitted for cost reporting periods beginning during FY 2005. These data reflect the multi-campus and New England deemed counties policies discussed above.

Under the HH PPS, we use the wage index value associated with the labor market in which the beneficiary's home is located. As has been our longstanding practice, any area not included in an MSA (urban area) is considered to be nonurban (§ 412.64(b)(1)(ii)(C)) and receives the statewide rural wage index value (see, for example, 65 FR 41173).

IV. Waiver of Proposed Rulemaking

We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a notice such as this take effect. We can waive this procedure, however, if we find good cause that a notice-and-comment procedure is impracticable, unnecessary, or contrary to the public interest and incorporate a statement of finding and its reasons in the notice issued.

We find that it is unnecessary, impracticable and contrary to the public interest to undertake proposed notice and comment rulemaking in this Notice. We believe it is unnecessary because the statute requires annual updates to the HH PPS rates and the methodologies used to update the rates have been previously subject to public comment; we are simply applying the methodology to the most recent data. With respect to the update of the outlier FDL ratio, we find that insofar as we have deviated from our usual methodology in this calendar year, such change is an analytical change. Moreover, we believe that the difficulty of deriving a new methodology to address the limited data discrepancies in localized areas of the country makes issuing a notice of proposed rulemaking in this instance impracticable. Moreover, it would be contrary to the public interest to undertake notice and comment rulemaking as it would impose a hardship on home health agencies and their patients by delaying publication of this update in order to solicit comments. Since it would pose additional harm to those home health agencies across the country that would be deemed ineligible for outlier payments because of these localized data discrepancies, applying the FDL analysis that we have used in past years is likewise contrary to the public interest for CY 2009. Therefore, we find good cause to waive notice and comment procedures for CY 2009.

V. Collection of Information Requirements

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 501 et seq. ).

VI. Regulatory Impact Analysis

A. Overall Impact

We have examined the impacts of this notice 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)).

Executive Order 12866, as amended, 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 rules with economically significant effects ($100 million or more in any 1 year). This notice, as defined by Executive Order 12866, is not an economically significant rule. This notice would not be considered major under the Congressional Review Act. The update set forth in this notice applies to Medicare payments under HH PPS in CY 2009. Accordingly, the following analysis describes the impact in CY 2009 only.

We estimate that the net impact in this notice, including a 2.75 percent reduction to the payment rate to account for the case-mix change adjustment, is estimated to be approximately $30 million in CY 2009 expenditures. This total estimated $30 million impact reflects the distributional effects of an updated wage index (−$20 million) as well as the 2.9 percent home health market basket increase (an estimated additional $490 million in CY 2009 expenditures attributable only to the CY 2009 home health market basket update), and the 2.75 percent decrease (−$440 million for the second year of a 4-year phase-in) to the HH PPS national standardized 60-day episode rate to account for the case-mix change adjustment under the HH PPS. The $30 million is reflected in column 3 of Table 5 as a 0.15 percent increase in expenditures when comparing the current CY 2008 system to the CY 2009 system.

The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $7 million to $34.5 million in any 1 year. For purposes of the RFA, approximately 75 percent of HHAs are considered small businesses according to the Small Business Administration's size standards with total revenues of $13.5 million or less in any 1 year. Individuals and States are not included in the definition of a small entity. As stated above, this notice will have an estimated positive effect upon small entities that are HHAs (see Section IV.B “Anticipated Effects”, of this rule, for supporting analysis).

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital Start Printed Page 65360as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. We have determined that this notice will not have a significant economic impact on the operations of a substantial number of small rural hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million adjusted for inflation. Using the Gross Domestic Price Deflator, the inflation adjusted threshold for 2008 is approximately $130 million. We believe this notice will not mandate expenditures in that amount.

Executive Order 13132 established 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 notice under the threshold criteria of Executive Order 13132, Federalism. We have determined that this notice would not have substantial direct effects on the rights, roles, and responsibilities of States.

B. Anticipated Effects

This notice updates the HH PPS rates contained in the CY 2008 HH PPS final rule with comment period. We use the latest data and best analysis available, but we do not attempt to predict behavioral responses to these changes, and we do not make adjustments for future changes in such variables as days or case-mix.

This analysis incorporates the latest estimates of growth in service use and payments under the Medicare home health benefit, based on the latest available Medicare claims from 2006. We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples of such possible events are newly-legislated general Medicare program funding changes made by the Congress, or changes specifically related to HHAs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, the MMA, the DRA, or new statutory provisions. Although these changes may not be specific to the HH PPS, the nature of the Medicare program is such that the changes may interact, and the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact upon HHAs.

Table 5 represents how home health agencies are likely to be affected by the policy changes described in this notice. Column one of this table classifies HHAs according to a number of characteristics including provider type, geographic region, and urban versus rural location. For the purposes of analyzing impacts on payments, we performed four simulations and compared them to each other. Based on our estimate that outliers, as a percentage of total HH PPS payments, will be at least 5 percent in CY 2008, the 2008 baseline, for the purposes of these simulations, we assumed that the full 5 percent outlay for outliers will be paid. The first simulation estimates 2008 payments under the current system (to include the 2008 wage index and 2008 payment rates). The second simulation estimates CY 2008 payments under the current system, but with the CY 2009 wage index. The second simulation produces an estimate of the effect of the CY 2009 wage index only. The third simulation estimates the effect of the CY 2009 payments using the CY 2009 payment rates and the CY 2008 wage index. The fourth simulation estimates CY 2009 payments using the new CY 2009 payment rates and CY 2009 wage index.

These four simulations allow us to demonstrate the effects of the new CY 2009 wage index and a new 2009 payment rates as a percentage change in estimated expenditures. Specifically, the second column of Table 5 shows the percent change due to the effects of the CY 2009 wage index. The third column of Table 5 shows the percent change due to the combined effects of the CY 2009 wage index and the CY 2009 home health market basket update and the case-mix reduction.

Column three shows the percentage change in estimated total payments in moving from the current CY 2008 to the revised CY 2009 system outlined in this notice. Our estimate of the change in total payments between CY 2008 and CY 2009 is an increase of approximately 0.15 percent.

In general, most HHAs are estimated to see increases in total payments from CY 2008 to CY 2009. The increases range from −0.01 percent for other voluntary/non-profit freestanding agencies to 0.25 percent for facility-based governmental HHAs.

The only rural HHA's estimated to see a decrease are free-standing, other voluntary/non-profit HHAs. The decrease is estimated to be 0.07 percent. In total, payments are estimated to increase 0.17 percent to HHAs in rural areas and 0.19 percent to HHAs in urban areas. The only urban HHAs estimated to see a decrease are facility-based voluntary/non-profits with an estimated decrease of 0.05 percent. Overall, payments are estimated to increase 0.15 percent to HHAs in urban areas.

HHAs in the South and the West are expected to experience increases of 0.08 percent and 1.56 percent respectively from CY 2008 to CY 2009. The North and the Midwest are estimated to experience decreases of 0.08 percent and 0.44 percent respectively. It is estimated that New England, East South Central, West South Central, West North Central and Pacific HHAs will experience percentage increases of 0.36 percent, 0.02 percent, 0.34 percent, 0.61 percent, and 2.21 percent respectively. Conversely, Mid Atlantic, South Atlantic, East North Central, and Mountain area HHAs are expected to experience decreases of 0.32 percent, 0.18 percent, 0.70 percent, and 0.09 percent respectively. In general, all HHAs of varying facility size are expected to experience increases (ranging from 0.04 percent to 0.53 percent) in total payments from CY 2008 to CY 2009.Start Printed Page 65361

Table 5—Impact by Agency Type

GroupPercent change due to the effects of the updated wage index onlyPercent change due to the effects of the updated wage index, the 2.9% home health market basket update, and the 2.75% reduction to the rates
Type of Facility
Free-Standing/Other Vol/NP−0.22−0.01
Free-Standing/Other Proprietary−0.090.24
Free-Standing/Other Government−0.110.07
Facility-Based Vol/NP−0.160.01
Facility-Based Proprietary−0.010.14
Facility-Based Government0.100.25
Subtotal: Freestanding−0.120.17
Subtotal: Facility-based−0.120.05
Subtotal: Vol/PNP−0.190.00
Subtotal: Proprietary−0.090.24
Subtotal: Government−0.010.16
Total−0.120.15
Type of Facility (Rural * Only)
Free-Standing/Other Vol/NP−0.22−0.07
Free-Standing/Other Proprietary0.070.23
Free-Standing/Other Government−0.160.01
Facility-Based Vol/NP0.060.21
Facility-Based Proprietary0.200.33
Facility-Based Government0.090.23
Type of Facility (Urban * Only)
Free-Standing/Other Vol/NP−0.220.00
Free-Standing/Other Proprietary−0.120.25
Free-Standing/Other Government−0.060.16
Facility-Based Vol/NP−0.220.05
Facility-Based Proprietary−0.160.01
Facility-Based Government0.110.28
Type of Facility (Urban * or Rural *)
Rural*0.010.17
Urban*−0.150.15
Total−0.120.15
Facility Location: Region *
North−0.30−0.08
South−0.250.08
Midwest−0.58−0.44
West1.201.56
Other−0.090.07
Total−0.120.15
Facility Location: Area of the Country
New England0.150.36
Mid Atlantic−0.55−0.32
South Atlantic−0.65−0.18
East South Central−0.110.02
West South Central0.060.34
East North Central−0.84−0.70
West North Central0.450.61
Mountain−0.31−0.09
Pacific1.802.21
Other−0.090.07
Total−0.120.15
Start Printed Page 65362
Facility Size (Number of First Episodes)
1 to 5−0.290.34
6 to 9−0.410.17
10 to 14−0.380.17
15 to 19−0.390.19
20 to 29−0.250.28
30 to 49−0.100.37
50 to 990.060.50
100 to 1990.070.36
200 or More−0.170.04
Total−0.120.15
Note: Based on a 20 percent sample of CY 2006 claims linked to OASIS assessments.
* Urban/rural status, for the purposes of these simulations, is based on the wage index on which episode payment is based. The wage index is based on the site of service of the beneficiary.

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

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

Start Signature

Dated: October 9, 2008.

Kerry Weems,

Acting Administrator, Centers for Medicare & Medicaid Services.

Approved: October 24, 2008.

Michael O. Leavitt,

Secretary.

End Signature

Note:

The following addenda will not be published in the Code of Federal Regulations.

Addendum A—CY 2009 Wage Index for Rural Areas by CBSA; Applicable Pre-floor and Pre-Reclassified Hospital Wage Index

CBSA codeNonurban areaWage index
01Alabama0.7587
02Alaska1.1898
03Arizona0.8453
04Arkansas0.7473
05California1.2275
06Colorado0.9570
07Connecticut1.1016
08Delaware0.9962
10Florida0.8504
11Georgia0.7612
12Hawaii1.0999
13Idaho0.7651
14Illinois0.8386
15Indiana0.8473
16Iowa0.8804
17Kansas0.8052
18Kentucky0.7803
19Louisiana0.7447
20Maine0.8644
21Maryland0.8883
22Massachusetts11.1670
23Michigan0.8887
24Minnesota0.9059
25Mississippi0.7584
26Missouri0.7982
27Montana0.8658
28Nebraska0.8730
29Nevada0.9382
30New Hampshire1.0219
31New Jersey 1
32New Mexico0.8812
33New York0.8145
34North Carolina0.8576
35North Dakota0.7205
36Ohio0.8588
37Oklahoma0.7732
38Oregon1.0218
39Pennsylvania0.8365
40Puerto Rico 10.4047
41Rhode Island 1
42South Carolina0.8538
43South Dakota0.8603
44Tennessee0.7789
45Texas0.7894
46Utah0.8267
47Vermont1.0079
48Virgin Islands0.6971
49Virginia0.7861
50Washington1.0181
51West Virginia0.7503
52Wisconsin0.9373
53Wyoming0.9315
65Guam0.9611
1 All counties within the State are classified as urban, with the exception of Massachusetts and Puerto Rico. Massachusetts and Puerto Rico have areas designated as rural, however, no short-term, acute care hospitals are located in the area(s) for CY 2009.

Addendum B—CY 2009 Wage Index for Urban Areas by CBSA; Applicable Pre-Floor and Pre-Reclassified Hospital Wage Index

CBSA codeUrban area (constituent counties)Wage index
10180Abilene, TX0.8097
 Callahan County, TX
 Jones County, TX
 Taylor County, TX
10380Aguadilla-Isabela-San Sebastián, PR0.3399
 Aguada Municipio, PR
 Aguadilla Municipio, PR
Start Printed Page 65363
 Añasco Municipio, PR
 Isabela Municipio, PR
 Lares Municipio, PR
 Moca Municipio, PR
 Rincón Municipio, PR
 San Sebastián Municipio, PR
10420Akron, OH0.8917
 Portage County, OH
 Summit County, OH
10500Albany, GA0.8703
 Baker County, GA
 Dougherty County, GA
 Lee County, GA
 Terrell County, GA
 Worth County, GA
10580Albany-Schenectady-Troy, NY0.8707
 Albany County, NY
 Rensselaer County, NY
 Saratoga County, NY
 Schenectady County, NY
 Schoharie County, NY
10740Albuquerque, NM0.9210
 Bernalillo County, NM
 Sandoval County, NM
 Torrance County, NM
 Valencia County, NM
10780Alexandria, LA0.8130
 Grant Parish, LA
 Rapides Parish, LA
10900Allentown-Bethlehem-Easton, PA-NJ0.9499
 Warren County, NJ
 Carbon County, PA
 Lehigh County, PA
 Northampton County, PA
11020Altoona, PA0.8521
 Blair County, PA
11100Amarillo, TX0.8927
 Armstrong County, TX
 Carson County, TX
 Potter County, TX
 Randall County, TX
11180Ames, IA0.9487
 Story County, IA
11260Anchorage, AK1.1931
 Anchorage Municipality, AK
 Matanuska-Susitna Borough, AK
11300Anderson, IN0.8760
 Madison County, IN
11340Anderson, SC0.9570
 Anderson County, SC
11460Ann Arbor, MI1.0445
 Washtenaw County, MI
11500Anniston-Oxford, AL0.7927
 Calhoun County, AL
11540Appleton, WI0.9440
 Calumet County, WI
 Outagamie County, WI
11700Asheville, NC0.9142
 Buncombe County, NC
 Haywood County, NC
 Henderson County, NC
 Madison County, NC
12020Athens-Clarke County, GA0.9591
 Clarke County, GA
 Madison County, GA
 Oconee County, GA
 Oglethorpe County, GA
12060Atlanta-Sandy Springs-Marietta, GA0.9754
 Barrow County, GA
 Bartow County, GA
 Butts County, GA
 Carroll County, GA
 Cherokee County, GA
Start Printed Page 65364
 Clayton County, GA
 Cobb County, GA
 Coweta County, GA
 Dawson County, GA
 DeKalb County, GA
 Douglas County, GA
 Fayette County, GA
 Forsyth County, GA
 Fulton County, GA
 Gwinnett County, GA
 Haralson County, GA
 Heard County, GA
 Henry County, GA
 Jasper County, GA
 Lamar County, GA
 Meriwether County, GA
 Newton County, GA
 Paulding County, GA
 Pickens County, GA
 Pike County, GA
 Rockdale County, GA
 Spalding County, GA
 Walton County, GA
12100Atlantic City, NJ1.1973
 Atlantic County, NJ
12220Auburn-Opelika, AL0.7544
 Lee County, AL
12260Augusta-Richmond County, GA-SC0.9615
 Burke County, GA
 Columbia County, GA
 McDuffie County, GA
 Richmond County, GA
 Aiken County, SC
 Edgefield County, SC
12420Austin-Round Rock, TX0.9536
 Bastrop County, TX
 Caldwell County, TX
 Hays County, TX
 Travis County, TX
 Williamson County, TX
12540Bakersfield, CA1.1189
 Kern County, CA
12580Baltimore-Towson, MD1.0055
 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, ME1.0174
 Penobscot County, ME
12700Barnstable Town, MA1.2643
 Barnstable County, MA
12940Baton Rouge, LA0.8163
 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, MI1.0120
 Calhoun County, MI
13020Bay City, MI0.9248
 Bay County, MI
13140Beaumont-Port Arthur, TX0.8479
 Hardin County, TX
 Jefferson County, TX
 Orange County, TX
13380Bellingham, WA1.1640
Start Printed Page 65365
 Whatcom County, WA
13460Bend, OR1.1375
 Deschutes County, OR
13644Bethesda-Frederick-Gaithersburg, MD1.0548
 Frederick County, MD
 Montgomery County, MD
13740Billings, MT0.8805
 Carbon County, MT
 Yellowstone County, MT
13780Binghamton, NY0.8574
 Broome County, NY
 Tioga County, NY
13820Birmingham-Hoover, AL0.8792
 Bibb County, AL
 Blount County, AL
 Chilton County, AL
 Jefferson County, AL
 St. Clair County, AL
 Shelby County, AL
 Walker County, AL
13900Bismarck, ND0.7148
 Burleigh County, ND
 Morton County, ND
13980Blacksburg-Christiansburg-Radford, VA0.8155
 Giles County, VA
 Montgomery County, VA
 Pulaski County, VA
 Radford City, VA
14020Bloomington, IN0.8979
 Greene County, IN
 Monroe County, IN
 Owen County, IN
14060Bloomington-Normal, IL0.9323
 McLean County, IL
14260Boise City-Nampa, ID0.9268
 Ada County, ID
 Boise County, ID
 Canyon County, ID
 Gem County, ID
 Owyhee County, ID
14484Boston-Quincy, MA1.1897
 Norfolk County, MA
 Plymouth County, MA
 Suffolk County, MA
14500Boulder, CO1.0302
 Boulder County, CO
14540Bowling Green, KY0.8388
 Edmonson County, KY
 Warren County, KY
14600Bradenton-Sarasota-Venice, FL0.9900
14740Bremerton-Silverdale, WA1.0770
 Kitsap County, WA
14860Bridgeport-Stamford-Norwalk, CT1.2868
 Fairfield County, CT
15180Brownsville-Harlingen, TX0.8916
 Cameron County, TX
15260Brunswick, GA0.9567
 Brantley County, GA
 Glynn County, GA
 McIntosh County, GA
15380Buffalo-Niagara Falls, NY0.9537
 Erie County, NY
 Niagara County, NY
15500Burlington, NC0.8736
 Alamance County, NC
15540Burlington-South Burlington, VT0.9254
 Chittenden County, VT
 Franklin County, VT
 Grand Isle County, VT
15764Cambridge-Newton-Framingham, MA1.1086
 Middlesex County, MA
15804Camden, NJ1.0346
 Burlington County, NJ
Start Printed Page 65366
 Camden County, NJ
 Gloucester County, NJ
15940Canton-Massillon, OH0.8841
 Carroll County, OH
 Stark County, OH
15980Cape Coral-Fort Myers, FL0.9396
 Lee County, FL
16180Carson City, NV1.0128
 Carson City, NV
16220Casper, WY0.9579
 Natrona County, WY
16300Cedar Rapids, IA0.8919
 Benton County, IA
 Jones County, IA
 Linn County, IA
16580Champaign-Urbana, IL0.9461
 Champaign County, IL
 Ford County, IL
 Piatt County, IL
16620Charleston, WV0.8275
 Boone County, WV
 Clay County, WV
 Kanawha County, WV
 Lincoln County, WV
 Putnam County, WV
16700Charleston-North Charleston, SC0.9209
 Berkeley County, SC
 Charleston County, SC
 Dorchester County, SC
16740Charlotte-Gastonia-Concord, NC-SC0.9595
 Anson County, NC
 Cabarrus County, NC
 Gaston County, NC
 Mecklenburg County, NC
 Union County, NC
 York County, SC
16820Charlottesville, VA0.9816
 Albemarle County, VA
 Fluvanna County, VA
 Greene County, VA
 Nelson County, VA
 Charlottesville City, VA
16860Chattanooga, TN-GA0.8878
 Catoosa County, GA
 Dade County, GA
 Walker County, GA
 Hamilton County, TN
 Marion County, TN
 Sequatchie County, TN
16940Cheyenne, WY0.9276
 Laramie County, WY
16974Chicago-Naperville-Joliet, IL1.0399
 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, CA1.0897
 Butte County, CA
17140Cincinnati-Middletown, OH-KY-IN0.9687
 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
Start Printed Page 65367
 Brown County, OH
 Butler County, OH
 Clermont County, OH
 Hamilton County, OH
 Warren County, OH
17300Clarksville, TN-KY0.8298
 Christian County, KY
 Trigg County, KY
 Montgomery County, TN
 Stewart County, TN
17420Cleveland, TN0.8010
 Bradley County, TN
 Polk County, TN
17460Cleveland-Elyria-Mentor, OH0.9241
 Cuyahoga County, OH
 Geauga County, OH
 Lake County, OH
 Lorain County, OH
 Medina County, OH
17660Coeur d'Alene, ID0.9322
 Kootenai County, ID
17780College Station-Bryan, TX0.9346
 Brazos County, TX
 Burleson County, TX
 Robertson County, TX
17820Colorado Springs, CO0.9977
 El Paso County, CO
 Teller County, CO
17860Columbia, MO0.8540
 Boone County, MO
 Howard County, MO
17900Columbia, SC0.8933
 Calhoun County, SC
 Fairfield County, SC
 Kershaw County, SC
 Lexington County, SC
 Richland County, SC
 Saluda County, SC
17980Columbus, GA-AL0.8739
 Russell County, AL
 Chattahoochee County, GA
 Harris County, GA
 Marion County, GA
 Muscogee County, GA
18020Columbus, IN0.9739
 Bartholomew County, IN
18140Columbus, OH0.9943
 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, TX0.8598
 Aransas County, TX
 Nueces County, TX
 San Patricio County, TX
18700Corvallis, OR1.1304
 Benton County, OR
19060Cumberland, MD-WV0.7816
 Allegany County, MD
 Mineral County, WV
19124Dallas-Plano-Irving, TX0.9945
 Collin County, TX
 Dallas County, TX
 Delta County, TX
 Denton County, TX
 Ellis County, TX
 Hunt County, TX
 Kaufman County, TX
 Rockwall County, TX
Start Printed Page 65368
19140Dalton, GA0.8705
 Murray County, GA
 Whitfield County, GA
19180Danville, IL0.9374
 Vermilion County, IL
19260Danville, VA0.8395
 Pittsylvania County, VA
 Danville City, VA
19340Davenport-Moline-Rock Island, IA-IL0.8435
 Henry County, IL
 Mercer County, IL
 Rock Island County, IL
 Scott County, IA
19380Dayton, OH0.9203
 Greene County, OH
 Miami County, OH
 Montgomery County, OH
 Preble County, OH
19460Decatur, AL0.7803
 Lawrence County, AL
 Morgan County, AL
19500Decatur, IL0.8145
 Macon County, IL
19660Deltona-Daytona Beach-Ormond Beach, FL0.8890
 Volusia County, FL
19740Denver-Aurora, CO1.0818
 Adams County, CO
 Arapahoe County, CO
 Broomfield County, CO
 Clear Creek County, CO
 Denver County, CO
 Douglas County, CO
 Elbert County, CO
 Gilpin County, CO
 Jefferson County, CO
 Park County, CO
19780Des Moines, IA0.9535
 Dallas County, IA
 Guthrie County, IA
 Madison County, IA
 Polk County, IA
 Warren County, IA
19804Detroit-Livonia-Dearborn, MI0.9958
 Wayne County, MI
20020Dothan, AL0.7613
 Geneva County, AL
 Henry County, AL
 Houston County, AL
20100Dover, DE1.0325
 Kent County, DE
20220Dubuque, IA0.8380
 Dubuque County, IA
20260Duluth, MN-WI1.0363
 Carlton County, MN
 St. Louis County, MN
 Douglas County, WI
20500Durham, NC0.9732
 Chatham County, NC
 Durham County, NC
 Orange County, NC
 Person County, NC
20740Eau Claire, WI0.9668
 Chippewa County, WI
 Eau Claire County, WI
20764Edison, NJ1.1283
 Middlesex County, NJ
 Monmouth County, NJ
 Ocean County, NJ
 Somerset County, NJ
20940El Centro, CA0.8746
 Imperial County, CA
21060Elizabethtown, KY0.8525
 Hardin County, KY
Start Printed Page 65369
 Larue County, KY
21140Elkhart-Goshen, IN0.9568
 Elkhart County, IN
21300Elmira, NY0.8247
 Chemung County, NY
21340El Paso, TX0.8694
 El Paso County, TX
21500Erie, PA0.8713
 Erie County, PA
21660Eugene-Springfield, OR1.1061
 Lane County, OR
21780Evansville, IN-KY0.8690
 Gibson County, IN
 Posey County, IN
 Vanderburgh County, IN
 Warrick County, IN
 Henderson County, KY
 Webster County, KY
21820Fairbanks, AK1.1297
 Fairbanks North Star Borough, AK
21940Fajardo, PR0.4061
 Ceiba Municipio, PR
 Fajardo Municipio, PR
 Luquillo Municipio, PR
22020Fargo, ND-MN0.8166
 Cass County, ND
 Clay County, MN
22140Farmington, NM0.8051
 San Juan County, NM
22180Fayetteville, NC0.9340
 Cumberland County, NC
 Hoke County, NC
22220Fayetteville-Springdale-Rogers, AR-MO0.8970
 Benton County, AR
 Madison County, AR
 Washington County, AR
 McDonald County, MO
22380Flagstaff, AZ1.1743
 Coconino County, AZ
22420Flint, MI1.1425
 Genesee County, MI
22500Florence, SC0.8130
 Darlington County, SC
 Florence County, SC
22520Florence-Muscle Shoals, AL0.7871
 Colbert County, AL
 Lauderdale County, AL
22540Fond du Lac, WI0.9293
 Fond du Lac County, WI
22660Fort Collins-Loveland, CO0.9867
 Larimer County, CO
22744Fort Lauderdale-Pompano Beach-Deerfield Beach, FL0.9946
 Broward County, FL
22900Fort Smith, AR-OK0.7697
 Crawford County, AR
 Franklin County, AR
 Sebastian County, AR
 Le Flore County, OK
 Sequoyah County, OK
23020Fort Walton Beach-Crestview-Destin, FL0.8769
 Okaloosa County, FL
23060Fort Wayne, IN0.9176
 Allen County, IN
 Wells County, IN
 Whitley County, IN
23104Fort Worth-Arlington, TX0.9709
 Johnson County, TX
 Parker County, TX
 Tarrant County, TX
 Wise County, TX
23420Fresno, CA1.1009
 Fresno County, CA
23460Gadsden, AL0.7983
Start Printed Page 65370
 Etowah County, AL
23540Gainesville, FL0.9312
 Alachua County, FL
 Gilchrist County, FL
23580Gainesville, GA0.9109
 Hall County, GA
23844Gary, IN0.9250
 Jasper County, IN
 Lake County, IN
 Newton County, IN
 Porter County, IN
24020Glens Falls, NY0.8473
 Warren County, NY
 Washington County, NY
24140Goldsboro, NC0.9143
 Wayne County, NC
24220Grand Forks, ND-MN0.7565
 Polk County, MN
 Grand Forks County, ND
24300Grand Junction, CO0.9812
 Mesa County, CO
24340Grand Rapids-Wyoming, MI0.9184
 Barry County, MI
 Ionia County, MI
 Kent County, MI
 Newaygo County, MI
24500Great Falls, MT0.8784
 Cascade County, MT
24540Greeley, CO0.9684
 Weld County, CO
24580Green Bay, WI0.9709
 Brown County, WI
 Kewaunee County, WI
 Oconto County, WI
24660Greensboro-High Point, NC0.9011
 Guilford County, NC
 Randolph County, NC
 Rockingham County, NC
24780Greenville, NC0.9448
 Greene County, NC
 Pitt County, NC
24860Greenville, SC0.9961
 Greenville County, SC
 Laurens County, SC
 Pickens County, SC
25020Guayama, PR0.3249
 Arroyo Municipio, PR
 Guayama Municipio, PR
 Patillas Municipio, PR
25060Gulfport-Biloxi, MS0.9029
 Hancock County, MS
 Harrison County, MS
 Stone County, MS
25180Hagerstown-Martinsburg, MD-WV0.8997
 Washington County, MD
 Berkeley County, WV
 Morgan County, WV
25260Hanford-Corcoran, CA1.0870
 Kings County, CA
25420Harrisburg-Carlisle, PA0.9153
 Cumberland County, PA
 Dauphin County, PA
 Perry County, PA
25500Harrisonburg, VA0.8894
 Rockingham County, VA
 Harrisonburg City, VA
25540Hartford-West Hartford-East Hartford, CT1.1069
 Hartford County, CT
 Litchfield County, CT
 Middlesex County, CT
 Tolland County, CT
25620Hattiesburg, MS0.7337
 Forrest County, MS
Start Printed Page 65371
 Lamar County, MS
 Perry County, MS
25860Hickory-Lenoir-Morganton, NC0.8976
 Alexander County, NC
 Burke County, NC
 Caldwell County, NC
 Catawba County, NC
25980 1Hinesville-Fort Stewart, GA0.9110
 Liberty County, GA
 Long County, GA
26100Holland-Grand Haven, MI0.9008
 Ottawa County, MI
26180Honolulu, HI1.1811
 Honolulu County, HI
26300Hot Springs, AR0.9113
 Garland County, AR
26380Houma-Bayou Cane-Thibodaux, LA0.7758
 Lafourche Parish, LA
 Terrebonne Parish, LA
26420Houston-Baytown-Sugar Land, TX0.9838
 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-OH0.9254
 Boyd County, KY
 Greenup County, KY
 Lawrence County, OH
 Cabell County, WV
 Wayne County, WV
26620Huntsville, AL0.9082
 Limestone County, AL
 Madison County, AL
26820Idaho Falls, ID0.9080
 Bonneville County, ID
 Jefferson County, ID
26900Indianapolis, IN0.9908
 Boone County, IN
 Brown County, IN
 Hamilton County, IN
 Hancock County, IN
 Hendricks County, IN
 Johnson County, IN
 Marion County, IN
 Morgan County, IN
 Putnam County, IN
 Shelby County, IN
26980Iowa City, IA0.9483
 Johnson County, IA
 Washington County, IA
27060Ithaca, NY0.9614
 Tompkins County, NY
27100Jackson, MI0.9309
 Jackson County, MI
27140Jackson, MS0.8067
 Copiah County, MS
 Hinds County, MS
 Madison County, MS
 Rankin County, MS
 Simpson County, MS
27180Jackson, TN0.8523
 Chester County, TN
 Madison County, TN
27260Jacksonville, FL0.8999
 Baker County, FL
 Clay County, FL
 Duval County, FL
Start Printed Page 65372
 Nassau County, FL
 St. Johns County, FL
27340Jacksonville, NC0.8177
 Onslow County, NC
27500Janesville, WI0.9662
 Rock County, WI
27620Jefferson City, MO0.8775
 Callaway County, MO
 Cole County, MO
 Moniteau County, MO
 Osage County, MO
27740Johnson City, TN0.7971
 Carter County, TN
 Unicoi County, TN
 Washington County, TN
27780Johnstown, PA0.7920
 Cambria County, PA
27860Jonesboro, AR0.7916
 Craighead County, AR
 Poinsett County, AR
27900Joplin, MO0.9406
 Jasper County, MO
 Newton County, MO
28020Kalamazoo-Portage, MI1.0801
 Kalamazoo County, MI
 Van Buren County, MI
28100Kankakee-Bradley, IL1.0485
 Kankakee County, IL
28140Kansas City, MO-KS0.9610
 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, WA0.9911
 Benton County, WA
 Franklin County, WA
28660Killeen-Temple-Fort Hood, TX0.8765
 Bell County, TX
 Coryell County, TX
 Lampasas County, TX
28700Kingsport-Bristol-Bristol, TN-VA0.7743
 Hawkins County, TN
 Sullivan County, TN
 Bristol City, VA
 Scott County, VA
 Washington County, VA
28740Kingston, NY0.9375
 Ulster County, NY
28940Knoxville, TN0.7881
 Anderson County, TN
 Blount County, TN
 Knox County, TN
 Loudon County, TN
 Union County, TN
29020Kokomo, IN0.9349
 Howard County, IN
 Tipton County, IN
29100La Crosse, WI-MN0.9758
 Houston County, MN
 La Crosse County, WI
29140Lafayette, IN0.9221
 Benton County, IN
Start Printed Page 65373
 Carroll County, IN
 Tippecanoe County, IN
29180Lafayette, LA0.8374
 Lafayette Parish, LA
 St. Martin Parish, LA
29340Lake Charles, LA0.7556
 Calcasieu Parish, LA
 Cameron Parish, LA
29404Lake County-Kenosha County, IL-WI1.0389
 Lake County, IL
 Kenosha County, WI
29420Lake Havasu City-Kingman, AZ0.9797
29460Lakeland, FL0.8530
 Polk County, FL
29540Lancaster, PA0.9363
 Lancaster County, PA
29620Lansing-East Lansing, MI0.9931
 Clinton County, MI
 Eaton County, MI
 Ingham County, MI
29700Laredo, TX0.8366
 Webb County, TX
29740Las Cruces, NM0.8929
 Dona Ana County, NM
29820Las Vegas-Paradise, NV1.1971
 Clark County, NV
29940Lawrence, KS0.8343
 Douglas County, KS
30020Lawton, OK0.8211
 Comanche County, OK
30140Lebanon, PA0.8954
 Lebanon County, PA
30300Lewiston, ID-WA0.9465
 Nez Perce County, ID
 Asotin County, WA
30340Lewiston-Auburn, ME0.9200
 Androscoggin County, ME
30460Lexington-Fayette, KY0.9110
 Bourbon County, KY
 Clark County, KY
 Fayette County, KY
 Jessamine County, KY
 Scott County, KY
 Woodford County, KY
30620Lima, OH0.9427
 Allen County, OH
30700Lincoln, NE0.9759
 Lancaster County, NE
 Seward County, NE
30780Little Rock-North Little Rock, AR0.8672
 Faulkner County, AR
 Grant County, AR
 Lonoke County, AR
 Perry County, AR
 Pulaski County, AR
 Saline County, AR
30860Logan, UT-ID0.8765
 Franklin County, ID
 Cache County, UT
30980Longview, TX0.8370
 Gregg County, TX
 Rusk County, TX
 Upshur County, TX
31020Longview, WA1.1207
 Cowlitz County, WA
31084Los Angeles-Long Beach-Glendale, CA1.2208
 Los Angeles County, CA
31140Louisville, KY-IN0.9249
 Clark County, IN
 Floyd County, IN
 Harrison County, IN
 Washington County, IN
 Bullitt County, KY
Start Printed Page 65374
 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, TX0.8731
 Crosby County, TX
 Lubbock County, TX
31340Lynchburg, VA0.8774
 Amherst County, VA
 Appomattox County, VA
 Bedford County, VA
 Campbell County, VA
 Bedford City, VA
 Lynchburg City, VA
31420Macon, GA0.9570
 Bibb County, GA
 Crawford County, GA
 Jones County, GA
 Monroe County, GA
 Twiggs County, GA
31460Madera, CA0.7939
 Madera County, CA
31540Madison, WI1.0967
 Columbia County, WI
 Dane County, WI
 Iowa County, WI
31700Manchester-Nashua, NH1.0359
 Hillsborough County, NH
 Merrimack County, NH
31900Mansfield, OH0.9330
 Richland County, OH
32420Mayagüez, PR0.3940
 Hormigueros Municipio, PR
 Mayagüez Municipio, PR
32580McAllen-Edinburg-Pharr, TX0.9009
 Hidalgo County, TX
32780Medford, OR1.0244
 Jackson County, OR
32820Memphis, TN-MS-AR0.9232
 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, CA1.2243
 Merced County, CA
33124Miami-Miami Beach-Kendall, FL0.9830
 Miami-Dade County, FL
33140Michigan City-La Porte, IN0.9159
 LaPorte County, IN
33260Midland, TX0.9827
 Midland County, TX
33340Milwaukee-Waukesha-West Allis, WI1.0080
 Milwaukee County, WI
 Ozaukee County, WI
 Washington County, WI
 Waukesha County, WI
33460Minneapolis-St. Paul-Bloomington, MN-WI1.1150
 Anoka County, MN
 Carver County, MN
 Chisago County, MN
 Dakota County, MN
 Hennepin County, MN
 Isanti County, MN
 Ramsey County, MN
 Scott County, MN
Start Printed Page 65375
 Sherburne County, MN
 Washington County, MN
 Wright County, MN
 Pierce County, WI
 St. Croix County, WI
33540Missoula, MT0.8973
 Missoula County, MT
33660Mobile, AL0.7908
 Mobile County, AL
33700Modesto, CA1.2194
 Stanislaus County, CA
33740Monroe, LA0.7900
 Ouachita Parish, LA
 Union Parish, LA
33780Monroe, MI0.8941
 Monroe County, MI
33860Montgomery, AL0.8283
 Autauga County, AL
 Elmore County, AL
 Lowndes County, AL
 Montgomery County, AL
34060Morgantown, WV0.8528
 Monongalia County, WV
 Preston County, WV
34100Morristown, TN0.7254
 Grainger County, TN
 Hamblen County, TN
 Jefferson County, TN
34580Mount Vernon-Anacortes, WA1.0292
 Skagit County, WA
34620Muncie, IN0.8489
 Delaware County, IN
34740Muskegon-Norton Shores, MI1.0055
 Muskegon County, MI
34820Myrtle Beach-Conway-North Myrtle Beach, SC0.8652
 Horry County, SC
34900Napa, CA1.4520
 Napa County, CA
34940Naples-Marco Island, FL0.9672
 Collier County, FL
34980Nashville-Davidson-Murfreesboro, TN0.9504
 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, NY1.2453
 Nassau County, NY
 Suffolk County, NY
35084Newark-Union, NJ-PA1.1731
 Essex County, NJ
 Hunterdon County, NJ
 Morris County, NJ
 Sussex County, NJ
 Union County, NJ
 Pike County, PA
35300New Haven-Milford, CT1.1742
 New Haven County, CT
35380New Orleans-Metairie-Kenner, LA0.9103
 Jefferson Parish, LA
 Orleans Parish, LA
 Plaquemines Parish, LA
 St. Bernard Parish, LA
 St. Charles Parish, LA
 St. John the Baptist Parish, LA
Start Printed Page 65376
 St. Tammany Parish, LA
35644New York-Wayne-White Plains, NY-NJ1.2885
 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, MI0.9066
 Berrien County, MI
35980Norwich-New London, CT1.1398
 New London County, CT
36084Oakland-Fremont-Hayward, CA1.6092
 Alameda County, CA
 Contra Costa County, CA
36100Ocala, FL0.8512
 Marion County, FL
36140Ocean City, NJ1.1496
 Cape May County, NJ
36220Odessa, TX0.9475
 Ector County, TX
36260Ogden-Clearfield, UT0.9153
 Davis County, UT
 Morgan County, UT
 Weber County, UT
36420Oklahoma City, OK0.8724
 Canadian County, OK
 Cleveland County, OK
 Grady County, OK
 Lincoln County, OK
 Logan County, OK
 McClain County, OK
 Oklahoma County, OK
36500Olympia, WA1.1537
 Thurston County, WA
36540Omaha-Council Bluffs, NE-IA0.9441
 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, FL0.9111
 Lake County, FL
 Orange County, FL
 Osceola County, FL
 Seminole County, FL
36780Oshkosh-Neenah, WI0.9474
 Winnebago County, WI
36980Owensboro, KY0.8685
 Daviess County, KY
 Hancock County, KY
 McLean County, KY
37100Oxnard-Thousand Oaks-Ventura, CA1.1951
 Ventura County, CA
37340Palm Bay-Melbourne-Titusville, FL0.9332
 Brevard County, FL
37380Palm Coast, FL0.8963
 Flagler County, FL
37460Panama City-Lynn Haven, FL0.8360
 Bay County, FL
37620Parkersburg-Marietta, WV-OH0.7867
 Washington County, OH
 Pleasants County, WV
 Wirt County, WV
 Wood County, WV
Start Printed Page 65377
37700Pascagoula, MS0.8102
 George County, MS
 Jackson County, MS
37764Peabody, MA1.0747
 Essex County, MA
37860Pensacola-Ferry Pass-Brent, FL0.8242
 Escambia County, FL
 Santa Rosa County, FL
37900Peoria, IL0.9038
 Marshall County, IL
 Peoria County, IL
 Stark County, IL
 Tazewell County, IL
 Woodford County, IL
37964Philadelphia, PA1.0979
 Bucks County, PA
 Chester County, PA
 Delaware County, PA
 Montgomery County, PA
 Philadelphia County, PA
38060Phoenix-Mesa-Scottsdale, AZ1.0379
 Maricopa County, AZ
 Pinal County, AZ
38220Pine Bluff, AR0.7926
 Cleveland County, AR
 Jefferson County, AR
 Lincoln County, AR
38300Pittsburgh, PA0.8678
 Allegheny County, PA
 Armstrong County, PA
 Beaver County, PA
 Butler County, PA
 Fayette County, PA
 Washington County, PA
 Westmoreland County, PA
38340Pittsfield, MA1.0445
 Berkshire County, MA
38540Pocatello, ID0.9343
 Bannock County, ID
 Power County, ID
38660Ponce, PR0.4289
 Juana Díaz Municipio, PR
 Ponce Municipio, PR
 Villalba Municipio, PR
38860Portland-South Portland-Biddeford, ME0.9942
 Cumberland County, ME
 Sagadahoc County, ME
 York County, ME
38900Portland-Vancouver-Beaverton, OR-WA1.1456
 Clackamas County, OR
 Columbia County, OR
 Multnomah County, OR
 Washington County, OR
 Yamhill County, OR
 Clark County, WA
 Skamania County, WA
38940Port St. Lucie-Fort Pierce, FL0.9870
 Martin County, FL
 St. Lucie County, FL
39100Poughkeepsie-Newburgh-Middletown, NY1.0920
 Dutchess County, NY
 Orange County, NY
39140Prescott, AZ1.0221
 Yavapai County, AZ
39300Providence-New Bedford-Fall River, RI-MA1.0696
 Bristol County, MA
 Bristol County, RI
 Kent County, RI
 Newport County, RI
 Providence County, RI
 Washington County, RI
39340Provo-Orem, UT0.9381
 Juab County, UT
Start Printed Page 65378
 Utah County, UT
39380Pueblo, CO0.8713
 Pueblo County, CO
39460Punta Gorda, FL0.8976
 Charlotte County, FL
39540Racine, WI0.9054
 Racine County, WI
39580Raleigh-Cary, NC0.9817
 Franklin County, NC
 Johnston County, NC
 Wake County, NC
39660Rapid City, SD0.9598
 Meade County, SD
 Pennington County, SD
39740Reading, PA0.9242
 Berks County, PA
39820Redding, CA1.3731
 Shasta County, CA
39900Reno-Sparks, NV1.0317
 Storey County, NV
 Washoe County, NV
40060Richmond, VA0.9363
 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, CA1.1468
 Riverside County, CA
 San Bernardino County, CA
40220Roanoke, VA0.8660
 Botetourt County, VA
 Craig County, VA
 Franklin County, VA
 Roanoke County, VA
 Roanoke City, VA
 Salem City, VA
40340Rochester, MN1.1214
 Dodge County, MN
 Olmsted County, MN
 Wabasha County, MN
40380Rochester, NY0.8811
 Livingston County, NY
 Monroe County, NY
 Ontario County, NY
 Orleans County, NY
 Wayne County, NY
40420Rockford, IL0.9835
 Boone County, IL
 Winnebago County, IL
40484Rockingham County-Strafford County, NH0.9926
 Rockingham County, NH
 Strafford County, NH
40580Rocky Mount, NC0.9031
 Edgecombe County, NC
 Nash County, NC
40660Rome, GA0.9134
 Floyd County, GA
Start Printed Page 65379
40900Sacramento—Arden-Arcade—Roseville, CA1.3572
 El Dorado County, CA
 Placer County, CA
 Sacramento County, CA
 Yolo County, CA
40980Saginaw-Saginaw Township North, MI0.8702
 Saginaw County, MI
41060St. Cloud, MN1.0976
 Benton County, MN
 Stearns County, MN
41100St. George, UT0.9021
 Washington County, UT
41140St. Joseph, MO-KS1.0380
 Doniphan County, KS
 Andrew County, MO
 Buchanan County, MO
 DeKalb County, MO
41180St. Louis, MO-IL0.9006
 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, OR1.0884
 Marion County, OR
 Polk County, OR
41500Salinas, CA1.4987
 Monterey County, CA
41540Salisbury, MD0.9246
 Somerset County, MD
 Wicomico County, MD
41620Salt Lake City, UT0.9158
 Salt Lake County, UT
 Summit County, UT
 Tooele County, UT
41660San Angelo, TX0.8424
 Irion County, TX
 Tom Green County, TX
41700San Antonio, TX0.8856
 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, CA1.1538
 San Diego County, CA
41780Sandusky, OH0.8870
 Erie County, OH
41884San Francisco-San Mateo-Redwood City, CA1.5529
 Marin County, CA
 San Francisco County, CA
 San Mateo County, CA
41900San Germán-Cabo Rojo, PR0.4756
 Cabo Rojo Municipio, PR
 Lajas Municipio, PR
 Sabana Grande Municipio, PR
 San Germán Municipio, PR
41940San Jose-Sunnyvale-Santa Clara, CA1.6141
Start Printed Page 65380
 San Benito County, CA
 Santa Clara County, CA
41980San Juan-Caguas-Guaynabo, PR0.4393
 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, CA1.2441
 San Luis Obispo County, CA
42044Santa Ana-Anaheim-Irvine, CA1.1993
 Orange County, CA
42060Santa Barbara-Santa Maria-Goleta, CA1.1909
 Santa Barbara County, CA
42100Santa Cruz-Watsonville, CA1.6429
 Santa Cruz County, CA
42140Santa Fe, NM1.0610
 Santa Fe County, NM
42220Santa Rosa-Petaluma, CA1.5528
 Sonoma County, CA
42340Savannah, GA0.9152
 Bryan County, GA
 Chatham County, GA
 Effingham County, GA
42540Scranton—Wilkes-Barre, PA0.8333
 Lackawanna County, PA
 Luzerne County, PA
 Wyoming County, PA
42644Seattle-Bellevue-Everett, WA1.1755
 King County, WA
 Snohomish County, WA
42680Sebastian-Vero Beach, FL0.9217
43100Sheboygan, WI0.8920
 Sheboygan County, WI
43300Sherman-Denison, TX0.9024
 Grayson County, TX
43340Shreveport-Bossier City, LA0.8442
Start Printed Page 65381
 Bossier Parish, LA
 Caddo Parish, LA
 De Soto Parish, LA
43580Sioux City, IA-NE-SD0.8915
 Woodbury County, IA
 Dakota County, NE
 Dixon County, NE
 Union County, SD
43620Sioux Falls, SD0.9354
 Lincoln County, SD
 McCook County, SD
 Minnehaha County, SD
 Turner County, SD
43780South Bend-Mishawaka, IN-MI0.9761
 St. Joseph County, IN
 Cass County, MI
43900Spartanburg, SC0.9025
 Spartanburg County, SC
44060Spokane, WA1.0559
 Spokane County, WA
44100Springfield, IL0.9102
 Menard County, IL
 Sangamon County, IL
44140Springfield, MA1.0405
 Franklin County, MA
 Hampden County, MA
 Hampshire County, MA
44180Springfield, MO0.8424
 Christian County, MO
 Dallas County, MO
 Greene County, MO
 Polk County, MO
 Webster County, MO
44220Springfield, OH0.8876
 Clark County, OH
44300State College, PA0.8937
 Centre County, PA
44700Stockton, CA1.2015
 San Joaquin County, CA
44940Sumter, SC0.8257
 Sumter County, SC
45060Syracuse, NY0.9787
 Madison County, NY
 Onondaga County, NY
 Oswego County, NY
45104Tacoma, WA1.1241
 Pierce County, WA
45220Tallahassee, FL0.8964
 Gadsden County, FL
 Jefferson County, FL
 Leon County, FL
 Wakulla County, FL
45300Tampa-St. Petersburg-Clearwater, FL0.8852
 Hernando County, FL
 Hillsborough County, FL
 Pasco County, FL
 Pinellas County, FL
45460Terre Haute, IN0.9085
 Clay County, IN
 Sullivan County, IN
 Vermillion County, IN
 Vigo County, IN
45500Texarkana, TX-Texarkana, AR0.8144
 Miller County, AR
 Bowie County, TX
45780Toledo, OH0.9407
 Fulton County, OH
 Lucas County, OH
 Ottawa County, OH
 Wood County, OH
45820Topeka, KS0.8756
 Jackson County, KS
 Jefferson County, KS
Start Printed Page 65382
 Osage County, KS
 Shawnee County, KS
 Wabaunsee County, KS
45940Trenton-Ewing, NJ1.0604
 Mercer County, NJ
46060Tucson, AZ0.9229
 Pima County, AZ
46140Tulsa, OK0.8445
 Creek County, OK
 Okmulgee County, OK
 Osage County, OK
 Pawnee County, OK
 Rogers County, OK
 Tulsa County, OK
 Wagoner County, OK
46220Tuscaloosa, AL0.8496
 Greene County, AL
 Hale County, AL
 Tuscaloosa County, AL
46340Tyler, TX0.8804
 Smith County, TX
46540Utica-Rome, NY0.8404
 Herkimer County, NY
 Oneida County, NY
46660Valdosta, GA0.8027
 Brooks County, GA
 Echols County, GA
 Lanier County, GA
 Lowndes County, GA
46700Vallejo-Fairfield, CA1.4359
 Solano County, CA
47020Victoria, TX0.8124
 Calhoun County, TX
 Goliad County, TX
 Victoria County, TX
47220Vineland-Millville-Bridgeton, NJ1.0366
 Cumberland County, NJ
47260Virginia Beach-Norfolk-Newport News, VA-NC0.8884
 Currituck County, NC
 Gloucester County, VA
 Isle of Wight County, VA
 James City County, VA
 Mathews County, VA
 Surry County, VA
 York County, VA
 Chesapeake City, VA
 Hampton City, VA
 Newport News City, VA
 Norfolk City, VA
 Poquoson City, VA
 Portsmouth City, VA
 Suffolk City, VA
 Virginia Beach City, VA
 Williamsburg City, VA
47300Visalia-Porterville, CA1.0144
 Tulare County, CA
47380Waco, TX0.8596
 McLennan County, TX
47580Warner Robins, GA0.8989
 Houston County, GA
47644Warren-Farmington Hills-Troy, MI0.9904
 Lapeer County, MI
 Livingston County, MI
 Macomb County, MI
 Oakland County, MI
 St. Clair County, MI
47894Washington-Arlington-Alexandria, DC-VA-MD-WV1.0827
 District of Columbia, DC
 Calvert County, MD
 Charles County, MD
 Prince George's County, MD
 Arlington County, VA
 Clarke County, VA
Start Printed Page 65383
 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, IA0.8490
 Black Hawk County, IA
 Bremer County, IA
 Grundy County, IA
48140Wausau, WI0.9615
 Marathon County, WI
48260Weirton-Steubenville, WV-OH0.8079
 Jefferson County, OH
 Brooke County, WV
 Hancock County, WV
48300Wenatchee, WA0.9544
 Chelan County, WA
 Douglas County, WA
48424West Palm Beach-Boca Raton-Boynton Beach, FL0.9757
 Palm Beach County, FL
48540Wheeling, WV-OH0.6955
 Belmont County, OH
 Marshall County, WV
 Ohio County, WV
48620Wichita, KS0.9069
 Butler County, KS
 Harvey County, KS
 Sedgwick County, KS
 Sumner County, KS
48660Wichita Falls, TX0.8832
 Archer County, TX
 Clay County, TX
 Wichita County, TX
48700Williamsport, PA0.8096
 Lycoming County, PA
48864Wilmington, DE-MD-NJ1.0696
 New Castle County, DE
 Cecil County, MD
 Salem County, NJ
48900Wilmington, NC0.9089
 Brunswick County, NC
 New Hanover County, NC
 Pender County, NC
49020Winchester, VA-WV0.9801
 Frederick County, VA
 Winchester City, VA
 Hampshire County, WV
49180Winston-Salem, NC0.9016
 Davie County, NC
 Forsyth County, NC
 Stokes County, NC
 Yadkin County, NC
49340Worcester, MA1.0836
 Worcester County, MA
49420Yakima, WA0.9948
 Yakima County, WA
49500Yauco, PR0.3432
 Guánica Municipio, PR
 Guayanilla Municipio, PR
 Peñuelas Municipio, PR
 Yauco Municipio, PR
49620York-Hanover, PA0.9518
 York County, PA
49660Youngstown-Warren-Boardman, OH-PA0.8915
Start Printed Page 65384
 Mahoning County, OH
 Trumbull County, OH
 Mercer County, PA
49700Yuba City, CA1.1137
 Sutter County, CA
 Yuba County, CA
49740Yuma, AZ0.9281
 Yuma County, AZ
1 At this time, there are no hospitals in these urban areas on which to base a wage index. Therefore, the urban wage index value is based on the average wage index of all urban areas within the State.
End Further Info End Preamble

[FR Doc. E8-26142 Filed 10-30-08; 4:15 pm]

BILLING CODE 4120-01-P