**Notice:** This CMS-approved document has been submitted to the Office
of the Federal Register (OFR) for publication and has been placed on
public display and is pending publication in the [Federal
Register]{.underline}.  The document may vary slightly from the
published document if minor editorial changes have been made during the
OFR review process.  Upon publication in the [Federal
Register]{.underline}, all regulations can be found at
[http://www.gpoaccess.gov/fr/]{.underline} and at
http://www.cms.hhs.gov/QuarterlyProviderUpdates/. The document published
in the [Federal Register]{.underline} is the official CMS-approved
document. 

# 

# DEPARTMENT OF HEALTH AND HUMAN SERVICES

**Centers for Medicare & Medicaid Services**

# 42 CFR Part 412 

**\[CMS-1393-P\]**

**RIN 0938-AO94**

Medicare Program; Prospective Payment System for Long‑Term Care
Hospitals RY 2009: Proposed Annual Payment Rate Updates, Policy Changes,
and Clarifications

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

**ACTION:** Proposed rule.

**SUMMARY:** This proposed rule would update the annual payment rates
for the Medicare prospective payment system (PPS) for inpatient hospital
services provided by long‑term care hospitals (LTCHs). In addition, we
are proposing to consolidate the annual July 1 update for payment rates
and the October 1 update for Medicare severity long-term care diagnosis
related group (MS‑LTC-DRG) weights to a single fiscal year (FY) update.

In this proposed rule, we are also clarifying various policy issues.

This proposed rule would also describe our evaluation of the possible
one-time adjustment to the Federal payment rate.

**DATES**: To be assured consideration, comments must be received at one
of the addresses provided below, no later than 5 p.m. on \[OFR---insert
date 60 days after the date of filing for public inspection at OFR.\]

**ADDRESSES:** In commenting, please refer to file code CMS‑1393‑P.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.

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

1\. [Electronically]{.underline}. You may submit electronic comments on
specific issues in this regulation to
[http://www.regulations.gov/]{.underline}. Follow the instructions under
the \"Comment or Submission\" tab and enter the file code to find the
document accepting comment.

2\. [By regular mail]{.underline}. You may mail written comments (one
original and two copies) to the following address ONLY:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

> Attention: CMS-1393-P,
>
> P.O. Box 8013,
>
> Baltimore, MD 21244-8013.

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

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

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-1393-P,

Mail Stop C4-26-05,

7500 Security Boulevard,

Baltimore, MD 21244-1850.

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

Room 445-G, Hubert H. Humphrey Building,

200 Independence Avenue, SW.,

> Washington, DC 20201; or
>
> 7500 Security Boulevard,
>
> Baltimore, MD 21244-1850.

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

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

[Submission of comments on paperwork requirements]{.underline}. You may
submit comments on this document\'s paperwork requirements by mailing
your comments to the addresses provided at the end of the \"Collection
of Information Requirements\" section in this document.

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

**FOR FURTHER INFORMATION CONTACT:**

Tzvi Hefter, (410) 786‑4487 (General information).

Judy Richter, (410) 786‑2590 (General information, payment adjustments
for special cases, onsite discharges and readmissions, interrupted
stays, co‑located providers, and short‑stay outliers).

Michele Hudson, (410) 786‑5490 (Calculation of the payment rates,
MS-LTC-DRGs, relative weights and case‑mix index, market basket, wage
index, budget neutrality, and other payment adjustments).

Ann Fagan, (410) 786‑5662 (Patient classification system).

Linda McKenna, (410) 786‑4537 (Payment adjustments and interrupted
stay).

Elizabeth Truong, (410) 786‑6005 (Federal rate update, budget
neutrality, other adjustments, and calculation of the payment rates).

Michael Treitel, (410) 786‑4552 (High cost outliers and cost-to-charge
ratios).

**Table of Contents**

I. Background

A. Legislative and Regulatory Authority

B. Criteria for Classification as a LTCH

1\. Classification as a LTCH

2\. Hospitals Excluded from the LTCH PPS

C. Transition Period for Implementation of the LTCH PPS

D. Limitation on Charges to Beneficiaries

E. Administrative Simplification Compliance Act (ASCA) and Health
Insurance Portability and Accountability Act (HIPAA) Compliance

II\. Summary of the Provisions of this Proposed Rule

III\. Medicare Severity Long-Term Care Diagnosis-Related Group (LTC‑DRG)
Classifications and Relative Weights

A. Background

B. Patient Classifications into MS-LTC‑DRGs

C. Organization of MS-LTC‑DRGs

D. Method for Updating the MS-LTC-DRG Classifications and Relative
Weights

1\. Background

2\. FY 2008 MS-LTC-DRG Relative Weights

IV\. Proposed Changes to the LTCH PPS Payment Rates and other Proposed
Changes for the 2009 LTCH PPS Rate Year

A. Overview of the Development of the Payment Rates

B. Proposed Consolidation of the Annual Updates for Payment and
MS-LTC-DRG Weights to One Annual Update

C. LTCH PPS Market Basket

1\. Overview of the RPL Market Basket

2\. Market Basket Estimate for the 2009 LTCH PPS Rate Year

D. Discussion of a One-time Prospective Adjustment to the Standard
Federal Rate

E. Proposed Standard Federal Rate for the 2009 LTCH PPS Rate Year

1\. Background

2\. Proposed Standard Federal Rate for the 2009 LTCH PPS Rate Year

F. Calculation of Proposed LTCH Prospective Payments for the 2009 LTCH
PPS Rate Year

1\. Proposed Adjustment for Area Wage Levels

a\. Background

b\. Proposed Updates to the Geographic Classifications/Labor Market Area
Definitions

\(1\) Background

\(2\) Proposed Update to the CBSA-based Labor Market Area Definitions

\(3\) New England Deemed Counties

\(4\) Proposed Codification of the Definitions of urban and rural under
42 CFR Part 412, subpart O

c\. Proposed Labor-Related Share

d\. Proposed Wage Index Data

2\. Proposed Adjustment for Cost‑of‑Living in Alaska and Hawaii

3\. Proposed Adjustment for High‑Cost Outliers (HCOs)

a\. Background

b\. Cost‑to‑Charge Ratios (CCRs)

c\. Establishment of the Fixed-Loss Amount

d\. Application of Outlier Policy to Short‑Stay Outlier (SSO) Cases

4\. Other Proposed Payment Adjustments

5\. Technical Correction to the Budget Neutrality Requirement at
§412.523(d)(2)

G. Proposed Conforming Changes

V. Computing the Proposed Adjusted Federal Prospective Payments for the
2009 LTCH PPS Rate Year

VI\. Monitoring

VII\. Method of Payment

VIII\. RTIs Research

IX\. Collection of Information Requirements

X. Regulatory Impact Analysis

A. Introduction

1\. Executive Order 12866

2\. Regulatory Flexibility Act (RFA)

3\. Impact on Rural Hospitals

4\. Unfunded Mandates

5\. Federalism

6\. Alternatives Considered

B. Anticipated Effects of Proposed Payment Rate Changes

1\. Budgetary Impact

2\. Impact on Providers

3\. Calculation of Prospective Payments

4\. Results

a\. Location

b\. Participation Date

c\. Ownership Control

d\. Census Region

e\. Bed size

5\. Effects on the Medicare Program

6\. Effects on Medicare Beneficiaries

C. Accounting Statement

Regulations Text

Addendum

Table 1: Proposed Long-Term Care Hospital Wage Index for Urban Areas for
Discharges Occurring from July 1, 2008 through September 30, 2009

Table 2: Proposed Long-Term Care Hospital Wage Index for Rural Areas for
Discharges Occurring from July 1, 2008 through September 30, 2009

Table 3: FY 2008 MS-LTC-DRG Relative Weights, Geometric Average Length
of Stay, Short-Stay Outlier Threshold and IPPS-Comparable Threshold (for
Short-Stay Outlier Cases)

**Acronyms**

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

3M 3M Health Information System

AHA American Hospital Association

AHIMA American Health Information Management Association

ALOS Average length of stay

ALTHA Acute Long Term Hospital Association

ASCA Administrative Simplification Compliance Act of 2002 (Pub. L.
107‑105)

BBA Balanced Budget Act of 1997 (Pub. L. 105‑33)

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

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

BLS Bureau of Labor Statistics

BN Budget neutrality

CBSA Core‑based statistical area

CC Complications and comorbidities

CCR Cost‑to‑charge ratio

C&M Coordination and maintenance

CMI Case‑mix index

CMS Centers for Medicare & Medicaid Services

COLA Cost of living adjustment

COP Condition of participation

CPI Consumer Price Index

CY Calendar year

DSH Disproportionate share of low‑income patients

DRGs Diagnosis‑related groups

ECI Employment Cost Index

FI Fiscal intermediary

FY Fiscal year

FFY Federal fiscal year

HCO High‑cost outlier

HCRIS Hospital cost report information system

HHA Home health agency

HHS (Department of) Health and Human Services

HIPAA Health Insurance Portability and Accountability Act (Pub. L.
104‑191)

HIPC Health Information Policy Council

HwHs Hospitals within hospitals

ICD‑9‑CM International Classification of Diseases, Ninth Revision,
Clinical Modification (codes)

IME Indirect medical education

I‑O Input-Output

IPF Inpatient psychiatric facility

IPPS \[Acute Care Hospital\] Inpatient Prospective Payment System

IRF Inpatient rehabilitation facility

LOS Length of stay

LTC‑DRG Long‑term care diagnosis‑related group

LTCH Long‑term care hospital

MAC Medicare Administrative Contractor

MCE Medicare code editor

MDC Major diagnostic categories

MedPAC Medicare Payment Advisory Commission

MedPAR Medicare provider analysis and review

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

MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007 (Pub. L.
110-173)

MSA Metropolitan statistical area

MS‑DRG Medicare severity diagnosis‑related group

MS-LTC‑DRG Medicare severity long‑term care diagnosis‑related group

NAICS North American Industrial Classification System

NALTH National Association of Long Term Hospitals

NCHS National Center for Health Statistics

OACT \[CMS'\] Office of the Actuary

OBRA 86 Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99‑509)

OMB Office of Management and Budget

OPM U.S. Office of Personnel Management

O.R. Operating room

OSCAR Online Survey Certification and Reporting (System)

PIP Periodic interim payment

PLI Professional liability insurance

PMSA Primary metropolitan statistical area

PPI Producer Price Indexes

PPS Prospective payment system

PSF Provider specific file

QIO Quality Improvement Organization (formerly Peer Review organization
(PRO))

RIA Regulatory impact analysis

RPL Rehabilitation psychiatric long-term care (hospital)

RTI Research Triangle Institute, International

RY Rate year (begins July 1 and ends June 30)

SIC Standard industrial code

SNF Skilled nursing facility

SSO Short‑stay outlier

TEFRA Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97‑248)

TEP Technical expert panel

UHDDS Uniform hospital discharge data set

**I. Background**

[A. Legislative and Regulatory Authority]{.underline}

Section 123 of the Medicare, Medicaid, and SCHIP (State Children's
Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106‑113) as amended by section 307(b) of the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
(BIPA) (Pub. L. 106‑554) provides for payment for both the operating and
capital‑related costs of hospital inpatient stays in long‑term care
hospitals (LTCHs) under Medicare Part A based on prospectively set
rates. The Medicare prospective payment system (PPS) for LTCHs applies
to hospitals described in section 1886(d)(1)(B)(iv) of the Social
Security Act (the Act), effective for cost reporting periods beginning
on or after October 1, 2002.

Section 1886(d)(1)(B)(iv)(I) of the Act defines a LTCH as \"a hospital
which has an average inpatient length of stay (as determined by the
Secretary) of greater than 25 days." Section 1886(d)(1)(B)(iv)(II) of
the Act also provides an alternative definition of LTCHs: specifically,
a hospital that first received payment under section 1886(d) of the Act
in 1986 and has an average inpatient length of stay (LOS) (as determined
by the Secretary of Health and Human Services (the Secretary)) of
greater than 20 days and has 80 percent or more of its annual Medicare
inpatient discharges with a principal diagnosis that reflects a finding
of neoplastic disease in the 12‑month cost reporting period ending in
fiscal year (FY) 1997.

Section 123 of the BBRA requires the PPS for LTCHs to be a "per
discharge" system with a diagnosis‑related group (DRG) based patient
classification system that reflects the differences in patient resources
and costs in LTCHs.

Section 307(b)(1) of the BIPA, among other things, mandates that the
Secretary shall examine, and may provide for, adjustments to payments
under the LTCH PPS, including adjustments to DRG weights, area wage
adjustments, geographic reclassification, outliers, updates, and a
disproportionate share adjustment.

In the August 30, 2002 **Federal Register**, we issued a final rule that
implemented the LTCH PPS authorized under BBRA and BIPA (67 FR 55954).
This system uses information from LTCH patient records to classify
patients into distinct MS-long‑term care diagnosis‑related groups
(MS-LTC‑DRGs) based on clinical characteristics and expected resource
needs. Payments are calculated for each MS-LTC‑DRG and provisions are
made for appropriate payment adjustments. Payment rates under the LTCH
PPS are updated annually and published in the **Federal Register**.

The LTCH PPS replaced the reasonable cost‑based payment system under the
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L.
97‑248) for payments for inpatient services provided by a LTCH with a
cost reporting period beginning on or after October 1, 2002. (The
regulations implementing the TEFRA reasonable cost‑based payment
provisions are located at 42 CFR part 413.) With the implementation of
the PPS for acute care hospitals authorized by the Social Security
Amendments of 1983 (Pub. L. 98‑21), which added section 1886(d) to the
Act, certain hospitals, including LTCHs, were excluded from the PPS for
acute care hospitals and were paid their reasonable costs for inpatient
services subject to a per discharge limitation or target amount under
the TEFRA system. For each cost reporting period, a hospital‑specific
ceiling on payments was determined by multiplying the hospital's updated
target amount by the number of total current year Medicare discharges.
(Generally, in this document when we refer to discharges, the intent is
to describe Medicare discharges.) The August 30, 2002 final rule further
details the payment policy under the TEFRA system (67 FR 55954).

In the August 30, 2002 final rule, we also presented an in‑depth
discussion of the LTCH PPS, including the patient classification system,
relative weights, payment rates, additional payments, and the BN
requirements mandated by section 123 of the BBRA. The same final rule
that established regulations for the LTCH PPS under 42 CFR part 412,
subpart O, also contained LTCH provisions related to covered inpatient
services, limitation on charges to beneficiaries, medical review
requirements, furnishing of inpatient hospital services directly or
under arrangement, and reporting and recordkeeping requirements. We
refer readers to the August 30, 2002 final rule for a comprehensive
discussion of the research and data that supported the establishment of
the LTCH PPS (67 FR 55954).

In the June 6, 2003 **Federal Register**, we published a final rule that
set forth the FY 2004 annual update of the payment rates for the
Medicare PPS for inpatient hospital services furnished by LTCHs
(68 FR 34122). It also changed the annual period for which the payment
rates are effective. The annual updated rates are now effective from
July 1 through June 30 instead of from October 1 through September 30.
We refer to the July through June time period as a "long‑term care
hospital rate year" (LTCH PPS rate year). In addition, we changed the
publication schedule for the annual update to allow for an effective
date of July 1. The payment amounts and factors used to determine the
annual update of the LTCH PPS Federal rate are based on a LTCH PPS rate
year. While the LTCH payment rate update is effective July 1, the annual
update of the DRG classifications and relative weights for LTCHs are
linked to the annual adjustments of the acute care hospital inpatient
DRGs and are effective each October 1. []{.mark}

In the Prospective Payment System for Long‑Term Care Hospitals RY 2007:
Annual Payment Rate Updates, Policy Changes, and Clarifications final
rule (71 FR 27798) (hereinafter referred to as the RY 2007 LTCH PPS
final rule), we set forth the 2007 LTCH PPS rate year annual update of
the payment rates for the Medicare PPS for inpatient hospital services
provided by LTCHs. We also adopted the "Rehabilitation, Psychiatric,
Long‑Term Care (RPL)" market basket under the LTCH PPS in place of the
excluded hospital with capital market basket. In addition, we
implemented a zero percent update to the LTCH PPS Federal rate for
RY 2007. We also revised the existing payment adjustment for short stay
outlier (SSO) cases by reducing part of the existing payment formula and
adding a fourth component to that payment formula. We also sunsetted the
surgical DRG exception to the payment policy established under the 3‑day
or less interruption of stay policy. Finally, we clarified the policy at
§412.534(c) for adjusting the LTCH PPS payment so that the LTCH PPS
payment is equivalent to what would otherwise be payable under
§412.1(a).

The Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (Pub.L.
110-173) was enacted on December 29, 2007 and has various effects on the
LTCH PPS. The new law's provisions also have varying time frames of
applicability. First, we note that certain provisions of the MMSEA
provided that Secretary shall not apply, for cost reporting periods
beginning on or after the date of the enactment of the Act (December 29,
2007) for a 3-year period: the extension of payment adjustments at
§412.534 to "grandfathered LTCHs" (a long term care hospital identified
by the amendment made by section 4417(a) of Pub. L. 105‑33); and the
payment adjustment at §412.536 to "freestanding" LTCHs. In addition, the
new law provides that the Secretary shall not apply, for the 3-year
period beginning on the date of enactment of the Act the revision to the
SSO policy at §412.529(c)(3)(i)that was finalized in 72 FR 26904 and
26992 and the one‑time adjustment to the payment rates provided for in
§412.523(d)(3). The statute also provides that the base rate for RY 2008
be the same as the base rate for RY 2007 (the revised base rate,
however, does not apply to discharges occurring on or after July 1, 2007
and before April 1, 2008); for a 3‑year moratorium (with specified
exceptions) on the establishment of new LTCHs, LTCH satellites, and on
the increase in the number of LTCH beds. The new law also revises in the
threshold percentages for certain co-located LTCHs and LTCH satellites
governed under §412.534. Finally, the Act provides for an expanded
review of medical necessity for admission and continued stay at LTCHs.
In this proposed rule we are proposing to establish the applicable
Federal rates for RY 2009 consistent with section 1886(m)(2) of the Act
as amended by MMSEA. We are also proposing to amend our regulations at
§412.523(d)(3) to change the methodology for the one-time budget
neutrality adjustment and to comply with section 114(c)(4) of
Pub. L. 110-173. We intend to address all other policy revisions
necessitated by the statutory changes of the new law in the future.

[B. Criteria for Classification as a LTCH]{.underline}

1\. Classification as a LTCH

Under the existing regulations at §412.23(e)(1) and (e)(2)(i), which
implement section 1886(d)(1)(B)(iv)(I) of the Act, to qualify to be paid
under the LTCH PPS, a hospital must have a provider agreement with
Medicare and must have an average Medicare inpatient LOS of greater than
25 days. Alternatively, §412.23(e)(2)(ii) states that for cost reporting
periods beginning on or after August 5, 1997, a hospital that was first
excluded from the PPS in 1986 and can demonstrate that at least
80 percent of its annual Medicare inpatient discharges in the 12‑month
cost reporting period ending in FY 1997 have a principal diagnosis that
reflects a finding of neoplastic disease must have an average inpatient
LOS for all patients, including both Medicare and non‑Medicare
inpatients, of greater than 20 days.

Section 412.23(e)(3) provides that, subject to the provisions of
paragraphs (e)(3)(ii) through (e)(3)(iv) of this section, the average
Medicare inpatient LOS, specified under §412.23(e)(2)(i) is calculated
by dividing the total number of covered and noncovered days of stay for
Medicare inpatients (less leave or pass days) by the number of total
Medicare discharges for the hospital\'s most recent complete cost
reporting period. Section 412.23 also provides that subject to the
provisions of paragraphs (e)(3)(ii) through (e)(3)(iv) of this section,
the average inpatient LOS specified under §412.23(e)(2)(ii) is
calculated by dividing the total number of days for all patients,
including both Medicare and non‑Medicare inpatients (less leave or pass
days) by the number of total discharges for the hospital's most recent
complete cost reporting period.

In the RY 2005 LTCH PPS final rule (69 FR 25674), we specified the
procedure for calculating a hospital's inpatient average length of stay
(ALOS) for purposes of classification as a LTCH. That is, if a patient's
stay includes days of care furnished during two or more separate
consecutive cost reporting periods, the total days of a patient's stay
would be reported in the cost reporting period during which the patient
is discharged (69 FR 25705). Therefore, we revised §412.23(e)(3)(ii) to
specify that, effective for cost reporting periods beginning on or after
July 1, 2004, in calculating a hospital's ALOS, if the days of an
inpatient stay involve days of care furnished during two or more
separate consecutive cost reporting periods, the total number of days of
the stay are considered to have occurred in the cost reporting period
during which the inpatient was discharged.

Fiscal intermediaries (FIs) verify that LTCHs meet the ALOS
requirements. We note that the inpatient days of a patient who is
admitted to a LTCH without any remaining Medicare days of coverage,
regardless of the fact that the patient is a Medicare beneficiary, will
not be included in the above calculation. Because Medicare would not be
paying for any of the patient's treatment, data on the patient's stay
would not be included in the Medicare claims processing systems. In
order for both covered and noncovered days of a LTCH hospitalization to
be included, a patient admitted to the LTCH must have at least 1
remaining benefit day (68 FR 34123).

The FI\'s determination of whether or not a hospital qualifies as an
LTCH is based on the hospital\'s discharge data from the hospital's most
recent complete cost reporting period as specified in §412.23(e)(3) and
is effective at the start of the hospital's next cost reporting period
as specified in §412.22(d). However, if the hospital does not meet the
ALOS requirement as specified in §412.23(e)(2)(i) or (ii), the hospital
may provide the FI with data indicating a change in the ALOS by the same
method for the period of at least 5 months of the immediately preceding
6‑month period (69 FR 25676). Our interpretation of §412.23(e)(3) was to
allow hospitals to submit data using a period of at least 5 months of
the most recent data from the immediately preceding 6‑month period.

As we stated in the FY 2004 Hospital Inpatient Prospective Payment
System (IPPS) final rule, published in the August 1, 2003 **Federal
Register**, prior to the implementation of the LTCH PPS, we did rely on
data from the most recently submitted cost report for purposes of
calculating the ALOS (68 FR 45464). The calculation to determine whether
an acute care hospital qualifies for LTCH status was based on total days
and discharges for LTCH inpatients. However, with the implementation of
the LTCH PPS, for the ALOS specified under §412.23(e)(2)(i), we revised
§412.23(e)(3)(i) to only count total days and discharges for Medicare
inpatients (67 FR 55970 through 55974). In addition, the ALOS specified
under §412.23(e)(2)(ii) is calculated by dividing the total number of
days for all patients, including both Medicare and non‑Medicare
inpatients (less leave or pass days) by the number of total discharges
for the hospital's most recent complete cost reporting period. As we
discussed in the FY 2004 IPPS final rule, we are unable to capture the
necessary data from our existing cost reporting forms (68 FR 45464).
Therefore, we notified FIs and LTCHs that until the cost reporting forms
are revised, for purposes of calculating the ALOS, we will be relying
upon census data extracted from Medicare Provider Analysis and Review
(MedPAR) files that reflect each LTCH's cost reporting period
(68 FR 45464). Requirements for hospitals seeking classification as
LTCHs that have undergone a change in ownership, as described in
§489.18, are set forth in §412.23(e)(3)(iv).

2\. Hospitals Excluded from the LTCH PPS

The following hospitals are paid under special payment provisions, as
described in §412.22(c), and therefore, are not subject to the LTCH PPS
rules:

● Veterans Administration hospitals.

● Hospitals that are reimbursed under State cost control systems
approved under 42 CFR part 403.

● Hospitals that are reimbursed in accordance with demonstration
projects authorized under section 402(a) of the Social Security
Amendments of 1967 (Pub. L. 90‑248) (42 U.S.C. 1395b‑1) or section
222(a) of the Social Security Amendments of 1972 (Pub. L. 92‑603) (42
U.S.C. 1395b‑1 (note)) (Statewide all‑payer systems, subject to the
rate‑of‑increase test at section 1814(b) of the Act).

● Nonparticipating hospitals furnishing emergency services to Medicare
beneficiaries.

[C. Transition Period for Implementation of the LTCH PPS]{.underline}

In the August 30, 2002 final rule (67 FR 55954), we provided for a
5‑year transition period. During this 5‑year transition period, a LTCH's
total payment under the PPS was based on an increasing percentage of the
Federal rate with a corresponding decrease in the percentage of the LTCH
PPS payment that is based on reasonable cost concepts. However,
effective for cost reporting periods beginning on or after
October 1, 2006, total LTCH PPS payments are based on 100 percent of the
Federal rate.

[D. Limitation on Charges to Beneficiaries]{.underline}

In the August 30, 2002 final rule, we presented an in‑depth discussion
of beneficiary liability under the LTCH PPS (67 FR 55974 through 55975).
In the RY 2005 LTCH PPS final rule (69 FR 25676), we clarified that the
discussion of beneficiary liability in the August 30, 2002 final rule
was not meant to establish rates or payments for, or define
Medicare‑eligible expenses. Under §412.507, if the Medicare payment to
the LTCH is the full LTC‑DRG payment amount, as consistent with other
established hospital prospective payment systems, a LTCH may not bill a
Medicare beneficiary for more than the deductible and coinsurance
amounts as specified under §409.82, §409.83, and §409.87 and for items
and services as specified under §489.30(a). However, under the LTCH PPS,
Medicare will only pay for days for which the beneficiary has coverage
until the SSO threshold is exceeded. Therefore, if the Medicare payment
was for a SSO case (§412.529) that was less than the full LTC‑DRG
payment amount because the beneficiary had insufficient remaining
Medicare days, the LTCH could also charge the beneficiary for services
delivered on those uncovered days (§412.507).

[E. Administrative Simplification Compliance Act (ASCA) and Health
Insurance Portability and Accountability Act (HIPAA)
Compliance]{.underline}

Claims submitted to Medicare must comply with both the Administrative
Simplification Compliance Act (ASCA) (Pub. L. 107‑105), and Health
Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L.
104‑191). Section 3 of the ASCA requires that the Medicare Program deny
payment under Part A or Part B for any expenses incurred for items or
services "for which a claim is submitted other than in an electronic
form specified by the Secretary." Section 1862(h) of the Act (as added
by section 3(a) of the ASCA) provides that the Secretary shall waive
such denial in two specific types of cases and may also waive such
denial "in such unusual cases as the Secretary finds appropriate" (68 FR
48805). Section 3 of the ASCA operates in the context of the HIPAA
regulations, which include, among other provisions, the transactions and
code sets standards requirements codified as 45 CFR parts 160 and 162,
subparts A and I through R (generally known as the Transactions Rule).
The Transactions Rule requires covered entities, including covered
health care providers, to conduct certain electronic healthcare
transactions according to the applicable transactions and code sets
standards.

**II. Summary of the Provisions of this Proposed Rule**

In this proposed rule, we propose to revise the LTCH PPS payment rate
update cycle and make other policy changes and clarifications. The
following is a summary of the major areas that we are addressing in this
proposed rule.

In section III. of this proposed rule, we discuss the LTCH PPS patient
classification and the relative weights which are linked to the annual
adjustments of the acute care hospital inpatient DRG system, and are
based on the annual revisions to the International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD‑9‑CM) codes
effective each October 1. In this section, we also summarize the
severity adjusted MS-LTC-DRGs and the development of the relative
weights for FY 2008 as established in the FY 2008 IPPS final rule with
comment period.

In section IV.B. of this proposed rule, we are proposing to extend the
rate year cycle for RY 2009 to a 15-month period, from July 1, 2008
through September 30, 2009. We would continue to have an update to the
MS‑LTC‑DRG classifications and weights effective for October 1, 2008. We
are proposing to have one consolidated annual update to both the rates
and the classifications and weights beginning October 1, 2009.

As discussed in section IV.E.2. of this proposed rule, we are proposing
a 3.5 percent market basket update to the LTCH PPS Federal rate for the
2009 LTCH PPS rate year based on the most recent market basket estimate
for the proposed 15‑month 2009 LTCH PPS rate year. Also in section IV.
of this proposed rule, we discuss the prospective payment rate for
RY 2009.

In section IV. D. of this proposed rule, we discuss the possible
one-time adjustment to the Federal payment rate under §412.523(d)(3).
Consistent with section 114(c)(4) of Pub. L. 110-173, we are not
proposing any adjustment under §412.523(d)(3). However, at this time, we
are proposing to make a change to the methodology and changes reflecting
the requirements of section 114(c)(4) of Pub. L. 110-173 to the
regulatory text.

In section VI. of this proposed rule, we discuss the proposed updates to
the payment rates, including the proposed revisions to the wage index,
the labor-related share, the cost-of-living adjustment (COLA) factors,
and the outlier threshold, for the 2009 LTCH PPS rate year.

In section IX. of this proposed rule, we discuss our on‑going monitoring
protocols under the LTCH PPS.

In section X. of this proposed rule, we present an update of Research
Triangle Institute's (RTI) analysis relating to the development of LTCH
patient‑and facility-level criteria.

In section XII. of this proposed rule, we analyze the impact of the
proposed changes presented in this proposed rule on Medicare
expenditures, Medicare‑participating LTCHs, and Medicare beneficiaries.

**III. Medicare Severity Long-Term Care Diagnosis-Related Group
(MS-LTC‑DRG) Classifications and Relative Weights**

**\[If you choose to comment on issues in this section, please include
the caption "MS-LTC-DRG CLASSIFICATIONS AND RELATIVE WEIGHTS" at the
beginning of your comments.\]**

# [A. Background]{.underline}

#  Section 123 of the BBRA requires that the Secretary implement a PPS for LTCHs (that is, a per discharge system with a DRG‑based patient classification system reflecting the differences in patient resources and costs). Section 307(b)(1) of the BIPA modified the requirements of section 123 of the BBRA by requiring that the Secretary examine \"the feasibility and the impact of basing payment under such a system (the LTCH PPS) on the use of existing (or refined) hospital DRGs that have been modified to account for different resource use of LTCH patients, as well as the use of the most recently available hospital discharge data.\"

When the LTCH PPS was implemented for cost reporting periods beginning
on or after October 1, 2002, we adopted the same DRG patient
classification system (that is, the CMS DRGs) that was utilized at that
time under the hospital inpatient prospective payment system (IPPS). As
a component of the LTCH PPS, we refer to the patient classification
system as the "LTC‑DRGs." As discussed in greater detail below, although
the patient classification system used under both the LTCH PPS and the
IPPS are the same, the relative weights are different. The established
relative weight methodology and data used under the LTCH PPS result in
LTC-DRG relative weights that reflect "the different resource use of
long-term care hospital patients consistent with the statute".

As part of our efforts to better recognize severity of illness among
patients, in the FY 2008 IPPS final rule with comment period (72 FR
47130), the Medicare Severity diagnosis related groups (MS-DRGs) and the
Medicare Severity long‑term care diagnosis related groups (MS-LTC-DRGs)
were adopted for the IPPS and the LTCH PPS, respectively, effective
October 1, 2007 (FY 2008). For a full description of the development and
implementation of the MS-DRGs and MS‑LTC‑DRGs, see the FY 2008 IPPS
final rule with comment period (72 FR 47141 through 47175 and 47277
through 47299). (We note that in that same final rule, we revised the
regulations at §412.503 to specify that for LTCH discharges occurring on
or after October 1, 2007, when applying the provisions of this subpart
for policy descriptions and payment calculations, all references to
LTC‑DRGs would be considered a reference to MS‑LTC-DRGs. For the
remainder of this section, we present the discussion in terms of the
current MS-LTC-DRG patient classification unless specifically referring
to the previous LTC-DRG patient classification system (that was in
effect before October 1, 2007).) We believe the MS-DRGs (and by
extension, the MS-LTC-DRGs) represent a substantial improvement over the
previous CMS DRGs in their ability to differentiate cases based on
severity of illness and resource consumption.

The MS-DRGs represent an increase in the number of DRGs by 207 (that is,
from 538 to 745) (72 FR 47171). In addition to improving the DRG
system's recognition of severity of illness, we believe the MS-DRGs are
responsive to the public comments that were made on the FY 2007 IPPS
proposed rule with respect to how we should undertake further DRG
reform. The MS-DRGs use the CMS DRGs as the starting point for revising
the DRG system to better recognize resource complexity and severity of
illness. We have generally retained all of the refinements and
improvements that have been made to the base DRGs over the years that
recognize the significant advancements in medical technology and changes
to medical practice.

# In accordance with section 123 of the BBRA as amended by section 307(b)(1) of the BIPA and §412.515, we use information derived from LTCH PPS patient records to classify LTCH discharges into distinct MS-LTC‑DRGs based on clinical characteristics and estimated resource needs. As stated above, the MS‑LTC‑DRGs used as the patient classification component of the LTCH PPS correspond to the hospital inpatient MS‑DRGs in the IPPS. We assign an appropriate weight to the MS‑LTC‑DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCHs. 

# In a departure from the IPPS, we use low volume MS‑LTC‑DRGs (less than 25 LTCH cases) in determining the MS-LTC‑DRG relative weights, since LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. To manage the large number of low volume MS‑LTC‑DRGs (all MS‑LTC‑DRGs with fewer than 25 LTCH cases), for purposes of determining the relative weights, we group low volume MS‑LTC‑DRGs into 5 quintiles based on average charge per discharge. (A detailed discussion of the application of the Lewin Group "quintile" model that was used to develop the LTC‑DRGs appears in the August 30, 2002 LTCH PPS final rule (67 FR 55978).) We also account for adjustments to payments for short-stay outlier (SSO) cases (that is, cases where the covered length of stay (LOS) at the LTCH is less than or equal to five‑sixths of the geometric ALOS for the MS‑LTC‑DRG), and we make adjustments to account for nonmonotonicity, when necessary (as described below in this section). 

# [B. Patient Classifications into MS‑LTC‑DRGs]{.underline}

# Generally, under the LTCH PPS, a Medicare payment is made at a predetermined specific rate for each discharge; that payment varies by the MS-LTC‑DRG to which a beneficiary\'s stay is assigned. Cases are classified into MS-LTC‑DRGs for payment based on the following six data elements:

Principal diagnosis.

Up to eight additional diagnoses.

Up to six procedures performed.

Age.

Sex.

Discharge status of the patient.

Upon the discharge of the patient from a LTCH, the LTCH must assign
appropriate diagnosis and procedure codes from the most current version
of the International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD‑9‑CM). HIPAA Transactions and Code Sets
Standards regulations at 45 CFR parts 160 and 162 require that no later
than October 16, 2003, all covered entities must comply with the
applicable requirements of subparts A and I through R of part 162. Among
other requirements, those provisions direct covered entities to use the
ASC X12N 837 Health Care Claim: Institutional, Volumes 1 and 2, version
4010, and the applicable standard medical data code sets for the
institutional health care claim or equivalent encounter information
transaction (see 45 CFR 162.1002 and 45 CFR 162.1102). For additional
information on the ICD-9-CM Coding System, refer to the FY 2008 IPPS
final rule with comment period (72 FR 47241 through 47243 and 47277
through 47281). We also refer readers to the detailed discussion on
correct coding practices in the August 30, 2002 LTCH PPS final rule
(67 FR 55981 through 55983). Additional coding instructions and examples
are published in the [Coding Clinic for ICD‑9‑CM]{.underline}.

Medicare contractors (that is, fiscal intermediaries (FIs), now called
Medicare Administrative Contractors (MACs)) enter the clinical and
demographic information into their claims processing systems and subject
this information to a series of automated screening processes called the
Medicare Code Editor (MCE). These screens are designed to identify cases
that require further review before assignment into a MS‑LTC‑DRG can be
made. During this process, the following types of cases are selected for
further development:

● Cases that are improperly coded. (For example, diagnoses are shown
that are inappropriate, given the sex of the patient. Code 68.69, Other
and unspecified radical abdominal hysterectomy, would be an
inappropriate code for a male.)

● Cases including surgical procedures not covered under Medicare. (For
example, organ transplant in a non‑approved transplant center.)

● Cases requiring more information. (For example, ICD‑9‑CM codes are
required to be entered at their highest level of specificity. There are
valid 3‑digit, 4‑digit, and 5‑digit codes. That is, code 262, Other
severe protein-calorie malnutrition, contains all appropriate digits,
but if it is reported with either fewer or more than 3 digits, the claim
will be rejected by the MCE as invalid.)

After screening through the MCE, each claim is classified into the
appropriate MS-LTC‑DRG by the Medicare LTCH GROUPER software. The
Medicare GROUPER software, which is used under the LTCH PPS, is
specialized computer software, and is the same GROUPER software program
used under the IPPS. The GROUPER software was developed as a means of
classifying each case into a MS-LTC-DRG on the basis of diagnosis and
procedure codes and other demographic information (age, sex, and
discharge status). Following the MS-LTC-DRG assignment, the Medicare
contractor (FI or MAC) determines the prospective payment amount by
using the Medicare PRICER program, which accounts for hospital‑specific
adjustments. Under the LTCH PPS, we provide an opportunity for the LTCH
to review the MS‑LTC‑DRG assignments made by the Medicare contractor and
to submit additional information within a specified timeframe as
specified in §412.513(c).

The GROUPER software is used both to classify past cases to measure
relative hospital resource consumption to establish the DRG weights and
to classify current cases for purposes of determining payment. The
records for all Medicare hospital inpatient discharges are maintained in
the MedPAR file. The data in this file are used to evaluate possible
MS‑DRG classification changes and to recalibrate the MS-DRG and
MS‑LTC‑DRG relative weights during CMS' annual update under both the
IPPS (§412.60(e)) and the LTCH PPS (§412.517), respectively. As
discussed in greater detail in section III.D. of this preamble, with the
implementation of section 503(a) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108‑173),
there is the possibility that one feature of the GROUPER software
program may be updated twice during a Federal FY (FFY) (October 1 and
April 1) as required by the statute for the IPPS (69 FR 48954 through
48957). Specifically, as we discussed in the FY 2008 IPPS final rule
with comment period (72 FR 47227 through 47278), diagnosis and procedure
codes for new medical technology have the potential to be created and
added to existing MS-DRGs (and MS-LTC-DRGs) in the middle of the FFY on
April 1. New codes would be added to their predecessor MS-DRGs and
MS‑LTC-DRGs; no new MS-DRGs would be created. Additionally, this policy
change will have no effect on the MS-LTC‑DRG relative weights (during
the FY), which will continue to be updated only once a year (October 1),
nor will there be any impact on Medicare payments under the LTCH PPS
during the FY as result of this policy. The use of the ICD‑9‑CM code set
is also compliant with the current requirements of the Transactions and
Code Sets Standards regulations at 45 CFR parts 160 and 162, published
in accordance with HIPAA.

# [C. Organization of the MS‑LTC‑DRGs]{.underline}

The MS-DRGs (used under the IPPS) and the MS-LTC-DRGs (used under the
LTCH PPS) are based on the CMS DRG structure. As noted above in this
section, we refer to the DRGs under the LTCH PPS as MS-LTC-DRGs although
they are structurally identical to the DRGs used under the IPPS. The
MS-DRGs are organized into 25 major diagnostic categories (MDCs), most
of which are based on a particular organ system of the body; the
remainder involve multiple organ systems (such as MDC 22, Burns). Within
most MDCs, cases are then divided into surgical DRGs and medical DRGs.
Surgical DRGs are assigned based on a surgical hierarchy that orders
operating room (O.R.) procedures or groups of O.R. procedures by
resource intensity. The GROUPER software program does not recognize all
ICD‑9‑CM procedure codes as procedures affecting DRG assignment, that
is, procedures which are not surgical (for example, EKG), or minor
surgical procedures (for example, 86.11, Biopsy of skin and subcutaneous
tissue).

In developing Version 25.0 of the GROUPER program (the FY 2008 MS-DRGs),
the diagnoses comprising the CC list were completely redefined. The
revised CC list is primarily comprised of significant acute disease,
acute exacerbations of significant chronic diseases, advanced or end
stage chronic diseases, and chronic diseases associated with extensive
debility. In general, most chronic diseases were not included on the
revised CC list. For a patient with a chronic disease, a significant
acute manifestation of the chronic disease was required to be present
and coded for the patient to be assigned a CC.

In addition to the revision of the CC list, each CC was also categorized
as a major CC (MCC) or a CC based on relative resource use.
Approximately 12 percent of all diagnoses codes were classified as a
major CC (MCC), 24 percent as a CC, and 64 percent as a non CC.
Diagnoses closely associated with mortality (ventricular fibrillation,
cardiac arrest, shock, and respiratory arrest) were assigned as an MCC
if the patient lived but as a non CC if the patient died.

The MCC, CC, and non CC categorization was used to subdivide the
surgical and medical DRGs into up to three levels, with a case being
assigned to the most resource intensive level (for example, a case with
two secondary diagnoses that are categorized as an MCC and a CC is
assigned to the MCC level). To create the MS-DRGs (and by extension, the
MS-LTC-DRGs) individual DRGs were subdivided into three, two, or one
level, depending on the CC impact on resources used for those cases.

As noted above in this section, further information on the development
and implementation of the MS-DRGs and MS-LTC-DRGs can be found in the FY
2008 IPPS final rule with comment period (72 FR 47138 through 47175 and
47277 through 47299).

[D. Method for Updating the MS-LTC-DRG Classifications and Relative
Weights]{.underline}

1\. Background

Under the LTCH PPS, relative weights for each MS-LTC‑DRG are a primary
element used to account for the variations in cost per discharge and
resource utilization among the payment groups (that is, the
MS-LTC‑DRGs). To ensure that Medicare patients classified to each
MS-LTC‑DRG have access to an appropriate level of services and to
encourage efficiency, each year based on the best available data, we
calculate a relative weight for each MS-LTC‑DRG that represents the
resources needed by an average inpatient LTCH case in that MS-LTC‑DRG.
For example, cases in a MS-LTC‑DRG with a relative weight of 2 will, on
average, cost twice as much as cases in a MS-LTC‑DRG with a relative
weight of 1. Under §412.517, the MS-LTC‑DRG classifications and
weighting factors (that is, relative weights) are adjusted annually to
reflect changes in factors affecting the relative use of LTCH resources,
including treatment patterns, technology and number of discharges.

In the June 6, 2003 LTCH PPS final rule (68 FR 34122 through 34125), we
changed the LTCH PPS annual payment rate update cycle to be effective
July 1 through June 30 instead of October 1 through September 30. In
addition, because the patient classification system utilized under the
LTCH PPS is the same DRG system that is used under the IPPS, in that
same final rule, we explained that the annual update of the LTC‑DRG
classifications and relative weights will continue to remain linked to
the annual reclassification and recalibration of the CMS DRGs used under
the IPPS (as is the case with the MS-DRGs effective for discharges
occurring on or after October 1, 2007 (see §412.503)). Therefore, we
specified that we will continue to update the LTC-DRG classifications
and relative weights to be effective for discharges occurring on or
after October 1 through September 30 each year. We further stated at
that time that we will publish the annual proposed and final update of
the LTC‑DRGs in same notice as the proposed and final update for the
IPPS (69 FR 34125). (We note that in section IV.B. of this preamble, we
are proposing to revise §412.535 in order to consolidate the annual July
1 and October 1 LTCH PPS update cycles, so that beginning with FY 2010,
both the annual update to the standard Federal rate (and other rate and
policy changes) and the annual update to the MS‑LTC‑DRGs would be
presented in a single **Federal Register** publication to be effective
on October 1 each year.) Under existing §412.535(b), the FY 2008 update
of the LTCH PPS patient classification system and relative weights was
presented in the FY 2008 IPPS final rule with comment (72 FR 47277
through 47299). For the reader's benefit, we are providing a summary of
the discussion presented in that final rule with comment in section
III.D.2. of this preamble.

For FY 2008, the MS-LTC‑DRG classifications and relative weights were
updated based on LTCH data from the FY 2006 MedPAR file, which contained
hospital bills data from the March 2007 update. The MS-LTC‑DRG patient
classification system for FY 2008 consists of 745 DRGs that formed the
basis of the Version 25.0 GROUPER program utilized under the LTCH PPS.
The 745  MS‑LTC‑DRGs included two "error DRGs." As in the IPPS, we
included two error DRGs in which cases that cannot be assigned to valid
DRGs will be grouped. These two error DRGs are MS‑LTC‑DRG 998 (Principal
Diagnosis Invalid as a Discharge Diagnosis) and MS-LTC‑DRG 999
(Ungroupable). The other 743 MS‑LTC‑DRGs are the same DRGs used in the
IPPS GROUPER program for FY 2008 (Version 25.0).

In the past, the annual update to the CMS DRGs was based on the annual
revisions to the ICD‑9‑CM codes and was effective each October 1. The
ICD‑9‑CM coding update process was revised as discussed in greater
detail in the FY 2005 IPPS final rule (69 FR 48953 through 48957).
Specifically, section 503(a) of the MMA includes a requirement for
updating diagnosis and procedure codes twice a year instead of the
former process of annual updates on October 1 of each year. This
requirement is included as part of the amendments to the Act relating to
recognition of new medical technology under the IPPS. (For additional
information on this provision, including its implementation and its
impact on the LTCH PPS, refer to the FY 2005 IPPS final rule
(69 FR 48953 through 48957) and the RY 2006 LTCH PPS final rule
(70 FR 24172 through 24177).) As noted above in this section, with the
implementation of section 503(a) of the MMA, there is the possibility
that one feature of the GROUPER software program may be updated twice
during a FFY (October 1 and April 1) as required by the statute for the
IPPS. Specifically, diagnosis and procedure codes for new medical
technology may be created and added to existing DRGs in the middle of
the FFY on April 1. No new MS-LTC‑DRGs will be created or deleted.
Consistent with our current practice, any changes to the MS-DRGs or
relative weights will be made at the beginning of the next FFY
(October 1). Therefore, there will not be any impact on MS-LTC‑DRG
payments under the LTCH PPS until the following October 1 (although the
new ICD‑9‑CM diagnosis and procedure codes would be recognized April 1).

As we explained in the FY 2008 IPPS final rule with comment period
(72 FR 47277), annual changes to the ICD‑9‑CM codes historically were
effective for discharges occurring on or after October 1 each year.
Thus, the manual and electronic versions of the GROUPER software, which
are based on the ICD‑9‑CM codes, were also revised annually and
effective for discharges occurring on or after October 1 each year. The
patient classification system used under the LTCH PPS (MS-LTC‑DRGs) is
the same DRG patient classification system used under the IPPS, which
historically had been updated annually and was effective for discharges
occurring on or after October 1 through September 30 each year. We have
also explained that since we do not publish a mid‑year IPPS rule, we
will assign any new diagnosis or procedure codes implemented on April 1
to the same DRG in which its predecessor code was assigned, so that
there will be no impact on the DRG assignments until the following
October 1. Any coding updates will be available through the Web sites
provided in section II.G.10. of the preamble of the FY 2008 IPPS final
rule with comment period (72 FR 47241 through 47243) and through the
Coding Clinic for ICD‑9‑CM. Publishers and software vendors currently
obtain code changes through these sources to update their code books and
software system. If new codes are implemented on April 1, revised code
books and software systems, including the GROUPER software program, will
be necessary because we must use current ICD‑9‑CM codes. Therefore, for
purposes of the LTCH PPS, because each ICD‑9‑CM code must be included in
the GROUPER algorithm to classify each case into a MS-LTC‑DRG, the
GROUPER software program used under the LTCH PPS would need to be
revised to accommodate any new codes.

At the September 2007 ICD‑9‑CM C&M Committee meeting, there were no
compelling requests for an April 1, 2008 implementation of new ICD‑9‑CM
codes, and therefore, we expect that the next update to the ICD‑9‑CM
coding system will not occur until October 1, 2008 (FY 2009). Therefore,
we expect that the ICD‑9‑CM coding set implemented on October 1, 2007,
will continue through September 30, 2008 (FY 2008). The next update to
the MS-LTC‑DRGs and relative weights for FY 2009 will be presented in
the FY 2009 IPPS proposed and final rules.

[2. FY 2008 MS-LTC‑DRG Relative Weights]{.underline}

In accordance with §412.523(c), we adjust the LTCH PPS standard Federal
rate by the MS-LTC‑DRG relative weights in determining payment to LTCHs
for each case. Relative weights for each MS-LTC‑DRG are a primary
element used to account for the variations in cost per discharge and
resource utilization among the payment groups as described in §412.515.
To ensure that Medicare patients who are classified to each MS-LTC‑DRG
have access to services and to encourage efficiency, we calculate a
relative weight for each MS-LTC‑DRG that represents the resources needed
by an average inpatient LTCH case in that MS-LTC‑DRG. For example, cases
in a MS-LTC‑DRG with a relative weight of 2 will, on average, cost twice
as much as cases in a MS-LTC‑DRG with a weight of 1.

As we discussed in the FY 2008 IPPS final rule with comment period
(72 FR 47282), the MS-LTC‑DRG relative weights effective under the LTCH
PPS for Federal FY 2008 were calculated using the March 2007 update of
FY 2006 MedPAR data and Version 25.0 of the GROUPER software.

LTCHs often specialize in certain areas, such as ventilator‑dependent
patients and rehabilitation or wound care. Some case types (DRGs) may be
treated, to a large extent, in hospitals that have (from a perspective
of charges) relatively high (or low) charges. Distribution of cases with
relatively high (or low) charges in specific MS-LTC‑DRGs has the
potential to inappropriately distort the measure of average charges. To
account for the fact that cases may not be randomly distributed across
LTCHs, we use a hospital‑specific relative value (HSRV) method to
calculate relative weights. We believe this method removes this
hospital‑specific source of bias in measuring average charges.
Specifically, we reduce the impact of the variation in charges across
providers on any particular MS‑LTC‑DRG relative weight by converting
each LTCH's charge for a case to a relative value based on that LTCH's
average charge. (See the FY 2008 IPPS final rule with comment period for
further information on the application of the HSRV methodology under the
LTCH PPS (72 FR 47282).)

To account for MS-LTC‑DRGs with low volume (that is, with fewer than
25 LTCH cases), we grouped those "low volume" MS‑LTC‑DRGs into 1 of 5
categories (quintiles) based on average charges for the purposes of
determining relative weights. Each of the low volume MS-LTC‑DRGs grouped
to a specific quintile received the same relative weight and ALOS using
the formula applied to the regular MS-LTC‑DRGs (25 or more cases). (See
the FY 2008 IPPS final rule with comment period for further explanation
of the development and composition of each of the 5 low volume quintiles
for FY 2008 (72 FR 47283 through 47288).)

After grouping the cases in the appropriate MS‑LTC‑DRG, generally, we
calculated the relative weights by first removing statistical outliers
and cases with a LOS of 7 days or less. Next, we adjusted the number of
cases remaining in each MS‑LTC‑DRG for the effect of SSO cases under
§412.529. The short‑stay adjusted discharges and corresponding charges
were used to calculate "relative adjusted weights" in each MS-LTC‑DRG
using the HSRV method. In determining the FY 2008 MS-LTC-DRG relative
weights, we also made adjustments, as necessary, to adjust for
nonmonotonicity for the severity levels within a specific base
MS-LTC-DRG. (Refer to the FY 2008 IPPS final rule with comment period
for further information on the treatment of severity levels and
adjustments for nonmonotically increasing relative weights for FY 2008
(72 FR 47282 through 47283 and 47293 through 47295).) Furthermore, we
determined FY 2008 MS‑LTC-DRG relative weights for the 185 MS-LTC‑DRGs
for which there were no LTCH cases in the database (that is, LTCH claims
from the FY 2006 LTCH MedPAR files). (A list of the FY 2008 "no‑volume"
MS-LTC‑DRGs and further explanation of their FY 2008 relative weight
assignment can be found in the FY 2008 IPPS final rule with comment
period (72 FR 47289 through 47293).)

In adopting the MS-LTC-DRGs beginning in FY 2008, we established a
2-year transition. Specifically, for FY 2008, the first year of the
transition, 50 percent of the relative weight for a MS-LTC-DRG is based
on the average LTC-DRG relative weight under Version 24.0 of the LTC-DRG
GROUPER. The remaining 50 percent of the relative weight is based on the
MS-LTC-DRG relative weight under Version 25.0 of the MS‑LTC-DRG GROUPER.
(See the FY 2008 IPPS final rule with comment period (72 FR 47295) for
additional details on the methodology used to determine the transition
blended MS-LTC-DRG relative weights for FY 2008.)

In the RY 2008 LTCH PPS final rule (72 FR 26882), under the broad
authority conferred upon the Secretary under section 123 of
Pub. L. 106-113 as amended by section 307(b) of Pub. L. 106‑554 to
develop the LTCH PPS, we established that beginning with the update for
FY 2008, the annual update to the MS‑LTC-DRG classifications and
relative weights will be done in a budget neutral manner such that
estimated aggregate LTCH PPS payments would be unaffected, that is,
would be neither greater than nor less than the estimated aggregate LTCH
PPS payments that would have been made without the MS‑LTC-DRG
classification and relative weight changes. Historically, we had not
updated the LTC‑DRGs in a budget neutral manner because we believed that
past fluctuations in the relative weights were primarily due to changes
in LTCH coding practices rather than changes in patient severity. In
light of the most recently available LTCH claims data at that time,
which indicated that LTCH claims data no longer appeared to
significantly reflect changes in LTCH coding practices in response to
the implementation of the LTCH PPS, we believed that, beginning with FY
2008, it is appropriate to update the MS-LTC-DRGs in a budget neutral
manner (that is, so that estimated aggregate LTCH PPS payments will
neither increase nor decrease). Accordingly, in that same final rule
with comment period, we established under §412.517(b) that the annual
update to the MS-LTC-DRG classifications and relative weights be done in
a budget neutral manner. (As noted above in section III.A. of this
preamble, we revised the regulations at §412.503 to specify that
"MS-LTC-DRG" is used in place of "LTC-DRG" for discharges occurring on
or after October 1, 2007.) Consistent with that provision, we updated
the MS‑LTC-DRG classifications and relative weights for FY 2008 based on
the most recent available data and included a budget neutrality
adjustment. For further details on the methodology and calculation of
the FY 2008 MS-LTC-DRG budget neutrality factor, refer to the FY 2008
IPPS final rule with comment period (72 FR 47295 through 47296).

Table 11 of the Addendum to the FY 2008 IPPS final rule with comment
period lists the MS‑LTC‑DRGs and their respective transition blended
budget neutral relative weights, geometric mean LOS, "short‑stay outlier
threshold" (that is, five‑sixths of the geometric mean LOS), and the
"IPPS Comparable Threshold" (that is, the IPPS geometric average length
of stay plus one standard deviation) for each MS-LTC-DRG for FY 2008
(see (72 FR 48143 through 48157), and the technical correction made in
the October 10, 2007 correction notice (72 FR 57733), which has been
reprinted in Table 3 of the Addendum of this for convenience).

As we noted previously in this section, there were no new ICD‑9‑CM code
requests for an April 1, 2008 update. Therefore, we expect that Version
25.0 of the MS-DRG GROUPER software established in the FY 2008 IPPS
final rule with comment period will continue to be effective until
October 1, 2008. Moreover, the MS-LTC‑DRGs and relative weights for
FY 2008 established in Table 11 of that same IPPS final rule with
comment period (78 FR 48143 through 48157) will continue to be effective
until October 1, 2008, (just as they would have been even if there had
been any new ICD‑9‑CM code requests for an April 1, 2008 update). We
note that Table 11 was corrected in the FY 2008 IPPS correction notice
that appeared in the October 10, 2007 **Federal Register** (72 FR 57733)
and is hereinafter referred to as the second FY 2008 IPPS correction
notice. Accordingly, Table 3 in the Addendum of this proposed rule lists
the MS‑LTC‑‑RGs and their respective relative weights, geometric ALOS,
"Short-Stay Outlier Threshold" and "IPPS Comparable Threshold" that we
will continue to use for the period of July 1, 2008 through
September 30, 2009. (As noted above, this table is the same as Table 11
of the Addendum to the FY 2008 IPPS final rule with comment period,
including the technical correction made in the second FY 2008 IPPS
correction notice (72 FR 57733), which has been reprinted in Table 3 of
the Addendum of this proposed rule for the reader's convenience.) We
expect the next update to the ICD‑9‑CM coding system to be presented in
the FY 2009 IPPS proposed rule (since we expect that there will be no
April 1, 2008 updates to the ICD‑9‑CM coding system). In addition, the
proposed MS-DRGs and GROUPER for FY 2009 that would be used for the IPPS
and the LTCH PPS, effective October 1, 2008, and the proposed update to
the MS-LTC-DRG relative weights for FY 2009 will be presented in the
IPPS FY 2009 proposed rule that will be published in the **Federal
Register**.

**IV. Proposed Changes to the LTCH PPS Payment Rates and other Proposed
Changes for the 2009 LTCH PPS Rate Year**

**\[If you choose to comment on issues in this section, please include
the caption "PROPOSED CHANGES TO LTCH PPS PAYMENT RATES FOR THE 2009
LTCH PPS RATE YEAR" at the beginning of your comments.\]**

[A. Overview of the Development of the Payment Rates]{.underline}

The LTCH PPS was effective beginning with a LTCH's first cost reporting
period beginning on or after October 1, 2002. Effective with that cost
reporting period, LTCHs are paid, during a 5‑year transition period, a
total LTCH prospective payment that is comprised of an increasing
proportion of the LTCH PPS Federal rate and a decreasing proportion
based on reasonable cost‑based principles, unless the hospital makes a
one‑time election to receive payment based on 100 percent of the Federal
rate, as specified in §412.533. New LTCHs (as defined at §412.23(e)(4))
are paid based on 100 percent of the Federal rate, with no phase‑in
transition payments.

The basic methodology for determining LTCH PPS Federal prospective
payment rates is set forth at §412.515 through §412.536. In this
section, we discuss the proposed factors that would be used to update
the LTCH PPS standard Federal rate for the 2009 LTCH PPS rate year that
would be effective for LTCH discharges occurring on or after
July 1, 2008 through September 30, 2009. When we implemented the LTCH
PPS in the August 30, 2002 LTCH PPS final rule (67 FR 56029 through
56031), we computed the LTCH PPS standard Federal payment rate for
FY 2003 by updating the best latest available (FY 1998 or FY 1999)
Medicare inpatient operating and capital cost data, using the excluded
hospital market basket.

Section 123(a)(1) of the BBRA requires that the PPS developed for LTCHs
be budget neutral for the initial year of implementation. Therefore, in
calculating the standard Federal rate under §412.523(d)(2), we set total
estimated LTCH PPS payments equal to estimated payments that would have
been made under the reasonable cost‑based payment methodology had the
LTCH PPS not been implemented. Section 307(a)(2) of the BIPA specified
that the increases to the target amounts and the cap on the target
amounts for LTCHs for FY 2002 provided for by section 307(a)(1) of the
BIPA shall not be considered in the development and implementation of
the LTCH PPS. Section 307(a)(2) of the BIPA also specified that enhanced
bonus payments for LTCHs provided for by section 122 of Pub. L. 106-113
were not to be taken into account in the development and implementation
of the LTCH PPS.

Furthermore, as specified at §412.523(d)(1), the standard Federal rate
is reduced by an adjustment factor to account for the estimated
proportion of outlier payments under the LTCH PPS to total estimated
LTCH PPS payments (8 percent). For further details on the development of
the FY 2003 standard Federal rate, see the August 30, 2002 LTCH PPS
final rule (67 FR 56027 through 56037), and for subsequent updates to
the LTCH PPS Federal rate, refer to the following final rules: RY 2004
LTCH PPS final rule (68 FR 34134 through 34140), RY 2005 LTCH PPS final
rule (69 FR 25682 through 25684), RY 2006 LTCH PPS final rule
(70 FR 24179 through 24180), RY 2007 LTCH PPS final rule (71 FR 27819
through 27827), and RY 2008 LTCH PPS final rule (72 FR 26870 through
27029).

[B. Proposed Consolidation of the Annual Updates for Payment and
MS-LTC-DRG Relative Weights to One Annual Update]{.underline}

In the August 30, 2002 final rule for the implementation of the LTCH
PPS, we established a publication schedule at §412.535 for publishing
information pertaining to the LTCH PPS. That schedule set a publication
date of on or before August 1 prior to the beginning of each FFY, which
coincided with the statutorily mandated publication schedule for the
IPPS (67 FR 55954). In the June 6, 2003 LTCH PPS final rule, we amended
§412.535. to provide that "(a) Information on the unadjusted Federal
payment rates and a description of the methodology and data used to
calculate the payment rates are published on or before May 1 prior to
the start of each long-term care hospital prospective payment system
rate year which begins July 1, unless for good cause it is published
after May 1, but before June 1. (b) Information on the LTC-DRG
classification and associated weighting factors is published on or
before August 1 prior to the beginning of each Federal fiscal year." At
the time, we explained that the LTC-DRG patient classifications used by
the LTCH PPS for FY 2003 are based directly on the same version of DRGs
used by the IPPS, that is, Grouper 20 (68 FR 34126). (We note, as
discussed above in section III of this proposed rule, effective for LTCH
PPS discharges occurring on or after October 1, 2007, all references to
LTC-DRGs and DRGs in the existing regulations are understood to
represent MS‑LTC‑DRGs. (See §412.503.)) Therefore, we did not make any
changes to the timing for the annual update for LTC-DRG classifications
and relative weights. The annual update to the DRG classifications and
relative weights continues to be published on a FFY cycle, as is the
update of the acute care hospital IPPS DRG system. Our intent in making
the change in the payment rate update schedule for the LTCH PPS was to
avoid concurrent publications of the annual updates for these two
significant payment systems for purposes of administrative feasibility
and efficiency. With this in mind, we changed the effective date for the
annual update of the LTCH PPS payment rate from October 1 to July 1 of
each year beginning with July 1, 2003. We believed this change would
help use our limited resources effectively and facilitate a timely
publication of both the IPPS and LTCH PPS proposed and final rules.
Thus, currently the annual update of the LTCH PPS Federal rates do not
coincide with the start of the FFY, but rather, are effective prior to
the FFY.

In this proposed rule, we are proposing a change to the current schedule
for the annual updates of the LTCH PPS Federal payment rates. We propose
to consolidate the rulemaking cycle for the annual update of the LTCH
PPS Federal payment rates and description of the methodology and data
used to calculate these payment rates, with the annual updating of the
MS-LTC-DRG classifications and associated weighting factors for LTCHs so
that the updates to the rates and the weights would both be effective on
October 1 each FFY. Under this proposal, the annual updates to the LTCH
PPS Federal rates would no longer be published with a July 1 effective
date.

In proposing this change to the LTCH PPS rulemaking schedule, we took
into account comments on prior rules as well as recent input from the
LTCH industry. After further considering those comments and concerns, we
agree that having the effective date of the annual update of the LTCH
PPS Federal payment rates on July 1 of each year while retaining the
October 1 effective date for updating LTC-DRG classifications and
weights has proved both burdensome and time-consuming for all parties
involved. Although a consolidated update may also be resource intensive,
it would eliminate some duplicative resource use. For example, some of
our resources used for the payment simulations that are used to estimate
LTCH PPS payments for purposes of the respective impact analyses are
duplicated for the annual LTCH PPS rate update and the annual MS-LTC-DRG
update. Moreover, we understand the concern that there are increased
costs involved in updating the billing systems of LTCHs to accommodate
two separate updates, one for the Federal rate and one for the DRG
weights, in the same cost reporting period.

We also the considered the possibility that two separate updates could
increase the potential for calculating payment errors under the LTCH
PPS.

In order to revise the payment rate update to an October 1 through
September 30 period, we propose to first extend the 2009 rate period to
September 30, 2009 such that RY 2009 would be 15 months. This proposed
15-month rate period would extend from July 1, 2008 through September
30, 2009. We believe that the additional 3 months to RY 2009 (July,
August and September), would provide for a smooth transition to a
consolidated annual update for both the LTCH PPS payment rates and the
LTCH PPS MS-LTC-DRG classifications and weighting factors. (We believe
that proposing to revise the payment rate update to an October 1 through
September 30 period by proposing to shorten RY 2009 such that it would
only be 3 months (that is, July 1, 2008 through September 30, 2008),
would exacerbate the current burdensome and time-consuming biannual
update process by resulting in two payment rate changes within a very
short (3 month) period of time.) Under this proposal, after the 2009
rate period, the rate period for the LTCH PPS payment rate and other
policy changes would be October 1 through September 30. (The annual
update to the MS-LTC-DRG classifications and relative weights would
continue to be effective on October 1.) The October through September
rate period would first begin with October 1, 2009. The next update to
the LTCH PPS Federal rates after RY 2009 would be for RY 2010. (We note
that if we finalize this proposal to move the annual LTCH PPS rate
update cycle to October 1 effective October 1, 2009, the LTCH PPS rate
year would coincide with Federal FY beginning in 2010.) We are proposing
to make a change to the regulations at §412.503 to redefine the LTCH
PPS' rate year to mean October 1 through September 30. We are also
proposing to revise §412.535 to reflect the proposed change to the
annual payment rate update cycle described above. The discussion of the
proposed 15‑month market basket update for the proposed 2009 rate year
can be found below in sections IV.D.2. and 3.of this proposed rule.

[C. LTCH PPS Market Basket]{.underline}

1\. Overview of the RPL Market Basket

Historically, the Medicare program has used a market basket to account
for price increases in the services furnished by providers. The market
basket used for the LTCH PPS includes both operating and capital‑related
costs of LTCHs because the LTCH PPS uses a single payment rate for both
operating and capital‑related costs. The development of the initial LTCH
PPS standard Federal rate for FY 2003, using the excluded hospital with
capital market basket, is discussed in further detail in the
August 30, 2002 LTCH PPS final rule (67 FR 56027 through 56033).

In the August 30, 2002 final rule (67 FR 56016 through 56017 and 56030),
which implemented the LTCH PPS, we established the use of the excluded
hospital with capital market basket as the LTCH PPS market basket. The
excluded hospital with capital market basket was also used to update the
limits on LTCHs' operating costs for inflation under the TEFRA
reasonable cost‑based payment system. We explained that we believe the
use of the excluded hospital with capital market basket to update LTCHs'
costs for inflation was appropriate because the excluded hospital market
basket (with a capital component) measures price increases of the
services furnished by excluded hospitals, including LTCHs. For further
details on the development of the excluded hospital with capital market
basket, see the RY 2004 LTCH PPS final rule (68 FR 34134 through 34137).

In the RY 2007 LTCH PPS final rule (71 FR 27810), we noted that based on
our research, we did not develop a market basket specific to LTCH
services. We are still unable to create a separate market basket
specifically for LTCHs due to the small number of facilities and the
limited amount of data that is reported (for instance, only
approximately 15 percent of LTCHs reported contract labor cost data for
2002). In that same final rule, under the broad authority conferred upon
the Secretary by section 123 of the BBRA as amended by section 307(b) of
the BIPA, we adopted the "Rehabilitation, Psychiatric and Long‑Term Care
(RPL) market basket" as the appropriate market basket of goods and
services under the LTCH PPS for discharges occurring on or after
July 1, 2006. Specifically, beginning with the 2007 LTCH PPS rate year,
for the LTCH PPS, we adopted the use of the RPL market basket based on
FY 2002 cost report data. We choose to use the FY 2002 Medicare cost
report data because it was the most recent, relatively complete cost
data for inpatient rehabilitation facilities (IRFs), inpatient
psychiatric facilities (IPF), and LTCHs available at the time of
rebasing.

The RPL market basket is determined based on the operating and capital
costs of IRFs, IPFs and LTCHs. All IRFs are now paid under the IRF PPS
Federal payment rate, all LTCHs are now paid 100 percent of the Federal
rate under the LTCH PPS, and most IPFs are transitioning to payment
based on 100 percent of the Federal per diem payment amount under the
IPF PPS (payments to IPFs will be based exclusively on 100 percent of
the Federal rate for cost reporting periods beginning on or after
January 1, 2008). As we explained in that same final rule, we believe a
market basket based on the data of IRFs, IPFs and LTCHs is appropriate
to use under the LTCH PPS since it is the best available data that
reflects the cost structures of LTCHs.

For further details on the development of the RPL market basket,
including the methodology for determining the operating and capital
portions of the RPL market basket, see the RY 2007 LTCH PPS final rule
(71 FR 27810 through 27817).

2\. Proposed Market Basket Estimate for the 2009 LTCH PPS Rate Year

As discussed in greater detail above in this section, for the 2009 LTCH
PPS rate year, we are proposing to consolidate the current LTCH PPS rate
year (payment rates and other policy changes) update and fiscal year
MS-LTC-DRG update into one annual update cycle. Presently, the next
payment rate update cycle would be effective July 1, 2008 through June
30, 2009. In proposing to consolidate the annual payment rate and
MS-LTC-DRG updates to be effective October 1 each year, we would extend
the next rate year update by 3 months (through September 30, 2009),
which would make the RY 2009 rate effective for a 15-month period.
Accordingly, for the proposed 2009 LTCH PPS rate year, we are proposing
to use a 15-month (that is, July 1, 2008 through September 30, 2009)
estimate of the RPL market basket based on the best available data.

Consistent with our historical practice, we estimate the RPL market
basket update based on Global Insight, Inc.'s forecast using the most
recent available data. Global Insight, Inc. is a nationally recognized
economic and financial forecasting firm that contracts with CMS to
forecast the components of CMS' market baskets. To determine a 15‑month
market basket update for RY 2009, we calculate the 5‑quarter moving
average index level for July 1, 2008 through September 30, 2009 and the
4‑quarter moving average index level for July 1, 2007 through June 30,
2008. The percent change in these two values represents the proposed
15‑month market basket update.

Based on Global Insight's 4th quarter 2007 forecast with history through
the 3rd quarter of 2007, the projected 15-month market basket estimate
for the proposed 15-month 2009 LTCH PPS rate year is 3.5 percent.
Therefore, consistent with our historical practice of estimating market
basket increases based on the best available data, we are proposing a
market basket update of 3.5 percent for the proposed 15‑month 2009 rate
year based on the proposed consolidation of the annual updates for
payment rates and MS-LTC-DRGs. Furthermore, because the proposed RY 2009
update is based on the most recent market basket estimate for the
15-month period (currently 3.5 percent), we are also proposing that if
more recent data are subsequently available (for example, a more recent
estimate of the market basket), we would use such data, if appropriate,
to determine the RY 2009 update in the final rule. (The proposed update
to the standard Federal rate for RY 2009 is discussed below in section
IV.E. of this preamble.)

We note that the most recent estimate of the RPL market basket for
July 1, 2008 through June 30, 2009, based on Global Insight's 4th
quarter 2007 forecast with history through the 3rd quarter of 2007, is
3.1 percent. We determine this 12‑month market basket update by
calculating the 4‑quarter moving average index level for July 1, 2008
through June 30, 2009 and the 4‑quarter moving average index level for
July 1, 2007 through June 30, 2008. The percent change in these two
values represents the proposed 12‑month market basket update. Consistent
with our historical practice of using market basket estimates based on
the most recent available data, if we were not proposing to consolidate
the two annual LTCH PPS payment system updates by proposing to extend
the 2009 LTCH PPS rate year by 3 months, we would have proposed a market
basket update for a 12 month RY 2009 of 3.1 percent, based on the most
recent estimate of the 12-month RPL market basket for July 1, 2008
through June 30, 2009.

[D. One-time Prospective Adjustment to the Standard Federal
Rate]{.underline}

As we discussed in the August 30, 2002 LTCH PPS final rule
(67 FR 56027), consistent with the statutory requirement for budget
neutrality in section 123(a)(1) of the BBRA, we estimated aggregate
payments under the LTCH PPS for FY 2003 to be equal to the estimated
aggregate payments that would be made if the LTCH PPS were not
implemented. Our methodology for estimating payments for purposes of the
budget neutrality calculations used the best available data at the time
and necessarily reflected several assumptions (for example, costs,
inflation factors and intensity of services provided). In conducting our
budget neutrality calculations, we took into account the statutory
requirement that certain statutory provisions that affect the level of
payments to LTCHs in years prior to the implementation of the LTCH PPS
shall not be taken into account in the development and implementation of
the LTCH PPS. Specifically, section 307(a)(2) of the BIPA requires that
the increases to the target amounts and the increases to the cap on the
target amounts for LTCHs provided for by section 307(a)(1) of the BIPA
(as set forth in section 1886(b)(3)(J) of the Act) and the enhanced
bonus payments for LTCHs provided for by section 122 of the BBRA (as set
forth in section 1886(b)(2)(E) of the Act) are not to be taken into
account in the development and implementation of the LTCH PPS.

As the LTCH PPS has progressed, we have been monitoring payment data in
order to evaluate whether there is a significant difference between the
payments estimated on the basis of the data available at the time of the
August 30, 2002 LTCH PPS final rule(67 FR 56027 through 56037) and
payment estimates based on more complete data that have become available
since that time. We indicated from the inception of the LTCH PPS that it
was possible for the aggregate amount of actual payments in FY 2003 to
be significantly higher or lower than the estimates on which the budget
neutrality calculations were based to the extent that later, more
complete data differ significantly from the data that were available at
the time of the original calculations.

Section 123(a)(1) of the BBRA, as amended by section 307(b) of BIPA,
provides broad authority to the Secretary in developing the LTCH PPS,
including the authority for establishing appropriate adjustments. Under
this broad authority to make appropriate adjustments, we provided in
§412.523(d)(3) of the regulations, for the possibility of making a
one‑time prospective adjustment to the LTCH PPS rates by July 1, 2008,
so that the effect of any significant difference between actual payments
and estimated payments for the first year of the LTCH PPS would not be
perpetuated in the LTCH PPS rates for future years.

In the RY 2008 LTCH PPS final rule (72 FR 26902), based on the best
available data at that time, we estimated that total Medicare program
payments for LTCH services over the next 5 LTCH PPS rate years would be
\$4.65 billion for the 2008 LTCH PPS rate year; \$4.85 billion for the
2009 LTCH PPS rate year; \$5.04 billion for the 2010 LTCH PPS rate year;
\$5.25 billion for the 2011 LTCH PPS rate year; and \$5.50 billion for
the 2012 LTCH PPS rate year.

In this proposed rule, consistent with the methodology established in
the August 30, 2002 final rule (67 FR 56036), and based on the most
recent available data, we estimate that total Medicare program payments
for LTCH services for the next 5 LTCH PPS rate years would be as shown
in Table 4.

**TABLE 4:**

+---------------------------------+------------------------------------+
| **LTCH PPS Rate Year**          | **Estimated Payments**             |
|                                 |                                    |
|                                 | **(\$ in billions)**               |
+---------------------------------+------------------------------------+
| 2009                            | 4.67                               |
+---------------------------------+------------------------------------+
| 2010                            | 4.82                               |
+---------------------------------+------------------------------------+
| 2011                            | 5.06                               |
+---------------------------------+------------------------------------+
| 2012                            | 5.36                               |
+---------------------------------+------------------------------------+
| 2013                            | 5.73                               |
+---------------------------------+------------------------------------+

In accordance with the methodology established in the August 30, 2002
LTCH PPS final rule (67 FR 56027 through 56037), these estimates are
based on the most recent available data. These estimates are also based
on our estimate of LTCH PPS rate year payments to LTCHs using CMS'
Office of the Actuary's (OACT) most recent estimate of the RPL market
basket of 3.1 percent for the 2009 LTCH PPS rate year, 2.8 percent for
the 2010 LTCH PPS rate year, 3.0 percent for the 2011 LTCH PPS and 2012
rate years, and 3.1 percent for the 2013 LTCH PPS rate year. (We note
that OACT develops its spending projections based on existing policy.
Therefore, changes that have not yet been implemented, including those
proposed in this proposed rule, and changes as a result of the recent
Medicare, Medicaid, and SCHIP Extension Act of 2007, are not reflected
in the spending projections shown in this section.) We also considered
OACT's most recent projections of changes in Medicare beneficiary
enrollment that estimate increases in Medicare fee‑for‑service
beneficiary enrollment of 0.6 percent in the 2009 LTCH PPS rate year,
0.7 percent in the 2010 LTCH PPS rate year, 1.2 percent in the 2011 LTCH
PPS rate year, 2.0 percent in the 2012 LTCH PPS rate year and, 2.5
percent in the 2013 LTCH PPS rate year. It is important to note that,
while we provide these estimates of future payments under the LTCH PPS
in order to provide a projected estimate of payments to LTCHs, these
estimates will be neither the basis for determining whether the one-time
budget neutrality adjustment available under §412.523(d)(3) should be
proposed, nor are these estimates the basis for any of the proposed
policy changes presented in this proposed rule. It is important to note
that any proposal regarding the one-time budget neutrality adjustment
would be based solely on the data related to FY 2003 that would be
available at the time of the proposal, rather than on projections of
payments under LTCH PPS for future years.

In the August 30, 2002 LTCH PPS final rule implementing the LTCH PPS
(67 FR 55954), we set forth the implementing regulations, based upon the
broad authority granted to the Secretary, under section 123 of the BBRA
(as amended by section 307(b) of the BIPA). Section 123(a)(1) of the
BBRA required that the system "maintain budget neutrality." The statute
requires the LTCH PPS to be budget neutral in FY 2003, so that estimated
aggregate payments under the LTCH PPS for FY 2003 should be equal to the
estimated aggregate payments that would be made if the LTCH PPS were not
implemented for FY 2003. The methodology for determining the LTCH PPS
standard Federal rate for FY 2003 that would "maintain budget
neutrality" is described in considerable detail in the August 30, 2002
final rule (67 FR 56027 through 56037). As we discussed previously in
this section, our methodology for estimating payments for the purposes
of budget neutrality calculations used the best available data, and
necessarily reflected assumptions in estimating aggregate payments that
would be made if the LTCH PPS was not implemented. In the
August 30, 2002 final rule, we also stated our intentions to monitor
LTCH PPS payment data to evaluate whether later data varied
significantly from the data available at the time of the original budget
neutrality calculations (for example, data related to inflation factors,
intensity of services provided, or behavioral response to the
implementation of the LTCH PPS). To the extent the later data
significantly differ from the data employed in the original
calculations, the aggregate amount of payments during FY 2003 based on
later data may be higher or lower than the estimates upon which the
budget neutrality calculations were based. In that same final rule, the
Secretary exercised his broad authority in establishing the LTCH PPS and
provided for the possibility of a one‑time prospective adjustment to the
LTCH PPS rates by October 1, 2006, in §412.523(d)(3). This deadline was
revised to July 1, 2008, in the RY 2007 LTCH PPS final rule. As we
discussed in the RY 2007 LTCH PPS final rule (71 FR 27842 through
27844), because the LTCH PPS was only recently implemented, sufficient
new data had not yet been generated that would enable us to conduct a
comprehensive reevaluation of our budget neutrality calculations.
Therefore, in that same final rule, we did not implement the one‑time
adjustment provided under §412.523(d)(3) so that the effect of any
significant difference between actual payments and estimated payments
for the first year of the LTCH PPS would not be perpetuated in the PPS
rates for future years. However, we stated that we would continue to
collect and interpret new data as it became available in order to
determine whether we should propose such an adjustment in the future.
Therefore, we revised §412.523(d)(3) by changing the original
October 1, 2006 deadline (established in the August 30, 2002 final rule
that implemented the LTCH PPS) to July 1, 2008, to postpone the possible
one-time adjustment due to the time lag in the availability of Medicare
data upon which a proposed adjustment would be based. We noted that
there is a lag time between the submission of claims data and cost
report data, and the availability of that data in the MedPAR files and
HCRIS, respectively. As also explained in that same final rule, we
believed that postponing the deadline of the possible one‑time
prospective adjustment to the LTCH PPS rates provided for in
§412.523(d)(3) to July 1, 2008, would allow our decisions regarding a
possible adjustment to be based on more complete and up‑to‑date data. It
should be noted that, in the years following the initial implementation
of the LTCH PPS, we have already adopted some revised policies and
adjustments to LTCH PPS payment levels. However, none of these revised
policies and payment adjustments have addressed the intended purpose of
the adjustment allowed under §412.523(d)(3) of the regulations, to
ensure that any significant difference between the original estimates
and calculations based on more recent data are not perpetuated in the
LTCH PPS rates for future years. For example, the adjustments that we
have made to account for coding changes in excess of real severity
increases in RY 2007 and RY 2008 were made to account for changes in
coding behavior in the years following the implementation of the LTCH
PPS, and not to address any issue regarding the budget neutrality
calculations that were used to establish the base rate for the LTCH PPS.

Section 114(c)(4) of MMSEA provides that the "Secretary shall not, for
the 3-year period beginning on the date of the enactment of this Act,
make the one-time prospective adjustment to long-term care hospital
prospective payment rates provided for in section 412.523(d)(3) of title
42, Code of Federal Regulations, or any similar provision." That
provision delays the effective date of any one-time budget neutrality
adjustment until no earlier than December 29, 2010. Therefore, we are
proposing to revise §412.523(d)(3) of the regulations to conform with
this requirement.

Prior to the enactment of the Medicare, Medicaid, and SCHIP Extension
Act of 2007, we had developed a methodology for evaluating whether to
propose a one-time budget neutrality adjustment under §412.523(d)(3) of
the regulations. In order to inform the public of our thinking, and to
stimulate comments for our consideration during the 3-year delay in
implementing any one-time budget neutrality adjustment under the law
referenced above, we have decided to discuss our analysis and its
results in this proposed rule. Evaluating the appropriateness of the
possible one‑time prospective adjustment under §412.523(d)(3) requires a
thorough review of the relevant LTCH data (as described below). When we
established the FY 2003 standard Federal rate in a budget neutral
manner, we used the most recent LTCH cost data available at that time
(that is, FY 1999 data), and trended that data forward to estimate what
Medicare would have paid to LTCHs in FY 2003 under the TEFRA payment
system if the PPS were not implemented for FY 2003 (67 FR 56033). We
have conducted a thorough review of the relevant data. We now have cost
data from FY 2002, representing the final year LTCHs were paid under the
TEFRA payment system. The cost report data for FY 2002 is comprised of a
high proportion of settled and audited cost reports submitted by LTCHs.
We also have payment data on the first year of the LTCH PPS (that is, FY
2003). On the basis of our review of these data sources, we developed a
potential methodology for determining whether the one-time adjustment
available under §412.523(d)(3) of the regulations should be proposed. On
the basis of this methodology, we have also determined a potential
method for computing an adjustment, if appropriate. Employing that
methodology, our analysis has indicated that a permanent adjustment
factor of 0.9625 to the LTCH PPS standard Federal rate could be
warranted. Consistent with the requirements of section 114(c)(4) of the
recently enacted Medicare, Medicaid, and SCHIP Extension Act of 2007, we
are not proposing any adjustment for the upcoming rate year. However, we
welcome public comment on our analysis, which we are presenting in this
proposed rule. We will consider these comments if and when we decide to
propose an actual adjustment. We note that in the final rule, we will
respond to any comments on our proposed changes to §412.523(d)(3) of the
regulations that would\-- (1) specify the methodology for the one-time
budget neutrality adjustment; and (2) implement the requirements of
section 114(c)(4) of Pub. L. 110-173, in the final rule.

In order to determine whether a one-time budget neutrality adjustment
could be warranted, it is necessary to estimate both aggregate payments
under the LTCH PPS for FY 2003 and the estimated aggregate payments that
would have been made under the TEFRA system in FY 2003 if the LTCH PPS
were not implemented. While we know actual TEFRA payments to LTCHs for
FY 2002, the last year of payment under that methodology, it is
necessary to estimate what TEFRA payments would have been in FY 2003 if
the new LTCH PPS had not been implemented. In developing our methodology
for evaluating a one-time adjustment, we considered whether we should
employ actual FY 2003 costs to calculate estimated TEFRA payments for FY
2003 or employ costs for FY 2002 trended forward to FY 2003 as the basis
for the calculation. Basing the estimate on actual FY 2003 costs would
avoid the need to employ any factor to update costs from FY 2002 to FY
2003. However, since FY 2003 was the first year of payment under the
LTCH PPS, the cost experience of LTCHs in that year would reflect their
response to the incentives provided by the new payment system, instead
of reflecting behavior under the reasonable cost payment system. Indeed,
implementation of an LTCH PPS should directly affect the behavior of
LTCHs, and therefore, the level of costs in LTCHs. One of the incentives
of a PPS is to improve efficiency in the delivery of care, which
generally results in decreased cost per discharge. For this reason,
employing FY 2003 costs directly could be a poor basis for estimating
payments that "would have been made if the LTCH PPS were not
implemented." On balance, we believe that trending forward for 1 year
the costs incurred under the last year of the TEFRA payment system poses
a smaller prospect for distortion than using costs incurred during the
subsequent year, when the incentives faced by LTCHs to reduce costs
could have had a significant effect. Therefore, we could base our
calculation of the estimated aggregate payments that would have been
made if the LTCH PPS were not implemented (that is, estimated FY 2003
TEFRA payments) on FY 2002 costs, trended forward to FY 2003 using the
excluded hospital market basket. It may be worth noting in this context
that some representatives of LTCHs have expressed concern that employing
FY 2003 costs directly would provide a poor basis upon which to estimate
payments that "would have been made if the LTCH PPS were not
implemented" for precisely the reasons we have just discussed. We
believe that basing the estimate of FY 2003 TEFRA payments on FY 2002
costs trended forward should satisfy these concerns.

In determining whether a one-time budget neutrality adjustment could be
warranted, the estimate of the payments that would have been made in FY
2003 under the TEFRA methodology should be compared to estimated
payments under the new LTCH PPS in FY 2003. The most direct way to
determine payments under the new LTCH PPS, of course, is simply to
aggregate the actual payments calculated under the LTCH PPS methodology
for the discharges that occurred during the first year of the LTCH PPS
(FY 2003). However, that approach raises an issue of consistency in the
use of data. The discharges for which we paid under the LTCH PPS during
FY 2003 are obviously not the same as the discharges for which costs
were incurred during the last year of payment under the TEFRA
methodology, FY 2002. For the reasons we have just discussed, we believe
that the best way to estimate the TEFRA payments that would have been
made to LTCHs during FY 2003 is to use inflated FY 2002 costs as a proxy
for FY 2003 costs. Comparing actual FY 2003 LTCH PPS payments to FY 2003
TEFRA payments estimated on the basis of FY 2002 discharges would amount
to a comparison between payments related to two different sets of
discharges, potentially skewing the results. Therefore consistency
suggests that, rather than comparing TEFRA payments based on FY 2002
costs updated to FY 2003, to aggregate LTCH PPS payments for discharges
that actually occurred in FY 2003, it would be preferable to compare
estimated TEFRA payments based on updated FY 2002 costs to the estimated
payments that would have been made under LTCH PPS methodology in FY 2003
for those same FY 2002 discharges. In other words, we believe that the
best approach would be to compare\--

Estimated aggregate FY 2003 TEFRA payments calculated on the basis of FY
2002 costs updated to FY 2003; to

Estimated aggregate payments that would have been made in FY 2003 under
the LTCH PPS methodology, by applying the FY 2003 LTCH payment rules to
the discharges that occurred in FY 2002.

In this way, we would ensure that we are comparing the estimated FY 2003
TEFRA payments, which are based on updated costs incurred for FY 2002
discharges to the estimated PPS payments that would have been made for
those same FY 2002 discharges under the new LTCH PPS payment
methodology.

Therefore, in the absence of the Medicare, Medicaid, and SCHIP Extension
Act of 2007, we would have proposed to employ the general methodology we
have just described to determine: (1) whether the one-time adjustment
available under §412.523(d)(3) of the regulations should be proposed for
RY 2009, and (2) if such adjustment should be proposed, the actual
proposed adjustment factor. In this proposed rule, we would revise the
current language of §412.523(d)(3) of the regulations to conform more
specifically with this preferred methodology. At the time of the final
LTCH PPS rule in 2002, we described the nature of the one-time
adjustment in very general terms. Specifically, that section currently
provides the following:

> The Secretary reviews payments under this prospective payment system
> and may make a one-time prospective adjustment to the long-term care
> hospital prospective payment system rates on or before July 1, 2008 so
> that the effect of any significant difference between actual payments
> and estimated payments for the first year of the long term care
> hospital prospective payment system is not perpetuated in the
> prospective payment rates for future years.

Our policy objective in providing for this one-time budget neutrality
adjustment has always been to ensure that computations based on the
earlier, necessarily limited (but at that time best available) data
available at the inception of the LTCH PPS would not be built
permanently into the rates if data available at a later date could
provide more accurate results. Prior to the thorough analysis we
conducted in preparation for this rate year, we had believed that the
only appropriate method for meeting this policy objective involved
employing actual payment data from the first year of payment under the
LTCH. As we have just discussed, we believe after a thorough evaluation
of the currently available data in the light of this policy objective,
that the most appropriate methodology for evaluating an adjustment to
the original budget neutrality adjustment does not involve comparing the
payments estimated in the original calculations against the "actual
payments... for the first year," strictly speaking. Rather, as just
discussed, considerations of consistency and other factors suggest that
the most appropriate comparison would employ an estimate of FY 2003 LTCH
PPS payments based on the same set of discharges (from FY 2002) which
are the basis for the best estimate of what would have been paid in
FY 2003 under the TEFRA system. As a result of this methodological
determination, under the broad authority of section 123 of the BBRA, as
amended by section 307(b) of BIPA, to make appropriate adjustments to
the LTCH PPS, we are proposing to revise §412.523(d)(3) to reflect the
preferred methodology more clearly. As we have discussed previously, we
are also proposing to revise that section of the regulations to
correspond with the requirements of section 114(c)(4) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007. Specifically, we are now
proposing to revise §412.523(d)(3) of the regulations to read as
follows:

> The Secretary reviews payments under this prospective payment system
> and may make a one-time prospective adjustment to the long-term care
> hospital prospective payment system rates no earlier than December 29,
> 2010, so that the effect of any significant difference between the
> data used in the original computations and more recent data to
> determine budget neutrality is not perpetuated in the prospective
> payment rates for future years.

Our proposed revision to §412.523(d)(3) of the regulations would
continue to provide that the Secretary may make a one-time adjustment to
the LTCH PPS rates in order to ensure that any "significant" difference
is not perpetuated in the LTCH PPS rates for future years. The
regulation does not specifically define what constitutes a significant
difference for this purpose. In the absence of section 114(c)(4) of the
Medicare, Medicaid, and SCHIP Extension Act of 2007, we would have
proposed to consider as "significant" any difference greater than or
equal to a 0.25 percentage point difference between the original budget
neutrality calculations and budget neutrality calculations based on the
more recent data now available. This threshold avoids making an
adjustment to account for very minor deviations between earlier and
later estimates of budget neutrality. It is also consistent with
thresholds that we have employed for similar purposes in prospective
payment systems. For example, under the capital IPPS, we make a forecast
error correction in the framework used to update the capital Federal
rate if a previous forecast of input prices varies by at least a 0.25
percentage point from actual input price changes (72 FR 47425). We do
not believe that we should treat differences greater than or equal to
0.25 percent as not "significant," since the effect of any difference
will be magnified as the rates are updated each year.

As discussed previously, absent the requirement of section 114(c)(4) of
the Medicare, Medicaid and SCHIP Extension Act of 2007, we would have
proposed to use FY 2002 LTCH costs as a basis for estimating FY 2003
LTCH TEFRA payments in evaluating whether to propose a one-time
prospective adjustment under §412.523(d)(3). We also would have proposed
to update the FY 2002 costs for inflation to FY 2003 by our Office of
the Actuary's current estimate of the actual increase in the excluded
hospital market basket from FY 2002 to FY 2003 of 4.2 percent. This
updated amount would serve as the proxy for actual FY 2003 TEFRA costs
in the proposed budget neutrality computation for purposes of
§412.523(d)(3). We estimated FY 2003 LTCH TEFRA payments using a
methodology that is similar in concept to the methodology we used to
estimate FY 2003 LTCH total payments under the TEFRA system when we
determined the initial standard Federal rate in the August 30, 2002
final rule (67 FR 56030 through 56033). We also made modifications to
the methodology we initially used to estimate FY 2003 LTCH TEFRA
payments because we are using data from a later period, as discussed in
greater detail below. In general, we estimated total payments under the
TEFRA payment system using the following steps:

● Estimate each LTCH's payment per discharge for inpatient operating
costs under the TEFRA system for FY 2003;

● Estimate each LTCH\'s payment per discharge for capital-related costs
for FY 2003; and

● Sum each LTCH\'s estimated operating and capital payment per case to
determine its estimated total FY 2003 TEFRA payment system payment per
discharge.

We discuss each of these steps in greater detail below.

The first step in the process of estimating total FY 2003 payments under
the TEFRA payment system is to estimate each LTCH's payment per
discharge for inpatient operating costs under the TEFRA. Until FY 1998,
the payment methodology for inpatient operating costs under the TEFRA
payment system was a relatively straightforward process. First, we
calculated a target amount by dividing the Medicare total inpatient
operating costs in a base year by the number of Medicare discharges. The
provider's TEFRA target amount was then updated by a rate-of-increase
percentage (§413.40(c)(3) of the regulations, as established by the
Congress, to determine the TEFRA target amount for the subsequent cost
reporting period (§413.40(c)(4)(i),(ii)). For any particular cost
reporting period, the Medicare payment for inpatient operating costs
would be the lesser of the hospital's reasonable costs, or the updated
target amount multiplied by the number of Medicare discharges during the
cost reporting period, that is, the TEFRA ceiling (§413.40(a)(3)).

The methodology described above, broadly speaking, is the general
approach that we would use to arrive at an estimate of what Medicare
payments for hospital inpatient operating costs would have been in
FY 2003 under the TEFRA payment system: each LTCH's FY 2003 target
amount would be calculated by updating its estimated FY 2002 target
amount per discharge by the full market basket percentage increase. The
sum of all LTCH payments for operating costs (TEFRA target amount
multiplied by Medicare discharges), bonus or relief payments, continuous
improvement bonus payments, and payments for capital‑related costs
yields, in general, the estimate of what total Medicare payments to
LTCHs would be in FY 2003 under the TEFRA payment system if the LTCH PPS
had not been implemented. 

However, because sections 4413 through 4419 of the BBA of 1997, section
122 of the BBRA of 1999, and section 307(a)(1) of the BIPA made numerous
changes to the TEFRA payment system, we had to make variations in the
method described above to arrive at the estimate of FY 2003 payments for
the inpatient operating costs of each LTCH under the TEFRA system,
depending on the participation date of the hospital. Specifically, we
must make the requisite computations differently for two classes of
hospitals, "existing" hospitals and "new" hospitals. (A detailed
explanation of the provisions affecting LTCHs, established by each of
the amendments, is found in the August 30, 2002 final rule that
implemented the LTCH PPS (67 FR 55959).) We discuss below these specific
BBA, BBRA, and BIPA changes, and their impact on the calculations of
estimated FY 2003 TEFRA payments for "existing" and "new" hospitals. As
discussed in greater detail below, we would employ two approaches to
estimate Medicare payments under the TEFRA system to LTCHs in FY 2003,
depending on how these changes in calculating TEFRA payments, as
established by the amendments, applied to each LTCH.

The first set of changes that we had to take into account were included
in the BBA. The BBA made significant changes to the TEFRA payment
methodology starting with cost reporting periods beginning on or after
October 1, 1997. While the changes were applicable to three types of
PPS-excluded providers (rehabilitation hospitals and units, psychiatric
hospitals and units, and LTCHs), the following discussion will address
the provisions of the amendments as they relate to LTCHs.

The first change to consider under BBA is section 4414 that established
caps on the TEFRA target amounts for cost reporting periods beginning on
or after October 1, 1997, for LTCHs that were paid as IPPS excluded
providers prior to that date. The cap was determined by taking the
75^th^ percentile of target amounts for cost reporting periods ending in
FY 1996 for each class of provider (rehabilitation hospitals and units,
psychiatric hospitals and units, and LTCHs), updating that amount by the
market basket percentage increases to FY 1998, and applying it to the
cost reporting period beginning on or after October 1, 1997 (62 FR
46018). The cap calculated for FY 1998 was updated by the applicable
market basket percentages to determine the cap amounts for cost
reporting periods beginning during FY 1999 through 2002. Providers
subject to the 75^th^ percentile cap were paid the lesser of their
inpatient operating costs or the TEFRA target amount, which was limited
by the 75^th^ percentile cap amount (67 FR 55959). In addition, section
4411 of the BBA established a formula for calculating the update factor
for FY 1999 through FY 2002 that was dependent on the relationship of a
provider's inpatient operating costs to its ceiling amount based on data
from the most recently available cost report. Section 121 of the BBRA
provided that the 75^th^ percentile cap amount should be wage adjusted
starting with cost reporting periods beginning on or after October 1,
1999 and before October 1, 2002.

The second change that we had to take into account was section 4415 of
the BBA. This provision revised the percentage factors used to determine
the amount of bonus and relief payments for LTCHs meeting specific
criteria. If a provider's net inpatient operating costs did not exceed
the hospital's ceiling, a bonus payment was made to the LTCH
(§413.40(d)(2) of the regulations). The bonus payment was the lower of
15 percent of the difference between the hospital's inpatient operating
costs and the ceiling, or 2 percent of the ceiling. In addition, relief
payments were made to providers whose net inpatient operating costs were
greater than 110 percent of the ceiling (or the adjusted ceiling, if
applicable). These relief payments were the lower of 50 percent of the
costs in excess of 110 percent of the ceiling or (or the adjusted
ceiling, if applicable) or 10 percent of the ceiling (or adjusted
ceiling, if applicable) (§413.40(d)(3)(ii) of the regulations).

The third change was an additional incentive established by section 4415
of the BBA, the continuous improvement bonus payment (CIB) for providers
meeting certain conditions and that kept their costs below the target
amount. Eligibility for the CIB required that a provider had three full
cost reporting periods as an IPPS-excluded provider prior to the
applicable fiscal year (62 FR 46019). To qualify for a CIB, a provider's
operating costs per discharge in the current cost reporting period had
to be lower than the least any of the following: its target amount; its
expected costs, that is, the lower of its target amount or inpatient
operating costs per discharge from the previous cost reporting period,
updated; or, its trended costs, that is, the inpatient operating costs
per discharge from its third full cost reporting period, updated by the
market basket percentage increase to the applicable fiscal year (62 FR
46019, §413.40(d)(5)(ii)(B) of the regulations). For providers with
their third or subsequent full cost reporting period ending in FY 1996,
trended costs are the lower of their inpatient operating costs per
discharge or target amount updated forward to the current year
(§413.40(d)(5)(ii)(A) of the regulations). The CIB payment equals the
lesser of 50 percent of the amount by which the operating costs were
less than expected costs, or, 1 percent of the ceiling(§413.40(d)(4) of
the regulations). Section 122 of the BBRA increased this percentage for
LTCH's for FY 2001 to 1.5 percent of the ceiling, and beginning in FY
2002, to 2 percent of the ceiling (§413.40(d)(4)(ii) and (iii) of the
regulations). The increase in the CIB percentage is not to be accounted
for in the development and implementation of the LTCH PPS in accordance
with section 307(a)(2) of BIPA.

The fourth change that we had to take into account was section 4416 of
the BBA which significantly revised the payment methodology for "new"
IPPS-excluded providers. This provision applies to three classes of
providers -- psychiatric hospitals and units, rehabilitation hospitals
and units, and LTCHs -- that were not paid as excluded hospitals prior
to October 1, 1997. The payment amount for a new provider for the first
12-month cost reporting period is the lower of its Medicare inpatient
operating cost per discharge or a limit based on 110 percent of the
national median of target amounts for the same class of hospital for
cost reporting periods ending in FY 1996, updated by the market basket
percentage increases to the applicable period, and wage-adjusted. The
payment limit in the second 12-month cost reporting period is the same
110 percent limit as for the first year(§413.40(f)(2)(ii) of the
regulations). A new provider's target amount would be established in its
third cost reporting period by updating the amount paid in its second
cost reporting period by the market basket percentage increase for
hospitals and hospital units excluded from the IPPS, applicable to the
specific year, as published annually in the **Federal Register**, which
then becomes the target amount for its third cost reporting period. The
target amount for the fourth and subsequent cost reporting periods is
determined by updating the target amount from the previous cost
reporting period by the applicable market basket percentage increase.

Finally, two provisions under BIPA were directed specifically at LTCHs.
Section 307(a)(1) of BIPA provided a 2 percent increase to the
wage-adjusted 75^th^ percentile cap for existing LTCHs for cost
reporting periods beginning in FY 2001, and a 25 percent increase to the
target amount for LTCHs, subject to the increased 75^th^ percentile cap.
However, it is important to note that in accordance with section
307(a)(2) of BIPA, the 2 percent increase to the 75^th^ percentile cap
and the 25 percent increase to the target amount were not to be taken
into account in the development and implementation of the LTCH PPS.

In order to determine what a LTCH's estimated payments would be under
TEFRA in FY 2003, we utilized cost report data for LTCHs from the
Hospital Cost Reporting Information System (HCRIS) for FYs 1999 through
2002. In addition, to determine whether a LTCH is "new," the
certification date for each LTCH was obtained from the On-line Survey &
Certification Automated Reporting (OSCAR) file. Based on the
certification date, a LTCH would either be a "new" LTCH, meaning a LTCH
that was not paid as an excluded hospital prior to October 1, 1997, or,
an "existing" LTCH, meaning a LTCH that was paid as an excluded hospital
prior to October 1, 1997. This could include a LTCH that was certified
as an LTCH on or after October 1, 1997, but was previously paid as
another type of IPPS-excluded provider prior to October 1, 1997. Our
approach to estimating Medicare payments in FY 2003 under the TEFRA
payment system varied somewhat, depending on whether an LTCH was
"existing" or "new" (as discussed in greater detail below).

Based on all these statutory changes mentioned above, the first step
would be to estimate FY 2003 inpatient operating payments under the
TEFRA system for "existing" LTCHs. "Existing" LTCHs are those receiving
payment as IPPS-excluded providers in cost reporting periods prior to
FY 1998. These LTCHs were subject to the 75^th^ percentile cap on their
target amounts. While section 307(a)(1) of BIPA provided for a 2 percent
increase to the 75^th^ percentile cap amount for LTCH's for cost
reporting periods beginning in FY 2001 and a 25 percent increase to the
target amount for cost reporting periods beginning in FY 2001 (subject
to the limiting or cap amount determined under section 1886(b)(3)(H) of
the Act), section 307(a)(2) of BIPA precluded accounting for these
increases in developing the LTCH PPS. In addition, section 122 of the
BBRA increased the CIB payment percentage to 1.5 percent for FY 2001 and
2.0 percent for FY 2002 (§413.40(d)(4)(ii) and (iii) of the
regulations). But these increases, also, are not to be accounted for in
the development and implementation of the LTCH PPS in accordance with
section 307(a)(2) of BIPA. Therefore, to ensure that these increases
would be excluded from the computations, as required by the statute, we
estimated an existing LTCH's FY 2003 target amount by starting with the
hospital's target amount from the FY 2000 cost report, the year prior to
when these increases were effective. Target amounts and payments for FY
2003 were simulated using the FY 2000 target amount in the hospital's
cost report and updating the target amount for each subsequent cost
reporting period by the applicable rate-of-increase percentage as
described in §413.40(c)(3)(vii) through FY 2002. The target amount from
FY 2002 is updated by the forecasted market basket percentage increase
of 3.5 percent to arrive at the FY 2003 target amount
(§413.40(c)(3)(viii)). (Note, the forecasted increase in the excluded
hospital market basket for FY 2003 of 3.5 percent was the applicable
rate‑of‑increase percentage used to update TEFRA target amounts in
accordance with §413.40(c)(3)(viii) in the FY 2003 IPPS final rule
(August 1, 2002, 67 FR 50289)). Based on more recent data, our Office of
the Actuary currently estimates an increase of 4.2 percent in the
excluded hospital market basket for FY 2003, which we used to update
LTCHs' FY 2002 costs to FY 2003, as described below.) In a small number
of cases where FY 2002 operating cost data were not available, we used
operating cost data from the most recent year available and trended it
forward to FY 2003. In addition, we estimated FY 2003 bonus or relief
payments without the inclusion of the 2 percent and 25 percent increases
to the cap amount and target amount, respectively, and without the 1.5
percent and 2.0 percent increases to the CIB payments, consistent with
section 307(a)(2) of BIPA as discussed above.

In addition, since comparisons are made between the target amount and
Medicare inpatient operating costs to determine bonus or relief
payments, we estimated FY 2003 operating costs for each LTCH by updating
its FY 2002 operating costs by the actual percentage increase in
operating costs for PPS-excluded hospitals from FY 2002 to FY 2003 (4.2
percent, as determined by OACT). The 3.5 percent market basket increase
used to update the TEFRA target amounts from FY 2002 to FY 2003 was the
forecast increase used at that time based on the most recent information
from OACT, at that time. However, because we now have more recent data
available for estimating the market basket increase for IPPS-excluded
hospitals from FY 2002 to FY 2003, we are using that more recent data
which OACT currently estimates that the IPPS-excluded hospital market
basket increase from FY 2002 to FY 2003 is 4.2 percent. As discussed
earlier, we estimated the FY 2003 operating costs using FY 2002 costs
rather than use the costs reported on the FY 2003 cost report.

The 75^th^ percentile cap for LTCHs for FY 2002, without the 2 percent
and 25 percent increases to the cap and target amount, respectively, was
\$30,783 for the wage-index adjusted labor‑related share, and \$12,238
for the nonlabor-related share. If a LTCH's costs and hospital-specific
target amount were above the 75^th^ percentile cap, Medicare's payment
under the TEFRA system would be the wage-index adjusted cap amount. If
under our payment model a LTCH's estimated FY 2002 TEFRA payment would
have been limited by the wage-adjusted 75^th^ percentile cap in FY 2002,
that amount would be updated by the forecasted market basket percentage
increase (of 3.5 percent) to FY 2003 to determine the LTCH's FY 2003
target amount that was used to estimate its TEFRA payment amount for FY
2003.

The second approach that we used to estimate FY 2003 hospital operating
payments under the TEFRA system applied to "new" LTCHs. A "new" LTCH is
one that was first paid as an IPPS excluded hospital on or after October
1, 1997. For a "new" LTCH, payment in the hospital's first 12-month cost
reporting period is the lower of its Medicare net inpatient operating
costs per discharge or the wage-adjusted 110 percent median amount
determined for that particular year (§413.40(f)(2)(ii) of the
regulations). For the hospital's second 12-month cost reporting period,
payment is the lower of their costs, or the same 110 percent median
amount that was used in the first cost reporting period, that is, it is
not updated. The hospital's "target amount" is established in the third
cost reporting period by updating the per discharge amount that was paid
in the prior cost reporting period by the estimated market basket
percentage increase for hospitals and hospital units excluded from the
IPPS, applicable to the specific year, as published annually in the
**Federal Register**. Therefore, if the LTCH was paid its costs in the
previous cost reporting period because costs were lower than the 110
percent median amount, the hospital's cost per discharge for the second
cost reporting period is updated and becomes the target amount for the
hospital's third cost reporting period. Target amounts for subsequent
cost reporting periods are determined by updating the previous year's
target amount by the applicable market basket percentage increase.

New LTCHs with their first 12-month cost reporting period beginning in
FY 1998, would have had a target amount calculated under section
1886(b)(7)(A)(ii) of the Act, in FY 2000. Therefore, as with the
"existing" LTCH's, in estimating the FY 2003 target amount, we used the
target amount from the FY 2000 cost report for those LTCHs and update
that target amount by the applicable estimated market basket percentage
increases as published annually in the **Federal Register** for the IPPS
final rule, without the 25 percent increase, to FY 2003. For LTCH's with
their first 12-month cost reporting period beginning in FY 1999, we used
the lower of their costs or target amount from their FY 2000 cost
report, and updated that amount by the applicable estimated market
basket percentage increase to establish the target amount in FY 2001,
without the 25 percent increase. From this point, we would continue to
update that target amount by the estimated market basket percentage
increases to FY 2003. It is necessary to compute an estimated target
amount for LTCHs that are "new" in FY 1999 in order to eliminate the
potential inclusion of the increase to the target amounts provided for
by section 307(a)(1) of BIPA (consistent with the statute).

The 25 percent increase (under section 307(a) of the BIPA) to the target
amount was not an issue for LTCH's with their first 12-month cost
reporting period beginning in FYs 2000, 2001, and 2002 because they
would not have a "target amount" based on sections 1886(b)(7)(A)(ii) of
the Act, in FY 2001. Rather, for these LTCHs, we would have proposed to
determine the estimated payment amount for their first 12-month cost
reporting period by looking at their certification date from the OSCAR
file, the applicable 110 percent median amount (adjusted by their
wage-index) and their costs from the applicable cost report, and then
proceed in accordance with the policy in §413.40(f)(2)(ii) of the
regulations, to arrive at estimated FY 2003 TEFRA payments.

In addition to the TEFRA payments for operating costs, and any bonus or
relief payments made, we also added \$10 million as an estimate of the
CIB payments that would have been made in FY 2003 under the TEFRA
payment system. We estimated this payment by using actual CIB payments
from the cost reports for FYs 1999 and 2000 as they would not include
the statutory increases to the target amount as discussed above, and
recalculated CIB payments for FYs 2001 and 2002 based on cost report
data. Based on these historical CIB payments, we estimated that CIB
payments in FY 2003 would have been approximately \$10 million. Just as
the TEFRA payments and bonus and relief payments had to be recalculated
in particular years to eliminate percentage increases that were not to
be included in our budget neutrality calculations, it was necessary to
recalculate the CIB payments in FYs 2001 and 2002 to eliminate the
percentage increases to these payments as provided for under section 122
of BBRA, but not to be accounted for in the development of the LTCH in
accordance with section 307(a)(2) of BIPA.

As we discussed above, the second step in estimating total payments
under the TEFRA payment system is to estimate each LTCH\'s payment per
discharge for capital-related costs. Under the TEFRA system, in
accordance with section 1886(g) of the Act, Medicare allowable capital
costs are paid on a reasonable cost basis. Therefore, we took each
LTCH\'s payment for capital‑related costs directly from the FY 2002 cost
report and updated it for inflation using the FY 2003 capital excluded
hospital market basket estimate of 0.7 percent, consistent with the
methodology used in the August 30, 2002 final rule (67 FR 56032) in
which we established the initial standard Federal rate. Thus, we
determined capital-related costs per case using capital cost data from
Worksheets D, Parts I and II, and total Medicare discharges for the cost
reporting period from worksheet S-3. (We note that since payments for
capital-related costs are on a reasonable-cost basis, capital payments
were the same for "existing" and "new" LTCHs.)

Once we have estimated total TEFRA payments as the sum of each LTCH\'s
estimated operating and capital payment per case, it is necessary to
estimate FY 2003 payments under the LTCH PPS. As we discussed above, in
evaluating the one-time prospective adjustment at §412.523(d)(3), we
believe that the best approach is to use FY 2002 LTCH claims data as a
proxy for estimating FY 2003 LTCH PPS payments. We note (as explained
below) that we used the same FY 2002 LTCH MedPAR data that was used to
develop the FY 2004 LTC-DRG relative weights in the FY 2004 IPPS final
rule (68 FR 45376). As we discussed in that final rule, there is a data
problem with the FY 2002 claims data for LTCHs where multiple bills for
the stay were submitted. Specifically, given the long stays at LTCHs,
some providers had submitted multiple bills for payment under the
reasonable cost-based reimbursement system for the same stay. In certain
LTCHs, hospital personnel apparently reported a different principal
diagnosis on each bill since, under the reasonable cost-based (TEFRA)
reimbursement system, payment was not dependent upon principal
diagnosis, as it is under a DRG-based PPS system. As a result of this
billing practice, we discovered that only data from the final bills were
being extracted for the MedPAR file. Therefore, it was possible that the
original MedPAR file was not receiving the correct principal diagnosis.
In that same IPPS final rule, we discussed how we addressed this problem
in the LTCH FY 2002 MedPAR data when we used that data to determine the
FY 2004 LTC-DRG relative weights. As stated above, for the evaluation of
the one-time budget neutrality adjustment at §412.523(d)(3) in this
proposed rule, we used the same "corrected" FY 2002 LTCH MedPAR data
that was used to develop the FY 2004 LTC-DRG relative weights. For the
reader's benefit, we are providing a summary of how we addressed the
multiple bill problem in the FY 2002 LTCH MedPAR data below. As we
explained in the FY 2004 IPPS final rule (68 FR 45376), we addressed
this problem by identifying all LTCH cases in the FY 2002 MedPAR file
for which multiple bills were submitted. For each of these cases,
beginning with the first bill and moving forward consecutively through
subsequent bills for that stay, we recorded the first unique diagnosis
codes up to 10 and the first unique procedure codes up to 10. We then
used these codes to appropriately group each LTCH case to a LTC‑DRG for
FY 2004.

We estimated FY 2003 LTCH PPS payments using the same general
methodology that we used to estimate FY 2003 payments under the LTCH PPS
(without a budget neutrality adjustment) when we determined the initial
standard Federal rate in the August 30, 2002 final rule (67 FR 56032).
Specifically, we estimated FY 2003 LTCH PPS payments for each LTCH by
simulating payments on a case-by-case basis by applying the final FY
2003 payment policies established in the August 30, 2002 final rule that
implemented the LTCH PPS (67 FR 55954) based on the LTCH case-specific
discharge information from the FY 2002 MedPAR files (as explained
above), and we also used LTCH provider-specific data from the FY 2003
provider specific file (PSF), as these were the data used by FIs to make
LTCH payments during the first year of the LTCH PPS (FY 2003). We used
the FY 2003 LTC‑DRG Grouper (Version 22.0) software program, relative
weights, and average length of stay (see 67 FR 55979 through 55995); we
made adjustments for differences in area wage levels established for FY
2003 as set forth at §412.525(c) using the appropriate phase-in wage
index values and cost-of-living for Alaska and Hawaii as set forth at
§412.525(b) established for FY 2003 (see 67 FR 56015 through 56020 and
56022, respectively); we made adjustments for short-stay outlier cases
based on the method for determining payment applicable for discharges
occurring during FY 2003 in accordance with §412.529(c)(1) (see
67 FR 55975 and 55995-56002); and we included additional payments for
high cost outlier cases as initially implemented in accordance with
former §412.525(a) for determining payments for discharges occurring in
FY 2003 and the FY 2003 fixed-loss amount of \$24,450 (see 67 FR 56023).
(We note that correctly billed interrupted stay cases under §412.531 are
single LTCH cases in the MedPAR files, and therefore, we estimated a
single LTCH PPS payment for those cases.) For purposes of this
calculation, we simulated case-by-case payments for each LTCH as if it
were paid based on 100 percent of the standard Federal rate in FY 2003
rather than the transition blend methodology set forth at §412.533. To
determine total estimated PPS payments for all LTCHs, we summed the
individual estimated LTCH PPS payments for each LTCH.

The next step we did to evaluate a potential one-time adjustment under
§412.523(d)(3) was to determine a case-weighted average estimated TEFRA
payment, consistent with the methodology used when we determined the
initial standard Federal rate in the August 30, 2002 final rule (68 FR
56032). This step is necessary in order to determine if there is any
difference between estimated total TEFRA payments and estimated LTCH PPS
payments in FY 2003. Each LTCH's estimated total FY 2003 TEFRA payment
per discharge was determined by summing its estimated FY 2003 operating
and capital payments under the TEFRA payment system based on FY 2002
cost report data (as described above), and dividing that amount by the
number of discharges from the FY 2002 cost report data. Next, we
determined each LTCH's average estimated TEFRA payment weighted for its
number of discharges in the FY 2002 MedPAR file (for the purpose of
estimating FY 2003 LTCH PPS payments, as discussed above) by multiplying
its average estimated total TEFRA payment per discharge by its number of
discharges in the FY 2002 MedPAR file.  We then estimated total
case-weighted TEFRA payments by summing each LTCH's (MedPAR)
case-weighted estimated FY 2003 TEFRA payments.  This estimated FY 2003
total TEFRA payment is compared to the estimated FY 2003 total LTCH PPS
payment in order to determine whether a one-time budget neutrality
adjustment would be appropriate.  (As discussed in greater detail above,
we are determining both estimated total FY 2003 TEFRA payments and
estimated total FY 2003 LTCH PPS payments based on FY 2002 cost report
and claims data, respectively.) Adjusting our estimate of FY 2003 TEFRA
payments for the number of discharges that we are using to estimate FY
2003 LTCH PPS payments ensures that the comparison of estimated
aggregate FY 2003 TEFRA payments to estimated aggregate FY 2003 LTCH PPS
payments is based on the same number of LTCH discharges.

Using the methodology and data described above, we have calculated that
estimated FY 2003 LTCH PPS payments are approximately 2.5 percent higher
than estimated payments to the same LTCHs in FY 2003 if the LTCH PPS had
not been implemented (that is, estimated total FY 2003 TEFRA payments). 
This analysis was based on approximately 91,300 LTCH cases for 250
LTCHs.  As discussed above, we would have proposed that any difference
greater than or equal to 0.25 percentage points "significant" for
purposes of determining whether the one-time budget neutrality
adjustment provided under §412.523(d)(3) may be warranted. Although we
project that estimated FY 2003 LTCH PPS payments are approximately 2.5
percent higher than estimated FY 2003 TEFRA payments, reducing the
standard Federal rate by 2.5 percent would not "maintain budget
neutrality" for FY 2003 (that is, estimated FY 2003 LTCH PPS payments
would not be equal to estimated FY 2003 TEFRA payments) because a
considerable number of LTCH discharges are projected to have received a
LTCH PPS payment in FY 2003 based on the estimated cost of the case
(rather than a payment based on the standard Federal rate) under the
payment adjustment for short-stay outlier (SSO) cases at §412.529.
Specifically, our payment data indicate that nearly 20 percent of
estimated FY 2003 LTCH PPS payments are SSO payments that were paid
based on estimated cost and not based on the LTCH PPS standard Federal
rate. These SSO cases that receive a payment based on the estimated cost
of the case are generally unaffected by any changes to the Federal rate
because the estimated cost of the case is determined by multiplying the
Medicare allowable charges by the LTCH's cost-to-charge ratio (see
§412.529(d)(2)). In other words, if we were to reduce the Federal rate
by 2.5 percent, estimated total FY 2003 LTCH PPS payments would still be
greater than estimated total FY 2003 TEFRA payments, and therefore would
not be budget neutral. This is because the estimated LTCH PPS payments
for those SSO cases that in FY 2003 were estimated to have been paid 120
percent of the estimated cost of the case generally are not affected
(that is, in this case, not lowered) by any budget neutrality factor
that would be applied to the standard Federal rate since those payments
are not derived from the Federal rate (as explained above).  Therefore,
it would be necessary to propose to offset the standard Federal rate by
a factor that is larger than 2.5 percent in order to ensure that
estimated total FY 2003 LTCH PPS payments would be equal to estimated
total FY 2003 TEFRA payments in order to "maintain budget neutrality." 
To determine the necessary adjustment factor that would need to be
applied to the standard Federal rate in order to "maintain budget
neutrality," we simulated FY 2003 LTCH PPS payments using the same
payment simulation model discussed above (that we used to estimate FY
2003 LTCH PPS payments without a budget neutrality factor). Using
iterative payment simulations using the data from the 250 LTCHs in our
database, we determined that a factor of 0.9625 (that is, approximately
3.75 percent (rather than 2.5 percent)) would need to be applied to the
standard Federal rate in order to make estimated total FY 2003 LTCH PPS
payments equal to estimated total FY 2003 TEFRA payments. 

In the absence of section 114(c)(4)of the Medicare, Medicaid, and SCHIP
Extension Act of 2007, we would have proposed to employ this methodology
in determining whether it would have been appropriate to propose a
one-time budget neutrality adjustment. As the discussion above
indicates, that analysis suggests that an adjustment of 3.75 percent to
the standard Federal rate would have been warranted. We expect to
address the issue again when it is closer to the time section 114(c)(4)
of the MMSEA permits us to implement a one-time adjustment under
§412.523(d)(3). In the meantime, we welcome comments on the methodology
that we have described. We would take these comments into account in
proposing to implement a one-time budget neutrality adjustment on or
after December 29, 2010. As noted above, we will respond to any comments
on our proposed changes to the methodology for the one-time budget
neutrality adjustment and proposed change to implement the requirements
of section 114(c)(4) of Pub. L. 110-173.

[E. Proposed Standard Federal Rate for the 2008 LTCH PPS Rate
Year]{.underline}

1\. Background

At §412.523(c)(3)(ii), for LTCH PPS rate years beginning RY 2004 through
RY 2006, we updated the standard Federal rate by a rate increase factor
to adjust for the most recent estimate of the increases in prices of an
appropriate market basket of goods and services for LTCHs. We
established the policy of annually updating the standard Federal rate
because at that time we believed that was the most appropriate method
for updating the LTCH PPS standard Federal rate annually for years after
FY 2003. When we moved the date of the annual update of the LTCH PPS
from October 1 to July 1 in the RY 2004 LTCH PPS final rule
(68 FR 34138), we revised §412.523(c)(3)accordingly. At that time, we
believed that was the most appropriate method for updating the LTCH PPS
standard Federal rate annually for years after RY 2004.

In the RY 2007 LTCH PPS final rule (71 FR 27818), we explained that
rather than solely using the most recent estimate of the LTCH PPS market
basket as the basis of the update factor for the Federal rate for
RY 2007, we believed it was appropriate to adjust the Federal rate to
account for the changes in coding practices (rather than patient
severity) as indicated by our ongoing monitoring activities. We
established at §412.523(c)(3)(iii) that the update to the standard
Federal rate for the 2007 LTCH PPS rate year was zero percent, based on
the most recent estimate of the LTCH PPS market basket at the time which
was offset by an adjustment to account for changes in case‑mix in prior
periods due to changes in coding practices rather than increased patient
severity in FY 2004. Therefore, effective from July 1, 2006 through
June 30, 2007, the standard rate was \$38,086.04 (71 FR 27818). For the
following year, we also considered changes in coding practices (rather
than patient severity) in establishing the update to the Federal rate
for the 2008 LTCH PPS rate year. In the RY 2008 final rule (72 FR 26887
through 27890), we adjusted the Federal rate based on the most recent
estimate of market basket (3.2 percent) and an adjustment to account for
changes in coding practices (2.49 percent) in FY 2005. Accordingly, we
established at §412.523(c)(3)(iv) that the update to the standard
Federal rate for RY 2008 was 0.71 percent. Consequently, in the RY 2008
final rule, we established the LTCH PPS standard Federal rate, effective
from July 1, 2007 through June 30, 2008, of \$38,356.45 (see 72 FR
26890).

As stated in section I.A. of this preamble, section 114(e)(1) of the
Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted on December
29, 2007 revises the base rate for RY 2008. Specifically, section
114(e)(1) of Pub. L. 110-173 adds a new subsection to the Act at
1886(m)(2), which provides that the base rate for RY 2008 "shall be the
same as the base rate for discharges for the hospital occurring during
the rate year ending in 2007." In addition, section 114(e)(2) of
Pub. L. 110-173 indicates that section 1886(m)(2) of the Act "shall not
apply to discharges occurring on or after July 1, 2007, and before April
1, 2008" (that is, the first 9 months of RY 2008). We note that the
statute uses the term "base rate," which is an undefined term in
§1886(m) of the ACT and in 42 CFR Part 412, subpart O. We are
interpreting that term to mean the standard Federal rate because we
believe the Congress meant to eliminate the 0.71 percent update from the
RY 2008 standard Federal rate.

If the term "base rate" used in the statute refers to the standard
Federal rate, then the standard Federal rate for RY 2008 would be the
same as the standard Federal rate for RY 2007 and the 0.71 percent
update finalized in the RY 2008 final rule would be reversed. We do not
believe that the term "base rate" could refer to the "unadjusted rate"
(that is, to determine the standard Federal rate for any given rate
year, the previous year's standard Federal rate, referred herein as the
"unadjusted rate", is updated by the current year's update factor.) If
the interpretation of "base rate" is the "unadjusted rate," it would
render meaningless the provision at the section 114(e)(1) of the MMSEA
and Congress does not legislate a nullity. The provision would be
meaningless under such an interpretation because even though the
unadjusted rate for RY 2008 would be the same as the unadjusted rate for
RY 2007, this unadjusted rate must still be updated by 0.71 percent, and
doing so would result in the same standard Federal rate for RY 2008 as
was adopted in the RY 2008 final rule. (The unadjusted rate must be
updated by 0.71 percent in order to determine the standard Federal rate
because it is the standard Federal rate that is the basis for Federal
prospective Ltch pps payments.) Consequently, LTCH PPS payments would be
unaffected by section 114(e)(1) of the Medicare, Medicaid, and SCHIP
Extension Act of 2007. We explain below why RY 2008 LTCH PPS payments
would be unaffected by section 114(e)(1) of Pub. L. 110-173 if "base
rate" means "unadjusted rate." Specifically, if "base rate" means the
"unadjusted rate," the RY 2007 "base rate" (that is, \$38,086.04) would
be the same as the standard Federal rate for RY 2007 (also \$38,086.04)
since we established a zero percent update for RY 2007.  Consequently,
if "base rate" is interpreted to mean "unadjusted rate," the "unadjusted
rate" for RY 2008 (\$38,086.04) would be the same as the RY 2007
"unadjusted rate" (\$38,086.04).  The RY 2008 "unadjusted rate" of
\$38,086.04 would subsequently be updated by the 0.71 percent update
factor finalized in the RY 2008 final rule, resulting in a standard
Federal rate for RY 2008 of \$38,356.45, which is the same standard
Federal rate that was actually finalized in the RY 2008 final rule and
which would continue to be the standard Federal rate for RY 2008 even if
section 114(e)(1) of MMSEA had not been enacted.  Since as we noted
above, Congress does not legislate a nullity, we therefore believe that
the term "base rate" used in section 114(e)(1) of MMSEA refers to the
standard Federal rate and not the "unadjusted rate." In subsequent
sections of this preamble, we shall be using the term standard Federal
rate instead of "base rate" when referencing the provision in section
114(e)(1) of MMSEA in order to avoid further confusion. As noted above,
the standard Federal rate for RY 2007 was \$38,086.04 (71 FR 27818).

2\. Proposed Standard Federal Rate for the 2009 LTCH PPS Rate Year

In the RY 2008 LTCH PPS final rule (72 FR 26890), we established a
standard Federal rate of \$38,356.45 for the 2008 LTCH PPS rate year
that was based on the best available data and policies established in
that final rule. As discussed above,

the Medicare, Medicaid, and SCHIP Extension Act of 2007, enacted on
December 29, 2007, revises the standard Federal rate for RY 2008 while
specifying that this rate "shall not apply to discharges occurring on or
after July 1, 2007, and before April 1, 2008" (that is, the first 9
months of RY 2008). Specifically, section 114(e)(1) of MMSEA provides
that under the new 1886(m)(2) to the Act provides that the standard
Federal rate for RY 2008 shall be the same as the standard Federal rate
for RY 2007 (which shall not apply to discharges occurring before April
1, 2008). Thus, the standard Federal rate for RY 2008 will be
\$38,086.04 (the same as standard Federal rate for 2007). In this
proposed rule, consistent with our historical practice, we are proposing
to update the standard Federal rate from the previous year (\$38,086.04)
to determine the proposed standard Federal rate for RY 2009. Under the
broad authority conferred upon the Secretary by section 123 of the BBRA
as amended by section 307(b) of the BIPA, we are proposing an annual
update to the standard Federal rate for the proposed 15-month 2009 rate
year based on the most recent LTCH PPS market basket estimate of 3.5
percent, as discussed above in section IV.C. of the preamble of this
proposed rule, and an adjustment of 0.9 percent to account for the
increase in case‑mix in a prior period (FY 2006) that resulted from
changes in coding practices rather than an increase in patient severity.

As we discussed in greater detail in the RY 2007 and RY 2008 LTCH PPS
final rules (71 FR 27819 through 27827 and 72 FR 26887 through 26890,
respectively), while we continue to believe that an update to the LTCH
PPS Federal rate year should be based on the most recent estimate of the
LTCH PPS market basket, we believe it is appropriate that the rate be
offset by an adjustment to account for any changes in coding practices
that do not reflect increased patient severity. Such an adjustment
protects the integrity of the Medicare Trust Funds by ensuring that the
LTCH PPS payment rates better reflect the true costs of treating LTCH
patients (71 FR 27819 through 27827).

We continue to believe that a proposed update to the LTCH PPS Federal
rate year should be based on the most recent estimate of the LTCH PPS
market basket, offset if appropriate by an adjustment to account for
changes in coding practices that do not reflect increased patient
severity. Furthermore, in the FY 2008 IPPS final rule, we did not
finalize the proposed case-mix budget neutrality factor for the adoption
of the severity adjusted MS-LTC-DRG patient classification system to the
FY 2008 MS‑LTC‑DRG relative weights. We stated in that rule that since
we have an established mechanism to adjust prospectively LTCH payments
to account for the effect of changes in coding from a previous year and
documentation which is based on actual LTCH data, and because at the
time of the final rule we were unable to determine an appropriate
adjustment factor applicable to LTCHs, we believed it was appropriate to
continue using the established process rather than making a prospective
adjustment based on an estimate of projected LTCH specific case-mix
change due to improved coding and documentation. We also stated that
consistent with past LTCH payment policy, we could propose to make
future adjustments to account for improvements in coding and
documentation that do not reflect real changes in case mix during these
years that we are implementing MS-LTC-DRGs. We also stated in that final
rule that we continue to believe more accurate and complete
documentation and coding will occur, and that we will continue to
monitor LTCHs' response to the MS-LTC-DRG transition and would propose
an adjustment factor to LTCHs to account prospectively for coding and
documentation changes if CMS is able to estimate an appropriate
adjustment factor applicable to LTCHs. In determining the proposed
update to the standard Federal rate for the 2009 LTCH PPS rate year, we
performed a CMI analysis using the most recent available LTCH claims
data (FY 2006 MedPAR files) and estimated the observed CMI change for
FY 2006 to be 1.9 percent (based on the most recent available LTCH
case‑mix data from FY 2005 compared to FY 2006). We continue to believe,
as discussed and for the same reasons stated in the RY 2008 final rule
(72 FR 26888 through 26890), that it is appropriate to utilize the
estimate of real CMI increase of 1.0 percent, based on the
well-established RAND study referred to in the RY 2008 final rule, as
the proxy for the portion of the observed 1.9 percent CMI increase from
FY 2005 to FY 2006 that represents real CMI changes for use in
determining the proposed RY 2009 Federal rate update. (A more detailed
discussion on the use of the RAND study estimate for real CMI change can
be found in the RY 2008 final rule appearing in the Federal Register on
May 11, 2007. (72 FR 26887 through 26890)). Accordingly, we believe that
0.9 percent (1.9 -- 1.0 = 0.9) of the observed 1.9 percent CMI increase
from FY 2005 to FY 2006 reflects CMS increase that is due to changes in
coding practices (rather than patient severity).

At this time, the most recent estimate of the LTCH PPS market basket is
3.5 percent as discussed above in section IV.C.2. of this proposed rule.
We are proposing to update the standard Federal Rate for RY 2009 based
on the full LTCH PPS market basket estimate of 3.5 percent and a
proposed adjustment to account for the increase in case-mix in the prior
period (FY 2006) that resulted from changes in coding practices of 0.9
percent. Therefore, the proposed update factor to the standard Federal
rate for RY 2009 is 2.6 percent (3.5 -- 0.9 = 2.6). That is, under the
broad authority conferred upon the Secretary under the BBRA and the
BIPA, we are proposing to specify under §412.523(c)(3)(v), that, for
discharges occurring on or after July 1, 2008 and on or before September
30, 2009, the standard Federal rate from the previous year would be
updated by 2.6 percent. In determining the proposed standard Federal
rate for RY 2009, we are applying the proposed 2.6 percent update to the
RY 2008 Federal rate of \$38,086.04), which is the same standard Federal
rate for discharges occurring during the rate year ending in 2007,
consistent with section 114(e)(1) of the Medicare, Medicaid, and SCHIP
Extension Act of 2007. Consequently, the proposed standard Federal rate
for RY 2009 would be \$39,076.28.

We also propose that if more recent data becomes available (such as a
more recent estimate of the LTCH PPS market basket), we would use that
data, if appropriate, to determine the update to the standard Federal
rate for the RY 2009 final rule, and thus, the Federal rate update noted
in the proposed regulation text at §412.523(c)(3)(v) could change.

[F. Calculation of Proposed LTCH Prospective Payments for the 2009 LTCH
PPS Rate Year]{.underline}

1\. Proposed Adjustment for Area Wage Levels

a\. Background

Under the authority of section 123 of the BBRA as amended by section
307(b) of the BIPA, we established an adjustment to the LTCH PPS Federal
rate to account for differences in LTCH area wage levels at §412.525(c).
The labor‑related share of the LTCH PPS Federal rate, currently
estimated by the FY 2002‑based RPL market basket (as discussed in
greater detail in section IV.C.1. of this preamble), is adjusted to
account for geographic differences in area wage levels by applying the
applicable LTCH PPS wage index. The applicable LTCH PPS wage index is
computed using wage data from inpatient acute care hospitals without
regard to reclassification under sections 1886(d)(8) or 1886(d)(10) of
the Act.

As we discussed in the August 30, 2002 LTCH PPS final rule
(67 FR 56015), when the LTCH PPS was implemented, we established a
5‑year transition to the full wage adjustment. The wage index adjustment
was completely phased‑in beginning with cost reporting periods beginning
in FY 2007. Therefore, for cost reporting periods beginning on or after
October 1, 2006, the applicable LTCH wage index values are the full
(five‑fifths) LTCH PPS wage index values calculated based on acute-care
hospital inpatient wage index data without taking into account
geographic reclassification under sections 1886(d)(8) and (d)(10) of the
Act. For additional information on the phase-in of the wage index
adjustment under the LTCH PPS, refer to the August 30, 2002 LTCH PPS
final rule (67 FR 56017 through 56019) and the RY 2008 LTCH PPS final
rule (72 FR 26891).

b\. Proposed Updates to the Geographic Classifications/Labor Market Area
Definitions

\(1\) Background

As discussed in the August 30, 2002 LTCH PPS final rule, which
implemented the LTCH PPS (67 FR 56015 through 56019), in establishing an
adjustment for area wage levels under §412.525(c), the labor‑related
portion of a LTCH's Federal prospective payment is adjusted by using an
appropriate wage index based on the labor market area in which the LTCH
is located. In the RY 2006 LTCH PPS final rule (70 FR 24184 through
24185), in regulations at §412.525(c), we revised the labor market area
definitions used under the LTCH PPS effective for discharges occurring
on or after July 1, 2005 based on the Office of Management and Budget's
(OMB's) Core Based Statistical Area (CBSA) designations based on 2000
Census data. We made this revision because we believe that those new
CBSA-based labor market area definitions will ensure that the LTCH PPS
wage index adjustment most appropriately accounts for and reflects the
relative hospital wage levels in the geographic area of the hospital as
compared to the national average hospital wage level. As set forth in
existing §412.525(c)(2), a LTCH's wage index is determined based on the
location of the LTCH in an urban or rural area as defined in
§412.64(b)(1)(ii)(A) through (C). An urban area under the LTCH PPS is
currently defined at §412.64(b)(1)(ii)(A) and (B). Under
§412.64(b)(1)(ii)(C), a rural area is defined as any area outside of an
urban area.

We note that these are the same CBSA‑based designations implemented for
acute care hospitals under the IPPS at §412.64(b) effective
October 1, 2004 (69 FR 49026 through 49034). For further discussion of
the labor market area (geographic classification) definitions currently
used under the LTCH PPS, see the RY 2006 LTCH PPS final rule
(70 FR 24182 through 24191).

\(2\) Proposed Update to the CBSA-based Labor Market Area Definitions

On December 18, 2006, OMB announced the inclusion of two new CBSAs and
the revision of designations for six areas (OMB Bulletin No. 07-01).
This OMB bulletin is available on the OMB Web site at
<http://www.whitehouse.gov/omb/bulletins/fy2007/b07-01.pdf>. The two new
CBSAs outlined in this bulletin are as follows:

● Lake Havasu-Kingman, Arizona (CBSA code 29420). This CBSA comes from
Mohave County, Arizona.

● Palm Coast, Florida (CBSA code 37380). This CBSA comes from Flager
County, Florida.

The six revised CBSA designations outlined in this bulletin are as
follows:

● Mauldin, South Carolina and Easley, South Carolina qualify as new
principal cities of the Greenville‑Mauldin‑Easley, South Carolina CBSA
(CBSA code 24860).

● Conway, Arkansas qualifies as a new principal city of the Little
Rock-North Little Rock-Conway, Arkansas CBSA (CBSA code 30780) .

● Goleta, California qualifies as a new principal city of the Santa
Barbara-Santa Maria-Goleta, California CBSA (CBSA code 42060).

● Franklin, Tennessee qualifies as a new principal city of the
Nashville-Davidson-Murfreesboro-Franklin, Tennessee CBSA (CBSA code
34980).

● Fort Pierce, Florida no longer qualifies as a principal city of the
Port St. Lucie-Fort Pierce, Florida CBSA; the new designation is Port
St. Lucie, Florida CBSA (CBSA code 38940).

● Essex County, Massachusetts Metropolitan Division was renamed as the
Peabody, Massachusetts Metropolitan Division, which changed the CBSA
code from 21604 to 37764.

We note that these six revised CBSA designations made in OMB Bulletin
No. 07-01 do not change the composition (constituent counties) of the
affected CBSAs; they only revise the CBSA titles (and the CBSA code for
the CBSA that consists of Essex county, MA).

In this proposed rule, under the broad authority conferred upon the
Secretary by section 123 of the BBRA, as amended by section 307(b) of
BIPA to determine appropriate adjustments under the LTCH PPS, we are
proposing to apply these changes to the current CBSA-based labor market
area definitions and geographic classifications used under the LTCH PPS
effective for discharges occurring on or after July 1, 2008. We believe
these revisions to the LTCH PPS CBSA-based labor market area
definitions, which are based on the most recent available data, would
ensure that the LTCH PPS wage index adjustment most appropriately
accounts for and reflects the relative hospital wage levels in the
geographic area of the hospital as compared to the national average
hospital wage level. (We note that we are currently not aware of any
LTCHs located in the two new proposed CBSAs (that is, proposed CBSA
29420 and proposed CBSA 37380), and as discussed above, the six proposed
revisions to the CBSA designations would only revise the CBSA titles
(and the CBSA code for the CBSA that consists of Essex county, MA).)
Accordingly, the proposed RY 2009 LTCH PPS wage index values presented
in Tables 1 and 2 in the Addendum of this proposed rule were calculated
based on the proposed revisions to the CBSA‑based labor market area
definitions described above. We also note that these revisions to the
CBSA-based designations were adopted under the IPPS effective beginning
October 1, 2007 (72 FR 47308 through 47309).

\(3\) Clarification of New England Deemed Counties

We are also taking this opportunity to address the change in the
treatment of "New England deemed counties" (that is, those counties in
New England listed in §412.64(b)(1)(ii)(B) that were deemed to be parts
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.
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, Sagadahoc County, and
Newport County) are also included in metropolitan statistical areas
defined by OMB and are considered urban under both the current IPPS and
LTCH PPS labor market area definitions in §412.64(b)(1)(ii)(A) (they
would also be urban under the proposed conforming changes to §412.503).
The remaining two, Litchfield County and Merrimack County, are
[geographically]{.underline} located in areas that are considered rural
under the current IPPS (and LTCH PPS) labor market area definitions
(however, they have been previously deemed urban under the IPPS in
certain circumstances as discussed below).

In the FY 2008 IPPS final rule with comment period (72 FR 47337 through
47338), §412.64(b)(1)(ii)(B) was revised such that the two "New England
deemed [counties]{.underline}" that are still considered rural by OMB
(Litchfield county, CT and Merrimack county, NH) are no longer
considered urban effective for discharges occurring on or after October
1, 2007, 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]{.underline} 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 LTCH PPS does not provide for such
geographic reclassification (67 FR 56019 through 56020)). 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 indices would be addressed in the respective payment system rules.
Accordingly, as stated above, we are taking this opportunity to clarify
the treatment of "New England deemed counties" under the LTCH PPS in
this proposed rule.

As discussed above, under existing §412.525(c)(2), a LTCH's wage index
is determined based on the location of the LTCH in an urban or rural
area as defined in §412.64(b)(1)(ii)(A) through (C). Under existing
§412.525(c)(2), an urban area under the LTCH PPS is currently defined at
§412.64(b)(1)(ii)(A) and (B), and a rural area is defined as any area
outside of an urban area in §412.64(b)(1)(ii)(C).

Historical changes to the labor market area/geographic classifications
and annual updates to the wage index values under the LTCH PPS have been
made effective July 1 each year. When we established the most recent
LTCH PPS payment rate update, effective for LTCH discharges occurring on
or after July 1, 2007 through June 30, 2008, we considered the "New
England deemed counties" (including Litchfield county, CT and Merrimack
county, NH) as urban for RY 2008 (in accordance with the definitions of
urban and rural stated in the RY 2008 LTCH PPS final rule (72 FR 26891)
and 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)). (See
72 FR 27004 and 27008, respectively).

As noted above, existing §412.525(c)(2) indicates that the terms "rural"
and "urban" as areas are defined according to the definitions of those
terms in §412.64(b)(1)(ii)(A) through (C). As Litchfield county, CT and
Merrimack county, NH would be considered rural areas in accordance with
our regulations at (§412.525(c)(2), these two counties will be "rural"
under the LTCH PPS effective with the next update of the LTCH PPS
payment rates, which will be July 1, 2008 (under the LTCH PPS effective
for discharges on or after July 1, 2008, Litchfield County, CT and
Merrimack County, NH are not urban under §412.64(b)(1)(ii)(A-B) and
therefore are rural under §412.64(b)(1)(ii)(c)). (We note that
Litchfield and Merrimack counties will also be rural under our proposed
§412.503, discussed in greater detail below, that would incorporate the
existing definitions of "urban" and "rural" areas.) Therefore,
Litchfield county, CT and Merrimack county, NH will be considered
"rural" effective for LTCH PPS discharges occurring on or after July 1,
2008, and will no longer be considered as being part of urban CBSA 25540
(Hartford-West Hartford-East Hartford, CT) and urban CBSA 31700
(Manchester-Nashua, NH), respectively. We note that currently we are not
aware of any LTCHs located in either Litchfield county, CT or Merrimack
county, NH. We also note that this policy is consistent with our policy
of not taking into account IPPS geographic reclassifications in
determining payments under the LTCH PPS. In addition, as discussed
above, in this section, effective for discharges on or after July 1,
2008, §412.64(b)(1)(ii)(B) is no longer applicable under the LTCH PPS.

\(4\) Proposed Codification of the Definitions of Urban and Rural under
42 CFR Part 412 Subpart O

Under the current regulations at §412.525(c), the labor-related portion
of the LTCH PPS Federal rate is adjusted to account for geographical
differences in the area wage levels using an appropriate wage index to
reflect the relative level of hospital wages and wage-related costs in
the geographic area (that is, urban or rural area) of the hospital
compared to the national average level of hospital wages and
wage-related costs annually. Currently, the application of the wage
index under existing §412.525(c)(2) is made on the basis of the location
of the facility in an urban or rural area as defined in
§412.64(b)(1)(ii)(A) through (C) (in 42 CFR Part 412 subpart D).

In light of regulatory construct discussed above where §412.525(c)
indicated that the terms "rural area" and "urban area" as defined
according to the definitions of those terms" under the IPPS in 42 CFR
Part 412 subpart D, we believe it may be administratively simpler to
have the LTCH PPS urban and rural labor market area definitions
self-contained in (§412.503) 42 CFR Part 412 subpart O rather than
cross-referring to the definitions of urban and rural in the IPPS
regulations in 42 CFR Part 412, Subpart D. This approach is similar to
the change we made in §412.525(a) for high cost outliers and §412.529
for short-stay outliers in the FY 2007 IPPS final rule when we embedded
within Subpart O the regulatory provisions concerning the determination
of cost-to-charge ratios (CCRs) and the reconciliation of outlier
payments (71 FR 48115 through 48122). Under the broad authority of §123
of the BBRA as amended by §307(b) of BIPA we are proposing to codify in
§412.503 the definitions for "urban area" and "rural area." The proposed
definitions for "urban area" and "rural area" in §412.503 would
incorporate the provisions of §412.62(f)(1)(ii) and (f)(1)(iii) as well
as §412.64(b)(1)(ii)(A) through (C). Furthermore, since, as explained
above in section IV.F.1.b.3., the definition of "urban area" at
§412.64(b)(1)(ii)(B) is no longer applicable under the LTCH PPS
effective for discharges occurring on or after July 1, 2008, and
therefore, the only remaining definition of "urban area" will be that of
a Metropolitan Statistical Area (MSA) as defined by the Executive Office
of Management and Budget. ([See]{.underline} 72 FR 47337 through 47338).
Thus, we omit the language of §412.64(b)(1)(ii)(B) from the proposed
definition of "urban area" that would be applicable to discharges
occurring on or after July 1, 2008 in proposed 412.503. We, however,
included the language from §412.64(b)(1)(ii)(A) in the proposed
definition of "urban area" that would be applicable to discharges
occurring on or after July 1, 2008 in proposed 412.503.

For the reason just described, we note that the proposed definitions of
"urban" and "rural" that would be effective for discharges occurring on
or after July 1, 2008 (in subparagraph (3) in the both the proposed
definition of "rural area" and the proposed definition of "urban area")
vary slightly from the wording in the current regulations at
§412.64(b)(1)(ii)(A) through (C); however, substantively the definitions
are the same. We believe that the slight difference in the wording of
412.503 more precisely conveys the treatment of New England deemed
counties under the LTCH PPS, as discussed above. As a conforming change,
we are also proposing to replace the cross-references to
§412.62(f)(1)(iii) and §412.64(b)(1)(ii)(A) through (C) in §412.525(c)
with references to the proposed definitions of "urban area" and "rural
area" at §412.503. Accordingly, we are proposing to revise §412.525(c)
to specify that the application of the LTCH PPS wage index would be made
on the basis of the location of the LTCH in an urban or rural area as
defined in proposed §412.503. As discussed in section VI.G.3. of this
proposed rule, we are also proposing to make conforming changes to the
regulations governing short-stay outlier payments (at §412.529) and the
special payment provisions for co-located LTCHs (at §412.534) and
free‑standing LTCHs (at §412.536), which refer to the definition of
urban and rural under the LTCH PPS.

c\. Proposed Labor‑Related Share

In the August 30, 2002 LTCH PPS final rule (67 FR 56016), we established
a labor‑related share of 72.885 percent based on the relative importance
of the labor‑related share of operating costs (wages and salaries,
employee benefits, professional fees, postal services, and all other
labor‑intensive services) and capital costs of the excluded hospital
with capital market basket based on FY 1992 data. We did not revise the
labor‑related share in RYs 2004 through 2006 while we conducted further
analysis to determine the most appropriate methodology and data for
determining the labor‑related share under the LTCH PPS (70 FR 24182).
After our research into the labor‑related share methodology was
complete, we revised the labor‑related share under the LTCH PPS in the
RY 2007 final rule (71 FR 27829). Specifically, beginning in RY 2007, we
established a labor‑related share based on the relative importance of
the labor‑related share of operating costs (wages and salaries, employee
benefits, professional fees, postal services, and all other
labor‑intensive services) and capital costs of the RPL market basket
based on FY 2002 data, as it is the best available data that reflect the
cost structure of LTCHs.

Consistent with our historical practice, the labor‑related share
currently used under the LTCH PPS is determined by identifying the
national average proportion of operating costs and capital costs that
are related to, influenced by, or vary with the local labor market.
Accordingly, in the RY 2008 LTCH PPS final rule (72 FR 26892), we
updated the LTCH PPS labor‑related share to 75.788 percent based on the
relative importance of the labor‑related share of operating costs (wages
and salaries, employee benefits, professional fees, and all other
labor‑intensive services) and capital costs of the RPL market basket
based on FY 2002 data from the first quarter of 2007.

As discussed in section IV.C.2. of this preamble, we now have data from
the 4th quarter of 2007 (with history through the 3rd quarter of 2007)
available for determining the labor‑related share of the FY 2002‑based
RPL market basket. Based on this more recent data, in this proposed
rule, under the broad authority conferred upon the Secretary by section
123 of the BBRA as amended by section 307(b) of the BIPA, consistent
with our historical practice of determining the labor‑related share by
identifying the national average proportion of operating costs and
capital costs that are related to, influenced by, or varies with the
local labor market, we are proposing to revise the LTCH PPS
labor‑related share from 75.788 percent to 75.920 percent based on the
relative importance of the labor‑related share of operating costs (wages
and salaries, employee benefits, professional fees, and all other
labor‑intensive services) and capital costs of the FY 2002‑based RPL
market basket from the fourth quarter of 2007, as shown in Table 1. The
proposed labor‑related share is the sum of the relative importance of
wages and salaries, fringe benefits, professional fees, labor‑intensive
services, and a portion of the capital share from an appropriate market
basket.

In this proposed rule, for RY 2009, we are proposing to use the
FY 2002‑based RPL market basket costs based on data from the fourth
quarter of 2007 to determine the labor‑related share for the LTCH PPS
effective for discharges occurring on or after July 1, 2008 and before
September 30, 2009, as this is the most recent available data. The
proposed labor‑related share for RY 2009 LTCH PPS would continue to be
the sum of the relative importance of each labor‑related cost category,
and would reflect the different rates of price change for these cost
categories between the base year (FY 2002) and the (15-month) 2009 LTCH
PPS rate year. (As discussed in greater detail above in section IV.B. of
this proposed rule, we are proposing to move the LTCH PPS annual payment
rate year beginning July 1^st^ to a rate year beginning October 1^st^
and have a 15-month rate year for 2009 (that is, July 1, 2008 through
September 30, 2009). Accordingly, we are proposing to use the 15-month
RY 2009 RPL market basket, discussed above, to determine the proposed
labor-related share for RY 2009 in this proposed rule. Consistent with
our historical practice of using the best data available, if more recent
data are available to determine the labor‑related share of the RPL
market basket (used under the LTCH PPS), we propose to use it for
determining the labor‑related share for the 2009 LTCH PPS rate year in
the final rule.

Based on the most recent available data, we are proposing that the sum
of the relative importance for the 2009 LTCH PPS rate year for operating
costs (wages and salaries, employee benefits, professional fees, and
labor‑intensive services) would be 71.965, as shown in Table 1. The
portion of capital that is influenced by the local labor market is still
estimated to be 46 percent, which is the same percentage used when we
established the current labor‑related share in the RY 2008 LTCH PPS
final rule. Since, based on the most recent available data, the relative
importance for capital would be 8.597 percent of the FY 2002‑based RPL
market basket for the 2009 LTCH PPS rate year, we are proposing to
multiply the estimated portion of capital influenced by the local labor
market (46 percent) by the relative importance for capital
(8.597 percent) to determine the proposed labor‑related share of capital
for the 2009 LTCH PPS rate year. The result would be 3.955 percent
(0.46 x 8.597 percent), which we would add to the proposed
71.965 percent for the operating cost amount to determine the proposed
total labor‑related share for the 2009 LTCH PPS rate year. Thus, based
on the latest available data, we are proposing to use a labor‑related
share of 75.920 percent (71.965 percent + 3.955 percent) under the LTCH
PPS for the 2009 LTCH PPS rate year. As noted above in this section,
this proposed labor‑related share is determined using the same
methodology as employed in calculating the current LTCH labor‑related
share (72 FR 26892) and the labor‑related shares used under the IRF PPS
and IPF PPS, which also use the RPL market basket.

Table 1 shows the 2008 LTCH PPS rate year relative importance
labor‑related share of the FY 2002‑based RPL market basket (established
in the RY 2008 LTCH PPS final rule) and the proposed 2009 LTCH PPS rate
year relative importance labor‑related share of the FY 2002‑based RPL
market basket.

**TABLE 1: RY 2008 Labor‑Related Share Relative Importance and Proposed
RY 2009 Labor‑Related Share Relative Importance of the FY 2002‑based RPL
Market Basket**

[]{.mark}

+-------------------------+-------------------+-----------------------+---+
| **Cost Category**       | **RY 2008**       | **Proposed RY 2009**  |   |
|                         |                   |                       |   |
|                         | **Relative        | **Relative            |   |
|                         | Importance^\*^**  | Importance**          |   |
+-------------------------+-------------------+-----------------------+---+
| Wages and Salaries      | 52.588            | 52.830                |   |
+-------------------------+-------------------+-----------------------+---+
| Employee Benefits       | 14.127            | 14.079                |   |
+-------------------------+-------------------+-----------------------+---+
| Professional fees       | 2.907             | 2.907                 |   |
+-------------------------+-------------------+-----------------------+---+
| All other labor         | 2.145             | 2.149                 |   |
| intensive services      |                   |                       |   |
+-------------------------+-------------------+-----------------------+---+
|                         |                   |                       |   |
+-------------------------+-------------------+-----------------------+---+
| Subtotal                | 71.767            | 71.965                |   |
+-------------------------+-------------------+-----------------------+---+
|                         |                   |                       |   |
+-------------------------+-------------------+-----------------------+---+
| Labor share of capital  | 4.021             | 3.955                 |   |
| costs                   |                   |                       |   |
+-------------------------+-------------------+-----------------------+---+
| Total Labor-related     | 75.788            | 75.920                |   |
| share                   |                   |                       |   |
+-------------------------+-------------------+-----------------------+---+

\* As established in the RY 2008 LTCH PPS final rule (72 FR 26892).

\*\* Other labor intensive services includes landscaping services,
services to buildings, detective and protective services, repair
services, laundry services, advertising, auto parking and repairs,
physical fitness facilities, and other government enterprises.

[]{.mark}

d\. Proposed Wage Index Data

Historically, under the LTCH PPS, we have established LTCH PPS wage
index values calculated from acute care IPPS hospital wage data without
taking into account geographic reclassification under sections
1886(d)(8) and (d)(10) of the Act. As we discussed in the
August 30, 2002 LTCH PPS final rule (67 FR 56019), since hospitals that
are excluded from the IPPS are not required to provide wage‑related
information on the Medicare cost report. Therefore, we would need to
establish instructions for the collection of this LTCH data as well as
develop some type of application and determination process before a
geographic reclassification adjustment under the LTCH PPS could be
implemented. Thus, the wage adjustment established under the LTCH PPS is
based on a LTCH\'s actual location without regard to the urban or rural
designation of any related or affiliated provider. Acute care hospital
inpatient wage index data are also used to establish the wage index
adjustment used in other Medicare PPSs, such as the IRF PPS, IPF PPS,
HHA PPS, and SNF PPS.

In the RY 2008 LTCH PPS final rule (72 FR 26893), we established LTCH
PPS wage index values for the RY 2008 calculated from the same data
(collected from cost reports submitted by hospitals for cost reporting
periods beginning during FY 2003) used to compute the FY 2007 acute care
hospital inpatient wage index data without taking into account
geographic reclassification under sections 1886(d)(8) and (d)(10) of the
Act because that was the best available data at that time. The LTCH PPS
wage index values applicable for discharges occurring on or after
July 1, 2007 through June 30, 2008 are shown in Table 1 (for urban
areas) and Table 2 (for rural areas) in the Addendum to the RY 2008 LTCH
PPS final rule (72 FR 26996 through 27019).

In this proposed rule, under the broad authority conferred upon the
Secretary by section 123 of the BBRA as amended by section 307(b) of
BIPA to determine appropriate adjustments under the LTCH PPS, we are
proposing that, for the RY 2009, 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 data without taking into account geographic
reclassification under sections 1886(d)(8) and (d)(10) of the Act would
be used to determine the applicable wage index values under the LTCH PPS
because these data (FY 2004) are the most recent complete data. (For
information on the data used to compute the FY 2008 IPPS wage index
refer to the FY 2008 IPPS final rule with comment period (72 FR 47308
through 47309, 47315)). We are proposing to continue to use IPPS wage
data as a proxy to determine the proposed LTCH wage index values for
RY 2009 because both LTCHs and acute‑care hospitals are required to meet
the same certification criteria set forth in section 1861(e) of the Act
to participate as a hospital in the Medicare program and they both
compete in the same labor markets, and therefore, experience similar
wage‑related costs. We note that the IPPS wage data used to determine
the proposed RY 2009 LTCH wage index values reflects our policy that was
adopted under the IPPS beginning in FY 2008 that apportions the wage
data for multicampus hospitals' located in different labor market 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)). For
the proposed RY 2009 LTCH PPS wage index, which is computed from IPPS
wage data submitted by hospitals for cost reporting periods beginning in
FY 2004 (just like the FY 2008 IPPS wage index), we allocated salaries
and hours to the campuses of two multicampus hospitals with campuses
that are located in different labor areas, one in Massachusetts and
another in Illinois. Thus, the proposed RY 2009 LTCH PPS wage index
values for 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) (refer to Table 1 in the
Addendum of this proposed rule). Furthermore, the proposed RY 2009 LTCH
PPS wage index values presented in this proposed rule were computed
consistent with the urban and rural geographic classifications (labor
market areas) discussed above in section IV.F.1.b. of this proposed rule
and consistent with pre-reclassified IPPS wage index policy (that is,
our historical policy of not taking into account IPPS geographic
reclassifications in determining payments under the LTCH PPS).
Specifically, we note that the wage data of the IPPS hospitals located
in Litchfield county, CT, and Merrimack county, NH, were included in the
calculation of the proposed RY 2009 LTCH PPS statewide rural wage index
values for Connecticut and New Hampshire, respectively (rather than
urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT) and urban
CBSA 31700 (Manchester-Nashua, NH), respectively). In addition, the
proposed RY 2009 wage index reflects our proposals (discussed in greater
detail below) to establish wage index values in urban and rural areas in
which there are no IPPS wage data from which to compute a wage index
value under our methodology described above. As noted above, the IPPS
wage data we are proposing to use are the same FY 2004 acute care
hospital inpatient wage data that were used to compute the FY 2008 wage
index currently used under the IPPS.

In this proposed rule, under the broad authority conferred upon the
Secretary by section 123 of the BBRA as amended by section 307(b) of
BIPA to determine appropriate adjustments under the LTCH PPS, we are
also proposing to establish a policy for determining LTCH PPS wage index
values for labor market areas in which there is no IPPS hospital wage
data from which to compute a wage index value under our methodology
described above. Currently, there are no LTCHs located in labor areas
where there is no IPPS hospital wage data (or IPPS hospitals). However,
we believe it is appropriate to establish a methodology for determining
LTCH PPS wage index values for these areas in the event that in the
future a LTCH should open in one of those areas. Thus, any LTCH that
would open in area in which there is no IPPS wage data for which to
compute a wage index based on our established methodology would have a
wage index value assigned to them for determining their LTCH PPS
payments. Under this proposal, each year we would determine a wage index
value for any area in which there is no IPPS wage data based on the
proposed methodologies described below. As IPPS hospitals may open or
close at any time, the number of areas without any IPPS wage data may
change from year to year, and even when an IPPS hospital does open in
area where there are currently no IPPS hospitals, because there is a
lag-time between the time a hospital opens or becomes an IPPS provider
and when the hospital's cost report wage data are available to include
in calculating the area wage index (see 72 FR 47323), we believe it is
appropriate to establish a methodology for determining LTCH PPS wage
index values for these areas, if necessary. Our proposed policies for
determining LTCH PPS wage index values for areas with no IPPS hospital
wage data are consistent with the policies that have been established
under other Medicare post-acute care PPSs, such as SNF and HHA, as well
as the IPPS.

The first situation for which we are proposing to establish a policy for
determining a LTCH PPS wage index value is for urban CBSAs with no IPPS
wage data. As discussed above, as IPPS wage data is dynamic, it is
possible that urban areas without IPPS wage data will vary in the
future. Consistent with the policy established under other PPSs, such as
the HHA (70 FR 40795 and 71 FR 65892 through 65893), we are proposing to
use an average of all of the urban areas within the State to serve as a
reasonable proxy for determining the LTCH PPS wage index for an urban
area without specific IPPS hospital wage index data. We believe that an
average of all of the urban areas within the State would be a reasonable
proxy for determining the LTCH PPS wage index for an urban area in the
State with no wage data because it is based on pre‑reclassified IPPS
wage data, it is easy to evaluate, and it uses the most geographically
similar relative wage‑related costs data available. (Our rationale for
using pre-reclassified IPPS wage data is discussed above in the
beginning of this section.) Based on the FY 2004 IPPS wage data that we
are proposing to use to determine the proposed RY 2009 LTCH PPS wage
index (discussed above), there is no IPPS wage data for the urban area
of Hinesville-Fort Stewart, GA (CBSA 25980). Consistent with our
proposal for determining a LTCH PPS wage index value for urban areas
with no IPPS wage data, in this proposed rule, we calculated the
proposed wage index value for RY 2009 for CBSA 25980 as the average of
the wage index values for all of the other urban areas within the State
of Georgia (that is, CBSAs 10500, 12020, 12060, 12260, 15260, 16860,
17980, 19140, 23580, 31420, 40660, 42340, 46660 and 47580) (refer to
Table 1 of the Addendum of this proposed rule). (As noted above, there
are currently no LTCHs located in CBSA 25980). We believe that this
policy could be readily applied to other urban CBSAs (besides CBSA
25980) that lack IPPS wage data (possibly due to acute-care hospitals
converting to a different provider type that does not submit the
appropriate wage data). However, if the proposed policy is adopted, we
may re-examine the application of this proposed policy should a similar
situation arise in the future.

The other situation for which we are proposing to establish a policy for
determining a LTCH PPS wage index value is for rural areas with no IPPS
wage data. As discussed above, as IPPS wage data is dynamic, it is
possible that rural areas without IPPS wage data will vary in the
future. Consistent with the policy established under other PPSs, such as
the HHA (71 FR 65905 through 65906) and the IPPS (72 FR 47323 through
47324), we are proposing to use the unweighted average of the wage
indices from all of the CBSAs that are contiguous to the rural counties
of the State to serve as a reasonable proxy in determining the LTCH PPS
wage index for a rural area without specific IPPS hospital wage index
data. For this purpose, we would define "contiguous" as sharing a
border. We are not able to apply a similar averaging in rural areas with
no wage data as we proposed above for urban areas with no wage data
because there is no rural hospital data available for averaging on a
state-wide basis. We believe that using an unweighted average of the
wage indices from all of the CBSAs that are contiguous to the rural
counties of the State would be a reasonable proxy for determining the
wage index for rural areas in a State with no wage data because it is
based on pre-reclassified IPPS wage data, it is easy to evaluate, and it
uses the most geographically similar relative wage‑related costs data
available. (Our rationale for using pre-reclassified IPPS wage data is
discussed above in the beginning of this section.)

Based on the FY 2004 IPPS data that we are proposing to use to determine
the proposed RY 2009 LTCH PPS wage index (discussed above), rural
Massachusetts (CBSA code 11) does not have any IPPS wage data.
Consistent with our proposal for determining a LTCH PPS wage index value
for rural areas with no IPPS hospital wage data, in this proposed rule,
we determined the proposed wage index value for RY 2009 rural
Massachusetts by computing the unweighted average of the wage indices
from all of the CBSAs that are contiguous to the rural counties in that
State. Specifically, in the case of Massachusetts, the entire rural area
consists of Dukes and Nantucket counties. We determined that the borders
of Dukes and Nantucket counties are "contiguous" with Barnstable County,
MA, and Bristol County, MA. Therefore, the proposed RY 2009 LTCH PPS
wage index value for rural Massachusetts would be computed as the
unweighted average of the proposed RY 2009 wage indexes for Barnstable
county and Bristol county (refer to Tables 1 and 2 of the Addendum of
this proposed rule). (As noted above, there are currently no LTCHs
located in rural Massachusetts.) We believe that this proposed policy
could be readily applied to other rural areas (besides Massachusetts)
that lack IPPS wage data (possibly due to acute-care hospitals
converting to a different provider type that does not submit the
appropriate wage data). However, if the proposed policy is adopted, we
may re-examine the application of this proposed policy should a similar
situation arise in the future.

The proposed RY 2009 LTCH wage index values that would be applicable for
LTCH discharges occurring on or after July 1, 2008 through September 30,
2009, are presented in Table 1 (for urban areas) and Table 2 (for rural
areas) in the Addendum of this proposed rule. As discussed in greater
detail above in section IV.B. of this preamble, we are proposing to move
the LTCH PPS annual payment rate update cycle from July 1 to October 1
and to have a 15‑month rate year for 2009 (that is, July 1, 2008 through
September 30, 2009). Therefore, we note that if our proposal to move the
LTCH PPS annual payment rate update cycle is finalized, the next
proposed update to the LTCH wage index values would be effective for
discharges occurring on or after October 1, 2009 (FY 2010). In addition,
as noted above, the wage index adjustment under the LTCH PPS was
completely phased in beginning with cost reporting periods beginning in
FY 2007 (that is, for cost reporting periods beginning on or after
October 1, 2006). Therefore, for LTCH PPS discharges occurring during RY
2009, the labor related portion of the standard Federal rate will be
adjusted by the applicable full (five fifths) proposed RY 2009 LTCH PPS
wage index value. (As noted above, the proposed RY 2009 LTCH PPS wage
index values are shown in Tables 1 and 2 of the Addendum to this
proposed rule).

2\. Proposed Adjustment for Cost‑of‑Living in Alaska and Hawaii

In the August 30, 2002 final rule (67 FR 56022), we established, under
§412.525(b), a COLA for LTCHs located in Alaska and Hawaii to account
for the higher costs incurred in those States. In the RY 2008 LTCH PPS
final rule (72 FR 26894), for RY 2008, we established a COLA to payments
for LTCHs located in Alaska and Hawaii by multiplying the standard
Federal payment rate by the appropriate factor listed in Table 3 of that
same final rule.

Similarly, in this proposed rule, under the broad authority conferred
upon the Secretary by section 123 of the BBRA as amended by section
307(b) of BIPA to determine appropriate adjustments under the LTCH PPS,
for RY 2009 we are proposing a COLA to payments to LTCHs located in
Alaska and Hawaii by multiplying the proposed standard Federal payment
rate by the proposed factors listed below in Table 2 because these are
currently the most recent available data. These proposed factors are
obtained from the U.S. Office of Personnel Management (OPM) and are
currently also used under the IPPS (72 FR 47422). In addition, we
propose that if OPM releases revised COLA factors before March 1, 2008,
we would use them for the development of LTCH PPS payments for RY 2009
and publish those revised COLA factors in the final rule.

**TABLE 2: Proposed Cost-of-Living Adjustment Factors for Alaska and
Hawaii Hospitals for the 2009 LTCH PPS Rate Year**

  ----------------------------------------------------------- -----------
  Alaska:                                                     

  City of Anchorage and 80-kilometer (50‑mile) radius by road 1.24

  City of Fairbanks and 80-kilometer (50‑mile) radius by road 1.24

  City of Juneau and 80-kilometer (50‑mile) radius by road    1.24

  All other areas of Alaska                                   1.25

  Hawaii:                                                     

  City and County of Honolulu                                 1.25

  County of Hawaii                                            1.17

  County of Kauai                                             1.25

  County of Maui and County of Kalawao                        1.25
  ----------------------------------------------------------- -----------

3\. Proposed Adjustment for High-Cost Outliers (HCOs)

a\. Background

Under the broad authority conferred upon the Secretary by section 123 of
the BBRA as amended by section 307(b) of BIPA, in the regulations at
§412.525(a), we established an adjustment for additional payments for
outlier cases that have extraordinarily high costs relative to the costs
of most discharges. Providing additional payments for outliers strongly
improves the accuracy of the LTCH PPS in determining resource costs at
the patient and hospital level. These additional payments reduce the
financial losses that would otherwise be incurred when treating patients
who require more costly care and, therefore, reduce the incentives to
underserve these patients. We set the outlier threshold before the
beginning of the applicable rate year so that total estimated outlier
payments are projected to equal 8 percent of total estimated payments
under the LTCH PPS. Outlier payments under the LTCH PPS are determined
consistent with the instructions issued for the IPPS outlier policy.

Under §412.525(a) (in conjunction with the revised definition of
"LTC-DRG" at §412.503), we make outlier payments for any discharges if
the estimated cost of a case exceeds the adjusted LTCH PPS payment for
the MS-LTC‑DRG plus a fixed‑loss amount. Specifically, in accordance
with §412.525(a)(3) (in conjunction with the revised definition of
"LTC-DRG" at §412.503), we pay outlier cases 80 percent of the
difference between the estimated cost of the patient case and the
outlier threshold (the sum of the adjusted Federal prospective payment
for the MS-LTC-DRG and the fixed-loss amount). The fixed‑loss amount is
the amount used to limit the loss that a hospital will incur under the
outlier policy for a case with unusually high costs. This results in
Medicare and the LTCH sharing financial risk in the treatment of
extraordinarily costly cases. Under the LTCH PPS HCO policy, the LTCH\'s
loss is limited to the fixed‑loss amount and a fixed percentage
(currently 80 percent) of costs above the outlier threshold (LTCH DRG
payment plus the fixed loss amount). The fixed percentage of costs is
called the marginal cost factor. We calculate the estimated cost of a
case by multiplying the Medicare allowable covered charge by the overall
hospital cost‑to‑charge ratio (CCR).

Under the LTCH PPS, we determine a fixed‑loss amount, that is, the
maximum loss that a LTCH can incur under the LTCH PPS for a case with
unusually high costs before the LTCH will receive any additional
payments. We calculate the fixed‑loss amount by estimating aggregate
payments with and without an outlier policy. The fixed‑loss amount will
result in estimated total outlier payments being projected to be equal
to 8 percent of projected total LTCH PPS payments. Currently, MedPAR
claims data and CCRs based on data from the most recent provider
specific file (PSF) (or to the applicable Statewide average CCR if a
LTCH's CCR data are faulty or unavailable) are used to establish a
fixed‑loss threshold amount under the LTCH PPS.

b\. Cost‑to‑Charge Ratios (CCRs)

The following is a discussion of cost-to-charge ratios (CCRs) used in
determining payments for high cost and short--stay outlier cases under
the LTCH PPS, at §412.525(a) and §412.529, respectively. Although this
section is specific to high cost outlier cases, because CCRs and the
policies and methodologies pertaining to them are used in determining
payments for both high cost and short‑ stay outlier cases, (as explained
below), we are discussing the determination of CCRs under the LTCH PPS
for both of these type of cases simultaneously. In section IV.G. of this
proposed rule, which discusses short-stay outlier (SSO) cases, we refer
the reader to this section of the preamble for a complete discussion on
the determination of CCRs.

In determining both high-cost outlier payments (at §412.525(a)) and
short-stay outlier payments (at §412.529), we calculate the estimated
cost of the case by multiplying the LTCH's overall CCR by the Medicare
allowable charges for the case. In general, we use the LTCH\'s overall
CCR, which is computed based on either the most recently settled cost
report or the most recent tentatively settled cost report, whichever is
from the latest cost reporting period, in accordance with
§412.525(a)(4)(iv)(B) and §412.529(c)(4)(iv)(B) for high cost outliers
and SSOs, respectively. (We note that in some instances we use an
alternative CCR, such as the statewide average CCR in accordance with
the regulations at §412.525(a)(4)(iv)(C) and §412.529(c)(4)(iv)(C), or a
CCR that is specified by CMS or that is requested by the hospital under
the provisions of the regulations at §412.525(a)(4)(iv)(A) and
§412.529(c)(4)(iv)(A).) Under the LTCH PPS, a single prospective payment
per discharge is made for both inpatient operating and capital‑related
costs. Therefore, we compute a single "overall" or "total" LTCH-specific
CCR based on the sum of LTCH operating and capital costs (as described
in Chapter 3, section 150.24, of the Medicare Claims Processing Manual
(CMS Pub. 100‑4)) as compared to total charges. Specifically, a LTCH's
CCR is calculated by dividing a LTCH's total Medicare costs (that is,
the sum of its operating and capital inpatient routine and ancillary
costs) by its total Medicare charges (that is, the sum of its operating
and capital inpatient routine and ancillary charges).

Generally, a LTCH is assigned the applicable statewide average CCR if,
among other things, a LTCH's CCR is found to be in excess of the
applicable maximum CCR threshold (that is, the LTCH CCR ceiling). This
is because CCRs above this threshold are most likely due to faulty data
reporting or entry, and, therefore, these CCRs should not be used to
identify and make payments for outlier cases. Such data are clearly
errors and should not be relied upon. Thus, under our established
policy, generally, if a LTCH's calculated CCR is above the applicable
ceiling, the applicable LTCH PPS statewide average CCR is assigned to
the LTCH instead of the CCR computed from its most recent (settled or
tentatively settled) cost report data.

In the FY 2008 IPPS final rule with comment period, in accordance with
§412.525(a)(4)(iv)(C)([2]{.underline}) for high-cost outliers and
§412.529(c)(4)(iv)(C)([2]{.underline}) for short-stay outliers, using
our established methodology for determining the LTCH total CCR ceiling,
based on IPPS total CCR data from the March 2007 update to the
Provider-Specific File (PSF), we established a total CCR ceiling of
1.284 under the LTCH PPS effective October 1, 2007 through September 30,
2008. (For further detail on our methodology for annually determining
the LTCH total CCR ceiling, we refer readers to the FY 2007 IPPS final
rule (71 FR 48119 through 48121) and the FY 2008 IPPS final rule with
comment period (72 FR 47403 through 47404).)

Our general methodology established for determining the statewide
average CCRs used under the LTCH PPS is similar to our established
methodology for determining the LTCH total CCR ceiling (described above)
since it is based on "total" IPPS CCR data. Under the LTCH PPS HCO
policy at §412.525(a)(4)(iv)(C) and the short-stay outlier policy at
§412.529(c)(4)(iv)(C), the FI may use a statewide average CCR, which is
established annually by CMS, if it is unable to determine an accurate
CCR for a LTCH in one of the following circumstances: (1) new LTCHs that
have not yet submitted their first Medicare cost report (for this
purpose, consistent with current policy, a new LTCH would be defined as
an entity that has not accepted assignment of an existing hospital\'s
provider agreement in accordance with §489.18); (2) LTCHs whose CCR is
in excess of the LTCH CCR ceiling (as discussed above); and (3) other
LTCHs for whom data with which to calculate a CCR are not available (for
example, missing or faulty data). (Other sources of data that the FI may
consider in determining a LTCH's CCR include data from a different cost
reporting period for the LTCH, data from the cost reporting period
preceding the period in which the hospital began to be paid as a LTCH
(that is, the period of at least 6 months that it was paid as a
short‑term acute care hospital), or data from other comparable LTCHs,
such as LTCHs in the same chain or in the same region.)

In the FY 2008 IPPS final rule with comment period, in accordance with
§412.525(a)(4)(iv)(C) for high-cost outliers and §412.529(c)(4)(iv)(C)
for short-stay outliers, using our established methodology for
determining the LTCH statewide average CCRs, based on the most recent
complete IPPS total CCR data from the March 2007 update of the PSF, the
LTCH PPS statewide average total CCRs for urban and rural hospitals
effective for discharges occurring on or after October 1, 2007, and
before October 1, 2008, are presented in Table 8C of the Addendum to
that final rule with comment period (72 FR 48127). (For further detail
on our methodology for annually determining the LTCH urban and rural
statewide average CCRs, we refer readers to the FY 2007 IPPS final rule
(71 FR 48119 through 48121) and FY 2008 IPPS final rule with comment
period (72 FR 47403 through 47404).)

We note, under the LTCH PPS high cost outlier policy at
§412.525(a)(4)(iv)(D) and the LTCH PPS SSO policy at
§412.529(c)(4)(iv)(D), the payments for high cost outlier and SSO cases,
respectively, are subject to reconciliation. Specifically, any
reconciliation of outlier payments is based on the CCR calculated based
on a ratio of costs to charges computed from the relevant cost report
and charge data determined at the time the cost report coinciding with
the discharge is settled. For additional information, refer to the RY
2008 LTCH PPS final rule (72 FR 26899 through 26900).

c\. Establishment of the Proposed Fixed-Loss Amount

When we implemented the LTCH PPS, as discussed in the August 30, 2002
LTCH PPS final rule (67 FR 56022 through 56026), under the broad
authority of section 123 of the BBRA as amended by section 307(b) of
BIPA, we established a fixed‑loss amount so that total estimated outlier
payments are projected to equal 8 percent of total estimated payments
under the LTCH PPS. To determine the fixed‑loss amount, we estimate
outlier payments and total LTCH PPS payments for each case using claims
data from the MedPAR files. Specifically, to determine the outlier
payment for each case, we estimate the cost of the case by multiplying
the Medicare covered charges from the claim by the LTCH's hospital
specific CCR. Under §412.525(a)(3) (in conjunction with the revised
definition of "LTC-DRG" at §412.503), if the estimated cost of the case
exceeds the outlier threshold (the sum of the adjusted Federal
prospective payment for the MS-LTC‑DRG and the fixed-loss amount), we
pay an outlier payment equal to 80 percent of the difference between the
estimated cost of the case and the outlier threshold (the sum of the
adjusted Federal prospective payment for the MS-LTC‑DRG and the
fixed‑loss amount).

In the RY 2008 LTCH PPS final rule (72 FR 26898), in calculating the
fixed‑loss amount that would result in estimated outlier payments
projected to be equal to 8 percent of total estimated payments for the
2008 LTCH PPS rate year, we used claims data from the December 2006
update of the FY 2006 MedPAR files and CCRs from the December 2006
update of the PSF, as that was the best available data at that time. We
believe that CCRs from the PSF are the best available CCR data for
determining estimated LTCH PPS payments for a given LTCH PPS rate year
because they are the most recently available CCRs actually used to make
LTCH PPS payments.

As we also discussed in the RY 2008 LTCH PPS rate year final rule
(72 FR 26898), we calculated a single fixed‑loss amount for the 2008
LTCH PPS rate year based on the version 24.0 of the GROUPER, which was
the version in effect as of the beginning of the LTCH PPS rate year
(that is, July 1, 2007 for the 2008 LTCH PPS rate year). In addition, we
applied the outlier policy under §412.525(a) in determining the
fixed‑loss amount for the 2008 LTCH PPS rate year; that is, we assigned
the applicable Statewide average CCR only to LTCHs whose CCRs exceeded
the ceiling (and not when they fell below the floor). Accordingly, we
used the FY 2007 LTCH PPS total CCR ceiling of 1.321 (72 FR 26898). As
noted in that same final rule, in determining the fixed‑loss amount for
the 2008 LTCH PPS rate year using the CCRs from the PSF, there were no
LTCHs with missing CCRs or with CCRs in excess of the current ceiling
and, therefore, there was no need for us to independently assign the
applicable Statewide average CCR to any LTCHs in determining the
fixed‑loss amount for the 2008 LTCH PPS rate year (as this may have
already been done by the FI in the PSF in accordance with the
established policy).

Accordingly, in 2008 LTCH PPS rate year final rule (72 FR 26898), as
amended by the RY 2008 correction notice (72 FR 36613), we established a
fixed‑loss amount of \$20,738 for the 2008 LTCH PPS rate year. Thus, we
pay an outlier case 80 percent of the difference between the estimated
cost of the case and the outlier threshold (the sum of the adjusted
Federal LTCH PPS payment for the MS-LTC‑DRG and the fixed‑loss amount of
\$20,738).

In this proposed rule, for the 2009 LTCH PPS rate year, we used the
March 2006 update of the FY 2006 MedPAR claims data to determine a
proposed fixed‑loss amount that would result in estimated outlier
payments projected to be equal to 8 percent of total estimated payments,
based on the policies described in this proposed rule, because these
data are the most recent complete LTCH data available. Consistent with
our historical practice of using the best data available, if more recent
LTCH claims data become available, we propose to use it for determining
the fixed‑loss amount for the 2009 LTCH PPS rate year in the final rule.
Furthermore, as noted previously, we determined the proposed fixed‑loss
amount based on the version of the GROUPER that would be in effect as of
the beginning of the 2009 LTCH PPS rate year (July 1, 2008), that is,
Version 25.0 of the GROUPER (as established in the FY 2008 IPPS final
rule (72 FR 47278)).

We also used CCRs from the July 2007 update of the PSF for determining
the proposed fixed‑loss amount for the 2009 LTCH PPS rate year as they
are currently the most recent complete available data. Consistent with
our historical practice of using the best data available, if more recent
CCR data are available, we propose to use it for determining the
fixed‑loss amount for the 2009 LTCH PPS rate year in the final rule.
Furthermore, in determining the proposed fixed‑loss amount for the 2009
LTCH PPS rate year, we used the current FY 2008 applicable LTCH "total"
CCR ceiling of 1.284 and LTCH Statewide average "total" CCRs established
in the FY 2008 IPPS final rule (72 FR 47404 and 48126 through 48127)
such that the current applicable Statewide average CCR would be assigned
if, among other things, a LTCH's CCR exceeded the current ceiling
(1.284). We note that in determining the proposed fixed‑loss amount for
the 2009 LTCH PPS rate year using the CCRs from the PSF, there was no
need for us to independently assign the applicable Statewide average CCR
to any LTCHs (as this may have already been done by the FI in the PSF in
accordance with our established policy). (Currently, the applicable
FY 2008 LTCH Statewide average CCRs can be found in Table 8C of the
FY 2008 IPPS final rule (72 FR 48126 through 48127).)

Accordingly, based on the data and policies described in this proposed
rule, we are proposing a fixed‑loss amount of \$21,199 for the 2009 LTCH
PPS rate year. Thus, we would pay an outlier case 80 percent of the
difference between the estimated cost of the case and the proposed
outlier threshold (the sum of the adjusted proposed Federal LTCH payment
for the MS-LTC‑DRG and the proposed fixed‑loss amount of \$21,199). We
note that the proposed fixed‑loss amount for the 2009 LTCH PPS rate year
is somewhat higher than the current fixed‑loss amount of \$20,738. In
addition to being based on the most recent available LTCH data to
estimate the cost of each LTCH case, this proposed change in the
fixed‑loss amount is primarily due to the projected increase in
estimated aggregate LTCH PPS payments that is expected to result from
the proposed 2.6 percent update to the Federal rate (discussed in
greater detail in section IV.E. of this preamble), in conjunction with
the proposed changes to the area wage adjustment (discussed in greater
detail in section IV.F.1. of this preamble) and the changes to the
MS-LTC‑DRG relative weights for FY 2008 (as discussed in the FY 2008
IPPS final rule (72 FR 47277 through 47299)). As discussed in greater
detail in the impact analysis presented in section XII. of this proposed
rule, we are projecting that the proposed changes would result in a
1.7 percent increase in estimated payments per discharge in RY 2009 as
compared to RY 2008, on average, for all LTCHs. Because of the estimated
increase in aggregate LTCH PPS payments proposed for the 2009 LTCH PPS
rate year (as discussed above in this section), we believe that an
increase in the proposed fixed‑loss amount is appropriate and necessary
to maintain the requirement that estimated outlier payments would be
projected to be equal to 8 percent of estimated total LTCH PPS payments,
as required under §412.525(a). As we discussed in the RY 2008 final rule
(72 FR 26897), maintaining the fixed‑loss amount at the current level
would result in HCO payments above the current regulatory requirement
that estimated outlier payments would be projected to equal 8 percent of
estimated total LTCH PPS payments. Based on the regression analysis that
was performed when we implemented the LTCH PPS (August 30, 2002 final
rule (67 FR 56022 through 56027)), we established the outlier target at
8 percent of estimated total LTCH PPS payments to allow us to achieve a
balance between the "conflicting considerations of the need to protect
hospitals with costly cases, while maintaining incentives to improve
overall efficiency" (67 FR 56024). That regression analysis also showed
that additional increments of outlier payments over 8 percent (that is,
raising the outlier target to a larger percentage than 8 percent) would
reduce financial risk, but by successively smaller amounts. Outlier
payments are budget neutral, and therefore, outlier payments are funded
by prospectively reducing the non‑outlier PPS payment rates by projected
total outlier payments. The higher the outlier target, the greater the
(prospective) reduction to the base payment would need to be applied to
the Federal rate to maintain BN.

As we discussed in the RY 2008 LTCH PPS final rule (72 FR 26898 through
26899), as an alternative to proposing to lower the fixed‑loss amount
for RY 2009, we examined adjusting the marginal cost factor (that is,
the percentage that Medicare will pay of the estimated cost of a case
that exceeds the sum of the adjusted Federal prospective payment for the
MS-LTC‑DRG and the fixed‑loss amount for LTCH PPS outlier cases as
specified in §412.525(a)(3) in conjunction with the revised definition
of "LTC-DRG" at §412.503), which is currently equal to 80 percent, as a
means of ensuring that estimated outlier payments would be projected to
equal 8 percent of estimated total LTCH PPS payments. When we initially
established the 80 percent marginal cost factor in the August 30, 2002
final rule (67 FR 56022 through 56027), we explained that our analysis
of payment‑to‑cost ratios for HCO cases showed that a marginal cost
factor of 80 percent appropriately addresses outlier cases that are
significantly more expensive than nonoutlier cases, while simultaneously
maintaining the integrity of the LTCH PPS.

In proposing increases to the fixed‑loss amount for RY 2007 and RY 2008
(71 FR 27834 and 72 FR 4799 through 4800 respectively), we also
solicited comments on whether we should revisit the regression analysis
discussed above in this section that was used to establish the existing
8 percent outlier target and 80 percent marginal cost factor, using the
most recent available data to evaluate whether the current outlier
target of 8 percent or the 80 percent marginal cost factor should be
adjusted, and therefore, could have resulted in less of an increase in
the fixed‑loss amount for RY 2007 and RY 2008, respectively. In response
to this solicitation in the RY 2007 proposed rule (as summarized in the
RY 2007 LTCH PPS final rule (71 FR 27834 through 27835)), several
commenters opposed any option that would allow us to revisit the
regression analysis that was used to establish the existing 80 percent
marginal cost factor and existing outlier target of 8 percent. The
commenters stated their belief that the LTCH PPS is still in its early
stages and further changes to the 80 percent marginal cost factor or
8 percent outlier target would result in instability to the system. The
commenters cautioned against making any premature changes to the factors
affecting HCO payments to LTCHs, particularly the marginal cost factor
and outlier target established by regulation when the LTCH PPS was
implemented. Also, the commenters agreed that keeping the marginal cost
factor at 80 percent and the outlier pool at 8 percent better identifies
LTCH patients that are truly unusually costly cases, and that this
policy appropriately addresses outlier cases that are significantly more
expensive than non‑outlier cases. Similarly, as summarized in the RY
2008 final rule (72 FR 26897), we received no comments in support of
revisiting the regression analysis discussed above that was used to
establish the existing 8 percent outlier target and 80 percent marginal
cost factor, using the most recent available data to evaluate whether
the current outlier target of 8 percent or the 80 percent marginal cost
factor should be adjusted in response to our solicitation on this issue.

In response to these comments, we agreed with the commenters that, based
on the regression analysis done for the implementation of the LTCH PPS
(August 30, 2002; 68 FR 56022 through 56026), a marginal cost factor of
80 percent and a outlier target of 8 percent best identifies LTCH
patients that are truly unusually costly cases, and that such a policy
appropriately addresses LTCH HCO cases that are significantly more
expensive than non‑outlier cases, which is consistent with our intent of
the LTCH HCO policy as stated when we implemented the LTCH PPS in the
August 30, 2002 final rule (67 FR 56025). Therefore, as supported by
many commenters, in both the RY 2007 final rule (71 FR 27835) and the RY
2008 final rule (72 FR 26898), we did not revisit the regression
analysis that was used to establish the existing 80 percent marginal
cost factor and existing outlier target of 8 percent, and therefore, did
not make any changes to the marginal cost factor or outlier target in
either of those final rules.

Although proposing to increase the fixed‑loss amount from \$20,738 to
\$21,199 (based on the policies presented in this proposed rule) would
increase the amount of the "loss" that a LTCH must incur under the LTCH
PPS for a case with unusually high costs before the LTCH would receive
any additional Medicare payments, as we discussed above and as we
explained in greater detail in the RY 2006 LTCH PPS final rule
(70 FR 24195 through 24196), we continue to believe that the existing
8 percent outlier target and 80 percent marginal cost factor continue to
adequately maintain the LTCHs' share of the financial risk in treating
the most costly patients and ensure the efficient delivery of services.
Accordingly, we are not proposing to adjust the existing 8 percent
outlier target or 80 percent marginal cost factor under the LTCH PPS HCO
policy at this time. However, we continue to be interested in any
comments that would support revisiting the analysis that was used to
establish the existing 8 percent outlier target and the existing
80 percent marginal cost factor, using the most recent available data to
evaluate whether any changes to the current HCO policy should be made,
and therefore, may result in a smaller increase (or even a decrease) in
the fixed‑loss amount for RY 2009.

For the reasons described above, we believe the proposed fixed-loss
amount of \$21,199 would appropriately identify unusually costly LTCH
cases while maintaining the integrity of the LTCH PPS. Thus, under the
broad authority of section 123(a)(1) of the BBRA and section 307(b)(1)
of BIPA, we are proposing a fixed‑loss amount of \$21,199 based on the
best available LTCH data and the policies presented in this proposed
rule because we believe a proposed increase in the fixed‑loss amount is
appropriate and necessary to maintain estimated outlier payments are
projected to be equal to 8 percent of estimated total LTCH PPS payments,
as required under §412.525(a).

d\. Application of Outlier Policy to Short-Stay Outlier (SSO) Cases

As we discussed in the August 30, 2002 final rule (67 FR 56026), under
some rare circumstances, a LTCH discharge could qualify as a SSO case
(as defined under §412.529 and discussed in section IV.G. of this
preamble) and also as a HCO case. In this scenario, a patient could be
hospitalized for less than five‑sixths of the geometric ALOS for the
specific MS-LTC‑DRG, and yet incur extraordinarily high treatment costs.
If the costs exceeded the high cost outlier threshold (that is, the SSO
payment plus the fixed‑loss amount), the discharge is eligible for
payment as a HCO. Thus, for a SSO case in the 2009 LTCH PPS rate year,
the HCO payment would be 80 percent of the difference between the
estimated cost of the case and the proposed outlier threshold (the sum
of the proposed fixed‑loss amount of \$21,199 and the amount paid under
the SSO policy as specified in §412.529).

4\. Other Payment Adjustments

Section 123(a)(1) of the BBRA, as amended by section 307(b) of BIPA,
granted the Secretary broad authority to determine appropriate
adjustments under the LTCH PPS, including whether (and how) to provide
for adjustments to reflect variations in the necessary costs of
treatment among LTCHs. In developing the LTCH PPS payment methodology,
we conducted extensive regression analyses of the relationship between
LTCH costs (including both operating and capital‑related costs per case)
and several factors that may affect costs such as the percent of
Medicaid patients treated, the percent of Supplemental Security Income
(SSI) patients treated, the hospital's geographic location, and training
residents in approved medical education programs (67 FR 56014). The
appropriateness of potential payment adjustments were evaluated based
upon whether including each adjustment increased the accuracy of
payments to LTCHs.

In the August 30, 2002 LTCH PPS final rule, we detailed the extensive
data analysis performed by our contractor, 3M Health Information Systems
(3M) and our resulting decisions to implement a COLA for LTCHs in Alaska
and Hawaii (§412.525(b)) and an adjustment to account for geographical
differences in area wage levels (§412.525(c)). In addition, we discussed
the extensive data analyses that led to the decision not to implement
adjustments for geographic reclassification, rural location, the
treatment of a disproportionate share of low‑income patients (DSH), or
indirect medical education (IME) costs. We also noted that we would
continue to collect data and revisit these determinations as additional
data became available. (For more detailed information, see 67 FR 56014
through 56027.)

When we implemented the LTCH PPS for FY 2003, we provided for a 5-year
transition period (§412.533), to allow LTCHs time to adjust to the new
payment system (67 FR 56038). For cost reporting periods beginning on or
after October 1, 2006, the final year of the 5‑year transition, LTCHs
are paid based on 100 percent of the Federal rate.

We continued to collect and interpret new data as they became available
to determine if these data support proposing any additional payment
adjustments. In both the RY 2007 and the RY 2008 LTCH PPS final rules,
we stated that we believed that it was appropriate to wait for the
conclusion of the 5-year transition to 100 percent of the Federal rate
under the LTCH PPS to maximize the availability of data that reflected
LTCH behavior in response to the implementation of the LTCH PPS. The
availability of this data would allow us to conduct a comprehensive
reevaluation of payment adjustments under the LTCH PPS. (See the RY 2007
and RY 2008 LTCH PPS final rules (71 FR 27839) and (72 FR 26900),
respectively.)  

Therefore, similar to the data analyses conducted at the inception of
the LTCH PPS for FY 2003, 3M evaluated LTCH data from the most recent
cost report files in our HCRIS database (updated through June 30, 2007)
for providers' cost reports beginning during fiscal years 2004 through
2006. We believe that in the 5-years since the start of the LTCH PPS,
there has been sufficient new data generated to allow for a
comprehensive reevaluation the appropriateness of payment adjustments
such as geographic reclassification, rural location, DSH, and IME under
the LTCH PPS at this time.

Our most recent data analysis which is based on the comprehensive data
analysis by 3M (referenced above), indicates that proposing payment
adjustments for geographic reclassification, rural location, DSH, or
indirect medical education (IME) costs would not improve the accuracy of
payments to LTCHs. (3M's "Report on LTCH Payment Methodology Review and
Results" is posted on our website at:
http://www.cms.hhs.gov/LongTermCareHospitalPPS/08_download.asp#TopOfPage

We believe that these analyses confirm our initial determinations as we
developed the LTCH PPS regarding the applicability of PPS payment
adjustments. Therefore, we are not proposing to adopt any additional
payment adjustments such as geographic reclassification, rural location,
DSH, or IME, as features of the LTCH PPS. Proposed policies for the RY
2009 wage index adjustment and the COLA are discussed in sections IV.D.1
and 2. of this proposed rule, respectively. Furthermore, now that the
5-year transition to the LTCH PPS is completed, we have collected data
that reflects LTCH behavior in response to the implementation of the
LTCH PPS. We believe that our above described analyses of LTCH PPS data
do not support the adoption of any additional payment adjustments. We
further believe that since 3M's recent analyses confirm policy
determinations that have been in place since the implementation of the
LTCH PPS for FY 2003, that annual data analyses related to potential
payment adjustments for geographic reclassification, rural location, DSH
or IME will not be necessary barring significant transformations in the
nature of the LTCH universe or substantial changes in Medicare payment
outcomes that warrant additional evaluation.

5\. Technical Correction to the Budget Neutrality Requirement at
§412.523(d)(2).

Section 123(a)(1) of the Pub. L. 106-113 requires that the PPS developed
for LTCHs be budget neutral for the initial year of implementation.
Furthermore, under section 307(a)(2) of the Pub. L. 106--554, the
increases to the target amounts and the cap on the target amounts for
LTCHs provided for by section 307(a)(1) of Pub. L. 106--554 (as set
forth in section 1886(b)(3)(J) of the Act), and the enhanced bonus
payments for LTCHs provided for by section 122 of Pub. L. 106‑113 (as
set forth in section 1886(b)(2)(E) of the Act) were not to be taken into
account in the development and implementation of the LTCH PPS.
Therefore, when we implemented the LTCH PPS, in the August 30, 2002
final rule (67 FR 56052), we established a budget neutrality requirement
at §412.523(d)(2) for calculating the standard Federal rate for FY 2003
such that estimated aggregate LTCH PPS payments were estimated to be
equal to estimated payments that would have been made to LTCHs under the
reasonable cost‑based payment methodology had the PPS for LTCHs not been
implemented, and, to implement section 307(a)(2) of the
Pub. L. 106--554, we excluded the effects of sections 1886(b)(2) and
(b)(3) of the Act.

We are proposing a technical correction to existing §412.523(d)(2) that
would more precisely describe the provisions of sections 1886(b)(2) and
(b)(3) of the Act that were not taken into account when determining the
standard Federal rate under §412.523(d). The current regulatory language
at §412.523(d)(2) cites the general sections of the Act which contain
the specific provisions set forth in §307(a)(2) of Pub. L. 106-554 that
the Secretary is required to not take into account in developing the
PPS. We believe that it is clearer and more precise to cite the specific
subparagraphs the Secretary did not take into account rather than to
cite the general sections of the Act of which such subparagraphs are a
part. In order to mitigate any confusion that may be caused by existing
regulations, we are proposing to make a technical correction at
§412.523(d)(2). Specifically, we are proposing to revise §412.523(d)(2)
to state that the effects of section 1886(b)(2)(E) of the Act (enhanced
bonus payments for LTCHs, as described above) and section 1886(b)(3)(J)
of the Act (increases to the hospital‑specific target amounts and the
cap on the target amounts for LTCHs, as described above) were excluded
in the development of the FY 2003 LTCH PPS standard Federal rate. This
technical correction would make the regulatory language consistent with
section 307(a)(2) of Pub. L. 106--113 and consistent with the
methodology we used to determine the LTCH PPS standard Federal rate
under §412.523, and it is not a change in policy. (Accordingly, no
adjustments to the LTCH PPS standard Federal rate computed under
§412.523(d) have been proposed in conjunction with this proposed
technical correction to §412.523(d)(2).)

G. Proposed Conforming Changes

Various regulations throughout 42 CFR Part 412 Subpart O indicate that
the terms "urban area" and "rural area" are defined according to the
definitions of "urban area" and "rural area" found in 42 CFR Part 412
Subpart D (the IPPS regulations). Specifically, §§412.525(c),
412.529(d)(4)(ii)(B) and (d)(4)(iii)(B), 412.534(d)(1), (f)(2)(ii), and
(f)(3)(ii), and 412.536(c)(1), (e)(2)(ii), and (e)(3)(ii) of Subpart O
refer to the definitions of "urban area" and "rural area" in either
§412.62(f)(1)(ii) and (f)(1)(iii) or §412.64(b)(1)(ii)(A)-(C) in 42 CFR
Part 412 Subpart D. As stated elsewhere in the preamble, we believe that
it is administratively simpler to define the terms "urban area" and
"rural area" in §412.503 rather than cross-referencing the definitions
of "urban area" and "rural area" in §412.62(f)(1)(ii) and
§412.62(f)(1)(iii) and §412.64(b)(1)(ii)(A)-(C). Consequently, in
section IV.F.1.b (4). of this regulation, we propose to add definitions
for "urban area" and "rural area" in §412.503 which would incorporate
the provisions of §412.62 (f)(1)(ii) and (f)(1)(iii) as well as
§ 412.64(b)(1)(ii)(A) through (C). Because we are proposing to define
"urban area" and "rural area" in §412.503, the citations to the
definitions of "urban area" and "rural area" in §412.62(f)(1)(ii) and
§412.62 (f)(1)(iii) and §412.64(b)(1)(ii)(A)-(C) which are found in
§§412.525(c), 412.529(d)(4)(ii)(B) and (d)(4)(iii)(B), 412.534(d)(1),
(f)(2)(ii), and (f)(3)(ii), and 412.536(c)(1), (e)(2)(ii), and
(e)(3)(ii) would need to be replaced with references to §412.503. We are
proposing to replace the above-described references with §412.503.

(We note that provisions of the Medicare, Medicaid, and SCHIP Extension
Act of 2007, enacted on December 29, 2007 require a 3‑year suspension of
the payment adjustments at §412.534 to "grandfathered LTCHs" and
application of §412.536 to "freestanding" LTCHs for cost reporting
periods beginning on or after the date of enactment of the legislation.
In addition, revisions to the short stay outlier policy, as well as
other changes to the regulations necessitated by MMSEA will be addressed
in a future notice.)

**VI. Computing the Proposed Adjusted Federal Prospective Payments for
the 2008 LTCH PPS Rate Year**

In accordance with §412.525 and as discussed in section IV.C. of this
proposed rule, the standard Federal rate is adjusted to account for
differences in area wages by multiplying the labor‑related share of the
standard Federal rate by the appropriate LTCH PPS wage index (as shown
in Tables 1 and 2 of Addendum A to this proposed rule). The standard
Federal rate is also adjusted to account for the higher costs of
hospitals in Alaska and Hawaii by multiplying the nonlabor‑related share
of the standard Federal rate by the appropriate cost‑of‑living factor
(shown in Table 3 in section IV.D.2 of this preamble). In the RY 2008
LTCH PPS final rule (72 FR 4776), we established a standard Federal rate
of \$38,356.45 for the 2008 LTCH PPS rate year. In this proposed rule,
based on the best available data and the proposed policies described in
this proposed rule, we are proposing that the standard Federal rate for
the 2009 LTCH PPS rate year would be \$39,076.28 as discussed in section
IV.C.3. of this preamble. We illustrate the methodology that would be
used to adjust the proposed Federal prospective payments for the 2009
LTCH PPS rate year in the following examples:

[Example:]{.underline}

During the 2009 LTCH PPS rate year, a Medicare patient is in a LTCH
located in Chicago, Illinois (CBSA 16974). The proposed full LTCH PPS
wage index value for CBSA 16974 is 1.0715 (see Table 1 in Addendum A to
this proposed rule). The Medicare patient is classified into MS-LTC‑DRG
28 (Spinal Procedures with MCC), which has a current relative weight of
1.1417 (see Table 3 of Addendum A to this proposed rule).

To calculate the LTCH's proposed total adjusted Federal prospective
payment for this Medicare patient, we compute the proposed wage‑adjusted
Federal prospective payment amount by multiplying the proposed
unadjusted standard Federal rate (\$39,076.28) by the proposed
labor‑related share (75.920 percent) and the proposed wage index value
(1.0715). This proposed wage‑adjusted amount is then added to the
nonlabor‑related portion of the proposed unadjusted standard Federal
rate (24.080 percent; adjusted for cost of living, if applicable) to
determine the proposed adjusted Federal rate, which is then multiplied
by the MS-LTC‑DRG relative weight (1.1417) to calculate the proposed
total adjusted Federal prospective payment for the 2009 LTCH PPS rate
year (\$47,035.13). Table 6 illustrates the components of the
calculations in this example.

**TABLE 6:**

  --------------------------------------------------- -------------------
  Unadjusted Proposed Standard Federal Prospective    \$39,076.28
  Payment Rate                                        

  Proposed Labor-Related Share                        x 0.75920

  Proposed Labor-Related Portion of the Federal Rate  = \$29,666.71

  Proposed Wage Index (CBSA 16974)                    x 1.0715

  Proposed Wage-Adjusted Labor Share of Federal Rate  = \$31,787.88

  Proposed Nonlabor-Related Portion of the Federal    \+ \$ 9,409.57
  Rate (\$39,076.28 x 0.24080)                        

  Proposed Adjusted Federal Rate Amount               = \$41,197.45

  MS-LTC-DRG 9 Relative Weight                        x 1.1417

  Proposed Total Adjusted Federal Prospective Payment = \$47,035.13
  --------------------------------------------------- -------------------

**VII. Monitoring**

In the August 30, 2002 final rule (67 FR 56014), we described an
on‑going monitoring component to the new LTCH PPS. Specifically, we
discussed on‑going analysis of the various policies that we believe
would provide equitable payment for stays that reflect less than the
full course of treatment and reduce the incentives for inappropriate
admissions, transfers, or premature discharges of patients that are
present in a discharge‑based PPS. As a result of our data analysis, we
have revisited a number of our original policies and have identified
behaviors by certain LTCHs that lead to inappropriate Medicare payments.

In the RY 2005 LTCH PPS final rule (69 FR 25692) we revised the
interruption of stay policy. We also established a payment adjustment
for LTCH HwHs and satellites in the FY 2005 IPPS final rule (69 FR 49191
through 49214). In the RY 2008 final rule, at §412.536, based on
additional data monitoring and analysis, we expanded this payment
adjustment to apply to LTCHs and LTCH satellites that were not
co-located with their referring hospitals.

In the RY 2007 and 2008 final rules (71 FR 27798 and 72 FR 28670), we
revised the SSO payment adjustment formula as a consequence of data
analyses which indicated that Medicare was overpaying for certain SSO
cases.

Although at this time, we are not proposing any new payment adjustments
that have resulted from our monitoring activity, we continue to pursue
our on‑going monitoring program that involves the CMS Office of Research
and Development (ORDI), existing QIO monitoring, and studies described
in the RY 2006 LTCH PPS final rule (70 FR 24211).

As we discussed in the RY 2004 LTCH PPS final rule (68 FR 34157), the
Medicare Payment Advisory Commission (MedPAC) endorsed our monitoring
activity. Furthermore, the Commission pursued an independent research
initiative that led to a section in MedPAC's June 2004 Report to
Congress entitled "Defining long‑term care hospitals". This study
included recommendations that we develop facility and patient criteria
for LTCH admission and treatment and that we require a review by QIOs to
evaluate whether LTCH admissions meet criteria for medical necessity
once the recommended facility and patient criteria are established (70
FR 24210). In response to the recommendation in MedPAC's June 2004
Report, we awarded a contract to Research Triangle Institute,
International (RTI), on September 27, 2004, to conduct a thorough
examination of the feasibility of implementing MedPAC's recommendations.

Both Part 1 and Part 2 of the RTI Report are available on our Web site
at
<http://www.cms.hhs.gov/LongTermCareHospitalPPS/02a_RTIReports.asp#TopOfPage>.
We also included the Executive Summary of RTI's final report in
Addendum B of the RY 2008 proposed rule (72 FR 4884 through 4886).

(A comprehensive discussion of RTI's continuing work is included at
section XI of this proposed rule.)

**VIII. Method of Payment**

Under §412.513, a Medicare LTCH patient is classified into a MS-LTC‑DRG
based on the principal diagnosis, up to eight additional (secondary)
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The MS-LTC‑DRG is used
to determine the Federal prospective payment that the LTCH will receive
for the Medicare‑covered Part A services the LTCH furnished during the
Medicare patient's stay. Under §412.541(a), the payment is based on the
submission of the discharge bill. The discharge bill also provides data
to allow for reclassifying the stay from payment at the full MS-LTC-DRG
rate to payment for a case as a SSO (under §412.529) or as an
interrupted stay (under §412.531), or to determine if the case will
qualify for a HCO payment (under §412.525(a)).

Accordingly, the ICD‑9‑CM codes and other information used to determine
if an adjustment to the full MS-LTC‑DRG payment is necessary (for
example, LOS or interrupted stay status) are recorded by the LTCH on the
Medicare patient's discharge bill and submitted to the Medicare FI for
processing. The payment represents payment in full, under §412.521(b),
for inpatient operating and capital‑related costs, but not for the costs
of an approved medical education program, bad debts, blood clotting
factors, anesthesia services by hospital‑employed nonphysician
anesthetists or the costs of photocopying and mailing medical records
requested by a Quality Improvement Organization (QIO), which are costs
paid outside the LTCH PPS.

As under the previous reasonable cost‑based payment system, under
§412.541(b), a LTCH may elect to be paid using the periodic interim
payment (PIP) method described in §413.64(h), based on the estimated
prospective payment for the year, and may be eligible to receive
accelerated payments as described in §413.64(g). We exclude HCO payments
that are paid upon submission of a discharge bill from the PIP amounts.
In addition, Part A costs that are not paid for under the LTCH PPS,
including Medicare costs of an approved medical education program, bad
debts, blood clotting factors, anesthesia services by hospital‑employed
nonphysician anesthetists and the costs of photocopying and mailing
medical records requested by a QIO, are subject to the interim payment
provisions as specified in §412.541(c).

Under §412.541(d), LTCHs with unusually long lengths of stay that are
not receiving payment under the PIP method may bill on an interim basis
(60 days after an admission and at intervals of at least 60 days after
the date of the first interim bill) and this should include any HCO
payment determined as of the last day for which the services have been
billed.

**IX. RTI's Research**

With the recommendations of MedPAC's June 2004 Report to Congress as a
point of departure, we awarded a contract to Research Triangle
Institute, International (RTI)at the start of FY 2005 for a
comprehensive evaluation of the feasibility of developing patient and
facility level characteristics for LTCHs that could distinguish LTCH
patients from those treated in other hospitals.

RTI completed this project in two phases. In Phase I, RTI prepared a
background report summarizing existing information regarding LTCHs'
current role in the Medicare system: their history as Medicare
participating providers; the types of patients they treat; the criteria
QIOs currently use to review appropriateness of care in these settings;
and the types of regulations they face as Medicare participating
providers. This work reviewed prior analyses of these issues and
included discussions with MedPAC, other researchers, CMS, the QIOs, and
the hospital associations.

In Phase II, RTI collected additional information on tools currently
used by the QIOs and the industry to assess patient appropriateness for
admission; analyzed claims to understand differences between short term
acute care hospital patients with outlier stays who were subsequently
treated in LTCHs compared to those who were not and differences between
patients who continued treatment as outliers in acute care hospitals
with patients who had been admitted to LTCH with the same DRGs; and
visited different types of hospitals to observe first‑hand how LTCH
patients differ from those in other settings and how this pattern varies
in different parts of the country. RTI worked with different
associations, including the National Association of Long Term Hospitals
(NALTH), the Acute Long Term Hospital Association (ALTHA), the American
Hospital Association (AHA), and the American Medical Rehabilitation
Providers Association (AMRPA), as well as several of the larger LTCH
chains. The final report for those phases submitted by RTI summarizes
these efforts and makes recommendations to CMS regarding LTCHs.

(We have posted the reports on both Phase I and Phase II of RTI's
research on our Web site at
<http://www.cms.hhs.gov/LongTermCareHospitalPPS/02a_RTIReports.asp#TopOfPage>)

In summary, RTI's research has resulted in an extensive and careful
analysis of the Medicare populations served by LTCHs, a comparison of
these populations with those treated in other acute settings, including
IPPS, IRFs, and Inpatient Psychiatric populations, as well as those
treated in less intensive settings such as SNFs.  This work included
analysis of Medicare data to compare patient characteristics and
provider costs for certain types of patients; regulatory requirements
governing program conditions of participation for these different types
of facilities; interviews with private sector developers of level of
care determinations; and site visits and interviews with physicians
treating these typical and frequently overlapping populations.

The results suggested that while there are some patients who require
very long term acute care hospitalization there are also many patients
whose LOS at the LTCH may trigger a short stay outlier payment,
suggesting that not all LTCH admissions had a LOS consistent with the
need for prolonged acute care hospitalization in an LTCH. While existing
patient criteria such as Interqual are useful for distinguishing between
the need for hospital‑level treatment and a less intensive level, such
as SNF care, RTI's analysis has determined that, in fact, the private
sector criteria failed to distinguish between patients at LTCHs and
patients at acute care hospitals. The criteria proposed by the National
Association for Long Term Hospitals (NALTH) also had this shortcoming.
While they identified the acute care patient, they failed to identify
differences between LTCH admissions\' clinical characteristics and those
treated in a general acute care hospital, in either a step down unit, or
in some cases, a general medical/surgery unit. 

On January 30, 2007, RTI convened a Technical Expert Panel (TEP)
comprised of physicians, nurses, and hospital administrators
representing, LTCHs, acute care hospitals, IRFs, and SNFs, all of which
represent the range of inpatient settings for treating medically complex
patients. The goal of this meeting was to identify a set of clinical
indicators that distinguish between the medically complex populations at
LTCHs and acute care hospitals , including ICU, step-down, and general
acute care. The panelists examined severity measures and treatment needs
for medically complex patients to define the point at which ICU or acute
care patients become appropriate for care at LTCHs. They focused on
patient criteria currently used by some providers and QIOs.
Presentations described existing systems for identifying medical
complexity and severity of illness for a particular patient. In
exchanges between the presenters and panel members , however, acute care
hospital physicians stated that acute care hospitals treated severely
ill patients with medically complex conditions for their entire episode
of care and that these measures were not useful for determining whether
the patient should be treated in an acute care hospital or a LTCH. After
discussion, the TEP participants reached a consensus that LTCHs provide
a service that is comparable to general acute step-down units and is not
unique to LTCHs.

Discussions with LTCH physicians and acute care hospital physicians
practicing in areas that lack LTCHs confirmed the results of RTI's data
analyses in demonstrating the widespread overlap in the patient
populations treated in LTCHs and those treated in acute care hospitals.
Though representatives from the LTCHs clearly described the medical
complexity and severity of illness of their patient populations, much of
the difference between the LTCH and acute hospital patient populations
was driven by geography and access to LTCH facilities. In the many areas
of the country without access to LTCH services, acute hospitals treat
the medically complex patients and receive an acute hospital IPPS
payment, or outlier payment in cases where the costs of care are very
high, rather than the much higher LTCH payment. As a result of the
discussion, claims by the LTCH industry that medically complex patients
treated in LTCHs were significantly different from medically complex
patients treated in acute settings were not confirmed, though panel
members did agree that more work may need to be done to measure outcomes
for medically complex patients treated in each of these settings. There
was also consensus among the panelists that quality of care was related
to treating a sufficient volume of these difficult cases, regardless of
provider setting.

On November 6, 2007, RTI convened a second TEP based upon the earlier
meeting and participant responses. As with the first TEP, panel members
included LTCH physicians and administrators, acute care physicians in
areas without LTCHs (for example, New York and northern New England),
physicians from SNFs in areas without LTCHs, and several IRF physicians.

There was an intentional focus at the second TEP on Medicare patients
with respiratory conditions requiring mechanical ventilation (vent
patients). RTI presented data showing the mechanical ventilator patients
were relatively homogenous in their likelihood of using LTCHs whereas
the medically complex (respiratory) patients were much more diverse in
their distributions making it more difficult to develop measurable
medical parameters and widely accepted treatment protocols for this
group. However, it was acknowledged that ventilator patients (referred
to as "vent patients" in the following discussion) comprise less than 15
percent of all LTCH patients. RTI believed that the category of
"medically complex" cases was too amorphous and the focus on vent
patients would allow for more meaningful comparisons between the
provider types. Nationwide, vent patients are treated in acute care
hospitals and in LTCHs while some IRFs and SNFs accept and treat this
group of patients. (We would also note that, as MedPAC found in its
June, 2004 Report to Congress, the highest predictor of LTCH use is
whether a patient has had a tracheotomy which is common in long-term
ventilator-dependent patients.(p. 125))

RTI presented two analyses of Medicare claims data based on episodes of
care constructed for beneficiaries with vent-related DRGs during their
initial (acute) admission. The first analysis compared outcomes for
patients living in areas with LTCHs, to outcomes for clinically similar
patients living in geographically comparable areas that had no LTCHs.
The second examined episodes of care only for beneficiaries in specific
states with several LTCHs, and compared outcomes for clinically similar
cases that remained in the acute care setting with those that were
referred to an LTCH. Both analyses used a "propensity score approach"
which groups patients according to the clinical and demographic
characteristics that predict LTCH referral.

The first analysis found that there was very little difference in
average episode length, Medicare cost, mortality or length of time
before being discharged home, between areas that have LTCHs and those
that do not. The second analysis found that results differed between
cases with the highest probability of using LTCHs (those medically
complex vent cases with tracheotomies, longer prior ICU stays), and
ventilator cases with lower probability of using LTCHs. In the small
group with a high likelihood, mortality was lower and the 60‑day
likelihood of being discharged home was higher for those referred to
LTCHs than for those staying in acute settings, while Medicare payments
were the same or less. Among the less complex cases, however, RTI found
that LTCH referral was associated with much higher costs and same or
worse performance in other outcome measures. These findings are very
similar to those noted by MedPAC in the Commission's June 2004 Report to
the Congress. (p. 126-127).

RTI also asked TEP members to evaluate 6 case vignettes and assess which
patients were appropriate for admission to their type of facility. The
case vignettes consisted of detailed medical histories of two
ventilator-dependent patients admitted for weaning, two wound care
patients, and two "medically complex" patients.

The TEP indicated that there were significant differences between the
level of patient morbidity that the acute care hospitals and LTCHs would
admit and treat as compared to the IRFs and also the SNFs, but that LTCH
patients and patients treated in IPPS acute care hospital step-down
units were virtually indistinguishable. In further discussion of
individual case vignettes, LTCH and acute care hospital physicians were
in accord regarding appropriate therapeutic dispositions for the
stabilized, post-ICU "critical care" patients and they agreed that such
patients could be appropriately treated in either acute care hospital
step-down units or in LTCHs. Therefore, although there was consensus
regarding the medical profile of such patients, it was also noted by one
acute care physician that this indicated that "there is no such thing as
an LTCH-only patient." On the other hand, acute care hospital physicians
noted that typically, in their facilities, their step-down units may
take a slightly less stable "critical care" patient than would be
treated in a LTCH, that is, patients that may have some unresolved
medical issues still being diagnosed especially if there was a need to
free-up an ICU bed. This was possible because such a patient would
continue treatment by the same physicians and have access to the full
range of acute care hospital services but also could return to the ICU
without significant difficulty, if necessary.

The panelists also discussed a realistic definition of patient stability
for "critical care" patients in different settings and whether this was
typically based upon "vital signs," dependence on "pressors,"
(intravenous drugs administered to raise blood pressure) or whether
patient stability was based on a physician's subjective determination
(for example, "I know it when I see it"). There was additional
clinically-oriented discussion of measures of medical stability (It was
also noted that while some of the "medically complex" patients currently
being treated in LTCHs would fall into the "critical care" category,
this is not the case for all of their patients.)

Panelists also addressed the intensity of nursing care required by a
"critical care" patient and the central role of the nurse to patient
ratio in identifying the level of care offered in a hospital. Both LTCHs
and IPPS step‑down units typically have a RN to patient ratio of 1‑to‑4
or 1‑to‑5. LTCH physicians emphasized the value of the LTCH "team
approach" to patient care to the agreement of the TEP's acute care
hospital physicians who noted that this approach is also the model that
is in place in their facilities. One physician noted that he had little
doubt that a "critical care" patient hospitalized at any of the acute
care hospitals or LTCHs represented at the TEP would receive an
equivalent and high level of treatment.

Members of the panel also indicated that discharges from acute care
hospitals to LTCHs (in areas where this is an option) often occur
because the LTCH is known to provide specialized treatment for
particular types of patients. It was also noted, however, that commonly,
hospital resources drive patient placement regarding the treatment of
very sick and expensive patients when there is an LTCH placement option.

Following the above exchanges, it was widely acknowledged by panelists
that measures distinguishing appropriate LTCH patients from patients
being treated in step-down units of acute care hospitals were not going
to be developed by the TEP. There were serious questions raised as to
whether developing such a product was even feasible. The group concurred
on the recommendations, listed below, for a treatment model for the type
of "critical care" patients who had been the focus of TEP:

● CMS should pay similar rates for similar patients regardless of
setting if [certain objective parameters]{.underline} associated with
patient care were present, among which were:

++ A critical mass of patients with the targeted conditions to ensure
sufficient experience in those areas for the health professionals in
that setting;

++ Patient-level criteria to identify appropriate cases for this level
of care, applicable regardless of setting;

++ Quality of care should be based on structure and process standards;

++ Interdisciplinary teams with physician leads, appropriate nurse
staffing levels; and inclusion of treating therapists (for example,
physical, respiratory, occupational);

● Both LTCHs and these IPPS step-down units meeting these standards
could be recognized as "Centers of Excellence" for patients defined as
critically ill.

TEP members decided not to include "patient outcomes" on the list of
recommendations because of concerns that a facility's recognition and/or
payment based on patient outcomes could lead to "cherry-picking" of less
sick patients which could lead to access problems for otherwise
appropriate patients.

In summary, there was a consensus at the end of RTI's second TEP that
LTCHs treat patients who are also treated by acute care hospitals. The
"critical care" post-ICU patient who LTCHs describe as their targeted
patient are treated throughout most of the country in acute care
hospital step-down units. The interdisciplinary team treatment model is
the standard both in many LTCHs and in many acute care hospitals with
step-down units. While by definition, the patients appropriate for
treatment in a LTCH require hospital-level care (as opposed to SNF
level), it is not clear that any criteria can be developed which
identifies patients who belong in a LTCH exclusively. 

RTI will continue to work on these issues in preparing its final report.
The results thus far have shown empirically, that LTCHs treat medically
stable but critically ill patients that are clinically indistinguishable
from those treated in step-down units of acute care hospitals. The work
has also confirmed earlier research showing that for cases other than
the vent patients discussed above in this section, that in the absence
of compelling data on patient outcomes, that treatment at an LTCH is
less cost-effective for the same DRGs than is treatment at acute care
hospitals for the same DRGs.

These TEPs have been important for furthering the discussion regarding
the feasibility of developing unique criteria for LTCH patients. Over
the past few years, the clinicians have agreed that LTCHs specialize in
treating critically ill patients with multiple comorbidities and other
longer term, acute level needs. This consensus contributes to
identifying an appropriate LTCH patient by acuity of illness as well as
LOS. Over the next few months, RTI will continue working with the
clinical community to make recommendations regarding payment and
treatment of critically ill patients, particularly in LTCHs. Further
work will expand on the Centers of Excellence concept to examine the
structure and process needed for such a designation. Additional analysis
will examine the relative costs and payments for these patients under
different payment systems.

# X. 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. 35).

# XI. Regulatory Impact Analysis

**\[If you choose to comment on issues in this section, please include
the caption "IMPACT" at the beginning of your comments.\]**

[A. Introduction]{.underline}

We have examined the impacts of this proposed rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L.
96‑354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of
1995 (UMRA) (Pub. L. 104‑4), and Executive Order 13132.

1\. Executive Order 12866

Executive Order 12866 (as amended by Executive Order 13258) directs
agencies to assess all costs and benefits of available regulatory
alternatives and, if regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, distributive impacts,
and equity). A regulatory impact analysis (RIA) must be prepared for
major rules with economically significant effects (\$100 million or more
in any one year). In the impact analysis, we are using the proposed
rates, factors and policies presented in this proposed rule, including
updated proposed wage index values, and the best available claims and
CCR data to estimate the change in proposed payments for the 2009 LTCH
PPS rate year. As stated in section I.A. of this preamble section
114(e)(1) of the MMSEA at the new section 1886(m)(2) to the Act revises
the standard Federal rate for RY 2008 by providing that the base rate
for RY 2008 shall be the same as the base rate for RY 2007 (in other
words, the standard Federal rate for RY 2008 is the same as the standard
Federal rate for 2007). Also, section 114(e)(2) of the provides that the
revised rate does not apply to discharges occurring on or after July 1,
2007, and before April 1, 2008. As noted in section IV.E. of this
preamble, the standard Federal rate for RY 2007 was \$38,086.04.
Furthermore, we note that section 114(c)(3) of MMSEA requires a 3-year
suspension of our implementation of the revisions to the SSO policy at
§412.529(c)(3)(i) that was finalized in the RY 2008 final rule. Both of
these revisions to RY 2008 LTCH PPS payments (that is, sections
114(c)(3) and (e)(1) through (2) of MMSEA) affect the modeling of
payments in this impact analysis, which we will discuss in greater
detail in section XVI.B.3. of this proposed rule. Based on the best
available data for 394 LTCHs, we estimate that the proposed update to
the standard Federal rate for RY 2009 (discussed in section IV.C. of the
preamble of this proposed rule) and the proposed changes to the area
wage adjustment (discussed in section IV.F.1. of the preamble of this
proposed rule), for the 2009 LTCH PPS rate year, in addition to an
estimated increase in short-stay and high cost outlier payments (as
discussed in greater detail below) would result in an increase in
estimated payments from the 2008 LTCH PPS rate year of approximately
\$124 million (or about 2.9 percent) for the 394 LTCHs in our database.
Based on the 394 LTCHs in our database, we estimate RY 2008 LTCH PPS
payments to be approximately \$4.32 billion and RY 2009 LTCH PPS
payments to be approximately \$4.44 billion. Because the combined
distributional effects and estimated changes to the Medicare program
payments would be greater than \$100 million, this proposed rule would
be considered a major economic rule, as defined in this section. We note
the approximately \$124 million for the projected increase in estimated
aggregate LTCH PPS payments resulting from the provisions presented in
this proposed rule does not reflect changes in LTCH admissions or
case-mix intensity in estimated LTCH PPS payments, which would also
affect overall payment changes. (We note that due to rounding, the
approximation of \$124 million is closer to the projected increase in
estimated aggregate LTCH PPS payments than the difference between the
approximately \$4.44 billion and approximately \$4.32 billion in
estimated RY 2008 and RY 2009 LTCH PPS payments, respectively.)

We note that the average combined effect of the proposed standard
Federal rate and area wage adjustment changes on estimated aggregate
payments cannot be computed by simply adding up the estimated averages
in columns 6 and 7 of Table 9 because each of those two columns are
intended to show the isolated impact of the respective proposed change
(that is, the proposed change to the standard Federal rate or the
proposed change to the area wage adjustment) on estimated payments for
RY 2009 as compared to RY 2008, and the interactive effects resulting
from both the proposed change to the standard Federal rate and proposed
change to the area wage adjustment are not accounted for in the modeling
of estimated payments to produce the percent change in each of these
columns. However, the interactive effects of all proposed changes are
taken into account in the modeling of estimated payments for RY 2009 as
compared to RY 2008 in Column 8 of Table 9. Notwithstanding this
limitation in comparing the various columns in Table 9, the difference
between the projected increase in payments per discharge from RY 2008 to
RY 2009 for all changes of 2.9 percent (column 8) and the sum of the
projected increase due to proposed change to the standard Federal rate
(2.2 percent in column 6) and the proposed change due to the area wage
adjustment (-0.1 percent in column 7) of 2.1 percent (that is, 2.2
percent + (-0.1 percent) = 2.1 percent) is mostly attributable to the
effect of the estimated increase in payments for HCO and SSO cases in
RY 2009 as compared to RY 2008. That is, in calculating the estimated
increase in payments from RY 2008 to RY 2009 for HCO and SSO cases, we
increased estimated costs by the applicable proposed market basket
(approximately 3.5 percent). We note, SSO cases comprise approximately
16 percent of estimated total LTCH PPS payments and HCO cases comprise
approximately 8 percent of estimated total LTCH PPS payments. The vast
majority of the payments for SSO cases (over 80 percent) are based on
the estimated cost of the case.

While the effects of the estimated increase in SSO and HCO payments and
the proposed change to the standard Federal rate which are projected to
increase estimated payments per discharge from RY 2008 to RY 2009, the
proposed changes to the area wage adjustment from RY 2008 to RY 2009 are
expected to result in a small decrease of 0.1 percent in estimated
aggregate LTCH PPS payments from the 2008 LTCH PPS rate year to the 2009
LTCH PPS rate year (see column 7 of Table 9). As discussed in section
IV.F.1. of this proposed rule, we are proposing to update the wage index
values for RY 2009 based on the most recent available data. In addition,
we are proposing to increase the labor‑related share from 75.788 percent
to 75.920 percent under the LTCH PPS for RY 2009 based on the most
recent available data on the relative importance of the labor‑related
share of operating and capital costs of the market basket applicable to
the LTCH PPS (also discussed in section IV.F.1. of this proposed rule).

2\. Regulatory Flexibility Act (RFA)

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
\$6.5 million to \$31.5 million in any 1 year. For further information,
see the Small Business Administration's regulation at 70 FR 72577,
December 6, 2005. Individuals and States are not included in the
definition of a small entity. Because we lack data on individual
hospital receipts, we cannot determine the number of small proprietary
LTCHs. Therefore, we assume that all LTCHs are considered small entities
for the purpose of the analysis that follows. Medicare FIs are not
considered to be small entities. The Secretary certifies that this
proposed rule would not have a significant economic impact on a
substantial number of small entities.

Currently, our database of 394 LTCHs includes the data for 88 non‑profit
(voluntary ownership control) LTCHs and 265 proprietary LTCHs. Of the
remaining 41 LTCHs, 25 LTCHs are Government‑owned and operated and the
ownership type of the other 16 LTCHs is unknown (as shown in Table 9).
The impact of the proposed payment rate and policy changes for the 2009
LTCH PPS rate year (including the proposed update to the standard
Federal rate and the proposed changes to the area wage adjustment) is
discussed in section XVI.B.4.c. of this proposed rule.

As we discuss in detail throughout the preamble of this proposed rule,
based on the most recent available LTCH data, we believe that the
provisions of this proposed rule would result in an increase in
estimated aggregate LTCH PPS payments and that the resulting LTCH PPS
payment amounts result in appropriate Medicare payments.

The impact analysis of the proposed payment rate and policy changes in
Table 9 shows that estimated payments per discharge are expected to
increase approximately 2.9 percent, on average, for all LTCHs from the
2008 LTCH PPS rate year as compared to the 2009 LTCH PPS rate year. We
are proposing a 2.6 percent increase to the standard Federal rate for
RY 2009 (as discussed in section IV.E. of this proposed rule). The
projected 2.9 percent increase in estimated payments per discharge from
the 2008 LTCH PPS rate year to the 2009 LTCH PPS rate year is
attributable to the proposed change to the rate, the area wage
adjustment (discussed in section IV.F.1. of this proposed rule) and
estimated increases in short-stay outlier (SSO) and high cost outlier
(HCO) payments (as discussed in greater detail below). That is, as Table
9 shows, the proposed change to the standard Federal rate is projected
to result in an estimated average increase of 2.2 percent in estimated
payments per discharge from RY 2008 to RY 2009, on average, for all
LTCHs, while the proposed changes to the area wage adjustment are
projected to result in an estimated decrease of 0.1 percent, on average,
for all LTCHs (columns 6 and 7 of Table 9, respectively). A thorough
discussion of the regulatory impact analysis for the proposed changes
presented in this proposed rule can be found below in section XVI.B.3.
of this proposed rule.

3\. Impact on Rural Hospitals

For purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. As shown in Table 9, we
are projecting a 2.6 percent increase in estimated payments per
discharge from the 2008 LTCH PPS rate year as compared to the 2009 LTCH
PPS rate year for rural LTCHs as a result of the proposed changes
presented in this proposed rule (that is, the proposed update to the
standard Federal rate discussed in section IV.E. of the preamble of this
proposed rule and the proposed changes to the area wage adjustment as
discussed in section IV.F.1. of the preamble of this proposed rule)
based on the data of the 25 rural LTCHs in our database of 394 LTCHs for
which complete data were available.

As shown in Table 9, the estimated increase in estimated LTCH PPS
payments from the 2008 LTCH PPS rate year as compared to the 2009 LTCH
PPS rate year for rural LTCHs is primarily due to the proposed update to
the standard Federal rate (as discussed in greater detail in section
IV.E. of the preamble of this proposed rule) and the proposed change in
the area wage adjustment (as discussed in greater detail in section
V.F.1. of the preamble of this proposed rule) in conjunction with the
estimated increased payments for SSO and HCO cases (as discussed below
in section XVI.B.3. of this proposed rule). We believe that the changes
to the area wage adjustment presented in this proposed rule (that is,
the proposed use of updated wage data and the proposed change in the
labor‑related share) would result in accurate and appropriate LTCH PPS
payments in RY 2009 since they are based on the most recent available
data. Such updated data appropriately reflect national differences in
area wage levels and identifies the portion of the proposed standard
Federal rate that should be adjusted to account for such differences in
area wages, thereby resulting in accurate and appropriate LTCH PPS
payments.

4\. Unfunded Mandates

Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any one year of
\$100 million in 1995 dollars, updated annually for inflation. That
threshold level is currently approximately \$120 million. This proposed
rule would not mandate any requirements for State, local, or tribal
governments, nor would it result in expenditures by the private sector
of \$120 million or more in any 1 year.

5\. Federalism

Executive Order 13132 establishes certain requirements that an agency
must meet when it publishes 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 examined this proposed rule under the criteria set forth in
Executive Order 13132 and have determined that this proposed rule would
not have any significant impact on the rights, roles, and
responsibilities of State, local, or tribal governments or preempt State
law, based on the 25 State and local LTCHs (that is, Government
ownership type) in our database of 394 LTCHs for which data were
available.

6\. Alternatives Considered

In the preamble of this proposed rule, we are setting forth the proposed
annual update to the payment rates for the LTCH PPS for RY 2009. In this
preamble, we specify the statutory authority for the provisions that are
presented, identify those proposed policies when discretion has been
exercised, and present rationale for our decisions as well as
alternatives that were considered, and solicit comments on suggested
alternatives from commenters (where relevant).

[B. Anticipated Effects of Proposed Payment Rate Changes]{.underline}

We discuss the impact of the proposed changes to the payment rates,
factors, and other payment rate policies presented in the preamble of
this proposed rule in terms of their estimated fiscal impact on the
Medicare budget and on LTCHs.

1\. Budgetary Impact

Section 123(a)(1) of the BBRA requires that the PPS developed for LTCHs
"maintain budget neutrality." We believe that the statute's mandate for
budget neutrality (BN) applies only to the first year of the
implementation of the LTCH PPS (that is, FY 2003). Therefore, in
calculating the FY 2003 standard Federal rate under §412.523(d)(2), we
set total estimated payments for FY 2003 under the LTCH PPS so that
estimated aggregate payments under the LTCH PPS are estimated to equal
the amount that would have been paid if the LTCH PPS had not been
implemented.

2\. Impact on Providers

The basic methodology for determining a per discharge LTCH PPS payment
is set forth in §412.515 through §412.536. In addition to the basic
MS-LTC‑DRG payment (standard Federal rate multiplied by the MS-LTC‑DRG
relative weight), we make adjustments for differences in area wage
levels, COLA for Alaska and Hawaii, and SSOs. Furthermore, LTCHs may
also receive HCO payments for those cases that qualify based on the
threshold established each rate year.

To understand the impact of the proposed changes to the LTCH PPS
payments discussed in section IV. of this proposed rule on different
categories of LTCHs for the 2009 LTCH PPS rate year, it is necessary to
estimate payments per discharge for the 2008 LTCH PPS rate year using
the rates, factors and policies established in the RY 2008 LTCH PPS
final rule (72 FR 26870 through 27029), the RY 2008 LTCH PPS correction
notice (72 FR 36613 through 36616) and the applicable sections of MMSEA
(as described in greater detail below in section XVI.B.3. of this
proposed rule). It is also necessary to estimate the proposed payments
per discharge that would be made under the proposed LTCH PPS rates,
factors and policies for the 2009 LTCH PPS rate year (as discussed in
the preamble of this proposed rule). We also evaluated the change in
estimated 2008 LTCH PPS rate year payments to estimated proposed 2009
LTCH PPS rate year payments (on a per discharge basis) for each category
of LTCHs.

Hospital groups were based on characteristics provided in the OSCAR
data, FY 2003 through FY 2005 cost report data in HCRIS, and PSF data.
Hospitals with incomplete characteristics were grouped into the
"unknown" category. Hospital groups include the following:

● Location: Large Urban/Other Urban/Rural.

● Participation date.

● Ownership control.

● Census region.

● Bed size.

To estimate the impacts of the proposed payment rates and policy changes
among the various categories of existing providers, we used LTCH cases
from the FY 2006 MedPAR file to estimate payments for RY 2008 and to
estimate proposed payments for RY 2009 for 394 LTCHs. While currently
there are just under 400 LTCHs, the most recent growth is predominantly
in for‑profit LTCHs that provide respiratory and ventilator‑dependent
patient care. We believe that the discharges from the FY 2006 MedPAR
data for the 394 LTCHs in our database, which includes 265 proprietary
LTCHs, provide sufficient representation in the MS-LTC‑DRGs containing
discharges for patients who received LTCH care for the most commonly
treated LTCH patients' diagnoses.

3\. Calculation of Prospective Payments

For purposes of this impact analysis, to estimate per discharge payments
under the LTCH PPS, we simulated payments on a case‑by‑case basis using
LTCH claims for the FY 2006 MedPAR files. In modeling estimated LTCH PPS
payments for both RY 2008 and RY 2009 in this impact analysis, we
applied the RY 2008 standard Federal rate (that is, \$38,086.04)
provided for by sections 114(e)(1) and (2) of Pub. L. 110-173, and the
SSO policy provided for by section 114(c)(3) of the MMSEA7 (that is,
excluding the revisions to the SSO policy at §412.529(c)(3)(i) of the
regulations). Although we realize that the effective date for the change
in the SSO policy during RY 2008 in the MMSEA is December 29, 2007, and
the revised standard Federal rate for RY 2008 is not applicable for
discharges occurring on or after July 1, 2007 and before April 1, 2008,
for purposes of this impact analysis, in estimating RY 2008 LTCH PPS
payments we applied both the revised SSO policy and revised standard
Federal rate for all of RY 2008. Similarly, in modeling LTCH PPS
payments to project the average change in estimated payments per
discharge from RY 2008 to RY 2009 due to the proposed change in the
standard Federal rate (column 6 of Table 9), rather than using the RY
2008 standard Federal rate finalized in the RY 2008 final rule, we
compared the RY 2008 "base rate" (which we interpret to mean the
standard Federal rate) mandated by section 114(e)(1) of the Medicare,
Medicaid and SCHIP Extension Act of 2007 (that is, \$38,086.04), to the
proposed RY 2009 standard Federal rate of \$39,076.28 (that is,
\$38,086.04 updated by 2.6 percent, as discussed in section IV.E. of
this proposed rule) in order to appropriately estimate the effect of
updating the rate by 2.6 percent. We took this approach for the impact
analysis in this proposed rule since for the last 3 months of the 2008
LTCH PPS rate year (that is, April 2008 through June 2008), which is the
3‑month period immediately preceding the start of the 2009 LTCH PPS rate
year, LTCHs will be paid in accordance with the RY 2008 standard Federal
rate and SSO policy established by section 114 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007. Therefore, for purposes of
the impact analysis in this proposed rule, we modeled the projected
changes in estimated payments from RY 2008 to RY 2009 based on computing
estimated RY 2008 LTCH PPS payments using a standard Federal rate of
\$38,086.04 and the corresponding change to the SSO policy, which
excludes the revisions to the SSO policy at §412.529(c)(3)(i), as if
those policies were applicable to all discharges occurring during
RY 2008. (Additional information on section 114 of the Medicare,
Medicaid and SCHIP Extension Act of 2007 can be found at section I.A. of
this proposed rule.)

Furthermore, in modeling estimated LTCH PPS payments for both RY 2008
and RY 2009 in this impact analysis, we applied the RY 2008 and proposed
RY 2009 adjustments for area wage differences (as described in section
IV.F.1. of the preamble of this proposed rule), and the COLA for Alaska
and Hawaii (as described in section IV.F.2. of the preamble of this
proposed rule). Specifically, we adjusted for area wage differences for
estimated 2008 LTCH PPS rate year payments using the current LTCH PPS
labor‑related share of 75.788 percent (72 FR 26892), the wage index
values established in the Tables 1 and 2 of the Addendum of the RY 2008
final rule (72 FR 26996 through 27019) and the COLA factors established
in Table 3 of the preamble of the RY 2008 final rule (72 FR 26894).
Similarly, we adjusted for area wage differences for estimated 2009 LTCH
PPS rate year payments using the proposed LTCH PPS labor‑related share
of 75.920 percent (see section IV.D.1.c. of this proposed rule), the
proposed wage index values presented in the Tables 1 and 2 of the
Addendum of this proposed rule and the proposed COLA factors established
in Table 3 of the preamble of this proposed rule.

As discussed above, we also accounted for the payment policy for
SSOs**.** We also estimated additional payments that would be made for
HCOs (as described in section IV.F.3. of this proposed rule). As noted
in section IV.F.4. of this proposed rule, we are not proposing to make
adjustments for rural location, geographic reclassification, indirect
medical education costs, or a DSH payment for the treatment of
low‑income patients because our most recent data analysis that reflects
LTCH behavior subsequent to the implementation of the LTCH PPS indicates
that proposing payment adjustments for geographic reclassification,
rural location, DSH, or indirect medical education costs would not
improve the accuracy of payments made under the LTCH PPS to LTCHs. (See
Section IV.F.4 ).

These impacts reflect the estimated "losses" or "gains" among the
various classifications of LTCHs for the 2008 LTCH PPS rate year
compared to the 2009 LTCH PPS rate year based on the proposed payment
rates and policy changes presented in this proposed rule. Table 9
illustrates the estimated aggregate impact of the LTCH PPS among various
classifications of LTCHs.

● The first column, LTCH Classification, identifies the type of LTCH.

● The second column lists the number of LTCHs of each classification
type.

● The third column identifies the number of LTCH cases.

● The fourth column shows the estimated payment per discharge for the
2008 LTCH PPS rate year (as described above).

● The fifth column shows the estimated proposed payment per discharge
for the 2009 LTCH PPS rate year (as described above).

● The sixth column shows the percentage change in estimated payments per
discharge from the 2008 LTCH PPS rate year to the 2009 LTCH PPS rate
year for proposed changes to the standard Federal rate (as discussed in
section IV.E. of the preamble of this proposed rule).

● The seventh column shows the percentage change in estimated payments
per discharge from the 2008 LTCH PPS rate year to the 2009 LTCH PPS rate
year for proposed changes to the area wage adjustment at §412.525(c) (as
discussed in section IV.D.1. of the preamble of this proposed rule).

● The eighth column shows the percentage change in estimated payments
per discharge from the 2008 LTCH PPS rate year (column 4) to the 2009
LTCH PPS rate year (column 5) for all proposed changes.

**TABLE 9: Projected Impact of Proposed Payment Rate and**

**Payment Rate Policy Changes to LTCH PPS Payments for RY 2009**

**(Estimated 2008 LTCH PPS Rate Year Payments Compared to**

**Estimated Proposed 2009 LTCH PPS Rate Year Payments^\*^)**

  -------------------------------------------------------------------------------------------------------------
  **LTCH             **Number   **Number   **Average   **Average   **Percent   **Percent Change  **Percent
  Classification**   of LTCHs** of LTCH    Estimated   Estimated   Change in   in Estimated      Change in
                                PPS        RY 2008     Proposed    Estimated   Payments Per      Estimated
                                Cases**    LTCH PPS    RY 2009     Payments    Discharge from RY Payments Per
                                           Payment Per LTCH PPS    Per         2008 to RY 2009   Discharge from
                                           Case^1^**   Payment Per Discharge   for Proposed      RY 2008 to RY
                                                       Case^2^**   from RY     Changes to the    2009 for All
                                                                   2008 to RY  Area Wage         Changes^5^**
                                                                   2009 for    Adjustment^4^**   
                                                                   Proposed                      
                                                                   Changes to                    
                                                                   the Federal                   
                                                                   Rate^3^**                     
  ------------------ ---------- ---------- ----------- ----------- ----------- ----------------- --------------
  **ALL PROVIDERS**  394        134,160    \$32,166    \$33,092    2.2         -0.1              2.9

                                                                                                 

  **BY LOCATION:**                                                                               

  **RURAL**          25         6,076      \$26,951    \$27,643    2.4         -0.5              2.6

  **URBAN**          369        128,084    \$32,414    \$33,351    2.2         -0.1              2.9

  **LARGE**          193        78,292     \$33,732    \$34,736    2.2         -0.1              3.0

  **OTHER**          176        49,792     \$30,341    \$31,172    2.3         -0.3              2.7

                                                                                                 

  **BY PARTICIPATION                                                                             
  DATE:**                                                                                        

  **BEFORE OCT.      28         9,779      \$27,864    \$28,849    2.2         0.4               3.5
  1983**                                                                                         

  **OCT. 1983 -      46         21,101     \$33,189    \$34,175    2.2         -0.1              3.0
  SEPT. 1993**                                                                                   

  **OCT. 1993 -      204        74,145     \$32,207    \$33,082    2.3         -0.3              2.7
  SEPT. 2002**                                                                                   

  **AFTER OCTOBER    112        28,598     \$32,793    \$33,783    2.3         0.0               3.0
  2002**                                                                                         

  **UNKNOWN**        4          537        \$31,300    \$32,442    2.3         0.7               3.6

                                                                                                 

  **BY OWNERSHIP                                                                                 
  TYPE:**                                                                                        

  **VOLUNTARY**      88         27,948     \$31,061    \$32,017    2.2         0.0               3.1

  **PROPRIETARY**    265        100,047    \$32,415    \$33,314    2.2         -0.2              2.8

  **GOVERNMENT**     25         3,692      \$33,984    \$35,155    2.1         0.1               3.4

  **UNKNOWN**        16         2,473      \$31,864    \$33,177    2.3         1.1               4.1

                                                                                                 

  **BY CENSUS                                                                                    
  REGION:**                                                                                      

  **NEW ENGLAND**    20         9,776      \$27,177    \$28,213    2.2         0.7               3.8

  **MIDDLE           36         10,756     \$31,851    \$32,629    2.2         -0.6              2.4
  ATLANTIC**                                                                                     

  **SOUTH ATLANTIC** 50         13,544     \$35,730    \$36,822    2.2         0.0               3.1

  **EAST NORTH       70         19,552     \$35,316    \$36,289    2.2         -0.2              2.8
  CENTRAL**                                                                                      

  **EAST SOUTH       30         8,667      \$32,736    \$33,565    2.2         -0.5              2.5
  CENTRAL**                                                                                      

  **WEST NORTH       18         5,350      \$34,325    \$35,378    2.2         0.0               3.1
  CENTRAL**                                                                                      

  **WEST SOUTH       130        51,441     \$28,779    \$29,538    2.3         -0.3              2.6
  CENTRAL**                                                                                      

  **MOUNTAIN**       22         5,804      \$35,089    \$36,143    2.2         0.0               3.0

  **PACIFIC**        18         9,270      \$41,129    \$42,633    2.1         0.6               3.7

                                                                                                 

  **BY BED SIZE:**                                                                               

  **BEDS: 0-24**     33         4,797      \$30,110    \$30,888    2.4         -0.5              2.6

  **BEDS: 25-49**    195        45,212     \$32,404    \$33,305    2.2         -0.2              2.8

  **BEDS: 50-74**    72         26,064     \$32,145    \$33,040    2.2         -0.2              2.8

  **BEDS: 75-124**   52         23,503     \$33,212    \$34,246    2.2         0.1               3.1

  **BEDS: 125-199**  21         17,567     \$32,088    \$33,013    2.2         -0.2              2.9

  **BEDS: 200 +**    21         17,017     \$30,781    \$31,717    2.2         0.0               3.0
  -------------------------------------------------------------------------------------------------------------

^1^ Estimated 2009 LTCH PPS rate year payments based on the proposed
payment rates and policy changes presented in the preamble of this
proposed rule.

^2^ Estimated 2008 LTCH PPS rate year payments based on the rates,
factors and policies established in the RY 2008 LTCH PPS final rule
(72 FR 26870 through 27029), the RY 2008 LTCH PPS correction notice
(72 FR 36613 through 36616) and the applicable sections of the Medicare,
Medicaid, and SCHIP Extension Act of 2007. As described in section
XVI.B.3. of this proposed rule, although we are aware that there are
different effective dates for the various provisions of MMSEA that
affect RY 2008 LTCH PPS payments, for the purpose of this impact
analysis, we modeled estimated RY 2008 payments as if those provisions
were applicable to discharges for the entire 2008 LTCH PPS rate year.
Specifically, in estimating RY 2008 LTCH PPS payments, we applied the RY
2008 Federal rate provided for by sections 114(e)(1) of the MMSEA (that
is, \$38,086.04), and the SSO policy provided for by section 114(c)(3)
of the MMSA (that is, excluding the revisions to the SSO policy at
§412.529(c)(3)(i)).

^3^ Percent change in estimated payments per discharge from the 2008
LTCH PPS rate year to the 2009 LTCH PPS rate year for the proposed
changes to the Federal rate, as discussed in section IV.E. of the
preamble of this proposed rule. (Note, because about 34 percent of all
LTCH cases are projected to receive a payment adjustment under the SSO
policy that is based either on the estimated cost of the case or the
"blend option" (which is based in part on the "IPPS comparable amount")
rather than the proposed Federal rate in RY 2009, the percent change in
estimated payments per discharge due to the proposed changes to the
Federal rate for most of the categories of LTCHs, 2.2 percent, is
somewhat less than the proposed update to the Federal rate of 2.6
percent.)

^4^ Percent change in estimated payments per discharge from the 2008
LTCH PPS rate year to the 2009 LTCH PPS rate year for proposed changes
to the area wage adjustment at §412.525(c) (as discussed in section
V.F.1. of the preamble of this proposed rule).

^5^ Percent change in estimated payments per discharge from the 2008
LTCH PPS rate year (as described in section XVI.B.3. of this proposed
rule) to the 2009 LTCH PPS rate year for all of the proposed changes
presented in the preamble of this proposed rule. Note, this column,
which shows the percent change in estimated payments per discharge for
all proposed changes, may not equal the sum of the percent changes in
estimated payments per discharge for proposed changes to the Federal
rate (column 6) and the proposed changes to the area wage adjustment
(column 7) due to the effect of estimated changes in both payments to
SSO cases that are paid based on estimated costs and aggregate HCO
payments (as discussed this proposed rule), as well as other interactive
effects that cannot be isolated.

4\. Results

Based on the most recent available data (as described previously for
394 LTCHs), we have prepared the following summary of the impact (as
shown in Table 9) of the proposed LTCH PPS payment rate and policy
changes presented in this proposed rule. The impact analysis in Table 9
shows that estimated payments per discharge are expected to increase
approximately 2.9 percent, on average, for all LTCHs from the 2008 LTCH
PPS rate year as compared to the 2009 LTCH PPS rate year as a result of
the proposed payment rate and policy changes presented in this proposed
rule. We note that although we are proposing a 2.6 percent increase to
the standard Federal rate for RY 2009, based on the latest proposed
market basket estimate (3.5 percent) and offset by the proposed coding
and documentation adjustment (0.9 percent), for most categories of
LTCHs, the impact analysis shown in Table 9 (column 7) only shows a
2.2 percent increase in estimated payments per discharge from RY 2008 to
RY 2009 as a result of the proposed change to the standard Federal rate.
The reason that this column shows an estimated 2.2 percent increase
rather than an estimated 2.6 percent increase (based on the proposed
2.6 percent update to the standard Federal rate) is because about
34 percent of all LTCH cases are projected to receive an SSO payment
that would be based either on the estimated cost of the case or the
"blend option" (which is based in part on the "IPPS comparable amount")
rather than a LTCH PPS payment based on the proposed standard Federal
rate. Therefore, because over 30 percent of [all]{.underline} LTCH PPS
cases would receive a payment that is not based fully on the proposed
standard Federal rate, the percent change in estimated payments per
discharge due to the proposed changes to the standard Federal rate for
most categories of LTCHs shown in Table 9 is projected to be 2.2
percent, which is somewhat less than the 2.6 percent proposed update to
the standard Federal rate. In addition to the proposed 2.6 percent
increase to the standard Federal rate for RY 2009, the projected percent
increase in estimated payments per discharge from the 2008 LTCH PPS rate
year to the 2009 LTCH PPS rate year of 2.9 percent shown in Table 9 (see
column 8) reflects the effect of increased HCO and SSO payments as we
discussed previously. That is, in calculating the estimated increase in
payments for HCO and SSO from RY 2008 to RY 2009, we increased costs by
the applying the proposed market basket (approximately 3.5 percent). As
noted above, SSOs comprise approximately 16 percent of total LTCH PPS
payments and high cost outliers comprise approximately 8 percent of
estimated total LTCH PPS payments. Furthermore, as discussed previously
in this regulatory impact analysis, the average increase in estimated
payments per discharge from the 2008 LTCH PPS rate year to the 2009 LTCH
PPS rate year, on average, for all LTCHs of approximately 2.9 (as shown
in Table 9) was determined by comparing estimated RY 2009 LTCH PPS
payments (using the proposed rates and policies discussed in the
preamble of this rule) to estimated RY 2008 LTCH PPS payments (as
described above in section XVI.B.3. of this regulatory impact analysis).

a\. Location

Based on the most recent available data, the majority of LTCHs are in
urban areas. Approximately 6 percent of the LTCHs are identified as
being located in a rural area, and approximately 5 percent of all LTCH
cases are treated in these rural hospitals. The impact analysis
presented in Table 9 shows that the average percent increase in
estimated payments per discharge for the 2008 LTCH PPS rate year
compared to the 2009 LTCH PPS rate year for all hospitals is 2.9 percent
for all proposed changes. For rural LTCHs, the percent change for all
proposed changes is estimated to be 2.6 percent, while for urban LTCHs,
we estimate this increase to be 2.9 percent. Large urban LTCHs are
projected to experience a 3.0 percent increase in estimated payments per
discharge from the 2008 LTCH PPS rate year compared to the 2009 LTCH PPS
rate year, while other urban LTCHs are projected to experience a
2.7 percent increase in estimated payments per discharge from the 2008
LTCH PPS rate year compared to the 2009 LTCH PPS rate year, as shown in
Table 9. Rural LTCHs are projected to experience a somewhat lower than
average increase in estimated payments per discharge for all proposed
changes primarily due to the proposed changes to the area wage
adjustment. That is, 68 percent of the LTCHs in these areas are expected
to experience a decrease in their wage index value from RY 2008 to RY
2009. In addition, because all LTCHs in rural areas have a wage index
value that is less than 1.0, the proposed increase to the labor-related
share (from 75.788 percent to 75.920 percent) would also contribute to
the estimated lower than average increase in estimated payments from RY
2008 to RY 2009 shown in column 8 of Table 9.

b\. Participation Date

LTCHs are grouped by participation date into four categories: (1) before
October 1983; (2) between October 1983 and September 1993; (3) between
October 1993 and September 2002; and (4) after October 2002. Based on
the most recent available data, the majority (approximately 52 percent)
of the LTCH cases are in hospitals that began participating between
October 1993 and September 2002, and are projected to experience a
slightly lower than average increase of 2.7 percent in estimated
payments per discharge from the 2008 LTCH PPS rate year compared to the
2009 LTCH PPS rate year, as shown in Table 9, mostly because
approximately 66 percent of hospitals in this category are projected to
experience a decrease in their wage index value from RY 2008 to RY 2009.
In addition, because the majority of hospitals (80 percent) in this
category have a wage index of less than 1.0, the proposed increase to
the labor-related share (from 75.788 percent to 75.920 percent) would
also contribute to the slightly lower than average increase in payments
from RY 2008 to RY 2009 shown in column 8 of Table 9.

LTCHs that began participating in Medicare between October 1983 and
September 1993, and those LTCHs that began participating in Medicare
after October 2002 are projected to experience close to the
average percent increase (3.0 percent) in estimated payments per
discharge from the 2008 LTCH PPS rate year compared to the 2009 LTCH PPS
rate year, as shown in Table 9. Approximately 12 percent of LTCHs began
participating in Medicare between October 1983 and September 1993 while
approximately 28 percent of LTCHs began participating in Medicare after
October 2002 (that is, the beginning of the LTCH PPS, which was
implemented for cost reporting periods beginning on or after
October 1, 2002).

LTCHs that began participating before October 1983 are projected to
experience a 3.5 percent increase in estimated payments per discharge
from the 2008 LTCH PPS rate year compared to the 2009 LTCH PPS rate year
(see Table 9). We are projecting that LTCHs that began participating in
Medicare before October 1983 would experience a larger than average
increase in estimated payments for RY 2009 as compared to RY 2008
primarily due to the proposed changes to the area wage adjustment. This
is because approximately 68 percent of the LTCHs that began
participating in Medicare before October 1983 are located in areas where
the proposed RY 2009 wage index value would be greater than the RY 2008
wage index value. In addition, because a significant number (75 percent)
of hospitals in this category have a wage index of greater than 1.0, the
proposed increase to the labor-related share (from 75.788 percent to
75.920 percent) would also contribute to the larger than average
increase in estimated payments from RY 2008 to RY 2009.

c\. Ownership Control

Other than LTCHs whose ownership control type is unknown, LTCHs are
grouped into three categories based on ownership control type:
voluntary; proprietary; and government. Based on the most recent
available data, approximately 6 percent of LTCHs are identified as
government‑owned and operated (see Table 9). We expect that for these
government‑owned and operated LTCHs, estimated 2009 LTCH PPS rate year
payments per discharge would increase 3.4 percent in comparison to the
2008 LTCH PPS rate year, as shown in Table 9. We are projecting that
government‑run LTCHs would experience a somewhat higher than average
increase in estimated payments in RY 2009 as compared to RY 2008
primarily due to the effect of the proposed changes to the area wage
adjustment. Specifically, LTCHs in this category are projected to
experience a higher than average increase in their estimated payments
from RY 2008 to RY 2009 due to the proposed changes to the area wage
adjustment primarily because the majority (60 percent) of hospitals in
this category would experience an increase in their wage index value
from RY 2008 to RY 2009.

We project that estimated 2009 LTCH PPS rate year payments per discharge
for voluntary LTCHs, which account for approximately 22 percent of
LTCHs, would increase near the average (3.1 percent) in comparison to
estimated 2008 LTCH PPS rate year payments (see Table 9).

The majority (approximately 67 percent) of LTCHs are identified as
proprietary. We project that 2009 LTCH PPS rate year estimated payments
per discharge for these proprietary LTCHs would increase 2.8 percent
(nearly average) in comparison to the 2008 LTCH PPS rate year (see
Table 9).

d\. Census Region

Estimated payments per discharge for the 2009 LTCH PPS rate year are
projected to increase for LTCHs located in all regions in comparison to
the 2008 LTCH PPS rate year. The percent increase in estimated payments
per discharge from the 2008 LTCH PPS rate year to the 2009 LTCH PPS rate
year for all regions is largely attributable to the proposed increase in
the standard Federal rate.

Of the 9 census regions, we project that the increase in proposed 2009
LTCH PPS rate year estimated payments per discharge in comparison to the
2008 LTCH PPS rate year would have the largest impact on LTCHs in the
New England and Pacific regions (3.8 percent and 3.7 percent,
respectively; see Table 9). LTCHs located in both the New England and
Pacific regions are expected to experience a larger than average
increase in estimated payments due to the proposed changes in the area
wage adjustment (0.7 percent for the New England region, and 0.6 percent
for the Pacific region, as shown in Table 9). This is because
approximately 85 percent of LTCHs located in the New England region and
all of LTCHs in the Pacific region are projected to experience an
increase in their wage index values for proposed RY 2009 as compared to
RY 2008.

We project that in comparison to the 2008 LTCH PPS rate year, the
proposed 2009 LTCH PPS rate year estimated payments per discharge for
LTCHs in the East North Central region would increase by approximately
2.8 percent (nearly average). For LTCHs located in the South Atlantic
and West North Central regions, we estimate that the slightly higher
than average projected increase (3.1 percent for each region) in
estimated payments per discharge for the 2009 LTCH PPS rate year
compared to the 2008 LTCH PPS rate year is largely a result of the
proposed changes to the area wage adjustment. That is, we estimate that
approximately 58 percent of hospitals in the South Atlantic region and
approximately 55 percent of hospitals in the West North Central region
would experience an increase in their wage index values from RY 2008 to
RY 2009. For LTCHs located in the Middle Atlantic, East South Central
and West South Central regions, we estimate that the somewhat lower than
average projected increase (2.4 percent, 2.5 percent, and 2.6 percent,
respectively) in estimated payments per discharge for the 2009 LTCH PPS
rate year compared to the 2008 LTCH PPS rate year is largely a result of
the proposed changes to the area wage adjustment. Specifically, nearly
all LTCHs in the Middle Atlantic region (approximately 89 percent) and
the majority of the hospitals in the East South Central region
(approximately 67 percent) and West South Central region (approximately
75 percent) would experience a decrease in their wage index value from
RY 2008 to RY 2009. Furthermore, because a significant number of
hospitals in these categories have a wage index of less than 1.0, the
proposed increase to the labor-related share (from 75.788 percent to
75.920 percent) would also contribute to the lower than average
estimated increase in payments from RY 2008 to RY 2009.

e\. Bed Size

LTCHs were grouped into seven categories based on bed size: 0‑24 beds;
25‑49 beds; 50‑74 beds; 75‑124 beds; 125‑199 beds; greater than 200
beds; and unknown bed size.

We are projecting an increase in estimated 2009 LTCH PPS rate year
payments per discharge in comparison to the 2008 LTCH PPS rate year for
all bed size categories. Most LTCHs are in bed size categories where
estimated 2009 LTCH PPS rate year payments per discharge are projected
to increase at or near the average increase of 2.9 percent for all
LTCHS, in comparison to the 2008 LTCH PPS rate year (that is, all LTCH
bed size categories except the category of LTCHs with 0-24 beds).
Specifically, estimated payments per discharge for the 2009 LTCH PPS
rate year are projected to increase for LTCHs with 25-49 and 50-74 beds
at 2.8 percent, for LTCHs with 75-124 beds at 3.1 percent, for LTCHs
with 125-199 beds at 2.9 percent, and for LTCHs with more than 200 beds,
at 3.0 percent.

Estimated payments per discharge for the 2009 LTCH PPS rate year for
LTCHs with 0-24 beds are projected to have a somewhat lower than average
increase in comparison to all hospitals (2.6 percent; see Table 9). This
lower than average increase in estimated payments per discharge for
LTCHs with 0-24 beds is largely due to the proposed changes to the area
wage adjustment. Specifically, LTCHs in this category are expected to
experience a larger than average decrease in their payments from RY 2008
to RY 2009 due to the proposed changes to the area wage adjustment
primarily because approximately 73 percent of the hospitals in this
category are projected to experience a decrease in their wage index
value from RY 2008 to RY 2009. In addition, because the majority
(approximately 91 percent) of hospitals in this category have a wage
index of less than 1.0, the proposed increase to the labor-related share
(from 75.788 percent to 75.920 percent) would also contribute to the
smaller than average increase in estmated payments from RY 2008 to RY
2009 shown in Table 9.

5\. Effect on the Medicare Program

Based on actuarial projections, an estimate of Medicare spending (total
estimated Medicare program payments) for LTCH services over the next
5 years based on current LTCH PPS policy (as established in previous
LTCH PPS final rules) is shown in Table 4 in section IV.D. of the
preamble of this proposed rule. As noted previously, we project that the
provisions of this proposed rule would result in an increase in
estimated aggregate LTCH PPS payments in RY 2009 of approximately
124 million (or about 2.9 percent) for the 394 LTCHs in our database.

Consistent with the statutory requirement for BN, as we discussed in the
August 30, 2002 final rule that implemented the LTCH PPS, in developing
the LTCH PPS, we intended estimated aggregate payments under the LTCH
PPS in FY 2003 be projected to equal the estimated aggregate payments
that would have been made if the LTCH PPS were not implemented. Our
methodology for estimating payments for purposes of the BN calculations
for determining the FY 2003 standard Federal rate used the best
available data and necessarily reflects assumptions. As discussed in
section IV.D. of this proposed rule, section 114(c)(4) of the Medicare,
Medicaid and SCHIP Extension Act of 2007 provides that the "Secretary
shall not, for the 3‑year period beginning on the date of the enactment
of this Act, make the one-time prospective adjustment to long-term care
hospital prospective payment rates provided for in section 412.523(d)(3)
of title 42, Code of Federal Regulations, or any similar provision."
That provision delays the effective date of any one-time budget
neutrality adjustment until no earlier than December 29, 2010. However,
prior to the enactment of the MMSEA of 2007, we had developed a
methodology for evaluating the appropriateness of proposing a one-time
budget neutrality adjustment under existing §412.523(d)(3). In order to
inform the public of our thinking, and to stimulate comments for our
consideration during the three-year delay in implementing any adjustment
under the recent legislation, we have presented our analysis and its
results in section IV.D. of the preamble of this proposed rule.

6\. Effect on Medicare Beneficiaries

Under the LTCH PPS, hospitals receive payment based on the average
resources consumed by patients for each diagnosis. We do not expect any
changes in the quality of care or access to services for Medicare
beneficiaries under the LTCH PPS, but we expect that paying
prospectively for LTCH services would enhance the efficiency of the
Medicare program.

D. Accounting Statement

####### As discussed in section XVI.A.1., the impact analysis of this proposed rule results in an increase in estimated aggregate payments of approximately \$124 million (or about 2.9 percent) for the 394 LTCHs in our database. Therefore, as required by OMB Circular A‑4 (available at <http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf>*)*, in Table 10, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. Table 10 provides our best estimate of the proposed increase in Medicare payments under the LTCH PPS as a result of the provisions presented in this proposed rule based on the data for the 394 LTCHs in our database. All expenditures are classified as transfers to Medicare providers (that is, LTCHs). 

**TABLE 10: Accounting Statement: Classification of Estimated
Expenditures, from the 2008 LTCH PPS Rate Year to the 2009 LTCH PPS Rate
Year \[In Millions\]**

+-----------------------------------+-----------------------------------+
| **Category**                      | ######### **TRANSFERS**           |
+-----------------------------------+-----------------------------------+
| Annualized Monetized Transfers    | Positive transfer - Estimated     |
|                                   | increase in expenditures: \$124   |
|                                   | million                           |
+-----------------------------------+-----------------------------------+
| ######## From Whom To Whom?       | Federal Government To LTCH        |
|                                   |                                   |
|                                   | Medicare Providers                |
+-----------------------------------+-----------------------------------+

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

# List of Subjects 

# 42 CFR Part 412 

### Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements. 

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

### **PART 412\--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES**

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

**Authority:** Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh) and section 124 of Pub. L. 106‑113 (113 Stat.
1501A--332), section 123 of Pub. L. 106-113, and section 307 of Pub. L.
106-554, and section 114 of Pub. L. 110-173.

**Subpart O---Prospective Payment System for Long Term Care Hospitals**

2\. Section 412.503 is amended by\--

A. Revising the definition of "Long-term care hospital prospective
payment system rate year".

B. Adding new definitions of \"rural\" and \"urban\" in alphabetical
order.

The revision and additions read as follows:

**§412.503 Definitions**

\* \* \* \* \*

[Long-term care hospital prospective payment system rate
year]{.underline} means----

\(1\) From July 1, 2003 and ending on or before June 30, 2008, the
12­‑month period of July 1 through June 30.

\(2\) From July 1, 2008 and ending on September 30, 2009, the 15‑month
period of July 1, 2008 through September 30, 2009.

\(3\) Beginning on or after October 1, 2009, the 12‑month period of
October 1 through September 30.

\* \* \* \* \*

[Rural area]{.underline} means\--(1) For cost reporting periods
beginning on or after October 1, 2002, with respect to discharges
occurring during the period covered by such cost reports but before July
1, 2005, an area defined in §412.62(f)(1)(iii);

\(2\) For discharges occurring on or after July 1, 2005, and before July
1, 2008, an area as defined in §412.64(b)(1)(ii)(C); and

\(3\) For discharges occurring on or after July 1, 2008, any area
outside an urban area.

[Urban area]{.underline} means\--(1) For cost reporting periods
beginning on or after October 1, 2002, with respect to discharges
occurring during the period covered by such cost reports but before
July 1, 2005, an area defined in §412.62(f)(1)(ii);

\(2\) For discharges occurring on or after July 1, 2005, and before July
1, 2008, an urban area means an area as defined in §412.64(b)(1)(ii)(A)
and (B); and

\(3\) For discharges occurring on or after July 1, 2008, a Metropolitan
Statistical Area, as defined by the Executive Office of Management and
Budget.

3\. Section 412.523 is amended by\--

A. Adding new paragraph (c)(3)(v).

B. Revising paragraph (d)(2) by removing the phrase "sections 1886(b)(2)
and (b)(3) of the Act" and adding "section 1886(b)(2)(E) and (b)(3)(J)
of the Act" in its place.

C. Revising paragraph (d)(3).

The addition and revisions read as follows:

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

\* \* \* \* \*

\(c\) \* \* \*

\(3\) \* \* \*

\(v\) [For long‑term care hospital prospective payment system rate year
beginning July 1, 2008 and ending September 30, 2009]{.underline}. The
standard Federal rate for long‑term care hospital prospective payment
system rate year beginning July 1, 2008 and ending September 30, 2009 is
the standard Federal rate for the previous long‑term care hospital
prospective payment system rate year updated by 2.6 percent. The
standard Federal rate is adjusted, as appropriate, as described in
paragraph (d) of this section.

(d)(3) The Secretary reviews payments under this prospective payment
system and may make a one-time prospective adjustment to the long-term
care hospital prospective payment system rates no earlier than December
29, 2010, so that the effect of any significant difference between the
data used in the original computations and more recent data to determine
budget neutrality is not perpetuated in the prospective payment rates
for future years.

\* \* \* \* \*

4\. Section 424.525 is amended by revising paragraph (c) to read as
follows:

**§412.525  Adjustments to the Federal prospective payment.**

\* \* \* \* \*

\(c\) [Adjustments for area levels]{.underline}*.* The labor portion of
a long‑term care hospital\'s Federal prospective payment is adjusted to
account for geographical differences in the area wage levels using an
appropriate wage index (established by CMS), which reflects the relative
level of hospital wages and wage-related costs in the geographic area
(that is, urban or rural area as determined in accordance with the
definitions set forth in §412.503) of the hospital compared to the
national average level of hospital wages and wage-related costs. The
appropriate wage index (established by CMS) is updated annually.

5\. Section 412.529 is amended by revising paragraphs (d)(4)(ii)(B) and
(d)(4)(iii)(B) to read as follows:

##### §412.529   Special payment provision for short-stay outliers. {#special-payment-provision-for-short-stay-outliers. .unnumbered}

\* \* \* \* \*

\(d\) \* \* \*

\(4\) \* \* \*

\(ii\) \* \* \*

\(B\) Is adjusted for different area wage levels based on the geographic
classifications set forth at §412.503 and the applicable hospital
inpatient prospective payment system labor‑related share, using the
applicable hospital inpatient prospective payment system wage index
value for nonreclassified hospitals. For LTCHs located in Alaska and
Hawaii, this amount is also adjusted by the applicable hospital
inpatient prospective payment system cost of living adjustment factors.

\* \* \* \* \*

\(iii\) *\* \** \*

\(B\) Is adjusted for the applicable geographic adjustment factors,
including local cost variation based on the geographic classifications
set forth at §412.503 and the applicable full hospital inpatient
prospective payment system wage index value for nonreclassified
hospitals and, applicable large urban location cost of living adjustment
factors for LTCHs in Alaska and Hawaii, if applicable.

\* \* \* \* \*

6\. Section 412.534 is amended by revising paragraphs (d)(1),
(f)(2)(ii), and (f)(3)(ii) to read as follows:

##### §412.534  Special payment provisions for long-term care hospitals within hospitals and satellites of long-term care hospitals. {#special-payment-provisions-for-long-term-care-hospitals-within-hospitals-and-satellites-of-long-term-care-hospitals. .unnumbered}

\* \* \* \* \*

\(d\) \* \* \*

\(1\) Subject to paragraphs (g) and (h) of this section, in the case of
a long-term care hospital or satellite facility that is located in a
rural area as defined in §412.503 and is co‑located with another
hospital for any cost reporting period beginning on or after October 1,
2004 in which the long-term care hospital or satellite facility has a
discharged Medicare inpatient population of whom more than 50 percent
were admitted to the long-term care hospital or satellite facility from
the co-located hospital, payments for the patients who are admitted from
the co-located hospital and who cause the long-term care hospital or
satellite facility to exceed the 50 percent threshold for discharged
patients who were admitted from the co‑located hospital are the lesser
of the amount otherwise payable under this subpart or the amount payable
under this subpart that is equivalent, as set forth in paragraph (f) of
this section, to the amount that were otherwise payable under subpart A,
§412.1(a). Payments for the remainder of the long‑term care hospital\'s
or satellite facility\'s patients are made under the rules in this
subpart at §412.500 through §412.541 with no adjustment under this
section.

\* \* \* \* \*

\(f\) \* \* \*

\(2\) *\* \* \**

\(ii\) Is adjusted for different area wage levels based on the
geographic classifications set forth at §412.503 and the applicable
hospital inpatient prospective payment system labor‑related share, using
the applicable hospital inpatient prospective payment system wage index
value for non-reclassified hospitals. For LTCHs located in Alaska and
Hawaii, this amount is also adjusted by the applicable hospital
inpatient prospective payment system cost of living adjustment factors;

\* \* \*

\(3\) \* \* \*

\(ii\) Is adjusted by the applicable geographic adjustment factors,
including local cost variation based on the applicable geographic
classifications set forth at §412.503 and the applicable full hospital
inpatient prospective payment system wage index value for
non-reclassified hospitals, applicable large urban location and cost of
living adjustment factors for LTCHs for Alaska and Hawaii, if
applicable;

\* \* \* \* \*

7\. Section 412.535 is amended by\--

A.  Revising the introductory text.

B.  Revising paragraph (a).

C.  Redesignating paragraph (b) as paragraph (d).

D.  Adding new paragraphs (b) and (c).

> The revisions and additions read as follows:

**§412.535 Publication of the Federal prospective payment rates.**

Except as specified in paragraph (b), CMS publishes information
pertaining to the long-term care hospital prospective payment system
effective for each annual update in the Federal Register.

\(a\) For the period beginning on or after July 1, 2003 and ending on
June 30, 2008 information on the unadjusted Federal payment rates and a
description of the methodology and data used to calculate the payment
rates are published on or before May 1 prior to the start of each
long‑term care hospital prospective payment system rate year which
begins July 1, unless for good cause it is published after May 1, but
before June 1.

\(b\) For the period beginning on July 1, 2008 and ending on
September 30, 2009, information of the unadjusted Federal payment rates
and a description of the methodology and data used to calculate the
payment rates are published on or before May 1 prior to the start of the
long-term care hospital prospective payment system rate year which
begins July 1, unless for good cause it is published after May 1, but
before June 1.

\(c\) For the period beginning on or after October 1, 2009, information
on the unadjusted Federal payment rates and a description of the
methodology and data used to calculate the payment rates are published
on or before August 1 prior to the start of the Federal fiscal year
which begins October 1, unless for good cause it is published after
August 1, but before September 1.

\* \* \* \* \*

7\. Section 412.536 is amended by revising paragraphs (c)(1),
(e)(2)(ii), and (e)(3)(ii) to read as follows.

##### §412.536  Special payment provisions for long-term care hospitals and satellites of long-term care hospitals that discharged Medicare patients admitted from a hospital not located in the same building or on the same campus as the long‑term care hospital or satellite of the long-term care hospital. {#special-payment-provisions-for-long-term-care-hospitals-and-satellites-of-long-term-care-hospitals-that-discharged-medicare-patients-admitted-from-a-hospital-not-located-in-the-same-building-or-on-the-same-campus-as-the-longterm-care-hospital-or-satellite-of-the-long-term-care-hospital. .unnumbered}

\* \* \* \* \*

\(c\) [Special treatment of rural hospitals]{.underline}. (1) Subject to
paragraph (f) of this section, in the case of a long-term care hospital
or long-term care hospital satellite facility that is located in a rural
area as defined in §412.503 that has a discharged Medicare inpatient
population of whom more than 50 percent were admitted to the long-term
care hospital or long‑term care hospital satellite facility from a
hospital not co‑located with the long-term care hospital or with the
satellite of a long-term care hospital, payment for the Medicare
discharges who are admitted from that hospital and who cause the
long-term care hospital or satellite facility to exceed the 50 percent
threshold for Medicare discharges is determined at the lesser of the
amount otherwise payable under this subpart or the amount payable under
this subpart that is equivalent, as set forth in paragraph (e) of this
section, to the amount that is otherwise payable under subpart A,
§412.1(a). Payments for the remainder of the long-term care hospital\'s
or long-term care hospital satellite facility\'s Medicare discharges
admitted from that referring hospital are made under the rules in this
subpart at §412.500 through §412.541 with no adjustment under this
section.

\* \* \* \* \*

\(e\) \* \* \*

\(2\) *\* \** \*

\(ii\) Is adjusted for different area wage levels based on the
geographic classifications defined at §412.503 and the applicable
hospital inpatient prospective payment system labor‑related share, using
the applicable hospital inpatient prospective payment system wage index
value for non‑reclassified hospitals. For long-term care hospitals
located in Alaska and Hawaii, this amount is also adjusted by the
applicable hospital inpatient prospective payment system cost of living
adjustment factors;

\* \* \* \* \*

\(3\) \* \* \*

\(ii\) Is adjusted by the applicable geographic adjustment factors,
including local cost variation based on the applicable geographic
classifications set forth at §412.503 and the applicable full hospital
inpatient prospective payment system wage index value for
non-reclassified hospitals, applicable large urban location and cost of
living adjustment factors for long-term care hospitals for Alaska and
Hawaii, if applicable;

\* \* \* \* \*

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

Dated: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

> **Kerry Weems,**
>
> [Acting Administrator,]{.underline}
>
> [Centers for Medicare & Medicaid Services.]{.underline}

Approved: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> **Michael O. Leavitt,**
>
> [Secretary.]{.underline}

**BILLING CODE 4120-01**

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

**ADDENDUM:**

Addendum A contains the tables referred to throughout the preamble to
this proposed rule. The tables presented below are as follows:

Table 1: Proposed Long-Term Care Hospital Wage Index for Urban Areas for
Discharges Occurring from July 1, 2008 through September 30, 2009

Table 2: Proposed Long-Term Care Hospital Wage Index for Rural Areas for
Discharges Occurring from July 1, 2008 through September 30, 2009

Table 3: FY 2008 MS-LTC-DRG Relative Weights, Geometric Average Length
of Stay, Short-Stay Outlier Threshold and IPPS-Comparable Threshold (for
Short-Stay Outlier Cases) (effective for discharges occurring on or
after July 1, 2008 through September 30, 2009)). (Note: This table is
the same information provided in Table 11 of the FY 2008 IPPS final rule
(72 FR 48143 through 48157), which has been reprinted here for
convenience. )

**TABLE 1: PROPOSED LONG‑TERM CARE HOSPITAL WAGE INDEX**

**FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM**

**JULY 1, 2008 THROUGH September 30, 2009**

+----------+-----------------------------------------------+----------+
| **CBSA   | **Urban Area**                                | **       |
| Code**   |                                               | Proposed |
|          | **(Constituent Counties)**                    | Wage     |
|          |                                               | Index**  |
+==========+===============================================+==========+
| 10180    | Abilene, TX                                   | 0.7957   |
|          |                                               |          |
|          | Callahan County, TX                           |          |
|          |                                               |          |
|          | Jones County, TX                              |          |
|          |                                               |          |
|          | Taylor County, TX                             |          |
+----------+-----------------------------------------------+----------+
| 10380    | Aguadilla-Isabela-San Sebastián, PR           | 0.3448   |
|          |                                               |          |
|          | Aguada Municipio, PR                          |          |
|          |                                               |          |
|          | Aguadilla Municipio, PR                       |          |
|          |                                               |          |
|          | Añasco Municipio, PR                          |          |
|          |                                               |          |
|          | Isabela Municipio, PR                         |          |
|          |                                               |          |
|          | Lares Municipio, PR                           |          |
|          |                                               |          |
|          | Moca Municipio, PR                            |          |
|          |                                               |          |
|          | Rincón Municipio, PR                          |          |
|          |                                               |          |
|          | San Sebastián Municipio, PR                   |          |
+----------+-----------------------------------------------+----------+
| 10420    | Akron, OH                                     | 0.8794   |
|          |                                               |          |
|          | Portage County, OH                            |          |
|          |                                               |          |
|          | Summit County, OH                             |          |
+----------+-----------------------------------------------+----------+
| 10500    | Albany, GA                                    | 0.8514   |
|          |                                               |          |
|          | Baker County, GA                              |          |
|          |                                               |          |
|          | Dougherty County, GA                          |          |
|          |                                               |          |
|          | Lee County, GA                                |          |
|          |                                               |          |
|          | Terrell County, GA                            |          |
|          |                                               |          |
|          | Worth County, GA                              |          |
+----------+-----------------------------------------------+----------+
| 10580    | Albany-Schenectady-Troy, NY                   | 0.8588   |
|          |                                               |          |
|          | Albany County, NY                             |          |
|          |                                               |          |
|          | Rensselaer County, NY                         |          |
|          |                                               |          |
|          | Saratoga County, NY                           |          |
|          |                                               |          |
|          | Schenectady County, NY                        |          |
|          |                                               |          |
|          | Schoharie County, NY                          |          |
+----------+-----------------------------------------------+----------+
| 10740    | Albuquerque, NM                               | 0.9554   |
|          |                                               |          |
|          | Bernalillo County, NM                         |          |
|          |                                               |          |
|          | Sandoval County, NM                           |          |
|          |                                               |          |
|          | Torrance County, NM                           |          |
|          |                                               |          |
|          | Valencia County, NM                           |          |
+----------+-----------------------------------------------+----------+
| 10780    | Alexandria, LA                                | 0.7979   |
|          |                                               |          |
|          | Grant Parish, LA                              |          |
|          |                                               |          |
|          | Rapides Parish, LA                            |          |
+----------+-----------------------------------------------+----------+
| 10900    | Allentown-Bethlehem-Easton, PA-NJ             | 0.9865   |
|          |                                               |          |
|          | Warren County, NJ                             |          |
|          |                                               |          |
|          | Carbon County, PA                             |          |
|          |                                               |          |
|          | Lehigh County, PA                             |          |
|          |                                               |          |
|          | Northampton County, PA                        |          |
+----------+-----------------------------------------------+----------+
| 11020    | Altoona, PA                                   | 0.8618   |
|          |                                               |          |
|          | Blair County, PA                              |          |
+----------+-----------------------------------------------+----------+
| 11100    | Amarillo, TX                                  | 0.9116   |
|          |                                               |          |
|          | Armstrong County, TX                          |          |
|          |                                               |          |
|          | Carson County, TX                             |          |
|          |                                               |          |
|          | Potter County, TX                             |          |
|          |                                               |          |
|          | Randall County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 11180    | Ames, IA                                      | 1.0046   |
|          |                                               |          |
|          | Story County, IA                              |          |
+----------+-----------------------------------------------+----------+
| 11260    | Anchorage, AK                                 | 1.1913   |
|          |                                               |          |
|          | Anchorage Municipality, AK                    |          |
|          |                                               |          |
|          | Matanuska-Susitna Borough, AK                 |          |
+----------+-----------------------------------------------+----------+
| 11300    | Anderson, IN                                  | 0.8827   |
|          |                                               |          |
|          | Madison County, IN                            |          |
+----------+-----------------------------------------------+----------+
| 11340    | Anderson, SC                                  | 0.9086   |
|          |                                               |          |
|          | Anderson County, SC                           |          |
+----------+-----------------------------------------------+----------+
| 11460    | Ann Arbor, MI                                 | 1.0539   |
|          |                                               |          |
|          | Washtenaw County, MI                          |          |
+----------+-----------------------------------------------+----------+
| 11500    | Anniston-Oxford, AL                           | 0.7926   |
|          |                                               |          |
|          | Calhoun County, AL                            |          |
+----------+-----------------------------------------------+----------+
| 11540    | Appleton, WI                                  | 0.9598   |
|          |                                               |          |
|          | Calumet County, WI                            |          |
|          |                                               |          |
|          | Outagamie County, WI                          |          |
+----------+-----------------------------------------------+----------+
| 11700    | Asheville, NC                                 | 0.9185   |
|          |                                               |          |
|          | Buncombe County, NC                           |          |
|          |                                               |          |
|          | Haywood County, NC                            |          |
|          |                                               |          |
|          | Henderson County, NC                          |          |
|          |                                               |          |
|          | Madison County, NC                            |          |
+----------+-----------------------------------------------+----------+
| 12020    | Athens-Clarke County, GA                      | 1.0517   |
|          |                                               |          |
|          | Clarke County, GA                             |          |
|          |                                               |          |
|          | Madison County, GA                            |          |
|          |                                               |          |
|          | Oconee County, GA                             |          |
|          |                                               |          |
|          | Oglethorpe County, GA                         |          |
+----------+-----------------------------------------------+----------+
| 12060    | Atlanta-Sandy Springs-Marietta, GA            | 0.9828   |
|          |                                               |          |
|          | Barrow County, GA                             |          |
|          |                                               |          |
|          | Bartow County, GA                             |          |
|          |                                               |          |
|          | Butts County, GA                              |          |
|          |                                               |          |
|          | Carroll County, GA                            |          |
|          |                                               |          |
|          | Cherokee County, GA                           |          |
|          |                                               |          |
|          | Clayton County, GA                            |          |
|          |                                               |          |
|          | Cobb County, GA                               |          |
|          |                                               |          |
|          | Coweta County, GA                             |          |
|          |                                               |          |
|          | Dawson County, GA                             |          |
|          |                                               |          |
|          | DeKalb County, GA                             |          |
|          |                                               |          |
|          | Douglas County, GA                            |          |
|          |                                               |          |
|          | Fayette County, GA                            |          |
|          |                                               |          |
|          | Forsyth County, GA                            |          |
|          |                                               |          |
|          | Fulton County, GA                             |          |
|          |                                               |          |
|          | Gwinnett County, GA                           |          |
|          |                                               |          |
|          | Haralson County, GA                           |          |
|          |                                               |          |
|          | Heard County, GA                              |          |
|          |                                               |          |
|          | Henry County, GA                              |          |
|          |                                               |          |
|          | Jasper County, GA                             |          |
|          |                                               |          |
|          | Lamar County, GA                              |          |
|          |                                               |          |
|          | Meriwether County, GA                         |          |
|          |                                               |          |
|          | Newton County, GA                             |          |
|          |                                               |          |
|          | Paulding County, GA                           |          |
|          |                                               |          |
|          | Pickens County, GA                            |          |
|          |                                               |          |
|          | Pike County, GA                               |          |
|          |                                               |          |
|          | Rockdale County, GA                           |          |
|          |                                               |          |
|          | Spalding County, GA                           |          |
|          |                                               |          |
|          | Walton County, GA                             |          |
+----------+-----------------------------------------------+----------+
| 12100    | Atlantic City, NJ                             | 1.2198   |
|          |                                               |          |
|          | Atlantic County, NJ                           |          |
+----------+-----------------------------------------------+----------+
| 12220    | Auburn-Opelika, AL                            | 0.8090   |
|          |                                               |          |
|          | Lee County, AL                                |          |
+----------+-----------------------------------------------+----------+
| 12260    | Augusta-Richmond County, GA-SC                | 0.9645   |
|          |                                               |          |
|          | Burke County, GA                              |          |
|          |                                               |          |
|          | Columbia County, GA                           |          |
|          |                                               |          |
|          | McDuffie County, GA                           |          |
|          |                                               |          |
|          | Richmond County, GA                           |          |
|          |                                               |          |
|          | Aiken County, SC                              |          |
|          |                                               |          |
|          | Edgefield County, SC                          |          |
+----------+-----------------------------------------------+----------+
| 12420    | Austin-Round Rock, TX                         | 0.9544   |
|          |                                               |          |
|          | Bastrop County, TX                            |          |
|          |                                               |          |
|          | Caldwell County, TX                           |          |
|          |                                               |          |
|          | Hays County, TX                               |          |
|          |                                               |          |
|          | Travis County, TX                             |          |
|          |                                               |          |
|          | Williamson County, TX                         |          |
+----------+-----------------------------------------------+----------+
| 12540    | Bakersfield, CA                               | 1.1051   |
|          |                                               |          |
|          | Kern County, CA                               |          |
+----------+-----------------------------------------------+----------+
| 12580    | Baltimore-Towson, MD                          | 1.0134   |
|          |                                               |          |
|          | Anne Arundel County, MD                       |          |
|          |                                               |          |
|          | Baltimore County, MD                          |          |
|          |                                               |          |
|          | Carroll County, MD                            |          |
|          |                                               |          |
|          | Harford County, MD                            |          |
|          |                                               |          |
|          | Howard County, MD                             |          |
|          |                                               |          |
|          | Queen Anne\'s County, MD                      |          |
|          |                                               |          |
|          | Baltimore City, MD                            |          |
+----------+-----------------------------------------------+----------+
| 12620    | Bangor, ME                                    | 0.9978   |
|          |                                               |          |
|          | Penobscot County, ME                          |          |
+----------+-----------------------------------------------+----------+
| 12700    | Barnstable Town, MA                           | 1.2603   |
|          |                                               |          |
|          | Barnstable County, MA                         |          |
+----------+-----------------------------------------------+----------+
| 12940    | Baton Rouge, LA                               | 0.8034   |
|          |                                               |          |
|          | 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                     |          |
+----------+-----------------------------------------------+----------+
| 12980    | Battle Creek, MI                              | 1.0179   |
|          |                                               |          |
|          | Calhoun County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 13020    | Bay City, MI                                  | 0.8897   |
|          |                                               |          |
|          | Bay County, MI                                |          |
+----------+-----------------------------------------------+----------+
| 13140    | Beaumont-Port Arthur, TX                      | 0.8531   |
|          |                                               |          |
|          | Hardin County, TX                             |          |
|          |                                               |          |
|          | Jefferson County, TX                          |          |
|          |                                               |          |
|          | Orange County, TX                             |          |
+----------+-----------------------------------------------+----------+
| 13380    | Bellingham, WA                                | 1.1474   |
|          |                                               |          |
|          | Whatcom County, WA                            |          |
+----------+-----------------------------------------------+----------+
| 13460    | Bend, OR                                      | 1.0942   |
|          |                                               |          |
|          | Deschutes County, OR                          |          |
+----------+-----------------------------------------------+----------+
| 13644    | Bethesda-Gaithersburg-Frederick, MD           | 1.0511   |
|          |                                               |          |
|          | Frederick County, MD                          |          |
|          |                                               |          |
|          | Montgomery County, MD                         |          |
+----------+-----------------------------------------------+----------+
| 13740    | Billings, MT                                  | 0.8666   |
|          |                                               |          |
|          | Carbon County, MT                             |          |
|          |                                               |          |
|          | Yellowstone County, MT                        |          |
+----------+-----------------------------------------------+----------+
| 13780    | Binghamton, NY                                | 0.8949   |
|          |                                               |          |
|          | Broome County, NY                             |          |
|          |                                               |          |
|          | Tioga County, NY                              |          |
+----------+-----------------------------------------------+----------+
| 13820    | Birmingham-Hoover, AL                         | 0.8898   |
|          |                                               |          |
|          | Bibb County, AL                               |          |
|          |                                               |          |
|          | Blount County, AL                             |          |
|          |                                               |          |
|          | Chilton County, AL                            |          |
|          |                                               |          |
|          | Jefferson County, AL                          |          |
|          |                                               |          |
|          | St. Clair County, AL                          |          |
|          |                                               |          |
|          | Shelby County, AL                             |          |
|          |                                               |          |
|          | Walker County, AL                             |          |
+----------+-----------------------------------------------+----------+
| 13900    | Bismarck, ND                                  | 0.7225   |
|          |                                               |          |
|          | Burleigh County, ND                           |          |
|          |                                               |          |
|          | Morton County, ND                             |          |
+----------+-----------------------------------------------+----------+
| 13980    | Blacksburg-Christiansburg-Radford, VA         | 0.8192   |
|          |                                               |          |
|          | Giles County, VA                              |          |
|          |                                               |          |
|          | Montgomery County, VA                         |          |
|          |                                               |          |
|          | Pulaski County, VA                            |          |
|          |                                               |          |
|          | Radford City, VA                              |          |
+----------+-----------------------------------------------+----------+
| 14020    | Bloomington, IN                               | 0.8915   |
|          |                                               |          |
|          | Greene County, IN                             |          |
|          |                                               |          |
|          | Monroe County, IN                             |          |
|          |                                               |          |
|          | Owen County, IN                               |          |
+----------+-----------------------------------------------+----------+
| 14060    | Bloomington-Normal, IL                        | 0.9325   |
|          |                                               |          |
|          | McLean County, IL                             |          |
+----------+-----------------------------------------------+----------+
| 14260    | Boise City-Nampa, ID                          | 0.9465   |
|          |                                               |          |
|          | Ada County, ID                                |          |
|          |                                               |          |
|          | Boise County, ID                              |          |
|          |                                               |          |
|          | Canyon County, ID                             |          |
|          |                                               |          |
|          | Gem County, ID                                |          |
|          |                                               |          |
|          | Owyhee County, ID                             |          |
+----------+-----------------------------------------------+----------+
| 14484    | Boston-Quincy, MA                             | 1.1792   |
|          |                                               |          |
|          | Norfolk County, MA                            |          |
|          |                                               |          |
|          | Plymouth County, MA                           |          |
|          |                                               |          |
|          | Suffolk County, MA                            |          |
+----------+-----------------------------------------------+----------+
| 14500    | Boulder, CO                                   | 1.0426   |
|          |                                               |          |
|          | Boulder County, CO                            |          |
+----------+-----------------------------------------------+----------+
| 14540    | Bowling Green, KY                             | 0.8159   |
|          |                                               |          |
|          | Edmonson County, KY                           |          |
|          |                                               |          |
|          | Warren County, KY                             |          |
+----------+-----------------------------------------------+----------+
| 14740    | Bremerton-Silverdale, WA                      | 1.0904   |
|          |                                               |          |
|          | Kitsap County, WA                             |          |
+----------+-----------------------------------------------+----------+
| 14860    | Bridgeport-Stamford-Norwalk, CT               | 1.2735   |
|          |                                               |          |
|          | Fairfield County, CT                          |          |
+----------+-----------------------------------------------+----------+
| 15180    | Brownsville-Harlingen, TX                     | 0.8914   |
|          |                                               |          |
|          | Cameron County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 15260    | Brunswick, GA                                 | 0.9475   |
|          |                                               |          |
|          | Brantley County, GA                           |          |
|          |                                               |          |
|          | Glynn County, GA                              |          |
|          |                                               |          |
|          | McIntosh County, GA                           |          |
+----------+-----------------------------------------------+----------+
| 15380    | Buffalo-Niagara Falls, NY                     | 0.9568   |
|          |                                               |          |
|          | Erie County, NY                               |          |
|          |                                               |          |
|          | Niagara County, NY                            |          |
+----------+-----------------------------------------------+----------+
| 15500    | Burlington, NC                                | 0.8747   |
|          |                                               |          |
|          | Alamance County, NC                           |          |
+----------+-----------------------------------------------+----------+
| 15540    | Burlington-South Burlington, VT               | 0.9660   |
|          |                                               |          |
|          | Chittenden County, VT                         |          |
|          |                                               |          |
|          | Franklin County, VT                           |          |
|          |                                               |          |
|          | Grand Isle County, VT                         |          |
+----------+-----------------------------------------------+----------+
| 15764    | Cambridge-Newton-Framingham, MA               | 1.1215   |
|          |                                               |          |
|          | Middlesex County, MA                          |          |
+----------+-----------------------------------------------+----------+
| 15804    | Camden, NJ                                    | 1.0411   |
|          |                                               |          |
|          | Burlington County, NJ                         |          |
|          |                                               |          |
|          | Camden County, NJ                             |          |
|          |                                               |          |
|          | Gloucester County, NJ                         |          |
+----------+-----------------------------------------------+----------+
| 15940    | Canton-Massillon, OH                          | 0.8935   |
|          |                                               |          |
|          | Carroll County, OH                            |          |
|          |                                               |          |
|          | Stark County, OH                              |          |
+----------+-----------------------------------------------+----------+
| 15980    | Cape Coral-Fort Myers, FL                     | 0.9396   |
|          |                                               |          |
|          | Lee County, FL                                |          |
+----------+-----------------------------------------------+----------+
| 16180    | Carson City, NV                               | 1.0003   |
|          |                                               |          |
|          | Carson City, NV                               |          |
+----------+-----------------------------------------------+----------+
| 16220    | Casper, WY                                    | 0.9385   |
|          |                                               |          |
|          | Natrona County, WY                            |          |
+----------+-----------------------------------------------+----------+
| 16300    | Cedar Rapids, IA                              | 0.8852   |
|          |                                               |          |
|          | Benton County, IA                             |          |
|          |                                               |          |
|          | Jones County, IA                              |          |
|          |                                               |          |
|          | Linn County, IA                               |          |
+----------+-----------------------------------------------+----------+
| 16580    | Champaign-Urbana, IL                          | 0.9392   |
|          |                                               |          |
|          | Champaign County, IL                          |          |
|          |                                               |          |
|          | Ford County, IL                               |          |
|          |                                               |          |
|          | Piatt County, IL                              |          |
+----------+-----------------------------------------------+----------+
| 16620    | Charleston, WV                                | 0.8289   |
|          |                                               |          |
|          | Boone County, WV                              |          |
|          |                                               |          |
|          | Clay County, WV                               |          |
|          |                                               |          |
|          | Kanawha County, WV                            |          |
|          |                                               |          |
|          | Lincoln County, WV                            |          |
|          |                                               |          |
|          | Putnam County, WV                             |          |
+----------+-----------------------------------------------+----------+
| 16700    | Charleston-North Charleston, SC               | 0.9124   |
|          |                                               |          |
|          | Berkeley County, SC                           |          |
|          |                                               |          |
|          | Charleston County, SC                         |          |
|          |                                               |          |
|          | Dorchester County, SC                         |          |
+----------+-----------------------------------------------+----------+
| 16740    | Charlotte-Gastonia-Concord, NC‑SC             | 0.9520   |
|          |                                               |          |
|          | Anson County, NC                              |          |
|          |                                               |          |
|          | Cabarrus County, NC                           |          |
|          |                                               |          |
|          | Gaston County, NC                             |          |
|          |                                               |          |
|          | Mecklenburg County, NC                        |          |
|          |                                               |          |
|          | Union County, NC                              |          |
|          |                                               |          |
|          | York County, SC                               |          |
+----------+-----------------------------------------------+----------+
| 16820    | Charlottesville, VA                           | 0.9277   |
|          |                                               |          |
|          | Albemarle County, VA                          |          |
|          |                                               |          |
|          | Fluvanna County, VA                           |          |
|          |                                               |          |
|          | Greene County, VA                             |          |
|          |                                               |          |
|          | Nelson County, VA                             |          |
|          |                                               |          |
|          | Charlottesville City, VA                      |          |
+----------+-----------------------------------------------+----------+
| 16860    | Chattanooga, TN-GA                            | 0.8994   |
|          |                                               |          |
|          | Catoosa County, GA                            |          |
|          |                                               |          |
|          | Dade County, GA                               |          |
|          |                                               |          |
|          | Walker County, GA                             |          |
|          |                                               |          |
|          | Hamilton County, TN                           |          |
|          |                                               |          |
|          | Marion County, TN                             |          |
|          |                                               |          |
|          | Sequatchie County, TN                         |          |
+----------+-----------------------------------------------+----------+
| 16940    | Cheyenne, WY                                  | 0.9308   |
|          |                                               |          |
|          | Laramie County, WY                            |          |
+----------+-----------------------------------------------+----------+
| 16974    | Chicago-Naperville-Joliet, IL                 | 1.0715   |
|          |                                               |          |
|          | Cook County, IL                               |          |
|          |                                               |          |
|          | DeKalb County, IL                             |          |
|          |                                               |          |
|          | DuPage County, IL                             |          |
|          |                                               |          |
|          | Grundy County, IL                             |          |
|          |                                               |          |
|          | Kane County, IL                               |          |
|          |                                               |          |
|          | Kendall County, IL                            |          |
|          |                                               |          |
|          | McHenry County, IL                            |          |
|          |                                               |          |
|          | Will County, IL                               |          |
+----------+-----------------------------------------------+----------+
| 17020    | Chico, CA                                     | 1.1290   |
|          |                                               |          |
|          | Butte County, CA                              |          |
+----------+-----------------------------------------------+----------+
| 17140    | Cincinnati-Middletown, OH-KY-IN               | 0.9784   |
|          |                                               |          |
|          | Dearborn County, IN                           |          |
|          |                                               |          |
|          | Franklin County, IN                           |          |
|          |                                               |          |
|          | Ohio County, IN                               |          |
|          |                                               |          |
|          | Boone County, KY                              |          |
|          |                                               |          |
|          | Bracken County, KY                            |          |
|          |                                               |          |
|          | Campbell County, KY                           |          |
|          |                                               |          |
|          | Gallatin County, KY                           |          |
|          |                                               |          |
|          | Grant County, KY                              |          |
|          |                                               |          |
|          | Kenton County, KY                             |          |
|          |                                               |          |
|          | Pendleton County, KY                          |          |
|          |                                               |          |
|          | Brown County, OH                              |          |
|          |                                               |          |
|          | Butler County, OH                             |          |
|          |                                               |          |
|          | Clermont County, OH                           |          |
|          |                                               |          |
|          | Hamilton County, OH                           |          |
|          |                                               |          |
|          | Warren County, OH                             |          |
+----------+-----------------------------------------------+----------+
| 17300    | Clarksville, TN-KY                            | 0.8251   |
|          |                                               |          |
|          | Christian County, KY                          |          |
|          |                                               |          |
|          | Trigg County, KY                              |          |
|          |                                               |          |
|          | Montgomery County, TN                         |          |
|          |                                               |          |
|          | Stewart County, TN                            |          |
+----------+-----------------------------------------------+----------+
| 17420    | Cleveland, TN                                 | 0.8052   |
|          |                                               |          |
|          | Bradley County, TN                            |          |
|          |                                               |          |
|          | Polk County, TN                               |          |
+----------+-----------------------------------------------+----------+
| 17460    | Cleveland-Elyria-Mentor, OH                   | 0.9339   |
|          |                                               |          |
|          | Cuyahoga County, OH                           |          |
|          |                                               |          |
|          | Geauga County, OH                             |          |
|          |                                               |          |
|          | Lake County, OH                               |          |
|          |                                               |          |
|          | Lorain County, OH                             |          |
|          |                                               |          |
|          | Medina County, OH                             |          |
+----------+-----------------------------------------------+----------+
| 17660    | Coeur d\'Alene, ID                            | 0.9532   |
|          |                                               |          |
|          | Kootenai County, ID                           |          |
+----------+-----------------------------------------------+----------+
| 17780    | College Station-Bryan, TX                     | 0.9358   |
|          |                                               |          |
|          | Brazos County, TX                             |          |
|          |                                               |          |
|          | Burleson County, TX                           |          |
|          |                                               |          |
|          | Robertson County, TX                          |          |
+----------+-----------------------------------------------+----------+
| 17820    | Colorado Springs, CO                          | 0.9719   |
|          |                                               |          |
|          | El Paso County, CO                            |          |
|          |                                               |          |
|          | Teller County, CO                             |          |
+----------+-----------------------------------------------+----------+
| 17860    | Columbia, MO                                  | 0.8658   |
|          |                                               |          |
|          | Boone County, MO                              |          |
|          |                                               |          |
|          | Howard County, MO                             |          |
+----------+-----------------------------------------------+----------+
| 17900    | Columbia, SC                                  | 0.8800   |
|          |                                               |          |
|          | Calhoun County, SC                            |          |
|          |                                               |          |
|          | Fairfield County, SC                          |          |
|          |                                               |          |
|          | Kershaw County, SC                            |          |
|          |                                               |          |
|          | Lexington County, SC                          |          |
|          |                                               |          |
|          | Richland County, SC                           |          |
|          |                                               |          |
|          | Saluda County, SC                             |          |
+----------+-----------------------------------------------+----------+
| 17980    | Columbus, GA-AL                               | 0.8729   |
|          |                                               |          |
|          | Russell County, AL                            |          |
|          |                                               |          |
|          | Chattahoochee County, GA                      |          |
|          |                                               |          |
|          | Harris County, GA                             |          |
|          |                                               |          |
|          | Marion County, GA                             |          |
|          |                                               |          |
|          | Muscogee County, GA                           |          |
+----------+-----------------------------------------------+----------+
| 18020    | Columbus, IN                                  | 0.9537   |
|          |                                               |          |
|          | Bartholomew County, IN                        |          |
+----------+-----------------------------------------------+----------+
| 18140    | Columbus, OH                                  | 1.0085   |
|          |                                               |          |
|          | Delaware County, OH                           |          |
|          |                                               |          |
|          | Fairfield County, OH                          |          |
|          |                                               |          |
|          | Franklin County, OH                           |          |
|          |                                               |          |
|          | Licking County, OH                            |          |
|          |                                               |          |
|          | Madison County, OH                            |          |
|          |                                               |          |
|          | Morrow County, OH                             |          |
|          |                                               |          |
|          | Pickaway County, OH                           |          |
|          |                                               |          |
|          | Union County, OH                              |          |
+----------+-----------------------------------------------+----------+
| 18580    | Corpus Christi, TX                            | 0.8588   |
|          |                                               |          |
|          | Aransas County, TX                            |          |
|          |                                               |          |
|          | Nueces County, TX                             |          |
|          |                                               |          |
|          | San Patricio County, TX                       |          |
+----------+-----------------------------------------------+----------+
| 18700    | Corvallis, OR                                 | 1.0959   |
|          |                                               |          |
|          | Benton County, OR                             |          |
+----------+-----------------------------------------------+----------+
| 19060    | Cumberland, MD-WV                             | 0.8294   |
|          |                                               |          |
|          | Allegany County, MD                           |          |
|          |                                               |          |
|          | Mineral County, WV                            |          |
+----------+-----------------------------------------------+----------+
| 19124    | Dallas-Plano-Irving, TX                       | 0.9915   |
|          |                                               |          |
|          | Collin County, TX                             |          |
|          |                                               |          |
|          | Dallas County, TX                             |          |
|          |                                               |          |
|          | Delta County, TX                              |          |
|          |                                               |          |
|          | Denton County, TX                             |          |
|          |                                               |          |
|          | Ellis County, TX                              |          |
|          |                                               |          |
|          | Hunt County, TX                               |          |
|          |                                               |          |
|          | Kaufman County, TX                            |          |
|          |                                               |          |
|          | Rockwall County, TX                           |          |
+----------+-----------------------------------------------+----------+
| 19140    | Dalton, GA                                    | 0.8760   |
|          |                                               |          |
|          | Murray County, GA                             |          |
|          |                                               |          |
|          | Whitfield County, GA                          |          |
+----------+-----------------------------------------------+----------+
| 19180    | Danville, IL                                  | 0.8957   |
|          |                                               |          |
|          | Vermilion County, IL                          |          |
+----------+-----------------------------------------------+----------+
| 19260    | Danville, VA                                  | 0.8240   |
|          |                                               |          |
|          | Pittsylvania County, VA                       |          |
|          |                                               |          |
|          | Danville City, VA                             |          |
+----------+-----------------------------------------------+----------+
| 19340    | Davenport-Moline-Rock Island, IA-IL           | 0.8830   |
|          |                                               |          |
|          | Henry County, IL                              |          |
|          |                                               |          |
|          | Mercer County, IL                             |          |
|          |                                               |          |
|          | Rock Island County, IL                        |          |
|          |                                               |          |
|          | Scott County, IA                              |          |
+----------+-----------------------------------------------+----------+
| 19380    | Dayton, OH                                    | 0.9190   |
|          |                                               |          |
|          | Greene County, OH                             |          |
|          |                                               |          |
|          | Miami County, OH                              |          |
|          |                                               |          |
|          | Montgomery County, OH                         |          |
|          |                                               |          |
|          | Preble County, OH                             |          |
+----------+-----------------------------------------------+----------+
| 19460    | Decatur, AL                                   | 0.7885   |
|          |                                               |          |
|          | Lawrence County, AL                           |          |
|          |                                               |          |
|          | Morgan County, AL                             |          |
+----------+-----------------------------------------------+----------+
| 19500    | Decatur, IL                                   | 0.8074   |
|          |                                               |          |
|          | Macon County, IL                              |          |
+----------+-----------------------------------------------+----------+
| 19660    | Deltona-Daytona Beach-Ormond Beach, FL        | 0.9031   |
|          |                                               |          |
|          | Volusia County, FL                            |          |
+----------+-----------------------------------------------+----------+
| 19740    | Denver-Aurora, CO                             | 1.0718   |
|          |                                               |          |
|          | 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                               |          |
+----------+-----------------------------------------------+----------+
| 19780    | Des Moines,-West Des Moines, IA               | 0.9226   |
|          |                                               |          |
|          | Dallas County, IA                             |          |
|          |                                               |          |
|          | Guthrie County, IA                            |          |
|          |                                               |          |
|          | Madison County, IA                            |          |
|          |                                               |          |
|          | Polk County, IA                               |          |
|          |                                               |          |
|          | Warren County, IA                             |          |
+----------+-----------------------------------------------+----------+
| 19804    | Detroit-Livonia-Dearborn, MI                  | 0.9999   |
|          |                                               |          |
|          | Wayne County, MI                              |          |
+----------+-----------------------------------------------+----------+
| 20020    | Dothan, AL                                    | 0.7270   |
|          |                                               |          |
|          | Geneva County, AL                             |          |
|          |                                               |          |
|          | Henry County, AL                              |          |
|          |                                               |          |
|          | Houston County, AL                            |          |
+----------+-----------------------------------------------+----------+
| 20100    | Dover, DE                                     | 1.0099   |
|          |                                               |          |
|          | Kent County, DE                               |          |
+----------+-----------------------------------------------+----------+
| 20220    | Dubuque, IA                                   | 0.9058   |
|          |                                               |          |
|          | Dubuque County, IA                            |          |
+----------+-----------------------------------------------+----------+
| 20260    | Duluth, MN-WI                                 | 0.9975   |
|          |                                               |          |
|          | Carlton County, MN                            |          |
|          |                                               |          |
|          | St. Louis County, MN                          |          |
|          |                                               |          |
|          | Douglas County, WI                            |          |
+----------+-----------------------------------------------+----------+
| 20500    | Durham, NC                                    | 0.9816   |
|          |                                               |          |
|          | Chatham County, NC                            |          |
|          |                                               |          |
|          | Durham County, NC                             |          |
|          |                                               |          |
|          | Orange County, NC                             |          |
|          |                                               |          |
|          | Person County, NC                             |          |
+----------+-----------------------------------------------+----------+
| 20740    | Eau Claire, WI                                | 0.9475   |
|          |                                               |          |
|          | Chippewa County, WI                           |          |
|          |                                               |          |
|          | Eau Claire County, WI                         |          |
+----------+-----------------------------------------------+----------+
| 20764    | Edison, NJ                                    | 1.1181   |
|          |                                               |          |
|          | Middlesex County, NJ                          |          |
|          |                                               |          |
|          | Monmouth County, NJ                           |          |
|          |                                               |          |
|          | Ocean County, NJ                              |          |
|          |                                               |          |
|          | Somerset County, NJ                           |          |
+----------+-----------------------------------------------+----------+
| 20940    | El Centro, CA                                 | 0.8914   |
|          |                                               |          |
|          | Imperial County, CA                           |          |
+----------+-----------------------------------------------+----------+
| 21060    | Elizabethtown, KY                             | 0.8711   |
|          |                                               |          |
|          | Hardin County, KY                             |          |
|          |                                               |          |
|          | Larue County, KY                              |          |
+----------+-----------------------------------------------+----------+
| 21140    | Elkhart-Goshen, IN                            | 0.9611   |
|          |                                               |          |
|          | Elkhart County, IN                            |          |
+----------+-----------------------------------------------+----------+
| 21300    | Elmira, NY                                    | 0.8264   |
|          |                                               |          |
|          | Chemung County, NY                            |          |
+----------+-----------------------------------------------+----------+
| 21340    | El Paso, TX                                   | 0.8989   |
|          |                                               |          |
|          | El Paso County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 21500    | Erie, PA                                      | 0.8495   |
|          |                                               |          |
|          | Erie County, PA                               |          |
+----------+-----------------------------------------------+----------+
| 21660    | Eugene-Springfield, OR                        | 1.0932   |
|          |                                               |          |
|          | Lane County, OR                               |          |
+----------+-----------------------------------------------+----------+
| 21780    | Evansville, IN-KY                             | 0.8662   |
|          |                                               |          |
|          | Gibson County, IN                             |          |
|          |                                               |          |
|          | Posey County, IN                              |          |
|          |                                               |          |
|          | Vanderburgh County, IN                        |          |
|          |                                               |          |
|          | Warrick County, IN                            |          |
|          |                                               |          |
|          | Henderson County, KY                          |          |
|          |                                               |          |
|          | Webster County, KY                            |          |
+----------+-----------------------------------------------+----------+
| 21820    | Fairbanks, AK                                 | 1.1050   |
|          |                                               |          |
|          | Fairbanks North Star Borough, AK              |          |
+----------+-----------------------------------------------+----------+
| 21940    | Fajardo, PR                                   | 0.4375   |
|          |                                               |          |
|          | Ceiba Municipio, PR                           |          |
|          |                                               |          |
|          | Fajardo Municipio, PR                         |          |
|          |                                               |          |
|          | Luquillo Municipio, PR                        |          |
+----------+-----------------------------------------------+----------+
| 22020    | Fargo, ND-MN                                  | 0.8042   |
|          |                                               |          |
|          | Cass County, ND                               |          |
|          |                                               |          |
|          | Clay County, MN                               |          |
+----------+-----------------------------------------------+----------+
| 22140    | Farmington, NM                                | 0.9587   |
|          |                                               |          |
|          | San Juan County, NM                           |          |
+----------+-----------------------------------------------+----------+
| 22180    | Fayetteville, NC                              | 0.9368   |
|          |                                               |          |
|          | Cumberland County, NC                         |          |
|          |                                               |          |
|          | Hoke County, NC                               |          |
+----------+-----------------------------------------------+----------+
| 22220    | Fayetteville-Springdale-Rogers, AR-MO         | 0.8742   |
|          |                                               |          |
|          | Benton County, AR                             |          |
|          |                                               |          |
|          | Madison County, AR                            |          |
|          |                                               |          |
|          | Washington County, AR                         |          |
|          |                                               |          |
|          | McDonald County, MO                           |          |
+----------+-----------------------------------------------+----------+
| 22380    | Flagstaff, AZ                                 | 1.1687   |
|          |                                               |          |
|          | Coconino County, AZ                           |          |
+----------+-----------------------------------------------+----------+
| 22420    | Flint, MI                                     | 1.1220   |
|          |                                               |          |
|          | Genesee County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 22500    | Florence, SC                                  | 0.8249   |
|          |                                               |          |
|          | Darlington County, SC                         |          |
|          |                                               |          |
|          | Florence County, SC                           |          |
+----------+-----------------------------------------------+----------+
| 22520    | Florence-Muscle Shoals, AL                    | 0.7680   |
|          |                                               |          |
|          | Colbert County, AL                            |          |
|          |                                               |          |
|          | Lauderdale County, AL                         |          |
+----------+-----------------------------------------------+----------+
| 22540    | Fond du Lac, WI                               | 0.9667   |
|          |                                               |          |
|          | Fond du Lac County, WI                        |          |
+----------+-----------------------------------------------+----------+
| 22660    | Fort Collins-Loveland, CO                     | 0.9897   |
|          |                                               |          |
|          | Larimer County, CO                            |          |
+----------+-----------------------------------------------+----------+
| 22744    | Fort Lauderdale-Pompano Beach-Deerfield       | 1.0229   |
|          | Beach, FL                                     |          |
|          |                                               |          |
|          | Broward County, FL                            |          |
+----------+-----------------------------------------------+----------+
| 22900    | Fort Smith, AR-OK                             | 0.7933   |
|          |                                               |          |
|          | Crawford County, AR                           |          |
|          |                                               |          |
|          | Franklin County, AR                           |          |
|          |                                               |          |
|          | Sebastian County, AR                          |          |
|          |                                               |          |
|          | Le Flore County, OK                           |          |
|          |                                               |          |
|          | Sequoyah County, OK                           |          |
+----------+-----------------------------------------------+----------+
| 23020    | Fort Walton Beach-Crestview-Destin, FL        | 0.8743   |
|          |                                               |          |
|          | Okaloosa County, FL                           |          |
+----------+-----------------------------------------------+----------+
| 23060    | Fort Wayne, IN                                | 0.9284   |
|          |                                               |          |
|          | Allen County, IN                              |          |
|          |                                               |          |
|          | Wells County, IN                              |          |
|          |                                               |          |
|          | Whitley County, IN                            |          |
+----------+-----------------------------------------------+----------+
| 23104    | Fort Worth-Arlington, TX                      | 0.9693   |
|          |                                               |          |
|          | Johnson County, TX                            |          |
|          |                                               |          |
|          | Parker County, TX                             |          |
|          |                                               |          |
|          | Tarrant County, TX                            |          |
|          |                                               |          |
|          | Wise County, TX                               |          |
+----------+-----------------------------------------------+----------+
| 23420    | Fresno, CA                                    | 1.0993   |
|          |                                               |          |
|          | Fresno County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 23460    | Gadsden, AL                                   | 0.8159   |
|          |                                               |          |
|          | Etowah County, AL                             |          |
+----------+-----------------------------------------------+----------+
| 23540    | Gainesville, FL                               | 0.9196   |
|          |                                               |          |
|          | Alachua County, FL                            |          |
|          |                                               |          |
|          | Gilchrist County, FL                          |          |
+----------+-----------------------------------------------+----------+
| 23580    | Gainesville, GA                               | 0.9216   |
|          |                                               |          |
|          | Hall County, GA                               |          |
+----------+-----------------------------------------------+----------+
| 23844    | Gary, IN                                      | 0.9224   |
|          |                                               |          |
|          | Jasper County, IN                             |          |
|          |                                               |          |
|          | Lake County, IN                               |          |
|          |                                               |          |
|          | Newton County, IN                             |          |
|          |                                               |          |
|          | Porter County, IN                             |          |
+----------+-----------------------------------------------+----------+
| 24020    | Glens Falls, NY                               | 0.8256   |
|          |                                               |          |
|          | Warren County, NY                             |          |
|          |                                               |          |
|          | Washington County, NY                         |          |
+----------+-----------------------------------------------+----------+
| 24140    | Goldsboro, NC                                 | 0.9288   |
|          |                                               |          |
|          | Wayne County, NC                              |          |
+----------+-----------------------------------------------+----------+
| 24220    | Grand Forks, ND-MN                            | 0.7881   |
|          |                                               |          |
|          | Polk County, MN                               |          |
|          |                                               |          |
|          | Grand Forks County, ND                        |          |
+----------+-----------------------------------------------+----------+
| 24300    | Grand Junction, CO                            | 0.9864   |
|          |                                               |          |
|          | Mesa County, CO                               |          |
+----------+-----------------------------------------------+----------+
| 24340    | Grand Rapids-Wyoming, MI                      | 0.9315   |
|          |                                               |          |
|          | Barry County, MI                              |          |
|          |                                               |          |
|          | Ionia County, MI                              |          |
|          |                                               |          |
|          | Kent County, MI                               |          |
|          |                                               |          |
|          | Newaygo County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 24500    | Great Falls, MT                               | 0.8675   |
|          |                                               |          |
|          | Cascade County, MT                            |          |
+----------+-----------------------------------------------+----------+
| 24540    | Greeley, CO                                   | 0.9658   |
|          |                                               |          |
|          | Weld County, CO                               |          |
+----------+-----------------------------------------------+----------+
| 24580    | Green Bay, WI                                 | 0.9727   |
|          |                                               |          |
|          | Brown County, WI                              |          |
|          |                                               |          |
|          | Kewaunee County, WI                           |          |
|          |                                               |          |
|          | Oconto County, WI                             |          |
+----------+-----------------------------------------------+----------+
| 24660    | Greensboro-High Point, NC                     | 0.9010   |
|          |                                               |          |
|          | Guilford County, NC                           |          |
|          |                                               |          |
|          | Randolph County, NC                           |          |
|          |                                               |          |
|          | Rockingham County, NC                         |          |
+----------+-----------------------------------------------+----------+
| 24780    | Greenville, NC                                | 0.9402   |
|          |                                               |          |
|          | Greene County, NC                             |          |
|          |                                               |          |
|          | Pitt County, NC                               |          |
+----------+-----------------------------------------------+----------+
| 24860    | Greenville-Mauldin-Easley, SC                 | 0.9860   |
|          |                                               |          |
|          | Greenville County, SC                         |          |
|          |                                               |          |
|          | Laurens County, SC                            |          |
|          |                                               |          |
|          | Pickens County, SC                            |          |
+----------+-----------------------------------------------+----------+
| 25020    | Guayama, PR                                   | 0.3064   |
|          |                                               |          |
|          | Arroyo Municipio, PR                          |          |
|          |                                               |          |
|          | Guayama Municipio, PR                         |          |
|          |                                               |          |
|          | Patillas Municipio, PR                        |          |
+----------+-----------------------------------------------+----------+
| 25060    | Gulfport-Biloxi, MS                           | 0.8773   |
|          |                                               |          |
|          | Hancock County, MS                            |          |
|          |                                               |          |
|          | Harrison County, MS                           |          |
|          |                                               |          |
|          | Stone County, MS                              |          |
+----------+-----------------------------------------------+----------+
| 25180    | Hagerstown-Martinsburg, MD-WV                 | 0.9013   |
|          |                                               |          |
|          | Washington County, MD                         |          |
|          |                                               |          |
|          | Berkeley County, WV                           |          |
|          |                                               |          |
|          | Morgan County, WV                             |          |
+----------+-----------------------------------------------+----------+
| 25260    | Hanford-Corcoran, CA                          | 1.0499   |
|          |                                               |          |
|          | Kings County, CA                              |          |
+----------+-----------------------------------------------+----------+
| 25420    | Harrisburg-Carlisle, PA                       | 0.9280   |
|          |                                               |          |
|          | Cumberland County, PA                         |          |
|          |                                               |          |
|          | Dauphin County, PA                            |          |
|          |                                               |          |
|          | Perry County, PA                              |          |
+----------+-----------------------------------------------+----------+
| 25500    | Harrisonburg, VA                              | 0.8867   |
|          |                                               |          |
|          | Rockingham County, VA                         |          |
|          |                                               |          |
|          | Harrisonburg City, VA                         |          |
+----------+-----------------------------------------------+----------+
| 25540    | Hartford-West Hartford-East Hartford, CT      | 1.0959   |
|          |                                               |          |
|          | Hartford County, CT                           |          |
|          |                                               |          |
|          | Middlesex County, CT                          |          |
|          |                                               |          |
|          | Tolland County, CT                            |          |
+----------+-----------------------------------------------+----------+
| 25620    | Hattiesburg, MS                               | 0.7366   |
|          |                                               |          |
|          | Forrest County, MS                            |          |
|          |                                               |          |
|          | Lamar County, MS                              |          |
|          |                                               |          |
|          | Perry County, MS                              |          |
+----------+-----------------------------------------------+----------+
| 25860    | Hickory-Lenoir-Morganton, NC                  | 0.9028   |
|          |                                               |          |
|          | Alexander County, NC                          |          |
|          |                                               |          |
|          | Burke County, NC                              |          |
|          |                                               |          |
|          | Caldwell County, NC                           |          |
|          |                                               |          |
|          | Catawba County, NC                            |          |
+----------+-----------------------------------------------+----------+
| 25980    | Hinesville-Fort Stewart, GA                   | 0.9187   |
|          |                                               |          |
|          | Liberty County, GA                            |          |
|          |                                               |          |
|          | Long County, GA                               |          |
+----------+-----------------------------------------------+----------+
| 26100    | Holland-Grand Haven, MI                       | 0.9006   |
|          |                                               |          |
|          | Ottawa County, MI                             |          |
+----------+-----------------------------------------------+----------+
| 26180    | Honolulu, HI                                  | 1.1556   |
|          |                                               |          |
|          | Honolulu County, HI                           |          |
+----------+-----------------------------------------------+----------+
| 26300    | Hot Springs, AR                               | 0.9109   |
|          |                                               |          |
|          | Garland County, AR                            |          |
+----------+-----------------------------------------------+----------+
| 26380    | Houma-Bayou Cane-Thibodaux, LA                | 0.7892   |
|          |                                               |          |
|          | Lafourche Parish, LA                          |          |
|          |                                               |          |
|          | Terrebonne Parish, LA                         |          |
+----------+-----------------------------------------------+----------+
| 26420    | Houston-Sugar Land-Baytown, TX                | 0.9939   |
|          |                                               |          |
|          | 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                             |          |
+----------+-----------------------------------------------+----------+
| 26580    | Huntington-Ashland, WV-KY-OH                  | 0.9041   |
|          |                                               |          |
|          | Boyd County, KY                               |          |
|          |                                               |          |
|          | Greenup County, KY                            |          |
|          |                                               |          |
|          | Lawrence County, OH                           |          |
|          |                                               |          |
|          | Cabell County, WV                             |          |
|          |                                               |          |
|          | Wayne County, WV                              |          |
+----------+-----------------------------------------------+----------+
| 26620    | Huntsville, AL                                | 0.9146   |
|          |                                               |          |
|          | Limestone County, AL                          |          |
|          |                                               |          |
|          | Madison County, AL                            |          |
+----------+-----------------------------------------------+----------+
| 26820    | Idaho Falls, ID                               | 0.9264   |
|          |                                               |          |
|          | Bonneville County, ID                         |          |
|          |                                               |          |
|          | Jefferson County, ID                          |          |
+----------+-----------------------------------------------+----------+
| 26900    | Indianapolis-Carmel, IN                       | 0.9844   |
|          |                                               |          |
|          | 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                             |          |
+----------+-----------------------------------------------+----------+
| 26980    | Iowa City, IA                                 | 0.9568   |
|          |                                               |          |
|          | Johnson County, IA                            |          |
|          |                                               |          |
|          | Washington County, IA                         |          |
+----------+-----------------------------------------------+----------+
| 27060    | Ithaca, NY                                    | 0.9630   |
|          |                                               |          |
|          | Tompkins County, NY                           |          |
+----------+-----------------------------------------------+----------+
| 27100    | Jackson, MI                                   | 0.9329   |
|          |                                               |          |
|          | Jackson County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 27140    | Jackson, MS                                   | 0.8011   |
|          |                                               |          |
|          | Copiah County, MS                             |          |
|          |                                               |          |
|          | Hinds County, MS                              |          |
|          |                                               |          |
|          | Madison County, MS                            |          |
|          |                                               |          |
|          | Rankin County, MS                             |          |
|          |                                               |          |
|          | Simpson County, MS                            |          |
+----------+-----------------------------------------------+----------+
| 27180    | Jackson, TN                                   | 0.8676   |
|          |                                               |          |
|          | Chester County, TN                            |          |
|          |                                               |          |
|          | Madison County, TN                            |          |
+----------+-----------------------------------------------+----------+
| 27260    | Jacksonville, FL                              | 0.9021   |
|          |                                               |          |
|          | Baker County, FL                              |          |
|          |                                               |          |
|          | Clay County, FL                               |          |
|          |                                               |          |
|          | Duval County, FL                              |          |
|          |                                               |          |
|          | Nassau County, FL                             |          |
|          |                                               |          |
|          | St. Johns County, FL                          |          |
+----------+-----------------------------------------------+----------+
| 27340    | Jacksonville, NC                              | 0.8079   |
|          |                                               |          |
|          | Onslow County, NC                             |          |
+----------+-----------------------------------------------+----------+
| 27500    | Janesville, WI                                | 0.9702   |
|          |                                               |          |
|          | Rock County, WI                               |          |
+----------+-----------------------------------------------+----------+
| 27620    | Jefferson City, MO                            | 0.8478   |
|          |                                               |          |
|          | Callaway County, MO                           |          |
|          |                                               |          |
|          | Cole County, MO                               |          |
|          |                                               |          |
|          | Moniteau County, MO                           |          |
|          |                                               |          |
|          | Osage County, MO                              |          |
+----------+-----------------------------------------------+----------+
| 27740    | Johnson City, TN                              | 0.7677   |
|          |                                               |          |
|          | Carter County, TN                             |          |
|          |                                               |          |
|          | Unicoi County, TN                             |          |
|          |                                               |          |
|          | Washington County, TN                         |          |
+----------+-----------------------------------------------+----------+
| 27780    | Johnstown, PA                                 | 0.7543   |
|          |                                               |          |
|          | Cambria County, PA                            |          |
+----------+-----------------------------------------------+----------+
| 27860    | Jonesboro, AR                                 | 0.7790   |
|          |                                               |          |
|          | Craighead County, AR                          |          |
|          |                                               |          |
|          | Poinsett County, AR                           |          |
+----------+-----------------------------------------------+----------+
| 27900    | Joplin, MO                                    | 0.8951   |
|          |                                               |          |
|          | Jasper County, MO                             |          |
|          |                                               |          |
|          | Newton County, MO                             |          |
+----------+-----------------------------------------------+----------+
| 28020    | Kalamazoo-Portage, MI                         | 1.0433   |
|          |                                               |          |
|          | Kalamazoo County, MI                          |          |
|          |                                               |          |
|          | Van Buren County, MI                          |          |
+----------+-----------------------------------------------+----------+
| 28100    | Kankakee-Bradley, IL                          | 1.0238   |
|          |                                               |          |
|          | Kankakee County, IL                           |          |
+----------+-----------------------------------------------+----------+
| 28140    | Kansas City, MO-KS                            | 0.9504   |
|          |                                               |          |
|          | 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                                |          |
+----------+-----------------------------------------------+----------+
| 28420    | Kennewick-Richland-Pasco, WA                  | 1.0075   |
|          |                                               |          |
|          | Benton County, WA                             |          |
|          |                                               |          |
|          | Franklin County, WA                           |          |
+----------+-----------------------------------------------+----------+
| 28660    | Killeen-Temple-Fort Hood, TX                  | 0.8249   |
|          |                                               |          |
|          | Bell County, TX                               |          |
|          |                                               |          |
|          | Coryell County, TX                            |          |
|          |                                               |          |
|          | Lampasas County, TX                           |          |
+----------+-----------------------------------------------+----------+
| 28700    | Kingsport-Bristol-Bristol, TN-VA              | 0.7658   |
|          |                                               |          |
|          | Hawkins County, TN                            |          |
|          |                                               |          |
|          | Sullivan County, TN                           |          |
|          |                                               |          |
|          | Bristol City, VA                              |          |
|          |                                               |          |
|          | Scott County, VA                              |          |
|          |                                               |          |
|          | Washington County, VA                         |          |
+----------+-----------------------------------------------+----------+
| 28740    | Kingston, NY                                  | 0.9556   |
|          |                                               |          |
|          | Ulster County, NY                             |          |
+----------+-----------------------------------------------+----------+
| 28940    | Knoxville, TN                                 | 0.8036   |
|          |                                               |          |
|          | Anderson County, TN                           |          |
|          |                                               |          |
|          | Blount County, TN                             |          |
|          |                                               |          |
|          | Knox County, TN                               |          |
|          |                                               |          |
|          | Loudon County, TN                             |          |
|          |                                               |          |
|          | Union County, TN                              |          |
+----------+-----------------------------------------------+----------+
| 29020    | +------------------------------------------+  | 0.9591   |
|          | | Kokomo, IN                               |  |          |
|          | |                                          |  |          |
|          | | Howard County, IN                        |  |          |
|          | |                                          |  |          |
|          | | Tipton County, IN                        |  |          |
|          | +------------------------------------------+  |          |
+----------+-----------------------------------------------+----------+
| 29100    | La Crosse, WI-MN                              | 0.9685   |
|          |                                               |          |
|          | Houston County, MN                            |          |
|          |                                               |          |
|          | La Crosse County, WI                          |          |
+----------+-----------------------------------------------+----------+
| 29140    | Lafayette, IN                                 | 0.8869   |
|          |                                               |          |
|          | Benton County, IN                             |          |
|          |                                               |          |
|          | Carroll County, IN                            |          |
|          |                                               |          |
|          | Tippecanoe County, IN                         |          |
+----------+-----------------------------------------------+----------+
| 29180    | Lafayette, LA                                 | 0.8247   |
|          |                                               |          |
|          | Lafayette Parish, LA                          |          |
|          |                                               |          |
|          | St. Martin Parish, LA                         |          |
+----------+-----------------------------------------------+----------+
| 29340    | Lake Charles, LA                              | 0.7777   |
|          |                                               |          |
|          | Calcasieu Parish, LA                          |          |
|          |                                               |          |
|          | Cameron Parish, LA                            |          |
+----------+-----------------------------------------------+----------+
| 29404    | Lake County-Kenosha County, IL-WI             | 1.0603   |
|          |                                               |          |
|          | Lake County, IL                               |          |
|          |                                               |          |
|          | Kenosha County, WI                            |          |
+----------+-----------------------------------------------+----------+
| 29420    | Lake Havasu City-Kingman, AZ                  | 0.9333   |
|          |                                               |          |
|          | Mohave County, AZ                             |          |
+----------+-----------------------------------------------+----------+
| 29460    | Lakeland, FL                                  | 0.8661   |
|          |                                               |          |
|          | Polk County, FL                               |          |
+----------+-----------------------------------------------+----------+
| 29540    | Lancaster, PA                                 | 0.9252   |
|          |                                               |          |
|          | Lancaster County, PA                          |          |
+----------+-----------------------------------------------+----------+
| 29620    | Lansing-East Lansing, MI                      | 1.0119   |
|          |                                               |          |
|          | Clinton County, MI                            |          |
|          |                                               |          |
|          | Eaton County, MI                              |          |
|          |                                               |          |
|          | Ingham County, MI                             |          |
+----------+-----------------------------------------------+----------+
| 29700    | Laredo, TX                                    | 0.8093   |
|          |                                               |          |
|          | Webb County, TX                               |          |
+----------+-----------------------------------------------+----------+
| 29740    | Las Cruces, NM                                | 0.8676   |
|          |                                               |          |
|          | Dona Ana County, NM                           |          |
+----------+-----------------------------------------------+----------+
| 29820    | Las Vegas-Paradise, NV                        | 1.1799   |
|          |                                               |          |
|          | Clark County, NV                              |          |
+----------+-----------------------------------------------+----------+
| 29940    | Lawrence, KS                                  | 0.8227   |
|          |                                               |          |
|          | Douglas County, KS                            |          |
+----------+-----------------------------------------------+----------+
| 30020    | Lawton, OK                                    | 0.8025   |
|          |                                               |          |
|          | Comanche County, OK                           |          |
+----------+-----------------------------------------------+----------+
| 30140    | Lebanon, PA                                   | 0.8192   |
|          |                                               |          |
|          | Lebanon County, PA                            |          |
+----------+-----------------------------------------------+----------+
| 30300    | Lewiston, ID-WA                               | 0.9454   |
|          |                                               |          |
|          | Nez Perce County, ID                          |          |
|          |                                               |          |
|          | Asotin County, WA                             |          |
+----------+-----------------------------------------------+----------+
| 30340    | Lewiston-Auburn, ME                           | 0.9193   |
|          |                                               |          |
|          | Androscoggin County, ME                       |          |
+----------+-----------------------------------------------+----------+
| 30460    | Lexington-Fayette, KY                         | 0.9191   |
|          |                                               |          |
|          | Bourbon County, KY                            |          |
|          |                                               |          |
|          | Clark County, KY                              |          |
|          |                                               |          |
|          | Fayette County, KY                            |          |
|          |                                               |          |
|          | Jessamine County, KY                          |          |
|          |                                               |          |
|          | Scott County, KY                              |          |
|          |                                               |          |
|          | Woodford County, KY                           |          |
+----------+-----------------------------------------------+----------+
| 30620    | Lima, OH                                      | 0.9424   |
|          |                                               |          |
|          | Allen County, OH                              |          |
+----------+-----------------------------------------------+----------+
| 30700    | Lincoln, NE                                   | 1.0051   |
|          |                                               |          |
|          | Lancaster County, NE                          |          |
|          |                                               |          |
|          | Seward County, NE                             |          |
+----------+-----------------------------------------------+----------+
| 30780    | Little Rock-North Little Rock-Conway, AR      | 0.8863   |
|          |                                               |          |
|          | Faulkner County, AR                           |          |
|          |                                               |          |
|          | Grant County, AR                              |          |
|          |                                               |          |
|          | Lonoke County, AR                             |          |
|          |                                               |          |
|          | Perry County, AR                              |          |
|          |                                               |          |
|          | Pulaski County, AR                            |          |
|          |                                               |          |
|          | Saline County, AR                             |          |
+----------+-----------------------------------------------+----------+
| 30860    | Logan, UT-ID                                  | 0.9183   |
|          |                                               |          |
|          | Franklin County, ID                           |          |
|          |                                               |          |
|          | Cache County, UT                              |          |
+----------+-----------------------------------------------+----------+
| 30980    | Longview, TX                                  | 0.8717   |
|          |                                               |          |
|          | Gregg County, TX                              |          |
|          |                                               |          |
|          | Rusk County, TX                               |          |
|          |                                               |          |
|          | Upshur County, TX                             |          |
+----------+-----------------------------------------------+----------+
| 31020    | Longview, WA                                  | 1.0827   |
|          |                                               |          |
|          | Cowlitz County, WA                            |          |
+----------+-----------------------------------------------+----------+
| 31084    | Los Angeles-Long Beach-Glendale, CA           | 1.1771   |
|          |                                               |          |
|          | Los Angeles County, CA                        |          |
+----------+-----------------------------------------------+----------+
| 31140    | Louisville-Jefferson County, KY-IN            | 0.9065   |
|          |                                               |          |
|          | Clark County, IN                              |          |
|          |                                               |          |
|          | Floyd County, IN                              |          |
|          |                                               |          |
|          | Harrison County, IN                           |          |
|          |                                               |          |
|          | Washington County, IN                         |          |
|          |                                               |          |
|          | Bullitt County, KY                            |          |
|          |                                               |          |
|          | Henry County, KY                              |          |
|          |                                               |          |
|          | Jefferson County, KY                          |          |
|          |                                               |          |
|          | Meade County, KY                              |          |
|          |                                               |          |
|          | Nelson County, KY                             |          |
|          |                                               |          |
|          | Oldham County, KY                             |          |
|          |                                               |          |
|          | Shelby County, KY                             |          |
|          |                                               |          |
|          | Spencer County, KY                            |          |
|          |                                               |          |
|          | Trimble County, KY                            |          |
+----------+-----------------------------------------------+----------+
| 31180    | Lubbock, TX                                   | 0.8680   |
|          |                                               |          |
|          | Crosby County, TX                             |          |
|          |                                               |          |
|          | Lubbock County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 31340    | Lynchburg, VA                                 | 0.8732   |
|          |                                               |          |
|          | Amherst County, VA                            |          |
|          |                                               |          |
|          | Appomattox County, VA                         |          |
|          |                                               |          |
|          | Bedford County, VA                            |          |
|          |                                               |          |
|          | Campbell County, VA                           |          |
|          |                                               |          |
|          | Bedford City, VA                              |          |
|          |                                               |          |
|          | Lynchburg City, VA                            |          |
+----------+-----------------------------------------------+----------+
| 31420    | Macon, GA                                     | 0.9541   |
|          |                                               |          |
|          | Bibb County, GA                               |          |
|          |                                               |          |
|          | Crawford County, GA                           |          |
|          |                                               |          |
|          | Jones County, GA                              |          |
|          |                                               |          |
|          | Monroe County, GA                             |          |
|          |                                               |          |
|          | Twiggs County, GA                             |          |
+----------+-----------------------------------------------+----------+
| 31460    | Madera, CA                                    | 0.8069   |
|          |                                               |          |
|          | Madera County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 31540    | Madison, WI                                   | 1.0935   |
|          |                                               |          |
|          | Columbia County, WI                           |          |
|          |                                               |          |
|          | Dane County, WI                               |          |
|          |                                               |          |
|          | Iowa County, WI                               |          |
+----------+-----------------------------------------------+----------+
| 31700    | Manchester-Nashua, NH                         | 1.0273   |
|          |                                               |          |
|          | Hillsborough County, NH                       |          |
+----------+-----------------------------------------------+----------+
| 31900    | Mansfield, OH                                 | 0.9271   |
|          |                                               |          |
|          | Richland County, OH                           |          |
+----------+-----------------------------------------------+----------+
| 32420    | Mayagüez, PR                                  | 0.3711   |
|          |                                               |          |
|          | Hormigueros Municipio, PR                     |          |
|          |                                               |          |
|          | Mayagüez Municipio, PR                        |          |
+----------+-----------------------------------------------+----------+
| 32580    | McAllen-Edinburg-Mission, TX                  | 0.9123   |
|          |                                               |          |
|          | Hidalgo County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 32780    | Medford, OR                                   | 1.0318   |
|          |                                               |          |
|          | Jackson County, OR                            |          |
+----------+-----------------------------------------------+----------+
| 32820    | Memphis, TN-MS-AR                             | 0.9250   |
|          |                                               |          |
|          | Crittenden County, AR                         |          |
|          |                                               |          |
|          | DeSoto County, MS                             |          |
|          |                                               |          |
|          | Marshall County, MS                           |          |
|          |                                               |          |
|          | Tate County, MS                               |          |
|          |                                               |          |
|          | Tunica County, MS                             |          |
|          |                                               |          |
|          | Fayette County, TN                            |          |
|          |                                               |          |
|          | Shelby County, TN                             |          |
|          |                                               |          |
|          | Tipton County, TN                             |          |
+----------+-----------------------------------------------+----------+
| 32900    | Merced, CA                                    | 1.2120   |
|          |                                               |          |
|          | Merced County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 33124    | Miami-Miami Beach-Kendall, FL                 | 1.0002   |
|          |                                               |          |
|          | Miami-Dade County, FL                         |          |
+----------+-----------------------------------------------+----------+
| 33140    | Michigan City-La Porte, IN                    | 0.8914   |
|          |                                               |          |
|          | LaPorte County, IN                            |          |
+----------+-----------------------------------------------+----------+
| 33260    | Midland, TX                                   | 1.0017   |
|          |                                               |          |
|          | Midland County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 33340    | Milwaukee-Waukesha-West Allis, WI             | 1.0214   |
|          |                                               |          |
|          | Milwaukee County, WI                          |          |
|          |                                               |          |
|          | Ozaukee County, WI                            |          |
|          |                                               |          |
|          | Washington County, WI                         |          |
|          |                                               |          |
|          | Waukesha County, WI                           |          |
+----------+-----------------------------------------------+----------+
| 33460    | Minneapolis-St. Paul-Bloomington, MN-WI       | 1.1093   |
|          |                                               |          |
|          | Anoka County, MN                              |          |
|          |                                               |          |
|          | Carver County, MN                             |          |
|          |                                               |          |
|          | Chisago County, MN                            |          |
|          |                                               |          |
|          | Dakota County, MN                             |          |
|          |                                               |          |
|          | Hennepin County, MN                           |          |
|          |                                               |          |
|          | Isanti County, MN                             |          |
|          |                                               |          |
|          | Ramsey County, MN                             |          |
|          |                                               |          |
|          | Scott County, MN                              |          |
|          |                                               |          |
|          | Sherburne County, MN                          |          |
|          |                                               |          |
|          | Washington County, MN                         |          |
|          |                                               |          |
|          | Wright County, MN                             |          |
|          |                                               |          |
|          | Pierce County, WI                             |          |
|          |                                               |          |
|          | St. Croix County, WI                          |          |
+----------+-----------------------------------------------+----------+
| 33540    | Missoula, MT                                  | 0.8953   |
|          |                                               |          |
|          | Missoula County, MT                           |          |
+----------+-----------------------------------------------+----------+
| 33660    | Mobile, AL                                    | 0.8033   |
|          |                                               |          |
|          | Mobile County, AL                             |          |
+----------+-----------------------------------------------+----------+
| 33700    | Modesto, CA                                   | 1.1962   |
|          |                                               |          |
|          | Stanislaus County, CA                         |          |
+----------+-----------------------------------------------+----------+
| 33740    | Monroe, LA                                    | 0.7832   |
|          |                                               |          |
|          | Ouachita Parish, LA                           |          |
|          |                                               |          |
|          | Union Parish, LA                              |          |
+----------+-----------------------------------------------+----------+
| 33780    | Monroe, MI                                    | 0.9414   |
|          |                                               |          |
|          | Monroe County, MI                             |          |
+----------+-----------------------------------------------+----------+
| 33860    | Montgomery, AL                                | 0.8088   |
|          |                                               |          |
|          | Autauga County, AL                            |          |
|          |                                               |          |
|          | Elmore County, AL                             |          |
|          |                                               |          |
|          | Lowndes County, AL                            |          |
|          |                                               |          |
|          | Montgomery County, AL                         |          |
+----------+-----------------------------------------------+----------+
| 34060    | Morgantown, WV                                | 0.8321   |
|          |                                               |          |
|          | Monongalia County, WV                         |          |
|          |                                               |          |
|          | Preston County, WV                            |          |
+----------+-----------------------------------------------+----------+
| 34100    | Morristown, TN                                | 0.7388   |
|          |                                               |          |
|          | Grainger County, TN                           |          |
|          |                                               |          |
|          | Hamblen County, TN                            |          |
|          |                                               |          |
|          | Jefferson County, TN                          |          |
+----------+-----------------------------------------------+----------+
| 34580    | Mount Vernon-Anacortes, WA                    | 1.0529   |
|          |                                               |          |
|          | Skagit County, WA                             |          |
+----------+-----------------------------------------------+----------+
| 34620    | Muncie, IN                                    | 0.8214   |
|          |                                               |          |
|          | Delaware County, IN                           |          |
+----------+-----------------------------------------------+----------+
| 34740    | Muskegon-Norton Shores, MI                    | 0.9836   |
|          |                                               |          |
|          | Muskegon County, MI                           |          |
+----------+-----------------------------------------------+----------+
| 34820    | Myrtle Beach-Conway-North Myrtle Beach, SC    | 0.8634   |
|          |                                               |          |
|          | Horry County, SC                              |          |
+----------+-----------------------------------------------+----------+
| 34900    | Napa, CA                                      | 1.4476   |
|          |                                               |          |
|          | Napa County, CA                               |          |
+----------+-----------------------------------------------+----------+
| 34940    | Naples-Marco Island, FL                       | 0.9487   |
|          |                                               |          |
|          | Collier County, FL                            |          |
+----------+-----------------------------------------------+----------+
| 34980    | Nashville-Davidson-Murfreesboro-Franklin, TN  | 0.9689   |
|          |                                               |          |
|          | 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                             |          |
+----------+-----------------------------------------------+----------+
| 35004    | Nassau-Suffolk, NY                            | 1.2640   |
|          |                                               |          |
|          | Nassau County, NY                             |          |
|          |                                               |          |
|          | Suffolk County, NY                            |          |
+----------+-----------------------------------------------+----------+
| 35084    | Newark-Union, NJ-PA                           | 1.1862   |
|          |                                               |          |
|          | Essex County, NJ                              |          |
|          |                                               |          |
|          | Hunterdon County, NJ                          |          |
|          |                                               |          |
|          | Morris County, NJ                             |          |
|          |                                               |          |
|          | Sussex County, NJ                             |          |
|          |                                               |          |
|          | Union County, NJ                              |          |
|          |                                               |          |
|          | Pike County, PA                               |          |
+----------+-----------------------------------------------+----------+
| 35300    | New Haven-Milford, CT                         | 1.1871   |
|          |                                               |          |
|          | New Haven County, CT                          |          |
+----------+-----------------------------------------------+----------+
| 35380    | New Orleans-Metairie-Kenner, LA               | 0.8897   |
|          |                                               |          |
|          | Jefferson Parish, LA                          |          |
|          |                                               |          |
|          | Orleans Parish, LA                            |          |
|          |                                               |          |
|          | Plaquemines Parish, LA                        |          |
|          |                                               |          |
|          | St. Bernard Parish, LA                        |          |
|          |                                               |          |
|          | St. Charles Parish, LA                        |          |
|          |                                               |          |
|          | St. John the Baptist Parish, LA               |          |
|          |                                               |          |
|          | St. Tammany Parish, LA                        |          |
+----------+-----------------------------------------------+----------+
| 35644    | New York-White Plains-Wayne, NY-NJ            | 1.3115   |
|          |                                               |          |
|          | 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                        |          |
+----------+-----------------------------------------------+----------+
| 35660    | Niles-Benton Harbor, MI                       | 0.9141   |
|          |                                               |          |
|          | Berrien County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 35980    | Norwich-New London, CT                        | 1.1432   |
|          |                                               |          |
|          | New London County, CT                         |          |
+----------+-----------------------------------------------+----------+
| 36084    | Oakland-Fremont-Hayward, CA                   | 1.5685   |
|          |                                               |          |
|          | Alameda County, CA                            |          |
|          |                                               |          |
|          | Contra Costa County, CA                       |          |
+----------+-----------------------------------------------+----------+
| 36100    | Ocala, FL                                     | 0.8627   |
|          |                                               |          |
|          | Marion County, FL                             |          |
+----------+-----------------------------------------------+----------+
| 36140    | Ocean City, NJ                                | 1.0988   |
|          |                                               |          |
|          | Cape May County, NJ                           |          |
+----------+-----------------------------------------------+----------+
| 36220    | Odessa, TX                                    | 1.0042   |
|          |                                               |          |
|          | Ector County, TX                              |          |
+----------+-----------------------------------------------+----------+
| 36260    | Ogden-Clearfield, UT                          | 0.9000   |
|          |                                               |          |
|          | Davis County, UT                              |          |
|          |                                               |          |
|          | Morgan County, UT                             |          |
|          |                                               |          |
|          | Weber County, UT                              |          |
+----------+-----------------------------------------------+----------+
| 36420    | Oklahoma City, OK                             | 0.8815   |
|          |                                               |          |
|          | Canadian County, OK                           |          |
|          |                                               |          |
|          | Cleveland County, OK                          |          |
|          |                                               |          |
|          | Grady County, OK                              |          |
|          |                                               |          |
|          | Lincoln County, OK                            |          |
|          |                                               |          |
|          | Logan County, OK                              |          |
|          |                                               |          |
|          | McClain County, OK                            |          |
|          |                                               |          |
|          | Oklahoma County, OK                           |          |
+----------+-----------------------------------------------+----------+
| 36500    | Olympia, WA                                   | 1.1512   |
|          |                                               |          |
|          | Thurston County, WA                           |          |
+----------+-----------------------------------------------+----------+
| 36540    | Omaha-Council Bluffs, NE-IA                   | 0.9561   |
|          |                                               |          |
|          | Harrison County, IA                           |          |
|          |                                               |          |
|          | Mills County, IA                              |          |
|          |                                               |          |
|          | Pottawattamie County, IA                      |          |
|          |                                               |          |
|          | Cass County, NE                               |          |
|          |                                               |          |
|          | Douglas County, NE                            |          |
|          |                                               |          |
|          | Sarpy County, NE                              |          |
|          |                                               |          |
|          | Saunders County, NE                           |          |
|          |                                               |          |
|          | Washington County, NE                         |          |
+----------+-----------------------------------------------+----------+
| 36740    | Orlando-Kissimmee, FL                         | 0.9226   |
|          |                                               |          |
|          | Lake County, FL                               |          |
|          |                                               |          |
|          | Orange County, FL                             |          |
|          |                                               |          |
|          | Osceola County, FL                            |          |
|          |                                               |          |
|          | Seminole County, FL                           |          |
+----------+-----------------------------------------------+----------+
| 36780    | Oshkosh-Neenah, WI                            | 0.9551   |
|          |                                               |          |
|          | Winnebago County, WI                          |          |
+----------+-----------------------------------------------+----------+
| 36980    | Owensboro, KY                                 | 0.8652   |
|          |                                               |          |
|          | Daviess County, KY                            |          |
|          |                                               |          |
|          | Hancock County, KY                            |          |
|          |                                               |          |
|          | McLean County, KY                             |          |
+----------+-----------------------------------------------+----------+
| 37100    | Oxnard-Thousand Oaks-Ventura, CA              | 1.1852   |
|          |                                               |          |
|          | Ventura County, CA                            |          |
+----------+-----------------------------------------------+----------+
| 37340    | Palm Bay-Melbourne-Titusville, FL             | 0.9325   |
|          |                                               |          |
|          | Brevard County, FL                            |          |
+----------+-----------------------------------------------+----------+
| 37380    | Palm Coast, FL                                | 0.8945   |
|          |                                               |          |
|          | Flager County, FL                             |          |
+----------+-----------------------------------------------+----------+
| 37460    | Panama City-Lynn Haven, FL                    | 0.8313   |
|          |                                               |          |
|          | Bay County, FL                                |          |
+----------+-----------------------------------------------+----------+
| 37620    | Parkersburg-Marietta-Vienna, WV-OH            | 0.8105   |
|          |                                               |          |
|          | Washington County, OH                         |          |
|          |                                               |          |
|          | Pleasants County, WV                          |          |
|          |                                               |          |
|          | Wirt County, WV                               |          |
|          |                                               |          |
|          | Wood County, WV                               |          |
+----------+-----------------------------------------------+----------+
| 37700    | Pascagoula, MS                                | 0.8647   |
|          |                                               |          |
|          | George County, MS                             |          |
|          |                                               |          |
|          | Jackson County, MS                            |          |
+----------+-----------------------------------------------+----------+
| 37764    | Peabody, MA                                   | 1.0650   |
|          |                                               |          |
|          | Essex County, MA                              |          |
+----------+-----------------------------------------------+----------+
| 37860    | Pensacola-Ferry Pass-Brent, FL                | 0.8281   |
|          |                                               |          |
|          | Escambia County, FL                           |          |
|          |                                               |          |
|          | Santa Rosa County, FL                         |          |
+----------+-----------------------------------------------+----------+
| 37900    | Peoria, IL                                    | 0.9299   |
|          |                                               |          |
|          | Marshall County, IL                           |          |
|          |                                               |          |
|          | Peoria County, IL                             |          |
|          |                                               |          |
|          | Stark County, IL                              |          |
|          |                                               |          |
|          | Tazewell County, IL                           |          |
|          |                                               |          |
|          | Woodford County, IL                           |          |
+----------+-----------------------------------------------+----------+
| 37964    | Philadelphia, PA                              | 1.0925   |
|          |                                               |          |
|          | Bucks County, PA                              |          |
|          |                                               |          |
|          | Chester County, PA                            |          |
|          |                                               |          |
|          | Delaware County, PA                           |          |
|          |                                               |          |
|          | Montgomery County, PA                         |          |
|          |                                               |          |
|          | Philadelphia County, PA                       |          |
+----------+-----------------------------------------------+----------+
| 38060    | Phoenix-Mesa-Scottsdale, AZ                   | 1.0264   |
|          |                                               |          |
|          | Maricopa County, AZ                           |          |
|          |                                               |          |
|          | Pinal County, AZ                              |          |
+----------+-----------------------------------------------+----------+
| 38220    | Pine Bluff, AR                                | 0.7839   |
|          |                                               |          |
|          | Cleveland County, AR                          |          |
|          |                                               |          |
|          | Jefferson County, AR                          |          |
|          |                                               |          |
|          | Lincoln County, AR                            |          |
+----------+-----------------------------------------------+----------+
| 38300    | Pittsburgh, PA                                | 0.8525   |
|          |                                               |          |
|          | Allegheny County, PA                          |          |
|          |                                               |          |
|          | Armstrong County, PA                          |          |
|          |                                               |          |
|          | Beaver County, PA                             |          |
|          |                                               |          |
|          | Butler County, PA                             |          |
|          |                                               |          |
|          | Fayette County, PA                            |          |
|          |                                               |          |
|          | Washington County, PA                         |          |
|          |                                               |          |
|          | Westmoreland County, PA                       |          |
+----------+-----------------------------------------------+----------+
| 38340    | Pittsfield, MA                                | 1.0091   |
|          |                                               |          |
|          | Berkshire County, MA                          |          |
+----------+-----------------------------------------------+----------+
| 38540    | Pocatello, ID                                 | 0.9465   |
|          |                                               |          |
|          | Bannock County, ID                            |          |
|          |                                               |          |
|          | Power County, ID                              |          |
+----------+-----------------------------------------------+----------+
| 38660    | Ponce, PR                                     | 0.4450   |
|          |                                               |          |
|          | Juana Díaz Municipio, PR                      |          |
|          |                                               |          |
|          | Ponce Municipio, PR                           |          |
|          |                                               |          |
|          | Villalba Municipio, PR                        |          |
+----------+-----------------------------------------------+----------+
| 38860    | Portland-South Portland-Biddeford, ME         | 1.0042   |
|          |                                               |          |
|          | Cumberland County, ME                         |          |
|          |                                               |          |
|          | Sagadahoc County, ME                          |          |
|          |                                               |          |
|          | York County, ME                               |          |
+----------+-----------------------------------------------+----------+
| 38900    | Portland-Vancouver-Beaverton, OR-WA           | 1.1498   |
|          |                                               |          |
|          | Clackamas County, OR                          |          |
|          |                                               |          |
|          | Columbia County, OR                           |          |
|          |                                               |          |
|          | Multnomah County, OR                          |          |
|          |                                               |          |
|          | Washington County, OR                         |          |
|          |                                               |          |
|          | Yamhill County, OR                            |          |
|          |                                               |          |
|          | Clark County, WA                              |          |
|          |                                               |          |
|          | Skamania County, WA                           |          |
+----------+-----------------------------------------------+----------+
| 38940    | Port St. Lucie, FL                            | 1.0016   |
|          |                                               |          |
|          | Martin County, FL                             |          |
|          |                                               |          |
|          | St. Lucie County, FL                          |          |
+----------+-----------------------------------------------+----------+
| 39100    | Poughkeepsie-Newburgh-Middletown, NY          | 1.0982   |
|          |                                               |          |
|          | Dutchess County, NY                           |          |
|          |                                               |          |
|          | Orange County, NY                             |          |
+----------+-----------------------------------------------+----------+
| 39140    | Prescott, AZ                                  | 1.0020   |
|          |                                               |          |
|          | Yavapai County, AZ                            |          |
+----------+-----------------------------------------------+----------+
| 39300    | Providence-New Bedford-Fall River, RI-MA      | 1.0574   |
|          |                                               |          |
|          | Bristol County, MA                            |          |
|          |                                               |          |
|          | Bristol County, RI                            |          |
|          |                                               |          |
|          | Kent County, RI                               |          |
|          |                                               |          |
|          | Newport County, RI                            |          |
|          |                                               |          |
|          | Providence County, RI                         |          |
|          |                                               |          |
|          | Washington County, RI                         |          |
+----------+-----------------------------------------------+----------+
| 39340    | Provo-Orem, UT                                | 0.9557   |
|          |                                               |          |
|          | Juab County, UT                               |          |
|          |                                               |          |
|          | Utah County, UT                               |          |
+----------+-----------------------------------------------+----------+
| 39380    | Pueblo, CO                                    | 0.8851   |
|          |                                               |          |
|          | Pueblo County, CO                             |          |
+----------+-----------------------------------------------+----------+
| 39460    | Punta Gorda, FL                               | 0.9254   |
|          |                                               |          |
|          | Charlotte County, FL                          |          |
+----------+-----------------------------------------------+----------+
| 39540    | Racine, WI                                    | 0.9498   |
|          |                                               |          |
|          | Racine County, WI                             |          |
+----------+-----------------------------------------------+----------+
| 39580    | Raleigh-Cary, NC                              | 0.9839   |
|          |                                               |          |
|          | Franklin County, NC                           |          |
|          |                                               |          |
|          | Johnston County, NC                           |          |
|          |                                               |          |
|          | Wake County, NC                               |          |
+----------+-----------------------------------------------+----------+
| 39660    | Rapid City, SD                                | 0.8811   |
|          |                                               |          |
|          | Meade County, SD                              |          |
|          |                                               |          |
|          | Pennington County, SD                         |          |
+----------+-----------------------------------------------+----------+
| 39740    | Reading, PA                                   | 0.9356   |
|          |                                               |          |
|          | Berks County, PA                              |          |
+----------+-----------------------------------------------+----------+
| 39820    | Redding, CA                                   | 1.3541   |
|          |                                               |          |
|          | Shasta County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 39900    | Reno-Sparks, NV                               | 1.0715   |
|          |                                               |          |
|          | Storey County, NV                             |          |
|          |                                               |          |
|          | Washoe County, NV                             |          |
+----------+-----------------------------------------------+----------+
| 40060    | Richmond, VA                                  | 0.9425   |
|          |                                               |          |
|          | 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                             |          |
+----------+-----------------------------------------------+----------+
| 40140    | Riverside-San Bernardino-Ontario, CA          | 1.1100   |
|          |                                               |          |
|          | Riverside County, CA                          |          |
|          |                                               |          |
|          | San Bernardino County, CA                     |          |
+----------+-----------------------------------------------+----------+
| 40220    | Roanoke, VA                                   | 0.8691   |
|          |                                               |          |
|          | Botetourt County, VA                          |          |
|          |                                               |          |
|          | Craig County, VA                              |          |
|          |                                               |          |
|          | Franklin County, VA                           |          |
|          |                                               |          |
|          | Roanoke County, VA                            |          |
|          |                                               |          |
|          | Roanoke City, VA                              |          |
|          |                                               |          |
|          | Salem City, VA                                |          |
+----------+-----------------------------------------------+----------+
| 40340    | Rochester, MN                                 | 1.0755   |
|          |                                               |          |
|          | Dodge County, MN                              |          |
|          |                                               |          |
|          | Olmsted County, MN                            |          |
|          |                                               |          |
|          | Wabasha County, MN                            |          |
+----------+-----------------------------------------------+----------+
| 40380    | Rochester, NY                                 | 0.8858   |
|          |                                               |          |
|          | Livingston County, NY                         |          |
|          |                                               |          |
|          | Monroe County, NY                             |          |
|          |                                               |          |
|          | Ontario County, NY                            |          |
|          |                                               |          |
|          | Orleans County, NY                            |          |
|          |                                               |          |
|          | Wayne County, NY                              |          |
+----------+-----------------------------------------------+----------+
| 40420    | Rockford, IL                                  | 0.9814   |
|          |                                               |          |
|          | Boone County, IL                              |          |
|          |                                               |          |
|          | Winnebago County, IL                          |          |
+----------+-----------------------------------------------+----------+
| 40484    | Rockingham County-Strafford County, NH        | 1.0111   |
|          |                                               |          |
|          | Rockingham County, NH                         |          |
|          |                                               |          |
|          | Strafford County, NH                          |          |
+----------+-----------------------------------------------+----------+
| 40580    | Rocky Mount, NC                               | 0.9001   |
|          |                                               |          |
|          | Edgecombe County, NC                          |          |
|          |                                               |          |
|          | Nash County, NC                               |          |
+----------+-----------------------------------------------+----------+
| 40660    | Rome, GA                                      | 0.9042   |
|          |                                               |          |
|          | Floyd County, GA                              |          |
+----------+-----------------------------------------------+----------+
| 40900    | Sacramento\--Arden-Arcade\--Roseville, CA     | 1.3505   |
|          |                                               |          |
|          | El Dorado County, CA                          |          |
|          |                                               |          |
|          | Placer County, CA                             |          |
|          |                                               |          |
|          | Sacramento County, CA                         |          |
|          |                                               |          |
|          | Yolo County, CA                               |          |
+----------+-----------------------------------------------+----------+
| 40980    | Saginaw-Saginaw Township North, MI            | 0.8812   |
|          |                                               |          |
|          | Saginaw County, MI                            |          |
+----------+-----------------------------------------------+----------+
| 41060    | St. Cloud, MN                                 | 1.0549   |
|          |                                               |          |
|          | Benton County, MN                             |          |
|          |                                               |          |
|          | Stearns County, MN                            |          |
+----------+-----------------------------------------------+----------+
| 41100    | St. George, UT                                | 0.9358   |
|          |                                               |          |
|          | Washington County, UT                         |          |
+----------+-----------------------------------------------+----------+
| 41140    | St. Joseph, MO-KS                             | 0.8762   |
|          |                                               |          |
|          | Doniphan County, KS                           |          |
|          |                                               |          |
|          | Andrew County, MO                             |          |
|          |                                               |          |
|          | Buchanan County, MO                           |          |
|          |                                               |          |
|          | DeKalb County, MO                             |          |
+----------+-----------------------------------------------+----------+
| 41180    | St. Louis, MO-IL                              | 0.9024   |
|          |                                               |          |
|          | 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                            |          |
+----------+-----------------------------------------------+----------+
| 41420    | Salem, OR                                     | 1.0572   |
|          |                                               |          |
|          | Marion County, OR                             |          |
|          |                                               |          |
|          | Polk County, OR                               |          |
+----------+-----------------------------------------------+----------+
| 41500    | Salinas, CA                                   | 1.4775   |
|          |                                               |          |
|          | Monterey County, CA                           |          |
+----------+-----------------------------------------------+----------+
| 41540    | Salisbury, MD                                 | 0.8994   |
|          |                                               |          |
|          | Somerset County, MD                           |          |
|          |                                               |          |
|          | Wicomico County, MD                           |          |
+----------+-----------------------------------------------+----------+
| 41620    | Salt Lake City, UT                            | 0.9399   |
|          |                                               |          |
|          | Salt Lake County, UT                          |          |
|          |                                               |          |
|          | Summit County, UT                             |          |
|          |                                               |          |
|          | Tooele County, UT                             |          |
+----------+-----------------------------------------------+----------+
| 41660    | San Angelo, TX                                | 0.8579   |
|          |                                               |          |
|          | Irion County, TX                              |          |
|          |                                               |          |
|          | Tom Green County, TX                          |          |
+----------+-----------------------------------------------+----------+
| 41700    | San Antonio, TX                               | 0.8834   |
|          |                                               |          |
|          | Atascosa County, TX                           |          |
|          |                                               |          |
|          | Bandera County, TX                            |          |
|          |                                               |          |
|          | Bexar County, TX                              |          |
|          |                                               |          |
|          | Comal County, TX                              |          |
|          |                                               |          |
|          | Guadalupe County, TX                          |          |
|          |                                               |          |
|          | Kendall County, TX                            |          |
|          |                                               |          |
|          | Medina County, TX                             |          |
|          |                                               |          |
|          | Wilson County, TX                             |          |
+----------+-----------------------------------------------+----------+
| 41740    | San Diego-Carlsbad-San Marcos, CA             | 1.1492   |
|          |                                               |          |
|          | San Diego County, CA                          |          |
+----------+-----------------------------------------------+----------+
| 41780    | Sandusky, OH                                  | 0.8822   |
|          |                                               |          |
|          | Erie County, OH                               |          |
+----------+-----------------------------------------------+----------+
| 41884    | San Francisco-San Mateo-Redwood City, CA      | 1.5195   |
|          |                                               |          |
|          | Marin County, CA                              |          |
|          |                                               |          |
|          | San Francisco County, CA                      |          |
|          |                                               |          |
|          | San Mateo County, CA                          |          |
+----------+-----------------------------------------------+----------+
| 41900    | San Germán-Cabo Rojo, PR                      | 0.4729   |
|          |                                               |          |
|          | Cabo Rojo Municipio, PR                       |          |
|          |                                               |          |
|          | Lajas Municipio, PR                           |          |
|          |                                               |          |
|          | Sabana Grande Municipio, PR                   |          |
|          |                                               |          |
|          | San Germán Municipio, PR                      |          |
+----------+-----------------------------------------------+----------+
| 41940    | San Jose-Sunnyvale-Santa Clara, CA            | 1.5735   |
|          |                                               |          |
|          | San Benito County, CA                         |          |
|          |                                               |          |
|          | Santa Clara County, CA                        |          |
+----------+-----------------------------------------------+----------+
| 41980    | San Juan-Caguas-Guaynabo, PR                  | 0.4528   |
|          |                                               |          |
|          | 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                         |          |
+----------+-----------------------------------------------+----------+
| 42020    | San Luis Obispo-Paso Robles, CA               | 1.2488   |
|          |                                               |          |
|          | San Luis Obispo County, CA                    |          |
+----------+-----------------------------------------------+----------+
| 42044    | Santa Ana-Anaheim-Irvine, CA                  | 1.1766   |
|          |                                               |          |
|          | Orange County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 42060    | Santa Barbara-Santa Maria-Goleta, CA          | 1.1714   |
|          |                                               |          |
|          | Santa Barbara County, CA                      |          |
+----------+-----------------------------------------------+----------+
| 42100    | Santa Cruz-Watsonville, CA                    | 1.6122   |
|          |                                               |          |
|          | Santa Cruz County, CA                         |          |
+----------+-----------------------------------------------+----------+
| 42140    | Santa Fe, NM                                  | 1.0734   |
|          |                                               |          |
|          | Santa Fe County, NM                           |          |
+----------+-----------------------------------------------+----------+
| 42220    | Santa Rosa-Petaluma, CA                       | 1.4696   |
|          |                                               |          |
|          | Sonoma County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 42260    | Sarasota-Bradenton-Venice, FL                 | 0.9933   |
|          |                                               |          |
|          | Manatee County, FL                            |          |
|          |                                               |          |
|          | Sarasota County, FL                           |          |
+----------+-----------------------------------------------+----------+
| 42340    | Savannah, GA                                  | 0.9131   |
|          |                                               |          |
|          | Bryan County, GA                              |          |
|          |                                               |          |
|          | Chatham County, GA                            |          |
|          |                                               |          |
|          | Effingham County, GA                          |          |
+----------+-----------------------------------------------+----------+
| 42540    | Scranton\--Wilkes-Barre, PA                   | 0.8457   |
|          |                                               |          |
|          | Lackawanna County, PA                         |          |
|          |                                               |          |
|          | Luzerne County, PA                            |          |
|          |                                               |          |
|          | Wyoming County, PA                            |          |
+----------+-----------------------------------------------+----------+
| 42644    | Seattle-Bellevue-Everett, WA                  | 1.1572   |
|          |                                               |          |
|          | King County, WA                               |          |
|          |                                               |          |
|          | Snohomish County, WA                          |          |
+----------+-----------------------------------------------+----------+
| 42680    | Sebastian-Vero Beach, FL                      | 0.9412   |
|          |                                               |          |
|          | Indian River County, FL                       |          |
+----------+-----------------------------------------------+----------+
| 43100    | Sheboygan, WI                                 | 0.8975   |
|          |                                               |          |
|          | Sheboygan County, WI                          |          |
+----------+-----------------------------------------------+----------+
| 43300    | Sherman-Denison, TX                           | 0.8320   |
|          |                                               |          |
|          | Grayson County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 43340    | Shreveport-Bossier City, LA                   | 0.8476   |
|          |                                               |          |
|          | Bossier Parish, LA                            |          |
|          |                                               |          |
|          | Caddo Parish, LA                              |          |
|          |                                               |          |
|          | De Soto Parish, LA                            |          |
+----------+-----------------------------------------------+----------+
| 43580    | Sioux City, IA-NE-SD                          | 0.9251   |
|          |                                               |          |
|          | Woodbury County, IA                           |          |
|          |                                               |          |
|          | Dakota County, NE                             |          |
|          |                                               |          |
|          | Dixon County, NE                              |          |
|          |                                               |          |
|          | Union County, SD                              |          |
+----------+-----------------------------------------------+----------+
| 43620    | Sioux Falls, SD                               | 0.9563   |
|          |                                               |          |
|          | Lincoln County, SD                            |          |
|          |                                               |          |
|          | McCook County, SD                             |          |
|          |                                               |          |
|          | Minnehaha County, SD                          |          |
|          |                                               |          |
|          | Turner County, SD                             |          |
+----------+-----------------------------------------------+----------+
| 43780    | South Bend-Mishawaka, IN-MI                   | 0.9617   |
|          |                                               |          |
|          | St. Joseph County, IN                         |          |
|          |                                               |          |
|          | Cass County, MI                               |          |
+----------+-----------------------------------------------+----------+
| 43900    | Spartanburg, SC                               | 0.9422   |
|          |                                               |          |
|          | Spartanburg County, SC                        |          |
+----------+-----------------------------------------------+----------+
| 44060    | Spokane, WA                                   | 1.0455   |
|          |                                               |          |
|          | Spokane County, WA                            |          |
+----------+-----------------------------------------------+----------+
| 44100    | Springfield, IL                               | 0.8944   |
|          |                                               |          |
|          | Menard County, IL                             |          |
|          |                                               |          |
|          | Sangamon County, IL                           |          |
+----------+-----------------------------------------------+----------+
| 44140    | Springfield, MA                               | 1.0366   |
|          |                                               |          |
|          | Franklin County, MA                           |          |
|          |                                               |          |
|          | Hampden County, MA                            |          |
|          |                                               |          |
|          | Hampshire County, MA                          |          |
+----------+-----------------------------------------------+----------+
| 44180    | Springfield, MO                               | 0.8695   |
|          |                                               |          |
|          | Christian County, MO                          |          |
|          |                                               |          |
|          | Dallas County, MO                             |          |
|          |                                               |          |
|          | Greene County, MO                             |          |
|          |                                               |          |
|          | Polk County, MO                               |          |
|          |                                               |          |
|          | Webster County, MO                            |          |
+----------+-----------------------------------------------+----------+
| 44220    | Springfield, OH                               | 0.8694   |
|          |                                               |          |
|          | Clark County, OH                              |          |
+----------+-----------------------------------------------+----------+
| 44300    | State College, PA                             | 0.8768   |
|          |                                               |          |
|          | Centre County, PA                             |          |
+----------+-----------------------------------------------+----------+
| 44700    | Stockton, CA                                  | 1.1855   |
|          |                                               |          |
|          | San Joaquin County, CA                        |          |
+----------+-----------------------------------------------+----------+
| 44940    | Sumter, SC                                    | 0.8599   |
|          |                                               |          |
|          | Sumter County, SC                             |          |
+----------+-----------------------------------------------+----------+
| 45060    | Syracuse, NY                                  | 0.9910   |
|          |                                               |          |
|          | Madison County, NY                            |          |
|          |                                               |          |
|          | Onondaga County, NY                           |          |
|          |                                               |          |
|          | Oswego County, NY                             |          |
+----------+-----------------------------------------------+----------+
| 45104    | Tacoma, WA                                    | 1.1055   |
|          |                                               |          |
|          | Pierce County, WA                             |          |
+----------+-----------------------------------------------+----------+
| 45220    | Tallahassee, FL                               | 0.9025   |
|          |                                               |          |
|          | Gadsden County, FL                            |          |
|          |                                               |          |
|          | Jefferson County, FL                          |          |
|          |                                               |          |
|          | Leon County, FL                               |          |
|          |                                               |          |
|          | Wakulla County, FL                            |          |
+----------+-----------------------------------------------+----------+
| 45300    | Tampa-St. Petersburg-Clearwater, FL           | 0.9020   |
|          |                                               |          |
|          | Hernando County, FL                           |          |
|          |                                               |          |
|          | Hillsborough County, FL                       |          |
|          |                                               |          |
|          | Pasco County, FL                              |          |
|          |                                               |          |
|          | Pinellas County, FL                           |          |
+----------+-----------------------------------------------+----------+
| 45460    | Terre Haute, IN                               | 0.8805   |
|          |                                               |          |
|          | Clay County, IN                               |          |
|          |                                               |          |
|          | Sullivan County, IN                           |          |
|          |                                               |          |
|          | Vermillion County, IN                         |          |
|          |                                               |          |
|          | Vigo County, IN                               |          |
+----------+-----------------------------------------------+----------+
| 45500    | Texarkana, TX-Texarkana, AR                   | 0.7770   |
|          |                                               |          |
|          | Miller County, AR                             |          |
|          |                                               |          |
|          | Bowie County, TX                              |          |
+----------+-----------------------------------------------+----------+
| 45780    | Toledo, OH                                    | 0.9431   |
|          |                                               |          |
|          | Fulton County, OH                             |          |
|          |                                               |          |
|          | Lucas County, OH                              |          |
|          |                                               |          |
|          | Ottawa County, OH                             |          |
|          |                                               |          |
|          | Wood County, OH                               |          |
+----------+-----------------------------------------------+----------+
| 45820    | Topeka, KS                                    | 0.8538   |
|          |                                               |          |
|          | Jackson County, KS                            |          |
|          |                                               |          |
|          | Jefferson County, KS                          |          |
|          |                                               |          |
|          | Osage County, KS                              |          |
|          |                                               |          |
|          | Shawnee County, KS                            |          |
|          |                                               |          |
|          | Wabaunsee County, KS                          |          |
+----------+-----------------------------------------------+----------+
| 45940    | Trenton-Ewing, NJ                             | 1.0699   |
|          |                                               |          |
|          | Mercer County, NJ                             |          |
+----------+-----------------------------------------------+----------+
| 46060    | Tucson, AZ                                    | 0.9245   |
|          |                                               |          |
|          | Pima County, AZ                               |          |
+----------+-----------------------------------------------+----------+
| 46140    | Tulsa, OK                                     | 0.8340   |
|          |                                               |          |
|          | Creek County, OK                              |          |
|          |                                               |          |
|          | Okmulgee County, OK                           |          |
|          |                                               |          |
|          | Osage County, OK                              |          |
|          |                                               |          |
|          | Pawnee County, OK                             |          |
|          |                                               |          |
|          | Rogers County, OK                             |          |
|          |                                               |          |
|          | Tulsa County, OK                              |          |
|          |                                               |          |
|          | Wagoner County, OK                            |          |
+----------+-----------------------------------------------+----------+
| 46220    | Tuscaloosa, AL                                | 0.8303   |
|          |                                               |          |
|          | Greene County, AL                             |          |
|          |                                               |          |
|          | Hale County, AL                               |          |
|          |                                               |          |
|          | Tuscaloosa County, AL                         |          |
+----------+-----------------------------------------------+----------+
| 46340    | Tyler, TX                                     | 0.9114   |
|          |                                               |          |
|          | Smith County, TX                              |          |
+----------+-----------------------------------------------+----------+
| 46540    | Utica-Rome, NY                                | 0.8486   |
|          |                                               |          |
|          | Herkimer County, NY                           |          |
|          |                                               |          |
|          | Oneida County, NY                             |          |
+----------+-----------------------------------------------+----------+
| 46660    | Valdosta, GA                                  | 0.8098   |
|          |                                               |          |
|          | Brooks County, GA                             |          |
|          |                                               |          |
|          | Echols County, GA                             |          |
|          |                                               |          |
|          | Lanier County, GA                             |          |
|          |                                               |          |
|          | Lowndes County, GA                            |          |
+----------+-----------------------------------------------+----------+
| 46700    | Vallejo-Fairfield, CA                         | 1.4666   |
|          |                                               |          |
|          | Solano County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 47020    | Victoria, TX                                  | 0.8302   |
|          |                                               |          |
|          | Calhoun County, TX                            |          |
|          |                                               |          |
|          | Goliad County, TX                             |          |
|          |                                               |          |
|          | Victoria County, TX                           |          |
+----------+-----------------------------------------------+----------+
| 47220    | Vineland-Millville-Bridgeton, NJ              | 1.0133   |
|          |                                               |          |
|          | Cumberland County, NJ                         |          |
+----------+-----------------------------------------------+----------+
| 47260    | Virginia Beach-Norfolk-Newport News, VA-NC    | 0.8818   |
|          |                                               |          |
|          | 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                         |          |
+----------+-----------------------------------------------+----------+
| 47300    | Visalia-Porterville, CA                       | 1.0091   |
|          |                                               |          |
|          | Tulare County, CA                             |          |
+----------+-----------------------------------------------+----------+
| 47380    | Waco, TX                                      | 0.8518   |
|          |                                               |          |
|          | McLennan County, TX                           |          |
+----------+-----------------------------------------------+----------+
| 47580    | Warner Robins, GA                             | 0.9128   |
|          |                                               |          |
|          | Houston County, GA                            |          |
+----------+-----------------------------------------------+----------+
| 47644    | Warren-Troy-Farmington Hills, MI              | 1.0001   |
|          |                                               |          |
|          | Lapeer County, MI                             |          |
|          |                                               |          |
|          | Livingston County, MI                         |          |
|          |                                               |          |
|          | Macomb County, MI                             |          |
|          |                                               |          |
|          | Oakland County, MI                            |          |
|          |                                               |          |
|          | St. Clair County, MI                          |          |
+----------+-----------------------------------------------+----------+
| 47894    | Washington-Arlington-Alexandria, DC-VA-MD-WV  | 1.0855   |
|          |                                               |          |
|          | District of Columbia, DC                      |          |
|          |                                               |          |
|          | Calvert County, MD                            |          |
|          |                                               |          |
|          | Charles County, MD                            |          |
|          |                                               |          |
|          | Prince George\'s County, MD                   |          |
|          |                                               |          |
|          | Arlington County, VA                          |          |
|          |                                               |          |
|          | Clarke County, VA                             |          |
|          |                                               |          |
|          | Fairfax County, VA                            |          |
|          |                                               |          |
|          | Fauquier County, VA                           |          |
|          |                                               |          |
|          | Loudoun County, VA                            |          |
|          |                                               |          |
|          | Prince William County, VA                     |          |
|          |                                               |          |
|          | Spotsylvania County, VA                       |          |
|          |                                               |          |
|          | Stafford County, VA                           |          |
|          |                                               |          |
|          | Warren County, VA                             |          |
|          |                                               |          |
|          | Alexandria City, VA                           |          |
|          |                                               |          |
|          | Fairfax City, VA                              |          |
|          |                                               |          |
|          | Falls Church City, VA                         |          |
|          |                                               |          |
|          | Fredericksburg City, VA                       |          |
|          |                                               |          |
|          | Manassas City, VA                             |          |
|          |                                               |          |
|          | Manassas Park City, VA                        |          |
|          |                                               |          |
|          | Jefferson County, WV                          |          |
+----------+-----------------------------------------------+----------+
| 47940    | Waterloo-Cedar Falls, IA                      | 0.8519   |
|          |                                               |          |
|          | Black Hawk County, IA                         |          |
|          |                                               |          |
|          | Bremer County, IA                             |          |
|          |                                               |          |
|          | Grundy County, IA                             |          |
+----------+-----------------------------------------------+----------+
| 48140    | Wausau, WI                                    | 0.9679   |
|          |                                               |          |
|          | Marathon County, WI                           |          |
+----------+-----------------------------------------------+----------+
| 48260    | Weirton-Steubenville, WV-OH                   | 0.7924   |
|          |                                               |          |
|          | Jefferson County, OH                          |          |
|          |                                               |          |
|          | Brooke County, WV                             |          |
|          |                                               |          |
|          | Hancock County, WV                            |          |
+----------+-----------------------------------------------+----------+
| 48300    | Wenatchee, WA                                 | 1.1469   |
|          |                                               |          |
|          | Chelan County, WA                             |          |
|          |                                               |          |
|          | Douglas County, WA                            |          |
+----------+-----------------------------------------------+----------+
| 48424    | West Palm Beach-Boca Raton-Boynton Beach, FL  | 0.9728   |
|          |                                               |          |
|          | Palm Beach County, FL                         |          |
+----------+-----------------------------------------------+----------+
| 48540    | Wheeling, WV-OH                               | 0.6961   |
|          |                                               |          |
|          | Belmont County, OH                            |          |
|          |                                               |          |
|          | Marshall County, WV                           |          |
|          |                                               |          |
|          | Ohio County, WV                               |          |
+----------+-----------------------------------------------+----------+
| 48620    | Wichita, KS                                   | 0.9062   |
|          |                                               |          |
|          | Butler County, KS                             |          |
|          |                                               |          |
|          | Harvey County, KS                             |          |
|          |                                               |          |
|          | Sedgwick County, KS                           |          |
|          |                                               |          |
|          | Sumner County, KS                             |          |
+----------+-----------------------------------------------+----------+
| 48660    | Wichita Falls, TX                             | 0.7920   |
|          |                                               |          |
|          | Archer County, TX                             |          |
|          |                                               |          |
|          | Clay County, TX                               |          |
|          |                                               |          |
|          | Wichita County, TX                            |          |
+----------+-----------------------------------------------+----------+
| 48700    | Williamsport, PA                              | 0.8043   |
|          |                                               |          |
|          | Lycoming County, PA                           |          |
+----------+-----------------------------------------------+----------+
| 48864    | Wilmington, DE-MD-NJ                          | 1.0824   |
|          |                                               |          |
|          | New Castle County, DE                         |          |
|          |                                               |          |
|          | Cecil County, MD                              |          |
|          |                                               |          |
|          | Salem County, NJ                              |          |
+----------+-----------------------------------------------+----------+
| 48900    | Wilmington, NC                                | 0.9410   |
|          |                                               |          |
|          | Brunswick County, NC                          |          |
|          |                                               |          |
|          | New Hanover County, NC                        |          |
|          |                                               |          |
|          | Pender County, NC                             |          |
+----------+-----------------------------------------------+----------+
| 49020    | Winchester, VA-WV                             | 0.9913   |
|          |                                               |          |
|          | Frederick County, VA                          |          |
|          |                                               |          |
|          | Winchester City, VA                           |          |
|          |                                               |          |
|          | Hampshire County, WV                          |          |
+----------+-----------------------------------------------+----------+
| 49180    | Winston-Salem, NC                             | 0.9118   |
|          |                                               |          |
|          | Davie County, NC                              |          |
|          |                                               |          |
|          | Forsyth County, NC                            |          |
|          |                                               |          |
|          | Stokes County, NC                             |          |
|          |                                               |          |
|          | Yadkin County, NC                             |          |
+----------+-----------------------------------------------+----------+
| 49340    | Worcester, MA                                 | 1.1287   |
|          |                                               |          |
|          | Worcester County, MA                          |          |
+----------+-----------------------------------------------+----------+
| 49420    | Yakima, WA                                    | 1.0267   |
|          |                                               |          |
|          | Yakima County, WA                             |          |
+----------+-----------------------------------------------+----------+
| 49500    | Yauco, PR                                     | 0.3284   |
|          |                                               |          |
|          | Guánica Municipio, PR                         |          |
|          |                                               |          |
|          | Guayanilla Municipio, PR                      |          |
|          |                                               |          |
|          | Peñuelas Municipio, PR                        |          |
|          |                                               |          |
|          | Yauco Municipio, PR                           |          |
+----------+-----------------------------------------------+----------+
| 49620    | York-Hanover, PA                              | 0.9359   |
|          |                                               |          |
|          | York County, PA                               |          |
+----------+-----------------------------------------------+----------+
| 49660    | Youngstown-Warren-Boardman, OH-PA             | 0.9002   |
|          |                                               |          |
|          | Mahoning County, OH                           |          |
|          |                                               |          |
|          | Trumbull County, OH                           |          |
|          |                                               |          |
|          | Mercer County, PA                             |          |
+----------+-----------------------------------------------+----------+
| 49700    | Yuba City, CA                                 | 1.0756   |
|          |                                               |          |
|          | Sutter County, CA                             |          |
|          |                                               |          |
|          | Yuba County, CA                               |          |
+----------+-----------------------------------------------+----------+
| 49740    | Yuma, AZ                                      | 0.9488   |
|          |                                               |          |
|          | Yuma County, AZ                               |          |
+----------+-----------------------------------------------+----------+

**TABLE 2: PROPOSED LONG-TERM CARE HOSPITAL WAGE INDEX FOR RURAL AREAS
FOR DISCHARGES OCCURRING FROM**

**JULY 1, 2008 THROUGH September 30, 2009**

+------------+-----------------------------------+---------------------+
| **CBSA     | **Nonurban Area**                 | **Proposed Wage     |
| Code**     |                                   | Index**             |
+============+===================================+=====================+
| 01         | Alabama                           | 0.7533              |
+------------+-----------------------------------+---------------------+
| 02         | Alaska                            | 1.2109              |
+------------+-----------------------------------+---------------------+
| 03         | Arizona                           | 0.8479              |
+------------+-----------------------------------+---------------------+
| 04         | Arkansas                          | 0.7371              |
+------------+-----------------------------------+---------------------+
| 05         | California                        | 1.2023              |
+------------+-----------------------------------+---------------------+
| 06         | # Colorado                        | 0.9704              |
+------------+-----------------------------------+---------------------+
| 07         | Connecticut                       | 1.1119              |
+------------+-----------------------------------+---------------------+
| 08         | Delaware                          | 0.9727              |
+------------+-----------------------------------+---------------------+
| 10         | Florida                           | 0.8465              |
+------------+-----------------------------------+---------------------+
| 11         | Georgia                           | 0.7659              |
+------------+-----------------------------------+---------------------+
| 12         | Hawaii                            | 1.0612              |
+------------+-----------------------------------+---------------------+
| 13         | Idaho                             | 0.7920              |
+------------+-----------------------------------+---------------------+
| 14         | Illinois                          | 0.8335              |
+------------+-----------------------------------+---------------------+
| 15         | Indiana                           | 0.8576              |
+------------+-----------------------------------+---------------------+
| 16         | Iowa                              | 0.8566              |
+------------+-----------------------------------+---------------------+
| 17         | Kansas                            | 0.7981              |
+------------+-----------------------------------+---------------------+
| 18         | Kentucky                          | 0.7793              |
+------------+-----------------------------------+---------------------+
| 19         | Louisiana                         | 0.7373              |
+------------+-----------------------------------+---------------------+
| 20         | Maine                             | 0.8476              |
+------------+-----------------------------------+---------------------+
| 21         | Maryland                          | 0.9034              |
+------------+-----------------------------------+---------------------+
| 22         | Massachusetts                     | 1.1589              |
+------------+-----------------------------------+---------------------+
| 23         | Michigan                          | 0.8953              |
+------------+-----------------------------------+---------------------+
| 24         | Minnesota                         | 0.9079              |
+------------+-----------------------------------+---------------------+
| 25         | Mississippi                       | 0.7700              |
+------------+-----------------------------------+---------------------+
| 26         | Missouri                          | 0.7930              |
+------------+-----------------------------------+---------------------+
| 27         | Montana                           | 0.8379              |
+------------+-----------------------------------+---------------------+
| 28         | Nebraska                          | 0.8849              |
+------------+-----------------------------------+---------------------+
| 29         | Nevada                            | 0.9272              |
+------------+-----------------------------------+---------------------+
| 30         | New Hampshire                     | 1.0470              |
+------------+-----------------------------------+---------------------+
| 31         | New Jersey^\*^                    | \-\-\-\-\--         |
+------------+-----------------------------------+---------------------+
| 32         | New Mexico                        | 0.8940              |
+------------+-----------------------------------+---------------------+
| 33         | New York                          | 0.8268              |
+------------+-----------------------------------+---------------------+
| 34         | North Carolina                    | 0.8603              |
+------------+-----------------------------------+---------------------+
| 35         | North Dakota                      | 0.7182              |
+------------+-----------------------------------+---------------------+
| 36         | Ohio                              | 0.8714              |
+------------+-----------------------------------+---------------------+
| 37         | Oklahoma                          | 0.7492              |
+------------+-----------------------------------+---------------------+
| 38         | Oregon                            | 0.9906              |
+------------+-----------------------------------+---------------------+
| 39         | Pennsylvania                      | 0.8385              |
+------------+-----------------------------------+---------------------+
| 41         | Rhode Island^\*^                  | \-\-\-\-\--         |
+------------+-----------------------------------+---------------------+
| 42         | # South Carolina                  | 0.8656              |
+------------+-----------------------------------+---------------------+
| 43         | South Dakota                      | 0.8549              |
+------------+-----------------------------------+---------------------+
| 44         | Tennessee                         | 0.7723              |
+------------+-----------------------------------+---------------------+
| 45         | Texas                             | 0.7968              |
+------------+-----------------------------------+---------------------+
| 46         | Utah                              | 0.8116              |
+------------+-----------------------------------+---------------------+
| 47         | Vermont                           | 0.9919              |
+------------+-----------------------------------+---------------------+
| 49         | Virginia                          | 0.7896              |
+------------+-----------------------------------+---------------------+
| 50         | Washington                        | 1.0259              |
+------------+-----------------------------------+---------------------+
| 51         | West Virginia                     | 0.7454              |
+------------+-----------------------------------+---------------------+
| 52         | Wisconsin                         | 0.9667              |
+------------+-----------------------------------+---------------------+
| 53         | Wyoming                           | 0.9287              |
+------------+-----------------------------------+---------------------+

^\*^ All counties within the State are classified as urban.

**TABLE 3: FY 2008 MS-LTC-DRGs, RELATIVE WEIGHTS, GEOMETRIC AVERAGE
LENGTH OF STAY, SHORT-STAY OUTLIER THRESHOLD AND IPPS-COMPARABLE
THRESHOLD**

  ---------------------------------------------------------------------------------------------------------------
  **MS-LTC-DRG**   **MS-DRG Title**                 **Relative    **Geometric   **Short Stay     **IPPS
                                                    Weight^1^**   Average       Outlier          Comparable
                                                                  Length Of     Threshold^2^**   Threshold^3^**
                                                                  Stay**                         
  ---------------- -------------------------------- ------------- ------------- ---------------- ----------------
  001              Heart transplant or implant of   0.0000        0.0           0.0              0.0
                   heart assist system w MCC                                                     

  002              Heart transplant or implant of   0.0000        0.0           0.0              0.0
                   heart assist system w/o MCC                                                   

  003              ECMO or trach w MV 96+ hrs or    4.2380        64.3          53.6             53.6
                   PDX exc face, mouth & neck w maj                                              
                   O.R.                                                                          

  004              Trach w MV 96+ hrs or PDX exc    3.0249        46.7          38.9             38.9
                   face, mouth & neck w/o maj O.R.                                               

  005              Liver transplant w MCC or        0.0000        0.0           0.0              0.0
                   intestinal transplant                                                         

  006              Liver transplant w/o MCC         0.0000        0.0           0.0              0.0

  007              Lung transplant                  0.0000        0.0           0.0              0.0

  008              Simultaneous pancreas/kidney     0.0000        0.0           0.0              0.0
                   transplant                                                                    

  009              Bone marrow transplant           1.1417        29.0          24.2             24.2

  010              Pancreas transplant              1.1417        29.0          24.2             0.0

  011              Tracheostomy for face,mouth &    1.5545        35.2          29.3             25.2
                   neck diagnoses w MCC                                                          

  012              Tracheostomy for face,mouth &    1.5545        35.2          29.3             16.7
                   neck diagnoses w CC                                                           

  013              Tracheostomy for face,mouth &    1.5545        35.2          29.3             11.2
                   neck diagnoses w/o CC/MCC                                                     

  020              Intracranial vascular procedures 1.5545        35.2          29.3             29.3
                   w PDX hemorrhage w MCC                                                        

  021              Intracranial vascular procedures 0.5472        20.3          16.9             16.9
                   w PDX hemorrhage w CC                                                         

  022              Intracranial vascular procedures 0.5472        20.3          16.9             16.1
                   w PDX hemorrhage w/o CC/MCC                                                   

  023              Cranio w major dev impl/acute    1.5545        35.2          29.3             22.2
                   complex CNS PDX w MCC or chemo                                                
                   implant                                                                       

  024              Cranio w major dev impl/acute    0.5472        20.3          16.9             15.8
                   complex CNS PDX w/o MCC                                                       

  025              Craniotomy & endovascular        1.5545        35.2          29.3             22.1
                   intracranial procedures w MCC                                                 

  026              Craniotomy & endovascular        1.5545        35.2          29.3             13.2
                   intracranial procedures w CC                                                  

  027              Craniotomy & endovascular        1.5545        35.2          29.3             7.5
                   intracranial procedures w/o                                                   
                   CC/MCC                                                                        

  028              Spinal procedures w MCC          1.1417        29.0          24.2             24.2

  029              Spinal procedures w CC or spinal 1.1417        29.0          24.2             12.4
                   neurostimulators                                                              

  030              Spinal procedures w/o CC/MCC     0.5472        20.3          16.9             5.9

  031              Ventricular shunt procedures w   1.5545        35.2          29.3             22.9
                   MCC                                                                           

  032              Ventricular shunt procedures w   0.5472        20.3          16.9             9.4
                   CC                                                                            

  033              Ventricular shunt procedures w/o 0.5472        20.3          16.9             4.7
                   CC/MCC                                                                        

  034              Carotid artery stent procedure w 1.5545        35.2          29.3             12.5
                   MCC                                                                           

  035              Carotid artery stent procedure w 1.1417        29.0          24.2             4.4
                   CC                                                                            

  036              Carotid artery stent procedure   1.1417        29.0          24.2             2.2
                   w/o CC/MCC                                                                    

  037              Extracranial procedures w MCC    1.5545        35.2          29.3             14.9

  038              Extracranial procedures w CC     1.1417        29.0          24.2             5.8

  039              Extracranial procedures w/o      1.1417        29.0          24.2             2.6
                   CC/MCC                                                                        

  040              Periph/cranial nerve & other     1.2704        36.2          30.2             22.7
                   nerv syst proc w MCC                                                          

  041              Periph/cranial nerve & other     1.0810        34.3          28.6             12.3
                   nerv syst proc w CC or periph                                                 
                   neurostim                                                                     

  042              Periph/cranial nerve & other     0.7305        22.9          19.1             5.7
                   nerv syst proc w/o CC/MCC                                                     

  052              Spinal disorders & injuries w    1.0629        32.3          26.9             10.7
                   CC/MCC                                                                        

  053              Spinal disorders & injuries w/o  1.0629        32.3          26.9             6.4
                   CC/MCC                                                                        

  054              Nervous system neoplasms w MCC   0.7205        23.6          19.7             11.7

  055              Nervous system neoplasms w/o MCC 0.6779        22.0          18.3             8.1

  056              Degenerative nervous system      0.7407        26.4          22.0             12.3
                   disorders w MCC                                                               

  057              Degenerative nervous system      0.6309        24.4          20.3             7.6
                   disorders w/o MCC                                                             

  058              Multiple sclerosis & cerebellar  0.7305        22.9          19.1             12.5
                   ataxia w MCC                                                                  

  059              Multiple sclerosis & cerebellar  0.5595        22.6          18.8             8.0
                   ataxia w CC                                                                   

  060              Multiple sclerosis & cerebellar  0.5472        20.3          16.9             6.2
                   ataxia w/o CC/MCC                                                             

  061              Acute ischemic stroke w use of   0.7897        24.2          20.2             16.0
                   thrombolytic agent w MCC                                                      

  062              Acute ischemic stroke w use of   0.6563        22.7          18.9             9.6
                   thrombolytic agent w CC                                                       

  063              Acute ischemic stroke w use of   0.5472        20.3          16.9             6.8
                   thrombolytic agent w/o CC/MCC                                                 

  064              Intracranial hemorrhage or       0.7746        25.1          20.9             12.7
                   cerebral infarction w MCC                                                     

  065              Intracranial hemorrhage or       0.6691        23.3          19.4             8.2
                   cerebral infarction w CC                                                      

  066              Intracranial hemorrhage or       0.5472        20.3          16.9             5.8
                   cerebral infarction w/o CC/MCC                                                

  067              Nonspecific cva & precerebral    0.5472        20.3          16.9             10.1
                   occlusion w/o infarct w MCC                                                   

  068              Nonspecific cva & precerebral    0.5472        20.3          16.9             5.6
                   occlusion w/o infarct w/o MCC                                                 

  069              Transient ischemia               0.5472        20.3          16.9             4.7

  070              Nonspecific cerebrovascular      0.7897        24.2          20.2             12.7
                   disorders w MCC                                                               

  071              Nonspecific cerebrovascular      0.6563        22.7          18.9             8.8
                   disorders w CC                                                                

  072              Nonspecific cerebrovascular      0.5472        20.3          16.9             5.8
                   disorders w/o CC/MCC                                                          

  073              Cranial & peripheral nerve       0.7849        25.6          21.3             10.2
                   disorders w MCC                                                               

  074              Cranial & peripheral nerve       0.6260        23.4          19.5             6.9
                   disorders w/o MCC                                                             

  075              Viral meningitis w CC/MCC        0.7305        22.9          19.1             12.1

  076              Viral meningitis w/o CC/MCC      0.5472        20.3          16.9             6.5

  077              Hypertensive encephalopathy w    0.7305        22.9          19.1             11.4
                   MCC                                                                           

  078              Hypertensive encephalopathy w CC 0.7305        22.9          19.1             7.2

  079              Hypertensive encephalopathy w/o  0.5472        20.3          16.9             5.3
                   CC/MCC                                                                        

  080              Nontraumatic stupor & coma w MCC 0.6312        24.6          20.5             7.8

  081              Nontraumatic stupor & coma w/o   0.5618        23.1          19.3             5.3
                   MCC                                                                           

  082              Traumatic stupor & coma, coma    0.8864        29.5          24.6             10.9
                   \>1 hr w MCC                                                                  

  083              Traumatic stupor & coma, coma    0.7305        22.9          19.1             8.6
                   \>1 hr w CC                                                                   

  084              Traumatic stupor & coma, coma    0.7305        22.9          19.1             4.9
                   \>1 hr w/o CC/MCC                                                             

  085              Traumatic stupor & coma, coma    0.9044        28.3          23.6             13.2
                   \<1 hr w MCC                                                                  

  086              Traumatic stupor & coma, coma    0.7437        25.1          20.9             8.2
                   \<1 hr w CC                                                                   

  087              Traumatic stupor & coma, coma    0.6361        20.4          17.0             5.3
                   \<1 hr w/o CC/MCC                                                             

  088              Concussion w MCC                 1.1417        29.0          24.2             9.9

  089              Concussion w CC                  1.1417        29.0          24.2             6.0

  090              Concussion w/o CC/MCC            1.1417        29.0          24.2             3.7

  091              Other disorders of nervous       0.8019        25.6          21.3             10.7
                   system w MCC                                                                  

  092              Other disorders of nervous       0.6704        22.0          18.3             6.9
                   system w CC                                                                   

  093              Other disorders of nervous       0.5811        20.1          16.8             4.9
                   system w/o CC/MCC                                                             

  094              Bacterial & tuberculous          1.0328        27.9          23.3             20.8
                   infections of nervous system w                                                
                   MCC                                                                           

  095              Bacterial & tuberculous          0.9306        27.0          22.5             14.9
                   infections of nervous system w                                                
                   CC                                                                            

  096              Bacterial & tuberculous          0.9306        27.0          22.5             10.1
                   infections of nervous system w/o                                              
                   CC/MCC                                                                        

  097              Non-bacterial infect of nervous  0.9289        26.8          22.3             19.6
                   sys exc viral meningitis w MCC                                                

  098              Non-bacterial infect of nervous  0.8629        22.7          18.9             13.7
                   sys exc viral meningitis w CC                                                 

  099              Non-bacterial infect of nervous  0.7305        22.9          19.1             10.1
                   sys exc viral meningitis w/o                                                  
                   CC/MCC                                                                        

  100              Seizures w MCC                   0.7904        26.5          22.1             10.1

  101              Seizures w/o MCC                 0.6177        21.4          17.8             5.8

  102              Headaches w MCC                  0.8249        25.0          20.8             8.1

  103              Headaches w/o MCC                0.8249        25.0          20.8             5.0

  113              Orbital procedures w CC/MCC      0.7305        22.9          19.1             9.2

  114              Orbital procedures w/o CC/MCC    0.7305        22.9          19.1             4.1

  115              Extraocular procedures except    0.8249        25.0          20.8             7.2
                   orbit                                                                         

  116              Intraocular procedures w CC/MCC  0.8249        25.0          20.8             5.2

  117              Intraocular procedures w/o       0.8249        25.0          20.8             2.8
                   CC/MCC                                                                        

  121              Acute major eye infections w     0.7305        22.9          19.1             9.1
                   CC/MCC                                                                        

  122              Acute major eye infections w/o   0.5472        20.3          16.9             6.3
                   CC/MCC                                                                        

  123              Neurological eye disorders       0.5472        20.3          16.9             4.5

  124              Other disorders of the eye w MCC 1.1417        29.0          24.2             8.4

  125              Other disorders of the eye w/o   0.8249        25.0          20.8             5.5
                   MCC                                                                           

  129              Major head & neck procedures w   1.1977        26.4          22.0             8.1
                   CC/MCC or major device                                                        

  130              Major head & neck procedures w/o 0.7305        22.9          19.1             4.8
                   CC/MCC                                                                        

  131              Cranial/facial procedures w      1.5545        35.2          29.3             9.5
                   CC/MCC                                                                        

  132              Cranial/facial procedures w/o    1.5545        35.2          29.3             4.0
                   CC/MCC                                                                        

  133              Other ear, nose, mouth & throat  0.7305        22.9          19.1             9.4
                   O.R. procedures w CC/MCC                                                      

  134              Other ear, nose, mouth & throat  0.7305        22.9          19.1             3.2
                   O.R. procedures w/o CC/MCC                                                    

  135              Sinus & mastoid procedures w     0.7305        22.9          19.1             10.8
                   CC/MCC                                                                        

  136              Sinus & mastoid procedures w/o   0.7305        22.9          19.1             3.9
                   CC/MCC                                                                        

  137              Mouth procedures w CC/MCC        1.5545        35.2          29.3             8.7

  138              Mouth procedures w/o CC/MCC      1.5545        35.2          29.3             3.7

  139              Salivary gland procedures        1.5545        35.2          29.3             2.5

  146              Ear, nose, mouth & throat        1.1977        26.4          22.0             16.9
                   malignancy w MCC                                                              

  147              Ear, nose, mouth & throat        1.0416        24.9          20.8             9.3
                   malignancy w CC                                                               

  148              Ear, nose, mouth & throat        0.7305        22.9          19.1             5.6
                   malignancy w/o CC/MCC                                                         

  149              Dysequilibrium                   0.5472        20.3          16.9             4.2

  150              Epistaxis w MCC                  0.7305        22.9          19.1             8.8

  151              Epistaxis w/o MCC                0.7305        22.9          19.1             4.5

  152              Otitis media & URI w MCC         0.7305        22.9          19.1             7.4

  153              Otitis media & URI w/o MCC       0.7305        22.9          19.1             5.2

  154              Nasal trauma & deformity w MCC   0.7703        21.0          17.5             10.5

  155              Nasal trauma & deformity w CC    0.7703        21.0          17.5             7.2

  156              Nasal trauma & deformity w/o     0.7305        22.9          19.1             4.9
                   CC/MCC                                                                        

  157              Dental & Oral Diseases w MCC     0.8249        25.0          20.8             11.3

  158              Dental & Oral Diseases w CC      0.8249        25.0          20.8             7.1

  159              Dental & Oral Diseases w/o       0.5472        20.3          16.9             4.8
                   CC/MCC                                                                        

  163              Major chest procedures w MCC     2.2157        39.7          33.1             23.6

  164              Major chest procedures w CC      1.5545        35.2          29.3             13.0

  165              Major chest procedures w/o       1.5545        35.2          29.3             8.3
                   CC/MCC                                                                        

  166              Other resp system O.R.           2.4392        42.3          35.3             20.6
                   procedures w MCC                                                              

  167              Other resp system O.R.           2.1594        38.0          31.7             13.1
                   procedures w CC                                                               

  168              Other resp system O.R.           1.1417        29.0          24.2             8.9
                   procedures w/o CC/MCC                                                         

  175              Pulmonary embolism w MCC         0.7160        22.0          18.3             11.6

  176              Pulmonary embolism w/o MCC       0.5989        20.1          16.8             8.4

  177              Respiratory infections &         0.8393        23.5          19.6             14.9
                   inflammations w MCC                                                           

  178              Respiratory infections &         0.7671        22.2          18.5             11.7
                   inflammations w CC                                                            

  179              Respiratory infections &         0.6885        19.0          15.8             8.9
                   inflammations w/o CC/MCC                                                      

  180              Respiratory neoplasms w MCC      0.8140        20.2          16.8             13.1

  181              Respiratory neoplasms w CC       0.7103        19.3          16.1             9.7

  182              Respiratory neoplasms w/o CC/MCC 0.5472        20.3          16.9             6.9

  183              Major chest trauma w MCC         0.5472        20.3          16.9             11.5

  184              Major chest trauma w CC          0.5472        20.3          16.9             7.3

  185              Major chest trauma w/o CC/MCC    0.5472        20.3          16.9             5.0

  186              Pleural effusion w MCC           0.8259        23.6          19.7             12.2

  187              Pleural effusion w CC            0.7042        21.1          17.6             8.8

  188              Pleural effusion w/o CC/MCC      0.7042        21.1          17.6             6.5

  189              Pulmonary edema & respiratory    0.9743        24.0          20.0             10.1
                   failure                                                                       

  190              Chronic obstructive pulmonary    0.6858        20.9          17.4             10.2
                   disease w MCC                                                                 

  191              Chronic obstructive pulmonary    0.6256        19.5          16.3             7.9
                   disease w CC                                                                  

  192              Chronic obstructive pulmonary    0.5832        17.2          14.3             6.2
                   disease w/o CC/MCC                                                            

  193              Simple pneumonia & pleurisy w    0.7088        21.6          18.0             10.9
                   MCC                                                                           

  194              Simple pneumonia & pleurisy w CC 0.6429        19.8          16.5             8.2

  195              Simple pneumonia & pleurisy w/o  0.5962        18.2          15.2             6.3
                   CC/MCC                                                                        

  196              Interstitial lung disease w MCC  0.6529        20.0          16.7             11.6

  197              Interstitial lung disease w CC   0.6133        19.6          16.3             8.5

  198              Interstitial lung disease w/o    0.5956        19.7          16.4             6.7
                   CC/MCC                                                                        

  199              Pneumothorax w MCC               0.8249        25.0          20.8             13.8

  200              Pneumothorax w CC                0.7305        22.9          19.1             8.3

  201              Pneumothorax w/o CC/MCC          0.5472        20.3          16.9             6.5

  202              Bronchitis & asthma w CC/MCC     0.6903        21.1          17.6             6.9

  203              Bronchitis & asthma w/o CC/MCC   0.5650        17.1          14.3             5.3

  204              Respiratory signs & symptoms     0.8187        22.0          18.3             4.4

  205              Other respiratory system         0.8207        22.4          18.7             9.0
                   diagnoses w MCC                                                               

  206              Other respiratory system         0.7667        21.5          17.9             5.5
                   diagnoses w/o MCC                                                             

  207              Respiratory system diagnosis w   2.0266        34.3          28.6             22.6
                   ventilator support 96+ hours                                                  

  208              Respiratory system diagnosis w   1.5514        27.8          23.2             12.5
                   ventilator support \<96 hours                                                 

  215              Other heart assist system        0.8249        25.0          20.8             20.5
                   implant                                                                       

  216              Cardiac valve & oth maj          1.5545        35.2          29.3             28.7
                   cardiothoracic proc w card cath                                               
                   w MCC                                                                         

  217              Cardiac valve & oth maj          0.8249        25.0          20.8             17.7
                   cardiothoracic proc w card cath                                               
                   w CC                                                                          

  218              Cardiac valve & oth maj          0.8249        25.0          20.8             12.7
                   cardiothoracic proc w card cath                                               
                   w/o CC/MCC                                                                    

  219              Cardiac valve & oth maj          1.5545        35.2          29.3             22.6
                   cardiothoracic proc w/o card                                                  
                   cath w MCC                                                                    

  220              Cardiac valve & oth maj          0.8249        25.0          20.8             12.5
                   cardiothoracic proc w/o card                                                  
                   cath w CC                                                                     

  221              Cardiac valve & oth maj          0.8249        25.0          20.8             8.7
                   cardiothoracic proc w/o card                                                  
                   cath w/o CC/MCC                                                               

  222              Cardiac defib implant w cardiac  1.5545        35.2          29.3             20.9
                   cath w AMI/HF/shock w MCC                                                     

  223              Cardiac defib implant w cardiac  1.5545        35.2          29.3             11.0
                   cath w AMI/HF/shock w/o MCC                                                   

  224              Cardiac defib implant w cardiac  1.5545        35.2          29.3             18.2
                   cath w/o AMI/HF/shock w MCC                                                   

  225              Cardiac defib implant w cardiac  1.5545        35.2          29.3             9.2
                   cath w/o AMI/HF/shock w/o MCC                                                 

  226              Cardiac defibrillator implant    1.5545        35.2          29.3             16.8
                   w/o cardiac cath w MCC                                                        

  227              Cardiac defibrillator implant    1.5545        35.2          29.3             4.1
                   w/o cardiac cath w/o MCC                                                      

  228              Other cardiothoracic procedures  1.5410        35.0          29.2             23.2
                   w MCC                                                                         

  229              Other cardiothoracic procedures  1.2681        30.8          25.7             13.5
                   w CC                                                                          

  230              Other cardiothoracic procedures  0.8249        25.0          20.8             10.2
                   w/o CC/MCC                                                                    

  231              Coronary bypass w PTCA w MCC     1.5545        35.2          29.3             20.9

  232              Coronary bypass w PTCA w/o MCC   0.8249        25.0          20.8             13.1

  233              Coronary bypass w cardiac cath w 1.5545        35.2          29.3             21.0
                   MCC                                                                           

  234              Coronary bypass w cardiac cath   0.8249        25.0          20.8             12.2
                   w/o MCC                                                                       

  235              Coronary bypass w/o cardiac cath 1.5545        35.2          29.3             17.0
                   w MCC                                                                         

  236              Coronary bypass w/o cardiac cath 0.8249        25.0          20.8             9.0
                   w/o MCC                                                                       

  237              Major cardiovasc procedures w    1.5545        35.2          29.3             19.6
                   MCC or thoracic aortic anuerysm                                               
                   repair                                                                        

  238              Major cardiovasc procedures w/o  0.8249        25.0          20.8             8.1
                   MCC                                                                           

  239              Amputation for circ sys          1.3794        37.4          31.2             24.7
                   disorders exc upper limb & toe w                                              
                   MCC                                                                           

  240              Amputation for circ sys          1.2872        36.1          30.1             16.6
                   disorders exc upper limb & toe w                                              
                   CC                                                                            

  241              Amputation for circ sys          1.1417        29.0          24.2             10.7
                   disorders exc upper limb & toe                                                
                   w/o CC/MCC                                                                    

  242              Permanent cardiac pacemaker      1.5545        35.2          29.3             14.5
                   implant w MCC                                                                 

  243              Permanent cardiac pacemaker      1.5545        35.2          29.3             8.5
                   implant w CC                                                                  

  244              Permanent cardiac pacemaker      1.1417        29.0          24.2             4.6
                   implant w/o CC/MCC                                                            

  245              AICD lead & generator procedures 0.7305        22.9          19.1             4.9

  246              Perc cardiovasc proc w           0.8249        25.0          20.8             9.1
                   drug-eluting stent w MCC or 4+                                                
                   vessels/stents                                                                

  247              Perc cardiovasc proc w           0.8249        25.0          20.8             3.3
                   drug-eluting stent w/o MCC                                                    

  248              Perc cardiovasc proc w           1.5545        35.2          29.3             10.3
                   non-drug-eluting stent w MCC or                                               
                   4+ ves/stents                                                                 

  249              Perc cardiovasc proc w           1.5545        35.2          29.3             3.9
                   non-drug-eluting stent w/o MCC                                                

  250              Perc cardiovasc proc w/o         0.8249        25.0          20.8             12.7
                   coronary artery stent or AMI w                                                
                   MCC                                                                           

  251              Perc cardiovasc proc w/o         0.8249        25.0          20.8             4.6
                   coronary artery stent or AMI w/o                                              
                   MCC                                                                           

  252              Other vascular procedures w MCC  1.5410        35.0          29.2             15.1

  253              Other vascular procedures w CC   1.2681        30.8          25.7             10.2

  254              Other vascular procedures w/o    0.8249        25.0          20.8             4.3
                   CC/MCC                                                                        

  255              Upper limb & toe amputation for  1.1713        33.7          28.1             16.7
                   circ system disorders w MCC                                                   

  256              Upper limb & toe amputation for  0.9516        29.4          24.5             12.3
                   circ system disorders w CC                                                    

  257              Upper limb & toe amputation for  0.9516        29.4          24.5             8.2
                   circ system disorders w/o CC/MCC                                              

  258              Cardiac pacemaker device         1.5545        35.2          29.3             12.6
                   replacement w MCC                                                             

  259              Cardiac pacemaker device         1.5545        35.2          29.3             4.0
                   replacement w/o MCC                                                           

  260              Cardiac pacemaker revision       1.5545        35.2          29.3             17.4
                   except device replacement w MCC                                               

  261              Cardiac pacemaker revision       0.5472        20.3          16.9             6.4
                   except device replacement w CC                                                

  262              Cardiac pacemaker revision       0.5472        20.3          16.9             3.7
                   except device replacement w/o                                                 
                   CC/MCC                                                                        

  263              Vein ligation & stripping        0.8249        25.0          20.8             9.2

  264              Other circulatory system O.R.    1.0667        31.6          26.3             15.4
                   procedures                                                                    

  280              Acute myocardial infarction,     0.7263        21.4          17.8             12.0
                   discharged alive w MCC                                                        

  281              Acute myocardial infarction,     0.6931        22.8          19.0             7.8
                   discharged alive w CC                                                         

  282              Acute myocardia infarction,      0.6931        22.8          19.0             5.1
                   discharged alive w/o CC/MCC                                                   

  283              Acute myocardial infarction,     0.6609        17.0          14.2             9.0
                   expired w MCC                                                                 

  284              Acute myocardial infarction,     0.6609        17.0          14.2             5.4
                   expired w CC                                                                  

  285              Acute myocardial infarction,     0.6609        17.0          14.2             3.3
                   expired w/o CC/MCC                                                            

  286              Circulatory disorders except     1.1417        29.0          24.2             11.6
                   AMI, w card cath w MCC                                                        

  287              Circulatory disorders except     0.8249        25.0          20.8             5.0
                   AMI, w card cath w/o MCC                                                      

  288              Acute & subacute endocarditis w  0.9082        26.4          22.0             19.7
                   MCC                                                                           

  289              Acute & subacute endocarditis w  0.8580        26.4          22.0             13.7
                   CC                                                                            

  290              Acute & subacute endocarditis    0.7664        25.5          21.3             10.6
                   w/o CC/MCC                                                                    

  291              Heart failure & shock w MCC      0.6968        21.4          17.8             10.7

  292              Heart failure & shock w CC       0.6252        20.4          17.0             7.7

  293              Heart failure & shock w/o CC/MCC 0.5775        18.5          15.4             5.6

  294              Deep vein thrombophlebitis w     0.8249        25.0          20.8             8.6
                   CC/MCC                                                                        

  295              Deep vein thrombophlebitis w/o   0.8249        25.0          20.8             6.7
                   CC/MCC                                                                        

  296              Cardiac arrest, unexplained w    0.6609        17.0          14.2             4.8
                   MCC                                                                           

  297              Cardiac arrest, unexplained w CC 0.6609        17.0          14.2             2.7

  298              Cardiac arrest, unexplained w/o  0.6609        17.0          14.2             1.9
                   CC/MCC                                                                        

  299              Peripheral vascular disorders w  0.7152        24.8          20.7             11.2
                   MCC                                                                           

  300              Peripheral vascular disorders w  0.6150        22.2          18.5             8.2
                   CC                                                                            

  301              Peripheral vascular disorders    0.5557        19.4          16.2             6.0
                   w/o CC/MCC                                                                    

  302              Atherosclerosis w MCC            0.6170        21.9          18.3             6.9

  303              Atherosclerosis w/o MCC          0.5673        20.5          17.1             3.9

  304              Hypertension w MCC               0.8249        25.0          20.8             8.3

  305              Hypertension w/o MCC             0.5856        22.6          18.8             4.4

  306              Cardiac congenital & valvular    0.8786        24.2          20.2             10.2
                   disorders w MCC                                                               

  307              Cardiac congenital & valvular    0.7767        23.1          19.3             5.5
                   disorders w/o MCC                                                             

  308              Cardiac arrhythmia & conduction  0.7431        24.7          20.6             9.3
                   disorders w MCC                                                               

  309              Cardiac arrhythmia & conduction  0.5940        20.4          17.0             6.2
                   disorders w CC                                                                

  310              Cardiac arrhythmia & conduction  0.5184        17.0          14.2             4.2
                   disorders w/o CC/MCC                                                          

  311              Angina pectoris                  0.7305        22.9          19.1             3.5

  312              Syncope & collapse               0.5336        19.7          16.4             4.9

  313              Chest pain                       0.5472        20.3          16.9             3.1

  314              Other circulatory system         0.8123        23.1          19.3             11.8
                   diagnoses w MCC                                                               

  315              Other circulatory system         0.7114        21.6          18.0             7.3
                   diagnoses w CC                                                                

  316              Other circulatory system         0.6243        18.9          15.8             4.7
                   diagnoses w/o CC/MCC                                                          

  326              Stomach, esophageal & duodenal   1.8646        36.2          30.2             28.1
                   proc w MCC                                                                    

  327              Stomach, esophageal & duodenal   1.5545        35.2          29.3             16.8
                   proc w CC                                                                     

  328              Stomach, esophageal & duodenal   0.5472        20.3          16.9             7.2
                   proc w/o CC/MCC                                                               

  329              Major small & large bowel        1.5545        35.2          29.3             25.3
                   procedures w MCC                                                              

  330              Major small & large bowel        1.5545        35.2          29.3             14.6
                   procedures w CC                                                               

  331              Major small & large bowel        0.5472        20.3          16.9             8.7
                   procedures w/o CC/MCC                                                         

  332              Rectal resection w MCC           1.5057        36.1          30.1             22.6

  333              Rectal resection w CC            1.3309        30.7          25.6             13.0

  334              Rectal resection w/o CC/MCC      0.8249        25.0          20.8             8.6

  335              Peritoneal adhesiolysis w MCC    1.5545        35.2          29.3             22.9

  336              Peritoneal adhesiolysis w CC     0.7305        22.9          19.1             14.6

  337              Peritoneal adhesiolysis w/o      0.7305        22.9          19.1             9.3
                   CC/MCC                                                                        

  338              Appendectomy w complicated       0.8884        24.1          20.1             16.7
                   principal diag w MCC                                                          

  339              Appendectomy w complicated       0.7667        22.2          18.5             10.8
                   principal diag w CC                                                           

  340              Appendectomy w complicated       0.6856        19.9          16.6             6.6
                   principal diag w/o CC/MCC                                                     

  341              Appendectomy w/o complicated     0.8884        24.1          20.1             12.0
                   principal diag w MCC                                                          

  342              Appendectomy w/o complicated     0.7667        22.2          18.5             6.8
                   principal diag w CC                                                           

  343              Appendectomy w/o complicated     0.6856        19.9          16.6             3.4
                   principal diag w/o CC/MCC                                                     

  344              Minor small & large bowel        0.8884        24.1          20.1             19.1
                   procedures w MCC                                                              

  345              Minor small & large bowel        0.7667        22.2          18.5             10.9
                   procedures w CC                                                               

  346              Minor small & large bowel        0.6856        19.9          16.6             7.4
                   procedures w/o CC/MCC                                                         

  347              Anal & stomal procedures w MCC   1.1417        29.0          24.2             13.8

  348              Anal & stomal procedures w CC    0.8249        25.0          20.8             8.9

  349              Anal & stomal procedures w/o     0.5472        20.3          16.9             4.7
                   CC/MCC                                                                        

  350              Inguinal & femoral hernia        1.5545        35.2          29.3             13.6
                   procedures w MCC                                                              

  351              Inguinal & femoral hernia        1.1417        29.0          24.2             7.4
                   procedures w CC                                                               

  352              Inguinal & femoral hernia        0.8249        25.0          20.8             3.7
                   procedures w/o CC/MCC                                                         

  353              Hernia procedures except         0.8249        25.0          20.8             14.5
                   inguinal & femoral w MCC                                                      

  354              Hernia procedures except         0.8249        25.0          20.8             8.2
                   inguinal & femoral w CC                                                       

  355              Hernia procedures except         0.8249        25.0          20.8             4.4
                   inguinal & femoral w/o CC/MCC                                                 

  356              Other digestive system O.R.      1.5057        36.1          30.1             22.5
                   procedures w MCC                                                              

  357              Other digestive system O.R.      1.3309        30.7          25.6             13.3
                   procedures w CC                                                               

  358              Other digestive system O.R.      0.8249        25.0          20.8             7.6
                   procedures w/o CC/MCC                                                         

  368              Major esophageal disorders w MCC 1.1417        29.0          24.2             10.5

  369              Major esophageal disorders w CC  1.1417        29.0          24.2             7.1

  370              Major esophageal disorders w/o   1.1417        29.0          24.2             5.2
                   CC/MCC                                                                        

  371              Major gastrointestinal disorders 0.8884        24.1          20.1             14.1
                   & peritoneal infections w MCC                                                 

  372              Major gastrointestinal disorders 0.7667        22.2          18.5             10.6
                   & peritoneal infections w CC                                                  

  373              Major gastrointestinal disorders 0.6856        19.9          16.6             7.7
                   & peritoneal infections w/o                                                   
                   CC/MCC                                                                        

  374              Digestive malignancy w MCC       0.8340        22.9          19.1             14.4

  375              Digestive malignancy w CC        0.7563        19.7          16.4             9.7

  376              Digestive malignancy w/o CC/MCC  0.5472        20.3          16.9             6.5

  377              G.I. hemorrhage w MCC            0.7032        22.5          18.8             10.3

  378              G.I. hemorrhage w CC             0.6334        21.5          17.9             6.8

  379              G.I. hemorrhage w/o CC/MCC       0.5472        20.3          16.9             5.2

  380              Complicated peptic ulcer w MCC   0.8249        25.0          20.8             11.4

  381              Complicated peptic ulcer w CC    0.8249        25.0          20.8             7.9

  382              Complicated peptic ulcer w/o     0.7305        22.9          19.1             5.5
                   CC/MCC                                                                        

  383              Uncomplicated peptic ulcer w MCC 0.8249        25.0          20.8             9.1

  384              Uncomplicated peptic ulcer w/o   0.7305        22.9          19.1             5.9
                   MCC                                                                           

  385              Inflammatory bowel disease w MCC 0.8874        24.6          20.5             14.4

  386              Inflammatory bowel disease w CC  0.7655        22.9          19.1             9.0

  387              Inflammatory bowel disease w/o   0.7655        22.9          19.1             6.9
                   CC/MCC                                                                        

  388              G.I. obstruction w MCC           0.8967        22.8          19.0             12.0

  389              G.I. obstruction w CC            0.7893        21.9          18.3             8.0

  390              G.I. obstruction w/o CC/MCC      0.7893        21.9          18.3             5.5

  391              Esophagitis, gastroent & misc    0.8509        24.4          20.3             8.7
                   digest disorders w MCC                                                        

  392              Esophagitis, gastroent & misc    0.6943        20.4          17.0             5.5
                   digest disorders w/o MCC                                                      

  393              Other digestive system diagnoses 0.9915        25.5          21.3             11.4
                   w MCC                                                                         

  394              Other digestive system diagnoses 0.8523        22.0          18.3             7.7
                   w CC                                                                          

  395              Other digestive system diagnoses 0.7214        20.9          17.4             5.3
                   w/o CC/MCC                                                                    

  405              Pancreas, liver & shunt          1.5545        35.2          29.3             29.0
                   procedures w MCC                                                              

  406              Pancreas, liver & shunt          1.5545        35.2          29.3             16.0
                   procedures w CC                                                               

  407              Pancreas, liver & shunt          1.1417        29.0          24.2             9.2
                   procedures w/o CC/MCC                                                         

  408              Biliary tract proc except only   1.5545        35.2          29.3             23.7
                   cholecyst w or w/o c.d.e. w MCC                                               

  409              Biliary tract proc except only   1.5545        35.2          29.3             15.4
                   cholecyst w or w/o c.d.e. w CC                                                

  410              Biliary tract proc except only   1.5545        35.2          29.3             10.6
                   cholecyst w or w/o c.d.e. w/o                                                 
                   CC/MCC                                                                        

  411              Cholecystectomy w c.d.e. w MCC   1.1417        29.0          24.2             20.3

  412              Cholecystectomy w c.d.e. w CC    1.1417        29.0          24.2             13.5

  413              Cholecystectomy w c.d.e. w/o     1.1417        29.0          24.2             9.3
                   CC/MCC                                                                        

  414              Cholecystectomy except by        1.1417        29.0          24.2             18.4
                   laparoscope w/o c.d.e. w MCC                                                  

  415              Cholecystectomy except by        1.1417        29.0          24.2             11.6
                   laparoscope w/o c.d.e. w CC                                                   

  416              Cholecystectomy except by        1.1417        29.0          24.2             7.5
                   laparoscope w/o c.d.e. w/o                                                    
                   CC/MCC                                                                        

  417              Laparoscopic cholecystectomy w/o 1.5545        35.2          29.3             13.5
                   c.d.e. w MCC                                                                  

  418              Laparoscopic cholecystectomy w/o 1.1417        29.0          24.2             9.0
                   c.d.e. w CC                                                                   

  419              Laparoscopic cholecystectomy w/o 1.1417        29.0          24.2             5.0
                   c.d.e. w/o CC/MCC                                                             

  420              Hepatobiliary diagnostic         1.1417        29.0          24.2             24.2
                   procedures w MCC                                                              

  421              Hepatobiliary diagnostic         0.8249        25.0          20.8             12.9
                   procedures w CC                                                               

  422              Hepatobiliary diagnostic         0.8249        25.0          20.8             7.3
                   procedures w/o CC/MCC                                                         

  423              Other hepatobiliary or pancreas  1.1417        29.0          24.2             24.2
                   O.R. procedures w MCC                                                         

  424              Other hepatobiliary or pancreas  0.8249        25.0          20.8             17.1
                   O.R. procedures w CC                                                          

  425              Other hepatobiliary or pancreas  0.8249        25.0          20.8             9.2
                   O.R. procedures w/o CC/MCC                                                    

  432              Cirrhosis & alcoholic hepatitis  0.6223        19.0          15.8             11.1
                   w MCC                                                                         

  433              Cirrhosis & alcoholic hepatitis  0.6223        19.0          15.8             7.7
                   w CC                                                                          

  434              Cirrhosis & alcoholic hepatitis  0.5472        20.3          16.9             5.7
                   w/o CC/MCC                                                                    

  435              Malignancy of hepatobiliary      0.7422        20.2          16.8             12.6
                   system or pancreas w MCC                                                      

  436              Malignancy of hepatobiliary      0.7086        19.6          16.3             9.5
                   system or pancreas w CC                                                       

  437              Malignancy of hepatobiliary      0.7086        19.6          16.3             7.1
                   system or pancreas w/o CC/MCC                                                 

  438              Disorders of pancreas except     1.0057        24.3          20.3             12.5
                   malignancy w MCC                                                              

  439              Disorders of pancreas except     0.8437        21.9          18.3             8.5
                   malignancy w CC                                                               

  440              Disorders of pancreas except     0.7204        18.8          15.7             5.9
                   malignancy w/o CC/MCC                                                         

  441              Disorders of liver except        0.7588        21.8          18.2             11.3
                   malig,cirr,alc hepa w MCC                                                     

  442              Disorders of liver except        0.6925        21.2          17.7             8.1
                   malig,cirr,alc hepa w CC                                                      

  443              Disorders of liver except        0.6925        21.2          17.7             6.0
                   malig,cirr,alc hepa w/o CC/MCC                                                

  444              Disorders of the biliary tract w 0.8181        24.0          20.0             10.7
                   MCC                                                                           

  445              Disorders of the biliary tract w 0.6977        21.7          18.1             7.6
                   CC                                                                            

  446              Disorders of the biliary tract   0.5472        20.3          16.9             5.2
                   w/o CC/MCC                                                                    

  453              Combined anterior/posterior      1.5545        35.2          29.3             24.9
                   spinal fusion w MCC                                                           

  454              Combined anterior/posterior      1.5545        35.2          29.3             12.7
                   spinal fusion w CC                                                            

  455              Combined anterior/posterior      1.5545        35.2          29.3             7.1
                   spinal fusion w/o CC/MCC                                                      

  456              Spinal fus exc cerv w spinal     1.5545        35.2          29.3             24.9
                   curv/malig/infec or 9+ fus w MCC                                              

  457              Spinal fus exc cerv w spinal     1.5545        35.2          29.3             11.6
                   curv/malig/infec or 9+ fus w CC                                               

  458              Spinal fus exc cerv w spinal     1.5545        35.2          29.3             6.8
                   curv/malig/infec or 9+ fus w/o                                                
                   CC/MCC                                                                        

  459              Spinal fusion except cervical w  1.5545        35.2          29.3             14.7
                   MCC                                                                           

  460              Spinal fusion except cervical    1.5545        35.2          29.3             6.4
                   w/o MCC                                                                       

  461              Bilateral or multiple major      1.5545        35.2          29.3             12.6
                   joint procs of lower extremity w                                              
                   MCC                                                                           

  462              Bilateral or multiple major      1.1417        29.0          24.2             5.8
                   joint procs of lower extremity                                                
                   w/o MCC                                                                       

  463              Wnd debrid & skn grft exc hand,  1.3514        38.8          32.3             27.4
                   for musculo-conn tiss dis w MCC                                               

  464              Wnd debrid & skn grft exc hand,  1.1906        36.3          30.3             16.8
                   for musculo-conn tiss dis w CC                                                

  465              Wnd debrid & skn grft exc hand,  1.0747        29.6          24.7             10.0
                   for musculo-conn tiss dis w/o                                                 
                   CC/MCC                                                                        

  466              Revision of hip or knee          1.5545        35.2          29.3             14.5
                   replacement w MCC                                                             

  467              Revision of hip or knee          1.5545        35.2          29.3             8.0
                   replacement w CC                                                              

  468              Revision of hip or knee          1.5545        35.2          29.3             5.5
                   replacement w/o CC/MCC                                                        

  469              Major joint replacement or       1.5545        35.2          29.3             12.6
                   reattachment of lower extremity                                               
                   w MCC                                                                         

  470              Major joint replacement or       1.5545        35.2          29.3             5.4
                   reattachment of lower extremity                                               
                   w/o MCC                                                                       

  471              Cervical spinal fusion w MCC     1.5545        35.2          29.3             17.3

  472              Cervical spinal fusion w CC      1.5545        35.2          29.3             7.0

  473              Cervical spinal fusion w/o       1.5545        35.2          29.3             2.9
                   CC/MCC                                                                        

  474              Amputation for musculoskeletal   1.3338        36.6          30.5             20.4
                   sys & conn tissue dis w MCC                                                   

  475              Amputation for musculoskeletal   1.1390        32.7          27.3             13.9
                   sys & conn tissue dis w CC                                                    

  476              Amputation for musculoskeletal   1.1390        32.7          27.3             8.0
                   sys & conn tissue dis w/o CC/MCC                                              

  477              Biopsies of musculoskeletal      1.5545        35.2          29.3             20.7
                   system & connective tissue w MCC                                              

  478              Biopsies of musculoskeletal      1.1417        29.0          24.2             11.9
                   system & connective tissue w CC                                               

  479              Biopsies of musculoskeletal      1.1417        29.0          24.2             4.3
                   system & connective tissue w/o                                                
                   CC/MCC                                                                        

  480              Hip & femur procedures except    1.5545        35.2          29.3             14.1
                   major joint w MCC                                                             

  481              Hip & femur procedures except    1.5545        35.2          29.3             8.4
                   major joint w CC                                                              

  482              Hip & femur procedures except    1.1417        29.0          24.2             6.8
                   major joint w/o CC/MCC                                                        

  483              Major joint & limb reattachment  1.5545        35.2          29.3             6.6
                   proc of upper extremity w CC/MCC                                              

  484              Major joint & limb reattachment  1.1417        29.0          24.2             3.6
                   proc of upper extremity w/o                                                   
                   CC/MCC                                                                        

  485              Knee procedures w pdx of         1.5545        35.2          29.3             18.9
                   infection w MCC                                                               

  486              Knee procedures w pdx of         1.1417        29.0          24.2             12.3
                   infection w CC                                                                

  487              Knee procedures w pdx of         1.1417        29.0          24.2             8.5
                   infection w/o CC/MCC                                                          

  488              Knee procedures w/o pdx of       1.5545        35.2          29.3             7.8
                   infection w CC/MCC                                                            

  489              Knee procedures w/o pdx of       1.5545        35.2          29.3             4.7
                   infection w/o CC/MCC                                                          

  490              Back & neck proc exc spinal      1.1417        29.0          24.2             7.6
                   fusion w CC/MCC or disc                                                       
                   device/neurostim                                                              

  491              Back & neck proc exc spinal      1.1417        29.0          24.2             3.4
                   fusion w/o CC/MCC                                                             

  492              Lower extrem & humer proc except 1.5545        35.2          29.3             13.6
                   hip,foot,femur w MCC                                                          

  493              Lower extrem & humer proc except 1.1417        29.0          24.2             8.2
                   hip,foot,femur w CC                                                           

  494              Lower extrem & humer proc except 0.8249        25.0          20.8             5.1
                   hip,foot,femur w/o CC/MCC                                                     

  495              Local excision & removal int fix 1.3650        38.1          31.8             18.2
                   devices exc hip & femur w MCC                                                 

  496              Local excision & removal int fix 1.1981        36.8          30.7             9.8
                   devices exc hip & femur w CC                                                  

  497              Local excision & removal int fix 1.1417        29.0          24.2             4.9
                   devices exc hip & femur w/o                                                   
                   CC/MCC                                                                        

  498              Local excision & removal int fix 1.5545        35.2          29.3             13.4
                   devices of hip & femur w CC/MCC                                               

  499              Local excision & removal int fix 0.7305        22.9          19.1             4.9
                   devices of hip & femur w/o                                                    
                   CC/MCC                                                                        

  500              Soft tissue procedures w MCC     1.3212        35.2          29.3             18.8

  501              Soft tissue procedures w CC      1.2903        30.7          25.6             9.6

  502              Soft tissue procedures w/o       0.8249        25.0          20.8             4.5
                   CC/MCC                                                                        

  503              Foot procedures w MCC            1.1417        29.0          24.2             14.6

  504              Foot procedures w CC             0.8249        25.0          20.8             10.5

  505              Foot procedures w/o CC/MCC       0.5472        20.3          16.9             5.3

  506              Major thumb or joint procedures  0.7305        22.9          19.1             5.0

  507              Major shoulder or elbow joint    0.8249        25.0          20.8             8.4
                   procedures w CC/MCC                                                           

  508              Major shoulder or elbow joint    0.8249        25.0          20.8             3.0
                   procedures w/o CC/MCC                                                         

  509              Arthroscopy                      0.5472        20.3          16.9             4.2

  510              Shoulder,elbow or forearm        1.1417        29.0          24.2             10.7
                   proc,exc major joint proc w MCC                                               

  511              Shoulder,elbow or forearm        1.1417        29.0          24.2             6.2
                   proc,exc major joint proc w CC                                                

  512              Shoulder,elbow or forearm        0.5472        20.3          16.9             3.1
                   proc,exc major joint proc w/o                                                 
                   CC/MCC                                                                        

  513              Hand or wrist proc, except major 1.5545        35.2          29.3             8.4
                   thumb or joint proc w CC/MCC                                                  

  514              Hand or wrist proc, except major 0.7305        22.9          19.1             4.0
                   thumb or joint proc w/o CC/MCC                                                

  515              Other musculoskelet sys & conn   1.3230        34.8          29.0             18.1
                   tiss O.R. proc w MCC                                                          

  516              Other musculoskelet sys & conn   1.1417        29.0          24.2             10.1
                   tiss O.R. proc w CC                                                           

  517              Other musculoskelet sys & conn   0.8249        25.0          20.8             4.5
                   tiss O.R. proc w/o CC/MCC                                                     

  533              Fractures of femur w MCC         0.8249        25.0          20.8             11.2

  534              Fractures of femur w/o MCC       0.7305        22.9          19.1             6.3

  535              Fractures of hip & pelvis w MCC  0.7305        22.9          19.1             10.1

  536              Fractures of hip & pelvis w/o    0.5998        23.7          19.8             6.0
                   MCC                                                                           

  537              Sprains, strains, & dislocations 0.5472        20.3          16.9             7.3
                   of hip, pelvis & thigh w CC/MCC                                               

  538              Sprains, strains, & dislocations 0.5472        20.3          16.9             4.8
                   of hip, pelvis & thigh w/o                                                    
                   CC/MCC                                                                        

  539              Osteomyelitis w MCC              0.9013        29.7          24.8             16.2

  540              Osteomyelitis w CC               0.8107        28.7          23.9             11.3

  541              Osteomyelitis w/o CC/MCC         0.7787        26.9          22.4             8.9

  542              Pathological fractures &         0.7359        21.7          18.1             14.0
                   musculoskelet & conn tiss malig                                               
                   w MCC                                                                         

  543              Pathological fractures &         0.6347        21.3          17.8             9.4
                   musculoskelet & conn tiss malig                                               
                   w CC                                                                          

  544              Pathological fractures &         0.5472        20.3          16.9             6.8
                   musculoskelet & conn tiss malig                                               
                   w/o CC/MCC                                                                    

  545              Connective tissue disorders w    0.8501        23.9          19.9             14.7
                   MCC                                                                           

  546              Connective tissue disorders w CC 0.6492        20.7          17.3             8.7

  547              Connective tissue disorders w/o  0.5472        20.3          16.9             6.1
                   CC/MCC                                                                        

  548              Septic arthritis w MCC           0.8584        28.2          23.5             15.0

  549              Septic arthritis w CC            0.7347        26.4          22.0             9.8

  550              Septic arthritis w/o CC/MCC      0.6704        23.5          19.6             7.2

  551              Medical back problems w MCC      0.7305        26.6          22.2             11.6

  552              Medical back problems w/o MCC    0.6022        22.8          19.0             6.5

  553              Bone diseases & arthropathies w  0.8249        25.0          20.8             9.6
                   MCC                                                                           

  554              Bone diseases & arthropathies    0.4822        20.5          17.1             5.8
                   w/o MCC                                                                       

  555              Signs & symptoms of              0.7305        22.9          19.1             7.8
                   musculoskeletal system & conn                                                 
                   tissue w MCC                                                                  

  556              Signs & symptoms of              0.7305        22.9          19.1             5.0
                   musculoskeletal system & conn                                                 
                   tissue w/o MCC                                                                

  557              Tendonitis, myositis & bursitis  0.8177        25.9          21.6             11.0
                   w MCC                                                                         

  558              Tendonitis, myositis & bursitis  0.6919        21.4          17.8             6.6
                   w/o MCC                                                                       

  559              Aftercare, musculoskeletal       0.7157        26.2          21.8             11.9
                   system & connective tissue w MCC                                              

  560              Aftercare, musculoskeletal       0.6393        24.6          20.5             7.5
                   system & connective tissue w CC                                               

  561              Aftercare, musculoskeletal       0.5889        21.7          18.1             4.2
                   system & connective tissue w/o                                                
                   CC/MCC                                                                        

  562              Fx, sprn, strn & disl except     1.1417        29.0          24.2             10.4
                   femur, hip, pelvis & thigh w MCC                                              

  563              Fx, sprn, strn & disl except     0.5472        20.3          16.9             5.7
                   femur, hip, pelvis & thigh w/o                                                
                   MCC                                                                           

  564              Other musculoskeletal sys &      0.8134        24.9          20.8             11.6
                   connective tissue diagnoses w                                                 
                   MCC                                                                           

  565              Other musculoskeletal sys &      0.7382        24.8          20.7             8.1
                   connective tissue diagnoses w CC                                              

  566              Other musculoskeletal sys &      0.6862        22.1          18.4             5.9
                   connective tissue diagnoses w/o                                               
                   CC/MCC                                                                        

  573              Skin graft &/or debrid for skn   1.3068        38.0          31.7             22.2
                   ulcer or cellulitis w MCC                                                     

  574              Skin graft &/or debrid for skn   1.1567        37.1          30.9             14.9
                   ulcer or cellulitis w CC                                                      

  575              Skin graft &/or debrid for skn   0.9938        31.7          26.4             9.4
                   ulcer or cellulitis w/o CC/MCC                                                

  576              Skin graft &/or debrid exc for   1.5545        35.2          29.3             20.3
                   skin ulcer or cellulitis w MCC                                                

  577              Skin graft &/or debrid exc for   1.1417        29.0          24.2             9.9
                   skin ulcer or cellulitis w CC                                                 

  578              Skin graft &/or debrid exc for   0.7305        22.9          19.1             5.4
                   skin ulcer or cellulitis w/o                                                  
                   CC/MCC                                                                        

  579              Other skin, subcut tiss & breast 1.2793        36.8          30.7             18.5
                   proc w MCC                                                                    

  580              Other skin, subcut tiss & breast 1.1001        34.8          29.0             9.0
                   proc w CC                                                                     

  581              Other skin, subcut tiss & breast 0.9100        29.9          24.9             3.9
                   proc w/o CC/MCC                                                               

  582              Mastectomy for malignancy w      1.5545        35.2          29.3             4.3
                   CC/MCC                                                                        

  583              Mastectomy for malignancy w/o    1.5545        35.2          29.3             2.6
                   CC/MCC                                                                        

  584              Breast biopsy, local excision &  1.1417        29.0          24.2             9.5
                   other breast procedures w CC/MCC                                              

  585              Breast biopsy, local excision &  1.1417        29.0          24.2             3.2
                   other breast procedures w/o                                                   
                   CC/MCC                                                                        

  592              Skin ulcers w MCC                0.8875        27.1          22.6             14.2

  593              Skin ulcers w CC                 0.7877        26.8          22.3             10.0

  594              Skin ulcers w/o CC/MCC           0.7342        24.3          20.3             7.7

  595              Major skin disorders w MCC       0.7525        24.5          20.4             13.2

  596              Major skin disorders w/o MCC     0.6155        23.8          19.8             7.6

  597              Malignant breast disorders w MCC 0.8249        25.0          20.8             13.7

  598              Malignant breast disorders w CC  0.7305        22.9          19.1             9.0

  599              Malignant breast disorders w/o   0.7305        22.9          19.1             5.7
                   CC/MCC                                                                        

  600              Non-malignant breast disorders w 0.7305        22.9          19.1             8.5
                   CC/MCC                                                                        

  601              Non-malignant breast disorders   0.7305        22.9          19.1             6.0
                   w/o CC/MCC                                                                    

  602              Cellulitis w MCC                 0.6643        22.5          18.8             11.1

  603              Cellulitis w/o MCC               0.5528        19.4          16.2             7.3

  604              Trauma to the skin, subcut tiss  0.8249        25.0          20.8             8.8
                   & breast w MCC                                                                

  605              Trauma to the skin, subcut tiss  0.5685        21.2          17.7             5.4
                   & breast w/o MCC                                                              

  606              Minor skin disorders w MCC       0.8324        23.2          19.3             9.5

  607              Minor skin disorders w/o MCC     0.6776        22.6          18.8             5.9

  614              Adrenal & pituitary procedures w 1.2008        33.1          27.6             11.6
                   CC/MCC                                                                        

  615              Adrenal & pituitary procedures   0.7305        22.9          19.1             5.1
                   w/o CC/MCC                                                                    

  616              Amputat of lower limb for        1.4505        41.0          34.2             24.2
                   endocrine,nutrit,& metabol dis w                                              
                   MCC                                                                           

  617              Amputat of lower limb for        1.2414        33.3          27.8             14.5
                   endocrine,nutrit,& metabol dis w                                              
                   CC                                                                            

  618              Amputat of lower limb for        0.8249        25.0          20.8             9.9
                   endocrine,nutrit,& metabol dis                                                
                   w/o CC/MCC                                                                    

  619              O.R. procedures for obesity w    0.8249        25.0          20.8             14.6
                   MCC                                                                           

  620              O.R. procedures for obesity w CC 0.8249        25.0          20.8             6.3

  621              O.R. procedures for obesity w/o  0.8249        25.0          20.8             3.6
                   CC/MCC                                                                        

  622              Skin grafts & wound debrid for   1.1462        35.6          29.7             21.1
                   endoc, nutrit & metab dis w MCC                                               

  623              Skin grafts & wound debrid for   1.0197        32.2          26.8             13.5
                   endoc, nutrit & metab dis w CC                                                

  624              Skin grafts & wound debrid for   0.8249        25.0          20.8             9.4
                   endoc, nutrit & metab dis w/o                                                 
                   CC/MCC                                                                        

  625              Thyroid, parathyroid &           1.3385        36.6          30.5             12.4
                   thyroglossal procedures w MCC                                                 

  626              Thyroid, parathyroid &           1.2008        33.1          27.6             5.0
                   thyroglossal procedures w CC                                                  

  627              Thyroid, parathyroid &           0.7305        22.9          19.1             2.1
                   thyroglossal procedures w/o                                                   
                   CC/MCC                                                                        

  628              Other endocrine, nutrit & metab  1.3385        36.6          30.5             20.1
                   O.R. proc w MCC                                                               

  629              Other endocrine, nutrit & metab  1.2008        33.1          27.6             14.3
                   O.R. proc w CC                                                                

  630              Other endocrine, nutrit & metab  0.7305        22.9          19.1             8.4
                   O.R. proc w/o CC/MCC                                                          

  637              Diabetes w MCC                   0.7726        25.8          21.5             9.8

  638              Diabetes w CC                    0.6757        24.0          20.0             6.7

  639              Diabetes w/o CC/MCC              0.6064        20.6          17.2             4.7

  640              Nutritional & misc metabolic     0.7879        23.2          19.3             9.1
                   disorders w MCC                                                               

  641              Nutritional & misc metabolic     0.6889        22.0          18.3             6.0
                   disorders w/o MCC                                                             

  642              Inborn errors of metabolism      0.7305        22.9          19.1             8.3

  643              Endocrine disorders w MCC        0.7358        24.9          20.8             12.4

  644              Endocrine disorders w CC         0.7358        24.9          20.8             8.6

  645              Endocrine disorders w/o CC/MCC   0.5472        20.3          16.9             6.1

  652              Kidney transplant                0.0000        0.0           0.0              0.0

  653              Major bladder procedures w MCC   1.1417        29.0          24.2             24.2

  654              Major bladder procedures w CC    0.7305        22.9          19.1             14.7

  655              Major bladder procedures w/o     0.5472        20.3          16.9             10.0
                   CC/MCC                                                                        

  656              Kidney & ureter procedures for   0.8249        25.0          20.8             16.8
                   neoplasm w MCC                                                                

  657              Kidney & ureter procedures       0.8249        25.0          20.8             9.2
                   forneoplasm w CC                                                              

  658              Kidney & ureter procedures for   0.8249        25.0          20.8             5.7
                   neoplasm w/o CC/MCC                                                           

  659              Kidney & ureter procedures for   1.1417        29.0          24.2             18.5
                   non-neoplasm w MCC                                                            

  660              Kidney & ureter procedures for   0.7305        22.9          19.1             10.6
                   non-neoplasm w CC                                                             

  661              Kidney & ureter procedures for   0.5472        20.3          16.9             5.1
                   non-neoplasm w/o CC/MCC                                                       

  662              Minor bladder procedures w MCC   0.8249        25.0          20.8             17.7

  663              Minor bladder procedures w CC    0.8249        25.0          20.8             8.5

  664              Minor bladder procedures w/o     1.5545        35.2          29.3             3.0
                   CC/MCC                                                                        

  665              Prostatectomy w MCC              0.8249        25.0          20.8             20.2

  666              Prostatectomy w CC               0.8249        25.0          20.8             10.7

  667              Prostatectomy w/o CC/MCC         1.1417        29.0          24.2             4.0

  668              Transurethral procedures w MCC   1.5545        35.2          29.3             14.4

  669              Transurethral procedures w CC    1.5545        35.2          29.3             7.0

  670              Transurethral procedures w/o     0.8249        25.0          20.8             3.7
                   CC/MCC                                                                        

  671              Urethral procedures w CC/MCC     0.7305        22.9          19.1             9.6

  672              Urethral procedures w/o CC/MCC   0.5472        20.3          16.9             3.8

  673              Other kidney & urinary tract     1.3255        33.6          28.0             17.6
                   procedures w MCC                                                              

  674              Other kidney & urinary tract     1.2557        30.6          25.5             11.1
                   procedures w CC                                                               

  675              Other kidney & urinary tract     1.1417        29.0          24.2             2.7
                   procedures w/o CC/MCC                                                         

  682              Renal failure w MCC              0.8553        23.6          19.7             12.1

  683              Renal failure w CC               0.7752        21.8          18.2             9.0

  684              Renal failure w/o CC/MCC         0.7121        20.5          17.1             5.9

  685              Admit for renal dialysis         0.7726        26.0          21.7             5.4

  686              Kidney & urinary tract neoplasms 0.8933        23.6          19.7             13.2
                   w MCC                                                                         

  687              Kidney & urinary tract neoplasms 0.7305        22.9          19.1             8.5
                   w CC                                                                          

  688              Kidney & urinary tract neoplasms 0.5472        20.3          16.9             5.1
                   w/o CC/MCC                                                                    

  689              Kidney & urinary tract           0.6624        22.9          19.1             9.9
                   infections w MCC                                                              

  690              Kidney & urinary tract           0.5655        20.2          16.8             6.6
                   infections w/o MCC                                                            

  691              Urinary stones w esw lithotripsy 1.5545        35.2          29.3             6.6
                   w CC/MCC                                                                      

  692              Urinary stones w esw lithotripsy 1.5545        35.2          29.3             3.4
                   w/o CC/MCC                                                                    

  693              Urinary stones w/o esw           0.7305        22.9          19.1             8.4
                   lithotripsy w MCC                                                             

  694              Urinary stones w/o esw           0.7305        22.9          19.1             3.9
                   lithotripsy w/o MCC                                                           

  695              Kidney & urinary tract signs &   0.8249        25.0          20.8             9.1
                   symptoms w MCC                                                                

  696              Kidney & urinary tract signs &   0.5472        20.3          16.9             5.0
                   symptoms w/o MCC                                                              

  697              Urethral stricture               0.5472        20.3          16.9             5.1

  698              Other kidney & urinary tract     0.7919        22.6          18.8             10.9
                   diagnoses w MCC                                                               

  699              Other kidney & urinary tract     0.7293        22.1          18.4             7.7
                   diagnoses w CC                                                                

  700              Other kidney & urinary tract     0.6052        19.6          16.3             5.4
                   diagnoses w/o CC/MCC                                                          

  707              Major male pelvic procedures w   0.7305        22.9          19.1             6.9
                   CC/MCC                                                                        

  708              Major male pelvic procedures w/o 0.5472        20.3          16.9             3.5
                   CC/MCC                                                                        

  709              Penis procedures w CC/MCC        1.1417        29.0          24.2             10.3

  710              Penis procedures w/o CC/MCC      1.1417        29.0          24.2             2.7

  711              Testes procedures w CC/MCC       1.1417        29.0          24.2             13.2

  712              Testes procedures w/o CC/MCC     1.1417        29.0          24.2             4.6

  713              Transurethral prostatectomy w    1.5545        35.2          29.3             6.5
                   CC/MCC                                                                        

  714              Transurethral prostatectomy w/o  0.5472        20.3          16.9             2.9
                   CC/MCC                                                                        

  715              Other male reproductive system   1.5545        35.2          29.3             10.1
                   O.R. proc for malignancy w                                                    
                   CC/MCC                                                                        

  716              Other male reproductive system   1.5545        35.2          29.3             2.0
                   O.R. proc for malignancy w/o                                                  
                   CC/MCC                                                                        

  717              Other male reproductive system   1.1417        29.0          24.2             12.4
                   O.R. proc exc malignancy w                                                    
                   CC/MCC                                                                        

  718              Other male reproductive system   0.5472        20.3          16.9             4.1
                   O.R. proc exc malignancy w/o                                                  
                   CC/MCC                                                                        

  722              Malignancy, male reproductive    0.8249        25.0          20.8             12.1
                   system w MCC                                                                  

  723              Malignancy, male reproductive    0.7305        22.9          19.1             8.6
                   system w CC                                                                   

  724              Malignancy, male reproductive    0.5472        20.3          16.9             5.3
                   system w/o CC/MCC                                                             

  725              Benign prostatic hypertrophy w   1.1417        29.0          24.2             9.0
                   MCC                                                                           

  726              Benign prostatic hypertrophy w/o 0.5472        20.3          16.9             5.5
                   MCC                                                                           

  727              Inflammation of the male         0.7754        25.9          21.6             10.4
                   reproductive system w MCC                                                     

  728              Inflammation of the male         0.6172        20.8          17.3             6.2
                   reproductive system w/o MCC                                                   

  729              Other male reproductive system   1.0319        26.6          22.2             8.4
                   diagnoses w CC/MCC                                                            

  730              Other male reproductive system   0.7305        22.9          19.1             4.9
                   diagnoses w/o CC/MCC                                                          

  734              Pelvic evisceration, rad         1.1417        29.0          24.2             11.8
                   hysterectomy & rad vulvectomy w                                               
                   CC/MCC                                                                        

  735              Pelvic evisceration, rad         0.5472        20.3          16.9             5.3
                   hysterectomy & rad vulvectomy                                                 
                   w/o CC/MCC                                                                    

  736              Uterine & adnexa proc for        1.1417        29.0          24.2             21.5
                   ovarian or adnexal malignancy w                                               
                   MCC                                                                           

  737              Uterine & adnexa proc for        0.8249        25.0          20.8             11.0
                   ovarian or adnexal malignancy w                                               
                   CC                                                                            

  738              Uterine & adnexa proc for        0.5472        20.3          16.9             5.6
                   ovarian or adnexal malignancy                                                 
                   w/o CC/MCC                                                                    

  739              Uterine,adnexa proc for          1.1417        29.0          24.2             15.9
                   non-ovarian/adnexal malig w MCC                                               

  740              Uterine,adnexa proc for          0.8249        25.0          20.8             7.7
                   non-ovarian/adnexal malig w CC                                                

  741              Uterine,adnexa proc for          0.5472        20.3          16.9             4.5
                   non-ovarian/adnexal malig w/o                                                 
                   CC/MCC                                                                        

  742              Uterine & adnexa proc for        0.8249        25.0          20.8             6.9
                   non-malignancy w CC/MCC                                                       

  743              Uterine & adnexa proc for        0.5472        20.3          16.9             3.3
                   non-malignancy w/o CC/MCC                                                     

  744              D&C, conization, laparascopy &   0.8249        25.0          20.8             9.3
                   tubal interruption w CC/MCC                                                   

  745              D&C, conization, laparascopy &   0.8249        25.0          20.8             3.8
                   tubal interruption w/o CC/MCC                                                 

  746              Vagina, cervix & vulva           0.8249        25.0          20.8             6.4
                   procedures w CC/MCC                                                           

  747              Vagina, cervix & vulva           0.8249        25.0          20.8             2.8
                   procedures w/o CC/MCC                                                         

  748              Female reproductive system       0.8249        25.0          20.8             2.6
                   reconstructive procedures                                                     

  749              Other female reproductive system 0.8249        25.0          20.8             16.3
                   O.R. procedures w CC/MCC                                                      

  750              Other female reproductive system 0.8249        25.0          20.8             5.1
                   O.R. procedures w/o CC/MCC                                                    

  754              Malignancy, female reproductive  1.1417        29.0          24.2             14.7
                   system w MCC                                                                  

  755              Malignancy, female reproductive  0.8249        25.0          20.8             9.1
                   system w CC                                                                   

  756              Malignancy, female reproductive  0.5472        20.3          16.9             5.1
                   system w/o CC/MCC                                                             

  757              Infections, female reproductive  0.8375        22.6          18.8             13.9
                   system w MCC                                                                  

  758              Infections, female reproductive  0.8317        27.2          22.7             9.5
                   system w CC                                                                   

  759              Infections, female reproductive  0.5472        20.3          16.9             7.2
                   system w/o CC/MCC                                                             

  760              Menstrual & other female         1.1417        29.0          24.2             6.0
                   reproductive system disorders w                                               
                   CC/MCC                                                                        

  761              Menstrual & other female         0.5472        20.3          16.9             3.8
                   reproductive system disorders                                                 
                   w/o CC/MCC                                                                    

  765              Cesarean section w CC/MCC        0.8249        25.0          20.8             7.4

  766              Cesarean section w/o CC/MCC      0.7305        22.9          19.1             4.3

  767              Vaginal delivery w sterilization 0.7305        22.9          19.1             4.1
                   &/or D&C                                                                      

  768              Vaginal delivery w O.R. proc     0.7305        22.9          19.1             8.9
                   except steril &/or D&C                                                        

  769              Postpartum & post abortion       0.7305        22.9          19.1             8.6
                   diagnoses w O.R. procedure                                                    

  770              Abortion w D&C, aspiration       0.7305        22.9          19.1             3.5
                   curettage or hysterotomy                                                      

  774              Vaginal delivery w complicating  0.7305        22.9          19.1             4.5
                   diagnoses                                                                     

  775              Vaginal delivery w/o             0.7305        22.9          19.1             3.1
                   complicating diagnoses                                                        

  776              Postpartum & post abortion       1.1417        29.0          24.2             5.4
                   diagnoses w/o O.R. procedure                                                  

  777              Ectopic pregnancy                0.7305        22.9          19.1             3.0

  778              Threatened abortion              0.5472        20.3          16.9             4.2

  779              Abortion w/o D&C                 0.5472        20.3          16.9             3.6

  780              False labor                      0.5472        20.3          16.9             2.7

  781              Other antepartum diagnoses w     1.1417        29.0          24.2             5.9
                   medical complications                                                         

  782              Other antepartum diagnoses w/o   0.5472        20.3          16.9             3.6
                   medical complications                                                         

  789              Neonates, died or transferred to 0.5472        20.3          16.9             1.5
                   another acute care facility                                                   

  790              Extreme immaturity or            0.5472        20.3          16.9             16.9
                   respiratory distress syndrome,                                                
                   neonate                                                                       

  791              Prematurity w major problems     1.1417        29.0          24.2             13.3

  792              Prematurity w/o major problems   0.5472        20.3          16.9             8.6

  793              Full term neonate w major        1.1417        29.0          24.2             17.6
                   problems                                                                      

  794              Neonate w other significant      1.1417        29.0          24.2             1.7
                   problems                                                                      

  795              Normal newborn                   0.5472        20.3          16.9             3.1

  799              Splenectomy w MCC                1.1417        29.0          24.2             23.5

  800              Splenectomy w CC                 0.8249        25.0          20.8             13.0

  801              Splenectomy w/o CC/MCC           0.8249        25.0          20.8             7.5

  802              Other O.R. proc of the blood &   1.5545        35.2          29.3             21.4
                   blood forming organs w MCC                                                    

  803              Other O.R. proc of the blood &   0.7305        22.9          19.1             10.8
                   blood forming organs w CC                                                     

  804              Other O.R. proc of the blood &   0.7305        22.9          19.1             5.2
                   blood forming organs w/o CC/MCC                                               

  808              Major hematol/immun diag exc     0.8009        20.7          17.3             12.8
                   sickle cell crisis & coagul w                                                 
                   MCC                                                                           

  809              Major hematol/immun diag exc     0.8009        20.7          17.3             7.9
                   sickle cell crisis & coagul w CC                                              

  810              Major hematol/immun diag exc     0.8009        20.7          17.3             6.2
                   sickle cell crisis & coagul w/o                                               
                   CC/MCC                                                                        

  811              Red blood cell disorders w MCC   0.6655        23.2          19.3             9.0

  812              Red blood cell disorders w/o MCC 0.5699        19.5          16.3             5.9

  813              Coagulation disorders            0.8015        21.5          17.9             8.3

  814              Reticuloendothelial & immunity   0.7474        22.6          18.8             11.7
                   disorders w MCC                                                               

  815              Reticuloendothelial & immunity   0.7305        22.9          19.1             7.8
                   disorders w CC                                                                

  816              Reticuloendothelial & immunity   0.7305        22.9          19.1             5.3
                   disorders w/o CC/MCC                                                          

  820              Lymphoma & leukemia w major O.R. 0.8249        25.0          20.8             20.8
                   procedure w MCC                                                               

  821              Lymphoma & leukemia w major O.R. 0.8249        25.0          20.8             13.3
                   procedure w CC                                                                

  822              Lymphoma & leukemia w major O.R. 0.8249        25.0          20.8             5.9
                   procedure w/o CC/MCC                                                          

  823              Lymphoma & non-acute leukemia w  1.1417        29.0          24.2             24.2
                   other O.R. proc w MCC                                                         

  824              Lymphoma & non-acute leukemia w  1.1417        29.0          24.2             14.8
                   other O.R. proc w CC                                                          

  825              Lymphoma & non-acute leukemia w  0.5472        20.3          16.9             7.8
                   other O.R. proc w/o CC/MCC                                                    

  826              Myeloprolif disord or poorly     0.8249        25.0          20.8             20.8
                   diff neopl w maj O.R. proc w MCC                                              

  827              Myeloprolif disord or poorly     0.8249        25.0          20.8             12.4
                   diff neopl w maj O.R. proc w CC                                               

  828              Myeloprolif disord or poorly     0.8249        25.0          20.8             5.9
                   diff neopl w maj O.R. proc w/o                                                
                   CC/MCC                                                                        

  829              Myeloprolif disord or poorly     1.5545        35.2          29.3             17.8
                   diff neopl w other O.R. proc w                                                
                   CC/MCC                                                                        

  830              Myeloprolif disord or poorly     1.5545        35.2          29.3             5.5
                   diff neopl w other O.R. proc w/o                                              
                   CC/MCC                                                                        

  834              Acute leukemia w/o major O.R.    1.1417        29.0          24.2             24.2
                   procedure w MCC                                                               

  835              Acute leukemia w/o major O.R.    0.8249        25.0          20.8             13.5
                   procedure w CC                                                                

  836              Acute leukemia w/o major O.R.    0.5472        20.3          16.9             8.0
                   procedure w/o CC/MCC                                                          

  837              Chemo w acute leukemia as sdx or 1.5545        35.2          29.3             29.3
                   w high dose chemo agent w MCC                                                 

  838              Chemo w acute leukemia as sdx w  0.8249        25.0          20.8             13.7
                   CC or high dose chemo agent                                                   

  839              Chemo w acute leukemia as sdx    1.5545        35.2          29.3             9.1
                   w/o CC/MCC                                                                    

  840              Lymphoma & non-acute leukemia w  0.8718        20.8          17.3             16.1
                   MCC                                                                           

  841              Lymphoma & non-acute leukemia w  0.8026        20.1          16.8             10.7
                   CC                                                                            

  842              Lymphoma & non-acute leukemia    0.7305        22.9          19.1             6.9
                   w/o CC/MCC                                                                    

  843              Other myeloprolif dis or poorly  1.1417        29.0          24.2             14.5
                   diff neopl diag w MCC                                                         

  844              Other myeloprolif dis or poorly  1.1417        29.0          24.2             9.7
                   diff neopl diag w CC                                                          

  845              Other myeloprolif dis or poorly  1.1417        29.0          24.2             6.8
                   diff neopl diag w/o CC/MCC                                                    

  846              Chemotherapy w/o acute leukemia  1.6788        37.4          31.2             13.8
                   as secondary diagnosis w MCC                                                  

  847              Chemotherapy w/o acute leukemia  1.4350        27.6          23.0             5.0
                   as secondary diagnosis w CC                                                   

  848              Chemotherapy w/o acute leukemia  0.7305        22.9          19.1             4.6
                   as secondary diagnosis w/o                                                    
                   CC/MCC                                                                        

  849              Radiotherapy                     0.8994        23.5          19.6             9.5

  853              Infectious & parasitic diseases  1.7687        38.1          31.8             27.6
                   w O.R. procedure w MCC                                                        

  854              Infectious & parasitic diseases  1.4381        30.8          25.7             17.4
                   w O.R. procedure w CC                                                         

  855              Infectious & parasitic diseases  0.7305        22.9          19.1             12.2
                   w O.R. procedure w/o CC/MCC                                                   

  856              Postoperative or post-traumatic  1.4470        36.1          30.1             26.5
                   infections w O.R. proc w MCC                                                  

  857              Postoperative or post-traumatic  1.1886        31.5          26.3             14.1
                   infections w O.R. proc w CC                                                   

  858              Postoperative or post-traumatic  1.1109        28.4          23.7             9.5
                   infections w O.R. proc w/o                                                    
                   CC/MCC                                                                        

  862              Postoperative & post-traumatic   0.8670        25.2          21.0             13.4
                   infections w MCC                                                              

  863              Postoperative & post-traumatic   0.7478        23.4          19.5             8.2
                   infections w/o MCC                                                            

  864              Fever of unknown origin          0.7305        22.9          19.1             6.4

  865              Viral illness w MCC              0.7823        21.8          18.2             11.0

  866              Viral illness w/o MCC            0.6431        21.2          17.7             5.4

  867              Other infectious & parasitic     1.0954        23.6          19.7             16.2
                   diseases diagnoses w MCC                                                      

  868              Other infectious & parasitic     0.8869        22.0          18.3             9.3
                   diseases diagnoses w CC                                                       

  869              Other infectious & parasitic     0.5472        20.3          16.9             6.8
                   diseases diagnoses w/o CC/MCC                                                 

  870              Septicemia w MV 96+ hours        1.9505        30.5          25.4             23.6

  871              Septicemia w/o MV 96+ hours w    0.8299        23.5          19.6             13.0
                   MCC                                                                           

  872              Septicemia w/o MV 96+ hours w/o  0.7340        21.9          18.3             9.1
                   MCC                                                                           

  876              O.R. procedure w principal       0.7305        22.9          19.1             19.1
                   diagnoses of mental illness                                                   

  880              Acute adjustment reaction &      0.5472        20.3          16.9             5.0
                   psychosocial dysfunction                                                      

  881              Depressive neuroses              0.5472        20.3          16.9             6.6

  882              Neuroses except depressive       0.5472        20.3          16.9             6.9

  883              Disorders of personality &       0.5472        20.3          16.9             11.8
                   impulse control                                                               

  884              Organic disturbances & mental    0.4883        23.3          19.4             8.3
                   retardation                                                                   

  885              Psychoses                        0.4140        23.8          19.8             12.3

  886              Behavioral & developmental       0.5472        20.3          16.9             9.4
                   disorders                                                                     

  887              Other mental disorder diagnoses  0.5472        20.3          16.9             7.1

  894              Alcohol/drug abuse or            0.5472        20.3          16.9             4.5
                   dependence, left ama                                                          

  895              Alcohol/drug abuse or dependence 0.5472        20.3          16.9             16.8
                   w rehabilitation therapy                                                      

  896              Alcohol/drug abuse or dependence 0.8249        25.0          20.8             10.6
                   w/o rehabilitation therapy w MCC                                              

  897              Alcohol/drug abuse or dependence 0.5472        20.3          16.9             6.4
                   w/o rehabilitation therapy w/o                                                
                   MCC                                                                           

  901              Wound debridements for injuries  1.3395        35.2          29.3             23.7
                   w MCC                                                                         

  902              Wound debridements for injuries  1.1605        33.5          27.9             12.9
                   w CC                                                                          

  903              Wound debridements for injuries  0.7305        22.9          19.1             7.9
                   w/o CC/MCC                                                                    

  904              Skin grafts for injuries w       1.3351        40.8          34.0             18.8
                   CC/MCC                                                                        

  905              Skin grafts for injuries w/o     0.7305        22.9          19.1             7.7
                   CC/MCC                                                                        

  906              Hand procedures for injuries     0.5472        20.3          16.9             4.9

  907              Other O.R. procedures for        1.6622        36.8          30.7             19.4
                   injuries w MCC                                                                

  908              Other O.R. procedures for        1.3966        34.1          28.4             11.3
                   injuries w CC                                                                 

  909              Other O.R. procedures for        0.8249        25.0          20.8             5.7
                   injuries w/o CC/MCC                                                           

  913              Traumatic injury w MCC           0.8462        26.9          22.4             10.0

  914              Traumatic injury w/o MCC         0.6448        21.9          18.3             5.3

  915              Allergic reactions w MCC         0.5472        20.3          16.9             7.5

  916              Allergic reactions w/o MCC       0.5472        20.3          16.9             3.2

  917              Poisoning & toxic effects of     0.7305        22.9          19.1             8.3
                   drugs w MCC                                                                   

  918              Poisoning & toxic effects of     0.7305        22.9          19.1             4.2
                   drugs w/o MCC                                                                 

  919              Complications of treatment w MCC 0.9858        26.3          21.9             10.1

  920              Complications of treatment w CC  0.8518        24.6          20.5             6.8

  921              Complications of treatment w/o   0.7511        23.0          19.2             4.5
                   CC/MCC                                                                        

  922              Other injury, poisoning & toxic  0.5472        20.3          16.9             10.0
                   effect diag w MCC                                                             

  923              Other injury, poisoning & toxic  0.5472        20.3          16.9             5.0
                   effect diag w/o MCC                                                           

  927              Extensive burns or full          1.5545        35.2          29.3             29.3
                   thickness burns w MV 96+ hrs w                                                
                   skin graft                                                                    

  928              Full thickness burn w skin graft 1.1417        29.0          24.2             24.2
                   or inhal inj w CC/MCC                                                         

  929              Full thickness burn w skin graft 0.7305        22.9          19.1             13.1
                   or inhal inj w/o CC/MCC                                                       

  933              Extensive burns or full          1.5545        35.2          29.3             8.5
                   thickness burns w MV 96+ hrs w/o                                              
                   skin graft                                                                    

  934              Full thickness burn w/o skin     0.6998        24.2          20.2             11.1
                   grft or inhal inj                                                             

  935              Non-extensive burns              0.7525        24.9          20.8             8.8

  939              O.R. proc w diagnoses of other   1.2500        33.8          28.2             18.9
                   contact w health services w MCC                                               

  940              O.R. proc w diagnoses of other   1.1066        33.8          28.2             10.5
                   contact w health services w CC                                                

  941              O.R. proc w diagnoses of other   0.9719        28.8          24.0             4.8
                   contact w health services w/o                                                 
                   CC/MCC                                                                        

  945              Rehabilitation w CC/MCC          0.5867        22.2          18.5             16.3

  946              Rehabilitation w/o CC/MCC        0.4935        18.9          15.8             11.7

  947              Signs & symptoms w MCC           0.6340        22.7          18.9             7.9

  948              Signs & symptoms w/o MCC         0.5642        23.4          19.5             5.3

  949              Aftercare w CC/MCC               0.6693        22.1          18.4             6.1

  950              Aftercare w/o CC/MCC             0.5735        18.5          15.4             5.1

  951              Other factors influencing health 1.5837        26.2          21.8             5.0
                   status                                                                        

  955              Craniotomy for multiple          1.5545        35.2          29.3             21.9
                   significant trauma                                                            

  956              Limb reattachment, hip & femur   0.7305        22.9          19.1             14.4
                   proc for multiple significant                                                 
                   trauma                                                                        

  957              Other O.R. procedures for        1.5545        35.2          29.3             29.1
                   multiple significant trauma w                                                 
                   MCC                                                                           

  958              Other O.R. procedures for        1.1417        29.0          24.2             17.9
                   multiple significant trauma w CC                                              

  959              Other O.R. procedures for        1.1417        29.0          24.2             9.9
                   multiple significant trauma w/o                                               
                   CC/MCC                                                                        

  963              Other multiple significant       1.5545        35.2          29.3             16.5
                   trauma w MCC                                                                  

  964              Other multiple significant       0.7305        22.9          19.1             10.2
                   trauma w CC                                                                   

  965              Other multiple significant       0.5472        20.3          16.9             6.5
                   trauma w/o CC/MCC                                                             

  969              HIV w extensive O.R. procedure w 1.5545        35.2          29.3             29.3
                   MCC                                                                           

  970              HIV w extensive O.R. procedure   1.5545        35.2          29.3             15.8
                   w/o MCC                                                                       

  974              HIV w major related condition w  0.8908        21.9          18.3             17.5
                   MCC                                                                           

  975              HIV w major related condition w  0.7492        21.3          17.8             11.5
                   CC                                                                            

  976              HIV w major related condition    0.7382        18.0          15.0             7.7
                   w/o CC/MCC                                                                    

  977              HIV w or w/o other related       0.7305        22.9          19.1             8.3
                   condition                                                                     

  981              Extensive O.R. procedure         2.2339        42.0          35.0             24.6
                   unrelated to principal diagnosis                                              
                   w MCC                                                                         

  982              Extensive O.R. procedure         1.8277        37.6          31.3             16.3
                   unrelated to principal diagnosis                                              
                   w CC                                                                          

  983              Extensive O.R. procedure         1.1417        29.0          24.2             9.0
                   unrelated to principal diagnosis                                              
                   w/o CC/MCC                                                                    

  984              Prostatic O.R. procedure         1.5545        35.2          29.3             23.7
                   unrelated to principal diagnosis                                              
                   w MCC                                                                         

  985              Prostatic O.R. procedure         1.1417        29.0          24.2             16.6
                   unrelated to principal diagnosis                                              
                   w CC                                                                          

  986              Prostatic O.R. procedure         1.1417        29.0          24.2             8.5
                   unrelated to principal diagnosis                                              
                   w/o CC/MCC                                                                    

  987              Non-extensive O.R. proc          1.6972        37.9          31.6             21.9
                   unrelated to principal diagnosis                                              
                   w MCC                                                                         

  988              Non-extensive O.R. proc          1.3386        33.2          27.7             13.2
                   unrelated to principal diagnosis                                              
                   w CC                                                                          

  989              Non-extensive O.R. proc          0.8249        25.0          20.8             6.7
                   unrelated to principal diagnosis                                              
                   w/o CC/MCC                                                                    

  998              Principal diagnosis invalid as   0.0000        0.0           0.0              0.0
                   discharge diagnosis                                                           

  999              Ungroupable                      0.0000        0.0           0.0              0.0
  ---------------------------------------------------------------------------------------------------------------

^1^ Transition blended relative weights for FY 2008 determined as
described in Step 7 in section II.I.4. of the preamble of the FY 2008
IPPS final rule (72 FR 47295).

^2^ The "short-stay outlier threshold" is calculated as 5/6ths of the
geometric average length of stay of the LTC-DRG (as specified at
§412.529(a), in conjunction with §412.503).

^3^ The "IPPS-comparable threshold" is calculated as one standard
deviation from the geometric average length of stay of the same DRG
under the IPPS as specified at §412.529(c)(3)(i).